Earlier this month, the Wall Street Journal Health Blog reported on several anti-smoking groups waging a campaign against Rango, a Paramount Pictures animation about animal characters in a Wild West town. In one scene, a character swallows a cigar and burps fire into the face of another character. Seemingly harmless fun in the world of animation, right? Well, not everyone thinks so… and the burping fire and possible physical scarring isn’t the issue here.
Smoke Free Movies, the American Legacy Foundation, the Campaign for Tobacco-Free Kids, and the American Academy for Pediatrics have rallied against the portrayal of smoking in Rango and other films marketed to children. (SceneSmoking provides a tally of the number of “smoking incidents” – over 50 – in Rango.) The groups maintain that exposing children to smoking on the silver screen leads to smoking in real life; thus, such films should have an R-rating. Rango is rated PG “for rude humor, language, action, and smoking.”
In response to the release of Rango, Cheryl Healton, CEO of the American Legacy Foundation, stated that
[t]he public health community has made great progress in making every studio aware of the harm to America’s youth when they release films with smoking and animated films are no exception…. Even the cartoon Joe Camel has long been barred from reaching children to sell cigarettes. So it is a mystery why Hollywood’s masters of storytelling and visual effects have not found a better way to depict their characters without the danger of influencing young people to light up.
Similarly, Smoke Free Movies took out a one-page advert in Variety and The Hollywood Reporter criticizing Paramount Pictures and the film industry for the depiction of tobacco use in Oscar-nominated films and citing National Cancer Institute research connecting silver screen exposure to an increased likelihood of real-life smoking. Stanton Glantz, director of the Center for Tobacco Control Research and Education at the University of California-San Francisco (and head of Smoke Free Movies), said “[a] lot of kids are going to start smoking because of this movie.” On the other side, Virginia Lam, a Paramount Pictures spokeswoman, replied that “[t]he images of smoking in the film, which primarily involves the animals, are portrayed by supporting characters and are not intended to be celebrated or emulated. Rango [the title character] is never depicted as smoking.”
So are these anti-smoking groups overreacting or must the Motion Picture Association of America (MPAA) reevaluate its ratings system? In August 2010, the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report printed some research that found “[e]xposure to onscreen smoking in movies increases the probability that youths will start smoking. Youths who are heavily exposed to onscreen smoking are approximately two to three times more likely to begin smoking than youths who are lightly exposed.” (Note Prof. Glantz contributed to that report.) USAToday has reported that “[o]f more than 2,500 movies rated from May 2007 to May 2010, nearly three-fourths of those that depicted smoking were rated R, and instances of smoking in films not rated R have declined” though this is not enough for the anti-smoking groups.
So what is the difference between a PG-rated film and an R-rated film? According to the MPAA, a PG-rated film requires
investigat[ion] by parents before they let their younger children attend. The PG rating indicates… that parents may consider some material unsuitable for their children, and parents should make that decision. The more mature themes in some PG-rated motion pictures may call for parental guidance. There may be some profanity and some depictions of violence or brief nudity. But these elements are not deemed so intense as to require that parents be strongly cautioned beyond the suggestion of parental guidance. There is no drug use content in a PG-rated motion picture.
(Emphasis added.) On the other hand, an R-rated film will
contain some adult material. An R-rated motion picture may include adult themes, adult activity, hard language, intense or persistent violence, sexually-oriented nudity, drug abuse or other elements, so that parents are counseled to take this rating very seriously. Children under 17 are not allowed to attend R-rated motion pictures unaccompanied by a parent or adult guardian. Parents are strongly urged to find out more about R-rated motion pictures in determining their suitability for their children. Generally, it is not appropriate for parents to bring their young children with them to R-rated motion pictures.
(Emphasis added.) Elizabeth Kaltman, a spokeswoman for the MPAA, told TheWrap that
underage smoking has always factored into movie ratings, but as of May 2007, all smoking is included as a ratings factor, along with language, nudity and other adult content. Kaltman adds that movies depicting smoking in a fantastical rather than realistic manner are more likely to receive slack on the ratings front.
As for Smoke Free Movies’ suggestion that smoking and the PG rating don’t mix? Kaltman notes that the purpose of the ratings system is to provide parents with information, not to service activists.
People younger than 18 years can’t buy cigarettes. Tobacco companies should not target children and teenagers. Should the same rules apply to tobacco use in films? How much responsibility should be imposed on the MPAA (whose rating system has been called into question by This Film Is Not Yet Rated and others) and how much responsibility should rest with parents who can choose not to take their children to a film with smoking in it? What about re-runs of television shows from the 1950s, 1960s and 1970s which show people smoking? Should Popeye, Maxwell Smart, and Lieutenant Columbo lose their pipe, cigarette, and cigar? As a kid, I saw re-runs of shows with these characters and I didn’t become a smoker. Should such shows be banned from television all-together so children aren’t exposed to smoking or only aired after 9pm to limit the chance of exposure? Where and when do we draw the line?
Filed under: Private Insurance, Proposed Legislation, Public Plan
On January 8th, 2010, the Alliance for Health Reform and The Commonwealth Fund co-sponsored and moderated a panel discussion on the health insurance exchanges that are being proposed in both the House and the Senate health reform bills. The panel consisted of Washington and Lee professor Timothy Jost, John Kingsdale of the Massachusetts Commonwealth Health Insurance Connector Authority, and Philip Vogel of the Connecticut Business and Industry Association (CBIA), which runs the non-profit CBIA Health Connections, a health insurance exchange for the state of Connecticut.
The co-sponsors have uploaded all of the event’s materials, including a webcast of the entire event, as well as all of the powerpoint slides and papers. All of this information can be found here.
Professor Jost and the Commonwealth fund created detailed charts comparing the differences between the two bills. Below is a reproduction of Professor Jost’s chart, which can be viewed by clicking on the thumbnails.
Both the House and the Senate bills would create new health insurance exchanges that would help consumers and employers navigate the purchase of health insurance. Though the common thread of a regulated marketplace runs through both bills, all three panelists noted the stark difference in the vision and implementation of the exchanges under the respective bills.
Below are some of the key distinctions between the two bills.
The House Bill — Public Option with Opt-Out Possibility
The House’s bill, H.R. 3962 (click here for entire pdf) provides for a federal exchange that would essentially eliminate the individual marketplace for health insurance going forward. A public plan would be offered that would reimburse providers at negotiated rates between those of Medicare and commercial rates. The applicable section of the House’s bill is Title III, entitled Health Insurance Exchange and Related Provisions.
Title III of the House Bill would create the Health Choices Administration with a Commissioner who would oversee the exchange. Citing Section 301 and 308 of the Bill, Professor Jost notes on page 17 of his paper:
The exchange operates at the national level, established within a new Health Choices Administration. The Commissioner of the HCA can, however, permit individual states or groups of states to administer an exchange within their territory in place of the national exchange if specific requirements are met, subject to revocation if the state ceases to meet the requirements of the bill. Even if the HCA delegates exchange authority to a state, the Commissioner retains enforcement authority and can further specify functions retained by the Commissioner and not delegated.
Thus, the House’s bill would create an exchange system that is fairly centralized and regulated, but with added flexibility. If the states fail to implement their own exchange then HHS will implement an exchange for them. Only those policies considered “grandfathered” could be sold outside of the exchange, and such “grandfathering” can only occur in the individual market. (See Section 202). Insurance offered inside the exchange would fit into one of four tiers: basic, enhanced, premium, and premium plus. (See Section 303). These tiers would correspond to different actuarial values of the plans. Subsidies would be provided on a sliding scale that is determined by the purchaser’s income.
The House bill would also limit the medical loss ratio of plans offered in the exchanges to 85 percent, largely prohibit the rescission of contracts, eliminate lifetime coverage limits, eliminate pre-existing condition exclusions, as well as require guaranteed issue and renewal of plans. Variations in premiums based on the age of the insured could only vary by a maximum of 2:1.
Not all of the panelists agreed with every provision. For example, Mr. Vogel took issue with the dependence on the medical loss ratio in regulating the market, instead arguing for a greater reliance on the “claim dollar” as a guide post.
Whether offered inside the exchange or grandfathered, all plans must meet certain requirements in terms of essential benefits, which would be determined by HHS, and would be based on the recommendation of the Health Benefits Advisory Committee–a public/private hybrid entity.
- Click here to jump to section 223 outlining the Health Benefits Advisory Committee
These benefits would include hospitalization, outpatient care, prescriptions drugs, equipment, and a host of other benefits.
- Click here to jump to the section 222 which details the essential benefits.
The House bill would also impose rules regarding the transparency of the plans offered in the exchange by requiring certain information about the plans to be disclosed.
The Senate Approach — No Public Option; Multistate Substitute Would Exist
For whatever reason, the Senate crafted a more complicated framework of exchanges.
A crucial point of divergence from the House bill is the Senate bill’s lack of a federally financed public plan offered through the exchange. However, as discussed below, part of the Senate plan attempts to act as a substitute. Another area of divergence is that existing individual and group plans may continue alongside newly created exchanges, in addition to any grandfathered plans. This is in stark distinction to the House bill that would eliminate some existing policies. Though as noted, the House bill would allow for some grandfathering.
The Senate’s exchange framework is based on section 1001 of the bill which provides that HHS will, with the help of the National Association of Insurance Commissioners (NAIC), craft standards regarding the minimum benefits and other aspects of the plans sold through the various exchanges.
In terms of the Senate’s framework for exchanges, it is as follows. The Senate bill will allow for a number of exchanges that would exist on variety of different governmental levels. Whereas the House bill envisions a more federal exchange system, the Senate bill would instead allow for state-based exchanges, multistate exchanges (i.e. regional), or substate exchanges.
- Click here for a pdf version of Senate bill, as passed.
For the individual and the small group markets, the Senate bill would require each state to create a American Health Benefit Exchange for individual purchasers of insurance, and a Small Business Health Options Program (SHOP) for small businesses purchasers. HHS would regulate these exchanges (See section 1321(a)(1)). These exchanges would be governed by regulations promulgated by HHS, unless the states adopt alternative standards that the HHS finds acceptable.
The state may combine the individual market exchanges with the small business (SHOP) exchanges. Additionally, states have the flexibility to establish regional exchanges or smaller subsidiary exchanges that target specific geographic areas within the state. (See Section 1311(f)). If the states do not create a system of either separate exchanges for individuals and small business, or some combination, HHS will establish an exchange or utilize a non-profit insurer to fill the void. See 1321(c).
The multistate exchanges are important, as they may mollify those who have been touting the idea of interstate health insurance offerings as a panacea for the woes of U.S. health insurance.
Regardless of how any states’ exchange(s) plays out, many of the important provisions of the Senate’s bill such as certain minimum benefits, the ban on lifetime or annual dollar limits, the ban on rescission, and medical loss ratio requirements would apply across the landscape of exchanges.
State Opt-Out Possible
Under the Senate bill, the states would be eligible in 2017 to opt-out of the federal requirements listed above if they can demonstrate that they are providing affordable coverage that is at least as affordable and comprehensive as the Bill requires. Alternatively, the state may be allowed to create a “public health plan” for those under 200% of the federal poverty level. Under this arrangement, the federal government would compensate the state for 95 percent of what would have been provided through premium tax credits as well as cost-sharing reduction payments. (See Section 1331).
Multistate plans: A Compromise?
One major amendment passed on December 24th was section 1334 which amended section 1333 which dealt with multistate exchanges. Under section 1334, The Office of Personnel Management (OPM)–the agency that governs the federal employees health benefit program (FEHB)–will enter into contracts with insurance carriers to offer at least 2 multistate plans through each exchange in each state. (See 1334(a)(1)). These plans will cover the individual and small group market. At least one of those plans must be a non-profit insurance plan, and must be in accordance with the general standards set forth for health insurance plans.
Though there would be a minimum level of benefits and protections required for all plans, the States would be entitled to offer multistate plans with more substantial benefits. However the state will have to defray the costs of the additional benefits.
Unlike the House bill which eliminates the state-based individual market, the Senate bill envisions exchanges that would co-exist with both the individual and small-group markets, and operate under the same rules. Though the Senate bill allows for flexibility, the subsidies provided by the federal government could only apply to insurance plans sold through the exchange.
One of the most important and controversial sections of the amended Senate bill is section 1334(a)(4), which specifies that, in administering the multistate plan, OPM will have the same bargaining power as they currently have for plans offered in the FEHB. Thus, OPM would be able to negotiate for a specified medical loss ratio and profit margin, as well as specified premium rates and any other terms in the “interest of the enrollees.” The goal is for these plans to be offered nationwide. Whether the OPM-run exchange will succeed is obviously yet to be determined, but some like Professor Timothy Jost are worried that the Senate’s plan to allow some plans to operate outside of the exchange complicates the federal government’s job in risk adjustment.
Filed under: Medicare, Proposed Legislation, Public Plan
A little while back Senator Joseph Lieberman stated that, seemingly contrary to his prior positions, he would not–and could not– support a bill which contained a public option–nor would he join in a vote to end a filibuster against the same. Relying heavily on the underlying analysis of Tim Noah, I opined at the time that perhaps we all needed to send Joe Lieberman a dollar so that he could vote his conscience as opposed to the will of Private Insurers: that the financial constraints involved in being an Independent (i.e., little or no infrastructural help from either the Democratic or Republican Parties) meant that Senator Lieberman, if he wished to continue being Senator Lieberman, would have to curry favor among donors to finance a bid for re-election.
I also noted that Chris Dodd, by virtue of his support for a public option and health reform in general, had alienated said Private Insurers and seemingly vacated his seat as “the Senator from Aetna.” I also noted that, as one might imagine, considering the sudden advent of available Aetna money, that a man (or Senator) from Aetna’s home town seeking money (such as Mr. Lieberman) might, somewhat understandably, look to align himself with the will and desires of that money. As much as it pains me to say, my antidote–sending Joe Lieberman a dollar with the words “Public Option” written on it– did not work. Sadly, the efforts of Yale students, who took a concilliatory approach in beseeching Senator Lieberman to back health reform, have seemingly not worked either.
Since then, Mr. Lieberman has come out in opposition to the plan to allow people from 55-64 years old to buy into Medicare. Unfortunately for Mr. Lieberman, he seems to be unaware of YouTube as a means of chronicling statements made on video. Back when he was attempting to explain his desertion of the Public Option he said (thank you Merril Goozner) this:
Filed under: Health Care Economics, Proposed Legislation, Public Plan
Thomas (Tim) Greaney
Saint Louis University School of Law
So maybe the two parties are coming together on health reform after all. Last night we learned that after days of “secret talks” among the “gang of ten” the Democrats have reached agreement to restructure their health care proposal. The changes are significant:
- ditch the already-watered-down public option plan;
- create a new insurance exchange “option” for individuals and small groups consisting of a nonprofit plan as negotiated by the Office of Personnel Management;
- expand Medicare eligibility to cover uninsured individuals aged 55-64.
What does the Democrats’ “public option ultralight” compromise have in common with Republicans’ alternative universe? Well, consider the latter’s proposal to open interstate competition for all health insurers–a move they promise will immediately lower health care costs. Besides being shameless attempts to offer simple solutions to complex problems, the two proposals are guilty of the same fundamental misunderstanding of health insurance. Simply put, they both ignore a critical economic truth of health insurance today: insurers require a provider network of hospitals and doctors or must have market leverage in order to negotiate for lower provider prices and for controls on excessive volume.
How, then, would a nonprofit insurer not presently competing in one of the concentrated markets succeed in putting competitive pressure on the incumbents? As one insurance industry observer put it ,
So, Kaiser Permanente, which operates with highly organized and capital intensive networks in its markets, would now come into a state where it has no networks and offer a plan? Blue Cross of Nebraska might offer an individual and small group plan in Rhode Island? Tufts Health Plan out of Boston might offer a plan in Oregon?
Based upon what network of providers in those places where they do not now do business?
Likewise, in expanding Medicare, the Dems are taking a page out of the Republican playbook. For the last several weeks, Senate Republicans have been loudly touting the benefits of Medicare. By their lights, not only does the program produce unmatched (and untouchable) health care services in terms of quality of care and beneficiary satisfaction, but any cost-cutting constitutes a betrayal of our commitment to seniors. As far as one can tell, the expansion proposal will do just that: offer the now-sacrosanct program to a few million almost-seniors. As to the other 20 million citizens, forced to shop for insurance through an exchange flawed by inadequate competition and inadequate subsidies? Well, maybe the Democrats will borrow the rhetoric of Republican National Chairman Michael Steele: this is no time for a “government-run health-care experiment.”
Filed under: EMR, Proposed Legislation, Public Plan
I had the opportunity to speak with one of our Health Law professors from private practice the other day (some professors teach full time, others teach only part time in addition to working full time as attorneys or judges), and he had been practicing (and teaching) health law for decades. He was both amazed and incensed: at our inability as a country to have a reasonable discussion about health care; that a provision to remunerate consultations regarding end of life issues somehow turned into “pulling the plug on grandma” and “death panel” sound bites–from people who should (or do) know better; and that people somehow believe that “rationing” doesn’t exist right now in the for profit health insurance system. “They speak as though their insurance policies are unlimited. They are not. There are insurers denying coverage all the time.”
This article in the New York Times’ Prescriptions won’t make him feel any better. It regards a recent chain email which tells of the impending forced implantation of microchips into patients as part of a government sponsored health plan.
…fears of death-panel bureaucrats voting to euthanize elderly Americans may pale in comparison to the latest fright point: according to a widely forwarded chain e-mail, the Democrats’ health care bill would require anybody who enrolls in a new government-run health insurance plan “to have a data-receiving microchip implanted in their bodies.”
The assertion would seem to tie together policy points from both the House-passed health care measure, which would create a government insurance plan, or public option, and the economic stimulus measure earlier this year, which approved billions of dollars for health information technology.
The widely distributed email is said to have prompted House Speaker Nancy Pelosi to issue a Myth Buster fact sheet:
Myth: People who enroll in the public health insurance option will be forced under the law to have a microchip implant.
Fact: The Affordable Health Care for America Act does not have any provision requiring any person to have a microchip — or anything else –implanted on their bodies for any reason.
The Times also notes that “Ms. Pelsoi’s office also noted that “PolitiFact — the Pulitzer-prize winning Web site — labeled this claim a ‘Pants on Fire’ lie, its highest degree of untruth.”