Monday, March 29, 2010


I think it's fine to oppose health reform if you know what it says. But if you have no clue what it says, you have no business undermining it. So take the plunge and read it here. And if that's too much for you, look up the key provisions on the Kaiser Family Foundation website here. But don't throw stones if you're uninformed. In the end, you don't hurt reform -- you just look dumb. And I don't want any of my readers to look dumb. Jennifer

Atul Gawande on Health Reform

On July 30, 1965, President Lyndon Johnson signed Medicare into law. In public memory, what ensued was the smooth establishment of a popular program, but in fact Medicare faced a year of nearly crippling rearguard attacks. The American Medical Association had waged war to try to stop the program, and doctors weren’t about to abandon the fight against “socialized medicine” simply because it had passed into law. The Ohio Medical Association, with ten thousand physician members, declared that it would boycott Medicare, and a nationwide movement began. Race proved an even more explosive issue. Many hospitals, especially in the South, were segregated, and the law required them to integrate in order to receive Medicare dollars. Alabama’s Governor George Wallace was among those who encouraged resistance; just two months before coverage was to begin, half the hospitals in a dozen Southern states had still refused to meet Medicare certification.

As you can read in the full text, neither revolt occurred.

Insurers already trying to avoid reform

The full NY Times article is here. Jennifer

Friday, March 26, 2010

Jesse Dylan's Health Quest

Read about my miraculous friend Jesse Dylan's quest to change health care via the internet here. Jennifer

House Passes Reconciliation Bill

One hundred years of fighting for health care, and it's over, at least for now. There will be fixes and tweaks over the years, but the battle for equality has scored a huge victory.

For all of you who helped, who called your members of Congress, who signed petitions, who spoke out, THANK YOU. Jennifer

Thursday, March 25, 2010

Breaking News: Senate Passes Reconciliation Bill

The Senate just passed the Reconciliation Bill by a vote of 56-43. Because two minor changes were made, the Bill goes back to the House for a final vote, and then this will be DONE! Jennifer

A Son's Tribute That Gets It Right

A moral, civil rights issue
By: Rep. Patrick Kennedy
March 25, 2010 05:28 AM EDT

‘No memorial oration or eulogy could more eloquently honor [his] memory than the earliest possible passage of the [bill] for which he fought so long. ... His heart and his soul are in this bill.”

These words are from a speech made at one of those critical moments in our nation’s history when the character of our country was at stake. In a divided America, the public rhetoric was so filled with vitriol that it belied the fact that all of us in public office share a common desire to do what is best for this country. A vocal minority used every dilatory tactic at its disposal to frustrate the will of the majority of the American people.

While the above quotation could easily refer to my father, and the context could easily describe the health care debate, those words were, in fact, spoken by my father on the Senate floor, as he rose to honor his brother, President John F. Kennedy, during the debate on the 1964 Civil Rights Act.

The parallels between the struggle for civil rights and the fight to make quality, affordable health care accessible to all Americans are significant. As Martin Luther King Jr. said, “Of all forms of inequality, injustice in health care is the most shocking and inhumane.”

My father always viewed health care in the context of civil rights.

Day in and day out, up close and often very personal, at home in Massachusetts and later here in Congress, on the trips we took to many different parts of the country, I saw him fight to make the dream of health care for all come true.

Whenever my siblings and I were ill, we knew that we had the good fortune to have a father who would make sure we received the best care. But as we recovered, it would be a painful reminder of the many millions of American sons and daughters who had little or no hope of getting anywhere near the quality of care we had. Because they lived in a country that locked and bolted the door against them.

My dad’s commitment to fight for those children as hard as he fought for us ingrained in me the understanding that we have to challenge the status quo. We learned from him that, in America, we could — and should — do better.

One telling aspect of health care, when it is compared with civil rights, is that the most vulnerable Americans are not those living at the edges of our society, for our poor have Medicaid, and our elderly have Medicare. It is the great middle class that is overlooked and ignored.

Like the civil rights legislation, some have called health care reform a government takeover or a government intrusion into personal life. But extending access to quality, affordable health care to all Americans is no less than the expansion of the principle of equal opportunity on which this nation was founded. It moves us closer to the ideals on which this country has thrived.

Shortly after the passage of the 1964 Civil Rights Act, a popular Republican politician warned, “Our natural, inalienable rights are now considered to be a dispensation of government, and freedom has never been so fragile, so close to slipping from our grasp as it is at this moment.”

The grim prophecies of Ronald Reagan, and those who shared his concerns, never materialized.

Instead, today it is unquestioned that the color of one’s skin or the context of one’s birth has no bearing on the opportunity to succeed in our society. That is because of the Civil Rights Act.

With the vote of the House on Sunday and the signature of the president on Tuesday, we have similarly brought a fundamental shift to how our country views the delivery of health care.

My father’s efforts — from Medicare to the State Children’s Health Insurance Program, from the Americans With Disabilities Act to Community Health Centers — were driven by his belief that the amount and quality of care that people receive should not be a function of their income. It is appalling and inexplicable that we are the only major industrialized nation in the world that does not have a national health service or national health insurance.

Health care is not only a civil rights issue. It is a moral issue. It is about the content of the character of our country. Now, the onus is on the U.S. Senate, that institution my father so dearly loved, to pass the Reconciliation Act and complete the great unfinished business of our society.

Patrick Kennedy is a Democratic member of Congress from Rhode Island.

It Ain't Over - Breaking Update

The Senate Parliamentarian struck two technical provisions from the health reform reconciliation measure, which means that, once the Senate votes, probably this afternoon, the reconciliation bill has to go back to the House for another vote. Although the House already voted in favor of the reconciliation package, because the Senate's version will be slightly different, the House has to vote again.

All reports this morning are that this will not be a problem. Although I can't find any detailed explanation of the provisions that were struck, all the papers are saying that they do not affect the substance of the bill. Indeed, they have to do with the student loan provisions that were combined into the health reform bill.

Hopefully, the Senate will finish tonight. Speaker Pelosi has kept the House in session all week in case another vote was needed, so hopefully, the House will vote tomorrow and the battle -- at least this round -- will be complete. Jennifer

Wednesday, March 24, 2010

Um . . . yes we DID!

US News and World Report -- Overblown Fears about Healthcare Reform

1. The government will take over 1/6 of the economy -- wrong.
2. The federal debt will explode -- very complicated.
3. Doctors will revolt -- NOT.
4. Businesses will suffer -- probably not.
5. Socialized medicine is on the way -- not happening.

The full text is here. Jennifer

Monday, March 22, 2010

NY Times on what the changes mean to you

The NY Times has a good summary here. Jennifer

PHASE 1: The House Passes Historic Health Reform

The House passed the Senate bill, and then they passed a package of changes that have to be passed by the Senate next. But as of today, health reform -- the imperfect Senate version -- is passed.

Here are highlights, courtesy of Kaiser Health News (although as I read them, this appears to be a summary that assumes the Senate passes the House package of changes):

The health overhaul package passed by the House Sunday and sent to the Senate for final action is the most far-reaching health legislation since the creation of the Medicare and Medicaid programs.

While the underlying Senate bill will become law as soon as President Barack Obama signs it, additional changes will occur if the Senate passes the reconciliation-bill part of the package. The following is a look at the impact of the entire package, which would extend insurance coverage to 32 million additional Americans by 2019, but also have an an effect on almost every citizen.

Here's where things stand and how you might be affected:

Q: I don't have health insurance. Would I have to get it, and what happens if I don't?

A: Under the legislation, most Americans would have to have insurance by 2014 or pay a penalty. The penalty would start at $95, or up to 1 percent of income, whichever is greater, and rise to $695, or 2.5 percent of income, by 2016. This is an individual limit; families have a limit of $2,085. Some people would be exempted from the insurance requirement, called an individual mandate, because of financial hardship or religious beliefs or if they are American Indians, for example.

Q: I want health insurance, but I can't afford it. What do I do?

A: Depending on your income, you might be eligible for Medicaid, the state-federal program for the poor and disabled, which would be expanded sharply beginning in 2014. Low-income adults, including those without children, would be eligible, as long as their incomes didn't exceed 133 percent of the federal poverty level, or $14,404 for individuals and $29,326 for a family of four, according to current poverty guidelines.

Q: What if I make too much for Medicaid but still can't afford coverage?

A: You might be eligible for government subsidies to help you pay for private insurance that would be sold in the new state-based insurance marketplaces, called exchanges, slated to begin operation in 2014.

Premium subsidies would be available for individuals and families with incomes between 133 percent and 400 percent of the poverty level, or $14,404 to $43,320 for individuals and $29,326 to $88,200 for a family of four.

The subsidies would be on a sliding scale. For example, a family of four earning 150 percent of the poverty level, or $33,075 a year, would have to pay 4 percent of its income, or $1,323, on premiums. A family with income of 400 percent of the poverty level would have to pay 9.5 percent, or $8,379.

In addition, if your income is below 400 percent of the poverty level, your out-of-pocket health expenses would be limited.

Q: How would the legislation affect the kind of insurance I could buy? Would it make it easier for me to get coverage, even if I have health problems?

A: If you have a medical condition, the bill would make it easier for you to get coverage; insurers would be barred from rejecting applicants based on health status once the exchanges are operating in 2014.

In the meantime, the bill would create a temporary high-risk insurance pool for people with medical problems who have been rejected by insurers and have been uninsured at least six months. That would occur this year.

And starting later this year, insurers could no longer exclude coverage for specific medical problems for children with pre-existing conditions, nor could they any longer set lifetime coverage limits for adults and kids.

In 2014, annual limits on coverage would be banned.

New policies sold on the exchanges would be required to cover a range of benefits, including hospitalizations, doctor visits, prescription drugs, maternity care and certain preventive tests.

Q: How would the legislation affect young adults?

A: If you're an unmarried adult younger than 26, you could stay on your parent's insurance coverage as long as you are not offered health coverage at work.

In addition, people in their 20s would be given the option of buying a "catastrophic" plan that would have lower premiums. The coverage would largely only kick in after the individual had $6,000 in out of pocket expenses.

Q: I own a small business. Would I have to buy insurance for my workers? What help could I get?

A: It depends on the size of your firm. Companies with fewer than 50 workers wouldn't face any penalties if they didn't offer insurance.

Companies could get tax credits to help buy insurance if they have 25 or fewer employees and a workforce with an average wage of up to $50,000. Tax credits of up to 35 percent of the cost of premiums would be available this year and would reach 50 percent in 2014. The full credits are for the smallest firms with low-wage workers; the subsidies shrink as companies' workforces and average wages rise.

Firms with more than 50 employees that do not offer coverage would have to pay a fee of up to $2,000 per full- time employee if any of their workers got government-subsidized insurance coverage in the exchanges. The first 30 workers would be excluded from the assessment.

Q: I'm over 65. How would the legislation affect seniors?

A: The Medicare prescription-drug benefit would be improved substantially. This year, seniors who enter the Part D coverage gap, known as the "doughnut hole," would get $250 to help pay for their medications.

Beyond that, drug company-discounts on brand-name drugs and federal subsidies and discounts for all drugs would gradually reduce the gap, eliminating it by 2020. That means that seniors, who now pay 100 percent of their drug costs once they hit the doughnut hole, would pay 25 percent.

And, as under current law, once seniors spend a certain amount on medications, they would get "catastrophic" coverage and pay only 5 percent of the cost of their medications.

Meanwhile, government payments to Medicare Advantage, the private-plan part of Medicare, would be cut sharply starting in 2011. If you're one of the 10 million enrollees, you could lose extra benefits that many of the plans offer, such as free eyeglasses, hearing aids and gym memberships. To cushion the blow to beneficiaries, the cuts to health plans in high-cost areas of the country such as New York City and South Florida – where seniors have enjoyed the richest benefits -- would be phased in over as many as seven years.

Beginning this year, the bill would make all Medicare preventive services, such as screenings for colon, prostate and breast cancer, free to beneficiaries.

Q: How much is all this going to cost? Will it increase my taxes?

A: The bill is estimated to cost $940 billion over a decade. But because of higher taxes and fees and billions of dollars in Medicare payment cuts to providers, the bill would narrow the federal budget deficit by $138 billion over 10 years, according to the Congressional Budget Office.

If you have a high income, you face higher taxes. Starting in 2013, individuals would pay a higher Medicare payroll tax of 2.35 percent on earnings of more than $200,000 a year and couples earning more than $250,000, up from the current 1.45 percent. In addition, you'd face an additional 3.8 percent tax on unearned income such as dividends and interest over the threshold.

Starting in 2018, the bill would also impose a 40 percent excise tax on the portion of most employer-sponsored health coverage (excluding dental and vision) that exceeds $10,200 a year for individuals and $27,500 for families.

The bill also would raise the threshold for deducting unreimbursed medical expenses from 7.5 percent of adjusted gross income to 10 percent.

The bill also would limit the amount of money you can put in a flexible spending account to pay medical expenses to $2,500 starting in 2013. Those using an indoor tanning salon will pay a 10 percent tax starting this year.

Q: What will happen to my premiums?

A: That's hard to predict and the subject of much debate. People who are sick might face lower premiums than otherwise because insurers wouldn't be permitted to charge sick people more; healthier people might pay more. Older people could still be charged more than younger people, but the gap couldn't be as large.

The bigger question is what happens to rising medical costs, which drive up premiums. Even proponents acknowledge that efforts in the legislation to control health costs, such as a new board to oversee Medicare spending, wouldn't have much of an effect for several years.

In November, a CBO report on how the legislation – which at that point had a tougher Cadillac tax – would affect premiums said big employers would see premiums stay flat or drop 3 percent compared to today's rates. It also noted that employees with small-group coverage might see their premiums stay the same. And Americans who received subsidies would see their premiums decline by up to 11 percent, according to the CBO.

Some of the items that go into effect in the first year include:

New help for some uninsured: People with a medical condition that has left them uninsurable may be able to enroll in a new federally subsidized insurance program that is to be established within 90 days. The legislation appropriates $5 billion for this, although that may not be enough to cover all who apply; it's not clear how much consumers would pay as their share of the cost. About 200,000 people are covered in similar state programs currently, at an estimated cost of $1 billion a year, says Karen Pollitz, a research professor at Georgetown University.

Discounts and free care in Medicare: The approximately 4 million Medicare beneficiaries who hit the so-called “doughnut hole” in the program’s drug plan will get a $250 rebate this year. Next year, their cost of drugs in the coverage gap will go down by 50 percent. Preventive care, such as some types of cancer screening, will be free of co-payments or deductibles starting in 2010.

Coverage of kids: Parents will be allowed to keep their children on their health insurance plan until age 26, unless the child is eligible for coverage through a job. Insurance plans cannot exclude pre-existing medical conditions from coverage for children under age 19, although insurers could still reject those children outright for coverage in the individual market until 2014.

Tax credits for businesses: Businesses with fewer than 25 employees and average wages of less than $50,000 could qualify for a tax credit of up to 35 percent of the cost of their premiums.

Changes to insurance: All existing insurance plans will be barred from imposing lifetime caps on coverage. Restrictions will also be placed on annual limits on coverage. Insurers can no longer cancel insurance retroactively for things other than outright fraud.

Government oversight: Insurers must report how much they spend on medical care versus administrative costs, a step that later will be followed by tighter government review of premium increases.

These are among the more than a dozen features of the new health care overhaul law that would take effect in 2010 under the measure passed Sunday. (Although the Senate bill approved Sunday by the House would become law with President Barack Obama's signature, Senate action is needed on the separately-passed House measure that would amend that law.) Other first-year items include a ban on lifetime limits on medical coverage, more oversight of premium increases and tax credits for some small businesses.

The big changes in the law – the ones that could affect tens of millions of people – don't kick in until at least 2014. Those include insurance marketplaces called “exchanges"; rules requiring insurers to accept all applicants, even those with health problems, and an expansion of state Medicaid programs.

Sunday, March 21, 2010

Sunday update

The latest news is that Representative John Larson says they have the votes in the House. They will not use "deem and pass" (see previous posts for explanation) -- they will vote on the Senate bill and then both the House and Senate will vote on a package of changes. It WILL pass. Vote is set for any time between 6 pm and midnight.

Today, we make history. Jennifer

Friday, March 19, 2010

The Health Reform End Game

This week-end, Congress begins the health reform end game. The details of the plan are now available for anybody to read here. The House will vote first on the bill already approved by the Senate with some important changes. The Senate will then vote only on the changes approved by the House. Since those changes have budget impact, the Senate will consider them under a procedure called reconciliation, which requires only a majority vote of 51 Senators, rather than a super-majority of 60 Senators. Once the Senate passes the changes, the bill will go to the President's desk to be signed. And we will be a little bit closer towards equality in health care.

The bill is far from perfect. It will be many years before we see the full effects of health reform. But within 90 days of passage, when you call me asking where you can get health insurance with a pre-existing condition, there will be a temporary high risk pool where you can get coverage right away, until the full program is up and running in 2014 and beyond.

And for me, that is really what this is all about: 30 million people who currently don't have insurance will have it. Deficits will be cut over 10 years by $138 billion. We will start to rein in the cost of health care while, at the same time, making sure that people who are sick -- people who today face tragic circumstances -- will have access to health care.

Is it perfect? Absolutely not. Will I be better off? No, indeed, I likely will be worse off. But I am prepared to give a little to ensure the well-being of 30 million uninsureds. And I am tremendously gratified and grateful to see us move off of the status quo and move towards a system that is more humane, and ultimately more affordable.

I understand that there is a lot of fear and mistrust about the reform plan. Who can really digest 2300 pages of arcane tax rules? Does anybody really know how this will all play out? Those fears are legitimate. I suspect that, as with any major piece of legislation, there will be many amendments over the coming years as the plan is implemented and honed.

But here are some things we know for sure:

1. This is NOT a government take-over of health care -- or at least no more of one than we already have. Health care in the form of Medicare and Medicaid already are run by the government. State Insurance Departments already regulate insurance companies. So all we are doing now is replacing old laws, regulations, and policies with new ones.

The primary way in which the governments (states, not federal) will be more involved in health care is the sale of health insurance through Exchanges, marketplaces where you will be able to go to see what plans are available to you, what they cost, and what will best suit your needs. Right now, most people have no clue what their options are. There are few really well-informed health insurance brokers, and few states really offer consumers a lot of information about their options that allow them to compare benefit plans and costs. This will change. You can be an informed consumer.

Second, everybody will be required to have insurance. This is necessary because, if we are going to require insurers to cover people with pre-existing conditions, we need to expand the pool of people who have insurance to include healthy people, too, thereby spreading the cost. However, Medicaid will be opened to adults earning up to 133% of the federal poverty level, and subsidies will be offered to those earning up to 400% of the federal poverty level. The penalty for not having insurance is phased in over many years, and it is very small. Small businesses will get tax credits for providing insurance, and large businesses will get penalized for failing to do so. To a large extent, then, the playing field is leveled so we can all have the same quality health care.

2. Sick people will be better off, on the whole. Once the Exchanges are up and running, there will be no more pre-existing condition exclusions; premiums cannot be tied to health history; policies cannot be canceled because you get sick; lifetime and annual caps on benefits are eliminated for new plans and phased out for old ones; children will be covered under their parents' plans to age 26; preventive care will be free.

And here's a piece we haven't talked about that is critical -- when ANY insurer denies coverage of anything, after you exhaust your right to appeal to the insurance company, EVERYBODY will have a right to an external, independent review of claim denials by an independent review organization, most likely run through state insurance departments. Today, this "external appeal" mechanism exists in all but 5 states, but it does not apply to self-funded plans. That will change; there will be independent review of all claims. The toughest appeals are won in these external appeals. This is a huge benefit to people who need new medications or who have rare or complex diseases.

Where's my reservation? There are those of us who have what have been called "Cadillac plans" -- plans that are very expensive, but that have essentially no out-of-pocket costs -- deductibles, copays, coinsurance. I have a Cadillac plan; it's what I bargain for with my employer in lieu of a salary increase. Under the new plan, Cadillac plans will be taxed out of existence, so people like me will have higher out of pocket costs.

However, even in this respect, the Bill includes limits. First, it won't happen until 2018, and I believe that there will be many new insurance options by that time. Second, the reform plan restricts the percentage of one's income that you can be required to pay on health care; above that, your care is covered 100% by your insurer. So yes, my out-of-pocket costs will increase, but not without limit.

And in the end, I evaluate public policy not solely based on what's best for me, but based, instead, on what's best for us all. And I have no reservation in telling you that this reform package is good for us as a whole.

3. Medicare recipients won't be worse off and probably will be better off. Over the next 10 years, the doughnut hole -- the coverage gap in Medicare coverage of prescription drugs -- will be phased out. That is a huge help to the chronically ill.

In addition, Medicare Advantage Plans no longer will operate as HMOs; they will have to pay for care on a fee-for-service basis. What this means is that they no longer will have incentives to deny coverage. Their premiums will be regulated so that they can't make unlimited profits off of the Medicare program. That is how we reduce Medicare costs without cutting benefits -- we eliminate profit instead of programs.


There are so many details that obviously I cannot cover in a summary. And because this is so big -- and because we (often reasonably) have come to mistrust our government officials -- I know it causes great concern and even fear. Much will only be known in the coming years as the plan is implemented.

But here's what I do know. I know that literally thousands of you have come to me for help with health insurance -- either you can't find it at all because of a pre-existing condition, or you can't pay for it, or it won't cover what you need. And I KNOW, with certainty, that in those respects, all of us will be better off.

I got a call recently from a young man with cyclic vomiting syndrome. He can't keep anything down. His teeth are literally melting. He was kicked out of the Army because of it; fired from every job because of it. He's applying for disability, but that takes months. In the meantime, he has no health care. He is about to lose his housing due to lack of funds. He all but told me that he sees his only choice as committing suicide. I tried to give him hope. I tried to make him promise to call me and talk to me and we would keep looking for answers together. But he and I both know that he is, right now, one of the forgotten. We as a society have simply decided to leave certain people behind.

The health reform plan isn't a panacea, but for this young man, there will be health care, and that means that there will be at least some answers. If he got treated and could maintain nutrition, maybe he could even work and live a decent life.

And so we choose between a status quo in which suicide -- and, less dramatically, bad health, death, and bankruptcy -- is a tragically rational option, and a plan that changes the status quo, gives people a little hope, provides real answers to some problems right away, and to many problems over the next few years. For me, the choice is an easy one.

"Of all the forms of inequality, injustice in health care is the most shocking and inhumane." Martin Luther King, Jr. Health reform is a step towards restoring our humanity. We MUST support it. However scary it is, however afraid we are to trust politicians, however imperfect a solution this is, the alternative -- a system in which people are driven to death, ruin, and suicide -- cannot be tolerated in the America we all want to believe in. Jennifer

From Kaiser Health News

Here are some of the major changes the reconciliation proposal would make to the Senate-passed bill:

HEFTIER SUBSIDIES: Compared to the Senate legislation, the reconciliation bill would provide more generous subsidies to low- and moderate-income Americans to help them buy health coverage.

THE MASERATI TAX: The levy on high-cost insurance plans is scaled back and delayed, rendering it more a "Maserati" than a "Cadillac" tax. It would apply only to the portion of plans costing more than $10,200 a year for individuals, up from $8,500, and $27,500 for families, up from $23,000. The tax wouldn't kick in until 2018, reducing the projected revenue to the government by 80 percent.

CLOSING THE DOUGHNUT HOLE: Unlike the Senate bill, the reconciliation measure would eventually close the coverage gap, called the "doughnut hole," for Medicare beneficiaries enrolled in Part D drug plans. (Currently, seniors who hit the gap must bear the full cost of their medications until they spend a certain amount, when coverage kicks back in.)

Under the new bill, seniors who hit the gap this year would get $250 to help cover the costs of their medications. Starting next year, they'd get a 50 percent discount on brand-name drugs, with the cost borne by the drug industry. In subsequent years, the discounts would expand and begin covering generic drugs, with the expense picked up by the government. By 2020, the discounts would reach 75 percent.

SHIFT IN MEDICARE ADVANTAGE PAYOUTS: Government payments to Medicare Advantage, the private-health plan alternative to traditional Medicare, would be cut back more steeply than under the Senate bill: $132 billion over 10 years, compared to $118 billion.

The government currently pays the private plans an average of 14 percent more than traditional Medicare. The new bill, besides reducing payments overall, would shift the funding; some high-cost areas would be paid 5 percent below traditional Medicare, while some lower-cost areas would be paid 15 percent more than traditional Medicare. The Senate's plan that would have shielded some areas of the country such as South Florida from major cuts was largely eliminated.

A RAISE FOR DOCTORS: Primary care doctors would get a Medicaid payment boost in the reconciliation bill. Beginning in 2013 and 2014, the doctors' payment rates would be on par with Medicare rates, which typically are about 20 percent higher than Medicaid. The goal is to ensure that there will be a sufficient number of doctors willing to care for the millions of additional people who would become eligible for Medicaid under the health care overhaul.

PUSHING UP THE MEDICARE TAX: The Senate bill adds 0.9 percent to the Medicare payroll tax on earned income above $200,000 for individuals, or $250,000 for couples. Under the reconciliation bill, starting in 2013, people in those income brackets also would face a 3.8 percent tax on investment income, such as interest, capital gains and dividends.

PENALTY FOR NOT HAVING INSURANCE: Under the new bill, most Americans without insurance would face an annual penalty, starting in 2014 at $95 – the same as in the Senate bill. But in following years, the penalties in the reconciliation bill are slightly different. Those without insurance in 2016, for example, would pay the greater of two alternatives: a flat fee of $695, down from the Senate’s $750, or 2.5 percent of their income, up from 2 percent in the Senate bill.

EXPANDING MEDICAID: The reconciliation package differs from the Senate-passed bill in several ways. It would delete a provision dubbed the "Cornhusker kickback" that would have exempted Nebraska from paying any cost of a Medicaid expansion included in the bill. But it would provide full federal funding to all states for newly eligible Medicaid recipients for three years. And it would give additional funding to states like Vermont and Maine that have already moved to cover adults without children, which isn't required under the Medicaid program.

MEDICARE SPENDING BOARD: The Senate bill would create an independent, 15-member board to recommend ways to control Medicare spending. The board remains in the reconciliation package, but would be expected to produce just about half of its original projected savings of $23 billion in the Senate bill. That's because the new proposal would make greater cuts in Medicare Advantage plans.

Congressman Larson in HuffPo on Health Reform

The Top Ten Immediate Benefits You'll Get When Health Care Reform Passes

As soon as health care passes, the American people will see immediate benefits. The legislation will:

  • Prohibit pre-existing condition exclusions for children in all new plans;

  • Provide immediate access to insurance for uninsured Americans who are uninsured because of a pre-existing condition through a temporary high-risk pool;

  • Prohibit dropping people from coverage when they get sick in all individual plans;

  • Lower seniors prescription drug prices by beginning to close the donut hole;

  • Offer tax credits to small businesses to purchase coverage;

  • Eliminate lifetime limits and restrictive annual limits on benefits in all plans;

  • Require plans to cover an enrollee's dependent children until age 26;

  • Require new plans to cover preventive services and immunizations without cost-sharing;

  • Ensure consumers have access to an effective internal and external appeals process to appeal new insurance plan decisions;

  • Require premium rebates to enrollees from insurers with high administrative expenditures and require public disclosure of the percent of premiums applied to overhead costs.

By enacting these provisions right away, and others over time, we will be able to lower costs for everyone and give all Americans and small businesses more control over their health care choices.

Thursday, March 18, 2010

More updates

President Barack Obama postponed his trip to Indonesia and Australia until June, White House press secretary Robert Gibbs announced. He was planning to leave Sunday, but the health care vote is expected Sunday as well. "Passage of health care reform is of paramount importance and the president is determined to see this battle through," Gibbs said.

Health Reform Reconciliation Highlights as of 3/15/2010

And so the Congressional Budget Office estimates begat the release of a twelve-page document entitled Highlights of the Health Reform Reconciliation Bill as of 3/15/2010.

Remember, we start with the Senate bill as our starting point. The following are the changes that are being negotiated. So the Senate bill gets passed by the House (or the House "deems" it passed -- see yesterday's post for explanation), and then both the House and Senate pass these changes, and we end up with the final version.

I'm not going to give you all 12 pages, but here are the things that matter to me and to the patients who come to me for help:

1. Tax credits/subsidies for health insurance premiums will extend to families earning up to 400% of the federal poverty level.

2. Premiums, deductibles, copays, and coinsurance are limited for low income families to a percentage of income on a sliding scale equal to or lower than what was in the Senate bill.

3. Reduces the penalty for people who don't buy insurance, and phases in the penalty over 3 years, while increasing the penalty on large employers who don't offer coverage.

4. Phases out the Medicare Part D doughnut hole over the next 10 years (not fast enough for me, but better than nothing).

5. Converts Medicare Advantage (HMO) rates to fee-for-service rates, which eliminates the insurers' incentive to deny coverage. Medicare Advantage premium rates will be regulated.

6. Delays implementation of the so-called "Cadillac tax" on high cost plans until 2018 and raises the threshold for those plans.

7. Increases the Medicare payroll tax for individuals with incomes over $200,000 and families with incomes over $250,000, and extends the tax to income from investments.

8. Requires insurers to disclose the way they set their premium rates and to justify "potentially unreasonable" premiums.

9. Federal funding for states extending Medicaid to individuals up to 133% of federal poverty level is greatly increased. The special "deal" for Nebraska is gone!

Remember, these are just the changes to the Senate bill, which means everything else in the Senate bill -- elimination of preexisting condition exclusions, phasing out of lifetime and annual caps, creation of a high risk pool for people with preexisting conditions almost immediately after the bill is passed, Medicaid eligibility for single adults with incomes under 133% of the federal poverty level, creation of the exchange (Senate bill would be state exchanges and it looks like that's not changing to federal) -- all of the things we've been talking about for months -- are still there. The exceptions are these express changes.

There is NO change to the Senate abortion language, so the House would accept the less harsh language that still ensures that no federal funds go to paying for abortions or for insurance premiums to cover abortions. Similarly, there is no change to the prohibition on legal immigrants' purchasing insurance through the exchanges.

Those are the highlights. There are lots of other provisions strengthening protections against fraud and abuse, imposing excise taxes on health care industry participants to help pay for reform, and so on. And there are notes all over the place saying that there is more language in the works, so this definitely isn't the final version. But the plan was to get the CBO estimate, ensure budget neutrality (and we actually have projected savings, so better than neutrality), then get to final language, and post the final language on the internet for 72 hours before any votes are taken.

For those of you who want to follow I'd be looking for the language to be posted here, or on the White House health reform page here, or possibly even the main White House site here. I'll do my best to stay on top of this for you over the coming days, although I won't be around on Saturday, so you're on your own for at least part of the week-end. If there are updates before then, I'll post them for you here. So keep checking in. Jennifer

CBO Estimates on Health Reform

The Congressional Budget Office has determined that the health reform plan will cost $940 billion over 10 years, but will trim the federal deficit by $130 billion in the first ten years and $1.2 trillion in the second ten years, House Majority Leader Steny Hoyer said. Those deficit numbers should help ease the worries of deficit hawks on the fence about supporting the bill.

Wednesday, March 17, 2010

NEW 2010 Edition of the Know Your Rights Handbook Available NOW!

For years, the Know Your Rights handbook has been a primary source for patients and patient advocates to learn about health and disability insurance, Social Security disability, employment discrimination, family and medical leave, educational equity, and resource location. The 2010 Edition is fully updated with the current details of the law. Includes sample health insurance appeal letters, Social Security application paperwork, summaries of case law on the Americans with Disabilities Act, Family & Medical Leave Act, and lots more. Purchase here. Jennifer

Quick Note on Deemed Passed

As if things hadn't gotten confusing and contrived enough, a new procedural option is emerging for passing health reform. Since the House doesn't trust the Senate to pass changes to the Senate bill, but the President has to sign the Senate bill before the House and Senate vote on those changes if the Senate uses the reconciliation process we've been talking about (below, ad nauseum), the House has come up with another option: pass the changes to the Senate bill, and that would mean that the underlying Senate bill was "deemed passed" -- passed as if the House had voted for it, even though they won't have done so. Passing health reform without having to take responsibility for voting for it -- interesting.

I don't know how realistic any of this is. It's clear that the Democrats in both the House and the Senate are having trouble coming up with the votes. Abortion is an issue. The public option is an issue. But the procedural mechanism is also a huge issue, and it's clear that the leadership is looking for a way to guarantee the House that the Senate bill will be fixed even if it's passed and signed by the President before any such changes have been enacted into law.

I'm desperate to see some form of health insurance reform pass because there must be an answer to the people who call me every day looking for a pathway to health care. I can't help keep thinking that if any of these members of Congress had to sit in my chair for a day, they'd have no problem getting this thing passed. It shouldn't take this much drama to get this done. After all, there's drama all around us -- an 18 year old who needs a kidney transplant; a woman who can't have the chemotherapy that's most likely to save her life; insurers turning somersaults to try to avoid paying for an expensive but effective treatment for a rare disease called neuromyelitis optica (NMO or Devic's disease), whose victims go blind (among other things).

We shouldn't need a "deemed past" end game. Health reform should be embraced as essential to our humanity. Jennifer

Friday, March 12, 2010

Last Chance on Chronic Disease Survey

Only 8 days left to take our chronic disease survey. We need 28 more people to hit 1500. Please take it here. Thanks. Jennifer

Health Reform Update

Here I am, your intrepid reporter, with your periodic update on health reform battles. It's really hard to know what to say or where things are going right now. There have been so many surprises.

The public option appears to be close to resurrection from being dead at least twice already. Again, this would not be government take-over of health care; it would simply allow Americans to choose to buy Medicare-like insurance instead of Blue Cross. It would be up to each of us to decide what we want. The biggest plus of having a public option would be that administrative costs would be lower than in the private sector, thereby lowering the cost of the public plan, forcing private plans to lower premiums to stay competitive. Simple and absolutely right. There are at least 45 votes for the public option if they do it as part of reconciliation, where they need only 50 votes in the Senate.

Remember reconciliation? In the Senate, for normal legislation to get to a vote, there must first be a vote for cloture, which requires a super-majority of 60 votes. However, for matters affecting the budget, they can use the reconciliation process, which requires only 50 votes. And we know Joe Biden would vote yes if there were a tie. I'm reading and hearing that there are at least 45 votes for the public option. Can we squeak one out? I don't think we're going to know the answer to this one until the minute the vote happens.

And reconciliation is not simple. There are parts of the health reform bill that don't relate to the budget. So the idea is that the House would pass the bill the Senate has already passed. After that, the Senate and the House would both pass the same reconciliation bill, and we're there. However, the House doesn't trust the Senate to pass an acceptable reconciliation bill. Also, the Congressional parliamentarian -- some guy nobody knows who's never been elected to anything but who gets to referee this melee -- has said that the President has to sign the Senate bill before it can be amended through the reconciliation process, so the President has to sign a bill he, too, is not really happy with, trusting Congress -- oy, vey -- to pass the fix pretty much right away. (Oy vey being a Congressional term of art, for those of you who don't know the name of the Parliamentarian).

And then there's abortion. There are House rabid anti-abortionites who want their version of the language limiting the use of federal funds for abortion, whereas most of the world is content with the Senate version. The Senate version would allow a woman to buy an insurance policy through the exchange (the marketplace, and these would be ONLY private insurance plans) but she'd have to write two checks every month so her private money pays for the abortion coverage, even if she gets a subsidy from the government to help her pay for the rest of her policy. That way, no public dollars can be used to fund abortion. The House version just says no plan that is sold through the exchange -- meaning no plan sold by any insurance company -- can include abortion. Which means a woman can't even spend her own money to buy coverage of abortion. While pretty much everyone agrees to set aside the issue and just accept the fact that federal funds cannot be used for abortions, there are a handful in the House -- maybe enough to derail reconciliation? -- who won't accept the Senate version and so won't vote for the changes that will be contained in the reconciliation bill. To me, it seems like these members are trying to eliminate even private insurance funding of abortion, so I think it's wrong and unfair and the Senate version, which I'm not crazy about, ought to be considered good enough.

But the votes on all of this are so close. And there's such reasonable distrust in Congress and of Congress -- most people agree that ending up with the Senate bill would pretty much stink, although actually, I still think it would be better than nothing. But the Senate bill with a reconciliation fix would be pretty darn good, and the Senate bill with reconciliation that includes the public option would be a home run.

I just wouldn't bet a thin dime on any of it. Jennifer

Tuesday, March 9, 2010

Loads of Hope, Hope for Better Times

Mark called yesterday. Just because he'd read my blog and I sounded down and he wanted to give me a pick me up. Jamie and Kate and Shawn -- the ever wondrous Shawn -- oogled and oggled over the article about me in Connecticut Magazine. I am very grateful.

Then my humidifier broke and there was water everywhere. Then my assistant called in sick. Then my Quickbooks broke, along with Excel.

Then an old, old client who calls whenever she has a problem called to say she got a speeding ticket because she was trying to run to a bathroom (I've been there, for sure).

Oy. I don't know what's going to happen next, but I'm afraid it won't be good.

We sick people seem to get piled on. I hope it stops. Soon. Jennifer

Friday, March 5, 2010

Five Years

Five years ago today, I began my work at Advocacy for Patients with Chronic Illness, Inc. I had already incorporated and gotten the tax exemption, but I hadn't told my partners or committed to doing this work full time until March 5, 2005.

I don't know what I was thinking. First, I know I thought it would be easier to get grant money to do what I do. After all, these services are so badly needed and nobody else is doing this -- there had to be foundations that would fund us. Wrong.

I thought I would partner with disease specific organizations like the Crohn's & Colitis Foundation of America, that they would include me and support me. Wrong again. Indeed, they had me train them thinking we would be working together, but I'm a schmuck and they won that round.

I knew there would be a huge need for my services, but I had no idea how bad the need would be. I had no idea how desperate people were. I knew things were hard for me -- the occasional insurance appeal, increasing premiums, employers giving me a hard time because I was sick -- but I never imagined the brutality so many people with chronic illnesses live with. Children -- sick children sent to truancy court! I had no idea.

I thought I could find answers, and although most of the time I do, there are problems for which there are no answers, and they are heart-breaking.

I do not feel accomplished after five years. I feel beaten down and exhausted and impotent. Yes, I do more than most people do. I do a lot. But I don't do enough. I can't There are too many people for whom there are no answers. There are too many people who just need money -- the one thing that's hardest to find.

I thought by now I'd have hired a second lawyer. I do have an assistant, thank goodness, but we don't have a second lawyer and won't any time soon. There's no money.

The world is too hard a place for people like me. I don't feel like celebrating today. I feel like going to bed and staying there for a long time.

I've been doing this for five years, but I'm completely fried. I can't bear the thought of another five. The fatigue overwhelms what should be a sense of accomplishment. I fight for every $50 donation. For foundations, we're either too small or we do work nationally or we're not really legal services because we don't go to court, or we're not in the health care category because we aren't care providers. Because we are unique, we are largely unfunded. Never mind the 1500 cases a year we resolve. That's not big enough for some of the larger foundations to invest in.

Sometimes I feel proud, but not today. Today, I just feel tired. How on earth can i keep this up? Finding answers for people for whom there are no answers other than a little of my time and my undying respect. Raising money in $5 or $50 increments. Begging for help, whether for my organization or for one of our clients. I don't know how much longer I can do this. And of course, with my disabilties, I have no other options.

So today is not a day I celebrate. Today is a day when tears come because I can't figure out where I'm going to get the energy or the money to do this tomorrow. Jennifer

Tuesday, March 2, 2010

Four Republican Ideas

Today, President Obama agreed to include four Republican ideas in his health plan:

The proposals Obama listed are: sending investigators disguised as patients to uncover fraud and waste; expanding medical malpractice reform pilot programs; increasing payments to Medicaid providers and expanding the use of health savings accounts.

There's nothing offensive in any of these ideas except that I've yet to meet a single person who did well using a health savings account. But once again, it seems to me that the President is trying overly hard to make it appear as though this is a bipartisan plan. If he hadn't spent months letting Senator Baucus beg Olympia Snowe for her votes, we'd have a plan already. Does he really think he's going to get even one Republican vote because he agrees to add these four elements.

I just don't think so. It takes two to tango. I don't think there's a single Republican ready or willing to dance with him. Jennifer


This health care thing is becoming an emotional roller-coaster ride. Obama's 11 page draft plan was close to the Senate version with a few tweaks. I could live with it. But then the summit fell flat -- splat -- on its face. The President kept trying to find something the opponents could live with. The opponents kept saying start over, blank slate, or there's nothing to talk about. I don't know about you, but if they start over with a blank piece of paper and we're stuck with another year of this haggling, I don't think I can stand it.

And then I heard Ezra Klein (WaPo) and some other talking heads talking about micor-reconciliation -- and then I think I got it. Weeks ago, I (and lots of others -- I can't take credit) advocated that the House pass the Senate bill and then pass the fixes through the process known as reconciliation -- measures that are related to the budget can pass the Senate by simple majority of 51 votes (with Joe Biden as number 51). Most of the things that have to be tweaked for the House to buy into the Senate compromise affect the budget, so this can be done. Lots of us in the health advocacy community have been arguing for this for weeks.

But it seems that there are a few things that people don't think would fit into reconciliation. For example, although I think federal funding of abortion (um, federal funding of anything) affects the budget, people are saying the fix for abortion funding can't be in reconciliation. There are a few other things like that.

So here's the deal. The House passes the Senate bill. The Senate passes micro-reconciliation, as does the House. Then they both -- maybe, some day -- get around to the issues they couldn't "fix" through micro-reconciliation.

Why micro? Nobody wants to pass the whole health care bill through an exception to the rules. Since the reconciliation would be a "micro" one, the idea is that most of the bill gets passed through normal channels, and President Obama's 11 pages become tweaks to the Senate bill -- 11 page micro-reconciliation -- and then it's done.

Since I could have lived with any reconciliation, I certainly can live with a micro one. And most of all, I'm really impressed with this political maneuver. They just invented micro-reconciliation. Remember, unless you were listening to MSNBC last night, you heard it here first! Jennifer

Thanks from Emily

Emily (the cat) asked me to write this in case Larry Bloom of Connecticut Magazine is still reading my blog. I've had my share of press exposure -- some welcome, some not, some I don't even know about -- but Larry Bloom wrote a lovely piece about me in the March issue of Connecticut Magazine. And here's the important part:

She leads and organization that employs a workforce of two, not counting to full-time lap sitter, a cat named Emily.

Well, Larry, you've made a real fan of yourself around here. Prancing around as if she were the Queen of Sheba (and she clearly is the queen of something), this press has gone directly to Emily's head.

The rest of the article is really lovely, too. It feels so very real. Larry "gets" me.

So much so that he knew that mentioning Emily at the top of the story would win me over. And it did. Jennifer