Who knew you could do this?

Reporting on S-chip has taught me so much about procedural tactics, it's kind of scary.

This week was no exception. Bush decided on Friday, after business hours, while Congress is in recess, that he is going to make it virtually impossible for any state to enroll children in S-chip if their families earn more than 250% of the federal poverty level. Under his news rules, if states want to insure children in families earning above 250%, they must:

• Enroll 95% of eligible children in families under 200% of the poverty level (This is impossible. No state does it.);
• Ensure that children in families over 250% are uninsured for a year before enrolling them;
• Charge kids in families over 250% premiums and copays at the same rates as private insurance;
• Ensure that the percentage of children enrolled in private insurance plans doesn't drop by more than 2% (to make sure that employees aren't dropping their private insurance left-and-right to run on over to public assistance, the Republicans' anti-Christ); and
• Create mechanisms to ensure that employers don't create policies that encourage employees to switch to public programs.

While it probably goes without saying, I think this new policy is stupid. Yes, I suppose Bush is technically within his rights to create it ... it just seems unnecessarily cruel to set states up for failure, and in turn, children. It really bugs me in its hypocrisies. Bush expects (or maybe he doesn't?) states to now strive for enrolling 95% of all eligible children at 200%, the law's "original intent" or whatever, but under Bush's SCHIP proposal, there wouldn't be enough money to pay for them long-term. What's the point of bringing children into the program, if two years down the line, you are going to have to kick them out when the program runs out of funding? In essence, he basically set up that rule to prevent states from covering children above 250%. Someone never told Bush "honesty is the best policy."

Obviously he can't tell the truth about what he's doing, though. He would sound like an asshole. Which I think perfectly describes what he just did, denying care to children and putting more burdens on states. He is being so incredibly inflexible about everything that is S-chip.

Real reporters' coverage available here and here and here.

Closure of King Harbor Hospital

Friday's announcement that Martin Luther King Jr. Harbor Hospital will close after losing $200 million of federal funding, after it failed a second CMS inspection, highlights yet another problem caused by having high numbers of uninsured residents.

King Harbor is one of the lowest-income areas of L.A., meaning most likely a large number of patients visiting the hospital for care would be uninsured or on Medicaid. Either way, the hospital was probably operating on larger debt than most other hospitals in higher income areas. While I'm sure all the hospital's problems cannot be blamed on funding (I really hate it when government entities blame all problems on inadequate funds -- **cough cough** -- FDA), I think it's safe to say that the hospital would have been able to hire more knowledgeable staff and run the place more efficiently with more funds from the very beginning.

In short, what I'm trying to say is that a vicious cycle exists within our current health care system:

• Uninsured/underinsured residents are less likely to receive care because they can't pay the bills;
• Hospitals that serve large numbers of uninsured/underinsured can't collect enough funds when they're patients can't pay, thus making it difficult to hire competent staff;
• Without competent staff, the hospital can't offer care worth paying for, and might end up the way of King Harbor, and the community loses access to care all over again.

I think that single-payer systems have a lot of problems, but I think in this situation they offer a benefit. When the government is paying for care, and the wealth of the patient is no longer a factor, all patients have a better shot at receiving high quality care. Our system simply reinforces an existing socioeconomic divide. Will there still be a divide under a single-payer system? Of course. There's no way of convincing a doctor to practice at a hospital if he or she is concerned about being shot driving to and from work. Same idea for rural areas. But at least wealth is taken out of the equation.

***

Last week, the Philadelphia Inquirer had a great opinion piece about health as a public good, as opposed to a private good, that I think relates to the problems with King Harbor. Columnist Chris Satullo writes,

Health care is a classic public good that should be supported by a social compact: The healthy should pay into the system to underwrite care for those who need it now, both as a matter of civic morality and self-interest. They need to support the system now so that it'll be there come the inevitable day when they'll need it.

...

The goal shouldn't be for government to supplant the private health-care market, but to tame it. States have tried, but only the feds can really do what's needed: Organize the market rationally so it covers all at a basic level, wastes less, and offers consumers intelligible, workable choices.

For more coverage about King Harbor, see here, here and here.

Now what?

With both the House and the Senate having passed substantially different versions of health care legislation, I'm intrigued to see how the conference committee is going to find some sort of viable solution. Both sides are saying, "here's this provision of our bill that can't change" and they seem completely at odds with each other.

In the House, both Dems and Republicans are saying that the tobacco tax increase can't go above 45 cents. Dems already lost 10 votes because of the tax in the first round, who knows how many more they'd lose if they increased the tax to the Senate level of 61 cents.

Meanwhile, Republican senators do not seem willing to even consider cuts to Medicare Advantage (complete bullshit if you ask me...). But the Senate already has the smaller expansion -- if you were to just collect funds from a 45 cent tax increase, it wouldn't even be enough to fund the $35 billion expansion. So basically senators have to find a completely different, non-controversial source of funding. I hope they're creative, because I'm not sure that exists.

My prediction: $35 billion expansion, with some of the House's Medicare provisions (definitely the reversal of scheduled physicians cuts, to be funded perhaps by the cuts to nursing and inpatient rehabilitation centers?), without the MA cuts. All to be funded with a 45-cent tax increase and "unidentified non-controversial tax" (I've heard that perhaps they could better collect back taxes, and that would get lawmakers the needed money).

What makes it even more tricky is the impending presidential veto. I wish Bush would get off his ideological high horse already. Leavitt is quoted in the NY Times as saying

Congress was jeopardizing health care for millions of needy children by passing bills that “the president will have no choice but to veto.”

Seriously, what an ass. So not only does the conference committee have to come up with something that most of the lawmakers can agree on, it also has to be veto-proof. That, or millions of children go without health insurance. No pressure Congress. No pressure at all.