June 2009 Archives

Members of Congress last week were considering three distinct employer mandate proposals. Which are the best and worst ideas -- from both a policy and political perspective?

• Idea 1: Senate Budget Chairman Kent Conrad, D-N.D., called a "free rider" alternative to the employer mandate a "live option," according to a June 25 report by CongressDaily. Instead of requiring employers to provide health coverage for their workers, they would have to contribute the cost of tax credits for eligible workers in an exchange. Employers also would have to contribute half of the national average Medicaid costs for workers enrolled in the low-income federal health care program.

• Idea 2: Sen. Christopher Dodd, D-Conn., said that the Health, Education, Labor and Pensions Committee bill could emerge with an employer "pay or play" proposal, but that it would not be a payroll fee. Dodd said the committee was considering the approach used in Massachusetts, where companies must pay $300 for every employee not offered insurance. However, he said the payment would be higher in the HELP bill.

• Idea 3: House Democrats are talking about requiring employers to offer a set contribution toward a benefit plan that met a minimum standard or pay an 8 percent payroll fee.

What should Congress do, and how should it treat small businesses?

6 responses: Uwe Reinhardt, Marilyn Werber Serafini, Jason Rosenbaum, John C. Goodman, Dan Danner, James P. Gelfand

Editor's Note: This week, former Senate Democratic leader Tom Daschle is providing the question and joining in the discussion.

It is increasingly likely that Congress will pass meaningful, comprehensive health reform this year. But that is the beginning, not the end, of changing the way our health system functions. Over the next 10 years, our country will continue to spend perhaps $35 trillion on health care with a new infrastructure that we hope will cover all Americans by providing greater access, better quality and lower cost. The big question is: Who will manage all of this? While the Center for Medicare and Medicaid Services manages the two largest federal health programs, we have no overall management authority. Imagine an aviation system without the FAA. Or our monetary system without the Federal Reserve Board.

Today, we have three big problems. First, our system (such as it is) is laden with stovepipes with little real integration. Federal health agencies have little or no coordination with each other. And there is even less between federal and commercial entities. Second, Congress is largely left with the virtually impossible responsibility of making managerial decisions that require extraordinary expertise and political courage. This is something that Congress is not equipped to do well. Third, as a result of the first two problems combined with a lack of transparency and no systemwide effort to address the need for quality enhancement, we have no systemwide infrastructure management. In large part, the lack of any coordination and integration of our massive health care labyrinth has led to massive inefficiency, a loss in quality and higher costs. How disappointing it would be if, after we pass meaningful change in health care policy, we fail to develop the infrastructure to implement and manage it.

We need a federal health board with the political autonomy, the expertise and the legal authority to make the tough decisions and to manage our system far better than it is managed now. The best time to do this would have been decades ago. No one knows how much quality improvement and cost reduction we could have experienced.

But the second best time is now.

-- Tom Daschle

9 responses: Marilyn Werber Serafini, Tom Daschle, Leonard D. Schaeffer, Stuart Butler, Marilyn Werber Serafini, Denis Cortese, James P. Gelfand, John C. Goodman, Newt Gingrich

The Senate Health, Education, Labor and Pensions Committee this week plans to mark up long-awaited health care reform legislation, and the Finance Committee will follow within a week. What is your final, most important, advice for lawmakers as they enter this critical stage?

While most of the elements in the bills were expected, such as individual and employer mandates, some new proposals are emerging. Sen. Kent Conrad, D-N.D., last week proposed a compromise public health plan that would create a system of pooling similar to a co-op that people could use to buy insurance. The co-op version of a public plan must be nonprofit; follow the same rules as private insurers; give members democratic control; be governed by an elected board; and return surpluses to members or reinvest them to allow for lower premiums or better benefits, according to a CongressDaily report.

HELP Committee Democrats' bill includes provisions allowing people to purchase long-term care insurance from the government and for young people to stay on their parents' policies until age 26. There's also a reinsurance plan for older, pre-Medicare retirees.

HELP did not include proposals on the most controversial topics, such as creation of a public health plan, and it didn't say how it would pay for the bill.

What's strong, what's missing, and what's wrong? What kinds of amendments make sense as committee members begin their markups?

Overhaul Hits Speed Bumps

Two days after a Congressional Budget Office estimate that the proposed health care overhaul will cost the federal government more than $1 trillion over the next decade, Democrats are scrambling to find new taxes to close the budget gap.

Meanwhile, a committee markup for the bill, which was slated to begin this week, has likely been delayed until after the July Fourth recess.

9 responses: Billy Tauzin, Marian Wright Edelman, Karen Davis, Marilyn Werber Serafini, Denis Cortese, Kenneth E. Thorpe, Tommy G. Thompson, Jason Rosenbaum, John C. Goodman

Should Congress be concerned with structuring an individual mandate to buy insurance and other health reform proposals so that they are not part of the federal budget, and therefore not considered a tax increase?

A Congressional Budget Office analysis issued May 27 suggested that such a mandate didn't have to be counted as part of the budget if premiums paid by individuals don't go through the government and there are sufficient private plan choices. For the entire analysis, click here.

How important is this distinction? Charges of big government and new taxes contributed to the death of health reform during the Clinton years, although the public has not been rebelling in recent months as the federal government becomes more involved in large, failing companies.

Also, how big is the federal government's financial risk if a mandate is included in the budget? Could it run into large federal expenditures in tough economic years, when more subsidies must go out but fewer premium payments are coming in?

4 responses: Tom Miller, Uwe Reinhardt, John Sheils, Robert J. Blendon

As Congress enters its final bill-writing stretch before marking up health reform legislation next month, does it appear lawmakers in the House and Senate are on track to meet their goal of passing a bill before August recess? Is it realistic to think the factions among Democrats in the House and both parties in the Senate can settle their differences in just a few weeks? If they show signs of slipping past the deadline, does it matter?

The Senate Finance Committee has followed a rigorous process the last couple of months to bring its members up to speed on health reform and options for improving and expanding coverage, not to mention paying for it. But as committee leaders attempt to forge a bipartisan agreement, they have yet to publicly make any decisions on what options would end up in legislation. The Senate Health, Education, Labor and Pensions Committee has worked almost exclusively behind closed doors and has yet to reach any public agreements with GOP members.

House Democrats are attempting to work in tandem, which now means collecting views from not only three key committee chairmen, but also different caucuses in the party. According to Ways and Means Chairman Charlie Rangel, D-N.Y., the committees have only just started developing a framework for health reform legislation.

9 responses: Jason Rosenbaum, Drew Altman, David Nexon, Jack Lewin, John C. Goodman, Ron Pollack, Karen Davis, Rep. John Dingell, D-Mich., Sen. Max Baucus, D-Mont.