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Edited on Tue Mar-09-10 02:41 PM by laughingliberal
Let me first take the most popular talking points that say it will be better than doing nothing:
1) 30 million more people will have access to health care.
2) People will no longer be forced into medical bankruptcies
The truth is 30 million more will be mandated to have a health insurance policy. Those who get a subsidy may be able to afford the premium but a lot of them will not be able to afford the deductibles or out of pocket expenses. So, if they can afford the premium and have a policy, they may still not be able to afford to access the actual care. So, many will have a policy but not access to health care and they will have an extra expense of paying a premium. Now, many make the point that the bill allows people to see a PCP without out of pocket expenses (a visit for a checkup, if you will).First off the premiums they are paying would, likely, be enough for them to see a doctor for a checkup to begin with. Many who could, perhaps, afford the checkup do not see a doctor because they can't afford any treatments if something is found and I know all about this cause I am one of those, now. This is very similar to the position they will be in with their new insurance policy: if they see their doctor and something is found to be seriously wrong, they have no access to the treatments for the condition without coming up with the deductible and out of pocket costs which will be out of reach for many. They may (and this is not likely) find providers who will treat them without them having met their deductible yet but they will be billed for the differences and then be forced into bankruptcy over the bills. This bill will not stop medical bankruptcies.
When you start talking of those who do not qualify for a subsidy, it gets less certain they will even have a policy unless they are pretty well heeled. People with this sort of money probably already have coverage. Federal policy guidelines would put a couple making 52,281 per year outside the level for a subsidy. If that same couple happens to be older their premium will be quite high (There is nothing really to force the price of premiums down. We can argue if it will slow the rate of increases in the future but they aren't coming down from today's levels). My husband and I were paying $1200 per month for our premiums and that was before we dropped it almost 3 years ago. We all know that premium could be up to around $1700 by now. But let's just assume this couple is still getting $1200 rate. That is 25% of their income which is like a second house note in my part of the country and more than a mortgage in a lot of the country. I know very few at this income level who could afford a second house. Add to that the deductibles and out of pocket expenses and this couple will, no way, be able to afford this coverage. Now, they will get a waiver so they are not fined (as the policy is more than 17% of their income) but they will still not have coverage. So, these people get nothing from the bill. Let's assume they are a bit younger than the above couple so their premium is just under 17% of their income. That's a couple who will be paying $740 per month. At that income level it might be doable but it will be a stretch depending on the cost of living in their area (and this is a huge problem with the Federal Poverty Guidelines, they do not take this into account and the price of housing is never considered but that's another discussion entirely). Let's assume their mortgage is $1200 per month because in my area that is a modest home. They are now darned close to 50% of their monthly income going out just for the mortgage and their health insurance. If they have a car note, they're really scrapping, now. A lot of these people will not be able to afford the coverage (and if they do, they will certainly go bankrupt over the out of pocket expenses should they wind up with a serious illness). If they opt not to obtain coverage they will be fined. The fine may be affordable but they still don't have coverage.
3) This bill will stop denials for preexisting conditions
I have always said people who can already afford coverage but have been denied due to preexisting conditions is one of 2 groups who will be helped by this bill. First off, you have to realize the community ratings system in the bill allows a multiplier of 3X for age and a lot of older people are the ones with preexisting conditions. So, they're in the same boat as all older Americans as far as being able to afford the coverage. Now, until some bought out asshole in the Senate slipped that loophole allowing rescissions to continue into the bill I would have said younger people with preexisting conditions would be helped by this bill if they can afford the coverage. But, with that loophole in there, now, it is not clear this is, necessarily, true. These may find themselves facing the same issue many face, already. They pay for the coverage for a period of time and, as soon as the insurance company decides they are tired of paying out for them, they will search their medical files and history, find a condition they neglected to mention on their application, and call it fraud and cancel their policy. There is nothing I've seen in the bill which changes that scenario. Once that loophole got in there my previous belief that those who could already afford coverage or younger people with a preexisting condition would be helped got a lot more uncertain.
4)This bill will end rescissions and you will be covered as long as you paid your premiums
Untrue and addressed above
5) This bill will stop insurance companies from imposing annual or lifetime limits
Half true. It will not allow lifetime caps but they weaseled in a loophole for annual caps
6) This will expand Medicaid coverage for the poor
True. This is the 2nd group I have always said would be better off with the bill than without it (and I am in this group, now) and this one that has not changed. This will be a group who does not have coverage now who will have it if the bill passes. But, before we get out the party hats, it is important to note, though, that many areas have no practitioners who take Medicaid patients as the reimbursement rates are abysmal. Finding a primary care provider is doable in some areas but specialists are out of reach almost everywhere (at least everywhere I have worked with this population). So I, cautiously, call this an improvement because those who have, previously, fallen just outside the guidelines will now be eligible. I'm not discounting this. It was always very frustrating to work with patients who really needed this help only to have the state decide they made $2 a month too much money. But, just like those in the above scenario, many of the people who fall into this group will now have 'coverage' but many of them will still have no access to health care. So, maybe some help, maybe not, is the status of this part depending on the person and their medical needs and the area in which they live.
It is worth taking a minute to look at the unintended consequences (because we all know there are always unintended consequences).
The downward pressure on the working and middle classes here can not be overlooked: You have to consider the couples spoken of in # 1 & 2 above. Let's assume this couple is in their 50's and their income is just below the 400% of FPL level. Let's say they are making $50,000 per year. They are not rich but they're making it. They bought their home here a while back so their mortgage is $900 per month-below the 25% of income guideline. They have to commute for work cause housing near the job is out of reach. They have one car note and another paid for car. Let's assume they are one of the rare couples in the country who managed to get to this age without taking on debt after stagnant/declining wages over the past 30 years. So, they qualify for a subisidy which limits their part of the premium payments to $5000 per year, a little over $415 per month. Well, that's doable. The 2nd car is getting a little long in the tooth and they had hoped for a newer one but they'll keep this one going as best they can and get a policy cause they are at an age where it's smart to do so. They'll figure something out, eventually. Well, they are stuck right where they are. Because if their income goes up just 5% they are outside the guideline for the subsidy. Now, their premium is $14,400 per year or $1200 per month. Where will they find that extra $785 per month? Hell, they couldn't find the extra $300 for a newer car. Their income increase of $166 per month will decrease their disposable income by more than $600 per month. Two choices here: 1) they do without the coverage and hope they don't get sick, or, 2) they suck it up, and one of them (let's say the wife) gets a part time job to pay for the coverage and buy the newer car. Their lives are not as good. They have less time together but they have the insurance and the newer car. Then, the wife is diagnosed with a very aggressive breast cancer and must start treatments immediately. She has to quit the part time job. In addition their policy has a $2000 deductible and a $5000 out of pocket cap for the year. They can no longer afford the premium, anyway. If, by some miracle, they manage to keep making the premium so she can get treatment, they are still at risk of going bankrupt over their part of the expenses. And, even if they remain healthy, these people are not, without some miracle, ever going to be financially in the same place they were before their income went up $166 per month.
Let's assume a better scenario for this couple. The wife gets a job that provides coverage and it's a union job, working for the state. The pay is about the same but the benefits are great! They are ecstatic! Their part of the premium passed on from their employer is only $250 per month and it has an actuarial value of 90% with a $500 deductible and maximum out of pocket expenses of $1000 per year. They have it made! Then the Senate bill passes as is. Ut oh! The premiums are at the level which will be taxed. The insurance company raises the rates. The state's budget shortfall is already getting desperate. They change to a lower cost policy. The wife's part of the premium goes up $50 per month and now the coverage is 70% and the deductible is $2000 per year with an out of pocket maximum of $5000 per year. This means $7,600 dollars out of their pocket if one of them get seriously ill.
Let's look at one more part of the bill that gets little press but is quite damaging. That's the Ensign amendment. Those who thought they're good whether the bill passes or not because they have coverage at work are in for a real treat over this. This allows insurance companies to sell policies to employers which can target people with certain conditions with premiums grossly higher than those without. Heh! People buying on their own may not be discriminated against for having a preexisting condition but those who get their coverage through work will not be so lucky. The employer will be able to force you into a 'wellness program' and, if you don't meet certain goals, you will be charged vastly more for your part of the premium. Some of these goals, we can argue, would be within the control of the employee like losing weight or quitting smoking. But one of the conditions will be high cholesterol. Not heart disease, mind you, just a number on a lab report. Most cholesterol problems are genetic. They are virtually intractable to patient behavioral changes. Even if you are not at risk for any heart disease due to your cholesterol level, you will be forced to take statins to lower this number or pay through the nose for the coverage. And, just for myself, if I didn't have some serious risk for heart disease I would not be taking a statin drug I don't need if I had a choice. Besides that do you really want your employer this intimately involved in the details of your health? This amendment was made possible by a last minute executive order signed by Bush which removed some of the HIPAA protections that allowed you to keep your protected health information private.
The employer mandate: The bill will not require employers to provide coverage but will fine them if they don't provide it and an employee qualifies for and gets a subsidy to buy from the exchange. Look for single mothers in lower paid occupations (a mother with one child will qualify for a subsidy if she makes up to $58,800 per year) to have a hell of a time getting hired.
There's more, like the effects of the cuts to Medicare which will, likely, lead to a new push for privatization of that system and a huge backlash against the party once people see the ill effects of the bill but I'll stop for now. I hope this has illustrated that those opposed to this bill are not just heartless people who don't care if Americans die in the streets without insurance but that we do have some really legitimate concerns here that this bill will not help many and it will do a lot of damage.
Perhaps, instead of screaming at the opponents, we should be screaming at our legislators and letting them know we are aware of the poison pills in this bill and want them out of there. Right now they see 2 groups of constituents: the bat shit crazy right wingers who oppose the bill without having any idea what's in it and the supporters who thing we're entering a new age of social justice with passage of the bill. They need to know there is a big group out here who are demanding some real reform of this system and we don't think this bill is it.
edited for punctuation
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