07 December 2011

Beyond the Mandate -- Why ObamaCare Matters

There was an op-ed in the LA Times written by one Ms Ward, a woman with breast cancer. It's well worth reading, and I'll quote some of it here, but the whole thing is worth the read:

I want to apologize to President Obama. But first, some background. 
I found out three weeks ago I have cancer. I'm 49 years old, have been married for almost 20 years and have two kids. My husband has his own small computer business, and I run a small nonprofit in the San Fernando Valley. ... With the recession, both of our businesses took a huge hit — my husband's income was cut in half, and the foundations that had supported my small nonprofit were going through their own tough times. We had to start using a home equity line of credit to pay for our health insurance premiums (which by that point cost as much as our monthly mortgage). When the bank capped our home equity line, we were forced to cash in my husband's IRA. The time finally came when we had to make a choice between paying our mortgage or paying for health insurance. We chose to keep our house. We made a nerve-racking gamble, and we lost. 
... If you are fortunate enough to still be employed and have insurance through your employers, you may feel insulated from the sufferings of people like me right now. But things can change abruptly. If you still have a good job with insurance, that doesn't mean that you're better than me, more deserving than me or smarter than me. It just means that you are luckier. And access to healthcare shouldn't depend on luck. 
Fortunately for me, I've been saved by the federal government's Pre-existing Condition Insurance Plan, something I had never heard of before needing it. It's part of President Obama's healthcare plan, one of the things that has already kicked in, and it guarantees access to insurance for U.S. citizens with preexisting conditions who have been uninsured for at least six months. The application was short, the premiums are affordable, and I have found the people who work in the administration office to be quite compassionate (nothing like the people I have dealt with over the years at other insurance companies.) It's not perfect, of course, and it still leaves many people in need out in the cold. But it's a start, and for me it's been a lifesaver — perhaps literally.

It hits home, for obvious reasons, but it's also important for another reason. So much of the battle over ObamaCare has focused on the Greatest Threat to Liberty Since Slavery, the individual mandate. It's utter, cynical, opportunistic bullshit, of course, since for years and years the mandate was the conservative counterproposal to further-reaching liberal plans. But after the PPACA passed, it was the only legal line of attack conservatives could find, and so here we sit, wondering what the most powerful man in America, Justice Anthony Kennedy, will do.

Will he strike down the entire law? Will he sever the mandate and leave the rest of the law? I have no clue. (I am assuming that the rest of the court will vote in their partisan blocs. Surprise me, guys!) But whenever this comes up in the media or in discussion, the flash point, the focus of the debate is the evil or awesome individual mandate.

What gets forgotten, though, is how much more is in the law than the mandate. While most of the attention during the drafting of the law rightly went to the plight of the uninsured and the near-universality of the coverage, much and more of the law was devoted to root-and-stem health insurance reform.

Reforms that help women like Ms Ward. Without the high-risk pool the PPACA established, she would be without any relief. State high-risk pools are unsubsidized and the premiums are unaffordable. The only reason this program is feasible is because it is temporary -- a bridge to 2014 when the insurance exchanges go into place, along with other critical insurance regulations.

Why does this matter? Because people like Ms Ward are in the individual market, and insurers individually underwrite each applicant -- and refuse those who are bad risks. Come 2014, every individual policy will have to go through each state's health insurance exchange, and they must conform to a number of new requirements. They cannot refuse any applicant. And they may no longer charge different premiums for patients with varying health histories, a feature called "Community Rating."

This is, it must be understood, how large insurers currently work. If you go work for Boeing, they don't ask you before you are hired whether your wife has breast cancer. All employees get charged the same, and the premiums for the entire pool adjust to cover the aggregate cost. All the PPACA does here is bring the same rules that the group market already works under to the individual market. And that's huge for so many people.

This is just one bit of the law that really matters to people, and that really will make the difference in the lives of so many Americans. And there is so much more. The requirement that insurers must spend 80% of premiums on actual healthcare. The prohibition on insurance "takebacks," or recissions. The expansion of coverage for kids. The requirement that premium increases must be reasonable and justified. Increased funding for primary care and community health clinics. And on and on.

So the next time you are inclined to go off on a spittle-flecked rant over the individual mandate (and I've emitted a few of my own), just pause and take a moment to remember that there is a lot more in this law than the mandate. I'm not going to persuade anybody who's already formed an opinion that the mandate really is good policy, but maybe I can remind them that a nuanced view of the law might be in order. It's not black and white. Regardless of the fate of the mandate, we should all be hoping that Justice Kennedy lets the rest of the law stand.


  1. Perhaps only tangentially related, but this reminds me of this:

  2. Wasn't watching this as closely as I should be. I thought the only up before the Supremes was the mandate, didn't know striking down the whole thing was even an option.

    Also, as someone who has paid for my family's insurance directly rather than through an employer for most of the past ten years I have to point out that this woman either has an amazing mortgage or was getting the worst deal ever on insurance. At no time were the premiums for my family (me, wife, two kids) more than a quarter of our mortgage.

    Have to watch read more about the actual case and the possible decisions. Striking down the whole thing would be likely to cause a fair amount of chaos.

  3. Up = option.
    Also should be an "and" near the beginning of that last paragraph.

    I really shouldn't post from the tablet. Thumb typing is not my forte.

  4. -Anyone know the technical details regarding HIPAA, continuous coverage, and catastrophic plans?

    I sympathize with this woman's plight but can't help but wonder if switching to a less expensive plan with the same insurer or obtaining an individual catastrophic plan prior to the onset of the illness would have enabled her to maintain coverage without foregoing insurance all together - even without community rating and the individual mandate.

  5. You forgot to mention that employer based insurance only works the way it does because of government regulation. It's illegal to ask an potential hire about his/her health status. Also, in order for health benefits to be non-taxable they must be nondiscriminatory. Meaning, a company can't have one health plan for the managers and another for the secretaries if they want health benefits to be non-taxable to the managers.

    26 USC Section 105

    "(4) Nondiscriminatory benefits
    A self-insured medical reimbursement plan does not meet the requirements of subparagraph (B) of paragraph (2) unless all benefits provided for participants who are highly compensated individuals are provided for all other participants."

  6. VinceRN, I don't know where you live or who lives in your family, but as someone that had to pay for coverage for my family of 5 for a while last Jan while my husband was laid off and trying to start his own business, I can tell you it was as much as our mortgage payment. I was working registry which meant that I had no health care benefits to roll my family on to.

    COBRA coverage for the whole family was twice our mortgage. My husband was diagnosed with high blood pressure right before his place of employment closed (go figure, your employer is swirling the drain, you might be a bit stressed and trying to get all your med visits in before the shit hits the fan) and he was flat out denied coverage. He went on COBRA for just himself, and the rest of us had a bare bones policy that included well child care for the 3 kids.

    The idea that you might have to choose between paying the house note or paying insurance doesn't seem unreasonable to me.

    He ended up taking a good position with great health benefits. The downside is that his plan for his own business was abandoned purely due to the economics of being self insured. We could have floated with my income and his new business income . It would have been tight, but it could have been done. Health care costs tipped us into the deep red.

  7. @Sherry Nelson - I live in western Washington, and worked agency most of my career, though I don;t at the moment. Through Blue Cross the most I ever pain was under $600 for my wife and I and our two kids.

    I just checked through the same company I used (biggest in this area I think) and they have two plans that are in that same price range for my family today.

    Certainly there are plans you can spend a couple grand a month on, but it's not really wise to do that. Plans are more expensive if you smoke, the answer to that is don';t smoke. Plans sometimes more expensive if you are going from uninsured into a new plan, so plan ahead, or act fact if you loose a job, at worst you have to make one COBRA payment.

    I had a high deductible plan that qualified me for an HSA which I put enough into to cover the expenses I figured we'd have. then had some cash set aside to cover the deductible in case of disaster.

    We could easily go back to this plan and be fine. We have the same doctors no unbder an employer plan that we had under the individual plan, and if we go back to the individual plan we would still have the same ones.

    I have found that with a little shopping, and being prepared, the individual health insurance market is no wehre near as bleak as it's often painted.

    We had our two daughters, one of whome spent a couple days in the NICU, on individual insurance. My wife had gall bladder surgery under it. We have had ER visits for stitches and other stuff, all with no problems.

  8. VinceRN -- My mom lives in the northwest, has a history of Stage 1 breast cancer 8 years ago, never a lapse in insurance and pays $550/month for a 5k deductible plan. She has shopped around extensively and even tried to get into the states high risk pool (can't because she has never been uninsured)

    In some states you cannot get high deductible insurance. Too many things (like infertility and chiropractic care) are required by law to be covered. (New York, for example.) A family of 4 cannot get basic health insurance for $600 in New York on the private market.

  9. Wow, nice baby with the bathwater speech. It is just that. I'm getting tired of pointing out you're better than this. Please stop proving me wrong.

    I believe the individual mandate to be unconstitutional (and you better pray it is found as such, or the Commerce Clause will be a buzzword for people who've never ever been political their whole lives for an unpleasant-to-you reason), and,

    If these individual parts of the law are Such a Great Thing, let's pass them on their own.

    No gigantic overweening mass of regs, just one at a time, time to look at them (I seem to recall a presidential candidate promising all legislation online for days prior to a vote, a promise, BTW, he was Constitutionally unable to keep, an odd breach for a Constitutional Scholar), and if they pass muster individually, pass them. If not, don't.

    If you have to bury some good stuff in the Pile of Crap, it's probably not a pony.

    (And for those who Truly Believe it's okay to trample some rights to get this as the law of the US, let's talk Patriot Act: there's probably a couple of gems in that coal shaft, right?)

  10. Allen,

    I call bullshit. You complain about the process (the bill's too big! we don't know what's in it! It's got some bad stuff!) when it was your team (or at least the other team) that poisoned the well to begin with.

    I remember 2009 very clearly -- and I remember the absolute and complete obstructionism the GOP tactically chose to pursue. There were zero -- zero -- compromises they were willing to make. Remember the gang of Six? Remember how the Dems allowed the process to last all the way through the summer hoping that the GOP's leaders or moderates would participate in a collaborative process and come up with a consensus bill? Remember how *pissed* liberals were at the limited, conservative nature of the bill and the way dozens of liberal priorities were pre-conceded? Remember how the GOP *all* walked away and decided they would rather not hand Obama this sort of victory because it would make him more likely to win re-election? 'Cause I do.

    There were many alternatives to the bill that ultimately passed. Some of them were much better. (remember wyden-bennet?) Maybe if the GOP had actually come to the table and -- yes, I know this is crazy talk -- made some compromises, then the final bill would have been better. Yes! The GOP could actually have improved a democratic bill! I am saying this.

    But they didn't. So the dems had to cater to assholes like Ben Nelson (remember the Cornhusker kickback?) and Joe Lieberman to get through a very imperfect bill. And they had to do it in a frenzied, hyper-partisan atmosphere that THE GOP CREATED. In that craziness, I am sure shit got slipped in through error or deliberate assholery. If the GOP leaders had put country ahead of party, I am sure the outcome would have been better.

    So please don't give me your condescending "you're better than this" shit.

  11. I have always been a strong conservative/libertarian. But time in Afghanistan changed my opinion about healthcare. We often risked our lives to help people get basic care-I lost 4 good friends on a simple mission to bring a doctor and vaccines to a village high in the mountains. With the opportunity to do it over again, we would do the same thing. War is horrible but it makes things more simple. If many of us literally risk our lives to bring healthcare to the children of people who try to kill us, then why can't the richest country in the history of the world find a way to bring healthcare to all of its citizens? Sadly, I don't have a good solution as to how, but I figure if we can fight for it then someone can honor that enough to figure it out.

  12. Shadowfax, I call hypocrite. The individual mandate is necessary and consititutional? If the Supreme Court is to uphold this nonsense, then the government can mandate that we purchase what ever they tell us to? Really? I hope the next Republican Congress mandates that all Americans purchase handguns. Wait, a minute? This is not acceptable to you? You wouldn't want the government to tell you to protect yourself, your family and your house with a gun? I didn't think so - for this reason you and all your liberal friends are complete hypocrites. There are 13 enumerated powers of Congress outlined in the Constitution - read them. None of them gives Congress the power to tell me what to buy.

    Now that I got that off my shoulders, lets address the other nonsense that is in this abomination. "Insurance companies must spend 80% of all premiums" - Otherwise known as the MLR (Medico Legal Ratio I believe) which is currently why so many companies have been forced to ask for waivers. Companies that hire high school/college students (and others) and provide health care USED to be able to afford the mini-med plans for otherwise healthy employees. These were low cost, low usage plans that are now subject to enormous fines under the Patient No Protection and Unaffordable Care Act. Hence the waivers, otherwise these businesses would go out of business. The original intent was to "stick it" to those rich, nasty, mean insurance companies, but as usual, dumbacrats seem to be completely blind to the unintended consequences. The fact that the federal government stops funding the new Medicaid exchanges after 2016 makes the whole bill look "affordable," but who is responsible after that? That's right, all the bankrupt states who cannot afford all the people CURRENTLY on Medicaid! Several surveys have shown that 40% of businesses are going to dump their plans and put their employees in the exchanges - how the hell are the states going to pay for all the people they already can't afford, plus all the NEW people? The original Obamacare estimates were that 10% of employers would dump their plans. That's a little lower than 40%. Then again, liberals were never very good with math. Preexisting conditions? This has to be the biggest joke of them all. If the medicaid exchanges cannot refuse me for having any preexisting conditions, then I intend to fully wait until I get sick and then sign up for coverage. Why should I pay for something that I don't have to buy until I need it? Oh that's right, that's the reason for the individual mandate. If I HAVE to buy it then the system won't collapse due to all those sensible people who will wait until they really need it. For this reason, if the mandate is deemed unconstitutional, the whole thing falls apart. You should not only be worried about Kennedy, but Kagan who MUST recuse herself due to her role in getting this disaster passed. Oh yeah, and the dumbacrats were too stupid to put in a severability clause that would have allowed the whole bill to stand if the mandate were deemed unconstitutional.

  13. continued...

    Lastly, say what you will about Republican opposition and stonewalling, at least they did it under approved parliamentary rules. I believe the dumbacrats used "reconciliation" for a non-budgetary matter, the whole "deemed passed" to avoid having the bill go to the committee of conferees, and to avoid them having to vote on matters they would never approve. Having to bribe Nelson and Landrieu with the Cornhusker Kickback and the Louisiana Purchase. The Republicans did present multiple bills, none of which were acceptable to the dumbacrats. I also recall a certain conference with Republican and dumbacrat leadership, as well as the Blamer in Chief refused to listen to the Republicans (I believe that was where the famous, "John, I won" quote came from - very mature Barry, very mature). I also recall he scolded one of them for actually bringing a copy of the bill with them to demonstrate the monstrosity that it was (and is). As I also recall the majority of Americans did not want this shoved down their throat either, as evidenced by pretty much every poll (not run by MSLSD or Daily Kos) before the bill was passed, as well as the elections of 2010 which the dumbacrats refuse to acknowledge as backlash against obamacare. Contrary to what the liberal regressives think, Americans are not dumb.

    BTW, shadowfax, will you buy a Browning or Smith & Wesson? Just curious.

  14. Obamacare will lead to a single-payer environment, and I've seen the end of that road. About 15 years ago, my mother slipped on some ice and broke her arm. She went to the ER, got X rays and a cast, her insurance paid. She was still too young for Medicare.

    She went to Rome, tripped on the ruins, and broke her other arm. It was a nasty spiral fracture that required surgery. She was admitted to the osteo ward.

    They were very impressed with her water-activated fiberglass-epoxy cast. They couldn't afford such a thing; she got a cheesecloth and plaster cast. Everyone felt sorry for her because she didn't know to bring her own pajamas. The hospital couldn't afford to provide a robe (joke about hospital robes all you want, folks, but making sure patients are dressed in sterile clothes is an important infection control measure, as I'm sure Shadowfax knows full well). She didn't know to bring her own silverware, and was left to eat a steak dinner with a single disposable plastic fork. The hospital couldn't afford stainless flatware for the patients. People were screaming in pain all night (the hospital couldn't afford painkillers). She rang the nurse and asked for water. The nurse felt so bad for her that she went and paid with her own money to get my mom a bottle of water. Everyone else knew to bring their own water, since either couldn't or wouldn't provide it. She asked when she would get surgery. "We don't know, dama; the surgeon only comes in three days a week. Maybe you'll be on the list." She wasn't, not that time, or the next, or the next. She asked the rest of the patients in her ward how long they'd been waiting for surgery. The short-timer (other than my mom) had been waiting six weeks. Everyone else had been waiting longer.

    She came home to the US, and was operated on within a day or two.

    My wife and I are uninsured. We have some health problems. Insurance is currently out of our reach. But I dread Obamacare.

  15. ER docs need to make a choice. If health care is a privilege of those with the money to pay for it, we need to fight to repeal EMTALA and send home anybody who cannot pay.

    Conversely, if we don't want to deny essential care to people who need it, we need to ensure they get it. Any system that accomplishes this is a form of universal health care.

    But if we don't want to make a clear choice, then patients will have no choice, and we should stop complaining if they come to the ER.


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