[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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Thursday, August 13th, 2009

[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 provides an introduction to the bill and my intent and discusses some of my thoughts on the legislative process and the duties of a citizen within that process. The next post in the series discusses the existing health care system in America and how this bill would change it.]

Because I guess I enjoy nothing more than researching silly claims made about government expenditures (see my previous post), I’ve read HR 3200. That’s right. I’ve read the health care bill.

That might be stating things a bit strongly, actually. I’ve read large parts of the bill and skimmed the rest. I’ve at least made my way through all 1018 pages. While doing so, I live-blogged my thoughts over at FriendFeed. But, now that I’m not trying to slog my way through a thousand pages of dense legalese, I want to slow the pace a bit and put down some more coherent thoughts.

Because in the last two days, I’ve certainly thought lots of thoughts. I’ve thought about health care, of course. And I’ve thought about the lousy state of discourse in our country where you don’t have to worry about facts and can just make things up. Beyond that, I’ve thought about the way Washington works on a procedural level and how their complete commitment to opacity makes it incredibly difficult —if not impossible— for the average citizen to actually keep up with what’s going on. And then I’ve wondered if it’s even worth trying and, assuming it is, how to judge when to make the effort and when to let things work themselves out.

Given the number of subjects I want to cover, it’s hard to find a starting place. Since this discussion will ultimately center around a single piece of legislation, I think I will start at the huge pile of pain that an act of Congress actually is.

The United States Code, roughly the laws of the land, is huge. I’m actually unable to find an estimate of just how many printed volumes it takes up; though the House’s Office of Law Revision Counsel makes CD-ROM iso available which they say is about 500MB of text. Whatever the actual numbers, it’s big.

So any new law enacted by Congress has to find its place within a almost unimaginably gigantic system. There’s almost no area that new legislation can touch which isn’t already covered by at least one existing law; and most areas will be touched by many. So invariably, any new legislation cannot just add to the existing body of law; it also has to change the existing body of law.

Over the centuries, they’ve picked an interesting way of doing this. The text of new laws modify existing laws with phrases like “strike the second sentence of section 57.206(b) of title 42, Code of Federal Regulations” and “insert the following text…” and so forth.

This was my first major issue when reading the bill. Even when reading every word, I could not be certain what it was actually saying without doing extensive cross referencing. For all I know, the second sentence of section 57.206b of title 42 of the Code of Federal Regulations says “Let it be established that Dick Cheney shall not eat babies.” the fairly innocuous sentence from the page 878 of HR3200 is actually going to let loose a torrent of infant cannibalism which will make the Old Testament seem tame by comparison.

Of course, I don’t think that the adjustments to existing law are really that bad. I strongly suspect that the struck sentence relates to guidelines for determining the financial need status of medical students applying for student loan and tuition payment programs. But I don’t know.

And since I set out on my trek through this horribly unentertaining legislation as a way to cure my own ignorance, the fact that I reached the end of it and still didn’t really know what it was talking about is irksome. Some opponent of health care reform could come up to me and say “The Democrats want to allow unfettered baby-eating! It’s in the bill! Read it!” and I’d like to say “I have read the bill and I am absolutely certain that there is no baby-eating provision in there.” but all I can actually say is “I have read the bill and I am fairly certain that there is no baby-eating provision in there.” Which is a slightly weaker argument.

If I had the time and a law library [ed: yes, I could use the Internet; but doing heavy research is almost always nicer with books. I don’t now why.], I could have followed all the references through and figured out the changes to existing law. Of course, if I wanted to really understand the changes in context, I would need to read that law as well.

HR3200 changed a lot of laws. If I were really dedicated to understanding what it was doing, the final bill would have been passed or defeated before I made it even halfway through. Since I’d probably also lose both my job and my girlfriend due to inattention, I decided to pick my battles.

For now, at least, I’ve decided to take the bill at face value. In sections where it’s changing a bunch of other laws one or two words at a time, I simply accept the headings in the bill I’m reading as a good faith explanation of intent. If anyone would like to put in the research to prove me wrong, I’d be happy to follow along. But I won’t be doing that work myself.

And of course, this is just one bill where I don’t really know how it’s doing. At any given point during the legislative year, there are dozens and dozens of bills being actively written, debated, and voted on. It would be impossible for me to keep up with all of that.

Fortunately, our Founders had the wisdom to foresee this exact situation and eschewed a direct democracy in favor of a republic. Since it’s impossible to keep up, I pay a few jokers to do it for me. And while I’m not terribly fond of these particular jokers, the system in general has worked out pretty well over the last couple hundred years.

Given that it’s not my responsibility to keep track of everything the government is doing and I don’t have the means to do so anyway, why did I decide to read this particular bill? Why did I finally decide that it was my civic duty to know what was happening in this particular case?

In large part, it’s because health care is a Very Important Issue. The only other time I’ve read a bill (well, a law in this case) was the Patriot Act. Because that was a seminal piece of legislation which completely rewrote civil liberties in America. I felt it important that I know what it actually did.

Health care is equally important. Real people die because of our current health care system every day. People I know and care deeply about can’t afford insurance and are purely at the mercy of others if they become catastrophically sick. It’s worth looking into for myself because it’s important.

The other main reason is that it’s a Very Important Issue which people are lying about. And they’re not just telling the standard lies one expects from a modern politician. They’re telling vicious, unconscionable, dangerous lies. Since I still have to believe that the best counter to a lie is the truth, I felt it important to arm myself with it.

And that’s why I had to educate myself on this issue more than most. Because it’s too important to let it be controlled by people who refuse to use the facts.

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