Friday, August 28, 2009

Heath Care Read

Here's a good read on the health care systems from around the world. I'm personally in favor of a universal single-payer system, but there are lots of good ways to do health care; and almost the rest of the industrialized world has adopted a way which is superior to how we do it.

And that has to be the bottom line in the health care debate: we're way behind the rest of the world in both cost and quality. (Of course, I'd also like to see government payment for abortion removed from, and conscience clauses put into the Obama plan.)

We'd like to help you learn to help yourself


Jeff said...

Removing government payment for abortion from the Obama plan will be easy. You know, since it's not in there in the first place.

Our problem is that we don't tax enough to get a decent health care system. We'd have to raise taxes significantly to get a single-payer universal system, and Americans are gonna avoid paying taxes if it kills 'em. Which, in a way, it is.

Matthew B. Novak said...

Jeff - I don't know where you're getting your info on the abortion thing, but you're wrong about it not being in the Obama plan. See, for example, the Stupak/Pitts amendment, which was an effort to remove payment for abortion from the plan. I've been following this issue pretty closely... public payment for abortion is still in the plan from everythign I've seen. If you have other info, please let me know about it - I'd love to check it out.

Re: Taxes. Yeah, it means "higher taxes". But it also means more take-home pay, provided employers take the money they're paying for employee health care and transfer that to wages. The Democrats are really messing up the Net-Savings argument on this.

Jeff said...

The way I understand it is this: Stupak/Pitts would have forbid insurance companies receiving federal subsidy money from covering abortions. This amendment was defeated. The Capps amendment, which passed, neither requires nor prohibits insurance companies from covering abortions.

So it's a distortion to say that Obamacare uses "government money for abortion." Rather, government pays insurers, who then choose what they'll cover on their own. It's kinda like saying Medicaid "pays for abortions" now because it pays OB/GYNs who might perform the procedure. Not a sound argument.

As long as private insurance is part of the health care plan, and as long as abortion is legal, subsidizing insurance and leaving the decision on what is covered regarding abortion up to the insurer and said insurer's conscience is the only way to go.

And with regard to taxes, it's still a tough sell since most people with health insurance don't pay for it out of their own pocket. They don't see the monthly cost - but they see their tax bill. Not saying that it's a bad argument, nor am I exonerating the Democrats for failing to make it. But it's a tougher one to make conceptually than you might think, since it's hard to convince people of the existence of hidden costs.

Matthew B. Novak said...

Jeff -

First off, as I understand it, the Stupak/Pitts amendment was designed not to forbid private insurance from covering abortion but was actually designed to remove a mandate that they do so.

If you read the text of The Capps Amendment (link following) you'll see it is essentially just a bookkeeping trick that doesn't really remove federal funding for abortion from Obamacare. It says "federal funds won't be used for abortion, those'll be the private funds." Of course, that just means the federal funds wil be shifted to cover the lack of private funds in other areas. It's little more than a money-shifting scheme. The federal government is still paying for abortions.

Perhaps even more offensive, the Capps Amendment says that there MUST be, in each insurance option, a plan that DOES cover abortion and one that doesn't. So it's still mandating the option of abortion coverage - insurance providers won't have the choice of not covering it. And that's not just the public plan, that's the private plans too.

Finally, the Capps Amendment specifically says that it is not a prohibition of coverage for abortion in the public plan.

In short, yeah, Obamacare is currently designed to provide public funding of abortion, through both private insurances (mandated to do so) and the public plan.

Jeff said...

Obnoxiously long wonky post to follow. Be forewarned.

From Stupak-Pitts: "No funds authorized under this Act (or an amendment made by this Act) may be used to pay for any abortion or to cover any part of the costs of any health plan that includes coverage of abortion..." (the ellipsis is the standard life-of-the-mother exception). Sounds more like what I said it was. Text here. This wouldn't forbid insurance companies from covering abortion, but it would mean that insurance companies would basically have to offer separate "abortion insurance" that federal funds can't pay for.

It appears there was a previous amendment offered by Stupak that does more what you said it does... "No provision of this Act (or an amendment made by this Act) shall impose, or shall be construed to impose, any requirement for coverage of abortion, or access to abortion, or to authorize or permit the recommendation for, or imposition of, any such requirement by or through the Health Benefits Advisory Committee, the Secretary of Health and Human Services, the Health Choices Commissioner, or any other government or quasi-government entity..." This amendment was also defeated.

The Capps amendment is far more annoyingly worded, so I can't quote the amendment like I did for Stupak-Pitts. Click the link below to read it yourself. But Catholics United has the best distillation of it I've read yet: "The amendment, put forth by California Democrat Lois Capps, clearly states that federal funds cannot be used to pay for so-called “elective” abortions, ensures that private plans participating in a proposed regional health care exchange system will neither be prohibited from nor required to pay for abortion services, prohibits the preemption of state abortion laws (such as those requiring parental notification and consent), and extends existing conscience protections to health care providers participating in the exchange. It also attempts to chart a common ground course by requiring at least one plan in each regional exchange to include, and one not to include, abortion coverage." It says that participants in subsidized private insurance must have access to both one plan that provides abortion and one plan that doesn't. This doesn't force insurers to insure abortion - it just recognizes that there'll be plans that do and plans that don't, and it requires the exchange to pick at least one of each as options.

Link here.

BeliefNet did a lot of the legwork here - they reprinted the text of all three amendments here.

Verdict? You're definitely wrong about Stupak-Pitts, at least the latest incarnation of it. It plainly forbids private insurers from covering abortion if they're accepting federal subsidy money from a client. But you're partially right about Capps. It does ensure that people can choose a health plan that provides abortion coverage. However, it doesn't allow federal funding for abortion via the public option.

And finally, I'm still not buying your "bookkeeping trick" argument. It's the same argument used against federal funding for "faith-based" charity initiatives, and I've come to think that it's a somewhat dishonest one. To demonstrate the absurdity of the argument... We can say that earned-income tax credit (EITC) money is meant to buy necessities. But by allowing poor people receiving the EITC to buy food, we let them save some of their own money, which might be used for an abortion. So the EITC funds abortion. Of course, this conclusion is ridiculous. That's because the argument is ridiculous.

Matthew B. Novak said...

Perhaps Stupak/Pitts did go farther than I had thought. Still, I'm in favor of it. And the primary point I was making remains... there was, in the first place, a requirement for abortion coverage.

As for the Capps Amendment... it keeps public financing of abortion (which, obviously, directly pays for abortion), and the "some plans will, some plans won't" distinction is what the Capps Amendment is trying to say it has. But what it actually says is that each provider MUST offer one of each. That means insurance companies don't have a choice to not offer abortion coverage. Even if individuals can elect to chose the plan w/o coverage, the insurance company is forced into offering that coverage.

As for the Catholics United editorial... I'm not convinced the guy is entirely right in his reading. Especially regarding the conscience clause issues...

As for the funding argument... Yes, I see your point. The bookkeeping argument can be taken to an absurd level, as in your example. But in a situation where we're discussing the funding of health care specifically there's a much greater connection between the funds being made available and the availability of abortion.

Here's another way of looking at it: Let's say you're going to grocery store and you need to buy a gallon of milk and some candy, and you've got $5. As it is, you can only afford $1 in candy after buying your $4 gallon of milk. But now I give you another $5 and say "you can buy any food with it except for candy." So what are you going to do? You're going to spend $4 of my $5 on milk, and your own $5 on candy. The end result of my giving you that $5, even though I put a restriction on it, is that you end up with $5 woth of candy - exactly what I didn't want. That's the same kind of book keeping trick that's being pulled with Capps.

Furthermore, I think it's distinguishable from the example you gave in that:
1. Your example deals with people who, even though they're getting additional income won't really have discretionary income as a result. Thus decreasing the likelihood of paying for abortions.
2. The correlation between the funds coming in and the "discretionary" funds going out in your example is tenious at best... they could spend those funds on anything, yes, but that's the distinguishing point - they can spend the funds on anything. In the healthcare funding realm there's a much smaller world of things the money can be spent on (only health care expenses), and one of the obvious choices would be "non-covered abortions". In the EITC scenario abortion is an unlikely resulting "personal" expense. In the health care scenario abortion is a VERY likely resulting "personal" expense.
3. We're actively engaged in a health care funding discussion here. We're making choices about what to cover and what not to cover. Thus, a book keeping/fund shifting scheme here is a decision made with full awareness. EITC wasn't designed to get around the problem of abortion funding. Capps is. That's just the reality, and, though the arguments are similiar in theory, the reality makes a huge difference here.

Now, let me also say, that I'll take Capps over nothing. I won't let the perfect be the enemy of the good. It's no Stupak/Pitts, but it's better than the original.

Jeff said...

Matt, I think with regards to public funding for abortion, the public option is still governed (like Medicaid) by the Hyde Amendment which forbids such things. I don't see anything in Capps that would overturn Hyde.

Again, with regards to the exchange thing, you're misreading it to some extent. It doesn't require individual insurers to offer abortion coverage, it requires the exchange to contain at least one plan that covers abortion and one plan that does not. Most insurers already have such plans, and so selecting at least one for the exchange forces nothing on the insurers either way. I can certainly see the pro-life argument against this provision - the exchange shouldn't be required to include a plan that covers abortion - but to say Capps is forcing abortion coverage on insurers is simply wrong.

And the "bookkeeping trick" thing is still dishonest. Your point, best as I can tell, is that people have more of their own money to spend on whatever they want after they receive government aid. Of course that's the case, and they can use that money on whatever they want. For example, abortion. Or ice-cream sandwiches. Or teddy bears. Why do you hate ice-cream sandwiches and teddy bears, Matt?

Facetiousness aside, it seems absurd to me to criticize a program that gives money to people because it might lead people to use some of their own money to buy something bad that they couldn't previously afford.

Matthew B. Novak said...

Jeff -

The language that make me think the Hyde Amendment has been undone:

"Nothing in this Act shall be construed as preventing the public health insurance option
from providing for or prohibiting coverage of services described in paragraph."

It doesn't explicitly say "coverage wil happen" but it DOES explicitly say "coverage isn't prohibitted." And that is inconsistent w/ Hyde.

I see what you're saying now about the health benefits exchange. I was misreading that it was insurances that had to offer abortion coverage, not the exchanges that buy into multiple insurance plans.

In some ways though, this is even more disturbing. As an individual, if I want to participate in a health insurance exchange - and contribute my private money to that exchange - I am necessarily going to be contributing to at least 1 plan that offers abortion. And it doesn't look like there's even a book keeping scheme to prevent this from happening in those cases, since that'll be the pooled private money paying for abortions, not the public funds that are "kept from paying for abortion."

On the book keeping scheme... I think you're misconstruing the idea a little bit. I'm not upset that individuals will have more of their own money to spend on anything, which might include abortions. Because

1. They won't have more of their own money. Once they buy into a plan they're saddled with a sunk cost. They're paying in their portion whether they're on an abortion plan or not. So at no point will the individual have more of their own money to spend at their discretion. Their own money is already burned through. It is misleading to say this is their own money. It's the cost of getting health insurance, and the money has already been spent once they buy into the plan.

2. No other services are treated this way. That means at no other point in the health care system will a patient "get back" some of their own money to use on personal procedures that aren't covered. Let's say service X and abortion are both things the goverment won't pay for. People who want those services are going to be out of pocket (more than they were in paying for the plan itself.). But now we've got a law that says the insurance companies MUST pay for abortion using the "private funds". But there's no similiar mandate for service X. That means the person who gets an abortion is uniquely priveledged. Whether we say we're giving them back some of their "own money" or we just say the service is payed for by the government the effect is the same. Service X people are still out-of-pocket. Abortion people are not. We've selected abortion as a special thing we want covered. I find that offensive.

3. People can't spend their hypothetical "own money" on anything... they can only spend it on health care costs. Obviously they're going to spend it on health care costs that aren't covered under the plan. That's an even more limited realm of choices. To say they can spend it on anything is misleading.

4. The end result. Like I highlighted in the candy example before, the bottom line is that because of our funding people are going to end up getting services that I disagree with. Your EITC example from earlier is distinguishable because of the tenious connection between EITC and payment for abortion. But here we're actually having the discussion and there's a direct link between health care coverage and paying for abortion. The proximity of the two makes all the difference. We are actively choosing whether or not to cover abortion. The Capps Amendment is a disingenious way of making sure abortions are paid for while saying we're not paying for them. You say it's dishonest to say we're actually paying for abortions. I look at the result, see that abortions are ultimately covered when they wouldn't have been before, and say it's dishonest to say we aren't paying for them.

Jeff said...

Matt - I see your point re: Hyde. But the "nothing in this Act" doesn't necessarily mean "nothing in other Acts." And I think the intent is to ban abortion from being covered under the public option, so that's worth something there, right?

Glad we're on the same page now re: the exchange issue.

And back to the bookkeeping scheme - I guess I don't understand what you're getting at here. Let's say you have $100 to buy insurance with. The policy without abortion is $500, the one with abortion is $600. And let's say you get a subsidy of $500. Well, guess what? You now have $100, and that is your own money. You can use the $100 to get the abortion option on your plan. Or you can buy ice-cream sandwiches (a LOT of 'em) with it.

I guess the assumption here is that insurance companies will do the bookkeeping themselves, offering an "abortion option" to plans that requires out-of-pocket payment rather than payment with subsidy cash.

Maybe you're worried this won't happen, and people will be receiving $600 subsidies to buy the whole plan, abortion included? As far as I can tell, that's your objection, right? What would be your solution, means testing to ensure that someone could afford regular health insurance with the subsidy but couldn't afford abortion insurance as well - in my hypothetical, making sure the subsidy isn't a dollar above $499, leaving our hypothetical customer to get $99 worth of ice-cream sandwiches?

"Bookkeeping" is an awesome word, by the way - three sets of double letters in a row.

Anonymous said...

Hi Matt,

I really enjoy reading your blog, though I've never commented, but I find this one pretty frustrating (and I'm not even sure why I'm writing, because I doubt I'll change your mind, but still...)

If you are paying into a health care insurance plan, you are paying into a system that provides a lot of things that you may not agree with (just as you are when you pay taxes). You are helping someone receive care who may have caused their own illness through their poor life-style choices (lots of examples I could list, but someone would find one offensive, but o.k., actually, I will. What if I didn't want to pay for cancer treatment for someone who has smoked for the last twenty years (beginning after it was obvious that smoking is a carcinogen) or for a liver replacement for someone who drank excessively? I don't get to make that decision - I can't say, "gee, I only want my insurance dollars to pay for treatments for others that I find morally acceptable". Besides, in most cases, I wouldn't get to choose my health insurer at all, much less get down to plans that, say, only insure people who eat in a healthy way, abstain from alcohol, drugs, and cigarettes, walk/bike to work, and use the gym regularly. If we could make those decisions, who is going to buy in to the system that allows people to do whatever they want to their bodies, and at the end of the day, it will be covered (and their premium won't individually increase because they are part of a group plan)? The only way to make that happen is to have a fee-for-service system that just says "you want this service, you pay for it individually, and if you can't afford it, too bad." Then, you wouldn't be subsidizing anyone but yourself. I don't think you would accept that choice, so we come back to having insurance or a universal single payer system that is mostly not tied to your specific medical situation. You pay money in, you get services out, but you don't get to say how much or little your fellow insureds use.

Here's another argument:
If you don't want to cover abortions, then why cover pregnancies? I'm thrilled that you and your wife are about to be parents, but why should I have to pay for that decision that you are making - it is not an illness that you can't help or couldn't foresee and save for - it is an elective decision. Abortions are legal, private, medical decisions, just the same as the decision to complete a pregnancy. If you think that abortions shouldn't be legal, private, medical decisions, lobby Congress to pass a constitutional amendment to say that abortions aren't legal, and then you would never have to pay for them directly (although if you had universal health care, you'd probably pay for the medical costs of cleaning up botched back-alley abortions). But, please, don't side-track the opportunity to have real health care reform in this country by arguing that one medical procedure shouldn't be covered when the obverse procedure is. If people have to purchase optional abortion coverage, then let them have to purchase optional pregnancy coverage too. That seems fair. Otherwise, I think Congress (and, even more so, State governments) should stay out of the way of allowing a doctor to give his/her patient the treatment that she needs. Period.

Anyway, those are my thoughts - but they really don't matter - I don't even have a voting representative in Congress, so my opinion is less than meaningless.

:) Elle

(And I really am excited for you, and if you are on Blue Cross, I'm delighted to help pay for baby Novak, as would I if you needed chemo or a new liver, but I would hope that you would, likewise, be willing to help me pay for any medical treatment that I needed, including preventing me from undergoing the risks associated with pregnancy if it wasn't something that I really wanted.)

Matthew B. Novak said...

Jeff -

I think I see the problem here... you're assuming the abortion plans will cost more than the non-abortion plans, and that abortion will be subsidized with that extra money. My understanding is that it's exactly the opposite - the abortion plan and the non-abortion plan will cost exactly the same. If I want to buy into a health exchange I'm gonna have to pony up my $100 whether I'm picking the plan with abortion or not, and then my $100 will be used to cover all the plans in that exchange, thus, even abortions.

My solution is basically to take the Stupak/Pitts amendment, and say "abortion can't be covered in any plan recieving a subsidy." Yeah, I'll admit it, I'd rather anyone who's getting an abortion be 100% responsible for the costs themselves. I'd feel the same way about euthenasia. But this gets me into my response to Elle... so...

Elle -

First off, thanks for posting. It's good to have another law-talking person on here. :-)

As for why I would limit coverage on abortion/euthenasia... it's because these are medical treatments that I have a moral objection to. Your smoking example is a good one to work with. Because let's say I have a moral objection to smoking (that's an overstatement of my feelings, but generally I'm anti-smoking). Does that mean I don't want us to pay for smokers to get new lungs? No. Because I'm not opposed to the treatment itself. Lung transplants are not a treatment I find morally offensive. I think it's a good thing to provide that health care treatment, and thus I would support providing that service to everyone who needed it, whether they were a smoker or not. I'm not making an assesment based on the person needing the treatment, but rather based on the moral quality of the treatment itself. Does that distinction make sense to you?

Now you're right too, that as things are right now we don't get a say. I'm pretty sure my health care dollars right now are paying for abortions. But we're engaged in a pretty unique debate right now, and as a nation we have the ability to say what we want covered or not. And for that reason, I'm going to take this opportunity to oppose coving abortion.

As for "pregnancy covered/abortion not"... I think you know better than that. It's far more than two sides of the same coin. It isn't like a health care decision where there are two acceptable treatments and we're not covering one of them. The reason I think abortion shouldn't be covered is because I have a philosophical view that says it's morally offensive to kill a fetus. That's the heart of the abortion debate. Presenting it as a simple 6-of-one/half-dozen-of-another choice doesn't do justice to the issues and ignores the very obvious distinctions between the two results.

Finally, please let me be clear. I support this health care reform. Heck, I'd go all the way to a single-payer universal coverage system. I don't want to derail it because of the abortion issue. (You should see the e-mails I've been sending back and forth with my relatives, where I've pretty much said "hey the abortion coverage is bad but don't fight this bill because of it"). I'll admit, it's a little bit of a nuanced position. I'm pro-health care reform, anti-abortion coverage. It's not a hard position to hold, and, I'd say, one that a lot of people do (see, for example, Catholics.)

So yes, I support this plan. I thought that was made clear in my original post. But just because I support the plan doesn't mean I don't have issues with it. And I'd like to see Congress respond to those issue. Capps is a step in the right direction, but doesn't go far enough. I'd like to see Stupak/Pitts pass. But either way, I'm going to support this bill (and I'll continue to try to convince people that abortion is wrong, regardless of the outcome of this health care bill).