Heading into the midterm elections, the level of vitriol and energy on the right continues to rise while those and the left feel demoralized, betrayed, and dispirited despite numerous legislative accomplishments by the Democratic Congress and President Obama.
Chief among those disappointments is the lack of single payer plan, or at the very least - a public option within the plan to allow people to avoid having to choose exclusively from health insurance agencies motivated entirely by profit, not patient satisfaction.
What many of us apparently don't know is the final version of the PPACA as passed actually does include something that functions as a public option, and in some ways may even be slightly better as scored by the CBO.
Here's one recent diary which wistfully pines for better non-profit options.
Where we should be talking about the future reforms we need - i.e., opening up Medicare to more Americans on an opt-in basis, creating a more powerful nonprofit option (whether it's negotiated on Medicare rates or not, putting patients ahead of profits), and reining in insurance company abuses and rate increases - instead, we're too busy attacking and ceding political turf to the Republicans, who did NOTHING to support reform and even lied about it to scare voters.My point here is this nonprofit option already exists.
The final Health Care bill included the "Non-For-Profit Option" as overseen by the Office of Personnel Management which scored just as well as the Public Option for Budget Reduction and Cost Savings according to CBO - so for those who desired downward pressure on costs, that's exactly what we have.
The Original Kennedy-Dodd Senate Bill did not include a Public Option and Scored at about $1 Trillion, but after the PO it was re-scored at $389 billion cheaper initially - but also that it's long term projection of over ten years would have increased the deficit by over half a billion
Indeed, according to CBO's July 2 score of the HELP bill, under the legislation, 21 million fewer Americans would be uninsured in 2019 than under current law. In a July 1 letter to members of the HELP committee, publicly released the following day, Kennedy and Dodd wrote that the "Congressional Budget Office has carefully reviewed our complete bill, and we are pleased to report that the CBO has scored it at $611.4 billion over 10 years, with the new coverage provisions scored at $597 billion" -- a cost they noted was a "significant reduction from earlier estimates." The preliminary score of the complete bill that the committee released stated that Title I of the bill would increase the deficit by $597 billion over 10 years.
See that? The Kennedy Bill with the PO included increased the deficit.
The final bill came in with a higher initial costs due to increased subsidies for low income insurance seekers, but long term deficit reductions were an almost $1.5 Trillion improvement over 20 years.
Comprehensive health care reform will cost the federal government $940 billion over a ten-year period, but will increase revenue and cut other costs by a greater amount, leading to a reduction of $138 billion in the federal deficit over the same period, according to an analysis by the Congressional Budget Office, a Democratic source tells HuffPost. It will cut the deficit by $1.2 trillion over the second ten year period.
The source said it also extends Medicare's solvency by at least nine years and reduces the rate of its growth by 1.4 percent, while closing the doughnut hole for seniors, meaning there will no longer be a gap in coverage of medication. The CBO also estimated it would extend coverage to 32 million additional people.
The Public Option was removed during negotiations with Sen. Joe Leiberman in the "Manager's Amendment". That amendment was scored by CBO here, where it showed that this option saves just as much of a cost savings as the Public Option did, in fact it came out $2 billion cheaper.
This estimate incorporates the effects of the manager’s amendment, which would make a number of changes to the Patient Protection and Affordable Care Act as originally proposed. The changes with the largest budgetary effects include: expanding eligibility for a small business tax credit; increasing penalties on certain uninsured people; replacing a "public plan" that would be run by the Department of Health and Human Services (HHS) with "multi-state" plans that would be offered under contract with the Office of Personnel Management (OPM); deleting provisions that would increase payment rates for physicians under Medicare; and increasing the payroll tax on higher-income individuals and families. Of the total deficit reduction of $132 billion projected to result from the legislation, the manager’s amendment accounts for about $2 billion, and the act as originally proposed accounts for the remaining $130 billion.
The proposal would call on OPM to contract for two national or multi-state health insurance plans—one of which would have to be nonprofit—that would be offered through the insurance exchanges.
Considering the intensity of the opposition against the public option, the Stealth Option was able to slip in under the wire without being noticed by the press, and largely without being noticed by the legislators themselves. As a result they haven't been able to respond back to their own constituents on the Left who loudly complain that they caved when the rubber met the road.
One of the few Democrats I've even seen bring this provision up was Sen. Mary Landrieu (at 11:58) as she was being attacked and criticized by Howard Dean. (Some of Dean's long list of criticisms here especially the ability to charge older people at 300% higher rate was removed, along with the "Louisiana Purchase" and "Cornhusker Kick-back" via Reconciliation after the House passed the Senate version of the bill with the Manager's Amendment)
Landrieu: In the Bill that the Governor now says he's not for, there is a national non-profit option that gives the same choices that members of Congress and Federal Employees have...
In all the twists and turns of the legislation - this point was completely lost. We have something that is just as good as what most of us wanted, and maybe having it going through in the background was best, because otherwise if it had gotten more focus and more press - just like Single Payer or the PO - it might have been stripped out too, but it wasn't. It slipped in under the radar, but now we need to drag out into the light.
Other issues criticizing the bill, which I've seen are arguments that it doesn't contain "cost controls" - this has especially been brought up by NYCEVE. in What happened to the promise to "control skyrocketing premiums"?!
However, the PPACA does have cost controls, it requires an 85% Medical Loss Ratio, which means that at least 85% of the money paid in as part of premiums has to go to actual care, not advertising, not overhead, not stock value.
NYCeve's next major complaint is that their aren't any limits on deductibles in "junk insurance" - but there will be for people buying employer based insurance outside of the Exchange through their employer.
(2) ANNUAL LIMITATION ON DEDUCTIBLES FOR EMPLOYER SPONSORED PLANS.—
(A) IN GENERAL.—In the case of a health plan offered
in the small group market, the deductible under the plan shall not exceed—
(i) $2,000 in the case of a plan covering a single
(ii) $4,000 in the case of any other plan.
The amounts under clauses (i) and (ii) may be increased by the maximum amount of reimbursement which is reasonably available to a participant under a flexible spending arrangement described in section 106(c)(2) of the Internal Revenue Code of 1986 (determined without regard to any salary reduction arrangement).
Prior to the actual implementation of the full plan in 2014, it's not that surprising that some insurers would try to price gouge before they get hit with the ban on life time limits, the 85% medical loss ratio, and the limit on out-of-pocket cost, however they do so at their own risk of being punished for it because there are penalties for Insurers who issue exorbitant rate hikes.
The law allows states that have, or plan to implement, measures that require insurance companies to justify their premium increases to be eligible for $250 million in new grants. Insurance companies with excessive or unjustified premium increases may not be able to participate in the new health insurance Exchanges in 2014.
If the companies try to jack up prices now before the Exchanges come online, as some appear to be doing - although these may be outliers according to the Kaiser Report which says that overall 2010 insurance rates have only increased between 3%-5% - they either have to justify it or not get any access to the new customers available in the exchanges.
Lastly on this point, if an insurer takes the risk of gouging anyway though the exchange, they can be forced to pay back their customers via rebates.
From the CBO
Several provisions regulating insurers were added, including a requirement for an insurer to provide rebates if its share of premiums going to administrative costs exceeds specified levels and a general prohibition on imposing annual limits on the amount of benefits that would be covered.
If insurers charge more than the 85% limit they have to GIVE THE DIFFERENCE BACK as a rebate. That would be what's called a Price Control.
Nyceve's issue with the junk insurance would not apply to the insurance offered through the Exchanges in 2014 which require that preventative care be offered for free (not with a high deductible), and that a fairly comprehensive minimum set of coverage - for the bronze plans - which haven't even been established by the Secretary of HHS yet be made available at a reasonably affordable price, with subsidies available for those who still can't afford them.Beyond Health Care the second major criticism of the Obama Administration has been their failure to address the War Crimes of the previous Administration and their overall handing of the "Rule of Law".
The problem isn't just with the Administration, it's with the Law itself and Congress failure to correct that law, although the SCOTUS has been gradually correcting much of this on their own.
After losing the Hamdan case the Bush Administration pushed through the Military Commissions Act which stripped Foreign Enemy Combatants of Habaeus protection, some of which was restored by Boumediene in regards to Gitmo, but as yet has not been restored for Bagram A.F.B. which is were the current detention sore festers. Thus Far the Courts have ruled against Bagram Habeas petitions in accordance with the MCA, but this issue has yet to reach SCOTUS.
On two levels, both via executive order and via both Hamdan & Boumediene at the SCOTUS Habeaus has been restored for Enemy Combatants - but not yet for those held in Bagram, and that is where Congress needs to act.
Don't like Warrantless Searches? Congress essentially Ratified them with the FISA Fix, so Congress needs to "Unfix" it. Unlike the Bush Administration, the Obama Administration's Justice Dept has been implementing the law as written even if it's a lousy law. The problem is the law itself, not the Administration who has pledged to uphold the law - even when that law sucks.
The investigation of Torture & Bush War Crimes has been handed off to a Special Prosecutor, and although there is no guarantee exactly what that prosecutor will do, or how far they will or won't take the case - it is clearly NOT fair to argue that the Administration has ignored the issue, they've done what they should have done which is let a prosecutor handle this outside of the political process, but under the law. The problem is with the law itself, specifically the MCA which effectively immunized many of these activities retroactively by re-writing the War Crimes Act to match the Bybee Standard (Torture equals Likely Death Only) during the lame-duck session of 2006 right after the Hamdan decision came down. Obama wasn't even in the Senate when that happened.
Admittedly Obama hasn't addressed this since campaigning but he has made it known that he realizes the MCA needs to be repealed and Habeaus restored, the Detainee Treatment Act needs an update to include civilians under Geneva and the AFM, the War Crimes Act needs an update which includes providing legal advice designed to deliberately circumvent the law, and Obama needs to get both Gitmo and Bagram closed down - but those are all works in progress (many of which were delayed by Health Care, The Stimulus and Financial Reform) as the Iraq and Afghanistan Wars wind down, not failures. Not yet.
Even though Bush is gone, he left behind a pile of bad laws that Congress needs to fix, not just Obama - and as a result we need the best possible Congress we can get if we're going to have any hope at all of addressing all of these continuing issues.
Right now Barbara Boxer is in Trouble. Russ Feingold - the only U.S. Senator to vote against the original Patriot Act - is threatened. We may have our issues with Blue Dogs like Mary Landrieu, but we can't let that frustration be taken out actual progressives like Boxer or Feingold. They need our help, and they need it NOW!
The facts are on our side, we don't have to feel bad or down about anything. This legislation is far from perfect and still has many fixes and changes need, but we're not likely to get any of that done with even fewer Democrats in Congress than we currently have. It's not time to give up, give in, or sit at home grumbling - it's time to Grab a Mop, double-down - and to ActBlue.
We all may our issues with how things went down, but one thing we can't do is let the Know Less-Than-Nothing Party steal the day and benefit from their own strategy of obstruction and obfuscation. We have to keep Congress in Democratic hands, at all costs.
Update Thanks for the Rescue: to save time let me quickly recap some of discussion that's occurred so far in the comments. Besides what I mention above there are several immediate or nearly immediate benefits of the PPACA that often goes under discussed amid all the teeth-gnashing over the public option/single-payer failure.
To address the problem of people not having access to health care due to pre-existing conditions until the Exchanges come online and ban them in 2014 - 34 States have implemented High-Risk Insurance Pools.
To address the problem of increasing premiums in the employer insurance market in the short term, there are Employer Tax Credits of up to 35% available to companies with 25 Employees or less, effective Jan 1, 2010. This could completely nullify premium rate hikes which seem to have been occurring as Nyceye describes.
In California alone over 400,000 Business are eligible for this credit.
Garnering little to no press attention when released in July, a report undertaken by Families USA and the Small Business Majority found that 80 percent of California’s small businesses with 25 or fewer employees will qualify for federal tax credits under the Patient Protection and Affordable Care Act starting this year. This means that of the state’s 571,200 small businesses, 465,500 are eligible for the tax credits in 2010. Of those, 30 percent – or 135,900 – qualify for the maximum tax credit amount.
Substantial funds have provided for the expansion of Medicaid for those who can not currently afford to buy care on the open market.
Effective April 1, 2010
States will be able to receive federal matching funds for covering some additional low-income individuals and families under Medicaid for whom federal funds were not previously available. This will make it easier for states that choose to do so to cover more of their residents.
Preventative Care as of September 23rd must be provided without co-pays or deductibles.
Effective for health plan years beginning on or after September 23, 2010
All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance.
The Non-Profit Option actually has another potential advantage over the Public Option because the Director of OPM has independent authority to negotiate their Medical Loss Ratio, Premiums and Profit Margin separate from the 85% MLR currently setup in the Exchanges.
SEC 1332 (3) NON-PROFIT ENTITIES.—In entering into contracts under paragraph (1), the Director shall ensure that at least one contract is entered into with a non-profit entity.
(4) ADMINISTRATION.—The Director shall implement this subsection in a manner similar to the manner in which the Director implements the contracting provisions with respect to carriers under the Federal employees health benefit program under chapter 89 of title 5, United States Code, including
(through negotiating with each multi-state plan)—
(A) a medical loss ratio;
(B) a profit margin;
(C) the premiums to be charged; and
(D) such other terms and conditions of coverage as are
in the interests of enrollees in such plans.
(5) AUTHORITY TO PROTECT CONSUMERS.—The Director may prohibit the offering of any multi-State health plan that does not meet the terms and conditions defined by the Director with respect to the elements described in subparagraphs (A)
through (D) of paragraph (4).
(b) ELIGIBILITY.—A health insurance issuer shall be eligible to enter into a contract under subsection (a)(1) if such issuer—
(1) agrees to offer a multi-State qualified health plan that meets the requirements of subsection (c) in each Exchange in each State;
It's fair to say than an MLR much higher than 85% could be negotiated, and that by requiring this contract to be established only for mult-state entities (just like the Holy "Purchase Care Across State-Lines" Grail that the GOP was clamoring for) better bulk pricing should be possible due to the larger economy of scale that the Federal Employee's Health Benefits Program, already administered by OPM, currently enjoys.
That potential price break wouldn't have been available to a public option that was being run and administered state by state.
All of these features are not going to completely pacify anyone who continues to want out-and-out Single Payer. There are two paths to achieving this, one is to raise of eliminate the means testing on Medicaid (in 2014 this actually happens and the eligibility restrictions are loosened), the other is to eliminate or lower the age requirement for Medicare and allow people to purchase it if they want (an option that was briefly considered as a compromise in the Senate, but not adpted.).
If we're going to continue to fight for something closer to full-on single payer, I think we should do it by continuing to close the gap between Medicaid and Medicare bit by bit which this bill at least partially does for those people who need it most. There's a lot of good stuff in this bill, and between now and 2014 we need to be fighting to make it even better - not let ourselves get rolled by the GOP.