Friday, March 18, 2011

So, which bill from today's Republicans did you enjoy more? [Updated: correction]

The one where Minnesota Republicans want to make it illegal for poor people to carry cash? [Added2: Not true.**] Or the one where the Republicans in the US Congress want to require the IRS to carry out abortion audits? (Remember to ask your rapist for a receipt, ladies!)

Details here, if you haven't already heard.

[Added] PZ:

So that's what they mean by the “War on Poverty”

** [Added2] Correction: This turns out not to be true. The bill says the people in the assistance program are "prohibited from withdrawing cash from an automatic teller machine or receiving cash from vendors with the EBT debit card." And later: "EBT cardholders may opt to have up to $20 per month accessible via automatic teller machine or receive up to $20 cash back from a vendor." (via, via.)


Brett said...

On the abortion thing:

"And in its zeal to make sure that no one anywhere ever gets an abortion, Republicans have decided that money you save via tax breaks or tax credits isn't your money after all. It's their money, and they want to make sure you spend it the way they want. "

Hm, so you mean it's Republicans I have to blame for the fact that my HSA doesn't cover non-prescription medications anymore? Thanks for clearing that up, I'd thought that was a Democratic idea...

bjkeefe said...

First, there's no relevance here. The point of my post is about the Republicans' obsession with abortion.

Second, even pretending your counterexample has relevance, that's a mighty weak nit to pick. If it weren't for the Republicans, you, and the overwhelming majority of the rest of the country, would without a doubt have much better insurance coverage, and this would have been true starting at least as far back as the early '90s.

As to the specific gripe about your OTC medications, meh. Either accept that there are no free lunches, and that at some point, there are going to be out-of-pocket payments required under any insurance plan, or if it's that crippling an expense, get your doctor to write you a prescription.

Brett said...

So, what you're saying is that it's not their money, it's your money, and I'm going to spend it the way YOU want...

You just disagree with the Republicans about when this policy kicks in. Not about whether the government gets to make such dictates.

bjkeefe said...

No, that's not what I'm saying. Although the cascade of pronouns makes it impossible for me to be sure what you're saying.

I am not sure about your second paragraph. In particular, I don't know what you mean about my supposed disagreement "with the Republicans about when this policy kicks in." Maybe you'd like to elaborate.

I will say this in the meantime: if you have any sort of insurance coverage, you are going to run up against various places where the plan doesn't cover, or doesn't completely cover, whatever it is you would like to obtain, be it meds, surgery, or some other kind of treatment. This is true whether you're getting your coverage from the government or a private company. Health care, like practically everything else, is a scarce good -- we cannot all have as much of it as we'd like without having to give up something for it. Basic fact of life.

I'll also say this: I find the entire discussion of health care policy tedious at best, and this sense is only aggravated when people bring in personal anecdotes to form the basis of their arguments.

My feeling about the matter in general is that there is a consensus that part of modern life means getting lots of health care. To my mind, the notion of how much is reasonable to expect is excessive, especially late in life. I also have a real distaste for the idea that "health care is a right." So, in any discussion of health care, I'm starting off pretty cranky.

To the degree that I can set aside my irritation, I'll accept that there is no changing the view that health care is of paramount concern to the overwhelming majority. Once I take that as a given, my impression is then that the costs are out of control, and that the spiraling growth has never shown any signs of diminishing under the hodgepodge "free market" system we have had in place for the past half century at least. Thus, if we are to get our long-term fiscal house in order, we have to figure out a way to put the brakes on how much it supposedly costs to get decent medical care.

My feeling about the government being part of it is that it's better than doing what we've been doing, which is basically leaving it at this: if you are lucky enough to get a good job, you get health insurance as a benefit. Or, that you can get some public assistance, but first you have to show that you're really hurting in life. Seems to me this has, among other bad effects, the trapping of people in jobs they don't like, excessive power given to employers who know this, and at the bottom end, incentives against trying to get oneself off the dole, not to mention putting off preventative or timely care, which typically results in a much larger cost to us all somewhere down the road.

Also, I'm a big fan of Clarke's dictum, about how you can measure the degree of advancement of a civilization by how well it takes care of its least fortunate.

So, in sum, I want costs contained on a national scale, and I don't want poor people needlessly suffering because our otherwise wealthy nation is dominated by better-off people who are way too fucking selfish.

jaed said...

As to the specific gripe about your OTC medications, meh. Either accept that there are no free lunches, and that at some point, there are going to be out-of-pocket payments required under any insurance plan, or if it's that crippling an expense, get your doctor to write you a prescription.

Brendan, I think you are not understanding the problem being described. He's not talking about insurance company coverage or "out-of-pocket payments"; he's talking about the fact that the medical insurance reform bill made HSA funds unusable for OTC medications.

An HSA is an account you can set up for medical expenses that insurance doesn't cover. It works in tandem with high-deductible insurance for major/unpredictable medical expenses. The idea is that you have a low-premium plan for stuff you can't cover, and cover the predictable expenses yourself, without going through an insurance plan. These HSA accounts are tax-free (like the employer payments for insurance premiums), which is where the government comes into the picture. Because they're tax-free, what they can be used for is limited by federal law.

It used to be that most medical expenses could be paid out of these accounts. This meant that someone with a condition that requires frequent use of OTC meds - allergies, for example - could pay for them out of their HSA account, without first paying income tax on that money. This meant that the cost of the meds did not go through an insurance company (with the associated overhead), and did not require a doctor's appointment (ditto). It was a good thing for the person who uses the medication (less expense) and for the medical-care system as a whole (less useless overhead).

Going to the doctor for a prescription is not a responsive suggestion, because Brendan would then have to pay the doctor's fee to get the prescription, plus pay the prescription price, which is usually higher than the price of the OTC version. (This is assuming it's even available as a prescription drug. Not all OTC medications are. It's also assuming the doctor is willing to provide a prescription for the medication for what are basically tax reasons, and not all doctors are willing to do that either.)

Brendan is annoyed because Congressional Democrats "decided that money he saved via tax breaks" wasn't his after all. It does seem parallel.

bjkeefe said...

You're right. When I saw Brett's "my HSA doesn't cover," I didn't process the acronym. I just read (over) it as though it meant some sort of insurance plan.

As to whether it's a good idea or a bad idea that OTC meds should be the kind of thing one can pay for out of an HSA, I'm sure people who buy a lot of OTC meds would like to get a tax break for that. As to whether its the best choice in light of an overall health insurance and health care policy, I've never thought about it. It's deeper in the weeds than I care to go.

Intuitively, it seems like a handout to people who generally don't need it as bad as some other people need other, more fundamental aspects of care -- poor people aren't generally in a position to set up an HSA, I wouldn't think -- but hey, if you and Brett and enough other people feel that strongly about it, I'm don't know why this couldn't be a tweak that could be made. I don't view what was passed last year as perfection, and I expect there are lots of things like this that will be considered. HCR is a process that we're still in the middle of, is the way I see it.

Anonymous said...

"Poor people aren't generally in a position to set up an HSA, I wouldn't think"

HSAs are available to the lowest income employees of the federal government, many companies and many state governments. Given that the wealthier are hit less by the extra tax burden on OTC purchases that do no go through an HSA, I would think you would be in favor of keeping this coverate - especially since it was a central argument for the original HSA tax legislation.

bjkeefe said...

The examples you give are not what I had in mind when I spoke of poor people.

jaed said...

I left a long and extremely brilliant ;-) comment yesterday. Blogger promptly ate it. Possibly I should take this as a sign not to clutter up other people's blogs with long posts - either that or remember to copy the text before I hit "Post".

A couple of points:

- One about poor people. It's true that people who are poor enough to qualify for Medicaid don't directly benefit from the tax exemption here, but I'm not sure why that's a reason to remove it. It seemed like such a strange comment to me, actually, that it's what caused me to be longwinded yesterday.

It benefits a lot of people who don't have so much that they can't feel the hit from having to pay more for needed medication. Some of these people have low enough incomes to qualify as working poor - and they need the reduction in taxes more, not less, particularly if they have a chronic condition that requires $$ medication. More generally, it makes medical care more efficient by removing insurance-company overhead from predictable expenses, where making insurance part of the picture really doesn't add anything. It doesn't seem to me that "but it doesn't directly benefit people with zero income" is a reason not to support it.

- The other about your offer to consider making a tweak to re-allow using HSAs for these expenses. I'm genuinely glad that you show flexibility about this. But... I don't think the medical-insurance reform bill can be tweaked in this way, because it goes against the basic philosophy of the bill.

The purpose of HSAs is to get insurance companies out of involvement with predictable medical expenses, so they (and their increased overhead) are only involved with major unpredictable things, the usual purpose of insurance. The way insurance is treated for tax purposes - employer-provided insurance is untaxed, but your own medical care is taxed - creates a lot of financial pressure to put everything on insurance, but this increases the cost because both providers and insurance companies then need to do a lot of paperwork for very minor expenses. The reason for HSAs is to equalize the tax treatment of insurance premiums with non-insurance medical expenses.

The medical-insurance reform, on the other hand, takes the position that everything should go through the insurance company. The "exchanges" will only permit minor variations on one sort of insurance plan - lo-deductible, high-premium, copay/coinsurance, with first-dollar coverage. Major-medical plans are not allowed under the bill. (HSAs are targeted in other ways, too - this thing about OTC medications is only the first one to be implemented.) So it's not really tweakable in this way, not without a *screech* change of direction to a philosophy that gives people more control.

bjkeefe said...

Sorry your last comment got eated. Yes, it's a good idea to switch over to an external text editor when things start getting long.

Doesn't bother me that you wanted to leave a long comment, though. Please feel free, now and forevermore.

As far as this topic goes, however, I am afraid that I just don't find it interesting, so I'm going to have to beg off replying.

jaed said...

NP. Thanks for reading.

Unknown said...

Y'all are confusing HSA with FSA. Health Savings Accounts are part of a specific kind of health insurance scheme that some employers now provide instead of or as a voluntary alternative to a more traditional PPO plan.

FSA plans are Flexible Spending Accounts, not tied to any health insurance scheme. You put away money pretax and use that money to pay for healthcare expenses not covered by your insurance. If you don't use it you lose it. OTC products are no longer *automatically* eligible expenses unless your doc puts in writing that you need it.

bjkeefe said...

Thanks for the clarification.