Sunday, December 20, 2009

Why Fight Now? A Single Payer View on the Public Option

Time to say a few things:

Health reform is important. The bills before Congress can make a difference for millions.

The President needs to win this one, soon. If the insurance industry can demoralize progressives over the holidays, the win comes on their terms. If progressives keep up the fight we could win.

The public option is not optional. It is our toe-hold on structural change.

Women and immigrants are more numerous and better organized than the turkeys who think we are wedge issues.

On the other hand, there is no organization that will swoop in and win this for us. Social justice, labor, women’s rights and other groups have been battered by 30 years of neoliberal economics and politics. Progressive political leaders in the Senate – Sanders, Brown and Burris - took their bows for talking up a single payer amendment that failed even more spectacularly than expected, and they ducked last minute appeals to them to cross Harry Reid and the White House by threatening a No vote.

Mike Huckabee is heading to Omaha to rally and revive the teabaggers. It won’t matter right now. Huckabee, like a lot of others, is building his lists and organization for other fights.

For those of us who think the next step toward health reform, however limited, should be at least a step forward and not a wholesale retreat on reproductive and immigrants’ rights, we will have to be enormously creative and persistent this week. Stay tuned..

Tuesday, December 15, 2009

Fight for Real Health Reform!

The President and the Senate are likely to meet on Tuesday regarding health reform. Following is a message to Congress and the President - please add your own, and call or write TODAY!

Also: links to statements below from the Congressional Progressive Caucus and Rekindling Reform

To Congress and the White House:

We need and support real health reform. Stick with us and demand a bill that preserves and expands the strongest points of House and Senate proposals, starting on day one:

1. A public option is critical to advance access, quality, affordability and cost control. A buy-in to the public Medicare program for ages 55-65 must also be affordable.

2. All plans must be affordable, limit out-of-pocket expenses, require fair financing by employers and high-income individuals, end insurance company abuses, and require insurance companies to spend at least 90% of revenues on health care.

The federal government should promote innovations in delivery and financing of health care, including more primary care providers and public health funding.

3. Defeat diversions on wedge issues:
Advance reproductive rights.

Assure that all people who live in the U.S., including immigrants, have access affordable, quality, culturally appropriate care.

4. Promote states’ ability to move to single payer systems.
This historic bill will be an important step forward. States must be empowered to advance to a single payer system.



Statement by Congressional Progressive Caucus:

Statement by Rekindling Reform:


We have won important victories for better access to affordable health care.
Enemies of reform are now out in force.
Progressives must stay informed and engaged to achieve a truly historic victory.

Saturday, December 12, 2009

The Senate Compromise: Does it Help?

The Senate compromise seems to be this:

For the slice of the population age 55 - 64 that would have gone into health exchanges with subsidies – uninsured, self-employed – let them instead buy in to Medicare. Except without subsidies.

The Medicare Part B premium is now means-tested – that is, based on annual income. It covers 25% of the cost of the program. Individuals earning less than $85,000 a year pay no premium; going up from there from about $44 a month to about $353 a month. Buying in to Part B alone could presumably cost 4 times those amounts, or between zero and $1400 a month. Plus the $155 deductible.

Offer the same group, under age 55, the choice of 2 nonprofit health plans, administered by the federal Office of Personnel Management.

No public option.

Til now we’ve heard that Congress would abolish lifetime caps on what the plans would pay. Now we’re hearing the caps may be back. (After which you’re on your own.)

The great thing about Medicare is that it has the clout of 40 million beneficiaries and the federal government when it comes time to negotiate with Sutter Health. So sure, add more folks in over there.

But. If they’re the oldest and sickest, and everyone under 55 is still left to the depredations of the private insurance industry…Well. Perhaps at least a few more of them will be covered.

And rumor has it that the Senate would also require the companies to spend 90% of the premium dollar on actual benefits (a big hike from the 70% or so that some plans spend now).

Ok marginally a little better than nothing. But so diluted from the House bill, in terms of a stepping stone to the future: less public involvement than any proposed public option (so less cost control), less affordability, less coverage. Makes you think that maybe the regular legislative process has some advantages over the Gang of 10 system.

Painful as it may be, and tempting as it is to go for expanding Medicare by any means necessary, it’s looking like getting something through the Senate, to be followed by a conference with the House’s better bill, is our best hope.

Wednesday, December 9, 2009

The Senate: Getting to the Public Option

It is important that health reform continue to move forward through the Senate. The most recent announcement offers some elements that sound attractive. As a whole, though, the package seems to leave a lot of gaping holes, that the Senators will need to address, or that will be resolved in conference.

What the proposal is, as far as we can tell:

Opening up something like the Federal Employees Health Benefits Plan (FEHBP) to the public, through the Office of Personnel Management.
Offering some or all people age 55-64 the chance to buy in to Medicare.
A trigger to create a public option in the future.

Progressives need 3 things:

1. An expanded role for the public sector, in order to effectively control the charges by health care providers: drug companies, hospitals, medical supply companies, hospitals. Doctors too. Private insurance companies have no stake in controlling prices and are often too weak to bargain successfully with organized providers.

2. To the extent there will continue to be private for-profit insurance companies in the mix, they need to be strictly regulated, so that the uninsured will have a fair shake at getting covered, and the insured and underinsured have a fair shake at getting our claims paid.

3. Subsidies to make insurance affordable, and to put some pressure on the government as prices rise.

Increasing enrollment in Medicare for seniors, while expanding coverage for middle age/middle income people, would be a great step forward.

But marginally opening up Medicare selectively to a subset of seniors does not accomplish these objectives. It likely will not increase significantly the number of beneficiaries; and they will be the most expensive to treat.

FEHBP has the same inflationary insurance spiral as any other set of private insurance plans. It does function somewhat like the proposed health insurance exchanges. It is not a public option. A trigger needs to be pulled now.

The Illinois Campaign for Better Health Care proposes this:

"It is NOT an either or - we demand a strong public option, strong insurance reforms, and expanding access to Medicare to all individuals 55 and older. Better yet, let everyone join Medicare."

Call your U.S. Member of Congress at 1-888-801-4426. Tell them:
For Democratic reps: "Stay firm on the public option plan on which you have already voted yes and on expanding Medicare eligibility."

For Republican reps: "Quit playing politics with my and my family's life. Support the American people and support health care reform."

What do you think?

Thursday, November 19, 2009

Real Health Reform: Positions for Progressives

What Now

It has been both an exhilarating time for progressives and a bumpy one: the House passed a bill (yay) with a public option (yay). These are victories for progressives, inside and outside of Congress: we made this happen.

But House leaders caved at the last minute to an anti-abortion spoiler, the Stupak-Pitts amendment, and dropped a popular provision proposed by Rep. Dennis Kucinich to protect states that opt for single payer systems from lawsuits under ERISA.

Many of us who both support and desperately need health reform are still trying to make sense of the news of the last week. Advocates and the public need to be unified and energized for the final push to get the best possible bill through the Senate and back through the conference committee with the House.

Here’s what we think all Senators need to hear, and why:

1. The House bill is a major achievement. Preserve and expand on its strong points, including the public option.
There is a lot here for access, quality, affordability and cost control, in fact more than there was in any of the bills that passed through the House Committees. The public option is likely to be more robust than the Congressional Budget Office’s preliminary projection.

2. We need to advance reproductive rights, not retreat.
The anti-abortion amendment is a real threat and a wake-up call.
We can beat it. Many members who voted “yes” on Stupak are on record as pro-choice.
Pro-choice energy can propel reform forward.

3. Protect single payer states from ERISA lawsuits.
It is important to continue to point this out and to organize for single payer, and against the for-profit private insurance industry States will be a far cry further in the march toward single payer if we can win waivers from federal obstacles including ERISA.

The House is still in play; they will be involved in the conference with the Senate, and will vote again on final passage. Our messages to House members depends on how they voted. (See Tables on p. 8):

1. Voted Yes on the bill and No on the Stupak Amendment (178 Democrats): Thank you! You’re the progressive Democratic majority. Help us win the ERISA waiver, and keep what we’ve won.
2. Voted Yes on the bill and Yes on Stupak: Stick with the bill and stick up for women. [For those historically pro-choice: Shame on you for voting Yes on Stupak]
3. Voted No on the bill and No on Stupak: Thanks for opposing Stupak. I’m asking you to stand up for health care reform now and support the bill.
4. Voted No on the bill and Yes on Stupak: We need health care reform now, and need our member of Congress to stick up for women. Will you change your vote and stand up for health reform and for women? [For those historically pro-choice: Shame on you for voting Yes on Stupak]

(for full statement and to see how Menbers voted go to:

Thursday, November 12, 2009

Anti-abortion amendment threatens all women, all health plans

Media coverage of the Stupak amendment underestimates its impact on privately-funded abortion. The impact is also being downplayed by the right.

This looks specifically at the language of the amendment to show how it:

1. Certainly eliminates the ability of any health insurance plan participating in the new health insurance exchange from covering abortions for any enrollee, if the plan accepts any enrollee who uses federal funds to pay any part of the premium. This would include the public option, but also any other plans that participate in the exchange.

It also prohibits any plan that would offer “affordability credits” from covering abortions.

2. Could eliminate current practices by 17 states to cover abortion under Medicaid, and prevent other states from doing so.

In addition, it has the following potential effects:

3. Can eliminate the ability of any health insurance plan covered by any part of HR 3962 to cover abortion, depending on the menaning of "any costs."

This could mean any health insurance plan offered through the new health insurance exchanges. The Exchanges, in turn, include both private insurance plans, and a public option.

4. Can eliminate all health insurance funding for abortion, depending on the meaning of "authorizes."

1. Certainly eliminates the ability of any health insurance plan participating in the new health insurance exchange from covering abortions for all enrollees, if the plan accepts any enrollee who uses federal funds to pay any part of the premium. In this way it restricts abortion coverage both to low-income and middle-income women who receive federal funds for subsidies. It also restricts coverage for women who pay entirely with their own funds. This would include the public option, but also any other plans that participate in the exchange.

There is general agreement that the amendment prevents health plans in the new health insurance exchanges from covering abortions, if they will accept women who use federal subsidies to pay part of their premiums.

This prohibition applies to all plans in the exchange. These include the public option, as well as all other private insurance plans in the exchange.

Some people (those earning up to 400% of the federal poverty limit, or about $88,000 for a family of 4) will use federal subsidies (or “affordability credits”) to pay for their premiums. Those people could not buy a health plan that covers abortion through the exchange.

It will apply even though the federal subsidies constitute only a part of the premium, and the rest is paid through private funds.

In addition, any plan that intends to enroll people who accept federal subsidies to help pay part of their premiums will not be able to cover abortion, for anyone who enrolls in the plan. This means women who do not accept federal subsidies, who pay the entire cost of insurance privately, cannot buy an insurance plan that covers abortion through the exchange, if the same health insurance plan covers women who do use the subsidies.

The bill offers women the ludicrous option of buying supplemental abortion plans, as long as they do so outside of the exchange and using their own money. Supplemental abortion plans cannot be purchased using affordability credits, which are public funds. This extra punch assures that in case the Supreme Court balks at outlawing abortion outright for millions of women with employer-provided insurance, women earning up to 400% of the poverty level who take advantage of public subsidies won't be able to use their insurance when they find out their birth control has failed.

All of this is worse than current law. Current law, through the Hyde amendment of 1976, says no federal funds can be used for abortion except if the mother’s life is in danger or in the case of rape or incest. Where the language is ambiguous, the Supreme Court will decide.

(a) IN GENERAL.- No funds authorized or appropriated by this Act (or an amendment made by this Act) may be used to pay for any abortion or to cover any part of the costs of any health plan that includes coverage of abortion, except in the case where a woman suffers from [life-threatening illness related to the pregnancy, or pregnancy is a result of rape or incest]."

2. Could eliminate current practices by 17 states to cover abortion under Medicaid.

17 states now find ways to use state funds to pay for abortion through Medicaid. Medicaid is a program for low-income women which is funded jointly by state and federal dollars. The amendment appears to explicitly prohibit this:

"(b) OPTION TO PURCHASE SEPARATE SUPPLEMENTAL COVERAGE OR PLAN. – Nothing in this section shall be construed as prohibiting any nonfederal entity (including an individual or State or local government) from purchasing separate supplemental coverage for abortions for which funding is prohibited under this section, or a plan that includes such abortions, so long as –
(2) such coverage or plan is not purchased using –
(B) other nonfederal funds required to receive a federal payment, including a State’s or locality’s contribution of Medicaid matching funds."

3. Could eliminate the ability of any health insurance plan covered by any part of HR 3962 to cover abortion, whether or not it includes people who use federal subsidies to pay for their premiums, depending on the menaning of "any costs."
This explicitly could mean any health insurance plan offered through the new health insurance exchanges, both private insurance plans, and the public option.

The amendment says “No funds authorized or appropriated by this act…may be used to …cover any part of the costs of any health plan that includes coverage of abortion.”

It also does not restrict the use of federal funds to premiums. “Any part of the costs of any health plan” could refer to the administrative costs of setting up a health insurance exchange.

There will be people covered in the Exchanges who do not receive any federal subsidies for their premiums. They will pay every penny of the premium out of their own pockets. Some others will pay the premium by a combination of funds from their employers and from themselves.

These people may not be able to buy a plan through the Exchange that covers abortion

4. Can eliminate all health insurance funding for abortion, depending on the meaning of "authorizes."

It says that no funds "authorized or appropriated" by HR 3962 can be used to pay for abortion or to cover the costs of any health plan that covers abortion. It does not limit the application of this prohibition to funds authorized by any section of the bill, to health insurance exchanges, or to the public option. It applies to every word in HR 3962.

It also doesn’t necessarily restrict its application to funds “authorized” by Congress to be paid through federal sources.

Authorization and appropriation are particular acts by Congress to direct public funds to various purposes. That could be what this language means. Which would be bad enough.

The bill also "authorizes" employers and individuals to contribute to health insurance. These are private funds. The funds can be used to buy health insurance entirely privately. Or they could be used to buy insurance within the new health insurance exchanges. It could mean that no health insurance plan purchased as a result of the bill can be used to pay for abortion. None. It is possible that no health plan that covers abortion could be offered through programs created by this bill.

In the case of ambiguity, the Supreme Court could make the final decision.

Monday, November 9, 2009


I think that HR 3962 offers many important improvements over the status quo, in the areas of coverage, affordability and quality, despite significant limitations, I will document these shortly.

The Stupak amendment however is exactly the poison pill it is meant to be. It virtually rolls back women's current legal right to choose abortion. It is an unacceptable political compromise. It cannot stand. Read it here:

It says that no funds "authorized or appropriated" by HR 3962 can be used to pay for abortion or to cover the costs of any health plan that covers abortion.

Authorization and appropriation are particular acts by Congress to direct public funds to various purposes. That could be what this language means. Which would be bad enough.

The bill also "authorizes" employers and individuals to contribute to health insurance. These are private funds. It could mean that no health insurance plan purchased under the auspices of the bill can be used to pay for abortion. None. It is possible that no health plan that covers abortion could be offered through programs created by this bill. This may be a debatable interpretation. If it is challenged, the Supreme Court will decide.

It adds that supplemental abortion plans cannot be purchased using affordability credits, which are public funds. This is an extra punch to be sure that just in case the Supreme Court balks at outlawing abortion outright for millions of women with employer-provided insurance, women earning up to 400% of the poverty level who take advantage of public subsidies won't be able to use their insurance once they find out their birth control has failed.

Why are we facing this devil's bargain at the 11th hour in this campaign? Where was the vigorous organizing and mobilization campaign to get the votes needed to pass this bill without dismantling women's hard-fought rights? Was it news to anyone that the Catholic bishops oppose abortion, that they have access to an energized constituency, or that this constituency represents a minority of opinion even among Catholics?

This is not a re-election pitch or a solicitation for funds, which usually prompts messages like these from our leaders. It is also not a proposal for a particular action, People will need to figure out together what to do about this.

Planned Parenthood to their credit suggests writing to the President, calling this the outrage that it is and calling for actual leadership. Good start.

Sunday, November 1, 2009

Is 2% Worth It?

Now we’re hearing that the public option is too puny to work. Is it true?

Let’s back up a minute, and look at the choices before us right now.

1. No change.
2. A reform bill with no public option.
3. A reform bill with a public option.

The insurance industry thinks #1 and #2 are just grand. (Despite what they say in public.) They’d like us to believe that #3 is so useless that we should settle for #1 or #2. Here’s why they are wrong:

The existence of a public option creates a wedge for the public sector. The public sector already covers people who are over 65, low-income, in the military, and others. Now it will start slicing into working age Americans. It will have the most bargaining clout to pay lower rates to providers – drug companies, hospitals and doctors - if it includes most of us right away, and can base reimbursement rates on Medicare, plus 5% for wiggle room.

Nancy Pelosi tried to get that. She came up short of the 218 votes needed. After a week of “whipping,” she proposed 2nd best: a public option that will negotiate rates with providers. It won’t save as much money as “Medicare plus 5%” version. Not a great performance by our elected members of Congress, who could’ve sided with the voters who use health care services instead of the industries that provide health care, or by the President of Change, who kept his elegant neck tucked in on that subject.

The Congressional Budget Office and Joint Tax Committee did some pretty quick math:
“By 2019, CBO and JCT estimate, the number of nonelderly people who are
uninsured would be reduced by about 36 million, leaving about 18 million
nonelderly residents uninsured (about one-third of whom would be
unauthorized immigrants). Under H.R. 3962, the share of legal nonelderly
residents with insurance coverage would rise from about 83 percent
currently to about 96 percent. Roughly 21 million people would purchase
their own coverage through the new insurance exchanges, and there would
be roughly 15 million more enrollees in Medicaid than the total number
projected for Medicaid and CHIP combined under current law. (Under the
bill, CHIP would no longer exist in 2019.) Relative to currently projected
levels, the number of people purchasing individual coverage outside of the
exchanges would decrease by about 6 million, and the number obtaining
coverage through employers would increase by about 6 million.

“Under the proposal, certain employers could allow all of their workers to
choose among the plans available in the exchanges, but those enrollees
would not be eligible to receive subsidies via the exchanges (and thus are
shown in Table 2 as enrollees in employment-based coverage rather than as
exchange enrollees). CBO and JCT expect that approximately 9 million
people would obtain coverage in that way in 2019, bringing the total
number of people enrolled in exchange plans to about 30 million in that
year. Roughly one-fifth of the people purchasing coverage through the
exchanges would enroll in the public plan, meaning that total enrollment in
that plan would be about 6 million.

“That estimate of enrollment reflects CBO’s assessment that a public plan
paying negotiated rates would attract a broad network of providers but
would typically have premiums that are somewhat higher than the average
premiums for the private plans in the exchanges. The rates the public plan
pays to providers would, on average, probably be comparable to the rates
paid by private insurers participating in the exchanges. The public plan
would have lower administrative costs than those private plans but would
probably engage in less management of utilization by its enrollees and
attract a less healthy pool of enrollees. (The effects of that “adverse
selection” on the public plan’s premiums would be only partially offset by
the “risk adjustment” procedures that would apply to all plans operating in
the exchanges.)”

This is a possible scenario. CBO and JCT are about as smart as anyone, and we need a guidepost in all this, Lord knows. But honestly. We know for sure the public plan will have lower administrative costs and no profits. Will it engage in less utilization management (read, frivolous denial of claims) compared to private insurance plans? We hope so – and we damn well plan to stop the insurance industry from that deadly business plan, too. Will it enroll fewer people, therefore be more expensive, therefore enroll sicker people, therefore be more expensive and enroll fewer people, etc.? Beats me.

Here’s what I’m pretty sure about. I don’t like Options #1 and #2. The public doesn’t either.

I think Option #3 gets us to the next step: coming out of this battle with a victory, and going back to the states to fight for single payer.

Some on the left meet up with the right on this point: they prefer Options #1 and #2. They say the House bill (Option #3) gives more money and power to the insurance industry than they have now. True. But so do Options #1 and #2. In fact, the only way the insurance industry gets less money is to get rid of them. A single payer program funded entirely by the government would accomplish this. We haven’t won the public’s support for that yet, and it’s not just because Max Baucus wouldn’t hold hearings on it.

A bill with Option #3 gives more power to the public sector, and arguably will save some money. It includes the following important benefits for people:

For the first time, most employers will have to contribute to the cost of health insurance. We’re the only system in the world that relies primarily on the workplace to get insurance, but we also have no requirement on employers to actually offer insurance or help pay for it. Right now about 130 million people get insurance through work, but another 27 million workers do not.

It requires individuals to buy insurance, but it provides subsidies to low- and middle-income individuals and families, so they can afford it. Is it affordable enough? Probably something to fight about.

Insurance company abuses will be prohibited: They won’t be able to exclude people with pre-existing conditions, or stop paying for your treatment once it turns out your sick. They’ll have to spend 85% of our premium dollars on actual health care, not executive bonuses and administration.

Costs: gives the government the authority to negotiate for drug prices.

Access: Many more people will qualify for Medicaid, the federal-state program for low-income people. The feds pick up most of the tab. People with COBRA can keep it until the new exchanges kick in, in 2013, and young people can stay on their parents’ plans til age 27. We still need it to start sooner.

Quality: Reform Medicare to encourage better quality of care, eliminate copayments for preventive care, and increase the number of primary care providers.

Is any old thing ok then? I think the victories so far on the public plan are important. We have to fight hard to keep it and strengthen it on the House side, and make sure it gets into the Senate bill in conference. And let’s hold on to each others’ email addresses. We’ll need them for the state single payer fights.

Wednesday, October 28, 2009

State single payer amendment pulled from House bill

Rep. Kucinich has announced that his amendment granting an ERISA waiver to single payer states will not be included in the health reform bill that Speaker Nancy Pelosi plans to introduce in the House, probably later this week. The amendment was passed in Committee. It has been a focus of support by progressives, and opposition by the corporate health care industry.

There will be a manager's amendment offered just before the vote on the floor of the House, next week or later.

Who could add the state single payer amendment back into the manager's amendment?

Speaker Nancy Pelosi (202) 225-0100
Rep. Henry Waxman (202) 225-3976
Rep. George Miller (202) 225-2095

Saturday, October 24, 2009

What Do Progressives Want?

What progressives want is the same thing the President wants: to build power for a majority in Congress and the country that will support our issues, and will perceive us as powerful; and to win the best possible health reform.

So far the President has played a pretty smart game. He kept the insurance industry at bay long enough that even the mainstream pundits are willing to say publicly that the industry has no credibility.

But it’s time to cut the cord.

Progressives need to play a smarter hand.

It’s important to sit in at insurance companies. But here’s the thing: 1. Insurance companies have no shame. They really don’t. 2. Even Republicans were willing to throw them under the train back in February. 3. They don’t vote.

Here are some people who vote: Senators Mary Landrieu, Louisiana; Blanche Lincoln, Arkansas; Joe Lieberman, Connecticut; Evan Bayh, Indiana; Ben Nelson. Nebraska

Take Mary Landrieu. She says she won’t support a public option because it would force the country to go bankrupt.

Now Mary Landrieu is not a stupid person. She knows that the CBO says a strong public option saves more money than negotiated rates or no public option.

She’s been elected twice in a Republican state, including in 2008 when Obama got only 40% of the vote.

Is she in the pocket of the insurance industry? The Center for Responsive Politics says she gets virtually no money from health interests, and raises half her money in-state. She’s the 47th least wealthy person in the Senate.

Does Louisiana need health reform? Here’s some information about Louisiana:

Second highest rate of female poverty in the US
Highest rate of black poverty
63% white
4th highest rate of uninsured for ages 0–64 (22%), 3rd highest for ages 19-64
One of the highest recipients in the country of federal Medicaid funds, one of the lowest in per capita Medicaid spending
35% of population live in primary care shortage area, 3rd highest % of population who didn’t see a doctor in the last year because of cost (18%)

In 2008 Obama lost to McCain, but Landrieu won among the same demographics that voted for Obama:
Younger people
African Americans
Among the 9% of voters who said health care was their most important issue, Landrieu got the widest issue-based margin over her opponent: 72% voted for her.

Why can’t a populist organizing campaign rile up some voters in New Orleans and environs to communicate with Senator Landrieu? And in Arkansas, Connecticut, Indiana and Nebraska; and the holdouts in the House. Harry Reid and Nancy Pelosi have signalled they're ready to play. Are we paying attention?

Saturday, October 17, 2009

No Excuse for Apathy

Eva Chrysanthe is my health care hero.

Back in January Senator Dianne Feinstein's staff were telling us she wasn't sure about her position on the public option because she was hearing a lot of opposition from people calling in from southern California opposing it. They seemed to be responding to talk radio shows.

A lot of people wrote articles about Dianne Feinstein's campaign contributions. She kept talking about what she was hearing from voters.

Eva networked with people inside Organizing for America and found 1200 people in the Bay Area who thought Dianne should represent us. They demonstrated, set up meetings, flooded her office with letters, petitions and emails. Dianne finally wrote a very long treatise on health reform, indicating that she was open to a public option; or maybe not. She heard about it from the voters.

Last week, Senator Feinstein was one of 30 senators to sign Sherrod Brown's statement supporting a public option. Period. Eva brought the staff a carrot cake.

Let's not get googly eyed about what we can accomplish. We're talking about a political system trying to manage an economy in deep crisis. The President, a charismatic figure who is well-informed about the health care issue on both the policy and personal levels, campaigned on expanding coverage for children.

But lookit, they're going to pass something here. How come no one knows that the public option as written doesn't start til 2013 and won't be open to most of us until years later, if ever? Are we expecting the media to do this job? The corporate owned media exist to manipulate our emotions between commercials so that we will feel sufficiently inadequate or bored to want to buy whatever the sponsors are selling, and definitely sufficiently cynical, apathetic and confused that we will not consider taking political action.

Some progressives also seem generally to think that dismissing and ridiculing the emerging proposal passes for analysis and agitation. Willingness to consider how we might influence the bill to set the stage for future progress has been compared to compromising on slavery (a great analogy, really - all they had to do in that case was stamp their feet and reframe the struggle as a fight for human rights, and by golly that was that).

Expanding Medicare to cover more people would've been a great thing to do. Max Baucus thought so. He proposed it in a Finance Committee document in January. It wasn't single payer for all, just for people over 55. Wimp. Must be due to his campaign contributions. Wonder how Baucus, the present obstacle to the public option, and the 4th poorest member of the Senate, stacks up against Sen. Rockefeller, the 4th richest:


Cycle Source of Funds, 2009-2010, Campaign Cmte only

Individual Contributions $5,989,921 52%
PAC Contributions $4,872,291 42%
Candidate self-financing $0 0%
Other $640,654 6%


Cycle Source of Funds, 2005-2010, Campaign Cmte only

Individual Contributions $3,756,635 63%
PAC Contributions $1,963,331 33%
Candidate self-financing $0 0%
Other $260,341 4%

Cycle Top vote-getting candidates Election Results
2008 Max Baucus* Amount Raised $11,602,479 Amount Spent:$9,305,359 Reelected
Bob Kelleher $0 $0
2002 Max Baucus* Amount Raised: $6,719,728 Amount Spent: $6,795,547 Reelected
Michael A. Taylor Amount Raised: Amount Spent: $1,839,020 $1,839,020

Cycle Top vote-getting candidates Election Results
2008 Jay Rockefeller* Amount Raised: $5,972,208 Amount Spent: $5,979,250 Reelected
Jay Wolfe Amount Raised: $123,862 Amount Spent:$123,720
2002 Jay Rockefeller* Amount Raised: $3,045,338 Amount Spent:$2,889,425 Reelected
Amount Raised: Jay Wolfe $136,373 Amount Spent:$136,373

Turns out they both raise most of their money out of state (Baucus 90%, Rockefeller 75%), virtually no one runs against them, and they spend most of what they raise to get re-elected. Why do they take different positions on the public option? Interesting question. In casting his vote, Baucus said that the public plan had a lot to recommend it, but it was his job to get the bill out of Committee. Sound like he's been getting calls from the White House?

It's great that people are sitting in at insurance companies. For the 3% of Americans who still thought health insurance companies had any legitimacy, aside from employees of the industry and their friends and relatives, it's probably a revelation. For the rest of us, a worthwhile way to spend time this week will be strongly suggesting to our friend in the White House, and our leaders in Congress, that they must cough up a program that is going to benefit people pretty quickly or else people will notice.

We need a strong public plan, that bases reimbursement on Medicare rates and uses Medicare providers so that it's affordable and viable. It should be a choice for each of us, in 2010. And we need an ERISA waiver for single payer states, so that they can convert to single payer without a lawsuit. For example people could cut and paste the following:

LETTER TO THE PRESIDENT, Senate Majority Leader Harry Reid, House Speaker Nancy Pelosi:

The Senate Finance Committee drama has concluded. The American public will not long remember whether or not any Republican voted for health reform. We do want to know if we'll get more affordable, reliable health care coverage, that provides relief soon. It's time to tell the President, House Speaker Pelosi and Senate Majority Leader Reid:

We need a public plan option with affordable premiums, that pays hospitals and doctors Medicare rates +5% and includes Medicare providers - and all of us want to have that choice in 2010! Put that up for a vote and we'll support you!

And the bill must include the state single payer option, proposed by Rep. Dennis Kucinich.

Thursday, October 8, 2009

CBO should score systemwide savings from health reform

Supporters of comprehensive, single payer health reform are looking forward to a report from the Congressional Budget Office on how much ths kind of system would cost. But in 1993, when I worked with Senator Wellstone on his S.491, the original national single payer bill, CBO's "score" was dramatic and groundbreaking for showing how much the system would save:

By definition any single payer system contributes to federal spending: the feds pick up the tab for all health care expenses. The important part is the escalating savings from single payer - more and more, the longer the system is in place. In its 1993 report, the CBO illustrated that the single payer system not only slows the rate of growth in health spending - what the President calls "bending the cost curve" - it saved more every year from total national health expenditures: a reduction of $67 billion in 2002, $110 billion in 2003.

Look at this:
(By calendar year, in billions of dollars)

1997 1998 1999 2000 2001 2002 2003
Total 1,163 1,263 1,372 1,488 1,613 1,748 1,894 2,052

Changes from Baseline (effects of the single payer bill)
Total a 60 59 35 4 (minus 29) (minus 67) -110

SOURCE: Congressional Budget Office,
a. Less than $500 million.

Now the CBO seems to be saying it will calculate only the cost to the federal government, sending the bill sponsors on the House side into exercises to cut promised benefits and alter other provisions to reduce the impact on the federal deficit. CBO should go back to answering the full range of critical questions for the American public, most notably: How much is this going to cost me? The answer is that single payer would save a ton.

Monday, October 5, 2009

Why It Matters: A Strong Public Plan, Medicare Rates, and Affordability

Let’s start from the end. You want health reform. Republicans say they want it. The insurance industry wants it. People who pay individually for health insurance want it - they can’t afford coverage. People with insurance want it – they too often have their claims denied – 1 in 5. 44,000 people die every year because they are uninsured. Medicare is going broke because prices are going up outside of the Medicare system, and lots of families are going bankrupt for the same reason.

To put the middle in the middle: Getting there means finding 218 members of the House of Representatives, plus 51 Senators, to convince the White House they will vote for reform.

Keeping it there after it passes means we all need to be able to afford it, and still get the care we need.

Here is the part to nail down this week: A strong public option, that pays Medicare rates and uses Medicare providers, is the only way to make the plan affordable.

There are 2 parts to making insurance affordable. The first part is limiting how much we pay providers – hospitals, doctors, drug companies. Basing payments on Medicare rates is the key here.

The second part is making sure these limits get passed back to you, in the form of lower insurance company premiums.

We need a strong public option for both.

The Congressional Budget Office says using Medicare rates saves $110 billion over 10 years, $85 billion more than a public option that doesn’t use Medicare rates.

Medicare already establishes payment rates to hospitals and doctors on behalf of 40 million Americans. These rates are accepted by all hospitals and most doctors, but aren’t susceptible to the hyper-inflation that has driven prices in the private sector over the last 10 years. Adding millions of enrollees to this system will help put the brake on payment rates.

So if the public plan limits payments to providers, how will that translate into lower premiums? The public plan won’t pay profits or bonuses, and will benefit from lower overhead than private plans. All the savings go right back to you, in the form of lower premiums.

Private insurance companies on the other hand can charge whatever they want, even if they are paying providers less. They have to charge higher premiums, to pay their shareholders and executives. This is true even if they paid less to hospitals and doctors – they have no reason to pass those savings on to you, in the form of lower premiums, and every reason to just do what they always do: hold onto the money themselves. Unless, of course, they have to compete with a public plan.

A public plan will charge lower rates, be affordable for people who need care, and set a standard on prices that both providers and insurance companies will have to compete with.

Will doctors still treat you if you are on the public plan, even if it pays less than private plans? For those who think Medicare rates are too low, the version of the public option linked to Medicare rates gives plenty of flexibility. First, we’re not talking about today’s Medicare rates. The bill will require changes in rates to address regional differences, including adjustments for rural areas, and ways to promote quality. Second, it provides an extra 5% (Medicare +5) for individual providers. Third, it allows any provider to opt out – and the decision can be made (and reversed) each year. Finally, it gives the HHS Secretary authority to go higher than Medicare rates if necessary to attract doctors, hospitals and other providers based on local conditions.

Why not negotiate the rates the new public plan will pay providers? Simple: They'll be higher. That's why providers and insurance companies want them. A new plan, with new enrollees, needs to build on the strongest platform we have. That's improved Medicare rates, with a cap of 5% extra. (Even a public plan with negotiated rates saves $25 billion more than relying solely on private insurers.)

Again: A public plan will charge lower rates, be affordable for people who need care, and set a standard on prices that both providers and insurance companies will have to compete with.

So here we are with the beginning for this week:

We need a public plan.
That pays Medicare rates plus 5%.
And includes Medicare providers.

Pass it on to 218 of your friends in the House, and 51 Senators.

Monday, September 14, 2009

A Town Hall Meeting That Worked: Sta. Clara, CA

I was heartened by Rep. Mike Honda's civil, orderly town hall meeting at Santa Clara University at 1 pm in Sunday. There were about 400 advocates for health reform, including a strong public option, and about a dozen or so opponents. At about 12:45, they showed a videotape of 3 local residents with health care stories, interspersed with facts about the number and percent of people in the country and the district who are suffering from lack of coverage, health-related bankruptcies, etc. I saw 2 of the people from the video in the crowd. They included: A retired county worker with an uninsured son; a woman whose grown son could not get coverage, having developed juvenile diabetes early in life; a man who identified himself as a Republican, and whose wife had a serious chronic condition that would never be covered if he lost his job and insurance.

Rep. Honda opened the meeting with a welcome, and a request for mutual respect. He called on constituents to submit written questions on index cards, including name and address; questions from constituents were chosen at random; he then invited the constituents to stand and pose their questions. Reflecting the crowd, most of the questioners spoke in favor of a strong public option, or a single payer. A few were opposed. We cheered every time he responded that he supported a strong public option, and had no plans to compromise on that; the dozen booed. We cheered for a brave young Latina who works in reproductive rights, and said that coverage for abortion was important to her; the dozen booed. (The cheers and boo's took a few seconds, then stopped; we all respected Rep. Honda's request for respect.) A few times Mike pointed out that the present system of private insurance had had quite a bit of time to work, if it was going to, and that too many people were hurting financially and physically (he gave details); it was time for a change. We all cheered. No one booed. The final 2 questioners asked how we could afford the President's health proposal, since similar socialistic systems like Great Britain are facing financial shortfalls. Mike said there is a way to do it, and we would. He promised to respond in writing to the remaining questions. That was it.

Outside an older man approached a younger fellow giving out water and wearing a pro-reform button. Tell me one government program that works! he demanded. Medicare, was the response. End of conversation.

Sunday, September 13, 2009

What We Need In a Health Reform Bill

What, specifically, do we need in a health reform bill? Here's the view from EQUAL partners. To download as a flyer, go to

EQUAL Health Reform That Meets Our Needs

Fight to keep what works in the bills we have:

• Regulate insurance: No denials for pre-existing conditions. Once you’re covered, you stay covered.
• Pass Dennis Kucinich’s state single payer amendment as part of the health reform bill.
Some states that have attempted to expand health care coverage have been successfully challenged in court under the Employee Retirement Income Security Act (ERISA), which says that only the federal government can pass laws “related to” employee benefit plans. The House bill would allow single payer states to override ERISA.
• Public health: HR 3200 and the Senate HELP bill shift resources to wellness and prevention.

Here’s what we must have!

A stronger public plan option. For too many of us, insurance doesn’t work or isn’t available or affordable. We need an affordable, dependable public plan that is open to anyone, and starts right away.

Putting federal spending in perspective: Partly to minimize federal outlays, HR 3200 delays the public plan until 2013, and it only covers individuals and small businesses initially. In fact, starting the public plan sooner, with higher enrollment, will be key to controlling costs. The Congressional Budget Office estimates that HR 3200 will require $1 Trillion in new federal expenses over 10 years, for subsidies and other benefits. This is equal to $100 Billion a year, or only 4% of current annual spending of $2.5 Trillion. An effective public program will have lower administrative expenses, provide competition to private plans, and act as a countervailing force against health care expenses that are rising twice as fast as inflation. It should be open as a choice to everyone, and very soon.

• Use Medicare’s reimbursement rates: The public plan will only control costs overall if it builds on the public sector’s leverage. It would save $75 billion over 10 years if it uses Medicare rates, vs. only $20 billion at most if it negotiates rates independently as proposed in Blue Dog amendments.
• Use Medicare’s provider network: The public plan should include all Medicare providers as a base. They can be allowed to opt out. (Included in Energy and Commerce as an amendment.)

Insurance company care share (loss ratio) 90%. Insurance companies now spend up to 30% of our premium dollars on administration, profits and bonuses. This feature would require them to spend 90% of our money on actual patient care. One version of HR 3200 would require a limit of 85%, but only for insurance plans that are part of the new Health Insurance Exchange, which would start in 2013.

Real affordability: the “affordability threshold” must remain 11% and sliding scale subsidies must be provided up to 400% of the Federal Poverty Guidelines.

Expand Medicaid - funded by the federal government, not states.

Eliminate age rating. HR 3200 allows insurance companies to charge older people at least twice as much as younger ones. Age rating will cost everyone more, and is a loophole for the for-profit insurance industry. While a few will pay the lowest premium, premiums for most will rise sharply. Community rating works. If everyone pays the same, risk is fairly spread. Insurers already use community pooling for large group, employer-sponsored insurance, under which most Americans with private insurance are covered.

Women’s health: Assure women have access to reproductive services. Respect women’s decisions.

EQUAL Health 􀂐 Equitable Quality Universal Affordable
The EQUAL Coalition includes public health, women’s groups, and advocates for Equitable, Quality. Universal, Affordable health care. * The Center for Policy Analysis * The California Public Health Association-North an affiliate of the American Public Health Association * Rekindling Reform * Older Women’s League San Francisco * California Women’s Agenda

Friday, September 11, 2009

The Speech

We have our work cut out for us.

The President snapped the country back from the delusional debates of August to the more rational debate about health reform. If he has created policy space, it is an opportunity we will need to exercise until the final vote.

In rebalancing the politics of reform, he called out both elected officials and pundits who have invoked scare tactics. He also reminded us explicitly that the deficits we face today are directly attributable to Republican policies of waging an unfinanced war, and tax cuts for the super-wealthy.

We’ll know if it was effective in part if advocates for reform continue to build momentum, at town hall meetings. Will the chorus on the right become more civil? The official Republican response by Rep. Boustany was indeed a respectful disagreement. Rep. Joe Wilson of South Carolina set a different and shocking standard, accusing the President of the United States of lying about an indisputable fact.

The President made the clearest possible case for the importance of insurance reform, describing the human and financial cost of our uniquely inhumane system. The baseline proposals remain, and they would be important: eliminating pre-existing conditions and recisssions.

He offered a new benefit: A guaranteed catastrophic plan to be made available beginning in 2010.

But he proposed a public option as one of a few possible alternatives to private, for-profit insurance plans, signaling openness to a cooperative or generic nonprofit plan, and calming concerns that such a plan could lead to a single payer system. Even at best, a “robust” public option would be hard pressed to muscle out private insurance. But it must have the basics to succeed on its own terms: open to everyone as a voluntary choice right away, using the government’s power to protect the public from predatory insurance companies. As policy, that means it should start out of the gate as a nationally administered program, with the clout to intervene with drug companies and other providers. It must build on Medicare’s rates to pay providers, and use Medicare’s network of doctors and hospitals. It is time to start saying: If the private insurance industry cannot survive on terms that benefit the people who need health care, it is not the government’s role to bail them out.

It was disturbing to hear the President refer more than once to his proposals as balancing the concerns of left and right. Single payer supporters and advocates for a public plan are his base and his field team. The teabaggers and opponents of any reform are not pulling the same way. Despite his nod to Sen. McCain’s proposal for catastrophic coverage, and Republicans’ interests in medical malpractice reform, none appeared interest in voting with the President afterwards.

His discussion about our skepticism of government was important. It is understandable that many are frustrated with a government that has been unresponsive and derelict for so long. But it is a system we can influence. Mobilizing for what we want is the road to generating energetic support, and demands that our elected officials act responsibly and effectively. Resorting to demonization breeds disaffection.

The challenge is before us: to hit the air waves, the Town Hall meetings, the mail to the President and Congress to demand the change we voted for.

Sunday, September 6, 2009

Obama's Health Care Speech: Ominous Warnings in NY Times

What will Obama say on Wednesday about health reform? Today's New York Times could be an ominous early warning. Expanding public sector clout is at the heart of any meaningful proposal to control health care costs, and to expand coverage. Over the past year, the Times has published a lot on the potential for a strong public option to get us there, and also given unusually wide visibility to a sure-fire solution, single payer. Today's edition is a reverse road map to defeat.

The editorial calls on the President to "stand tough for a large and comprehensive plan," and "point out the cynicism of Republican opponents who are late-blooming advocates of deficit reduction," having passed passed "tax cuts for wealthy Americans that will cost more than $1.7 trillion over 10 years."

What is his wiggle room? Go for insurance reforms, and hold strong for a public plan, but, "if he decides to bargain it away later, he should insist, minimally, that a strong public plan be introduced if private insurers fail to hold costs down in the future." To echo Barney Frank, on what planet have the editors been spending most of their time? Apparently it will now be up to the public that voted for change to demand it.

It gets worse. The editorial goes on to bemoan that neither party has a "sure-fire solution to rein in medical inflation" while improving quality of care. Well, sure we do, and the Times has coeverd it. The news pages report on deliberations with former Clinton-era advisors, recounting the errors of failing to pass health reform, once having opened the door, and pointing out candidate Obama's relatively moderate positions on universal coverage.

It's time to take stock. It's been a bad summer. Opponents of reform, and of the Administration, have had one clear goal: Stop it. They've had the expansive coffers of the insurance industry to draw upon. Advocates have been taken aback at the teabaggers' vitriol, unhinged demeanor, and outright threats.

The union movement and other organizations that have led reform movements in the past have been weakened by decades of economic globalization and at least 8 years of vicious political attacks. In the face of shockingly hard times for many, we in the public appear to be struggling but stunned. And yes, there's been some internecine squabbling among reform factions.

But we have resources, and we should have leadership. The President and his team showed us they know how to run a great ad campaign. They likely calculated that they couldn't eliminate the insurance industry in one fell swoop; and they lost a great legislative strategist in Ted Kennedy. But isn't there a Plan B? The Congressional Progressive Caucus has done a great job of describing what a strong public option should be: open to all from day one, building on Medicare's reimbursement rates and provider base. They have had constraints in articulating and conveying these views to the public. There must be a way to support the President while using their considerable clout to mobilize support for the reform they know we need.

Health care can be a wonky issue. It can also shake us up and build alliances. If we need to pass something let’s make it a step forward, for policy and politics.

Between now and Wednesday, we need to tell the White House we expect to hear a call to arms. We knew all along that voting for President would not be the last thing we had to do to achieve social change. Hopefully, it was at least the first.

Monday, August 31, 2009

Sen. Feinstein: Time to Lead on Health Reform!

Sen. Feinstein has issued, at long last, a thoughtful statement on health reform. There is much to applaud, but there is too much unresolved. She makes the case that this is a vital issue for our state. We should demand clearer leadership on her part.

She rightly notes that California stands to benefit from reducing our high percentage of uninsured, and must protect our extensive system of public hospitals and safety net clinics. She recognizes that most Californians want relief both from the health insurance
industry’s exorbitant premiums and from its unfair practices. She demands that private insurance companies limit spending on administration and profits to no more than ten percent of revenues – a critical issue, and a level even better than the House’s bill. She supports offering the option of a public insurance plan.

However, while criticizing current proposals for not going far enough to assure that health care will be affordable, she opposes the necessary subsidies on abstract grounds of deficit control. She takes the opportunity for an unjustified swipe at entitlements generally, reviving the call for a commission to review not only Medicare, which is threatened by runaway costs in the private system that it cannot control, but also Social Security, a perfectly solvent system that requires well known tweaks to survive with no difficulty.

Finally, she bows to the possibility that a nonprofit coop could take the place of a public plan, in providing an effective and competitive counterpoint to private insurance. This concept has no legs, as everyone knows but the small-state senators whose judgment she questions.

Sen. Feinstein does not serve on the Senate Finance Committee, which has yet to offer a bill. But the people of our state desperately need reform, and we’ve fought for it actively. We have twice passed single payer legislation, the gold standard for effective reform. It is time for Sen. Feinstein to join the majority of the state’s Congressional delegation in unequivocal support for a bill that includes a meaningful public plan option, available to everyone, and that finally makes health care affordable. She’s halfway there. She should complete her deliberations by the time the Senate reconvenes next week.

Saturday, August 15, 2009

Pickpockets and the Public Plan

Ever had your pocket picked? Chances are they charmed you, scared you, surrounded you - in short, distracted you while they grabbed your wallet. Enough said.

So let's get back to the important issue in health reform: the Public Plan. You can have health coverage that is better than what you have, that is more affordable, covers many more of us, and improves quality You need a strong public plan.

The Congressional Progressive Caucus isn't calling for a strong public plan, really. They should.

People who say a public plan can't work are wrong. They should reconsider.

A strong public plan should be open to everyone who's not on Medicare, beginning in 2010.

The House bill says it would start in 2013 - after the next presidential election - and include only a few of us - self-employed, unemployed, employees of small businesses.

The Senate is proposing to have no public plan at all - just a straight cash transfer to your friendly neighborhood insurance conglomerate. (Which is really a way of making sure nothing passes.)

Why does this matter? The public plan needs to have enough people in it so that it can do what Medicare does: influence how the rest of the system works. Bend the cost curve. Improve quality. Provide your doctor, nurse practitioner and acupuncturist with comparative effectiveness studies so you get better care on the first visit. This will scare some of the teabaggers and it apparently scares the hell out of the insurance industry.

This, however, is change we can believe in.

That plus one more thing: we need a state option for single payer, so we can take the next step towards truly universal coverage.

People are mobilizing in remarkable ways to demonstrate why we need real health reform now. Giving out free care to long lines of people in desperate need. Showing up in scrubs at Town Hall meetings. Explaining that Medicare is a government program and we like it.

We need to do one more thing: make it worth it when we win. Take a picket sign for a Real Public Plan. Tell your neighbors. Tell your member of Congress. Tell your talk shows. The insurance industry and their pickpockets do not speak for us. We need real health reform, and this is the time to fight for it.

Need some talking points? Go to

Sunday, August 9, 2009

thugs and health policy

Missing the point: Facing down the gangs disrupting her Town Hall on health reform last week with cries against the "government takeover," HHS Secretary Kathleen Sebelius responded, "But this isn't a single payer plan!"

Single payer advocates, recognizing that our gold standard cannot pass this year, taunt supporters of a public plan for saying that our gold standard cannot pass this year.

Meanwhile, the economic stagnation that gripped the poor in the 1990s and never let up is nipping at the heels of the middle class. The financial and housing meltdowns are taking place at a time when countervailing forces to corporate power are hard to find. Private sector unionization rates hover at about 7.6% (the public sector is over 40%; 16 million of America's 130 million wage workers belong to a union).

The public may be favorably disposed toward a public health plan, but probably fewer than 100 can describe how it would work, when it would start (2013), or what it would mean to them personally (would likely help). Meanwhile, right wing blogs and the Republican party are succeeding in whipping up fury on an issue even wonks think of as arcane. Let's assume most of these people are operatives, as were the Bush v. Gore mobs in 2000. The point is, they have organized, well-funded leaders, with a stake in the direction of this wobbly nation and our increasingly ethereal economy.

Maybe we need to rethink the conversation we need to be thinking about.

Thursday, July 30, 2009

And You Thought 1984 Was So Last Century: Blue Dogs Claim "Savings"

The Blue Dog Dems are pulling a fast one, this time claiming that more is less.

These "fiscal conservatives" on the House Energy and Commerce Committee have reached a temporary agreement to do the following: raise Medicare payments to (their) rural hospitals; shift the cost of Medicaid expansions away from the feds and on to (their) poor states; and to increase all provider reimbursement rates under the public plan. (see clips below.) This all will add about $10 billion a year to the bill.

To the public: We will have a busy month in August, getting the Senate to come up with something the House can live with; and getting Speaker Pelosi and other Dem leaders to craft a House bill that the Progressive Caucus can vote for, and which, by the way, would really be fiscally conservative."The new proposal includes a public health insurance option to compete against private insurers, but it does not tie the payments to Medicare's rates of reimbursement to health-care providers, something many liberal lawmakers had sought. Instead, it calls for the health secretary to negotiate rates with hospitals and doctors, just as private insurance companies do. Rural health-care providers generally receive less in Medicare reimbursements than their urban counterparts, and delinking the public plan from Medicare was considered critical for conservative Democrats" (Kane and Murray, 7/30). The New York Times : "Medicaid would be expanded, as under the original bill, but states would pay a small share of the additional costs, perhaps 7 percent. The federal government would have paid all the additional cost under the original bill. People with low or moderate incomes could still get federal subsidies to help them buy insurance, but they might have to spend slightly more of their own income — a maximum of 12 percent, rather than 11 percent" (Pear and Herszenhorn, 7/29). Kaiser Health News reports that Rep. Mike Ross, D-Ark., "said that, all told, the revised bill would cost $100 billion less over 10 years, although precisely how that would be accomplished will be unclear until the CBO prepares a cost analysis of the overall bill. House senior Democratic aides said that the demands for revised reimbursement rates and more protection for small businesses would actually add $100 billion to the cost of the bill, and would have to be offset with savings elsewhere."

Sunday, July 19, 2009

More on HR 3200: Public plan delayed, affordability uncertain

John Gilman ( and Ellen R. Shafffer

· State benefit mandates – to continue these mandates, state will have to pay any additional cost of affordability credits in the Exchange that are due to the mandates. With tight state budgets, states are likely to drop these benefit mandates, which will effectively reduce the scope of coverage for all state residents whether insured in or outside the Exchange.

· Delayed Implementation of Health Insurance Exchange, Public Option, and Affordability Credits and limited access once implemented.
o Exchanges do not go into effect until 2013. In that year the only employers that may insure through the Exchange are those with 10 or fewer employees. Individuals without other coverage may also enroll, but if they have been offered coverage by their employer they will not be eligible for any affordability credits.
o Beginning in 2014, any employer with 20 or fewer employees may enroll in the Exchange. Individuals without other coverage may also enroll, but if they have been offered coverage by their employer they will be eligible for affordability credits, but only if the employee’s share of premium exceeds 11% of adjusted gross income and the employee’s family income does not exceed 400% FPL.
o Beginning in 2015, and beyond, the Health Care Commissioner may, but is not required to, expand employer participation to larger employers.
· There is an individual mandate to have insurance but Affordability Credits are limited. These credits are not available unless you receive coverage through the exchange, and even then, they are not available through the exchange if you have declined coverage from your employer unless your share of premium under your employer’s plan exceeds 11% of your income.
o For those that qualify, Affordability Credits provide some protection for those with the lowest incomes, but these credits quickly phase-out and are not available for much of the middle class. Anyone with family income above 400% FPL ($43,320 for an individual; $88,200 for a family of four) is not eligible for any subsidy. The following are examples of health care costs for people buying coverage through the exchange:
§ A single person with $16,000 annual income would receive a subsidy and pay no more than a $480 per year premium (3% of income), while having a cost sharing burden of 3-5% of medical costs.
§ A couple with family income of $35,000 would receive a subsidy and pay no more than a $2450 per year premium (7% of income), while having a cost sharing burden of 15% of medical costs with an out-of-pocket family limit of $10,000 per year.
§ A family of three, with family income of $72,000 would receive a subsidy and pay no more than a $7920 per year premium (11% of income), while having a cost sharing burden of up to 30% of medical costs with an out-of-pocket family limit of $10,000 per year.
§ A family of four with family income of $90,000 would not be eligible for any premium subsidy and in addition could expect to have a cost sharing burden of up to 30% of medical costs with an out-of-pocket family limit of $10,000 per year. According to the California HealthCare Foundation, in 2008, the average total family premium for an employer sponsored PPO in California $1251/month ($15,012/year). This family would be paying over 16% of its income just for the health care premium.
· The bill permits a basic insurance plan to have high out-of-pocket expenses. Cost sharing under the basic plan can be up to 30% of medical costs, with out-of-pocket limits of $5000 per individual and $10,000 per family.
· Although the bill offers “enhanced” and “premium” plans with reduced cost sharing–it appears that everyone is entitled to the “basic” plan. The enhanced and premium plans have less cost sharing but higher premiums. Low and middle-income workers will likely not be able to buy enhanced and premium plans because they will not be able to afford the higher premiums, so they will be stuck with the basic plan and its high-cost sharing.
· Play or Pay. Employers must “play” (offer health insurance to employees) or “pay” (pay a fee to the Health Insurance Exchange Trust Fund).
o If the employer plays, the minimum employer contribution to premium (for full-time employees) is 72.5% of the premium cost for a single employee and 65% for family coverage. That means the employee with family coverage may pay 35% of the premium cost of his or her policy. (According to the California HealthCare Foundation, single employees in California pay on average 12% of premium costs, while employees with family coverage pay 24% of premium costs.)
o Employers that choose to pay must pay an amount equal to 8% of total wages (The amount is less for employers with payrolls of up to $400,000). When the employer chooses to pay, none of the amount paid by the employer is credited to his or her employees, who must obtain insurance through the exchange. Many of these employees will find themselves paying for the full cost of their insurance. See the above discussion for Affordability Credit subsidies available through the Exchange.
· State-based health insurance exchange – States, or groups of states, can form their own health insurance exchange. However, it appears that such an exchange would NOT be required to offer a public option. (See Section 208)
· State benefit mandates – to continue these mandates, state will have to pay any additional cost of affordability credits in the Exchange that are due to the mandates. With tight state budgets, states are likely to drop these benefit mandates, which will effectively reduce the scope of coverage for all state residents whether insured in or outside the Exchange.

· Essential community providers: The bill requires that only basic plans contract with essential community providers? [Page 90 - Sec 204 (b)(6)]

· Prohibits cost sharing for preventive benefits
· Establishes a minimum Medical Loss Ratio, BUT leaves exact ratio to be set by the Secretary of HHS, (effective 1/1/2011)
· Limits policy rescissions (effective 10/1/2010)
· Public Option –Provides incentives for Medicare providers to be public option providers (assures broad, diverse panel of providers)Page 122-123 – Sec 223 (b)(1) – 5% incentive to Medicare providers who also participate in Public Option]

· Medicaid improvements
o Expands coverage: Requires state Medicaid programs to cover childless adults, parents, and individuals with disabilities with incomes up to 133% FPL. Requires state Medicaid programs to cover newborns up to the first 60 days of life who do not have other coverage. These expansions will be paid 100% by federal government. BUT, these expansions do not go into effect until 2013.
o Improves primary care reimbursement: Requires state Medicaid programs to reimburse for primary care services at no less than 80% of Medicare rates in 2010, 90% in 2011, and 100% thereafter. The incremental cost of this increased reimbursement will be paid 100% by federal government.
o Establishes a five-year Medicaid Medical Home pilot program, with 90% federal matching funds for community care workers for the first two years and 75% federal matching for next three years.
o Increases pharmaceutical manufacturer rebates for brand-name drugs purchased by State Medicaid programs from 15.1% of average manufacturers’ price to 22.1%.
· Establishes the Center for Comparative Effectiveness Research

Uncertain effect
· Options for certain individuals to enroll in Medicaid or receive insurance through the Exchange (probably good)
· Eliminate SCHIP; transitions SCHIP eligibles into Exchange, but no earlier than 2013.
· 2.5% tax penalty (2.5% of modified AGI) for failure to obtain coverage, but not to exceed average premium cost; hardship exception available. (If you pass the “hardship test” your prize is not having to pay the penalty and not having health insurance.)
· Up to 50% employer tax credit for premiums paid by small employers with low wage workers
o Phases out beginning at over $20,000/ year average wage, fully at $40,000
o Phases out beginning at 11 employees; fully at 25
o Does not apply to any employee earning over $80,000
· Requires state maintenance of effort (MOE) for Medicaid and CHIP eligibility as of June 16, 2009. This assures that eligibility does not contract (good), but how able are states to do this, given their bleak budget picture.

Wednesday, July 15, 2009

The Good, the Bad and the Murky: Health Reform on July 14

Here’s (a partial, one-person view of) what happened:

The House released a 1,017 page reform bill, summarized in 35 pages, promising progress and peril over the next 4 years. It improves affordability of health insurance, and proposes to regulate “rescissions” and other worst practices. The public plan option is semi-strong: it’s available to anyone who gets coverage through the new Health Insurance Exchange, but it’s less affordable for people covered by an employer. And it postpones indefinitely including large employers in the Exchange, running the risk that the Exchange and the public plan will drown in high payments for people likely to need health care.
Bill and summary online:

More below on the new House bill.

The Senate Health, Education, Labor and Pension (HELP) Committee gamely marched through amendments to its bill. Sen. Bernie Sanders’ state single payer amendment elicits shining and shameful moments: Strong statements of support from Senators Tom Harkin (“We have a dysfunctional system”), Jeff Merkley, and Sherrod Brown. Listen To Your Staff Demerit for Barbara Mikulski (“Can’t states enact single payer anyway?” [She is reminded that states need waivers for ERISA, and transfers of federal funds.] “Oh.” She still voted No. The amendment failed, but may come up again to the full Senate.) Hero award to Kennedy chief staffer David Bowen, at the table full time, accurately describing every technical foible of the draft bill, and every amendment.

The Mainstream Media fuss about the tab. Washington Post and NYT focus on taxes on the wealthiest. Very not the point.

Preliminary Details: The House Bill: Big questions for consumers and providers are: Will it make insurance affordable and dependable?

The bill targets the worst insurance company abuses: pre-existing condition exclusions, rescissions of coverage after the fact, denial of coverage or renewal to sick people. They will have to spend most of the premiums on health care. But enforcing these rules will depend on the existence of a real alternative. Here’s the murky part.

Most employers will have to offer insurance, covering about 70% of the premium, or pay an 8% payroll tax to a Health Insurance Exchange. The Exchange offers Qualified Health Benefits Plans that meet certain rules. The Public Plan is one of the options. Anyone eligible for the Exchange can enroll in the Public Plan. (Why do I see images of Holly Hunter demanding that George Clooney prove he is “bona fide”?)

But until 2013, the Exchange is open only to individuals without coverage, and to small employers.

And after 2013, it is up to the new Health Choices Commissioner to determine whether or not larger employers will be included.

There are affordability limits on what individuals will have to pay, that are better than proposed earlier: Sliding scale subsidies for premiums up to 400% of the federal poverty limit, if premiums cost more than 11% of your adjusted gross income. There are limits on total out-of-pocket spending (premiums, co-pays, deductibles).But: Subsidies in the first 3 years are only available to those who do not have an affordable offer of employer-sponsored insurance.
So you can quit your employer's crummy plan if you don't like it, and join another plan offered thru the Exchange, as long as you can afford to do so without the affordability credits, until 2013.

Payments to providers would be tied to Medicare rates. This is a boon to cost control and affordability in the long run. (There are other benefits that keep provides in the plan.)

Drug Bust: The Health Choices Commissioner can negotiate for drug prices.

The Medicare doughnut hole will close – by 2023!!! We can do better.

Quality Improvements: Many good proposals to improve the quality of care, through Medicare and other programs. The bill would tilt reimbursement and training to primary care providers, gerontologists, and nurse midwives. Needed funds for prevention and public health.
State Options. Still to be explored; from the Summary:
Sec. 208. Optional operation of State-based health insurance exchanges. Permits states to offer their own Exchange or join with a group of states to create their own exchange in lieu of the federal Health Insurance Exchange, provided that the state(s) perform all of the duties of the federal Exchange as approved by the Health Choices Commissioner. The Commissioner has authority to terminate state exchanges if they are not meeting their obligations.

Coming up: House Committee mark-ups starting – today! Get online. Take notes. One way or the other, history is happening.

Monday, July 6, 2009

Thursday, July 2, 2009

Senate HELP Bill Doesn't Help Enough

The health reform bill that will be introduced next week in the Senate Committee on Health, Education, Labor and Pensions (HELP) includes a public plan, but it just skims being adequate. The Center for Policy Analysis has set two key benchmarks for an effective public plan: 1) broad eligibility, to assure a large and stable risk pool; and 2) the government's ability to set reasonable reimbursement rates, in order to control costs.

A letter from Senators Kennedy and Dodd on July 1 promised a strong public option that can keep costs down, expand coverage, and offer affordable options for coverage. The portion of the chairman's mark, released today (July 2), describes a public plan referred to as a Community Health Insurance option (Title XXXI, Subtitle A - Affordable Choices, Sec. 3106).

Eligibility. Employees with access to coverage from work are excluded from enrolling in the Community Health Insurance option (Subtitle B, Sec. 3111,(b)(C); and Sec. 3116 (4)(a)(4)(v)IV), pp. 132-133). An individual who is eligible for employer-sponsored coverage can join the public plan only if the workplace plan's coverage doesn't meet the standard for minimm qualifying coverage, or if it is not affordable ((4)(v)(IV) and (4)(B)pp.132-4). A plan is unaffordable if the premium is greater than 12.5% of the indivudual's adjusted gross income (AGI) (Sec. 3103, p. 70) An employee with an AGI of $50,000 a year, who pays $500 a month for insurance, would not qualify to join the Community option. $50,000 times 12.5% equals $6.250, more than the annual premium of $6,000. An individual with an AGI of $100,000, paying $12,000 a year for family coverage, also just misses the 12.5% mark, which is $12,500. If the same person paid $13,000 a year for coverage she would qualify.

Reimbursement Rates. The Community option cannot reimburse health care providers for a rate higher in aggregate than the average reimbursement rates paid by health insurers through the Gateway (Sec, 3106. (6) p. 80). While this is some limitation, it does not stanch inflation in health spending nearly as much as pegging reimbursement to a fixed rate set by the public sector, as Medicare does.

Affordability. Employers are required to pay at least 60% of the premium for workplace insurance. But if they choose not to buy insurance, they are required to pay on $750 a year per worker to a state fund. Since this is far less than the average annual cost of most premiums, the incentive is for the employer to drop coverage. This would pave the way for more people enrolling in the public plan - as long as that plan is affordable.

Individuals are required to pay from 1% of 12.5% of their annual income, on a sliding scale, for health insurance premiums.

It is widely expected that the Senate will pass a more conservative proposal than the House. The chairs should improve their proposals to make the public plan widely and immediately available, as well as affordable. If they do not, hopefully there will be constructive amendments from other Senators on the Committee.

Friday, June 26, 2009

Sanders State Single Payer Amendment Introduced

I am in DC, where Senator Bernie Sanders has introduced an amendment to the coverage section of the Senate HELP Committee's draft health reform bill. The amendment would provide funding to up to 2 states a year to establish state-based single payer systems, if the states apply to do so.

We will have more information soon on the full text of the amendment, and suggestions on how to build support for it, especially during the Congressional recess that has just begun. It will be presented for a vote in Committee sometime after Congress reconvenes on July 7.

The amendment is the work of Sen. Sanders and his staff, but our Center was pleased to play a small role in providing advice on drafting. In substance, it mirrors a state single payer amendment proposed by Sen. Paul Wellstone in 1994, as part of the consideration of the Clinton health reform proposal. It was passed by the same Senate HELP Committee at that time (though the Committee had a slightly different name then). (Although the Committee passed this amendment in 1994, and a whole bill, the bill as a whole died before it could come to the floor for a vote.)

Saturday, June 20, 2009

House Opens Door to Strong Public Insurance Plan, Improves Medicare;

House Opens Door to Strong Public Insurance Plan, Improves Medicare;
Extensive Measures to Control Costs, Improve Quality, Require a Strong Public Plan

The House Tri-Committee health reform discussion draft includes a number of positive features for coverage, affordability and cost control, while remaining silent on some key issues. The bulk of the bill makes important proposals to improve the quality of care and prevention, but these will have the greatest impact in areas the government can control, such as Medicare. Coverage and financing for the system as a whole remain fragmented, meaning that these proposals will have limited effectiveness on cost controls and quality of care overall.

This projection could change substantially depending on how the public plan is structured. The draft bill proposes to use Medicare reimubursement rates to pay providers, a key feature for cost control. The House should not compromise on this.

The other essential issue is assuring sufficient enrollment in the public plan so that it can do what the private, for-profit insurance industry fears the most: compete fairly. As written, it seems to allow employees to choose the public plan, but does not provide the same level of subsidies to premium payments. The House must complete the bill to strengthen the public plan.

The basic benefits package for the public plan expands Medicare benefits to include maternity and well-baby coverage.

The joint proposal by three House Committees – Energy and Commerce, Education and Labor, and Ways and Means – requires private insurance plans to spend at least 85% on patient care, institutes price negotiation for prescription drugs under Medicare, and these additional features:

All health insurance plans would have to spend at least 85% of revenues on patient care.

Basic benefits include maternity and well-baby care.

A new public insurance plan would have these features:
· Supported through premiums, after federal subsidies for initial start-up costs.
o This could jeopardize the plan’s financial sustainability.
· Reimbursement rates for providers on Medicare, and can vary by 5%.
· Prescription drug prices negotiated by Secretary of HHS
· Innovative payment arrangements with incentives to improve quality, reduce health disparities, address geographic variation in provision of services, prevent or manage chronic illness, provide care that is integrated, patient-centered, quality and efficient.
· No balance billing: providers cannot charge more than established rates.
· Subsidies for premiums and other cost-sharing available to persons at 400% of the federal poverty level.
o This is a reasonable level but needs to be adjusted geographically to address urban areas with high costs of living
o Subsidy not available to individuals who are eligible for an employer-provided health plan that offers similar financial support. However, in this case premium cost limited to 1% to 10% of family income (determined on a sliding scale).

Employers must contribute to the cost of a health plan provided to employees, or pay into the Health Insurance Exchange.
Employers contribute at least 72.5% of the premium for the lowest cost plan.
Must cover full time employees and dependents.
Contributions pro-rated for part-time
Employer self-insured plans qualify as providing coverage (p. 119, Sec, 321)
Penalty for non-compliance is $100/day
Exemption for small employers, not defined (p.151) . Credits for Small Business Employee health coverage expenses (.p.153)

Individual Tax on uninsured (p. 136, Part VIII, Sec. 59B): 2% of adjusted gross income, limited by a formula, and no greater than the annual national average premium.
Exceptions for non-resident aliens, religious conscience
In all other respects, individual responsibility is not defined (Title III, p. 114)

Medicare, Medicaid, VA, Tricare remain. (p. 141)

Interim programs (p.163) to include a reinsurance program to assist early retirees

Medicare and Medicaid Improvements (p.164)
In addition to standard rate readjustments:
Sec. 1151 aims to reduce preventable hospital readmissions
Sec. D Medicare Advantage Plans – eliminates Regional Plan Stabilization Fund
Sec. 1171 Limits out of pocket costs

Subtitle E. Improvements to Medicare Part D
(Earlier sec. of bill authorizes HHS to negotiate rates)
Sec. 1181. Drug manufacturers must provide rebates
Sec. 1182. Closes doughnut hole!!!
Sec. 1184. Benefits for AIDS, Indian Health Service drug programs

Title IV – Quality p.423

full bill online

Thursday, June 18, 2009

Blue Dog Dems: Call Them on Real Health Reform!

Want to know who's holding up a vote on a strong public plan option?

51 House Blue Dog Democrats are gonna vote on health reform Here's what they intend to do. The faith community has targeted these errant Dems and gotten CA members to back off on the 'trigger' proposal. Thank you!!! Looking forward to other reports. - Ellen Shaffer

Blue Dog positions on health reform: The Blue Dog Coalition strongly supports health care reform that lowers costs for families and small businesses, increases choice and competition, and allows individuals to keep their doctor. We are concerned, however, about a “Medicare-like” public option and its ability to achieve all of the benefits put forth by its proponents. How a public option is constructed and allowed to compete are critically important to ensuring families have the ability to keep their current health coverage and continue to see the doctor of their choice. While the Blue Dog membership has not endorsed a public option, we feel that should a public option be included in comprehensive health reform, it should adhere to the following conditions at a minimum: • Adheres to the Free Market: Medicare payment rates, which include structural payment inequities involving lower reimbursement to rural areas, must not be used as the basis for reimbursement. Rather, rates must be negotiated between the plan and its providers as is the case currently for all health insurance plans. Available Only as a Fallback: The availability of a public option would occur only as a fallback and in the absence of adequate competition and cost containment. Fundamental insurance market reforms and increased choice through the Exchange should improve access and contribute to lower costs. However, should the private plans fail to meet specific availability and cost targets, a public option would be triggered and be allowed to compete on a level playing field subject to the conditions outlined above. General Description: The Blue Dog Coalition - who celebrated 15 years of leadership in 2009 - has built a reputation as a serious player in the policy arena, promoting positions which bridge the gap between ideological extremes. Many of the group's policy proposals have been praised as fair, responsible, and positive additions to a Congressional environment too often marked as partisan and antagonistic. The 51 conservative and moderate Democrats in the group hail from every region of the country, although the group acknowledges some southern ancestry which accounts for the group's nickname. Taken from the South's longtime description of a party loyalist as one who would vote for a yellow dog if it were on the ballot as a Democrat, the "Blue Dog" moniker was taken by members of The Coalition because their moderate-to-conservative-views had been "choked blue" by their party in the years leading up to the 1994 election.

*B*lue Dog Leadership Team*_ *__* Rep. Stephanie Herseth Sandlin (SD), Blue Dog Co-Chair for Administration Rep. Baron Hill (IN-09), Blue Dog Co-Chair for Policy Rep. Charlie Melancon (LA-03), Blue Dog Co-Chair for Communications Rep. Heath Shuler (NC-11), Blue Dog Whip

*_Blue Dog Members_* Altmire, Jason (PA-04) Arcuri, Mike (NY-24) Baca, Joe (CA-43) Barrow, John (GA-12) Berry, Marion (AR-01) Bishop, Sanford (GA-02) Boren, Dan (OK-02) Boswell, Leonard (IA-03) Boyd, Allen (FL-02) Bright, Bobby (AL-02) Cardoza, Dennis (CA-18) Carney, Christopher (PA-10) Chandler, Ben (KY-06) Childers, Travis (MS-01) Cooper, Jim (TN-05) Costa, Jim (CA-20) Cuellar, Henry (TX-28) Davis, Lincoln (TN-04) Donnelly, Joe (IN-02) Ellsworth, Brad (IN-08) Giffords, Gabrielle (AZ-08) Gordon, Bart (TN-06) Griffith, Parker (AL-05) Harman, Jane (CA-36) Herseth Sandlin, Stephanie (SD) Hill, Baron (IN-09) Holden, Tim (PA-17) Kratovil, Jr., Frank (MD-01) McIntyre, Mike (NC-07) Marshall, Jim (GA-03) Matheson, Jim (UT-02) Melancon, Charlie (LA-03) Michaud, Mike (ME-02) Minnick, Walt (ID-01) Mitchell, Harry (AZ-05) Moore, Dennis (KS-03) Murphy, Patrick (PA-08) Nye, Glenn (VA-02) Peterson, Collin (MN-07) Pomeroy, Earl (ND) Ross, Mike (AR-04) Salazar, John (CO-03) Sanchez, Loretta (CA-47) Schiff, Adam (CA-29) Scott, David (GA-13) Shuler, Heath (NC-11) Space, Zack (OH-18) Tanner, John (TN-08) Taylor, Gene (MS-04) Thompson, Mike (CA-01) Wilson, Charles (OH-06)

Health Care Leadership: *_Health Care_* /Mike Ross, Chairman/ /Marion Berry, Vice-Chairman/ /Zack Space, Vice-Chairman/ /Parker Griffith, Vice-Chairman/ / / Mike Thompson Jim Cooper Travis Childers David Scott Earl Pomeroy John Barrow Charlie Wilson John Tanner Collin Peterson Jim Matheson

Wednesday, June 3, 2009


As advocates for public health, we value proposals by the Senate Finance Committee and the Obama Administration to encourage prevention, fund public health functions, expand the public health workforce, and reduce health disparities. All could improve the health of our nation, and help reduce the burden and the costs of illness. We offer initial comments on strengthening these proposals.

However, these measures can only help to control unsustainable health care costs if they are aligned with reforms of the fragmented system for reimbursing and financing care. Finance Committee proposals would begin this process through Medicare. A new public insurance plan must extend these reforms systemwide.

Public health is integral to health reform. Public health agencies, programs and policies protect and improve our health as individuals and communities, and provide coverage and care directly to many. Greater investments in public health are essential to protect against new strains of the flu and the effects of climate change, to treat chronic illnesses early, and to address the factors that undermine health and drive up costs, such as tobacco use, obesity, social and economic inequalities, and unsafe communities.

Health reform is essential to public health. Universal coverage for affordable health care would improve individuals’ physical health as well as the financial and social security of communities and the nation. Reorienting health care spending priorities could unleash resources for public health.

However, our fragmented, investor-driven financing system routinely defeats savings from improvements in health status and in the quality of care. Private insurers, drug companies, equipment suppliers and hospital chains are able to soak up every dollar we might save by focusing primarily on health care features most visible to consumers but limiting needed benefits that are essential for the nation’s health and pocket book. A system whose core responsibility is to share holder profit leads to cherry picking low risk beneficiaries, limiting as many benefits as possible and providing an extra service or product, or charging a higher price. Instead of reducing costs, potential savings are diverted instead into high administrative expenses and profits..

Americans do not use more pharmaceuticals, doctor visits or hospital days than people in other countries – in fact we in the U.S. use fewer. We are acutely aware that even people with insurance too often face limits on needed services. As a result of our fragmented investor-driven system, the U.S. pays higher prices per unit of service, compared with other countries, and experiences, and also experiences more intensive use of new technologies.

The Senate Finance Committee proposals address these problems in one important system which the federal government can influence directly: Medicare, which covers people over age 65 and some people with disabilities. These proposals combine financial and organizational incentives to provide appropriate, high quality care. Because Medicare is a publicly financed, publicly administered program, the Finance Committee is able to serve the public by proposing to control Medicare’s costs.

The most effective reform would be to improve and expand Medicare’s ability to control costs to all Americans. Strengthening and expanding public insurance programs builds on what works best in our system.
A transitional policy solution is to offer a public insurance plan, similar to Medicare, that can succeed in covering a stable, substantial population sufficiently substantial to influence and realign the costs and quality of care. A strong public plan could use careful levers to control costs by limiting the use of unnecessary revenue-driven care that compromises patient safety.
We have an historic opportunity to transform the human suffering and economic disruption caused by the fragmented and competitive nature of the investor-driven health care financing system, and by the underfundiung of public health programs and policies. We call on Congress to enact legislation that would include the following recommendations:

I.Establish a Public Insurance Plan, with key features to assure that it improves coverage, affordability and quality of care.
Our goals are universal, affordable coverage, with fair and stable financing, that controls costs; an accountable delivery system that offers quality, appropriate, accessible and equitable care; eliminating social and economic disparities that undermine health; and a strong public health system.[iii]

II. Reform Medicare: Implement incentives to cMedicare reimbursement policies ontrol costs and improve quality, and extend eligibility to people under age 65.
We support the Finance Committee’s proposals for incentives to control costs and improve the quality of care through Medicare, which will be strengthened if applied to a larger population through the public insurance plan.


III. Improve public health, reduce health inequalities and address social determinants of health.
We support Finance Committee initiatives to improve preventive health services through Medicare, to address health disparities, and to expand the health care workforce. They should be expanded to strengthen the public health infrastructure, and prevention at the community-level, and to implement national policies and programs that address the political, social, economic and environmental forces and policies that shape health and can prevent illness.

[1] The Congressional Budget Office has observed (Health care activities at CBO, December 10, 2007): The main factor [contributing to the large projected increase in federal spending on Medicare and Medicaid] is excess cost growth-or the extent to which the increase in health care spending exceeds the growth of the economy. Substantial evidence exists that more expensive care does not always mean higher-quality care. (
[2] Anderson, Gerard, et al, It’s the Prices, Stupid: why the US is so different from other countries, Health Affairs 22(3) May/June 2003.
[iii] EQUAL Criteria for Health Reform. In 2008, the Center for Policy Analysis and a network of organizations representing public health and women’s health formed EQUAL Health, for Equitable, Quality, Universal, Affordable health care. The Criteria to Evaluate Health Care Reform (2008) calls for universal, affordable coverage, with fair and stable financing, that controls costs; an accountable delivery system that offers quality, appropriate, accessible and equitable care; eliminating social and economic disparities that undermine health; and a strong public health system.[iii]

Full testimony at