I was talking with a friend last night who reads the blog, and he asked, "So, are you guys for or against the health care plan?" And others have called our reaction to the House plan "lukewarm." Well, there are good things and bad things about the two plans in the legislature now (Sal vs. Trav); here’s my quick and dirty take on the components, using the Globe’s comparison chart as a template. (The Globe’s summary language is in italics.)
The House:
- "Cover 95 percent of theuninsured within three years." Obviously that’s good. Not complete, but good.
- "Individualsmust buy health insurance if they can afford it, or face a financialpenalty." Problematic, to say the least. Who’s to say who can afford what? The House plan does soften the blow by subsidizing lower income folks to buy insurance, but it’s probably high-deductible "semi-insurance". Not so great.
- "Employers with morethan 10 workers must provide coverage or face a payroll tax." Well, you’ve got to have a cutoff somewhere, and it’ll be arbitrary no matter what, but it makes the marginal cost for adding that 11th worker pretty darn steep. Could use some tinkering.
- "About $600million from payroll taxes and the state’s settlement with tobaccocompanies would pay for Medicaid expansion and subsidize purchases ofprivate insurance." Fine — the Medicaid expansion is the best part. Big Government is frankly our friend in health insurance. If you’re a single-payer fan, that simply has to be the biggest step forward.
- "The state would seek to enroll those currently eligible for Medicaid who have yet to sign up for it. But the Housealso would raise income limits for Medicaid eligibility, allowing an additional 205,000 people to enroll." See above. This is the best and most critical part.
- "A stripped-down private insurance plan would be offered to eligible residents for less than$200 a month; the plans may have high deductibles." Argh… can you say perverse incentives? Yes, I grudgingly accept that it’s better for people to be covered for expensive cases, but in health care, the first dollar is the best dollar. You want people to spend the first dollar so they don’t end up needing expensive care. (Smacks forehead.)
- "Supporterscall the House plan the most ambitious of the proposals, with newgovernment spending and new requirements on businesses. They say itwould encourage employers to provide insurance and reward those thatalready do." Yes — a little employer arm-twisting is frankly necessary. If employers don’t want to give their workers insurance, then they can get out of the van and start pushing for single-payer. As I’ve said before, "Neither" is not an option. Sorry.
- "Business groups fear that the plan, because of the payroll tax, would make the state less economicallycompetitive. Romney could veto a final bill if it contains the tax." Well, it would make our workforce healthier and more productive in the long run; take some burden off of companies that do offer insurance; and yes, put a burden on those who don’t. Come on — the correction of incentives is definitely an improvement on the status quo. We’ve done pretty well in this state by investing in education and other social goods; it’s time to look for long-term advantages in public health.
So really, I’m very warm to certain things and very cool to others.
The Senate plan:
- "Cover half the state’s uninsured in two years." Uh… hello?
- "Companiesthat have at least 50 employees and do not provide health insurancewould be forced to reimburse the state when employees seek treatmentfrom ‘free care pool.’" Fine, but that’s not the same as having insurance, i.e. first dollar (therefore preventative) coverage. Inferior to the House proposal.
- "The Senate would not require individuals tocarry health insurance." Less controversial, and yet probably more costly to the already-insured taxpayer than the House mandate. Go figure.
- "TheSenate plan would push to enroll 70,000 residents eligible forMassHealth who haven’t signed up." Inferior to the House plan. Eligibility should be expanded.
- "The plan would also increase Medicaidrates to hospitals and doctors who treat them." Obviously important to hospitals — I’m not well versed on this end.
- "Itencourages insurers to offer low-cost, scaled-back health plans to theself-employed, small businesses, andindividuals who don’t qualify for Medicaid but cannot affordtraditional insurance. It would be up to insurance companies to developthe plans." See my "first dollar" rant above. The insurance companies haven’t come out with any such plans, so for now this is wishful thinking.
- "TheSenate plan doesn’t aim to cover everyone immediately, so it isconsidered more realistic and less heavy-handed. It has fewerrequirements for employers and doesn’t require individuals to buyinsurance." What’s this bill supposed to do again?
- "Critics worry that the Senate bill doesn’t fully solve the problem of the uninsured." Ya think?
I’m also wondering what happened to the re-insurance part of Travaglini’s original plan, which would make the state share costs for medical expenses above a certain level. The MassACT ballot initiative contains such a provision. A similar arrangement has lowered premiums in New York State across the board.
Health Care for All has more on the Senate bill. Ughhhhhhhhhhh…
Please share widely!
How is the MassACT plan good? It only covers 80%. Shouldn’t we be talking about FULL coverage? All of the plans need majoring reworking.
Andy: Sure we should. Romney’s plan supposedly insures 100% — but what is that “insurance”? It’s not comprehensive, it’s high-deductible semi-insurance — in other words, people will be forced to buy a product that’s not much good.So yeah, 80% is less than 100%, but the plan was calculated because it seemed politically feasible, financially affordable, and a good return on investment since folks covered would be really covered. Is it the end-all and be-all? Heck no. For that we need the federal government to do single-payer… Who knows? That may happen sooner than we realize.
Yes, I didn’t mention the Romney plan because the 100% sounds good but, as you seem to be getting at the way he gets there is no good. Romney’s law seems pointless to create such a “mandate.” I just think that with sentiment in the public and in the Statehouse as it is we must push past political feasibility and make real reform. If you are at all interested, I have a post on my take of the different plans here.
What they should first do is try to restructure the insurance/HMO system and create a public-private partnership to create a centralized, secure, user-friendly database of healthcare information used in all doctor’s offices, specialists’ offices, dentists’ offices, pharmacies, insurance companies, etc. After that, quality of care would go up, and cost would go down pretty far. Once we get cost under control as much as possible, more people will be able to afford insurance and take control of their own lives. After that, we can talk about high-deductible plans, expanding Medicaid, individual mandates, and getting healthcare to everyone…
I saw your post, and was sort of responding to that as well.”Push through political feasibility”… Well, that’s the real problem with pro-health care folks in general. We’re trapped between demanding too much — since there is always strong political resistance to any reform — and then getting nothing, or demanding too little. My bottom line is that even an imperfect plan will make a huge difference to many people. That 80% in the MassACT plan is not an abstraction: those are real people we’re talking about. (Yes, so are the other 20%.)See our interview with John McDonough for more on strategy.
Charley, for truly universal coverage, we don’t need the federal government to do single payer. We need the Democratic controlled veto-proof Massachusetts legislature to do it. Let’s not make the real solution seem to be some shadow on the distant horizon.
FD, this is the last I’ll say about strategy, and then we’ll just have to agree to disagree: I signed on to the HCFA/MassACT approach because it was well-organized, there was a lot of grassroots energy, and it seemed like legislation that would help a lot of people. I got involved through Greater Boston Interfaith Organization, who has done yeomens’ work in pushing this thing as far as it’s gone.Now, I never thought that this was the “endgame”, as Deval Patrick puts it; it’s not perfect legislation. Single-payer is superior.But you know what? Politics is not just about holding the right opinions. It’s about being able to mobilize constituencies, pressure and persuade elected leaders, and get actual legislation passed in an adversarial environment. The GBIO/MassACT/HCFA folks were up for that; the single-payer folks are simply not as well-organized. When the single-payer folks can get hundreds and thousands of people to show up at legislative hearings and rallies; when they can put the screws to elected leaders; when they can become a tipping-point power in the activist game in MA; when they can get 100,000 signatures for their legislation; then they can complain about how we’re not being ambitious enough.I’ll just repeat: Having the right opinion is not enough. You have to fight and scrap for everything you get.You have the last word.
The single payer movement was gutted when a lot of well meaning folks who hold similar opinions to yours got wobbly and bailed.And when legislators, like a particular newly elected senator, say that they agree that single payer is the most sensible option for fixing our systemically broken system, but quit before the fight because the ‘political climate’ is too daunting for them.And it’s a shame. Massachusetts is perfectly positioned to make affordable, universal healthcare a reality. Yet, we’re about to accept another half loaf. . . . (last word>) . . again.
The most instructive part of the initial post is “”The plan would also increase Medicaid rates to hospitals and doctors who treat them.” Obviously important to hospitals — I’m not well versed on this end.”Should fees be set by the government? What happens when, as is happening, costs of practice increase? Might physicians leave the state? Retire? Government regulation to increase access to care, more often than not, has the reverse impact of reducing access for the very people the laws are supposed to help.I am also impressed by the comment from FD “Massachusetts is perfectly positioned to make affordable, universal healthcare a reality”explain again- please- and be very specific, how single payer is to be funded, how it will decrease costs, how you will decrease utilization of healthcare services of the 20% of the population that uses 80% of the resources? If you plan to create “multidisciplinary clinics” for complex disease management– how would you get physicians to work there? who should build the buildings? who should manage the programs? might the massive increase in oversight costs eliminate the perceived efficiencies that single payer could provide? what should happen to the thousands of Mass residents employed by insurance companies now? who should pay for their unemployment? would they be absorbed by the government bureaucracy?Until I can get answers to these questions (and more), I cannot support any single payer system.
I’m afraid that Charley might think that I’m reneging on our gentlemans implied agreement, but to respond your questions Eric,explain again- please- and be very specific, how single payer is to be funded, how it will decrease costs, how you will decrease utilization of healthcare services of the 20% of the population that uses 80% of the resources?First, every dollar that currently funds all of the myriad state healthcare programs (i.e MassHealth, Insurance Partnership, Free Care pool, etc. etc. etc.) every fiscal year would be rolled into a publicly administered system.Secondly, a levy of some sort (Tax! There, I said it! Tax! Tax! Tax!) would be collected from the public. This should probably lower costs for most everyone. For example, if you are contributing $3,600 a year to your health plan, and that system is eliminated and replaced with a publicly funded pool that would require a $2,600 per annum assessment (tax! tax! tax!), you’ve come out ahead financially, and you get portable, guaranteed, comprehensive health coverage to boot. Some sort of means testing for low income residents (ala Medicaid) would be put into place to determine contribution rates.Also, several studies have pegged administative costs of the current system to be around 30% of every healthcare dollar spent. Single Payer costs are projected to be around 5%.If you plan to create “multidisciplinary clinics” for complex disease management– how would you get physicians to work there?Under the Health Care Trust Bill, the basic structure of clinics and facilities is not expected to change. Clinics and hospitals will continue to practice as before, however the billing apparatus would change, as would the current problem of patients having to go to specific clinics (some far from home) just because of what network or plan the clinic/physician belong to. Who should build the buildings?New facilities would be funded (or at least subsidized) by the Health Care Trust. This will allow underserved areas (i.e. inner city neighborhoods, many rural Western Mass. communities) to apply for local clinics. This has been a continuing problem because for-profit healthcare networks don’t want to build in these communities. I don’t think that a new Botox clinic on Beacon Hill would be able to qualify for public funds. They would have to build that themselves.who should manage the programs?I would refer you to the text of the bill:http://www.mass.gov/legis/bills/senate/st00/st00755.htmI don’t want to accidentally misstate anything.might the massive increase in oversight costs eliminate the perceived efficiencies that single payer could provide?Not sure what you mean by oversight costs.what should happen to the thousands of Mass residents employed by insurance companies now?Well, this will suck a little for them. However, the Health Care Trust Bill does aknowledge this and makes funding provisions for job retraining and placement positions within the new Trust. This is a dilemma similar to the fate of well meaning tobacco farmers. I’m not sure that it would really be thousands of people thrown out of work, but I don’t want to downplay this issue either.who should pay for their unemployment?See above. And remember, they won’t lose any of their health benefits if they have to change employers.would they be absorbed by the government bureaucracy?See above.And regarding the insurance industry, remember that if Massachusetts adopts a Single Payer healthcare system (aka Apocalypse), insurance companies will continue to be able to gouge consumers in 49 of 50 states. And they will continue to be able to underwrite life, home, auto, legal, etc. etc. etc. policies in Massachusetts. There just won’t be a healthcare market for them here anymore. That’s all.Until I can get answers to these questions (and more), I cannot support any single payer system.
FD- you should be commended for spending the time to answer my questions. I still do not think it will save money over time– the $2600 vs $3600 figure I think is wishful thinking, but that kind of detail allows for some debate.Thank you.