Monthly Archive for April, 2010

Most people who are making noise about the health care bill have no idea what it includes. It was actually surprisingly difficult for me to find a good analysis of what it actually does [link].
I would appreciate it greatly if anyone commenting is very specific about what they do or don’t like, based on what is actually in the bill. If you are referencing something not in my above summary, please provide detailed documentation. Thanks.

Individual Requirements
I’m actually in favor of mandatory insurance. Currently, hospitals are mandated to provide emergency care to anyone who needs it, so I think it is legitimate for patients to be mandated to have coverage. Providing help to those with income between 133% and 400% of the poverty line is something I support less enthusiastically, but I would be willing to help this group purchase at least catastrophe insurance. $700 / person per year (up to 3 in household or 2.5% of household income) penalty seems reasonable, so long as this money goes toward a fund to reimburse hospitals for unpaid ER care.

Employer Requirements
I don’t think insurance should be an employer mandate, so I disagree with the penalties for employers who don’t insure their employees. The current tax situation that makes it cheaper for employers to buy insurance should be fixed. The “free choice voucher” that allows an employee to buy their own insurance though is a good thing, and should not be limited to employees under 400% of the poverty line. Ideally, I’d like to see everyone have private insurance plans funded by pre-tax dollars, and this approach moves in the correct direction.

Medicaid
Ideally, I’d like to see the needy helped by private charities funded by voluntary donations. That said, I am willing to see government provide “essential health benefits” to those under 133% of the poverty line, particularly for children under this level. Children are not capable of pursuing their own best interests, and cannot be held accountable for parents who fail to contribute sufficiently to the economy. My main concern is what constitutes “essential health benefits”, and how efficiently this program is run. I don’t trust our government to do a good job with it based on past performance, but would be thrilled to be proven wrong.

Cost Subsidies
I’m not entirely opposed to the credits, though I think they should be tied to “bronze” plans rather than “silver” plans. Basing the subsidies on the second lowest cost option seems to make sense though, as does tying the subsidy to a percentage of income and the total cost to percentage of GDP. My biggest fears here are that the verifications won’t be done effectively, and that the GDP limit will be ignored or changed rather than reducing benefits if this becomes too expensive.

On the positive side, I’d like to see hard GDP limits placed on all spending bills, with a requirement for a 2/3 majority to increase any such limits. We really need to end runaway spending programs, and this could be a feasible way to approach it.

Subsidies to Employers
I still don’t like the idea that employers proxy insurance purchases by their employees, so I’d rather see the government subsidize the employee than the employer. Anything that continues to benefit the employed over the self-employed is undesirable.

Tax Changes
Most of the increases I am ok with, though reducing useability of flexible spending and health savings accounts is a step in the wrong direction. Such accounts should be encouraged in every way possible, since they reduce the need for high cost insurance plans. Increasing taxes across the health field is likely to further increase health care costs in the US, again a move in the wrong direction. On a positive note, even trying to offset spending increases with tax increases is a good thing, and shames the behavior by the Republicans over the last decade.

Insurance Exchanges
Making it easier for people to buy and sell plans is only a good thing. Distinguishing between “employers” and “random groups buying together” seems to be a bad thing though, since any group of equivelant size should be considered equally. I do NOT think such exchanges should need to validate residency status, they are selling a product to an individual and group and the only thing they should be concerned about is the relative health of the members of that group. I think that encouraging co-ops is a great idea, and could well help reduce expenses in the health industry. My main concern is that the funding for such groups should be repaid to the federal government, and that these groups should be allowed freedom to operate themselves independently.

Benefit Tiers
I like anything that makes it easier for consumers to make an informed purchase. This seems to do that quite effectively. I’d like to see the health insurance mandate reduced to allow any citizen to buy only a catastrophic plan if they so choose (not just those under 30). With a strong health savings account and health loan program, this could be the only kind of insurance needed.

Detailed rules
I actually like the renewal guarantee requirement. The current situation of raising rates through the roof when someone gets sick is simply wrong. People pay good money for insurance they don’t currently need so that if they get sick they will be covered. If the insurer can’t predict their probability of getting sick in advance, they shouldn’t be able to change rates except based on age and intentional lifestyle decisions. This is the number 1 abuse by insurance companies, and needs to be fixed.

I’m concerned about the rest of the rules. I do think that in an emergency, a plan should be expected to cover any reasonable services. The rest of the requirements seem like they run the risk of telling the provider how to do their job though, and could drive health care costs up if they are not well designed. I don’t see anything obviously dangerous, but it makes me uncomfortable.

Benefit Design
This has to be done right: “Create an essential health benefits package that provides a comprehensive set of services, covers at least 60% of the actuarial value of the covered benefits, limits annual cost-sharing to the current law
HSA limits ($5,950/individual and $11,900/family in 2010), and is not more extensive than the typical employer plan.” As stated, I have no current objections though.

Still to come:
Changes to Private Insurance
State Role
Cost Containment
Improving Quality/Health System Performance
Prevention/Wellness
Long-Tern Care
Other Investments