Sunday, November 01, 2009

HR676: Political Fool's Gold

In discussions around the blogosphere about HR3962, the House Health Care Bill, some individuals suggest that at 1990 pages it was simply bloated and used the 30 page HR676 (Single Payer) as a clean, easy, effective alternative. Which led me to wonder "How the Hell can you reform the entire U.S. Code as it relates to health care in 30 pages?" So I read the bill and found out that it is a mirage. HR676 is so far from a political starter as to be literally laughable. To see why I offer some language and interpretation.
One of the most fervent promoters of HR676 is Physicians for a National Health Program (PNHP) and who naturally have a web page with all kinds of resources for defenders, including of course a link to the full text of the bill. So as a public service I suggest people wanting to push back on my analysis start there:

What I propose is a section by section analysis of the bill in real terms at each point asking the question "How do you sell this?" I don't think you can, once you get beyond the aspiration of Universal Single Payer, one which I share fully, there really is nothing here. So---
(a) SHORTTITLE.—This Act may be cited as the ‘‘United States National Health Care Act or the Expanded and Improved Medicare for All Act’’.
(b) TABLEOFCONTENTS.—The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Definitions and terms
Sec. 101. Eligibility and registration.
Sec. 102. Benefits and portability.
Sec. 103. Qualification of participating providers.
Sec. 104. Prohibition against duplicating coverage.
Subtitle A—Budgeting and Payments
Sec. 201. Budgeting process.
Sec. 202. Payment of providers and health care clinicians.
Sec. 203. Payment for long-term care.
Sec. 204. Mental health services.
Sec. 205. Payment for prescription medications, medical supplies, and medically necessary assistive equipment.
Sec. 206. Consultation in establishing reimbursement levels.
Subtitle B—Funding
Sec. 211. Overview: funding the USNHC Program.
Sec. 212. Appropriations for existing programs.
Sec. 301. Public administration; appointment of Director.
Sec. 302. Office of Quality Control.
Sec. 303. Regional and State administration; employment of displaced clerical workers.
Sec. 304. Confidential Electronic Patient Record System.
Sec. 305. National Board of Universal Quality and Access.
Sec. 401. Treatment of VA and IHS health programs.
Sec. 402. Public health and prevention.
Sec. 403. Reduction in health disparities.
Sec. 501. Effective date.

Sec. 101: "(a) IN GENERAL.—All individuals residing in the United States (including any territory of the United States) are covered under the USNHC Program entitling them to a universal, best quality standard of care."

"(c) PRESUMPTION.—Individuals who present themselves for covered services from a participating provider shall be presumed to be eligible for benefits under this Act, but shall complete an application for benefits in order to receive a United States National Health Insurance Card and have payment made for such benefits."

Meaning that undocumented workers and people on student and work visas are covered fully. A further provision covers tourists and visitors but provides some vague language about reimbursement and payment by the home country.

(a) IN GENERAL.—The health care benefits under this Act cover all medically necessary services, including at least the following: (1) Primary care and prevention. (2) Inpatient care. (3) Outpatient care. (4) Emergency care. (5) Prescription drugs. (6) Durable medical equipment. (7) Long-term care. (8) Palliative care. (9) Mental health services. (10) The full scope of dental services (other than cosmetic dentistry). (11) Substance abuse treatment services. (12) Chiropractic services. (13) Basic vision care and vision correction (other than laser vision correction for cosmetic purposes). (14) Hearing services, including coverage of hearing aids. (15) Podiatric care. (b) PORTABILITY.—Such benefits are available through any licensed health care clinician anywhere in the United States that is legally qualified to provide the benefits. (c) NO COST-SHARING.—No deductibles, copayments, coinsurance, or other cost-sharing shall be imposed with respect to covered benefits."

I particularly like the "at least". Want weekly chiropractic and acupuncture visits? Designer prescription sunglasses? Six-months at the Betty Ford Clinic? You got it, and at ZERO out-of-pocket expense. Great for that undocumented landscaper with a bad back or for hypochondriacs, but ya think this might get kind of expensive overall?

(1) IN GENERAL.—No institution may be a participating provider unless it is a public or not-for-profit institution. Private physicians, private clinics, and private health care providers shall continue to operate as private entities, but are prohibited from being investor owned."

Sorry Walgreens and Payless, goodbye Perle Vision, and oh yeah if you want to open a mental health clinic anywhere be sure to able to finance it on your own. And don't make a profit on selling any product or service. What about existing institutions? Not to worry-Uncle Sam will compensate you for "reasonable financial losses incurred as a result of the conversion from for-profit to non-profit status. "

(a) IN GENERAL.—It is unlawful for a private health insurer to sell health insurance coverage that duplicates the benefits provided under this Act"

Subtitle A—Budgeting and Payments

The government pays for everything including construction of health facilities and all equipment.


All health care institutions get paid a single monthly payment. Physicians, dentists, pharmacists, optometrists, nurse practioners can either be salaried or get payment on a single set fee schedule. Which allows no variation because it will be established with the following criteria.

"(B) CONSIDERATIONS.—In establishing such schedule, the Director shall take into consideration the following:
(i) The need for a uniform national standard.
(ii) The goal of ensuring that physicians, clinicians, pharmacists, and other medical professionals be compensated at a rate which reflects their expertise and the value of their services, regardless of geographic region and past fee schedules."

"Subtitle B—Funding"

"(c) FUNDING.—
(1) IN GENERAL.—There are appropriated to the USNHC Trust Fund amounts sufficient to carry out this Act from the following sources:
(A) Existing sources of Federal Government revenues for health care.
(B) Increasing personal income taxes on the top 5 percent income earners.
(C) Instituting a modest and progressive excise tax on payroll and self-employment income.
(D) Instituting a small tax on stock and bond transactions. "

Okay we will tax the top 5 percent of income at some unknown rate plus payroll at some unknown but graduated rate plus a similar unknown transaction tax. Good luck to the CBO in scoring that. Because they'll need it.

Title III: Administration

Set up bureaucracy

Title IV: Other provisions


(a) VA HEALTH PROGRAMS.—This Act provides for health programs of the Department of Veterans’ Affairs to initially remain independent for the 10-year period that begins on the date of the establishment of the USNHC Program. After such 10-year period, the Congress shall reevaluate whether such programs shall remain independent or be integrated into the USNHC Program.
(b) INDIAN HEALTH SERVICE PROGRAMS.—This Act provides for health programs of the Indian Health Service to initially remain independent for the 5-year period that begins on the date of the establishment of the USNHC Program, after which such programs shall be integrated into the USNHC Program. "

Likely elimination of the VA system. Certain elimination of IHS.

Title V: Effective date

Except as otherwise specifically provided, this Act shall take effect on the first day of the first year that begins more than 1 year after the date of the enactment of this Act, and shall apply to items and services furnished on or after such date."

Oh yeah and we will get the conversion of the entire health care delivery system from for-profit to non-profit including all necessary buy-outs in a single year.

Sorry, this is not a serious policy proposal, this is an aspirational manifesto that would take the U.S. health system far beyond even the British NHS. Under this system only the ultra-rich could ever dream of having a private room or a private nurse, everyone else is reduced to the lowest common denominator. It is common to hear commenters saying "no one is contemplating a government take-over of the medical system" or "no one is proposing an NHS system". Well sorry this is exactly that. The only terms that describe a system that makes all for-profit delivery of all medical, dental, mental health, substance abuse, vision and long-term care ILLEGAL and further makes any private insurance supplements ILLEGAL would set off all kinds of rhetorical alarms.

Progressives come on! I don't care how much of a bleeding heart you may have but do you really want to go to the country on the platform of "We provided universal free coverage to all illegal immigrants while abolishing the VA hospital system, oh and the Pharmacy section at your supermarket. Vote for us!" This is not serious policy, this is just posturing for effect. This bill demagogues itself.


Anonymous said...

The Canadian federal legal framework is either 15 or 17 pdf pages...According to the Fraser Institute folks who follow the issue and who sent it to me last week.

rand dawson Siltcoos Lake Oregon

Bruce Webb said...

I suggest there is a big difference between a 'legal framework' and 'implementing legislation' where much of the text is devoted to adopting new language to existing U.S. Code.

A large part of H.R.3962 is devoted to "delete existing sec 1234 of the Blah, Blah, Blah Act of 1998 and replace it with ---" where the dashes represent new code language.

Plus I would have to look at such things as formatting. These bills are double spaced in large type with big indents on each numbered line. It is not as simple as "15-17" vs "1990".

Bruce Webb said...
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