I have followed the last few days of oral arguments before the supreme court on the Affordable Care Act with interest. I still haven't developed an official opinion about the bill but for the most part find myself agreeing with most of the provisions in the law. However, the law is so complex and so huge I don't feel like I know everything about it, which worries me. I don't want to go into practice in a few years and get blindsided by some provision I wasn't aware of.
Health care in the US is sort of a mess. CNN recently did a story on a little girl who had a rare medical condition that required frequent, expensive medical care to keep her alive. Her parents rejoiced when the law was passed because it eliminated the lifetime spending cap. I think in this specific case the cap was at $5 million and the little girl was only 3 and up to around $3 million in care. Her parents were worried that she'd be kicked off the plan as soon as she hit her limit and her parents would have no way to pay for her care.
I have to spend one half day every other week with a family practice physician in Centerville. Last week when I was in I met a woman who had a son that she was not able to get coverage for because he had a "pre-existing condition." His father had been laid off, lost health insurance, and the boy lost coverage for more than a month, making insurance companies able to deny coverage based upon pre-existing condition. His parents were now facing bankruptcy trying to pay for his medical care because he was uninsurable.
As I understand it, this current bill really is contingent on the individual mandate, and it makes economic sense. How can you ask insurance companies to cover more expensive people (those with pre-existing conditions, no more lifetime limits) without increasing the base of healthy people to spread the cost out. Listening to the arguments it does sound to me like the individual mandate is indeed unconstitutional and an overreach of federal power. With that being said, what can we do to fix these problems?
I don't think any of us wants to see people with pre-existing conditions denied health insurance, nor do we want to see 5 year old girls kicked off their health insurance because they were born with an expensive medical condition. This seems like a very tough problem to tackle, and I certainly don't have the answers.
What do you guys think?
"Sort of" a mess? That's the understatement of the year.
ReplyDeleteHealth care is a complete train wreck. I don't have the answers either, but one that looks like universal, socialized medicine (which is certainly where Obama and the libs want to take us) a la Canada, the UK, etc. does not appeal to me in the least, with its long wait times, much lower quality, rationing, etc.
On the other hand, it sucks that health insurance and health care is so expensive. The third party payer system (government or insurance companies) and defensive medicine (thank you trial lawyers!) are partly to blame. But requiring insurers to cover everything and everyone under the sun, however, will only increase those costs. We've seen that happen in MA, where the premiums have skyrocketed, even though people there (including the young and healthy) are required to have it.
It seems to me that with the status quo, you'll continue to have all the sob stories about bankruptcy, high costs, death and what have you. But eventually, with universal coverage, you'll end up with the same thing.
On a side note, I find it interesting that some high-profile democratic talking heads are trying to preempt the Supremes striking down the mandate or the whole Obamacare law by spinning that as "the best thing that could happen to the Democratic Party."
I feel just likethe rest of you guys about this. Sure, i think it is very sad that some people will have a disease that is soo rare and soo expensive that neither they or their insurance company can afford to keep up with their medications. Unfortunately, there is no good solution to this problem. I think the individual mandate will fall. The swing justices both seemed pretty skeptical about its constitutionality. Maybe one thing that could be done is to expand medicaid...sort of. I am usually not a proponent of expanding government services too much, but i think there is a need. With millions of people without insurance, there is a blatant hole in the system and it seems like the people most affected are those that are too rich for government handouts, but can't afford to make it on their own. Maybe, instead of just giving out free health care to all, or shoving it down our throats (both of which seem to be goals of the current administration), they could set up a tiered system. Something like 2 standard deviations below the poverty line gets free medicaid and as your income level raises, so does the premium you must pay for medicaid. That way, it would be partially self funded, and open the doors for the in-betweeners to have access to decent health care as well.
ReplyDeleteLook at you Ryan, a Glenn Beck listening closet democrat. Just kidding.
ReplyDeleteThis sounds like a public option with income limits. I am not opposed to it but I think you'd have a hard time getting republicans to support it. I could see democrats going for this idea. The healthcare bill sort of had this in mind when it promised to hand out subsidies to people who couldn't afford health insurance.
I watched Mitt Romney and Jay Leno talk about this issue on the Tonight Show a couple nights ago. Jay brought some good points up to Romney. Jay said he knew people that weren't able to get insurance because they had pre-existing conditions, and were happy about the prospect of being able to obtain health insurance once the law took full effect. Romney said he thought health insurers should not be able to deny people coverage with pre-existing conditions ONLY if they maintained insurance. Jay pointed out there are many people who haven't been able to afford insurance at one point or another and do have pre-existing conditions, and thus are uninsurable. Mitt Romney responded it isn't fair for someone to wait until they get sick before they go out and get health insurance. And he has a point.
While it may be unconstitutional, the mandate solves this problem. If everyone is required by law to have insurance, everyone has to pay in even when they are healthy so you have no free-loaders waiting to buy insurance only until you get sick. People who aren't able to afford insurance can receive subsidies from the government that makes the premiums more doable. The mandate makes sense on paper, and this law can't survive without it.
So this is the question I've been asking myself and others. The mandate is an overreach of federal power. It is unconstitutional. But would it make things better? Should we set aside principle in this one case to make a broken system a little less broken? I'm sure there are those who will argue this law will make things worse, but at this point I don't see the evidence for that claim. It may make things more expensive as we all shoulder the cost of caring for people who exceed lifetime limits or seek medical care now that they have health coverage, but will it make things worse?
I guess my more republican side of me says that if you refuse to buy into the system, you either assume the responsibility of paying for the services yourself or you are choosing to not receive the services.
ReplyDeleteSorry I was just about to post another long-winded comment, but then realized there was a much simpler approach.
ReplyDeleteSo essentially I have 2 problems with the question you posed ("The mandate is an overreach of federal power. It is unconstitutional. But would it make things better?")
Problem 1: Whoever said that any infringement of the constitution wouldn't have any benefit...? Wouldn't that make the Constitution kind of lame and pointless if it was just intuitively obvious to everyone in the first place? Why even bother listing the bill of rights if nobody's inclined to violate them anyway because there's no benefit? Who's going to vote for the candidate to says "I promise to violate all kinds of liberties, and you won't get ANYTHING out of it!"
I guess what I'm saying is you're only looking at the upside...and frankly I'm a little disturbed at how easily you brush off the chilling downside, i.e. the "it is UNCONSTITUTIONAL" part! You say that as if it's just no big deal...and I'm sorry but I just don't get where you're coming from there?! Are you really to the point where the Constitution has no value to you?
So I guess that my literal answer to your question would be "No, it wouldn't make things better...BECAUSE IT VIOLATES THE FREAKING CONSTITUTION!!" It's like you're not even factoring that into whether things can be said to be an improvement
Problem #2: You didn't say this outright in your question, but I got the impression that you felt like Obamacare is the ONLY viable solution, or that perhaps any Constitutional reform couldn't solve these problems. I'm sorry, but (if I understand you correctly) I'm just NOT willing to accept those terms!! Why jump to the worst-case scenario, i.e. that the Constitution doesn't allow for any effective health-care reforms?! This may seem stubborn, but I hardly think the almost entirely Democratic Congress that passed Obamacare (with some VERY shady tricks, moreover) was concerned about making sure that law was as faithful to the Constitution as it could possibly be without losing its effectiveness. Sorry but that just seems naive to me...
Now I know they CLAIMED it was all about expanding coverage and reforming the system (insert any imaginable platitude here), but if you can't see the political component to it then frankly that's just a little naive. Call me a cynic, but I think the political motivations were the primary concern, while the Utopian vision of curing the sick was (if anything) kind of...well, secondary. Don't get me wrong I'm not saying there are NO benefits to it, or that it would actually be worse than our current system, I just think it was a clever excuse to subvert the constitution and make a MASSIVE political power-grab. ...just sayin'...
So here's my concern: don't let these politicians fool you when they denigrate the Constitution as some kind of obstacle to ...Utopia I guess. The Constitution is only an obstacle to a power-hungry politician/would-be tyrant!! Personally when I hear politicians whining about how their hands are tied by the Constitution then I feel nothing but pure RELIEF because I thereby know that it's still doing it's job, i.e. preserving our freedom!!
And even if, on the other hand, the Constitution has in fact become too much of an obstruction in a certain way (in this case making it impossible to reform the health insurance industry), then I have an entirely different and MUCH better solution: it's called an AMENDMENT!! If the need really is that urgent then it shouldn't be too hard to securing an amendment: that way at least you can solve the current problem without throwing the baby out with the bath water, as it were...
Jeff raises a good point. The Constitution defines what the government can and can't do. Among the very few things the government *can't* do under the commerce clause is mandate citizens to engage in commerce so it can then constitutionally regulate that commerce. It may or may not be a barrier to some people's idea of "making things better," but it is a limit on the government's power nonetheless. If enough people are on board with removing that barrier, there is a process for that by amending the Constitution.
DeleteLet's transfer the "it may be unconstitutional, but it will make things better" logic to a different context so you can see the problem with that approach. Many feel that if the government banned the citizenry from acquiring firearms, this would "make things better" by greatly reducing violence, homicide, crime, etc. The 2nd Amendment, however, prohibits this by enshrining the people's right to bear arms in the Constitution. As an avid hunter, aren't you glad the 2nd amendment protects you from those who want to unconstitutionally infringe on your right to bear arms? How would you feel if politicians wanted to try to "solve the problems" of social violence at the constitution's expense? Though it may be a barrier to what some people may feel would reduce a host of social problems, the 2nd Amendment is a check on government power nonetheless. Again, if enough people are on board with removing that check, there is a process for that via amendment.
The point I'm trying to make is that the Supreme Court should not be in the business of picking and choosing which constitutional provisions are worth enforcing and which ones aren't, so long as that disregard for the constitution is justified because they feel it will "make things better."
Peggy Noonan's take on the Supreme Court arguments:
Delete"Now this week the Supreme Court arguments on ObamaCare, which have made that law look so hollow, so careless, that it amounts to a characterological indictment of the administration. The constitutional law professor from the University of Chicago didn't notice the centerpiece of his agenda was not constitutional? How did that happen?
Maybe a stinging decision is coming, maybe not, but in a purely political sense this is how it looks: We were in crisis in 2009—we still are—and instead of doing something strong and pertinent about our economic woes, the president wasted history's time. He wasted time that was precious—the debt clock is still ticking!—by following an imaginary bunny that disappeared down a rabbit hole.
The high court's hearings gave off an overall air not of political misfeasance but malfeasance."
Here's the entire article:
http://online.wsj.com/article/declarations.html
I loved the post and the comments all. To analyze the very good and very complex question Creighton posed, I think it is useful to divide up the issues into component parts and look at each separately. Put the herd in a corral, and separate the heifers from the steers from the calves from the bulls. Then deal with each.
ReplyDeleteLet's look at the question without implicating the Constitution (of the United States). How can we do that? Limit the question to what can be done within a particular state, like Utah. An individual mandate would not be unconstitutional (U.S.), because the Commerce Clause / limited powers are not implicated, and Utah has the Police Power. (Also assume there is no Obamacare, because with Obamacare in place, who knows, maybe we get into the preemption doctrine under the supremacy clause and the states' hands are tied - another Pandora's-box nightmare!)
So, what can Utah do to truly address the messy shame that is payment for healthcare?
My idea is a "sandwich," but I've already said enough and am interested in hearing what your ideas are.
@Jeff: "You say that as if it's just no big deal...and I'm sorry but I just don't get where you're coming from there?! Are you really to the point where the Constitution has no value to you?"
DeleteYea man I hate that old antiquated document that laid the foundation for the greatest country in the history of the world. It has no value to me. I think we should make Obama king, Joe Biden the prince, and Nancy Pelosi the princess that conservative pundits have been calling her for years, let's just make it official!
"You didn't say this outright in your question, but I got the impression that you felt like Obamacare is the ONLY viable solution"
Hmm perhaps the last sentence of my post could have solved your problem here.
"This seems like a very tough problem to tackle, and I certainly don't have the answers.
What do you guys think?"
I think Obamacare is one way to tackle the problem but I never said it was the best way because I don't know the best way. I am open to different solutions but so far have heard none out of the Republican party (except for Romneycare, which by the way enjoys a 3:1 favorability rating in Massachusetts despite the higher premiums). Perhaps a state approach is the better way to go, although it doesn't seem like very many states are getting out in front of this problem.
Here's what would happen in my perfect world and it may surprise you by how Republicanish it sounds. In my perfect world there would only be catastrophic health insurance with very low premiums and say a $5,000 deductible and perhaps a prescription plan. People would have health savings accounts with money they saved with hopefully around $5,000 dollars in it. When they needed a certain healthcare service they would do what most people do when they need a service, call around, research, go online, and find the cheapest service with the best quality. They would ask what tests were being ordered, they would be much smarter consumers, and costs would go down. Lifetime limits would be illegal, and I don't have a solution for pre-existing conditions yet, but when I think of one I will let you know.
Look at you, Creighton, an Obama-loving closet Republican! JK.
DeleteI totally back your perfect world proposal 100%. Ron Paul makes almost the EXACT same case as you did in his book "The Revolution" by pointing out that that was how things were in the health care field before the government got involved in the 60's. Before that, people had catastrophic insurance for the big stuff, and market forces, healthy competition for services, and people paying directly for the services kept the prices down.
I agree with you there, but I disagree with your claim, widely peddled by the administration and by its media cheerleaders, that the Republicans haven't done anything on health care reform. This is baloney. I was on the Hill to see this first hand as an intern in Republican Senator Bennett's office. At that time (2008), he co-sponsored with Democratic Senator Ron Wyden a truly bipartisan bill called the "Healthy Americans Act." I'll let you google and wikipedia search it, but I thought that, although not perfect, there were lots of good ideas in there. Unlike Obamacare, it was actually attracting support from both sides of the aisle, and even better, the CBO informally estimated that it would be roughly budget neutral. Compare that to Obamacare, which worsens the budget by 230 billion over the next 10 years, as estimated by the nonpartisan CBO last year. (http://www.factcheck.org/2011/01/a-budget-busting-law/) I was sad to see that the HAA ultimately died in the Senate.
This is just one example of many to debunk the myth the the Republicans haven't done anything on health care. A quick google search for "republican health care proposals" will lead you to others.
"So, what can Utah do to truly address the messy shame that is payment for healthcare?
DeleteMy idea is a "sandwich," but I've already said enough and am interested in hearing what your ideas are."
I want to hear your idea Chris!
Lol ya Creighton, I really like your ideas as well. :) Sorry I got a little defensive about the Constitution, by the way, I think I misread your intentions there.
DeleteSo the only other positive suggestions I would add to your basic formula would be to have it include some good tort reforms, and competition across state lines. Also I would encourage you to seriously look into Paul Ryan's relevant proposals such as the proposed medicare reforms his new alternative budget to Obama's.
I know this is from FOX, so it comes with the obligatory pro-right spin, but I thought this was an interesting article written by a physician who's office sees where the rubber meets the road with Obamacare. Thought I'd pass it along:
ReplyDeletehttp://www.foxnews.com/opinion/2012/03/30/what-doctor-knows-about-obamacare/
I read the opinion, and he brings up some valid points. However, I have met other physicians who feel differently. For one of my community practicums I had to follow a hospice doctor around once a week for a month. He took us out to lunch and I asked him about some of this stuff. I asked him which was worse to deal with, medicare or health insurance. He said health insurance was a million times worse and they were always trying to screw him over. He said there was more red tape with medicare, but he'd rather deal with the red tape than the constant fighting he had to do with the health insurance company to be reimbursed. This is the fundamental problem with health insurance, they are trying to make a profit by screwing you and screwing the physician. The system just does not make sense.
ReplyDeleteI ran into this problem right before I went to medical school. I went to the physician and he ordered several tests of things he was worried about (they were titer's to make sure I was immunized against several diseases I may come in contact with during my career.) I assumed my health insurance would pay for it, so I went along with the tests. Well about a month later I got a bill saying my health insurance would not cover the costs of the tests and the tests were $650. I called and they claimed that this test was for "administrative purposes" and they refused to pay.
Before I pay $650 for anything I spend lots of time researching the best place to obtain this product or service, I wait for special deals, I ask other people, but all of these are taken away from me with health insurance. There were a couple other options I could have done besides this test but because the way the system works, those choices were taken away from me. Health care is missing this free market attribute right now because of health insurance. There's got to be a better way.
This story illustrates why insurance sucks. I've got many of my own as well, but I'll spare you. It also underscores why paying directly with cash for services serves to keep costs down. Several service providers I've dealt with have offered me sizable discounts if I pay cash because it saves them the headache dealing with the third party payer.
DeleteYesterday, I asked my non-political friend (well, he says he is an independent but doesn't follow politics hardly at all), who is in the last year of med school rotations, about this issue. He said that between 90 and 95% of the physicians he's worked with on rotations are firmly against Obamacare, many of whom voted for the man. I then asked him why, and he went into a lengthy answer that about put me to sleep. He ended it by saying, "it's difficult to realize how Obamacare will affect you unless you've worked in the industry for a long time." Too bad it was me on the other end of that discussion and not you. You would have got more out of it than I did.
I wish I was on the end of it too. Despite how it seems, I am still very undecided about this legislation. I'm frustrated we couldn't come up with something both sides could support. I feel like the bill is EXTREMELY long and complicated. I would love to listen to a panel of experts debate the pros and cons of the bill. Articles I read about the bill are so biased one way or the other that it's hard to get a fair evaluation. I was going to read it myself but I haven't been to law school so I could barely follow the legal language.
DeleteDon't feel bad, not even the Supreme Court Justices themselves want to subject themselves to that task! Justice Scalia, with tongue in cheek, invoked the 8th Amendment's prohibition of 'cruel and unusual punishment' to get him out of reading the 2700 page bill line by line.
DeleteThere is no free lunch! An illusion is that insurance companies or the government will pay for it. Like the illusion that if we borrow the money from China it will never have to be repaid. Premiums or taxes or rationing or stagnation of innovation - there will always be a price to pay for what may seem like free stuff. It is important not to forget the Forgotten Man.
ReplyDeleteSo, Creighton, you have already described parts of the "sandwich." The bun on top is catastrophic insurance with an individual mandate. the bun on the bottom is government provided health services. The meat in the middle is a free market for health services other than government provided and within the deductible / co-pay of the catastrophic insurance.
I had catastrophic insurance once. Through the ABA (before you had to be employed by the same company to form a group). The deductible was $25,000.00. There was an annual and a lifetime limit, and as tragic as may be the result in some cases, even many cases, the limit is necessary to avoid tragedies on the other side, like systems and people broken down because of burdensome taxes or premiums. The premiums for my catastrophic coverage worked out to be less than $25 a month.
For the bottom bun, I believe there are some health services that, in a developed nation, it is uncivilized, not to mention stupid and expensive, not to be provided at a minimum. Vaccinations, pre-natal care, and perhaps emergency room services are among these. On these it may be worthwhile and more efficient than having a capitalist system, to have a government health service hire health care providers and run facilities so these are covered, at least minimally. These may not be top-notch, like the County Hospital in Houston vs. M.D. Anderson or Memorial, but anybody who needed them could have access to them. Perhaps there would be a means test so that those who could afford to pay the freight could defray some of the taxes. Tort reform at this level would look alot like Worker's Compensation, or government-run health services would enjoy sovereign immunity, getting rid of the litigation and defensive practice of medicine problems (on the bottom bun) altogether.
In between the buns, some of the reforms in the HAA that Devin talked about could work. In order to work well in the middle, the government should avoid dictating what kind of coverages are allowed. HSA's would be encouraged. Tax deductibility would be removed as an issue, and different groups could form, not dependent on employment status. I'm not sure about pre-existing conditions, but I am confident that if we are not shooting for a one-size-fits-all health system (two buns and a middle), a free-market competitive middle would be far more efficient. The problem I see with insurance is that it is expected to be the means both of purchasing basic health care (like dental insurance that covers cleanings - which is NOT insurance at all), as well as covering multi-million dollar events.
Anyway, that is the sandwich. It would be hard for a single state to implement it, what with Medicaid, Medicare, and federal tax laws messign it all up, but it would be nice if the federal government would back off and let states have a go.
That's the "sandwich."
Funny, when I said there is no free lunch, and tied it to a healthcare sandwich, I didn't realize I was making a prediction. Here is the headline from an article by Rosie Gray on BuzzFeed, posted today:
ReplyDelete"Romney, Ryan Accused of Bribing Voters with Sandwiches: Subgate?"
So maybe there is a free lunch for the voter that the candidate has to pay for later by answering a complaint with the Wisconsin Government Accountability Board (acronym "GAB")
I like the sandwich.
ReplyDeleteOne of the huge problems that our country is facing as we move forward is obesity and obesity-related disease. Obesity increases the risk of diabetes, heart disease, cancer, hypertension, arthritis, and a host of of other conditions. The most recent statistics I have seen shows the obesity rate among adults at about 40% (obesity in this case means a Body Mass Index of over 30, so if you're 6 feet tall weighing more than about 230 pounds you're classified as obese). There is no way that health costs are going to come down as the nation gets more unhealthy. Unfortunately the obesity rate is higher among the poor and minorities. Some studies show the rate flattening out a bit, but my personal feeling is that we may see life expectancy decrease on average because of this.
If I eat healthy, exercise, keep my weight down, and try to stay healthy my whole life, is it really my responsibility to help shoulder the costs of those who didn't make the effort that I did? I don't think it is. (The closet republican in me once again, he surfaces every once in awhile.)
I know the answer to problems isn't always more government and more taxes, but why not consider a junk food/fast food tax to help with these costs? We did it long ago with cigarettes and that (plus numerous public campaigns) has drastically reduced the incidence of smoking and lung cancer. Would the same type of campaign work in the fight against obesity?
My proposal would be to raise taxes on products like sugary soda, fast food, and in general certain foods that don't hit a standard of health. Use the revenue generated to help fund medicaid and medicare.
Right now you can use food stamps to buy any food product, you could only buy skittles every month if you wanted to. If I was the president I would suggest that those receiving food stamp assistance (about 40 million people nationwide if I'm not mistaken?) not be able to purchase soda and candy with food stamps. In addition to that, I would require those receiving benefits to meet with a dietician once every 3 months, much like WIC does, to try and help people gain knowledge of how to eat more healthy.
Instead of just raising taxes on the 1%ers, why not shift some of the burden indirectly to the people that contribute to the higher costs of health care?
Thanks for the thumbs up on the sandwich. The purpose of taxes is to raise revenue to run the government for the proper functions of government. When we use taxes as a vehicle to promote other goverment policies then things get weird, skewed, distorted.
ReplyDeleteIt has become routine, though, for taxes to be used as the vehicle for all kinds of wealth redistribution, subsidies, and indirect regulation. Some taxes are more akin to user fees, which I have no beef with. When gas taxes are used for road improvements, that is OK in my book. Green energy tax credits, and deductions for mortgage interest don't make sense.
I'm a pretty conflicted about cigarette taxes. Why make addicts pay extra so funds can be raised to discourage future users? or worse, Have extra money to run the government? The notion that these taxes go to defray health costs due to smoking isn't nearly as direct as having gas taxes go to roads.
Until government is willing to ban tobacco or treat it as a controlled substance, I just can't see regulating obesity-causing foods. First things first.
Besides, freedom has its own virtues. If government is less involved in healthcare, then the justification that government should regulate bad foods to save the government costs just melts away, and all that is left is the state's penchant for restricting freedom. I don't think the state should spare anyone from bad health choices. Proper labeling is good. Education is good. Those who want to keep the government out of the bedroom ought to also be interested in keeping the government out of the kitchen.
I'm hoping one of you conservative guys can do a post comparing and contrasting the budgets proposed by Barack Obama and Paul Ryan.....
ReplyDeleteNot sure it deserves a post. The comparison that matters: Obama's budget failed on a 414 to 0 vote in the House. The Senate hasn't bothered with a budget in three years, so Ryan's budget, passed in the House, will not see the light of day in the Senate until there is a Republican majority there.
Delete