Health Care Reform Bill HR 3962

Patients have been asking me what I think of the government's efforts at reforming our health care system.

I've posted once or twice in this before covering the general principles and how US health care stacks up in terms of cost, administration and quality compared world-wide.

More recent patient inquiries were more along the lines of how I, as a doctor, feel about the specific proposals and how I see it affecting me and my patients. Up to now, there hasn't been much I could specifically say since the reform bill before the US House of Representatives was a work in progress. That is, until last night when it passed the House. Reform must now be approved by the US Senate, so it's quite likely that it will be different than the present House Bill before it is presented to the President of the United States for signature into law.

At present, HR 3962:

• Would take effect by 2013
• Would require Americans to purchase medical insurance or pay a penalty of 2.5% of income, subject to exemption due to hardship
• Would expand Medicaid/MediCal to be able to cover about 30 million Americans who currently are too poor to buy private insurance, but too "rich" to be eligible for Medicaid or MediCal (MediCal is the California version of Medicaid, which is a Federal program providing insurance to people close to the poverty line)
  
• Would close MediCare's "donut hole" in Part D drug coverage, and change incentives in the currently scandal-prone MediCare Advantage insurance products
  
• Would lift the exemption of health insurance companies from anti-trust laws, which up to now have kept them from being investigated for their practices
• Would forbid insurance companies from denying insurance based on gender or pre-existing medical conditions
• Would forbid insurance companies from the practice of rescission, in which they investigate you background upon receiving expensive claims to find ways to retroactively deny your coverage
• Would create a governmentally sponsored "public option" for those who choose it over privately available insurance.
• Would forbid covering the cost of abortions except in cases of rape, incest or threat to the health of the pregnant woman using Federal funds rendered to insurance products
• Would, according to the Congressional Budget Office, be cost neutral
• Would be partially funded through a 5.4% income surtax on couples filing jointly over $1Million in income, or individuals filing over $500,000 in income
• Would also be funded by changes in the existing MediCare and Medicaid programs, details of which are unclear at the time of this writing (the bill is about 2,000 pages long)
• Would help to fund continuing medical education for doctors and nurses

Personal politics aside, I think this is a step in a good direction. I cannot see a problem with a cost-neutral program that would make affordable health insurance available to over 96% of our fellow Americans.

Requiring everyone to have health insurance is common sense. Otherwise, healthy people skip insurance leaving sick people as the main insurance participants which results in continually increasing costs. This gets passed on as increasing premiums in a system that still has to fully and publicly absorb the costs of the healthy uninsureds when the get ill or injured. It makes as much sense as requiring auto insurance, which protects every driver against the possibility of having to pay out of your own insurance even though the other driver was at fault but has no insurance.

As to the carve-out of Federal funds to public and private insurances in the coverage of abortion, from a purely pragmatic point of view that's going to be a real accounting nightmare. From an ethical point of view, I think it's pretty silly since everyone pays taxes that pay for things that one may not use or like. That's just the nature of taxation, government and shared resources in a democratic (as opposed to theocratic or dictatorial) society.

I do hope that some provisions for enforcement are made; it's one thing to illegalize price-fixing and rescission by insurance companies, and quite another to enforce it.

I still remember receiving my settlement checks from several major insurance companies a few years ago in which the were sued in class action filings under RICO statutes and chose to settle rather than undergo a public trial during the heydays of the HMO's. It's not good when every single one of the country's biggest health insurance companies are basically willing to admit that their business practices are indistinguishable from the Mafia.

I also look forward to the day that I don't lose patients from my practice because of a change in their employment or their boss's choice of insurance.

Frankly, I also look to the possibility of lower insurance costs without lower insurance quality for my practice.

I don't know how this will effect my bottom line, though if the "public option" were to reimburse at MediCare rates plus 5%, that would be just fine. The days are long gone when insurances paid much above flat MediCare rates unless you were the biggest fish in the pond. MediCare+5 along with MediCare (independently of the Reform Bill) considering lowering reimbursement of expensive procedures in order to increase payments to primary care services would be mighty welcome to little guys in the trenches like me!