Posts Tagged ‘national health reform’

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Public option revival

Monday, October 26th, 2009

What’s Goin’ On: Untangling the debate on public option
The big story of the week was undoubtedly the political resurgence and maneuvering around the public option – a resurgence we’re glad to see. But with legislative leaders keeping their cards close to the vest and pundits spinning the news based on what they hope is true, it is hard to untangle what is really going on (Good mainstream media coverage in the New York Times and the Washington Post.)

So here’s a special Insider devoted (mostly) to trying to get the story right. (With the caveat that it could change by the time you read this).

Housewarming
There are over 200 votes for the “robust” public option, the one with rates based on Medicare, but the magic number is 218 and it’s still not nailed down. House leadership is trying both to round up a few more votes and to test out other possibilities. But whether a different approach, e.g. a public option with negotiated rates, does any better is open to question, since such a proposal may lose more support from progressives than it gains from more conservative members of the caucus.

The upshot? Progressives need to continue their big push this week to find those last few votes.

The revival of public option in the Senate
Ever since polling revealed that a public option wasn’t a deal breaker to members of the Blue Dog caucus, the question in the House has been not whether a public option would be included, but what version.

It’s a different story in the Senate.  Olympia Snowe’s vote in Finance initially seemed to seal the deal against inclusion of a public option in the Senate, but a number of factors have kept it alive.  Persistence from both organizing groups such as Health Care for America Now, among others, and champions in the Senate such as Sen. Schumer, who has worked to find a version of public option that would secure support from conservatives, has been instrumental.

The self-inflicted wounds of the insurance industry also factored in.  By squarely attacking the Senate Finance proposal—the most industry-friendly of any of the bills on the table—the insurers convinced some members that they were trying to kill health reform, and no accommodation would be possible.  Another factor that has flown mostly below the radar is the ripple effect from the President’s insistence that a bill clock in at under $900 billion. And here’s where the public option and affordability story lines start to run together.

While the SFC proposal was scored under $900 billion, the relatively skimpy benefits and high premiums were concerning to the Democratic caucus and many reform supporters.   Without adequate affordability provisions, the underlying structure of health reform—insurance reform coupled with an individual mandate—is unworkable.

Fixing the affordability problem requires not only additional revenue, but cost-effectiveness measures in order to create enough “head room” under the $900 billion ceiling to find that revenue, and there, the public option is an important part of the solution.  By reducing the price-tag of reform, inclusion of a public option becomes a “two-fer”—a proposal that enjoys broad support within the caucus and that also addresses cost issues.

Senate Democratic leaders seem to be leaning toward inclusion of a public option that gives states the ability to opt out.  This way, leaders give Democratic conservatives a chance to vote to strip the provision but protect it by setting up the vote so that 60 votes are required to delete it instead of add it.  (It’s a strategy Ezra Klein says made the White House and Sens. Baucus and Snowe none too happy.)

This strategy works if and only if all the members of the Democratic caucus agree to at least stick with the party to break a filibuster – even if they vote no on the underlying bill.

That’s because they will almost certainly lose Sen.Snowe (and fail to pick up Sen. Collins) with this strategy.  As the failed cloture vote on a permanent fix for Medicare physician fees last week demonstrated, there is no guarantee that the Senate leadership can hold all 60 members. If a cloture vote on a bill with a public option fails, leadership might have to go back to a trigger or some other option, but only as a last resort if all else fails.

Read the rest of the Health Reform Insider on the Community Catalyst National Reform page, or subscribe to the Health Policy Hub by email to the get the Insider each week.

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Too bad they can’t vote

Monday, October 19th, 2009

A substantial and growing cadre of prominent Republicans have come out in favor of health reform recently. A partial list: former majority leaders Bob Dole, Howard Baker and Bill Frist (who this week disputed critics who claimed that Obama was promoting socialized medicine), California Governor Schwarzenegger, former HHS Secretary Tommy Thompson, and former CMS chief Mark McClellan.  Not exactly a fringe element.

Yet there’s been no sign that these endorsements will move Republicans in Congress.  Maybe it’s something in the water in Washington, or maybe it’s just an indication of the extent of ideological or simply partisan polarization that so few sitting Republicans are willing to join party elder-statesmen in moving reform forward.  Right now, the calculus in the Republican caucus seems firmly set on continuing its near-unanimous opposition to reform – and carrying it into the 2010 elections and beyond (just in case you thought this issue was going away after passage.)

The Ladies from Maine Part I: Snowe Fall
Sen. Olympia Snowe’s aye vote on the Finance Committee reform bill ended intense speculation over which way the senior Senator from Maine would go.  To many, her vote suggests that she agrees with assessments that a yes vote in Finance gives her more leverage over the process going forward than continuing to dangle the carrot of her possible future support.  Snowe is now positioned to limit the movement of the bill to the left as it’s combined with the more liberal HELP bill, to be a key decision-maker on floor amendments, and perhaps even to have a formal role in conference committee.

In the eyes of the beholder
What is it that Sen. Snowe wants as the process moves forward?  One priority is preventing the inclusion of a public option except as a fallback.  A second Snowe priority is affordability.  At the same time, she has opposed most of the options on the table advanced to make better subsidies available.

A contradiction?  Not necessarily.  Affordability in Sen. Snowe’s eyes seems to be more about slimming down the coverage people would receive rather than making subsidies better—an idea that is getting some support in Democratic quarters, as well, even though the Finance bill already offers much less generous coverage than other proposals, particularly for low-wage workers.  Common Sense Affordability Protections, a paper released today by Community Catalyst and PICO, highlights the problems for low-income people in the Finance proposal and makes recommendations for how to fix them.

The Ladies from Maine Part 2: As Snowe goes so goes Collins?
Late last week, Sen. Susan Collins (R-ME) indicated her openness to supporting reform.  This is welcome news in some quarters because of the challenge of getting 60 votes even with support from Sen. Snowe.  On the other hand, Collins’ statement triggers some alarm bells.

The concern she voiced over potential cuts to Medicare benefits (and misrepresenting what is in the bill) should be read as coded opposition to eliminating current overpayments to Medicare Advantage plans and other efforts to reduce Medicare spending  — measures that form an important part of the financing of the Senate bill.

This wouldn’t be such a problem if the Senate weren’t already having such a difficult time agreeing on revenue options.

But attacks on the current financing mix continue, especially from medical device manufacturers concerned about new fees they would have to pay, and from unions and progressives unhappy with the proposed tax on insurers who offer high-cost plans.  This tax is almost certain to be passed on to enrollees and would fall disproportionately on states with high health care costs and firms with older workers.  Senate negotiators are working to modify both of these revenue sources but the struggle will be not to lose revenue in the process.

Read the rest of the Health Reform Insider here.

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G-Force

Friday, October 9th, 2009

So now we wait.

The hurry-up-and-wait that has characterized Congress’s movement on health reform is par for the legislative course, especially a bill such as important and many-parted as health reform. But much of that waiting wasn’t on deliberations of the full committee or mark ups but watching the picky-eater-at-dinnertime progress made by the Group of Six, a set of negotiators Sen. Max Baucus handpicked and strove to keep at the table. The Senators represented a lot of wide open spaces — Montana, Iowa, Wyoming, North Dakota, Maine and New Mexico – but not very many people.  8.4 million, to be more precise, or about pi percent of the U.S. population.

As the summer turned to fall, the Group of Six came to give new meaning to “bipartisanship,” and left the committee scrambling to nip and tuck the bill in order to wring from it some small measure of Republican support.  This week, there’s news that Senate Majority Leader Harry Reid is handpicking a smaller team from the Finance and HELP committees to merge the two Senate bills. So far, he’s up to two. Part of this is just the nature of the law-making process – bills get merged in rooms with a certain number of people in them, as Jonathan Chait at The Treatment pointed out.  But from a straight representative viewpoint, a table for three or four or six from land-rich, people-scarce parts of the country necessarily excludes the interests of the majority of the U.S.

The self-winnowing Group of Six experience stands in stark contrast to another big news-making decision made last month in Pittsburgh, when the informal economic group the G-8 decided to handoff its power to the G-20. Such a move acknowledges new global economic realities: the countries in the G-8 (Canada, France, Germany, Italy, Japan, Russia, U.K., and U.S.) represent about 14 percent of the world population, while those in the G-20 represent two-thirds of the world’s people and 85 percent of its gross national product.

I admit that population and economic production are just two of many, many metrics, and do not suggest that world economic decisions, or health care ones, must be closely-tied to some population algorithm. That’s not how things work. But symbolically speaking, expanding and sharing the decision-making power respects certain global realities, can build public buy-in and is, if incompletely, more democratic.  As with many acts of small-d democratization, having more people at the table makes the group more likely to make decisions that are good for more people.

Sure, it’s utilitarian of me to say so, but health reform, too, should be based on decisions that do more good for more people. But just by the numbers, that’s not how it has played out lately. You have to wonder if the unrepresentative nature of the process made it easier for the final product out of Senate Finance Committee to be tilted more toward the needs of special interests than to those of many low- and moderate-income people, especially the uninsured.

–Kate Petersen, Health Policy Hub blogger

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The Great Consensus Hunt: Search for a public option

Tuesday, October 6th, 2009

Despite the support of many Senators, led by Sens. Rockefeller and Schumer, the effort to add a public option to the Senate Finance bill fell short.  Significant opposition from conservative Democrats both on and off the committee makes it hard to see how a public option as currently formulated can pass the Senate as long as 60 votes are needed.

Nonetheless, the strong showing in the Finance Committee has led to an ongoing search for a formulation that will satisfy both the left and right in the party.  One possibility is that conservative Democrats would agree to vote with the majority of Democrats to break a Republican filibuster, but would still be given a chance to vote against the public option.  Another approach is to find one or more new approaches that can satisfy both wings of the party.  With that end in mind, both Sens. Cantwell (D-WA) and Carper (D-DE) have offered new ideas for consideration. (See below).

Cantwell: harnessing state purchasing power, but consumer protections needed

An adopted amendment sponsored by Sen. Cantwell (D-WA) would allow states to negotiate for coverage on behalf of low-income enrollees instead of having them buy coverage through the Exchange.  Presumably states would contract with Medicaid managed care organizations (MCOs) (at rates higher than Medicaid, but lower than commercial insurance) or directly with organized networks of providers.  The proposal is similar in structure to the Washington Basic Health Plan and, in some respects, to Commonwealth Care in Massachusetts.

While it would likely put some downward pressure on insurance rates, the Cantwell amendment has some significant weaknesses.  First, unlike a Medicaid waiver, which must be budget neutral, the federal government gets a cut off the top.  States would receive only 85 percent of the money that would otherwise be available for subsidies for low-income people.  If a state chose this option, savings would accrue automatically to the federal government while the state would be at financial risk for providing a benefit package equivalent to what would have been available in the Exchange, but with less money.  This could give states incentives to skimp on coverage for enrollees.

To the extent states are able to negotiate additional savings, nothing in Cantwell’s proposal requires that any portion of those savings be used to reduce premiums, cost-sharing or improve benefits for the low-income enrollees who would be required to participate in the plan.  Finally, the process for building the program at the state level and room for consumer input there are unclear.  In order to make this proposal work for low-income enrollees:

•    States should get 100 percent of tax credit, maintaining budget neutrality to the federal government
•    Savings should be required to be reinvested in better coverage for program participants
•    Access to providers in the “basic health plan” should be at least as good as in Exchange plans for higher-income enrollees
•    States would need to ensure that the Basic Health Plan was coordinated with both Medicaid and the Exchange to ensure seamless coverage for enrollees
•    Rules should be put in place to make the program development transparent at the state level and ensure opportunity for public input.

Carper: State flexibility to create a public option

Another idea making the rounds, but not included in the SFC bill, is a proposal offered by Sen. Carper as an alternative to forming insurance co-ops.  It would allow states to offer either a public option or open the state employee program to the Exchange population.  While this would give some states an opportunity to experiment with a public option, Sen. Carper’s proposal gives governors a veto that cannot be over-ridden.  a public plan would be available only if a governor and the legislature agree. (Presumably, though it’s not clearly-worded in the proposal, the co-op would be put in place in the absence of an agreement).  As with the Cantwell amendment, the Carper proposal has some merit, but it doesn’t make a public option available uniformly across the country.  As a result, it is likely to get a cold reception from advocates of the public option, both in and outside Congress.

But a proposal like Sen. Carper’s, if it can pass the Senate, does have the advantage of “raising the floor” in eventual negotiations with the House.  In the meantime, Senators and advocacy groups will continue their efforts to secure as much support as possible for the public option in the Senate.  Even if it does not pass, getting a yes vote from over 50 Democrats will strengthen the public option’s prospects in House-Senate negotiations.

It’s Snowe-time

As we’ve observed here before, Sen. Snowe has been the most closely-watched member of the Senate.  Despite all the tea-leaf reading of her committee votes, her position on the SFC bill is still unclear.  But the time for Sen. Snowe to either fish or cut bait is rapidly approaching.

If she votes with the rest of the Republicans against the SFC bill, it will be very hard to convince other members of the Democratic caucus, already frustrated by long months fruitlessly courting the GOP, that they should continue to offer concessions with no assurance of support.  On the other hand, if she votes for the bill coming out of SFC there will continue to be substantial deference to her views, both during the merger with HELP and beyond.

A closer look at the age-rating debate

Sen. Baucus revised his original proposal to narrow the permissible variation in premiums from 5:1 to 4:1 based on age – a move in the right direction though such a wide rating band will still leave insurance unaffordable for many, and should be brought in line with the 2:1 rating proposed in the Senate HELP and House bills. But even 4:1 drew a sharply-worded letter from the insurance industry claiming that it would cause young people to drop out of the risk pool and make coverage more expensive overall. It’s worth reality-testing this common argument against tight rate bands.

The experience that insurers draw on to support their claim is what happened to costs in some states with guaranteed issue and community rating.  But these states were operating without the benefit of income-related subsidies or an individual responsibility requirement – both components of national reform.  With reform, age will be irrelevant for most people with income below 400 percent of the federal poverty line (FPL) buying non-group insurance; They will pay an income-related premium regardless of age.  Only above the subsidy line does age become a meaningful factor, and there the difference is stark.

A 25-year-old making $45,000 buying insurance with a 2:1 rate band (as in the House and HELP bills) would pay about 6.75 percent of her income for coverage).  A 64-year-old with the same income would have to pay about 13.5 percent of hers.  If the age bands remain at 4:1 as Senate Finance proposes, the 25-year-old will be able to get insurance for less than 5 percent of her income, but the 64-year-old would have to pay 19 percent of her income just for premiums.

So despite the insurers’ claims, a 2:1 age band will not make insurance prohibitively expensive for young people, but failing to reduce age-related discrimination more than the Senate Finance bill has so far will leave older adults without affordable options.

House Update: tough sledding ahead

During the Senate Finance mark up, the House has been working out of spotlight, a lack of attention that has probably been welcome to House leaders, who face major challenges to putting together final version of bill.  A debate reminiscent of the Energy and Commerce committee one in July is going on, and has so far kept House leaders from settling on a public option approach.  House Democrats can only lose 39 votes and still retain a majority. More than that have already committed to oppose a plan that does not tie reimbursement in the public option to Medicare rates, but it’s not clear that there are enough votes from Blue Dogs and other more conservative members to pass such a strong public option.

Several other contentious issues remain unresolved, especially how the House will lower the price tag of their bill without gutting affordability protections, and how to resolve concerns about the financing provisions.  A bill isn’t expected on the floor for at least two weeks (although once a bill does go to the floor, the House can move much more quickly than the Senate).

(from the Health Reform Insider, which you can read in full here).

–Michael Miller, Director of Strategic Policy

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Partly cloudy with a chance of Snowe

Tuesday, September 29th, 2009

The Senate Finance Committee returns to its mark up today, and for health reform junkies, the number one spectator sport of the moment has become watching committee member Sen. Olympia Snowe’s every move like they were tea leaves to her votes.

Over the course of the debate, Snowe’s support has taken on great importance. It would help the Democratic leadership hold onto their own conservative members and could even pave the way for several more Republican votes in support of reform.  And a series of committee votes on which she has voted with Sen. Baucus has sparked speculation that Snowe is moving toward a yes vote on the overall bill.

For her part, the senior Senator from Maine is keeping her cards close to the vest.  While Snowe’s support would be a political dream-come-true for Senate leadership and the White House, liberals in and out of Congress have less reason to be enthusiastic, since Snowe has been clear that she does not support a public insurance plan except as a fallback in the event that there are not an adequate number of private options.

With the Finance mark-up  slated to wrap this week, we’ll be watching to see how the committee addresses affordability, the public option and employer responsibility – and of course, Sen. Snowe’s votes on these issues and the final bill.

For more, check out the Health Reform Insider.

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Handicapping the Baucus plan

Tuesday, September 22nd, 2009

With no commitments of Republican support, Chairman Baucus can only afford to lose two Democratic votes and still get a bill out of committee.  Sen. Rockefeller (D-WV) has already committed publicly to opposing the bill in its current form, and Sen. Menendez (D-NJ) has indicated that he might not support the bill due to concerns over the treatment of immigrants. With most other Democrats on the Finance Committee expressing some degree of concern, the Chairman will have to make significant changes in the coming week.  The challenge will be to come up with modifications that will satisfy both liberal and conservative members.

By now, the key issues that the committee will have to resolve are familiar—they are most of the same ones that bedeviled the inconclusive bipartisan negotiations that preceded the release of the Baucus plan.

We recap the most significant ones and assess their prospects in this week’s Health Reform Insider.

–Michael Miller, Director of Strategic Policy

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The MD factor: Majority of physicians back public insurance options, study shows

Wednesday, September 16th, 2009

A study released this week in the New England journal of Medicine found that a large majority of physicians support the expansion of publicly-backed health insurance programs. The survey, funded by The Robert Wood Johnson Foundation, polled over 5000 randomly-selected physicians from a broad range of specialties, practice setting, and regions, and the findings represent the opinions of more than 2100 respondents contacted between June – Sept. 2009.

The large majority of respondents – 73 percent – supported a public option in health reform; most surveyed (62 percent) said they think health reform should include a combination of public and private options, mirroring the principles President Obama, three House committees and a Senate committee have all put forward.  A majority of American Medical Association members surveyed also supported a public option.

And in a finding that rebuffs some reform opponents’ claims that expanding or fortifying Medicare would hurt practicing doctors, there was strong, cross-specialty support for expanding Medicare to those ages 55-64.  Check out the paper’s helpful bar graph to see what we mean.

The authors acknowledge that though the American Medical Association’s stand on reform has wavered and changed during health care debates, past and present, it has most recently come out in support of a House reform proposal that includes significant coverage expansions through subsidized private insurance and a public option.   These findings demonstrate that this position is now more consistent with individual physicians’ views on health reform today.  The authors write:

Physicians’ groups have strongly influenced efforts in health care reform throughout modern U.S. history and in so doing may have often obscured the collective views of individual physicians across the spectrum of specialties, interests, and regional affiliations. Given the enormity of the current effort to reform health care and its potential effect on future generations of Americans, policymakers need to hear the views of the whole range of physicians on the key elements of reform.

Both authors, physicians at Mt. Sinai School of Medicine, are members of the National Physicians Alliance. You can hear them talk about their findings on NPR’s All Things Considered.

–Kate Petersen

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Full Court Press

Monday, September 14th, 2009

President Obama’s all-out effort to wrest the health care conversation from the right wing and more at the Health Reform Insider, Community Catalyst’s weekly take on what’s happening in national reform.

–Kate Petersen

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Welcome to the Health Policy Hub!

Wednesday, September 9th, 2009

Today, Community Catalyst proudly launches our new blog, Health Policy Hub. While the word “policy” may sound a bit wonky to some, we hope to hit the wonk-life balance by providing interesting commentary on all things health care without coming off like policy geeks who spend our lunch hours ruminating over subtitle c of section 101(B) of Title I of the Acts of…Obviously, no one here does that.

We’ll bring you the insights, expertise and opinions of our Community Catalyst colleagues who have years of experience (we won’t say how many) and numerous successes working to improve health care at the local, state and national level. They’ve been on the ground organizing grass roots advocacy groups, at the table negotiating with insurers, hospitals and policymakers, and on their Blackberries working around the clock to ensure consumer interests are represented in our health care system. We’ll look at many issues – from health care reform to children’s health to making our hospitals more accountable to the communities they serve – through a consumer lens. We’ll also check in with our state and national partners on their efforts to make health care better, accessible and affordable.

Like any blog, Health Policy Hub’s success hinges on our ability to keep content fresh and interesting. We will work hard to make that happen. But we also need you readers to help out with the interesting part – sharing what you’ve heard and letting us know what you think. We welcome your comments, and hope this is the start of a lively and thought-provoking conversation.

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