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.

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