This started out as a note on Facebook to my friends, which I compiled at the request of my wife, many of whose friends were venting various accusations about the historic reform just passed. I pulled this together from various sources, but unfortunately no longer have the links to them. I have high confidence that this synopsis is accurate.
After the synopsis is my own analysis of the complaints I've seen aired by some about this package. It may be late in the game, but for those still sorting it out (like this diarist), it may be helpful.
See below the fold. Facts first, then analysis.
First, here are the facts, and then some analysis of the complaints:
Cost: $940 billion over ten years.
Deficit:Would reduce the deficit by $143 billion over the first ten years. That is an updated Congressional Budget Office (the neutral referee that analyzes budgetary impacts of all proposed legislation) estimate. Their first preliminary estimate said it would reduce the deficit by $130 billion over ten years. Would reduce the deficit by $1.2 trillion dollars in the second ten years.
Coverage: Would expand coverage to 32 million Americans who are currently uninsured.
Health Insurance Exchanges:
• The uninsured and self-employed would be able to purchase insurance through state-based exchanges with subsidies available to individuals and families with income between the 133 percent and 400 percent of poverty level. These exchanges will have large pools of participants, which means that they will be able to negotiate good rates with insurance companies who want their business.
• A temporary high-risk pool will be set up immediately to cover adults with pre-existing conditions. Health care exchanges will eliminate the program in 2014.
• Separate exchanges would be created for small businesses to purchase coverage -- effective 2014.
• Funding will be made available to states to establish exchanges within one year of enactment and until January 1, 2015.
• Businesses with less than 50 employees will be eligible for tax credits covering up to 50% of employee health insurance premiums, effective immediately.
Subsidies:
• Individuals and families who make between 100 percent - 400 percent of the Federal Poverty Level (FPL) and want to purchase their own health insurance on an exchange are eligible for subsidies. They cannot be eligible for Medicare, Medicaid and cannot be covered by an employer. Eligible buyers receive premium credits and there is a cap for how much they have to contribute to their premiums on a sliding scale. Federal Poverty Level for family of four is $22,050.
Paying for the Plan:
• Medicare Payroll tax on investment income -- Starting in 2012, the Medicare Payroll Tax will be expanded to include unearned income. That will be a 3.8 percent tax on investment income for families making more than $250,000 per year ($200,000 for individuals). In other words, this will apply only to the wealthiest Americans.
• Excise Tax -- Beginning in 2018, insurance companies will pay a 40 percent excise tax on so-called "Cadillac" high-end insurance plans worth over $27,500 for families ($10,200 for individuals). Dental and vision plans are exempt and will not be counted in the total cost of a family's plan. This starts to get at the divide between the high-deductible plans that are all that most Americans can now afford and the ritzy care that the rich now have. If you can afford it, fine, buy it: but you're also going to help pay for those less fortunate than you are.
• Tanning Tax -- 10 percent excise tax on indoor tanning services. Sounds weird, but artificial tanning contributes heavily to skin cancers that we all end up paying for through either elevated insurance premiums or by paying for care for the uninsured. And it's a luxury--no one NEEDS tanning.
Medicare:
• Closes the Medicare prescription drug "donut hole" by 2020. Seniors who hit the donut hole by 2010 will receive a $250 rebate. This will save thousands of lives, all by itself.
• Beginning in 2011, seniors in the gap will receive a 50 percent discount on brand name drugs, also saving thousands of lives. The bill also includes $500 billion in Medicare cuts over the next decade, due to improved senior health from the balance of the bill.
Medicaid:
• Expands Medicaid to include 133 percent of federal poverty level which is $29,327 for a family of four.
• Requires states to expand Medicaid to include childless adults starting in 2014.
• Federal Government pays 100 percent of costs for covering newly eligible individuals through 2016.
• Illegal immigrants are not eligible for Medicaid.
Insurance Reforms:
• Six months after enactment, insurance companies could no longer denying children coverage based on a preexisting condition. Starting in 2014, insurance companies cannot deny coverage to anyone with preexisting conditions.
• Insurance companies must allow children to stay on their parent's insurance plans until age 26.
• Lifetime caps on the amount of insurance benefits an individual can receive will be banned immediately. Annual caps will be limited, and banned in 2014.
• New plans must cover checkups and other preventative care without co-pays. All plans will be affected by 2018.
• Recissions are banned: Insurance companies can no longer cut someone when he or she gets sick.
• Insurers must now reveal how much money is spent on overhead.
• Any new plan must now implement an appeals process for coverage determinations and claims.
• New screening procedures will be implemented to help eliminate health insurance fraud and waste.
• Starting January 1, 2011, insurers in the individual and small group market will be required to spend 80 percent of their premium dollars on medical services. Insurers in the large group market will be required to spend 85 percent of their premium dollars on medical services. Any insurers who don't meet those thresholds will be required to provide rebates to their policyholders. Nonprofits like Blue Cross and Kaiser which fail to meet these standards will not be able to take advantage of IRS tax benefits (in other words, they'll be taxed like for-profit companies).
• Starting in 2011, insurance companies will be required to submit justification for requested premium increases. Any company with excessive or unjustified premium increases may not be able to participate in the new health insurance exchanges--in other words, they may not be allowed to access the new pool of 30+ million customers.
Abortion:
• The bill segregates private insurance premium funds from taxpayer funds. Individuals would have to pay for abortion coverage by making two separate payments, private funds would have to be kept in a separate account from federal and taxpayer funds.
• No health care plan would be required to offer abortion coverage. States could pass legislation choosing to opt out of offering abortion coverage through the exchange.
• Separately, anti-abortion Democrats worked out language with the White House on an executive order that would state that no federal funds can be used to pay for abortions except in the case of rape, incest or health of the mother.
Individual Mandate:
• In 2014, everyone must purchase health insurance or face a $695 annual fine. There are some exceptions for low-income people.
Employer Mandate:
• Technically, there is no employer mandate. Employers with more than 50 employees must provide health insurance or pay a fine of $2000 per worker each year if any worker receives federal subsidies to purchase health insurance. Fines applied to entire number of employees minus some allowances.
Immigration:
• Illegal immigrants will not be allowed to buy health insurance in the exchanges -- even if they pay completely with their own money.
Analysis and notes:
- There is no public option in the bill. However, it does still expand coverage to about 30 million more Americans, with mechanisms to cover them if they can't afford to pay for insurance themselves, and it lays the groundwork for a future public option if the insurance exchanges do not achieve sufficient cost containment.
- Yes, some of the provisions don't kick in for a few years. So what? The system we have now is in collapse. Insurance companies are routinely canceling people's coverage because they get sick, or on the basis of "pre-existing conditions" which can be as trivial as acne, PMS, or headache. Seriously: do the research.
- Yes, there are mandates. People are going to be required to get insurance. To those who are all exercised about this, I say: What, are you an 8-year-old, wanting to be showered with presents and candy at no cost? Do you believe that if we had a UK-style public health system, that wouldn't require you to pay a bunch of money, too? If you can afford to pay, any system is going to expect you to pay!
Health care costs money. This program gets people coverage, reins in the worst abuses of the insurance industry (and puts them on notice that they are not above regulation), and it does it in a way that requires that those who can afford it buy their own, while finding ways to cover those who can't, mostly paid for by the wealthy. I can't see any downside to that.
- On the abortion issue, note that the provisions on abortion don't change ANYTHING from how things are now. Ever since 1976, the federal Hyde Amendment has banned expenditure of federal funds for abortions except in case of rape or to protect the health of the mother. That's the law. All this gesticulating about abortion is POSTURING: it's been posturing on the part of people like Bart Stupak, and it's posturing on the part of NOW and NARAL. The language in the bill and the executive order changes NOTHING--period.
- If you're still howling, let me ask: exactly what part of banning the practice of tossing children off their parents' insurance because they're diabetic do you disapprove of? How many of the 30 million who will now have access to medical care do you think are expendible? What, exactly, do you think is wrong with saving 1.3 TRILLION dollars over the next 20 years while saving the lives of your fellow citizens?
If you hate the bill because of the insurance mandate, personally I have to say I have zero respect for that position. The only people likely to hold it are the wealthy and those who are young and healthy. You know what? Young, healthy people get in car wrecks, too, and if they're uninsured, we all end up paying for their care. But if they're in an insurance pool, they help to keep costs down because they pay premiums but don't need as much care as the elderly and ill.
Think that's unfair? Tough. It's called "social responsibility".
Face it: part of our problem in this country is that we have become a soft, entitled and selfish culture. Too many Americans--especially those of libertarian bent--get all exercised about their "rights" but don't want to have any responsibilities laid on them which balance those rights. They act like a two-year-old the minute that they hear they are going to be made to do something by government, however reasonable. "I have a God-given right to own a fully functional tank! And what do you mean, I don't have the right to dump this stuff in the water--it runs through MAH PROPUHTY!"
We are citizens of this country and that means that we have responsibilities to one another as well as to ourselves and our families. This bill could not have worked without an insurance mandate--the only new enrollees seeking insurance would have been those who are ill, and there's no way to make an affordable insurance pool using only those participants.
There are reasons why the Republicans are bent sideways about this. It is a stake to the heart of their idea that government should do nothing and "market forces"--meaning, fuck the poor--should be the sole arbiters of who gets what.
It's not the whole enchilada, and it does grate that insurance companies, which we all hate, will make money on it. But believe me, this is a total game-changer for them, and they know that if the exchanges don't work out, they're going to be competing with a government program for the middle class pretty damned soon.
Those of us who want things to get better in this country would do well to dump the cynicism act and laud progress when it happens. It took tremendous courage and work on the part of thousands of people--including a lot of politicians--for this advance to happen. If you ain't cheering, you either ain't informed, ain't public-minded, or both.
/soapbox