[Ed: Over the course of a couple of days, I read the primary health care bill before the United States Congress with the intention to blog my thoughts. It turns out that I had too many thoughts to reasonably fit into a single blog post. So I’ve decided to split it up into multiple entries. There will be at least two; probably three.


This post uses the bill to start figuring out just what’s wrong with the health care system in the first place. It then looks at some of the specific provisions in the bill to see what actually is and is not in it.

For an introduction to the bill and the major issues with written legislation in the United States, you should read my first post on the subject. In the next and final installment, I will try to put the first two posts into the larger context, as I see it.]

The American health care system is big. You just won’t believe how vastly, hugely, mind-bogglingly big it is. I mean, you may think it’s a long way down the road to the chemist’s, but that’s just peanuts to the American health care system. In it’s current incarnation, it’s a mishmash of for-profit and non-profit hospitals, doctors who may-or-may-not actually work for the hospitals they practice in, smaller private practices, personal insurance plans, company insurance plans, medical-only-credit-cards, drug companies, HSAs, FSAs, CHIPS, Medicare, Medicaid, and probably a host of smaller state-level programs. This is all either regulated (in the case of private interests) or created and run (in the case of public institutions) by a large collection of different laws.

For good or ill, this existing system is not going anywhere. The existing institutions are too firmly entrenched and there’s far too much money involved. The length of this bill, often criticized as being too complicated, is a reflection of that. From the most liberal Democrats’ perspective, I think the best sort of health care bill would be one that started with “The Medicaid program is hereby destroyed. The Medicare program is hereby destroyed. Existing medical insurers are no longer authorized to insure or render payments for medical services.” and build a new one from there. But that’s not a bill that would pass.

This bill instead slightly modifies all of the existing systems. Since those systems are spread out across many laws, it must be mutate dozens of existing laws – some slightly and some extensively. The bill authors obviously took great care here leading me to believe that they realize the house-of-cards nature of the whole thing. Unfortunately, this approach makes the whole thing incredibly challenging to figure out. So while I think I sussed out the major changes and initiatives, I undoubtedly missed many minor things.

One notable consequence of this, before I move on, is that the appropriations are spread throughout the bill. There’s no single tally of just how much the authors are setting aside “out of any funds in the Treasury not otherwise appropriated” to pay for all of this and I didn’t try to add it up myself out of fear that I’d miss something. I’m sure someone has done that work, but a quick Google search didn’t turn up anything. Send me a link and I’ll add it here.

The only obvious tax increases I noticed are on page 197 and 198. These add some additional taxes on joint incomes above $350,000, married-but-separate incomes above $175,000 and single incomes above $280,000. I make far less than any of these amounts, so I’m personally okay with it. There may be other tax increases in the many modifications to existing laws, but I can’t point to them. If you have any coverage of additional taxes, send me a link and I’ll add it here.

More complete coverage of the bill is available elsewhere, but I do want to cover some of the highlights.

Page 39 defines plain language. You know. If it ever comes up in conversation.Later, page 578 defines good faith. It’s a little worrisome that these aren’t already defined somewhere, but there it is.

The bill would set up a health insurance exchange. As near as I can tell, this is sort of a clearinghouse of appropriate insurance plans provided both by private companies and the government. A qualified individual can go through the exchange to pick and enroll in a plan. Oversight for the exchange itself and plans offered through the exchange will be provided by a commissioner who must seek advice from certain expert panels. Among other things, the commissioner will be empowered to provide oversight on both pricing and coverage for the plans.

Lacking the trained mind of a lawyer, it’s not entirely clear to me if all health insurance plans in the United States will have to be part of the exchange. However, I believe this is the intent of the bill and will go forward with that assumption. If you’ve got a link that demonstrates a clearer understanding, send it to me and I’ll add it here.

One bit that provides some evidence for my assumption starts on page 16. It basically says that any existing non-employment-based health insurance plans will be grandfathered in and automatically considered exchange-eligible, regardless if their terms actually meet the exchange’s requirements. The big provisio is that these grandfathered plans will not be able to enroll new customers (unless the new enrollee is a dependent of someone already on the plan). Furthermore, the insurance company cannot raise the premiums on these existing plans unless they raise the premiums on all of their other plans by the same amount.

This is basically the fulfillment of the President’s guarantee that if you have insurance that you’re happy with, the government will not force you to change.

There’s a pretty big exception, though. After five years, any health insurance plan you get through work will have to meet all of the exchange standards. Considering how often employers shift their health insurance plans anyway, the idea of a person being allowed to keep what they’re happy with in this case is pretty nebulous anyway. So I’m okay with this exception. But I’m surprised I haven’t heard more hay about it from the President’s opponents as it would be pretty easy to construe it as dishonesty on his part.

Once all health insurance is under the health exchange umbrella, the point-person for citizens’ issues with their coverage will be the health exchange ombudsman. Among other duties, this official is charged with explaining health care options to people in plain English (or plain Spanish). This is the official who will help people deal with red tape. And while it’s not spelled out in the bill, I assume that the ombudsman will often be the first person who deals oversight: when serious complaints are made to the ombudsman, he can then take those to the commissioner who can investigate with actual regulatory power. Whether this will make a difference in the average person’s quality of coverage remains to be seen and could certainly be a matter for spirited debate; but I’m hopeful.

In general, there will be a mandate requiring everyone in the United States to have health insurance. Anyone who already has health insurance and likes it can meet that mandate by keeping their existing plan (thanks to the grandfather provision discussed above). Anyone on Medicare or Medicaid can satisfy the mandate as these programs are updated by the law to meet the new health exchange requirements. It’s the same for anyone in the military or under VA care.

Anyone else can either enroll in one of the plans offered on the exchange, enroll in an employer-provided exchange-quality plan, or enroll in the new public health plan. And finally, just to make sure that everything is first-amendment compliant, if your religion says you can’t have health insurance, you can get an exemption from the mandate.

People who are not able to afford health insurance will receive affordability credits based on income for both premiums and copays. The actual values are on pages 135-143 if you’d like to look at them. I honestly do not know enough about poverty and incomes to know if these credits are sufficient; but our government has gotten practiced at welfare programs so I suspect they’re reasonable (assuming you consider any welfare reasonable; which is also a matter for vigorous debate).

Please note: no matter what you may have heard, no illegal aliens will receive any federal payouts for affordability credits. It’s in the bill on page 143. It’s in bold. Anyone who tells you otherwise is lying to you and you should probably ask yourself why they would be doing that. (Just for the sake of completeness, page 697 describes harsh penalties for any undocumented immigrants trying to get Medicare benefits. So much for bleeding hearts.)

Page 116 describes and creates the public health plan and starts off with saying that it must follow the exact same rules as the private plans. Page 119 requires that the plan’s premiums will need to be high enough to cover all of the plan’s costs. So anything you’ve heard about the government running at a loss is untrue. (It’s true that the government will help low-income folks with the premiums; but I believe they’d also spend those same credits on private exchange plans. So that doesn’t hurt competition. As always, send me a link if I’m wrong.)

Payments to health care providers (including drug costs) from the public plan will be set along Medicare rates. So private plans will be required to compete with the public plan as if it were Medicare. But private plans already have to compete with Medicare. So I do not see that this is an undue burden upon them. Similarly, doctors have been maintaining profitability with Medicare for many years now so I do not see that it is a burden on them either. Opinions on this can vary, of course. And they certainly do.

After establishing all of this, the bill spends hundreds and hundreds of pages modifying existing laws. It modifies the tax laws to account for the new taxes on the wealthy and it modifies Medicare and Medicaid to bring them inline with the new health exchange guidelines. Without doing significant cross-referencing, these pages are mostly incomprehensible. If you have a source that’s done the work to piece all these new laws together, send it to me and I’ll add a link here.

There are a few clear provisions in all of this that I’ll discuss, though. The bill requires all the changes to Medicare to be budget-neutral. This is probably a good thing; but “budget-neutral” is a phrase you here from Washington a lot while the national debt climbs ever higher. So it’s probably meaningless. Still, the authors of the legislation thought it was worth throwing in.

Page 425, probably the most well-known part of the bill at this point, is part of the Medicare changes. Let me be absolutely clear about this: Pages 425-430 of HR3200 DO NOT create death panels of any kind. Anyone who tells you otherwise is lying in an incredibly awful and possibly evil way and you have to ask yourself why they’d do such a reprehensible thing.

As it happens, what these pages actually do is really quite sensible. They provide money for old people to talk to their doctors and the doctors get paid for it. That’s it. Specifically, it provides money for them to have conversations about the end of their lives. Unfortunately, elderly people die and it’s not anybody’s fault. We can’t stop it from happening (though I’m sure there are researchers working on the problem), but we can try to make it as easy as possible on both the person facing the end of her life and that person’s loved ones.

These conversations will be an opportunity for a person to get information from their doctor about what’s going to happen as they approach death. If they have illnesses, they’ll be able to find out what the long-term effects of that illness will be. They’ll be able to get information about long-term treatment options and what the effects of those treatment options will be. And yes, this will be an opportunity for them to learn about living wills. It will be an opportunity for them to decide for themselves how they want to die.

There’s no money in this bill for euthanasia (indeed: it’s still illegal). There’s no money in this bill for forced abortions (also illegal). The bill does not specify that seniors should be denied treatment just because they’re old. This part of the bill is clearly intended to give information to people about their own lives. That is not scary. It is not dangerous. It is, instead, a recognition that we should value our older citizens as if they were human beings and give them all the information they need to make decisions about their own lives.

Things quickly become a little bit lighter on page 443. This is where the government provides incentives to health care providers to drive down costs. It’s impossible for me to say if this will be effective or not; but there is one bright spot. The bill requires measurements and reports on the ROI from these incentives to be given to Congress by 2012. We aren’t just throwing our money down a hole. We’re throwing our money down a hole and then shining a flashlight after it to see where it went. Let’s call it evidence-based governance. (Of course, it will then be up to Congress to make decisions on what does and doesn’t work. God help us all.)

As part of lowering costs, the bill will establish a center for studying the comparative effectiveness of treatments. It does not take that much farther though, as it provides no guidelines for the use of that information in determining health care pricing and pay-outs. Still, the information will be out there, and doctors will be able to use it as they see fit.

The bill will establish a Public Health Investment Fund (see page 859) with $88.7 billion over 10 years. The money from this fund will be used to train new doctors and nurses and to provide continuing training to existing doctors and nurses. It will fund public clinics and clinics at public schools so everyone has access to a doctor without having to take a trip to the emergency room; hopefully this will get people to the doctor sooner before their treatments become vastly more expensive. It will pay for a corps of government doctors who can be dispatched to rural areas that can’t necessarily private practices.

The government will also put significant funds towards promoting general wellness in the populace. The bill doesn’t spell it out (or if it does, my eyes glazed right past it; it’s a really tiring read), but I suspect this will involve things like public service announcements and cheaper healthy meals in public schools.

These initiatives will hopefully lead to a healthier populace which will be a huge win in all sorts of ways. It might even lower health care costs.

So that’s HR3200 in a nutshell. That’s certainly not everything; just the things that stood out as the most important during my reading. I covered a few more areas while I was live-blogging the actual reading of the bill. And, of course, if you really want to know what’s in it, you’ll have to read it for yourself. Or pay a lawyer to do it for you.

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