Countdown to the Real Work on Health Care Reform

With a commitment of 60 votes, Senate Majority Leader Harry Reid unveiled the manager’s mark of the Patient Protection and Affordable Care Act or, as it is better known, the Senate’s health care reform bill. After day long negotiations over abortion and other issues, Senator Ben Nelson agreed to vote in favor of bringing the bill to the Senate floor.

The manager’s mark of HR 3590 identifies the changes made to the  original Senate health care reform legislation (in other words, if you want to read the bill you have to read both the original and the most recent document). As has been widely reported, there are some provisions of the legislation specifically aimed at securing the support of Senator Ben Nelson of Nebraska. For example, the health care reform bill will increase state spending on Medicaid. The Senate bill reimburses states for this extra cost until 2017 at which time the federal matching funds are phased out. Except for Nebraska where the federal government would pay for Medicaid expansion forever. (Or, to be realistic, until Congress takes the subsidy away).

There’s a host of other provisions of interest. A government-run health plan is out of the bill, much to the frustration and dismay of liberals. Carriers would be required to maintain a medical loss ratio of 80 percent for small group and individual products while meeting a minimum 85 percent MLR for their large group block of business. Rating differences based on age would be limited to a 3-to-1 ratio. However, states could increase the minimum medical loss ratios or narrow the age-based rating difference. There’s new language concerning abortions, one of the inducements to get Senator Nelson’s vote, although this language is apparently not strong enough for anti-abortion Democrats in the House.

The Office of Personnel Management would create a copy of the Federal Employee Health Benefit Plan featuring private carriers. (It appears both for-profit and non-profit plans could participate in this new program, but I may be reading it wrong and only non-profits are permitted). There’s a host of preventive/wellness programs, pilot projects and other provisions aimed at addressing costs. And it would allow carriers meeting certain federal standards to offer coverage in other states through state exchanges.

(I received an email from a conservative broker blasting this provision as removing the ability for “the Citizens of a State having a say on State Laws and Mandates!” Which is pretty funny considering it’s at the center of Republican reform proposals, was a part of Senator John McCain’s health care reform platform when he ran for president, and is not much different than the Associated Health Plans advocated by conservatives for over a decade. Sometimes it seems to be less about the underlying public policy and more about who makes a proposal that drives the reaction.)

The bottom line is that Senator Reid did what he needed to do to cobble together 60 votes in the Senate. What, in the words of former Majority Leader Tom Daschle, is the equivalent of shoveling 60 frogs into a wheelbarrow.)  As a result, the Senate will pass health care reform.

And that’s when the fun begins. There are substantial differences between the House and Senate versions of health care reform. Perhaps Speaker Nancy Pelosi, recognizing the greater challenge Senator Reid has in rounding up votes, will instruct House negotiators to quickly adopt the Senate version of health care reform. This could result in a bill passing Congress in very early January.

More likely, however, House and Senate negotiators will struggle to refine the legislation. The result will be closer to the Senate version than what passed the House, but it would not be the same HR 3590 that will pass the Senate. This process will take significantly longer, perhaps most of January. While unlikely, the conference committee has the power to start with a blank piece of paper and write a brand new bill.

My guess is Speaker Pelosi will focus on a few key modifications to the Senate bill. So long as it doesn’t cause one of Senator Reid’s frogs to jump out of the wheelbarrow these will be accepted. The result will a relatively short conference committee leading to a final vote on health care reform by mid-January.

What’s significant is that the playoff season is almost over. The World Series (that would be the conference committee) is about to begin. Which means the real work of writing health care reform legislation is about to begin.

Added December 21, 2009: Memorandum from the Congressional Budget Office to Senator Harry Reid summarizing their analysis of the Patient Protection and Affordable Care Act and to a blog posting by CBO Director  Douglas Elmendorf concerning a correction to the calculation of federal reductions beyond 2019.

The High Cost of Simplistic Health Care Reform

Representatives Jim Langevin, a Rhode Island Democrat, and Christopher Shays, a Republican from Connecticut, introduced legislation this week to create a nationwide health insurance plan similar to the Federal Employee Health Benefits Program. This is an idea that blossoms every Congressional session like the cherry blossoms near the Jefferson Memorial. There’s an internal logic to the proposal which is compelling: every American should have the same health care coverage as members of Congress.

The concept is similar to the managed competition initiative developed by the Clinton Administration in the early 90’s.  As described by the Kaiser Family Foundation’s KaiserNetwork.org, uninsured residents would be required to enroll in a health plan that meets national standards. Individuals would pay up to 28 percent of the premiums. Employers would either offer their workers coverage or pay up to $12,000 per employee to finance their coverage through the FEHBP-type purchasing pool.

That this kind of reform was introduced — again — isn’t what caught my eye. It’s the potential price tag: $12,000 per employee. A California Employer Health Benefits Survey in 2007 found employers in the state pay monthly premiums of about $374 for each employee. That comes to slightly less than $4,500 per year. Double this real world premium average and the Langevin/Shays proposal still seems to apply a 25 percent surcharge.

Maybe I’m missing something in their formula, but this does seem to point out a problem with overly simplistic approaches to health care reform. They sound good, but don’t always hang together well. And cost is not the only problem. The population served by the FEHBP tends to be well educated and, as federal employees, have a support network to help them make it through the annual open enrollment program. It tends to service a healthier population than the overall country, too. Duplicating that system for the general public won’t be nearly as straightforward as its advocates hope.

Even with all it’s problems — and it’s high cost — the Langevin/Shays proposal should be part of the mix when the next Administration begins to address the nation’s health care system. So should a single payer system. So should health care vouchers and every other idea out there. It’s important for the presidential candidates to explain their approach to health care reform. But once the real work begins, it would be more helpful for the next president to identify the goal and set the parameters, then let all ideas flourish. Even those that are too simplistic for their own good.