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Chicken Soup for the Reformer's Soul
Another chilly day in Buffalo, so I have warm chicken soup on my mind...
As our "health care reform chicken soup" is created in this next stage and bills are merged, I started to wonder what are vital ingredients needed to make the tastiest, most nourishing final masterpiece that will inspire rave reviews. Personally, I think the below ingredients (which I saw posted in the Washington Monthly) are essential to that delicious health care reform chicken soup. So my question to you is: what do you think are the vital ingredients that should be included in the recipe for the best health care reform chicken soup? Try not to worry about whether they are realisitc in terms of support. Just list the ideal ingredients you see as important. Do you agree with those below? Disagree? Any additions or amendments?
Bon Appetite!
From the New Republic via Washington Monthly:
‘…The Top Ten Things Worth Fighting For
by Jonathan Cohn
1. Increase the subsidies. The House and HELP bill have sliding scale subsidies that extend to people making up to four times the poverty line, or about $88,000 a year for a family of four. Finance’s bill stops the subsidies at three times the poverty level, although there’s some assistance above it, and offers less help to even those who still qualify. This is a strength of the House and HELP bill and might, in theory, seem like an easy thing to save, since virtually everybody says they worry about reform not making insurance sufficiently affordable. But more subsidies require more money. The options are out there: A tax on sugary sodas, the House's millionaire surcharge, or President Obama's proposal to cap charitable deductions. But it's when you start talking taxes than the centrists start backing away from the table.
2. Bolster the protection against high expenses. There’s no reason anybody should face out-of-pocket expenses of more than a few thousand dollars. The House and HELP bills come closer to meeting this standard, although even the protection even in those bills could stand some improvement. This, too, is not so controversial in theory. Everybody, left and right, wants insurance that protects people. But establishing a higher baseline of protection will--like more subsidies--require more funding, to subsidize the more generous insurance. That's really where the challenge lies. There may be a way out of this. If you give insurers leeways for slightly higher deductibles, the money that frees up is enough to require much tighter limits on overall out-of-pocket spending. Or so I am told. It'd be better, though, just to come up with more money.
3. Get tough with providers and producers. Both the drug industry and the hospital industry got sweetheart deals. And since the White House was a party to these agreements, rewriting them may not possible, or at least politically realistic. But there may be chances to tweak them and, if so, Congress should take them. Under the current deal, it doesn’t appear either the drug industry or the hospitals will actually be giving up much revenue; if anything, they might come out ahead. Surely it makes sense to ask them for a larger financial sacrifice, particularly if it can be done in a way that fosters more efficient care that would help reduce overall health care spending down the road. Remember, the most important aspect of these deals isn't the cash it frees up in the short term but the behavior changes it fosters in the long run. By the way, while Congress is at it, it might want to look at the other key industry groups--namely, doctors and device-makers.
4. Get a public plan (or something that serves the same purpose). Passing a fully fledged public plan, the kind that has all of the bargaining power that its architects originally envisioned, still seems like a long shot. The Senate votes just aren’t there. But idea of a public plan, or something like it, is definitely getting a second look from lawmakers who once dismissed the idea out of hand. The reasons are pretty simple: The idea continues to poll well, at least in isolation, and it eases anxiety about the requirement that everybody get insurance. The most likely scenario, I continue to think, is to arrive at some sort of trigger. But a well-designed trigger might still do some good. The key is designing one that would actually scare insurers, enough to make them provide the kind of affordable coverage we all want.
5. Strengthen the exchanges. The House doesn’t get much credit for this, but it got the exchange structures almost exactly right. In their bills, the exchanges would be national, rather than state-based, with authority to police insurers aggressively and bargain hard for lower prices. The model here is the Massachusetts Connector’s management of the CommonwealthCare program, which has successfully held down premiums for its enrollees. This is not what the insurance companies want, which tells you why it’s so important. But the idea may yet win out. According to my colleague Suzy Khimm, Olympia Snowe is already thinking along those lines.
6. Preserve the Medicare Commission. Letting Congress micromanage Medicare payment policy is a bad idea, unless you’re a lobbyist looking to get special treatment for the hospital, professional group, or maker of medical ware that pays your salary. Let an independent commission make recommendations, and then force Congress to vote on them up-or-down, as they do for closing military bases. The Finance Committee endorsed this idea. So has the president. The House disagrees. And the lobbyists are doing their best to make sure the House prevails.
7. Save the benefits tax. This is another piece Finance got right and the House, in my opinion, got wrong. Taxing high-value health benefits does more than raise revenue that can, in turn, finance subsidies. It also sets off a chain reaction that, according to most experts, will lead to lower health care spending. The Finance bill has protections that exempt workers in high-risk jobs, as the unions (rightly) asked, but the unions are trying to kill it anyway. That’d be a mistake, unless they can present an alternative--a politically realistic alternative--that can both raise money and reduce federal spending in the long run. Personally, I'd love to see labor give on this in exchange for a public plan or better subsidies, two priorities they have--to their great credit--been pushing. (For more on the excise tax and why it makes sense, consult the Center on Budget and Policy Priorities.)
8. Stiffen the individual mandate. There’s a reason that Obama, after campaigning against the mandate as a presidential candidate, has changed his mind since taking office. It’s a good idea, for all sorts of policy reasons. (Chief among them: It guarantees a broad risk pool, in which we all share the burden of paying for the high medical expenses a few of us will be unlucky enough to face.) But nobody wants to make people buy insurance they can’t afford, which was something that worried Senate Finance members as the debate came to a close. The smart answer would have been to embrace generous subsidies and strong affordability protection. That’s what HELP and the House committees did. Instead, Finance took the easy way out and just started gutting the mandate.
9. Keep a real employer mandate. Here, again, a concession to centrists--and, in particular, Snowe--has substantially weakened the Finance bill. An employer mandate is essential not so much for the revenue it generates as for the role it plays in preserving employer-sponsored insurance, at least in the short term. (Letting it whither away in the long term would be fine with many people, including me.) Snowe’s aversion to the idea is a major reason why the Finance Committee opted instead to go with a “free rider” provision that could actually introduce some perverse incentives, like discouraging workers from hiring low income employees. (The way it works, companies who didn’t provide coverage would pay a fee only if their workers ended up in federally subsidized coverage--i.e., if they were low income.) The House and HELP bills have much stronger employer requirements--and should be preserved.
10. Open the exchanges. This is Ron Wyden’s idea, as popular among pundits as it is reviled by labor and business. Under his proposal, somebody with access to employer-sponsored insurance could decline it, enrolling instead in a policy made available through an insurance exchange. And, critically, they could take their employer contribution with them. Wyden says it would give all Americans more choices, which is true, and that it would introduce more competition to the insurance market, which is also true. It would have to be crafted very carefully, to make sure--among other things--that all the healthy people don't aggregate in either the employer plans or the exchanges. But that seems feasable.
http://www.tnr.com/blog/the-treatment/the-top-ten-things-worth-fighting...’
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I agree with you that #4 the public option is the most important ingredient if we want real reform. When considering #7, save the benefits tax, one should make sure the high premiums are for a high value package. Many high premiums (ours included) are "Cadillac premiums" for "KIA policies" for which the insurance company punishes you for passing the age of 60 and for actually using the policy.
Someone (I think it was Wendell Potter) suggested that our rallying cry should be, "Do you TRUST the insurance industry???"
Of the options stated I agree that #4 is probably the best bet, But I think part of the current approach to solving the health expense crisis is putting the cart before the horse. I don't see how medical costs will ever be "affordable" until a couple of other things happen.
1. We need to train our doctors with less cost (somehow!). Tuition per year runs from a low of 7,100 (10,234 w/fees) for a public school, resident student to a high of 48,386 (51,968 w/fees) for a private school, non-resident student (http://services.aamc.org/tsfreports/). This is for the first year so for the minimum 4 years of schooling a student is looking at a range of $28,400 ($40,936) to 193,544 (207,872). Add textbooks running 100 - 200 bucks (figure what 4 - 6 books/semester?). Well you can see how the expenses kind of pile up.. And that is just the start, for a GP. Any specialization is going to add 2 - 4 years of expense.
2. Do the prices charged for medical supplies really reflect the expense of providing them? In other words, is there a hefty surcharge for being a specialty item that isn't really warrented? I know that free market forces should take care of that, but when the supplier pool is limited free market forces don't work as effectively.
3. Does every hospital have to have the latest whiz-bang bit of technology? Obviously, there are some real cons with this as a cost cuttng measure.
4. Is there a reason why nurse practitioners can not be used as front line (so to speak) medical personnel? Do I really need a Dr. to stitch up a cut? or to tell me I have a cold? Also fraught with problems.
sixteen-you make some great points! I may be in the minority, but when I went to my OGBYN for check-ups during my pregnancies, I was fine with the option of seeing the NP. She was excellent, more personable than my doctor, and I did not have to wait as long. They can certainly be utilized more.
On another note, I just saw this on MSNBC:
Boehner also encouraged President Obama to live up to his campaign promise to conduct the writing of health care legislation in the open. "The president during the campaign last year said that when we got to this part of the process, that it'd be a big open room, that he'd invite in the CSPAN cameras," but instead, Boehner said, "the bill is being written in the dark of night."
Careful what you wish for, Boehner. I think it would be great to see the negotiations on CSPAN, especially if someone was in there making the case for a public option and we saw the influence of the insurance lobby first hand as they made excuse after excuse.
My sister-in-law is a nurse practitioner, preemies to 1 year olds. As I understand it, they have nearly the depth of medical training, in a very very narrow range.
A lot less expensive to train and very useful in emergancy room situations when a lot of what you see are broken bones, cuts, fevers and like such. However we had a critical care unit (run by a for profit hospital) in town that was primarily staffed by nurse practitioners with doctors on call. The idea was this is were you go if your kid isn't feeling well, sprained ankles, stubborn fevers, anything that that there wasn't a risk of dying or permanent damage if you didn't get immediate hospitalization, and the emergancy room for those with strokes, heart attack, gunshots etc. Apparently it was not able to earn its keep, but on the other hand the only way I heard about it was when the paper said it was closing. How well would it have done if it was properly advertised? I don't know, but I do know that a similar critical care unit opened - not associated with the hospital (staffed by doctors) and appears to be quite busy each time in the last 5 years I've ended up going in there, even though it gets bad reviews (wait times are horrible).
Premium increases may make all policies subject to being taxed as "Cadillac" plans. I've lifted highlights from an article on the msnbc website. The whole article is worth reading.
With annual “open enrollment” season approaching for choosing health care options, get ready to pay more. No matter what happens with national health care reform, employers already are shifting part of the rising cost of care to employees.
For decades, most company-sponsored health plans gave employees relatively little financial responsibility for the cost of their care — often a small “co-pay” portion of a medical bill or prescription refill. But the relentless rise in health care, often invisible to workers, has prompted companies to begin passing along those steeper costs.
The sharp increase in health insurance premiums is hitting both employers and employees hard. Over the past decade, the average annual health insurance premium for all workers rose 131 percent to $13,375 — or more than four times the rate of inflation, according to the Kaiser Family Foundation. In response, some companies have dropped coverage altogether. As of this year, 60 percent of employers offered health benefits — down from 69 percent in 2000.
Some employers are offering workers a choice: Pay a higher premium for your current low deductible or pay a much lower premium with a much higher annual deductible — the amount you're responsible for paying out of pocket before full coverage kicks in.
Those higher deductibles can range from $1,000 to as much as $5,000; employers typically then contribute a portion of that amount to an account employees can use to pay their medical bills.
Some employers are offering workers a choice: Pay a higher premium for your current low deductible or pay a much lower premium with a much higher annual deductible — the amount you're responsible for paying out of pocket before full coverage kicks in.
Employers have borne the brunt of the increased cost of health care, but they also have been passing along costs to workers at a healthy clip. This year, some 22 percent of workers paid a deductible of at least $1,000, up from just 10 percent in 2006, according to the Kaiser survey. Another 16 percent of companies said they’re “very likely” to raise deductibles next year; 21 percent said they’re “very likely” to raise employees’ contribution to premiums.
1. Yeah, I really don't think that increasing the subsidies is the answer. I'm making $40k-$50k a year for a family of five, and yet while things are tough from time-to-time I don't consider myself "poor". I don't want or need any public assistance.
2. But some people want *no* out of pocket expenses. I don't think that that's right, except for people who are truly poor. Most of us have no problem paying some money out of our pocket for routine medical care, which also helps us to remember that regardless of our conditions that medical care does cost real money. I mean, it shouldn't be enought to force people into bankruptcy unless they are already over extended in their finances.
3. Agreed. Medical care is valuable, but there is a limit to the value.
4. Agreed. Public plan is essential.
5. I don't know a lot about the exchanges so I can neither agree nor disagree. Unless it is related to point 10.
6. Agreed, I think. Again, I'm not too informed on this idea.
7. I'm confused on this one -- are you saying that health benefits should be taxed? If so, I agree. We need to separate employment from health insurance and vice-versa.
8. I'm a little torn on this, and I've heard about the possible unconstitutionality of this. Especially I don't like the idea of penalties which are important to the insurance industry. I think that people should have a choice -- either buy private insurance or be enrolled in the public option. Of course, if you are enrolled in the public option and make more than whatever subsidy level is eventually approved, then you will be paying for it anyway.
9. I'm a little confused on this one. For me, in order to finally break the chain between employment and health insurance, I think that any kind of employer mandate is a bad idea. Still, kinda uninformed on the issue.
10. Absolutely!
I heard another point/idea on the radio but right now I can't remember it. I'll try and I'll post it if I do remember.
"If all mankind minus one were of one opinion, mankind would be no more justified in silencing that one person than he, if he had the power, would be justified in silencing mankind." ~John Stuart Mill, On Liberty, 1859
(from article in main post)
7. Save the benefits tax. This is another piece Finance got right and the House, in my opinion, got wrong. Taxing high-value health benefits does more than raise revenue that can, in turn, finance subsidies. It also sets off a chain reaction that, according to most experts, will lead to lower health care spending. The Finance bill has protections that exempt workers in high-risk jobs, as the unions (rightly) asked, but the unions are trying to kill it anyway. That’d be a mistake, unless they can present an alternative--a politically realistic alternative--that can both raise money and reduce federal spending in the long run. Personally, I'd love to see labor give on this in exchange for a public plan or better subsidies, two priorities they have--to their great credit--been pushing. (For more on the excise tax and why it makes sense, consult the Center on Budget and Policy Priorities.)
(from Tin)
7. I'm confused on this one -- are you saying that health benefits should be taxed? If so, I agree. We need to separate employment from health insurance and vice-versa.
(from Kelly)
I think his main point is that health benefits should be taxed. I agree that the unions should concede this point in exchange for a strong public option. With "cushions" that will likely be in place for high-risk workers, I don't think it's worth the fight for unions.
Thanks, Kelly. It's just a little hard to parse, IMO. I think I understand a bit better though.
"If all mankind minus one were of one opinion, mankind would be no more justified in silencing that one person than he, if he had the power, would be justified in silencing mankind." ~John Stuart Mill, On Liberty, 1859
Heh, I almost think so too. Almost.
"If all mankind minus one were of one opinion, mankind would be no more justified in silencing that one person than he, if he had the power, would be justified in silencing mankind." ~John Stuart Mill, On Liberty, 1859
My health communication class (part of my required courses for my masters) is focusing on Healthcare Policymaking and Organizational Rhetoric right now.
It's very timely (was not planned that way, but more serendipitous). The book we're using was written around 2002 or 2003 and many of the essays, articles and research were from the late 1990s.
I will try to synthesize some of it and write a post capsulizing some of the more salient points.
One of the more interesting being: Everything old is new again. The healthcare reform opposition and proponents are using the same scripts and the same strategies that each have used for the last 100 years on this issue. Yes, I said 100 years. It seems Teddy Roosevelt was one of the first political leaders to advocate for national health insurance in an attempt to address the healthcare needs of Spanish American War Veterans.