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Monday, September 25, 2017

"As the Secretary shall determine." The Cassidy-Graham bill

July 27 update: GOP withdraws the Cassidy-Graham bill.
"We didn't have the votes."


I reviewed the text of this latest "Obamacare Repeal" bill over the weekend ("Cassidy-Graham"; I got my copy from Senator's Cassidy's Senate web page).



 My pdf copy runs 141 pages. Wide, 2-inch page margins, double-spaced, with line numbering, and mostly heavily indented body text. 25,352 words, inclusive.

There's not much "there" there. Were this a single-spaced Word document with std 1" margins, no line numbers, and no block indentations, it'd probably run about 25 pages -- of utter lack of detail and specificity.

Totally sufficient to govern 18% of the U.S. economy, right?

78 references to "the Secretary" (of HHS, Tom Price), all going to the Secretary's broad regulatory and administrative authority and discretion ("...as the Secretary shall determine").
"...as the Secretary shall determine" is long a staple of legislation, generally (which is why we have the voluminous Code of Federal Regulations), albeit a convention that Republicans hated about Obamacare, never passing up an opportunity to rail against the law's discretionary regulatory provisions.
 In fairness, to the latter point, the phrase "Secretary shall" appears 866 times in the 974-pg (single-spaced 2" margins) Obamacare law. "Secretary determines"? 159 times. "by the Secretary"? 558 times. The phrase "be careful watch you ask for" comes to mind, given that "the Secretary" is now Tom Price.

 Oh, btw, the phrase "affordable coverage" only shows up 12 times -- four of those in section headers.
38 Cassidy-Graham references to "waivers," going to the Secretary's authority to grant them to states that apply for exemptions to certain core coverage obligations imposed by the still-not-"repealed"-though-financially-eviscerated PPACA ("Obamacare").

12 hits for "affordable," all going to nullifying funding sections of "the Affordable Care Act."

That's it for now. Though, I know they're trying to add some Alaska bribe money provisions to buy Lisa Murkowski's vote, having lost Senator McCain.

Nicholas Bagley on some of the slim particulars:
…So what the hell does section 204 mean? Can states discriminate on the basis of health status or not? Who knows?

The craziest thing is that the sloppy drafting may be intentional. It reads to me like a deliberate effort to allow senators to read whatever they want to into the bill. Senator Cassidy and other moderates can claim it preserves the protections for preexisting conditions. Senator Cruz and other conservatives can claim it doesn’t…
Stay tuned. Federal FY clock runs out this Saturday. I will then be down in Santa Clara at the onsite Hyatt Regency prepping for Sunday's start of the Annual Health 2.0 Conference.


Stay tuned. Substantive Cassidy-Graham updates as they become available.

UPDATES
 
New at The New Yorker, from an excellent long-read article:
Is Health Care a Right?
It’s a question that divides Americans, including those from my home town. But it’s possible to find common ground.
By Atul Gawande

Is health care a right? The United States remains the only developed country in the world unable to come to agreement on an answer. Earlier this year, I was visiting Athens, Ohio, the town in the Appalachian foothills where I grew up. The battle over whether to repeal, replace, or repair the Affordable Care Act raged then, as it continues to rage now. So I began asking people whether they thought that health care was a right. The responses were always interesting…

...Liberals often say that conservative voters who oppose government-guaranteed health care and yet support Medicare are either hypocrites or dunces. But Monna, like almost everyone I spoke to, understood perfectly well what Medicare was and was glad to have it.

I asked her what made it different.

“We all pay in for that,” she pointed out, “and we all benefit.” That made all the difference in the world. From the moment we earn an income, we all contribute to Medicare, and, in return, when we reach sixty-five we can all count on it, regardless of our circumstances. There is genuine reciprocity. You don’t know whether you’ll need more health care than you pay for or less. Her husband thus far has needed much less than he’s paid for. Others need more. But we all get the same deal, and, she felt, that’s what makes it O.K.

“I believe one hundred per cent that Medicare needs to exist the way it does,” she said. This was how almost everyone I spoke to saw it. To them, Medicare was less about a universal right than about a universal agreement on how much we give and how much we get.

Understanding this seems key to breaking the current political impasse. The deal we each get on health care has a profound impact on our lives—on our savings, on our well-being, on our life expectancy. In the American health-care system, however, different people get astonishingly different deals. That disparity is having a corrosive effect on how we view our country, our government, and one another.

The Oxford political philosopher Henry Shue observed that our typical way of looking at rights is incomplete. People are used to thinking of rights as moral trump cards, near-absolute requirements that all of us can demand. But, Shue argued, rights are as much about our duties as about our freedoms. Even the basic right to physical security—to be free of threats or harm—has no meaning without a vast system of police departments, courts, and prisons, a system that requires extracting large amounts of money and effort from others. Once costs and mechanisms of implementation enter the picture, things get complicated. Trade-offs now have to be considered. And saying that something is a basic right starts to seem the equivalent of saying only, “It is very, very important.”

Shue held that what we really mean by “basic rights” are those which are necessary in order for us to enjoy any rights or privileges at all. In his analysis, basic rights include physical security, water, shelter, and health care. Meeting these basics is, he maintained, among government’s highest purposes and priorities. But how much aid and protection a society should provide, given the costs, is ultimately a complex choice for democracies. Debate often becomes focussed on the scale of the benefits conferred and the costs extracted. Yet the critical question may be how widely shared these benefits and costs are…

The reason goes back to a seemingly innocuous decision made during the Second World War, when a huge part of the workforce was sent off to fight. To keep labor costs from skyrocketing, the Roosevelt Administration imposed a wage freeze. Employers and unions wanted some flexibility, in order to attract desired employees, so the Administration permitted increases in health-insurance benefits, and made them tax-exempt. It didn’t seem a big thing. But, ever since, we’ve been trying to figure out how to cover the vast portion of the country that doesn’t have employer-provided health insurance: low-wage workers, children, retirees, the unemployed, small-business owners, the self-employed, the disabled. We’ve had to stitch together different rules and systems for each of these categories, and the result is an unholy, expensive mess that leaves millions unprotected.

No other country in the world has built its health-care system this way, and, in the era of the gig economy, it’s becoming only more problematic. Between 2005 and 2015, according to analysis by the economists Alan Krueger and Lawrence Katz, ninety-four per cent of net job growth has been in “alternative work arrangements”—freelancing, independent contracting, temping, and the like—which typically offer no health benefits. And we’ve all found ourselves battling over who deserves less and who deserves more…

Medical discoveries have enabled the average American to live eighty years or longer, and with a higher quality of life than ever before. Achieving this requires access not only to emergency care but also, crucially, to routine care and medicines, which is how we stave off and manage the series of chronic health issues that accumulate with long life. We get high blood pressure and hepatitis, diabetes and depression, cholesterol problems and colon cancer. Those who can’t afford the requisite care get sicker and die sooner. Yet, in a country where pretty much everyone has trash pickup and K-12 schooling for the kids, we’ve been reluctant to address our Second World War mistake and establish a basic system of health-care coverage that’s open to all. Some even argue that such a system is un-American, stepping beyond the powers the Founders envisioned for our government…

These days, trust in our major professions—in politicians, journalists, business leaders—is at a low ebb. Members of the medical profession are an exception; they still command relatively high levels of trust. It does not seem a coincidence that medical centers are commonly the most culturally, politically, economically, and racially diverse institutions you will find in a community. These are places devoted to making sure that all lives have equal worth. But they also pride themselves on having some of the hardest-working, best-trained, and most innovative people in society. This isn’t to say that doctors, nurses, and others in health care fully live up to the values they profess. We can be condescending and heedless of the costs we impose on patients’ lives and bank accounts. We still often fail in our commitment to treating equally everyone who comes through our doors. But we’re embarrassed by this. We are expected to do better every day…
Well worth your time. Read all of it.

As good a time as any to review "An American Sickness."


ANOTHER UPDATE

From my iPhone.


"Likely dooming it." Maybe.

UPDATE

Well, that didn't take long.


Don't kid yourselves that they won't keep trying. Moreover, given the substantial "Secretarial discretion" in the PPACA, they will certainly keep up with the Obamacare sabotage tactics.
ADDENDUM: THE PRICE IS NOT RIGHT
____________
 
More to come...

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