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It's been a busy day in health care, and health insurance, reform today

Obama, in the Rose Garden, speaking to a gathering of physicians today:

Every one of you here today took an oath when you entered the medical profession. It was not an oath that you would spend a lot of time on the phone with insurance companies. (Laughter.) It was not an oath that you would have to turn away patients who you know could use your help. You did not devote your lives to be bean counters or paper pushers. You took an oath so that you could heal people. You did it so you could save lives.

Truer words were never spoken. Unfortunately, the rest of the speech is petty much about reforming insurance.

Among the groups represented: the American Medical Association, the National Medical Association, the Family Physicians, the American College of Physicians, the Doctors for America, American College of Pediatrics, and American College of Cardiology. Do you see PNHP mentioned in there? How about the Mad As Hell Doctors? Nope.

At the last minute, Mad As Hell Dr Paul Hochfeld was admitted [sound familiar?] His remarks afterward:

Upon emerging from the gathering in the Rose Garden, which consisted mainly of a speech by the president to the assembly, he said: “Unfortunately, the current bills in Congress and the similar measures supported by the president will not fix the health care crisis - they will only perpetuate the miserable situation we presently have. These incremental reforms will leave the for-profit, private insurance industry in the driver’s seat. The insurance companies will continue to deny claims and raise premiums. Tens of millions will remain uninsured and underinsured. There will be no cost control.

“Today, instead of a health care system, we have a for-profit private-insurance-based sick-care non-system,” he said. “The president should use the current Medicare system and quickly improve and expand it to all people in our nation. In addition, only those who are knowledgeable in public health, health policy and health economics and who do not have ties to the health industry should write the health legislation. Those who themselves or whose families have directly suffered because of the deficiencies of the current non-system should also be involved in the drafting of the bill. The health insurance and pharmaceutical industries, on the other hand, have demonstrated beyond a shadow of a doubt that they are only interested in corporate profits. They should be kept out of the room.”


Hochfeld said that many physicians whom he spoke with at the gathering share his opinion that the health care reform process has been corrupted by corporate money from the health industry, but feel some kind of action is needed.

Meanwhile, outside the hallowed Garden, David Swanson and some 50-100 anti-war, pro-single-payer protesters were arrested.

The president was holding a press conference inside the White House fence with a bunch of doctors who oppose serious healthcare reform. Donna Smith, star of Michael Moore's "Sicko", was standing next to me and telling me that every patient who had appeared in that movie had determined that the healthcare bills now under consideration in Washington would not have done anything to help them and won't now.

Hundreds of peace activists made their way to the White House sidewalk. We joined with some doctors and nurses who were not permitted to take part in the events inside because they support single-payer healthcare. We shouted "Healthcare Not Warfare." We shouted "Troops Home Now. End Warfare." We shouted "Single Payer Now. End Warfare." We made a lot of noise, but we were in the street rather than on the forbidden sidewalk. And there was an incredibly noisy truck behind us that had chosen this moment to clean Pennsylvania Avenue with pressurized hoses.

We moved down the street and the truck came too. But we made a lot more noise. Prisoners in orange from Witness Against Torture chained themselves to the White House fence. So did Cindy Sheehan whose son died in Iraq. Veterans for Peace displayed US, Afghan, and Iraqi coffins and read the names of the dead and shouted: "Mourn the dead! Heal the wounded! End the wars!" The National Campaign for Nonviolent Resistance, the World Can't Wait, and lots of other groups joined in. Many of us donned black shirts, white placards with the names of dead troops or civilians, and white masks: the March of the Dead. We marched on the sidewalk in front of the White House in silence.

Then the police horses came at us. The police tried to drive us into the street with their horses, but we lay down on the sidewalk, and they didn't trample us. Instead they put police tape around a huge area, moved everyone else out of it, gave three warnings, and began arresting people. We lay on the sidewalk for approximately two hours, rode with lights and sirens blaring in an escorted caravan of vans and buses to the jail, and were out within an hour with tickets to pay $100 fines or challenge in court.

Oh, almost forgot... Apple, barraged by single payer advocates, relented and the iSinglePayer iPhone App has been approved.

Update: Whatever did we do before phones/faxes/email/Twitter? Anthony Weiner debated Betsy 'Death Panels' McCaughey today. I like this Weiner quote:

"Get the idea out of your head," he said, "that this is a free market." If your appendix ruptures, you don't have the option of treating a different, cheaper organ."

but the kossacks seem to be quite taken with this:

She said, "funding the uninsured by slashing Medicare, that's like snatching purses from little old ladies."

Weiner's response, on taking the floor again, was that this was like "debating a pyromaniac in a strawman factory." "What did she just say? We're going to steal senior citizens' purses?"

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selise's picture
Submitted by selise on

Hundreds of peace activists made their way to the White House sidewalk. We joined with some doctors and nurses who were not permitted to take part in the events inside because they support single-payer healthcare. We shouted "Healthcare Not Warfare." We shouted "Troops Home Now. End Warfare." We shouted "Single Payer Now. End Warfare."

i love this! solidarity and drawing the connections in a committed and inspiring way.

Submitted by hipparchia on

[i'm a huge fan of o/t comments, because good discussions show up in the oddest places sometimes. feel free to threadjack any of my posts anytime.]

first, it looks like i need to be taking lessons from *you*. good work there! outshines anything i'm ever likely to write.

jason is paid to not analyze the legislation, only to be a cheerleader for it. the 'legislative team' -- if they ever get around to looking up the relevant passage[s] to your question -- are going to tell him how to spin it if/when he does answer you.

medically necessary, eh? [don't you wish we were in canada?]

i'll go through the entire 1000+ pages of hr3200 [the main bill, i'll skip the various amendments for now] as it's posted at the energy and commerce committee website and 'comment serially' here on the parts that look like they might apply.

Submitted by hipparchia on

[pg 26]

(c) NO RESTRICTIONS ON COVERAGE UNRELATED TO CLINICAL APPROPRIATENESS.—A qualified health benefits plan may not impose any restriction (other than cost sharing) unrelated to clinical appropriateness on the coverage of the health care items and services.

gah. do they purposely write this crap vaguely and convolutedly, or are their brains just mush and they can't help it?

i think this means that if the insurance company decides to not cover something, it has to be based on 'clinical appropriateness' which i suppose translates roughly to 'medical necessity'. in plain english, that ought to mean that if it's medically necessary they have to cover it.

i think you and ralphbon are 100% correct here on insurance companies and how they decide what's medically necessary [or clinically appropriate]. this paragraph doesn't say explicitly one way or the other who [doctor? insurance company?] gets to make that decision on what's 'clinically appropriate'. i'll keep a sharp lookout through the rest of the bill to see if this gets clarified in a later section.

BDBlue's picture
Submitted by BDBlue on

and how lawsuits are driving up healthcare costs, this bill is a lawyer's dream. It's what would be referred to as a "Lawyer Full Employment Act" among some of my colleagues.

Submitted by hipparchia on

if this bill passes, i may have to see about going to law school.

selise's picture
Submitted by selise on

appreciate that.

i don't mind cheerleading so long as it's honest, not misleading, etc. it's the spin and outright not true stuff (when not acknowledged, we all make mistakes) that drive me nuts.

Submitted by hipparchia on

so long as it's for single payer! but yeah. honesty is greatly to be desired.


there's a disclaimer at the bottom of the page: Nothing within this site or linked to by this site constitutes investment advice (snort). we were discussing a while back if that needed to be expanded to add medical and legal advice, and in my case, it should be extended to insurance advice. i've got friends and family who were in the insurance biz [most of them retired and glad they got out before it got to be this bad] and i once had my own business that i ended up not expanding precisely because, after looking long and carefully into all the insurance ramifications, it just plain didn't look worth the hassle for the small added amount of money i was probably going to end up making.

so take it all with a grain of salt. or several grains!

okanogen's picture
Submitted by okanogen on

You could read that as appropriate to the clinic, not necessarily the patient. I'm sure some will.

Submitted by hipparchia on

otoh, those who are opposed to rationing of various kinds are asking that any comparative effectiveness research be based on clinical effectiveness, and not on cost effectiveness, which suggests that the phrase clinical appropriateness carries the connotation of appropriate for the patient.

still, they're all weasel words, and we don't know what's going to be in the final bill anyway.

ot, i finally found my street french books, which inform me that you might need to relabel your poney [maybe lambert can conjugate the verbs] using either baiser [to fuck] or baisouiller [variation of baiser] or maybe even bourriquer [to screw like a donkey]. and then there's my favorite website, babelfish, which translates fucking pony as poney foutu, which i have to admit looks pretty good: ou est mon poney foutu?

Submitted by hipparchia on

[pg 27-30]

(a) IN GENERAL.—In this division, the term ‘‘essential benefits package’’ means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security, that—
(1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice;

'generally accepted standards of medical practice' sounds good, but insurance companies have been distorting the way medicine is practiced in this country for 20-30 years now, so it's still difficult to read the tea leaves here on whether the doctor or the insurance company is going to get to define the 'generally accepted standards'.

skipping subparagraphs 2, 3, 4 [they're mostly about affordability] --

(5) is equivalent, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage.

so if the average employer-sponsored plan in your area is crappy on what is medically necessary, apparently the health exchange doesn't have to offer you anything better.

(b) MINIMUM SERVICES TO BE COVERED.—The items and services described in this subsection are the following:
(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic services, including emergency department services.
(3) Professional services of physicians and other health professionals.
(4) Such services, equipment, and supplies incident to the services of a physician’s or a health professional’s delivery of care in institutional settings, physician offices, patients’ homes or place of residence, or other settings, as appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services.
(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention.
(9) Maternity care.
(10) Well baby and well child care and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age.

item 8 on that list refers to an established set of guidelines, but everything else is fuzzy, so... so far it still looks like your doctor could recommend sending you to the hospital [or a particular drug or test, etc] for something and the insurance company could, if it wanted to, decide that something else would be clinically appropriate.


[skipping paragraphs 1 and 2, because they're about annual limits and calculating affordability]

(A) IN GENERAL.—The cost-sharing under the essential benefits package shall be designed to provide a level of coverage that is designed to provide benefits that are actuarially equivalent to approximately 70 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph (B).
(B) REFERENCE BENEFITS PACKAGE DESCRIBED.—The reference benefits package described in this subparagraph is the essential benefits package if there were no cost-sharing imposed.

the essential benefits package is that list of 10 items, from hospitalization through well baby and well child care. the reference benefits package would be the one where the insurance company sells you a plan that pays for 100% of everything listed in items 1-10. insurance companies will have to offer as their lowest-value plan one that is designed to pay for approximately 70% [instead of 100%] of the benefits listed in 1-10.

the kicker is the phrase actuarially equivalent.

this means that the insurance companies get to decide how much they'll pay for each individual item, just so long as the whole adds up to about 70% of the total costs that an 'average' person would incur if they were covered by that plan. this means they could design one plan to pay generously for cancer coverage, and poorly for say heart surgery, and design a second plan to pay generously for well baby care [kids are cheap] and poorly for the ills that older [expensive!] adults might need, and design a third plan to pay generously for [you get the idea] -- just so long as they can show that each plan would add up to pay about 70% of what the the 'full coverage' plan would pay.

so if you bought a plan that was generous on diabetes care [because maybe diabetes runs in your family] but less so on cancer [because maybe nobody in your family gets cancer] and your kids get leukemia, you could theoretically end up with a plan that doesn't have to pay very much [if at all] for growth hormone.

Submitted by hipparchia on

this is a long section [pg 30-35], and i won't bore you with much in the way of direct quotes, but it's about setting up a committee, modeled on medpac, that would determine possible changes to the essential benefits package described above, and to the cost-sharing arrangements.

so, if health care costs continue to rise unacceptably, i can foresee the benefits package being cut, or the cost-sharing increased, or both.

you might be interested in the composition of the committee:

(5) PARTICIPATION.—The membership of the Health Benefits Advisory Committee shall at least reflect providers, consumer representatives, employers, labor, health insurance issuers, experts in health care financing and delivery, experts in racial and ethnic disparities, experts in care for those with disabilities, representatives of relevant governmental agencies. and at least one practicing physician or other health professional and an expert on children’s health and shall represent a balance among various sectors of the health care system so that no single sector unduly influences the recommendations of such Committee.

i like that part about no one sector unduly influencing the committee, but i'd like it a whole lot better if insurance companies and employers were completely out of the mix.

Submitted by hipparchia on


this section [pg 35-37] is about how the secretary of hhs is to implement the recommendations of the benefits committee described in sec 123. fine and dandy, but it invokes 5 USC 553 - Sec. 553. Rule making about which i know nothing, nothing, i say. does this give the public [or congress] more power over the process, or less?

BDBlue's picture
Submitted by BDBlue on

5 U.S.C. 553 is the section of the APA that sets out how agencies make rules. In most cases, agencies make rules by publishing in the Federal Register a Notice of Proposed Rulemaking (NPRM) that provides the public with a certain number of days to comment on the proposed rule. Agencies can also hold hearings on rule proposals, but in my experience this doesn't happen all that often.

Anyway, after the comment period closes, the agency re-examines its rule to see if it's still the right way to go or if people have raised concerns that need to be addressed in the final rule. The final rule does not have to match the NPRM, although it cannot exceed the scope of the NPRM, that is anything in the final rule must be a natural outgrowth of the original NPRM and be something a reasonable commenter would know to comment on from reading the NPRM. If the agency wants to change the rule so that it isn't even close to the NPRM, it needs to release a new NPRM and go through the process again. Nothing takes effect until the final rule is issued.

Note that in addition to addressing what the rule is trying to do, there are often other considerations that must also be addressed in any NPRM and final rule, depending on the agency. Some agencies have to address environmental impact. Almost everyone as far as I know has to address the Paperwork Reduction Act. So there's a lot that goes into these things. And the final rule generally includes an analysis of the comments received and why the agency agreed or didn't with the suggested change. In cases where you get lots of comments, that can take a long time.

In some cases, agencies will bypass the NPRM and issue an interim rule effective immediately and then follow up with comments on that and a final rule. This isn't the preferred method and can be, as most everything with the APA, subject to legal challenge. Usually that happens on issues related to public safety, emergencies, or something else where people need regulatory guidance immediately. Whether the healthcare bill will fall into this category or not, I'm not sure. Perhaps if I get a chance, I'll look back and see how they handled the Medicare Drug Benefit.

Finally, all final rules are sent to Congress where they have some time period (60 days, IIRC) to vote to undo them. If Congress does nothing, then the rule takes effect. It is rare that Congress overturns a rulemaking.

I'm not sure I got all the details right. It's late, I'm tired and I have only a little bit of experience in this are, but this should provide a start.

If I get a moment, I'll try to also put a post together about agency deference and how rules can be challenged.

As always, I might be a lawyer (then again maybe I just play one on the internets), but either way I'm not your lawyer.

Submitted by hipparchia on

Finally, all final rules are sent to Congress where they have some time period (60 days) to vote to undo them. Rarely happens.

this si where it would be soooooo wonderful for all of us to be in medicare -- everybody is afraid of the old folks lobby. even my somewhere-to-the-right-of-george-bush congresscritter voted the way aarp told him to on the proposed medicare reimbursement changes last summer.

Submitted by hipparchia on

[pg 37-38]

there's an inside appeals process [in which you appeal to the insurance company if your claim is denied, subject to 29 C.F.R. § 2560.503-1 Claims procedure.] and there's an outside appeals process [in which you appeal to someone or something that's not associated with the insurance company if your claim is denied] and it even looks like if you live in a state where the insurance laws are consumer-friendly, you could appeal there too for help with denied claims.

always nice to have fallback protections, but i've been through insurance claims appeals processes before [as a formerly-insured person]. that's a nice long section looking for all the world like it's chock-full of protections for patients.

ha. looks good on paper, but irl, not so much.

Submitted by hipparchia on

there's some stuff to dig into about the public option [pg 116-128]. it's possible that the public option could be run like an hmo, instead of like the traditional fee-for-service medicare, but that's a post for another day.

selise's picture
Submitted by selise on

many thanks to you, hip, and to bdblue. bookmarked for future reference.

Submitted by lambert on

What this shows is that the A list isn't very relevant. The MAHD did this solely with an old-fashioned media event: A bus tour across the country.

Notice also that this was far more effective than the demonstrators, as such, at least in spreading the message and getting in the door.

Submitted by hipparchia on

i forget where [healthcare-now, maybe], that hochfeld, the mahd who got in, says he got in simply because he had the chutzpah to just walk in the door, following all the doctors who had real invites, as though he belonged to their group.