On this Easter Sunday, Rev. Hurmon Hamilton of Greater Boston Interfaith Organization expresses grave concern that the individual mandate is about to be lowered on individuals who can’t afford it:
Chapter 58 raised the hopes of the uninsured in our state, and also the hopes of millions of uninsured around our nation, as our success forced onto the national stage a fresh healthcare debate. For better or for worse, our success is linked to the future of millions across our country. Yet, one year later, less than a week before the Connector Board votes on a new affordability schedule that may be anything but affordable, the hope and promise of healthcare reform is close to being crucified. And I am not sure of the possibility of its resurrection.
GBIO’s position is that the individual mandate should for now exempt those individuals who make less than $50,000, or $100,000 for a family. Those figures are based on workshops that they did themselves on folks who might be affected by the new law. (I participated in one.) No, they weren’t scientific, but the numbers they use sound sensible.
And this points up the essential structural problem with our health care reform, which no amount of happy-talk (or deserved praise*) is going to fix: We need to get everyone into the insurance pool to spread risk around — that was the whole point of the individual mandate. But you can’t get blood from a turnip: There are many people who simply can’t afford the premiums or the cost-sharing. And the ones who make the sacrifice and get the health insurance are likely to be the ones who need the care the most, i.e. bad risks. Oops. And yes, we knew this was going to happen. Basically, we took a huge structural problem in health care finance and in the form of the personal mandate, dumped it on the working class — the folks least able to pay it.
(I want to point out that as far as I can tell, I think the Connector folks and the Patrick administration have heretofore acted competently, well, and in good faith. But under the current structure, there simply isn’t a good answer to this problem. They’ve been put in an impossible position and are doing the best they can.)
What’s the solution? The state could subsidize people more thoroughly: up to 500% of poverty level, for instance. That costs lots of money, but you’re more likely to get everyone insured — though still not certain. Look at the problems they’re having enlisting folks who already do get subsidies. Think we have a revenue problem now?
But really, that’s simply got to be the way of things to come. Gov. Patrick says health care is a social good, and I agree with him wholeheartedly. Both corporate and patient advocates currently call for a greater government role — and unfortunately that requires money.
—-
Listen folks, I know this stuff is boring, but I’m really interested in your opinions for the way forward. What set of problems are you willing to put up with: Higher taxes? Or a “doughnut hole” class of people who have been left behind in our health care reform — with financial disaster looming for the system? And what are willing to do to help our leaders implement the change that you recommend? (Yes, I’m looking for a wider circle of interest than our health care regulars here — not that they’re not welcome, as always.)
Yes to GBIO’s position re. exemptions! Better yet: abandon the law. All Democrats should call it the Romney plan and give it up. If the power of government is used to force me to pay money, I call it a tax. This law amounts to a big tax increase–sent to profit-making corporations. Why should any Democrat support that? We don’t need insurance; we need health care. And we need to challenge the easy acceptance of “expert” opinion on health care, which has helped to send costs soaring. I really wonder: did my tax money (for Medicare, Medicaid, etc.) and insurance premiums go to pay for the millions of women who bought into the propaganda put out not just by big pharm but also by doctors and academics (just look at chapters on health or sexuality or aging in intro psych texts of five years ago or so)and took hormone replacement therapy–which ended up creating health problems? or for turning millions of children being taught to pop pills for every problem, as soaring numbers are given drugs for ADHD, depression, and who knows what else? (Heh people, it wasn’t that long ago that the “experts” said that children couldn’t “have” depression because according to the then-dominant Freudian theory they hadn’t reached the necessary stage of psychosexual development. Now, two-year-olds are given drugs for bipolar disorder.)
The logic of funding things through taxes is that people with more ability to pay pay more, and those with less ability pay less. It also saves a ton of paperwork.
<
p>
Imagine if the logic behind the current health care set up were used in other areas of governemnt. “Each group of 500 houses must hire and pay the salary of 1 police officer.” “Each parent must send their child to a private school.” “Each household is expected to provide one firework for the July 4 celebration.” I could continue. What a nightmare that would be.
<
p>
The fact that they passed an individual mandate, and Democrats cheered for it, says that something is very wrong.
And it bears repeating:
<
p>
“The fact that they passed an individual mandate, and Democrats cheered for it, says that something is very wrong.”
<
p>
What this means is that the emperor has no clothes, and yet most folks are demurely looking away muttering, “oh my, doesn’t he look, um, nice”… and are instead fretting about this pesky health reform law that our Democratic legislature passed and enacted despite veto-proof majority over Romney!!!!!!
<
p>
One reason this law is so fatally flawed is that it contains practically NO MEANINGFUL cost control measures or reforms of our wasteful hc financing and delivery mechanisms (that raj touches on quite well). What follows is a beginning list of a few of the major cost control reforms that must be taken ASAP if we are to maintain the newly expanded coverage for the poor and keep the entire hc system from bankrupting more families, and from bankrupting the state!!! (remember that pesky budget deficit of >$1Bil?)
<
p>
HC Affordability requires serious cost control measures in 4 major areas: 1) Ins. industry waste, 2) provider system waste, 3) pharma waste and abusively high prices, 4) disease prevention and chronic illness management. Some of these cost controls challenge special interests so now you get a glimpse at why these weren’t done as part of state health reform. Pathetic.
<
p>
Current opportunities for hc cost control required for affordable hc:
<
p>
1. Various bills that have been filed allowing private employers, municipalities, and individuals to opt-in to the GIC, MassHealth or Commonwealth Care as coverage options.
(Kaprelian is lead sponsor of the GIC/municipalities bill)
<
p>
2. Jehlen bill requiring health insurers to spend 90% on health care services (what a novel idea, hc dollars spent on hc!!)
<
p>
3. Tolman bill to establish uniform billing – creates one standard form for all hc billing in the state
<
p>
4. Montigney bill to start the long overdue state bulk purchasing of pharmaceuticals, maybe at first just for Masshealth and GIC (that are funded with our taxpayer dollars) then expand it
<
p>
5. Hynes/Tolman bill to establish a Mass. Health Care Trust for Universal HC with streamlined single payer financing
<
p>
There was a well attended Feb. 27 legislative briefing on these major cost control reforms. As I waited in line to get in to the standing room only hearing room I chatted with someone from the AG’s office and requested they take a fresh look at our state’s health insurers being subsidized by taxpayers with their tax exempt “public charity” status. Yes, BCBS and Partners HC System, etc are tax exempt charities. Subsidized heavily by us taxpayer saps. Sigh…
<
p>
At least the State House News wrote a good article on the Feb 27 briefing:
<
p>
This is exactly what has been clearly communicated to legislators, gov-elect Patrick, GBIO leaders and other ACT2 leaders. From. Day. One. (last April). Tragic that so much time and energy has been spent on an unworkable plan. To learn more about cost control work for affordable hc and other needed system reforms visit Alliance to Defend Health Care and MassCare, and for an entirely different reform approach, learn about the citizens Health Care Amendment that began in 2002. Thanks.
You might get it.
<
p>
Previous poster had good points. How about this one: Who is going to provide the service and the administrative support? Most healthcare workers now are burned out from the present workload. The numbers of nurses who leave nursing after only one to three years after they receive licensure is staggering.
<
p>
Fifty percent of the healthcare workers I have worked with over the years were competent to excellent. Twenty five per cent needed to be watched, Twenty five percent had no business seeing a patient for any reason.
<
p>
The enormity of the cost will be incomprehensible. As we speak, medicare and medicaid are ready to break the bank and boomers will be hitting the peak of health care needs not for five years.
<
p>
This universal healthcare legislation was pie in the sky nonsense cooked up as feel good legislation to garner votes, with no thought to the law of unintended consequence.
<
p>
If you want to put a 10% sales tax on every article, food product, service, and goods sold in USA, you may be able to finance this program, however, if you have all the money you’ve ever dreamed of and no health care providers then what good is it. It will pay for expensive funerals.
Please don’t come up with the idea of going overseas for healthcare workers. They already despise us for pillaging
the competent healthcare workers worldwide for our never ending healthcare consumption.
<
p>
Working class?
Yeah, I don’t have a good shorthand way to describe folks between $30k and $50k. I know “class” is kind of a loaded term, and I’m open to other suggestions.
Just a personal observation, when I was young, my wife and I went without. Young people today have a big problem with going “without”. IMHO much of the foreclosure issues todayin the housing market, credit card debt, bankruptcy issues all stem from this problem: poor money management, inability to prioritize expenditure, and inability to sacrifice.
said the same thing about your generation.
Just sayin’.
I’ll give you two examples.
<
p>
In the US, our primary health care is provided by Lahey clinic. In Germany a small physician practice.
<
p>
One. Lahey: x-rays are taken by a technician, interpreted by a radiologist and the interpretation provided to a primary care physician for diagnosis. Three people.
<
p>
Germany: they actually had an x-ray machine when we first went there. The physician conducted the x-ray himself. And he discovered something (a benign cyst) that he opined had probably been there for decades, but had gone unobserved by Lahey or any other US physician.
<
p>
Score, 1 for the Germans.
<
p>
Two. Lahey: ultrasounds are taken by a technician, interpreted by (somebody) and the interpretation provided by a primary care physician for diagnosis. Three people, yet again.
<
p>
Germany: the last time we were at the physicians office the physician conducted the ultrasound himself. He interpreted the results himself. He even showed me the screen. (Have you ever seen your kidneys, or your beating heart? Fantastic!) Again, one person. And this was a small office.
<
p>
Score, 2 for the Germans.
<
p>
One significant reason that the health care personnel in the USofA are overburdened is that they are improperly deployed. Why are three people needed to do a task in the US, where one person in Germany–the doctor him/herself can perform the same task? They have nurses in the German physicians office, but they seem to spend their time doing patient care that doesn’t require physician attention, instead of filling out paperwork–as RNs increasingly do in the US.
I believe the state should scrap the state health care law after it becomes evident (e.g., by June 1) that the substantial co-insurance, high deductibles, and limited coverage scope of all the approved private health insurance plans lead to significant segment of uninsured and underinsured working-class Massachusetts residents would rather endure the state income tax penalty than purchase one of the state-approved and subsidized plans. Some better ideas for improving access to health insurance in Massachusetts include providing subsidies to the insured and underinsured in the form of sliding scale state refundable tax credits and providing the uninsured and the underinsured an opportunity to buy into, at a reduced cost, the state employee health care system.
<
p>
The plans that the state has approved will collapse leaving the state health care law on life support if, as I expect, significant percentage of relatively young and healthy uninsured and underinsured Massachusetts residents choose to forego purchasing one of these dubious private health care insurance plans because they are not sufficently attractive in terms of cost and scope of coverage.
<
p>
This above development will likely occur because the state-subsidized and approved insurance plans require close to 100% take-up by the entire risk pool of uninsured and underinsured Massachusetts residents in order for these seven private insurance plans to be fiscally self-sustaining. The state’s dubious and risky gamble that it can achieve close to 100% participation has other troubling health care implications for those uninsured residents who simply cannot afford to purchase one of these private plans. Namely, Massachusetts, as a condition of federal approval of its health care reform plan, had to agree to eliminate its uncompensated (free) care pool, in order to obtain a necessary federal waiver from the federal Department of Health and Human Services to pass and implement the state’s health care law. The state’s free care pool funds pay for, among other things, the Emergency Room services and other medical services received by the uninsured. I urge all Massachusetts residents interested in health care to participate and closely follow the upcoming developments and public meetings and hearings in April and May of the [Commonwealth Connector Board http://www.mass.gov. Many other states are closely watching how Massachusetts manages this high-stakes health care policy gamble to learn whether it can serve as a model for extending access to cost-effective health care to the uninsured and underinsured in other states. Personally, I wouldn’t bet either my house or my physical and psychological health on the Massachusetts individual mandate law being a model for anything other than “How Not to Do Health Care in the States.”
…what is this supposed to mean
<
p>
GBIO’s position is that the individual mandate should for now exempt those individuals who make less than $50,000, or $100,000 for a family.
<
p>
Are the exempted people supposed to be covered by something like Medicaid? If not by that, what?
<
p>
I’m sorry, but these half-assed US state based measures aren’t going to do anything to address the medical care financing issues–that’s what they are, financing issues. Require everyone to pay something, allow for private insurance for those who have high enough income, and the problem will be half (well maybe 1/3) the way solved. That’s the German model.
<
p>
Germans can be dumb–as was shown by Daimler’s purchase of Chrysler–but they aren’t stupid.
In other words, GBIO finds the imposition of the personal mandate on these folks to be worse than making them pay for their own coverage. It’s a question of them taking a gamble vs. almost certainly impoverishing some folks.
<
p>
It’s an awful choice, no question.
but here are two ways (not mutually exclusive) I could imagine the state making progress in this arena.
<
p>
1. Cover all moms-to-be and their newborns. All coverage, pre- and post-natal. Doctors visits, nutritionists if need be, alcohol, drug, and tobacco counseling for addict moms-to-be, appropriate care while mom is in labor, and post-natal health care for mom and baby, maybe for 6 months.
<
p>
Do this for all moms-to-be. It takes that off the hands of insurance companies altogether. This way, insurance rates “should” be lower for everyone, we take away most of the paperwork nonsense (from a payment perspective) in that area of health, etc. Furthermore, who hates babies? They also hate apple pie and freedom, and love the terrorists. I’m tongue in cheek, but think about it: what newborn baby doesn’t deserve a good doctor? We were all newborns at one time, and most of us will produce newborns of our own.
Once you’ve got that set, extend the time line on the newborns to 12 months. Then 2 years. Then 3, 4, 5. Etc. Just work that health care angle on those who have no control over their health care situation, taking that burden off of the insurance companies which helps lower costs for individuals (connector et al) and for businesses (helping MA gain a competitive advantage). If the claims of a more cost efficient system are true, we’ll see them play out. If the claims of waiting lists are true, we’ll see them play out.
2. Let the state pay for the boring stuff. Shots (flu, tetanus, polio, HPV, etc). Schedule based age-appropriate screenings (cancer of ______, etc). You get the jist. The kind of thing that good public policy suggests that every person obtain. Use your doctor and 100% bill the state (keeping it off of the insurance company’s bill cycle and paperwork), or go to a hospital/clinic that processes all of these kinds of procedures. Pay nothing for them. It reduces paperwork and the expense load on insurance companies, and makes paper processing easier for doctors — all the while encouraging good, basic health for all people, which is good public health policy.
Why not take one (or both) of these approaches? Instead of snapping fingers and going single payer, why not do it for specific and rational classes of people (moms & babies) or specific and rational health issues (screenings, shots, etc)? If it works well, people will notice and clamor for more. If it doesn’t, people will notice and we won’t have scrapped a system that doesn’t work some, but is also working for many.
That being said. I believe everyone, without exception pays. If you derive any support from the state or feds, that support payment will be diminished to pay for your healthcare by an appropriate amount.
<
p>
How about the healthcare abusers, The frequent flyers?
As we all are well aware there are people in our society that consume incredible amounts of healthcare dollars for their particular prediliction(s). What are we to do in this circumstance?
<
p>
This problem (if there is one) is far greater in scope and complexity than many thought and prior to putting pen to paper to enact legislation.Is our healthcare so “broken” that we have to enact this program to feel good about ourselves? The more I think about this, the more I think we are going down the wrong road.
<
p>
…#2.
<
p>
I’ll pass on #1 for the moment, because it would take a lot more consideration that I’m willing to give it for the moment.
<
p>
But, let me ask you this. What has happened to the notion in the USofa of public health? The vaccinations that you are referring to should be a measure of public health, and should be covered by…the public. When I was a child in public school in Cincinnati in the late 1950s virtually everyone had the sugar cube–the Sabin polio vaccine. It was a matter of public health. (My uncle was crippled by child-onset polio.)
<
p>
I don’t know how much the polio vaccine cost the public health authorities in the late 1950s/early 1960s. But the cost for the HPV series is–as the Germans would say–a Wahnsinn. The corruption by big Pharma in the USofA is enormous.
As you are well aware the profit motive impacts everything we do. If there is no profit, then it doesn’t get done.
Pharmaceutical companies obviously make a lot of money. Is there an acceptable amount of money that a commodity is worth and who decides. We all know that “price controls” wreak havoc at least historically.
<
p>
Years ago, vaccinations and immunizations were mandated by law. Now we have folks that have challenged that successfully and choose not to immunize their children for an assortment of reasons. Common sense for the common good isn’t any longer. The cost? Childhood pharmaceuticals are not the over riding issue, it’s the cost of delivery and the ambulance chasers. I have no idea what pharmaceutical companies pay in liability insurance , but I have no doubt that it would make a significant dent in the public debt.
<
p>
I have no idea how many people forego immunization due to cost, I have an inking it is negligable. There is so much free stuff out there that it is quite surprising, especially when it comes to kids. I would suggest that my experience in working in medicine is that people that forego what is available as a freeboe or minimal cost do so due to ignorance or sheer laziness.
run out of HRSA to take the liability burden that you worry about off of vaccine manufacturers. I know about this in part b/c in the late 80’s I worked as a research assistant for the people who largely wrote the bill while congressional staffers, before I became a nurse and educator.
<
p>
MCRD, what is it that you do “working in medicine”? (I worry about this due to your statement “the profit motive impacts everything we do. If there is no profit, then it doesn’t get done.” Yikes, remind me never to go for care where you work.)
…I have no idea what pharmaceutical companies pay in liability insurance…
<
p>
I suspect, but cannot prove, that pharma companies are pretty much self-insured, given their size. You seem to ignore the fact that most large companies are pretty much self-insured for all forms of insurance. They may have re-insurance, but that would be about it. They might make use of “insurance” companies for claims processing, but that’s about it.
<
p>
Let’s get to the substance of your comment, which is actually quite interesting.
<
p>
Years ago, vaccinations and immunizations were mandated by law. Now we have folks that have challenged that successfully and choose not to immunize their children for an assortment of reasons.
<
p>
I’m not sure that the first is correct. Vaccinations were required of children attending public school, for obvious reasons–communicable diseases that might be contracted in public school. As I’ve mentioned, the community does have a right to defend itself against contagion.
<
p>
As to the second, if they do not want to be part of the community, they are free not to be. But the community has a right to protect itself from a public health standpoint, and that is a point, that you apparently don’t wish to address.
<
p>
Pharmaceutical companies obviously make a lot of money. Is there an acceptable amount of money that a commodity is worth and who decides.
<
p>
I am not going to opine whether or not the cost of the HPV vaccination regimine is appropriate. I seriously am not. I have no idea how the vaccine was developed, who paid for its development, who paid for its tests, and so forth.
<
p>
But I will tell you this. The Salk and Sabin polio vaccines were administered at no cost to the recipients at public schools in the 1950s and 1960s. Obviously, the price was paid from somewhere, but they were not paid by the recipients. I seriously cannot understand why, 40 years later, a vaccine regimine (the HPV) to be widely distributed is supposed to cost US$300. There is something strange going on there.