It's time for us to start thinking about "outside the Public Option box" things to bargain for that would allow those on record as opposed to it to save face, get a much stronger HCR, get expansion sooner than 2014, and possibly even lower the cost.
Budget Director Peter Orzag has thrown down the gauntlet to show him a way to insure more people for the same amount of money.
This diary focuses on 2 critical things:
- Expanding present single-payer government programs
- Decreasing or eliminating the "risk factors" that make insurance prohibitive for many
(There are other things of course, like requiring that insurance companies pass on savings from HCR to policy holders, setting up an opt-in single-payer system for states, and Medicare-for-All).
With both sides seemingly set in concrete on anything termed a Public Option, it may be time to think of horse-trading to get the most effective HCR possible. I try to lay out several critically important alternatives which aren't being discussed much yet but need to be thought of when the "horse-trading" starts. Things that may well be more important than a weak public option and that are worth bargaining for.
HCR basically taxes the wealthy $1 trillion to pay for insurance for the poor. That's fine but it mainly does so by subsidizing insurance company policies on the assumption they will not simply raise their rates. The amount expended on subsidies for the lowest income levels means that the amounts of subsidies for moderate-low income levels is surprisingly little as this calculator will show you:
http://healthreform.kff.org/...
A "Public Option" may only cover 1 million people who cannot get insurance because of health or employment status and would probably charge above average rates.
Of course the Medicare-for-All proposal is wonderful, as is Senator Sanders S703 bill to allow states to opt-in to a single-payer system. But what if they don't get the votes either?
Howard Dean and Bernie Sanders agreed on MSNBC a few days ago that perhaps we should look to diminishing risk factors and expansion of Medicaid as alternatives to what is becoming a poor HCR bill:
http://www.msnbc.msn.com/...
1) RISK ADJUSTMENT
Many European countries like the Netherlands, Germany, Belgium and Switzerland have found that the most important barrier to universal coverage is risk factors. For many because of age and health factors insurance is prohibitive. They establish risk factor subsidy boards to pay companies for risk factor adjustments so premiums can be uniform.
http://en.wikipedia.org/...
In both the House and Senate bills there is a limitation that no policy may cost more than 200% of the lowest one because of risk factors. 200% is a lot, especially for people who are older uninsured people with low income. In fact, as is mentioned in the above video of Dean and Sanders at minute 4, Vermont presently limits risk factor premium differences to 20%. (The proposal to allow interstate insurance sales would override such regulations in progressive states).
If "pre-existing conditions" are prohibited as risk factors, why isn't age considered a pre-existing condition?
2)EXPANDING MEDICAID & OTHER SINGLE PAYER PLANS
In 2008, Medicaid provided health coverage and services to approximately 49 million low-income children, pregnant women, elderly persons, and disabled individuals. Federal Medicaid outlays were estimated to be only $204 billion in 2008. Even with states paying about 43%, that's 49 million covered for a total well under $400 Billion.
The Congressional Budget Office predicts that the House proposal would add 11 million to the Medicaid rolls, accounting for about a third of the estimated 40 million uninsured Americans who would gain health insurance under the proposal. The CBO also says that by using the 150% FPL, the House bill saves more than $100 billion over the Senate's 133% FPL.
A previous version of the House bill carried an estimated cost of $1.04 trillion over 10 years, but House negotiators were able to lower the price tag to less than $900 Billion in part by expanding Medicaid coverage to a broader slice of the population, the equivalent of all individuals who earn about $16,200 per year. The original House legislation had sought an increase to 133 percent of the federal poverty level, or about $14,400 per year, the same level proposed in the Senate bill.
The adjustment reflects findings by congressional budget analysts that covering the poor through Medicaid -- which pays providers far less than Medicare -- is far more cost-effective than offering subsidies for private insurance policies, something the bill would provide to middle class individuals who lack access to affordable coverage through their
employers.
http://www.washingtonpost.com/...
This $100 billion in savings is in spite of the fact that the House bill puts the medicaid expansion in effect a year earlier than the Senate bill! (the House bill would allow states to expand Medicaid in 2010 and require it by 2011 and of course politically getting as many benefits to people by 2010 is critical).
133% FPL is about $29,000 for a family of four while 150%FPL is about $33,000.
An article in The New England Journal of Medicine summarizes this even better:
According to the CBO's estimates for the House bill, per capita federal costs in 2019 would be $5,926 for coverage through an exchange, as compared with $1,826 for coverage through a Medicaid expansion. States will continue to bear a portion of the cost of Medicaid, which explains in part why it will be less expensive. In addition, Medicaid generally pays providers less than commercial insurers do, contains no profit component, and has lower administrative overhead costs than do private insurers.
http://content.nejm.org/...
That means that each Medicaid insured costs federal and state governments about $3,000, less than half what it will cost to insure each person under the subsidy program.
Medicaid payments currently assist nearly 60 percent of all nursing home residents and about 37 percent of all childbirths in the United States. The Federal Government pays on average 57 percent of Medicaid expenses.
Medicaid is rapidly becoming a managed-care program with options:
During the 1990s, many states received waivers from the Federal government to create Medicaid managed care programs. Under managed care, Medicaid recipients are enrolled in a private health plan, which receives a fixed monthly premium from the state. The health plan is then responsible for providing for all or most of the recipient's healthcare needs. Today, all but a few states use managed care to provide coverage to a significant proportion of Medicaid enrollees. Nationwide, roughly 60% of enrollees are enrolled in managed care plans. Core eligibility groups of poor children and parents are most likely to be enrolled in managed care, while the aged and disabled eligibility groups more often remain in traditional "fee for service" Medicaid.
Some states operate a program known as the Health Insurance Premium Payment Program (HIPP). This program allows a Medicaid recipient to have private health insurance paid for by Medicaid. As of 2008 relatively few states had premium assistance programs and enrollment was relatively low. Interest in this approach remained high, however.
On November 25, 2008, a new federal rule was passed that allows states to charge premiums and higher co-payments to Medicaid participants.
http://en.wikipedia.org/...
Both HCR plans call for uniform US rules for Medicaid eligibility and subsidize states' expenses for any expansion for a number of years.(10 years in the House version, 5 years in the Senate's) Onerous state rules requiring applicants be practically destitute and not own homes were done away with a few years ago, presently applicants can have up to $500,000 equity in a home:
http://www.nytimes.com/...
Is vast expansion of Medicaid impossible to get by conservatives? Even the American Enterprise Institute supports a large expansion of Medicaid:
http://www.aei.org/...
There is also the option of letting people buy-in to the Veteran's Administration Health Plan:
http://www.huffingtonpost.com/...
And there are proposals to allow states to opt-in to a single-payer plan.
And there is a very valid reason to expand dental coverage in plans:
http://www.digitaljournal.com/...
As for the bad items we should be trying to get rid of, two come to mind (other than Stupak):
- The proposal to allow health insurance companies to sell across state lines and avoid progressive state regulations and,
- The proposed Independent Medicare Board which could unilaterally decrease Medicare benefits in the future (for Parts C and D at least) if their expenses are greater than anticipated.
The best suggestions for Medicare-for-All and other needed changes I've seen are a discussion between Robert Reich, Paul Starr and Robert Kuttner at:
http://www.prospect.org/...
For those who want to read a very good extensive summary and comparison of the HCR proposals I highly suggest this article:
http://healthaffairs.org/...