Orrin Hatch: “Do You Realize They’re Going to Subsidize Families Making More than $80,000 A Year?”—What Reform Will Mean For You and Your Family

Appearing on CNN yesterday morning, Senator Orrin Hatch (R, Utah) groused about what he called the “Europeanization” of health care. Translated, that means that we have decided to take a more collective approach to survival. If you cannot afford health insurance, your fellow citizens will help you pay for it.

Hatch is correct: in 2014, a family of four earning $88,200 (or four times the federal poverty level) will get a subsidy to help buy insurance in the new Exchanges. $88,200 may sound like a fortune if you live in Idaho (where median income for a family of four is $58,000), but in Maryland, Massachusetts, Connecticut, and New Jersey, $88,200 is actually less than median income for a family of four. Even in New Hampshire, median income for a family of four is $87,396. (Half of all families of four earn less; half earn more. In other words, a family that size bringing home $88,200 in New Hampshire is smack dab in the middle of the pack.)  See this fascinating table that shows median income for individuals as well as families including of two to six people in all fifty states. It’s startling to see how widely incomes vary in different parts of the country.

Medical Professionals Must Lead: This is Your Revolution--Atul Gawande

Writing on the New Yorker’s “News Desk” today, Boston surgeon Atul Gawande laid out the challenge that health care reform poses for hospital administrators, physicians, nurses and every other professional in our health care system. (By professionals, I mean people who realize that they must put the interests of a sick person ahead of their own interests. I have met pharmacists, lab workers, home health care workers and many others who take this responsibility seriously. In many cases, this is why they chose the job.)

Gawande writes: “What made the passage of health reform historic is that, after almost a century of effort to reverse this, hope has arrived.

“We as a nation—and in particular those of us in medicine—now have work to do to defend and deliver on this promise and to address the legitimate concerns about costs while making health care better for everyone. But that is the remarkable thing. We have finally been given the work to do.”

Yes, this legislation gives medical professionals an opportunity to take the power back from the for-profit corporations that now, to a very large degree, run health care in this country. Today, even nonprofit insurers and hospitals are affected by for-profits. They must compete with them, and thus, in many cases, they have begun to imitate them.

But health care professionals can help only if they understand that reform is all about rewarding  patient-centered, evidence-based medicine. Medicine should not be profit-driven. Those who think of medicine as a “business,” like any other, will be out of luck.

“I Am Not Bound to Win, But I Am Bound to Be True”

So many said it would never happen. But now, on Sunday, March 21, 2010, it appears that reformers have the votes.. Rep.  Bart Stupak, the leader of the anti-abortion hold-outs, has announced that he will vote "yes." - (Under the agreement, President Barack Obama will  sign an executive order ensuring that no federal funding will go to pay for abortion under the health reform plan  This really doesn't change anything. Stupak got nothing except face-time on television.)

At last, Congress is about to take the first step toward transforming what we euphemistically call our health care "system."  In the years ahead, the laissez-faire chaos that puts profits ahead of people will be regulated, with an eye to providing affordable, evidence-based, patient-centered care for all.

Since I began writing this blog, I have predicted that Medicare reform would pave the way for health care reform, and this bill makes that possible. Under the legislation, Congress will no longer be in a position to thwart Medicare’s efforts to rein in spending by eliminating waste. Not everyone is happy about this. Over at Politico.com former Republican Senator Bill Frist and former Democratic Senator John Breaux register their protest in a column titled "Keep Medicare in Congress' Hands."

Under reform, politicians and lobbyists will no longer have the power to decide what Medicare pays for and how it pays for it. Frist and Breaux put their finger on a critical change at the very heart of the legislation when they complain that an “Independent Payment Advisory Board,” made up of physicians and health care experts, will be able to propose changes in Medicare payments that “become law unless Congress enacts its own proposal to achieve the same level of cuts.”  Legislators will be loathe to take responsibility for cuts. Moreover “Congressional leaders will have to muster . . . .a super-majority of votes if they want to overturn the board’s decisions.”

Dan Rather on President Obama, LBJ and HCR:

Last night, I saw Dan Rather on the  Rachel Maddow show.  Some people have suggested that today, the country is polarized the way it was in the 1960s. But Rather reminds us that when Congress passed Medicare in 1965, President Johnson was operating in a very different landscape.  Reading this interview, one realizes what President Obama has been up against. He beings by observing that, if he succeeds, President Obama will be making history:

RATHER: “It will be the signature achievement of this first term, perhaps the only term, but a signature achievement of President Obama`s this term. And whether one likes it or not, disagrees with it or not, it takes up the line that started with Social Security, ran through Medicare and Medicaid, which was passed more than 40 years ago, 45 years ago, and it will be put in that category. [Rather is not saying that Obama will be a one-term president. But he is suggesting that even if he only has four years, he will have accomplished more than the vast majority of two-term presidents.-mm]

“And if it passes, and if it is put into effect, I expect it will be in the first paragraph of President Obama`s obituary, that he passed health care reform, partly because so many presidents — President Johnson was successful, but President.

MADDOW: When Lyndon Johnson was able to get Medicare passed in 1965, is there any useful comparison to make or contrast to draw between the political environment in which he was able to make that happen in `65, and the way — and the environment in which Obama has been able to presumably make this happen if he does it?

RATHER: Well, there are certainly a lot of contrasts. First of all, remember that President Johnson got this landmark legislation, Medicare and Medicaid, passed in the wake of the assassination of President Kennedy. He ascended to the presidency. And the country was aching to not only appear to be, but to be united.  [this is very true--mm]

I have my doubts whether President Johnson could have gotten Medicare and Medicaid pass if it had not been for the assassination of President Kennedy and the mood the country was into after that. Then, the second thing, that there was — certainly it was political warfare, and the kind of no holds barred political warfare. But nothing like the polarization in Washington and nothing like the polarization in the country existed at that time.

MADDOW: Really?

RATHER: And –

MADDOW: I always think that — I look at the polarization we have now and I think oh every generation must think that they`re the most polarized time ever.

RATHER: No.

MADDOW: You think we are actually. . . . [here, one realizes how young Maddow is—mm]

Truth Squad: Fox on Health Care Reform and Small Businesses

Fox strikes again.

Appearing as a guest host on Fox & Friends yesterday Dana Perino asserted that the health care reform bill's Medicare investment tax on those making over $200,000 a year is "so disturbing ... because the people who make that money are the small business owners."

I addressed this issue in September, in an online debate with Phil Kerpen Director of Policy, American for Prosperity on PBS NOW (See www.healthbeatblog.org dated Sept. 25, 2009) At the time, reformers in the House had proposed asking households reporting joint income over $350,000 to pay an extra 1 percent on earnings over that amount, while those earning over $500,000 would pay 1.5 percent; and millionaires would pay a 5.4 percent surtax on earnings over $1 million.

Kerpen claimed that this would create a horrific burden on small businesses that are “the engine of job creation and economic growth. Most so-called ‘wealthy Americans’ are simply small business people,” he argued, “who pay their business taxes on their regular tax returns.”

In the rebuttal I pointed out that according to the non-partisan Joint Committee on Taxation only about 4.1 percent of small businesses would be affected by a tax on incomes over $350,000—and that’s only if you used “the broadest definition of a small business owner—anyone with as much as $1 of business income.” The truth is that while quite a few Americans earning over $350,000 a year own an interest in a small business, few small businesses actually deliver $350,000 in profit. Indeed, JCT reports that 50 percent of small business owners earn less than 1/3 of their income from the business. (If you’ve ever tried to start a small business, you know just how difficult it is to make money.) Most “wealthy Americans” are not small business owners—or if they do own a small business, it is not the source of their wealth.

But you have to hand to it to the conservatives, once they get their hands on a piece of misinformation, they’re like a dog with a dirty bone in its mouth--they’re loathe to give it up. So yesterday a Fox host suggested that the tax in the reconciliation bill will impose a serious hardship on small businesses. Under the new bill that Congress will be voting on in the next few days (perhaps as soon as Sunday) , the Medicare tax for individual earning over $200,000 and married couples earning over $250,000 expands. (Today Americans in these higher tax brackets pay a 1.45% payroll tax on wages to help fund Medicare. The Senate bill would have raised that tax to 2.35% for individuals reporting wages over $200,000 ,and couples bringing home more than $250,000. The reconciliation bill expands the 2.35% tax to include not just earned income, but investment income (dividends and capital gains, as well as “gross income from a trade or business involving passive activities” ) for those at the top of the income ladder.

Highlights from the Reconciliation Bill, and Maggie’s Comments on the Changes

Overall, the changes in the reconciliation bill will make the Senate bill more progressive—and fairer.

My prediction: the bill will pass. Those who oppose universal coverage are becoming angrier, louder, more abusive, and more frantic. This is because they realize that they are losing, and now they are just flailing about.

This evening (Thursday) I heard Bart Stupak acknowledge, on “Hardball with Chris Matthews”, that while the Democrats may not have the votes today, by Sunday, they could well have them. On this, I agree with Stupak.

Below, the details of the new bill, and my comments in red.

Under the new reconciliation bill:

• Low-income and middle-income families will have an easier time affording premiums. The tax credits for health insurance premiums are more generous for individuals and families with incomes between 250% and 400% of the federal poverty level (FPL)—i.e.  individuals earning less than $41,500,  or a family of three earning less than $70,400. When compared to the Senate bill, the legislation also cuts cost-sharing for individuals and families with incomes between 100% and 250% FPL.

Comment:  Research shows  that when a low-income family of four (for instance a family earning less than $22,000) is required to share in health care costs, too often they delay needed care.  For these families, even a $15 co-pay can be a barrier. Fifteen dollars will buy groceries for two dinners for a family of four (e.g. spaghetti with tomato sauce and bread).  Middle-income families who don’t have help from an employer also need the higher subsidies that the new bill provides.

• Six months after the bill is enacted, all existing health insurance plans are prohibited from imposing life-time limits on payouts or refusing to cover children suffering from pre-existing conditions.   Excessive waiting periods before insurance kicks in also will be banned, and insurers will be required to provide coverage for non-dependent children up to age 26 on their parent’s polices.  (Parents will pay extra for the coverage, but adult children will get better deals than many would on their own.) Beginning in 2014, group health plans will no longer be able to exclude adults based on pre-existing conditions. Annual limits on how much an insurer will pay out will be restricted beginning six months after enactment, and prohibited starting in 2014.

Comment: Limits on how much insurers will pay out annually or over a lifetime can condemn individuals to death. If you have the bad luck to be diagnosed with a very expensive disease that might require years of pricey treatments (MS for example, or childhood cancers) your insurance can easily “max out”—even though treatment that might cure you (in the case of some childhood cancers where we have been making great progress)-- or at least give you many additional years of life.

• The “Cadillac Tax” on expensive health insurance plans has been pushed back five years and won’t go into effect until 2018. The thresholds also have been raised: the tax will apply only to individual plans that cost $10,200 or more (up from $8,500) or family plans that fetch $25,500 (up from $23,000). Dental and vision plans would not be included.  Under the new bill, there is no special deal for unions.

Comment:  In my view, this is a positive change. As I have argued in the past, the Cadillac tax could hit middle-income families.

• While the Cadillac tax is rolled back, the Medicare tax for wealthy individuals earning over $200,000 and married couples who earn over $250,000 rises.  Today, they pay a 1.45% payroll tax on wages. The Senate bill would raise that tax to 2.35%. The reconciliation bill expands the tax to include investment income (dividends, capital gains, etc.) as well as earned income. It still applies only to individuals who show income over $200,000 and couples who report income over $250,000.

Comment:  This tax makes up for the cut-back and push-back on the Cadillac tax. In contrast to the Cadillac tax , this tax is limited to those at the very top of the income ladder. Unlike the middle-class, those earning over $200,000  have  enjoyed significant tax breaks and income hikes in recent years. They are in a much better position to afford the increase. It’s worth noting that other countries tax investment income to help fund healthcare.

"Medicalizing" Life

How much medical care do we want in our lives? H. Gilbert Welch poses this question in his excellent op-ed piece for the LA Times entitled, “The Medicalization of Life”  and tells us that the answer will be vitally important for reining in the spiraling cost of health care.

We’ve written a lot about cutting out the waste and over-treatment that is inherently part of our profit-driven health care system. The culprits are clear: Too many scans, too many diagnostic tests, too much surgery and too many prescriptions for expensive new drugs. But despite increasing evidence of where cuts can be made, we’ve always assumed that Americans help drive health care spending with their constant demand for newer and more advanced treatments and technologies.

The Top Ten Immediate Benefits Americans Will Receive When Health Care Reform Passes

Today, the Democratic Caucus of the House listed the provisions of the health reform bill that will take effect “as soon as health care passes,”

 The legislation would:

• Prohibit pre-existing condition exclusions for children in all new plans;
• Provide immediate access to insurance for uninsured Americans who are uninsured because of a pre-existing condition through a temporary high-risk pool;
• Prohibit dropping people from coverage when they get sick in all individual plans;
• Lower seniors prescription drug prices by beginning to close the donut hole;
• Offer tax credits to small businesses to purchase coverage;
• Eliminate lifetime limits and restrictive annual limits on benefits in all plans;
• Require plans to cover an enrollee’s dependent children until age 26;
• Require new plans to cover preventive services and immunizations without cost-sharing;
• Ensure consumers have access to an effective internal and external appeals process to appeal new insurance plan decisions;
• Require premium rebates to enrollees from insurers with high administrative expenditures and require public disclosure of the percent of premiums applied to overhead costs.

“By enacting these provisions right away, and others over time” the Caucus declares, “we will be able to lower costs for everyone and give all Americans and small businesses more control over their health care choices
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A Culture of Fear and Intimidation: Reforming Medical Education

Even as we set out to reform U.S. health care, we continue to train medical students as if they were going to work in the old, broken system. Today, everything about medical education needs to be re-thought, from how we select students for admission to med schools to what we teach them about how to provide safe, patient-centered care.

A shocking new report from the  Lucien Institute at the National Patient Safety Foundation reveals how today’s medical schools fail their students as it lifts the curtain on a culture of  “abuse, shame and blame”  that undermines professional morale, inhibits teamwork-- and ultimately puts patient safety at risk.   (Thanks to Dr. Diane Meier for calling attention to this report on Twitter.)

Lots of Bark, Little Bite in State Efforts to Block Health Reform

Last week, Virginia became the first state in the nation to pass a law that aims to block the individual mandate for health coverage, a key element of  President Obama’s health reform plan.

Virginia has a history of defying federal action—most notoriously when the state failed to follow school desegregation orders in the 1950’s. But this time the state is not alone in launching legislation to challenge key elements of federal health reform. On March 9, Utah and Idaho both passed bills through their state assemblies that would invalidate the individual mandate that people buy health insurance. Similar “health care freedom” legislation—in the form of statutes and ballot measures—has now been proposed in some 34 other states.