GeoCreationism.com

This is a bit of a departure (again), but our bodies are God’s creation, so why not review the bill that purports to help us care for God’s creation, right?  Let me say right of the bat, I don’t want this health-care reform bill.  But, I know that people with my perspective are often fooled by the most extreme of us to believe falsehoods that simply make us look like fools to the people that I think are wrongfully touting this bill… and when we look fools to them, we’ve got no argument.  So, here we go.

The excerpts that I keep seeing over and over again are the exact same “experpts” from the bill.  You can see a complete of them at freerepublic. Unfortunately, they are all paraphrases and not quotes, and paraphrases, treated as quotes, can only make you look like a fool.  However, the list does serve as a good outline to study from, right?  Well, I think I’ll read through everything (as I get the time), so I can address the right-intentioned wrong-headedness I’ve been seeing.

To provide affordable, quality health care for all Americans

and reduce the growth in health care spending, and

for other purposes.

Well, in the bill’s stated purpose, they’ve already lost me.  Notice the wording: “…and reduce the growth in health care spending.”  It doesn’t say “… and reduce the spending” or “… and reduce the cost.”  But the growth in the spending… not even the growth in cost!  That tells me that congress knows they may not be able to do anything about health care costs.  And in that case, what are they doing this for?

Well, let us suppose costs don’t go down, and that even the growth in costs does not go down.  How then do you reduce the growth in spending?  One way is reduce the need for care.  Help us to spend our money more wisely by reducing the amount of unnecessary tests and treatments that occur, and that might work. Too bad they don’t come out and say that.  If they did, I might support it!  But they don’t, which leaves another possibility, which is one that people such as me are afraid of…

Besides reducing spending on needless care, you can all reduce the growth in spending by reducing people’s access to care.  Again, they do not actually say they are going to do this, but the purpose, as worded, would not rule it out.  Does the bill itself rule it out?  I don’t know yet.  I hope so.

Another aspect of this is the word “affordable”.  How do you make care affordable?  As stated above, you make sure only necessary treatments are performed.  Another is to provide only the care one can afford.  If the growth in costs are not cut, then withholding care is the only alternative.

But then there is the phrase “quality health care”.  What constitutes quality?  I don’t know.  It’s a rather subjective term, and someone will have to define it.  Who?  Me? Will I get to decide what constitutes quality care for my family?  Well, if quality care is unaffordable by my standards, then the only way to meet the bill’s stated purpose is to appointment someone who will determine the definition of “quality” for me.

Then, there is phrase “for all Americans”.  Wow.  That’s the scary one, because people leave their jobs, and employers are free to choose the insurance they provide.  So, how do you provide care to that out-of-work American, and who does the providing?  The only answer the government can possibly come up with is, **the government**.

And then finally, “for other purposes”.  Now that one scares me, because what else is this bill going to do?  I guess I have to read it.

5 (a) PURPOSE.—
6 (1) IN GENERAL.—The purpose of this division

7 is to provide affordable, quality health care for all

8 Americans and reduce the growth in health care

9 spending. — Page 4  

Again, the purpose is not to cut costs, but reduce the growth in spending.

13 so that all Americans have coverage of essential

14 health benefits. — Page  5

I was already wondering what they consider “quality”.  Now I want to know what they consider “essential”.

On page 8, the bill refers us to section 202(d)(2) for a definition of “acceptable coverage”.  Okay, what is “acceptable coverage”?  That would be on page 76, line 6.

(A)”Coverage under a qualified health benefits plan.”

What does “qualified” mean?  I would have much preferred something that simply refers to the coverage I already have, but no.  I have to keep searching to find out what “qualified” means.

12 (B) GRANDFATHERED HEALTH INSURANCE
13 COVERAGE; COVERAGE UNDER CURRENT GROUP
14 HEALTH PLAN.—Coverage under a grand
15 fathered health insurance coverage (as defined
16 in subsection (a) of section 102) or under a
17 current group health plan (described in sub18
section (b) of such section).

The others don’t apply to most Americans.  So what is “grandfathered” health insurance? Wording like this usually refers to something is will being disqualified for new applicants, but can be retained by current holders.  Well, it refers us to section 102(a) for more…

1 SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT
2 COVERAGE.
3 (a) GRANDFATHERED HEALTH INSURANCE COV4
ERAGE DEFINED.—Subject to the succeeding provisions of
5 this section, for purposes of establishing acceptable cov6
erage under this division, the term ‘‘grandfathered health
7 insurance coverage’’ means individual health insurance
8 coverage that is offered and in force and effect before the
9 first day of Y1 if the following conditions are met:
10 (1) LIMITATION ON NEW ENROLLMENT.—
11 (A) IN GENERAL.—Except as provided in
12 this paragraph, the individual health insurance
13 issuer offering such coverage does not enroll
14 any individual in such coverage if the first
15 effective date of coverage is on or after the first
16 day of Y1.
17 (B) DEPENDENT COVERAGE PER
18 MITTED.—Subparagraph (A) shall not affect
19 the subsequent enrollment of a dependent of an
20 individual who is covered as of such first day.
21 (2) LIMITATION ON CHANGES IN TERMS OR
22 CONDITIONS.—Subject to paragraph (3) and except
23 as required by law, the issuer does not change any
24 of its terms or conditions, including benefits and
25 cost-sharing, from those in effect as of the day be26
fore the first day of Y1.

In other words, grandfathered health insurance is any individual policy that stops issuing insurance after the law goes into effect.  In other words, these are ‘individual’ policies, not group policies.

Note that private individual policies are not covered under any other definitions of acceptable coverage.  Therefore, the law is making illegal all new purchases of individual policies. Once all grandfathered policies have been canceled for one reason or another, only group policies will remain. So what if you aren’t employed, and so cannot participate in group coverage?  Then, you would fall under 102 (2)(A), which reads, “Coverage under a qualified health benefits plan.” Unfortunately it doesn’t say what that is, but I suspect it is defined in section 101. Well, we’ll get to that one below. But first, let’s back to the group plans. What is acceptable group coverage?

8 (b) GRACE PERIOD FOR CURRENT EMPLOYMENT9
BASED HEALTH PLANS.—
10 (1) GRACE PERIOD.—
11 (A) IN GENERAL.—The Commissioner
12 shall establish a grace period whereby, for plan
13 years beginning after the end of the 5-year pe
14 riod beginning with Y1, an employment-based
15 health plan in operation as of the day before
16 the first day of Y1 must meet the same require
17 ments as apply to a qualified health benefits
18 plan under section 101, including the essential
19 benefit package requirement under section 121.
20 (B) EXCEPTION FOR LIMITED BENEFITS
21 PLANS.—Subparagraph (A) shall not apply to
22 an employment-based health plan in which the
23 coverage consists only of one or more of the fol24
lowing:
1 (i) Any coverage described in section
2 3001(a)(1)(B)(ii)(IV) of division B of the
3 American Recovery and Reinvestment Act
4 of 2009 (PL 111–5).
5 (ii) Excepted benefits (as defined in
6 section 733(c) of the Employee Retirement
7 Income Security Act of 1974), including
8 coverage under a specified disease or ill9
ness policy described in paragraph (3)(A)
10 of such section.
11 (iii) Such other limited benefits as the
12 Commissioner may specify.
13 In no case shall an employment-based health
14 plan in which the coverage consists only of one
15 or more of the coverage or benefits described in
16 clauses (i) through (iii) be treated as acceptable
17 coverage under this division
18 (2) TRANSITIONAL TREATMENT AS ACCEPT19
ABLE COVERAGE.—During the grace period specified
20 in paragraph (1)(A), an employment-based health
21 plan that is described in such paragraph shall be
22 treated as acceptable coverage under this division. 

Okay, first notice paragraph (B) above. No employee plan offering limited benefits will be allowed.  In other words, if your policy does not cover you completely, it is not an acceptable plan.  If this is the result of your employer’s choice, then this will result in full coverage for you.  If this the result of your own choice, that choice is being taken away.  Either one will result in higher costs (higher premium for full coverage) or lower pay (so your employer can pay the higher premium) for you.

So, let’s go back to paragraph (A).  That would be all full-coverage group health plans offered through your employer, and those will be allowed to stay as they are for 5 years.  After that, they will be required to change to look like those plans specified in sections 101 and 121.  So what will plans have to look like after 5 years? Well before we go there, this is also, I believe the kind of coverage that someone with individual coverage will have to switch to, as provided (most likely) by the government.  So what does that coverage look like?

18 SEC. 101. REQUIREMENTS REFORMING HEALTH INSUR19
ANCE MARKETPLACE.
20 (a) PURPOSE.—The purpose of this title is to estab
21 lish standards to ensure that new health insurance cov
22 erage and employment-based health plans that are offered
23 meet standards guaranteeing access to affordable cov
24 erage, essential benefits, and other consumer protections.

It says “new”, but as we’ve seen, all group plans provided through private insurance or employment will have to look like this, because the clause describing them refers to here!  And all people with individual plans will have to switch to something that looks like this.  So, this section is not just referring to new insurance, but to practically ALL insurance (publich employment plans, medicare, medical, and VA are excluded).  So what must ALL insurance look like?

1 (b) REQUIREMENTS FOR QUALIFIED HEALTH BENE2
FITS PLANS.—On or after the first day of Y1, a health
3 benefits plan shall not be a qualified health benefits plan
4 under this division unless the plan meets the applicable
5 requirements of the following subtitles for the type of plan
6 and plan year involved:
7 (1) Subtitle B (relating to affordable coverage).
8 (2) Subtitle C (relating to essential benefits).
9 (3) Subtitle D (relating to consumer protec
10 tion).
11 (c) TERMINOLOGY.—In this division:
12 (1) ENROLLMENT IN EMPLOYMENT-BASED
13 HEALTH PLANS.—An individual shall be treated as
14 being ‘‘enrolled’’ in an employment-based health
15 plan if the individual is a participant or beneficiary
16 (as such terms are defined in section 3(7) and 3(8),
17 respectively, of the Employee Retirement Income Se18
curity Act of 1974) in such plan.
19 (2) INDIVIDUAL AND GROUP HEALTH INSUR20
ANCE COVERAGE.—The terms ‘‘individual health in21
surance coverage’’ and ‘‘group health insurance cov22
erage’’ mean health insurance coverage offered in
23 the individual market or large or small group mar24
ket, respectively, as defined in section 2791 of the
25 Public Health Service Act.

Hmmmm… more cross-references.   Fine then, but at least it seems that I’ll be getting some of my questions answered, regarding what “affordable” and “essential” mean.  Oohh. And “consumer protection”, too.  I wasn’t expecting that one.

15 Subtitle B—Standards Guaran16
teeing Access to Affordable Cov17
erage
18 SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLU19
SIONS.
20 A qualified health benefits plan may not impose any
21 pre-existing condition exclusion (as defined in section
22 2701(b)(1)(A) of the Public Health Service Act) or other23
wise impose any limit or condition on the coverage under
24 the plan with respect to an individual or dependent based
25 on any health status-related factors (as defined in section
1 2791(d)(9) of the Public Health Service Act) in relation
2 to the individual or dependent.

As upset as I’ve been regards to my own insurability for pre-existing conditions (not as bad as most, but it’s happened), I just don’t see how you can control costs by not having ANY ANY ANY limitations on what is or is not covered for pre-existing conditions.  And this is in the Affordability section?  Right. Frankly, this looks like enough to either send private insurance to the poor house, or people won’t be able to be covered because of all the pre-existing conditions.  OR, perhaps insurance companies will simply slash a given benefit to everyone equally, in order to say that their not discriminating against people with pre-existing conditions.  If they do that, then everyone loses.  And what if the coverage is insufficient for the person with a pre-existing condition?  Well that’s too bad, because as we saw above, limited plans will now be outlawed (i.e., not “acceptable”)!

And I still don’t know what the standard coverage is yet…  let’s keep reading:

3 SEC. 112. GUARANTEED ISSUE AND RENEWAL FOR IN4
SURED PLANS.
5 The requirements of sections 2711 (other than sub6
sections (c) and (e)) and 2712 (other than paragraphs (3),
7 and (6) of subsection (b) and subsection (e)) of the Public
8 Health Service Act, relating to guaranteed availability and
9 renewability of health insurance coverage, shall apply to
10 individuals and employers in all individual and group
11 health insurance coverage, whether offered to individuals
12 or employers through the Health Insurance Exchange,
13 through any employment-based health plan, or otherwise,
14 in the same manner as such sections apply to employers
15 and health insurance coverage offered in the small group
16 market, except that such section 2712(b)(1) shall apply
17 only if, before nonrenewal or discontinuation of coverage,
18 the issuer has provided the enrollee with notice of non19
payment of premiums and there is a grace period during
20 which the enrollees has an opportunity to correct such
21 nonpayment. Rescissions of such coverage shall be prohib22
ited except in cases of fraud as defined in sections
23 2712(b)(2) of such Act.

Well, I’m not going to look up the Public Health Service Act.  However, from what I can tell here, this just means that you cannot be canceled from your plan, except for failure to pay.  Again, what does this have to do with affordability?  Forcing the insurance company to keep you as a customer can only drive prices up, not down.  The only possibility I see here is if “renewability” is a reference to chargin you an “affordable” price, but I don’t think so, because if you cannot afford it, it says above that your non-payment will be the acceptable reason to drop you.  So, this certainly doesn’t protect the poor… well, I guess they have medical, medicare, etc.?  But what if they don’t qualify for that, and cannot the pay the premium of their group plan?  I don’t see how the government will be meeting its goal of insuring “all” Americans… that aspect would simply reduce back to what we have now… millions of unemployed Americans!

Ah! I think the next section will address affordability!

1 SEC. 113. INSURANCE RATING RULES.
2 (a) IN GENERAL.—The premium rate charged for an
3 insured qualified health benefits plan may not vary except
4 as follows:
5 (1) LIMITED AGE VARIATION PERMITTED.—By
6 age (within such age categories as the Commissioner
7 shall specify) so long as the ratio of the highest such
8 premium to the lowest such premium does not ex9
ceed the ratio of 2 to 1.

Well, this will end up reducing rates for those currently paying the most, and will raise rates for those currengly paying the least… and because of sections 111 and 112 above, the average rate would have to go up, if levels of care remained the same for most people, and went up for people with pre-existing or currently cancelable (debilitating?) conditions.  In other words, costs will spread more equitably, but not necessarily more fairly (in my opinion).

10 (2) BY AREA.—By premium rating area (as
11 permitted by State insurance regulators or, in the
12 case of Exchange-participating health benefits plans,
13 as specified by the Commissioner in consultation
14 with such regulators).
15 (3) BY FAMILY ENROLLMENT.—By family en16
rollment (such as variations within categories and
17 compositions of families) so long as the ratio of the
18 premium for family enrollment (or enrollments) to
19 the premium for individual enrollment is uniform, as
20 specified under State law and consistent with rules
21 of the Commissioner.

Interesting.  You can still be charged more or less based on where you live.  That’s good, but surprising.  The Family Enrollment one makes sense, too.  Okay, so those are the general guidelines.  It seems ageism is the only thing they’re compensating for here.

22 (b) STUDY AND REPORTS.—
23 (1) STUDY.—The Commissioner, in coordina
24 tion with the Secretary of Health and Human Serv
25 ices and the Secretary of Labor, shall conduct a
26 study of the large group insured and self-insured
1 employer health care markets. Such study shall ex
2 amine the following:
3 (A) The types of employers by key charac
4 teristics, including size, that purchase insured
5 products versus those that self-insure.
6 (B) The similarities and differences be
7 tween typical insured and self-insured health
8 plans.
9 (C) The financial solvency and capital re
10 serve levels of employers that self-insure by em
11 ployer size.
12 (D) The risk of self-insured employers not
13 being able to pay obligations or otherwise be
14 coming financially insolvent.
15 (E) The extent to which rating rules are
16 likely to cause adverse selection in the large
17 group market or to encourage small and mid
18 size employers to self-insure

Hmmm… they’re awfully concerned about self-insured businesses.  Well, I would like to think that if a company was capable of providing insurance that is completely within the guidelines, they would be allowed to do so.  Well, look at what they plan to do with the report…

19 (2) REPORTS.—Not later than 18 months after
20 the date of the enactment of this Act, the Commis
21 sioner shall submit to Congress and the applicable
22 agencies a report on the study conducted under
23 paragraph (1). Such report shall include any rec
24 ommendations the Commissioner deems appropriate
25 to ensure that the law does not provide incentives
1 for small and mid-size employers to self-insure or
2 create adverse selection in the risk pools of large
3 group insurers and self-insured employers. Not later
4 than 18 months after the first day of Y1, the Com
5 missioner shall submit to Congress and the applica
6 ble agencies an updated report on such study, in
7 cluding updates on such recommendations.

Okay.  Look at lines 25 and 1 above.  It means that if there is any incentive to self-insure, that incentive is not given by the law. It could also mean that such incentives are actually illegal, but I kind of doubt that.  I think this just means things like tax breaks and such… at least I hope so.

Now look at lines 2 and 3… it is making sure that the law does not create adverse selection in the risk pools of large group insurers an self-insured employers.  What does this mean?  Well, suppose someone self-insures.  They’re particular risk pool is defined by their employees.  What if this company’s employees has fewer than usual pre-existing conditions represented?  That would create a disparity between the cost of insuring that company’s employees and the cost of insuring an average person who is in a normal group plan… because the average person’s premium would have to be high enough to bear some fraction of someone else’s coverage; the person working for a self-insured company would get to pay a lower premium.  The risk pools would be adversely selected. Is that clear now? So, lines 2 and 3 are saying that the law should provide no incentive that results in these adversely selected risk pools.

So, if the law provides no explicit incentive to self-insure, then what kind of recommendation could be made on line 7 above?  Costs are what they are right?  The risk pools are what they are right?  What can the law do if someone self-insures despite the absence of an explicit legal incentive?  Well, the way I interpret this, the absence of a disincentive for self-insurance would qualify as an incentive for self-insurance.  Therefore, to remove that incentive requires the introduction of a dsincentive… which would allow making self-insurance illegal or at least impossible to provide.  This one line could make it possible to tax self-insurance to the point of non-affordability… then the employer joins one of the “accepted” plans, and all is right with the world.

4 SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS.
5 (a) IN GENERAL.—A qualified health benefits plan
6 that uses a provider network for items and services shall
7 meet such standards respecting provider networks as the
8 Commissioner may establish to assure the adequacy of
9 such networks in ensuring enrollee access to such items
10 and services and transparency in the cost-sharing differen
11 tials between in-network coverage and out-of-network cov
12 erage.

What I think this means is that network-based plans may not exclude doctors from their network for purposes of saving their customers money.  For example, if chiropractors are not covered by your network, your co-pay for going to one will be higher than for going to your dermatologist who is in the network.  This forces you to bear more of the burden for your care when you go to an out-of-network doctor.  So, logically, a plan would either have to cover your chiropractor (or whatever type of doctor we’re talking above) at the in-network rate, or would have to provide chiropractors within the network that you can choose from.  This does not appear to prohibit you from going out of network if you still want to go to a particular doctor; my guess is that your plan just has to show a good faith effort at giving you choices within the network.  Then, if you still go out of network, that’s your business.  Okay.  The disadvantage here is that it forces the insurance company to cover more expensive treatments at the same rate as less expensive ones… which would probably raise rates overall for everyone.

17 SEC. 116. ENSURING VALUE AND LOWER PREMIUMS.
18 (a) IN GENERAL.—A qualified health benefits plan
19 shall meet a medical loss ratio as defined by the Commis
20 sioner. For any plan year in which the qualified health
21 benefits plan does not meet such medical loss ratio, QHBP
22 offering entity shall provide in a manner specified by the
23 Commissioner for rebates to enrollees of payment suffi
24 cient to meet such loss ratio.

Okay, this one is key. It seems to mean that your health plan is limited in the profits it makes, as defined by a “medical loss ratio”, and the Commissioner can pick any medical loss ratio he chooses.  So, if health care is still too expensive (or too profitable), then the medical loss ratio can simply be adjusted down to the point of “affordability”!! But, I guess they do limit it…

1 (b) BUILDING ON INTERIM RULES.—In imple2
menting subsection (a), the Commissioner shall build on
3 the definition and methodology developed by the Secretary
4 of Health and Human Services under the amendments
5 made by section 161 for determining how to calculate the
6 medical loss ratio. Such methodology shall be set at the
7 highest level medical loss ratio possible that is designed
8 to ensure adequate participation by QHBP offering enti
9 ties, competition in the health insurance market in and
10 out of the Health Insurance Exchange, and value for con
11 sumers so that their premiums are used for services.

So, the commissioner’s job is essentially to allow just enough, but only enough, profitability to keep providers in business.  Well, that certainly ruins the profit motive of running a health insurance provider!  

I’ll pick up on this later.

Some remaining questions:

1. What does “quality” mean?
2. What does “essential” mean?
3. What are “other purposes”?
4. Can the government, under this bill, reduce availibility of care as the means to reduce the growth in spending on care? to increase the affordability of care?
5. How will the government guarantee care for “all” Americans, such as people in between jobs?

 

This entry was posted on Friday, August 14th, 2009 at 10:19 pm and is filed under Book Reviews, Health Care. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.