A Dissection of the Health Care Reform

I have updated this report with newer facts and figures to demonstrate that my predictions are already being proven correct. Linda de Sosa 6/28/2012 Original preface: Assuming many Americans have not had time to do research, I am compiling information from studies and government sources, adding questions to assess logic and ideas generated from many sources for solutions. 3/18/2010 First, why do we need it? Possibilities mentioned are a. The US Healthcare system is not good b. The US Healthcare system is good, but not enough people have access c. The US Healthcare system is good, but healthcare or insurance costs too much What is the quality of the US health care system? 1) Look at Infant mortality (percentage of infants not living to one year of age) The US rate is high, relative to other countries (6.8%) What are the causes? d. Higher rate of very low birth weight infants in US (12.4%) and rising rapidly i. Primarily teen mothers and mothers 40+ (Source: CDC study) ii. For older mothers, directly related to higher multiple births (fertility treatments, not lack of health care) iii. Younger mother analysis 1. Mothers younger among American Indian, black, Mexicans, and Puerto Ricans 2. Mothers younger in Alabama, Arizona, Arkansas, DC, Georgia, Louisiana, Mississippi, Nevada, New Mexico, Oklahoma, South Carolina, Tennessee, Texas. iv. US infant preterm mortality rate is actually higher than other countries, indicating better health care e. Decreases significantly if we could reduce low birth weight – suggests improved access to prenatal care for teens and improved teen pregnancy prevention programs f. Small rate variation due to US increased definition of live birth i. Several countries do not consider a birth live unless it is over a certain weight or gestation week – Norway, Czech Republic, France, Ireland, Netherlands, Poland ii. Accounts for some, but not large amount of our lag g. The top 3 causes of infant mortality (equally 43% of the cases) are congenital malformations, disorders leading to low birth weight and gestation, and sudden infant death syndrome. Therefore, infant mortality does not indict health care quality itself. 2) Look at average age at death in US a. Not a valid measure of quality of health care i. If you compare the death rate of a tribe of motorcyclists riding fast without helmets with a tribe that walks everywhere, which one would have a lower average age at death? Have we even discussed health care? b. Average age at death is a function of life and habits, not health care Linda de Sosa, Houston TX

i. Stress, Obesity, smoking, bad nutrition, sedentary lifestyle 3) Look at innovation a. 50% of pharmaceutical patents come from US b. Large percentage of Nobel prize winners in medicine (84%) c. CT and MRI machine quantity relative to other countries d. Where are the best medical centers in the world – where do people go when they need help from all over the world? e. Example of Von Hippel Lindau clinics (rare disease) i. 11 countries have clinics to treat ii. 10 countries have 13 clinics iii. The US has 24 clinics, 3 in Houston alone. 4) Ignore UN comparative measures that are politically charged and based on invalid criteria a. Example – heavy deduction for “fairness” where a country would receive a higher score for 2 persons dying since they had equal treatment versus one living. b. High rating for Cuba with such a broken system outside the capital that they don’t even have bandages. 5) Do health insurance companies receive obscene profits? a. The latest study showed they only received 2.2% profit, down from 6%. That is substantially less than most industries. b. Since the companies are public, the profits actually go to shareholders c. Profits from others in the health industry are used for research and breakthroughs that can fuel future profits. Rather than bemoan our health care system, we need to increase access First, we need to understand the problem Here is an analysis of health insurance (Source: Census bureau 2008) Total people Insured Not Insured Government Care Medicare Medicaid Other (VA, government employees) Private Health Care Employee Private Pay Of the 46.3 million not covered, why? Make over $75,000 so assume voluntary Eligible for Medicaid or CHIP for Children Illegally in Country Other 7.5 14 9.5 15.3 Linda de Sosa, Houston TX 301.4million 255.1 46.3 87.4 43 42.6 1.8 201 176.3 24.7 66.7% 58.5% 8.2%

84.6% 15.4% 29.0%

Of these, young invincibles Therefore, those who are involuntarily uninsured are a segment of 15.3 million


The uninsured are disproportionately in the South and West, American Indian, and Hispanic (30.7%). Even discounting the illegal proportion of Hispanics, a Hispanic cultural bias against insurance was indicated. In addition, the states with the highest percentage of involuntary uninsured are Texas, New Mexico, Louisiana, Florida, Arkansas, Arizona, Oklahoma, Mississippi, and Alabama. Analysis shows that the difference in state income per person was also a large indicator. In other words, these states have lower incomes per person and so fewer people can afford insurance. Therefore, these states would need more financial help if they are going to increase their percentage of people insured. Conclusion: We have a great system, but we must increase access and lower costs. So, does the bill do this? How to evaluate any bill 1) Does it fix the problem or meet the need without injuring other parties? 2) Is it Constitutional? 3) Is it something the nation can afford? Does it fix the problem? 1) The bill raises taxes. a. Cost analysis below shows cost overruns. b. Health care subsidies for poor c. Those who choose not to get insured are penalized (or jailed!). [Update – during the battle for passage, these were called penalties. During the judicial battle, these were called taxes] d. Taxes high cost insurance plans in the future 2) The bill penalizes seniors a. There is a 21% decrease in payments to providers who accept Medicare b. Currently, 50% of doctors do not accept Medicare alone because it reimburses 8% less than the cost - so that number will increase. [Update: headline 3/5/2011 – Opt-outs hit record in Texas] c. Kelsey-Seybold Clinic, the largest private multispecialty physician group in Houston, does not accept Medicare without additional insurance. If this number decreases further, then either seniors will have to pay more, or their care will have to be rationed. d. Lower Medicare Advantage subsidies - $131.9 billion over 10 years (page 13 CBO) e. Holds future provider payments to less than inflation. The Senate CBO report states on page 19: i. It is unclear whether such a reduction in the growth rate could be achieved, and if so, whether it would be accomplished through greater efficiencies in the delivery of health care or would reduce access to care or diminish the quality of care. 3) Those on Medicaid will be penalized. a. Fewer doctors accept Medicaid than Medicare since Medicaid pays only 72% of Medicare. When that decreases substantially, Medicaid patients will have few options. b. Only 40% of doctors will accept new Medicaid patients currently. 4) The bill will lead to decreased numbers of doctors and increased patients, leading to rationing. a. If the potential income for a medical career decreases, fewer people will train as doctors

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b. Current doctors will explore other options, which has already happened. Many OB/gyns have switched careers due to the high malpractice insurance. c. There already is a current shortage of general practitioners i. If current trends continue, the U.S. will be short by about 125,000 family care doctors by 2020, according to Dr. Ted Epperly, president of the American Academy of Family Physicians board. (msnbc.com, Wed., June 24, 2009) ii. There are huge wage differences between specialists and generalists. 1. The difference is driven largely by Medicare-related reimbursement rates, which pay more to doctors who perform specific procedures than to doctors who diagnose and treat general illness. d. [Update – 6 years ago, doctors owned 2/3 of medical practices. 2012 – 2/3 owned by larger institutions according to the Medical Group Management Association. This consolidation, while driving some efficiencies, limits treatment choice. Rules about data compilation, reporting and compliance requirements, and data technology greatly increase overhead ] 5) The bill leaves 23 million people still uninsured. (CBO estimate page 7) a. Deducting their estimate of 8.9 million unauthorized aliens, we have 14.09 million still uninsured. That is nearly the number we currently have involuntarily uninsured. (Estimate calculated using figures on p.7) 6) The bill will increase unemployment. a. Requires businesses over 50 employees to provide health care i. If you have a business, would you want to receive a profit? ii. If your costs were going to increase since you were required to pay for healthcare, how would you balance that? Chances are good, you would decrease your number of employees. THEREFORE, unemployment goes up under this plan. b. The bill would supplement the cost of insurance for those who earn up to 400% of the poverty level ($22050 for a family of 4 in 2009). For a family of 4, that would mean anyone earning up to $88200 would receive help paying for insurance. When someone uses that supplement, their employer is fined. Therefore, many employers will either lay people off or make them temporary or contract workers to avoid this. 7) Our premiums will increase. a. Younger persons no longer get discounts based on the fact they are less likely to need services (as in auto insurance) Compare New Jersey (where this already occurs) vs Pennsylvania rates to see evidence of this. b. Insurance companies will be required to cover everyone, even those with major expenses, spreading the costs to everyone. c. WellPoint insurance company evaluated its actuarial data in the 14 states where it runs Blue Cross plans for small businesses and individuals (which is more meaningful than aggregating the data nationally). Premiums went up by as much as triple for some ages when cost differences could not be used to price the policies. (WSJ, October 28, 2009). d. The CBO analysis of the bill shows they expect premiums to increase. i. http://www.cbo.gov/ftpdocs/107xx/doc10781/11-30-Premiums.pdf e. UPDATE: Even AARP who fought so hard for the bill has raised premiums. i. http://washingtonexaminer.com/blogs/beltway-confidential/2010/11/and-now-same-aarpfolks-who-helped-bring-you-obamacare-13-percent-

Linda de Sosa, Houston TX


UPDATE – As of May 31, 2011, seven entire states and 1,372 businesses, unions and other institutions
have received waivers from the law. http://washingtonexaminer.com/blogs/opinion-zone/2011/05/more-obamaadministration-allies-get-waivers-costly-obamacare-mandates#ixzz1ORAkuyXh These have been granted for exemptions to companies, unions, and states that do not want to have to pay for plans meeting the requirements


the health care bill. These waivers are issued: “to prevent either a large increase in premiums or a
significant decrease in access to coverage” according to HHS.

http://www.hhs.gov/ociio/regulations/approved_applications_for_waiver.html g. UPDATE - There is a huge accusation of political favoritism in these waivers. Of the 204 new Obamacare waivers President Barack Obama’s administration approved in April, 2011, 38 are for fancy eateries, hip nightclubs and decadent hotels in Nancy Pelosi’s Northern California district. The plans newly approved for waivers cover more than 160,000 people, bringing to nearly 3.1 million the number of individuals in plans exempted from the health law’s requirements. Of the participants receiving waivers, more than half – over 1.55 million – are in union plans, raising questions of why such a disproportionate share of union members are receiving waivers from the law’s requirements. In addition, it was revealed in March, 2011 that there is a program in the bill called the Early Retiree Reinsurance Program which is allocated $5 billion from June 2010-January, 2014. It subsidizes unions, states, and companies that commit to provide health insurance for early retirees. Currently, $2 billion has already been spent and the largest single recipient so far has been the UAW ($206.8 million). Many other unions, both governmental and private, have received these payouts that no one was aware existed. h. [UPDATE -A survey, released in August by the Washington-based National Business Group on Health,
showed a majority of large employers revising health-benefit programs for 2011 in response to the legislation -- with nearly two-thirds (63 percent) planning to increase premiums for employees and 60 percent considering dropping retiree-health coverage in the future. UPDATE - In late September, Oak Brook, Ill.-based McDonald's informed the U.S. Department of Health and Human Services that the law's requirements may force it to drop coverage for 29,500 low-wage employees. Other companies and unions are threatening to drop their coverage as well, including the United Federation of Teachers (potentially affecting 351,000 people) and San Diego-based Jack in the Box (with 1,130 workers affected). In response, the Obama administration announced a week later, on Oct. 7, that 30 employers, including McDonald's, Jack in the Box and the teachers' union, would receive one-year waivers that would allow them to maintain minimal coverage below the new law's standards. A total of 115,000 McDonald's plans were excused. UPDATE - Manufacturing conglomerate 3M Co., based in St. Paul, Minn., announced on Oct. 5 that it will no longer offer health insurance to retirees beginning in 2013. UPDATE - On Oct. 8, the Business Insider website reported that Microsoft told its employees it would scale back its heretofore-generous employee-healthcare program -- and that workers would have to start paying for some of their benefits beginning in 2013


j. k.

8) The bill is unfair. a. Critical that we do not get into a situation of shortage since if allocation is needed in times of shortage, proposed “Complete Lives System” a) Complete Lives System by Dr. Ezekiel Emanuel, top medical advisor to Obama and brother of Rahm Emanuel, White House Chief of Staff b) Quoted in the Lancet, Volume 373, Issue 9661, pages 423-431, 31 January 2009 a. Prioritise adolescents and young adults over infants due to previous investment in education and parental care as well as developed personality b. Prioritise those with better prognoses, even if young adults, so do not spend disproportionately large amounts of resources Linda de Sosa, Houston TX

c. Older adults have already lived their lives and have had the opportunity to be the age of young adolescents so lower priority c) [Update – Obama signaled his intent when appointed Dr. Donald Berwick to be the administrator for Medicare and Medicaid, avoiding the nomination process until the new Congress was seated. Dr Berwick has said, “I am romantic about the NHS (England’s socialized medical system); I love it”. He said in an interview in June, 2010, that “the social budget is limited. The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open.” It was announced on March 6, 2011 that his nomination will be withdrawn since it will not be passed. d) [Update: A British physician has estimated 130,000 patients are put on the “death pathway” yearly which prematurely ends their lives. http://www.dailymail.co.uk/news/article2161869/Top-doctors-chilling-claim-The-NHS-kills-130-000-elderly-patientsyear.html#ixzz1yKojnjl8 b. Requires everyone pay close to the same amount for insurance i. Young subsidizing the old (in addition to current subsidies in payroll taxes) ii. Young need average of only $1500 per year in health care iii. Penalized if don’t take insurance (up to $695) c. Currently, the legislative branch controls the guideline and rule setting process as designated in the Social Security Act. i. State programs, auto insurance programs, state worker comp programs all use these guidelines ii. The current health insurance reform program shifts these rights to Health and Human Services (Senate) and a Health Choices Commission (House), both of which are directed by the White House (Lack of oversight, no judicial review) d. UPDATE – 733 waivers have been granted for exemptions to companies that do not want to have to pay for plans meeting the requirements of the health care bill. http://www.hhs.gov/ociio/regulations/approved_applications_for_waiver.html 9) The bill creates more bureaucracy. The House health care plan creates 111 new bureaucracies. (I have the sections and page numbers for each) The Senate health care plan creates 118 new boards, commissions, and programs. 10) [UPDATE: The bill inserts the government into our personal medical decisions. Section 3002 and 3007 describes penalties for physicians who deviate from protocols. In addition, the HHS secretary is given the power to remove services from Medicare.] 11) [UPDATE: Many companies are considering dumping their current health care insurance plans and will choose to pay the penalty. It is not constitutional. 1) Making health insurance mandatory is not constitutional a. There is no power in the Constitution to force this. 1) Not the equivalent of auto insurance since you can choose not to drive 2) Even car insurance only requires liability insurance, not comprehensive

Linda de Sosa, Houston TX

3) UPDATE – in arguments in the 4th circuit court of appeals on May 12, 2011, Neal K. Katyal, acting solicitor general acknowledged that the law was unlike any other law in American history. He also admitted that he believed Congress COULD force individuals to buy certain food like, for instance, wheat! b. Some have said that the Preamble statement, “promote the general welfare” covers this. 1) The preamble does not confer any power to the government, however. 2) Jacobson v. Massachusetts, 197 U.S. 11, 22 (1905) ("Although th[e] preamble indicates the general purposes for which the people ordained and established the Constitution, it has never been regarded as the source of any substantive power conferred on the government of the United States, or on any of its departments."); United States v. Boyer, 85 F. 425, 430–31 (W.D. Mo. 1898) ("The preamble never can be resorted to, to enlarge the powers confided to the general government, or any of its departments. It cannot confer any power per se. It can never amount, by implication, to an enlargement of any power expressly given. It can never be the legitimate source of any implied power, when otherwise withdrawn from the constitution. Its true office is to expound the nature and extent and application of the powers actually conferred by the constitution, and not substantively to create them." c. Some say the interstate commerce clause gives the federal government the right to regulate it. However, that was to make sure there were no tariffs for goods going between states. When you go to the doctor, it has nothing to do with commercial purposes. 2) The bill orders the states to make payments for health care. When the Constitution was created, it gave only 17 specific authorities and the rest was given to the states or the individual. Health care is not one of them. And the federal government cannot order the states to pay for something. That is why the national speed limit was done through financial incentives, not orders. a. Additionally, the states are not treated equally in the bill which is against equal protection under the law. (Think the Louisiana Purchase or the special money going to Connecticut and North Dakota to get congressmen to vote for the bill.) 3) UPDATE: The bill has been ruled unconstitutional twice
“It is difficult to imagine that a nation which began, at least in part, as the result of opposition to a British mandate giving the East India Company a monopoly and imposing a nominal tax on all tea sold in America would have set out to create a government with the power to force people to buy tea in the first place,” the ruling says. “It would be a radical departure from existing case law to hold that Congress can regulate inactivity under the Commerce Clause. If it has the power to compel an otherwise passive individual into a commercial transaction with a third party merely by asserting — as was done in the act — that compelling the actual transaction is itself “commercial and economic in nature, and substantially affects interstate commerce,” it is not hyperbolizing to suggest that Congress could do almost anything it wanted,” the ruling says. “The mere status of being without health insurance, in and of itself, has absolutely no impact whatsoever on interstate commerce (not ’slight,’ ‘trivial,’ or ‘indirect,’ but no impact whatsoever) — at least not any more so than the status of being without any particular good or service,” the ruling says.

4) UPDATE: the Supreme Court’s ruling says the mandate must be considered a tax to be constitutional. Had they called the penalty a tax during the bill’s discussion, it would most likely not have gone through. They specifically argued that the healthcare act was not a tax during the debate for passage. While in court, the White House lawyers argued that it was a tax and therefore, could be levied. In addition, another argument that they utilized – cost shifting – has also been proven invalid. The argument was that when hospitals/doctors have to pay for uninsured patients, they charge the paying clients more. Therefore, it is a hidden tax (estimated by Congress at Linda de Sosa, Houston TX

$43 billion yearly). However, two peer-reviewed studies in Health Affairs in 2008 and the Journal of Health Economics in 2007 found from zero cost shift among doctors and a maximum increase of 1.7% in private insurance premiums. Instead, the Congress relied on a non-peer review and seriously flawed study commissioned by FamiliesUSA, an advocacy group for increased government involvement in healthcare. The reason why the cost shifting/hidden tax is so low is because they did not take into account $40-50 billion spent per year by charitable organizations and all levels of government (3/4 of the cost). Reference: Hoover Institution and John Cogan 3/11/2011 The cost of the health care bill is vastly underestimated. 1) Analysis of the CBO March 18, 2010 report clearly shows this if you read the fine print. [Update: Douglas HoltzEakin, former CBO director, reinforced these numbers below on 3/21/2010 in the Wall Street Journal.] a. The cost estimate of $940 billion does not include $10 billion for IRS infrastructure changes (page 12Senate bill CBO report ), $10 billion for HHS changes (page 12- Senate bill CBO report), or increased costs to the states of increased Medicaid enrollment ($20 billion+ – fine print on page 8 of new report) as specified by the CBO. The new numbers allocate $1 billion for HHS changes (section 1005), leaving a net undercounting of $9 billion. [Update: Mr Holtz-Eakin says $114 billion operational costs were left unfunded.] *UPDATE on states’ costs. Robert Wood Johnson Foundation figures determine that the program would cost the states at least $118 billion through 2023, including 12 million newly eligible for Medicaid. This is consistent with the CBO January 2011 budget report which projects faster growth in Medicaid enrollment in light of the healthcare reform law. The 2010 report projected that 76 million people will be enrolled in Medicaid in 2020, while the new report predicts the number will be closer to 97 million in 2021.] b. Assumes that Congress will pass the 21% decrease for Medicare payments. They have not been able to do this for the past several years politically nor is it viable since the costs are already higher than the current payment. CBO notes this as well as the fact that it continues to hold future cost increases to less than inflation. This adds $186 billion to the cost according to the Senate CBO report. i. UPDATE: Not only did they not pass the decrease, but the Democrats said the Republicans were insensitive to even propose it. ii. UPDATE: The new January 2011 CBO report states that Medicare spending will increase $250 billion if Congress continues to not pass these cuts. By 2012, the healthcare bill assumes there will be a 25% cut in Medicare based on the 2003 law that has continually been delayed. c. They also question a seemingly random number for savings in Medicare. [Update – this amount is $463 billion and since Medicare is already in danger of failure, this savings will not materialize according to the chief actuary for Medicare] d. New CLASS Act, which creates a long term insurance program in this bill, starts collecting premiums which will be needed to pay out benefits later. However, they are unfairly using these premiums ($70.2 billion) to offset the cost of the health care bill (page 18 of the new CBO report). CBO also is unsure if this program will be successful in any case. e. The bill starts collecting taxes and penalties long before the benefits are paid out. If one ignores the first 5 set up years and looks at just the 2nd 5 years, the costs are $714 billion and the income is $732 billion with a net income of $18 billion over 5 years or $36 if it is doubled to make 10 years. That is a lot less than the touted $119 billion. Also, the gross cost of $940 billion to keep the bill just shy of the President’s goal of $1 trillion – if you just count years 6-10, the cost is $869 billion. If you double that to make 10 years, your gross cost is $1.7 trillion.

Linda de Sosa, Houston TX

[UPDATE – Mr Holtz-Eakin revealed that the bill requires corporations to deposit $8 billion in higher estimated tax payments in 2014. However, their tax rate is unchanged so this money will just be applied toward taxes as usual the following year.] g. UPDATE - The law allows for many areas to have discretionary costs which are either not specified or only the first year is specified. In addition, the March CBO report only gave the new authorizations and not the continuation of existing programs. In a CBO report dated 5/11/2010, they estimate that the authorized costs are an increase of $106 billion over 2010-2019. However, there was a 2 page table of programs that cannot be totaled since they only specify “such sums as necessary”. h. [Update – the bill uses $53 billion in higher Social Security taxes to offset spending, assuming employers will switch from paying a higher salary to paying for healthcare. However, this money will need to be given in the future to the participants since they will earn more benefits with a higher wage so it is not a savings.] i. The bill is merged with an unrelated bill on education which masks the true numbers. Of the $19.8 billion in the projected deficit decrease in table 5, $19.4 is from the education program. (p 23 new report) j. [UPDATEs from above] $39+250+70.2+8+(114-39)+53 +463+19.4 + 106= $1,076 trillion undercounted in addition to the higher estimate above and not counting the increase to the states of $98 billion. This does not take into account the fact that all the revenues are random guesses as to who will continue with their Cadillac plans and who will pay penalties rather than purchase insurance. In the words of the CBO, “The same substantial degree of uncertainty that surrounds CBO and JCT’s estimates of the impact that the proposal would have on insurance coverage rates and the federal budget also accompanies this analysis of the proposal’s effects on premiums.” http://www.cbo.gov/ftpdocs/107xx/doc10781/11-30Premiums.pdf 2) Health and Human Services Department Analysis (nonpartisan governmental entity) of the Senate bill found that: - Nation’s Health care bill will increase of $234 billion over 10 years - Unrealistic to squeeze $493 billion in savings from Medicare over 10 years [Update: August, 2010, the Medicare trustees triggered a funding warning that the program was becoming insolvent. And, on April 22, 2010, Richard Foster, the chief actuary of Medicare, advised that the savings are not there and that the cuts will need to come in payment reductions. He said, as quoted in the New York Times, “Overall national health
expenditures under the health reform act would increase by a total of $311 billion,” or nine-tenths of 1 percent, compared with the amounts that would otherwise be spent from 2010 to 2019. In his report, sent to Congress Thursday night, Mr. Foster said that some provisions of the law, including cutbacks in Medicare payments to health care providers and a tax on high-cost employer-sponsored coverage, would slow the growth of health costs. But he said the savings “would be more than offset through 2019 by the higher health expenditures resulting from the coverage expansions.”


http://www.cms.gov/ActuarialStudies/Downloads/PPACA_2010-04-22.pdf ] - New Long term care insurance (CLASS) plan faces a significant risk of failure 3) CBO (Dec 19, 2009) doubted that the nonprofit insurance companies would materialize (what is the incentive to create them?) 4) Previous health care bill cost estimates have been historically underestimated Linda de Sosa, Houston TX

(WSJ, Oct 20, 2009 – Health Costs and History) a. Medicaid – House Ways and Means Committee estimated first year costs of $238million. Instead, it was $1 billion. Current cost: $251 billion. b. Medicare – 1965, congress said it would cost $12 billion in 1990. It was $90 billion. Hospitalization was supposed to be $9 billion, it was $67 billion. c. The costs are nearly always higher because of the entitlement nature of it. d. One exception is the 2003 Medicare prescription drug bill. Costs are 1/3rd below projections due to lower than expected participation and because of savings from generic drugs due to competition occurring in the private market where people are selecting less costly drug plans. This illustrates the benefit of letting the private market operate rather than the government controlling prices. What about endorsements? It is important to look at the groups endorsing it and their incentives [UPDATE: Republican record requests for the details of meetings between the White House officials and interest groups on healthcare were denied in March 2011 by White House lawyer Robert Bauer due to expense and executive branch confidentiality.] 1) The AMA endorsed the bill a. Current law causing 21% cut in physicians’ reimbursements. They hoped to avoid it. i. Actual law required 5-6% reduction, but Congress has rolled this over each year so 21% is what they are currently up to and has been used to blackmail doctors’ organizations 2) AARP endorsed the bill a. Main supplier of insurance that covers the gap between Medicare and actual costs. b. Bush 43 passed Medicare Advantage program which is a subsidized lower cost alternative to Medigap. 10 million seniors switched, hurting AARP income. c. Current bill eliminates this subsidy so seniors will have to pay more and AARP will make more. d. UPDATE: the Department of Health and Human Services (HHS) rate review rules, which it finalized in May, 2011, exempt “Medigap” policy providers, like the AARP, from oversight when such providers increase payment rates for their supplemental insurance plans. Insurance providers who aren’t exempt from Obamacare’s rate review rules are required to publicly release and explain some health care payment rate increases. The AARP is the nation’s biggest seller of Medigap policies, or supplemental healthcare plans that add onto what Medicare won’t cover for seniors. 3) Pharmaceutical companies endorsed it a. Got a 10 year limit of $80 billion on cuts in prescription drug costs b. Got assurances that the government will bar low cost drugs from Canada and abroad 4) Medical device manufacturers DID NOT endorse it a. As a result, the Senate Finance Committee imposed a tax on medical devices like automated wheelchairs, pacemakers, stents, prosthetic limbs, and artificial knees and hips. 5) The conservative Democrats a. Ben Nelson held out his vote until he received $45 million so Nebraska will not have to pay the new Medicaid funds that all the other states must pay. b. Mary Landrieu held out her vote for $300 million for Louisiana

CONCLUSION: This bill should not be passed. We have issues with health care costs and access that must be addressed. This bill, however, has so many negatives, it could dangerously hurt our excellent
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health care system and damage our struggling economy. Instead, we should directly address the cost and access issues with the suggestions on the following pages.

Linda de Sosa, Houston TX

Cost savings suggestions
Indicated Solutions to improve access (besides lowering cost of insurance) Educate and enroll those who are already eligible for Medicaid – streamline procedure For younger, make it easier to enroll so increase the age where they are eligible to be on their parents’ plan to 26 Educate the Native Americans and Hispanics on the benefits of insurance Focus subsidy dollars on evidence-based mental health outpatient care and outreach. Focus subsidy dollars for insurance in states with lower income per person. Those who are involuntarily uninsured have fewer checkups, blood pressure checks, flu shots, and preventive tests like mammograms and pap smears. Low cost clinics could provide these. Consider increasing the minimum eligibility income for Medicaid Current eligibility is set by each state, but the minimum requirements are 1) Meet Aid to Families with Dependent Children eligibility 2) Pregnant women and children under 6 with income at or below 133% poverty a. Poverty level currently $10, 830 for a single person and $22,050 for a family of 4 3) Children 6-19 with family income to poverty level 4) Caretakers for those with children 18 and under 5) SSI recipients (disabled) 6) Those living in medical institutions with monthly income up to 300% of SSI income 7) Medically needy (pregnant, children, blind) with too much money to meet the requirements above Increased access for those with medical issues 1) Guaranteed renewal protection (encourages to get insurance when well) 2) High risk pools a. Ie, Texas has a high risk pool where the maximum premium is 200% of regular How do we lower health care costs? 1) The current bill incorporates many savings that should be adopted. 2) Tort Reform reduces costs to doctors a. Statute of limitation b. Cap noneconomic damages to $250,000 Examples of success Texas (Perryman Group study in April 2008, added 430,000 Texans to rolls http://www.tlrfoundation.com/perryman-group-report Unnecessary tests to protect the doctor c. Medical malpractice records across state lines Encourage discipline of incompetent doctors rather than relying on self-policing d. Trial lawyers will lobby to not have this happen. 3) Simplify administration a. Standardize electronic exchange formats and sharing for information between patients, providers, and insurance companies Linda de Sosa, Houston TX





b. Enhance information sharing between healthcare providers on patients i. Example – Amalga c. Email benefit summaries ER Analysis a. What conditions are more serious, treat accordingly (see Superfreakonomics p77) b. Immediate payment required for noninsured, nonemergency cases i. Encouragement of low cost clinics 1. Incentives for doctors 2. Locations in pharmacies, low income places, schools, churches c. Federal data show that elderly and mental illness/substance abusers are the most frequent users of the ER. (HHS Medical Expenditure Panel Survey) i. Study ways to lower their visits Improve health care fraud enforcement a. Utilize technology and manpower b. Current fraud estimated at $47 million in a federal report (Houston Chronicle – Questionable Medicare Claims hit $47 billion Nov. 14, 2009) i. States that aggressive action to date has yielded little improvement c. Focus on centers of high fraud Examine barriers to cost reductions a. Nongovernmental panel of players b. Identification of legal barriers c. Incentives for more treatment, not results i. Currently make more with the more treatments, ie oncologists make half income from chemo ii. Hard to tell patients the truth about odds. Perhaps have cancer consultants who can lay out the benefits vs the risks. Many solid mass tumors hardly respond. Lots of pain for 1-2 months of additional life. Lay it out realistically and let the patient decide. d. How do we reward innovation? i. Marc W Kirschner, Elizabeth Marincola, and Elizabeth Olmsted Teisberg, The Role of Biomedical Research in Healthcare Reform, Science 266 (October 7, 1994) ii. Biodesign Innovation among business people, doctors, and engineers (Stanford professor – Stefanos Zenios) 1. Expand access by reducing costs Examine causes of health issues and seek to improve a. CT Scanners may cause 29,000 future cancers – 2 studies by the National Cancer Institute (Amy Berrington de Gonzales) and UCSF as cited in the Archives of Internal Medicine i. Variation of doses between machines and operators ii. Nonexplantion of risks and overprescription – Need cost-benefit analysis each time b. Teen pregnancy prenatal care and prevention c. Obesity, smoking, and stress reduction i. Tax deductible weight loss programs ii. Find alternate uses for tobacco to maintain jobs, but lower smoking (ie hemp for marijuana) iii. Physical education for children iv. Nutrition information Linda de Sosa, Houston TX

v. Incorporate required wellness and disease management programs into Medicare, Medicaid, and the VA vi. Provide employers with incentives for implementing wellness programs d. Actively educate about mental health as those with untreated mental health conditions have much higher rates of other illnesses like heart disease and diabetes. e. Well care covered 100% f. Insurance programs offering vouchers for appointments g. SIDS causes and prevention h. Information on causes of congenital malformations (like smoking and alcohol) i. Increase information on the necessity of prenatal care, especially in high risk states like Texas and Tennessee 8) Examine methods to reward results a. More doctor interactions actually increases mortality rate (see Superfreakonomics p82) 9) Reimburse Medicaid and Medicare at the same rate as the Federal Employees Health Benefit Plan 10) Remove the limit on medical care costs for itemized deduction tax filers How do we lower insurance costs beyond reducing health care costs? 1) Increase competition a. Compete across state lines. i. University of Minnesota Steve Parente additional 12 million enrolled b. Web portal to ease comparisons between policies for individuals and employers 2) Spread Risk 1) Small businesses pool together to purchase insurance to spread risk 3) Study possible tax credit enhancements to help reduce the cost of insurance i. Tax Credits for insurance costs for employers and individuals 1) Also improves portability ii. Promote use of Health Savings Account iii. Look for tax favored status iv. Change the self-employed health insurance deduction to adjusted gross income into a fully deductible business expense 4) Improved payment innovations a. Payable semi annually for Medicaid 5) Study the efficacy of reinsurance programs

Linda de Sosa, Houston TX

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