Is the House Health Care Bill Better than Nothing?

Well, the House health reform bill -- known to Republicans as the Government Takeover -- finally passed after one of Congress's longer, less enlightening debates. Two stalwarts of the single-payer movement split their votes; John Conyers voted for it; Dennis Kucinich against. Kucinich was right.

Conservative rhetoric notwithstanding, the House bill is not a "government takeover." I wish it were. Instead, it enshrines and subsidizes the "takeover" by the investor-owned insurance industry that occurred after the failure of the Clinton reform effort in 1994. To be sure, the bill has a few good provisions (expansion of Medicaid, for example), but they are marginal. It also provides for some regulation of the industry (no denial of coverage because of pre-existing conditions, for example), but since it doesn't regulate premiums, the industry can respond to any regulation that threatens its profits by simply raising its rates. The bill also does very little to curb the perverse incentives that lead doctors to over-treat the well-insured. And quite apart from its content, the bill is so complicated and convoluted that it would take a staggering apparatus to administer it and try to enforce its regulations.

What does the insurance industry get out of it? Tens of millions of new customers, courtesy of the mandate and taxpayer subsidies. And not just any kind of customer, but the youngest, healthiest customers -- those least likely to use their insurance. The bill permits insurers to charge twice as much for older people as for younger ones. So older under-65's will be more likely to go without insurance, even if they have to pay fines. That's OK with the industry, since these would be among their sickest customers. (Shouldn't age be considered a pre-existing condition?)

Insurers also won't have to cover those younger people most likely to get sick, because they will tend to use the public option (which is not an "option" at all, but a program projected to cover only 6 million uninsured Americans). So instead of the public option providing competition for the insurance industry, as originally envisioned, it's been turned into a dumping ground for a small number of people whom private insurers would rather not have to cover anyway.

If a similar bill emerges from the Senate and the reconciliation process, and is ultimately passed, what will happen?

First, health costs will continue to skyrocket, even faster than they are now, as taxpayer dollars are pumped into the private sector. The response of payers -- government and employers -- will be to shrink benefits and increase deductibles and co-payments. Yes, more people will have insurance, but it will cover less and less, and be more expensive to use.

But, you say, the Congressional Budget Office has said the House bill will be a little better than budget-neutral over ten years. That may be, although the assumptions are arguable. Note, though, that the CBO is not concerned with total health costs, only with costs to the government. And it is particularly concerned with Medicare, the biggest contributor to federal deficits. The House bill would take money out of Medicare, and divert it to the private sector and, to some extent, to Medicaid. The remaining costs of the legislation would be paid for by taxes on the wealthy. But although the bill might pay for itself, it does nothing to solve the problem of runaway inflation in the system as a whole. It's a shell game in which money is moved from one part of our fragmented system to another.

Here is my program for real reform:

Recommendation #1: Drop the Medicare eligibility age from 65 to 55. This should be an expansion of traditional Medicare, not a new program. Gradually, over several years, drop the age decade by decade, until everyone is covered by Medicare. Costs: Obviously, this would increase Medicare costs, but it would help decrease costs to the health system as a whole, because Medicare is so much more efficient (overhead of about 3% vs. 20% for private insurance). And it's a better program, because it ensures that everyone has access to a uniform package of benefits.

Recommendation #2: Increase Medicare fees for primary care doctors and reduce them for procedure-oriented specialists. Specialists such as cardiologists and gastroenterologists are now excessively rewarded for doing tests and procedures, many of which, in the opinion of experts, are not medically indicated. Not surprisingly, we have too many specialists, and they perform too many tests and procedures. Costs: This would greatly reduce costs to Medicare, and the reform would almost certainly be adopted throughout the wider health system.

Recommendation #3: Medicare should monitor doctors' practice patterns for evidence of excess, and gradually reduce fees of doctors who habitually order significantly more tests and procedures than the average for the specialty. Costs: Again, this would greatly reduce costs, and probably be widely adopted.

Recommendation #4: Provide generous subsidies to medical students entering primary care, with higher subsidies for those who practice in underserved areas of the country for at least two years. Costs: This initial, rather modest investment in ending our shortage of primary care doctors would have long-term benefits, in terms of both costs and quality of care.

Recommendation #5: Repeal the provision of the Medicare drug benefit that prohibits Medicare from negotiating with drug companies for lower prices. (The House bill calls for this.) That prohibition has been a bonanza for the pharmaceutical industry. For negotiations to be meaningful, there must be a list (formulary) of drugs deemed cost-effective. This is how the Veterans Affairs System obtains some of the lowest drug prices of any insurer in the country. Costs: If Medicare paid the same prices as the Veterans Affairs System, its expenditures on brand-name drugs would be a small fraction of what they are now.

Is the House bill better than nothing? I don't think so. It simply throws more money into a dysfunctional and unsustainable system, with only a few improvements at the edges, and it augments the central role of the investor-owned insurance industry. The danger is that as costs continue to rise and coverage becomes less comprehensive, people will conclude that we've tried health reform and it didn't work. But the real problem will be that we didn't really try it. I would rather see us do nothing now, and have a better chance of trying again later and then doing it right.

 

Comments

[medicare4all]

To those who say "it costs too much", put it in perspective -- one trillion dollars over ten years is just about what we spend on Afghanistan "over ten years".

Health care for all, or Afghanistan (WHY are we there?) YOU CHOOSE.

[medicare4all]

It is heartbreaking that the issue of our time is being orchestrated in Congress (our-taxpayer-paid representatives!) by the vile and corrupt health "insurance" and other, for-profit (against the law in all countries), health care providing interests. It sickens me that our publicly-owned airwaves are sold to them to spew their ... lies. There outta be a law (there used to be, until REAGAN changed the media-ownership rules, followed by CLINTON who gave them carte-blanche).

We will not be a democracy again until campaign finance reform is enacted that restores sanity to our law-making out of the hands of the corporate interests!

If there is one issue young voters should latch on to, it is IT. Removing corporate interests from the coffers of our elected officials. We should enact free TV and radio and newspaper coverage for elections, AT ALL LEVELS. No more breakfasts and cocktail parties for candidates, financed by the vested interests.

In Europe, and other parts of the world, the election campaigns last 3-4 weeks. Media time is free. The people (except in Italy where the prime minister, Berlusconi, owns 95% of the newspapers, radio and TV) usually get their first choice. There are anomalies, but on the whole, elections (as long as electronic voting is not in the equation) are fair and accepted. Those are my two-and -a-half cents.

Germany recently banned electronic voting

http://www.inteldaily.com/news/173/ARTICLE/12343/2009-10-23.html

[killmenow]

The costs of war and of campaigns is not even on the radar of the Democrats, let alone the Republicans, and not even the Congressional Progressive Caucus. Nothing in the US will change at all in any way whatsoever until all of that corporate and business money is out of politics entirely.

[lobear00]

A typical congress, its obvious the Insurance Industry once again helped the useless members of congress write the 1900 page so-called healthcare reform bill. Hey" members of congress all the other nations don't let people get rich off other folks.

Members of congress try doing something right for a change! go out into the world and find out how the other nations are making it work for them. And 'Yes" you will have to stop and take the profit out of the healthcare industry, and out of the pockets of the CEOs who just can't help themselves from being the "Greedy" little snakes " that they are. Try dropping the 1900 worthless bill down to 100 pages.

[medicare4all]

Two pages, lobear -- Medicare for All, as of January First, 2010.

[patsydecline]

do you think all these wingnutz and teabaggers would be putting up with having their collective souls being sold to the highest bidder and their life and death decisions made by a numbers cruncher...if they hadn't been sold that heaven is down the road with hard work and sacrifice... i think 'god' has become corporate america's best lobbyist

[Joehio]

Is the House Health Care Bill Better than Nothing? The answer is NO. As Dr. Angell states, this bill will do nothing to contain spiralling health care costs. It is another taxpayer-funded bailout for the LAST two industries that would need a bailout: Insurance and Big Pharma. Passing this bill will enshrine the status quo for at least another generation and saddle the average American taxpayer with a whopping bill to boot. This is as bad or worse than the Wall Street bailouts. We are better off waiting until the situation gets worse and there's a lot more pain. Then maybe the crescendo of the public's outrage will drown out the siren song of the lobbyists in the ears of some politicians.

[krocklin]

A little progress has been made. The country is averse to change generally. A larger majority has to see a decline in their situation, a la the Great Depression, before an FDR like radical can get more or the country behind him than Obama can currently.
At least a dialogue and maybe slight incremental change towards more sensible debates without so many lobbyists and false propaganda from the Far Right.

[exmate]

How much are CEOs of health care insurance companies entitled to be paid yearly ? For making health care in the USA twice per capita than anywhere else in the world?
Aetna Ronald A. Williams: $23,045,834 Cigna H. Edward Hanway: $25,839,777 Coventry Dale B. Wolf : $14,869,823 Health Net Jay M. Gellert: $3,686,230 Humana Michael McCallister: $10,312,557 U.Health Grp Stephen J. Hemsley: $13,164,529 WellPoint Angela Braly (2007): $9,094,271 L. Glasscock (2006): $23,886,169 Ins. Co. & CEO With 2008 Total CEO Compensation THIS IS OBSCENE Aetna, Ronald A. Williams: $24,300,112 Cigna, H. Edward Hanway: $12,236,740 Coventry, Dale Wolf: $9,047,469 Health Net, Jay Gellert: $4,425,355 Humana, Michael McCallister: $4,764,309 U. Health Group, Stephen J. Hemsley: $3,241,042 Wellpoint, Angela Braly: $9,844,212. THAT IS ONE ENTITLEMENT THAT WE COULD DO WITHOUT.

[exmate]

In France health care costs 1/2 of what it costs per capita in the USA. Many feel the French have the best health care in the world. The USA has been ranked at #37.......­..........­..........­..........­..........­..........­.
France has shown us what is possible. It would involve changing many things to get from here to there. Two changes are within the realm of possibility. We could adopt the Indana approach to medical malpractice with its compensation fund paid into by physicians and panel of physicians which oversees malpractice cases and which should be a model for the nation. The Left would fight this. If we were to nationalize the health care insurance companies, the Right would invoke the Slippery Slope Fallacy and say that Communism is not far behind. If we could get past the rhetoric of the Left and Right, we could get somewhere

[exmate]

The health insurance companies have been pimping off of health care professionals long enough. They need to be nationalized and their corporate mission changed to one of providing funds for health care instead of NOT providing health care. The CEOs and top management can keep their ill-gotten gains. They can even keep their jobs but their mission would no longer be to generate obscene profits for themselves at the expense of the patients. They should not be entitled to continue to exploit health care for their own greedy benefit. That is one entitlement that we can do without.””

[Indon]

Way to make me depressed. The House bill, as written, is the closest thing to reform we had any chance of seeing made reality, at all.

At this rate, the only way to improve anything in our country is going to have to involve beating all the rich people to death so they can't bribe their way out of it!

*grumble*

[pyro]

Spot on Indon. I've been saying this for years: We are going to have to EAT THE RICH!!

[exmate]

How much are CEOs of health care insurance companies entitled to be paid yearly ? For making health care in the USA twice per capita than anywhere else in the world?
Aetna Ronald A. Williams: $23,045,834 Cigna H. Edward Hanway: $25,839,777 Coventry Dale B. Wolf : $14,869,823 Health Net Jay M. Gellert: $3,686,230 Humana Michael McCallister: $10,312,557 U.Health Grp Stephen J. Hemsley: $13,164,529 WellPoint Angela Braly (2007): $9,094,271 L. Glasscock (2006): $23,886,169 .. THIS IS OBSCENE: . THIS IS ONE ENTITLEMENT THAT WE COULD DO WITHOUT.

[medicare4all]

pyro -- no, we TAX THE RICH back to what they were paying when Reagan came along (35% over what they got over 4-5 million dollars, a decent living). If they don't like it, we ratchet it back to what it was when Eisenhower was president (90 % of what they made over 4-5 million dollars, a fair living then, if you ask me --back when we had a solid middle class, the 1950s). What isn't taught in school today is how the rich paid more then than they do today. Reason being that they used our TAXPAYER-funded military, highways, schools, police, firefighters, clean air and clean water to an extent that justified their paying more, because we were the owners, and they could afford it, as their FAIR SHARE, and the corporatists were using more than their fair share of the "commons" (military, roads, etc.)

Restoring the rich paying their fair share of taxes is the ONLY way to save our democracy. Democracy means OF THE PEOPLE, BY THE PEOPLE, FOR THE PEOPLE. Not rule by the rich, or the corporations, for their SOLE BENEFIT.

[kdp59]

she's spot on!

Democrats better "get it" real soon.

any REAL Health insurance reform needs the follwing, or it will be the death of the democratic party, IMO.

1) cost controls of premiums by either
A) a non-profit insurance option open to EVERYONE
B) Simple cost controls on ALL insurance premiums.

2) an EMPLOYER Mandate to cover at least 50% of the cost of ALL employees' premiums.

3) a limit on total out of pocket cost per household for healthcare expenses each year, based on a % of total income per houshold.


all of the above WILL create health insurance reform thats helps the Middle/working class in our nation.

there IS a populist movement building ( I would argue has been coming for over 25 years now), the Bank bailouts and this "great recession" we are in has sped it up, IMO.

The democratic party ignores this movement at it's own peril , I really beleive.

time for the democrats to get BACK to the roots of the party and to start doing things that actually HELPS the Middle/Working class.....or they just might be swept away by the coming wave.

[jmpurser]

This is STILL the best column I've read in this "debate". Real change leading to a real solution and it's even "incremental" and "pragmatic" in the original (pre Obama) definitions of the words.

When a politician is really MEANS to deliver health care reform they'll come out with a plan like this. Until you see that you can rest assured that you're being lied to by anyone who tries to sell you some other plan.

[Darwin256]

It is best to get it passed because:

It will show we can take on the insurance companies and win. If it does not pass, people will begin to believe that it isn't worth trying, that we simply cannot beat these people.

If Dr. Angell is right and costs go up, she and others can say "we told you so". The arguments against a real public option will be as meaningless as ever.

[jmpurser]

The bill before congress is a wet dream for the insurance industry. We are not "taking them on" much less winning. We're rolling over and giving them the entire American medical industry.

It was corporate welfare from the moment Obama took single payer "off the table".

[exmate]

The health insurance companies have been pimping off of health care professionals long enough. They need to be nationalized and their corporate mission changed to one of providing funds for health care instead of NOT providing health care. The CEOs and top management can keep their ill-gotten gains. They can even keep their jobs but their mission would no longer be to generate obscene profits for themselves at the expense of the patients. They should not be entitled to continue to exploit health care for their own greedy benefit. That is one entitlement that we can do without.””

[carldi]

I love Dr. Angell but I must take issue with her conclusion. "I would rather see us do nothing now, and have a better chance of trying again later and then doing it right." My opinion is that "later" will probably mean fewer votes. It is almost certain that the Republican party will gain enough strength (votes, both Rep and Dem) to defeat any health care bill that Pres. Obama puts forth, so to my mind, it's now or almost never. Better to have an imperfect bill (was there ever a perfect one?) than no bill at all. Every long journey still starts with a single step.

[jmpurser]

This is only an "imperfect bill" in the sense that it does not perfectly suit the insurance and pharmaceutical industries. Almost, but not perfectly.

As a "health care reform" bill it is something that real health care reform will have to recover from. If it is a "first step" it is a first step down the wrong road.

[socialtalker]

socalgal38 said "What insurance company do you work for? It never fails that as soon as something comes out a bunch of insurance salesman try to sell it to the American people. ...
If you don't work for an insurance company you need to get your head out of the sand, and stop trying to sell something so you can feel like you accomplished something."
posted Nov 12, 2009 at 01:25:00

NO I AM NOT IN THE INSURANCE BUSINESS. i have nothing to do with the insurance business, aside from paying out of pocket health premiums every month. you seem to have a lot of issues, among which are posting a lot of stuff saying nothing. with all the insults you dont bother to address my point.
the theory that "doing nothing" is going to be better that this bill so we can expedite single payer sometime in the future. thats a good theory, but its just that a theory. it could be right, could be wrong.
i only believe there is an alternative to

in the meantime i dont even begin to understand your patronizing, condescending sneer against my suggestion of single payer dental- something everyone can benefit from and help open up the way to full health single payer.
everybody is trying to "sell" their argument here, the author and yourself included.