Gofal Fforddiadwy?
Enriched insurers main outcome of Obama health plan
Tachwedd 2009 By Roger Bybee
fersiwn argraffydd cyfeillgar Tudalen ZSpace Bybee
Like a photograph slowly developing, recognizable features of the Democratic health care reform plan are finally taking shape. Insurers stand to receive $465 billion in subsidies via the Senate Finance Committee version of reform, while those citizens failing to pay for private insurance could face fines ($750 for failure to buy single coverage, $1,900 on family policies), all without an effective "public option" that would serve as a measuring stick to monitor and discipline private insurers. Moreover, many Americans—perhaps 25 million—will remain uninsured.
"Obviously, this plan won’t work because middle-income people are right at the border line, caught between unaffordable premiums and unaffordable out of pocket expenses," said Dr. Don McCanne of Physicians for a National Health Program. This perverse outcome should be no surprise, given that former Wellpoint insurance lobbyist Liz Fowler played a central role in helping Senate Finance Chair Max Baucus (D-MT) write the committee’s $829 billion bill, which is serving as the framework for reconciling the differences among the three main Democratic bills. (According to the Mae'r Washington Post, Cribiniodd Baucus $3 miliwn mewn cyfraniadau ymgyrch gan y sectorau iechyd ac yswiriant rhwng 2003 a 2008, sef cyfanswm o 20 y cant o gyfanswm ei gyfraniadau.)
The new mandate is a product that is "both defective and unreliable," in the words of Dr. Steffie Woolhandler of Harvard Medical School. The required payments in the least-expensive "silver" plan, for example, will be far out of reach for many middle-class families. Before receiving any coverage, families making $54,000 must shell out $5,000 in deductibles before their insurance kicks in, along with paying out another $5,300 in premiums.
Os yw premiymau'n fwy na 12 y cant o incwm y teulu, bydd y llywodraeth ffederal yn darparu cymorthdaliadau i wneud yswiriant yn fwy fforddiadwy. Fodd bynnag, nid yw'r cymhorthdal yn berthnasol i'r symiau sylweddol y gellir eu tynnu. Yn mhellach, yn ol y New York Times (9/6/09), "To compare health plans, experts often focus on the percentage of medical expenses paid by insurance, on average, for a given population. This figure ranges from 70 percent to 95 percent under the House bill’s options, but it would be less than 70 percent under Mr. Baucus’s proposal."
Mae cynllun Baucus, sydd i fod i ddechrau yn 2013, yn cael ei gynnig ar adeg pan fo 41 y cant o Americanwyr eisoes wedi nodi anhawster i dalu biliau gofal iechyd, yn ôl adroddiad 2007 Colli tir, a gyhoeddwyd gan Gronfa'r Gymanwlad. Byddai effaith cynllun Baucus / Wellpoint mor llym nes bod y Democratiaid wedi dechrau sgramblo i'w leddfu trwy ychwanegu llawer mwy o gyllid Medicaid (NYT, 9/30/09).
Thus, the most promising part of the sweeping "omnibus" reform bill is a provision for virtually immediate help for the low-income uninsured. While the exact scale of the new assistance to low-income people is uncertain, a number of Democrats see pumping up Medicaid as a means of helping both poor and middle-class families. Separate bills in the Senate and House also contain provisions inserted by Sen. Bernie Sanders (I-VT) and Rep. James Clyburn (D-SC) that would quadruple the level of spending for community health centers because: "Even if universal health care were enacted, there would still be some 60 million Americans located in areas without doctors, so the community health centers are vital for providing primary care, dental care, and mental health treatment," explained a Sanders spokesperson.
Yr Opsiwn Cyhoeddus
Lacking a public option, the plan has been scorned by Dr. Howard Dean, former Democratic national chair, as "a giveaway to the health insurance industry." What makes this giveaway so extraordinary is that the health insurance industry is one of America’s most unpopular institutions. The favorability ratings of the health insurance industry are lower than the tobacco industry. A 2009 UDA Heddiw survey revealed that just 4 percent regard the insurers as "honest and trustworthy."
The industry’s windfall is an appalling comment on the hollowness of American democracy in the face of overwhelming corporate power. While largely reviled by the public, the for-profit health insurance industry has been warmly welcomed by the Congress, the White House, and elite media as a legitimate and valuable ally in the cause of reform. This same gulf between elite and popular opinion was visible in the near-total exclusion by elites of the most popular model for reform, the "single-payer" or "Medicare for all" proposal.
Efallai y cynhaliwyd y pôl mwyaf awdurdodol ar un talwr gan Wythnos Fusnes (5/16/05), because it explicitly referred to systems where the government has essentially replaced the private insurance industry: "67 percent of all Americans think it’s a good idea to guarantee healthcare for all US citizens, as Canada and Britain do, with just 27 percent dissenting." But the single-payer plan was immediately ruled "off the table" in Baucus’s words: "We are Americans. We’re different from Canada; we’re different from the United Kingdom" He was presumably not referring to the United States’ distinctively poor health outcomes (e.g., higher infant mortality, shorter longevity) delivered at much higher per-capita cost ($7,290 for the U.S.) when he spoke of the American "difference."
President Obama has similarly excluded the single-payer plan from consideration. Obama, once an advocate of single-payer while an Illinois state senator, now argues, "The vast majority of people currently get health care from their employers and you’ve got this system that’s already in place. We don’t want a huge disruption as we go into health care reform where suddenly we’re trying to completely reinvent one-sixth of the economy."
Obama’s argument was forcefully refuted by Dr. Marcia Angell of Harvard Medical School on "Bill Moyers Journal": "What he has essentially advocated is throwing more money into the current system…. Our problem is that we spend two-and-a-half times as much per person on health care as other advanced countries, the average of other advanced countries. And we don’t get our money’s worth. So, now he says, okay, this is a terribly inefficient, wasteful system. Let’s throw some more money into it."
Moreover, the transition to a single-payer system need not be "disruptive," as it involves replacing the bureaucracy, rules, and paperwork imposed by 1,500 health insurers with one public entity and one comprehensive set of benefits. Recall that in a pre-computer era, tens of millions of senior citizens were enrolled in Medicare just 11 months after President Lyndon Johnson signed the bill in 1965.
For-profit insurers are eager for the version of "reform" now under consideration. Also standing to benefit are major non-profit insurers whose motives and mode of operation is virtually identical to the for-profits, such as Blue Cross/Blue Shield, Kaiser Permanente, HealthPartners, and Group Health of Puget Sound. "The only thing the insurers are willing to accept is a lot of new customers, at whatever premium, and they’ll be happy with that," Angell reports.
In exchange for the universal mandate, America’s Health Insurance Plans (the 1,300-member insurer trade association) has agreed to do away with pre-existing conditions after one year in considering applications or coverage of specific illnesses. However, the provision may prove difficult to enforce. As United Electrical workers political director Chris Townsend told me, "What’s to stop them from denying you on the basis of a bad credit record with medical bills?" Further, "In exchange for issuing policies to sick people, insurers get to jack up premiums for older people…letting them charge four times more," writes long-time health advocate Trudy Lieberman (Adolygiad Newyddiaduraeth Columbia, 9/23/09).
The Baucus plan also lacks a strong "pay or play" employer mandate, with small fees for failing to provide insurance, so that corporations will continue to undercut their competition by withholding expensive health benefits. And it proposes that key regulations for the health insurance industry be unilaterally written, without Congressional review, by a private group of state insurance commissioners, long known for their servility to the industry and their lack of transparency (LA Times 9/28/09).
Cyfraniadau Strategol
Tcerddodd cwmnïau fferyllol i mewn i'r ddadl iechyd bresennol fel y diwydiant â'r gyfradd elw uchaf. Yn ôl Angel yn ei llyfr Y Gwir am Gwmnïau Cyffuriau, yn 2001, mwynhaodd y diwydiant cyffuriau gyfradd elw o 18.5 y cant wedi'i fesur fel enillion cyfartalog ar werthiannau. At hynny, yn 2002, enillodd y 10 corfforaeth cyffuriau mwyaf proffidiol $35.9 biliwn - mwy na'r 490 o gorfforaethau eraill ar y Fortune 500 gyda'i gilydd.
Rhwng 2000 a 2007, saethodd elw yswirwyr iechyd mawr i fyny 428 y cant. Roedd iawndal Prif Swyddog Gweithredol yn y 10 yswiriwr mwyaf yn $11.9 miliwn ar gyfartaledd yn 2008. Yn ystod y cyfnod 2000-2005, cynyddodd yswirwyr iechyd eu staffio 32 y cant er mwyn craffu'n fwy effeithiol ar hawliadau cleifion er mwyn atal taliadau ac awdurdodiad a thrwy hynny sicrhau'r elw mwyaf. Gyda'r fiwrocratiaeth helaeth hon, swyddogion gweithredol â chyflogau uchel, ac elw enfawr, nid yw'n syndod bod costau gweinyddol yn defnyddio 31 y cant o wariant gofal iechyd preifat America. (O'i gymharu, dim ond 3 y cant yw'r costau gweinyddol o dan Medicare.) Mae costau gweinyddol gormodol yswirwyr er elw yn gyfystyr â gwariant blynyddol diangen o ryw $400 biliwn, yn ôl astudiaeth yn 2003 dan arweiniad Woolhandler ac ymchwilwyr eraill o Ysgol Feddygol Harvard.
Yn y cyfamser, mae teuluoedd sy'n gweithio wedi dioddef o bremiymau llawer uwch, sydd wedi cynyddu 131 y cant ers 1999. Dringodd premiymau blynyddol ar gyfer cwmpas iechyd teulu i $13,375 yn 2009, gyda gweithwyr a'u teuluoedd yn cyfrannu cyfran o $3,515 ar gyfartaledd, mwy na dwbl yr hyn a dalwyd ganddynt. naw mlynedd yn ôl. Mae nifer cynyddol o gyflogwyr yn syml wedi rhoi'r gorau i'r ddarpariaeth iechyd fel rhywbeth anfforddiadwy. Gadawyd tua 47 miliwn heb yswiriant hyd yn oed cyn dyfodiad y dirywiad economaidd presennol. Yn ôl astudiaeth gan ymchwilwyr Ysgol Feddygol Harvard, ers y dirywiad, amcangyfrifir bod 14,000 o bobl wedi cael eu gorfodi i'r rhengoedd bob dydd ac mae bod heb yswiriant yn arwain at amcangyfrif o 45,000 o farwolaethau ataliadwy bob blwyddyn. Darganfu astudiaeth gan Gymdeithas Nyrsys California fod yswirwyr er elw yn gwrthod, ar gyfartaledd, 21 y cant o'r holl hawliadau iechyd yng Nghaliffornia, gyda Cigna yn gwrthod 40 y cant rhyfeddol. Felly mae miliynau o Americanwyr wedi wynebu oedi diddiwedd ac ymyrraeth uniongyrchol yn y berthynas meddyg-claf o ran pa driniaethau y bydd yswirwyr er elw yn eu hawdurdodi ac yn talu amdanynt. Maent hefyd wedi dod ar draws arferion bilio dyblyg a thwyllodrus yn aml.
"It will take at least a decade for real change," McCanne ruefully predicts. "It will take about four years for the national insurance exchange to be set up for the uninsured and then at least another six years before people conclude that it simply doesn’t work. What’s going to wake people up is that middle Americans are going to find out that they still can’t pay for health insurance or health care. Even if they can afford insurance premiums, they’ll be unable to afford the out of pocket deductibles."
Yn anffodus, mae gan yswirwyr er elw a chorfforaethau fferyllol adnoddau enfawr sydd wedi bod yn effeithiol wrth ddylanwadu ar y Gyngres, Mae'r diwydiant gofal iechyd yn ei gyfanrwydd yn cyflogi mwy na phedwar lobïwr fesul aelod o'r Gyngres. Mae mwy na 350 o gyn-aelodau o'r Gyngres neu gynorthwywyr cyngresol wedi'u cyflogi i lobïo am ddiwygio ar ffurf diwydiant. Mae Big Pharma yn unig yn gwario symiau enfawr. Yn ôl y Mae'r Washington Post: "The hirings are part of a record-breaking influence campaign by the health-care industry, which is spending more than $1.4 million a day on lobbying in the current fight, according to disclosure records. And even in a city where lobbying is a part of life, the scale of the effort has drawn attention. For example, the Pharmaceutical Research and Manufacturers of America (PhRMA) doubled its spending to nearly $7 million in the first quarter of 2009, followed by Pfizer, with more than $6 million."
Health-care interests have been both generous and strategic in their campaign contributions. "[The health insurance industry] has donated more than $19 million to federal candidates since 2007, 56 percent of which has gone to Democrats," reported Wythnos Fusnes. In particular, conservative "Blue Dog" Democrats who have generally been highly sympathetic to the industry have received about 25 percent more than their fellow Democrats, according to the Center for Responsive Politics.
Elite Vs. Public View of Insurers
One of the most misunderstood components of the health-care debate is the "public option." Many Americans assume that it is a voluntary version of the single-payer model, which would somehow exist alongside the for-profit insurers, a view reinforced by hysterical Republican attacks that it would lead to a single-payer system or "socialized medicine." Others have understood it as an extension of Medicare which anyone could choose to join—a far cry from the three major Democratic bills. Finally, a large number of supporters—including many progressives in Congress—see it as a critical element necessary as a measuring stick for the performance and premium levels of the for-profit industry and, thus, the only effective cost-control mechanism (if the option was broadly inclusive).
A NY Times/CBS poll released September 24 shows a stunning 65 percent majority (with just 26 percent opposed) for "the government offering everyone coverage in a government-administered health insurance plan—something like coverage that people 65 and over get—that would compete with private health insurance plan." A 47 percent plurality of Republicans favored such a plan. Unfortunately, the public option will not be able to live up to that vision. No public plan put forth thus far would offer it to all Americans.
As written now, the Baucus plan offers a weak network of cooperatives hatched by Sen. Kent Conrad (D-ND) as its version of the public option. "These non-profit insurance cooperatives would be pitted against already-existing for-profit insurers who have well-established provider networks and quasi-monopolistic market share," notes Kip Sullivan, a Minnesota health activist and author of Y Llanast Gofal Iechyd.
Further, the final version of the public option will almost certainly force any public health-insurance entity to conduct itself exactly like private for-profit insurers. Even advocates of the public option like Sen. Charles Schumer (D-NY) have spoken of forcing the new public option plan to operate "on a level playing field" with private insurers who have long monopolized markets in many states. Under these rules, the public option will neither serve as a vibrant alternative nor be in a position to force down premium costs. "The public option would face the same administrative and marketing costs of insurers and trying to gain entry to the same delivery system," points out McCanne. "The public option won’t be able to do anything to cut costs. If the public option has to function on a ‘level playing field,’ it will be forced to function like any private insurance company."
Ar ben hynny, bydd yr opsiwn cyhoeddus ar agor i ddechrau dim ond i bobl sydd newydd eu hyswirio sy'n dewis yr opsiwn trwy Gyfnewidfeydd Yswiriant Iechyd. Bydd y cofrestriad yn gyfyngedig i 25 i 30 miliwn tan 2019 - gan roi dim ond ychydig bach o'r farchnad i'r opsiwn cyhoeddus, ynghyd ag anfanteision eraill.
Cafodd yr opsiwn cyhoeddus ergyd yn ôl ar 29 Medi mewn pleidlais gan Bwyllgor Cyllid y Senedd. Yn dilyn dwy bleidlais o 15-8 yn erbyn gwahanol amrywiadau o’r opsiwn cyhoeddus—nid oedd y naill na’r llall yn agos at y model a ffefrir gan 65 y cant yn y fersiwn diweddar. NY Times/CBS poll—Baucus smirked, "No one shows me how to get to 60 votes with a public option." However, public option advocates are considering a procedure under which they would assemble 60 votes to defeat a Republic filibuster and then use a "reconciliation" procedure that would require only 51 votes for the public option.
Yn y Tŷ, mae mwy na 60 aelod o’r Cawcws Blaengar, gyda chefnogaeth Llywydd newydd AFL-CIO Richard Trumka, yn mynnu na fydd unrhyw gynllun gofal iechyd yn pasio heb opsiwn cyhoeddus cryf. Yn anffodus, nid yw opsiwn cryf wedi'i lunio eto. Ar hyn o bryd, mae blaengarwyr yn rhoi llawer gormod o bwysau ar ddwy linell yn unig o fil Tŷ HR 3200, yn ôl dadansoddiad Kip Sullivan, ac o ystyried cymhlethdod eithafol y ddeddfwriaeth, bydd yn gymharol hawdd i hyd yn oed flaengar, â bwriadau da. cyngreswyr i'w gwerthu ar opsiwn cyhoeddus di-ddannedd.
Woolhandler worries that the final Democratic plan will be a national version of the highly unpopular Massachusetts "reform" plan enacted by Republican Mitt Romney: an individual mandate, high premiums, fines for those who don’t buy insurance, and a lack of cost controls on insurers and providers. "It will be Massachusetts writ large," predicts Woolhandler.
Ar hyn o bryd, yr unig fan disglair sy'n parhau i fod yn gynigion ar gyfer cofrestriad Medicaid sydd wedi'i ehangu'n sylweddol a mwy o ganolfannau iechyd cymunedol ar gyfer pobl incwm isel. Gwarant o sylw iechyd i bawb? Rhyddid rhag ymyrraeth fiwrocrataidd gyson gan yswirwyr? Gofal iechyd sy'n fforddiadwy? Am y tro, bydd yr hawliau hyn - sylfaenol ym mhob gwlad ddatblygedig arall - yn parhau i fod yn freuddwyd a ohiriwyd yn yr UD
Mae Roger Bybee yn awdur llawrydd ac yn ymgynghorydd cyhoeddusrwydd blaengar y mae ei waith wedi ymddangos ynddo Dollars & Sense, The Progressive, Monitor amlwladol, American Prospect, ac Polisi Tramor dan sylw.
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