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.

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Erdogan’s purge was too big and too organised to be a mere reaction to the failed coup

There is a specific word for the melancholy of Istanbul. The city is suffering a mighty bout of something like hüzün at the moment. 

Even at the worst of times Istanbul is a beautiful city, and the Bosphorus is a remarkable stretch of sea. Turks get very irritated if you call it a river. They are right. The Bosphorus has a life and energy that a river could never equal. Spend five minutes watching the Bosphorus and you can understand why Orhan Pamuk, Turkey’s Nobel laureate for literature, became fixated by it as he grew up, tracking the movements of the ocean-going vessels, the warships and the freighters as they steamed between Asia and Europe.

I went to an Ottoman palace on the Asian side of the Bosphorus, waiting to interview the former prime minister Ahmet Davu­toglu. He was pushed out of office two months ago by President Recep Tayyip Erdogan when he appeared to be too wedded to the clauses in the Turkish constitution which say that the prime minister is the head of government and the president is a ceremonial head of state. Erdogan was happy with that when he was prime minister. But now he’s president, he wants to change the constitution. If Erdogan can win the vote in parliament he will, in effect, be rubber-stamping the reality he has created since he became president. In the days since the attempted coup, no one has had any doubt about who is the power in the land.

 

City of melancholy

The view from the Ottoman palace was magnificent. Beneath a luscious, pine-shaded garden an oil tanker plied its way towards the Black Sea. Small ferries dodged across the sea lanes. It was not, I hasten to add, Davutoglu’s private residence. It had just been borrowed, for the backdrop. But it reminded a Turkish friend of something she had heard once from the AKP, Erdogan’s ruling party: that they would not rest until they were living in the apartments with balconies and gardens overlooking the Bosphorus that had always been the preserve of the secular elite they wanted to replace.

Pamuk also writes about hüzün, the melancholy that afflicts the citizens of Istanbul. It comes, he says, from the city’s history and its decline, the foghorns on the Bosphorus, from tumbledown walls that have been ruins since the fall of the Byzantine empire, unemployed men in tea houses, covered women waiting for buses that never come, pelting rain and dark evenings: the city’s whole fabric and all the lives within it. “My starting point,” Pamuk wrote, “was the emotion that a child might feel while looking through a steamy window.”

Istanbul is suffering a mighty bout of something like hüzün at the moment. In Pamuk’s work the citizens of Istanbul take a perverse pride in hüzün. No one in Istanbul, or elsewhere in Turkey, can draw comfort from what is happening now. Erdogan’s opponents wonder what kind of future they can have in his Turkey. I think I sensed it, too, in the triumphalist crowds of Erdogan supporters that have been gathering day after day since the coup was defeated.

 

Down with the generals

Erdogan’s opponents are not downcast because the coup failed; a big reason why it did was that it had no public support. Turks know way too much about the authoritarian ways of military rule to want it back. The melancholy is because Erdogan is using the coup to entrench himself even more deeply in power. The purge looks too far-reaching, too organised and too big to have been a quick reaction to the attempt on his power. Instead it seems to be a plan that was waiting to be used.

Turkey is a deeply unhappy country. It is hard to imagine now, but when the Arab uprisings happened in 2011 it seemed to be a model for the Middle East. It had elections and an economy that worked and grew. When I asked Davutoglu around that time whether there would be a new Ottoman sphere of influence for the 21st century, he smiled modestly, denied any such ambition and went on to explain that the 2011 uprisings were the true succession to the Ottoman empire. A century of European, and then American, domination was ending. It had been a false start in Middle Eastern history. Now it was back on track. The people of the region were deciding their futures, and perhaps Turkey would have a role, almost like a big brother.

Turkey’s position – straddling east and west, facing Europe and Asia – is the key to its history and its future. It could be, should be, a rock of stability in a desperately un­stable part of the world. But it isn’t, and that is a problem for all of us.

 

Contagion of war

The coup did not come out of a clear sky. Turkey was in deep crisis before the attempt was made. Part of the problem has come from Erdogan’s divisive policies. He has led the AKP to successive election victories since it first won in 2002. But the policies of his governments have not been inclusive. As long as his supporters are happy, the president seems unconcerned about the resentment and opposition he is generating on the other side of politics.

Perhaps that was inevitable. His mission, as a political Islamist, was to change the country, to end the power of secular elites, including the army, which had been dominant since Mustafa Kemal Atatürk created modern Turkey after the collapse of the Ottoman empire. And there is also the influence of chaos and war in the Middle East. Turkey has borders with Iraq and Syria, and is deeply involved in their wars. The borders do not stop the contagion of violence. Hundreds of people have died in the past year in bomb attacks in Turkish cities, some carried out by the jihadists of so-called Islamic State, and some sent by Kurdish separatists working under the PKK.

It is a horrible mix. Erdogan might be able to deal with it better if he had used the attempted coup to try to unite Turkey. All the parliamentary parties condemned it. But instead, he has turned the power of the state against his opponents. More rough times lie ahead.

Jeremy Bowen is the BBC’s Middle East editor. He tweets @bowenbbc

This article first appeared in the 28 July 2016 issue of the New Statesman, Summer Double Issue