The Moral Healthcare Blog

Health Reform Implementation Timeline – Kaiser Family Foundation

This is a TERRIFIC summary of the Health Reform Bill.

I challenge anyone who has been against this bill to read this and tell me that this is a bad thing.

I am reaffirmed in my faith in government to do good things, as TR said,

“The poorest way to face life is to face it with a sneer. There are many men who feel a kind of twister pride in cynicism; there are many who confine themselves to criticism of the way others do what they themselves dare not even attempt. There is no more unhealthy being, no man less worthy of respect, than he who either really holds, or feigns to hold, an attitude of sneering disbelief toward all that is great and lofty, whether in achievement or in that noble effort which, even if it fails, comes to second achievement.”

O’Neill Institute » Legal Solutions in Health Reform » The Constitutionality of Mandates to Purchase Health Insurance

Paper Summary
Health insurance mandates have been a component of many recent health care reform proposals. Because a federal requirement that individuals transfer money to a private party is unprecedented, a number of legal issues must be examined.
This paper analyzes whether Congress can legislate a health insurance mandate and the potential legal challenges that might arise, given such a mandate. The analysis of legal challenges to health insurance mandates applies to federal individual mandates, but can also apply to a federal mandate requiring employers to purchase health insurance for their employees. There are no Constitutional barriers for Congress to legislate a health insurance mandate as long as the mandate is properly designed and executed, as discussed below.
This paper also considers the likelihood of any change in the current judicial approach to these legal questions.
Download the Executive Summary (2pp.)
Download the Paper (25pp.)

About the Author
Mark A. Hall, J.D., is the Fred D. and Elizabeth L. Turnage Professor of Law and Public Health at Wake Forest University School of Law and School of Medicine. He is also an Associate in Management at the Babcock School of Management, all of which are located in Winston-Salem, NC.

And, courtesy of Scott R. of DFA,

“Some of my libertarian friends balk at what looks like an individual mandate. But remember, someone has to pay for the health care that must, by law, be provided: Either the individual pays or the taxpayers pay. A free ride on government is not libertarian.” – Mitt Romney, 2006

Think Progress » Catholic nuns break with bishops and urge passage of health care reform.

Ok, the nuns are for it:

The health care bill that has been passed by the Senate and that will be voted on by the House will expand coverage to over 30 million uninsured Americans. While it is an imperfect measure, it is a crucial next step in realizing health care for all. It will invest in preventative care. It will bar insurers from denying coverage based on pre-existing conditions. It will make crucial investments in community health centers that largely serve poor women and children. And despite false claims to the contrary, the Senate bill will not provide taxpayer funding for elective abortions. It will uphold longstanding conscience protections and it will make historic new investments – $250 million – in support of pregnant women. This is the REAL pro-life stance, and we as Catholics are all for it.

So is the Catholic Health Association and prominent Catholic and Evangelical scholars.

What’s up with those darned Bishops?

Go to the ThinkProgress link at the top for all the links.

T.R. Reid – Universal health care tends to cut the abortion rate

Increasing health-care coverage is one of the most powerful tools for reducing the number of abortions — a fact proved by years of experience in other industrialized nations. All the other advanced, free-market democracies provide health-care coverage for everybody. And all of them have lower rates of abortion than does the United States.

This is not a coincidence. There’s a direct connection between greater health coverage and lower abortion rates. To oppose expanded coverage in the name of restricting abortion gets things exactly backward. It’s like saying you won’t fix the broken furnace in a schoolhouse because you’re against pneumonia. Nonsense! Fixing the furnace will reduce the rate of pneumonia. In the same way, expanding health-care coverage will reduce the rate of abortion.

One of the commenters posted a useful link from the BBC on abortion rules in Europe.

Slate: Why Stupak is Wrong

Slate: Why Stupak is Wrong
Because this keeps coming up and needs addressed, Slate’s Timothy Noah explains:

“If you go to Page 2069 through Page 2078 [of the Senate bill],” Stupak told George Stephanopoulos on March 4 on Good Morning America, “you will find in there the federal government would directly subsidize abortions, plus every enrollee in the Office of Personnel Management-enrolled plan, every enrollee has to pay a minimum of one dollar per month toward reproductive rights, which includes abortions.” Stupak is here referring to the exchanges created under health reform and to a nonprofit plan managed by the Office of Personnel Management that would be sold through the exchanges. The latter was a consolation prize to supporters of a public-option government health insurance program that didn’t make it into the bill.
Let’s go to Page 2069 through Page 2078 of the Senate-passed bill. It says, “If a qualified plan provides [abortion] coverage … the issuer of the plan shall not use any amount attributable to [health reform’s government-funding mechanisms] for purposes of paying for such services.” (This is on Page 2072.) That seems pretty straightforward. No government funding for abortions. (Except in the case of rape, incest, or a threat to the mother’s life—the same exceptions granted under current law.) If a health insurer selling through the exchanges wishes to offer abortion coverage—the federal government may not require it to do so, and the state where the exchange is located may (the bill states) pass a law forbidding it to do so—then the insurer must collect from each enrollee (regardless of sex or age) a separate payment to cover abortion.
The insurer must keep this pool of money separate to ensure it won’t be commingled with so much as a nickel of government subsidy. (This is on Pages 2072-2074.) Stupak is right that anyone who enrolls through the exchange in a health plan that covers abortions must pay a nominal sum (defined on Page 125 of the bill as not less than “$1 per enrollee, per month”) into the specially segregated abortion fund. But Stupak is wrong to say this applies to “every
enrollee.” If an enrollee objects morally to spending one un-government-subsidized dollar to cover abortion, then he or she can simply choose a different health plan offered through the exchange, one that doesn’t cover abortions. (Under the Senate bill, every insurance exchange must offer at least one abortion-free health plan.)
One dollar exceeds health insurers’ actual cost in providing abortion coverage. In fact, it’s entirely symbolic. The law stipulates that in calculating abortions’ cost, insurers may consider how much they spend to finance abortions but not how much they save in foregone prenatal care, delivery, or postnatal care. (This is on Pages 2074-2075.) This is to keep insurers from pondering the gruesome reality—one they surely know already—that covering abortions actually saves them money. For health insurers, the true cost of abortion coverage is less than zero, because hospitals and doctors charge less to perform abortions than they do to tend pregnant women before, during, and after childbirth. (Ironically, only the Senate bill—not the House bill—provides some small counterweight to this calculus by increasing aid for adoption assistance.)
What really rankles Stupak (and the bishops) isn’t that the Senate bill commits taxpayer dollars to funding abortion. Rather, it’s that the Senate bill commits taxpayer dollars to people
who buy private insurance policies that happen to cover abortion at nominal cost to the purchaser (even the poorest of the poor can spare $1 a month) and no cost at all to the insurer. Stupak and the bishops don’t have a beef with government spending. They have a beef with market economics.

Physician Incomes Internationale

Responding to my post about doctors stepping up for health reform over at FireDogLake, wigwam linked to a couple great pieces from the NY Times. ( I have a Google Alert on “physicians salaries incomes,” so I don’t know how I missed them, but, here they are now.)

In order, Uwe Reinhardt pointed out in a post about Rationing Doctors’ Pay

When Medicare reduces its payments to doctors, it rations money to them. It does not directly ration the health care the doctors might render patients.

If physicians refuse to treat patients at the lower fees, it is they who ration health care, even if the incentive to do so came from Medicare.

While I doubt that the payments to radiologists and cardiologists actually will be cut by 21 percent soon — more on that next time — let us suppose it were so. Would there then be “few radiologists and cardiologists working” after such a fee cut?

Presumably, the afflicted physicians would withhold their services only from Medicare and Medicaid patients, assuming that private insurers pay more. But
could most radiologists and cardiologists actually earn an adequate livelihood only from privately insured patients? I have my doubts.

Like everyone else, radiologists and cardiologists certainly can claim to be sorely underpaid relative to the extraordinarily high compensation of bankers and corporate executives, which appears to have little correlation with contributions to society. But relative to their colleagues in internal medicine, pediatrics and family practice, radiologists and cardiologists actually are very well paid.

…

So even if Medicare cut fees of radiologists and cardiologists by 21 percent, the income of these specialists would still exceed that of their colleagues in primary care by 60 percent or more.

…

The only question then is whether such fee increases [for primary care] will come at the expense of taxpayers or from other parts of the health care sector, perhaps even the more highly paid medical specialties, including radiology and cardiology. That is a political call.

Reading through just a few of the comments revealed this gem:

As someone who is training to be a radiologist, I have mixed feelings about what you’re saying. While you are correct that Radiologists and Cardiologists do make more than primary care physicians, there is also a reason for that. Specifically, it is that when primary care physicians can’t figure something out, who do they turn to? SPECIALISTS. We train for MUCH longer than primary care docs (often times greater than twice as long) and this is the reason that we are paid more per RVU. We also have more responsibility; in fact, the levels of responsibility are worlds apart. While a primary care doctor can always turn to a specialist for help, we have no one to turn to… The buck stops with us, we are the final authority.

Wow. Sounds like our friend suffering amongst us “less skilled physicians” from last year.

Subsequently, CATHERINE RAMPELL cracked open the Congressional Research Service’s analysis of the OECD database to find out “How Much Do Doctors in Other Countries Make?”

As a country’s wealth rises, so should doctors’ pay. But even accounting for this trend, the United States pays doctors more than its wealth would predict.

According to this model, the 2007 report says, “The U.S. position above the trendline indicates that specialists are paid approximately $50,000 more than would be predicted by the high U.S. GDP. General practitioners are paid roughly $30,000 more than the U.S. GDP would predict, and nurses are paid $8,000 more.”

But it’s important to keep in mind, the report notes, that health care professionals in other O.E.C.D. countries pay much less (if anything) for their medical educations than do their American counterparts. In other words, doctors and nurses in the rest of the industrialized world start their medical careers with much less student loan debt compared to medical graduates in the United States.

Rampell also links to the MGMA report on American physician income, which you may find either eye opening or eye popping.

NEJM — Have Physicians Stepped Up for Reform?

NEJM — Medicine’s Ethical Responsibility for Health Care Reform — The Top Five List

The medical profession’s reaction has been quite different. Although major professional organizations have endorsed various reform measures, no promises have been made in terms of cutting any future medical costs. Indeed, in some cases, physician support has been made contingent on promises that physicians’ income would not be negatively affected by reform.

It is appropriate to question the ethics of organized medicine’s public stance. Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests — including their financial interests. None of the for-profit health care industries that have promised cost savings have taken such an oath. How can physicians, alone among the “special interests” affected by health care reform, justify demanding protection from revenue losses?

Dr. Brody makes some interesting points about physicians’ role in health care reform, including the general unwillingness of organized medicine to step up and make concessions on income or to vigorously work on the problem of practice variation.

He is only partially correct in his assessment of organized medicine’s advocacy role this time around. I think it is a real accomplishment, an unprecedented consensus, that the ten largest physician organizations have come out in support of the House Bill, which includes many very important reforms including the public option.

What amazes me is that this has NO currency in the media. Does anyone know this fact? Does anyone realize how monumental this should be? So regardless of whether organized medicine has made the right offers or concessions in this current debate, the fact that they have stood up, in many cases with much pushback from conservative members and advocated for health reform is a big deal.

Secondly, even if organized medicine’s endorsement of reform has not taken the form some of us would like (single payer, Bismarkian insurance), individual physicians, in surveys published in the NEJM have indicated overwhelming willingness to make a deal (i.e., accept a public option) and accept concessions.

a large majority of respondents (78%) agreed that physicians have a professional obligation to address societal health policy issues. Majorities also agreed that every physician is professionally obligated to care for the uninsured or underinsured (73%), and most were willing to accept limits on reimbursement for expensive drugs and procedures for the sake of expanding access to basic health care (67%). By contrast, physicians were divided almost equally about cost-effectiveness analysis; just over half (54%) reported having a moral objection to using such data “to determine which treatments will be offered to patients.

…the 28% of physicians who consider themselves conservative were consistently less enthusiastic about professional responsibilities pertaining to health care reform.

So i would differ with Dr. Brody’s assessment that physicians and organized medicine have not stepped up adequately.

The problem, as I see it, is that the media and the pro-reform contingent in Congress, have done an abysmal job of letting the public know that the people whose opinions they value most in this debate – physicians – are overwhelmingly in favor of reform.

What we see in the media are the conservative physicians in congress (Sens. Coburn and Barrasso, Congressman Boustany) who are ridiculously out of touch with mainstream physicians. Though in touch with the angry tea partiers and the admittedly sizable contingent of conservative American physicians (not accidentally all of these physicians practicing in high income specialties – ob/gyn, orthopedics and surgical subspecialties ), they do not represent the thinking of most physicians.

Furthermore, as Dr. Brody rightly points out, physicians have a higher duty to our patients than to our own narrow self interest. But here, again, physicians have acknowledged this in a formal way in the Charter on Medical Professionalism, published in 2004 by the American College of Physicians and endorsed by more than 50 major national and international medical organizations:

Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category

It seems pretty clear that physicians have answered the call, but somehow, in spite of opinion polling showing how highly the public values our opinion, nobody has noticed.

AlterNet: Ayn Rand, Hugely Popular Author and Inspiration to Right-Wing Leaders, Was a Big Admirer of Serial Killer

If you knew Ayn Rand was a bit whacked, you had no idea…

So what, and who, was Ayn Rand for and against? The best way to get to the bottom of it is to take a look at how she developed the superhero of her novel, Atlas Shrugged, John Galt. Back in the late 1920s, as Ayn Rand was working out her philosophy, she became enthralled by a real-life American serial killer, William Edward Hickman, whose gruesome, sadistic dismemberment of 12-year-old girl named Marion Parker in 1927 shocked the nation. Rand filled her early notebooks with worshipful praise of Hickman.

According to biographer Jennifer Burns, author of Goddess of the Market, Rand was so smitten by Hickman that she modeled her first literary creation — Danny Renahan, the protagonist of her unfinished first novel, The Little Street — on him.What did Rand admire so much about Hickman?

His sociopathic qualities: “Other people do not exist for him, and he does not see why they should,” she wrote, gushing that Hickman had “no regard whatsoever for all that society holds sacred, and with a consciousness all his own. He has the true, innate psychology of a Superman. He can never realize and feel ‘other people.'”This echoes almost word for word Rand’s later description of her character Howard Roark, the hero of her novel The Fountainhead: “He was born without the ability to consider others.”

Individual Irresponsibility in the President’s Healthcare Reform Plan

A response to the above titled post from “Health Leaders”

“The result is that nearly everyone will be “covered” whether they’re insured or not. They’ll be treated, and someone else will pay the cost. That’s the way it is now, and that’s the way it will continue to be if these bills pass—just under a different mechanism.”

And with considerably fewer uninsured to require that cost shifting. That’s the whole point, isn’t it? Less uninsured.

Look, a certain percentage of the population will always try to game the system, by paying the penalty rather than buying insurance. But even those people will stop that behavior as soon as someone in their family has an illness requiring more than a couple visits to the doctor. So, yes there are gamers, but most people want to do the right thing, I still believe.

“Premiums from commercial insurers will be sky-high, if commercial plans even continue to exist long-term.”

That’s not what the CBO says.

“What better way to get the deeply unpopular public option back in the mix in a few years?”

Except it isn’t unpopular, except with the Fox News crowd, who still think it is some sort of Sino-Soviet hybrid system.

And, just for the record, the 10 largest physicians organizations support reform with the option.

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