Landmark – a must read

by Donnajean Ward

Landmark: The Inside Story of America’s New Health-Care Law and What It Means for Us AlBy The Staff of the Washington Post

In about 200 clear and concise pages, the ins and outs of “Obamacare” are navigated and, guess what, it’s not all that complicated.  From “How we got here” to “Judging Success” this small books makes pretty short work of the contentious legislation and it lays out the nuts and bolts in such a sane and straightforward way that it leaves you wondering what all the fuss is about.

The book starts with a handful of ripping yarns as background.  First up, lessons learned from “Hillarycare” (Do not write a bill, Do not emphasize the problems of the uninsured, Move fast, and Neutralize the opposition) to the special interest deals side bargains (the Cornhusker Kickback!), and one of Congress’s last gasp of bi-partisanship (remember the “Gang of Six?”), culminating in Nancy Pelosi, triumphant in passing healthcare legislation — but bloody and slightly bowed by her concession to Catholic Bishops and Rep. Stupak over abortion. 

And then?  “Panic. Despair. Back-stabbing. Recrimination. Calibrations and recalibrations” as Joe Lieberman throws a wrench into the works on the Senate side.  But we know how this one ends.  In the words of the President, “we answered the call of history” and Congress passed H.R.3590: The Patient Protection and Affordable Care Act.

After the dramatic lead up one would expect the next chapters to be a boring letdown but no, Part II of the book answers so many questions, defines so much jargon, and does such a good job of laying out the good the bad and the ugly that I found myself breezing through the chapters with an “aha moment” at every turn.  The donut hole explained!  Re-importation of drugs, expanding Medicare, shopping at exchanges, the individual mandate (and more!) are clearly explained along with a few helpful charts and graphs.  The list of changes and benefits is a long one:

  • Making insurance available to those with pre-existing conditions
  • Bans on cancelling insurance except in cases of fraud
  • Bans on lifetime and annual limits on benefits
  • Forcing insurance companies to spend 80% of insurance premiums on health care (instead of marketing or admin costs)
  • Keeping children on parents’ insurance up to age 26
  • Better drug benefits
  • Long-term care insurance
  • Pay parity for nurse-practitioners and nurse-midwives
  • Greater parity for mental health benefits
  • Incentives for preventative care
  • A common standard for Medicaid eligibility (and opening up the program to poor adults without children)
  • Even a smattering of tort reform.

That’s the good news.  The bad news is that all that good stuff costs $938 billion (over the next ten years) according to official estimates.  Of course the Congressional Budget Office (CBO) has “determined that the Patient Protection and Affordable Care Act, as amended, is fully paid for” but it’s also true that while the law does try to “limit the impact on state budgets” there is real uncertainty about the costs of running the exchanges for the states.

The book concludes with two “what ifs:”

  1. If the law is working, the vast majority of uninsured will have signed up for coverage (and) . . . Insurers will resemble well regulated public utilities . . . the exchanges will become the new foundation for health insurance . . . as more workers buy their own insurance in the exchanges and employers make up in higher wages the savings they gain from no longer paying for health benefits.
  2. If the law is not working…many Americans may begin skirting the mandate (and) people who are in the exchanges may find the premiums un-affordable . . . if healthier people decide not to buy coverage.

Of course, we’ll have to wait and see which scenario prevails.  In the meantime, pick up a copy of Landmark and read all about it for yourself.