Lawyer: I went through the transcript with a highlighter to mark places where he actually said something concrete. I got to page 3 before I found anything.
Nurse: Overall, I think he’s doing a good job with this– it’s actually politically quite a tightrope between being too vague and making concrete promises that have to be shifted in some way later, and this always bites you in the ass. That said, it’s kind of disapointing to see how safe the approach is. While I recognize that it is largely impossible to enact sweeping dramatic change in a democracy which is beholden to so many interested parties, I wish it wasn’t. There are so many roots of the problems we have with healthcare delivery that are not addressed in this proposal– in a way, we are treating symptoms instead of making smart lifestyle choices. But I suppose that’s inevitable. Sigh.
Here are the substantive points he made, one by one:
1. We’d better build on what we have, rather than trying to build a whole new system.
Lawyer: Agree!
Nurse: Reluctantly agree out of pragmatism, not true belief.
2. This plan has three basic goals.
a. More security and stability for people who have insurance
b. Insurance for people who don’t have it
c. Slow the growth of health care costs
Lawyer: He doesn’t say much about how (c) is going to happen…
Nurse: And indeed, a lot of the most promising ways to do that are not possible in what amounts to a conservative (in the true sense of the word) reform effort.
3. Insurance regulation:
a.companies can’t deny coverage for preexisting conditions or drop/water down coverage when you get sick.
b. No arbitrary limits on how much coverage you get
c. Limits on out-of-pocket charges
d. Routine check-ups and preventive care must be covered
Lawyer: I mean, yeah.
Nurse: Right, this should be obvious. It’s not, but it should be. Even if this was the only thing that changed, we’d be better off.
4. Rather than out-right legislating what insurance companies must do, we will make these above reforms requirements for joining the health insurance exchange. Companies will want to join it so that they can compete for new customers. The exchange will give customers bargaining leverage.
Lawyer: I think this is a sound approach. Better to make people want to do things your way than to try to force them. Anyway, it worked with the whole drinking age thing. As long as it actually works. And insurance companies do actually participate. And follow the rules. Anybody know how this is actually going to function?
Nurse: It’s a tasty carrot. Mmm. carrots.
5. Tax credits for individuals and small businesses who can’t afford insurance, based on need.
6. Immediate low-cost, minimal coverage for the currently uninsured.
Lawyer: Um… details?
Nurse: Provided by? And covering. . .? People who can’t pay are still given care, but they are generally bankrupted by it. Maybe we are just getting around that.
7. People will be required to carry basic health insurance (just like auto insurance.) Businesses required to at least chip in. (Hardship waivers.)
Nurse: This at least makes sense, if we are going in a insurance-based model (See my previous post for a little discussion on that).
8. (wait for it…) Yes, there will be a public option available as part of the insurance exchange. (As one of many options.) CBO estimates that fewer than 5% of Americans would choose this option. The option will be self-sufficient, relying on the premiums it collects.
Lawyer: Wow, that low estimate makes me super-nervous.
Nurse: I think this is an essential part of the plan, not just in what it will actually do, but in the message it says. I do worry that it won’t truly be self-sufficient because people who elect it may have reasons not to buy private insurance or may find it too expensive. Depends on how the rest of that regultion reform plays out.
Lawyer: That’s too bad. Because people seem to be saying that it’s going down the crapper.
9. This will be paid for by cutting wasteful spending we already have, rather than expanding the deficit. If the projected savings don’t happen, we’ll cut spending, rather than adding to the deficit. Medicare trust will not pay for it.
Lawyer: Sounds good in theory. But I have a feeling that substantial savings will take a long time. I mean, longer than four years. Because our spending is really wasteful, yes, but we can’t just snap our fingers and quit doing that.
Nurse: And this is one place where we really need a cultural shift to fix it. A cultural shift involving how physicians and patients conceive of thorough care, and how malpractice suits are both perceived and actually used. Which leads into the next issue.
10. We’ll have some sort of panel to reduce defensive medicine. HHS is going to handle it. (vague, fuzzy, proclomations.)
Lawyer: I want to hear more about this! Ring ring, hello, Kathleen? Can we talk?
Nurse: Again, this is a deeply rooted cultural issue, in a way. I think we need some good evidence-based practice here– which means we need some research.
Lawyer: cf. Stimulus Bill.
Nurse: I have heard vaguely about studies which show that high-tech intervention can actually be harmful rather than helpful– as in using electronic fetal monitoring, which has been shown to cause unnecessary c-sections with no better outcomes, yet it’s become a standard of practice. HHS, can you work on this angle??
11. Poor Teddy Kennedy! This was his dying wish! Also, as he said, this is a moral issue, not just a policy issue.
Lawyer: Aww. Shot to the heart.
Nurse: Ok. Cool.
12. People thought we were socialists back when we invented social security and medicare, too, but can’t we all agree now that we need those things and they were a good idea?
Lawyer: JEEZ, thanks Obama, I’ve been trying to tell people that for a while now.
Nurse: well, what’s wrong with socialists? And another thing: he talks about requiring insurance to cover preventive care, but I think we could make huge progress by going a step further and offering incentives for preventive care. Maybe that would just be smart business for an insurance company, I don’t know– but i think it would help!
Lawyer: Mmm, more carrots. Carrot cake. I have to go…
