ObamaCare: Worse Than Doing Nothing?

Keeping the Insurance Companies in Command by RUSSELL MOKHIBER


That’s the conclusion of single payer advocate Dr. Quentin Young, national coordinator for Physicians for a National Health Program (PNHP), in his just released autobiography – Everybody In, Nobody Out: Memoirs of a Rebel Without a Pause.

“Had I been in Congress, I would have unequivocally voted against Obamacare,” Young writes. “It’s a bad bill. Whether it’s worse than what we have now could be argued. We rather think because of its ability to enshrine and solidify the corporate domination of the health system, it’s worse than what we have now. But whether it is somewhat better or a lot worse is immaterial. The health system isn’t working in this country — fiscally, medically, socially, morally.”

Young rejects the idea that President Obama should have compromised on single payer in the face of industry opposition.

“I don’t have any sympathy for the idea that the president had to compromise because his opposition was strong,” Young writes. “Winning is not always winning the election. Winning is making a huge fight and then taking the fight to the people — re-electing people who are supporting your program and defeating those who aren’t.”

Young first met the young Barack Obama in the mid-1990s at social gatherings.

At the time, Obama was lecturing at the University of Chicago Law School and practicing law.

“We did not become bosom buddies after a few of these social gatherings — I just viewed him as a nice, bright guy living in the neighborhood,” Young says.

When Obama ran for the Illinois Senate, Young supported him.

“I was happy with his views on health care,” Young writes. “He recognized that major reform was necessary and indicated support for a single-payer approach. No blushing friend, I took every opportunity to solidify his position. While not an official adviser, I tried to influence him as much as I could. My colleagues and I sent him notes touting the advantages of single-payer and the form it might take and talked with him and his staff about it whenever I had the chance.”

“I felt I did influence him,” Young said.

When Obama ran for the Senate in 2003, Obama told the Illinois AFL-CIO:

“I happen to be a proponent of a single payer universal health care program. I see no reason why the United States of America, the wealthiest country in the history of the world, spending 14 percent of its Gross National Product on health care cannot provide basic health insurance to everybody. And that’s what Jim is talking about when he says everybody in, nobody out. A single payer health care plan, a universal health care plan. And that’s what I’d like to see. But as all of you know, we may not get there immediately. Because first we have to take back the White House, we have to take back the Senate, and we have to take back the House.”

But just a year later, Obama had flipped and came out against single payer in Illinois.

“I was very disappointed by his move to the right to keep the insurance companies in command,” Young told the Springfield State Journal Register in 2004. “I’m not accusing him of lying or misconduct. I’m accusing him of a lack of courage.”

But despite Obama’s “lack of courage,” Young supported Obama in his run for U.S. Senate and later for president. Young was just setting himself up for more disappointment.

At a town hall meeting in Portsmouth, New Hampshire in August 2009, Obama was asked whether he supported a universal health care plan.

“First of all, I want to make a distinction between a universal plan versus a single-payer plan, because those are two different things,” Obama said.

“A single-payer plan would be a plan like Medicare for all, or the kind of plan that they have in Canada, where basically government is the only person — is the only entity that pays for all health care. Everybody has a government-paid-for plan, even though in, depending on which country, the doctors are still private or the hospitals might still be private. In some countries, the doctors work for the government and the hospitals are owned by the government. But the point is, is that government pays for everything, like Medicare for all. That is a single-payer plan.”

“I have not said that I was a single-payer supporter because, frankly, we historically have had a employer-based system in this country with private insurers, and for us to transition to a system like that I believe would be too disruptive. So what would end up happening would be, a lot of people who currently have employer-based health care would suddenly find themselves dropped, and they would have to go into an entirely new system that had not been fully set up yet. And I would be concerned about the potential destructiveness of that kind of transition.”

“All right? So I’m not promoting a single-payer plan,” Obama said.

In March 2010, Congress passed the Affordable Care Act — Obamacare — by a narrow margin.

“PNHP’s policy experts did a line-by-line examination of the bill and, while acknowledging that it contains some modest benefits that make changes around the edges of our existing system, basically gave it two thumbs down,” Young writes. “To this day, much to the chagrin of many of our friends who wanted reform, I remain adamant in my rejection of Obamacare.”

“Why? We want a system that excludes the private insurance companies,” Young writes. “ We demand such exclusion not because these companies are good or evil (although we think they’re pretty evil). Rather, the reason to exclude them is that they don’t address the needs of the American people.”

Young also rejects the idea of a “public option,” pushed by Democrats such as Howard Dean. A public option “would not have made any significant difference on the overall impact” of Obamacare “contrary to the view of many progressive who believed that it would,” Young says.

“Since WWII, we have learned a lot about disease and certainly have had dramatic improvements in what we can do,” Young writes. “I’m talking about surgery of the heart, vaccination, nutrition issues. All these things have been largely defined in the last half-century. We’ve had something approaching a 12-year life expectancy rise just from scientific intervention.”

“We have all this knowledge, all these options, but we have a very backward financing and delivery system and the result is a great deal of human suffering,” Young says. “And that’s why we remain opposed to the Affordable Care Act. We think we have a winning proposition despite the reality in Congress. Polls repeatedly vindicate our position. A solid majority of the public and 59 percent of doctors support the single payer approach.”

“President Obama could have made it happen,” Young says. “He could have stuck to all the virtues of single payer. And I won’t deny he may have been defeated in the first round. There’s no question that this fight has been dirty and it’s going to get dirtier.”

Beyond Obamacare: How a Single-Payer System Can Save US Health Care

Wednesday, April 24, 2013 by Common Dreams
by Dave Dvorak, MD

As physicians, health care leaders and legislators grapple with the complex changes brought by the Affordable Care Act (ACA), many are concerned that even after the law is fully implemented, hundreds of thousands of people will remain uninsured while health care costs continue to spiral.

What if there were a simple, streamlined solution that would guarantee health coverage while saving billions of dollars? A growing number of physicians are endorsing what they consider to be such a solution: single-payer health care. Weary of having to comply with hundreds of different insurance plans’ administrative requirements while their patients are denied needed tests and treatments, these physicians are drawn to the simplicity, cost-effectiveness and truly universal coverage offered by a single-payer system.

Their views were supported by an independent analysis last year demonstrating that with a state-based single-payer system, every person could have comprehensive coverage while the state would save billions annually.

A deeply flawed system

The desire for meaningful reform comes in the face of the U.S. health care system’s long-recognized dysfunction. Despite health care accounting for 18 percent of the nation’s economy—twice that of other wealthy democracies—48 million Americans lack health coverage. Another 29 million are underinsured, having poor coverage that exposes them to unaffordable out-of-pocket expenses. Health insurance premiums have doubled over the past decade, with the average annual cost for family coverage now exceeding $15,700; and health care costs now account for two-thirds of personal bankruptcy filings in the United States.

At the root of these problems is the fact that we have a fragmented, highly inefficient system. Employed Americans younger than 65 years of age have job- based insurance, if their employer chose to provide it; the elderly and disabled are covered through Medicare; the poor by Medicaid; military veterans through the Veterans Administration; and American Indians through the Indian Health Service. Persons who do not fall into any of those categories must try to purchase individual coverage in the private market, where it is often prohibitively expensive or unobtainable if they have a pre-existing health condition.

Owing largely to this fragmentation and inefficiency, a staggering 31 percent of U.S. health care spending goes toward administrative costs, rather than care itself. Inefficiency exists at both the provider and payer level. To care for their patients and get paid for their work, physicians and hospitals must contend with the intricacies of numerous insurance plans—which tests and procedures they cover, which drugs are on their formularies, which providers are in their network. Meanwhile, private health insurance companies divert a considerable share of the premiums they collect toward advertising and marketing, sales teams, underwriters, lobbyists, executive salaries and shareholder profits. The top five private insurers in the United States paid out $12.2 billion in profits to investors in 2009, a year when nearly 3 million Americans lost their health coverage.

The ACA of 2010, known widely as Obamacare, is expected to extend coverage to 32 million more Americans But it accomplishes this goal primarily by expanding the current fragmented, inefficient system and maintaining the central role of the private insurance industry in providing coverage. As a result, the ACA is expected to do little to rein in health care spending. Furthermore, it will fall far short of achieving universal coverage, as tens of millions of Americans will remain uninsured after its full implementation.

The solution

The central feature of a single-payer health care system would be one health plan that covers all citizens, regardless of their employment status, age, income or health status. Having a public fund that pays for care would slash administrative inefficiencies and eliminate profit-taking by the private insurance industry.

Under a single-payer system, the way society pays for health care would change, but the market-based health care delivery system would remain. Physicians and hospitals would continue to compete with one another based on service, quality of care and reputation. The chief difference is that they would bill a single entity for their services, rather than numerous insurers.

Individuals would benefit immensely by having continuous coverage that is decoupled from their employment. This would alleviate “job lock,” in which people remain in undesirable employment situations in order to maintain coverage. In a single-payer system, individuals could choose to see any provider, in contrast to the current system in which choice is restricted to those who are in-network. Deductibles and copays would be minimal or eliminated, removing cost as a barrier to obtaining needed care.

A single-payer system would be funded through savings on administrative costs, along with modest taxes that would replace the premiums and out-of-pocket expenses currently paid by individuals and businesses. The cost savings to individuals, businesses and government would be considerable. The nonpartisan U.S. General Accounting Office concluded that single- payer health care would save the United States nearly $400 billion per year, enough to cover all of the uninsured.

Physician support for a simplified, universal health care system is robust and growing. A 2008 survey published in Annals of Internal Medicine found that 59 percent of physicians supported a national health insurance system—up from 49 percent in 2002. Physicians for a National Health Program, a national organization advocating for single-payer reform, reports a membership of 18,000. In Minnesota, single payer has been formally endorsed by nearly 800 physicians, other providers and medical students.

Recognizing the implausibility of achieving single-payer reform at the national level in the current political climate, many single-payer advocates have turned their attention to state-level reform. The ACA provides for “state innovation waivers” to be granted beginning in 2017, allowing states to implement creative plans they believe would work best for them. With this in mind, organized single-payer movements have taken root in states as varied as Colorado, Hawaii, Illinois, New York, California, Oregon and Vermont. Vermont’s governor and Legislature passed a law in 2011 setting the path for the state to move toward single payer.

Conclusion

With nearly 50 million uninsured people in the United States and skyrocketing health costs, the need for profound reform of our health system could not be more clear. The ACA is a start, but it will fall far short of achieving universal coverage, and it allows unsustainable spending growth to continue. Single-payer health care would eliminate administrative waste and inefficiency, thereby creating an opportunity to achieve truly universal, cost-effective health care.

A Tale of Two Healthcare Plans

Wednesday, September 12, 2012 by Reuters

by David Cay Johnston

 

 

No issue affecting taxes so clearly divides the two parties in the U.S. election as healthcare. The two parties, in their platforms, describe very different approaches to healthcare economics. Both use political plastic surgery to cover up ugly truths.

The stakes are huge. Americans spend $2.64 per person for healthcare for each purchasing power equivalent dollar spent by the 33 other countries that make up the Organization for Economic Cooperation and Development. The OECD data shows the U.S. spends $8,233 per capita compared with an average of $3,118 in the other 33 countries.

A growing share of federal tax dollars, in direct spending and in tax breaks, is going to U.S. healthcare as the population ages, even though about one in six Americans lacks health insurance.

America‘s healthcare system, more accurately described as a non-system sick care system, totaled 17.6 percent of the economy in 2010, compared to an average of 9.2 percent in the other 33 countries, as the OECD data shows.

In the United States, total public and private cost of healthcare is significantly greater than the total of corporate and individual income taxes, as well as payroll taxes. For each dollar paid in all three of those taxes in 2010, healthcare came to $1.29.

If we just lowered our costs to those of France, which has universal care in what is widely regarded as one of the best systems if not the best, it would save almost as much money as Americans paid in individual income taxes in 2010. The French spend 6 percentage points less of their economy on healthcare. In the United States, the individual income tax in 2010 came to 6.3 percent of the U. S. economy, the lowest since Truman was president.

Take a look at your pay stub to get an idea of the kind of money being spent on a system that fosters bankruptcy, bedevils small business and ranks 31st among the 34 OECD countries in preventing premature death.

REPUBLICAN PLAN
The Republicans say the federal government is “structurally and financially broken” and that “three programs - Medicare, Medicaid, and Social Security – account for over 40 percent of total spending,” which is “harming job creation and growth, (while) projections of future spending growth are nothing short of catastrophic, both economically and socially.”

The Republicans promise to “empower millions of seniors to control their personal healthcare decisions,” a vow immediately followed by a promise to cut federal spending.

The clearest explanation of what that would mean comes from Representative Paul Ryan, the Republican vice presidential nominee. Before he started obfuscating, Ryan laid out his plans in detail. He boasted that by changing Medicare from a plan that provides treatment for every older American into one that gives seniors a fixed sum to buy their own health insurance, taxpayers would save through 2084 the present equivalent of $4.9 trillion.

What Ryan did not mention is that his plan would also mean $8 of increased private spending by seniors and the disabled for each tax dollar saved.

We know how Ryan’s plan would raise total costs because David Rosnick and Dean Baker, economists at the Center for Economic Policy and Research which promotes government policies that it says would benefit workers and the poor, used the same formula that Ryan (or his staff) applied to the same Congressional Budget Office data, but on private medical care spending. Ryan’s spokesman did not respond to requests for comment.

Beyond the fact that it makes no sense to spend $8 to save $1, older people do not have the money. A tenth of Americans age 75 and older live below the official poverty line. Another 24 percent have only saved a tad more.

Every indicator shows that Americans have not enough for their old age and that a shrinking number have pensions while the Republicans now in charge of the party want to cut Social Security benefits, if not kill the program.

So why would any Americans under age 55, whose healthcare benefits Ryan wants to cut when they reach 65, think they can afford to spend $8 to save $1? Recently Ryan has softened his plan to let those who wish stay in traditional Medicare. Since anyone not rich who can count would stick with Medicare, Ryan’s promised taxpayer savings would never materialize.

Alan Grayson, the combative one-term Democratic representative from Florida, got it right when he said on the House floor in 2009: “The Republican plan – don’t get sick and if you do get sick die quickly.”

DEMOCRATS FAVOR UNIVERSAL CARE

 The Democratic platform calls for universal healthcare. “We will end the outrage of unaffordable, unavailable healthcare,” they say, though after six decades that party promise remains unfulfilled.

President Barack Obama‘s Patient Protection and Affordable Care Act will enable those with pre-existing conditions and twenty-somethings without work to get health insurance. But the plan does nothing to address the larger economic problem. American healthcare costs too much and needs replacement, not a nip and tuck.

Portugal, with half the income per person as America, provides universal healthcare. Cuba, the CIA tells us, ranks 40th in infant mortality, while the United States is nine steps lower at 49th, an astonishing fact given U.S. spending compared to the poverty induced by Castro’s collectivist economic policies.

Doing worse than Portugal and Cuba is, in my view, not just costly but immoral.

Just as Republicans are trying to limit the franchise, so are they trying to limit who gets healthcare. The Democrats are better only because they recognize that universal care can be cheaper while removing an annoying and costly distraction from business.

Death and taxes will always be with us. What we need is to spend less on taxes while doing the best we can to stave off death.

Your corporate democracy

Supreme Court Leaves Romney in the Cold

Friday, June 29, 2012 by TruthDig.com

by Robert Scheer

Mitt Romney is an idiot or, even worse, is pretending to be one. His tantrum of a response on Thursday to the Supreme Court’s health care decision was pure playground: As president I will own the ball, and the game will be played by rules that leave me a winner.

That game has already been called in a decision written by the top-ranking conservative jurist, and shorn of the constitutional objection; Barack Obama’s health care plan now will be judged by its practical outcomes. Romney’s promise that “I will act to repeal Obamacare” from “my first day as president of the United States” is a prescription of destructive gridlock for a program already well under way. 

By immediately committing to reverse a health care reform based on the very program he implemented as governor of Massachusetts, Romney has gone to war with himself. Obviously, neither he nor his advisers has yet grasped that the decision written by Chief Justice John Roberts has changed the terms of the debate.

The issue is no longer one of states’ rights. That would have been the case if the court had relied on the Constitution’s commerce clause, leaving Romney to argue that it was legal for his state to have required a mandate but is illegal for the feds to do so. However, the court decision, based as it is on the right of the government to raise taxes to pay for a public need, makes the states’ rights claim irrelevant. 

The issue faced by the court was the same on the federal level as it was on the state level; if the public, through its government, must ultimately bear the cost of caring for the uninsured—as would be so in any society possessed of even a modicum of shared social responsibility—then it can vote to levy taxes to finance that effort.

Why did Massachusetts under Romneycare have a right to tax to pay for mandated health care but the federal government would have no such right? All the Obama campaign needs to do is play that video clip from April 12, 2006, when Romney signed into law a Massachusetts mandate, justifying his tax penalty on those who failed to comply by saying it would help “hundreds of thousands of people ... have healthier and happier lives.” President Obama could claim correctly that he added 30 million Americans, not blessed to be living in Massachusetts, to the healthy and happy category.

Clearly the Romney campaign staff was not prepared for what it must now view as Justice Roberts’ betrayal. Based on the oral proceedings of the court, Romney’s aides felt assured that Justice Anthony Kennedy would join his four conservative colleagues in voting to reverse the law.

“My guess is that they’re not sleeping real well at the White House tonight,” Romney chortled the day before the ruling. With egg on his face the morning after, a subdued Romney, standing behind a podium sign promising to “Repeal and Replace Obamacare,” committed to sinking into a political swamp of winless contradictions.

The danger for Romney is in the word “replace,” for there is no way he will persuade even a Republican-dominated Congress to get rid of the obviously popular requirements of the new law, now declared constitutional. While the mandatory aspect—pay for insurance or pay a fine—remains unpopular, not so the programs that expand medical coverage to the uninsured. Three-quarters of those polled by The Associated Press said they wanted Congress, instead of sticking with the status quo, to come up with a new plan if the court threw this one out.

Romney’s devil is now in the details. What exactly in this massive overhaul, much of it widely popular although costly, would he shed? The court already has limited federal pressure on the states to increase assistance to the poor. Bereft of that handy demagogues’ argument, Romney and his fellow critics are left with eviscerating programs that assist the struggling middle class through obviously fairer access to heath care than has been provided previously by the insurance industry.

If Romney now dares to oppose the popular items in the bill, such as requirements for the insurance companies to cover young adult children or people with pre-existing medical conditions, he is finished as a candidate before he begins. And if it is the universal coverage mandate that he would eliminate, he is left with the government stepping in to fund the good stuff, and that is what the Republican right derides as socialized medicine.

This is the petard that now hoists Romney.

America Needs Healthcare, Not Health Insurance

Ironically, the Roberts Court could actually be the instrument that leads us toward something approaching a rational, affordable healthcare provision.
By Marshall Auerback and L. Randall Wray, AlterNet
Posted on March 30, 2012

In Friday's New York Times, Paul Krugman argues that the Supreme Court conservatives grasping for reasons why Congress lacks the power to do anything that they don’t like have forgotten an important distinction: the one between a judge and a politician. We're not sure this is correct. It's always been the case that for all of their lofty protestations of being "above politics," the Supreme Court has been political, whether it be the Warren Court or today's Roberts Court.

That said, we're not sure the Supremes are wrong to question the constitutionality of a private health insurance mandate that Krugman seems so keen to defend, asking: "Is requiring that people pay a tax that finances health coverage O.K., while requiring that they purchase insurance is unconstitutional?"

Historically, Krugman has been one of the most eloquent critics of the insurance-based model. Yet he makes the mistake common to many progressive defenders of Obama’s healthcare bill: He conflates two distinct issues and thereby masks the fundamental flaw underlying the entire approach. Private health insurance is not synonymous with healthcare. There is a big difference between levying a tax for a public good (i.e. healthcare) versus forcing people to buy a service from a private health insurance company, which is by no means synonymous with healthcare.

Using insurers to provide funding is a complex, costly and distorting method of financing healthcare. Imagine sending your weekly grocery bill to an insurance clerk for review and having the grocer reimbursed by the insurer to whom you have been paying “food insurance” premiums—with some of your purchases excluded from coverage at the whim of the insurer. Is there any plausible reason for putting an insurance agent between you and your grocer? No. Then why should an insurer stand between you and your healthcare provider? And why should you be forced to contribute to such an arbitrary scheme?

Furthermore, it is important to note how unusual the United States is—no other comparable nation (in terms of high per capita income) lacks universal healthcare coverage, and many nations that are much poorer provide universal access. And in most of the nations that are similar in other respects to the United States, government plays a much bigger role in healthcare delivery and in financing the system.

“Reform” measures actually promote the status quo by pulling more people into an expensive healthcare system that is managed and funded by insurers. Since two-thirds of household bankruptcies are due to healthcare costs, forcing people to turn over an even larger portion of their income to insurance companies will further erode household finances and exacerbate the problem. This is despite the fact that research by, among others, David U. Himmelstein and Steffie Woolhandler, demonstrates that single-payer reform could save about $380 billion annually that's currently wasted on insurers' overhead and the unnecessary paperwork (and screen-work) they inflict on hospitals, doctors and patients.

Even under today’s “reforms” in the Affordable Health Care Act, healthcare remains a function of employment, which preserves a significant cost disadvantage for U.S. corporations and is particularly unappealing during periods of high unemployment.

The US is the only country in the world where healthcare has become a marginal cost of doing business, thereby putting US corporations at a significant cost disadvantage vis a vis their foreign competition.

The reality is that healthcare is not a service that should be funded by insurance companies. An individual should insure against expensive and undesirable calamities: tornadoes, fires, auto accidents. These need to be insurable risks, or insurance will not be made available. This means the events need to be reasonably random and relatively rare, with calculable probabilities that do not change much over time. We need to make sure that the existence of insurance does not increase the probability of insured losses. This is why we are not allowed to insure our neighbor’s house.

Insurance works by using the premiums paid in by all of the insured to cover the losses that infrequently visit a small subset of them. Of course, insurance always turns out to be a bad deal for almost all of the insured—the return is hugely negative because most of the insured never collect benefits. The insurance company’s operating costs and profit margins are more or less equal to the net losses suffered by its policyholders.

Ideally, insurance premiums ought to be linked to individual risks; if this actually changed behavior so that risk fell, so much the better. That would reduce the costs to those policyholders who do not experience insured events, and would also increase the insurance companies’ profitability. Competition among insurers would then reduce the premiums for those whose behavior modifications had reduced risks.

In practice, people are put into classes—say, “over age 55 with no accidents or moving violations” in the case of auto insurance. Some people are uninsurable—the attendant risks are too high. For example, someone who repeatedly wrecks cars while driving drunk will not be able to purchase insurance. The government might help out by taking away the driver’s license, in which case the insurer could not sell insurance even if it were willing to take on the risk. Further, one cannot insure a burning house against fire because it is, well, already on fire. And even if insurance had already been purchased, the insurer could deny a claim if it determined that the policyholder was at fault.

The insured try to get into the low-risk, low-premium classes; the insurers try to sort people by risk and to narrow risk classes. To be sure, insurers do not want to avoid all risks—given a risk/return trade-off, higher-risk individuals will be charged higher premiums. Problems for the insurer arise if high-risk individuals are placed in low-risk classes and thus enjoy inappropriately low premiums. The problem for many individuals is that appropriately priced premiums will be unaffordable. At the extreme, if the probability of an insurable event approaches certainty, the premium that must be charged equals the expected loss, plus the insurance company’s operating costs and profits.

However, it is likely that high-risk individuals would refuse insurance long before premiums reached that level, since they will be better off paying out of pocket. With costs skewed toward the less healthy part of the population that bought this insurance, the insurance company would invariably seek to mitigate this impact on cost through a process of pre-screening to identify those likely to require expensive treatment, and either rejecting their applications or charging significantly higher premiums to compensate.

Again, this tends to guarantee that the uninsured pool is the most at risk. In any event, once an insurance policy is written, the insurer does its best to deny claims. It will look at the fine print and try to find exclusions and uncover preexisting conditions (say, faulty wiring) that would invalidate the claim.

From the narrow perspective of the insurance companies, all of this is good business practice. Even under a system which denies coverage on the basis of pre-existing conditions (the quid pro quo for the mandate), the legislation gives ample scope for the insurance companies to limit coverage. Sarah Palin was right. There are death panels in our healthcare system: they’re called health insurance companies.

And the reality is that as human beings we are all a bundle of “pre-existing conditions.” From the day of our birth, each of us is a little bundle of preexisting conditions—congenital abnormalities and genetic predispositions to disease or, perhaps, risky behavior. Many of these conditions will only be discovered much later, probably in a doctor’s office. The health insurer will likely remain in the dark until a bill is submitted for payment. It then must seek a way to deny the claim. The insurer will check the fine print and patient records for exclusions and preexisting conditions. Often, insurers automatically issue a denial, forcing patients to file an appeal. Again, good business practice for an insurance company, but lousy if the objective is guaranteed healthcare provision.

Given today’s political constraints, perhaps a full “single-payer” option might not be feasible, but one earlier variant of the proposed healthcare legislation did feature a Medicare buy-in. In effect, if the Supreme Court does strike down the major provisions of the Obama healthcare plan, Congress could easily use Senate reconciliation and expand Medicare via the Senate’s buy-in provisions (the House can approve this on the basis of a simple majority vote). The Congressional Budget Office has already signed off on this as a means of saving money (“budget savings” is in some respects a nonsensical concept, but it provides the necessary political cover to deploy what is essentially a budgetary procedure).

More important, the expansion of Medicare would provide a genuine “public option” that, by competing against private insurance companies (which would presumably no longer have any genuine cost constraints given that the ban to deny coverage on the basis of pre-existing conditions would likely be struck down with the individual mandate), would help control costs. It would also help solve the problem of preexisting. And because Medicare does not deny coverage on the basis of pre-existing conditions, it is actually far more cost effective than private health insurance. As James K. Galbraith notes in The Predator State (2008):

“Public health insurance entities such as Medicare do not evaluate risk because they are universal. Therefore, they save the major cost associated with private health insurance. They pay their personnel at civil servant salary scales and are under no obligation to provide a return to shareholders via dividends or meet a target rate of return. Insurance in general is therefore intrinsically a service that the public sector can competently provide at lower cost than the private sector, and from the standpoint of the entire population, selective provision of private health insurance is invariably inferior to universal public provision. “

In other words, this brings us closer to the “ideal” low-cost universal insurance plan that has long been advocated by people like Paul Krugman. Allowing a Medicare buy-in to Americans under age 65 would give people a genuine alternative to private health insurance and thereby render the whole issue of denying coverage on the basis of preexisting conditions moot. And it would substantially enhance the global competitiveness of American corporations.

A Medicare buy-in would also have the added benefit of getting us closer to a single-payer system, which is a far more rational way to control healthcare costs, largely due to the administrative complexity associated with our current patchwork system and the corresponding inability to bargain with suppliers, especially drug companies, for lower prices. Residents of the United States notoriously pay much higher prices for prescription drugs than residents of other advanced countries, including Canada. This proposal would also give American healthcare consumers far more bang for their buck than the current legislation. It would indeed be the height of historic irony if the Roberts Supreme Court was the instrument that led us away from a private health insurance based system toward something approaching a rational, affordable healthcare provision.

CNN: Health reform mandate ‘looks like it’s going to be struck down’

By Stephen C. Webster - RAW Story
Tuesday, March 27, 2012

In an afternoon update from the steps of the U.S. Supreme Court, CNN senior legal analyst andNew Yorker writer Jeffrey Toobin said that justices appeared to be highly skeptical of the law’s “individual mandate,” which would require every American to purchase some form of private health insurance.

“This law looks like it’s going to be struck down,” he said, remarking on the seemingly wary reactions of the justices. “I’m telling you, all of the predictions, including mine, that the justices would not have a problem with this law were wrong.”

He added that Justice Kennedy, largely considered to be the key swing vote on the case, appeared extremely skeptical of the individual mandate as well.

The Supreme Court has been hearing arguments for and against President Barack Obama’s health reforms since Monday, but there is no ruling yet and it remains unclear where the justices will fall on the issue. It all still hinges on several competing factors, and the court might not even issue a decision on the mandate until it takes effect in 2014.

A recent survey of former Supreme Court clerks and lawyers who have argued before the court found that over 50 percent expect the individual mandate to be upheld. Only 35 percent thought it would be struck down.

Uninsured Will Still Need The Money To Meet The Mandate

by YUKI NOGUCHI - NPR Morning Edition

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On Tuesday, the Supreme Court hears its second day of testimony about the Affordable Care Act. At issue is a central tenet of that law: whether it's legal to require individuals to purchase health care.
But apart from the legal debate, there are questions about the economics of the mandate. Some — like Peggy Bodner of Portland, Ore. — worry it may be difficult to find the money to pay for health insurance, even with government subsidies.

Bodner lost medical insurance when she lost her job three years ago. She has since found part-time work at the Oregon Zoo, but it pays half as much as her old job and doesn't offer health benefits. Despite being 41 and healthy, insuring herself under the most basic plan would cost at least $100 a month — more, Bodner says, than she can afford.

"It doesn't factor in the fact that I'm a nonsmoker, that I eat a balanced, low-fat diet, that I walk for exercise," she says. "None of those things are calculated in. And I'm like, 'OK, well what kind of a plan do you have for someone like me?' "

Starting in 2014, the law — if it's upheld — will require people like Bodner to get insurance. Oregon and all the other states will start running health care exchanges that match buyers with a selection of private insurance plans. The federal government will subsidize these plans on a sliding scale, which means people or families making up to four times the poverty level will get some help.

But for Bodner, even with the federal subsidy, a middle-range plan would still cost well over $100 a month — too much, she says, given her income barely meets her needs right now.

How Many Americans Would State Health Care Exchanges Serve?

*Estimated 2016 numbers

Source: Congressional Budget Office

Credit: Alyson Hurt

"To try and put another $100 or something like that into the budget, either something would have to go, or I would just be like, 'I can't afford this insurance; I'm not taking it,' " she says.

Under the new law, Bodner must either buy a plan or pay a fine that escalates every year she doesn't get insurance. But unless the penalty exceeds the cost of insurance, she says, she would probably just take the penalty.

Bodner's dilemma strikes at a critical question: Will the estimated 16 million people who will be required to buy subsidized insurance under the mandate actually do so?

Success of the law, after all, depends on the participation of all the key players. In order for it to work, states have to set up the exchange, insurance companies have to offer plans, and consumers need to be motivated to buy the insurance. Simply put, insurance works better when it involves large numbers — that way, both the risk andadministrative costs can be distributed across many participants.

Alan Weil, executive director of the National Academy for State Health Policy, acknowledges everyone won't immediately sign up.

"There will be people who look in their pockets and say, 'I would love to be insured, but even with this subsidy, the amount that I have to pay is more than I feel I can pay,' " Weil says. "But the overwhelming response is going to be 'I finally have coverage within reach.' "

Weil says that just as other government medical programs became more popular over time, he expects people will warm to this one. Without the mandate, however, too many would opt out while a disproportionate number of sick people would opt in. According to Weil, that would destroy the system's economics.

"Remember, we've also eliminated pre-existing condition exclusions (No they didn't, they pooled those patients based on 2009 numbers--EVERYONE with a pre-existing condition won't be covered--jef) and the higher rates people pay when they're sicker," he says. "You put all of those things together and you say, 'We are going to make coverage more affordable.' And most people will respond to that. Because we've done that, we really do need everyone participating. And so we need the mandate."

That should be an easy sell to Jordan Lund. During a brief period when his family wasn't covered, his son racked up a $27,000 emergency bill.

Lund and his wife each have medical conditions, and they have also lost their jobs four times in the past year — facts that make Lund very aware of both the perils of nothaving insurance and the perils of having to pay for it.

"If somebody doesn't have money for health insurance, they're not going to have money for a fine, either," Lund says. "So it's not a matter of you can't get blood from a stone."

For now, he says, he's just hoping to hang onto his job so won't have to make a choice.

Did John Roberts Throw A Wrench In Major Argument Against ‘Obamacare’?

BRIAN BEUTLER MARCH 26, 2012 - TPM

In a little-noticed exchange Monday, conservative Supreme Court Chief Justice John Roberts may have tipped his hand that he’s entertaining the possibility that the health care law’s individual mandate can be upheld on a constitutional basis that’s different from the one supporters and opponents have made central to their arguments.

For over a year now, observers and experts have assumed that the court’s final decision will hinge on the extent of Congress’ power to regulate interstate commerce. But the justices could also upend that conventional wisdom, and in a worrying sign for the plaintiffs on Monday, Roberts unexpectedly highlighted one way they could do that.

In an exchange with a plaintiffs attorney, Roberts suggested he’s skeptical that the mandate and its penalties can be treated separately and may have opened the door to finding that Congress’ power to impose the mandate springs from its broad taxing power.

“The idea that the mandate is something separate from whether you want to call it a penalty or tax just doesn’t seem to make much sense,” Roberts said, over strong objections from attorney Gregory Katsas. “It’s a command. A mandate is a command. If there is nothing behind the command, it’s sort of, well what happens if you don’t file the mandate? And the answer is nothing. It seems very artificial to separate the punishment from the crime. … Why would you have a requirement that is completely toothless? You know, buy insurance or else. Or else what? Or else nothing.”

That wasn’t what the challengers wanted to hear. A key feature of their argument is that the individual mandate is distinct from the fine the government will assess on people who fail to purchase insurance. They say the case isn’t about Congress’ power to tax or penalize people but rather about its power to force people to take actions they may not want to take. Roberts dismissed this distinction.

The question now is how far-reaching the implications of that dismissal are. It’s possible that Roberts was linking the mandate and its enforcement mechanism for the purpose of answering a much narrower question — that it wasn’t a tip-of-the-hand at all. But if the two measures are linked, then the court could easily conclude they both stem from the same power, and give them the green light.

“Struck me too,” said Timothy Jost, a legal scholar and supporter of the health care law, who has followed these arguments very closely. “This is a big problem for the states’ Medicaid argument and might even support the federal government’s argument that the mandate is an exercise of the taxing power.”

The states want to avoid that at all costs — the taxing power is far too broad. In a written brief, attorneys for the state respondents noted, “The federal government’s last ditch effort to abandon its earlier rhetoric and defend the mandate as a tax fails for the simple reason that, regardless of its enforcement mechanism, the mandate itself is not a tax.”

Roberts suggested Monday that distinguishing between the two might not be so easy.

Randy Barnett, a constitutional scholar and one of the architects of the legal challenge, isn’t concerned just yet. He thinks Roberts’ critique was limited to the narrower subject of Monday’s arguments over whether the court has the jurisdiction to rule on the merits of the case yet, given that nobody will be assessed a fee for violating the mandate until 2015.

“The only thing I think Chief Justice Roberts was expressing resistance to was our argument that the mandate was separate from the penalty for purposes of the [Anti-Injunction Act],” Barnett said in an email. “That is only one of the bases on which the AIA does not foreclose consideration on the merits. I don’t think he was signaling anything at all about the constitutionality of the mandate penalty, the subject of tomorrow’s argument. If he was, however, I expect to get a much better sense of that tomorrow so we won’t have to wait long to find out.”

Healthcare Showdown: Supreme Court Hears Arguments over Legality of 'Obamacare'

Monday, March 26, 2012 by Common Dreams
Supreme Court may determine the fate of Obama's landmark health reform

The Supreme Court began hearing oral arguments this morning that will determine if the Patient Protection and Affordable Care Act of 2010 (otherwise known as Obamacare) violates the Constitution. The arguments are expected to last three days and will analyze the legality of several key aspects of the bill. The most pressing questions the Court will hear relates to the lawfulness of the individual mandate -- a provision that mandates consumers purchase health insurance or face a tax penalty -- and whether or not the law can remain on the books if the mandate is struck down.

Republican opponents of the law hope a decision to overturn Obamacare, and effectively derail Obama’s most hard-fought legislative accomplishment from his first term, would serve as a decisive political victory for conservatives. Progressives are generally more supportive of the Patient Protections and Affordable Care Act, viewing it as a step towards addressing the nation’s healthcare woes. The United States currently has more than 46 million citizens without any insurance and an estimated 20,000 people die each year due to a lack of health insurance. The United States also has the most expensive healthcare in the world, accounting for about 17 percent of the nation’s gross domestic product -- almost twice as much as other developed nations.

Some progressives, however, are skeptical of the benefits of an individual mandate, an idea that first entered the national debate in 2005 when Mitt Romney, then-Governor of Massachusetts, signed a health reform bill implementing an individual mandate in Massachusetts. Kuttner, writing in the Huffington Post, argues that progressives would be better of pursuing a single-payer healthcare system, which “would have been beyond constitutional challenge.”

“Medicare is a single payer program for the elderly, and nobody challenges its constitutionality. Toss out the mandate, and single-payer might be taken more seriously.,” Kuttner writes. “Bottom line: If the Court were to overturn the individual mandate, one of the worst provisions of the Affordable Care Act, it would be no tragedy. It might well do some wider good.”

* * *

Absolutely everything you need to know about health reform’s Supreme Court debut
(The Washington Post):

The individual mandate
What it is: The most-contested part of the health reform law, the Affordable Care Act’s individual mandate requires nearly all Americans to carry health insurance. The legal question centers on whether such a regulation is permissible under the Commerce Clause, which allows the federal government to regulate interstate activity. 

What they’ll argue: Health reform opponents contend that the decision not to do something — namely, not buy health insurance — is economic inactivity, rather than activity, and therefore not a behavior the federal government can regulate. Health reform supporters argue that the decision to not purchase health insurance has an economic effect. An individual without coverage, for example, may not have the money to pay for an emergency room visit, sticking hospitals or taxpayers with the bill. 

When it happens: Tuesday, March 27, 10 a.m. - 12 p.m.
Why it matters: With no penalty for not purchasing health insurance, but a requirement for insurers to accept anyone still standing, many expect the costs of insurance would skyrocket. Congress could, theoretically, replace the individual mandate with another policy that doesn’t run afoul of the activity-inactivity distinction but it is unlikely that congressional Republicans would permit such a fix, at least in the near term.

* * *

Health Reform's Day In Court: Don't Bet The Farm On The Mandate (Robert Kuttner, The Huffington Post):

Opponents argue that the mandate represents a new, dangerous, and unconstitutional infringement on liberty. The decision will be treated by commentators as either a huge victory or momentous defeat for President Obama, and either another dangerous over-reach by a right-wing court, or a prudent retreat by the court's conservatives. 

But this may be a complete misreading of the logic and the stakes. 

The individual mandate may or may not be unconstitutional, but it's dubious policy. And it would not be a fatal setback if the Court did find that it violated the Constitution. 

The Administration, in my view anyway, has made both a tactical and a Constitutional error in arguing that if the mandate is unconstitutional, so are other key provisions of the act. If the Court were to strike down the mandate but not the rest of the Act, the insurance industry would be all over Congress to find another way to solve the free-rider problem. As my colleague Paul Starr has demonstrated, that would not be difficult. 

Instead of being required to purchase private insurance, people without employer-provided insurance or access to Medicaid could be given a choice -- either buy affordable insurance through the exchanges, or deliberately opt-out of coverage. But if they opted out, they would be precluded from getting insurance through the exchanges for five years. This use of incentives would be constitutional, and would be sufficient to induce most people to get insurance, but less coercively than a mandate. Starr also proposes that people could pay an annual fee to preserve their right to buy insurance after a waiting period of only a year. 

The point is that if the best we can do politically is a mixed system such as the Affordable Care Act, there are perfectly good alternatives to a mandate should the mandate be struck down. 

There is also a delicious irony here. If conservatives on the Court were to decide that a federal mandate requiring citizens to purchase commercial products has no basis in the Constitution, it would usefully doom another favorite conservative project -- privatization of Social Security. Obviously, if Congress cannot require citizens to buy private health insurance, neither can Congress use tax dollars to require citizens to purchase commercial pension offerings.
[...] 

One further irony: As a little-noticed amicus brief by two organizations and fifty physicians who support national health insurance points out, if the government had simply enacted a single payer program, it would have been beyond constitutional challenge -- because government has an unambiguous power to tax and to use the revenues for public purposes. Medicare is a single payer program for the elderly, and nobody challenges its constitutionality. Toss out the mandate, and single-payer might be taken more seriously. 

Bottom line: If the Court were to overturn the individual mandate, one of the worst provisions of the Affordable Care Act, it would be no tragedy. It might well do some wider good.

* * *

Herman Cain, Tea Party Activists Rally Against 'Obamacare' (ABC News):

Hundreds of Tea Party activists rallied in Washington today, demonstrating just days before the Supreme Court hears arguments on the constitutionality of the Affordable Care Act. With the outline of the U.S. Capitol behind them, conservative organizers urged the judiciary to overturn the legislation and called for the defeat of President Obama in the November election. 

Former Republican presidential candidate Herman Cain was the keynote speaker at the event. Standing in a light rain, Cain told supporters he may not have survived his battle with cancer had he sought treatment under the new law. 

“That’s what this is about,” Cain said. “The freedom to choose our own doctors. The freedom to choose our own health insurance plan.” 

Virginia Attorney General Ken Cuccinelli told the crowd the upcoming elections were their chance to restore the Constitution. His state is one of 26 challenging the Affordable Care Act through lawsuits in the high court. 

“[President Obama] and this administration represent the greatest set of lawbreakers to ever run the federal government in our lifetimes,” Cuccinelli said. “The rule of law itself is at stake.”

America’s Lost Decade

Economics Without Facts

by MARK WEISBROT

 

The American Economic Association’s annual meetings are a scary sight, with thousands of economists all gathered in the same place – a veritable weapon of mass destruction.

Chicago was the lucky city for 2012 this past weekend, and I had just finished participating in an interesting panel on “The Economics of Regime Change,” when I stumbled over to see what the big budget experts had to say about “The Political Economy of the U.S. Debt and Deficits.”

The session was introduced by UC Berkeley economist Alan Auerbach, who put up a graph of the United States’ rising debt-to-GDP ratio, and warned of dire consequences if Congress didn’t do something about it.  Yawn.

But the panelists got off to a good start, with Alan Blinder of Princeton, former vice-chairman of the U.S. Federal Reserve, describing the public discussion of the U.S. national debt as generally ranging from “ludicrous to horrific.”  True that.  He asked and answered four questions: 

(1) Is there any urgency (to reduce the deficit or debt)?  No.  The government can borrow short term at negative real interest rates, and long-term at about zero.  The world is paying us to hold their money. That is anything but a debt crisis.

The Fed is out of bullets, he said – referring to the fact that the U.S. Federal Reserve had lowered short-term rates to zero and had used quantitative easing to help keep long-term rates low.  So we need more fiscal stimulus, preferably spending that focuses on actually creating jobs. Amen.

(2)  Should we focus on the next decade? No, he said, and noted that the Congressional Budget Office’s (CBO’s) budget deficit projections over the next decade are about 3.6 percent of GDP, which is not much to get agitated about.  Also true.

(3) Is government spending the problem?  No, he said, it’s health care costs, and mainly the rising price of health care (i.e not the aging of the population).   Most important truth yet !  (More on this below).

(4)  Is the public really up in arms about the deficit?  No, actually they care more about the economy and jobs.  As they should.

Blinder concluded that since this is an election year, we can forget about having any fact-based discussion of these issues in 2012.  Happy New Year, he said, and the audience laughed.

Well that was refreshing, I thought — an economist telling the unvarnished truth to hundreds of his people at the annual meetings. But a rapid descent into Hell was imminent.

Former CBO director Douglas Holtz-Eakin was next, talking about the need to “repair” Social Security and Medicare.  The United States has all the characteristics of countries that run into trouble, he said. Then he warned that the U.S. is going to end up like Greece.  This is one of the dumbest things that anyone with an economics degree can say.

Hello, Mr. Holtz-Eakin!  Have you ever heard of the U.S. dollar, the world’s key reserve currency? The United States is not going to end up like Greece any sooner than it will end up like Haiti or Burkina Faso. A country that can pay its foreign public debt in its own currency and runs its own central bank does not end up like Greece.  In fact, even Japan is not going to end up like Greece, and Japan has a gross public debt of about 220 percent of its GDP, more than twice the size of ours and vastly larger – again relative to its economy — than that of Greece.  And the yen is nowhere near the dollar in its importance as an international reserve currency.  But the Japanese government is still borrowing at just 1 percent interest rates for its 10-year bonds.

At this point it was clear that this panel, other than Blinder, was living in a dystopian fantasy world. Next up was Rudy Penner of the Urban Insitute, another former CBO director. His perspective was not much different from that of Auerbach or Holtz-Eakin.

He complained about the polarization of the political process, which prevents the two major parties from reaching an agreement.  It’s not partisanship, he said – House Speaker Tip O’Neill and President Ronald Reagan knew how to be partisan but they were able to reach agreement on the 1983 Social Security package and the 1986 tax reforms.  And yadda yadda.  He might have added that we have had 25 years of lying about Social Security since then, and even Reagan didn’t dare try to privatize Social Security.  And of course Social Security can currently pay all promised benefits for the next 24 years without any changes.

These arguments about polarization really beg the question:  From the viewpoint of the 99 percent, it’s not polarization, but weakness in defending our interests that is the problem.  President Obama compromised much more than he should have last year, offering cuts to Social Security and Medicare in exchange for a long-term budget deal.  The 99 percent are just lucky that the Republicans are too extremist to make this kind of a “grand bargain” with Obama.

The last panelist was Alice Rivlin of the Brookings Institution, another former CBO budget director and Fed vice-chair, as well as a member of the President’s (2010) National Commission on Fiscal Responsibility and Reform.   She agreed with Blinder that we need more stimulus.  But we can only get this if we agree to long-run spending cuts, including Social Security, of course.  Yuck. This is a political strategy that is sure to end in disaster, given the prevailing state of misinformation and disinformation.

During the discussion, Blinder – who identified himself as a Democrat – expressed his frustration in not being able to convince fellow Democrats to cut Social Security.  Double yuck. The average Social Security check is about $1,177 a month,  and a majority of senior citizens are getting most of their meager income from Social Security. Why these people insist on creating more poverty among the elderly, especially when the program is solvent for decades to come, is beyond me.

I got to ask the first question for the panel.  I called attention to Blinder’s presentation of the long-term budget problem as almost completely a problem of the rising price of health care.  I pointed out that you could take any country with a life expectancy greater than ours – including the other high-income countries – and put their per capita health care costs into our budget, and the long-term budget deficit would turn into a surplus.  My question was simple: Are Americans so inherently different from other nationalities that we can’t have similar health care costs?  And if not, then why are we talking about long-term budget problems instead of how to fix our health care system?

None of the panelists offered a serious answer to this question.  Auerbach, the moderator, said that other countries have rising health care costs, too. And some of the others said or implied that health care costs were rising at an unsustainable pace worldwide.

But this is nonsense.  The United States pays about twice as much per person for health care as other high-income countries – and still leaves 50 million people uninsured. This is a result of a dysfunctional health care system that has had health care prices rising much faster than those of other high-income countries for decades.

What the budget hawks are basically telling us is that we must assume that insurance and pharmaceutical companies will have a veto over the provisions of health care reform for decades to come.  And that therefore we must find other ways to make up for these excessive costs, including cutting Social Security and other government spending, and pushing us into higher rates of poverty and inequality than we already have.

And even worse in the short run, all this crap about the deficit and the debt will be used to block the necessary stimulus measures – “stimulus” has already become a dirty word that Democratic politicians are afraid to utter.  This means high unemployment and a lot of unnecessary misery in the world’s richest country for the foreseeable future.

A dismal performance for the dismal science, on some of the most important issues of the day. Of course there are other economists, including Nobel Prize winners such as Paul Krugman, Joe Stiglitz, and Robert Solow (full disclosure: the latter two are members of CEPR’s advisory board), who would offer more sensible views.  But this panel was, sadly, representative of economists with the most influence on public policy.

With a brain trust like this, a lost decade for America looks likely – unless the citizenry can steer a different course.

Mocking the Dying, Profiting off the Work of Uninsured Artists

The American Disease
by DAVE LINDORFF

The first thing that needs to be said to the heartless boneheads who, at the last Republican presidential debate, cheered at the idea of letting a hypothetical 30-year-old cancer victim who hadn’t bought health insurance die, is that this is no mere hypothetical situation. The second thing that needs to be said is that most such people in real life don’t “refuse to get” health insurance. They either cannot afford it (and their employer doesn’t provide it), or they are rejected by insurers because of pre-existing conditions.

If you are a young person, earning a take-home salary of perhaps $20,000, are trying to raise two kids on your own, and you live in Texas, for example (Medicaid eligibility is set state by state), you would not be eligible for Medicaid coverage. Your two kids would supposedly be eligible, but not you. Meanwhile, if your employer, like most employers who are paying minimum wage, doesn’t offer some kind of group policy, if you were lucky enough not to be rejected for some pre-existing medical condition like diabetes or a heart murmer or something, you’d have to come up with perhaps $3,000 to cover yourself with a plan that would not pay for doctor visits, just major hospital bills. But say you were paying $800 a month for rent, and another $3000 a year to keep some 12-year-old rust-bucket of a vehicle insured and on the road to get you to work and home. That would only leave you $7,000 to feed and clothe your kids and yourself. Would you take $3000 of that to pay for health insurance for yourself and reduce your money for living expenses to $4000 for the year?

Of course not!  It would be coming right out of your childrens’ mouths!

All over America, especially these days with one in five of us either out of work or working at some job like the one described above or worse, while looking for a decently paying job, millions of individuals and families are struggling with this desperate problem.

And what happens is this. First off, they don’t go to the doctor when they get sick, or when they feel that something is wrong — say they see rectal bleeding, or feel a lump somewhere that a lump shouldn’t be, or they feel dizzy, or whatever. They soldier on and hope it will go away.

That’s what a dear friend of mine, a writer married to an actor, did. When her family fell on hard times between gigs, they found themselves without insurance coverage. Without any insurance, and with two kids to support, she did not go for regular physical checkups, which were expensive, so a cancer that might have been spotted early and taken care of, had she been covered and gone for regular doctor visits, was able to grow and metastacize. Worse, because she had a cancer, she could not get insured even when her husband got a job that offered coverage.  The only reason she got into a hospital at all was that her doctor, at some personal risk for violating the rules, had her wheeled into a big New York hospital right past the financial intake office, and got her assigned to a bed, from which she could not be evicted once admitted. She ultimately died of her cancer.  Ironically, she had for years been a fierce advocate for women’s health and for insurance coverage for all freelance writers like herself.

The morally challenged scum who heartily and heartlessly cheered for the death of a hypothetical 30-year-old were really cheering for the death of my friend, and millions like her.

But this obscenity goes much further.

I read in Daily Kos about the fate of a 63-year-old guitar maker, Steve Patience, whose sister eloquently raged at the laughing “assholes” whom she said were actually mocking her own brother.  She explained that he had devoted his life to making beautiful hand-made guitars, working 14-hour days, but never earning enough to get by (her family had had to help him out on occasion just to keep things going). He could not afford health insurance, but at 63, though he had been forced to retire to get Social Security benefits, he was two years too young for Medicare when he learned he had metastatic cancer.  A hospital emergency room wouldn’t even examine him despite rectal bleeding and intense pain and just sent him home on pain relievers. When he was finally — too late — seen and diagnosed with cancer, thanks to $2000 that friends provided for him to be seen by a proctologist, it took six weeks to get the hospital to let him in. It wanted $20,000 up front just for use of a room for the examination procedure. Only when his heart started to fail did he get admitted as an emergency patient. Some emergency! It was like making an auto accident victim with a head injury wait six weeks to be admitted for an MRI to spot a blood clot in the brain.

This is health care in America today for those without the resources to buy insurance.

I thought about this some more, recently, when I sat down to play my guitar, a hand-made 1972 instrument built by J.W. Gower, an independent maker who worked out of a trailer at his home outside Nashville. It’s an extraordinary instrument–apparently the second he built (the first is in the Nashville Guitar Hall of Fame). I don’t know if Gower had health insurance, but it’s a fair bet he never had any. The thought of such a master craftsman or his co-builder wife having to forego medical care for lack of insurance, or even having to worry about such a thing, makes me sick.

Most of the things of beauty that enrich our lives — guitars, harpsichords, hand-crafted pottery, paintings, beautiful music of all genres, etc. — are created by artists and artisans who barely earn enough to live on. They do the work they do because they love it, but they earn so little at it that the idea of health insurance is a luxury that many don’t even bother thinking about.

Basically most of them just hope not to get sick, or to die fast when they do.

The rest of us, who buy their creations, or who listen to their music or watch their plays or drink from their mugs, don’t even do that. We just forget about their problems.

And then there are those who enjoy the fruits of these artists’ labor and turn around and laugh at them when they do get seriously ill.

There are others who are even more obscene still, though. They don’t laugh at the suffering of the poor. Rather, they actively work to keep them that way. I’m thinking here of the real scum — the Wall Street bankers, huge pharmaceutical companies, insurance firms (including Blue Cross), and other giant industries that have lobbied hard to block real health care reform, such as expansion of Medicare to cover everyone — and who then will, with no sense of shame, put something like fine baroque music on their telephone “hold” system to add a touch of class to the “customer experience.”  Meanwhile, many of the musicians who perform that music can’t even afford health insurance.

It’s bad enough that we as a society close our eyes to the suffering of the tens of millions who are unable to get decent health care in this richest country in ther world. It’s worse yet that some obnoxious jerks are so blinded by their fears, their ignorance or their rank ideology of smug selfishness and greed that they can mock that suffering, but it’s purely evil that corporations and the wealthy can avail themselves of works of art and craftsmanship and pose as connoisseurs, and even use those creations to help generate profits for themselves, while actively working to block all efforts to make health care available to the creators of those things.

Enough! It’s time for us to do what the rest of the civilized modern world has done, and establish a system of Medicare for all Americans, cradle to grave, as is advocated by Physicians for a National Health Program.

Consumer Advocates Fear Healthcare Law Will Favor Business

Wednesday, September 7, 2011 by the McClatchy Newspapers

by Mary Agnes Carey and Marilyn Serafini 

 

 

WASHINGTON — Publicly, consumer and patient advocates continue to cheer wildly for last year's health care law. Behind the scenes, however, some worry that they're losing a few key battles to the insurance and business communities.

They point to a long-sought provision in the law that entitles patients to external reviews if insurers won't pay for a medical service, and they charge that recent regulations limit its effectiveness. One of their biggest gripes? It allows insurers to choose their own "external" reviewers.

"Advocates who have dealt with the external review process believe that it's pretty clear that if (a reviewer) is being chosen by an employer (or insurer) it's not independent," said Timothy Jost, a professor at Washington and Lee University School of Law.

"There's been a growing sentiment (in the administration), and it's been there from the beginning, even before health reform passed, of bending to business. Now it's reaching the boiling point" -- former Obama White House officialErin Shields, a spokeswoman for the Department of Health and Human Services, said the administration was "working to ensure a balanced approach" toward all stakeholders. "The Affordable Care Act provides some of the most important protections for health care consumers in history," Shields said.

With more regulations on the way, including one that will define which benefits insurers must include in many health plans, some consumer and patient advocates worry that the appeals rule could be a harbinger of things to come.

One former Obama administration official said there was cause for concern.

"There's been a growing sentiment (in the administration), and it's been there from the beginning, even before health reform passed, of bending to business. Now it's reaching the boiling point," said the former White House official, who spoke only on the condition of anonymity because of the issue's sensitivity.

To be sure, how these rules are written can significantly help — or hurt — consumers, insurers and businesses, and that presents the White House with a tough balancing act. While it needs to reassure individuals that the law won't disrupt their current coverage or make it more expensive, the White House also has to appease the employers and insurers who must make that happen.

Even when they feel slighted, consumer and patient groups are reluctant to complain.
"There is a sentiment in the health care community that they don't want to push too hard," said Carmen Balber, the director of Consumer Watchdog's Washington office.

Consumer advocates are well aware that any controversy surrounding an implementation decision that favors them could be used by opponents as another argument to repeal the law or defeat Obama in 2012.

"They all understand that, if he loses, the law and all of its patient protections, including, of course, all of the insurance reforms and coverage expansions, will be at severe peril," said Chris Jennings, a health care consultant who was a senior health care adviser to President Bill Clinton.

Balber complained that the administration had made the external appeals rule more business-friendly since its initial version was published last year. In the version released this year, a consumer's ability to file an "external appeal" shrank from four months to 60 days, and the scope of what could be appealed narrowed considerably.

It also limited appeals to quarrels that involve "medical judgment" or a rescission of coverage, when an insurer cancels coverage, said Stephen Finan, senior policy director for the American Cancer Society's Cancer Action Network. Those changes mean that patients won't be able to appeal anything that falls into the category of contractual disputes, such as whether a particular service or drug is covered, he said.

But reviews must be conducted by independent review organizations, which are "independent and not part of insurance companies," HHS' Shields noted.

Patient and consumer groups criticize other aspects of the law's implementation, including:

• It allows insurers to sit on boards that govern exchanges, the marketplaces created in the health law where eligible consumers and small businesses can start purchasing coverage in 2014.
   
• They find the law too vague on what happens if states want to run either an exchange for small businesses or one for individuals, but not both. "If you start dividing core functions and responsibilities and authority between the states and the federal government, that one-stop-shopping concept could disappear very quickly," Finan said.
   
• It chose to base workers' eligibility for federal insurance subsidies on the cost of individual coverage, rather than a family's premium. People who have employer-sponsored insurance can receive federal subsidies to buy insurance on the exchanges if the coverage costs more than 9.5 percent of their incomes. Many more people would qualify if the subsidies were tied to the cost of family coverage.

Looking ahead, consumer advocates are nervously awaiting a so-called essential-benefits regulation, which will decide which medical services insurers must offer in health plans sold in the exchanges as well as in the individual and small group markets.

A key goal of the health law was to ensure that comprehensive health policies were offered to individuals and small groups. "There are a lot of plans on the market today that cover very little in the way of prescription drugs or severely limit hospital benefits," said Edwin Park, the vice president for health policy at the Center on Budget and Policy Priorities.