Now that the passage of the package seems assured I am pondering my own feelings about it.
For many the vote on Health Care Reform today is an easy one to react to. My good friends on the left will watch the vote with varying levels of celebration, a feeling of triumph and optimism for the future. My equally good friends on the right will watch the results with varying levels of dismay, ranging from disappointment to outrage over what they see as a major mistake.
For me, the reaction is not as easily defined. This is not an uncommon situation for me, since I do not strongly fit in either the left or the right and frequently the issues are sharply defined for most.
As most of you already know I do strongly support reforming our health care system. It is clearly broken and if we do not do something to fix it then we are simply heading towards the cliff with our eyes closed. That is not an option.
I like many of the provisions of the package being passed through Congress today. Things like restricting the ability of insurance companies to deny coverage for pre-existing conditions, limiting their ability to cancel when you become ill, placing limits on things like lifetime maximums or annual copayments. I think these are important reforms
I also am pleased to see some effort being made towards fixing the doughnut hole in Medicare as well as improve the system of payments to providers under the program.
I am even supportive of the mandate for individual coverage. I take this position not because I think the government should be in the business of telling people what to do but rather because those without coverage will inevitably fall back on the public system for treatment and it is not fair for them to do so.
So on that level I am hopeful that these elements of the bill will work to improve the current situation.
At the same time there are some serious questions that continue to plague me.
For one, during the discussions with the GOP one of the proposals that the President was increasing funding to investigate fraud. But this was dropped from the final bill. There is also no medical malpractice and/or tort reform contained in the bill. I think if we are truly going to control costs that we need to address all sides of the problem and that includes controlling the cost of malpractice insurance for doctors and hospitals.
As I previously wrote, I am also concerned about some of the specifics of the mandate. For me the basic mandate should be just that, basic. You should be required to have coverage to insure that if you get sick or have an accident that the public system won’t be burdened with your treatment. At the same time, if you want a slightly lower premium in exchange for slightly higher copayment or deductibles that should also be your choice.
But looking at the current plan it seems quite possible that people who currently have basic plans could be forced to upgrade to plans they really do not need. If we are looking to control costs and reform things, it hardly seems fair to make a middle class individual or a family pay higher premiums.
To be fair we don’t know for sure what the costs will be, but as I discussed in an earlier post, the estimates from the CBO suggest that many of us could see our costs rise. It is possible that these costs could be offset by the proposed subsidies, but I have to wonder if it would be less expensive to simply skip the subsidy part and allow the more basic plans.
I’m also concerned about the impact of the Cadillac tax, which would be a tax on high end insurance plans. On the one hand the law seems to require people to purchase more extensive (and more expensive) plans while on the other hand it is placing taxes on some of those plans.
Even worse, as I also discussed in a prior post, there seems to be a two tiered system where a plan offered through a union employer is exempted until 2018 while one offered through a non union employer would seem to be subject to the tax. This does not seem fair to me. If the general argument is those with more expensive plans should have to pay then everyone should have to pay, or they need to find a new option.
Finally there is the general issue of cost. I know that the CBO says it will save money in the long term and I certainly hope that they are correct. But for all the ‘non partisan’ labels you apply, we all know that the CBO is going to lean a little to the party in power and that like any employee they are going to tend to give the boss the answer he or she wants.
This is not to suggest fraud or any outright dishonesty, simply that there is no way to be sure what will happen in the future and that it would be foolish to think that given several possible options as to how to run the numbers that the CBO is going to side with the party in power (and would do the same if the GOP were in charge).
Indeed if you look at most of the prior cost estimates on things ranging from Medicare to prescription drugs, tax cuts, etc the costs were often badly underestimated.
Of course we may not know for some time how these proposals will pan out since many of them do not take effect for years (mostly either in 2014 or 2018). I believe most of the things I like go into effect more or less immediately and so that may leave us time to look at the things I am worried about.
In addition we have no idea how the various court challenges will pan out (it seems probable that at least the mandate portion will be challenged by several states and there is also talk of a challenge on the delay in the Cadillac tax).
So I like the general outlines of the package being passed today but I have serious concerns about unintended consequences as well as the lack of what I see as some key elements. Obviously we can try to fix those problems in the future, but that does not entirely assuage my concerns.
So I am hopeful that the good aspects of the bill will work to have the desired effects. At the same time I maintain a level of unease about those I am not sure about. Nobody will be happier than me if those concerns are unwarranted, but I suspect this will be far from the end of the legislation.