Felicia Cohn asked a lot of good questions about the health care quandaries in America, but she didn’t answer any of them.
Cohn is the director of medical bioethics for Kaiser Permanente Orange County, as well as the director of medical ethics at the University of California, Irvine School of Medicine. She spoke at Oregon State University on May 6th, giving a talk titled “The Principle of Justice: What You Need to Know to Understand Health Care Reform.” She spoke to a crowd of about fifty people, addressing a group that ranged from senior citizens to medical doctors to students who were assigned to see the talk by their instructors at OSU.
“Is there a right to health care?” Cohn asked at the beginning of her talk. She went on to define what a “right” actually is, calling it a “justified claim that individuals can make on others or upon society.”
“How do we allocate health care?” Cohn offered several options, such as allocating according the a person’s merits, need, age, or individual contributions, but avoided making any stands on which options might be better than others.
Cohn spoke for an hour and a half, and asked a lot of hard questions that were designed to provoke thought.
“What kinds of health care services will exist in a society?”
“What degree of care will be available?”
“How will the power and control of these services be distributed?”
She didn’t answer any of these questions. What she did do, and do well, was provide a framework for thinking about the answers, though, by explaining the “principles of justice.” She discussed the goals of justice as applied to the health care debate, stressing the need to consider the availability of competent or superior care and resources, the opportunities to access that care, the need to respect a person’s autonomy, and what the benefits to individuals and society as a whole might be.
At the end of her talk, Cohn pointed out a lot of thought-provoking statistics, such as the fact that the United States ranks 14th in the world in actually preventing preventable deaths, or that the US ranks 24th in the world for life expectancy. She pointed out that our health care spending will reach 2.5 trillion in 2009. By 2018, it’ll be over 4 trillion. She also mentioned that of all the bankruptcies filed in 2007, 62 percent of them were due to medical expenses.
These kinds of figures might indicate a need for reform in the US health care system, but Cohn stopped short of making that point, instead challenging her audience to consider justice and fairness, and draw their own conclusions.
At a Glance: The Principle of Justice: What You Need to Know to Understand Health Care Reform
Who: Felicia Cohn, PhD, UC Irvine School of Medicine, Faculty Profile
What: Public talk, titled “The Principle of Justice: What You Need to Know to Understand Health Care Reform”
When: Thursday, May 6th, at 7pm
Where: Kearney Hall Room 112, 1491 S.W. Campus Way
Further Information: New Kaiser Permanente Director Speaks on Health Care Reform
Image from here.
Original Preview Article:
On February 25th, 1990, Terri Shiavo collapsed and eventually fell into a persistent vegetative state. For the next fifteen years, she would be cared for in various medical institutions in the state of Florida. In 1998, Terri’s husband, Michael, filed a petition to have her feeding tube removed, allowing Terri to die. This petition started a seven year court battle over the legal, moral, and medical ethics involved in Terri Shiavo’s case.
This is exactly the sort of case the field of medical bioethics was developed to address.
Felicia Cohn is a leading voice in the field of medical bioethics, and she’ll be talking at Oregon State University on Thursday, May 6th. Her talk is titled “The Principle of Justice: What You Need to Know to Understand Health Care Reform.” Considering the roll that talk of “death panels” played in the furor over the passing of the recent health care reform bill, and the fact that one of Cohn’s areas of research is end-of-life care, this promises to be an interesting talk.
Cohn is the director of medical bioethics for Kaiser Permanente Orange County, as well as the director of medical ethics at the University of California, Irvine School of Medicine. She also developed the ethics curriculum for the School of Medicine, and conducts research in the areas of end-of-life care, along with family violence, patient safety, and medical education. Cohn helped to edit and publish The Ethics of Bioethics: Mapping the Moral Landscape, and she’s a senior scientist at the Center to Improve Care of the Dying at The George Washington University.
Her talk will be held at Kearney Hall, in Room 112, at seven pm, on May 6th. Entry is free, and open to the public.
I’ve been checking in on the media frenzy off and on all day, and folks, despite what Fox News, Glenn Beck, Rush Limbaugh, and the Republicans are telling you, HR 3590, the health care reform bill, is not the end of the world. It’s not government take-over. It’s not socialized medicine. In fact, one of the reasons progressive liberals have been so annoyed with HR 3590 is because it doesn’t go far enough in those directions. We were the folks who were cheering on single-payer and universal health care, remember. If some of us seemed a bit bummed with the bill, it’s because it doesn’t do the things we want done, either.
But, and I cannot stress this enough, it’s better than nothing, which is what we had before.
So, what does HR 3590 actually do? Let’s check that out.
H.R. 3590 is divided into ten titles. The text of the bill cannot be meaningfully read from front to back as printed, because the tenth title is a list of amendments to the previous nine titles. These amendments must be applied to the titles and sections to which they refer before the bill can be interpreted properly.
The bill contains provisions that go into effect six months after its passage, and provisions going into effect in 2014.
Key provisions of the bill include measures to:
Effective six months after passage
- Prevent insurers from denying coverage to people with preexisting conditions.
- Insurance policies must cover preventative care without requiring co-pays
- $250 drug cost rebate for seniors
- All insurers are fully prohibited from establishing lifetime spending caps.
- All insurers are fully prohibited from discriminating against or charging higher rates for children based on preexisting conditions.
- Children and young adults will be permitted to remain on their parents insurance plan until their 27th birthday.
Effective in 2014
- All insurers are fully prohibited from discriminating against or charging higher rates for adult individuals based on preexisting medical conditions.
- All insurers are fully prohibited from establishing annual spending caps.
- Expand Medicaid eligibility; individuals with income up to 133% of the poverty line qualify for coverage
- Establish health insurance exchanges, and subsidization of insurance premiums for individuals with income up to 400 percent of the poverty line.
- Offer tax credits to small businesses who have less than 25 employees and provide health care benefits for them.
- Impose a tax penalty on employers with over fifty employees who do not offer health insurance to their workers.
- Impose an annual fine on individuals who do not obtain health insurance; exemptions to fine in cases of financial hardship, religious beliefs.
- Creation of a new voluntary long-term care insurance program.
- Creation of tax credits for individuals who purchase private insurance policies
- Employed individuals who pay more than 9.5% of their income on health insurance premiums will be permitted to purchase insurance policies from a state-controlled health insurance option
- Pay for new spending, in part, through spending and coverage cuts in Medicare Advantage, slowing the growth of Medicare provider payments, reducing Medicare and Medicaid drug reimbursement rate, cutting other Medicare and Medicaid spending.
- Revenue increases from a new $2,500 limit on tax-free contributions to flexible spending accounts (FSAs), which allow for payment of health costs.
- Raising various taxes, and creating a new excise tax for high cost “Cadillac” insurance plans.
Effective by 2018
- All existing health insurance plans must cover preventative care and checkups without co-payment.
Analysis
The Congressional Budget Office (CBO) wrote:
the legislation would establish a mandate for most legal residents of the United States to obtain health insurance; set up insurance exchanges through which certain individuals and families could receive federal subsidies to substantially reduce the cost of purchasing that coverage; significantly expand eligibility for Medicaid; substantially reduce the growth of Medicare’s payment rates for most services (relative to the growth rates projected under current law); impose an excise tax on insurance plans with relatively high premiums; and make various other changes to the federal tax code, Medicare, Medicaid, and other programs.
Bloomberg wrote:
A 383-page amendment Reid offered [December 19] made some major and minor changes to the proposed legislation. Gone was a new government-run insurance program, or public option, designed to compete with private insurers. As an alternative, the U.S. Office of Personnel Management, which oversees benefits for all civilian federal workers and members of Congress, would contract with private insurers to offer multistate plans on the insurance exchange. Reid dropped plans for a tax on cosmetic surgery, dubbed the ‘Bo-tax,’ in favor of a 10 percent levy on indoor tanning salons. And he raised a Medicare payroll tax hike to 0.9 percent, from 0.5 percent earlier, on individuals earning more than $200,000 or families making more than $250,000. Reid also boosted penalties for companies that don’t provide health insurance. Any company with more than 50 employees could face a penalty of $750 per worker, multiplied by the total number of full-time workers it employs, if just one obtains subsidized coverage through an exchange. That’s up from a penalty of $400 in an earlier draft.
Senate majority leader Harry Reid said the bill would cover an additional 31 million uninsured Americans that do not have benefits, bringing full coverage to 94% of all Americans. Reid further stated that the bill will cost $848 billion over 10 years, while reducing deficits by $130 billion by adding new taxes and fees while reducing the growth of Medicare.
Surgeon Atul Gawande wrote in The New Yorker that the bill contains a variety of pilot programs that may have a significant impact on cost and quality over the long-run, although these have not been factored into CBO cost estimates. He stated these pilot programs cover nearly every idea healthcare experts advocate, except malpractice/tort reform. He argued that a trial and error strategy, combined with industry and government partnership, is how the U.S. overcame a similar challenge in the agriculture industry in the early 20th century.
Okay, so one of the things we see mentioned up there is the FPL, or Federal Poverty Line. You can see what that is here. So, that means any one single individual who’s making less than 20 to 25 thousand (depending on the state and my quick estimate of the math) a year will qualify for Medicaid. That’s great news. I’ve been one of the people who fall into that category. In fact, the best job I ever held only paid me about $19,000 a year, and the insurance it offered was a total joke. You can’t buy your own insurance on $19,000 a year. In fact, in Midland, Michigan, if you live very frugally, you can just about manage to pay your bills on $19,000 a year. And by “pay your bills”, I’m talking the very basic bills, like rent, groceries, lights, heat, if you’re lucky and don’t mind being chilly in the winter, and don’t plan on eating much. I include this information because I’m aware that quite a lot of the folks who are protesting this bill make enough money that they don’t realize what it’s like to live on less.
So, to distill this bill down to its very basics, it gets more poor and working poor onto Medicaid, while providing tax increases on the very rich to pay for that. It mandates that everyone must buy insurance, much like you have to buy car insurance, or you’ll face a stiff tax penalty at the end of the year. But, it offers subsidies to those in the lower and mid levels of the working class who must buy their own insurance out of pocket, and it penalizes businesses over fifty employees who A) aren’t paying their people enough to buy their own insurance, and B) aren’t offering them an insurance plan, either.
Now, let’s talk about those subsidies. From the Christian Science Monitor:
Let’s start with people who are unemployed, self-employed, or work for businesses that don’t offer insurance. Beginning in 2014 (that’s right, this is four years away), these people would be able to shop for coverage in new “health exchanges,” a sort of online bazaar in which insurers would hawk different kinds of plans. We’ll talk more about how these malls might work in our next story.
Congressional budget experts figure that about 25 million people will shop for coverage in these exchanges. That’s a pretty big market. Of these, about 19 million are likely to be eligible for financial aid.
The cutoff level would be an income of four times the federal poverty level. For one person, that’s about $44,000 a year. For a family of four, the comparable figure is about $88,000.
Subsidies would be figured on a sliding scale, with those who make less getting a bigger boost and those nearer the top getting a smaller one.
The formula is pretty complicated. Basically, though, people who make three or four times the poverty level would get enough federal money so that they would not have to pay more than about 10 percent of their income for a decent health insurance package.
A lot of people are complaining about what HR 3590 is going to cost us, claiming it’s going to drive us bankrupt. It’s not. The Congressional Budget Office says HR 3590 is going to save us over a trillion dollars in the next 20 years. These guys are the hard-nosed, pessimistic number crunchers in charge of keeping Congress informed on budget stuff. They claim HR 3590 is not only going to even out, it’s going to save us money, and some folks are saying that the CBO was being a bit on the conservative side with that estimate. Here’s another awesome article on how HR 3590 is going to save us money: How Health Care Reform Reduces the Deficit in 5 Not-So-Easy Steps.
Now, with all that having been said, we still need to pass the Health Care and Education Affordability Reconciliation Act of 2010, which is the Act that includes the fixes for HR 3590 that the House wanted to pass with “deem and pass”. This is the one the Senate Republicans are making noise about opposing, and the one that they wanted to pass through reconciliation — ‘scuze me, OMGRECONCILIATION — to prevent the Republicans filibustering it.
From the Wiki: “The Health Care and Education Affordability Reconciliation Act is divided into two titles, one addressing health care reform and the other addressing student loan reform. Title I would increase Medicaid subsidies to the states, raise the threshold for the excise tax on the “Cadillac”, or high-value, insurance plans excise tax and delay implementation of the tax until 2018. Title II would modify student loans by ending government subsidies to private lenders.” That doesn’t tell us much, but I’m still gathering information on that, so we’ll have to leave it for part four.
So, tomorrow(ish), part four: The Next Step.
(An excellent article about HR 3590 in the Christian Science Monitor: Health Care Reform Bill 101: What the Bill Means to You. Also, image from here.)
We’ve seen an awful lot of really bad behavior out of the Republicans since Obama was elected president. We’re used to shady dealings out of the Republicans, after eight years of their shenanigans under the Bush Administration, but illegal wars and unconstitutional laws aren’t bad behavior, per se. I’m talking about the things Republicans, and their proxies, the Tea Partiers, are saying and doing, in public.
First, I think we can safely dispense with the notion that the Tea Partiers are an independent movement. (Sources: 1, 2.) Whether they realize it or not, they’re simply pawns of the conservatives. The Tea Party, in its various iterations, are funded by conservative political groups, lobbyists, and politicians. Their rallies are frequently managed and put together by groups who are either A) in it for the money, B) in it to aim the Tea Party towards a goal neocons want to see met, or C) a combination of the two. In the end, Tea Partiers are dupes, and other than to consider the ramifications of having a large number of duped minions at your beck and call, and what it means to incite them to their current behavior and then align yourself with that behavior, they are easily ignorable.
So, let’s take a moment to talk about some of the things the Republicans are doing. They’ve aligned themselves with and are pandering to the Tea Party, a group — a small group, no less — of angry, hate-filled, frequently racist, regularly ignorant protesters, incited and organized by Fox News and other neocon contributors. Despite repeated and robust attempts on the part of the president and Democrats in Congress to bring them in and include their ideas in health care reform, Republicans have obstructed health care reform at every turn, combating it with outright lies.
For example: The President held bipartisan health care reform summits in both 2009 and 2010, trying to bring both Republicans and Democrats to the table to sort out their differences. (Source, also, great health care reform time line in the sidebar.) The president held a televised meeting with Republicans, where he endorsed quite a few Republican ideas for health care reform (Source). Despite that Republicans have repeatedly said they aren’t being listened to, there are several Republican ideas in the current health care reform bill. (Source.) Republicans embraced and repeated the “Death Panel” lies ad nauseum, among others. (Source.)
We’ve put up with Michele Bachmann, John Boehner, and Joe Lieberman, who brought health care reform to a screeching halt all by himself last year. We dealt with the August town hall meetings, where proceedings ended in shouting and near violence (Sources: 1, 2, 3), incited by conservative astroturf groups. Even today, if you’re watching the coverage of the vote in the House, you’re listening to Republicans lie, lie, and lie, and ally themselves with the small group of vocal, vulgar, near-violent protesters outside. Again, and again, Republicans claim they aren’t being listened to, that health care reform hasn’t been bipartisan, when the president and Democrats in both houses have bent over backwards to work with them, when many of their proposals have been included in the current health care reform. Despite Democrats pandering to the Republican minority, Republicans still refuse to vote for health care reform.
We’ve witnessed gross amounts of hypocrisy, and lies so thin and easily disproved that it’s offensive that Republicans thought they could float them past us unnoticed. We’ve been told that this bill is unconstitutional, with no real proof to back that up. We’ve been told that the bill will bankrupt us, when the CBO says that’s plainly not the case.
The question is why? And the answer is a little sad, and a little scary, because as far as I can tell, it’s got to do with money, and power.
Let’s look at what the Republicans are actually doing, in opposing health care reform. By opposing health care reform, Republicans are representing two groups of people. The first group is the larger of the two, and it’s made up of people who believe the Republican lies about health care reform. They think that we’ll be killing their grandmothers and forcing them to go to blood-stained, government-run clinics staffed by Josef Mengela wannabes, while bankrupting America and giving away free health care to illegal immigrants. The second group, which is much smaller, is made up of extremely rich people who don’t want to pay more taxes, and the health insurance industry. And, since that first group is basically only against health care because they’ve bought the Republican lies, Republicans are not exactly representing them, they’re using them. They are, in fact, shock troops, mobilized to provide a public face to a protest that only exists because Republicans have mislead their constituents.
Which means, Republicans are actually only representing rich people and the insurance industry.
Other, better, writers than me, have said the same thing. It sounds like the easy way out. “Republicans are wholly-owned subsidiaries of the private insurance industry, that’s why they’re doing this.” It seems like there must be more to it than that, right? No one wants to believe that an entire political party, and one of the big two, at that, is so deeply corrupt that they’d throw the entirety of the country under the bus to line their own pockets. That’s part of the reason why so many believe Republican lies, actually. No one wants to face the idea that they’re being so utterly screwed by their chosen political party. Oh, sure, we all think politicians are corrupt and devious, that’s the common wisdom. But, it’s one thing to say it, and a whole other thing to stare it in the face.
Republicans spent eight years under Bush, lining their own pockets and extending their own governmental powers. In fact, that “deem and pass” that Republicans were having such fits about? They put it into practice. Five years ago. Reconciliation? Republicans in the Senate abused that half to death under Bush. And that’s only the start of it. Republicans have been telling you about smaller government and fiscal conservatism and so forth for decades, now, while simultaneously expanding federal government power and reach and spending tax money like lottery winnings. That’s fact. The numbers and the history back me up on that, and you can look it up for yourselves. Bush presided over the most spending and the most government expansion, like, ever.
And why? Because Republicans are bought and paid for by large corporate interests, like the tobacco lobby, the insurance industry, and so forth. In 2009, when the Republicans lost the majority, we watched them scramble about and dither around like a bunch of chickens with their heads cut off. Why? Because political parties who are not in power don’t get to make rules, and hence, don’t get to make money the same way the majority does. So what we’re watching here is mad scramble on the part of the Republicans to prove that A) even in the minority, they have the power to get things done, and B) stir up enough garbage that they have a chance of getting voted back into the majority, so they do have political power again.
So that they can continue to make laws that benefit their corporate backers, and continue to make money, and continue to stay in power.
Politics, all politics, run on two things: money, and power. I’m not saying the Democrats are better. But I am saying they have a history of not being quite so goddamn crass about it. I am saying that Democrats put a little more emphasis on keeping power and making money by helping grassroots interests, as opposed to corporate interests.
Tomorrow: So, What’s Actually In HR 3590?
(Image from here.)
It’s a good thing we’ve got Wikipedia to rely on. Trying to find solid information about the health care reform bills has been like jerking teeth out of my own head.
The problem with trying to keep oneself informed about health care reform is that the debate has become so outrageous that digging through the lies, propaganda, and outright bullshit has become nigh unto impossible. Doing a simple Google search about health care reform in general, or specific bits of it, loads your search results down with right-wing conspiracy theory crap and/or fluff pieces from the government and the media. It’s like people are afraid to just come right out and say what’s in the damn bills.
So, this week, I’m going to do a series of posts about health care reform, including the drama surrounding the bills, and including what’s actually in the bills.
We all remember how this works from School House Rock, right? Good. Okay, so, the House passed their bill, HR 3962, IE, the one with the public option, on to Senate. The Senate completely rewrote that bill, into HR 3590, IE, the one without the public option. (There are more differences than that, obviously, but for the sake of simplicity …)
Now, either branch can write a bill, but to go on to the president, that bill has to be voted on and passed in both houses. There are rules governing what kinds of bills can be written in which branches, which basically boils down to, constitutionally, health care reform has to originate in the House. The Senate can’t write that kind of bill. They can, however, rewrite and amend the bill, which is what they did, resulting in HR 3590. HR 3590, due to amendments and rewriting, must now be re-passed in the House. That’s what we’re working on now.
The Drama: Democrats on both sides are being pissy about the differences between the two bills. The House is bent out of shape because there’s no public option in HR 3590, Blue Dog Democrats are jacked over the abortion language, and the Senate claims it can’t pass a bill with the public option, because they don’t have the votes. Meanwhile, the Republicans are basically obstructing the whole thing, out of what they’re calling “moral principle”, and the rest of us call “juvenile knee-jerk jackassery”. If the Republicans do now, or ever did, have any actual point to obstructing health care reform, it’s largely been lost to bullshit and demagoguery. Slowly but surely, the House and Senate Democrats are getting their crap together, which means we’ve steadily inched closer to having a bill which could pass both branches and head on to the president. Which brings us to …
OMGRECONCILIATION, which is, according to the Republicans, a tool of the Devil, and according to reality, “a legislative process of the United States Senate intended to allow consideration of a contentious budget bill without the threat of filibuster.” You can read a bit about how it works here. I’ll wait.
Got it? Okay. Moving right along. Basically, the health reform bill counts for the reconciliation process because they have to be funded. Since we’re talking money and government budget, we can kick the bill into reconciliation, and pass it that way, leaving the Republicans no chance to filibuster. We have to consider this option because the Republicans have threatened to filibuster the Senate bill pretty much regardless.
But first, the House has to pass HR 3590. Which brings us to “deem and pass”.
The newest drama wrinkle in this affair is “deem and pass”, which is, according to the Republicans, OMGWTFBBQILLEGAL, and, according to reality, a “procedural measure used by the U.S. House of Representatives to approve legislation. If the full House votes to approve a legislative rule that contains such a provision, the House then deems a second bill as also approved without requiring a separate vote, as long as that second bill is specified in the rule. That is, if the vote on the rule passes, then the second bill is passed as part of the rule vote.” However, on this one, the Republicans might actually have a point. As it stands, “deem and pass” is actually part of the House procedural rules, and has been used before for other things, but might not be legally correct to use in this instance. This circumstance might leave loopholes for the Republicans to pursue the matter in court after the bill has been passed, which, frankly, opens one hell of a can of worms.
Basically, you’ve got your house bill, your senate bill, and an 11-page Act the President and his advisers wrote which reconciles (Not OMGRECONCILIATION, but just regular compromise between the differences of the two bills) the two bills. The house is considering using “deem and pass” to pass the president’s Act, and also pass the bill at the same time. So, they want to vote to pass the Act, which would also pass the bill without an actual up or down vote on the bill. This may or may not be legal. There’s a whole lot of sticky procedural legalities that could be argued either way on the issue, which leaves me thinking that if there might be loopholes, don’t do it that way. Suck it up and get it done ironclad, amiright? Well, that would take longer, and lord knows we don’t want this dragging on anymore than it has to, which is the way some folks in the House are apparently thinking.
To sum up: The House wrote a bill and sent it to the Senate. The Senate rewrote the bill into something they thought they could pass in the Senate, and sent it back to the House for a another vote. Along the way, the president’s Act, which addresses the differences between the two bills and turns them into something both branches think they can vote on, was tacked on. Currently, the House must pass HR 3590 and the president’s Act, legally. Then, it can go back to the Senate, which is where OMGRECONCILIATION might take place, since the Republicans are threatening to filibuster anything and everything that comes their way.
Tomorrow: Why the Republicans Are Being Jackasses.
Further sources: Health Care Reform in the United States. Image from here.
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Re: Health Care "Reform"
Keith Olbermann agrees with me about the health care reform bill.