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