- Stumbling toward Comprehensive Reform
- political deadlock
- the American path to health insurance
- Frustrated ambitions, liberal and conservative
- the shaping of the Clinton health plan (Starr was part of the Clinton's huge team of experts, and has fascinating inside information.
- getting to no
- the rise of a reform consensus 2006-2008
- Romney and MA model
- toward minimally invasive reform
- making 2008 a healthcare election
- Obama and the rollercoaster to reform
- why healthcare reform passed and climate legislation didn't
Overall, Starr contends that the goal of the ACA was to align one major institution (healthcare) so that it agrees more closely with principles of justice and efficiency. Starr presents the ACA's provisions as they bear upon central problems of public philosophy.
fairness and equality
Rights versus obligations of individuals and states. For states, the question is whether healthcare is a service that the community has an obligation to provide (like basic education). If it is, then the principle of "actuarial fairness" should be abandon. Rather than each person paying for what they use, the cost of care should be spread over the healthy and sick evenly "to avoid imposing burdens on the sick that effectively bar them from access to medical care" (242). Starr invites consideration of the European ideal of "solidarity". He is careful to delineate that the "moral interest in ensuring care for the sick does not require shared responsibility for services such as cosmetic surgery or amenities such as private hospital rooms" (242).
Starr notes that we do have one federal right to health care, The Emergency Medical Treatment and Active Labor Act but that this is funded by shifting costs to insured patients, "a hidden transfer that the American public has apparently preferred to being openly taxed for the same purpose" (242). The ACA "attempts to extend shared responsibility without entirely banishing actuarial fairness, and it makes the health insurance system more inclusive without flattening its tiered and unequal structure" (243). In an unregulated insurance market, the liability equals 11:1 between a 60yo and a 20yo American. That means older adults would pay 11 times as much for insurance. A pure "community rating" insurance would charge these people the same amount. The ACA limits differences in rates to a 3:1 ratio. Ironically the increased burden falls largely on the poor and middle class who are under 400% (this is where subsidies stop) of the poverty line because those over this level buy insurance independently and most get it through employers, few of which ask older workers to pay more than younger workers for insurance.
While libertarians cringe at the young paying for the old, shared responsibility can be described as "enlightened self-interest" as those young workers will almost inevitably be old soon enough.
Subsidies were clarified as a way to make insurance premiums a scaled percentage of income, so that premiums are 3-4% of income for the working poor, and up to 9% of income for those at 400% of poverty level. They're calculated based on second lowest priced silver plan in each area.
The levels are also explained clearly:
Bronze covers 60% of healthcare costs
Silver covers 70%
Gold covers 80%
Platinum covers 90%
Rights versus obligations of individuals and states. For states, the question is whether healthcare is a service that the community has an obligation to provide (like basic education). If it is, then the principle of "actuarial fairness" should be abandon. Rather than each person paying for what they use, the cost of care should be spread over the healthy and sick evenly "to avoid imposing burdens on the sick that effectively bar them from access to medical care" (242). Starr invites consideration of the European ideal of "solidarity". He is careful to delineate that the "moral interest in ensuring care for the sick does not require shared responsibility for services such as cosmetic surgery or amenities such as private hospital rooms" (242).
Starr notes that we do have one federal right to health care, The Emergency Medical Treatment and Active Labor Act but that this is funded by shifting costs to insured patients, "a hidden transfer that the American public has apparently preferred to being openly taxed for the same purpose" (242). The ACA "attempts to extend shared responsibility without entirely banishing actuarial fairness, and it makes the health insurance system more inclusive without flattening its tiered and unequal structure" (243). In an unregulated insurance market, the liability equals 11:1 between a 60yo and a 20yo American. That means older adults would pay 11 times as much for insurance. A pure "community rating" insurance would charge these people the same amount. The ACA limits differences in rates to a 3:1 ratio. Ironically the increased burden falls largely on the poor and middle class who are under 400% (this is where subsidies stop) of the poverty line because those over this level buy insurance independently and most get it through employers, few of which ask older workers to pay more than younger workers for insurance.
While libertarians cringe at the young paying for the old, shared responsibility can be described as "enlightened self-interest" as those young workers will almost inevitably be old soon enough.
Subsidies were clarified as a way to make insurance premiums a scaled percentage of income, so that premiums are 3-4% of income for the working poor, and up to 9% of income for those at 400% of poverty level. They're calculated based on second lowest priced silver plan in each area.
The levels are also explained clearly:
Bronze covers 60% of healthcare costs
Silver covers 70%
Gold covers 80%
Platinum covers 90%
responsibility and freedom
Conservatives support freedom while liberals support equality? Starr argues that a conservatives are using a "shriveled conception of freedom" that fails to recognize that "health itself is a matter of personal freedom" (247). He reminds libertarians that "there are no rights without a government to protect them" and that "freedom is impossible without the framework of law that the state upholds". Starr recognizes that conservatives fear "arbitrary and capricious" government power, but reminds them that these same interests should motivate them to be concerned about private power, such as that of an insurance company. A law that wields government power in order to reduce arbitrary and unreasonable private powers "may also increase individual freedom".
federalism and finance
The subsidiarity principle has solid rationale for keeping decisions at no higher level of government than is necessary. "History complicates theory". Leaving healthcare to the states would mean "denying access to medical care and insurance" for "millions of the poor and near-poor in the South and Southwest" (253).
Financing is complicated.
health and the public household
Health insurance as insurance against unexpected costs or as prepayment for medical services? If you believe the former, than moral hazard is a big deal, and people should pay out of pocket for ordinary expenses. The prepayment model conceives that limiting coverate to catastrophic costs "creates perverse incentives favoring technologically intensive services to the neglect of primary care and prevention" (259).
The ACA supports new nonprofit Patient Centered Outcomes Research Institute to compare clinical effectiveness. "But the law bars use of the findings as mandates or guidelines for coverage or payment" (263). If the Independent Payment Advisory Board gets struck down by the supreme court there will be trouble, because "if we cannot say no to paying for services that are clinically ineffective, we will surely have no choice but to limit services that are clinically valuable" (263).
The Peculiar Struggle
"Other democracies long ago resolved whether they have an obligation to provide care for the sick and protection against medical costs" (279).
Conservatives support freedom while liberals support equality? Starr argues that a conservatives are using a "shriveled conception of freedom" that fails to recognize that "health itself is a matter of personal freedom" (247). He reminds libertarians that "there are no rights without a government to protect them" and that "freedom is impossible without the framework of law that the state upholds". Starr recognizes that conservatives fear "arbitrary and capricious" government power, but reminds them that these same interests should motivate them to be concerned about private power, such as that of an insurance company. A law that wields government power in order to reduce arbitrary and unreasonable private powers "may also increase individual freedom".
federalism and finance
The subsidiarity principle has solid rationale for keeping decisions at no higher level of government than is necessary. "History complicates theory". Leaving healthcare to the states would mean "denying access to medical care and insurance" for "millions of the poor and near-poor in the South and Southwest" (253).
Financing is complicated.
health and the public household
Health insurance as insurance against unexpected costs or as prepayment for medical services? If you believe the former, than moral hazard is a big deal, and people should pay out of pocket for ordinary expenses. The prepayment model conceives that limiting coverate to catastrophic costs "creates perverse incentives favoring technologically intensive services to the neglect of primary care and prevention" (259).
The ACA supports new nonprofit Patient Centered Outcomes Research Institute to compare clinical effectiveness. "But the law bars use of the findings as mandates or guidelines for coverage or payment" (263). If the Independent Payment Advisory Board gets struck down by the supreme court there will be trouble, because "if we cannot say no to paying for services that are clinically ineffective, we will surely have no choice but to limit services that are clinically valuable" (263).
"Other democracies long ago resolved whether they have an obligation to provide care for the sick and protection against medical costs" (279).
"If the special interests were arrayed on one side and the suffering masses on the other, the conflict would fit easily into a familiar populist picture of the world. But though the health insurers, drug companies, and other interests profit from the health system, they are not alone responsible for maintaining it. The bias against change also comes from members of the protected public. No other major democracy created a financing system that provides the biggest tax breaks to the people with the best private insurance; no other major democracy established a separate program for the elderly. A variety of other programs protect particular groups. These partial measures have become major obstacles to the efforts to control costs and to extend protection to the uninsured. The resistance to reform didn't arise because Americans were such determined individualists that they rejected all government help; much of the resistance has come from members of an entitled majority with a privileged position in the public-subsidy system. The potency of these entitlements lies in the psychology of self-exemption they instill; the beneficiaries do not understand themselves as benefiting from government assistance or as sharing a common condition with the excluded. The tax subsidies are nearly invisible to those who receive them; Medicare invites the elderly to believe that they have earned its benefits, whereas other claimants have not. Morally armed, they can reject helping others in need as a matter of high principle; after all, Americans shouldn't look to the government for help" (280).
