Health Care: Pelosi Working To Limit Democratic Defections
• "Although confident of victory" on the House's health-care reform vote Saturday, "Speaker Nancy Pelosi (Calif.) and other Democratic leaders were working" Thursday "to limit defections to the roughly 25 Democrats viewed as 'hard no' votes," the Washington Post reports. "There will be 258 Democrats in the House by the time the vote takes place, but to secure the 218 votes needed for passage -- and with prospects dim for Republican converts -- Pelosi can afford to lose no more than 40 members of her caucus."
• "House leaders are likely to bow to pressure from the Congressional Hispanic Caucus and leave tighter restrictions for undocumented immigrants out of the healthcare overhaul, but avoiding conflict in the House could set up a brutal battle with the Senate and possibly" Obama, CongressDailyAM (subscription) reports.
Health insurers woke up policymakers and the public with claims that health reform bills on the table would increase insurance premiums -- not decrease them.
When it comes to affordability for individuals, what is most important to remember as members of Congress move forward with reform legislation? Are premium subsidies set properly at about 400 percent of the federal poverty level? How far up the income scale should Medicaid reach? What percentage of income should a person be required to spend on health care before they qualify for an exemption?
-- Marilyn Werber Serafini, NationalJournal.com
5 responses: Karen Davis, John Rother, Sen. Ron Wyden, D-Ore., Ron Pollack, Drew Altman
Are there any downsides to creating a national public health insurance option and allowing states to opt out? Would it do any good?
Senate Democratic leaders seem intrigued with the idea. CongressDaily on Friday quoted Sen. Charles Schumer, D-N.Y., as saying, "Liberals live with it. Moderates live with it. It's in the middle."
But what about the policy implications? While such a proposal could potentially get enough votes to pass Congress, would a public option really lower costs if only some states offered it? How many would opt out, and why?
-- Marilyn Werber Serafini, NationalJournal.com
8 responses: Len Nichols, Denis Cortese, Jason Rosenbaum, James P. Gelfand, Karen Ignagni, Michael F. Cannon, Sec. Mike Leavitt, Paul B. Ginsburg
How should Congress define universal coverage? The Senate Finance Committee bill is estimated to cover 94 percent of the population. Massachusetts has covered 97 percent of its population through its health reform, although it had a relatively low level of uninsured to begin with.
What is the best way to define universal coverage, and what are the most important factors that could keep the nation from getting there? How many of the uninsured should be covered under health reform?
-- Marilyn Werber Serafini, NationalJournal.com
8 responses: Michael F. Cannon, John C. Goodman, Uwe Reinhardt, Uwe Reinhardt, Michael F. Cannon, Ron Pollack, John C. Goodman, Uwe Reinhardt
How much merit is there to 11th-hour insurance industry claims that the health reform bill scheduled for a vote in the Senate Finance Committee this week would raise insurance premiums? And how big a problem is it that the industry, which had generally been cooperative in the reform effort, is now lashing out?
America's Health Insurance Plans Sunday created a stir when it released a report commissioned from PriceWaterhouse Coopers that pointed to four provisions in the Finance Committee bill as potentially increasing private insurance costs for individuals, families and businesses above what their costs would be minus reform. With the enactment of four specific provisions, the cost of coverage would increase by 111 percent, according to the report. The problems, it says, are "insurance market reforms coupled with a weak coverage requirement, a new tax on high-cost health care plans, cost-shifting as a result of cuts to Medicare, and new taxes on several health care sectors."
With these provisions in place, would health insurers still benefit from reform?
-- Marilyn Werber Serafini, NationalJournal.com
11 responses: Michael F. Cannon, Rep. Pete Stark, D-Calif., Jason Rosenbaum, Karen Davis, Henry Simmons, Drew Altman, Ron Pollack, John C. Goodman, Michael F. Cannon, Len Nichols, Marilyn Werber Serafini
Updated at 5:48 p.m. on Oct. 7.
The Congressional Budget Office and the staff of the Joint Committee on Taxation have issued a preliminary analysis of the Senate Finance Committee chairman's mark for the America's Healthy Future Act of 2009. They note it would reduce the federal budget deficits by $81 billion over the 2010-2019 period. Here are excerpts from CBO Director Douglas Elmendorf's blog:
"The estimate includes a projected net cost of $518 billion over 10 years for the proposed expansions in insurance coverage. That net cost itself reflects a gross total of $829 billion in credits and subsidies provided through the exchanges, increased net outlays for Medicaid and the Children's Health Insurance Program (CHIP), and tax credits for small employers; those costs are partly offset by $201 billion in revenues from the excise tax on high-premium insurance plans and $110 billion in net savings from other sources. The net cost of the coverage expansions would be more than offset by the combination of other spending changes that CBO estimates would save $404 billion over the 10 years and other provisions that JCT and CBO estimate would increase federal revenues by $196 billion over the same period. In subsequent years, the collective effect of those provisions would probably be continued reductions in federal budget deficits. Those estimates are all subject to substantial uncertainty.
"By 2019, CBO and JCT estimate, the number of nonelderly people who are uninsured would be reduced by about 29 million, leaving about 25 million nonelderly residents uninsured (about one-third of whom would be unauthorized immigrants). Under the proposal, the share of legal nonelderly residents with insurance coverage would rise from about 83 percent currently to about 94 percent. Roughly 23 million people would purchase their own coverage through the new insurance exchanges, and there would be roughly 14 million more enrollees in Medicaid and CHIP than is projected under current law. Relative to currently projected levels, the number of people either purchasing individual coverage outside the exchanges or obtaining coverage through employers would decline by several million.
"All told, the proposal would reduce the federal deficit by $12 billion in 2019, CBO and JCT estimate. After that, the added revenues and cost savings are projected to grow more rapidly than the cost of the coverage expansion."
What's your take?
Is it realistic to think that most doctors will radically change their practice structure to assimilate into broad multi-specialty practices and potentially become employees of large, integrated health systems?
Today, most doctors still operate in small group practices. Yet, major congressional health reform bills are counting on doctors to significantly change their business model. They hold up large, integrated health care systems like the Mayo Clinic and the Cleveland Clinic, both of which employ doctors, as models. They propose accountable care organizations, which would require doctors to at least affiliate with physicians of other specialties. They also propose bundling payments, which would necessitate financial arrangements with other types of medical providers.
Will doctors really buy into this? Would such a system improve quality and lower costs?
-- Marilyn Werber Serafini, NationalJournal.com
14 responses: Henry Simmons, Michael F. Cannon, Karen Davis, Uwe Reinhardt, Marilyn Werber Serafini, Jason Rosenbaum, Ron Pollack, Marilyn Werber Serafini, Jack Lewin, John C. Goodman, J. James Rohack, Darrell G. Kirch, Paul B. Ginsburg, Denis Cortese
Health reform advocates are all for promoting wellness, but there's a controversy brewing about whether change should come through legislation or employers, and whether people who fall short of wellness standards should be penalized.
The health reform bill approved by the Senate Health Education Labor and Pensions Committee would allow insurers to charge people who do not meet wellness standards premiums that are up to 30 percent higher.
Safeway CEO Steve Burd wants Congress allow employers to offer health care discounts to those meeting certain wellness standards.
Critics argue that runs counter to efforts in the major health reform bills that would prohibit insurers from charging people different prices on the basis of health status or pre-existing conditions. "Some find it ironic that even as Congress moves toward restricting such practices in the individual market, it is considering allowing employers to move in the other direction," National Journal correspondent Julie Kosterlitz writes in an article (subscription) on the subject on September 26.
"We are deeply concerned about the suggestion that Safeway has to provide discounts on premiums that are dependent on achieving health outcomes," says Dick Woodruff, senior director of federal relations at the American Cancer Society Cancer Action Network. "It's real simple: It's bringing back rating for pre-existing conditions. That defeats everything that we're trying to accomplish" with health reform.
What is the best approach, and what are the dangers?
-- Marilyn Werber Serafini, NationalJournal.com
4 responses: Kenneth E. Thorpe, John C. Goodman, Len Nichols, Donna Shalala
Each health reform bill in Congress achieves part of its insurance coverage expansion by increasing eligibility for Medicaid.
The latest health reform proposal, from Senate Finance Chairman Max Baucus, D-Mont., would expand Medicaid to all U.S. citizens who earn up to 133 percent of the federal poverty level (which is $14,400 for an individual and $30,000 for a family of four), beginning in 2014. Those earning 100 percent to 133 percent of poverty could take Medicaid or a private health insurance plan offered through a health insurance exchange. (The bill approved by several House committees also expands coverage to 133 percent of poverty, while the bill approved by the Senate Health, Education, Labor and Pensions Committee expands eligibility to 150 percent of poverty.)
Because Medicaid is funded jointly by the federal and state governments, there is concern that expanding the program would put significant new financial pressure on already tight state budgets. Under the Baucus proposal, the federal government would pick up more of the tab than it does now for newly eligible people (as much as 95 cents of every dollar it costs to cover these people in some areas).
What should the state's contribution be? What level of out-of-pocket payments should be required for beneficiaries, and what benefits should they receive? How should providers be paid?
-- Marilyn Werber Serafini, NationalJournal.com
4 responses: Karen Davis, Grace-Marie Turner, John C. Goodman, Ron Pollack
Updated at 11:53 a.m. on Sept. 16.
Is state experimentation on medical malpractice reform the right solution?
In his Sept. 9 speech to Congress, President Obama attempted to appeal to Republicans by embracing a plan by President Bush to authorize demonstration projects in individual states to test approaches to malpractice reform. "I don't believe malpractice reform is a silver bullet, but I have talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs," he said. "So I am proposing that we move forward on a range of ideas about how to put patient safety first and let doctors focus on practicing medicine." Obama said he was directing his Secretary of Health and Human Services "to move forward on this initiative today."
In National Journal's regular poll of Congressional Insiders, 68 percent of the Democrats surveyed said they would support a health care reform package that included tort reform, compared to 34 percent of Republicans. The idea was opposed by 29 percent of Democrats and 47 percent of Republicans.
Could malpractice reform significantly reduce health care costs? Would you like to see malpractice reform be incorporated into health care reform?
Senate Finance Chairman Max Baucus, D-Mont., unveiled a health care reform plan Wednesday that would cost $856 billion over 10 years. The committee will begin consideration next week. Here are the details, as released from his office. What are your impressions?
-- Marilyn Werber Serafini, NationalJournal.com
13 responses: Karen Davis, J. James Rohack, Jason Rosenbaum, Marilyn Werber Serafini, Marilyn Werber Serafini, Jack Lewin, J. James Rohack, John C. Goodman, Karen Davis, Newt Gingrich, John C. Goodman, Paul B. Ginsburg, Raymond C. Scheppach
Updated at 8:10 p.m. on Sept. 9.
What is the single most important point that President Obama made in his speech to Congress? Will his speech break the stalemate in Congress?
(This question asked previously: What is the best thing Obama could say in his speech to Congress Wednesday night to improve chances for health reform legislation this year?)
-- Marilyn Werber Serafini, NationalJournal.com
24 responses: Grace-Marie Turner, Stuart Butler, Jack Lewin, Sen. Chuck Grassley, R-Iowa, John C. Goodman, Len Nichols, J. James Rohack, Jason Rosenbaum, Sen. Mike Enzi, R-Wyoming, Ron Pollack, Karen Davis, Rep. John Dingell, D-Mich., Rep. Pete Stark, D-Calif., Karen Ignagni, Rep. Henry Waxman, D-Calif., Marilyn Werber Serafini, David B. Kendall, Marilyn Werber Serafini, Henry Simmons, John C. Goodman, Marilyn Werber Serafini, John C. Goodman, Uwe Reinhardt, Donna Shalala
How much more should insurers be allowed to charge older people than younger people?
So far, health care reform legislation in Congress has included language to allow insurers to charge older people twice as much as their younger counterparts. While that would lower premiums for people at, say, 60, whose medical costs might be higher, it would raise premiums for the younger, generally healthier, generation.
But legislators have given some consideration to allowing insurers to charge older people five times as much as younger people, which more closely resembles the differential today.
Which makes more sense, and how important is this distinction? Is age rating even something the government should regulate?
-- Marilyn Werber Serafini, NationalJournal.com
8 responses: John C. Goodman, Len Nichols, Scott P. Serota, Stuart Butler, Uwe Reinhardt, John C. Goodman, Uwe Reinhardt, John Rother
