Archive for September, 2009

An Amendment to Head off “Death Panels”

September 19, 2009

There has been much discussion of the possibility of “Death Panels” being imposed by the Health Care Reform plans being considered by the House and Senate.    While such “Death Panels” are not explicitly referred to in the bills, anyone who has read my previous pieces understands that the complex bureaucracy being created by the new bills could easily create  “cost-effective” protocols for coverage, and/or benefits, and/or treatment that would limit access to expensive treatments that are deemed to yield  little benefit especially for the elderly or severely impaired.  In fact, Dr. Ezekiel Emanuel is known to favor such schemes and has rationalized them using a communitarian ethic to replace the outdated Hippocratic Oath (see “President Obama’s Rationer-in-Chief” which is in the links) .  It is well-known that Dr. Emanuel’s opinion helps inform the President’s vision, and that opinion did indeed, seem to be reflected in Mr. Obama’s response to Ms. Sturm  regarding her mother’s pacemaker in the now-famous Town Hall meeting held June 24 at the White House.  I have written a separate piece on this titled “The President’s Real Waterloo – a Pacemaker”  which is located elsewhere in this blog. 

But to summarize, Mr. Obama first indicated the woman could not get a pacemaker because it wouldn’t be sufficiently better than alternative, less expensive “painkillers,” and then changed his mind when he heard the woman had had to be hospitalized for arrhythmia a number of times at great expense.  Mr. Obama indicated that “if we’ve got experts who are looking at this and they are advising doctors across the board that the pacemaker may ultimately save money, then we potentially could have done that…” that is, give her the pacemaker.  These “experts” who are “advising doctors” how to “save money” sounded pretty much like a “cost effective treatment panel” which, if it interprets data the literal way Mr. Obama appeared to do that night, might easily turn into a “Death Panel.” 

Often, in Socialized Medicine bureaucracies, the tool which provides the rationale that may be used to deny the elderly and severely impaired access to treatment is the so-called “Quality Adjusted Life Year” or QALY.  In fact, this concept may already be manifesting itself in the Medicare system.  Essentially, economists attempt to place value on one additional year of life adjusted for your quality of life after treatment, prorate that value according to how long a given treatment is expected to prolong life, and then compare that to the cost of the treatment.  As an example – let’s say you reside in the UK and your QALY for a given procedure at your age is about $20,000 and it is expected to prolong your life for about 3 1/2 years.  That means if the procedure costs less than 3.5 x $20,000 = $70,000, then you might get it (provided there is no alternative treatment that yields a similar benefit at a lower cost – i.e.  ‘comparative effectiveness’ – the subject of a future post).  However, if the procedure costs more than $70,000, then it cannot be justified and, under the British system, you will simply not receive this treatment even if there are no other suitable alternative treatments available.  To those of us who are used to receiving health care according to the U. S. model, this denial of access to treatment to certain categories of individuals by a bureaucracy is exactly what we mean by a “death panel” – that is, the bureaucratically mandated “end-of- therapeutic care” which results in the “end of life.”  And the worst thing about it is that it is not some villainous insurance company to whom the patient owes no allegiance and against whom the patient might have recourse, but rather the Government itself, rendering ultimate judgment.  

Of course, we have heard the President repeatedly scoff at the idea of “Death Panels,” or that he is going to “pull the plug on Granny.”  These scenarios, he claims, are based totally on “misinformation”  spread by “fearmongers” who are, perhaps, evil individuals in the  insurance industry.  Actually, our fears are based on Mr. President’s own words regarding the woman’s pacemaker, and he is the one spreading the “misinformation” that critics are referring to a literal “death panel” convened for each patient rather than an actuarial scheme devised by his “experts” to save money.  But let’s just accept his premise for now.  Fine, Mr. President, if the bills are “not envisioned”  to deny access  to health care to the elderly and impaired based on a cost-effectiveness rationale, then you, and your colleagues in the Congress, should have no objection to an amendment that, essentially, just clarifies that this very kind of cost-effective rationale, which denies access to care in the health care systems of other countries, will not be allowed in our system. 

I believe the natural place for such an amendment occurs relatively early in the House bill, H R 3200 -in Section 122 which describes the requirements for “An Essential Benefits Package.”  This section, beginning on page 26 of the bill defines the essential benefits package as 

“health benefits coverage … to ensure the provision of quality health care and financial security, that —

[paragraph—(a)(3)] does not impose any annual or lifetime limit on the coverage of covered health care items and services;”

This requirement is aimed at current private insurance coverage which, in many cases, includes such annual or lifetime maximum expenditures.  I think it follows naturally that this paragraph would also forbid  the maximum payout schemes typically employed by Government Bureaucracies under Socialized Medicine systems to limit treatment of the elderly.  My proposed amendment reads:

“[Paragraph—(a)(3)] does not impose any annual or lifetime limit on the coverage of covered health care items and services. No health benefits coverage based on, or restricted by, the concept of “Quality Adjusted Life Years” or similar actuarial valuation of additional expected life years which, effectively, imposes a limit on coverage for certain individuals, shall be deemed to meet the requirements of this section;”

If there are no cost-effective “Death Panels,” envisioned, then this amendment should go sailing through.  It is merely a clarification of the word “limit” in the original text.  I think it could even be argued that a close reading of “limit” in the original paragraph, makes this clarifying amendment unnecessary.  Nevertheless, in my opinion, such an amendment would have no chance whatsoever of passing.  Why? Because it would definitively close the door on an essential element of cost savings envisioned down the road by Dr. Emanuel and Mr. Obama.  Cost savings achieved by limiting access to therapeutic treatment by the big users of health care resources – the old and severely ill – through regulations and guidelines yet to be devised and implemented.

I have heard folks in the media implying that the phrase  “I want my Country back,”  is a manifestation of racism on the part of protestors.  However, to me it means something else. When I was growing up, we believed that how we treated the weakest among us indicated how strong we were as a Nation.   That is the Country “I want back.” Now we are divided one against the other and the weakest seem to have little voice.  I think this is a frightening new Country – like Speaker Pelosi, I too am frightened – but I am most frightened by her vision of a Government that can impose its will on the citizens regardless of their wishes.

I propose we perform an experiment.  Take my draft “harmless”  amendment – reword it – make it your own – make it even blander and more harmless.  Send it to your Congress Person as I have already sent it to mine, and challenge them to propose it merely as a clarification that there are no silly “Death Panels” hiding in the woodwork.  If some Congress Person does this and the amendment passes, that would be a great victory.  If no one takes up the challenge or the amendment  gets defeated, all I ask it that you join me in remaining extremely skeptical about the Administration’s ultimate intentions regarding health cost control, and the quality of Public Health that may result.

The Skeptic

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The Empire Strikes Back

September 16, 2009

As we predicted, the President’s speech to Congress may actually have resulted in decreased popularity of the Health Care Reform effort. A new Washington Post poll indicates that 54 percent of Americans say the more they hear about the plan the less they like it. Only 41 percent of Americans say they like the program better the more they hear Mr. Obama talk about it.

In the face of this continuing unpopularity of Health Care Reform, some Democrats and many media commentators seem to be resorting to a familiar, but unfortunate, formula – opponents of the President’s program are being characterized as “racists.” In the last several days, we have seen the initial denial of the importance of the Washington D.C. protest, followed by a slowly growing chorus of voices on the left describing the protestors as people who simply cannot accept an African-American President.

At first the message from the media was that ” a small but disturbing” fraction of the protestors were “racists.”  But then, on September 15,  former President James Carter described this fraction as “the majority” of the protestors.  Other Democratic voices have echoed this sentiment, and the media are running with it. 

The “skeptic” being a “fact nerd,” does not ususally engage in such nebulous discussions, however, this is a blatant attempt to turn the conversation away from the truly disastrously bad legislation currently being considered by Congress which threatens to ruin Health Care in this Country.   Therefore, this scheme must be whack-a-moled right back down into the fertilized dirt from which it emerged.

The reason so many people are so upset about health care reform has nothing to do with Mr. Obama’s race, and only a little to do with Mr. Obama’s politics. (However, interestingly, the remainder of Mr. Obama’s political agenda is indeed threatened by the unpopularity of Health Care Reform and his refusal to tone down his selling rhetoric ). Rather, it is the classic reaction that can be observed when something very  important to people is taken away from them, and is replaced with something totally unknown. Polls show that people generally like the quality of their current health care, but they believe it is not so good for others who are less fortunate. People are willing to help others, provided it does not result in a degradation of the quality of their own health care. Recently, many people (especially Seniors) have started to realize that the new program has the potential to disastrously degrade not only their own health care, but also the health care provided to the poor, whom this reform effort is intended to benefit.  In fact, the only sure winners seem to be the Federal Bureaucracy and the very largest Drug, Hopsital, Insurance, Union, and Pharamaceutical giants.  As this realization emerges,  a good portion of the Public has become outraged that Health Care, as we know it , is being forcefully wrested from our grasp, to no ultimate purpose except to expand the power of the already-powerful, and there is tremendous frustration at our relative powerlessness to keep this from happening.

That is why Maureen Dowd’s aural hallucination regarding Joe Wilson’s “You lie!” (‘You lie Boy!’ according to Ms. Dowd) is so absurd.  The term “boy” is generally used in a contemptuous manner to display rank and power over the object of the term. Mr. Wilson’s outburst, on the other hand, is the sort of spluttering, shocked, outraged, “You can’t possibly have said that!” response associated with true powerlessness.  As described in a previous post, Mr. Obama bears a lot of the responsibility for these sorts of reactions because he has been relentlessly resorting to campaign rhetoric and populist exhortations to his followers to “cheerlead” these flawed bills to victory (“We can’t wait!”). Mr. Obama, from the first Town Hall at the White House, has carefully excluded opposing voices from the conversation, and therefore his repeated misrepresentations  have gone largely unchallenged. The speech to the Joint Session of Congress was just another in a long string of events staged in controlled environments where “cheerleading” is encouraged while the possibility of honest debate is totally quashed. 

Representative Wilson’s act of defiance resonated with us not because we are “racists,” but rather because it seized back the conversation, if only for a brief moment, and put the authoritarians on notice that even their cherry-picked, controlled environments are not “truth-free zones.”  The message is that this debate will indeed go forward, despite the President’s insistence that it is over. 

That seizing of the conversation (which incidentally resulted in changes to the Senate bill which tend to validate Mr. Wilson’s point), coupled with the huge D.C. protest turnout, was a heavy blow to the proponents of Government-controlled health care.  We can now expect the “Empire” of the Left, and their minions in the media, to continue their vicious smear campaign which uses “racist” as the new N-word to characterize critics who oppose the proposed “reform” measures.

President Obama’s Real Waterloo – a Pacemaker

September 7, 2009

 

After a tumultuous August marked by repeated attempts by President Obama to calm Americans’ fears and sell them on his version of health care reform, we are now faced with the prospect of more of the same as we head into Wednesday’s Presidential Address to the joint session of Congress.  As we endure this endless process of “Mad Men” meets the Presidency, along with  President Obama’s dwindling audience, we are no nearer to accepting Mr. Obama’s words regarding his health care program.  With Mr. Obama in full campaign mode, the “facts” he tells us about his health care program are not some reliable bedrock to build a health care system on, but rather the “facts” underlying a political campaign promise – understood by all to be spun and twisted into the most desirable shape for the purpose of persuading.  In this continuing process of campaigning, rather than governing, President Obama is losing not only approval ratings, and political capital, but also his very credibility.

Before we hear Mr. Obama’s revised “vision” of “health insurance reform” that has been tweaked and focus-tested for our current consumption, let’s return to his original and least practiced attempt to describe this vision – the attempt that has, perhaps sounded the most discordant note in the whole debate, and which may have permanently damaged his efforts to move health care reform forward. This occurred during the June 24 town hall meeting at the White House, when he was asked by Ms. Jane Sturm whether “any consideration” would have been allowed for her 100 year old mother’s “spirit” as she sought a pacemaker to address her arrhythmia problems ( a pacemaker which, under the present Medicare system, had indeed been implanted, giving the woman five more years of life to date).  There are several disquieting passages in Mr. Obama’s response that invite our scrutiny and analysis.

1. “I don’t think that we can make judgments based on people’s spirit. That would be a pretty subjective decision to be making. I think we have to have rules that say that we are going to provide good, quality care for all people –”

Clearly Mr. Obama thinks “we have to have rules” to determine when patients will receive an intervention such as a pacemaker.  It seems that the professional “judgments” made by the woman’s physicians, were “pretty subjective” and not a sufficient basis “…to provide good, quality care for all people.”  It would seem that the “rules” Mr. Obama wants would lay out how “all people” with this condition/diagnosis will be treated.  Such “rules” are clearly not included in the bills we are considering. These could come later in implementing regulations or in some of the broad authorities granted to the bureaucracies, perhaps through issuing guidance.  This is one of the truly disconcerting aspects of the proposed bills, because we don’t actually know the shape of the final plan, yet we are being asked to give the Government bureaucracy broad authority to flesh out that plan later as they see fit. 

2. “End-of-life care is one of the most difficult, sensitive decisions we’re going to have to make. I don’t want bureaucracies making those decisions.”

“End-of-life” is a term generally reserved for the last months of life. But since Ms. Sturm has already informed the President that her mother has lived for 5 years subsequent to the pacemaker implant, Mr. Obama is obviously using the term in a different manner.  Mr. Obama appears to mean that denying Ms. Sturm’s mother a pacemaker would, most likely, have ended her life, and that this is the “difficult, sensitive decision” he is talking about – a decision, in effect, to end care which, in turn, results in the “end-of-life.”  Immediately he senses he is in trouble and says that “I don’t want bureaucracies making those decisions.”  However, later on in the conversation he seems to rely on the bureaucracy to “let doctors know” what the decision should be, if not for the decision itself.

3. “But what we can do is make sure that at least some of the waste that exists in the system that’s not making anybody’s mom better, that is loading up on additional tests or additional drugs that the evidence shows is not necessarily going to improve care, that at least we can let doctors know, and your mom know, that you know what, maybe this isn’t going to help, maybe you’re better off not having the surgery, but taking the painkiller.”

This statement is central to how the system will work and seems to indicate the intention to use “evidence”-based medicine to identify appropriate treatment options and to use comparative effectiveness analysis to determine which treatment option – in this case, therapeutic pacemaker vs. palliative drug – is more cost-effective.  These concepts – evidence-based medicine and comparative effectiveness – have notoriously been used by the National Institute for Health and Clinical Excellence (NICE) of the British National Health Service to deny elderly patients access to various treatment modalities.   The House bill, indeed, establishes a “Center for Comparative Effectiveness Research.”  To implement the comparative effectiveness template, we seem to have a set of known and agreed upon “rules” so that “we can let doctors know and your mom know” the most cost-effective treatment regime for her demographic group.   The “we,” who, is charged with letting folks know, seems to be the Government, so published regulations or guidelines would seem to be the likely mechanism to  “let doctors know.”  Clearly, the bureaucracy is back in the decision-making loop after their previous banishment by the President. 

4. “But understand that those decisions are already being made in one way or another. If they’re not being made under Medicare and Medicaid, they’re being made by private insurers…”

Yes, and this is, perhaps, the crucial point of this exchange – Ms. Sturm was able, under the present “broken” system, to find a doctor who made a decision to give her mom the pacemaker, and Medicare supported that decision.  In Mr. Obama’s system, when “the evidence shows” a certain treatment “is not necessarily going to improve care”  then “we can let doctors know” … how to treat this type of patient.  So, basically all doctors will have the same evidence and treatment guidelines/regulations and are likely to reach the same treatment decision.   In brief, under Mr. Obama’s system Ms. Sturm will probably not be able to find a doctor who will decide to give her mother a pacemaker – period.  Mr. Obama’s often repeated disclaimer that these “decisions are already being made” completely, (and, perhaps, intentionally) misses the point, because the decisions that are currently being made under our “broken” system appear much more flexible, appealable, personalized, and humane than those that will be made under Mr. Obama’s system!

5.  In response to Ms. Sturm’s statement that her mother’s repeated hospitalizations prior to receiving the pacemaker may have cost Medicare more money than the pacemaker procedure itself Mr. Obama stated:

“Well, and that’s a good example of where if we’ve got experts who are looking at this and they are advising doctors across the board that the pacemaker may ultimately save money, then we potentially could have done that faster. I mean, this can cut both ways.”

Clearly Mr. Obama envisions that “experts” will be “looking at this” diagnosis and demographic, and “advising doctors”  what treatments “may ultimately save money.”   This “advising” is done at the behest of “we,” (the Government).  However, what the “experts” are “looking at” isn’t this specific case of Ms. Sturm’s mother, but rather they are “advising … across the board,” referring to all such cases.  So, in Mr. Obama’s mind, this new information revealed by Ms. Sturm is just more “evidence” that would be statistically factored into the rule or guideline that will be developed by the “experts” for “all people” in this demographic and with this condition/diagnosis.  This unbelievable exchange shows that under Mr. Obama’s system, treatment guidelines will be devised “across the board”  by the “experts” based on statistical “evidence” which is not related to any specific patient’s situation or their doctor’s “judgment” or preference. The decisions that Mr. Obama says are currently ” being made in one way or another” are, in fact, based on the traditional doctor-patient relationship.   Mr. Obama has seemingly replaced that with the bureaucratic expert-doctor relationship.  The patient apparently has no voice or advocate.

Perhaps the most chilling aspect of this last exchange is how easily Mr. Obama flip-flops on providing the pacemaker once he discovers that the Government might actually “save money” by providing it.  His new position is that maybe we “could have done that faster,” … as opposed to not at all, as he previously indicated.  The medical appropriateness of the two treatment options were not changed by Ms. Sturm’s additional information.  Only their relative cost-effectiveness changed, and therefore Mr. Obama’s bureaucratic judgment of what is appropriate treatment, has also changed.  The patient’s health and quality of life are never even mentioned by Mr. Obama! This purely cost-driven sensibility reflects our worst fear regarding Government-guided health care, and illustrates the inherent clash of interests between the individual citizen-patient (who desires quality health care) and the Government-guider/provider (whose primary goal is to conserve resources for the bureaucracy and for other, more worthy, citizens).

So, back to the health care system that Mr. Obama envisions.  What did we learn about it from this exchange?

  • It relies on the principles of “evidence”-based medicine rather than on physicians’ professional “judgments.”     
  • It employs comparative effectiveness cost analyses performed in advance by “experts” to inform physicians’ “sensitive decisions” which are recognized to result in “end-of-life.”   (is anyone surprised that some see “Death Panels?”)
  • It is comprehensive – applying to all cases “across the board” that are linked by common factors of demography and diagnosis – there are no exemptions for individuals. 
  • The traditional doctor-patient relationship will be superseded by “expert” opinion and guidance for key treatment decisions
  • It employs published “rules” that are most likely regulations or guidelines for care, linked to payment. 
  • These “rules” will be developed by “experts” (perhaps the Center for Comparative Effectiveness Research, among others).  These “rules” are not yet known to us because they are not described in the bills. Once the bills are enacted, Government bureaucracies will have a relatively free hand to develop whatever rules they wish. 
  • It is cost-driven, and appears to not give any consideration to ‘quality of life’ factors.  

This is what we heard on the evening of June 24, 2009, and Mr. Obama has said nothing equally frank and unscripted since that time that would lead us to think this is not, indeed, his “vision” of health care as we move forward.  True, not everyone has played it back with this degree of relentless scrutiny, but nevertheless, this exchange lingers as a vaguely disquieting memory in the public consciousness, coloring our perception of the proposed health care reforms. Mr. Obama will need to do more than just deliver a good technical speech about “Health Insurance Reform” on Wednesday night.  The President needs to dispel the public’s justifiable misgivings about his “vision” of health care itself.   A good start would be to totally repudiate the robotic, almost amoral response he gave to Ms. Sturm during the June 24 Town Hall meeting.   I doubt that he can do so, because I believe that, unfortunately, this unrehearsed response goes to the very heart of Mr. Obama’s nightmarish “vision” for us all. 

The Skeptic

Can you “Keep your insurance” under the proposed health care reform bill (H R 3200)?

September 1, 2009

Within the health care “debate” there is an ongoing battle of language and spin. The word “keep” has always been a reassuring word to the Public – in a world of “change,” you might be able to “keep” some things stable and comfortable and safe, and also “keep” them for yourself.  But beyond the “spin” game, does H R 3200 really allow people to “keep” their current insurance coverage?  We need to look at the bill – pages 16 and 17 under “SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE.”  This section creates two tiers of “keeping” – one for “individual health insurance coverage” that you have purchased for yourself – another for “employment-based health plans” that are group plans provided by employers to their employees.  First let’s look at the “individual insurance coverage”

“(a) GRANDFATHERED HEALTH INSURANCE COVERAGE DEFINED.—Subject to the succeeding provisions of this section, for purposes of establishing acceptable coverage under this division, the term ‘‘grandfathered health insurance coverage’’ means individual health insurance coverage that is offered and in force and effect before the first day of Y1 if the following conditions are met:

“(1) LIMITATION ON NEW ENROLLMENT.—
(A) IN GENERAL.—Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1.”

So your individual health insurance coverage is  “grandfathered” for an indefinite period of time on the condition that your insurer does not add any new members to your plan (except new dependents of policy holders) after the effective date of the Act.  Now let’s move on to the second condition for “grandfathered” coverage

“(2) LIMITATION ON CHANGES IN TERMS OR CONDITIONS.—
Subject to paragraph (3) and except as required by law, the issuer does not change any of its terms or conditions, including benefits and cost-sharing, from those in effect as of the day before the first day of Y1.”

So your insurer cannot make any change to the “terms or conditions” of your coverage including”benefits” or “cost-sharing,” that is, your out of pocket expenses, such as copays. Insurers will probably try to not make such changes initially, but it may be difficult for them to maintain the status quo as time goes by.  This is made more difficult by Condition #1.  Because of the prohibition against adding any new members to the plan, the pool will start shrinking due to attrition.  This attrition will be exacerbated by the fact that the competing (non-grandfathered”)  “exchange participating”  plans, including the “public option,” will not be limited in terms of enrollment;  some will develop very large pools and they will be able to make economies of scale and undercut the pricing of the “grandfathered” plans, so your fellow pool-mates will start to jump ship to cheaper plans, thus draining the pool quicker.   The traditional pools for individual health insurance are not that large to begin with, so the “grandfathered” plans may start to feel the “squeeze” within a relativeley short time .  When these plans become unprofitable for the insurers, they could change the coverage or the rates and effectively offload you to an “exchange participating” plan. 

Now let’s look at your current “employment-based” insurance coverage.  For these plans, the bill proposes a five year “grace period” before they become “qualified plans.”

“(1) GRACE PERIOD.—
(A) IN GENERAL.—The Commissioner shall establish a grace period whereby, for plan years beginning after the end of the 5-year period beginning with Y1, an employment-based health plan in operation as of the day before the first day of Y1 must meet the same requirements as apply to a qualified health benefits plan under section 101, including the essential benefit package requirement under section 121.”

So your employment-based coverage is not “grandfathered,” but rather is temporarily exempted from the requirements for the qualified health benefits plans.  However, almost immediately your employment-based plan will come into competition with the other options in H.R. 3200.  These include the other qualified plans that will be offered.  Your employer, realizing that they will need to make a change within 5 years, and wanting to establish predictability and continuity of costs, may wish to get a head start and convert to a “qualified plan” sooner than that.  Also, H R 3200 allows your employer to pay a penalty of up to 8% of your salary, to off-load you to the “Public Option.”  This is actually quite an attractive option for many employers who may pay 10% to 15% of salary for your current coverage.    H R 3200 recognizes that the “qualified plans” and the “public option” will be financially attractive to employers, and so, in Section 202, the bill attempts to slow down the hemorrhaging by phasing in the eligibility – only smallest employers will be eligible to participate in the first year, with large employers not becoming eligible until the third year.  At that point, however, the changeover should proceed swiftly. In fact, it appears very likely that the majority of individuals currently enrolled in traditional employment-based plans will be forced into new “qualified” plans (Private and Public) before we reach the 5-year mark. 

But, if your employer stays the course and you do manage to stay in your current plan, at the end of 5 years, your  “employment based” plan must meet the same requirements that apply to a qualified health benefits plan. This means that, at a minimum, it will need to jump two difficult hurdles – maximum “cost sharing” limits – limits on so called “out of pocket” expenses – and no “annual or lifetime limit on the coverage of covered health care items and services.” In addition, there will be other requirements “mandated” for your insurance, and, most likely, in terms of cost, it will become less attractive than it seems now, and, basically, it will become just like all the other “qualified plans ” on the exchange.

So what exactly does this mean?  The answer is that we don’t totally understand the ramifications of your current coverage morphing into a “qualified plan.”  Not all the requirements have been written yet, and some will require regulations that, as yet, have not even been outlined to the Public.   However, it is very likely that there will be changes relating to the structure of the delivery and payment system.  What is not clear is whether these changes will be mandatory, or will just be a byproduct of the “competition” that the Administration is always talking about.  Essentially, look for the Public Option to be run as a very large scale HMO with very low costs.  In order to compete with the pricing of the “Public Option,” many private plans may also choose the HMO format.  However,  the Government could also “require” competing private plans to become HMO’s  through the leverage they hold by providing “affordability credits” to insurers to subsidize premiums for lower income participants.   Once a business accepts Government funding, they may be asked to make all kinds of changes, as the banks and car companies have discovered. 

Changing the private insurance health service delivery scheme to an HMO model would certainly be in keeping with the long-term goals of the Government to emphasize primary care and reduce access to specialists.  This approach is partly dictated by the Government’s pragmatic desire to control access to health care resources, but these folks may also harbor an ideological bias favoring the primary care or “people’s” doctor who is trained to be “socially conscious” as described by Dr. Ezekiel Emanuel, over the self-absorbed, greedy(amputating feet for big bucks), absurdly personal (slavishly following the Hippocratic Oath), and socially ignorant (advocating expensive treatment for individual patients ) specialist.  But … that is the subject of another post …

So, to wrap up, lets ask our question again –  Can you “keep your insurance” under the proposed health care reform bill (H R 3200)?

For “individual plans” the answer is “yes,” but … since they will not be allowed any new members, it is hard to imagine that they will last longer than 5 to 10 years.

For employment-based plans the answer has to be “no” – employers will desert the current plans in droves within 5 years and you will have no say in the matter.

With all the “spin” that is being put out on this subject by the proponents of  H R 3200, you need to

Stay Skeptical!


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