Now that the House is set to debate the merged healthcare bill, we need to make sure they get it right!
Now that the full U.S. House is set to begin debate this week on the merged healthcare bill, it is essential to understand the provisions of the nearly 2,000-page bill and register our opinions with our elected officials. This is the last chance to try to get it right in the house.
One of the key questions about the bill is its cost. According to the November 2, 2009, issue of the Wall Street Journal, the estimated gross cost of the Democratic House legislation is $1.055 trillion over 10 years (http://online.wsj.com/article/SB125711811707721639.html). Such estimates in the past have been low—partly because they do not take into account the expansion of healthcare demand that follows an increase in government subsidies. When demand rises while supply stays the same or falls, prices increase, often dramatically.
Before we get to the main problems of the House bill, apart from cost, let’s take a moment to note some positive features. The main thing that is positive about it is a new regard for the concept of wellness and prevention. Even this is far from perfect. These terms are not defined as they should be. Without the right definitions, prevention can be turned into a program of more and more invasive tests and drugs for younger and younger people. Here is how prevention is specifically addressed in the bill:
Prevention: Wellness program grants for small employers (Section 112)
Grants may equal up to 50 percent of the amount of money an employer spends on qualified wellness programs. A program must include three of the following:
1) Education
2) Engagement (i.e., wellness-program components on site)
3) Behavioral change (supportive programs, self-help materials, etc.) linked to nutrition, physical fitness, obesity, etc.
4) Supportive on-site component (i.e., nutritious food available on site)
A program may not be mandated for employees, must be based on current science and approved by the secretaries of HHS and Labor. A program may provide financial incentives for employees and must ensure that personal information remains private.
National Prevention and Wellness Strategy (Section 3121)
A plan will be developed that includes national priorities and utilizes evidence-based clinical and community prevention and wellness activities.
- There will be a transparent public comment period designed to give special interests less opportunity to completely dominate.
- Composition will include the heads of appropriate health agencies, federal departments, nonprofits and the Task Force on Clinical Preventive Services (see below).
Task Force on Clinical Preventive Services (Section 3131)
Under AHRQ (Agency for Healthcare Review and Quality), the task force shall review and update preventive services as supported by science.
- Composition will include experts in related fields, such as disease prevention.
- A stakeholders’ board will provide consultation. This board shall include consumers, payers, federal agencies, and both public and private groups with an interest in clinical prevention.
Task Force on Community Preventive Services (Section 3132)
This task force will be similarly constructed and operated as the Task Force on Clinical Preventive Services (see above). Its mission is to review community prevention services and disseminate evidence-based recommendations.
Research grants available to study prevention specifically (Section 3141)
Grant program to study whether subsidizing individual wellness choices is beneficial (Section 3143)
The program will focus on tobacco cessation and obesity. If incentives prove to be helpful, these shall be included in the Essential Benefits Healthcare Package (see below).
Grant program (to states) for delivery of community prevention and wellness programs (Section 3151)
Grants to promote healthy behaviors in medically underserved communities (Section 399V)
Areas of focus include poor nutrition, physical activity, tobacco use, mental-health problems and dangerous sexual behavior.
Community grant program specifically addressing obesity with nutrition and physical activity (Section 399w-1)
Nutrition labeling on menu items at chain restaurants and in vending machines (Section 2572)
Prevention: Essential Benefits (basic mandated healthcare package) includes preventive coverage (Section 222)
CDC-recommended vaccines and preventive measures rated A or B by the Task Force on Clinical Preventive Services shall be covered. Note that although nutrition counseling, for example, is covered for those who have indications toward certain disease (a positive step), they are the only consumers covered. Truly preventive medicine, including a focus on maintaining optimal health with diet, supplements, and exercise, is not covered.
Prevention covered for Medicare, Medicaid and CHIP plans defined as above.
Money available for preventive training in medical school (Section 2234)
Note: There is no definition of prevention.
Cost-Sharing is prohibited for preventive services.
The intent seems to be to ensure that consumers are not burdened with co-pays and deductibles for covered preventive services. The term “cost sharing” includes deductibles, coinsurance, copayments, and similar charges, but does not include premiums, balance billing amounts for non-network providers, or spending for non-covered services. (General Definitions) A strict reading of the definition of “cost-sharing” may prevent out-of-pocket payment for medical services otherwise covered by qualifying health insurance, as is already the case with Medicare. You may not be able to pay privately for your healthcare options of choice!
With regard to prevention, it is as if Congress has heard the music, but still can’t carry the tune. In other areas, Congress is not even hearing the music, for example in requiring but not protecting the privacy of personal electronic health records (EHR).
EHR – All qualified health-benefits plans are required to use electronic health records (Section 237)
Privacy is gutted and doctors’ use of integrative therapies may be jeopardized.
EHR – Study to determine how best to motivate small providers to use EHR (Section 263)
Concerns about the use of electronic medical/health records (as noted above).
If a practitioner participates in Medicare, they are automatically deemed to participate in public option unless they opt out. (Section 323)
This bill of course brings in a national insurance mandate. A mandate means that government must define health and healthcare and healthcare insurance policies. The problem is that government is not equipped to do these things. Healthcare is a discovery process and needs to keep changing based on new science and what people prefer. The bill specifically includes both:
Employer mandate (Section 413)
Employer must provide coverage or pay a tax equal to 8 percent of the average wages paid by the employer in lieu of coverage. Note that there is a sliding scale for the smallest employers, those with payrolls less than $750,000. Payrolls under $500,000 are exempted from taxes.
Consumer mandate
Individuals must purchase qualified health benefits through the state exchange system unless grandfathered in with existing coverage. There are three different levels from which to choose. Those who have difficulty paying can apply for credits. Note that employer-offered healthcare plans cannot be grandfathered, and that individual plans, although they can be grandfathered, must not be altered in any way. The public option will be offered through the state exchange system.
- Individuals who do not have qualifying coverage will be taxed at 2.5 percent of their AGI divided by an amount specified by the IRS. (Section 59B)
- Catastrophic and similar packages will no longer be available. These packages have enabled people to buy natural healthcare on their own while still being covered for major medical. This vital option will disappear.
Excise tax on the wealthy (Section 59c)
For those filing jointly, a modified AGI exceeding $1 million will be taxed at 5.4 percent. If filing separately, AGI exceeding $500,000 is taxed at 5.4 percent. The trouble with this plan is that money pulled into healthcare from outside healthcare will just drive up prices. As prices rise, the money will in effect disappear. And of course if new taxes are used for healthcare, they can’t be used for deficit reduction. Millionaires in the US control about 10% of the income. No amount of taxes on 10% of the income will pay for healthcare and reduce government deficits.
Comparative Effectiveness Research is supposed to ensure that healthcare money is not wasted. But how can government decide what is effective and what is not? Will government just listen to special interests?
Comparative Effectiveness Research (CER) is not a transparent process and doesn’t include representation of integrative medicine, subjecting the process to abuse by special interests
CER says that there must be a transparent process but does not specify public comment for all steps in the process. (This is required in the Senate finance bill.) Any entity can submit research, making it likely that companies with the most money will dominate.
Cap on Flex-Spending Account (FSA) contributions at $2,500 (Section 532)
Currently, the contribution level is unlimited. This is another way to make natural medicine more expensive for consumers.
Medicine Cabinet Tax (Section 531)
Americans would no longer be able to purchase over-the-counter medicines with their FSA, Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA).
Increase in the non-qualified Health Savings Account (HSA) distribution penalty from 10 percent to 20 percent (Section 533)
This makes HSAs less attractive and paves the way for HSA pre-verification. In other words, “big brother” tells you how to use them.
School-based health clinics to include mental screening and mental-health treatment programs (Section 2511)
Prozac for those children deemed socially anxious is a likely outcome.
No child left unimmunized against influenza (Section 2524)
Grants to help ensure all young schoolchildren are immunized – through schools. Vaccine safety ignored.
Natural medicine along with the freedom for consumers to choose and practitioners to practice should not be a casualty of the current healthcare debate. Make sure your elected officials hear from you regarding this critical legislation. Let’s preserve healthcare freedom of choice at all costs.