Category: health care Page 29 of 35

I had to go through this language for another purpose, so let’s see how HCR affects recissions and denial of care. (A recission is cancelling the policy, denial of care means denying a specific treatment.)

Here’s the recission language.

‘‘SEC. 2712. PROHIBITION ON RESCISSIONS.
‘‘A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not rescind such plan or coverage with respect to an enrollee once the enrollee is covered under such plan or coverage involved, except that this section shall not apply to a covered individual who has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage. Such plan or coverage may not be cancelled except with prior notice to the enrollee,

The denial of care and appeals language is as follows.

‘‘SEC. 2719. APPEALS PROCESS.

‘‘A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum—

‘‘(1) have in effect an internal claims appeal process;

‘‘(2) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 2793 to assist such enrollees with the appeals processes;

‘‘(3) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process; and

‘‘(4) provide an external review process for such plans and issuers that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated
by the National Association of Insurance Commissioners and is binding on such plans.’’.

I’ve taken a look at the NAIC model reg referenced.  As I read it:

If company A denies care or rescinds:

a) the client must appeal to the company itself.

b) if that fails, the client may appeal to an external arbiter.  However, either the company has to agree to this or the insurance commissioner has to override the company’s decision.  (The criteria are pretty straightforward and making a false negative would be hard to do absent just lying.)

If care is urgent and the doctor agrees the client may skip the internal appeals process and go straight to external appeal, with the same caveat that the insurer must agree or the insurance company must override the decision of the insurer.

Actually, this is pretty decent.  The obvious ways to try and game it are:

1) to force as many non-urgent appeals to take the maximum time in the internal review (30 days), then kick them to external (between everything, 3 to 4 months).
2) Snow the external review organizations under by denying as much as possible, and forcing times up.  This won’t do squat on recissions, but on denial of care a certain # of people will die (or get better) and that will save some money.  You do pay for external reviews, but it’s unlikely to be more than the cost of really sick people’s care.
3) Game the insurance commissioner.  The insurance commissioner decides who does the external review.  Some reviewers will find for the companies/plaintiffs more than others.

Like any compliance based activity this bill requires the compliance agencies to do their jobs, but actually, this is written fairly tightly.  I think, from a strict bottom line perspective, it’ll probably turn out to be worth still trying to deny care to really sick people who aren’t mortally ill, to buy yourself 3 or 4 months worth of surcease from bills.  Also, the harder you make it to get care, the more likely they are to drop your company and find a new one, so hassling them into the ground might be good business practice.

In terms of recissions, it really is a matter of the definition of fraud.  If forgetting to put anything on the application form or getting something wrong on the form (say getting dates slightly wrong about some illness from 2 decades ago) is fraud, they can still get a lot of people rescinded.  If not, and if you can’t deny care due to prior conditions, then why would they be, then in fact it will be damn hard to rescind policies.

Another question is simply of  penalties.  If I, as a company, simply say “no, I don’t care what the law is I’m not going to obey it”, what is the penalty?  As with coal mining companies who simply accept fines as a cost of doing business, it may be worth breaking the law.

The final point is that much of this seems (if I’m reading this correctly) to be handled by the State Insurance commissioners.  Some of them are really good (New York, for example).  Some of them are captured by the industry or have very few resources.

Bottom Line: Recissions as such are probably a thing of the past once the bill goes into full effect, unless regulators completely fall down on the job.  Denial of care will probably still continue, though you’ll eventually be able to force them to give it to you, they can and probably will deny as often as they can to drive down costs and try and drive you to another company, if you’re an expensive (ie. very sick) customer.

So, an acquaintance just told me that what’s wrong with US healthcare is so unique and complicated that no simple solution would work, and that if a simple solution (like copying another country’s system) would work, it would already have been done.

In one sense, of course, he’s correct.  No other country’s system can happen (as opposed to work) in the US because the US system is so corrupted by special interest monies that no such system can pass.  Likewise, every health care system is experiencing inflation faster than GDP growth.

In another sense, this is simply incorrect, since other systems cost 2/3rds what the US does and provide better care while covering everyone. The American belief that what works elsewhere won’t work in America is just BS. To use just one example, before Canada moved to single payer our per capita costs were higher than America’s. When we moved to single payer, they dropped to about 2/3rds of yours.

Yes, other country’s solutions will work. If you bother to try them rather than coming up with specious reasons why they won’t work. Very simple variations on a few themes have worked in EVERY SINGLE country that has tried them. Yet somehow the US is supposed to be this unique flower which is so different that nothing will work.

Yeah, right. American exceptionalism turned perverse. “We can’t learn from other people because we’re so unique, so we’ll just have to continue writhing hopelessly, letting people die and paying too much.”

The simple truth is that most problems aren’t that complicated.  They really, really aren’t.  There is great confusion between the words hard and complicated, as well as between easy and simple.

It’s simple to stop smoking.  Just don’t smoke anymore.  But it’s bloody hard.  It’s simple enough to get in shape—work out.  But it can be very hard.

America is fucked up in extremes that don’t apply to other nations, simply because it is the heart of the Empire, the Hegemonic Power.  It is the place which is most corrupt.  That makes things a lot harder.  But it does not mean that policy solutions which have worked elsewhere wouldn’t work in the US, it means it is hard to get those policy solutions into effect, and once in effect to protect them from regulatory capture (which, as an aside, is why single payer is superior to a Swiss style system for the US, because it is not nearly as subject to regulatory capture.)

But the fundamental point is simpler.  America and Americans are not some special, unique flower, so different from anyone else that whatever has been done in another place or time won’t work in the US or doesn’t apply to the US.

Grow the fuck up.  The belief that you are a special unique flower unlike anyone else is the illness of adolescents, which they are expected to get over by the end of their sophomore year in college, or after a couple backbreaking humiliating years in shitty jobs.

If you won’t cure yourself of this belief, the world will do so for you.  It’s been trying, with things like the financial crisis, and having your ass whipped by insurgents who don’t spent one millionth what you do on the military, but your heads are very thick.  Rest assured, however, that the world will keep trying.  And if it’s necessary to smash your heads in to get through to you, it will.

Ask the Russians about that…

whether it will help some people, or harm some people.  It will do both.

Some people will get care they wouldn’t have otherwise.  People on Medicare will have half the “donut hole” for drug coverage covered, some people will get insurance who would have otherwise been refused.  Etc…

But here’s something which WILL happen as a result of this bill: some people who are not on Medicare will not be able to afford their medicine, due to the ban on reimportation and the increase in time before generics are allowed on the market. Many of them will die, others will go bankrupt.

Others will be forced to buy insurance they can’t afford, and will be fined if they don’t.  That money will have been money they would have used to buy out-of-pocket health insurance.  They will be harmed by this bill.

The excise tax will inexorably make employer provided health care plans worse, meaning more and more things won’t be covered by good plans (aka: plans that cover what you need.

Some women who need abortions won’t be able to afford them, and some of them will wind up bearing children they don’t want or will go to back alley abortion methods, and some of them will die or be permanently injured by so doing.

The point is that while there is no denying that some people will be better off under this bill there is also no denying that some people will be worse off. People will die who wouldn’t have without this bill, people will live who wouldn’t have without this bill. People will not go bankrupt because of this bill, people will go bankrupt because of the bill.

The question is not “will some people benefit” or “will some people be harmed”, the question is “on the balance does this bill do more good than harm?”

I come down on the side that says it does more harm than good. I may be wrong, I may be right. We won’t know for a good 10 years or so.

If I’m wrong, I’ll admit it and eat crow.

But I think I’ll be missing a meal.

And whether it does more good than harm, having the Federal government mandate that people buy a private product that costs as much, in many cases, as their tax bill, or the IRS will fine them, sets a bad precedent.  Saving a private industry which was in a death spiral (the insurance companies were only maintaining profits by cutting customers) sets a horrible precedent.  And refusing to do the right thing, which would have cost less, well, doesn’t set a precedent, but does continue a very tiresome trend of the US being unwilling to do the brain dead simple thing that has worked everywhere else, because its government is captured by moneyed interests.

Jane’s right on this:

The White House is telling people that if they don’t pass this bill, it will be a disaster for Democrats in the fall. That’s abject nonsense — their “fallback plan” for health care doesn’t have the toxic mandate that makes the IRS the collection agency for Blue Cross/Blue Shield, or any of the abortion issues that inflame both pro- and anti-choice groups.  It’s a better bill on the merits anyway, and most of the country wouldn’t know the difference over a bill that doesn’t kick in until 2014 anyway.

Kill the health care bill, pass the fixes that can be put through, minus the mandate and abortion restrictions.  Sounds like a win to me.

So, there’s a push on for a vote, now that Massa has been forced out and the kneecappers have made clear what happens to progressives who won’t play ball on HCR.

The bottom line is that health care reform is a giveaway to special interests, funded by cuts from Medicare and forcing people to buy insurance or pay or a fine.  There’s some decent stuff in it, but less than folks think (for example, old folks can be charged multiple times what young folks are).

I’m still opposed.  I don’t think the good outweighs the bad.  This is not a case of “we can get better if it fails”, this is a case of “this is worse than nothing.”