Political pundits are saying that the upset Massachusetts election of Scott Brown to fill Sen. Edward Kennedy's seat is in large part due to anger about the process of health reform: secretive, heavy handed, and peppered with grubby and unfair deals. But I wager that this has obscured the many details of the actual product the public would have to live with. As Congress takes a deep breath and reconsiders the expansive 2,700-page bill passed by the Senate on December 24 and promoted as the one that could be pushed through the House and onto the president's desk unchanged, the rest of us might want to take a closer read, too. Flip through the bill, and get a sense of just what it entails. Here are a few of the many items that pop out and are worthy of some public airing.
1. The Internal Revenue Service would be the health-reform enforcer. Once the government requires everyone to have health insurance, the IRS would move in as the monitor, proactively checking to be sure that the health insurance plans you and 300 million other Americans carry are acceptable to the secretary of health and human services. If you flunked, the IRS would impose a fine for every month you'd been lacking and use its ferocious tax-collecting skills—theoretically including the threat of jail time—to make sure you paid up.
2. The secretary of HHS would get the job of dictating uniform rules for the day-to-day operations and administration of all of the nation's private health plans, even down to the computer programs the plans must buy. Plans themselves would become enforcers, too, as they would be banned from working with doctors, hospitals, or other groups that don't provide written proof to them that they are abiding by government rules. (There's lots of uncertainty, since the rules are yet to be made.) The feds would regularly audit the internal workings of these enterprises, and deviations would trigger stiff daily penalties that could add up to as much as $20 million a year.
3. Your health records would become part of a giant national electronic medical records system. At first, doctors and hospitals would get monetary rewards from the feds for buying into a government-certified electronic medical record system. Those who didn't buy in would eventually be fined. It is not yet clear whether patients would be allowed to keep their records out of the national system, as many states are trying to arrange for their own statewide record systems. British efforts in this area may be telling: Fears of breached medical privacy have haunted the attempt to create such a system, which was supposed to have been completed by 2005. Many British patients have been resistant to signing up and were not encouraged by a survey that showed two thirds of general practitioners were reluctant to sign on as well. Privacy issues need full airing.
4. You wouldn't have a choice of what essential insurance benefits to buy. The feds would regularly review and choose the comprehensive package everyone must own, one size for all, getting their input from a small policy group in Washington. In the bill, it's a rich and expensive package that pays for a wide range of benefits, from approved gym memberships to regular end-of-life medical consultations when you get older, whether you want them or not. But it leaves odd exceptions some might prefer instead, like routine dental or vision care for adults. You would have to pay extra to cover your eyes and teeth.
5. Bye-bye, PSAs. The government would listen to its own appointed task force to decide what cancer screening would be covered in its prevention programs. After women rose up to protest the task force's new breast cancer screening rules issued last November, ones that would have cut out mammograms for women in their 40s and those over age 74, the Senate made an awkward mammogram exception, at least for now. But most men haven't realized that they would lose, too: Prostate cancer screening with routine prostate-specific antigen tests is on the line, since the government's prevention advisers flunk the tests, for any age, as either unhelpful or insufficiently supported by evidence. That means routine PSAs would not be covered, even though urologists caring for patients recommend offering routine screening, discussing the risks and benefits, to every man, starting as early as 40 years of age. The government's choice would trump all.
6. Since repeat hospitalizations of sick and recurrently ill elderly patients are a big financial drain on Medicare, they get a big thumbs down. The government would track readmissions of older patients as red flags of poor performance and cut hospital payment accordingly, without determining if the individual admission was medically justified or lifesaving. That's one way to intimidate practitioners, particularly the weaker ones, and influence their medical decisions every time one of their elderly patients needs emergency care.
[Find out how the new Medicare would differ from your parents' plan.]
7. Much of the health reform bill runs far afield of its two spoken purposes: covering the uninsured and controlling cost. For example, a few favorite diseases get the thumbs-up for more public attention, research, and spending, sometimes in a contradictory way. Even though the government's own preventive task force wants to cut back (if not delete) routine breast self-examination, doctor's examinations, and mammograms in younger women, another part of the health reform bill is devoted to getting young women, specifically, to become more aware of early breast-cancer detection, supporting media campaigns, counseling efforts, and creating a dedicated advisory committee in HHS. Other sections are similarly devoted to congenital heart disease and diabetes. These are important, but why enlarge this bill with efforts already covered under legislation for the Centers for Disease Control and Prevention and the National Institutes of Health? To be sure, if the bill were to give a fair shake to everyone's diseases, it would be a gazillion times longer than it is already.
8. While abortion coverage is hotly contested, pregnant college students would get generous social welfare benefits. Grants would be available to universities and colleges to provide for the special needs of students having and parenting babies, and even adopting. That includes flexible classes, telecommuting, baby-sitting, education to improve parenting skills for moms and dads, marriage counseling, maternity clothes, baby clothing, food, formula, and baby furniture.
9. Gun owners would get special privacy and other protections. Those who own or use firearms would not have to tell their doctor about it, and the Department of HHS would not be permitted to have a database of gun owners that might link the gun habit to health. Also, insurance companies couldn't charge gun owners higher premiums, as they can tobacco users. Does this mean that without such formal dispensation, Americans would be somehow forced to spill the beans about any and all other behaviors or encounters that might be seen by some as medically threatening?