The Constitutionality of the Health Care Bill

Opponents of the Health Care Bill, including the Attorney Generals of several states are planning to sue the government over the ‘unconstitutionality’ of the bill. “They are expected to sue over the bill’s mandate that requires everyone to buy health insurance” saying that it infringes on ‘state sovereignty’. Yet federal law always trumps state law.
Furthermore, under the commerce clause (Article I, Section 8 of The Constitution) Congress has the power to regulate activities that, taken cumulatively, have a substantial effect on interstate commerce. People not purchasing health insurance unquestionably has this effect. Everyone, at some point in their lives will need health care, and requiring people to have health insurance to offset the costs of taxpayers having to pay for people who don’t have health insurance creates a scenario where no one will be an undo burden on the government. You would think that republicans would like this as it is a lesson in personal responsibility.

Secondly, there are precedents in place under the ‘tax and spend’ power of the Constitution- namely with Social Security. The government taxes the people in order to provide Social Security. This would be no different, requiring richer people to pay more in to the system to fund health care, and poor people might receive less of a tax refund to fund their portion of health care, but they will receive the benefit, and pay their fair share of the burden. If certain states want to take the new health care bill to court under the premise of unconstitutionality, they are basically saying that Medicare, and Social Security are also unconstitutional. This is political suicide, and is basically saying that “it takes away a person’s right to be uninsured.” U.S. Rep. Robert C. “Bobby” Scott also points out that “We wouldn’t have gotten this far if there were serious constitutional problems with the legislation,” obviously. Our president is a constitutional lawyer. I think he knows his stuff.

The Health Care Bill is Too Expensive

The ways that this health care bill will save money are difficult to understand, but I will do my best to try to present the issues as I understand them.

First, with everyone insured, it will change how people ‘consume’ medical care, lessening duplications of services and creating a continuity of care which is good for people, their health and the medical pocket book. Right now, someone (the tax payer) is paying for every single person who is currently uninsured- every time they go to the doctor or hospital.

A competitive insurance market will be created. Instead of companies competing to sign up the healthiest people and avoid the sickest (which is extremely business-centered and not at all people-centered) there will be health care insurance ‘exchanges’ that will force insurance products to cover a minimum level of medical services that will need to be presented in a way that the average person can understand. The insurer can not deny coverage based on a pre-existing condition, can not jack up rates without answering to regulators and will be able to be fairly rated by consumers. This will force transparency by insurance companies because it will still be a free market. People will have the tendency to go with insurance plans that are easy to understand, have a clear indication of benefits and are competitive on price and quality. This should in theory drive up quality and drive down prices.

One argument I am hearing about the expense is that if insurance companies are forced to lower their premiums, it will result in less compensation for doctors and other health care providers forcing them out of the profession. This is untrue. “Physicians spend on average about 140 hours and $68,000 a year just dealing with health insurance bureaucracy.… By simplifying and standardizing paperwork and computerizing medical records, doctors will be able to focus on caring for their patients instead of dealing with bureaucracy.” I know of several health care providers who have actually left the profession BECAUSE of insurance companies. Most doctors enter in to the health care profession to help people, but spend their time dealing more with insurance.

One of the other proposals to cut costs is to create a medicare ‘commission’ which is in essence a regulatory board that will balance the budget of Medicare. This board will not have to answer to Congress or any lobbyists and will be charged with one task: providing good care at a good price and eliminating fraud and duplications of service. The board will consist of just 15 people.

The plan will tax “Cadillac Plans” which opponents of health care reform love to bring up. But as it is explained here, it makes total sense.
Employers are allowed to deduct the cost of employee health care 100% tax free. Most of these employees don’t know how much their insurance actually costs because their business pays for most of it, and even though the 30% or so that’s deducted from your paycheck continues to go up and up each year, there is no incentive (or choice) to keep those costs down. This tax would allow a company to receive 100% tax breaks for each employee whose insurance costs $27,500 annually, but would only enjoy 40% tax savings on any amount over that. $27,500 per person is a very expensive health plan and presumably the other parts of health care reform will drive down the cost of insurance creating a scenario where businesses will not be ‘punished’ for offering health insurance as the costs will come under the rather high threshold of $27,500. (This threshold will also grow with inflation). “The idea isn’t that people will pay this tax. It’s that they, or their employers, will evade it by choosing insurance that holds its costs down more aggressively. ”

The next part is what they call “Medicare bundling”, but I call the very real beginnings of evidenced-based practice. Again, Mr. Ezra Klein explains it so nicely: Right now doctors are paid for what they sell, rather than having a proven plan of care to address each medical condition. Doctors will not be paid for quantity of treatment, but for quality of treatment. This will change the way that medicine is practiced for the better as people will start looking at what works, rather than take a million shots in the dark. It will help to streamline medical practice, where people are working collectively to innovate care toward the best possible outcomes and hopefully collaborate and move quality of care forward. (No more old doctors practicing the same way that they learned to in medical school.)

The Congressional Budget Office (CBO) has crunched the numbers and by conservative estimates predicts that all these changes will actually reduce our federal deficit by more than a trillion dollars over the next 20 years. Currently the US spends more on health care than nearly every other country in the world. (16% of the GDP)

Choice, Immigration and Abortion

Illegal immigrants are not allowed to opt in to this plan, and will not be treated because they don’t have insurance. Only insured people (every legal resident) will be treated.

Abortion is simply not funded in any way, shape or form.

The loudest voices of opposition toward all these cost cutting measures are saying that people will have no ‘choice’. You will have a choice. You will be able to choose an affordable, clearly delineated health care plan. You will be expected to pay for it, but most of the people barking the loudest already do. It will not cost you any more than it does now, and it will actually provide more benefits as it will not keep you married to a bad job, or boot you out should you become ill. There will also be no lifetime ‘cap’ on your insurance. Plus- it would expand coverage for another 32 million american people. PEOPLE! That is after all what this is about! People.

Yes, everyone will be ‘forced’ to get insurance creating a mandatory stability in their lives. The poorest of the poor will not be living out on the street just to pay for their medical insurance. People will pay what they can afford, but will not be permitted to create a burden on the system by ‘opting out’. (Taxpayers currently pay for many uninsured people).

Of course there are a lot of ‘what ifs’ and people are afraid of change and the role of ‘big government’, but the fact is this. We are among the wealthiest nations in the world. We have way too many people whose quality of life is directly affected by their access to health insurance or health care. To me, it’s absolutely unacceptable. As I said to a friend earlier today, I would much rather help to fund someone’s health insurance with my tax dollars, than someone’s war. This is not about politics. This is about people’s lives, and their quality of life. Too many people live without knowing the hardships that people face when they have health care issues and no insurance. What about those who live in fear of being dropped by insurance because they get sick? The system is just too screwed up to sit back and do nothing about it.

I had another friend tell me that people in other countries hate us because we are free, and that’s why we should be spending our money on wars and other such things that keep us ‘safe’, rather than on silly, unconstitutional things like health care for the masses. There are many people in this country that do not feel ‘free’, because their hands are tied by the interests of large health care corporations who are NOT looking out for people, other than maybe their stock holders. They live in fear every day that they are one illness away from homelessness. They are not making this shit up. This is real. And it may not be you, or your neighbor, but there are at least 40 million of them out there and many of them are the people, or the children of those people who fought in your stupid wars.

I think that President Obama, and Nancy Pelosi are very brave. They can’t know how this is all going to pan out, but they being human, and thoughtful, have taken their best shot at it based on all the information they could get their hands on it. How can people oppose something that could potentially do such wonderful things to help so many people? I believe we need to follow our country’s Constitution, and also believe STRONGLY in our right to oppose and speak freely. But I also believe that people need to develop a little compassion and look into the future and realize that good health for everyone is good for ALL OF US and the government can actually help. We’ve all seen where deregulation has gotten us, and all the government hopes to do is create a system of checks and balances into an industry that desperately needs them.

Maybe we can lead our world by example, rather than by force and eventually shut down the ‘hate us because we are free’ people by offering a model of hope and change. These people hate us because they don’t have what we do, but if they know that change is possible, maybe a small few will seek to building something rather than destroy it. That momentum can be strong once set in motion. All we need is a little compassion and faith.

Medicaid reimbursement will be available for Certified Professional Midwives working in licensed birthing centers. I am hoping this will open up the door for midwives to open up birthing centers all across the nation, allowing low income women living in rural and underserved areas better access to midwifery-based maternal and child care. This is a win-win situation for women and midwives-hopefully providing choices in health care that more effectively address the cultural differences in the communities where these women live. When women feel honored, and are being cared for and served by providers that understand their culture, language and social norms, it will create an environment of support and empathy-rather than one that may leave women feeling scared and powerless at a very vulnerable time in their lives. Midwives can now effectively serve these women knowing that their work will be paid for by insurance.

The law puts in to place the Equitable Reimbursement Act for Certified Nurse Midwives. Previously, Certified Nurse Midwives were reimbursed by Medicare (federal) at a rate 35% less than other providers creating a barrier to health care for women receiving Medicare. Now, Certified Nurse Midwives will be able to provide care to poor and at-risk populations at full reimbursement rates, creating a scenario where CNM’s will be able to market their services to these populations who could greatly benefit from a midwife model of care.

Pre-existing conditions such as previous c-section, pregnancy and history of domestic violence will no longer be held against women and used against them to deny them health coverage. This has been a ridiculous state of affairs that has been going on for decades. If a woman of childbearing age was applying for health insurance, her premiums would be higher simply because there was the possibility that she might become pregnant in the future. This happened to me. I’m very pleased about this particular provision.

Although I was a bit dismayed to read about the executive order they needed to enact to ensure that abortion services are not covered under the new legislation, evidence has suggested that women who have access to health care are less likely to have abortions in the first place- thereby reducing the abortion rate. The issue is covered nicely here. I understand how the issue of abortion is such a hot button, and I really feel that our society is not ready for abortion to be federally funded- but maybe someday…

All in all, this a great victory for those of us in health care-and for all women. Congratulations Democrats! I am really proud of our leaders for getting this passed in the face of such opposition.

You go girls! : )

In their statement, they say, “We have witnessed firsthand the impact of our national health care crisis, particularly its impact on women, children and people who are poor. We see the toll on families who have delayed seeking care due to a lack of health insurance coverage or lack of funds with which to pay high deductibles and co-pays. We have counseled and prayed with men, women and children who have been denied health care coverage by insurance companies. We have witnessed early and avoidable deaths because of delayed medical treatment.”

Apparently some Catholics, 59,000 of them are in touch with human rights over politics and are able to reason beyond untrue sound bites related to abortion. “And despite false claims to the contrary, the Senate bill will not provide taxpayer funding for elective abortions.”… “This is the REAL pro-life stance, and we as Catholics are all for it.”

Oh, if only their ‘brothers’ would listen to them…

Dr. James is aiming to take a bit of the ‘intuition’ out of medicine and replace it with evidence-based practice and his successes have been impressive. However, with evidenced-based practice comes protocols- and many doctors enjoy the autonomy of acting without specific rules which is why many people think that his approach will never catch on. Too bad, because he really is on to something.

One part of the article talks about how Intermountain Hospital (where his projects are taking place) has reduced the number of perterm deliveries and the number of babies who spend time in their neonatal-intensive-care unit. They did this by creating a committee back in 1998 whose prime success has been to reduce the number of elective inductions (births that are induced without medical reason). They felt that the risks to neonates outweighed the convenience that elective induction afforded doctors and patients, plus induced labors were generally longer and resulted in more C-sections. Since 1999 ACOG has recommended that no elective inductions be performed before 39 weeks, yet around the country roughly 30% of inductions are done before 39 weeks. Back in 1998, Intermountain shared that figure of around 30% early inductions. When the committee adopted the protocol, the rate began to fall and now hovers around less than 2%. YAY! The number of newborns with respiratory problems has also dropped as did the C-section rate of those doctors that complied to the protocol.

This was my favorite part: “One hospital in southwest Utah has gone so far as to allow nurses to refuse a doctor’s early induction orders unless the medical director gives permission” (!)

As I was reading this article, it really made me pause and think about autonomy and protocols. I basically quit nursing because I felt I didn’t have any autonomy. Nursing school teaches you to think critically and independently, yet on the job we are expected to follow a doctor’s order with no questions asked. We are expected to adhere to a very clear set of standards and protocols for each duty we perform. The doctor on the other hand is trained to ‘follow intuition’ and is given license to treat in any way he or she sees fit, almost balking at rules or protocol irregardless of the evidence. It makes me think that if we could move to a model of evidence-based practice, doctors and nurses would be able to work more as a team, nurses would be able to hold doctors accountable for crappy practices and it might result in happier nurses. I would even argue that a move to evidence-based medicine could even help solve the nursing shortage. Most smart women these days don’t want to be nurses- mainly because it’s hard work in a thankless environment. But if a nurse could be an important part of a medical TEAM whose goal was to provide good outcomes for patients, then maybe more people would be attracted to the profession.