A REVIEW OF KEY POINTS IN THE HEALTH PLAN



A REVIEW OF KEY POINTS IN THE HEALTH PLAN

In the pages which follow is a synopsis of items in the House version of the Health Care Plan (SB 3500) now in the works. Our representatives in Washington D.C. may not have read all 1000+ Pages but others have. There are three divisions, divided into titles and subtitles.

Division A —affordable health care choices

Title 1 protections and standards for qualified Health benefits plans

Page 21` - Defines premium rate variance limits

Page 22 – Line 19 et seq ,mandates that Gov’t oversee all employers that self insure to be sure that adverse selection isn’t being incentivized (Comment: some feel that this effectively mandates reporting and possible auditing of all self-insuring employers

Page 23 Lines 8-10 Mandated parity in mental health and substance abuse disorder benefits.

Page 26 – Essential benefits package (EBP) to be part of all plans

Page 28 – no cost sharing for preventative services, part of a list of 10 listed specific services to be in all plans

Page 29 Lines 4-16 - healthcare co-payments are capped. Those under EBP are limited as to co-payments and certain mandated wellness payments are free. .

Page 30 Sec 123 - there will be a gov’t committee that decides what treatments/benefits are offered under EBP There will presumably be the option of having more costly plans with greater benefits.

Page 33 Line 15 – Enhanced Premium Plans (EPP) - an enhanced package

Pages 34-41 – Committee details

Pages 41-42 - The Health Choices Commissioner post established to choose benefits to be mandated in future –

Comment: Critics note that there will not be unlimited buyer benefit choice, but the fact is this has never has been true for any plan. The question is for whom will there now be greater or lesser options – the answer is that no one knows. The Commissioner will make the determination. Examples: Medical savings accounts presently allow for purchase of over the counter drugs, some say this should not be allowed since they’re not tax deductible. Alternative therapies such as acupuncture are not currently covered by some plans although they are tax deductible, some say they should be. Big issue of controversy: abortions – prevented from Federally subsidized Medicaid payment by Hyde amendment, but allowed by some private insurance plans. At this writing subsidizing premiums for such plans would be in effect an indirect subsidy, which has drawn fire from pro-life groups.

Pages 50-51 Section 152 – Health care will be provided “without regard to personal characteristics extraneous to the provision of high quality health care or related services.” – this provision is read by some as applying to ALL resident non US citizens, illegal or otherwise. This apparent loophole regarding illegal aliens seems to be closed by other provisions, but it is not clear.

Pages 54 – 56 line 16 et seq Policy rescission restricted except for fraud with review process mandated

Page 57 – standardization of records –

Comment: this is expected to facilitate major cost reductions, although this is based on estimates

Page 58 – Lines 5-13 Gov’t within two years of adoption will have real-time access to individual finances, including tax records, and a National ID HealthCard may be issued as a means of readily determining co-payment ability!

Page 59 Lines 21-24 - Gov’t will have direct access to all patient bank accts for electronic funds transfer of co-payment amounts.

Page 65 Sec 164 - Is a subsidized plan for retirees and their families in selected groups.

Comment: Critics say this is directed at mostly at helping ACORN affiliates (ACORN is a democrat party leaning political action group close to President Obama which registers voters and is seen as a prime beneficiary of the stimulus bill because of the 2010 census. Conservatives bristle at anything which can possibly benefit this group), but the language draws a broader brush. Proponents say this actually is directed at employer/union reinsurance arrangements.

Page 72 Lines 8-14 et seq Sect 201-202 Government is creating, as part of the new Health Choices Administration, a Health Care Exchange to bring private Health Care plans under government oversight.

Comment: Some feel this is a prelude to government control and eventually a single payer system – President Obama in past addresses has said he envisions “single payer” as the ultimate result in 15-20 years, although he now offers assurances that there will be no immediate changes for those with plans in place.

Proponents say that the intent here is “to rein in private insurance companies by banning underwriting practices that have prevented millions of Americans from obtaining affordable insurance. Insurers would, for example, have to accept all applicants and offer a minimum package of benefits, to be defined by the federal government.” (New York Times)

Fact: The exact functionality of the Exchange has been left open. It allows two very different state versions, in Massachusetts and Utah, to remain functional with options for more in other states as well (see pages 111-115, below) as a possible tug-of-war between private plans and a possible competing government plan.

Page 84 Sec 203 – Government will mandate all benefit packages for private Health Care plans in the Exchange.

Page 85 Line 7 - Specs for four different Benefit Levels for Plans: Basic, enhanced Premium and Premium Plus

Comment by critics: “The Government will ration your Healthcare!  AARP members - your health care ultimately will be rationed. Given finite resources and an increased pool of resources its inevitable.”

Our comment: As noted earlier, all plans (private and public) already do cap services at some level. The nuance here is not “rationing, to be or not to be” but how will future rationing be done? Some feel cost demands will ultimately have to force rationing European style.

Page 91 Lines 4-7 – Government mandates culturally and linguistic appropriate services..... Critics: “Example - Translation for illegal aliens – because there is nothing in this bill excluding services for those illegally in this country. Proponents: “False – illegal aliens cannot have benefits under this bill”

Page 95 Lines 8-18 - The Government will use local groups to sign up individuals for the government Health Care plan. Comment: Critics assert this means more money for ACORN & AmeriCorps, who are already involved in voter registration and the 2010 census using stimulus funds

Page 102 Lines 12-18 - Medicaid Eligible Individuals will be automatically enrolled in Medicaid (In California this is called Medi-Cal) if they aren’t participating in an Exchange plan. No choice – and no provision for guaranteed reimbursement to states for their increased costs as a result. Comment: Critics assert that this will lead to underfunding and higher taxes at State level

Page 110 Taxes on those not complying Comment: The law’s code based references do not make clear what is being charged but it amounts to a 2.5% of annual gross income tax on individuals not getting coverage, a 2-6% of annual gross income tax on micro employers ($250,000 – 400,000 annual payroll) not providing employee coverage and 8% on all other employers (those with over $400,000 payroll). Effectively this means those with no income go under Medicaid, everyone else either gets or provides coverage or pays a fine.

Pages 111 – 115 In addition to the Federal insurance exchange states can, with Federal approval, have one State exchange in lieu of having the Federal exchange operate in their State, but ultimate authority resides with the Federal Commissioner.

Pages 116 et seq – Subtitle B - Public insurance option – Comment: this is presently the most controversial part of the plan and threatens to be a deal killer. To get the votes of Blue Dog democrats Congressional leadership agreed to jettison it, only to have the progressive wing of the Democrat party threaten to bolt if it is not included. It provides for start-up funding of $2 billion dollars to be amortized over 10 years and offering initial patient and practitioner benefits similar to Medicare with an option for more later.

Page 124 Lines 24-25 - No "judicial review" shall be permitted against the government company – Comment: critics charge that this gives the government company effective monopoly power relative to other firms.

Page 125 – Sec 224 - Government can mandate streamlining of payment procedures – Comment: this is a step regarded as essential to reducing costs.

Page 127 Lines 1-16 - Doctors/AMA - The Government will regulate what health care professionals can make relative to the public (government operated) plan. Comment: A study by the Lewin group projects that by using Medicare rates “premiums for the public plan would be approximately 25 percent less than those obtainable in the private sector.”

Page 128 Subtitle C – Individual Affordability Credits – some individuals who have enrolled in basic plans will have all or part of their premiums paid by the government; the Federal government will also underwrite the cost of seeing if a person qualifies for State Medicaid. Costs of enhanced or premium plans will not be subsidized.

Pages 132 et seq – eligibility for premium reimbursement: does require lawful presence in the United States and is based on other factors including income. If premiums for employer offered plan would exceed 11% of family income there will be assistance. There will also be assistance according to a formula based on excess over Federal Poverty Level (FPL) as outlined on page 137. There would be allowances for family size and geographic variation with the Commissioner or delegate establishing the amount in each case. Comment: The formula is not easily understood, but news reports indicate that a portion of premiums would potentially be subsidized to some degrees up to a household income of $70,000. Section 246 on page 143 specifically excludes undocumented aliens from any credits.

Page 145 Line 15-17 - An Employer must auto enroll employees into public operated plan if employee doesn’t otherwise cooperate .

 

Page 149 Lines 16-24 - Any Employer w/payroll 400k & above who does not provide at least pub option benefits pays 8% tax on all payroll.

Page 150 Lines 9-13 – An employer with payroll between 251k & 400k who doesn’t provide at least public option benefits pays 2-6% tax on all payroll.

Page 153 Line 7 – employers will now be audited by the Federal health department separate from income tax, payroll tax and sales tax audits. Details through Pages 166 list possible penalties concluding with Section 322. .

Page 167 Title IV – IRS Code Amendments

Page 167 Lines 18-23 - Any individual who doesn’t have acceptable health care according to government will be taxed 2.5%, with an exception for religious objectors if approved by Commissioner (Pages 171, line 5).

Page 170 Lines 1-3 - Any nonresident alien is exempt from penalty taxes

Comment: Critics say this means that you and I will pay for them – more accurately, they’re not here or are here temporarily or illegally. Either was, they will have no coverage because they’re subject to rules in countries where they reside. Left open is question of services,

Page 195 - Officers & employees of Health Care Administration (and its State counterparts) will have access to all American taxpayer financial/personal tax records to determine eligibility for premium subsidies.

Page 197 – Surtaxes of 1-5.4% on individuals with income over $350,000 ($175,000 MFS)

Page 203 Lines 14-15 - "The tax imposed under this section shall not be treated as a tax"  Comment: Yes, it actually says that, although in complete context it makes more sense – the surtax isn’t counted as a tax in certain calculations..

Page 215 – DIVISION B - MEDICARE AND MEDICAID IMPROVEMENTS

Page 223 – 237 Productivity mandates for various medical providers

Page 239 Lines 14-24 - Gov’t establishing targets for cost reductions for Medicaid – Comment: Critics say seniors, low income, poor will inevitably be most affected. Another critique: that the biggest single cost, high malpractice rates mandated by lack of tort reform, isn’t addressed.

Page 241 Lines 6-8 - Doctors, doesn’t matter what the specialty, are to be treated the same for purposes of cost reduction targets. .

Page 253 Lines 10-18 - Government sets value of Dr's time, professional judgments, etc.

Comment: the formula here (RVU = Relative Value Unit) is one already commonly used for Medicare and is generally accepted by practitioners. That’s why the AMA etc aren’t hollering about this.

Page 265 Sec 1131 - Gov’t mandates & controls productivity for Medicare – Comment: critics say the intent is to extend Medicare standards to private Health Care coverage, a charge proponents deny.

Page 268 Sec 1141 - Fed Gov’t regulates rental & purchase of power driven wheelchairs.

Comment: this is merely a modification of existing law’s legal description and applies to Medicare recipients.

Page 272 Sec. 1145 - Treatment of certain cancer hospitals –

Comment: Critics say “Cancer patients - welcome to rationing! “ Actually, as stated previously, rationing already exists and of necessity.

Page 280 Sec 1151 - The government will penalize hospitals for what the government deems “preventable readmissions. Comment: this is directed at “patent dumping” – a practice some hospitals have engaged in.

Pages 299 – 306 - Section 1152 Pilot program for acute care service bundling

Comment: this is but one of several such test programs included in the bill. Considering that medical services comprise 1/7 of the national economy a few carefully selected pilot programs are not a bad idea. Whether Congress should be micro-mandating them as part of a national Health Care bill is another matter, but including seemingly extraneous material is not unusual for Washington laws.

Page 311, Line 15, Section 1155 – Mandated productivity improvement targets for home health services

Comment: Critics say that, similar to other mandated targets, there is little consensus as to how this is to be accomplished without lower levels of service.

Page 312 – Limitations on physicians regarding hospital referrals

Comment: the target seems to be disclosure of conflict of interest where a doctor owns part of the hospital.

Page 317 Lines 13-20 – seeming prohibition on ownership/investment.

Comment: Disclosure is one thing – now, critics say, Government tells Drs. what/how much they can own, a critical factor in rural areas. No, say proponents, this refers specifically to self-referring, a practice that has been abused

Pages 317-318 Lines 21-25,1-3 - prohibition on expansion - Government mandates if physician owned hospitals can/cannot expand.

Pages 321-323 - Hospitals have opportunity to apply for exception BUT community input required. Comment: Critics say this means control by groups like ACORN; in fact public review of this type activity has been law since 1980.

Page 328 – Section 1157 – mandate of study of “geographic adjustment factors under Medicare.” Comment: or: “how many seniors go to the sunbelt for retirement and what does this do to skew numbers and service demands. “

Page 330 - Section 1158 - revision of Medicare payment systems to address geographic inequities.

Page 331 – Subtitle D - Medicare Advantage Reforms

Page 335 Lines 16-25 Pages 336-339 – Government mandates establishment of “outcome based measures”. Comment: This is characterized by critics as “Health Care the way the government wants it – i.e. rationing.” Actually private plans already have similar gauges.

Page 341 Lines 3-9 - Gov’t has authority to disqualify Medicare Advantage Plans, HMOs, etc.

Comment: this is designed, say critics, to force participants into the government Heath Care plan. The government already has the power to disqualify advantage plans – that doesn’t mean they will or that participants wouldn’t switch to another advantage plan. Without a government run plan the objection evaporates. Advantage plans simply replace the multiple payees under regular Medicare with a monthly payment to a provider like Kaiser or PacifiCare (Secure Horizons)

Page 342-351 deal with administrative rule adjustments to existing law concerning which no one seems to be upset.

Page 354 Sec 1177 – Government will restrict enrollment of Special Needs?

Comment: totally unfortunate phrasing – actually this section read in totality extends current rules from tax year 2011 to tax year 2016

Pages 355-378 Section 1181 et seq – gradual reduction of Medicare Part D coverage gap

Comment: This is the prescription drug benefit for seniors – out of pocket costs are to be reduced and drug companies mandated to cooperate. The latter have reportedly already agreed to their part and there seems to be general agreement that this part is all good.

Pages 379 Sec 1191 – Subtitle F Medicare Rural Access Protection

Comment: Critics say “Government creates more bureaucracy - Telehealth Advisory Committee. Can you say HC by phone?” The fact is there is a shortage of services in rural areas and existing telehealth technology has proven a boon. The bill expands it and provides an advisory agency for future guidance. Not on the surface a bad idea.

Pages 425-429 Section 1233 Lines 4-12 - Gov’t mandates “Advance Care Planning Consultation”.

Comment: Some critics, such as former New York Lt. Gov Betsy McCaughy, now Chmn of the Committee to Reduce Infectious Death, have contended that this means mandatory “end of life” counseling. “Nonsense,” replies Jim Dau of the AARP, which lobbied for the provision. Seniors, beginning in 2011, will now be able to have Medicare pay once every five years for advance care counseling by a physician, nurse practitioner, or physician’s assistant if they so desire (its not mandatory) , more often if there is major illness (Page 429).

Page 425 Lines 17-19 - Gov’t paid counseling will also be available regarding living wills, durable powers of attorney etc..

Comment: the wording of the law as presently written (Pages 428 ln 14) seems to indicate that this document counseling would be done by the same persons doing the advance care counseling; a legal or tax professional would seem more appropriate – perhaps a CSA?

Page 425 Lines 22-25, 426 Lines 1-3 – Government provides approved list of end of life resources, guiding you in death. Comment: Critics decry this; proponents note that the idea of a list of referral resources began with a Republican several years ago

Page 427 Lines 15-24 - Government mandates standardized state program for orders for end of life and uniform training for administration thereof.

Comment: Some say that this means that the Gov’t now has a say in how your life ends, True – but the say has to do with the formalities of implementing the decisions laid out and chosen by the individual. Today various jurisdictions and specialties interpret things individually. .

Page 429 Lines 1-9 - An "Advance Care Planning Consultation" will be available more frequently than every five years if a patients health deteriorates.

Page 429 Lines 10-12 - "Advance Care Consultation" may include formulation of an order for end of life plans.

Comment: some say this is an “an order from the government,” effectively sanctioning euthanasia (mercy killing) but this appears to be a stretch – line 8 on page 30 stipulates consent by the individual and line 5 requires conformity to local state law – currently only Oregon allows euthanasia. .

Pages 429 Lines 13-25 - The government will specify which medical professionals can implement any kind of advance care directive .

Page 430 Lines 11-15 - The government will be involved in deciding the level of end of life treatment.

Comment: According to a study released by the Agency for Healthcare Research and Quality, part of the Department of Health and Human Services “For two decades, care in the last year of life has represented over one-fourth of Medicare's budget. ”Says the study, which involved a sampling of 241,000 Medicare patients, ”Overall mean Medicare expenditures in years 2 and 3 before death were less than $10,000, but they rose to $24,700 in the last year of life.“ It therefore appears that any effort to reduce Medicare outlays must necessarily involve itself with this area.

Page 434 – Rebate of premiums and special enrollment for certain persons retroactive to 2005

Page 438 – Establishment of demonstration program for patient decision making

Page 443 TITLE III PROMOTING PRiMARY CARE, MENTAL HEALTH

SERVICES, AND COORDINATED CARE

Sect 1301 - accountable care organization pilot program by 2012.

Page 460 Sec. 1302. Medical home pilot program to be established and run by

“Community Based Home Medical Services - Nonprofit orgs.” Comment: To some critics this means “Hello, ACORN Medical Services” but that is only conjecture. As proponents note ACORN has not expressed interest nor does it have the expertise needed for this function. $1.5 billion is appropriated for this through the year 2016 (Pages 477, lines 15-20)

Pages 479 et seq Sect 1303 – 1307 payment incentives and directives for selected primary care services.

Page 489 Sec 1308 - The government will now cover Marriage & Family therapy, and define who gets to offer such therapy.

Pages 494 et seq – government will cover Mental Health Services including defining, creating, rationing those services.

Page 498 Access to vaccines by those covered by Social Security is expanded, with emphasis on influenza

Page 501 - TITLE IV—QUALITY

Subtitle A—Comparative Effectiveness Research

Section 1401. Comparative effectiveness research. Comment: yet another monitoring project, this one with both a commission and a bureaucracy – details continue to page 524,

Page 525 - Subtitle B—Nursing Home Transparency

Comment: The Federal government is getting into long term care oversight, previously a State responsibility, in a big way. This topic continues on to page 619 – at 94 pages this is the biggest single section in the act.

Page 620 - Subtitle C—Quality Measurements

Sec. 1441. Establishment of national priorities for quality improvement.

A triennial cycle for reviewing this area is established. Subsequent sections thru page 634 build on this premise.

Pages 635 - 653 - Subtitle D—Physician Payments Sunshine Provision

Section 1451 et seq – provision is made for disclosing relationships between service providers and manufacturers/suppliers

Pages 654 - 659 Subtitle E—Public Reporting on Health Care-Associated

Infections

Section 1461 et seq. tightens existing reporting requirements

Pages 650 – 685 Title V—Medicare Graduate Medical Education

Sec. 1501 etc Distribution of unused residency positions. and other rules

Pages 686 - 739 Title Vi—Program Integrity

Sec. 1601 et seq . Increased funding and flexibility to fight fraud and abuse with

Designated penalties plus program and provider protections, including mandated submission and resolution of reimbursement requests within six months, access to financial; and medical records by enforcement authorities and

“Elimination of duplication between the healthcare integrity and protection data bank and the national practitioner data bank.”

Pages 740 – 816 Title Vii—Medicaid And CHIP

Deals with relationship between Medicaid patients (including Children’s Health Insurance Plans – aka CHIP) and the Federal/State Insurance Exchanges, as well as Puerto Rico and American possessions – at 76 pages this is the second biggest section in the House bill

Pages 816 – 819 - Section 1781 et seq. – technical corrections and extensions of prior law

Page 820 -1 TITLE VIII—Revenue-Related Provisions

Section 1801 – Identifying likely non-qualified low income persons

Pages 825 -828 Section 1802 – financing Comparative Effectiveness Research

Trust Fund;

Page 829 – Insurance policy per capita tax

Pages 836 – 855 TITLE IX—Miscellaneous Provisions

Section 1901 et seq – several prior provisions repealed, gainsharing extended, home visitations for selected poverty level children provided for, with special provision for Indian tribes, coordination of dual benefit eligibility

Pages 856 - 964 Division C—Public Health And Workforce Development

Increases funding for Community Health Centers, establishes a National Health Service Corps, authorizes and funds training for various support functions including a “Public Health Workforce Corps” and promotion of a “prevention and Wellness Program” gives rural discounts, , .

Pages 965-979 – Quality and surveillance rules

Pages 979-1017 Other provisions

Rural hospital drug discounts, school based health clinic grants establishes a national medical device registry, and a nursing training grant program.

Page 1018 – If a State and its subdivisions don’t adhere to employer obligations all Public Health Service funding can be lost. Comment: do it our way, or else!

Obama's “Crazy” Health-Care Plan

Republicans claim Obama's health-care surtax will be an epic job-killing disaster. Are they right? Not exactly—but the truth is even worse.

By Rehan Salam

Barack Obama's success was built in no small part on his ability to connect with the large and growing share of American voters who are college-educated, affluent, and have a fondness for arugula. Though Obama campaigned on raising taxes for families making more than $250,000 and cutting taxes for everyone else, he won a majority of voters in households earning $200,000 or more a year. To tax-loathing Republicans, this was a bit like plump chickens enthusiastically voting for Frank Perdue. So when House Democrats called for a stiff surtax on wealthy households, one thing you couldn't say is that the proposal came without warning.

Not surprisingly, Republicans have declared war on the surtax, claiming it will be an epic job-killing disaster, and more than a few Democrats have raised the same objection, albeit in slightly less apocalyptic tones. \\

Nancy Pelosi is already backing away from the proposal, no doubt after being cornered in an alleyway by a gang of knife-wielding limousine liberals. The fear is that a surtax will turn America into a nightmare version of Europe, where tax rates are punishingly high and many of the young and ambitious plot to escape them. Are they right?

Actually, no. Despite obscenely high tax rates, a number of northern European economies have managed to survive and even thrive. They've pulled this off by tightly linking taxes to benefits. You want free health care? In Europe, you pay for it through a heavy consumption tax called the VAT, or value-added tax. Whenever you buy a haircut or a pair of jeans or a flat-screen television, you're paying for the welfare state. What we've done for the past twenty years, and what a surtax will only sharpen, is move in the opposite direction: we've separated taxes from benefits.

The appeal of the surtax to Democrats should be obvious. Paying for expanding health-care coverage to the 42 million uninsured will be extremely expensive. Over 10 years, it will cost at least a trillion dollars, even if we make absurdly generous assumptions about cost savings. Rather than have struggling single moms foot the bill, the Democratic left figures it makes moral and practical sense to charge highfliers who will have to sacrifice, say, a summer home in Provence rather than fresh fruits and vegetables for their young.

Like it or not, though, the superrich really are different from you and me. Republicans rightly emphasize that successful entrepreneurs drive growth and create jobs, etc. But they're also pretty good at dodging taxes through the clever use of mile-wide loopholes. Unscrupulous lawyers and accountants are salivating at the prospect of marginal tax rates approaching 50 percent. Don't be shocked if tax avoidance starts reaching Russian levels. Worse still, the superrich are footloose. While Palm Beach probably won't secede from the Union to become part of the Cayman Islands, we'll almost certainly see a spike in the number of tax exiles.

Then there is the fact that relying on a small slice of the population to pay the bills means revenues will always be unstable. New York City and California became dangerously dependent on a small class of ultrasuccessful citizens, and the end of the boom has led to a painful contraction of revenues.

The proposed surtax would raise roughly $544 billion, which is impressively huge. But it won't come close to paying for universal health care. One of the best revenue-raising ideas, taxing employer-provided health benefits, is a political non-starter: the unions are bitterly opposed and Barack Obama savaged John McCain for proposing the same thing during the campaign. And even that wouldn't get you all the way there. Then there is a whole slew of gimmicks, like a tax on sugary beverages, that would raise modest amounts in comparison.

If we were serious about solving the revenue problem, we'd look to, well, Europe. By moving towards European-style consumption taxes, we'd create a more stable revenue base—even in a recession, you still need to buy stuff—and we'd be less vulnerable to the skullduggery of rich tax cheats. As for the noble entrepreneurs who are the foundation of our prosperity, their investments would be treated more favorably than under the current tax code. Everybody wins! Or almost everybody wins.

The Senate has actually considered using a VAT to pay for coverage expansion. A 5 percent VAT would raise more than enough revenue to pay for the health care plans currently on the table. The problem is that under these proposals, everyone would pay the VAT, but only some—namely the currently uninsured—would directly benefit. The way to solve this problem is to move to a system in which employers get out of the health care business entirely and a VAT finances a system of sliding subsidies for all workers to buy private insurance. Chances are this approach will never see the light of day. It is, alas, the only approach that will actually work.

Reihan Salam is a fellow at the New America Foundation and the co-author of Grand New Party.\

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Historical footnotes: in 1944, with Corporations offering health care as a means of offering job incentives despite wage price controls, President Roosevelt ran on a platform of introducing national health care; it never happened as labor insisted on tying it to labor contracts and right to work states balked.

In 1974, a scandal-weakened Richard Nixon was prepared to agree to a universal-health-care compromise plan brokered by Ted Kennedy. But ultimately congressional liberals and left-leaning interest groups killed the plan, anticipating better times to come after the midterm elections. Thirty-five years later, you don't see anyone who thinks that was a smart move.

In 1994 Bill and Hillary Clinton saw their cherished dream of national health care collapse because of overstretching.

Now we have a multifaceted system of Medicare, Medicaid, VA Insurance, Employer Plans, Private Plans, Medical Savings Accounts and self-insurance struggling with spiraling costs of 8% a year. A good portion of costs are due to over-testing to avoid malpractice accusations, soaring malpractice premiums, and inefficient record sharing and reimbursement billing techniques.

At least 30 million (more if you include illegal aliens) have no plan at all – forcing emergency rooms to serve as the provider of last resort. Others are deterred from using their care because of co-pays and low income. The status quo is unsustainable long term – the question is what should be done.

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