This is a Fiat Lex healthcare reform post. Enter at your own risk.

So I've gone and bitten the bullet; I've decided to do a healthcare post.

This is thanks to Amber for linking me to "The Doctor Is In", whose most recent post is also about the healthcare reform bill. His links to the Library of Congress and HTML versions of HR 3200 always time out for me--I guess a lot of people are reading that thing!--but I found another link to the proposed healthcare reform bill which has worked well for me all afternoon. Later on in my post, you will need this link if you want to look up my textevs. I cite both by section and paragraph numbers and by page numbers.

Dr. Bob brings up summaries of some key things which he finds worrisome, with a refreshing lack of reliance on polemic. (In other words, no rightist "totalitarian zmobies killz ur granma while gubmint breaks into ur house 2 force vitamins down ur froat!" and no leftist "this bill is a fixeverything and must pass immediately 2 save all the childrens or else ur greedy fatcat who hatez teh poor!") So if you have inclination and time, do go read him! I agree with him on the worrisome-ness of several key points, and he presents them more succinctly than I will.

To briefly sum up my reaction to HR 3200:
It has taken socialized medicine and privatized medicine and combined the worst aspects of both. It is a well-intentioned piece of crap. I do not think that it will work. Although even if it does get passed, I might possibly be able to afford to keep my internet on--if I take up selling drugs, or offload a kidney, or quit smoking for a year and sell an ovary. And I will enjoy all the healthcare, so that'll be some comfort.

Personally I want us to have fully socialized medicine like France and Canada and England. Healthcare is one of those things for which demand is so ridiculously inelastic (people's need for it is not sensitive to price) that socializing it is the only sensible course of action, just because of the economies of scale (things, even bureaucratic institutions, get cheaper when you buy in bulk). But I am getting both sidetracked and ahead of myself!

Back to our new friend the document, namely HR 3200.

My love of long, complicated, unbelievably boring documents goes back to childhood. As a child, I would apply for those "sweepstakes by mail" things. Y'know, the ones which made it very easy to enter the sweepstakes if you ordered a throw pillow or set of 36 coasters with seashell pictures on them, but extremely complicated and fiddly to correctly enter without purchasing anything. American law requires all sweepstakes to be enterable without a purchase, but it's not in the sweepstakes company's interest to make it easy for you to do. So I developed a cheeky sense of pride in my ability to wade through tiny, tiny print and successfully foil those who meant said tiny print to prevent me from getting things for free. I never did win anything, but the skill set and the cheeky pride persisted.

The key thing with a government document is to ignore the fact that it's over a thousand pages long and filled with paragraph upon paragraph of impenetrable detail. The strategy that tends to work for me is to zero in on indexes, write down the page numbers of any pertinent thing I find via use of said indexes, and always, always follow up on it when one paragraph references another paragraph. Seriously. Don't get blinded by those paragraph and section numbers. In general, if you have to follow through multiple citations and change which keywords you're following once or twice, the information you get at the end of the search will be very useful indeed.

In wading back and forth through HR 3200 I was interested in a few basic, netspeakable questions:

--What we get to has?
--How much we pay for get this?
--What is catch?!?

Here is what I found.

What we get to has?

p.8, Title I Section A (c)
"Acceptable coverage" (as defined on p.76-7, II A 202(d)(2)) essentially means being enrolled in a qualified health benefits plan created under the new rules, a healthcare plan one already had under the old rules, Medicare, Medicaid, armed forces health plans incl. Tricare, or VA benefits.

Minimum acceptable coverage under the new rules would mean enrollment in a "basic plan."
A "basic plan" (according to p.85, II A 203(c)) is a plan which contains the "benefits package required under title I for a qualified health benefits plan."
"essential benefits package" includes the following "minimum services to be covered" (copied from p.27-28, I C 122(b)):
"(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."

How much we pay for get this?

The first part of the answer to this question deals with premiums.

An "affordable premium amount" (according to p.135, II C 243(b)(1)) is calculated as:
"The affordable premium amount specified in this subsection for an individual for monthly premium in a plan year shall be equal to 1⁄12 of the product of—
(A) the premium percentage limit specified in paragraph (2) for the individual based upon
the individual’s family income for the plan year;
(B) the individual’s family income for such plan year."

Paragraph II C 243(b)(2) contains a chart which I'll copy shortly, but first I want to go over the formula real quick. A is the percentage bracket you fall within on the chart, and B is your family's yearly income. So your "affordable premium" = A*B/12.

The chart from page 137 is below. I've removed the actuarial values because I don't know what they mean, and shortened the descriptions for the columns. Since this bill provides for the healthcare reform act to be phased in over three years, the affordability percentage slowly increases as the plan progresses. "FPL" stands for the federal poverty line--I'll copy that chart in a moment.

Income % of FPL.........Yr 1.....Yr 3
133% through 150%....1.5%....3%
150% through 200%....3%......5%
200% through 250%....5%......7%
250% through 300%....7%......9%
300% through 350%....9%......10%
350% through 400%....10%....11%

This chart gives us the values for A in the equation above. "A" is your "affordable premium amount", and is thus the maximum percentage of your income which must be dedicated to your health insurance premium. From what I read in II C, the law seems to work as follows. If your monthly insurance premium is greater than "A" and your income is less than or equal to 400% of the FPL, then you get "affordability credits" to pay the difference between your provider's premium and whatever "A" is for you. These credits are paid directly from the government to your provider (p.129 II C 241(a)(2)) and can't be received as cash (p.132 II C 241(e)).

The FPL guidelines are as follows:

Family size...Yearly income

So, let's take me for example. For tax purposes, I am a one-person household, so the FPL for me is $10,830 per year. If, at my new deli job, I were to work all 35 of my hours per week all 52 weeks of the year, my gross yearly income would be $16,380. I'd be earning 151% of the FPL amount. This puts me in the second bracket (150-200%), so in Year 3 under this bill, "B" in my equation will be 5%. Let's calculate my "affordable premium amount"!

(16,380)*(.05)/12 = $68.25

It does seem pretty reasonable. Kinda-sorta.
Except that my net pay, in this highly likely scenario, is about $1120 per month. And I live in Chicago, and have utilities and things in addition to rent. So even if I get off my duff and get food stamps already (and we assume I eat no food which is not purchased with food stamps), $68.25 is still a prohibitively huge amount. There is no freaking way I can afford to pay that. At least not if I want to remain a smoker and also keep electric, gas (which gets crazy spensive in the winter), phone/internet service, and the ability to pay $2.25 per ride to take the train to and from work 6 days a week. Oh, and do laundry at my local laundromat, since my building has no laundry machines.

People with higher incomes, on the other hand, seem to be upset about the cost-sharing stuff. I have not been able to find specifics on cost-sharing beyond the following:

Regarding enhanced, premium, and premium-plus plans (from p.87, II A 203(c)):
"(3) ENHANCED PLAN.—A enhanced plan shall offer, in addition to the level of benefits under the basic plan, a lower level of cost-sharing as provided under title I consistent with section 123(b)(5)(A).
(4) PREMIUM PLAN.—A premium plan shall offer, in addition to the level of benefits under the basic plan, a lower level of cost-sharing as provided under title I consistent with section 123(b)(5)(B).
(5) PREMIUM-PLUS PLAN.—A premium-plus plan is a premium plan that also provides additional benefits, such as adult oral health and vision care, approved by the Commissioner. The portion of the premium that is attributable to such additional benefits shall be separately specified.
(6) RANGE OF PERMISSIBLE VARIATION IN COST-SHARING.—The Commissioner shall establish a permissible range of variation of cost-sharing for each basic, enhanced, and premium plan, except with respect to any benefit for which there is no cost sharing permitted under the essential benefits package. Such variation shall permit a variation of not more than plus (or minus) 10 percent in cost-sharing with respect to each benefit category specified under section 122."

Let me sum that up, briefly. (Although I'm sure you're all a-quiver to see what's in section 123(b)(5)! I know I am!)

Basic plans charge the amounts we learned how to calculate above and provide the services listed above. Enhanced and premium plans reduce the amount of cost-sharing, although the total reduction in cost-sharing (per p.87, II A 203(c)(6)) cannot exceed 10%. Whatever that means. Cost-sharing money applies only to the list of "minimum services to be covered" I have copied above (from p.27-28, I C 122(b)).

Premium plans not only reduce cost-sharing; they also provide vision and dental care. I have no idea what effect the three tiers have on premium amounts, although I have some vague idea that, after Year 3 of this bill (per p.131, II C 241(c)(2)), affordability credits can also apply to enhanced and premium plan, premiums.

(Why the crap didn't they choose another word for the super-cool plan, knowing that "premium" already has another definition in an insurance context? Arrgh!)

If anyone with a more proprietary interest than me in the cost-sharing math is willing to look up some more textev on this issue, I would be truly grateful. Perhaps my dear stalwart cohort of readers would also be grateful for further textev--though who knows but they themselves?

By the by, before I copy/paste it, section I C 123 is entitled "Health Benefits Advisory Committee", and 123(a)(2) says that if this bill were passed today, Surgeon General Sanjay Gupta would be the chair of the advisory committee. Honestly I myself don't know much, if anything, about Dr. Gupta because I am lazy. So make of that whatever you will. And tell me about it!

Anyway, here's p.30, I C 123(b)(5):

(A) ENHANCED PLAN.—The level of cost sharing for enhanced plans shall be designed so that such plans have benefits that are actuarially equivalent to approximately 85 percent of the actuarial value of the benefits provided under the reference benefits package described in section 122(c)(3)(B).
(B) PREMIUM PLAN.—The level of cost sharing for premium plans shall be designed so that such plans have benefits that are actuarially equivalent to approximately 95 percent of the actuarial value of the benefits provided under the reference benefits package described in section 122(c)(3)(B)."

Ohhh, that's what those actuarial values were for. I think. Y'know, those actuarial values in the table from page 137, which I left out 'cause I didn't know what they were for. Maybe this is what they're for? You look it up, if you've got the brain energy! I'm'a move on to my last point now.

What is catch?!?

(per p.167-8, IV A 401(a)): If you do not get health insurance, you will be taxed. The tax for failure to buy health insurance coverage will not exceed your "affordable premium amount." It is calculated according to the following formula:
"In the case of any individual who does not meet the requirements of subsection (d) at any time during the taxable year, there is hereby imposed a tax equal to 2.5 percent of the excess of—
(1) the taxpayer’s modified adjusted gross income for the taxable year, over
(2) the amount of gross income specified in section 6012(a)(1) with respect to the taxpayer."

I'm assuming this refers to 6012(a)(1) of the Internal Revenue Code, since the health care reform bill only goes as high as 2541. After much digging--way too much digging--here's section 6012 of the Internal Revenue Code. If you don't get it, don't worry; I don't get it either. If you do get it, please explain it to me. This magnificent bastard of a document has eaten my brain.

As for another thing I was troubled about, I'm having trouble finding a part where individuals have to comply with certain government-defined health maintenance standards in order to obtain coverage. If you have found it or know where it is, please point it out to me. I did find the part where employers have to fulfill certain standards in order to be approved providers (starting on p. 143, III B 311), but that's less scary and more sensible.

This deep digging into labyrinthine documents only reconfirms my initial suspicion. Namely--on the one hand, fully socialized medicine would be better for me personally, at least. And on the other hand, yes everyone is angry, yes everyone should be angry, but everyone is angry at the wrong things for the wrong reasons. And that makes me angry! Rrrreow!

I'm going to quit now while I still have a head on my shoulders. I've spent, not counting bathroom and food prep breaks and one brief phone break, around five hours on this post, so I better be freakin' done with it.

Hasta mañana, ladies, gentlemen and persons of indeterminate gender. I'm'a go play Solitaire and drink beer until KoL rollover now.


Bjørn Østman said...

Thanks for posting this. What does KoL stand for? ;)

Amber E said...


Is a multi-player online turn based game where your stick figure adventures in various areas to complete quests. It is generally funny. It is also free which is nice.

Great post. Thank you for doing what I haven't done which is to read the bloody thing. I get annoyed at our politicians for not reading things they vote for. I will have to reread your post a few times because you have so great analysis and have even done the math for me.

Love the Dr. Bob paragraph it is funny. My only suggestion for further thought is not with your analysis of the bill, which is excellent but with the idea that government bureaucratic institutions would be more efficient.

However I agree with you that people are getting upset about wrong things. I do not want socialized medicien because I think you will get less care and I want you to have care. However it looks like we are not trying to copy Canada exactly but instead are getting a different sucky over complicated thing. Article I found interesting about Canada:
Perhaps we should research to see if we can find you health insurance for less than $68.25 per month?

Again kudos for the rational, non emotional reading and analysis.

Anonymous said...


Kingdom of Loathing is a wonderful, hilarious game. Amber's description is pretty much right on. But I need to mention that, no matter what your favorite pop culture phenomena, they are probably referenced somewhere in the game. My favorites include the quote from the band The Refreshments, and the show Sanford and Son. :-D

This really does get to the heart of the issue, I think. Mandatory payments from people with no money is just bad news. I'm lucky that I haven't needed a doctor visit in a while, because our system as a whole is about as bad as it can be. Still, there has to be a better way than this.

Unrepentant said...

You guys getting prescription drugs paid? I don't believe it.

They shouldn't commit to that. Here everybody buys their own meds.

Amber E said...

Oh, and I love the crazy cat picture

Fiat Lex said...

Bjørn -

Thanks for stopping by! I always enjoy your blog, even though I can't always think of something to comment. XD And I do hope you try KoL. I have proselytized for it so successfully it makes me laugh.

Amber -

Glad you liked it! :) Even with all the time spent, I still only managed to do a little of the math. But I think it was the most interesting bits! And it was kind of fun, like a treasure hunt. For one lime beans. In an enormous hill of regular beans. Heehee.

I like that Canada article. I didn't know that Canada has actually banned private insurance; that does seem crazy. People rich enough to be able to afford private healthcare plans should be able to get them. I just think that, inefficient as government sometimes is, it tends to be able to do really big vaguely standardizable things with a reasonable degree of effectiveness.

The main reason I want there to be some kind of "socialized" medicine is as follows. If I were still working as a temp (instead of a permanent job at a huge chain store with a union through which I'lleventually qualify for benefits) for me it really would be a choice between government-sponsored healthcare and no healthcare at all. Remember last year when I got that benign ovarian cyst that turned out not to need an operation? Yeah, I still owe Rush almost $5 grand for that. And I won't be able to use their ER again 'till I get on a payment plan.

Let the rich keep their private plans. Let everyone who cannot afford any kind of healthcare plan get a government-run plan that costs them very little, if it can't be made to cost them nothing. Otherwise, not just the 10% or so of the population who is unemployed, but also those workers who are employed as temps or at small businesses with no group plans, will be in the same boat I was in last fall. That is not a good boat to be in.

Ach, there go the emotions I was trying so hard to leave out of the main post! XP Plese, forgive my indulgence there. It is a story you know already, so perhaps you will not mind so much.

I dunno about getting me a plan for less than 68.25 per month. I used to work for MetLife, remember, so I'd done calculations on me and some of my housemates when we were all living with Dad in Elgin. As a 22-year-old smoker you still can't really get a basic healthcare plan for less than $90 or so a month. For a non-smoker I think it goes down to like $70 a month, but I'm not sure cause it's been a couple years. As for Dave--fahgeddaboudit. Unless he works for a big company with a group plan or gets some kind of government mojo, his priors mean he's not getting coverage for less than $300 a month, if that.

Speaking of which, do you have a healthcare plan through your work? Because I hate the thought of you getting sick and being in the aforementioned boat!

I am glad you liked the kittehs though. :) The ones on the section headings, I added at the last minute to counteract the boringness of the official documentese, but they turned out pretty apropos. And the one at the end, indeed, is priceless.

Fiat Lex said...

(Dangit, I'd generate 4096 characters every day before breakfast if I had the time.)

Dave -

I'm glad it captured your interest!

Yeah, there's some pretty fishy-smelling stuff in here. Although the more I think about it the more I edge, in my own mind, towards "mollified". Think about it. At the moment you would probably qualify for "affordability credits" under the proposed system, maybe all the way down to zero. Three percent of zero is still zero, and all.

Unrepentant -

Us getting prescription drugs paid would be awesome. Maybe that would finally give the pharm companies some incentive to stop calculating their earnings in terms of 200% profits. And I could go back on Lexapro if I felt I needed it, or maybe some equivalent drug that doesn't have the unfortunate side effect that one did for me. XP And the next time I needed penicillin it would be free maybe? That would be awesome.

But of course you guys don't get free prescriptions. Your government healthcare system is the only game in town. And every dollar they spend to pay for drugs comes directly out of a nurse's salary, or something.

Amber E said...

Thank you for the reply. Just so ya know I do DEFINITELY want you to have access to medical care. Glad you liked the Canada article. My fear is that if medicine becomes more 'socialized' poor and middle class will have even less access to health care. Not on purpose, I am not positing evil plotting but just with red tapes snarles of delay.

The government is not so effective with individualized things like personal health. Sure I think they can have a reasonable degree of effectiveness with things like vaccinations. Time sensitive things like trauma injuries and appendicitis? Well I know most people in Chicago want their ambulance to take them to a private hospital not Cook County beacuse of the wait times.

It is not that the medical staff doesn't care, they do I'm sure. But private companies have to understand efficient resource allocation be that nurses, admitting clerks, drubs or beds to survive.

Basically things that can be advanced planned I think the government can do just fine at. But I am terribly afraid that for some disease if one treatment worked really well for 80% of patients but not at all for 20% precious treatment time would be lost while your doctor had to argue with extra pencil pusher people that it was necessary.

Some diseases have a fast course. Right now sometimes people get suspicious lumps biopsied anywhere from the same day to within a week of seeing their doctor. We have all heard stories about - oh it is probably nothing but we will just biopsy this to be safe. Then they find out it is like stage 4 cancer and if they had waited a month or two for a biopsy they could have died.

I do think our health care system desperately needs reform. I am just afraid that the well meant changes currently proposed will not have the desired outcome.

FYI I believe a 'payment plan' for hospital bills can be even something like $10 a month but with a tight budget that can be a stretch.

Oh, have you ever checked these folks out?

They have several locations around Chicago as well as being in several other states. While they do not treat emergencies, major illness or broken bones (and they would have have worked for the cyst unfortunately) they are great for routine things and they don't charge hundreds of dollars.

Sometime I can tell you what I think would fix healthcare but it is not particularly important as I am not a senator or congressman nor am I any kind of expert they would listen too....

Oh, I have United Healthcare Choice Plus through work and it seems fine, I just have a co-pay.

Perhaps a subject for another post.

Temps get the short end of the stick in general. You and I have both temped. Some single parents or people with other reasons for needing flexibility may temp for years and not get raises, not get healthcare and not have a 401k. I know when Mom had a long term temp thing after X number of consecutive weeks she got healthcare but it was still more spendy than mine is and not all agencies do that.

I would be actually fine with my job not subsidizing healthcare, instead paying me what they spend on it and me buying private insurance just like we by car insurance. Temps, small business owners and entrepreneurs, the unemployed (and under employed) etc. often go without healthcare and it stinks.

kisekileia said...

Honestly, I think the fact that Canada has banned private health care is a good part of why we've been able to maintain a public system that works. If the rich and powerful have to use the public system, they'll be motivated to keep it working well. If they don't, they won't be.

The Everlasting Dave said...


Precisely. Anyone who is against real health care reform hasn't had to spend meaningful time in a U.S. hospital. Maybe there is no way to stop mandatory payments while providing care to everyone, but I'd really love to see Obama take a hammer to the pharmaceutical industry and see what he can bash out of it.