“With all of the controversy and rhetoric surrounding the requirement, it seemed a good time to take an objective, detailed look at how it will actually work.

“Plus, even though it doesn’t go into effect until 2014, we wanted to write about the individual responsibility requirement because it is the foundation on which much of health reform rests.  It allows the country to move forward with popular insurance reforms, such as the ban on excluding people from coverage if they are sick, and plays a major role in expanding coverage.”

Read the rest of the post that cites some of the themes that arose while working on the Q&A at “Say Ahhh! A Children’s Health Policy Blog,” or read the resource on our website.

– Katherine Howitt, policy analyst

The Affordable Care Act included $30 million in 2010 to fund state ombudsman offices and CAPs (Section 1002).  The grant guidelines for those funds are slated to come out in the next few weeks, and the grants will likely go to states, who will decide how to best use the funds.

While we’re not quite sure how the guidelines will read or play out in implementation, we have  some core criteria we think are necessary to providing consumers accurate, understandable information and helping them navigate the new world of health care.

1.     Be truly independent.  Consumers should be able to trust that the information and enrollment assistance they get is unbiased – not informed by state budget problems or politics.  Especially as 20 states’ attorneys general actively oppose health reform, consumer assistance programs should ensure there’s a wall between state and political issues and helping consumers.
2.    States need to do more than they already do.  Many states are currently overwhelmed and understaffed because of budget woes.  Consumer assistance programs need to be separate and robust from current activities in state Administrations – and actually have the capacity to provide necessary help, navigation and information.
3.    Meet the needs of the community.  Consumer assistance needs to be culturally and linguistically competent, and provided by people who understand working with vulnerable populations.  A well-trained staff should be trusted by members of the community, including people at different levels of income and insurance options (from Medicaid to private insurance).
4.    Allow for feedback to policymakers.  A critical reason for consumer assistance is the ability to get real-time, on-the-ground information about what’s working and what’s not.  Regular feedback to state and local policymakers can help improve health reform implementation
5.    Ensure every state has a consumer assistance program.  Even if a state does not set up a program, the federal government should be able to contract directly with an organization to carry out these important duties.

Based on these elements, we think that the best option for CAPs in most states is often non-profit community advocacy organizations.  Examples like Health Care for All Massachusetts’s Helpline, New York’s Community Health Advocates, and Health Assist Tennessee have shown us that strong consumer assistance programs can mean the difference between a failed attempt and successful reforms. The Helpline in Massachusetts saw their call volume increase from 500 to 4000 per month after the passage of that state’s health reforms in 2006.  People call with questions from enrollment assistance to help with paperwork to navigating the health system.
We hope that the grant guidelines will explicitly permit states to contract or partner with community organizations to provide consumer assistance.  We have seen these models work, and know that they are trusted sources of health care information for communities and families looking for help in understanding a system that’s about to get bigger and more complex.

– Christine Barber, senior policy analyst

Now sitting on Governor’s desk is a bill that strips the state exchange of offering any kind of abortion coverage to consumers– even through an optional rider.  Similar to the flurry of anti-reform constitutional amendments being adopted across many states, this legislation is based on a model developed by the Americans United for Life (AUL), a non-profit law and policy group.  The model, entitled “The Federal Abortion-Mandate Opt-Out Act,” is in the pipeline in almost 30 states, according to AUL.  Thus far, Mississippi, Arizona, Tennessee and Louisiana have passed the prohibition measure – the measure was vetoed in Oklahoma and Florida.

Claiming to be founded upon a pro-family platform, AUL aspires to stall the progress of health care reform by barring consumers from some patient services.  Yet eliminating family planning services from exchanges does not promote a family friendly policy environment – but supporting gender equity does.  According to the National Law Center for Women, 17 percent of Missouri women forgo needed care due to their higher cost of health care – these include a broad range of services.  Women in Missouri are, on average, poorer than men and tend to work for small businesses that do not offer health coverage.  This is not only a strain on women and their health but also their families.

Advocates can challenge these flawed attempts to dismantle health reform and propose a broader pro-family agenda by driving home the message of gender equity.   A pro-family message is one that encompasses supporting all women at all times in their lives – daughters, sisters, wives, mothers, and grandmothers alike.  Other states have stepped up to rid their health care systems of inequitable gender rating that charge women as much as 4-48 percent more than men for the same health care policy.

However, these positive steps are not without their critics.  Before Colorado passed its ban on gender rating in the individual market this past spring (in the week following health reform passage), an insurance underwriter commented to the legislature that perhaps “we should ‘blame God’ because men’s parts were on the outside and women’s parts were on the inside.”  State Senator Morgan Carroll responded to his comment by suggesting “perhaps his brain is on the outside.”  Further, Rep. Jim Kerr suggested that women enjoyed shopping and perhaps they should do a better job shopping for health insurance.

The absurdity of the discussion makes you laugh and grimace simultaneously – but the issue remains in play in many states.  Women are often the center of their families, before and after they procreate – a real pro-family policy would be for all to acknowledge their right to a healthy and long life.  So, show me gender equity!

–Eva Marie Stahl, policy consultant

Here’s why. As we pointed out last week, a national Exchange isn’t likely to be the savings boon some claim, since many of the factors that influence an insurance market are local. And while folks like Igor Volsky at Wonk Room and Jon Cohn at The Treatment worry that some states are bound to execute insurance regulation more poorly than others, a future federal administration hostile to health reform could undermine the whole thing (see Bush administration for examples).

So it seems, with all these variables floating around, that those of us concerned about the availability of quality insurance that consumers can afford should, instead of hitching our Exchange wagon to a state or federal horse, make a list of criteria that add up to a strong Exchange – at the state or federal level. We went ahead and did that. Here’s our top ten.

1. Authority to negotiate and contract with health plans. The House bill provides the Exchange stronger authority to choose insurers based on their plans’ benefits, provider networks and value. Experience from Massachusetts’s Exchange (the Connector) has shown that offering selective plans provides clear insurance choices and can help hold down cost.

2. Create one insurance pool. Insurers will be insurers, and if they are able to create separate risk pools inside and outside of the Exchange, (and, say, attract healthier people outside the Exchange) they will. The House addresses this problem by requiring all individual market plans to be sold only through the Exchange. The Senate bill requires insurers to pool risk both inside and outside of the Exchange, but it’s unclear that this will do the trick.

3. Maximize market authority. An Exchange can only hold down insurer costs if it has market authority—and to have this, the Exchange needs to cover a significant share of people. It’s important to broaden, not carve up, insurance markets to provide Exchanges with enough covered lives to be able to negotiate good prices and coverage with insurers. The Senate does the opposite, proposing to split up the individual and small-group insurance markets into two separate Exchanges.  Instead, both markets should be included in one Exchange.

4. Require qualified benefit plans inside and outside the Exchange. In the Senate bill, “qualified plans”—plans that must offer an essential benefit package—are required only inside of the Exchange. Without rules about benefits and cost-sharing outside of the Exchange, insurers may attempt to design benefits in a way that reduces their risk (and costs). An essential benefit package should be required in and outside of an Exchange.

5. Public oversight and involvement. Another important lesson from Massachusetts’s Exchange/Connector is that it works best when all debate and decisions are subject to open meeting laws and consumers are represented in decision-making. This should be strengthened whether the Exchange is at the federal or state level.

6. Ensure clear, transparent information. One of the main reasons for an Exchange is to provide easy-to-understand information about health plans that helps people make informed choices about their coverage. The Senate bill has stronger requirements on providing this information—and includes things like in-depth descriptions of coverage and cost-sharing scenarios for common medical services, like pregnancy or chronic illness. The Senate Exchanges also use Navigators, run by trade organizations or community-based non-profits, to provide information and one-on-one assistance with enrollment in health plans.

7. Prohibit conflicts of interest. The Exchange is a marketplace for choosing insurance options, and should be neutral.  There should be strong standards to ensure that insurers, insurance agents, providers, and others who would profit from enrollment cannot govern the Exchange.

8. Offer plans with similar benefits and cost-sharing to help people make meaningful comparisons. Both House and Senate bills define the levels of coverage through “tiers” based on actuarial values (or the share of medical expenses the health plan pays for a standard member) to facilitate comparisons by consumers. However, using actuarial values as a way to standardize plans still allows for major differences in benefit limits and cost-sharing (even among plans in the same tier) and makes comparisons difficult for normal people.

To increase the comparability of plans, the merged bill should create tighter benefits and cost-sharing restrictions among plan tiers.

9. Regulate insurers. An Exchange should regulate insurers, including oversight of premium increases, marketing and profits. To monitor the impact of these requirements, Exchanges should collect data on compliance, and make this information available to the public.

10. Create fair insurance rules. An Exchange is only as strong as its insurance regulations. The House bill has stronger limits on the amount that premiums may vary (for instance, the House allows premiums to vary based on age, constrained to a 2:1 ratio; the Senate allows a 3:1 ratio).

–Christine Barber, senior policy analyst

Health reform does not succeed or fail by the public option, despite what Dean and others seem to suggest. This is not to say that the public option wasn’t important—at least as it was originally imagined (see Michael’s post here.) But we and others like Jonathan Cohn have pointed out the success of reform ultimately depends on strong subsidies, insurance reform and improvements in care delivery—things that are still in the bill.

Perhaps it’s because they hitched their wagons so closely to the Obama’s Technicolor campaign and the ’08 election that Dean, Kos and Co. feel such betrayal in the real-world policy give and take happening in the final stretch of health care reform.  And I’ll admit, it’s easy to see how eight years under the Bush administration could lead one to believe that everything is a black-white issue.

But that kind of thinking—a rugby-like mentality in which health reform is a game with a scoreboard—fails both the spirit of reform and the work that’s been done.  By dismissing health reform with such invective, Dean, Kos and the choir of liberals singing their tune haven fallen to the very same faulty syllogistic thinking they shun the “teabaggers” for: Giving any ground is akin to surrender and defeat, and the yield of such defeat must therefore be waste.

But it’s not.  It’s important to see how far health reform has come, within a year of an administration for whom reform was nearly always a dirty word. If, under the Bush Administration, we could have gotten any one of the things that are in the reform packages now – federal matching funds for all low-income people, say, or a ban on pre-existing conditions exclusions – the champagne would have flowed on the Left bank.  But now, the public option is out and folks are headed for the hills.

Far from the “so-called reform” Kos rolls his eyes at, the improvements this bill will make are real: Expanded coverage to hundreds of thousands of people who now go uninsured, critical insurance reforms that will protect American families from losing coverage and medical debt, subsidies to help people buy coverage who can’t afford to now, and innovations in the way the systems delivers and assesses care. Yes, it’s flawed. It doesn’t give low-wage workers help and health security fast enough, for instance. But it gets people help, and binning the whole thing and starting over leaves those people stranded.

Health care reform may have been a presidential campaign promise of Obama’s, but it wasn’t by bashing insurers that the candidates won support for health reform – it was because they were offering to help people who desperately need it.  Health care, despite what some of the news networks insist, is not a Democratic or Republican issue. It’s about helping people. It is about starting to mend a really broken system, and beginning to re-imagine how a country takes care of it’s sick and frail. To try things out and see what works. And it’s sure not a panacea. But when was it ever going to be?

All victories are partial. The Voting Rights Act was a victory by any standard, but it didn’t stop racial discrimination in the U.S. – it made way for a succession of other, smaller victories that helped turn back systemic racism. Passing Medicare was a victory – but not all at once. Coverage for the disabled, and the drug benefit, came later, and this bill continues those efforts to make the program work better. Despite the suggestions of these critics, it’s near impossible to get a project as complex and all-encompassing as reform right on the first try. But we need to make a first try, and the Congress recognizes that.

The flaws and compromises in the health reform proposals are not reason to dismiss them but to instead commit to the process of reform and the act of helping people. We should enact the best bill possible, then start working to make it better. Those bent on merely measuring the gap between Perfect Health Reform and what the Congress is working on now are selling their country short.

–Kate Petersen, Health Policy Hub

Basically, the fate of the public option has always been bound up with the rules of the Senate and the willingness of the Senate to pursue a path that did not require 60 votes.  While there are 60 votes in the Democratic caucus, several members have staked unalterable opposition to a bill that includes a government-run insurance plan—in any form.

That means that to pass a bill with a public option Democrats had to either go the route of “budget reconciliation,” which requires only a simple majority, or take the “nuclear option” and change the rules of the Senate to bypass a filibuster. (You may remember that Republicans threatened the “nuclear option” when they controlled the Senate and Democrats were blocking a number of Bush nominees to the federal court, but there’s been no real discussion of amending Senate rules to make it possible to pass health care reform.)

While reconciliation remains a technical possibility, and has all along, the clock really ran out on it during health reform’s slow walk through the Senate.  When a bill finally cleared Finance, Majority Leader Reid had, in theory, a last chance to combine the HELP and Finance bills in a way that would move via budget reconciliation.

But major technical challenges, a lengthy process, and the perceived political liabilities to doing reform with a narrower base of political support closed the door on reconciliation, and with it, any real chance that the public option would make it through the process in any recognizable form (notwithstanding the compromise version included in the bill Reid brought to the Senate floor.)

Well before a group of conservative and liberal Democrats started meeting to discuss alternatives, and a bevy of liberal bloggers began to toll its death knells, the public option had been significantly compromised from the original vision.  That vision contained two key elements: Universal availability, and Medicare-based networks, pricing and administration.

Universal availability went first, with the public option restricted to those who would purchase coverage through the exchange.  Medicare-based pricing fell in the House when many members from rural districts opposed using Medicare as basis for payment.

What survived would have had, in the short run, a modest impact on health insurance, an impact that  with potential to grow over time. Without 60 votes in the Senate or an alternative path, the question has always been more when than if it would get removed.

What’s the alternative?
With the public option out, the question remains: What will take its place?  The Senate is remaining very close-mouthed about the details of the negotiated alternative pending a CBO score later this week.

Elements of the alternative appear to include creating a national network of not-for-profit health plans overseen by the Office of Personnel Management (The same office that oversees the federal employee health plan), funding for CHIP through 2015 (instead of the current 2013), stricter regulation of private insurance, e.g. requiring 90 cents of every dollar to be spent on health benefits, and reducing the Medicare eligibility age to allow younger people to buy in, perhaps starting at age 55.  A proposal to also expand Medicaid to 150 percent FPL, as the House bill does, was discussed but rejected.

Several House progressives signaled that they would be prepared to entertain a Medicare expansion as an alternative to the public option, where the idea has long been popular.

But even before the deal has become available for public inspection it has taken fire from hospitals and doctors.  One Dem and an increasingly infamous Independent who negotiated the deal have started backing away from it, leaving its fate very much in doubt.  (Ironically, the only thing that could possibly resurrect the public option is if the conservative Democrats become too intransigent, forcing Senate leadership to reconsider budget reconciliation despite its difficulties.)

The Road, and November baseball
Little time remains to close a deal if the Senate intends, as it says, to complete their work before Santa’s circumnavigation.  Senate rules require a certain amount of time to elapse before the motion to halt debate can be acted on, so unless we see both the public option compromise and the Senate “Manager’s amendment” this week, it’s likely that the Christmas deadline will slip.  Once the Senate does act, there will be enormous pressure to seal a deal with the House, and fast.

There has been a lot of speculation this past week over whether Congress will bypass the conference committee process altogether, instead having the two chambers informally negotiate a small number of amendments that the House would pass and send back to the Senate for concurrence.  Failing that, leadership is seeking a very compressed conference process—Speaker Pelosi has said she thought they could do it in 48 hours.

While the pressure to wrap up is undeniable, the significant gulf between the House and Senate on financing, affordability, abortion, employer responsibility, and access for immigrants will make reaching a quick conclusion difficult.  (See our rundown of the issue gaps in last week’s Insider.)

President Obama wants health reform done before the State of the Union address and he may push the address into February to make that possible. Kind of like November baseball, but less hats.

–Michael Miller, director of strategic policy

photo courtesy of aflcio2008 on flickr

But an earlier national reform experience—President Richard Nixon’s attempts to pass a comprehensive health insurance plan in 1971 and again in 1974—provide an equally important cautionary tale as we reform supporters look at Majority Leader Reid’s bill today, with all its imperfections, and look at getting from here to the Rose Garden.

In 1971, Nixon came before Congress proposed a national health strategy that would have required all employers to provide employees coverage with minimum benefit standards, created subsidies for low- and middle-income families, established caps on cost-sharing for families, built state exchanges or pools for those ineligible for Medicaid or employer plans, and instituted cost containment measures. But Democrats rejected Nixon’s proposal.  It wasn’t universal health care, they said, and what we needed was universal health care.  By ’74, the common wisdom was that Watergate would sweep Nixon out of office, and the country would elect a Democratic president who would shepherd in Real Health Reform.

It’s been 35 years since Nixon proposed his Comprehensive Health Insurance Plan. Then, health care costs were just over 7 percent of the Gross Domestic Product; today, they account for over 16 percent.  In 1974, there were 25 million uninsured Americans Nixon sought to cover. Estimates suggest there are almost twice that many today.

While not perfect, Nixon’s bill is one that most any Congressional supporter of reform would call a big victory if passed today.  But it didn’t, in part because of opposition from progressives. And that opposition, so vocal then, can be heard again in today’s debate, saying this isn’t universal health care, and what we need is universal health care. And until we get that, we’ll just wait. “I would rather see us do nothing now,” former New England Journal of Medicine editor Marcia Angell wrote after the House bill came out, “and have a better chance of trying again later and then doing it right.”

But commentators like Ezra Klein have pointed out that things tend not to go like that. With each generation that passes on health reform, the vision gets smaller, and the political hurdles bigger.

“For a growing number of Americans, the cost of care is becoming prohibitive.  And even those who can afford most care may find themselves impoverished by a catastrophic medical expenditure…Things do not have to be this way. We can change these conditions–indeed, we must change them if we are to fulfill our promise as a nation. Good health care should be readily available to all of our citizens.”

That was Nixon, in 1971. His words and his health reform proposal came in the wake of the Great Society, when it was still widely accepted that government was on the side of the people.  It’s hard to imagine anyone in Republican leadership making such a promise today. With the exception of Sen. Snowe, those who lead the GOP today seem to deny, as dogma, a constructive role for government in the lives of ordinary people.

History should be corrective agent enough to show that scrapping the possible in favor of some more ideal plan at some future time is not the moral ground—it’s the opposite. Waiting means leaving millions of people at risk; people who are right now uninsured, who are unprotected by inadequate plans, or who are desperately holding onto employer coverage they risk losing in the worst jobs economy in generations.

History (and the ghost of Nixon’s health reform proposal) asks that we stay at the table and make these bills as good as possible.  But sometimes we need to remind each other of history, and how close it still is, and what is asking us to do.

–Kate Petersen, Health Policy Hub blogger

Photo credit: Wikimedia commons

Concerns that the bills as written do not do enough to “bend the cost curve” are being voiced more strongly, but aggressive cost containment action risks upsetting the fragile support for reform among health-industry stakeholders.  In other corners, advocates are raising concerns that reform does not do enough to improve coverage for children, and may actually leave some children worse off.  This issue of the Insider gives an overview of each of these difficult issues, and where the debate seems to be heading.

Choice: Getting Beyond Getting to No
As the House was taking a historic vote last week to pass a major health care overhaul, a long-simmering conflict over abortion burst into the open and now complicates further action.  In order to secure a narrow victory in the House, leadership agreed to allow a vote on the Stupak amendment, which went beyond the compromise that had previously been approved by the House Energy and Commerce Committee and the Senate Finance Committee.  The Stupak amendment, named after Rep. Bart Stupak (D-MI), precludes coverage of abortions in the public insurance plan and also in any plan sold through the Exchange that receives subsidy dollars.  After intense lobbying by the U.S. Conference of Catholic Bishops and conservative Protestant groups, the amendment passed, and though pro-choice members of the House voted against it, they were left with a choice of voting for a health reform bill with Stupak, or rejecting health reform entirely.

As we know, they voted to keep health reform legislation moving forward. But as many as 40 House members have indicated that they will not vote in favor of the legislation if the same restrictive language comes back from a House-Senate conference committee.  At the same time, Rep. Stupak has warned that tinkering with the language could result in defeat of reform in the House, and Sen. Ben Nelson has announced that he wants to see similar language in the Senate bill, which is likely to complicate Majority Leader Reid’s efforts to secure 60 votes there.

But the anti-choice camp does not hold all the cards.  There is no guarantee that including Stupak-like language in the Senate wouldn’t cost as many votes as it would gain.  And if abortion foes overplay their hand and block a Senate compromise, it could force a bill to go to budget reconciliation, in which case language like Stupak’s would certainly be stricken as being non-germane (a major criteria for the budget reconciliation process).  Whether that would then lead to ultimate defeat in House or whether a bill rewritten for reconciliation would find some other way to thread the needle is a purely hypothetical question at this time, but it’s pretty clear that Stupak does not and cannot represent the last word on abortion coverage in health reform.

Bottom line: Expect a lot of conflict and an eventual, new compromise on abortion coverage to emerge from the Senate process.

The Cost Containment Conundrum
A growing chorus is emphasizing that “bending the cost curve,” not only for the public sector but for the private sector, as well, should be a central element of reform. (Notably absent from the choir is the general public, who is much more concerned about how much they have to pay out-of-pocket for premiums and co-payments than with the global cost of reform.) Two new reports cast a spotlight on this issue.

A report last week from the Business Roundtable (BRT) emphasized the potential for cost containment and held out a tantalizing carrot: major business backing for reform, which could be an important counterweight to opposition from groups such as the Chamber of Commerce and National Federation of Independent Businesses.

The politics of cost containment remain tricky. Much of the agenda advanced by the BRT, including malpractice reform and cautions about over-reliance on public sector spending cuts that could lead to cost being shifted to private payers, is likely to be warmly embraced by the health care industry.

But many proposals, such as increasing reliance on “value-based benefit design” (insurance benefits that include financial incentives not to use services considered to have little value or to not be cost-effective) and financial incentives for providers to adhere to best practice guidelines could touch off another round of controversy about “government rationing” similar to the “death panel” flap this past summer.  The report embraces the use of wellness incentives in employer health plans, but these provisions have raised concerns from many consumer advocates who worry that they are just a back door way to charge sick people more once such practices are supposedly eliminated by the proposed insurance reforms.  BRT also advocates for broader adoption of payment reductions for hospitals for preventable complications and readmissions, a recommendation the hospital industry is likely to resist.

At the same time, a new report by the CMS Office of the Actuary finds that the House legislation is unlikely to have a substantial impact on the overall growth of health spending (either positive or negative), and raises doubts about the ability of Congress to go through with proposed long term Medicare spending reductions.  The CMS Actuary’s report is already providing talking points for reform opponents, even though such opponents are also likely to fight changes that would drive costs down.

We should note that both bills out of the Senate made bigger inroads into delivery system reform than the final House bill did, and since such reforms are the biggest source of real cost containment, we anticipate the combined Senate bill will do better at bending the curve.

Bottom line: Expect “bending the curve” to play a much more prominent role in the Senate debate than it did in the House.  Look for Senate leaders to walk the tightrope by coming up with additional cost saving strategies to coax moderates on board without scaring of support from the health care industry.

Fault Lines on Immigrant Access
Immigrant rights groups have tried to keep immigration reform separate from health reform.  But after persistent attacks on immigrants in the context of health reform, coupled with responses from the Obama administration and Democratic leaders that were less vigorous and supportive than expected, many have come to feel that a more public case for health access for immigrants needs to be made.

Advocates for immigrant equality are focused on eliminating the five-year waiting period on coverage for legal immigrants in Medicaid and Medicare, preventing discrimination against legal immigrants in “mixed status” families (where some family members are citizens or legal immigrants and one or more members may lack legal authorization to be in the country), securing coverage for children regardless of their legal status, and allowing undocumented immigrants to purchase coverage with their own funds in the health insurance Exchange.  Reform opponents are likely to introduce amendments on the Senate floor to establish a five-year waiting period on subsidies for legal immigrants and to increase verification requirements in an effort to weed out any undocumented immigrants from getting coverage.

Bottom line: Expect Senate Democrats to beat back Republican attempts to add further restrictions on immigrant access.  Lifting the five-year bar on Medicaid access is a dark horse issue, but could come into play in conference committee because it saves money and conferees will be searching for adequate revenue and savings to pay for reform.

Will kids lose ground under reform?
Support for improving children’s health care is broad both within Congress and the general public, but lawmakers are struggling to figure out how to best integrate the current structure of children’s health coverage into a reformed system in a way that preserves the current benefits that children have.  The House and the Senate are taking distinctly different approaches—each of which has pros and cons—which will set up a challenging dynamic for conference committee.

In the recently passed House bill, Medicaid is expanded 150 percent of the federal poverty line and states that have Medicaid eligibility levels above this threshold will continue to cover children under Medicaid.  Once the Exchange is up and running, CHIP is eliminated and children on CHIP are transferred to the Exchange.

In contrast, in the Senate Finance proposal, Medicaid is only expanded to 133 percent FPL, but CHIP is maintained until 2019 (though the Finance proposal does not include funding for CHIP beyond 2013).  After 2019, CHIP would presumably be eliminated and CHIP kids would be moved to the Exchange.  States would also be free to roll back Medicaid coverage to the federally specified minimum.

The upside of the House approach is that it does more to preserve and expand Medicaid, the most comprehensive coverage for low-income children. When children are moved to the Exchange, they will be able to get the same coverage as their parents, and will no longer be subjected to the waiting lists and other enrollment restrictions some state CHIP programs feature.  The downside of the House approach is that even though premiums and cost-sharing are lower in the House than in the Senate, many moderate-income families could find themselves paying more and getting less for children’s coverage.  And the lack of a phase-in period for transition from CHIP to the Exchange could create confusion and gaps in coverage in the short run.

In the Senate, the current successes of CHIP would be preserved, at least in the short run, and any transition made more gradual.  On the other hand, there is no funding for the CHIP extension, which could mean another reauthorization fight in the offing, and if children are eventually moved over to the Exchange, their premiums and cost-sharing would not be as good as that offered in the House.  Additionally, the Senate bill would mean that some Medicaid children would lose eligibility and have to rely on the less comprehensive Exchange.

Bottom line: Who the heck knows?

Waiting for Harry
Although a Senate CBO score and a bill are expected any day, it’s unlikely that substantive debate will begin in the Senate before December.  While still possible for the Senate to move health reform legislation before the end of the year, it’s virtually certain that a bill will not go to the President’s desk before 2010.

–Michael Miller, Director of Strategic Policy

Republican leaders defended their proposal’s meager impact on reducing the number of uninsured by saying that it is only meant to reduce costs, but even on these terms it does less than the Affordable Health Care for America Act (the House leadership plan).

According to the nonpartisan CBO, the House Republican plan would reduce non-group premiums by about 5-8 percent. MIT health economist Jonathan Gruber recently analyzed CBO data on AHCA, and found that even for those purchasing coverage without a subsidy, the House plan would do better, reducing premiums by about 12 percent while simultaneously providing better benefits. For those eligible for subsidies, the reduction is of course much greater.

CBO also found that the Republican alternative would only cover about 3 million people—compared to 36 million covered by AHCA—and still manages to reduce the federal deficit less than AHCA does.

So minimal is the Republican plan when weighed against the challenges confronting our health care system that one analyst dubbed it “the dollar store version of health reform.”

Since the plan has no chance of passage, one has to wonder if the primary motivation for introducing it was to further delay CBO scoring of the Senate measure. By this criterion, at least, it can be judged a modest success.

–Michael Miller, Director of Strategic Policy

Instead, they put out a bill that includes a public insurance plan that would negotiate rates with providers.  The CBO projects this version would save less money, so Leadership made up for the lost savings by proposing a further expansion of Medicaid to 150 percent FPL instead of the 133 percent that cleared committee in the original bills.

Community Catalyst is strongly supportive of the House bill, which goes beyond earlier drafts in a number of respects. It includes a national insurance Exchange that also gives states the option of creating their own Exchanges, new rules that prevent insurers from denying coverage to people with pre-existing conditions or charging people more because they are sick, expands Medicaid, adds a long-term care insurance program for disabled adults, requires health plans to allow young people through age 26 to remain on their parents’ policy, and eliminates the Medicare doughnut hole by 2019, rather than 2024.

Compared to the bill taking shape in the Senate, the House bill is likely to provide better benefits, better subsidies and more progressive financing while reducing the federal deficit and still costing less than the $900 billion ceiling set by President Obama.  Compared to the Senate, the House leadership appears more willing to take on segments of the health care industry and also includes a more significant employer responsibility provision.  (As a result, it faces stiffer opposition from these interest groups, though insurers are opposing the Senate bill as well).  However, according to some analysts, the House legislation does less to reduce spending over the long run than the proposal that passed the Senate Finance Committee.

While the House bill represents a huge step toward quality affordable health care for all, it includes a couple of notable weaknesses. The bill bars most workers who have employer-sponsored insurance from receiving subsidies in the health insurance Exchange.  Instead, workers would be required to take up their employer offer of coverage unless its cost exceeds 12 percent of their income, a requirement that would be too burdensome for low-wage workers.  A better approach would be to exempt workers from the mandate requirement on a sliding scale, as Massachusetts does.

A second problem is that the House legislation assumes that coverage is “always affordable” for people whose income exceeds 400 percent of the federal poverty line.  This provision would be burdensome, especially for older adults with income just above the cut-off point for subsidies.  Although the bill limits premium variation based on age, an older person could still pay twice as much as young adult, leaving them with a very substantial premium liability. Establishing a ceiling on how much people could be required to pay for coverage, regardless of income, would remedy this problem.

The House bill also eliminates the Children’s Health Insurance Program, known as CHIP, and assumes that children who are not Medicaid eligible will get their coverage through employer plans or through the Exchange.

There a number of potential benefits to moving children off of CHIP, not least of which is moving away from a block grant program that gives states the ability to offer relatively limited coverage (flexibility that states have not generally utilized to date) and instead give children a federal guarantee of coverage.

But while under law, CHIP plans may be limited, in practice most states have provided kids with comprehensive coverage.  As a result, children transferring from CHIP to Exchange coverage could see their benefits reduced and their costs increase.   Preserving CHIIP as a program that provided additional benefits and cost-sharing protections for children in families above the income eligibility threshold for Medicaid could help ensure that children get the health care they need.

For more details on the House bill see this updated Community Catalyst summary and discussion.

218, that elusive magic number
As the House prepares for floor action as soon as this week, several hurdles to passage still stand.  Here are the three main sticking points:.

•    Abortion
A number of House Democrats, led by Michigan Representative Bart Stupak, want to have a vote on language that would preclude plans that receive federal subsidies from including abortion coverage.  The current language in the House bill separates out the cost of abortion coverage from a benefits package, and requires the value of subsidies to be calculated without it. But Stupak wants a stricter prohibition on abortion coverage and claims to have the support of 40 House Democrats, which could be enough to block reform if they do not get their requested vote.

•    Immigrant Coverage
A debate is simmering within the House about whether to adopt a provision, favored by President Obama, that would prohibit undocumented immigrants from buying insurance coverage through the Exchange, even with their own money.  Many progressives, especially members of the Congressional Hispanic Caucus, are concerned about the lack of equal treatment for legal immigrants.  Advocates and lawmakers are now contemplating whether to push for an amendment that would give states the option to receive federal matching funds to cover certain legal immigrants through Medicaid.

•    Public Option
While the House leadership believes they lack the votes for a public option tied to Medicare rates, some progressives still want a chance to vote on that amendment and may block action if they don’t get it.

All of these issues could be addressed in a “manager’s amendment” or in the rule that will govern debate in the House later this week.

Affordability woes in the Senate
In case you missed it in our Friday blog post, the Senate is still struggling with the affordability issue.

While sources on the Hill confirm that the Senate is trying to make badly-needed affordability improvements for moderate-income households, they are trying to do it while still reducing fees paid by medical device manufacturers and an excise tax on high-cost insurance plans.  As a result, the best idea the Senate appears able to come up with at this point is to reduce premiums for moderate-income households by raising them for those at the bottom (We compared this proposal with the SFC bill and House leadership plan here.)

Timetable Update
House: The House plans to start floor debate late this week and to finish no later than Thanksgiving.

Senate: A backlog of work at CBO has slowed progress on the Senate side.  Given the slower pace of debate in the Senate, and with Veteran’s Day and Thanksgiving on the holiday horizon, the Senate is unlikely finish debate this month, though there is still a good chance they will finish before Christmas.  That means though, that resolving the differences between the House and the Senate will likely extend into next year.

Shameless plug department

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–Michael Miller, Director of Strategic Policy