Wednesday, December 16, 2009

Health reform and the realistic limits of our capacity for change...

It sounds crazy as I type this, but I believe that the health reform bill that will pass will not go nearly far enough and I think it was the right decision for the White House to urge the Senate to appease the moderates and counsel restraint. The public option might be the right way to go, but it isn't the only way to get there. And this idea of expanding Medicare to 55-64 with a buy in as an alternative to the public option is like getting turned down for $50 and then asking for $50,000.

The bill that passes will do a number of really important things.

1. It creates a mandate that all people have health insurance (like the auto insurance mandate) that meets a certain minimum level of coverage. This will most likely be catastrophic coverage.
a. The penalty for not having coverage will be either a 2.5% tax on adjusted annual income (House Bill) or $750/person up to a family of four (Senate Bill)

2. It will create a payroll tax for businesses that don't provide some level of coverage to employees to help offset the cost of those employees buying coverage and help cover the cost of subsidies for people who are below a certain income threshold.

3. It will regulate insurance companies.
a. They will no longer be able to turn away people for pre-existing conditions or arbitrarily cut peoples coverage when they get sick.
b. They will only be allowed to charge one rate for insurance that is not based on health status (huge for people with HIV, Hep-C, Diabetes, etc.).
c. They will not be allowed to create annual maximum coverage levels (many cut off at $100K or $1 million) or maximum coverage levels for the life of the policy (not annual, but overall)

4. It will expand Medicaid to cover all individuals up to either 133% of the Federal Poverty Level (House) or 150% of FPL (Senate)

5. It will remove anti-trust exemptions for health and malpractice insurers (interstate competition)

6. It will limit medical loss ratios to 85% (the amount of revenues from health insurance premiums that is spent to pay for the medical services covered by the plan.)

7. It will create health insurance exchanges (like in the Mass reform from 2006) This will:
a. Improve competition
b. Allow states also to create & regulate exchanges
c. Create Co-ops (like Kaiser, GroupHealth of Puget Sound and the Mayo Clinic to name a few)

8. It will address affordability
a. Sliding scale for families up to 400% of FPL
b. Small employer tax credit

9. It will create a health savings account system for pharmaceutical coverage

They are looking at ways to pay for this. One idea is a 5.4% tax on adjusted income for those making over $500,000 per year.

The Senate bill was scored by the Congressional Budget Office as being deficit neutral (i.e. cost savings will balance new costs).

So there I have painted a very rosey picture for you. That certainly isn't the totality of this bill. It doesn't do enough to control the cost of health care in this country, the regulation doesn't go far enough (in my opinion). A medical loss ratio of 85% is a joke (considering that the VA is like 98% and Medicare is 95%). There are many short comings.

My personal belief is that we should look at the Dutch health reform from a couple years ago as a model. It is a highly regulated private sector system.

Here's a link

But if this is all that passes, and I think it will pass, it will be a huge step forward for health care in this country. That doesn't mean that the game is done. As with all public policy issues, you drink a beer, celebrate the victory and wake up the next day and begin anew (also true for climate change at COP15 and the Cap and Trade legislation).

Tuesday, December 15, 2009

Is COP15 the problem or the solution? And, freedom of speech vs. freedom of participation

I have been tracking the “goings on” of the COP15 climate conference in Copenhagen. In the process, one of the blogs I have been following is called: Liz to Copenhagen.

Today she wrote:

“There are a series of high-level meetings taking place this Friday with 115 heads of state, and I guess they don’t want us riffraff getting in their way. So, the UN has set up a system.

  • 7000 NGOs are allowed in tomorrow. This is 7000 out of the 35 000 who have applied for accreditation.
  • 1000 are allowed in on Thursday.
  • 90 are allowed in on Friday during the head-of-state meetings.

“I wholeheartedly disapprove! This is contrary to the principles of the UN and the UNFCCC as a transparent forum for staging events, networking, expressing grievances, and trying to urge our leaders to take civil society into account as they make decisions.

“A system of double badges will be put into place in addition to the usual badge check and security line. The secondary badges will be distributed to 33% of the NGO delegation in question. The other 2/3 just do without. What this means for the youth constituency, and SustainUS specifically, is that (in addition to destroying our sole line of wireless communication) we each receive a number each day, which we must strategically divide among our extended delegation of 99. This means we go in pre-scheduled shifts, and youth must shift our headquarters to outside the Bella Center. The worst part is that they didn’t even give SustainUS 33%–they gave us 24 badges.

“The youth movement has been working diligently throughout the last several years to gain recognition as a serious stakeholder in this process. It has all been eradicated with the stroke of a pen. We are most displeased. This is exactly the sort of thing the UN needs not to be doing at this point.

“No surprise, but–when you consider that the youth have been called the moral voice of the UN, I guess this shows what role morality plays in the real world.”

I have two responses to this post. First, I praise her energy and enthusiasm. Second, as I wrote in a comment on her blog:

“I was just saying on my Facebook: ‘There is a misconception in this country that freedom of speech = freedom to be listened to. I have a right to ignore what you are saying!’ Allowing 7000 NGOs in seems very reasonable, to me. There is a lot of redundancy in that 35,000.”

In a second comment, I wrote:

“What number should be allowed in on Friday when the heads of state meet? 30,000? 10,000? 7000? 500? Does that seem reasonable? Does it seem like any more than 90 would facilitate a productive session?

“I must admit, it seems to me that the “youth movement’s” exclusion on Friday only eradicates their efforts if you choose to see it that way. Perhaps part of that effort was electing one Presidential candidate or another. Perhaps it has placed a spotlight on this effort.

“I am a firm believer in open government and consensus making and allowing citizen input, but at some point in our “republic” (and that is what we are, not a pure democracy) we elect people to be in the room and see us across the finish line. If they fail to do that, we can choose to hold them accountable. We can choose to trust them or not, that is an individual choice. With this President, and the political reality in the United States such as it is, I choose to trust that he will get us the best deal that he can. It won’t go far enough for me, but it never was going to go far enough for me. Other countries would see to that, even if my country did not.”

My question is; what is the alternative? The day after Copenhagen we start anew to keep the ball rolling forward.