Public Plan
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)
The Good, the Bad, and the Stupid in Yesterday's Public Option Debate
Published September 30, 2009 @ 12:01AM PT
Yesterday was public option day in the Senate Finance Committee mark-up, as amendments by Sens. Rockefeller and Schumer that would have created public health insurance options for the Baucus bill were debated for hours before going down to defeat. Outlets like Huffington Post and the Politico promised everything short of actual bloodshed in a Democrat vs. Democrat battle royale. But that didn’t even remotely happen. Instead, we got an honest-to-God debate. But senators will be senators, and there was some inanity to be had as well.
These were weighty issues, and they got the consideration they deserved. From Sen. Rockefeller’s impassioned arguments that private insurance companies have treated the American people so badly that they need and deserve the security of a public option; to Sen. Grassley’s stern admonishment against introducing a player into the marketplace who could come to dominate it; to Sen. Schumer being the first politician I’ve heard yet make the argument that those already with insurance would see lower costs due to the competition from a public option, there was much matter here.
For a sampling, check out Sen. Rockefeller’s argument and questions for the Senate Finance Committee policy staff:
Good stuff! Tough questions! And no willful ignorance in sight. Sadly, the whole day did not match this level of erudition. Also demonstrated during the proceedings is that some of our senators aren’t quite masters of reading comprehension.
Sen. Kent Conrad had to go and ruin the erudition when, once again, he held up France as an example of universal health care that works even though it’s not government-run. Conrad seems to have preposterously newly gotten this observation from T.R. Reid’s new book, which he read just a few weeks ago. To which I say, Senator, please stop skimming! (Regular readers of this blog will remember that French citizens are covered for public hospitals and most doctors through the government-run program Sécurité Sociale, which the supplement with complimentary private insurance on top). Weirdly, this complete misreading of the French system served as the basis for Conrad voting against both public option amendments, even when his initial complaint of too-low Medicare rates for the Rockefeller version was sated by the Schumer version.
Similar, opponents of the public option constantly cited a study that suggested that millions -- no, tens of millions -- no, hundreds of millions would sign up for a public option, leading to the crumbling of private insurance. Of course, this was not the projection of the Congressional Budget Office, the authoritative estimated numbers which Sen. Kyl later referred half-jokingly as “our holy grail.” The CBO projects only 10, maybe 15 million people would sign up for a public option, were it offered alongside equivalent private insurance plans in the Health Exchange for individuals and small businesses.
No Sens. Grassley et al. were quoting the Lewin Group’s analysis of a public option, which dramatically estimated 103.4 million people would enroll in it, with 83.4 million leaving private insurance to do so. There’s a huge problem here -- well, two, really. That Lewin Group model presumes the public option would be available to everyone, but it’s not. Only small businesses and individuals can sign up for it. It also presumes that the public option pay providers based on Medicare rates -- something the Rockefeller version would do for two years only, and the Schumer version would never do. In short, the entire model does not apply to what they’re talking about. You won’t hear Grassley or Hatch or Ensign or anyone else quote the other set of numbers from the Lewin Group -- the ones that more accurately model the proposal in the amendments and conclude 78% of people in private insurance now would stay right where they are, with a modest 33.6 million enrolling for the public option. This despite the fact that it’s in the exact same report!
Oh, and by the way, I’ve made this plea before, so I may as well copy it verbatim: “please, please, for the love of God, please find someone else to crunch your numbers. The Lewin Group is a wholly-owned subsidiary of Ingenix, the database company that provides information on provider rates for most of the major insurance companies, and is itself a division of UnitedHealth, the nation’s largest insurer.”
Yesterday’s Senate Finance Committee showed several members at their best. It also showed several members flunking basic reading comprehension.
So let me ask you -- how nervous should we be that the latter group of senators were the ones who successfully voted down the public option amendments?
The Public Option: Wanted, Dead or Alive
Published September 29, 2009 @ 05:28PM PT
If you could pick one day to stay home from work for the purposes of watching C-SPAN, today should have been it. For five hours, the members of the Senate Finance Committee considered two amendments that would have added a public health insurance option to the Baucus bill, one by Jay Rockefeller (WV) and one by Charles Schumer (NY). Both amendments failed, but there are at least three other opportunities for a public option to come out on top. And the inescapable fact is that more and more Democrats are facing their do-or-die moment -- and choosing the public option.
The box score: Rockefeller’s version, which would have used Medicare rates for providers and hospitals for two years to jump-start the plan, and then segue to negotiated rates like any other insurance plan, failed by an 8-15 vote. Schumer’s version, which uses negotiated rates from day 1, similar to what’s in the Senate HELP bill and the most recent version of HR 3200, failed by a 10-13 vote. No Republicans vote for either amendment, and neither did Sens. Blanche Lincoln (AR), Kent Conrad (ND), or Chairman Max Baucus (MT).
Meanwhile, in the non-Beltway version of the United States, Kaiser Family Foundation released yet another poll which showed that not only is the public option remain popular among the American people, it’s slightly more popular than health care reform in general. For months now, this tracking poll asks if people would favor “[c]reating a government-administered public health insurance option similar to Medicare to compete with private insurance plans.” In this latest poll, 58% responded in the affirmative. When asked if they think it’s “more important than ever” to reform health care, 57% say yes. Not bad for a public option that has been declared “dead” just about every week this summer.
Actually, the public option is less popular in Kaiser than in other polls, if you can believe it, including the New England Journal of Medicine poll which found 63% of doctors favored it -- a poll frequently cited by the Democrats on the committee today. Republican Senator John Ensign at one point asked why, if the public health insurance option was so popular, Democrats were having such a time getting to 60 votes. It was a confrontational question. But for all of its bravado (and his completely lame follow-up that “maybe it isn’t popular after all” -- you’re a senator; don’t tell me you’re not obsessively checking the polls, buddy), it’s the right question. Why excuse did the Democrats on the committee have for voting against it?
Well, Baucus, whose white paper on health care advocated a public option and who praised it today, still voted against it using the argument that he didn’t believe that it would pass in the Senate. It’s kind of a brilliant self-fulfilling argument, if you think about it. The next time I can’t finish a project on time, I’m going to try telling my boss, “I’m not going to finish this project because I believe it won’t be finished.” Conrad seemed most worked up about the fact that the public option would be government-run. He even went so far as to praise, once again, the French health care system for being entirely private -- a description sure to startle the French. As for Senator Lincoln, God only knows. She didn’t even attend the debate, and voted by proxy.
But I wasn’t surprised by any of those no votes. I will admit I was quite surprised by both Nelson (FL) and Carper (DE) voting for Schumer’s amendment, scarcely a few weeks after both suggested they’d only vote for a public option with a trigger. Bingaman (NM) was part of the “gang of six” who delivered an option-less bill, but he voted for both amendments. Two months ago, I would have put Cantwell (WA) in the “probably no” column. Today she was a co-sponsor of Schumer’s amendment. And my biggest surprise of the day is the announcement by Sen. Tom Harkin, new chair of the HELP committee, that he had the votes to “comfortably” get a public option passed in the Senate (if not yet enough to defeat a filibuster.)
We’ll see another round of “is the public option dead or alive” punditry after the events of today. But the one point that seems indisputable is it doesn’t matter what the Senate Finance Committee does or does not do -- the public option is necessary, it’s popular in Congress, popular in the White House, and popular across the country. As such, it can’t be counted out until the final vote is tallied.
(Photo credit: http://www.flickr.com/photos/jaytamboli/ / CC BY 2.0)
When It Comes to Laws, Understanding Is Better than Reading
Published September 27, 2009 @ 06:23PM PT
“Read the bill” was a common refrain at congressional town halls throughout August. I agreed with the general principle -- members of Congress should understand what they’re voting on before they vote on it. Regular folks should also be paying attention to the political process, if for no other reason than to learn whether their representative is putting their interest first. But reading the text is no guarantee that you’ll understand what you’re reading, as many frustrated American citizens also learned this summer. Reading the bill isn’t a good in and of itself. It's only a good if it yields understanding.
In fact, there are three distinct areas where the focus on "scripta sola" -- only the text of the bill -- actually harms our understanding of what’s going on in health reform.
1.) What the hell are they talking about, anyway?
I’ve lost count of the number of people who’ve said or written to me that “this is the worse legalese that I’ve ever read.” I’m always tempted to ask, “How many bills have you read before, exactly?” Legalese might not exactly be like reading another language, but it’s at least like reading Chaucer or Shakespeare -- if you’re used to reading or hearing it, it’s not that difficult. But as many a seventh grader has learned, getting to the “used to the language” stage can be a true pain.
That’s why we’ve seen so many viral emails spreading misinformation – it’s almost too easy to make your standard bill language sound vaguely menacing. Context clues are not much help when you don’t know the context in the first place.
2.) The text of the bill is only one part of the debate
The "read the bill" flare-up erupted this week into the debate that took up entirely too much of the first day of mark-up in the Senate Finance Committee. Traditionally, no matter if the chair is a Republican or a Democrat, he submits a “Chairman’s mark” for a bill. This presents the full content of the bill in plain English (or as close as they can get), and helpfully also highlights how these provisions are or are not different than current law. The amendments are similarly presented in plain English, argued in plain English, and adapted. After the process is over, the bill is translated into legal language. If there are any discrepancies, the plain English version prevails.
CBO Estimates for the Gazillionth Time that Public Option Saves Money
Published September 25, 2009 @ 11:05AM PT
OK, this is just getting plum silly.
You don't hear as much these days about how giving people the choice of enrolling in a government-administered insurance plan based on Medicare as one of many options in the Exchange marketplace will cause the end of private insurance as we know it (the Congressional Budget Office score predicting only 10-15 million people would enroll in a public option certainly put the damper on that myth). But you do hear all the time from Republicans and so-called moderate Democrats that "we can't afford a public option." They're playing on the confusion that "the public option" is the entirety of health reform, which it certainly is not. In fact, the public option is a net cost-saver. The Congressional Budget Office confirmed for the umpteenth time today that having it as part of health reform saves money for all of us.
To review, the CBO scored the Senate Health, Education, Labor and Pension Committee bill twice -- once with an employer mandate and public option and once without. They found that a health care package with employers sharing responsibility and including a public option cost $400 billion less one that didn't have those items. Then they scored just the public option in the initial draft of the House bill and found that having it saved money -- $150 billion less -- vs. not having it.
Still, the so-called "fiscal conservative" Blue Dogs have made the public option one of their chief complaints. They don't want to see the public option use reimbursement tied to Medicare rates and prefer that it negotiate rates directly with providers like any other insurance plan. In fact, they made this their major demand back in July when they held the House Energy & Commerce mark-up hostage. Ultimately, Rep. Waxman relented, the public option was modified in the way the Blue Dogs wanted, and the mark-up continued. Of course, as we move towards a full floor debate in the House, some prominent Blue Dogs like Mike "Take my pharmacy -- please!" Ross are saying they now won't vote for a bill with a public option regardless. Speaker Pelosi in turn has declared she'll submit her own amendment to reinstate the original version of the public option, including piggybacking off Medicare rates. Today, I see on Congress Daily that CBO has not only scored the public option again, but we can now compare whether the Pelosi option or the Blue Dog option save more money. The answer: the Pelosi option, overwhelmingly ($110 billion vs. $25 billion for the Blue Dogs).
OK. We get it! Using Medicare rates for the public option makes the whole package some $85 billion cheaper. But why should we care? Well, first of all, the public option, like any private insurance plan, is paid for by premiums from its customers combined with tax credits for low- and middle-income individuals and families that enable them to afford said premiums. As Ezra Klein points out, "the $85 billion reflects reduced federal spending on subsidies because premiums in the public plan will be lower. Savings to individuals and businesses paying lower premiums will be much larger than $85 billion, and politically, much more important." It's not just that it's cheaper for the government, it's cheaper for the customers -- and that's likely to have an influence on the costs for everyone in the Exchange by forcing the costs down for private insurance as well. That's what we mean by competition. Competition is not just an abstract good. It's good because it forces these insurance monopolies to give you a better deal.
It's not a surprise that CBO scores much better savings with a public option than without, and with a stronger public option than a weaker one, all while maintaining the number of people enrolling in the public option will remain modest. What is a surprise is that anyone is continuing to listen to the anti-public option rhetoric from the increasingly inappropriately named "fiscal conservatives" in the Democratic party. Put another way, when the hell did it become "fiscally conservative" to stubbornly insist that one of the most popular elements of health care reform cost more?
(Photo credit: http://www.flickr.com/photos/pixelspin/ / CC BY-ND 2.0)
Do We Dare Hope for a Senate Finance Committee Deal?
Published September 21, 2009 @ 05:16PM PT
The opening statements haven’t yet been read. The first amendment hasn’t been voted on. The spinning and posturing has regrettably only just begun. But for all that, might the Senate Finance Committee only be days away from completing their work and passing a bill out of committee?
I didn’t think so last week, but am beginning to be persuaded upon perusing the amendments to the Baucus bill. Yes, the total is now up to a staggering 564 proposed amendments. You’d think that would translate to weeks of work, especially given the theater of the Senate Health, Education, Labor and Pensions Committee mark-up, where Republicans requested -- and received! -- votes on amendments that the Democrats were willing to accept by unanimous consent. And granted, the glut of Republican amendments foredoomed to failure, either because they would dramatically weaken the ability of Americans to purchase high-quality, affordable insurance or because, well, they’re just silly (Sen. Hatch’s “letter U” amendment, or the request to change every instance of the word “fee” into the word “tax”) makes it seem like we have a long way to go. But there are some intriguing amendments from Republicans among the dreck – and the dreck can’t last forever.
The real reasons for optimism come from the either side of the committee room -- not just with Democrats but with Sen. Olympia Snowe. Looking at what these senators wish to change, we honestly don’t have that far to go to find a compromise that will net 12 or 13 votes, enough to pass out of committee. And that’s the key for momentum. We don’t necessarily need a deal that can pass the Senate or both Houses of Congress out of the next week or two. We just need a deal that can be passed out of committee. We need to keep the ball rolling.
Ezra Klein summarizes the differences as being about affordability, financing and the public option. Sen. Max Baucus himself opened the door to the affordability question, with his own amendment to increase subsidies by some $28 billion. We’ll see what that translates to in terms of a detailed proposal, but clearly he’s not feeling bound to the skimpy affordability provisions he negotiated with Republicans Grassley and Enzi during the “gang of six” meetings -- particularly since neither gentleman seems inclined to vote for the package they helped negotiate. Sen. Olympia Snowe’s set of amendments would also dramatically help increase affordability and access to the plans in the Health Exchange. There’s every reason for optimism. There’s a real deal to be had here.
Financing is, of course, more difficult. That excise tax on the most expensive health insurance plans is likely to stick around, at least through a Senate Finance Committee mark-up. But, counter-intuitively, that’s not a bad thing. Sen. Carper is the only Democrat to propose a new financing scheme, and it’s one that most members of the committee have already rejected. Sen. Rockefeller’s slight modification -- adding a cap itemized deductions for the wealthy at 35% (instead of 39%) -- may just provide the wiggle-room to make the excise tax less onerous; Baucus already seems inclined to make it happen. Barring a left-field crazy idea, there's a compromise to be had here, as well.
That leaves us with what this health reform fight always seems to boil down to: the public option. That will generate a hell of a lot of fireworks. But the fate of the public option won’t be sealed in the Senate Finance mark-up. There’s still merging the Finance and the HELP bill (which contains a public option), and then merging the Senate bill with the House bill (which also contains a public option). But we need a bill out of Senate Finance before we can even begin that mud-wrestling.
So two out of three controversial issues may actually be solved relatively easily -- at least enough for a bill to pass out of committee. Or it could be an epic legislative train-wreck. But on this eve before the politicking begins again in earnest, at least, there is cause for hope.
(Photo is in the public domain.)
