No vision or decisive action


Anger continues to grow towards world leaders around the globe. We see it following so-called free elections. It surfaces at climate conventions. In piazzas in Italy. We feel it in our own living rooms as we sit and watch CSPAN cover an inept U.S. legislature. We see so-called representatives blatantly disregarding the desires of the majority of a population wishing to have better health care.

Suggestions for helping resolve the world climate crisis are nothing more than pathetic near-term solutions having inconsequential long-term effect, amounting to nothing more than "spin."  With such puny measures, coupled with the arrogance of those arriving in their private limos and jets, there may not even be a "long-term" to worry about. The suggested half-measures of buying credits while allowing pollution, condones behavior known to be unacceptable, and favors the rich.  Money is not going to turn down the world's thermostat. Money is not the cure. It is the problem.  Businesses believe they will lose money if there are any measures of substance taken to resolve our climate issues.

And the anger over health care?  Polls vary slightly, but all indicate that the majority of  the U.S. population wants to have a "public option" for health insurance (but not a government-run system for health care delivery).  The legislature does not appear to be listening.  Seemingly willing only to serve the interests of the private insurance industry, they are constructing a nightmare of mandated coverage, policed by the government on that industry's behalf.

No proposed solution has directly dealt with the fact that the key reason most Americans lack insurance is because rates, set by this industry, are simply not affordable.  Currently, neither premiums nor "shared costs" (those not covered after one's premiums are paid) are within the reach of those who are "uninsured."  It is why they are uninsured.  This seems obvious. However, in both House and Senate bills, suggested premiums, deductibles and uncovered amounts will be based on "industry input."

Amanda Knox may have done "suspect" cartwheels in a police station in Italy.  But does anyone, other than Howard Dean, think that the insurance industry isn't doing a few cartwheels of its own at this point?

Climate and health care issues directly and deeply touch all world populations.  Currently, there is too much focus on finding short term "solutions" and then "spinning" them to gain acceptance.

People are tired of platitudes and politics.  We need someone to be bold and lead.  Leadership does not mean sitting on top of the heap. Leadership is not positioning, or a photo-opportunity, or great individual press coverage. It is not throwing money at someone else and telling them to go solve their problems with it.  It is impelling others, through both inspiration and action, through both articulated dreams and decisive deeds, to take actions themselves that align with the better vision for all.

Leadership must answer to the population it serves, be it national or global. To poorly paraphrase Nietzche: "To command is nothing, if no one obeys."  A corollary: "To follow is nothing, if no one is leading."

House reprise, variations and all without needed clarity
On Friday,  I downloaded the Senate's 2,000+ page version of their "Patient Protection and Affordable Care Act," and began reading.  As with the House's reform bill,  key aspects of its structure make it difficult for various constituencies to ascertain effects on them of the proposed system.

Bureaucracy is in evidence from page one, literally. I actually downloaded the Bill twice because, after the first download, it seemed a completely unrelated bill was somehow substituted. The confusion stems from the apparent need to utilize an existing totally unrelated bill (about first-time homebuyers for members of the Armed Forces) as a "work around" to get the actual health care reform bill onto the floor of the Senate.  So, the unrelated bill was used, striking out the bulk of its contents, and substituting in their place the terms for the health care reform bill.  It is tough to admit that for such critical legislation our current system of government required a "work around" from the get go. Not an auspicious start.

For the curious, here is that beginning on page one:


In general, much of the Senate's bill contains the same annoying legalese, lack of page numbering and lack of clarifying footers that are in the House's bill.  There are references and substitutions of fragments of other legislation without full context. If one enjoys reading IRS instructions for doing taxes, one will have the same pleasure in reading this legislation. As with taxes, if this system goes forward, I'm sure an entire industry will evolve to handle explanations, exceptions, processing claims, and requesting subsidies under this new system (begging the question: how will someone afford this help if one actually qualifies for a subsidy?).

The bill mentions implementing a system for rebates when an insurer reports excess profits. Rebates! A system that has scammed many Americans, enough to make the 5 o-clock news on several occasions.  Businesses have made huge profits through the rebate system. Does anyone believe this purchasing ploy would not be here today if it weren't profitable? What is our comfort level, our trust in an industry's reporting system, when we know it would not serve their profit motive?

Reports. This bill has extensive reporting requirements of not only insurers, but of care providers. One wonders who will do all the report preparation as well as the reading of these reports.  Existing personnel?  Or additional hires?  All this reporting will surely not be done without expense.   And who is going to bear the burden of that expense? (Directly or indirectly.)  Perhaps we can take heart in that more jobs will be created, however tedious and time consuming they may be.  And, we may experience first hand the expression "death by a thousand paper cuts."

There are references to platinum, gold, silver, bronze and yet another plan that does not even get a "medal" rating.  Perhaps, as my father used to say, it won't be worth "a plug nickel." More disturbing than this built-in class structure for care, we, as individuals, cannot determine where we might be in this picture or how we will navigate through the system.  One cannot specifically determine what will be available, nor what it will cost.  Or, if the full system will become for each of us (depending on our geographic location) simply irrelevant.  One might live potentially in a State that could refuse to have an "insurance exchange."  Yet, the one thing we can be sure of is that participation will be mandated or we shall be penalized.

As one reads this bill, one experiences a jarring reminder that those who are legislating on our behalf have lived in a privileged and moneyed world.  There is reference to $2,000 and $8,000 deductibles, as if average Americans would deem this type of yearly expenditure "reasonable" in addition to whatever are "affordable" premiums.  Again, "affordability" in the bill is something that will be determined based on "reviews."  The Senate's bill, indicates those who are older can "only" be charged 3 times what a younger person is charged.  (The House's bill, as you may recall, "limited" this ratio to 2 times.)  The lack of definition of what the lower amount would be limited to, however, leaves these ratios on equally nebulous and dangerous footing.

The Senate bill, as with the House's, contains details at a highly specific level for many areas, but conspicuous by their absence are specifics on the details most critical to the average American.  It does not allow an individual to determine, even as an estimate, "What will this cost me?" and "What will I get for that?"

Our clients know that before priorities are set or decisions made, it is imperative that specific understanding be gained about factors or elements of a decision.  Terms, such as "affordable," must be clarified specifically so that all understand and agree with its definition.  Clarifications must go further to ensure that "those who are not in the room" are also able to understand.  "Reasonable" must be defined in terms that are clear, either through references that are clearly understood, or by an example.

Without such explication, there will always be an open invitation for subsequent "interpretation." The arguments that then ensue are guaranteed.  If we could only be assured that this needed clarity would be determined during the three weeks of expected debate in the Senate!  Ah, but this is unlikely. In politics, vagueness is a means of protection.  For politicians, not for the people served.  Obscurity is introduced to "reach agreement across the aisle." A most dangerous maneuver. Vagueness is not a solution.  My Irish friends often quote a saying that when one tries to sit on two stools, one falls in between.

Who in fact has taken over whom?

The House health care reform bill...i.e., the insurance reform bill... passed by a slim margin of 5, with 39 Democrats apparently realizing "being a Democrat" is not the sole reason to vote for a bill.  There is some comfort in seeing that "dissent."  Decisions should not be made solely for one reason, and despite politics, the need to "close ranks" on a vote is not a criteria of the decision itself.

Since the Bill has now passed, a review of some pertinent parameters of direct costs for the average citizen might be enlightening:

• Insurance coverage will be mandatory, and the penalty for not having insurance, will be 2.5% of adjusted gross income.

If one does obligingly go along with the mandatory purchase of health insurance, then the following costs will be encountered by an individual:

• "Cost sharing" to be "capped" at $5,000/year (premiums not included). Let's hope we can schedule our illnesses to fall entirely within one year.

• A $1,500 deductible/year (which, so generously, will go towards the $5K "cost sharing"). We should be grateful that in addition to premiums, we'll still be paying up to "only" $1,500  before what we paid for with the premiums kicks in.

And, yes, what of the premiums?  From a citizen's point of view, premiums have been one of the major roadblocks to acquiring health insurance.  In the Bill, the dollar amount remains unspecified.  The terms for premiums are:

• that they do not count towards the capped "cost sharing" 
• they can increase as the insured person's age increases
• that the highest premium charged is "restricted" to not be more than twice the lowest premium charge.

The Bill's direct wording is as follows:

(1) PREMIUM.—The monthly premium charged to eligible individuals for coverage under the program (A) may vary by age so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 2 to 1; (B) shall be set at a level that does not exceed 125 percent of the prevailing standard rate for comparable coverage in the individual market; and (C) shall be adjusted for geographic variation in costs. Health insurance issuers shall provide such information as the Secretary may require to determine prevailing standard rates under this paragraph.

Unseemly low end premiums will allow even more onerous premiums for those aging, but not yet on Medicare.  Yet we are to take comfort in that the rates for the low end will be set by information from none other than the insurance industry.  They "will provide information... to determine prevailing standard rates."

This would all be bad enough, if we were free to choose not to participate in such a scheme. But, now, the industry will additionally have the government providing enforcement on their behalf through the IRS.

Reports of "Kill the Bill" rallies indicated that most of those marchers believed that the government was "taking over health care." This evidences a most skillful manipulation. More apparent is that it is the insurance industry that has taken control over health care, even more so than they enjoy today.  The industry has secured a market, and through law, is binding the government into a role of being an enforcement agency for their interests.

The future could not be rosier for the insurance industry. Guaranteed premiums for 308 million citizens.  High deductibles.  Law enforcement at no charge. No private industry ever had it so good.

Many in Congress forgot that addressing the viewpoints and requirements of each constituency is necessary for support of any decision by those whom it will affect.  They lost sight of their purpose.

Our "representatives" constructed a system that was driven by and favors the most powerful constituency, not the constituency that is most affected.  The original intent of providing health care to all Americans, was exchanged for obtaining money from all citizens.  Gives new meaning to the term "Health Insurance Exchange."

Good intentions, but serious consequences

In my continued perusal of the 1,990-page House health care bill, I have come upon an interesting exception to the mandatory purchase of insurance. It will become a rather nice loophole, or at least a good alternative if one cannot face the proposed $5,000 medical insurance "cost sharing" (after unspecified premiums, but including a $1,500 deductible) each year for individuals, and if one does not wish to pay the proposed 2.5% of adjusted gross income penalty for not having insurance.

"(5) RELIGIOUS CONSCIENCE EXEMPTION.— 
(A) IN GENERAL.—Subsection (a) shall not apply to any individual (and any qualifying child residing with such individual) for any period if such individual has in effect an exemption which certifies that such individual is a member of a recognized religious sect or division thereof described in section 1402(g)(1) and an adherent of established tenets or teachings of such sect or division as described in such section." 

Cause-and-effect thinking is critical while making decisions. Simply asking "If we resolve this issue in this manner, what might happen?"  It is hard to imagine such a test having been made before the above clause was made a part of the Bill.

What will happen when people "find" religion, and then later "lose" it at the time their health becomes critically endangered?

Is the government overstepping its scope by declaring which religions in the U.S. are considered "valid" religions?  How would that designated list of "acceptable religions" sit with those who believe choice of faith and belief systems are the individual right of citizens in this country and do not necessarily require belonging to an "established" religion?

From a slightly different angle, there are other questions that arise:

If persons of any faith are still required to contribute to the public school system, even if they send their children to their own faith's system of schools, why should persons be exempt from a mandatory payment into a health system based on their religious belief?  One can understand rejecting all forms of health care offered to one on religious grounds.  However, just as one might refuse a public education, it would seem that the obligation to pay for the country's health system, as with education, should not be waived.

Cans of worms are being opened with some of the exemptions that are being included in this Bill, because while overly detailed focus has been put on some areas, the potential follow on effects in others have not been carefully anticipated.

Is health care a right?
In Monday's post, I wrote about the need for clarity and simplicity in the structure of any "document" that organizes elements of a decision. All decision-makers need to be able to quickly and readily access information, so that they can make an intelligent decision.

Perhaps of more importance, is reaching agreement on the objective of the decision that one hopes to achieve. Clarification of this ultimate objective must precede detailed descriptions of actions which may or may not help achieve that end.

Although the House Bill starts with the statement "To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes" this statement starts well, but ends poorly. The last clause obscures the purpose by referencing undefined purposes.  The tiny little word "all" (in reference to "all Americans") is dwarfed by the other verbiage.

Fundamentally the question that must first be answered:
Is health care a right of citizens of the U.S.?

Secondly, if so, is this Act affirming that right?

Thirdly, if the second is true, why is anyone still speaking about "acceptable levels of uninsured, or underinsured" Americans?

There has been a good deal of drifting away from the original purpose.  The criticism by some persons that this "reform" is more about insurance than about health care stems validly from the fact that most actions are now dealing with insurance (even the White House site defends this reform as "Health Insurance Reform"). This reform is not being framed in terms of "rights" to health care.  The Act, itself, adopts a short name referencing "Affordability" but nothing about "Accessibility" in its title.

Affordability is but one factor in terms of Accessibility.  Insurance is but a means to make health care accessible to some.  Ironically, it is also a factor that has resulted in health care becoming inaccessible to others.

As the focus on "options" has shifted to types of insurance, we need to ask why.   Investigators always say to "follow the money."  Who benefits more from focusing on the ins and outs of insurance than in clarifying the rights of citizens?

A simple vote by every member of Congress to answer whether health care, not health insurance, is a right of a U.S. citizen or not is needed.  Once we have the answer to that question, it would be infinitely easier to create a system relating to funding it, alternatives as to how it could be provided and if and what type of "industry" will be needed and structured to support it.

The Bill refers to "building on what works in today's health care system."  "What works" is never enumerated. Perhaps there is nothing to point to specifically. More likely the statement is a euphemism for not letting go of a system.  But this system has allowed some to amass a fortune from the misfortune of others, and those same entities are now strategically keeping the question of "rights" of "all" citizens out of the discussion.

A clear statement of context will always clarify the better actions to take.  And some must be very concerned that, if that context were to change, "building on what we have" might not, indeed, be the best move.

In the weeds, fractured, and in legalese

Any decision, and especially one of great import, needs to be structured for clarity.  Having said that...

On October 29th the House produced a bill for health care reform. Rather than just accept the media's interpretation of it, I undertook the review of its 1,990 pages last night.  I made it to page 334. I still intend to finish, but some things are already apparent.

I wonder how many reporters have, and more importantly, how many Representatives will fully read and fully understand it in its present structure.  How can one?

Six aspects of the structure cause concern:

1. Not every Representative in the House is a lawyer, yet the language could not be more "legalese" or more tangled in its convolutions.

Example:

"In any case in which agreement with respect to the provisions required under subparagraph (B) for any fiscal year has not been reached as of the first day of such fiscal year, the latest agreement with respect to such provisions shall be deemed in effect on an interim basis for such fiscal year until such time as an agreement relating to such provisions is subsequently reached."

We should demand that Representatives, as authors of bills, "take a page" from this Bill itself (page 121 to be exact) in which they admonish others to use "plain language:"

"The term ‘‘plain language’’ means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is concise, well-organized, and follows other best practices of plain language writing."

2. Instead of defining terms in the designated area called "Definitions," the Bill makes reference to definitions buried across the 1,990 pages of the document, as well as definitions found in other documents.

Example:

"GENERAL DEFINITIONS.—Except as otherwise provided, in this division: 
(1) ACCEPTABLE COVERAGE.—The term ‘‘acceptable coverage’’ has the meaning given such term in section 302(d)(2). 
(2) BASIC PLAN.—The term ‘‘basic plan’’ has the meaning given such term in section 303(c). 
(6) EMPLOYMENT-BASED HEALTH PLAN.—The term ‘‘employment-based health plan’’ (A) means a group health plan (as defined in section 733(a)(1) of the Employee Retirement Income Security Act of 1974); "

NOTE: Since the Table of Contents does not include page numbers, nor do the footers indicate location, quickly locating "section 302(d)(2)," or section "303(c)" or others (in other Acts) to learn the definition of terms is pretty much impossible.  The reader is likely to read for some time, without knowledge of terms' meaning, before learning actual meaning. This invites misunderstanding.  It begs the question, "Is this misleading structure intentional?"

3. Not constructed in terms of constituencies, the Bill obscures the full picture being painted for each, i.e., for user/patient, provider (doctor/hospital, etc.), insurance provider, small business, large business, government (administration and oversight), government (tax: implications, administration, penalties).  As it now stands, each constituency's roles and responsibilities are fractured and spread throughout 1,990 pages. 

4. This Bill is neither a stand-alone read, nor action.  In it are Amendments to other legislation: e.g., to the Social Security Act, and the IRS tax code.  These Amendments are literally sprinkled throughout the document.  More importantly, they are made purely by reference to excerpted portions of phrases.  Full context is obscured, as in the example below:

Example:

"PAYROLL TAXES.— 
(A) Section 3121(a)(2) of such Code is amended (i) by striking 'or any of his dependents' in the matter preceding subparagraph (A) and inserting ', any of his dependents, or any eligible beneficiary (within the meaning of section 106(g)) with respect to the employee',"

5. Always a dangerous thing to do, there are numerous sections that appear to repeat themselves. In some (but not all) cases, there are slight alterations. For clarity, an element should appear once and in one location, and should include any variations (revealing their relevancy and rationale).  As the Bill currently is written, without being able to ascertain quickly a context for each current repetition (caused by lack of footers indicating location/context), further confusion is invited.  For a bill that includes proposed use of technology as a solution, it amazes one that the simple management of footers, so basic to all word processing, has been overlooked.  Again, it begs the question, "Is this obfuscation intentional?"

6. The Congress is so "into the weeds" that this Bill pre-empts the work that is the purview of an administrative body. One wonders what the Department of Health, Education and Welfare's (HEW) job is.

An example of "the weeds:"

"WHERE SERVICE IS FURNISHED
For purposes of paying the additional amount specified in paragraph (1), if the Secretary uses the 5-digit postal ZIP Code where the service is furnished, the dominant county of the postal ZIP Code (as determined by the United States Postal Service, or otherwise) shall be used to determine whether the postal ZIP Code is in a county described in subparagraph (A). "

In summary...

When did Congress drift from the role model of the Founding Fathers when it came to succinct frameworks of clarity?  The entire Bill of Rights is on one page. Consider that document's Eighth Amendment in its entirety: "Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted." Period.  Paragraph.  End of entire Amendment.

Our clients know that a directorial body's responsibility is to provide a framework for management and staff to refine subsequently into an implementation plan.  That is the "direction" and the scope expected from such a body.  A "Zip Code level" of detail is far beyond being a framework.

The U.S. public have been advised that the "devil is in the details."  However, the devil in this case appears to be the modern day Congress' assumption that they must be in charge of the details, and that approval of a framework for further work is impossible without their dotting all i's and crossing all t's.

Viewpoints matter
Earlier this month (Oct. 9, 2009) I ranked the attributes of an "ideal" health care system that I, as a potential user of the system, would desire. The New York Times recently published the "features" of the differing proposals in committees and houses of Congress. I decided to weigh how well each proposal met my criteria.  (The chart to the right shows the outcome. Any not crossing the midline fall short of at least one very important attribute I weighted earlier.)  Additionally, as options, I included the status quo, as well as the UK and the Canadian systems from what little I know about them.

Congress' proposals were difficult to rank, because descriptions were primarily focused on the "rules of participation" and "penalties for non-participation." These descriptors were insufficient to understand the "offerings" given to user/patients of a system of health care, but were more about administration.  A potential user/patient is less concerned about the cost to the government or the effect on businesses (small or large).  While viable concerns of some constituencies, they are not reflective of the user/patient constituency.

For most individuals, a key area of concern is "affordability." But "affordability" remains nebulous in the descriptions:

• "Premiums will not be allowed to be raised because of pre-existing conditions." A noble statement, but one that does not address the fact that premiums may be too high in the first place.

• "Shopping at an exchange." If all prices at the exchange are too high, then "affordability" remains an issue for many.  As an example, has anyone "shopped around" for better interest rates at a bank recently? Does it seem as if one is dealing with a banking cartel?  In that light, do we think that there will be sufficient incentive for any insurance company to lower its rates if it can observe that its competition is profiting more?

• A "cap" of $5,000 per individual has been bandied about. Is this reasonable, given that the federal minimum wage ($7.25/hour) would only provide an individual with approximately $13,700/year after taxes?  How is that individual to survive on the remaining amount, if $5,000 is taken from it to cover health care costs?  Is this realistic? Even a tax credit for the full $5,000 would only put $63/month back in the pockets of these individuals.  What will that buy them?  Paying the $750 penalty that is suggested, would provide them with $1,081/month to deal with the immediate realities of life.  Would this not seem the more pragmatic action to take?

That said, is the Congress (having "offered" such a deal to these individuals that they then "refuse") going to return to their voter base with a clear conscience saying they created a "reformed" system?  That this was the best they could do?

Assessing the same proposals from the point of view of the insurance industry, is a more rosy picture:

• Under all proposed systems, the industry will have a captive market. Subscribing to insurance will be mandatory. 
• The government will police on the industry's behalf, through penalties. 
• There is no mention of regulations for or mandated lowering of pricing of premiums, or co-pays.
• There are no guarantees re personal choice of doctors.
• There are no regulations about qualifications for doctors participating in plans.
• There is a wide array of "levels" of care being spoken about. 
• There no longer is talk of the "right" to health care. Instead this has been replaced with "acceptable numbers" for the number of people uninsured. "Insured" can actually be insurance that plays out to be as one congressman deemed it, "pseudo-insurance." But, no one is mandating regulations to prevent this type of fraud. 
• The complexity itself in the descriptions of plans, in fact, adds to the industry's ability to manipulate for their profit. 

More is to be gained than lost from the insurance industry point of view.

Beyond these questions, going through the assessment exercise reveals some important aspects of this decision. The White House's "idea" for health care as initially assessed, due to our lack of knowledge as to specifics, is better than the actual proposals at hand. This is not unusual.  Concepts that are loosely defined typically are interpreted more generously.  It is always advisable to return to an assessment as details are uncovered about a project.  When "guidelines" evolve into specifics, we often see the more realistic ranking of a project.

If there are multiple constituencies involved in determining "what matters," the degree of influence of each (their voice's weighting) must also be factored in to the assessment.

In health care reform, we are dealing with multiple constituencies, with differing viewpoints: The citizen, as potential patient/user.  The citizen as taxpayer.  Big corporations.  Small businesses.  The private insurance industry.  The government as a representative of the people.  To get on the same page, we may need to start separately.  But instead of trying to convince the other constituencies of our own values as factors for their judgment, we need to integrate all viewpoints.  This does not mean homogenization of viewpoints, but it does mean a a type of "triangulation" in the judgment of options.  This is what is currently missing, and why pot shots can be so easily made about each proposal, and why one viewpoint, one that is an expert in getting heard but is not necessarily representing what is best, is beginning to dominate.