Today is the deadline for comments on interim federal regulations on what constitutes a preventive health care service. This is relevant because under the new health care reform law, preventive health care services are to be provided without co-payments and deductibles. Which somehow raises the apparently puzzling question as to whether contraception (defined as methods to prevent pregnancy) is preventive.
Or related to health.
The Obama administration isn't sure about this, and so has asked the Institute of Medicine to study it. This isn't really the question.
The question is: Do men have sex?
Based on substantial empirical evidence, though no new primary research, I assert: They do.
I further assert (and this is recent news as of the last few thousand years) that there are statistically zero pregnancies that occur without the involvement of sperm. This is most commonly supplied by a man known to the prospective mother, but could be supplied through artificial insemination.There were about 4.2 million U.S.births in 2009.
I appreciate that it is women who become pregnant. I appreciate and am an active participant in the women's health movement. There are health conditions that actually occur only in women (cervical cancer) or mostly in women (breast cancer), and gender-related factors that determine female well-being, life chances and longevity.
But I submit that contraception, conception and pregnancy are biological events that involve both males and females; and usually, not to be coy about it, sex.
Now here is how the new regulations will work: Every other on-its-face preventive service will be provided without extra cost-sharing. Starting on Sept. 23.
The Department of Health and Human Services was so eager to get this done that it is issuing interim regulations, meaning we can still submit comments on proposed regulations but meanwhile the interim regs will go into effect. But the Institute of Medicine is going to have to determine whether contraception really is preventive, and related to health, and a service. That will take till August 2011. Then, assuming that they do so affirmatively determine, it will be about another year before you get your IUD, birth control pills -- or vasectomy -- without an additional copay.
We in the women's health movement are going about this all wrong. Contraception is not about protecting women, at least not alone. Contraception is about the rights of men to have sex. In fact, contraception should be the corollary of every prescription for Viagra. In fact, that was the argument Jackie Speier used successfully, when she was a state senator, to get contraception covered by Califormia insurance plans.
Men, whatever else you think about health care reform, I think most of you know and like your female partners. (And LGBT adoptive and assisted technology parents generally feel the same.) You share, at least, the financial and emotional expenses of child-rearing, to say nothing of pregnancy; and if you don't, well, we have laws about that, too. So drop a note by clicking here to the EQUAL Health Network, and we'll let HHS know you know where babies come from. They need your help. You're so big and strong.
Friday, September 17, 2010
Wednesday, August 25, 2010
Medical Loss Ratio and Public Health: Questions Linger
Should insurance companies be able to get off the hook for paying rebates to customers, who may believe their company is unfairly denying them specific medical care in order to save money, by virtue of engaging in health promotion campaigns?
Last week the National Association of Insurance Commissioners issued proposed rules for measuring the Medical Loss Ratio (MLR), a key instrument for controlling health insurance premiums. The MLR is the 80-85% of premiums that the new health care reform law requires insurance companies to spend on medical care, or improvements to the quality of care, as opposed to administration. Companies that fail to meet that test must give suscribers a rebate. The usually out-gunned consumer representatives at the NAIC supported the state insurance commissioners' vote to adopt the proposed rules unanimously, claiming a victory against insurance industry lobbyists.
But a key provision that slipped through threatens both the effectiveness of the MLR, and the integrity of public health departments. The U.S. Department of Health and Human Services (HHS) is backing a late amendment that would allow insurance companies to count their collaborations with public health departments as quality improvements.
What this means: Partnerships between private, for-profit health insurance companies and cash-strapped public health departments would be counted as part of the expenditures of your premium dollars to improve your health.
The key question is this: Should insurance companies be able to get off the hook for paying rebates to customers, who may believe their company is unfairly denying them specific medical care in order to save money, by virtue of engaging in health promotion campaigns?
Even assuming you like the idea of entrusting health promotion campaigns to your health insurance company, is the MLR a remotely suitable mechanism for encouraging them to engage in these canpaigns?
This is a classic mismatch of policy priorities. The MLR is meant to compel your insurance company to direct your premiums to pay for your health care. If your premium dollars are going to programs that benefit any non-subscriber. it shouldn't count against your right to a rebate. On the other hand, public health departments are meant to use your tax dollars to improve the health of your community. There are simply no grounds to divert public health department efforts to serve subscibers to a particular health plan.
There aren't a lot of these partnerships now - at least not legitimate ones. Most often they take the form of marketing campaigns that happen to focus on public health issues such as smoking cessation. If this rule stands, we can likely look forward to increasing insurance industry incursions into public health territory. So what? At least 3 things: 1. Premium dollars will be further frittered away on marketing campaigns re-dubbed as "health awareness." 2. Real public health department initiatives, and funding for same, will be undermined as already scarce public health staff are diverted to determining whether particular insurance company campaigns are legitimate or not. 3. Smoking cessation campaigns, for exanple, can help insurance companies identify and then cherry-pick customers, either excluding smokers from coverage, or charging them more (the excess charges remain legal even after new rules take effect in 2014).
Interestingly, the insurance industry is also lobbying not to count investment income, or the taxes they pay on investment income, as, well, income, for purposes of calclating the MLR. Those are the taxes that they should be paying to support our state and local health departments.
HHS has to "certify" the NAIC's recommendations before they take effect. The EQUAL Health Network says this one should get a recall.
Background online: http://www.centerforpolicyanalysis.org/index.php/2010/08/equal-to-naic-regs-for-the-public-not-for-insurance-co-s/
Last week the National Association of Insurance Commissioners issued proposed rules for measuring the Medical Loss Ratio (MLR), a key instrument for controlling health insurance premiums. The MLR is the 80-85% of premiums that the new health care reform law requires insurance companies to spend on medical care, or improvements to the quality of care, as opposed to administration. Companies that fail to meet that test must give suscribers a rebate. The usually out-gunned consumer representatives at the NAIC supported the state insurance commissioners' vote to adopt the proposed rules unanimously, claiming a victory against insurance industry lobbyists.
But a key provision that slipped through threatens both the effectiveness of the MLR, and the integrity of public health departments. The U.S. Department of Health and Human Services (HHS) is backing a late amendment that would allow insurance companies to count their collaborations with public health departments as quality improvements.
What this means: Partnerships between private, for-profit health insurance companies and cash-strapped public health departments would be counted as part of the expenditures of your premium dollars to improve your health.
The key question is this: Should insurance companies be able to get off the hook for paying rebates to customers, who may believe their company is unfairly denying them specific medical care in order to save money, by virtue of engaging in health promotion campaigns?
Even assuming you like the idea of entrusting health promotion campaigns to your health insurance company, is the MLR a remotely suitable mechanism for encouraging them to engage in these canpaigns?
This is a classic mismatch of policy priorities. The MLR is meant to compel your insurance company to direct your premiums to pay for your health care. If your premium dollars are going to programs that benefit any non-subscriber. it shouldn't count against your right to a rebate. On the other hand, public health departments are meant to use your tax dollars to improve the health of your community. There are simply no grounds to divert public health department efforts to serve subscibers to a particular health plan.
There aren't a lot of these partnerships now - at least not legitimate ones. Most often they take the form of marketing campaigns that happen to focus on public health issues such as smoking cessation. If this rule stands, we can likely look forward to increasing insurance industry incursions into public health territory. So what? At least 3 things: 1. Premium dollars will be further frittered away on marketing campaigns re-dubbed as "health awareness." 2. Real public health department initiatives, and funding for same, will be undermined as already scarce public health staff are diverted to determining whether particular insurance company campaigns are legitimate or not. 3. Smoking cessation campaigns, for exanple, can help insurance companies identify and then cherry-pick customers, either excluding smokers from coverage, or charging them more (the excess charges remain legal even after new rules take effect in 2014).
Interestingly, the insurance industry is also lobbying not to count investment income, or the taxes they pay on investment income, as, well, income, for purposes of calclating the MLR. Those are the taxes that they should be paying to support our state and local health departments.
HHS has to "certify" the NAIC's recommendations before they take effect. The EQUAL Health Network says this one should get a recall.
Background online: http://www.centerforpolicyanalysis.org/index.php/2010/08/equal-to-naic-regs-for-the-public-not-for-insurance-co-s/
Thursday, August 12, 2010
Insurance co.s want to make you healthy! They also have a bridge for sale
The still-fragile Affordable Care Act (ACA) gives the public a fighting chance at reining in health insurance premiums. But we’re going to have to wrestle with the insurance industry every step of the way. As the National Association of Insurance Commissioners (NAIC) convenes in Seattle today, the public has the imperative to stick up for ourselves. Here’s what’s at stake in this round.
Starting in September, health insurance plans are required to spend at least 80-85% of the premium we pay them on actual health care. Executive bonuses, administration, marketing and profits are limited to the other 15% (in large plans) to 20% (in small plans). This is supposed to incentivize the insurance industry to operate efficiently and to negotiate assertively with health care providers. rather than simply passing on cost increases to consumers.
The $2.5 trillion dollar question is this: how do you define actual health care? The Secretary of Health and Human Services defines this figure, known as the Medical Loss Ratio (MLR), after consulting with the NAIC. And the insurance industry has not been shy.
The insurance industry is asking the NAIC to define the MLR to its advantage, by counting marketing programs, including those with public health themes, as medical expenses, rather than the administrative expenses they clearly are.
The aims of the relevant section of the law (Sec. 2718) - low cost care that offers value to consumers – conflict with the financial imperatives of the health insurance industry, to maximize profits and returns to shareholders, as well as administration, including executive compensation. Proposals by the insurance industry call for calculating the MLR in a way that will frustrate the aims of the law. The MLR is a ratio, with all medical claims (in the numerator), divided by total premiums (in the denominator). A high MLR means that the insurance company is spending a relatively higher share of premium income on its members' medical care and less for administration and profit. A low MLR means that the insurance company is returning less in medical care benefits to its members while retaining more for executives and shareholders; this can also signal a solid opportunity for investors.
To fairly achieve an 85% MLR, a company would have to show that the amount spent on medical claims (in the numerator) is high relative to premiums. But companies can frustrate the intent of the law by defining medical claims to include other expenses, including expenses typically considered part of administration.
The Senate Commerce Committee has documented that, "At least one company, WellPoint, has already ‘reclassified’ more than half a billion dollars of administrative expenses as medical expenses, and a leading industry analyst recently released a report explaining how the new law gives for-profit insurers a powerful new incentive to ‘MLR shift’ their previously identified administrative expenses."
The ACA standard for including expenditures for non-clinical care as a medical expense (that is, in the numerator) is that it must "improve health care quality." It’s hard to imagine this test will be met by the few occasions of insurance companies’ co-sponsoring visible public health events, nor do they justify skewing the MLR in ways that would raise premiums, or requiring the additional administrative effort to determine whether or not it is in itself an administrative or medical expense.
In our letter to the HHS and NAIC, the EQUAL Health Network urged, "The NAIC and HHS should discourage efforts by insurance companies to create and benefit from insubstantial programs that masquerade as clinical treatments. These programs should be properly counted as the administrative expenses that they are. Otherwise, a proliferation of such programs, if regarded as clinical care, would have the exact opposite of the intended effect of the measure: it would cause health care expenditures to balloon, and dilute value for consumers."
What About Their Investments?
The ACA standard applies only to insurers' premium revenues. Yet patients and payors should be equally concerned about how an insurer uses income from its investment of the sums it extracted from previous years’ patient premiums. A more appropriate standard would measure the share of insurers' total revenues devoted to care, as some analysts have urged.
NAIC committees have been working largely outside of the public’s view to draft standards. In our letter, the EQUAL Health Network urged, "It is vital that rate review and other pressures be strong enough to prevent insurers from simply raising premiums in order to offset the limit on their administration/profit share. It will also be important to create an ongoing public process to set and review the initial regulations which are required to begin in September, 2010. Public comment on this system's achievements and limitations will provide assessments of the system's success, and offer the groundwork for constructive and equitable adjustments to the rules."
Starting in September, health insurance plans are required to spend at least 80-85% of the premium we pay them on actual health care. Executive bonuses, administration, marketing and profits are limited to the other 15% (in large plans) to 20% (in small plans). This is supposed to incentivize the insurance industry to operate efficiently and to negotiate assertively with health care providers. rather than simply passing on cost increases to consumers.
The $2.5 trillion dollar question is this: how do you define actual health care? The Secretary of Health and Human Services defines this figure, known as the Medical Loss Ratio (MLR), after consulting with the NAIC. And the insurance industry has not been shy.
The insurance industry is asking the NAIC to define the MLR to its advantage, by counting marketing programs, including those with public health themes, as medical expenses, rather than the administrative expenses they clearly are.
The aims of the relevant section of the law (Sec. 2718) - low cost care that offers value to consumers – conflict with the financial imperatives of the health insurance industry, to maximize profits and returns to shareholders, as well as administration, including executive compensation. Proposals by the insurance industry call for calculating the MLR in a way that will frustrate the aims of the law. The MLR is a ratio, with all medical claims (in the numerator), divided by total premiums (in the denominator). A high MLR means that the insurance company is spending a relatively higher share of premium income on its members' medical care and less for administration and profit. A low MLR means that the insurance company is returning less in medical care benefits to its members while retaining more for executives and shareholders; this can also signal a solid opportunity for investors.
To fairly achieve an 85% MLR, a company would have to show that the amount spent on medical claims (in the numerator) is high relative to premiums. But companies can frustrate the intent of the law by defining medical claims to include other expenses, including expenses typically considered part of administration.
The Senate Commerce Committee has documented that, "At least one company, WellPoint, has already ‘reclassified’ more than half a billion dollars of administrative expenses as medical expenses, and a leading industry analyst recently released a report explaining how the new law gives for-profit insurers a powerful new incentive to ‘MLR shift’ their previously identified administrative expenses."
The ACA standard for including expenditures for non-clinical care as a medical expense (that is, in the numerator) is that it must "improve health care quality." It’s hard to imagine this test will be met by the few occasions of insurance companies’ co-sponsoring visible public health events, nor do they justify skewing the MLR in ways that would raise premiums, or requiring the additional administrative effort to determine whether or not it is in itself an administrative or medical expense.
In our letter to the HHS and NAIC, the EQUAL Health Network urged, "The NAIC and HHS should discourage efforts by insurance companies to create and benefit from insubstantial programs that masquerade as clinical treatments. These programs should be properly counted as the administrative expenses that they are. Otherwise, a proliferation of such programs, if regarded as clinical care, would have the exact opposite of the intended effect of the measure: it would cause health care expenditures to balloon, and dilute value for consumers."
What About Their Investments?
The ACA standard applies only to insurers' premium revenues. Yet patients and payors should be equally concerned about how an insurer uses income from its investment of the sums it extracted from previous years’ patient premiums. A more appropriate standard would measure the share of insurers' total revenues devoted to care, as some analysts have urged.
NAIC committees have been working largely outside of the public’s view to draft standards. In our letter, the EQUAL Health Network urged, "It is vital that rate review and other pressures be strong enough to prevent insurers from simply raising premiums in order to offset the limit on their administration/profit share. It will also be important to create an ongoing public process to set and review the initial regulations which are required to begin in September, 2010. Public comment on this system's achievements and limitations will provide assessments of the system's success, and offer the groundwork for constructive and equitable adjustments to the rules."
Saturday, July 24, 2010
Why Fight About Liz Fowler? Because We Need to Get Real
Progressives failed to prevail on important policy debates during health care reform, including on the public option. There is no doubt that this was a central victory for the insurance industry. The retreat into magical thinking holds that we can measure the how the industry got its way by measuring campaign contributions, and drawing totally unfounded conclusions about the role of indivduals like Liz Fowler and Max Baucus. The record does not support this simplistic though appealing analysis:
According to the Center for Responsive Politics (opensecrets.org), the largest health insurance PACs gave more money in 2008 to Henry Waxman than to Max Baucus (and it wasn't much, at that). Waxman voted yes on the public option; Baucus voted no.
They gave more to the House, which voted yes on the public option, than to the Senate, which voted no.
PACs:
Wellpoint Inc Contributions to Federal Candidates, 2008
House
Total to Democrats: $152,000
Total to Republicans: $260,100
Senate
Total to Democrats: $48,900
Total to Republicans: $98,500
UnitedHealth Group Contributions to Federal Candidates, 2008
House
Total to Democrats: $138,700
Total to Republicans: $100,500
Senate
Total to Democrats: $71,500
Total to Republicans: $58,300
Henry Waxman: $3,000 - yes on public option
Max Baucus: $1,500 - no on public option
What's my analysis? Over time we'll sort out who did what to whom. It's comforting and titillating to believe that there were a few culprits, and that we've found the main one in Liz. We could note alternatively many more profound truths about how disconnected much of the country is from advocacy at the national level, a pattern that persists, and which we can affect. Retreating into Fox News-style sensationalism is not a substitute for analysis.
According to the Center for Responsive Politics (opensecrets.org), the largest health insurance PACs gave more money in 2008 to Henry Waxman than to Max Baucus (and it wasn't much, at that). Waxman voted yes on the public option; Baucus voted no.
They gave more to the House, which voted yes on the public option, than to the Senate, which voted no.
PACs:
Wellpoint Inc Contributions to Federal Candidates, 2008
House
Total to Democrats: $152,000
Total to Republicans: $260,100
Senate
Total to Democrats: $48,900
Total to Republicans: $98,500
UnitedHealth Group Contributions to Federal Candidates, 2008
House
Total to Democrats: $138,700
Total to Republicans: $100,500
Senate
Total to Democrats: $71,500
Total to Republicans: $58,300
Henry Waxman: $3,000 - yes on public option
Max Baucus: $1,500 - no on public option
What's my analysis? Over time we'll sort out who did what to whom. It's comforting and titillating to believe that there were a few culprits, and that we've found the main one in Liz. We could note alternatively many more profound truths about how disconnected much of the country is from advocacy at the national level, a pattern that persists, and which we can affect. Retreating into Fox News-style sensationalism is not a substitute for analysis.
Tuesday, July 20, 2010
New HHS Abortion Restriction Goes Beyond Current Law
Oppose Restrictions for Abortion Access in the Federal Pre-existing Condition Insurance Plans
Post-script:
This time they did not have to do it. There was no Ben Nelson, no Joe Lieberman. No applicable federal law. Not even much to lose. The Obama Administration chose to deny abortion funding in the new high risk pools, due to start next month. These enrollees will be among the most vulnerable women in the US: uninsured, with an existing health condition. The high risk pools were not already subject to the infamous Executive Order banning use of federal funds for abortion through the health insurance exchanges (due to start in 2014). The Executive Order was part of the price for heath reform. Well, ok, something to be fixed down the road. The road seems to have come to our door.
Why did the Administration extend this bad ruling to the high risk pools? Anti-choice groups went viral about the President betraying them if he did not extend to the already unconscionable Executive Oder to the high risk pools. Who thanked him? The Catholic bishops.
We have allowed abortion to become toxic. A procedure experienced by at least a third of women during our lives has been stigmatized. It is not enough to appoint and elect many fine, smart, progressive women – and pro-choice men – to government. They need, and we need, militant mobilized advocacy for reproductive choice and justice.
Keely Monroe, Lisa Kernan Social Justice Fellow; Ellen R. Shaffer, Co-Director; EQUAL Health Network
The Department of Health and Human Services has released an announcement stating that abortion coverage may only be obtained in the new high risk pool plans in cases of rape or incest, or where the life of the woman would be endangered. This wording mirrors the restrictions articulated in the Hyde Amendments to certain appropriations bills. (See below for full text of announcement)
As federal law currently stands, there are no restrictions placed upon federal or state money regarding abortion coverage in the Pre-existing Condition Insurance Plans (PCIP). The PCIPs are temporary insurance pools to provide insurance coverage to those deemed “high risk,” meaning the individual has some kind of pre-existing condition.
Because no law specifically addresses PCIPs and abortion coverage, the HHS statement would create a new sphere of abortion restrictions, undermining women’s reproductive autonomy.
The EQUAL Health Network believes these new restrictions are a response to pressure from anti-choice activist groups, and are unwarranted.
None of the current federal abortion restrictions that are in place apply to the PCIPs. The Hyde Amendment, which restricts abortion coverage to rape or incest, or where the life of the woman is in danger, only applies to funding appropriated through the Departments of Labor and Health and Human Services, including Medicaid. The appropriations for the Federal Employee Health Benefits Plan also restrict abortion coverage, but this clearly does not apply to the PCIPs.
In addition to nonexistent precedent for this action in prior federal law, there is no precedent in the Patient Protection and Affordable Acre Act (PPACA). The Nelson Amendment, adopted in the new law, only applies to plans obtained in the healthcare exchanges, which will not be active until 2014. Lastly, the Executive Order that the President signed regarding abortion coverage through PPACA gives no indication that it was meant to apply to more than the healthcare exchanges and community health centers.
The abortion coverage restrictions placed on the PCIPs is reminiscent of the Stupak Amendment first seen in the House version of PPACA, but later removed. The Stupak restrictions would have forbidden use of any funds, even those procured privately or through states, to provide abortion coverage to individuals participating in the PCIPs.
Objections to the White House and HHS Secretary Kathleen Sebelius.
White House:
Call: 202 456 1111
Email: public@who.eop.gov
Department of Health and Human Services
Call: 877 696 6775
Email: healthinsurance@hhs.gov
References:
Raising Women’s Voices
http://www.raisingwomensvoices.net/raisingwomensvoices-blog/2010/7/15/white-house-hhs-restrict-abortion-coverage-in-high-risk-pool.html#entry8268887
Jessica Arons from the Center of American Progress
http://www.rhrealitycheck.org/blog/2010/07/15/obama-administration-applies-stupak-amendment-high-risk-pools
Text of HHS announcement:
As is the case with FEHB plans currently, and with the Affordable Care Act and the President’s related Executive Order more generally, in Pennsylvania and in all other states abortions will not be covered in the Pre-existing Condition Insurance Plan (PCIB) except in the cases of rape or incest, or where the life of the woman would be endangered.
Our policy is the same for both state and federally-run PCIP programs. We will reiterate this policy in guidance to those running the Pre-existing Condition Insurance Plan at both the state and federal levels. The contracts to operate the Pre-existing Condition Insurance Plan include a requirement to follow all federal laws and guidance.
Post-script:
This time they did not have to do it. There was no Ben Nelson, no Joe Lieberman. No applicable federal law. Not even much to lose. The Obama Administration chose to deny abortion funding in the new high risk pools, due to start next month. These enrollees will be among the most vulnerable women in the US: uninsured, with an existing health condition. The high risk pools were not already subject to the infamous Executive Order banning use of federal funds for abortion through the health insurance exchanges (due to start in 2014). The Executive Order was part of the price for heath reform. Well, ok, something to be fixed down the road. The road seems to have come to our door.
Why did the Administration extend this bad ruling to the high risk pools? Anti-choice groups went viral about the President betraying them if he did not extend to the already unconscionable Executive Oder to the high risk pools. Who thanked him? The Catholic bishops.
We have allowed abortion to become toxic. A procedure experienced by at least a third of women during our lives has been stigmatized. It is not enough to appoint and elect many fine, smart, progressive women – and pro-choice men – to government. They need, and we need, militant mobilized advocacy for reproductive choice and justice.
Keely Monroe, Lisa Kernan Social Justice Fellow; Ellen R. Shaffer, Co-Director; EQUAL Health Network
The Department of Health and Human Services has released an announcement stating that abortion coverage may only be obtained in the new high risk pool plans in cases of rape or incest, or where the life of the woman would be endangered. This wording mirrors the restrictions articulated in the Hyde Amendments to certain appropriations bills. (See below for full text of announcement)
As federal law currently stands, there are no restrictions placed upon federal or state money regarding abortion coverage in the Pre-existing Condition Insurance Plans (PCIP). The PCIPs are temporary insurance pools to provide insurance coverage to those deemed “high risk,” meaning the individual has some kind of pre-existing condition.
Because no law specifically addresses PCIPs and abortion coverage, the HHS statement would create a new sphere of abortion restrictions, undermining women’s reproductive autonomy.
The EQUAL Health Network believes these new restrictions are a response to pressure from anti-choice activist groups, and are unwarranted.
None of the current federal abortion restrictions that are in place apply to the PCIPs. The Hyde Amendment, which restricts abortion coverage to rape or incest, or where the life of the woman is in danger, only applies to funding appropriated through the Departments of Labor and Health and Human Services, including Medicaid. The appropriations for the Federal Employee Health Benefits Plan also restrict abortion coverage, but this clearly does not apply to the PCIPs.
In addition to nonexistent precedent for this action in prior federal law, there is no precedent in the Patient Protection and Affordable Acre Act (PPACA). The Nelson Amendment, adopted in the new law, only applies to plans obtained in the healthcare exchanges, which will not be active until 2014. Lastly, the Executive Order that the President signed regarding abortion coverage through PPACA gives no indication that it was meant to apply to more than the healthcare exchanges and community health centers.
The abortion coverage restrictions placed on the PCIPs is reminiscent of the Stupak Amendment first seen in the House version of PPACA, but later removed. The Stupak restrictions would have forbidden use of any funds, even those procured privately or through states, to provide abortion coverage to individuals participating in the PCIPs.
Objections to the White House and HHS Secretary Kathleen Sebelius.
White House:
Call: 202 456 1111
Email: public@who.eop.gov
Department of Health and Human Services
Call: 877 696 6775
Email: healthinsurance@hhs.gov
References:
Raising Women’s Voices
http://www.raisingwomensvoices.net/raisingwomensvoices-blog/2010/7/15/white-house-hhs-restrict-abortion-coverage-in-high-risk-pool.html#entry8268887
Jessica Arons from the Center of American Progress
http://www.rhrealitycheck.org/blog/2010/07/15/obama-administration-applies-stupak-amendment-high-risk-pools
Text of HHS announcement:
As is the case with FEHB plans currently, and with the Affordable Care Act and the President’s related Executive Order more generally, in Pennsylvania and in all other states abortions will not be covered in the Pre-existing Condition Insurance Plan (PCIB) except in the cases of rape or incest, or where the life of the woman would be endangered.
Our policy is the same for both state and federally-run PCIP programs. We will reiterate this policy in guidance to those running the Pre-existing Condition Insurance Plan at both the state and federal levels. The contracts to operate the Pre-existing Condition Insurance Plan include a requirement to follow all federal laws and guidance.
Sunday, July 11, 2010
Immigration is a NAFTA Problem. This is Not Big News
It's too bad the governors worrying that challenging the Arizona law will hurt their chances in the upcoming election can't find the NYT article on February 18, 2007 by Louis Uchitelle, explaining precisely how NAFTA has driven Mexicans out of their own fields and factories and into the U.S.' Years later, all the misguided policy gurus at the Peterson Institiute can say is "oops," (and let's dismantle Social Security while we're at it). Concerned about creating jobs and stemming the deficit? Reverse NAFTA and CAFTA, and invest in education and social programs. We need leaders who will follow the President's example, and exhibit leadership.
Here's the news from the NY Times, over 3 years ago.
February 18, 2007
The Nation
Nafta Should Have Stopped Illegal Immigration, Right?
By LOUIS UCHITELLE
THE North American Free Trade Agreement, enacted by Congress 14 years ago, held out an alluring promise: the agreement would reduce illegal immigration from Mexico. Mexicans, the argument went, would enjoy the prosperity and employment that the trade agreement would undoubtedly generate — and not feel the need to cross the border into the United States.
But today the number of illegal migrants has only continued to rise. Why didn’t Nafta curb this immigration? The answer is complicated, of course. But a major factor lies in the assumptions made in drafting the trade agreement, assumptions about the way governments would behave (that is, rationally) and the way markets would respond (rationally, as well).
Neither happened, yet Nafta remains the model for trade agreements with developing Latin countries, including the Central American Free Trade Agreement, passed by Congress in 2005. Three more Nafta-like agreements are now pending in Congress — with Panama, Columbia and Peru.
When Nafta finally became a reality, on Jan. 1, 1994, American investment flooded into Mexico, mostly to finance factories that manufacture automobiles, appliances, TV sets, apparel and the like. The expectation was that the Mexican government would do its part by investing billions of dollars in roads, schooling, sanitation, housing and other needs to accommodate the new factories as they spread through the country.
It was more than an expectation. Many Mexican officials in the government of President Carlos Salinas de Gortari assured the Clinton administration that the investment would take place, and believed it themselves, said Gary Hufbauer, a senior fellow at the Peter G. Peterson Institute for International Economics in Washington who campaigned for Nafta in the early 1990s.
“It just did not happen,” he said.
Absent that investment, foreign factories congregated in the north, within 300 miles of the American border, where some infrastructure already existed. “Monterrey is quite good,” Mr. Hufbauer said, “but in a lot of other cities the infrastructure is terrible, not even enough running water or electricity in poor neighborhoods. People get temporary jobs, but that is all.”
Meanwhile, Mexican manufacturers, once protected by tariffs on a host of products, were driven out of business as less expensive, higher quality merchandise flowed into the country. Later, China, with its even-cheaper labor, added to the pressure, luring away manufacturers and jobs.
Indeed, despite the influx of foreign-owned factories, total manufacturing employment in Mexico declined to 3.5 million by 2004 from a high of 4.1 million in 2000, according to a calculation of Robert A. Blecker, an American University economist.
As relatively well-paying jobs disappeared, Mexico’s average wage for production workers, already low, fell further behind the average hourly pay of production workers in the United States, and Mexicans responded by migrating.
“The main thing that would have stemmed the flow of people across the border was a rapid increase in wages in Mexico,” said Dani Rodrik, an economist and trade specialist at Harvard’s John F. Kennedy School of Government. “And that certainly has not happened.”
Something similar occurred in agriculture. The assumption was that tens of thousands of farmers who cultivated corn would act “rationally” and continue farming, even as less expensive corn imported from the United States flooded the market. The farmers, it was assumed, would switch to growing strawberries and vegetables — with some help from foreign investment — and then export these crops to the United States. Instead, the farmers exported themselves, partly because the Mexican government decided to reduce tariffs on corn even faster than Nafta required, according to Philip Martin, an agricultural economist at the University of California, Davis.
“We understood that the transition from corn to strawberries would not be smooth,” Professor Martin said. “But we did not think there would be almost no transition.”
A financial crisis also dashed expectations. One expectation was that the Mexican economy, driven by Nafta, would grow rapidly, generating jobs and keeping Mexicans home. The peso crisis of 1994-95, however, provoked a steep recession, and while there was some big growth later, the average annual growth rate over Nafta’s lifetime has been less than 3 percent.
The financial crisis struck just months after Nafta came into existence, undermining, early on, the Mexican government’s ability to spend money on roads, education and other necessary government functions.
“We underestimated Mexico’s deficits in physical and human infrastructure,” said J. Bradford DeLong, an economist at the University of California, Berkeley, and a Treasury official in the Clinton administration.
But, he says, without Nafta the migration would have been even greater. For instance, he says, there would not have been as much investment in the north of the country.
Finally, the steady flow of Mexicans to the United States has produced a momentum of its own — what Jeffrey Passel, a demographer at the Pew Hispanic Institute, calls a “network effect,” in which young Mexicans travel to the United States in growing numbers to join the growing number of family members already here.
The upshot is that Mexican migration to the United States has risen to 500,000 a year from less than 400,000 in the early 1990s, before Nafta, Mr. Passel estimates. Roughly 80 percent to 85 percent of immigrants are here illegally, he says.
The peso crisis, recession, the network effect — their impact may have been beyond anyone’s control, but not the assumptions about how the market and the government would act.
“We have indeed had one disappointment after another on this score,” Mr. Rodrik said, noting that the same assumption about government spending is part and parcel of the agreements, now before Congress, with Columbia, Peru and Panama.
While there is opposition to these proposals, it is mainly from Democrats who want a better safety net for American workers who might be hurt.
The European Union, in contrast, assumes little about government spending on the part of economically weaker nations joining it. The union itself has hugely subsidized the improved services needed by entering countries like Portugal, Spain, Greece and Poland, rather than leave financing to the relatively meager resources of entering countries.
The money is used not only for public investment, Mr. Rodrik noted, but also to subsidize companies setting up operations in the new countries and to support government budgets.
“I am not saying Nafta was a bad agreement,” Mr. Rodrik said. “But more than a trade agreement is required for countries to converge economically. And Nafta has been viewed as a shortcut to convergence without having to do all the other stuff.”
Here's the news from the NY Times, over 3 years ago.
February 18, 2007
The Nation
Nafta Should Have Stopped Illegal Immigration, Right?
By LOUIS UCHITELLE
THE North American Free Trade Agreement, enacted by Congress 14 years ago, held out an alluring promise: the agreement would reduce illegal immigration from Mexico. Mexicans, the argument went, would enjoy the prosperity and employment that the trade agreement would undoubtedly generate — and not feel the need to cross the border into the United States.
But today the number of illegal migrants has only continued to rise. Why didn’t Nafta curb this immigration? The answer is complicated, of course. But a major factor lies in the assumptions made in drafting the trade agreement, assumptions about the way governments would behave (that is, rationally) and the way markets would respond (rationally, as well).
Neither happened, yet Nafta remains the model for trade agreements with developing Latin countries, including the Central American Free Trade Agreement, passed by Congress in 2005. Three more Nafta-like agreements are now pending in Congress — with Panama, Columbia and Peru.
When Nafta finally became a reality, on Jan. 1, 1994, American investment flooded into Mexico, mostly to finance factories that manufacture automobiles, appliances, TV sets, apparel and the like. The expectation was that the Mexican government would do its part by investing billions of dollars in roads, schooling, sanitation, housing and other needs to accommodate the new factories as they spread through the country.
It was more than an expectation. Many Mexican officials in the government of President Carlos Salinas de Gortari assured the Clinton administration that the investment would take place, and believed it themselves, said Gary Hufbauer, a senior fellow at the Peter G. Peterson Institute for International Economics in Washington who campaigned for Nafta in the early 1990s.
“It just did not happen,” he said.
Absent that investment, foreign factories congregated in the north, within 300 miles of the American border, where some infrastructure already existed. “Monterrey is quite good,” Mr. Hufbauer said, “but in a lot of other cities the infrastructure is terrible, not even enough running water or electricity in poor neighborhoods. People get temporary jobs, but that is all.”
Meanwhile, Mexican manufacturers, once protected by tariffs on a host of products, were driven out of business as less expensive, higher quality merchandise flowed into the country. Later, China, with its even-cheaper labor, added to the pressure, luring away manufacturers and jobs.
Indeed, despite the influx of foreign-owned factories, total manufacturing employment in Mexico declined to 3.5 million by 2004 from a high of 4.1 million in 2000, according to a calculation of Robert A. Blecker, an American University economist.
As relatively well-paying jobs disappeared, Mexico’s average wage for production workers, already low, fell further behind the average hourly pay of production workers in the United States, and Mexicans responded by migrating.
“The main thing that would have stemmed the flow of people across the border was a rapid increase in wages in Mexico,” said Dani Rodrik, an economist and trade specialist at Harvard’s John F. Kennedy School of Government. “And that certainly has not happened.”
Something similar occurred in agriculture. The assumption was that tens of thousands of farmers who cultivated corn would act “rationally” and continue farming, even as less expensive corn imported from the United States flooded the market. The farmers, it was assumed, would switch to growing strawberries and vegetables — with some help from foreign investment — and then export these crops to the United States. Instead, the farmers exported themselves, partly because the Mexican government decided to reduce tariffs on corn even faster than Nafta required, according to Philip Martin, an agricultural economist at the University of California, Davis.
“We understood that the transition from corn to strawberries would not be smooth,” Professor Martin said. “But we did not think there would be almost no transition.”
A financial crisis also dashed expectations. One expectation was that the Mexican economy, driven by Nafta, would grow rapidly, generating jobs and keeping Mexicans home. The peso crisis of 1994-95, however, provoked a steep recession, and while there was some big growth later, the average annual growth rate over Nafta’s lifetime has been less than 3 percent.
The financial crisis struck just months after Nafta came into existence, undermining, early on, the Mexican government’s ability to spend money on roads, education and other necessary government functions.
“We underestimated Mexico’s deficits in physical and human infrastructure,” said J. Bradford DeLong, an economist at the University of California, Berkeley, and a Treasury official in the Clinton administration.
But, he says, without Nafta the migration would have been even greater. For instance, he says, there would not have been as much investment in the north of the country.
Finally, the steady flow of Mexicans to the United States has produced a momentum of its own — what Jeffrey Passel, a demographer at the Pew Hispanic Institute, calls a “network effect,” in which young Mexicans travel to the United States in growing numbers to join the growing number of family members already here.
The upshot is that Mexican migration to the United States has risen to 500,000 a year from less than 400,000 in the early 1990s, before Nafta, Mr. Passel estimates. Roughly 80 percent to 85 percent of immigrants are here illegally, he says.
The peso crisis, recession, the network effect — their impact may have been beyond anyone’s control, but not the assumptions about how the market and the government would act.
“We have indeed had one disappointment after another on this score,” Mr. Rodrik said, noting that the same assumption about government spending is part and parcel of the agreements, now before Congress, with Columbia, Peru and Panama.
While there is opposition to these proposals, it is mainly from Democrats who want a better safety net for American workers who might be hurt.
The European Union, in contrast, assumes little about government spending on the part of economically weaker nations joining it. The union itself has hugely subsidized the improved services needed by entering countries like Portugal, Spain, Greece and Poland, rather than leave financing to the relatively meager resources of entering countries.
The money is used not only for public investment, Mr. Rodrik noted, but also to subsidize companies setting up operations in the new countries and to support government budgets.
“I am not saying Nafta was a bad agreement,” Mr. Rodrik said. “But more than a trade agreement is required for countries to converge economically. And Nafta has been viewed as a shortcut to convergence without having to do all the other stuff.”
Friday, June 25, 2010
U.S. scores dead last again in healthcare study: Health reform can help
The annual Commonwealth Fund study has found once again that the U.S. stacks up last in five measures of healthcare -- quality, efficiency, access to care, equity and healthy lives, compared with Britain, Canada, Germany, Netherlands, Australia and New Zealand. All these countries spend a fraction on health care compared with the U.S.
The new health reform law could address some of these deficiencies. But the findings are under attack from defenders of the status quo who claim in part that the problem is not in our health care system, but in our poverty rate.
Countries do have to do a number of things right to actually improve health:
1. Cover everyone for ready access to health care, to nip problems before they escalate, and to control chronic conditions with medicines or lifestyle changes.
2. Treat acute cases by well trained teams that have access to information about how to diagnose and treat hospitalized patients safely, and have the financial and organizational incentives to do so.
3. Reduce inequities that aggravate poor health, particularly economic differences between rich and poor, and social discrimination based on race, gender, sexuality, disability, etc. The stress of relative powerlessness takes a physical toll and compounds the lack of resources that can buy healthy circumstances: Violence-free neighborhoods where outdoor exercise is safe, healthy food and time to prepare it, spending on social programs like education and income support, information about sexual and physical health, as well as good health care.
4. Finally, it should be affordable so that everyone can use it, including those who need it most. This usually means authorizing the government to play a major role in negotiating prices with the health care industry.
U.S. is deplorably deficient in these areas of performance. And it doesn't all happen in lower-income states like Mississippi. Access is unquestionably a function in part of coverage and is equally wretched in California (where policy has been held hostage for decades to arcane but effective rules against social spending) as in the south. Preventable hospitalizations for chronic conditions vary by county as well as state and reflect poor access to primary care as well as demographic variables. Patient safety is a function of systems, and adequate staffing. Outside of the VA system, our acute care hospitals have insufficient standards for safe and efficient performance, which compromises patient safety and outcomes. In addition, uncontrolled high prices for overuse of medical technology drives the costs of care in the U.S.
Does all this, or even the promise that it will improve as reforms are implemented, justify cutting payments to disproportionate share (DSH) hospitals, as the new law proposes? Very debatable.
However. Let's grant that the U.S. has a higher percent of poor people than other countries, that people of color are disproportionately poor, and that poorer people in the U.S. tend to be in worse health. Dr. Richard Cooper, for one, suggests that the main reason we are outspending the world on health care is that we are spending more money taking care of our poor who are sick.
To the extent that this is true, it is only possibly the case because we take care of poor people in the worst possible way - not through universal access to timely primary care, but through crisis medicine when even U.S. standards generally would not tolerate outright denials of care.
We should have fewer poor people. Race should no longer be associated with poverty. Relatively lower income should no longer determine the degree of power and control over life circumstances that are in turn associated with longevity and good health (nor for that matter should gender, sexuality, religion, or most demographic factors and lifestyle choices; age of course is the exception.). We should not only continue to document these pernicious trends, we should turn our scholarship and advocacy to redressing them. Furthermore, our health care system can contribute to social equity, and presently does poorly.
An unspoken argument is that poverty and race account not only for our higher health care spending butt also for our worse health outcomes, so it will not help to look to reforms of the health care delivery system for solutions. I don't know whether rates of medical errors or C-sections (or misuse of neonatal intensive care units) are higher in the U.S. than in, say, Finland. I know that they are higher than they should be, that they are not disproportionately prevalent in "poverty ghettos," and that they contribute to unjustifiable costs and poor outcomes. Reforming the health care delivery system should not be an excuse for failing to remedy social inequalities. Pointing to inequalities cannot divert attention from the inefficiencies and remediable deficiencies in our delivery system.
The new health reform law and ongoing HHS initiatives make reasonable efforts to acknowledge and address access, inequalities, and delivery system reforms. They won't be as successful as they could be in a single payer system like Medicare and the VA, but even a single payer system in the U.S. would have to implement the kind of delivery and organizational reforms that are now before us.
The new health reform law could address some of these deficiencies. But the findings are under attack from defenders of the status quo who claim in part that the problem is not in our health care system, but in our poverty rate.
Countries do have to do a number of things right to actually improve health:
1. Cover everyone for ready access to health care, to nip problems before they escalate, and to control chronic conditions with medicines or lifestyle changes.
2. Treat acute cases by well trained teams that have access to information about how to diagnose and treat hospitalized patients safely, and have the financial and organizational incentives to do so.
3. Reduce inequities that aggravate poor health, particularly economic differences between rich and poor, and social discrimination based on race, gender, sexuality, disability, etc. The stress of relative powerlessness takes a physical toll and compounds the lack of resources that can buy healthy circumstances: Violence-free neighborhoods where outdoor exercise is safe, healthy food and time to prepare it, spending on social programs like education and income support, information about sexual and physical health, as well as good health care.
4. Finally, it should be affordable so that everyone can use it, including those who need it most. This usually means authorizing the government to play a major role in negotiating prices with the health care industry.
U.S. is deplorably deficient in these areas of performance. And it doesn't all happen in lower-income states like Mississippi. Access is unquestionably a function in part of coverage and is equally wretched in California (where policy has been held hostage for decades to arcane but effective rules against social spending) as in the south. Preventable hospitalizations for chronic conditions vary by county as well as state and reflect poor access to primary care as well as demographic variables. Patient safety is a function of systems, and adequate staffing. Outside of the VA system, our acute care hospitals have insufficient standards for safe and efficient performance, which compromises patient safety and outcomes. In addition, uncontrolled high prices for overuse of medical technology drives the costs of care in the U.S.
Does all this, or even the promise that it will improve as reforms are implemented, justify cutting payments to disproportionate share (DSH) hospitals, as the new law proposes? Very debatable.
However. Let's grant that the U.S. has a higher percent of poor people than other countries, that people of color are disproportionately poor, and that poorer people in the U.S. tend to be in worse health. Dr. Richard Cooper, for one, suggests that the main reason we are outspending the world on health care is that we are spending more money taking care of our poor who are sick.
To the extent that this is true, it is only possibly the case because we take care of poor people in the worst possible way - not through universal access to timely primary care, but through crisis medicine when even U.S. standards generally would not tolerate outright denials of care.
We should have fewer poor people. Race should no longer be associated with poverty. Relatively lower income should no longer determine the degree of power and control over life circumstances that are in turn associated with longevity and good health (nor for that matter should gender, sexuality, religion, or most demographic factors and lifestyle choices; age of course is the exception.). We should not only continue to document these pernicious trends, we should turn our scholarship and advocacy to redressing them. Furthermore, our health care system can contribute to social equity, and presently does poorly.
An unspoken argument is that poverty and race account not only for our higher health care spending butt also for our worse health outcomes, so it will not help to look to reforms of the health care delivery system for solutions. I don't know whether rates of medical errors or C-sections (or misuse of neonatal intensive care units) are higher in the U.S. than in, say, Finland. I know that they are higher than they should be, that they are not disproportionately prevalent in "poverty ghettos," and that they contribute to unjustifiable costs and poor outcomes. Reforming the health care delivery system should not be an excuse for failing to remedy social inequalities. Pointing to inequalities cannot divert attention from the inefficiencies and remediable deficiencies in our delivery system.
The new health reform law and ongoing HHS initiatives make reasonable efforts to acknowledge and address access, inequalities, and delivery system reforms. They won't be as successful as they could be in a single payer system like Medicare and the VA, but even a single payer system in the U.S. would have to implement the kind of delivery and organizational reforms that are now before us.
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