Obamacare, and the word "essential"

This diary is a very difficult one for me to write. As a recent convert to the Obama camp from the Edwards camp, a
decision I made out of practicality not out of an actual preference, I am particularly troubled by what I see as a weak and poorly defined healthcare plan.

It was not my desire to write a hit diary, especially for the only remaining candidate who I believe has a real
opportunity to bring a progressive agenda to the Whitehouse. However, my personal top issue is healthcare, so, for me,
no examination of the available candidates can leave that particular stone unturned.

Now that I have upturned that stone and begun examining in detail what scurries away, I feel it's my duty to report my
findings to the Dkos community below the jump.

One of the biggest problems with health insurance is not just it's cost, or it's availability, or even exclusions for pre-existing conditions. It's what it does not cover and the arbitrary way in which coverage decisions are made. With half of all bankruptcies in this country being the direct result of healthcare costs including costs incurred by supposedly insured Americans, it is surely this element that is the most pernicious.

To that end, I decided to do a little digging. In researching all three of the front running democratic candidates plans I have found Obama's plan to be the weakest. While he will make available the Federal Employees Health Benefits Program to all Americans, if one looks at the plans contained within that program you see the same crooked organizations that have been ripping off and murdering Americans by spreadsheet for years.

These companies, all of them, systematically refuse payment or refuse full payment for treatable conditions often in direct conflict with the decisions made by attending physicians. This leaves the "insured" at the mercy of bean counters who's only real interest is in saving money, not in providing care.

As we saw in the case of Nataline Sarkisiyan, there is litterally no limit to how far they are willing to go to withhold coverage for medically necessary treatment. Indeed, if the patient dies, so much the better, as they won't have to deal with any further medical expenses.

Obama's plan will be "similar" to the FEHB program and states that "The plan will cover all essential medical services, including preventive, maternity and mental health care." The problem here is that little word "essential". Who determines what is "essential"? Indeed this same word can be found throughout insurance company healthplan literature today. It represents no fundamental shift from the current corrupt system to anything better. All this plan does that is different is to force insurance companies to accept all comers.

Since these are the same vampiric for-profit insurance mega-coroporations that we have today, we don't have far to look to get an idea how they are likely to react. Indeed, it seems likely that it will be business as usual except that since they now have to accept everyone, they will have to find some way to withhold benefits even more than they do now to insure that their profits are not reduced by loads of new high-risk clientelle.

If past is at all prologue, it's a pretty safe bet that will come in the form of denial of coverage for "non-essential" services. If a plan like this is to work, then the power to make the decision about what is essential or not must not be left in the hands of the insurance companies. I don't see anything at all in Obama's plan that addresses this issue.

Clinton's plan, conversely would make a plan modelled after traditional medicare available to all, and Edwards would simply expand actual medicare itself to be available to all. Traditional medicare has the distinction of managing costs BETTER (pdf file) than private insurance and leaving the decisions as to what is essential service in the hands of attending physicians rather than in the hands of for-profit corporate beancounters.

Barack Obama needs to be challenged on the details of his plan, specifically as regards how "essential" treatment is determined and by whom. That little word could be the difference between real reform and business as usual.

•  Vampiric for-profit insurance mega-corps

  Since these are the same vampiric for-profit insurance mega-coroporations that we have today, we don't have far to look to get an idea how they are likely to react. Indeed, it seems likely that it will be business as usual except that since they now have to accept everyone, they will have to find some way to withhold benefits even more than they do now to insure that their profits are not reduced by loads of new high-risk clientelle.

  That's the basic problem with all of the frontrunners' plans.

  The only thing that makes me favor Obama's is it doesn't force you to get into that corrupt game.  (And the insurance companies hate that.)

  by slaney black on Wed Jan 16, 2008 at 02:03:04 PM PDT

  •  Yeah all the way up until you get sick

    Then on top of your medical care costs you can get fined.

    The diarist is right the plan is weak.

    by cwaltz on Wed Jan 16, 2008 at 02:14:47 PM PDT

  •  "That corrupt game" = health insurance?

    And your personal alternative is ... what? Going naked? By choice?

    And when you find yourself with a condition - which will everlastingly be 'pre-existing', of course - and get hit with that first $50k/mo medical bill, who do you expect to pay for your care?

    Me. I thought so. Mind if I don't tip your comment?

    by Clem Yeobright on Wed Jan 16, 2008 at 02:19:41 PM PDT

    •  Yeah

      it'll be terrible to dsign up for the public plan...The people on this fucking website are driving me fucking nuts.

      UHC is the holy grail of leftie politics.

      by Salo on Wed Jan 16, 2008 at 02:48:07 PM PDT

      •  Part of the problem

        is that alot of people may not fully realize that Edwards has proposed state run health care pools that include a public system that is based on the Medicare model. They don't realize that his plan has an enforcement mechanism. How could they? It isn't like the site owner hasn't been telling us the differences are minute. As it were Vanilla French Vanilla ice cream and Vanilla yogurt. Too bad we aren't picking a tasty dessert instead of policies that will affect millions and our direction for 4 years.

        What's important apparently is how you perform in polls and whether or not you can finance yourself. Sigh.

        by cwaltz on Wed Jan 16, 2008 at 03:20:56 PM PDT

•  Good point.

  Been a while since I've fired off an e-mail to the campaign.  This should be fixed.

  by Pegasus on Wed Jan 16, 2008 at 02:03:25 PM PDT

•  That's quite a bit made up.

  Edwards' plan doesn't let anyone else into Medicare who's not already in it.

  by DemocraticLuntz on Wed Jan 16, 2008 at 02:09:08 PM PDT

  •  That's not true!

    by ceenatoli on Wed Jan 16, 2008 at 02:15:29 PM PDT

  •  What?

    That's just not true.

    by RIP Russ on Wed Jan 16, 2008 at 02:16:24 PM PDT

  •  However

    Edwards plan creates state run health care that requires private companies to compete with them. It forces the private companies to decide where their priorities lie. If they want to survive they will have to compete with an agency that runs on the Medicare model.

    The biggest problem with Edwards plan is cost. Creating the infrastructure will no doubt be expensive. I think that it is an expenditure that is essential though considering the inflated cost of health care.

    by cwaltz on Wed Jan 16, 2008 at 02:19:09 PM PDT

    •  And those state run health care plans ...

      ... are modeled on Medicare.

      And I disagree that the infrastructure will "be costly" ... by getting cost shifting of indigent and freeloader care off the system and using the infrastructure for information gathering on effectiveness of outcomes, the infrastructure should more than pay for itself.

      by BruceMcF on Wed Jan 16, 2008 at 04:04:27 PM PDT

•  None of the frontrunners' plans...

  ...fundamentally alter the perverse incentive structure of the present system, or place enough emphasis on controlling costs through early intervention and prevention. We need to move from a health insurance to a health care model -- where the highest objective is maximizing health and well being, NOT profits.

  I have a strong preference for the single-payer model, but even a multi-payer alternative that provides a baseline of universal care to everyone and allows people to buy supplementary private insurance, would be better than the mandate approach.

  by Autarkh on Wed Jan 16, 2008 at 02:10:49 PM PDT

  •  If any private insurers must ...

    ... offer their plan in the health care market under no exclusions for pre-existing conditions and community rating, and standing outside the health care market means they are excluded from the "pay" side of employer pay or play and excluded from the tax credits for lower income households (extending well beyond 50% of households) ...

    ... and private insurance in a health market must pay out 85% of premiums collected for health care services ...

    ... and every health care market has a public plan available, modeled on Medicare ...

    well, then, yes, that is a fundamental alteration to the perverse incentive structure.

    by BruceMcF on Wed Jan 16, 2008 at 04:07:29 PM PDT

•  Moreover, it's not THE FEHBP, it's similar to it.

  And I highly doubt there are problems with the benefits available under the FEHBP, since that's what members of Congress receive, and they would definitely pass modifications if they had problems with it.

  by DemocraticLuntz on Wed Jan 16, 2008 at 02:12:06 PM PDT

•  Here's the thing

  I personally think all three of the front-runners' plans suck ass.

  You're right that the worst problem with health insurance is that insurance companies -- and boards -- have the ability to effectively murder someone because it cuts into their bottom lines to provide necessary care.

  The problem is that none of the candidates has the only real, long-term solution in their plan. To wit: a provision that insurers, public and private, shall pay for all treatment that is certified by a physician as medically necessary. Without this provision -- and more importantly, the President behind it -- all the plans become little more than corporate welfare for insurance companies.

  And without this, I see no real difference between the three plans. To me, they're all garbage.

  by maxomai on Wed Jan 16, 2008 at 02:14:36 PM PDT

  •  I'll listen to Moore and Krugman instead

    who both say that Edwards' plan gets us closer to UHC.  

    by ceenatoli on Wed Jan 16, 2008 at 02:19:13 PM PDT

  •  Edwards isn't perfect

    but it does have a mechanism that would allow us to phase into single payer if the insurance companies chose profit as their priority instead of cost effective health care that works for both the providers, patients and administrators.

    by cwaltz on Wed Jan 16, 2008 at 02:22:03 PM PDT

  •  Agreed.

    All of them seek to broaden insurance coverage without attacking the root cause of the problem -- a fucked up  paradigm. It's not that we aren't spending enough on health -- we already spend more than any other country, as a % of GDP -- it's that we insist on providing it in a way that, empirically, cannot work.

    We don't need to reach an accommodation with the insurance industry. We need to replace it. We don't need to bargain with drug companies over exorbitant prices, we need to demand something in return for the lavish R&D subsidies provided at considerable taxpayer expense.

    You'd think Edwards, with all his talk of excessive corporate power, would have gotten the point, and used this opportunity to propose something really progressive: not-for-profit healthcare as a right of citizenship.

    by Autarkh on Wed Jan 16, 2008 at 02:25:01 PM PDT

  •  Medical Costs

    I believe in Universal Healthcare and Obama has said if he were starting from scratch he would go single payer, but at this point we need to work with what we have. Just to give a sense of this stuff Holland is now in the final stages of a 20 year transition in how there Healthcare is funded. This idea that we can turn on a dime is ridiculous. In addition we can just continue paying for all medical treatments and have Universal healthcare is absurd.

    My sister just finished her PhD in epidemiology (and it was not funded by a pharmacuetical company). Basically, it showed that two different ways of treat abdominal sepsis had the same clincal result (one was just 3 times more expensive than the other) - but doctor's are very slow on picking up on more cost effective techniques.

    My brother in-law is an ER doctor and sees late stage cancer patients come in and there treating physicians have not told them they are going to die (which they are). We spend a lot amount of our healthcare dollars on late stage care. All medical systems have cost-effectivness guidelines. The UK for example basically has guidelines for when to walk away from a patient. These are not just right-wing horror stories. My father waited 4 months for a by-pass operation, that in the states generally takes a day (in Holland).

    I think what you are saying is that medical decisions need to be taken out of the hands insurance companies. That I agree with. Some sort of citizens board with physicians that determine what the level of care is, is probably needed. But to expect everyone to have healthcare and to have that healthcare do everything that is possible is just fiscally irresponsible and a pipe dream. There will be cost-benefit analysis, the question is who gets to do it.

    by benb on Wed Jan 16, 2008 at 02:54:36 PM PDT

    •  Benb

      Don't you think if you take the cost-benefit decision away from HMOs (and given to a citizens board) they will simply walk away from the business?  I do.  The second they determine government regulation prevents them from making their profits, they'll get out.  Or alternatively, they'll account for the additional cost and increase their premiums further.

      I agree that you can't go single payer on a dime, but what can be done on a dime is that we as a country can decide that single payer without a for-profit insurance industry as middle man is where we need to move.

      by HobbyWizard on Wed Jan 16, 2008 at 03:07:19 PM PDT

      •  I agree with this

        What I was disagreeing with the original poster is that every decision can be left in each doctor's hands. This isn't really feasible. But as you say, putting in place any of there plans will probably make a lot of the companies involved fall away and then you will have your path to single payer (all the plans would probably cause that). But, we need to be honest about the trade-offs you cannot have everyone getting everything they need, especially as the options for what people can get get more and more exotic.

        by benb on Wed Jan 16, 2008 at 03:29:01 PM PDT

    •  Incorrect

      We are now approaching a projected cost of 2 trillion dollars on the Iraq war. In a recent video of a republican congressman's town hall meeting I say (I wish I could remember which one) he himself had stated that the projected cost of an immediate and complete conversion to a government provided universal health care system would be about 1 trillion dollars.

      If we can afford to piss away 2 trillion on killing little brown people in Iraq for nothing more than our president's ego, then we can certainly affort to spend half that much on the healthcare of our own citizenry.

      Which would you rather see your tax money spent on?

      by MaverickModerate on Wed Jan 16, 2008 at 03:13:32 PM PDT

      •  Again, I agree

        There are much better uses for our funds than the war. There was a slate article today about the fact that probably 10k was spent by doctor's try to assess why two people had diarrhea. Then they asked the patients about their diets and basically the diet chewing gum they were chewing was causing their issue. We have to understand how amazing how medical technology today is, but it is also costly. And so if every problem requires every test and everyone gets that it just does not work. Leaving that decision up to every individual doctor doesn't work, because doctor's have there own incentives for not being honest (it is hard to tell people they are dieing for example, it is sometimes easier to run another test). That said leaving the decision in the hands of insurance companies is also a terrible idea. Acting like there are no trade offs is living in a fairy tale land. I have lived in a country with universal healthcare (Holland) and they would never trade it for our system. But don't act like all the problems are solved.

        I want us to be honest about the situation. I have watched my grandmother have 6 months added to her life (her cardiologist was the same as David Letterman's) and $100,000s that cost are not worth the fact that my sister-in-law is a ob in a urban hospital and almost none of her patients have pre-natal care. I am willing to trade 6 months of my grandmother's life (and she would have been as well) for pre-natal care for 100s of women. Are you willing to make that trade off?

        by benb on Wed Jan 16, 2008 at 03:40:57 PM PDT

        •  This is a false argument

          and attempts to frame the discussion in terms of a false choice  that seem sensible on the surface but is in fact only a republican talking point. You are not the only person who lived in a foreign country.

          I lived in a 3rd world country that happens to be 15 slots higher on the WHO list than the US (Colombia, number 22, US number 37).

          Their system is far from perfect, but they manage to successfully make healthcare available to 100% of their citizenry. They do so with a mixture of 3 tiers of health insurance, one completely government provided free of charge to their poorest citizens (similar to medicare), one government provided at a nominal fee for the middle class, and private insurance is available for those who can afford it.

          If a banana republic in the midst of a 40 year civil war can manage to do that, the richest country on Earth can do it as well. There is no excuse and no trade off necessary.

          This country has within it's grasp the capability of providing world class care to all of it's citizens. It's high time it does so.

          by MaverickModerate on Wed Jan 16, 2008 at 10:10:54 PM PDT

          •  It is basic economics

            Read the section on EPS. I don't know the system, but it looks like the EPS has treatment discretion (and they abuse it).

            Everyone cannot have everything all the time. My argument was not that we could not have 100% coverage. My argument was that we could not have 100% coverage with doctor's having full discretion over treatment. This does not exist anywhere. It is not a right-wing talking point to say so. I will say it again, I believe in Univeral coverage (I said that in the first comment). The original commentor suggested that doctor's have full discretion, that is a nonsense position.

            by benb on Thu Jan 17, 2008 at 12:32:31 AM PDT

            •  I don't have to read it, I lived it

              But I read it anyway. In practice, the only real discretion on EPS is whether it is accepted, not whether acceptors of it dispense treatment.

              Whether doctors have discretion is not really the argument I am making, it is whether for-profit insurance companies have that discretion. And I contend that they absolutely should not have it. We have laws that protect the poor from having their gas cut off in the middle of the winter because if that discretion were left to the gas companies, people would die in large numbers every winter. The same dynamic should be at work with respect to insurance companies.

              I'm not saying that Colombia's system is a perfect system, but let's face it, Colombia is a 3rd world country that is 15 slots higher on the WHO list than the US is. I don't know anybody there who would swap their system for ours.

              We can provide universal healthcare and we can do it overnight, and anybody who argues that we can't needs their own lesson in economics. This is not Colombia and it's not Holland. It's the richest country on Earth. It's all a matter of directing our resources appropriately. As I have said before, if we can afford to spend Trillions of dollars to fight un-necessary and ill advised wars, we can certainly afford to do what even 3rd world countries in the midst of their own 40 year civil wars can do.

              by MaverickModerate on Thu Jan 17, 2008 at 09:05:39 AM PDT

•  How much do you know about Medicare?

  Expanding it to all would mean millions of additional people getting extremely inadequate coverage.  General Medicare has no coverage for prescriptions, extremely limited access to durable medical equipment, no dental or vision coverage, and extremely high hospital deductibles that can be charged multiple times per year.  

  Medicare also does not guarantee access to affordable care.  Providers are not required to treat Medicare beneficiaries.  If they do treat them, they are not required to participate in Medicare's pricing and payment system.  It's called accepting assignment and it is completely voluntary.  Providers can move in and out of accepting assignment and they are not required to notify patients when they do.

  I could go on and on...

  by clonecone on Wed Jan 16, 2008 at 02:18:55 PM PDT

  •  Untitled

    What would likely happen in a single-payer/Medicare expansion America is that supplemental insurance policies would start popping up akin to those in France, for instance.  If all Americans were covered under Medicare, how could a physician stay in business by declining to accept it?  They might want more than Medicare pays, and that's where supplemental might fill the gap, and the supplemental provider has to pay up if Medicare does.  (I know this isn't Edwards' plan, btw.)

    Further, so much of our healthcare dollar goes  towards the eternal battle between providers and insurers, that a lot of money could be saved under a single payer system that accepted the providers' decisions about what is medically necessary treatment for a given patient.

    by HobbyWizard on Wed Jan 16, 2008 at 02:31:11 PM PDT

    •  There are plenty of supplementals

      available now.  They are extremely expensive and they are offered by the major insurance companies.  If the goal is move away from insurance industry control, why build a system that relies on insurance companies to pay for essential services?

      by clonecone on Wed Jan 16, 2008 at 02:34:42 PM PDT

      •  Well....

        I think under a single-payer plan, overal medical costs would decline due to administrative savings (doctors no longer expend money fighting the HMOs, as I mentioned above), narrowing the difference between Medicare payouts and what a provider would like to be paid for medical services.  So I don't see supplemental as a requirement, per se, for citizens.  If they want to pay the difference out of pocket, or only use physicians who don't charge a premium, then they can.  Obviously, the devil will be in whether single-payer can corral costs and bring them into line with those in countries that have those systems.  And of course, it wouldn't be free - FICA would increase for everyone to fund it.  That's the single biggest advantage true single payer has - it forces the young and healthy to contribute via payroll deductions.

        I certainly agree with the consensus expressed here that herding people to HMOs who are then entitled to pick and choose the healthy and leave those in ill health to the government is neither sensible or moral.  Romney's Mass plan that criminalizes the uninsured at least forces participating insurers to accept registrants regardless of pre-existing conditions and doesn't allow them to decline future coverage if a long-term health issue arises.  That should be the bare minimum in any plan involving the for-profit insurers.

        by HobbyWizard on Wed Jan 16, 2008 at 02:55:51 PM PDT

  •  I beleive you are talking about managed medicare

    not traditional medicare. I was on traditional medicare, or to be more precise, my daughter was, for about a year when she was an infant. There were NO copays and NO deductibles and just about every doctor accepted it.

    It's acceptance was virtually universal and no service was ever turned down or even questioned. Conversely, once we were on private insurance, we had copays, deductibles, acceptance differences. That was the reality, and to my knowledge, it still is.

    In the case of both Clinton and Edwards' plans, it is traditional medicare that they will either emulate or extend, not managed.

    by MaverickModerate on Wed Jan 16, 2008 at 02:56:10 PM PDT

    •  No, I'm talking about Original Medicare.

      Managed care is a completely different thing and has nothing to do with my comment.

      I encourage you and everyone else to read the 2008 Medicare and You Handbook. (pdf)  I work for Medicare so I know this stuff like the back of my hand.  

      Part B has an annual deductible.  It is $135 in 2008. It also has a 20% co-pay after the deductible is met. (page 33.)  

      Part A has a deductible of $1,024 per benefit period for the first 60 days of hospitalization and $256 per day for days 61-90.  Page 111.

      Now, what is a benefit period?  

      A benefit period begins on the day you you go into a hospital or skilled nursing facility. The benefit period ends when you haven't received any inpatient hospital care (or skilled care in an SNF) for 60 days in a row,

      Page 103.

      That means you can have multiple benefit periods, and therefore mulitiple $1,024 deductibles in a calendar year.

      by clonecone on Wed Jan 16, 2008 at 03:14:47 PM PDT

•  Can Someone Tell Me How To Post a Photo?

  by GB1437a on Wed Jan 16, 2008 at 02:23:57 PM PDT

  •  Here is a link to the faq about posting pics.

    http://dkosopedia.com/...

    Hope that helps. ;)

    by TheSwampDweller on Wed Jan 16, 2008 at 02:30:58 PM PDT

•  I look at it a little

  differently.  Regardless of who gets ellected the next President will have to move his plan through Congress.  I think Obama has the best chance of getting the legislation enacted without material changes to it.

  I also think Obama's name on the ticket will increase voter turnout and help downticket Dems more than Hillary or Edwards.  That would make getting healthcare reform passed that much easier.

  My understanding is that Obama's plan is a first step towards Universal Health care.  If anyone thinks the next president will be able to instantly enact major health care reform, or universal health care, they are most likely wrong.  

  by nisleib on Wed Jan 16, 2008 at 02:24:02 PM PDT

  •  Exactly--while I have little if any hope

    of seeing UHC in the next 8 years, a candidate with a mandate behind him/her will have the BEST chance of getting us on track to it.  

    One thing is sure about Hillary; we know her plan, we know she'll try to enact it, we know the Republicans will do everything possible to block and weaken it, then we'll be stuck with whatever's left and that will be the end of it.

    I want more!

    by oscarsmom on Wed Jan 16, 2008 at 03:23:36 PM PDT

•  it doesn't matter that much

  Candidate's health care "plans" are more statements of principle than actual plans.  The legislature writes the plan, not the president, and the odds of a president's plan going through the legislative process unscathed are, um, minimal.

  I'd like it if ALL the plans were tougher than they are, but I'm not faulting any of the candidates for it.  They're all saying they'll do something, and what they're suggesting isn't stupid or counterproductive like the GOP plans.  That's enough for me.

  by Leggy Starlitz on Wed Jan 16, 2008 at 02:33:43 PM PDT

  •  Good point, but

    if we consider that each plan is really a starting point, it seems to me that those which start from a weakend position are unlikely to advance to a stronger one in dealing with the normal give and take of the legislative process.

    by MaverickModerate on Wed Jan 16, 2008 at 03:01:38 PM PDT

•  The details...hmm...

  Particularly with healthcare, there was an analogy I thought was fitting:

  Candidates arguing over details of their health care plans is like a bunch of homeless guys arguing over which Porsche they're going to buy.

  By the time any of these plans make it through congress, they'll be significantly different, and any differences that we might observe now will be obscured by the transformations the house and the senate will make.

  by barath on Wed Jan 16, 2008 at 04:19:40 PM PDT