How Low Can We Go?

Even when a televised “summit” gathers the highest level of government officials, the search for common ground may descend to the lowest common denominator, at best, or just provide a more artificial replay of their respective twin peaks of political posturing, at worst (e.g. trying to turn Rep. Ryan’s Roadmap into Roadkill). In the case of this year’s mirage of health reform, we probably should count on rewarding the soft bigotry of low expectations. In any case, a more realistic objective would not be to finally achieve grudging capitulation by either hyper partisan side this year, but rather a somewhat clearer presentation to this fall’s cranky voters of how and why they differ.

The electoral majority of November 2008 reflected in Congress has grown badly out of synch with a de facto popular majority that balks at swallowing an indigestible prescription for comprehensive overhaul of health care policies and practices. But since it’s still February, let’s rerun health policy Groundhog Day with a drive-by look at several of the listed congressional Republican proposals that have drawn little serious scrutiny until now. Buckle up before we buckle down, in short order:

1. More seriously structured high-risk pool concepts are laudable, but they need much more extensive funding to do the job than even a $25 billion appropriation can handle. The latter figure is closer to a one-year cost than a ten-year budget estimate. It would be better to keep the subsidized premium threshold for high risks at 200 percent of standard rates, but then supplement it with an additional set of income-related subsidies. More affluent high-risk individuals still would be much better off in paying for only a portion of their actual health expenses through more expensive, but capped, insurance premiums. For a broader analysis, see http://www.aei.org/article/101189 .

2. Extending HIPAA’s group market portability protections against pre-existing conditions to the individual market is a reasonable compromise that would limit just-in-time coverage gaming and provide a strong near-mandate incentive to maintain continuous insurance coverage (http://www.aei.org/speech/100065 ). Dropping the COBRA exhaustion requirement is overdue. Further attention is needed for treatment of first-time entrants to the insurance market. A one-time open season (an Oklahoma land rush for health coverage) might not be administratively manageable. Another alternative would allow previously uninsured entrants of the future to be risk-rated initially whenever it’s worth the underwriting expense, before applying long-term guaranteed renewability protection to later changes in their predictable health risk status.

3. Eliminating health insurance spending caps is the latest junk food of health policy. But this approach fails to replace them with more transparent alternatives for acknowledging the need to manage the overall costs of the most persistently catastrophic medical conditions in line with exhaustible resource limits, yet provide a special override process for special cases.

4. The actual incidence of ex post rescissions falls well short of their anecdotal power. The limited amounts of current problems are usually matters of inadequate state regulatory performance (not enforcing existing laws effectively, rather than needing new ones). Creating a new federal appeals apparatus will add the appearance of more vigorous arm waving and finger pointing, but it’s unlikely to generate much business.

5. It’s probably no more harmful to try to bribe states to do the right thing (reduce costs and expand affordable coverage) than to bribe them to do the wrong thing (leverage the federal matching fund formula for Medicaid and squeeze provider reimbursement levels even lower). But why don’t the states already have enough incentive to want to fix their own coverage, cost, and budget problems? (See previous sentence).

6. If larger risk pools alone could constrain rising health care costs, health benefits expenses (and their growth rates) for large self-insured employers would be lower than they actually are. Merely averaging the costs of health risks does not necessarily reduce them; it mostly redistributes them. But if they can’t love the pool they’re with, smaller employers should be allowed to be with the pool they love. However, the CHOICE bill (HR 859) does a better job of not just beating the near-dead AHP horse, by focusing on captive insurers and catastrophic costs instead.

7. Perhaps a decade from now, we will hear that “30 is the new 25.”

8. Interstate insurance purchasing is no panacea, but it will shave insurance premiums downward in the individual and (more importantly) small group markets if structured to encourage vigorous competition among states in their respective brands of insurance regulation and among more insurers facing fewer barriers to entry. The realistic size of the insurannce cost variation due to the regulatory wedge among states, however, is closer to 10-15 percent of premium levels at best. And the more extensive the safeguards that are added to the interstate competition process, the less the competition-driven premium savings will be.

9. Small ball for HSAs

10. (Damage) caps are crude weapons but they don’t fire blanks. Most of the CBO-scored savings in the Boehner bill come from medical liability reforms.

11. Repeal of the CER Council removes one danger of centralized rationing but fails to replace it with a more pluralistic approach to competition in value measurement and enhancement. Remarkably enough, a late insertion into the Senate-passed Patient Protection and Affordable Care Act in section 10332 would begin to make Medicare data more available for external performance measurement and help jump start a better process.

Given the history of Republican obstructionism on health care, the offer by the President for a summit was an extremely generous one. In fact, it took Republican leadership all of two minutes to completely shoot down the idea and demand Obama and Democrats scrap the health care reform bills that have already been passed. Here's House Minority Leader John Boehner:

The best way to start on real, bipartisan reform would be to scrap those bills and focus on the kind of step-by-step improvements that will lower health care costs and expand access.

And Senate Minority Leader Mitch McConnell:

If we are to reach a bipartisan consensus, the White House can start by shelving the current health spending bill, and with it their goal of slashing a half trillion dollars from Medicare and raising a half trillion in new taxes.

If the only way to get "bipartisan support" is to scrap Democratic ideas and go with Republican ones, this summit won't get very far.

The quick dismissals of this new summit only highlight the fact that Republicans been brought to the table repeatedly over the last year as health care discussions have progressed, and they've aired their ideas many times over. In every instance, their response to offers of negotiation was to say no to any health care reform, and in every instance their alternative ideas were found wanting.

Republicans have had ample opportunities to contribute constructively to the debate.

The President launched his health care push with a bipartisan summit very much like this new one back in March of 2009. Leading Republicans attended, from Senator Chuck Grassley, the highest ranking Republican on the Finance Committee, on down.

At the summit, Senator Grassley used the national podium to fear-monger about the public option, saying that:

"Forcing free market plans to compete with these government-run programs would create an unlevel playing field and inevitably doom true competition. Ultimately, we would be left with a single government-run program controlling all of the market.”

At the same event, the insurance industry's top lobbyist, Karen Ignagni of AHIP, lied to the President's face and said that insurance companies were in favor of reform:

"We want to work with you. We want to work with the members of Congress on a bipartisan basis here. You have our commitment. We hear the American people about what's not working. We've taken that seriously. You have our commitment to play, to contribute, and to help pass health care reform this year."

Just months later, the insurance industry would begin funneling tens of millions of dollars to the Chamber of Commerce, who acted as a front group running ads to kill health care reform on behalf of the industry.

The summit produced a report full of ideas [pdf], a great many of which were incorporated into health reform legislation. And yet, Republicans still opposed the very idea of health reform.

After the summit, health care legislation went through no less than five committees in Congress - Ways & Means, Energy & Commerce, and Education & Labor in the House and Finance and HELP in the Senate. In every one of those committees, Republicans were part of negotiations and had the opportunity to advocate for their ideas and offer amendments. In every one of those committees, Republican amendments were indeed accepted into the legislation being written. For example, the HELP committee accepted 160 Republican amendments into their bill. And yet no Republican on any committee, with the exception of Olympia Snowe on the Finance Committee, ended up voting for the legislation in committee.

In the Senate Finance Committee, Republicans got even more opportunities to shape legislation. Chairman Baucus negotiated with the "gang of six," three Republicans and three Democrats, for months, working towards a bipartisan agreement. These were closed-door meetings - the exact type Republicans accuse Democrats of using to "ram through" health care - and yet when it came down to votes, only Olympia Snowe crossed the aisle to vote for the Finance Committee bill.

That Finance Committee bill then became the basis for the bill on the Senate floor. Republicans in the Senate again had opportunities to offer amendments, but when it came time for a vote, even Olympia Snowe was brought in line by the party of NO and not one Republican voted for the bill. Similarly in the House, Republicans offered a whoefully inadequate "alternative" health care bill and then voted en masse - with the exception of Rep. Cao of Louisiana - against health care reform, despite their involvement in the process.

At every step of the way, Republicans continued to say NO to health care reform while offering the same stale "solutions." The fullest display of Republican ideas on health care is evident in the "alternative" health care bill House Minority Leader John Boehner offered as a substitute to the Democratic health care bill in the House.

To recap, the bill offered by Republicans would:

• Allow insurance companies to continue to deny care for pre-existing conditions
• Cover only 3 million more people [pdf], as opposed to 40 million for the Democratic plan
• Raise insurance premiums on those of us who get sick
• Save less money than the Democratic plan

The ideas Republicans rely on to "reform" health care similarly are do-nothing proposals.

• Tort reform? CBO says it wouldn't cut health care costs.
• Buying insurance across state lines? It's nothing but a gift to the insurance companies, allowing them to do business in the least-regulated states.
• And then there's the Republicans' main money-saver, at least according to the budget the proposed last year: Privatize Medicare and Medicaid, leaving our nation's old and poor at the mercy of the insurance industry.

Democrats have already given Republicans - the minority party who lost the 2008 elections in a national referendum on their failed policies - an incredibly generous number of chances to inject their ideas into the health care debate. And at every step of the way, Republicans have proposed the same policies that do nothing to solve the health care crisis. And then, even when some of those policies have been adopted, they've turned around and voted against health care reform.

It would be nice if Republicans want to help the country solve its health care crisis. But given what's already happened in the year-long health care reform process, it's clear that Republicans have already made up their minds not to solve America's problems and instead say NO for political gain.

It's up to Congress - Democrats in Congress - to move forward and finish health care reform right by majority rule. It's what the country voted to give them the majority to do in 2008.

By Jenny Luray, President, Susan G. Komen for the Cure Advocacy Alliance

It is good that leaders from both sides of the aisle are planning to come together and talk. We hope this will lead to a viable health reform plan that protects cancer patients and survivors from discriminatory health insurance practices and unaffordable out-of-pocket costs. These patient protections are one area where there is large bipartisan agreement. As such, we hope the talks lead to their adoption and quick implementation.

Another way this summit could make a real impact would be for a portion of the time to be dedicated to examining ways to help people who are currently losing access to vital state-based health programs for the uninsured and underinsured, such as the federal/state National Breast and Cervical Cancer Early Detection Program. Without this program, many underserved women will not get cancer screenings, leading to later diagnoses, more advanced cancers, and lower chances of survival. This is literally a life-or-death issue.

State screening programs are fairly inexpensive — just a rounding error in an overall state budget — but the value to the women they serve is invaluable. Early detection is not only important to the women whose lives are saved, but they can also be important to states’ bottom-line, as treatment for later-stage tumors are much more expensive, increasing the impact on state and/or federal budgets down the road. Yet these and other vital health programs find themselves on the chopping block.

We understand state budgets are in crisis. As a result, taxes are being increased. Services are being slashed. Every program is a target, including those that make up the fabric of the nation’s health care safety net.

California faces by far the worst situation. Governor Schwarzenegger has proposed cuts to the state's breast cancer screening program, adding on to the deep cuts to the program that went into effect on January 1, which included the total elimination of services to woman age 40 to 49 and a suspension of services for all other new patients for the remainder of the fiscal year which ends July 1. The governor has also proposed completely eliminating the state’s breast cancer treatment program for low-income women if additional resources are not secured from the federal government.

The seven Komen for the Cure Affiliates in California protested the state’s cuts to screening in Sacramento yesterday. Along with the Assembly’s Women’s Caucus, our advocates sold baked goods on the Capitol steps to raise awareness and to help fund screening programs. After a full day of meetings with Members of the State Assembly, they lit the Capitol pink in honor and memory of women who have fought battles with breast cancer.

With a growing and aging population – and without early detection and treatment – the eventual expenses of caring for women with breast cancer will continue to grow, further increasing Medicaid and Medicare costs and state and federal budget deficits. This is a fact not lost of the some in the California Legislature. In a budget hearing on the Every Woman Counts programs this week, Assembly Member Sandre Swanson noted that "cutting screening just increases treatment costs for the state down the road. We're shoving off costs into the future and costing lives in the meantime."

These cuts are devastating to a program that is already dangerously underfunded. A recent study by the Government Accountability Office (GAO) reveals that the screening program only screens about 15 percent of eligible women. About 26 percent of eligible women are screened by other providers, such as free clinics and mobile vans, some of which are funded by Komen Affiliates. Yet, the GAO noted these resources are limited and often not available in rural or other underserved areas — shockingly, 60 percent of eligible women do not receive recommended breast cancer screening from any provider – a disturbing revelation that is much higher than previously understood and underscores the need for access to affordable insurance.

Without the assistance of the federal/state screening program, many of these underserved women will delay or completely forego recommended screenings, leading to later diagnoses, larger tumors at diagnosis, fewer treatment options and lower chances for survival. When breast cancer is detected early, before it spreads beyond the breast, the 5-year relative survival rate is 98 percent. Once the cancer spreads to other parts of the body, survival rates plummet to 23 percent.

And it’s not just cancer screening that’s at risk. 10,000 parents in Arizona lost health coverage they received through KidCare; Massachusetts cut funding for subsidized health insurance for 28,000 legal immigrants; Rhode Island eliminated health coverage for 1,000 low-income parents; Minnesota cancelled a health insurance program for 29,500 low-income adults; California increased cost-sharing for families of 1 million children in CHIP; and Washington is increasing premiums for a health plan serving low-income residents, leading 7,000 to 17,000 enrollees to leave the program.

It doesn’t have to be this way. If leaders in Washington, D.C. really want to do something about health care, they should include in their “summit” ways to solve this growing crisis, too.

The problem with the Republican plan is that it does not put even a serious dent into the triple problems of cost, quality and access to care.

But, the again, the Obama plan doesn't either.

So if I have to choose, I'll take the plan that doesn't solve the problems while spending the least amount of taxpayer money.

A televised summit is hardly the best way to build bipartisanship. A competent marriage counselor would never advise a separated couple to discuss their differences on national TV (with their legal and political advisers feeding them soundbytes). President Obama would have invited the GOP leaders to a private "beer summit" at the White House or Camp David if he were really serious. That said, he could still work across the aisle to achieve compromise in several areas. Among them:

• A firm Republican commitment to achieving affordable coverage for all Americans in annual stages, starting now, in return for a WH agreement to scale the current bills way back.
• A package of insurance reforms, such as extending HIPAA, designed to deal with pre-existing conditions.
• An agreement to provide states funding to address high-risk and chronically ill Americans through high-risk pools. In addtion, giving states legislative waivers for left or right ideas to expand coverage -- eg through the bipartisan Baldwin-Price House bill.
• An overhaul of the tax treatment of private health coverage to make it efficient and to provide cost-reducing incentives -- limiting the tax exclusion by income to finance better tax relief for those who need it to afford coverage.