Tag Archives: patient protection affordable care act

Faith-based health cost sharing


I saw a very interesting program by Dan Rather last week, with one feature on faith-based healthcare cost sharing plans.  Under PPACA, people can opt for these plans and be exempt from the private insurer mandate.  Members pay a small fee monthly, but instead of paying to the plan itself, they are instructed to send their checks directly to another member who has incurred costs.  A central computerized system keeps track of where money is supposed to go.

Dan pointed out several concerning points about these plans.  They are not actually insurance plans backed by any sort of contract guarantee– if the total pot runs dry, members have no recourse to get payment.  Payment rates to hospitals and providers aren’t negotiated, so members would have to pay the full price for services.  If you’ve ever had a procedure done in a hospital, you know the huge discrepancy between the initial hospital charge and the final payment after insurance write-offs.  Important services like mental illness treatment, addiction treatment,   preventive care, chronic condition medication and contraception are not covered at all.  And there are lengthy waiting periods for pre-existing condition coverage (for example, 7 years after treatment for cancer).  Members have to promise not to smoke, use addictive substances or break religious rules about sex.

The natural result would be that membership would  be skewed towards healthy people– another example of cherry picking.  People who need care will have to get private insurance and will shift our overall risk pool towards higher cost enrollees.  If these entities really take off,  the rest of us will have to pay higher premiums.  Even though I dislike PPACA and the mandate to pay private corporations for shoddy products, if we are going to have the mandate there should not be loopholes like this.

I was interested that during all the smug talk from members about how they were more responsible with their healthy lifestyles, the camera zoned in on the handfuls of cookies they were holding during meetings!  And every one of the members shown was overweight if not obese.  I mention this NOT to blame obesity on moral choices, since I think the evidence is powerful that fat gain doesn’t result from poor self-discipline, but just to show the hypocrisy involved.  Although Dan didn’t comment verbally, the videographer was not very subtle.

As a Christian, the whole thing was depressing to me on a deeper level.  One of these groups calls itself  “Samaritan Ministries.”  If you haven’t read the Good Samaritan parable in a while, go check it out.  What a gross misuse of the story!  Yes, members are sharing resources as early Christian groups are said to have done, described in another part of the Bible.  But their behavior is exactly the opposite of what Jesus was teaching in the Good Samaritan parable.  The parable was about our duty to treat strangers, even those far outside our social circles, as neighbors deserving of care.  It is not in any way a virtue for members of the health plan to share with people they approve of, especially knowing they may benefit themselves.  By excluding non-Christians, they are behaving  just like those who saw the injured man in the parable and passed him by.   I know all of us fall short of perfect neighborliness, but generally we ought to have the sense to be embarrassed about it.  At least we shouldn’t boast about our selfishness on national television.

Maybe the rest of us can form a new religion with a simple statement of faith — “Everybody in, Nobody out.”  This faith organization would allow members to be part of any other faith simultaneously or be atheist.  Instead of forming a faith-based health plan, however, members would naturally want to support legislation enacting  “Improved Medicare for All”, an actual insurance, with no body part excluded.   We would send our contributions through taxes and ask the government to manage distribution of payments to private doctors and hospitals.   Under our plan, insurance would cover believers and non-believers alike.  Anybody want to sign up?  Go to www.pnhp.org— all are welcome.

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Patient Protection and Affordable Care Act, Part 33


If you have been following along with these posts, you may have noticed it has been several weeks since I’ve done an installment on PPACA.  It seemed to me that many of the sections were becoming fairly repetitive.  I’ve decided to continue reading the original text as before but blogging mainly  on the high points– the changes I think may be more significant to our actual care.  Please post a comment if you ever have a question on one of the original points.

Today I’ll cover Section 3201 regarding Medicare Advantage (MA) plans.  This is a long, complicated section!  It will make some changes to how we pay these privately administered plans, in an attempt to save money.  In case you don’t know what MA plans are, they are alternative choices to traditional Medicare run by private corporations.  Remembering that the average traditional Medicare overhead runs about 3%, you may guess that the cost per person of MA plans to our country is higher, to account for the always higher overhead of private plans– and you would be correct.  On average they cost at least 12% more per person (to our government) than traditional Medicare plans.  If the changes made by PPACA do save money as hoped, do you expect the corporations to roll over and accept lower profits?  That was a rhetorical question.  They will accomplish their steadily increasing profit margin by raising premiums to enrollees and/or cutting services (which can often, as you’ve learned, be accomplished by underhandedly making the payment process for some services more difficult for patients rather than changing any of the official policies). 

You might think these obstacles and frustrations would deter patients from choosing an MA plan.  What actually happens is that healthy people who rarely have to seek care and thus don’t encounter difficulties pay for these plans, enjoying some of the perks like health club discounts and so on.  Those who get sick tend to return to traditional Medicare, so the MA plans can indirectly cherry pick enrollees.  This is a completely losing situation for us as taxpayers and to me it demonstrates how powerful corporations can get legislation favorable to them that hurts the country overall.

Before PPACA, MA plans bid for payment by the government against a benchmark.  If they bid more than the benchmark, they had to issue a rebate to the government (but remember, even the benchmark cost per person is higher than traditional Medicare).  If they bid less, they got the extra money to keep as profit, so we didn’t save anything at all in the national budget.  Again, they could bid less both because they got more money anyway than traditional Medicare and because they found ways to not pay for services.  With PPACA, the extra money from “underbidding” won’t be given out automatically but will be used as incentive payments for care coordination (which has been demonstrated not to save money) or to get higher quality ratings.  MA plans will also have to give rebates to enrollees if they save money.  Since they will certainly raise premiums, this will be like a clothing store raising prices and then having a sale with a little bit of that price raise marked off.

MA plans are rated on a 1 to 5 star scale based on a combination of measures given by HEDIS (healthcare effectiveness data and information set), CAHPS (consumer access of healthcare provider systems), CMS (Center for Medicare and Medicaid Services), HOS (Health outcomes survey) and IRE (independent review entity).  These include consumer opinions of quality– whether all these ratings really measure quality of care is very much in question.  Be that as it may, MA plans getting 4 or 5 stars are rare only about 15%.  In Alabama, less than 1% of MA plans make it to 4 stars or more.

So how do the star ratings of MA plans compare to traditional Medicare?  I don’t know the answer– www.medicare.gov lists the star rating for Medicare as “not available.”  I googled it also to see if anyone else had by chance estimated a star rating and couldn’t find one.  But maybe we can take as a proxy the rating comparison of Medicare plus a prescription drug plan versus MA plus a prescription drug plan, since the only variable is Medicare vs MA.  In my zipcode, MA plus drug plans have star ratings from 2.5 to 3.  Traditional Medicare has ratings from 2.5 to 5!  That implies that the quality rating of traditional Medicare is very high and that the lower end of those ratings has more to do with the chosen drug plan.  You can go to this website and search for the same information by your own zipcode.

Did you know that a single MA plans can be sole in multiple states?  Even with this supposed cost-cutting strategy to consumers of selling across state lines, costs have just continued to rise.

We had a chance in PPACA to just get rid of these expensive MA plans and didn’t do it.  Traditional Medicare offers both lower cost and higher quality than private plans.  This is the best example of a head to head test of government managed payment and private corporation payment– and we have the answer.  Private corporate Medicare insurers just can’t do anything right (other than rake in the big bucks).  Now I’ll sing my favorite refrain– it’s time to throw out the private insurers and have one improved Medicare for All.

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Patient Protection and Affordable Care Act, Part 32


Four sections today– two that are shorter and less interesting, so I’m going to go a little out of order and get those done first.  Section 3138 addresses “Certain Cancer Hospitals.”  These are hospitals which already get special adjustments by Medicare for their inpatient costs (because of the high cost of chemotherapy and so on), and now there will be a study to see if the outpatient costs for those hospitals are also higher.  If that turns out to be the case, the costs after Jan 1, 2011 will be adjusted.  Interestingly, though, no deadline for the study completion is given.  I can’t tell how long HHS would have to go back and pay the extra money.  Section 3141 is a method of calculating the Medicare hospital wage index floor, which is supposed to go back to the way it was in 2008– a national wage index adjustment will be made, with less regional variation.  Not enough detail in this short section to help me know exactly what this would mean.

Section 3139 is about “Biosimilar Biological Products.”  Biologic drugs, compared to “chemical” drugs, are larger, more complicated molecules that are taken from living organisms, including plants, animals, and microbes.  Hormones such as insulin, vaccines, and genetically engineered monoclonal antibody treatments like the newer rheumatoid arthritis medicines fall into this category.  For some reason I can’t understand, no one ever calls medicines directly taken from plants, like echinacea or digitalis, biologics.  Isn’t penicillin really a biologic?  It came from a mold.  If that’s because of the molecule size, I never did find a cutoff for what’s considered small or large.  Anyway, biologics don’t fall under the same rules as generics, because the new companies can’t necessarily exactly duplicate the original molecule (companies that make generics aren’t given anyone’s secret recipe– they have to analyse it and figure out the chemical structure on their own).  Usually when generics come out, they are much much cheaper than the original, but “biosimilar” biologics will not be as cheap.  This section adjusts what Medicare will pay by adding 6% of the original biologic price to the new biosimilar price.  Sounds like Medicare is agreeing to pay more for these drugs than other organizations will be paying, which makes zero sense to me.  Even worse than saying, as we already do, that Medicare can’t negotiate prices with drug companies.

Section 3140 is a “demonstration project” to see how it would work to allow Medicare patients to receive both hospice and traditional Medicare services at the same time, measured in terms of care quality and cost.  The hospice idea is being adjusted in some ways– turns out it isn’t so easy to draw lines between whether a person can only get comfort care (pain meds, feedings, fluids) or “curative” care like surgeries or chemotherapy.  This is partly because some of the curative therapies are also palliative– they may lessen a person’s symptoms and actually wind up making the dying process more comfortable.  It is also hard for people to have to make a choice– humans don’t really think in such definite terms and we resist giving up hope.  So integrating the two parts of medical care does make sense– it would allow a person with a potentially fatal illness to have an easier transition into hospice type care, while continuing other aspects of care that may have a chance of helping.  I’ll be interested to see how this turns out.

These continue to be issues we’d have to address under any payment system.  But if we had a single payer, with one negotiated rate for drug company payments, I don’t think we’d have to have complicated laws that lock us in to paying higher rates than drugs are worth.  The other developed countries are able to pay far less for the same drugs than we do, because they don’t allow themselves to be manipulated like this.  It isn’t that a Medicare for All couldn’t make bad deals– it is that we’d all have a dog in the fight, the payments would be transparent, and we could collectively have a means to tell them to cut it out if they misbehaved.  If Congress had to pay the same prices we pay, as well as all the highly paid executives, and it was clear that this money was coming directly from their pockets, I do not think they would put up with such money-wasting practices.  But if the rich and powerful don’t have to endure the effects of wasted money, then they have no incentive to pitch in and fix it.  And that’s the same for any function of government.  Laws and systems that only apply to a portion of us are at higher risk of being unfairly applied or of poorer quality.

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Is PPACA severable?


So much has happened in the last several days around healthcare reform that I hardly know where to start– I had planned to say something about Vermont’s progress towards single payer this week, but clearly the hot topic is the Patient Protection and Affordable Care Act (PPACA) and whether it will be ruled unconstitutional in whole or in part.  Many commentators much more educated in legal matters than I have already weighed in, so I’m not going to try and duplicate anything.   But since I’ve been reading PPACA, you know I have my two cents.

Having read about a third of the entire law, line by line, I have not been convinced PPACA will result in the kind of healthcare system we desperately need.  At the beginning, I really worked to try and keep an open mind in case there were a few good bits.  Very quickly, however, I realized even the sections which could have been great had too many loopholes to work.   If you’ve been following my posts, I’m sure you know that!  And I’ve said I don’t think repealing it is the way to go.  Replacing it with a better law would be much more efficient.  Who wants to go back to the way it was before?  We got into this whole thing because so many people were suffering under the old system, and repealing PPACA won’t do anything to fix that.  If you have a patient whose heart transplant is failing, you don’t take it out before you have a new one to put in.

Many of us were pretty well convinced that Congress would wind up chipping away at PPACA brick by brick, twiddling away their time instead of giving us something better.  The recent decision by a federal judge may be a game changer.  There are some complicated arguments involving interstate commerce that affect the constitutionality of the individual mandate.  Some of it gets close to trying to define the word “is”!  Whether a mandate is constitutional or not, I am offended that PPACA forces me to give up about 30% of my healthcare money to be wasted on administrative costs and to profit rich executives who don’t make me healthier.  Those folks did not earn the right to my money, but now they can have it by law.  If we had the system I want, a National Health Insurance, even though we’d still be required to pay a tax, we’d know substantially all of the money was to be used for our collective needs and not to line the pockets of insurance executives.   Some of my money would be used to help pay insurance for people who could not afford to contribute much, but that is a feature of all taxes.  My local tax money that gets used to help maintain city parks means everyone in the community gets to enjoy a beautiful green space, not just people who paid taxes.  In this analogy, the private insurance mandate is like making me pay for the private home gardens of insurance executives.  All we can hope is that they’ll give us a few green beans if we ask nicely.

The federal judge made a huge leap beyond the individual mandate, saying the whole law is now unconstitutional.  Florida has jumped in immediately– PPACA is no longer in effect there as of yesterday.! When I first heard talk about nonseverability, which started immediately after it was passed, I honestly thought the idea was silly.  Everything I had read about it said that a law only had to specify nonseverability and that otherwise severability was the default.  The federal judge gave one basis I hadn’t known (not surprising since I’m not a lawyer)– that there is precedent for inferring nonseverability if legislators initially had the word “severable” in and then took it out.

The argument about PPACA being like a “finely tuned watch”, so that it is impossible to only take out the parts dependent on a mandate?  Sorry, that doesn’t fly with me.  Mish-mash is a better description!  Most of the parts I’ve reviewed in the last few months have absolutely nothing to do with private insurance reform– they apply only to Medicare.  I’m sure the insurers will say anything at all in the law that reins in excessive profits and overhead has something to do with the mandate– they are already saying PPACA has caused increased premiums when this is obviously untrue.  Very little of the law is that closely affected by the mandate, other than the rules about pre-existing conditions.  The truth is not that this judge couldn’t figure out how to do surgery on the law but that he didn’t want to read 2400 pages to see what was in it.  (Let’s be charitable and leave out the possibility that he went with a political bias).  I asked my husband if tediousness was unconstitutional and he said no.

On the other hand, if PPACA is going to wind up having to be repealed or invalidated before we have a chance at getting better legislation, maybe a quick ending is better.  I started reading PPACA and blogging on it knowing it would take me a few years– figured it was a way of keeping National Health Insurance out there as an idea.  Maybe we’ll have a chance sooner than I thought .  Now is the time to insist that expanded, improved Medicare for All be put on the table and given an serious look.  HR 676, the Conyers bill, is good to go!

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Patient Protection and Affordable Care Act, Part 31


Wow– if the courts continue deciding against PPACA, I might not have to keep reading it!  I still prefer the idea of introducing a better law that would simply replace it, instead of this multi-step process.  But I’m glad the whole issue is heating up again because it gives us a chance to talk more about alternatives, such as a National Health Insurance to cover all of us.  I’ll say more about this in a separate post soon.

Today I’m going to review three short sections, some of which I confess to not being able to fully figure out.  If any of you can chime in to explain, please do!  First, section3135, “Modification of Equipment Utilization Factor for Advanced Imaging Services”.  The actual law says it applies to “expensive diagnostic imaging equipment” but doesn’t specifiy which equipment qualifies– my CCH explanation says this means specifically diagnostic MRI, CT, nuclear medicine (such as bone scans), and PET scans.  So, not just regular x-ray machines.  The payment rates will be adjusted to reflect an anticipated increase in number of procedures done because of the new law (more people with insurance) to a “75% assumption”.  I have been unable so far to find out what the prior “assumption” was.  It never does clearly say whether this results in increased payments or decreased payments, although there is a hint that it is supposed to decrease Medicare’s expenses– so I’m guessing decreased payments to providers.  Thinking about how increased utilization of equipment works, I can see how a doctor’s expenses could either increase OR decrease.  If a center had one MRI that wasn’t being fully used, then more patients using it would make it easier for them to pay for the one machine.  But there is a pretty good waiting time when I need a patient to have an MRI–  short of a dire emergency, it can take a week or two to get an opening.  So I have a hard time believing utilization was less than 75%!  Maybe in rural areas.  Wouldn’t this mean that to accomodate more patients, centers would have to purchase extra equipment?  So then their expenses would rise– if the increase could fill up appointment time for 2 machines, fine, but what if the second machine doesn’t get fully booked?  Then centers wouldn’t buy more machines and waiting times for the single machines would be longer.

The same section also decreases the technical part of payments for times when a patient makes one visit and “consecutive” body parts are imaged.  For instance, if someone is doing a CT of a thigh and a lower leg, they shouldn’t get paid the full fee for both– the prep time is shorter.  (This applies only to the technical part– positioning the patient and so on– not to the payment a radiologist gets to interpret the film). I think that makes good sense as long as the reduction is not excessive– people do  have to be repositioned and settings can be different for different body parts.

Section 3136 changes the payments for Medicare wheelchairs.  There was a lot of fraud billing Medicare for lump sum payments of power-driven wheelchairs instead of monthly rentals, so from now on only  “complex rehabilitative” power-driven wheelchairs can be billed as a single lump sum.  Power-driven chairs go back to monthly rentals.  If anyone thinks this could have negative effects, please comment.

Section 3137 is a Hospital Wage Index Improvement (again, Medicare specific).  There is one sentence saying wages for 2010 will be paid at 2009 index rates– I don’t know if this is good or bad.  Does not say anything at all about the whole of 2011.  By December 2011, CMS (Center for Medicare and Medicaid Services) is supposed to have decided how to adjust future payments/ index calculations, based on relative geographic wages.  It is supposed to minimize differences between city and rural areas and take into account the effect of changes on providers.  An interesting feature is that it is supposed to address the “occupational mix, such as staffing practices and ratios.”  Seems like this would include what types of nursing support staff are employed.  Some offices employ more RN’s (which I generally prefer), but there is an increasing move to employ staff with less training, sometimes with RN supervision and sometimes not.  I should mention here that I have worked with excellent MA’s and LPN’s and would absolutely not want one of those people to be insulted– I’m talking about the average person.  I have a friend who has no nurses at all in his practice– he does everything himself, including vaccines, to save money.  It is hard for me to imagine practicing without my nurse– we are a team.  Although sometimes I wonder if she could practice without me!  Lots of times she tells me the diagnosis before I even go in the room– I have to get her to hold off until the students are out of earshot, so they have a chance to figure it out themselves.

This section doesn’t make clear whether payments would decrease or increase for hospitals with more Medical Assistants vs RN’s, but I would think they intend to decrease them.  Which seems like it would further reduce the number of RN’s hospitals hire, in their attempt to stay ahead of the curve and make a profit.  I really hope that doesn’t happen.  Especially in the hospital setting, that scares me– “vital sign technicians” can record a blood pressure on a baby that belongs with an adult and would be an emergency for an infant, but they don’t know what it means so they just write it down.  They don’t repeat it or call us.  Almost always, this was because the baby was crying and the reading was inaccurate– or the cuff size was too small.  But it’s those times when the high blood pressure was real that have worried me.  We get so used to saying, “oh, that can’t be right” that it’s tempting to ignore a strange number– but I have always insisted that they either re-do it until it is correct or until I was sure that the baby actually had a problem.  I have worked in several different hospitals, so for the record I’m not pointing fingers at any specific place.

Think about how the sections I just reviewed would be affected (or not) by the mandate to buy insurance– I’ll talk about that in the next post.

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Patient Protection and Affordable Care Act, Part 30


I’m happy to tell you I won’t be throwing any math at you today!  I’m going to review section 3134, on misvalued codes under the Physician Fee Schedule.  As I’ve explained previously, doctors have to translate what we do into various “codes” in order to bill for our services.  There are codes for specific diagnoses– some of those are so common that I actually remember them (I bet there is a more fruitful use of neurons), like v20.2 for a well child visit or 799.29 for behavior problems.  Our computer system brings up a code when I put in a description, so I don’t really have to memorize anything, but sometimes it is hard to get their language to match up with what’s really going on with a patient.  I was very happy a few years ago when they added a code for “fussy baby”!  There’s even one for “feared complaint unfounded”, which means a patient thought there was something wrong but it was normal (like a parent bringing a newborn in for a lump in the abdomen that turns out to be the normal bottom of the breastbone, which just pokes up a little more in some babies).

Then there are the codes for the services we provide to address those diagnoses, and these are the ones this section is covering.  We have various levels of service for sick visits, codes for checkups, and codes for procedures and medications given.  HHS is supposed to look at the codes which have shown the fastest growth– the ones being used more and more often– to see if these are being overpaid.  They will look at times when we bill multiple codes for a single service– insurers love to figure out ways to “bundle” those, which this section calls consolidating.  And they will focus especially on codes with low relative values billed multiple times in one treatment.

I have some concerns about this, especially in relation to checkups.  At different ages, we perform a different set of services, some of which are fairly time-consuming.  The basic visit codes for a checkup is the same for all, but we add extra codes to describe the services that vary.  For instance, we do standardized developmental screening on some children 5 and under, which take some time– we need to be able to bill more for that.  We do hearing and vision at some visits– can you guess how much time it takes to get a hearing screen on a wiggly 4 year old?  If a child is already getting those tests elsewhere, we don’t do them, of course.  Some insurers won’t pay for these time-consuming services already– and they have used the same kind of reasoning, that we should only bill the single visit code no matter how much we do.

The part about codes with low relative values billed multiple times in a visit reminds me of vaccines.  Pediatricians have fought for years to get paid fairly for giving vaccines.  We are often barely paid enough to cover just the purchase price (and sometimes not even that), let alone the associated overhead costs such as nursing time and storage (the freezer/ refrigerator temperatures have to be perfect and must be monitored frequently).  We’ve finally started getting a small “administration fee”, which is supposed to pay for the supplies like needles and syringes, the nursing documentation time, copying and giving out the required Vaccine Information Sheets, and counseling the parents about risks and benefits.  It doesn’t actually cover those costs, so giving vaccines is a money-losing endeavor for most pediatricians– we do it because of the great benefit to our patients. 

If we give multiple shots at one checkup, we are supposed to be paid an administration fee for each of them.  There are several combination vaccines now– we love those because it is so much less stressful for the children.  But we get paid less each time a combination becomes available, and we still have to counsel about each component.  At the very least, we should still be paid for the additional injection fees.  If the people making up these fee schedules had to give shots they’d be very certain that we earn our money, in physical exertion if nothing else, for giving the second and third vaccines in a visit (at least to children).  I guess adults don’t try and break free to run down the hall after the first shot.

What happens when insurers bundle codes that were previously billed separately?  If the change in payment is large enough, sometimes doctors do bizarre things to try and make up the difference.  Like bring children back in on separate days for each vaccine or component of a visit, which is inconvenient and expensive for families.  This kind of thing already happens, and it will just get worse.

This section also instructs HHS to review some RBRVS that were “Harvard valued”.  The RBRVS (relative value resource based system) is a way of deciding how much certain services are worth– the original scheme was put out by Harvard employees.  It has tended to grossly weight payment towards procedures while undervaluing cognitive services (asking the right questions, thinking about a patient’s problem and deciding what to do).  If HHS really does develop a more reasonable payment schedule, patients wouldn’t be billed astronomical fees for 10 minute surgical procedures, so this is good.  In reviewing the codes, HHS is supposed to consider time, mental effort, judgement, skill, physical effort and stress, in addition to the practice expense (overhead) and malpractice expense. 

I notice they have still left out a factor I consider more important than all of those above– the actual value of a service to the patient.  Some very expensive services provide very little proven benefit, but are done more and more often since they are so lucrative.  I’m thinking of something like the previously very popular knee arthroscopies now out of favor.  These involved putting small scopes inside of people’s knee joints to “smooth out” the cartilage.  Orthopedists were doing huge numbers of these, until someone finally did a study with a sham incision, where half the patients just had a little nick in the skin but no scope inserted– and found out that faking the procedure worked just as well as doing it.  Of all medical services, procedures tend to be the least studied in comparison to placebo, and the most expensive overall.  I believe that people shouldn’t be able to charge large amounts for doing something if we don’t have any idea whether it is helpful or not.

I do think it is past time to review and adjust fee schedules and that this is part of controlling costs.  But I will also say that we wouldn’t need to cut payments for legitimate services if we had a reasonable overall plan for running health insurance– such as a single national taxpayer funded health insurance.  We could save so much money by removing private health insurance corporations from the system that it would leave enough to fund insurance for all of us.

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Wasting time


I opened the Huntsville Times today to find a front page article about how proud our new 5th district Congressman Mo Brooks is that he voted to repeal healthcare reform.  The article went on to review the current strategic plan– undercut the Patient Protection and Affordable Healthcare Act (PPACA) by removing funding, repealing it piece by piece, and the 2012 elections.

The vote yesterday wasn’t actually the most worrisome of those tactics.  It didn’t wind up taking a whole lot of time, and we knew they were going to do it.  It won’t get passed by the Senate– the House knew good and well it was just a symbolic gesture.  Funding could be a problem, but from what I’m seeing, insurers are already finding ways to get around the intentions of PPACA anyway, so I don’t know if that part will make much difference either.

The part that really worries me is the “piece by piece” idea.  PPACA is about 2400 pages long– it would be entirely possible for Congress to completely avoid getting anything useful done for years by arguing over each little snippet.  I know, someone is going to say “you expected them to do something useful?  Do you need to go to the doctor?”  But this is serious.  We have so many important issues to address right now, in addition to healthcare– the economy, climate change, and international relations among others.  I have been wondering if we need to start talking about a Constitutional Amendment to clarify the definition of “corporation”, so that a status  for liability and tax filings doesn’t continue to be expanded into every meaning of personhood out there.  I’m sure you can all think of some important legislative work that needs doing!  We absolutely cannot afford to waste this much time.

Every so often, someone mentions some alternate method of reform that would replace PPACA (in the “repeal and replace” mantra).  But these are all useless, very partial ideas– no kind of comprehensive strategy.  For instance, we’re still hearing that the solution is to allow health insurers to sell products across state lines, with the reasoning that more competition makes insurance cheaper.  I’ve already talked about that error in another post– even though Alabama has one private insurer with a near monopoly, there are other states with multiple competing products– and health insurance in those states is exactly no cheaper than it is anywhere else.  Why on earth would we want to propose a strategy that has already failed?

Mostly, though, all we’re getting is the repeal part, for several likely reasons.  Mainly I think they have no idea what to do as a useful replacement, so it sounds better to them to just drag their feet and fiddle around for at least another 2 years. 

If you’ve been following my slow reading of PPACA (I’ll put part 30 out today), you know I’m not a fan.  The law is long, unnecessarily complex, and full of loopholes.  It is not going to get us the kind of healthcare system we need, not for our physical or economic wellbeing.  But the silly time-frittering Congress has embarked on now is not the answer. Even if they were successful in gutting PPACA, we would still be left with the system that helped put us into economic meltdown and killed 45,000 people a year.  The better strategy is the one laid out in HR 676, also known as the improved, expanded Medicare for All bill.  Instead of tortuously hacking away at PPACA, HR 676 simply institutes a single payer health insurance for all of us, simultaneously invalidating the parts of PPACA that no longer apply. 

Mo Brooks did get one thing right.  The Times quoted him as saying “people will literally live or die based on the decisions we’re making.”  He has chosen to be on the death panel for those with no insurance.  What will you choose?

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