US health-care reform by numbers

We go behind the figures that have dominated debate on the Senate bill

The US Senate has voted in favour of the historic health-care reform bill today. The bill -- which some critics say has been heavily compromised and others say not enough -- must now be reconciled with a different version passed by the House of Representatives, a process that will begin in mid-January.

This landmark move follows months of political wrangling. It has been a process characterised by vicious partisan debate, wildly varying figures and exaggerated statements (remember the controversy over the NHS having "death panels"?). Here, we go behind the numbers to see what the costs will be, who stands to benefit, and what's been going on behind the scenes.

On 19 November, the Senate majority leader, Harry Reid, unveiled the health-care bill. He said that it would cover 94 per cent of the population, extending coverage to 31 million uninsured people, at a cost of $848bn over ten years.

Are there really 31 million people uninsured?

The number is actually much higher, but the question of which of these people are deserving of government assistance is hotly disputed.

According to the US Census Bureau, there were 47 million people who at some point had no insurance at all in 2009. That's more than 15 per cent of the population. However, the uninsured is a fluid group, and this oft-quoted figure includes the short-term uninsured -- those between jobs, or recent immigrants.

The non-partisan Kaiser Family Foundation found that 79 per cent of these people are American citizens (the remainder are immigrants). Two-thirds of those citizens are near or below the poverty line.

The figure of 31 million in the bill is less than the overall number of 47 million, because the bill is aimed at the long-term uninsured, and caters for US citizens only.

Republicans have disputed the figure, claiming that when you remove nine million non-citizens, about ten million covered by Medicaid or other contingency plans, five million childless adults (apparently not deserving of health insurance) and ten million who are a comfortable distance from the poverty line, the number of those actually uninsured is 10.6 million.

Where did the $848bn figure come from?

The Congressional Budget Office (CBO) cost element of $848bn given by Reid was cut down -- at least in part -- by delaying many elements of the bill from 2013 to 2014. The delayed elements include the establishment of insurance exchanges and subsidies for the poor.

But where is the money coming from?

This is a crucial difference between the bill in the Senate and the one in the House of Representatives. Let's deal with the Senate bill (the one voted on today). Most of the funding for this would come from a tax on high-end, or "Cadillac" insurance. It would be assessed for plans valued at $8,500 for individuals or $23,000 for families, with higher thresholds for high-risk workers and people living in states with costlier premiums.

There would also be an increase on Medicare payroll tax for top earners, with the rate rising from 1.45 per cent to 1.95 per cent for couples earning more than $250,000. A 5 per cent tax would be levied on elective cosmetic medical procedures.

What about the claim that health care will consume 20 per cent of GDP by 2017?

First, it's worth noting that the Centres for Medicare and Medicaid Services, which made this claim, said pretty much exactly the same thing in 2006 (slightly different figures, same conclusion).

It's not true. A study in the journal Health Affairs, published in August 2008, found that covering all of the uninsured within the existing private-based US health-care system would increase national spending on health care by $122.6bn, which would represent a 5 per cent increase in health-care spending, amounting to 0.8 per cent of GDP. It included the caveat that the details of the plan could push government spending higher.

Dr Leonard Rodberg, a US academic, gave testimony to the Congressional Forum on National Lessons for Health Reform in April this year. He argued that a single-payer national health insurance plan would not cost the US any more than it was already spending, while providing every American with comprehensive health care and building in mechanisms to contain future growth in costs.

On the subject of rising costs, the Kaiser Family Foundation found that family insurance premiums (currently paid partly by employers and partly by the employee) will average $30,800 by 2019, if increases stick to the average of the past ten years. This year, the average premium for a family policy offered at work was $13,300, up from $5,800 in 1999.

The money behind the scenes

America's lobby groups are notoriously powerful, and the health-care industry is a big hitter. It has spent hundreds of millions of dollars this year alone.

Most of this goes on donations to strategically important politicians. Senator Joe Lieberman, an independent who caucuses with the Democrats, has received more than $110,000 in donations from a single health insurance company, Aetna, this year alone.

There are six registered health-care lobbyists for every member of Congress.

Meanwhile, the Obama administration has been offering financial incentives of its own. The government will fund Medicaid, the insurance plan for the poor, in Nebraska -- led by Senator Ben Nelson, one of the most conservative Democrats -- at a reported cost of $100m.

It has also been reported that Vermont will receive $600m over ten years, while Massachusetts will receive $500m.

 

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Samira Shackle is a freelance journalist, who tweets @samirashackle. She was formerly a staff writer for the New Statesman.

A pro-union march in 2014. Photo: Getty
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The legacy of sectarianism is still poisoning the air of Scotland

Ruth Davidson has reinstated two Stirling councillors who posted anti-Catholic and racist messages on social media. That this kind of cretinous guff still goes on in my hometown in 2017 raises my hackles.

Kenny Dalglish was a bluenose: as a boy in the mid-60s, he and his father would make the short journey to Ibrox to cheer on Rangers, then Scotland’s most successful team. With the football allegiance came a cultural one, too. Or, probably, the other way round.

Wee Kenny could play a bit, obviously, and dreamed that his beloved Gers would sign him up. But, as Richard T Kelly writes in Keegan and Dalglish, his enjoyable new double biography of the two footballing greats, "Rangers had a certain preference for big lads, or else lads with an obvious turn of pace; and Dalglish, despite his promise, had neither of those easy attributes."

Rangers’ loss was Celtic’s gain, but it took some effort. The former, writes Kelly, "was the club of the Queen, the Union, Scotland’s Protestant majority… founded by Freemasons and members of the Orange Order, strongly tied to the shipyards of Govan. Glasgow Celtic was the team of Irish Catholic patriots, revolutionary Fenians and Home Rulers, begun as a charitable organisation… a means to bolster the faith and keep the flock out of the clutches of Protestant soup kitchens. It was going to be a serious step across a threshold for Dalglish to accept the overtures of Celtic."

In the end, Jock Stein dispatched his number two, the unhelpfully named Sean Fallon, to meet the young starlet’s family. "Fallon entered a domestic environment he felt to be 'a bit tense' -  a Rangers house, a lion’s den, if you will. Fallon even picked up the sense that Bill [Dalglish’s father] might rather his son pursue [an] apprenticeship in joinery."

The deal was done ("My dream was to become a professional footballer – the location was just a detail," Dalglish would later say) and the most gifted player Scotland has ever produced went on to make his reputation kitted out in green and white stripes rather than royal blue -  a quirk of those difficult times for which those of us classed as Fenian bastards rather than Orange bastards will be forever grateful.

Growing up in west and central Scotland, it was hard to avoid being designated as one type of bastard or the other, even if you supported a team outwith the Old Firm or had no interest in football at all. Thanks to 19th century immigration, the terrible religio-political divide of Ulster was the dominant cultural force even in Stirling, the town around 25 miles from Glasgow where I grew up and where I now live again. If you went to the Catholic school, as I did, you were a Fenian; if you went to the Proddy (officially, non-demominational) school, you were a Hun. You mostly hung around with your own, and youthful animosity and occasional violence was largely directed across the religious barricades. We knew the IRA slogans and the words to the Irish rebel songs; they had the UVF and the Red Hand of Ulster. We went to the Cubs, they went to the Boys’ Brigade. We got used to the Orange Walks delivering an extra-loud thump on the drums as they passed the chapel inside which we were performing our obligatory Sunday observance.

At the time – around the early and mid 80s – such pursuit of identity might not have been much more than a juvenile game, but it was part of something more serious. It was still the case that Catholics were unemployable in significant Scottish industries – "which school did you got to, son?" was the killer interview question if your answer began with "Saint". This included the media: in the late 90s, when I joined the Daily Record – the "Daily Ranger" to Celtic fans (its Sunday sister, the Sunday Mail, was known to Rangers fans as the "Sunday Liam") – vestiges of this prejudice, and the anecdotes that proved it, were still in the air.

The climate is undoubtedly better now. Secularisation has played its part - my own daughters attend non-denominational schools – even if, as the sportswriter Simon Kuper has observed, many are "not about to give up their ancient traditions just because they no longer believe in God". The peace process in Northern Ireland and important gestures such as the late public friendship between Ian Paisley Sr and Martin McGuinness have made a difference. And I suppose the collapse of Rangers as a footballing force, amid financial corruption that saw them dumped into the bottom tier of Scottish football, helped.

But the sensitivity remains. The 2014 Scottish independence referendum broke down in part across tribal lines, with many Celtic supporters, once Labour, now SNP, loudly backing a Yes vote, while Rangers fans were on the No side. The prospect of Brexit creating a significant border between the north and south of Ireland, which could inflame recently and shallowly buried tensions, makes one shudder. And even locally, the old enmities continue to raise their grubby heads. Ruth Davidson, leader of the Scottish Tories, is currently taking flak for allowing the reinstatement of two Stirling councillors who had posted anti-Catholic and racist messages on social media prior to their election. The pair have apologised and agreed to take part in diversity training, but I confess that this kind of cretinous guff still goes on in my hometown in 2017 raises my hackles. The rawness remains.

That this is so was brought to me a few years ago when I filed a column containing the word ‘sectarianism’ to a Scottish newspaper. Though the context had nothing to do with Catholic/Protestant or Celtic/Rangers, the editor asked me to remove it. "It’ll be deliberately misunderstood by one side or the other, and probably both," he said. "It’s not worth the hassle. In Scotland I’m afraid it never is."

Chris Deerin is the New Statesman's contributing editor (Scotland).