The Pitfalls Of Health Care Reform

By Big Tent Democrat, Section Other Politics
Posted on Tue Nov 10, 2009 at 08:54:16 AM EST
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A lot folks have just realized some of the pitfalls of health care reform. I've always understood that any public insurance program, be it Medicare, Medicaid or a public option, will exclude undocumented aliens and coverage for abortion, it seems as if this is news to a lot of people. While there is debate as to the meaning of the Stupak Amendment, let assume the best and that it gets amended to reflect merely Hyde Amendment prohibitions -- what will that mean? What it has always meant - no federal funds for health insurance and/or care for abortions and no health insurance and/or care at all for undocumented aliens.

Suppose however that without the Stupak Amendment, health care reform can not pass - what then? Do we jettison the entire effort? Or can we limit the damage a Stupak Amendment or Hyde Amendment does? I think we can limit it. I have two suggestions - exclude the individual mandate (but maintain, as the House does, the employer mandate) and eliminate the exchange. More . .

The individual mandate is problematic in that it forces individual to purchase insurance. Since individuals who cannot afford insurance will still be mandated, they are forced to purchase insurance with federal government subsidies, the use of the subsidies will require that these individuals purchase insurance that does not cover abortions. To avoid this, the mandates should be eliminated and the federal subsidies could be made voluntary. Under this scenario, no one would be forced to purchase insurance that does not cover abortions, but they would have that option, including the option to purchase public health insurance (the public option.)

Similarly, elimination of the exchange will remove the threat that insurance companies will strip abortion coverage from their policies in order to qualify for the exchange. Of course many will do so in order to be eligible for the federal subsidies, but this is the case with state run Medicaid programs (remember the largest expansion of coverage under health care reform comes from the increase in Medicaid eligibility.)

Personally, I think these are not very damaging changes to health care reform as it stands now. I do not like the individual mandate because I do not believe it is fair in an environment where affordability is not guaranteed.

Similarly, I believe the exchanges are merely a Rube Goldberg contraption that do nothing to make health insurance affordable. Losing the exchange is simply not important.

As always, I believe the key to health care reform is a public option. Of course, as everyone has noted, it is severely restricted in its reach now, but I believe in the camel nose under the tent aspect. Its reach can be expanded. Its reach, I predict, WILL be expanded. But it must be put in place to be able to be expanded.

So there you have it - my compromise plan for health care reform with a Hyde/Stupak Amendment. It attempts to limit the effects of the Stupak/Hyde provisions while saving the essential aspect of health care reform - a public option.

Speaking for me only

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The Pitfalls Of Health Care Reform | 47 comments (47 topical)

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For the record (5.00 / 3) (#3)
by Big Tent Democrat on Tue Nov 10, 2009 at 09:06:16 AM EST

I am unconvinced that the Stupak Amendment is anything but an extension of the Hyde Amendment to the new programs created by the health care reform proposals.

I read Jeralyn's post on it and the Mother Jones article, but the logic is not apparent to me.

The creation of new federal subsidies and a public option are what extends the Hyde Amendment, through the Stupak Amendment. Since the exchange is limited to person who will qualify for the federal subsidies and/or the public option, the Stupak Amendment seems to me merely an extension of Hyde to these new federal programs.

The problem is the idea that the exchange will be the vehicle of expansion, and thus include more than individuals relying on federal dollars.

I am not a fan of the exchange, so I have no compunction in jettisoning it. I believe the vehicle for expansion should be the public option.

Now of course the public options subject to Hyde Amendment restrictions, as is Medicaid (generally not an issue for Medicare recipients.)

We have a problem with the Hyde Amendment. But it is not a creation of the Stupak Amendment. It is a long standing problem.

I guess what I am saying is the shock being expressed that abortion is not covered by federal dollars in the health care reform proposals is surprising to me.

But passing Stupak (5.00 / 3) (#7)
by lilburro on Tue Nov 10, 2009 at 09:16:10 AM EST

makes it seem as though we don't have a problem with the Hyde Amendment. And if the public option is the camel's nose under the tent, then it follows Stupak is as well. Although I have found many of the comments here on the subject needlessly insulting, I do think the uproar is needed.


: I have a new post coming up (5.00 / 1) (#10)
by Big Tent Democrat on Tue Nov 10, 2009 at 09:21:12 AM EST

addressing that. It is similar to this one, but more to the point of eliminating private insurance from the subsidy program.
Now, the problem with the Hyde Amendment is long standing and I agree with Obama that it will not be solved in this legislation.

I think the shock (5.00 / 2) (#15)
by gyrfalcon on Tue Nov 10, 2009 at 09:31:33 AM EST

at least for me, is the idea that Stupak extends Hyde where it hadn't gone before federally, to indirect subsidies-- if that's in fact what it does. There's been so much disagreement on exactly what Stupak does, and I'm not competent to unravel it.

Hyde is a fact and will continue to be a fact probably for generations. I can't imagine anybody who was even remotely aware of abortion politics could have thought abortion coverage would be in any public option itself.

But I honestly did not expect that abortion coverage would be forbidden in any policy even partly subsidized, much less that wholly unsubsidized policies available through an exchange would be banned. This seems to me a very dangerous expansion of Hyde.

My understanding from following this over these months was that Stupak et al were agitating to have Hyde specifically affirmed in the health care bill, something superfluous and silly but politically advantageous to pols with pro-life constituencies.

What came out instead in the Stupak amendment appears to have gone well beyond that, and given its last-minute introduction, I'm not convinced that was any better understood among House members than it is among commentators and pundits.


I do not understand your comment (none / 0) (#17)
by Big Tent Democrat on Tue Nov 10, 2009 at 09:34:40 AM EST

"The shock, at least for me, is the idea that Stupak extends Hyde where it hadn't gone before federally, to indirect subsidies-"

What indirect subsidies are you talking about? These are direct federal subsidies to be used to purchase insurance on the exchange. The Stupak Amendment is like the Hyde Amendment with respect to Medicaid.

The concern, as I understand it, is that since private insurance companies will participate in the exchange, that they will eliminate abortion coverage.

The solution is simple, if that is the concern, eliminate private insurance companies from the federal subsidies. Have all federal subsidies only be applicable to the public option.


Sorry (none / 0) (#21)
by gyrfalcon on Tue Nov 10, 2009 at 10:00:36 AM EST

poor phrasing on my part. "Indirect" meaning that anything being even partly subsidized by taxpayer money, like the exchange, are deemed to be "funding abortion" under the principle that money is fungible, as opposed to the government specifically providing or subsidizing abortion services per se. By that standard, women who have an abortion would be barred from receiving any federal money for anything. IOW, where's the end point to this?

I'm 100 percent for eliminating private insurance companies from the whole scheme as long as the public option is available to everyone. Ain't gonna happen, though, so I'd like to see a repudiation of the Stupak amendment.


To be honest (5.00 / 1) (#23)
by Big Tent Democrat on Tue Nov 10, 2009 at 10:13:18 AM EST

I think if someone made this proposal, the Stupak Amendment would be in serious jeopardy as the insurance companies would come out in force to protect their spoils.


: Though... (none / 0) (#29)
by kdog on Tue Nov 10, 2009 at 10:48:00 AM EST

insurance cos...like their Wall St. brethren... have shown a penchant for slaying their golden goose with greed...with any luck they'd stick to their Stupak guns and they'd lose the whole ball of taxpayer wax.
Never mind...their congressional brethren would ever force them to eat their just desserts or anything:)

Bah, just about anything could be considered (5.00 / 1) (#28)
by Dan the Man on Tue Nov 10, 2009 at 10:46:15 AM EST

subsidizing or funding abortion. For example, right now the government provides police protection for abortion providers to protect them from murder. Could this police protection be considered "subsidizing abortion" or "funding abortion"? Sure, because without the police protection, the anti-choicers would've murdered all of the abortion providers and abortions would no longer be performed. Trying to extend "subsidizing" or "funding" to mean just about anything merely makes using the word "subsidizing" and "funding" useless and silly.


: Exactly (none / 0) (#41)
by gyrfalcon on Tue Nov 10, 2009 at 11:58:02 AM EST

If what I'm reading about the Stupak amendment is right (and it may not be), that's precisely the point. There's more than one camel's nose under the tent here.

How's this logic? (5.00 / 1) (#25)
by BobTinKY on Tue Nov 10, 2009 at 10:17:40 AM EST

Given the Hyde Amendment has been on the books for over 30 years, wouldn't a reviewing court presume that Stupak was meant to cover something other than what had already been covered by Hyde? And wouldn't that something different have to be more, not less than Hyde?

For a court to do otherwise, it seems to me, is to render the Stupak Amendment nugatory.


I just think Stupak ... (none / 0) (#11)
by Robot Porter on Tue Nov 10, 2009 at 09:21:26 AM EST

makes the Hyde provision apply to more people, hence, more people are upset.


Terrific idea!!!!! (5.00 / 1) (#6)
by Militarytracy on Tue Nov 10, 2009 at 09:13:31 AM EST

And dare I mention that an abortion costs an insurance company a whole lot less than a pregnancy carried to term. Since we know that insurance companies secretly care only about money and the making of it........getting rid of the exchanges that will do little in real life could mean that the insurance companies will choose to cover a procedure that protects women's rights and also whether anybody likes it or not is less expensive for them.

While (5.00 / 1) (#20)
by Ga6thDem on Tue Nov 10, 2009 at 09:59:35 AM EST

you have good ideas, at this point I'm going for just throwing the whole thing in the trash. The mandates are NOT going to go away and I'm sure you know that. Frankly, I'd rather see things passed piecemeal at this point: expand Medicaid in a bill. Let people have subsidized private insurance in another bill etc.

The exchange isn't going away (5.00 / 3) (#33)
by Anne on Tue Nov 10, 2009 at 11:12:19 AM EST

either; it was the only way to make the public option palatable for many in the Congress. I'm pretty sure that if you made the exchange go away, the next thing up to the plate would be co-ops or triggers - there's just no way we're going to get a "stand-alone" public option, not as long as the insurance industry is in charge.

And all the anti-choice Dems are going to hang onto to any mechanism that extends the reach of the Stupak amendment, and they are going to hold their support hostage to make sure it stays.

Now that the process has gotten this far, all we're doing now is rearranging the furniture and kidding ourselves that we've totally redecorated the room.


Yes, (5.00 / 1) (#36)
by Ga6thDem on Tue Nov 10, 2009 at 11:18:36 AM EST

it has become a joke. The more they "work on it" the worse the bill gets. I can only wait to see what the Senate comes up with/snark./


Write to your Senators (none / 0) (#39)
by Inspector Gadget on Tue Nov 10, 2009 at 11:24:58 AM EST

to let them know what is important to you. They can't (and won't try) read minds.


: I have (5.00 / 2) (#44)
by Zorba on Tue Nov 10, 2009 at 12:30:56 PM EST

done this. I have also notified the DNC, Organizing for America, the DCCC and the DSCC that if Stupak passes, they will be receiving no more money from me- ever. Nor will any individual Democrats who vote for this. Instead, I will give those funds to any organization who is working/will work for funding abortions for lower-income women who are seeking them.

The biggest pitfall... (5.00 / 5) (#31)
by Dadler on Tue Nov 10, 2009 at 10:56:24 AM EST

...is calling something reform when it isn't. And a huge handout to private corporations who can only profit by jacking premiums and denying care is not reform. It is simply a gargantuan form of corporate welfare. Again.

Also, I'm still curious, would any man really still be supportive of this if it refused to cover "men's health issues"? Seriously. Do you think, Tent, you would still support this if it meant no coverage for penis, testicles, prostate, etc? If it refused to cover, for men, sexually transmitted diseases? I seriously doubt any would.

Lastly, let's be honest: our government, especially since Reagan has become entirely corrupted by corporate cash. Logic tells me, at any rate, that corporate America is not going to go along with this unless they are guaranteed big profits in return. With the backroom drug deal/knife in the back Obama cut with pharmaceuticals, what on earth makes anyone think that the rest of the "reform" will not end up being simply another similar sellout?

While I'd like to believe in the camel's nose theory, I am also aware that every day our government becomes more and more corrupted to a degree not seen. This is a NEW gilded age, not of the robber baron, but the robber CULTURE. I am having a hard time accepting the logic that the government is working in anyone's interest but those who line their pockets. And that logic and reason are VERY hard to overcome. Last time I did try to overcome similar roadblocks of the mind, I ended up in pretty bad shape.

I hope this all works out, but right now all I see is money going from our pockets to theirs, with the result being junk insurance, not health care, and, I will always repeat, a continuance of our very poor medical paradigm that, essentially, reject's the mind's roll in disease and illness, and treats us all like we're nothing but machines with broken parts. That paradigm is going to kill any "benefit" we see, and I think the industry knows this. Reform would be in our thinking about our health, our mind/body connection, just as much as it is financial.

And NO ONE is talking about ANYthing but the financial, which obviously is important, but if it comes with the same medical industry paradigm about our health, well, we're not going to see anything but poorer health and emptier pockets.

Getting rid of the individual mandate (5.00 / 3) (#32)
by Makarov on Tue Nov 10, 2009 at 11:06:05 AM EST

is the only way I could not vehemently oppose current proposals.

Overall, I feel a mandate without any mechanism to regulate premium prices or claims denials outweighs the benefits of subsidies and expanded Medicaid coverage.

While some people will certainly gain insurance coverage (most of it junk insurance with deductibles and relatively high out of pocket caps), others will lose it as they're priced out of good, affordable insurance plans. Simply put, as soon as you force everyone to buy insurance and subsidize it for those of modest means, you're creating an incentive for insurers to raise prices. Moreover, the (already too high) out of pocket caps will not apply to health care received "out of network".

HR 3962 was a bad bill before the pro-sepsis amendment.

Funny thing about Stupak, (5.00 / 1) (#34)
by vicndabx on Tue Nov 10, 2009 at 11:13:37 AM EST

not sure if it was even needed since it was already in the bill:

p. 246

(3) PROHIBITION OF USE OF PUBLIC FUNDS
12 FOR ABORTION COVERAGE.--An affordability credit
13 may not be used for payment for services described 14 in section 222(d)(4)(A).

Section 222(d)(4)(A):
p. 110

1 (3) COVERAGE UNDER PUBLIC HEALTH INSUR
2 ANCE OPTION.--The public health insurance option
3 shall provide coverage for services described in para
4 graph (4)(B). Nothing in this Act shall be construed
5 as preventing the public health insurance option
6 from providing for or prohibiting coverage of serv
7 ices described in paragraph (4)(A).
8 (4) ABORTION SERVICES.--
9 (A) ABORTIONS FOR WHICH PUBLIC FUND
10 ING IS PROHIBITED.--The services described in
11 this subparagraph are abortions for which the
12 expenditure of Federal funds appropriated for
13 the Department of Health and Human Services
14 is not permitted, based on the law as in effect
15 as of the date that is 6 months before the be
16 ginning of the plan year involved.
17 (B) ABORTIONS FOR WHICH PUBLIC FUND
18 ING IS ALLOWED.--The services described in
19 this subparagraph are abortions for which the
20 expenditure of Federal funds appropriated for
21 the Department of Health and Human Services
22 is permitted, based on the law as in effect as
23 of the date that is 6 months before the begin
24 ning of the plan year involved.

I'm missing where anything Stupak says changes this. Is this simply a case of failure to RTFM?

Makes you wonder (5.00 / 1) (#38)
by Inspector Gadget on Tue Nov 10, 2009 at 11:23:06 AM EST

how many representatives voted without knowing what the bill actually said. Did you hear one Democrat speak out that Stupak's add-on was unnecessary? I would have hoped that Pelosi knew the bill well enough to refuse to allow discussion on Stupak's contribution citing redundancy as the reason.


Indeed. (none / 0) (#40)
by vicndabx on Tue Nov 10, 2009 at 11:41:14 AM EST

Could this all be a show? For who's benefit? Let me get out the 11-dimensional chess rule book.....


: Could well be a show..... (none / 0) (#42)
by Inspector Gadget on Tue Nov 10, 2009 at 12:19:46 PM EST

Received a letter from a Senator yesterday saying that more than $1M a day is being handed out in campaign contributions by special interests trying to stop the HCR bill from getting through....and those elected officials who want it to pass also feel they need to be bought by the people who want them to vote in favor. So, looking for contributions and making sure you hold out long enough for all the little lobbyists to get to your bank can easily be a major reason behind all the waffling.

Aww d@mn sorry (none / 0) (#35)
by vicndabx on Tue Nov 10, 2009 at 11:14:34 AM EST

posted this in the wrong thread. Apologies.


BTD, so in your changes ... (none / 0) (#1)
by Robot Porter on Tue Nov 10, 2009 at 09:03:07 AM EST

would you make all those previously eligible for the exchange now eligible for the public option?

Yes (5.00 / 1) (#4)
by Big Tent Democrat on Tue Nov 10, 2009 at 09:08:13 AM EST

AND eligible for federal subsidies to purchase insurance under the public option.

Instead of having federal subsidies for the purchase of private insurance, I would apply the federal subsidies to the purchase of public option insurance.

Full disclosure - I have never liked the exchanges.


I like it ... (5.00 / 1) (#9)
by Robot Porter on Tue Nov 10, 2009 at 09:19:27 AM EST

because that would give the Public Option the toe-hold it needs to expand, and make it more likely to succeed.

It starts to look like a real public option when it's extended to the self-employed and some small businesses.

Are your changes likely? Maybe not. But a lot of people thought the public option was dead months ago. And it's still in there.

I also think it's smart to use the progressive energy over the Stupak amendment to foster these changes.


That's my point (5.00 / 2) (#16)
by Big Tent Democrat on Tue Nov 10, 2009 at 09:31:36 AM EST

Pivot off of the Stupak Amendment and make the choice elimination of the exchanges or elimination of the Stupak Amendment.


: But those procuring insurance through the public (none / 0) (#26)
by BobTinKY on Tue Nov 10, 2009 at 10:26:20 AM EST

option relying upon federal subsidies would, per Hyde, not have insurance coverage for abortion?
Just trying to understand your proposal.

Is removing the individual mandate... (none / 0) (#2)
by Addison on Tue Nov 10, 2009 at 09:04:20 AM EST

...even a remote possibility?

It seems like that was practically the first thing in the proto-bill months back. I don't think anyone outside of the insurance companies like mandates (Obama was famously against them in the primary, Clinton for), they were just deemed "necessary" policywise and politically and away we went. I can't imagine it being jettisoned without causing the insurance companies to go into such conniptions that half of Congress gets freaked out and refuses to vote for the bill.

Likewise, the exchange has too many Village and Congressional Godparents to be left out in the cold...

You seem to have suggested eliminating two of the most unlikely elements to get axed. I could be wrong.

The exchanges are not important (5.00 / 1) (#5)
by Big Tent Democrat on Tue Nov 10, 2009 at 09:09:45 AM EST

to health care reform. Indeed, they are a hindrance.

To simplify matters, I would eliminate the individual mandate, but keep the federal subsidies and allow those funds to be applied for use in the purchase of public option insurance.


Simpler times. (5.00 / 2) (#8)
by Addison on Tue Nov 10, 2009 at 09:16:18 AM EST

I think you're right on the policy if the goal is to actually move toward doing what HCR is supposed to do. But you're going back to a "simpler time" when common sense on how to get uninsured people insured hadn't been mauled by committees, deals, fancy wonk toys and such.

But they'd never let you get rid of exchanges or the mandate now. Many of these people would rather pass a bill with ONLY exchanges and individual mandates, if it were possible.


: The Stupak Amendment can be useful to us (5.00 / 1) (#12)
by Big Tent Democrat on Tue Nov 10, 2009 at 09:21:57 AM EST

in pushing back against this.

Yes, but w/o the mandate (none / 0) (#13)
by vicndabx on Tue Nov 10, 2009 at 09:28:27 AM EST

where are you getting the money for the subsidies?


The mandate does not create the (none / 0) (#14)
by Big Tent Democrat on Tue Nov 10, 2009 at 09:30:40 AM EST

subsidy money.


I think he's saying (none / 0) (#18)
by Samuel on Tue Nov 10, 2009 at 09:43:59 AM EST

that lack of a mandate increases the amount of subsidy money necessary. People will not sign-up/pay into a policy when they're healthy when they can buy the same upon becoming sick. Technically at that point it's no longer insurance.


The opposite would be true actually (none / 0) (#19)
by Big Tent Democrat on Tue Nov 10, 2009 at 09:45:33 AM EST

since no one is mandated, less people will apply for the subsidy.


I'm not sure exactly which subsidy we're discussin (none / 0) (#22)
by Samuel on Tue Nov 10, 2009 at 10:04:56 AM EST

But as far as overall costs:

In a non-mandate system that guarantees condition-independent coverage, it is very likely an individual's personal contribution to any insurer's capital pool will have been zero until they get sick. Whether the government subsidized along the way or reimbursed a private insurer the cost of treatment afterwards does not necessarily change the cost associated with a specific individual. What does change is their personal contribution to any capital pool.


The discussion is about (none / 0) (#24)
by Big Tent Democrat on Tue Nov 10, 2009 at 10:14:16 AM EST

the direct federal subsidy for the purchase of insurance.

Though I must say I find it ironic that the libertarian is here posting comments in defense of the mandate.


: Yea (none / 0) (#27)
by Samuel on Tue Nov 10, 2009 at 10:28:37 AM EST

so removing the mandate will increase the net amount of subsidization as a means to offset the loss in personal contributions. Right?
I wouldn't associate myself with the libertarian party in anyway (they're a philosophical contradiction).
Yes, it is ironic. Being modest enough to not consider myself or anyone capable of running such a system does not preclude me from criticizing the details offered by those who are not.

Initially not on the first $20B (none / 0) (#30)
by vicndabx on Tue Nov 10, 2009 at 10:48:19 AM EST

but long term the mandate/tax/fine is what (PO advocates hope) fills up the treasury pot. W/O the mandate there's no money for the exchange thru which the PO is currently offered. While I agree that there's no need (at least as I see it) for the exchange, the house bill as passed requires it.


: No (none / 0) (#46)
by Big Tent Democrat on Tue Nov 10, 2009 at 12:39:06 PM EST

A mandate requires people buy insurance.
With an exchange, they do not have to purchase public insurance.

This one (none / 0) (#37)
by lilburro on Tue Nov 10, 2009 at 11:22:52 AM EST

seems custom made for BTD...

Snowe Could Lose to Primary Challenger

Is there any chance Madam President could change parties? Her approval is higher among Dems. Or just become a Lieberman type...god.

I'm just dreaming, but.... (none / 0) (#43)
by christinep on Tue Nov 10, 2009 at 12:26:27 PM EST

If Sen. Snowe is one of those old-time New England Republicans who would never think of anything other than once-a-Republican, always a Republican, then she would concentrate on weathering the storm from the right or some appeasement there. But--and here's the dream--at this stage of her life/career and seeing "moderate" Republicans crumble all around her, the label of Independent might be enticing. Not quite Bernie Sanders, of course. (And forget slippery Joe L) Still...perhaps something could be worked out with her in Maine for a level of support on Reid's bill. Stranger things have happened. And the icing would be that, amongst all the sturm & drang, there is always was and--a good bonus--Joe L of the Joe L party will be twirling alone.


: Well she is up for reelection (none / 0) (#45)
by lilburro on Tue Nov 10, 2009 at 12:36:05 PM EST

in I think 2012. So that is one problem. But she has sent signals she's fed up with the whacko wing of the GOP before (her statement after Specter switched) so it's possible she could bail.

Brilliant (none / 0) (#47)
by Alien Abductee on Tue Nov 10, 2009 at 05:21:27 PM EST

especially when coupled with no federal subsidies for purchase of private insurance, just for the public plan. It would be good if this idea could get some traction.