Posts Tagged ‘health care reform’

Websites like wine: healthcare.gov good now, getting better

Friday, July 2nd, 2010

HealthCare.gov: Take health care into your own hands Learn MoreThe web portal Healthcare.gov (@healthcaregov for all you twitterheads out there) went live, launching ahead of its July 1 deadline by hours Wednesday night. HHS deserves props for this site: not only was it delivered ahead of schedule, but it’s spiffy-looking, easy to use, and full of important info to help people get covered.

The website is what it says – a door through which consumers can check out what private insurance plans are available to them, depending on their age, state, current coverage, and health conditions.  There’s also information about public programs, like Medicaid, and how reforms in the new law affect people soon – such as the small business tax credit, high-risk pools for people with pre-existing conditions, and the ability of young people to join or stay on their parents’ plan till age 26.

If you haven’t checked it out yet, you should. We did a walk-through ourselves yesterday and were impressed by the clear, appealing design, the plain-language navigation to help consumers find out what their options are and, oh yeah, all that information.

In October, a more in-depth version will launch, and will include rates, coverage exclusions and other pricing information—a level of detail we think is critical for consumers looking for insurance options. To our mind, the more information, the better. And we’d like to see the portal move toward standard benefit descriptions that help people make “apples-to-apples” comparisons.

Other things we’d like to see on Healthcare.gov?  We think the website should include all private insurance products, such Medicare Advantage and Medigap plans. Right now, it doesn’t.

And it would be great instead of just describing and giving contact info or redirects to public programs, like state Medicaid agencies, if someone visiting the website could determine whether they were eligible and if so, enroll online.  Downloading an application, printing it out, finding out where to submit it, and getting there is often too many steps in a process that could be moved online. A report by the Urban Institute in January showed that there are 9.8 million uninsured individuals who are eligible for but not enrolled in Medicaid, and a one-stop online enrollment platform on the portal makes a lot of sense to help those people get health care coverage.

We’re glad to see that patient protections in the new law – what the administration’s calling the “patient bill of rights” – are prominent and spelled out clearly on the site.  In the future, we’d like healthcare.gov to point to consumer assistance programs, too, especially non-profit ones, which have a great track record of helping people navigate the system, determine eligibility, and enroll.

And for consumers with medical bills, we also want to make sure that the portal makes hospital financial assistance policies available, prominent, and easily searchable on healthcare.gov. We’re encouraged that there seems to be placeholder language about free and reduced care where more specific policy information will go in the future

Certainly there is room to refine and build. But this is day two. And improvements are already underway. In fact, a banner stretched across the top of every page says “Health care is getting better. So is HealthCare.gov. Help us improve by adding your comments”—this thing is a work in progress. But it’s also a work of progress, one we’ve proudly bookmarked.

–Kate Petersen, Health Policy Hub

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Health Reform Insider Goes to the Toast and Polls

Tuesday, March 30th, 2010

President Obama signed the final piece of the health reform package today. So before we do anything else and get caught up in the next round of debate, here’s a toast to all those who have worked so hard over the past year to get us this far.

And what goes better with toast than a bill summary?

(We couldn’t think of anything, either.)

So now what?
Congress’s work on health reform is complete (at least for now) but with barely a pause for breath, the hissy fit against reform has continued, merely shifting venue to the states and the upcoming fall elections. Public outreach is still needed, both because a number of provisions take effect very quickly (here they are), and the ongoing smear campaign against reform.

Thirty something
As we mentioned last week, legislators in over 30 states have filed legislative proposals or constitutional amendments regarding health reform. Although there are a few variations on the theme, the main claim is that Congress does not have the authority to impose a tax penalty on people who do not have qualifying health insurance.

And a dozen or so Attorneys General have filed suit against the federal government, claiming, among other things, that it does not have the authority to condition federal Medicaid matching funds on states meeting federal eligibility criteria, because to do so would impose costs on the states. (This is a strange argument, since the federal government has been doing exactly that since the beginning of the Medicaid program.)

Analysts have concluded that the proposed challenges lack legal merit. See:

But merits shmerits. Remember, the goal here isn’t to build sound legal cases but to gin up fervor to elect anti-reform members to Congress (or in the case of the AGs often to get themselves elected to higher office) and create a screen of apparent public opposition to reform for state officials intent on foot-dragging to hide behind.

They may also be trying to force the administration to make a potentially damaging public admission that the individual mandate constitutes a tax—thus violating an Obama campaign pledge.

A dead end strategy?
Given some truly awful recent Supreme Court decisions, no one can afford to laugh at the prospects of litigation, even though most nonpartisan analysts have concluded that they are without merit.

Still, challenges aside, there is reason to be optimistic about the future of reform.

First, the status quo is unsustainable—and more and more civic leaders are recognizing that. Reform opponents have no meaningful alternative that will address the rising costs and rising numbers of uninsured that are undermining the system.

Second, reform does a number of popular things (insurance reforms and subsidies, say) that will be not only be difficult to undo, but also difficult to separate from some of the less-popular aspects.

Third, reform creates more winners than losers among interest groups. There are not that many stakeholders who have a vested interest in repealing (not to be mistaken for amending) key parts of reform. Hospitals, doctors and drug companies can all find provisions they do not like but on balance, the extension of coverage to more than 30 million people will be good for the health care industry. States have concerns about the cost of the Medicaid expansion, but the expansion is 100 percent federally-financed in the short run, and provisions like increasing the Medicaid drug rebate rate will reduce state costs.

What about businesses? Although some may have concerns about the “free rider” provisions, only a very small percentage of employers will actually be subject to any penalties (The Congressional Research Service estimates only about 5 percent).

So too with the individual mandate. Most people already have private or public insurance or would voluntarily purchase coverage once a subsidy is available. The mandate is a tool to ensure the broadest possible risk pool and to prevent people from churning off and on health insurance on an as-I-need-it basis.

But if Massachusetts is any guide, the mandate will (notwithstanding the political furor of the moment) be, in practice, fairly acceptable to the general public.

Even the insurance industry, which spent millions to defeat reform, may think twice before getting behind a repeal effort. Especially since if the effort is only partly successful, it could be left with new requirements to cover high-risk and high-cost individuals without the guarantee of a bigger and on average healthier subscriber base.

And it looks, early on anyways, that public opinion is swinging toward reform.

This may be the case in part because broadstroke polling has always overstated the opposition—polls and stories before reform passed often failed to break out the anti-reformers from those who were unhappy with the current bills because they wanted reform to go further.

But new post-reform polls (check out this Five-Thirty-Eight post) that have gone deeper show an upward trend of support for reform.

Those, for instance, who say the law is a step in the right direction are unlikely to see repeal as anything but two steps back.

The question becomes: How much of the public can be made to believe things that are not true about health care reform—and for how long—now that it is law?

And here, there’s some cause for concern that goes beyond the persistent misunderstandings of what is in the law. A recent Harris poll shows 23 percent of adults in the US (41 percent of Republicans) think that President Obama wants to use an economic collapse or terrorist attack to assume dictatorial powers, and 24 percent of Republicans think President Obama may be the anti-Christ. We may surmise that these folks are unlikely to be persuaded on health care no matter what advocates (or anyone else) says or does.

On the other hand, as Nate Silver noted in the above link, public support seems to be going toward reform, though it is too soon to say whether this is a long-term trend.

The best thing advocates can do is go out and explain what reform really does (and what it doesn’t do). The more public understands reform, the less support there will be for a rejectionist agenda. Reaching out to constituencies that will benefit from early improvements (again, check out our Quick Win fact sheet)—including seniors, small businesses and children and adults with pre-existing conditions—are a good place to begin.

Seniors have generally been more opposed to reform than most age groups, and opponents have consistently claimed that reform is bad for Medicare. The first changes that seniors will see is the beginning of a phase out of the doughnut hole and new preventive care benefits in Medicare.

Many small businesses are probably unaware that they are exempt from “free rider penalties” or that the new law includes an immediate tax credit for small, low-wage businesses that offer health insurance.

For children and adults with major or chronic conditions, the bill has provisions to, immediately eliminate pre-existing conditions for children (pending HHS regulation), allow young adults to remain on their parents’ plan, eliminate lifetime benefit caps and create (or enhance) a high risk pool, and will provide immediate benefits for children and young adults with special health care needs.

Implementation: a three-piece puzzle

Going forward the keys to successful implementation include:

-An aggressive effort to build public support for reform

-Engagement at the state and federal level around the state laws and state and federal regulations that will govern the details of implementation

-Maintaining and strengthening the Medicaid program during the interim period when the states’ fiscal crisis is still squeezing the program and new federal coverage rules have not yet kicked in.

We’ll look at the way these three interlocking pieces fit together and developments in the weeks ahead.

–Michael Miller, director of strategic policy

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48

Friday, March 19th, 2010

I don’t watch the show 24, but here at the Hub, I’m getting the idea. Health care reform in real time. The clock running down on the House vote. And for this blogger, not a whole lot of commercial breaks.

Here is a summary of the bill, with a little discussion on each section about what changed, what hasn’t, and what it means.

As you know, it has been a long road and a few hairpin turns to get here. The next 48 hours can change the course of health care in this country for millions of families.

Despite the political heat, passing this bill won’t be remembered as a political win. If we pass it, it will be a win for people. It’s a step toward taking better care of each other. It is about changing a system that works for companies, not human beings.

You know your networks. You know the numbers. And you know that pro-reform voices are vital to passing this historic legislation.

Let’s get this done. See you Sunday.

–Kate Petersen, Health Policy Hub

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Land Ho!

Monday, March 15th, 2010

After a stormy voyage of more than a year, this Monday morning finds the good ship health reform within sight of a final vote. The tentative timetable has a CBO score out today or tomorrow, Rules Committee action on Wednesday and a vote before the end of the week.

Our understanding is that House leaders are leaning toward a single vote on the Obama fixes that will contain a clause passing the Senate bill passed upon passage of the amendments. That way, House members who are unhappy with the Senate bill will never actually have to vote on it. We do not expect House leadership to wait for all the votes to be locked down before going to the floor, but instead think they will schedule the vote once they are close and try to round up the last few yeses as the debate and vote are happening.

Deconstructing the Opposition Strategy: Be Very Afraid

The Republicans’ strategy at this point boils down to trying to scare the House Democrats into voting no. Their two main lines of attack are:

  1. The Senate won’t pass the fix-it bill, leaving the House stuck with the Senate bill.
  2. It will mean electoral trouble for Democrats in the fall.

Let’s break down each argument:

The first argument has shifted in recent weeks. Originally, the Republicans tried to play on the institutional distrust between House and Senate, suggesting that if House members “took the plunge,” Senate Democrats would leave them high and dry. But as more and more Senate Democrats committed to voting yes on a package of amendments (at least the necessary 50 have done so) the power of this scare tactic has waned, and so Republicans now threaten instead to gum up the works, making passage as hard as possible.

As we observed before, the bill that comes to the Senate will be small and will contain things that are easy to support—e.g. closing the Medicare doughnut hole, increasing federal funding for Medicaid, taking out special deals. Though Republicans certainly might play obstruction games, such parliamentary delay tactics may not play out the way they hope—think of the way Gingrich shutting down government in the 90s backfired with the public.

The second line of attack is that if Congressional Democrats vote yes, it will cost them their jobs. Republicans recently put out a poll from districts of swing members purporting to show that vote for reform would hurt their electoral chances. Whether a coordinated part of the strategy or on their own initiative, two former Democratic pollsters made the same argument in a Washington Post op-ed.

What makes the piece fishy is that a) the only polling they cite is from Rassmussen, a polling company with a well-known “house effect” in favor of conservatives and Republicans  and b) they conclude that what the Democrats should do is essentially pass the House Republican health care proposal (you can compare the GOP proposal to Obama’s plan here).

A more fair reading of the polling:

  • People want major change
  • The main elements of the reform bill are popular, and some are very popular.
  • People don’t know what’s in the bill. As Jon Stewart pointed out (watch at 4:05), there have been not a few misinformation campaigns to take the credit there. But once they learn what’s actually in the bill, they like it a whole lot better.

As the President has become more active in the debate and pushed out a clearer message about what reform does—eliminate insurance company abuses, provide people with security of never losing their coverage, provide tax credits to small business to help them afford insurance—public support has trended up.

Not to say that there aren’t some fundamental glitches in public opinion. Voters think a bipartisan bill is important, and that Democrats should keep working with Republicans until they get it. What the media have failed to convey is that

  1. the bill is supported by Republicans, including governors, former Senate leaders and former administration officials and
  2. the bill is essentially what Republican Senators proposed as an alternative to the Clinton plan in the 90s.

Finally, what should be clear after the Blair House summit is that there is no hope of getting any kind of bipartisan agreement, short of giving up and passing the Republican plan. It would be much more meaningful if pollsters confined their questions to the real choices that are available instead of setting up straw men.

Polls aside, there’s no doubt Democrats are sailing into a stiff headwind right now. The President’s party usually loses seats in the midterm, and this year the persistently high unemployment is fueling voter discontent. Discontent is aimed at incumbents generally, but with a large number of House seats to defend in historically Republican-voting districts, and with incumbent Senate Democrats from conservative states like North Dakota and Indiana retiring, the GOP could see substantial pick-ups. Add in the expected flood of corporate cash into the elections courtesy of the Supreme Court and it is shaping up to be a tough year for Democrats, indeed.

But the fundamental political question persists: are Democrats helped or hurt by failure to pass health reform? They are already on the hook for voting yes and attack ads are already being produced. Flip-flopping is famously unpopular in politics and is unlikely to win a pass from reform opponents in the election. Passing reform gives House Democrats a concrete historic accomplishment with which to fight back.

It don’t come easy: Math in the House
In November, the House health care reform bill passed with  220 votes. Currently with vacancies, 216 are needed to win.  If everyone who voted yes last time votes yes again, reform passes. But House leaders can’t count on every yes vote remaining in place, so every yes-to-no vote must be offset by finding a no-to-yes.

Here are three places where votes are at risk:

Abortion
The number of Democrats willing to ‘vote off’ because of abortion seems to be declining.  A recent letter from pro-life clerics and theologians looked at the abortion provisions in the Senate bill, chapter and verse, and concludes that the bill does not provide federal funding for abortion.  Several members who voted for the Stupak amendment have publicly reached the same conclusion. And although Stupak claimed that he has about 12 members who will stick with him in voting off, his camp seems to be shrinking as the reality that the Senate bill does not allow federal funds for abortion has begun to sink in. Most analysts put the total number of no votes on account of abortion at five or six.

Immigration
The Senate bill bars undocumented immigrants from purchasing health insurance through the new insurance Exchanges even if they use their own money. It also fails to provide equal coverage to legal immigrants, continuing a ban on federal matching funds for state Medicaid coverage and offering instead less comprehensive and more costly coverage in the Exchange. As a result, a number of lawmakers in the Congressional Hispanic Caucus have said that they were leaning toward a no vote.  The issue is further complicated by the fact that the provision relating to undocumented individuals cannot be addressed via budget reconciliation.

But a Medicaid provision that gives states at least the option to cover legal immigrants could be addressed in reconciliation.  While most states would probably not take up the option, the measure could at least provide fiscal relief and perhaps better coverage in those states who now cover legal immigrants with 100 percent of state dollars.

How possible is this? Remember that in the initial House vote in November, there was an 11th hour change on abortion. It’s still possible that House leaders and the President will see the light on Medicaid for immigrants, especially if it is the only remaining obstacle to passage. However, even if this last-minute adjustment is made, the legislation does not go far enough in providing equal access to coverage for immigrants, which only underscores the importance of comprehensive immigration reform (check out this weekend’s march here).

The Scott Brown effect
In the wake of the election of Republican Senator Scott Brown, the Massachusetts delegation has become visibly uneasy about reform. Despite compelling evidence that the Brown election did not turn on the candidates’ positions on health care,  some members of the normally solidly liberal Massachusetts delegation have indicated concern about moving forward, though not all have given the same reasons.  It’s hard to imagine that Massachusetts Democrats would actually sink national health care reform. But as the Brown election proved, nothing can be taken for granted—even in Massachusetts.

Coming soon

Stay tuned for updates this week as the CBO score becomes available and we get more clarity about the vote schedule.

-Michael Miller, director of strategic policy

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The Point: The Incredible, Uncoverable Leg

Wednesday, March 3rd, 2010

In this installment of The Point, Hub blogger Kate Petersen’s mother tells about her attempts to get both legs covered by a single health plan. Easy, you say…

I am a speech and language pathologist in a public school system in Arizona. My husband is a retired Public Health Service officer with excellent federal health insurance, and additionally he works full-time as an epidemiologist at a nonprofit organization.  In addition to his federal health benefits, he has  also subscribed to the insurance program offered by his employer so as to cover our daughters as dependents, and to provide primary insurance for me.

My story begins in May 2005 when I was going to an awards dinner. Late on the afternoon of the dinner, after my two-mile exercise walk, I decided that I certainly needed a new frock for the dinner and slipped on sandals to take a brief walk-through of our local outdoor mall.  I succeeded in finding a new dress, but was running very late in getting ready, so I was running across a street in the mall area to get to my car, when the side of my sandal hit a pot hole in the street between brick pavers and I fell.  I continued on my way and went to the dinner, but I had trouble walking and so afterward my husband took me to the emergency room.

I had a non-dislocated fracture of my right ankle.  With a standard course of treatment of casting and non-weight-bearing for six weeks, followed by a walking boot, I gradually returned to full function.  There are no residuals from the fracture.

In 2007, my husband’s business changed insurance companies, and the monthly premium substantially increased.  We considered buying our own policy in order to maintain my coverage and that of my remaining dependent daughter, who was still in college.  My husband got several quotes through an insurance broker who came to the house to ask the ‘few questions’ before collecting the fee and signing us up.

After a lengthy discussion, he told me I would be covered with the exception of my right leg…Not ankle—leg!   I told the agent that there was no follow-up care to my simple fracture, my right leg was uninvolved, and that I was back to hiking and exercising and had been for two years. But he was unswayed in his pronouncement that my right LEG would never be covered.

Needless to say, my husband and I signed up for his company’s group insurance with a higher premium after all, to avoid my leg exclusion.  If the broker agent had only asked the right questions, he would have found out that I had also had a minor surgical procedure on my right index finger earlier that year to remove a cyst – again, without any further treatment. Perhaps then he could have offered me insurance with an entire right SIDE exclusion!

With health care reform,  companies would be barred for denying people with pre-existing conditions coverage – pre-existing conditions that I found out can be specious and exaggerated at the expense of consumers.

Our current system of health insurance coverage is sad and unfair, and I am so grateful to the President, Congress, and all the advocates who are devoting their time and energy to seeking change and justice in the health insurance system so that people get health care benefits they so badly need.


Do you care about changing the health care system? Send your support of health care reform to Congress by signing the petition now (the link works today!)  then sending it on to your family, friends and coworkers.


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Reaching the Summit

Wednesday, February 24th, 2010

Must-see TV

If you’re not already planning to tune in to the President’s health care summit tomorrow, maybe it’s time to reconsider. It will be streamed live here, from 10 AM-4 PM Eastern. Forget Lindsey Vonn and The Office baby special: This is must-see TV.

And if you can’t convince your boss that six hours of C-SPAN is equivalent to 30 minutes for lunch, you can follow the Hub’s twitter feed right from your desktop for a live analysis of what’s going down at Blair House (and maybe a little reform haiku thrown in, too.)

Reaching the Summit

With the release of his plan—really a series of amendments to the Senate-passed Patient Protection and Affordable Care Act (PPACA)—President Obama  is ready to embark on the last leg of the health reform journey. Key changes in the proposal include:

•    Improvements in affordability for low- and moderate-income families in the Exchange. Relative to the Senate bill, most families will either pay less and/or get better benefits.

•    Stronger oversight of health insurance premiums. The proposal would give the HHS Secretary the power to deny or modify excessive premium increases as well as strengthen the ability of state insurance regulators to oversee rates.

•    Phasing out of the coverage gap known as the “doughnut hole” in Medicare Part D, making prescription drugs more affordable for seniors.

•    Increased Medicaid funding for all states (and territories), while eliminating the special funding deal for Nebraska.

•    Equalizing the treatment of union and nonunion health benefits with regard to the excise tax on high-cost plans and also adjusting for age, occupation and gender of workers so that firms with an older and sicker workforce would not be hit as hard.

The President also proposed a series of payment integrity and anti-fraud measures to reduce payment errors in Medicare and Medicaid, drawn largely from Republican proposals. (Full summary of the proposal is available here).

Democratic leaders in the House and Senate have reacted positively to the President’s proposal and seem poised to move forward with reform post-summit, with or without a bipartisan agreement that no one is expecting.

Interestingly, not all of the President’s proposals seem to fit neatly into the rules of budget reconciliation. This suggests that some ideas, such as increasing federal authority over insurance rates, will have to get 60 votes in the Senate in order to survive. However, this is likely a win-win for the Democrats: either the rate regulation provision stays in, or Republicans will have to go on record as siding with insurers against consumers on insurance rates.

Summit Watching Guide

The President has continued to sound the theme of bipartisanship by posting on a website all of the Republican-backed ideas already included in PPACA, and offering to post a Republican proposal or statement of principles side-by-side with the President’s plan.    Republican Congressional leaders, however, aren’t having any of it.

The continued trash-talking of the summit obscures the dirty little not-so-secret that the difference between the Republican and Democratic proposals is not about different means to reach the same end, but entirely different ends.

First, Congressional Republicans by and large reject the premise that all Americans should have guaranteed access to secure affordable health insurance and health care. Secondly, they reject the idea that a stronger public-interest watchdog and a new set of rules is needed to correct fundamental weaknesses in the current health insurance market.These are the central premises of the plans put forward by the President and Congressional Democrats and they are beliefs strongly held by the majority of Americans, notwithstanding their skittishness and disillusionment with the process. (Read Real Reform, Community Catalyst’s analysis of the differences between the approaches put forward by the President and the Republicans here.)

At least one prominent Republican, California Governor Arnold Schwarzenegger, has been willing to call out his party on their stance—calling the demand that the summit start with a blank piece of paper “bogus.” (Now that’s a maverick.)

Because the divide between the two parties is so fundamental, at the summit itself we can expect neither a real attempt to reach bipartisan agreement, nor even a real debate over the merits of various policies.

Instead this will be a battle of competing narratives. The President and Congressional Democrats will to try to focus the discussion on the problems with the status quo and substantive ideas for addressing those problems, while the Republican will try to reinforce their anti-government mantra. (If watching 4 to 6 hours of this kind of sparring is not your idea of fun, you can liven it up by taking a drink every time a Republican says “job-killing big government takeover.”)

Look for a special post-summit Insider Friday!

–Michael Miller, director of strategic policy

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Health Care Surprise (but keep your eye on the prize)

Monday, February 8th, 2010

Yesterday, in a surprise move to many (though apparently not to Majority Leader Reid or Speaker Pelosi, who immediately issued statements of support) President Obama invited Congressional leaders from both parties to a televised half-day health care reform summit on February 25.

The summit appears to be a major effort by the administration to redirect the debate over reform.  With the main health reform storyline focusing on the food fight between the House and Senate over who doesn’t trust whom and who needs to Go First,  it’s no wonder Congressional leadership embraced the new direction.  A summit several weeks in the future gives them more time to work through their differences free from the daily white smoke watch.

The summit will also gives the administration an opportunity to highlight the many positive aspects of reform and to point out weaknesses and inconsistencies in Republican arguments.  (For example, how can Republicans attack health reform for reducing Medicare spending when their own proposal includes a far more draconian cut?) We saw versions of this dialogue when Obama engaged in a give and take at the Congressional Republican retreat a few weeks back.  Obama and Congressional Democrats can repudiate certain controversial provisions, such as the special Medicaid subsidy for Nebraska. The setting–live TV–directly answers the public’s concern about secret negotiations with a much more open and transparent discussion.

As was true at the Republican Congressional retreat, there is very little chance of substantive changes in position from either side.  Republicans believe they are winning the debate on health reform and so have little reason to shift gears as the election approaches.  And even if the Republicans were willing and the administration were tempted to cut a deal, it seems likely that any significant shift to the right would cost the administration more in Democrats’ support than it could ever pick up from Republicans, especially in the House.

The main downside risk is that the summit delays the timetable for enacting reform by several weeks, and possibly longer, if discussion continues beyond the initial meeting.  Getting a fix-it bill through reconciliation is not a fast or simple procedure, and budget rules make it harder as time goes on.  As the days of the Congressional session slip away and elections approach, a crowded Congressional calendar and an aversion to taking tough votes right before facing the voters will add to the difficulty of getting reform done. But with health reform failing to command majority support from the public,  who lacks understanding of the bill and has concerns about the process, what’s there to lose?

Eyes on the prize

In the midst of all the political calculations and positioning, it is more important than ever to reassert how crucial covering the uninsured, slowing the growth of health care costs, improving the quality of care and ending abusive insurance industry practices is to our nation’s health and financial well-being.

Ultimately, this is not about Democrats or Republicans.  It’s not about achieving electoral advantage.  It’s about finally tackling one of the toughest social problems that confronts our country–one whose resolution has eluded policymakers for too many years.  It’s time to get reform done.

–Michael Miller, director of strategic policy

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Of Doughnuts and Dragons: The Health Reform Insider

Wednesday, January 6th, 2010

Though a series of critical votes happened in the last month, not to mention the holidays, the issues that define negotiations between the House and Senate remain largely the same (check out our list if you need a refresher). Here’s an update on a few of those, and the process ahead.

The Overall Process
Reports that the House and Senate will bypass a formal conference committee and informally negotiate a bill instead have been circulating for over a month but, in one of those mysteries of the news cycle, the plan has recently become a hot topic.

The other important process piece (though also not really news) is that the Senate bill is expected to be the starting point for negotiations, and the House will likely have to wage a limited number of battles to make changes.  Defining what that list will include is The Task for House Democratic leaders now as they seek to hold together their own fractious caucus.  One item almost certain to make the list is closing the Medicare Part D “doughnut hole.”  Indeed, Senate leaders have already stated publicly their intention to close the Part D coverage gap—though how to pay for it remains a matter of intense debate, with House members arguing that funding should come from the drug industry, and the Senate perhaps less keen to go that route (as the specter of its summer deal with PhRMA looms.)

Financing
As we reported in December (and said many times before that), in the coverage debate, financing is the key.  Most observers believe that the excise tax on high-cost health benefits in the Senate bill will be further scaled back in negotiations with the House.  A critical and related issue—probably the most important one you never hear talked about–is one we flagged just before Christmas: How the price tag of reform gets calculated.

By our reckoning (see last week’s post), the Senate bill provides only a little over $600 billion in assistance to make coverage affordable for low- and moderate-income families, while the House comes in at around $900 billion.  Those extra $300 billion in assistance translate into a year’s worth of coverage (at the front) and more financial protection to low- and moderate-income uninsured people.

So the big financing questions left are: Will the House accounting prevail? And what, if anything, replaces the money lost from the excise tax? The answers to those questions determine whether there is any possibility of doing better than the Senate on critical affordability measures or by accelerating the implementation timetable.

Exchange Exchange
It looks now like the House is going to make a major push to swap out the Senate proposal for state-based insurance Exchanges in favor of a national Exchange as in the House bill.   (States could still opt to run their own if they met federal standards.)  With that in mind, here’s a brief overview of the pros and cons of state and federal Exchanges.

A national Exchange benefits from uniformity and is likely to have lower administrative costs than 50 state Exchanges would. A national Exchange also reduces the problems that could stem from state governments being unable or unwilling to take on the new responsibilities envisioned in the Senate bill. It’s also possible that a national Exchange would have somewhat better negotiating leverage with national insurance plans, at least in small states.

But the price tag difference between a national Exchange and state Exchanges is likely less than many proponents of a national Exchange who tout a federal model’s savings believe.  The bulk of health care costs are determined by underlying local conditions, and a national Exchange will have little influence over those factors.  In addition, while it’s likely that states will vary in how well they rise to the new challenge, at least some are likely to do an excellent job.  If a future federal administration were to be hostile to health reform, the entire Exchange for the whole country could be undermined; recall that this was a problem for many executive agencies in the previous administration.

Finally, a national Exchange is no more a safeguard against the influence of the health care industry than are state Exchanges.  In fact, the geographic remoteness of Washington from most of the country poses no real obstacle to special interests seeking to influence decisions, but does limit the ability of consumers to engage directly in the decision-making process or hold decision-makers accountable.

In the end, state versus national Exchange is of less importance than are the rules under which any Exchanges must operate and the underlying structure of insurance regulation.  So for example, a bill should ensure that there is no conflict of interest in Exchange governance and that business is conducted subject to open meeting laws, as well as provide for consumer representation in Exchange governance.

It is also important not to carve insurance markets up into distinct pieces: for instance, not to split up non-group and small-group insurance, or allow separate risk pools to operate both within and outside the Exchange. The bill should also empower the Exchange to exclude insurers if it is determined that they do not meet standards for providing good value.

On many of these issues, the House does in fact do better than the Senate, as well as on matters  of insurance regulation such as limiting rate variation based on age and clearly eliminating annual and lifetime limits on coverage.

Bottom line? If the House wants to fight about Exchanges, they should focus on the issues that matter most.

Immigrant access
Discrimination against immigrants remains a problematic aspect of reform, but the Senate seemed to make progress as reports indicate that leadership agreed to eliminate the ban on federal Medicaid matching funds for immigrants who have been in the country for less than five years.

We hope that, in negotiations,  the House will match the Senate’s willingness to remove the “5-year bar,” but won’t trade this progress for legal immigrants for its rightful opposition to the Senate proposal to bar undocumented immigrants from the Exchange, even when paying entirely with their own money—a provision supported by the Obama administration.

It’s also unclear just how many states would take advantage of the new matching funds option when, by doing nothing, they can leave the entire cost of covering low-income recent immigrants to the federal government.  The only fair alternative would be to give legal immigrants equal access to Medicaid, but state-based opposition to this fix has proved insurmountable thus far.

Next Dragon in the RoadDragon
Though negotiations between the House and Senate are far from finalized, reform opponents are already gearing up for a multi-pronged attack on the legislation, including legal challenges, state constitutional amendments and ballot initiatives.

Those who argue that these challenges have little legal merit are missing a larger point.  This strategy is first a political one, and only secondarily aims to change the course of the short-run health care debate.

First, given the pace of implementation, the Presidential election of 2012 becomes pivotal.  A change of administration that year would likely cripple implementation, perhaps fatally.  Campaigns being developed now are largely geared toward building a base of activists for 2012.

Even if they are unable to unseat Obama, Republicans see health reform as a wedge issue they can use to regain control of Congress.  Failing that, by defeating some vulnerable and prominent supporters of reform, opponents hope to create a chilling effect that will dampen the willingness in Congress to pursue further reform.

What this means for reform supporters is that—far from final negotiations curtaining the show—a new act in the saga of U.S. health care reform  is about to begin.


–Michael Miller, director of strategic policy

photo courtesy  of austinevan at flickr creative commons

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