Public Plan
Then There Were Two - Senate HELP Votes Bill Out of Committee
Published July 16, 2009 @ 12:29AM PT
The Senate Health, Education, Labor and Pensions Committee voted along party lines to advance its bill for comprehensive health care reform to the floor of the Senate. This makes it the first of three – although the House will be working on its bill through 3 committees, they’ll be working on the same bill. There were lots of sage congratulatory words and even a pensive release from Sen. Ted Kennedy, who has not been able to attend any of the hearings or mark-ups in person because of his illness. But because so much of the week has been focused on what the President had to say or about the House bill, the Senate HELP proceedings have largely flown under the radar. So the obvious question is – how did they do?
Well, if you haven’t seen any of the mark-ups, let me show you the single best three minutes.
No, this isn’t a parody scene on The Office. Sen. Chris Dodd and the Democrats offered to accept without revision 65 amendments authored by Republican committee members. The Republican members didn’t want them accepted – they wanted votes. Why? Pretty much just to run out the clock.
And the kick in the pants is after scores of non-preposterous Republican amendments were accepted (check out some of the amusing ones here and here) were accepted, all the Republicans on the committee voted against the bill so they could loudly complain the process wasn’t “bipartisan.” Classy.
So how much did the bill improve or decline under this marathon month of mark-up? The short version is it’s largely the same bill, with changes so minute that I’m having trouble telling the difference. That’s a great thing, by the way – Dodd could easily have given away the farm for a bipartisan vote that would never have been forthcoming. The most intriguing amendment was a requirement that federal elected officials would be required to enroll in the public plan (called the “Community Health Insurance Option” in the bill) once it’s created. Republicans thought they were being clever when they offered it, but Dodd and others called their bluff. (For the record, I think this is a phenomenal idea -- I’d throw the whole Federal Employee Benefits Program pool in there while you’re at it!)
How different is the Senate HELP bill from what’s being worked on in the other committees? Well, we can’t compare it yet to the Finance bill, which doesn’t yet exist. The general structure of the House and HELP bills may not be identical twins, but clearly they’re fraternal. A lot of people say the HELP bill is watered down – certainly, the initial principles outline released by Kennedy was bolder than the detailed bill we actually have. The employer pay (contribute to a fund) or play (give your employees benefits) is weaker than what’s in the House: Wall Street Journal did some estimations and found that a 50-person company with a $2.5 million payroll would pay $200,000 as part of the employer mandate in the House bill, but only $37,500 in the HELP bill. The cost of premiums in the Gateway/Exchange for families at 400% of poverty is a little higher than the House. The cap on how much you spend out-of-pocket is higher, too. The eligibility for people to get their insurance through the Gateway/Exchange would be more closed (the Congressional Budget Office thinks we’d be talking 20 million+ in the Gateways instead of the 30 million + for the House, with those extra millions staying in employer-provided insurance). The “community health insurance option” would need to negotiate rates with providers from the get-go, meaning it’d take longer to set-up and would have less of an immediate effect on costs – although hey, the Senate HELP bill doesn’t suggest that it will push off creating a public plan until 2013, so it may be faster after all.
All true. But considering that the Senate is traditionally the place where a good reform goes to get crushed or die, it’s remarkable all the same that we’re really talking about degrees rather than a fundamentally different or even a gutted plan. The HELP bill’s new regulations on insurance is just as strong, its commitment to developing the provider workforce we need is just as strong, the ideas for improving quality for insured and uninsured alike are just as strong, and its focus on primary and prevention to transform us from a mediocre quality “disease care system” instead of a high-performing health care system is just as extensive.
The Senate HELP bill, for reasons of jurisdiction, can’t outline how it would pay for reform or modify anything relating to Medicare and Medicaid. But presuming Senate Finance sticks to the script, the CBO estimates it will cover 97% of Americans. You may or may not agree with the approach Congress and the President have taken, but it can’t be denied that this is a pretty significant milestone on the road to reform.
Jungle gyms and all.
Why Does the House Push Off Full Reform Until 2013?
Published July 15, 2009 @ 08:01PM PT
It is the single most frequently asked question I get about the new House bill, HR 3200: why doesn’t it make its major push to expand coverage until 2013? The top two bullet points on the House bill’s summary call for the creation of a Health Insurance Exchange and a public health insurance option. Yet according to a document obtained by The Treatment’s Jon Cohn, those elements won’t be open for business until Year Four. What’s going on here? And what can we expect to get right off the bat to make the health care we currently have better for the insured and uninsured alike?
My own guess is that we’re looking at two real problems of U.S. health care at work – one policy based, the other political.
The policy reason for delaying before opening up a Health Exchange where the uninsured and small businesses alike could purchase standardized, transparent and comprehensive plans – and where all businesses would be able to purchase plans by 2015 – reflects the state of our workforce, and the experience of Massachusetts. Giving everyone coverage does not guarantee there are adequate physicians, health care providers and facilities. In fact, we know there’s not -- shortages, particularly in primary care, are noticeable even today. Massachusetts, for all of its physician density, had rather lengthy wait times for a doctor’s appointment even before it pushed its reform. But once hundreds of thousands of people suddenly had coverage and began calling around, it could no longer be ignored.
The same is true of the U.S. as a whole – particularly if the legislation pushes primary care and prevention as much as the House bill, we’re going to hit a real snag waiting for enough primary care providers to tend to the 37 million+ who suddenly have coverage. Looking at the accomplishments scheduled for 2010-2012, they focus disproportionately on provider development: eliminating the SGR fix in Medicare; increasing primary care reimbursement for Medicare and Medicaid; more funding for the National Health Service Corps for primary care; and jump-starting the programs designed to increase our supply of doctors and nurses are all Year One (2010) priorities. Even the items unrelated to workforce development all have to do with delivery system reform. Community health centers get their investment right away, since they’re going to be important in the delivery of care in rural and out-of-hospital settings. Administrative simplification by regulation and Health IT start up right away. Programs to ramp up preventative care start right away. In fact, the delivery system reforms are the only piece of the puzzle that would all get accomplished in year one! Given the years that it takes to develop primary care doctors and even nurse practitioners, that still won’t be enough time. But any head start is a necessary one to prevent a dysfunctional disconnect between supply and demand.
The CBO Smiles on the House Bill (HR 3200)
Published July 15, 2009 @ 05:01AM PT
Basically, Henry Waxman, Charlie Rangel and George Miller did not want me to watch the All-Star Game tonight. What other possible reason could they have for dropping a 1,018 full bill version of HR 3200 – The America’s Affordable Health Choices Act on Tuesday night?
I have not yet read the full bill, but I have perused the many of the policy materials on the Education and Labor Committee blog, did a quick spot check of specific sections, and of course read the excellent commentary by Ezra Klein, Jon Cohn and Igor Volsky – who even includes putatively “sexy facts” in his chart break down of the features from the score by the Congressional Budget Office. The best part of the bill was how little surprised I was by its features. After all, it tracks very well to the draft House bill that was released weeks ago in terms of structure and features, and its mechanisms for new revenue were already telegraphed by Rep. Rangel of Ways and Means. It also comports along the same lines as the plan that all Democratic candidates – including Barack Obama – ran on.
The question was what would the Congressional Budget Office think? The House bill was always seen as more robust than either the version coming from Senate Health, Education, Labor and Pensions or Senate Finance – meaning it was anticipated to be more expensive. What would the CBO say it cost, and how many Americans would it really cover?
There’s a reason for looking at the CBO as a looming, potential threat to the viability of getting reform enacted. During the Bill Clinton effort, the CBO made the determination that all premiums paid to the network of private HMOs that formed the backbone of that plan should count as federal income. Even though it didn’t change the reality of how much money Clinton’s plan would have cost, it changed the political perception of his program as an unprecedented expansion of the federal government. A plan that was already reeling received a knockout blow.
One need only look at the miscommunication and brouhaha that arose a month and a half ago when the CBO released preliminary numbers on 2/3 of the Senate HELP bill showing it cost over $1 trillion over 10 years but would only cover a few million more people to realize a bad score could stop reform in its tracks.
That’s why it’s so gratifying that CBO has given the House a good score – indeed, better than I anticipated. In what are admittedly preliminary numbers – the bill may still change during markup and amendment, the CBO scores the complete House package as costing $1.042 trillion over 10 years, well under the $1.5 trillion or more anticipated by many. It would also be effective, with approximately 97% of Americans receiving coverage through public programs like Medicare and Medicaid, their employer, or through the Health Exchange transparent marketplace for comprehensive benefits, with its subsidy credits to make health insurance affordable as a fraction of your income.
The Public Plan Is a Cost-SAVER
Published July 10, 2009 @ 02:58PM PT
By far, the most aggravating question I've heard on whether we should give people the choice between private insurance and a robust, government-administered public health insurance option is “How would we pay for it?” I’ve heard from conservatives who gave me doom and gloom about how it would make the health care package even more expensive (and disingenuous statements like those from Sen. Lindsay Graham attributing all the cost of health care reform on the public plan). I’ve also heard from progressives who launched into an impassioned argument that it would be worth the cost because what it would do for quality and access. And each time, I’ve begun whacking my head against the wall.
Because the public plan would not add to the cost of health care reform. Indeed, it would save money. And the Congressional Budget Office, according to an exclusive report from The New Republic’s Jon Cohn, has my back on this.
Now the total health care reform package will have to involve new spending the federal government. Right now the government pays for only a fraction of health care costs. If the government assumes more of the cost for health care through subsidization, or even just commits to smart investments to improve quality, it can’t do that without raising new revenue or finding cuts elsewhere. We can – and will – debate whether it is worth the investment to do so (although given that you’re bothering to read a blog entitled “Universal Health Care,” I have a hunch on your likely answer.)
But the public plan within that package will not, in aggregate, add to that cost. The point of the public plan is that it’s a competitor. It exists alongside private insurance in the Health Exchange. It has the exact same subsidies from the Exchange as private insurance. It charges participants premiums, like the private insurance plans in the Exchange. But it doesn’t have the same aim as private insurance – instead of focusing on making a profit or satisfying investors, it focuses on making people healthier and making health care cheaper. By competing against private insurance on cost and quality, so the theory goes, we force private insurance to finally have an incentive to improve on both. If the public plan costs money from the Federal Treasury to set-up and operate – well, that would be the opposite of its intent.
Our first clue that the public plan would be scored as a cost-saver by the all important “umpires” at the CBO was when the revised Senate HELP bill, with a moderately strong public plan, an employer mandate and a well-defined individual mandate – came in nearly $400 billion cheaper than the initial score of the bill without these provisions. But the new House preliminary score is even better. As Cohn puts it, “preliminary estimates from the Congressional Budget Office suggest that a strong public option--the kind that the House of Representatives is putting in its reform bill--should net somewhere in the neighborhood of $150 billion in savings over ten years.” That is just for the public health insurance option itself – the first time we’ve seen a score on this feature. As many (including Ezra Klein) will note, that’s not as much savings as we would see if we had a public plan that was open to everyone, not just the uninsured and some businesses, or if we had a public plan that could rely on Medicare rates instead of negotiating rates with providers. As single-payer advocates will note, that’s also nothing compared to the administrative savings to be gained from a Medicare for All system over that same timeframe.
But it’s worth repeating again, and again, and again: having the public health insurance option doesn’t cost money. It saves money.
So the question for those looking to water it down, either with a “trigger” option to delay it, or a health co-op which may take years to net the same savings, or with some other system of compromised state-level or nonprofit plans that won’t achieve the same savings is – how can we afford the extra money for your compromise?
(Photo credit: Darren Hester on Flickr.)
"Hey, Wait a Second -- This Bill Sucks"
Published July 08, 2009 @ 10:05PM PT
Someone once referred to it as the Bugs Bunny “What am I doing?!?” moment. It’s that classic scene when everyone’s favorite wiseacre realizes what he's doing just stopped making sense – politely agreeing that Marvin the Martian should blow up Earth, for example – and literally stops himself in his tracks. Congressional Democrats seem to be having this moment right now. The House has produced a bill that largely tracks to achieving the health care reform platform the presidential candidates ran on; the Senate Health, Education, Labor and Pensions Committee does so in a somewhat weaker way. The Senate Finance Committee and Sen. Max Baucus, on the other hand, was poised to deliver a negotiated, watered-down bill, with quite a number of unproven and cockamamie gimmicks specifically designed to appeal to Chuck Grassley and in an attempt to be bipartisan.
It’s time to look at the end products and say, “If what bipartisanship nets us is a sucky bill… it’s probably no longer worth it.”
First into the fray was Senate Majority Leader Harry Reid, with a wake-up call that got people talking. As first reported in Roll Call, “Reid told Baucus that taxing health benefits and failing to include a strong government-run insurance option of some sort in his bill would cost 10 to 15 Democratic votes; Reid told Baucus it wasn’t worth securing the support of Grassley and at best a few additional Republicans.” Jon Cohn on The Treatment quickly established what might be called the progressive blogger consensus: “Bipartisanship is good but a sound health reform bill is better. If winning over just one or even a handful of Republicans means gutting the bill, it's not worth it.” This same “trade 2 Republican votes for 15 Democratic ones” cost benefit analysis is doubtlessly what prompted Chuck Schumer to prophesy that the public health insurance option – which is as popular as taxing health benefits is unpopular with the general public – would be included in the bill one way or the other.
Reid’s was the loudest voice, but far from the only one. Sen. Bernie Sanders who has been supporting the public plan as a backup to his own single-payer bill, declared, “I think that it is fair to say that there are a number of us who would not be voting for anything resembling a Baucus-type plan as we understand it right now.” Rep. Raúl Grijalva, co-chair of the Congressional Progressive Caucus, sounded the alarm over a perceived openness on the part of White House Chief of Staff Rahm Emmanuel to the trigger option, whereby a public plan would be kicked down a road for a few years and only come into play if private insurance hadn’t proven capable of bringing down the costs of health care by themselves: “I want to be crystal clear that any such trigger for a strong public plan option is a non-starter with a majority of the Members of the Progressive Caucus.” Translation: good luck getting such a thing passed through the House. Granted, the progressive caucus has been sending out releases regularly against the trigger, the health co-op, and anything that waters down the subsidies to make health insurance affordable to low- and middle-class families. Rep. Henry Waxman, one of the chairs of the “Tri-Committee” which is wrote the draft health care bill in the house and is guiding it in for a landing, hasn’t ventured into the fray on these debates in the Senate… until today, when an interview with him was entitled, “House Dems Won’t Budge on Public Option.”
Here’s the political reality – it was always a good idea to try for bipartisanship on a bill that would so dramatically change the lives of Americans across the country, both those with and without insurance. But, and this is an important but, only if the process somehow led to a better bill or, at least, an air of legitimacy. From the “Washington takeover” rhetoric in the House, to John McCain’s snotty but factually correct tweet, “peeling off an R or 2 is not real negotiation”, to Tom Coburn’s war on jungle gyms, that whiff of bipartisan legitimacy just ain’t coming.
Everyone keeps looking to the bipartisanship of the Senate Finance Bill as a test of its success. This is fundamentally misguided, dangerous and flat-out wrong. The ONLY test of its success is whether it gives every American a chance at quality, affordable health care. If we’re rushing an ineffective and half-baked co-op proposal, or leaving families making between $60,000 and $80,000 a year with no affordable health care options, or creating an unpopular and easy to demonize new tax on health benefits just to peel of “an R or 2”, that’s the equivalent of Marvin the Martian holding the Illudium Q-36 Explosive Space Modulator in his hands.
(Photo credit: Hey Paul on Flickr.)
Health Co-Ops Yield Modest Improvements... After 60 Years or So
Published July 06, 2009 @ 10:46PM PT
Somehow, the Senate Finance Committee is still talking about Sen. Kent Conrad’s largely useless “compromise” of creating a health co-op with federal seed money instead of creating a Medicare-like public health insurance option to compete with private insurers. It’s not clear who they’re talking to. The Republicans on the committee have been underwhelming in their faint praise of the idea, and the more progressive Democrats on the committee say straight up that it’s no substitute. But it’s clear the focus is on compromise, and not the effectiveness of the policy to actually address the problems of rising costs, mediocre quality and a system that leaves too many – both with and without insurance – behind.
Clue number one, of course, is that we already have co-ops. Almost by definition, if your solution is something we already have, then it won’t change the game.
Kaiser Health News summarizes the recent Bloomberg article on how the most effective health co-ops have developed: “Washington State's insurance commissioner, Michael Kreidler, praised Washington's existing co-op, Group Health Cooperative, a 600,000 member plan that employs 922 doctors and 1,700 nurses, but noted that it took 60 years to develop, the paper says, adding: ‘While Group Health's premiums are generally no cheaper than competitors', the plan has been less aggressive than private companies at trying to purge sicker, costlier patients.’”
So the Senate Finance Committee is prepared to punt on expanding public coverage and breaking the monopoly of for-profit insurance that, as Wendell Potter said, “has proven itself an untrustworthy partner to its customers, to the doctors and hospitals who deliver care, and to the state and federal governments that attempt to regulate it.” They’re willing to ignore the 72% of Americans who say they favor giving people the choice between public and private coverage (including 50% of Republicans). In its place, they want to give us a “compromise” ill-defined co-op that won’t provide any more affordable coverage than regular insurance, will still seek to cherry-pick healthy patients and avoid sicker ones, but will just be nicer about it? Gosh, that sounds empowering.
Oh, and it will take at least a generation – maybe up to 60 years – to yield that level of unspectacular results?
Would that we had that long to wait. But America isn't Rip Van Winkle. Our families, our businesses and your state and federal budgets need help now.
They need more prodding – tell the Senate Finance Committee a health co-op is no subsitute for a public health insurance option.
(Photo credit: Archie McPhee on Flickr).
Who's In the News Today?
Published July 06, 2009 @ 07:27PM PT
It's the calm before the storm. With the July 4 recess over, Congress will once again be taking up comprehensive health care in both chambers. There are a lot of balls still up in the air with regards to timing, and even more for policy. The House bill is still more or less on track for a full vote by the end of July, but the Senate bill may be pushed back to August 7 or later. Given the likely difficulty in reconciling a progressive Senate Health, Education, Labor and Pensions bill with a "bipartisan" Senate Finance bill, I wouldn't write that date in pen.
So before we return to our regularly scheduled debates about affordability, circus-like amendment process, and largely-ignored speeches from the House floor about rationing, socialism, and other Frank Luntz greatest hits, here's a quick roundup of who managed to make news over the holiday weekend:
1.) Chuck Schumer will not be denied
Say this for the senior Senator from New York - once he owns an issue, he's not letting go. Months ago, Schumer was designated the point man on getting the public health insurance option into the Senate Finance Committee bill. Since then, he has blasted away at how non-competitive insurance companies are during a committee hearing, make himself the go-to guy for negative quotes about the "trigger", joined Sherrod Brown of Ohio and the president as the most frequent public defenders of the public plan, and even seemed to begin to wear down Kent "Co-Op" Conrad's resistance to the idea.
He raised quite a few eyebrows on "Face the Nation" on Sunday when he boldly declared, "Make no mistake about it, the president is for this strongly. There will be a public option in the final bill." But he made the calculus behind his thinking even more clear in an interview with the Huffington Post that could basically be summarized as, "Democrats have 60 votes - what the hell are we waiting for?" (His actual quote was, "If you did a consensus within the Democratic Party, you would find the level-playing-field public option to be the answer. And now that we have 60 votes, it seems to me like we don't have to turn it inside out for something we don't like.")
Spoken like a man who, as head of the DSCC for the last two cycles, knows what he's talking about.
2.) Wendell Potter will not be silent
Potter is the former Cigna and Humana executive who two weeks ago delivered dramatic testimony pulling back the curtain on the business practices of the for-profit insurance industry. It's hard to forget his description of health insurance as "a Wall Street-run system that has proven itself an untrustworthy partner to its customers, to the doctors and hospitals who deliver care, and to the state and federal governments that attempt to regulate it."
AHIP and others in the industry may have hoped that would be the last they'd hear from him. No chance. Potter is now a blogger with the Center for Media and Democracy, and he's already hard at work "call[ing] out misleading statements and statistics, outright lies and illogical assertions by opponents of meaningful health care reform-and to rat out the front groups that insurers and other special interests are funding to kill reform or, failing that, shape it to their benefit."
You can bet I just added him to my "must read" list.
3.) The revolving door for lobbyists is alive and well, and working on health care
A frightening graphic in the Washington Post today details just how frequently the Congressional bodies who are now working on reform legislation are being lobbied by people who use to work for them. As the caption reads, "at least 50 former employees of the Senate Finance Committee or its members now lobby on behalf of the health-care industry, in many cases for more than one client." The graphic tells a tale all by itself, particularly for Max Baucus and Chuck Grassley, who are now being lobbied by their former chief of staff and former health policy advisors, who represent many, many, many clients among Big Pharma, Big Insurance and hospitals or nursing homes:
We all knew that the forces of the status quo were well-funded, well-researched, and well-connected. But I don't think any of us quite realized that in addition to their money, their influence and their access, they had one advantage that those of us at the grassroots just don't have: the buddies of those who are calling the shots.
(Photo credit: Atomische on Flickr.)
