Obama and Congress
Democrats Borrow the Tea Party Approach
Published October 08, 2009 @ 10:59AM PT
Rachel Maddow just announced an amazing three-part Democratic strategy to ensure healthcare reform, and it’s an attention-getter (see the first 4:50 of the video clip.) We’re all fairly familiar with part three, using the reconciliation process to pass a bill with just 51 votes, instead of 60. But it’s the first two steps that borrow from the Tea Party approach.
It’s power broker time, ramping up techniques to dramatically increase political pressure for healthcare reform. That pressure is specifically aimed at 6 key Democratic senators who must allow a vote. What's the first step? Massive free health clinics in Arkansas, Louisiana, Nebraska, Nevada, and Montana. Hoping to shame senators Max Baucus, Mary Landrieu, Blanche Lincon, Mark Pryor, Ben Nelson, and Senate Majority Leader Harry Reid, doctors and nurses will donate their time to provide free care to thousands of the senators’ constituents who can’t afford it, making for a dramatic and heart-wrenching third-world spectacle. Houston’s recent clinic drew 1,500 people seeking treatment.
Second, if seeing thousands of their constituents in need of care doesn’t shame them, two major (and nameless) power brokers are encouraging a Senate strategy to revoke Democratic chairmanships if they block healthcare reform. Specifically, committee chairmen and sub-committee chairman who allow Republicans to force a 60-vote requirement, regardless of whether these chairmen ultimately vote in favor of the bill, will have their leadership positions revoked. Yep, that would be busting a Lieutenant Colonel down to Private in a very public demotion. It’s head-cracking time!
Last but not least, they will invoke the reconciliation rules. Just like the Republicans did to pass the $1.3 trillion and $350 billion Bush tax cuts. Apparently Republican Senator James Inhoff can’t remember that period in history, so it must have been in some other country. Maybe Canada?
Faulty Math in CBO Senate Healthcare Bill Analysis
Published October 08, 2009 @ 06:00AM PT
Well, the CBO definitely got one thing right in its financial analysis of the Senate Finance Committee’s health bill. In commenting on Kent Conrad’s nonprofit co-op idea, it wrote that they "seem unlikely to establish a significant medical presence in many areas of the country." I already shared my opinion on co-ops as destined-to-fail recycling attempts.
Other than that, though, here is their 10 year breakdown of the bill:
- Cost: $829 billion
- Benefit: $81 billion in reduced federal deficits
- Coverage: Increase from 83% to 94% of Americans
- Uninsured Reduction: 29 million
- Missing: $200 billion in Medicare physician payment increases
- Risk: 15% low-income subsidy cuts to abide by Obama’s budget-neutral failsafe mechanism
The SFC bill’s lower cost sent House Democrats scrambling to reduce HR 3200’s cost under the $900 billion limit set by the president, even though their plan would cover 8 million more people than the SFC’s. Part of their strategy may be to move 7 million low-income individuals onto Medicaid instead of providing subsidies for private insurance.
Which brings me to my point. They realized something most of us haven’t. Much of the budgeting exercise has been based on faulty math because the largest cost factor is an unknown – private insurance costs. Higher education provides a useful, though painfully similar, example.
Senate Finance Committee Weakens Insurance Exchanges
Published October 06, 2009 @ 06:00AM PT
Goings-on in Maine are taking a deserved media hammering this week. First Brave New Films puts out a hard-hitting clip about Wellpoint suing the state to increase its profits. Then it leaks out that last Thursday, Maine Senator Olympia Snowe was the main reason Massachusetts Senator John Kerry's amendment to strengthen insurance exchange consumer protections in the Senate Finance Committee (SFC) bill didn't pass. I'd hate to find out those two things are related.
First, a little background. Maine is a guaranteed issue state, meaning insurers may not deny you coverage based on health status. They must also offer policies with standard benefits, co-payments, and co-insurance, and may only exclude pre-existing conditions for 6 months (this is sounding pretty good, no?) Anthem, a Wellpoint subsidiary, in return asked the state of Maine to guarantee it at least a 3% profit margin off its just 12,000 members. Maine said no. So Anthem is suing the state.
Now, about Kerry's proposed SFC bill amendment. Called "Empowering State Exchanges to be Prudent Purchasers," it sought to protect consumers with stronger state standards for insurance exchanges. HR 3200 and the Senate HELP bill have these protections built in; the SFC bill creates more of a Wild West of insurance exchanges. Just what we need.
3 Recycling Blunders in Failed Healthcare Policy
Published October 05, 2009 @ 06:00AM PT
Washington, D.C. denizens have done it again. Under the guise of innovative compromise, they have recycled Bush Jr.’s failed “Great Healthcare Bailout of 2002.” Never heard of it? Well, bailouts weren’t the Hollywood stars then that they are today. They called them strategies instead. This one went straight into the failed policy bucket.
Observe: In 2002, Bush tried giving away $40 million in grants to high-risk pools "as part of the Bush Administration's broad strategy for expanding access to health care for the more than 40 million Americans without health insurance." Um, the plan was to spend $1 per person? Really? But I digress.
If You Don't Like What You Have... Tough
Published October 02, 2009 @ 04:02PM PT
If you’ve been anywhere near a TV these past two weeks when the goings-on at the Senate Finance Committee were discussed, you likely saw committee-member Sen. Ron Wyden of Oregon hocking something called the “Free Choice Amendment.” Last night, the amendment was dismissed without even the benefit of a vote. It took with it an opportunity to solve a major problem in the health care reform plan moving through Congress: how do we answer those who have stable benefits through their employer when they ask, “What’s in it for me?”
Of course, I would argue there are myriad ways that everyone's experience with health care will be better after reform: from more primary care doctors to investments in quality to the protections of insurance market reform. But I understand how those benefits may not feel immediate; many of them may take years before those who have good insurance already even noticed the system was better. But Wyden’s amendment would have been an immediate change for the better. The official mantra for the reform effort is the now cliché, “If you like the coverage you have, you can keep it.” But there’s never been an answer to the question, “What if I don’t like the coverage I have, but it’s all my boss offers me?” Wyden’s amendment would have fixed that, too.
The simplest explanation is that Wyden’s amendment would open up the Exchange to anyone who wanted it, rather than limiting it to individuals or businesses of a certain size. Your choice of health insurance plan wouldn’t be limited by who your employer wanted to negotiate with, and the coverage and costs wouldn’t be limited to how successfully your employer negotiated. You don’t want the unreliable customer service and hassles of Pain in the Butt Insurance? Go find a comprehensive plan that fits your needs on the Exchange, be it Aetna, United, or (dare we dream?) the public health insurance option. As Ezra Klein puts it, “If the Free Choice Act had passed, politicians could have made a very simple argument to the insured: When this bill becomes law, you will have insurance choices just like those enjoyed by a member of Congress or a government employee.” If you’ll recall, that’s the bargain Democratic candidates have offered the American people since John Kerry in ’04.
It’s a radical change, to be sure. But it’s one that would make the rest of the bill work better. The effectiveness of the Exchange depends on how many people are in it. The more people buying from it, the bigger the bargaining clout and the better deals we’d be offered. We’ve spent a lot of time arguing whether a public option should have negotiated rates or rates based on Medicare, but neither one of those choices would make a public option as strong as making it available to everyone. Critics of the amendment claim that it will lead to young, healthy workers spurning their employer’s plan, leaving behind a population of older sicker, workers, making the plan more expensive for the company, and increasing the temptation to drop it. Opening up the Exchanges, they argue, will lead to catastrophe for employer-based insurance. Maybe. I haven’t seen numbers to support this argument (the Congressional Budget Office thinks this result is pretty unlikely). But I’m personally unconvinced. Isn’t the much better answer to this concern to apply the consumer protections and insurance market reforms that are so highly touted -- including risk adjustment, not allowing companies to charge different rates based on health, and severely limiting variance in rates by age -- to employer-based insurance?
Wyden’s amendment fell not because Republicans don’t like it (Sen. John Ensign gave an impromptu speech in favor of it), and not because Democrats don’t like it, since many have often used the inherent inefficiencies and inequalities of the employer-based system when they’ve argued for a Medicare for All single-payer approach. No, the people who really hate it are special interests. “Employers don’t like it,” Jon Cohn writes, “benefits managers don’t like it, unions don’t like it -- in each case, because it means these groups have less control over, or stand to derive less loyalty from, workers over health care decision-making.” It's also one of the casualties of bending over to make the pledge "If you like what you have, you can keep it" as close to being fulfilled as possible. Ironically, the same catchphrase designed to assuage us that our coverage won't get worse is getting in the way of making our coverage better.
There is a silver lining in that Wyden is likely to try again from the floor of the Senate. And even if he fails there, too, this isn’t the type of idea to go away. Once we have a stable, functioning Exchange, it can always be expanded at a future date. And rest assured, if we’re only reserving choice and competition to those who are currently uninsured, it’s only a matter of time before the rest of us say, “Yo, what about us?!”
(Photo credit: http://www.flickr.com/photos/pirateyjoe/ / CC BY-SA 2.0)
Healthcare Reform Following the Football Playbook
Published October 02, 2009 @ 06:00AM PT
I’m a healthcare wonk in a year of unprecedented healthcare reform activity, very jaded by all the political gamesmanship that goes with it. So reading a recent Yahoo news story, I encountered lots of familiar themes.
There were comments on ridiculous votes, and how the archaic system is designed to protect power and allow cronies to fleece the public. Dan Wetzel, the author, bemoaned that policy is:
“… determined by a popularity vote from people who … [have] proven good for two things, voting based on marketing and reputation, and subscribing to a groupthink mentality that assures their ballot doesn’t stand out.”
Can't Make Your Policy Federal? Empower the States.
Published October 01, 2009 @ 05:54PM PT
It’s been a dominant theme in how Congress has handled health care since the creation of Medicaid. Can’t find a way to federalize your policy? Then downscale it to empower states to take it on themselves. That strategy was on full display today as members of the Senate Finance Committee, unable to overcome stiff resistance from a more-or-less unified Republican nay-saying, and the strangely conservative votes of one Sen. Blanche Lincoln, opted to kick it to the states. It’s like sending a baseball player to the minors -- flourish there, and you may actually make it back to the Big Show to become federal law.
Two amendments and one proposal yet to be drafted as an amendment made this “Empower the States” day in the Senate Finance Committee.
Sen. Ron Wyden (D-OR), a creative and progressive force on the issue of health care, got an amendment pass that might well be called the “You show us how it’s done” amendment. In the Baucus bill, states are given a certain amount of federal money to create the Exchanges. Rather than one big Exchange, each state has its own -- granting it greater autonomy in terms of design, making sure all plans abide by state-level regulations, etc. Wyden’s amendment takes it a step further. So long as the states create coverage for all of its citizens that’s as affordable, comprehensive and high-quality as an Exchange would have been, and has all the protections in terms of insurance reform and caps on out-of-pocket expenses that the plans in the Exchange would have had, and the legislature and the governor agree to apply for a waiver to the Secretary of HHS... you can do whatever you want.
So your state could create an Exchange, like Massachusetts. It could add the uninsured into the existing program for state workers and retirees, like Sustinet in Connecticut. It could create a state-level public option. Hell, it could create a statewide single-payer plan like many states (including New York) are already contemplating. Those with long memories will remember this was a scarcely-noticed but important provision of the Wyden-Bennett health care bill as well. It’s not just punting the tough decisions to the states. It’s giving them the ball and giving them the money to make it happen.
Not quite as comprehensive is the amendment by Sen. Maria Cantwell (D-WA), which passed with the support of all Democrats except -- you guessed it -- Lincoln. Washington State doesn’t have a public option or anything remotely like it. What they have instead is something called Washington Basic Health, where the most likely to be uninsured are eligible to purchase private insurance. Essentially, the State of Washington acts like a mega-employer, with the uninsured below 200% of the poverty line (about $44,000 for a family of four) as its “employees.” The state uses the size of its pool to negotiate great rates on premiums from four insurance companies -- much cheaper than this population could afford on the open market, with better coverage and smaller deductibles and out-of-pocket expenses. The individual or family gets to choose which plan they want.
Cantwell’s amendment allows states to set up their own version of Washington Basic Health. The rest of the Baucus bill already provides Medicaid for up to 133% of the federal poverty line, so this Basic Health plan would cover those between 133-200% where, as Sen. Cantwell notes, “75 percent of the uninsured population lives.” There would be extra protection for individuals -- participating plans would have to spend 85% of the cost of premium on health care, more stringent than plans in the Exchange. The state would get the subsidies that would normally go to individuals of that income range in the Exchange and use them to subsidize the cost of the Basic Health plans. On the plus side, this has dramatically saved money in Washington State, as they’ve negotiated for fantastic discounts. On the minus, if a state set up a Basic Health system of their own, people in that income window couldn’t opt-out and get a plan on the Exchange. The state gets the subsidies, not them. Plus Washington Basic Health itself is demonstrating the problem with relying on a state solution during a time of economic crisis. Go to its Web site and you’ll see a waiting list to get into Washington Basic Health and a warning of jacked up rates – both the results of the state’s fiscal crisis.
Finally, we’re hearing more and more of a proposal by Sen. Tom Carper to empower states to produce state-level public options -- a much less effective version that has popped up from time to time from the likes of Secretary Sebelius, Tom Daschle, and Bob Dole, among others. Carper’s exact plan is as yet vague, but it reinforces the trend of the day.
Relying on state governments for what you can’t push through at a federal level may have some downside, but its biggest upside is it allows the more progressive states the opportunity to lead. We could look to Canada, where their single-payer system spread province-by-province. But better examples are right here in the U.S. After all, Medicaid is set to federalize coverage to 133% of the poverty line -- a threshold that some states have already reached. The concept of the Health Exchange is liberally borrowed from Massachusetts (Utah has its own Exchange, and California tried to get one in its health care reform attempt in 2007-2008). Today’s minor league players may be tomorrow’s rookie of the year.
(Photo credit: http://www.flickr.com/photos/aurenh/ / CC BY 2.0)
