Por Ricardo Roselló Nevares
En nuestra última columna, establecimos la importancia de que el gobierno tenga una filosofía y visión clara de los servicios de salud que recibe la ciudadanía. Vimos igualmente cómo se desarrollaron en Puerto Rico dos sistemas paralelos de prestación de servicios médicos: uno privado, con las mejores instalaciones para las personas pudientes; y otro público, pagado enteramente por el gobierno, con servicios deficientes, para la población médico indigente. El sistema público creaba dependencia, pues el gobierno tenía dominio sobre la población necesitada. También se prestaba para la manipulación política, y llegó a tal punto ¡que hasta los alcaldes dispensaban recetas!
Debido a esta condición dual, ineficiente y costosa, se dio un cambio radical de paradigma durante los años 90, cuando el gobierno deja atrás su rol de proveedor directo de servicios y se convierte en un comprador de seguros de salud para la población. Esta nueva visión logró mejorías significativas en los servicios médicos para la población médico indigente. De hecho, para el año 2000, Puerto Rico llegó a ser una de las pocas jurisdicciones en el mundo, y la única en todo Estados Unidos, donde el virtualmente el 100 por ciento de la población contaba con cobertura médica. El nuevo paradigma creó asimismo una tendencia de ahorros para el fisco, ya que adquirir seguros médicos para la población resultaba significativamente más económico que mantener hospitales y centros de tratamiento.
Pero, ¿qué ha pasado desde entonces para que nuestro sistema de salud se encuentre nuevamente en una situación precaria?
Luego del 2000, dos administraciones de gobierno subsiguientes, que esbozaban una filosofía de dependencia del pueblo en el gobierno, decidieron dar marcha atrás a los logros alcanzados. Se mantiene, en parte, la tarjeta de salud el gobierno, pero se regresa nuevamente la inversión pública (a menor escala) en proveer servicios directos al pueblo. Para sufragar esos costos, se decide recortar la cantidad de personas en el plan médico, y como resultado, sobre 400 mil puertorriqueños se quedaron sin tarjeta de salud.
Para el 2009, se implementa el plan ‘Mi Salud’, cuya filosofía es la misma que la de los años 90. No obstante, el plan está enfrentando dificultades que no había tenido antes. ¿Por qué? La debacle actual se puede resumir en tres puntos:
Presupuesto de los años 90: Se estableció el sistema con un presupuesto que no tomó en consideración el valor del dólar (ha bajado 30 por ciento) y los costos de las medicinas y tratamientos médicos (han subido 50 por ciento). (Fuente: Bureau of Labor Statistics, Congressional Budget Office)Tres aseguradoras vs. ocho en los 90: Tener varias aseguradoras crea diversificación y competencia, lo que ayuda a mantener costos bajos y servicios eficientes. Si sólo tres aseguradoras se encargan de 1.3 millones de beneficiarios, se le da demasiado poder a estas tres empresas, y se corre el riesgo de que si una cae (como sucedió), entonces queda un tercio de los beneficiarios sin cubierta médica.
Eliminación de médicos primarios como ‘gate keepers’ (porteros) del sistema: Muchas aseguradoras usan a los médicos primarios como un ‘control’ para evitar el uso abusivo de sus planes. Luego de examinar al paciente, el médico primario indica si ese paciente necesita verse con un especialista. Al eliminar el ‘gate keeper’ del plan del gobierno, se agiliza el proceso, pues el paciente va al especialista directamente. Eso en principio es bueno, pero también los especialistas son muchísimo más caros que los médicos primarios. Por ende, el costo para el sistema será mucho más alto.
Por estas razones, el plan Mi Salud, de seguir como está diseñado ahora, está destinado a fracasar. Entonces, ¿cómo evitamos que fracase?
Algunos han sugerido un modelo de ‘single payer’ o pagador único, donde el gobierno, en vez de ser comprador de un seguro médico, se convertiría en asegurador. Esto crea nuevas realidades: (1) como asegurador, el gobierno será el que carga con el riesgo total del sistema; (2) tendrá que desarrollar un aparato burocrático para substituir las aseguradoras, el cual no existe; (3) el gobierno carece de peritaje en este área; (4) se eliminaría el sector privado de seguros de salud en Puerto Rico (el sector más grande en la industria de seguros en PR), lo que significaría eliminar la competencia, junto a miles de trabajos (el sector médico completo, representa 6% de nuestra fuerza laboral); (5) el gobierno ha tenido un historial negativo manejando servicios de salud, como fue evidenciado durante los 70 y 80; (6) se le vuelve a dar demasiado poder al gobierno y se le quita al ciudadano. ¡Imagínate que no te cubran no por ser de un partido u otro!
La sugerencia del pagador único crea el mismo problema que teníamos hace 25 a 30 años: un sistema ineficiente, inefectivo, controlador y politizado.
En vez, la sugerencia es mantener la estrategia de comprador de un seguro, donde el gobierno hace lo que sabe hacer (pagar, fiscalizar), y deja el mercado privado, especializado y ágil que provea mejores servicios. También restituir al médico primario como ‘gate keeper’ para mantener los costos del sistema mucho más bajos. Y por último, inducir la participación de más aseguradoras para ampliar las redes y la competencia.
En términos del financiamiento del sistema sugerido, se requiere que todos compartamos las responsabilidades. Que el gobierno (estatal, federal) se encargue de proveer seguros a las poblaciones con menos recursos económicos y más vulnerables (ej. envejecientes). A la clase media trabajadora, que se le dé un subsidio significativo mediante mecanismos ofrecidos en la reforma nacional de Obama (Centro de Intercambio de Seguros). La empresa privada, que tenga la responsabilidad de proveer seguros para sus empleados con cierto nivel de ingreso, a cambio de incentivos contributivos. Y los individuos, tendrán que participar en los gastos, como deducibles y copagos.
Este modelo se puede implementar ya. Se necesita legislación. Y si queremos ir más lejos, se puede enmendar la Constitución a fin de proveerle el derecho a la salud a todos los puertorriqueños.
Como podemos ver, tanto la visión como el diseño integral del sistema son fundamentales para una ejecución efectiva. Los modelos donde el gobierno juega un rol que sobrepasa su capacidad de peritaje con el propósito de obtener más control sobre el pueblo reducen la calidad y eficiencia del servicio, y aumentan la dependencia del individuo. Este tipo de modelo es un microcosmo del sistema sociopolítico del ELA, y mientras sigamos con este sistema sociopolítico, tendremos terreno fértil para fomentar modelos similares de ineficiencia, control gubernamental y dependencia del pueblo, no sólo en la salud, sino en otros renglones como la economía, la educación, y demás.
Está en nosotros reconocer esta tendencia y requerir un cambio a un modelo sociopolítico que ponga el poder nuevamente en manos del pueblo.
Mostrando entradas con la etiqueta Healthcare Reform. Mostrar todas las entradas
Mostrando entradas con la etiqueta Healthcare Reform. Mostrar todas las entradas
jueves, 11 de agosto de 2011
viernes, 7 de enero de 2011
CBO’s Preliminary Analysis of H.R. 2, the Repealing the Job-Killing Health Care Law Act
CBO’s Preliminary Analysis of H.R. 2, the Repealing the Job-Killing Health Care Law Act
The House of Representatives is planning to consider a bill (H.R. 2) to repeal the major health care legislation enacted last March—that is, the Patient Protection and Affordable Care Act (PPACA) and the provisions of the Health Care and Education Reconciliation Act of 2010 that are related to health care. CBO has not yet developed a detailed estimate of the budgetary impact of repealing that legislation, although it is working with the staff of the Joint Committee on Taxation (JCT) to complete such an estimate in the near future. Because Congressional deliberations on H.R. 2 are beginning, CBO today issued a less-detailed preliminary analysis of that legislation.
Because CBO and JCT estimated that the March 2010 health care legislation would reduce budget deficits over the 2010–2019 period and in subsequent years, we expect that repealing that legislation would increase budget deficits. The resulting increase in deficits projected for fiscal years 2012 through 2019 is likely to be similar in size to—but not exactly the same as—the reduction in deficits that was originally estimated to result from the enacted legislation.
The forthcoming detailed estimate will reflect a number of developments that have occurred since CBO and JCT produced the cost estimate for the March 2010 legislation, including changes in the economic outlook, technical revisions to CBO’s projections of program spending, the initial steps that have been taken to implement the new laws, and enactment of legislation that modified those laws. Those developments will probably not have a major effect on the overall budgetary impact of repealing the legislation. In addition, CBO has seen no evidence to date that the steps that will be taken to implement the March legislation—or the ways in which participants in the health care and health financing systems will respond to that legislation—will yield overall budgetary effects that differ significantly from the ones that CBO and JCT projected earlier. We cannot predict whether the various changes that will be incorporated in the detailed estimate will increase or decrease the estimated impact of H.R. 2 on federal deficits through 2019.
The estimate for H.R. 2 will differ in one significant way from the estimate for the enacted health care legislation. The original estimate covered the period from 2010 through 2019, the period used for Congressional budget enforcement procedures when the legislation was being considered; new estimates will span the period from 2012 to 2021.
Today’s letter describes—in broad terms and on a preliminary basis—CBO’s assessment of the effects that repealing PPACA and the relevant provisions of the Reconciliation Act would have on federal budget deficits, the federal government’s budgetary commitment to health care, the number of people with health insurance, and health insurance premiums in the private market. (Repealing the provisions of that legislation would also have a variety of other effects on the health care and health insurance systems that this letter, like previous CBO cost estimates, does not address.)
Impact on the Federal Budget in the First Decade
As a result of changes in direct spending and revenues, CBO expects that enacting H.R. 2 would probably increase federal budget deficits over the 2012–2019 period by a total of roughly $145 billion (on the basis of the original estimate), plus or minus the effects of technical and economic changes that CBO and JCT will include in the forthcoming estimate. Adding two more years (through 2021) brings the projected increase in deficits to something in the vicinity of $230 billion, plus or minus the effects of technical and economic changes.
Those projections do not include any potential savings in discretionary spending, which is governed by annual appropriation acts. By CBO’s estimates, repeal of the health care legislation would probably reduce the appropriations needed by the Internal Revenue Service by between $5 billion and $10 billion over 10 years. Similar savings would accrue to the Department of Health and Human Services.
There is no clear basis for projecting other effects of H.R. 2 on discretionary spending. PPACA contained a number of authorizations for future appropriations, which, if left in place, might or might not result in additional appropriations. For example, most of the authorizations were for activities that were already being carried out under current law or that were previously authorized and that PPACA authorized for future years. Thus, repeal of the PPACA authorizations might or might not result in discretionary savings associated with those authorizations.
Impact on the Federal Budget Beyond the First 10 Years
CBO estimates that enacting H.R. 2 would increase federal deficits in the decade after 2019 by an amount that is in a broad range around one-half percent of GDP, plus or minus the effects of technical and economic changes that CBO and JCT will include in the forthcoming estimate. For the decade beginning after 2021, the effect of H.R. 2 on federal deficits as a share of the economy would probably be somewhat larger.
As with all of CBO’s cost estimates, these estimates—both for the first 10 years and beyond—reflect an assumption that the provisions of current law would otherwise remain unchanged throughout the projection period and that the legislation being considered would be enacted and implemented in its current form. CBO’s responsibility to the Congress is to estimate the effects of proposals as written and not to forecast future legislation. However, current law now includes a number of policies that might be difficult to sustain over a long period of time. If those policies or other key aspects of the original legislation would have subsequently been modified or implemented incompletely, then the budgetary effects of repealing PPACA and the relevant provisions of the Reconciliation Act could be quite different—but CBO cannot forecast future changes in law or assume such changes in its estimates.
Effects on the Federal Budgetary Commitment to Health Care
CBO uses the term “federal budgetary commitment to health care” to describe the sum of net federal outlays for health programs and tax preferences for health care. H.R. 2 would roughly reverse the outcome projected for the original legislation, diminishing the federal budgetary commitment to health care over the next decade and increasing it in subsequent years.
Effects on the Number of People with Health Insurance
Under H.R. 2, about 32 million fewer nonelderly people would have health insurance in 2019, leaving a total of about 54 million nonelderly people uninsured. The share of legal nonelderly residents with insurance coverage in 2019 would be about 83 percent, compared with a projected share of 94 percent under current law (and 83 percent currently).
Effects on Health Insurance Premiums
If H.R. 2 was enacted, premiums for health insurance in the individual market would be somewhat lower than under current law, mostly because the average insurance policy in this market would cover a smaller share of enrollees’ costs for health care and a slightly narrower range of benefits. Although premiums in the individual market would be lower, on average, under H.R. 2 than under current law, many people would end up paying more for health insurance—because under current law, the majority of enrollees purchasing coverage in that market would receive subsidies via the insurance exchanges, and H.R. 2 would eliminate those subsidies.
Premiums for employment-based coverage obtained through large employers would be slightly higher under H.R. 2 than under current law. Premiums for employment-based coverage obtained through small employers might be slightly higher or slightly lower (reflecting uncertainty about the impact of the enacted legislation on premiums in that market).
Letter to Speaker of House Hon. John Boehner
Originally posted on CBO Director's Blog.
The House of Representatives is planning to consider a bill (H.R. 2) to repeal the major health care legislation enacted last March—that is, the Patient Protection and Affordable Care Act (PPACA) and the provisions of the Health Care and Education Reconciliation Act of 2010 that are related to health care. CBO has not yet developed a detailed estimate of the budgetary impact of repealing that legislation, although it is working with the staff of the Joint Committee on Taxation (JCT) to complete such an estimate in the near future. Because Congressional deliberations on H.R. 2 are beginning, CBO today issued a less-detailed preliminary analysis of that legislation.
Because CBO and JCT estimated that the March 2010 health care legislation would reduce budget deficits over the 2010–2019 period and in subsequent years, we expect that repealing that legislation would increase budget deficits. The resulting increase in deficits projected for fiscal years 2012 through 2019 is likely to be similar in size to—but not exactly the same as—the reduction in deficits that was originally estimated to result from the enacted legislation.
The forthcoming detailed estimate will reflect a number of developments that have occurred since CBO and JCT produced the cost estimate for the March 2010 legislation, including changes in the economic outlook, technical revisions to CBO’s projections of program spending, the initial steps that have been taken to implement the new laws, and enactment of legislation that modified those laws. Those developments will probably not have a major effect on the overall budgetary impact of repealing the legislation. In addition, CBO has seen no evidence to date that the steps that will be taken to implement the March legislation—or the ways in which participants in the health care and health financing systems will respond to that legislation—will yield overall budgetary effects that differ significantly from the ones that CBO and JCT projected earlier. We cannot predict whether the various changes that will be incorporated in the detailed estimate will increase or decrease the estimated impact of H.R. 2 on federal deficits through 2019.
The estimate for H.R. 2 will differ in one significant way from the estimate for the enacted health care legislation. The original estimate covered the period from 2010 through 2019, the period used for Congressional budget enforcement procedures when the legislation was being considered; new estimates will span the period from 2012 to 2021.
Today’s letter describes—in broad terms and on a preliminary basis—CBO’s assessment of the effects that repealing PPACA and the relevant provisions of the Reconciliation Act would have on federal budget deficits, the federal government’s budgetary commitment to health care, the number of people with health insurance, and health insurance premiums in the private market. (Repealing the provisions of that legislation would also have a variety of other effects on the health care and health insurance systems that this letter, like previous CBO cost estimates, does not address.)
Impact on the Federal Budget in the First Decade
As a result of changes in direct spending and revenues, CBO expects that enacting H.R. 2 would probably increase federal budget deficits over the 2012–2019 period by a total of roughly $145 billion (on the basis of the original estimate), plus or minus the effects of technical and economic changes that CBO and JCT will include in the forthcoming estimate. Adding two more years (through 2021) brings the projected increase in deficits to something in the vicinity of $230 billion, plus or minus the effects of technical and economic changes.
Those projections do not include any potential savings in discretionary spending, which is governed by annual appropriation acts. By CBO’s estimates, repeal of the health care legislation would probably reduce the appropriations needed by the Internal Revenue Service by between $5 billion and $10 billion over 10 years. Similar savings would accrue to the Department of Health and Human Services.
There is no clear basis for projecting other effects of H.R. 2 on discretionary spending. PPACA contained a number of authorizations for future appropriations, which, if left in place, might or might not result in additional appropriations. For example, most of the authorizations were for activities that were already being carried out under current law or that were previously authorized and that PPACA authorized for future years. Thus, repeal of the PPACA authorizations might or might not result in discretionary savings associated with those authorizations.
Impact on the Federal Budget Beyond the First 10 Years
CBO estimates that enacting H.R. 2 would increase federal deficits in the decade after 2019 by an amount that is in a broad range around one-half percent of GDP, plus or minus the effects of technical and economic changes that CBO and JCT will include in the forthcoming estimate. For the decade beginning after 2021, the effect of H.R. 2 on federal deficits as a share of the economy would probably be somewhat larger.
As with all of CBO’s cost estimates, these estimates—both for the first 10 years and beyond—reflect an assumption that the provisions of current law would otherwise remain unchanged throughout the projection period and that the legislation being considered would be enacted and implemented in its current form. CBO’s responsibility to the Congress is to estimate the effects of proposals as written and not to forecast future legislation. However, current law now includes a number of policies that might be difficult to sustain over a long period of time. If those policies or other key aspects of the original legislation would have subsequently been modified or implemented incompletely, then the budgetary effects of repealing PPACA and the relevant provisions of the Reconciliation Act could be quite different—but CBO cannot forecast future changes in law or assume such changes in its estimates.
Effects on the Federal Budgetary Commitment to Health Care
CBO uses the term “federal budgetary commitment to health care” to describe the sum of net federal outlays for health programs and tax preferences for health care. H.R. 2 would roughly reverse the outcome projected for the original legislation, diminishing the federal budgetary commitment to health care over the next decade and increasing it in subsequent years.
Effects on the Number of People with Health Insurance
Under H.R. 2, about 32 million fewer nonelderly people would have health insurance in 2019, leaving a total of about 54 million nonelderly people uninsured. The share of legal nonelderly residents with insurance coverage in 2019 would be about 83 percent, compared with a projected share of 94 percent under current law (and 83 percent currently).
Effects on Health Insurance Premiums
If H.R. 2 was enacted, premiums for health insurance in the individual market would be somewhat lower than under current law, mostly because the average insurance policy in this market would cover a smaller share of enrollees’ costs for health care and a slightly narrower range of benefits. Although premiums in the individual market would be lower, on average, under H.R. 2 than under current law, many people would end up paying more for health insurance—because under current law, the majority of enrollees purchasing coverage in that market would receive subsidies via the insurance exchanges, and H.R. 2 would eliminate those subsidies.
Premiums for employment-based coverage obtained through large employers would be slightly higher under H.R. 2 than under current law. Premiums for employment-based coverage obtained through small employers might be slightly higher or slightly lower (reflecting uncertainty about the impact of the enacted legislation on premiums in that market).
Letter to Speaker of House Hon. John Boehner
Originally posted on CBO Director's Blog.
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