We should resolve now that the health of this nation is a national concern; that financial barriers in the way of attaining health shall be removed; that the health of all it's citizens deserves the help of all the nation.- Harry S. Truman
So began that journey over 60 years ago for affordable, quality health care for all. And so began President after President after President after President failing to come even close to this goal.
But this year was different. With a committed President, a committed Speaker, and a committed Senate Majority leader -- combined with lopsided Congressional majorities -- Democrats were determined to succeed in what had eluded Congress after Congress after Congress after Congress and President after President after President after President.
And that struggle began. Milestone after milestone was achieved. Chris Dodd became the second HELP committee chairman to pass a health care reform bill. George Miller became the second Education & Labor Committee Chairman to pass a health care reform bill. Charlie Rangel also earned his place in history as a Ways & Committee Chair passing health care reform. Henry Waxman managed to succeed where his former Chairman, John Dingell, failed. Max Baucus succeed where Russell Long and Daniel Patrick Moynihan failed. Nancy Pelosi succeed where Sam Rayburn, Tom Foley, and Tip O'Neill all failed. Harry Reid succeeded where Lyndon Johnson, Mike Mansfield, and George Mitchell all failed.
And so now the largest domestic policy change in at least 25-30 years -- probably more like 45 years -- is now in conference Committee. Lesser people would have quit much sooner.
And of course conferences are never fun for House member. A House member always hate how 240 House members can vote for something, but somehow that provision doesn't get through because such a provision can only get 58 votes for cloture in the Senate. It's even worse when a bill is so sweeping and such a must-pass piece of legislation that members know they will have to make significant sacrifices to get a bill passed. You don't want to be known in party history as the Bill Buckner of one of the party's greatest aspirations over the last 60 years.
Below this diary lists negotiable and non-negotiable health care reform items passed by the House, then explains the reasons for each, and finally gives solutions for possible political compromises.
First, here are some important links describing the bills:
- Text of the Senate bill (H.R. 3590)
- Text of the House bill (H.R. 3962)
- Sen. Stabenow's section-by-section analysis of the Senate bill
- Sen. Casey's long summary of the Senate bill
- House Ways & Means Committee's section-by-section analysis of the House bill
- Kaiser Family Foundation's comparison chart of the House/Senate bills
- Center for Budget and Policy Priorities comparison of subsidies in House and Senate bill
Next, we must define the central purpose of the bill. To me, that central purpose is to create a sustainable health care system that protects every American from having large medical expenses for essential care, and shield them from its consequences (i.e., bankruptcy, death). This, I believe, is what Democrats have aspired for the last 60 years. We should always keep this in the back of our minds when we think of changing this bill, and think about the provisions that acheive this central purpose.
We also must take into account the core questions that will determine the bill's political fate (granted I would never consider myself to be politically astute). Will people be able to afford the premiums even with the subsidies? Even if people are able to afford the premiums, will people be able to afford the cost-sharing? Will the bill make health insurance affordable for everyone and not just some average person? Will the people who purchase health insurance on the Exchange have a similar risk profile to those in employer-based health insurance? Will there be enough regulations to have insurance companies on the Exchange compete on the quality of their services rather than the people who they select?
With that just mentioned, here is the list I came up with negotiables and non-negotiables for the House:
What's negotiable in the House bill:
- Public option
- Anti-trust exemption
- Medical loss ratio
- Death panels
- Excise tax
What's not negotiable in the House bill:
- Subsidies from 133-300 percent FPL
- Minimum actuarial value (70 percent and no catastrophic plans)
- Insurance rating rules (2:1 on age, no smoker rating)
- Applying insurance rating rules and minimum benefit packages to all markets -- including the self-insured
- Having an HHS study to prevent adverse selection in self-insured plans
- Eliminating the "prevention and wellness" discounts
- Individual mandate (no 8% income exemption if you're going to tighten the rating rules and increase the minimum actuarial value)
- OPM Sub-Exchange
- Prudent purchaser language
- A prohibition of non-group insurance plans being sold outside the Exchange
- Limitations for benefit variation on the Exchange (no benefits allowed outside of the minimum benefits package allowed on the lower tiers, and limited variation for cost-sharing arrangements for each benefit category)
- Limits on claim processing time
Below explains my reasoning.
Any public option at negotiated rates or weaker will improve the bill at most by 5 percent, as Nate Silver points out. The CBO notes that because the public option is likely to attract a less healthy group of people than the private plans on the Exchange, it's premiums will be slightly higher than private plans on the Exchange. The level of political capital involved simply isn't worth the political gain.
Like the inclusion of public option, I support repeal of the anti-trust exemption on principle, but its repeal will lower premiums by at most 10 percent and probably more like 5 percent. But when combined with a stronger individual mandate (meaning a higher income exemption than the Senate bill's 8 percent and the House's 2.5% income tax penalty), narrowing the age rating from 3:1 (the Senate bill) to 2:1 (the House bill) will lower premiums for adults ages 55-64 -- those who have the most trouble getting health insurance on the individual insurance market -- by 20-40 percent. Which is more important?
Increasing the minimum medical loss ratio runs into the same problems as the public option and ending the anti-trust repeal -- so much political capital for so little gain -- like a 5 percent improvement in the bill.
For those who think the individual mandate when combined with the absence of the public option, ending the anti-trust exemption, and a higher minimum medical loss ratio will cause insurance companies to jack up prices, please read Sec. 1313(e)(2) of the Senate bill and Sec. 304(a)(2) of the House bill, which has a similar provision. Here is Sec. 1313(e)(2) of the Senate bill:
(2) PREMIUM CONSIDERATIONS.—The Exchange shall require health plans seeking certification as qualified health plans to submit a justification for any premium increase prior to implementation of the increase. Such plans shall prominently post such information on their websites. The Exchange may take this information, and the information and the recommendations provided to the Exchange by the State under section 2794(b)(1) of the Public Health Service Act (relating to patterns or practices of excessive or unjustified premium increases), into consideration when determining whether to make such health plan available through the Exchange. The Exchange shall take into account any excess of premium growth outside the Exchange as compared to the rate of such growth inside the Exchange, including information reported by the States.
In other words, insurance companies each year are required to show and justify their rate increases to the Exchange Board. If the Exchange Board finds these rate increases to be unjustified, and the insurance company sticks their middle finger at them, then the Exchange Board can kick the insurance company off the Exchange. So there is a failsafe provision for insurance companies jacking up their prices.
The House bill's provisions on which plans are and aren't allowed in on the Exchange are even stronger. Here's Sec. 304(a)(2) of the House bill:
(2) SOLICITING AND NEGOTIATING BIDS; CONTRACTS-
(A) BID SOLICITATION- The Commissioner shall solicit bids from QHBP offering entities for the offering of Exchange-participating health benefits plans. Such bids shall include justification for proposed premiums.
(B) BID REVIEW AND NEGOTIATION- The Commissioner shall, based upon a review of such bids including the premiums and their affordability, negotiate with such entities for the offering of such plans.
(C) DENIAL OF EXCESSIVE PREMIUMS- The Commissioner shall deny excessive premiums and premium increases.
(D) CONTRACTS- The Commissioner shall enter into contracts with such entities for the offering of such plans through the Health Insurance Exchange under terms (consistent with this title) negotiated between the Commissioner and such entities.
In other words, in the House bill, the Exchange Board can prohibit an insurance company from even going on the Exchange if the Exchange Board finds the company's rates to be unreasonable, and the insurance company doesn't remedy this. And like the Senate bill, the House bill also requires insurance companies to show and justify their rate increases each year, and allows the Exchange Board to kick the insurance company off the Exchange if the Board finds the insurance company's rate increases to be excessive, and the insurance company sticks their middle finger at the Exchange Board.
Bringing back the death panels are another negotiable item. 40 percent of a person's health care expenditures are in the last year of their life -- much of it in the last month. As Ellen Goodman ably points out, 25 percent of Medicare dollars ($500 billion/yr.) are spent in the last year of someone's life -- much of it in the last month. It could be argued the House's end-of-life care provision could bring more savings to the federal government and national health expenditures than does the public option -- even one tied to Medicare rates. This is just another item -- whether you support or oppose it, and I strongly support it -- that is not worth fighting over.
Reducing or eliminating the revenue raised through the excise tax or some other method of spending the tax subsidy for employer-provided health insurance more equitably is another negotiable item. As has been pointed out before, I don't find Sens. Lincoln, Landrieu, and Nelson's demand that the bill be financed entirely through the health care system to be unreasonable. Financing the bill entirely through the health care system is the only way to make the bill deficit neutral over the very long-run as health care experts have warned us that only health care costs rise as fast as health care costs. Millionaire income simply doesn't rise as fast as health care costs, so the millionaire tax amounts to installing a ticking time bomb of when you have to raise taxes on the middle-class to fund universal health insurance. And of course, the excise tax is significantly progressive -- certainly more progressive than a blanket health care income tax, a payroll tax, or a sales tax -- simply because those who aren't lucky enough to get their health insurance through their employer -- those who won't be affected by the excise tax -- tend to have lower incomes than those who do. So the reducing or eliminating the revenue raised from reducing the percentage of the premiums taxpayers subsidize for high-end plans is not a fight worth picking, either. The demands of Sens. Lincoln, Landrieu, and Nelson could be far, far worse. So long as they and other moderate Democrats are willing to sign onto the ambition of the Senate bill -- which is captured in the medical underwriting limits (the prohibition of pre-existing clauses, guaranteed issue underwriting, guaranteed renewability, and the adjusted community rating), the minimum benefits package, the individual mandate, the subsidies, and the creation of the Health Insurance Exchange, and possibly the employer mandate -- I'm willing to give them some latitude. Heck, I doubt there are 50 votes for the House's millionaire tax as they go into effect in 2010 and the excise tax goes into effect in 2013.
So what's worth fighting for? Well, I think the answers are pretty obvious.
Increasing the subsidies is one of the most obvious items as one of the biggest items determining this bill's long-term political fate is whether or not people are able to afford the premiums. I think it's pretty obvious that this will improve the bill vastly more than any of the items I mentioned aren't worth fighting for. The House's subsidy levels from 133-300 percent FPL are substantially better than that of the Senate. A hotel worker earning $24,000/yr. with an asmatic child (150-200 percent FPL), for example, would pay 5.5 percent of their income for a policy having 93 percent actuarial value (see below examples on cost-sharing from actuarial values) under the House bill, but pay 6.3 percent of their income for a policy having 80 percent actuarial value under the Senate bill. And of course, because every dollar counts for people with incomes this low, this is a big difference in health care expenditures for this family.
Increasing the minimum level of coverage an insurance policy is required to have and banning catastrophic policies for young people is another one of those non-negotiable items. Another major item determining the bill's long-term political fate is whether or not people can afford the cost-sharing. If people find their insurance policy to be useless, that will be a recipe for political backlash. The House's minimum actuarial value, which is the proportion of the expenditures paid by the insurance company for everyone in the plan, is 70 percent; the Senate's minimum actuarial value is 60 percent. The table below shows cost-sharing arrangements at various actuarial values on the Massachusetts Connector:
Below is a table showing what plans at given actuarial values look like on the Massachusetts Connector:
|Plan Provision||Bronze Low Tier HMO Design -- Actuarial Value: 56%||Silver Low Tier HMO Design -- Actuarial Value: 67-70%||Silver High Tier HMO Design -- Actuarial Value: 79-81%||Gold Tier HMO Design -- Actuarial Value: 93%|
|Annual Deductible (individual/family)||$2,000/$4,000||$1,000/$2,000||none||none|
|Out-of-Pocket Maximum (individual/family)||$5,000/$10,000||$2,000/$4,000||$2,000/$4,000||none|
|Routine Physical/Routine GYN Exam/Well-Child Care||$25||$20||$20||$20|
|Routine Vision Exam||$25||$20||$30||$20|
|Primary Care Visit Copay||deductible, then $25||$20||$25||$20|
|Specialty Care Visit Copay||deductible, then $25||$20||$25||$30|
|Generic Prescription Drugs||deductible, then $15||$15||$15||$15|
|Preferred Brand Name Prescription Drugs||deductible, then 50% co-insurance||$30||50% co-insurance||$30|
|Non-Preferred Brand Name Prescription Drugs||deductible, then 50% co-insurance||$50||50% co-insurance||$50|
|Inpatient Hospitalization||deductible, then 20% co-insurance||deductible, then $0||$500/admission||$150/admission|
|Diagnostic Lab||deductible, then 20% co-insurance||deductible, then $0||$0||$25|
|Diagnostic X-Ray||deductible, then 20% co-insurance||deductible, then $0||$0||$25|
|Diagnostic CT/MRI/MRA/PET Scan||deductible, then 20% co-insurance||deductible, then 20% co-insurance||$100||$75|
|Physical Therapy||deductible, then 20% co-insurance||deductible, then $0||$25||$20|
|Mental Health Outpatient Office Visits||deductible, then $25||$20||$25||$20|
|Durable Medical Equipment||deductible, then 20% co-insurance/$1,000 limit||deductible, then 20% co-insurance/$1,000 limit||20% co-insurance/$1,000 limit||20% co-insurance/$1,000 limit|
Now obviously this is not an apples-to-apples comparison as preventative care in the current bill will be free, and there are different methods for measuring acturial value. But the table does give you a rough estimate of what cost-sharing arrangements will look like under a given acturial value. Clearly, even a 70 percent actuarial value policy has significant cost-sharing. Hopefully, this figure will be increased.
Narrowing the age rating to 2:1, eliminating the smoker rating, and applying these rating rules to all insurance markets is yet another non-negotiable item. Whether health insurance is not only affordable to to the average person, but is also affordable to both your 27-year-old bachelor who plays quarterback on you office's flag football team and whether the bill is affordable to the 62-year-old widow who needs a wheelchair to get around. The Senate's 3:1 age, 1.5:1 smoker rating is a vast improvement over the status quo, but it's not clear whether it will be enough to make health insurance affordable enough for adults. The Bay State has the same rating rules as that of the House -- 2:1 age rating, and no smoker rating -- and a 93% actuarial value policy for a 64-year-old Bostonian runs for $830/mo. to $1,000/mo. on the Connector. For an empty-nester couple this age and having this zip code, a 93% actuarial value policy runs between $1,740/mo. and $2,000/mo. That's pretty expensive.
And the smoker rating simply needs to be trashed -- it's simply not going to work. Someone's geographic region, family structure, and age can easily be verified by a database. Smoking status -- not so much. Allowing insurers to vary premiums by smoking status will require a blood test for everyone on the Exchange -- including their children. That sounds like a recipe for political backlash. Also, smokers tend to live riskier lifestyles than non-smokers (i.e., They tend to be heavier drinkers than non-smokers, more reckless drivers than non-smokers, etc.). These lifestyle choices are captured in the smoker rating, so even a 17-year-old smoker will have significantly higher average claims costs than a 17-year-old non-smoker not necessarily because of the dangers of smoking but because of the risky lifestyles for which smoking status is a proxy. Penalyzing lifestyle choices through the underwriting process leads to a slippery slope. If you want to penalize certain lifestyle choices, don't do it through the medical underwriting process -- do it through sin taxes (i.e., cigarette) and reducing subsidies for consumption of goods you find unhealthy (i.e., sugar). Also, sin taxes have the ability to penalize by consumption level -- something an insurance rating does not have: you're either a smoker or a non-smoker.
The most important reason for applying the rating rules and minimum benefits packages to all markets and the self-insured, as the House bill does and the Senate bill doesn't, is interactive effects of the excise tax. Without applying the rating rules to all markets, employees in high-risk professions and organizions with older workforces could be severely adversely affected by the tax as their premiums are generally higher than the average profession. The new rating rules prohibit the varying of premiums by profession, so people in high-risk professions will see a significant discount in their premiums just from the community rating alone. The minimum benefits packages must also be included in order to prevent adverse selection by benefits and more important give employees the same minimum benefits as those in the individual and small group market.
A major problem with applying the community rating to all markets is that the self-insured, which comprises of 48-60 percent of employer-based health insurance. So long as companies with healthier employees and/or more predictible costs, those employers who self-insure will continue to bear the risk themselves, and leave employers with bigger users of health insurance in a pool with a larger percentage of big users of health insurance than if the self-insured were present. The House bill, which immediately subjects the self-insured to the community rating, has a five-year grace period until the self-insured are subject to the minimum benefit packages, and has the HHS Secretary conduct a study on how to prevent adverse selection in these markets. The Senate bill has no such provision. For the community rating and minimum benefits packages to be applied to all insurance markets, there needs to be some provision preventing adverse selection. The House has such; the Senate does not.
The "prevention and wellness" discounts are just medical underwrting, which this bill proposes to limit significantly, done by the employer rather than the insurance company. The employer is allowed to give a discount to someone who joins a gym, quits smoking, or engages in some other healthy behavior. Sounds good, right? Well, what happens when you get pregnant or have some health problems preventing you from exercising regularly? Then you face higher premiums than your healthier colleague who exercises regularly. Well, then you say these people should be allowed doctor's notes? Well, then if then a larger percentage of employees get discounts, then the others have to make up the costs with even higher premiums. So who might be the kind of person who gets penalized? The single mother who works two jobs to feed her kids, and doesn't have time to exercise. But the purpose of the bill was to ban discrimination by people's circumstances, and this "prevention and wellness" discount certainly does that -- albeit unintentionally. That's why this provision has to go: the single mother being discussed could face a 50 percent increase in her premiums if the 30 percent discount in the Senate bill is allowed.
Particularly if you are going to tighten the rating rules and increase the minimum level of coverage an insurance policy is required to have, then you have to strengthen the individual mandate as more young, healthy people -- seeing higher premiums from both more subsidation to older older adults and being required to purchase more coverage, will be exempt from the mandate, and choose to go bare. The individual mandate helps make health insurance more affordable for everyone. The more people who are in the system, the more risk is spread, and the more affordable health insurance is for everyone.
Ezra Klein best explains what would happen with a community rating (where everyone pays the same rate) without the individual mandate -- the healthiest people, who will be paying significantly more than their expected average claims cost, will choose to go bare. This will increase premiums for everyone -- as the average aggregate expected claims cost will increase without the healthiest people on the plan. Then the next healthiest group of people -- seeing insurance as a bad investment for them with their increased premiums -- will choose to go bare, again increasing the average aggregate expected claims costs for everyone. This trend of the healthiest people dropping out will continue -- eventually pricing the sickest people out of the market because they will have to pay premiums much closer to their average claims costs.
The individual mandate is another non-negotiable item in the House bill. is also about making health insurance more affordable for everyone. The more people who are in the system, the more risk is spread, and the more affordable health insurance is for everyone. In this bill, the cyclist and the diabetic of the same region, family structure, age, and possibly smoking status pay the same rate for the same policy. The mother of the child born with heart problems pays the same rate for the same policy as the divorced father whose son set the school record for fastest mile time. The marathon runner pays the same rate for the same policy as the guy who needs to down a six-pack of beer every night to fall asleep. In addition, the bachelor, the post-menopause woman, and the sterilized couple are all required to purchase maternity care. The Mormon is required to purchase alcoholism treatment. The triathlete is required to purchase durable medical equipment. That is the magic of this bill. There needs to be something to prevent healthy people from going bare until the get sick so health insurance is affordable for the diabetic child, the person in the powered wheelchair, the person with cancer, etc. The individual mandate is that vehicle.
With the higher minimum actuarial value and the tighter insurance rating rules, insurance premiums will increase for younger people. With the Senate's 8 percent income exemption, many will become exempt from the mandate, choose to go bare, and this will increase premiums for everyone else. This is probably why Harry Reid had to set his minimum actuarial value at 60 percent and couldn't get his age rating tighter than 3:1 -- if he did, then too many young, healthy people would have been exempt from the mandate, and the bill would have been too cost-ineffective. So if you increase the minimum actuarial value and tighter the rating rules, you're going to have to increase the percentage of a person's income someone will have to pay for premiums before becoming exempt from the individual mandate -- somewhere around 14-15 percent.
One of the most important policies in this bill is the Exchange. Having the strongest Exchange with the strongest bargaining power is absolutely essential. A federal Exchange with the ability not to approve of plans that don't have justifiable premiums is very important. As noted above, the House is much better in this provision than the Senate.
As has been said many times, insurance is not like going to the widget store to purchase a bunch of widgets. In the widget business, expenses are relatively predictable for the widget company. Not so much for insurance as average claims costs are highly unpredictable. As Wendell Potter explains, 10 percent of the population accounts for 62 percent of health care expenditures. Which is why insurance companies spend so much time trying to weed out bad risks: they know very well it's the difference between being financially viable and not being financially viable. One of the main purposes of this bill is to make buying insurance more like buying a widget -- insurers will compete on their prices and the quality of their services rather than which people they select. The next non-negotiables pertain to this.
The idea of having the OPM-administered sub-Exchange -- as the Senate bill does -- seems like something having a similar effect as allowing insurers to operate across state lines. If there are two health care systems, and one has a stricter standard than the other system, then a much greater percentage of people with low average claims costs will flock to the system with the most lax rules while those who are older and sicker will be left to a pool themselves. The OPM-administered sub-Exchange could be that dumping ground for sick people. My fears, unfortunately have been confirmed by health industry expert Bob Laszewski.
In order to prevent adverse selection -- meaning the people with low average claims costs migrate one way, and leave the big users of health insurance in a pool to themselves, making health insurance unaffordable to the big users -- all non-group insurance policies must be required to be sold inside the Exchange. The House bill prohibits non-group policies from being offered outside the Exchange; the Senate bill allows non-group policies to be sold outside the Exchange. The House must prevail on this provision.
Another non-negotiable item from the House bill is its prohibition of insurance companies offering services outside of those on the minimum benefits package. One of the ways insurance companies like to select the best risks is on the benefits they offer. Having ample dental and eye coverage -- two items very attractive to people with low average claims costs -- but skimping on mental health and durable medical equipment -- two items not so attractive to healthy people and generally used by people with high average claims costs -- is one such example. Both the House and Senate bills require items such as mental health, durable medical equipment, and other items attractive to people with high average claims costs to be covered in an insurance policy. By limiting the plans on the Exchange to cover only the items in the minimum benefits package, insurance companies are limited in their ability to cherry-pick non-users off the benefits they offer. The House bill -- except on the Premium Plus Tier, where people will have to buy an insurance policy having a minimum 95% actuarial value policy of the required services before buying discounted gym membership, dental and eye care -- does this (and insurance companies who offer on the Premium Plus tier have to offer on all Tiers). The Senate bill allows on all tiers insurers to offer items more attractive to young and healthy people -- i.e., discounted gym membership, eye care, and dental care -- once the minimum services have met the minimum actuarial value of the plan's tier. So in the Senate bill, a 27-year-old bachelor could buy a policy on the Bronze tier actuarially equivalent of plans on the Silver or Gold tier just because the gym membership, dental plans, eye care and other benefits could add 20% to the actuarial value, and such a plan still could be considerably cheaper than a Silver or a Gold Tier plan simply because the plans on the Bronze Tier have a much younger, healthier risk pool. This is problematic.
Such a bill should also prohibit insurance companies from significantly varying cost-sharing for a specific benefit category. Again, insurance companies can cherry-pick the non-users by having lower cost-sharing for those services used by people with low average claims costs, and having higher cost-sharing for benefits used by people with high average claims costs. The House bill limits variation in cost sharing for a given benefit category to plus or minus 10 percent for this reason. The Senate has the HHS Secretary determine the allowable variance in cost-sharing by actuarial value. This absolutely must be done right.
Another way insurance companies like to cherry-pick healthy people is by giving those with high average claims costs a difficult time on getting their reimbursements. You must place time limits on the ability of insurance companies to give people with average high claims costs a difficult time. Both bills have "reasonable" time limits on claims processing, but the House's provisions seem less ambiguous than the Senate's bill.
This section entertains possible compromises that could occur between the House and the Senate. Because health insurance is not like, say, economic stimulus, and has such huge interactive effects, it's important that you not just split the difference, and call it a day. Otherwise, you'll have half a bridge instead of half a loaf. You have to take into account how a provision affects other provisions in the bill. If, for example, you tighten the insurance rating rules and/or increase the minimum level of coverage an insurance policy must have to be sold, then you have to see how that will affect how many young, healthy people will now be exempt from the mandate, choose to go bare, and make health insurance less affordable for the big users of health insurance. So it's best that you not just split the difference, but say, "The House should get provision(s) X if the Senate gets provision(s) Y."
On the excise tax, a possible compromise would be that the Senate gets its excise tax, but the House gets its insurance rating rules (2:1 age, no smoker rating, no "prevention and wellness" discount), which that and the minimum benefits packages are applied to all markets -- including the self-insured. In addition, because the tighter rating rules mean higher premiums for younger adults, and more young adults qualify for the 8 percent income exemption on the individual mandate, the House should also get its version of the individual mandate -- merely a hardship exemption, and a 2.5 percent penalty -- so some of the benefits to older adults aren't blunted by too many young people deciding to go bare.
On the public option, a good compromise would be the Senate gets its way on the public option, but the House gets its federal Exchange, "prudent purchaser language," prohibition of plans being allowed to be sold outside the Exchange, and its prohibition of allowing benefits outside of the minimum benefits package to be offered on the basic, enhanced, and premium tiers, its limitations on claims processing times, and its employer mandate.
On the anti-trust exemption and the medical loss ratio, the Senate should get its version of the two, but the House should get its subsidy levels for 100-300 percent FPL, and its 70 percent minimum actuarial value.
So there are some potential compromises. Sure there are some disappointments and huge ones, but that's to be expected when the stakes are as high as they are in this bill. But this bill never was about "sticking it to the man." It was always about what happens to the uninsured secretary when she wakes up one morning and notices a lump on her breast. It was always about about whether an uninsured hotel worker can afford the $20,000 heart surgery for his daughter. It was always about whether or not the waitress can currently afford her $8,000 deductible policy when her 15-year-old son is in the hospital after having a blackout in class. It was always about addressing serious problems with serious consequences. We are in short talking about the difference between life and death for many people. The Institute of Medicine estimates that from 2000-2006, 137,000 Americans died because of lack of health insurance. A lot of people will die unnecessarily if this bill is not passed. That is not something I'm willing to allow happen very easily.
The bill may merely be a starter home, but it's a lot easier to paint a room than to rebuild its foundation. Similarly, it's a lot easier to increase the subsidies, narrow the age rating, increase the minimum actuarial value, improve the employer mandate, or establish a public option once you've got subsidies, an adjusted community rating, a strong individual mandate, a minimum benefits package, and an Exchange in place. Even better, some of those items -- increasing the subsides and improving the employer mandate, or enacting a public option -- can be passed through the budget reconcilliation process.
In short, the reason this bill is so good is because our current system is so bad. Too many Americans desperate for help with only their government to turn to have waited far too long for justice and relief, and this bill provides a large number of these people with that help.
Under the even Senate bill, the federal government will for the first time take responsibility for providing health insurance to Americans other than the elderly and the indigent. 31 million Americans will gain health insurance. Tens of thousands of lives will be saved. Tens of thousands of medical bankruptcies will be averted. That's nothing to feel bad about.
This may not be perfect, but it is our time's calling. History will not be kind to us if we do not pass this bill. We are on the brink of succeeding where Presidents over the last 60 years have failed. So maybe we can't get everything we want, but we can say we met our time's moral challenge to bend the moral arc of the universe a little bit more towards justice.
Recommended reading: slinkerwink has a good diary today on the advantages of having a federal Exchange.