Healthcare Reform Thread

[Drake Tungsten]

Centrist Dems unite to fight left on health

The House's two most conservative caucuses, the Blue Dogs and New Democrats, are banding together to come up with shared principles on healthcare and counter a process many see skewing to the left.

The two groups, which combined have 131 members — more than half the House Democratic Caucus — have been holding meetings to see where they can agree on a healthcare plan.

"We're looking at things like what the structure of a public plan would look like," said Rep. Ron Kind (D-Wis.).

Democratic leaders have taken note. Kind said House Speaker Nancy Pelosi (D-Calif.) called a meeting with New Democrats and Blue Dogs in her office Wednesday to discuss healthcare. The results of that meeting were not known at press time.

There is concern among centrists in the caucus that the draft bill, to be released Friday, will reflect some of the more liberal ideas in the caucus, although leadership has already rejected the idea of a single-payer system. It is being put together by the House Education and Labor, Energy and Commerce and Ways and Means committees.

"You have a bunch of crazy liberal chairs and their crazy liberal staffers, and they want to lay down a marker," said a senior Democratic aide.

The two caucuses have already put out separate written principles on healthcare that are similar, expressing reservations about a public option and opposing a "Medicare-like" system.

Where they differ is on the Blue Dogs' demand that the public option should be a last resort, kicking in only if reforms fail to achieve cost savings and there isn't enough competition. New Democrats have made no such request.

"Their principles mirror ours, except for the trigger," said an aide to a Blue Dog member active in the health debate.

Both groups say they're concerned about a public plan, and specifically don't want it to look like Medicare, which is exactly what the Congressional Progressive Caucus and the Congressional Black Caucus are pushing for.

Both sets of principles are geared toward making sure any public plan won't gain a competitive advantage over private insurance plans.

The 69-member Progressive Caucus threatened that its members will vote against healthcare legislation if it doesn't have a "robust public plan."

http://thehill.com/leading-the-news/centrist-dems-make-voices-heard-on-healthcare-2009-06-17.html

[Ramo]

1. Thanks for the response.

2. Wow, a lot of that was gibberish to me. I think I'm a bit behind in this. Next time I have a few hours I want to kill, I know how to kill them.

-Arrian

Sorry, I'd meant to concisely differentiate Daschle/Dole/Baker from the [more] plausible alternatives. I covered some of this lingo before, but I forgot that it is spread over a large number of posts. Anyways, here's an attempt at a summary:

Due to a set of historical decisions in WWII and its aftermath (the employer tax deduction and the failure to pass single payer legislation), we have a system largely built on employer-based insurance. When Clinton decided to re-engineer health care, as we all know, he created a monstrously complicated piece of legislation that was disastrously sold. A key argument against his plan would be that it could disrupt the lives and doctor-patient relationships of large numbers of people. When designing new legislation, health wonks figured that the new system would have to allow people who are satisfied to keep their coverage. So building upon the current employer-based system became a political necessity, regardless of everything else reform would do.

There are some people who disagree with this attitude. McCain, infamously, proposed to replace employer tax deduction with a pittance (a flat $2k tax credit). Wyden-Bennett is an interesting (and genuinely bipartisan!) piece of legislation, but is going nowhere for reasons I don't fully realize; there's a good argument to say that it's better than the proposals on the table (because it seriously tackles cost control).

But we're not going that way. So, starting with the current employer based system, you have a set of gaping holes:
1. Small businesses can't create sufficiently large risk pools to qualify for affordable health insurance. And it's even worse for the self-employed, who lose out on the employer tax deduction.
2. The safety net for adults under 65 is basically non-existent, and the safety net for kids could be a hell of a lot better.
3. Health care inflation is astonishingly high (IIRC, with a 6% annualized growth rate). This threatens to undermine everything, including the federal government's ability to pay for Medicare/Medicaid.

Health care is currently under two committee jurisdictions in the Senate. HELP is chaired by Ted Kennedy, and its Dem members are mostly in the left wing of the caucus. Finance is chaired by Max Baucus, and its Dem members are in the right wing of the caucus (but further to the right than HELP is to the left). Because the legislation affects entitlements (Medicare and Medicaid), Finance has the stronger claim (it's not entirely clear to me why HELP has any claim). The House is taking a unified approach, and is lead by Henry Waxman - a very solid progressive. And of course, there's Obama's bully pulpit (which will be important during House-Senate reconciliation).

During the primaries, Edwards released a plan that the Democratic Party largely adopted. The central points are:
a. You can opt into what's called a health insurance exchange. The idea is that you enter into a very large risk pool, and have your choice of health care insurers. To deal with any selection biases that segregate this pool, you have to mandate a certain class of employers to insure their employees or pay into the system, mandate individuals to enter the system, and heavily regulate the private insurers. The key parts to this regulation would be prohibit discrimination based on pre-existing conditions, and impose a limited range in which insurers can vary premium costs. You can also use this exchange to impose other reforms, such as a standardized adminstrative procedure. This is the centerpiece of health care reform, even if no one ever talks about it.
b. You drastically expand coverage. Full coverage through Medicaid would apply to some multiple of the federal poverty level, and subsidies (for your choice of insurer) would gradually decline up to some cutoff. If Dino or anyone else who ought to be is paying attention, this is the cost sink.
c. Because this costs money (upwards of $100 billion/year), you have a set of revenue sources and spending cuts. The key cuts would be in Medicare/Medicaid (i.e. fixing the Bush prescription drug boondoggle, among other things). An interesting idea that folks have been throwing around is to deal with Medicare like the military base closing institution, BRAC. The problem with eliminating wasteful procedures is that some Congressional power broker will complain, and reverse it. So instead you present a set of recommendations which Congress can approve on an up or down vote as a whole. The main sources of funding would be the employer mandate (if an employer doesn't provide insurance, it funds some portion of this person's premium in the exchange) and capping the employer tax deduction (which has a very regressive effect).
d. To impose long-term cost discipline, ideally you'd like a public option. And any option with a modicum of political support would be funded by premiums, not tax dollars. Just to be clear. Peer reviewed studies suggest that you can cut 20-30% by using a quasi-monopoly scale to bargain with medical providers. This is the "strong" public option that we've been referring to in this thread.

All of the players agree with the exchange, which is good news.

Medicaid expansion is obviously contentious, given its pricetag. For the House and HELP full coverage is 150% of the federal poverty level (IIRC). For Finance, it's 100%. The cutoff for the House is 400%, for HELP is 500%, and Finance is 300% (this is a mild surprise, since everyone expected the House to be to the left of HELP). For kids and certain other classes of individuals, these multipliers are higher. I don't know where Daschle stands, but reporting I've read puts it somewhere to the right of HELP. I don't think Obama has put out any specifics here. I'd like to see us end up with a more generous, HELP-like, safety net.

Financing the bill is going to be complicated. Most of this is still up in the air. As I said, the cuts in Medicare that Daschle et al. were talking about is twice as high as the figure that Obama has mentioned, so I'm dubious about its practicality. It's reasonable to assume that the House and HELP will be tougher with the employer mandate than Finance. And because there aren't a lot of extra pots of money (a set of other options have been shot down), we're probably going to see a cap on the employer deduction, even though Obama is rather lukewarm about it. I'm pretty unattached about funding, as long as it is funded. As I said earlier, the less we have to rely on Medicare cuts, the better our fiscal outlook will be.

And of course, the most open issue of contention is the public option. Finance has come out in favor of providing the starting capital for health insurance cooperatives, while having fewer costs than the private market, wouldn't have the bargaining ability of a single payer. Daschle proposes state-based public options (again, small risk pools, low bargaining ability). If a set of metrics regarding cost control and coverage aren't met, a national public option kicks in after some time period. I'd prefer that to co-ops, but obviously not ideal. HELP is still negotiating its position, but hopefully it will come down on the side of a strong option. I don't remember if the House put out anything definitively, but they're pretty much guaranteed to have a strong option. And Obama is for the strong option.

I hope that was helpful. We'll have a much better idea what the specifics will be in a few weeks.

[Ramo]

An update from the House:

There appears to be a strong public option.

They also open up the possibility of other funding sources, namely a 1.5% VAT. The reason why they're considering that route is that a relatively limited funding (on the order of a $ trillion over ten years) can actually be found in the health care system. The dilemma is that route would make it a lot harder to sell the plan to the public. In general, though, a VAT is probably not a bad idea. I don't mind a slightly flatter tax distribution if the welfare state becomes a lot more robust. That's the tradeoff that much of the rest of world has made, and those models appear to be superior.

[Ben Kenobi]

But Canada still does have universal, free health care which costs the Canadian taxpayers far, far less than Americans in total pay for their health care. Canadians also have a longer lifespan and a smaller infant mortality rate [as do the citizens of EVERY country which has single payer

.

The problem is that they shut down private clinics. The only other options are to go to the US and pay for timely care.

The only reason the system survives up here is because of the US private option. Take that away with Obamacare, and the overseas clinics will boom.

[Ramo]

Ben. Can you explain how "Obamacare" would lead to the shut down of "private clinics?"

[Drake Tungsten]

http://www.washingtonpost.com/wp-dyn/content/article/2009/06/19/AR2009061902334.html

http://beltwayblips.dailyradar.com/video/sen_russ_feingold_d_wi_ultimate_goal_of_health_reform/

Feingold

[Ramo]

Do you believe that every clinic in Canada is publicly run?

[Ramo]

Hint: there's a world of difference between single payer health care models (i.e., Medicare, Canada) and where the government directly adminsters health care/"socialized medicine" (Veterans Administration, UK). This debate would be less ****ed if right wingers were willing to concern themselves with things like "details."

[Drake Tungsten]

Are you talking to me or Ben? It seems like me, but that would be stupid as I didn't say anything about Canada...

[Ramo]

Depends on whether your post was totally random, or a response to mine. It sure looks like you were responding to me (and introduced a common right wing fallacy).

The relevance here is that Canada has a single payer system, administered largely by the private sector.

[Drake Tungsten]

How could you interpret Russ Feingold and George Will talking honestly about the real purpose of including a strong public option in an American healthcare reform bill as a response to you and Ben arguing about the Canadian healthcare system?

[Ramo]

I obviously wasn't arguing about the Canadian system. See the post directly above yours.

But I suppose you have your plausible deniability.

[Drake Tungsten]

I haven't really been paying attention to your posts in this thread since you decided to abandon any pretense of ingenuousness. You could learn a thing or two from Feingold.

[Ramo]

I think I've repeated that I want to see a single payer for primary care a few times, in this thread alone. It's a nice way to introduce long term cost control.

I see that you're still unable to back up your bald assertion about Kennedy backing a tax payer funded public option.

[notyoueither]

The relevance here is that Canada has a single payer system, administered largely by the private sector.

Nope.

At any rate, I strongly suggest that Americans not compare to Canada, and that Canadians do not compare to the US. We are each others' bogeymen, to be trotted out to scare the hell out of people whenever the subject of change is brought up.