You can keep your insurance--Probably not

My assiduous readers will remember this detailed post of mine in which I discussed the repeated claim that if you like your current insurance plan, nothing will change under Obamacare, you can keep you plan. "Move along folks. Nothing to see here but us Democrats helping poor people. You gotta problem with that?"

There I discussed both the elimination of catastrophic-only policies and the setting of all benefits (maximum as well as minimum) by the government for all plans.

Now, post-passage of Obamacare, we hear about something else: So-called "mini-med" plans can and probably will be eliminated under Obamacare by government rules. These are often used for poorer workers such as part-timers or waiters who cannot afford more expensive plans. Poof, gone.

Obamacare--the gift that keeps on giving.

Wow, that's some admission

In this article we find quotations from a liberal journalist, John Cassidy, admitting that Obamacare won't work economically as promised but that the real goal is to "make America a more equitable country." (Why did I have to use Google to find the article by Cassidy? Why didn't the WSJ do that for me and provide a link? Anyway, here's the whole piece by Cassidy.) Cassidy says that "expanding health-care coverage now and worrying later about its long-term consequences is an eminently defensible strategy" and also that some "subterfuge" may be necessary for the desirable end of establishing an entitlement program that will be hard to dislodge later.

This reminds me of the old story about Russia. A Russian peasant picks up a bottle and rubs it, and out pops a genie. The genie offers him a wish, at which point the peasant goes into a long complaint about how unfair it is that his neighbor Ivan has a goat while the peasant with the genie bottle has no goat. "Oh, I see," says the genie. "Then your wish is that I would give you a goat, too?" "No!" says the peasant. "That's not it at all. I want Ivan's goat to die!"

HT: VFR

Great condensation of the President's speech on health care

I ought to write something profound about 9/11, but I cannot think of anything profound to say all by my lonesome. At W4 it has been done much better.

I also ought to, and plan to, put up a post about the murder of a pro-life sign-holder here in Michigan. I plan to do that at W4, most likely tomorrow.

In the meanwhile, via VFR, here is an absolutely hilarious condensation of the President's speech on health care. Read it for fun. Here are a few favorite bits:

If you have insurance, you’ll be able to keep it. If you don’t, that’s bad, because people who have insurance have to pay for you. That’s not fair to the people who pay insurance. Really, it’s kind of socialistic. So, I’ll make you buy insurance, unless you can’t, in which case I’ll make other people buy it for you.

There’s waste, fraud and abuse in health care, which is why it needs to be taken over by the government.

People who say bad things about my health care plan are liars and dreadful human beings. There needs to be more civility in this discussion. Bush caused 9-11. People who say bad things about my health care plan are trying to scare people, and everybody’s going to die if we don’t get this thing passed now.

Obamacare and abortion

Per Bill Luse's suggestion here, I have posted here a piece on Obamacare and abortion. The short version is, yeah, it looks like it will pay for abortions, but with an accounting fig leaf thrown in to make it look like it doesn't. And the Commissioner (remember him?) gets to decide how much of the premiums is going for abortion coverage. And in an even stranger twist (see the update), poor people who get the "public option" may even be required to pay a bit extra so that the plan can contain full abortion coverage while claiming that federal money isn't paying for it.

Addendum to that post: Michael Gerson puts the point pretty well here:

[T]his is a cover, if not a con. By the nature of health insurance, premiums are not devoted to specific procedures; they support insurance plans. It matters nothing in practice if a premium dollar comes from government or the individual -- both enable the same coverage. If the federal government directly funds an insurance plan that includes elective abortion, it cannot claim it is not paying for elective abortions.

And as NRLC points out here, the government will be collecting and funneling even the "private" premiums to the "private" insurance plans. This fits with my impression of the bill here, according to which it would be the federal government who made the contracts with "health care exchange" insurance plans. So the money is passing through the government's hands anyway, making the distinction between "premiums" and "subsidies" even more artificial.

I've also just updated the W4 post to include some additional information about the "public option" and abortion coverage. Update is at the end of the post.

HT Keith Pavlischek for link to Gerson article

Since when is more bad stuff an improvement?

If there's one thing I get tired of...okay, there are lots of things I get tired of. I can't pick one. But one of the things I get tired of in listening to liberals and pseudo-conservatives talk about health care is the exceedingly stupid argument, "We already have that." For example, "Your HMO already sets reasonable and customary costs, so we already have rationing." So how does it make it better to have one committee making all such decisions for the whole country? This is beyond me. At least now, if an employer gets fed up with the HMO he has for his employees, he can, you know...change! Or if, like some friends of mine, you are self-employed, you can buy catastrophic-only insurance. Or even, shocking thought, live for a while without health insurance and try to stay healthy. People have options. Nationalized Obamacare means way fewer options. Saying that we already have some micromanaging bureaucrats messing with our health care on an HMO-by-HMO basis is hardly an argument for going much, much farther in the same direction and putting everybody under a single health care Kommissar.

Or how about this one? "If your employer's insurance company pays for abortion and you have to pay part of your premiums, you are already paying towards other people's abortions in some sense, so why shouldn't federal government money cover abortions?" Um, because there is now at least the possibility for some people to get out of this. If you own your own business, for example, or have a say in the health care plan you choose or that your employer chooses, you can maybe get one without abortion coverage. Federal coverage means no options. It's that simple.

Here is a good, properly alarmist column giving a possible future scenario in which a person pleads for his life before a death panel. Now, I'm going to go one better on the liberals. I'm going to anticipate them. Here we go: We already have death panels before which people plead for their loved ones. They are called hospital ethics boards. Yep, that's right, and you've probably heard horror stories like I have about ethics boards trying to cut off life support for loved ones. So far the stories I've heard have been of ventilators and of difficulties getting PEG surgery in the first place. (I remember one case where a baby was kept on an NG tube, pretty apparently because the hospital was hoping she would die before they needed to put in a PEG tube. She did die, as I recall, but at least she had food in her tummy.) But worse things are no doubt coming.

But does that mean it would be better to have one committee for everyone? By no means. We can still hope that some hospitals and hospices are better than others. It isn't all handed down from On High.

This "argument from present system junkiness" is itself a piece of junk and should be scrapped.

You'll be able to keep your insurance? Probably not.

We all know by now that Obama's line is that if you like your insurance, you'll be able to keep it. Nothing to see here, folks. Move along. The only things that will change are the things that need to change. It's just a matter of helping people not presently covered.

This assumption makes it intensely frustrating to discuss this issue with liberals and even with some "conservatives." Which is why I'm posting about it here. When conservatives point out the provisions in the health care bill for a committee and a powerful Commissioner (always capitalized in the bill) to set benefits, payments, etc., and express worries about rationing, liberals shrug it off. On their view, this is simply a limitation on something that is going to exist on top of what we already have, so how can it be giving us less than we already have? On their view, it's a win-win situation. People who don't have coverage now can hardly be worse off by getting coverage they don't have, and if it isn't all they could wish for or desire, well, they are still better off than they are now. And people already covered by insurance should have no worries, because giving coverage to other people can't possibly harm them. What are we, envious of the good fortune of the presently unfortunate?

There are enormous problems with this line of reasoning, starting with the fact that there is more reason to believe that under the new bill even the people presently using Medicare would have their benefits restricted more, and restricted by invidious criteria such as whether or not they have dementia or their quality of life. Here is just one example of restrictions on benefits: As this analysis--with quotations from the law--shows (read point #1), readmissions for particular conditions will not be paid for until and unless a hospital has discharged a certain number of other patients within a certain period of time for that same condition! This is apparently not a regulation presently in place, and this is therefore new rationing of the most blatant kind. So the "win-win" implication is highly dubious right from the get-go. Update: (8/13/09) On this particular point and on further study of the bill, I have decided to correct the details of John David Lewis's analysis here. It appears that the way the rationing would work, rather, would be that the government would have an abstract and complex ratio worked out for how many readmissions for that condition the hospital had in excess of the "expected" readmissions. The hospital would then be penalized for that excess by having its payments cut for the year as a whole by a particular sum of money worked out, again, in an abstruse fashion by the bureaucrats. This is a slightly different mechanism from the "discharging a certain number of other patients" mechanism Lewis implies, but it still is, obviously, direct rationing of readmissions. It motivates hospitals by punishment not to readmit patients.

Moreover, as the same analysis shows (point #3), catastrophic-only policies, such as some prudent and non-wealthy Americans presently have (I know some myself), appear to be outlawed altogether. So if that's your plan, you will certainly have to drop it. And (see point #4) employers will be pushed toward dropping employer coverage and pushing people into the "public option," because the tax the employer has to pay if it does not cover its employees for health insurance will often be less than paying for the present health insurance benefits.

But the problems with the liberal win-win assumption, which is just a variation on the perennial problem in which liberals make false "all else being equal" assumptions, seem to me to go even farther than that.

To see why, let's start with something that Investors Business Daily brought up--the question of enrolling new people in an insurance plan after the new law goes into effect. As reported here, IBD noticed that the bill outlaws, somehow, enrolling new members in health insurance plans after the bill goes into effect. This point was to some degree corrected and finessed by the Heritage Foundation, here, by pointing out that what is actually outlawed is enrolling new members in plans other than "health care exchange" plans. So insurance companies can enroll new members after the law goes into effect, but they can only enroll them in plans that conform to heavy new federal regulations.

The Heritage Foundation rightly points out the heavy costs and economic problems with these regulations. What they don't expressly mention is this: The benefits packages of insurance programs in the health care exchange are set by the same committee that sets the benefits package for the "public option" (the federal health care for people without any insurance), and they appear to be set in such a way as to be identical to the parallel public option plans (with names like "basic," "premium," and "premium plus"). What this means, as far as I can see, is that once the legislation is in effect, all private insurance companies will be able to enroll new people only in plans that are exactly the same as the similarly-named government plans in terms of benefits--clones, in fact, of the government plans, with benefits decisions being made by the very same people that decide the benefits levels, etc., for government plans. In other words, "private" insurance will be indistinguishable from "public option," by regulation.

Now, one could argue that the insurance plans can cover people at higher levels if those people happened to be enrolled in the plan before the new legislation goes into effect. But that is enormously unlikely. And it is also enormously unlikely that employers would cover old employees differently from new employees. The union negotiators would not allow it, if nothing else. I cannot imagine that Blue Cross Blue Shield of Michigan (my insurance company) will continue ad infinitum to maintain a separate plan with better benefits operating on "old" rules--which, however, are dying out in the nature of the case because they can't enroll any new customers--for people like me who happened to be enrolled before Year One of Obamacare while setting up an entirely different, heavily regulated plan for all new enrollees. Obviously, they will just accept Health Care Exchange status for their present plans and conform them to the new regulations.

The only real question is this: Are the benefits settings for health care exchange plans minimum requirements or maximum? Liberals seem to assume they are minimum requirements. Even Obama's stumbling analogy to the Post Office and Federal Express seems to imply the same--that the private sector will still be allowed to offer better plans than anything the government is offering, and pay doctors accordingly, if they can get people to buy them. But I have my serious doubts. Let's look at some of the language of section 203 of the bill. To see the full language of the bill at this point, you will need to go to section 203. Under the "public option," the bill already has three levels of coverage, called "basic, enhanced, and premium." The benefits for these plans under the "public option" are set by the Commission, as stated already in section 123 of the bill. That these are maximum benefits under the "public option" is not in question--the whole point of having the commission set these benefit levels under the public option is to define what people are entitled to and to place some limitation on this entitlement. The new plan is going to break the bank as it is.

Now, when it comes to the exchange participating plans (that is, the only private plans that will be allowed to enroll new members after the law goes into effect), here is some of the language:

(A) IN GENERAL- A basic plan shall offer the essential benefits package required under title I for a qualified health benefits plan.

(3) ENHANCED PLAN- A enhanced plan shall offer, in addition to the level of benefits under the basic plan, a lower level of cost-sharing as provided under title I consistent with section 123(b)(5)(A).

(4) PREMIUM PLAN- A premium plan shall offer, in addition to the level of benefits under the basic plan, a lower level of cost-sharing as provided under title I consistent with section 123(b)(5)(B).

The appearance here is very much that these plans are being set up as clones of the public option plans. But there is more evidence to that effect when it comes to the supposedly gold-plated "premium plus" plans:

(5) PREMIUM-PLUS PLAN- A premium-plus plan is a premium plan that also provides additional benefits, such as adult oral health and vision care, approved by the Commissioner. The portion of the premium that is attributable to such additional benefits shall be separately specified. [Emphasis added]

Do you see that? The only mention of the possibility that private plans might offer additional benefits not included in the government plan specifies that such additional benefits have to be approved by the Commissioner. I cannot see any way to interpret this except that the benefits levels otherwise are maximum benefits levels and that any way in which the benefits in the private sector are better than those in the public sector must be pre-approved by the government bureaucrat in charge of the system as a whole. And the examples given, vision and dental care, are pretty minimal thus far. The idea that the entire high quality of the health care system (not rationing re-admissions, not limiting physician payments, and so forth) might be carried by such extra benefits and might be allowed by the Commissioner, is highly, highly dubious. And in any event, when the extra benefits of ostensibly private plans require the permission of a government bureaucrat before they can even be offered, this is hardly a continuation of business as usual beyond some government-guaranteed minimum!

But there's more evidence that the government will set a ceiling as well as a floor to private packages. In section 203b it is specified that the exchange-participating entities may not offer more than one plan of each kind in a defined "service area." This certainly looks like a limitation on competition. It appears that the Commissioner will be able to guarantee that there are only a limited number of "private" plans (the scare quotes are becoming increasingly appropriate) available for any given area, which certainly calls into question the idea that people will simply be able to keep receiving insurance of the kind they already have without any benefit limits set by the government.

But there is still more evidence. At the end of section 203, there is a paragraph on state-mandated benefits which may go beyond federally mandated benefits. One might think this section irrelevant to the question at issue, but it isn't.

(d) Treatment of State Benefit Mandates- Insofar as a State requires a health insurance issuer offering health insurance coverage to include benefits beyond the essential benefits package, such requirement shall continue to apply to an Exchange-participating health benefits plan, if the State has entered into an arrangement satisfactory to the Commissioner to reimburse the Commissioner for the amount of any net increase in affordability premium credits under subtitle C as a result of an increase in premium in basic plans as a result of application of such requirement.

Why is this evidence that the government will be setting ceilings on coverage under private plans? Because when a state mandates coverage of benefits the federal government hasn't approved, the state has to pay the federal government the difference in premiums brought about by the additional required coverage. Think about that. This is supposedly talking about private plans. Why is the state having to pay the federal government the extra money rather than just paying the higher premiums to the private plans? After all, that's what the liberals are telling us it would be like for us individuals: If you can pay the higher premium, you can get a better plan, as good as you like. But this section makes it evident that exchange participating plans (the only ones allowed to enroll new members after the law goes into effect) have their premiums effectively capped by the federal government. The federal government enters into a contract which the Commissioner negotiates with the insurer to provide the coverage (this is spelled out in detail in section 204), and no provision is made for private people simply to pay more for whatever better coverage they can find. If additional coverage is required by the state, the state must pay the additional premium that coverage requires to the federal government, who presumably pays it to the insurance company with which it has entered into a contract. No similar provision is even made for private individuals, and in any event, the existence of the federal government as a middleman makes it absolutely evident that this is by no means business as usual. Think about it: Does the federal government contract with UPS and Fedex? In order to get a service from Fedex, do you have to pay the additional cost to the federal government who then passes it on to UPS, with whom it has a contract for offering mail services to the public? Of course not. This is nothing even remotely like private free enterprise, even in the supposedly private plans.

And since the federal government is negotiating the contracts, and since the exchange plans operate only under federal contract and by federal permission, the federal government will have every motive and full power for capping premiums and hence capping benefits.

It seems to me that the case is very strong: So-called private plans that can enroll new members under Obamacare will not be permitted to compete simply by offering better benefits than the government plan offers, with such benefits paid for by willing individual customers or even employers.

So I don't think you'll be able to keep your insurance, or your health care system, for that matter, even if you like it.

Disclaimer: I am not a lawyer, nor do I play one on the Internet. This is entirely my own analysis, except for the portions expressly noted as coming from other people. It makes me a tad nervous that no one else has said already what I am saying here, and I am open to correction. But the more I look at the bill itself, the more convinced I am that I am right.

Obamacare post

I don't know how many of these I will do. The whole thing is very discouraging.

First, here are links to some of my comments and one post about the end-of-life counseling provision in Obamacare. No, it's not technically mandatory. Yes, it is very disturbing, especially given that the doctors initiate it and that there is no doubt at all that doctors will be pressured to keep costs down. Here I want to link again, as I do in one of the comments, to a post Wesley Smith did on a "model" advance directive. It is as objectionable as can be. The default language has the patient refusing artificial nutrition and hydration and even consenting to be experimented on. The patient must cross out anything he doesn't want; otherwise when he signs it becomes ostensibly "his wish." This is beyond all doubt the kind of thing that would be used in these doctor-initiated counseling sessions. Much too complicated for people to be left to get together with a family lawyer and write their own, you know!

In my comments here I note that Charles Lane of The Washington Post, while doing us a service in pointing out the non-benignity of the end-of-life counseling, has probably even underestimated the danger, since he shows no understanding of what it means to refuse nutrition and hydration.

In my comments here I talk about David Blumenthal and Ezekiel Emmanuel, already very important advisers to the Obama admin on healthcare, and their panting and drooling desire to ration care and to get physicians to stop worrying about that pesky and costly Hippocratic oath. This is especially important, because Section 123 of the Obamacare Bill (yes, I just read the section myself, in case you are wondering) sets up a committee that will have the power to decide on what benefits will be covered by the government health care plans and also by "private" plans that are brought under government control through the "Health Care Exchange" (sections 201-203). Anyone who cannot see that a) such a committee, including its commissioner, will be staffed by the likes of Blumenthal and Emmanuel and that b) this committee will have enormous power over health care in America once this bill passes is just simply a fool.

More later. I hope this is informative and helpful as far as it goes. Sorry for all the links.

Be careful what you pray for

I've been watching on Facebook recently as some friends (who almost certainly don't read this blog, and who are unknown to anyone who does read this blog) advocate Obamacare. I've kept my mouth shut. I'm not overwhelmingly surprised to see them do so, for various reasons, just a bit inclined to sigh. One of them said, "If Obama thinks he can do better, why not let him have a shot at it? It can't be worse than it is." How is one to respond to such a comment? Obama--like a kid with matches and gasoline. But hey, if he thinks by lighting the gas in the middle of the living room he can improve the decor, why not let him have a shot at it? It can't be worse than it is.

Sigh.

They should be careful what they wish for. They might get it. So, for the "can't be worse than it is" file, here is a story of the experience one family had with the wonders of socialized medicine up north in Canada. Short version--their daughter had to wait for hours with a horribly broken arm while stony-eyed receptionists made them stick to their place in line behind the sore throats. Then she was put on morphine for hours. Then she was sent immediately into surgery, where the combination of morphine for hours followed immediately by general anesthesia nearly killed her. She survived and is fine now, but none of it should have happened.

I do really wish that people who want to go in with an axe, or let our Reckless Reformer-in-Chief go in with an axe, and "try to make things better" would stop a little and count their blessings first.

HT VFR