• 2010 Early Deliverables:  New high-risk pool; some immediate consumer protections and insurance reforms; premium rate disclosures and oversight;
• Major Coverage Reforms in 2013 or 2014:  Health Insurance Exchanges create marketplace for insurance under new reforms that prohibit denial or pricing based on health status; premium assistance and out-of-pocket caps, Medicaid expansion for poorest; individual and employer responsibility with exemptions for small firms and financial hardship; 
• Improved Medicare coverage for prescription drugs and preventive care
• Both bills fully paid for through budget savings and revenue increases:  both reduce federal deficit by more than $100 billion in the first 10 years, and continue to reduce it in the second decade.

Key Differences to Negotiate:

• Financing:  House progressive income taxes versus Senate excise taxes on high-cost health benefits.
• Affordability: House much better for low-income premiums and all incomes on cost-share and benefits; Senate premiums better for moderate-income.  Obvious solution = best of both bills, but where will the money come from?
• Exchanges and Insurance Regulation:  House bill tighter oversight, more consumer-friendly regulation of the insurance industry, Health Insurance Exchange greater negotiation power.
• Abortion:  Both bills prohibit direct federal support or subsidy for abortion coverage.  Issue is whether Exchanges can sell coverage that includes abortion as an “add-on” paid for by the consumer.
• Public Option:  House has a moderately weak model and Senate has none, though would have OPM contract with insurers to offer minimum of 2 plans that meet “qualified health plan” standards and at least one of these must be non-profit.
• Employer Responsibility:  House includes a “pay or play” provision, Senate charges employers penalties only if their employees actually access subsidized coverage.
• Undocumented immigrants:  Senate bill prohibits undocumented from buying insurance through the exchange, even with their own funds.  House does not and Congressional Hispanic Caucus opposes Senate language.
• Closing the Medicare Part D “doughnut hole”:  How to pay for this is the issue.

For more on the differences, see the Community Catalyst blog and the House Tri-Committee staff comparison of key differences

I find that claim astonishing and assume that people making it must have pretty good health security with good coverage today and little fear that they’ll lose that coverage if they get sick or lose/change their job.  Clearly, the health reform bills are not perfect, and the Senate bill in particular has much room for improvement.  We support a public option and are disappointed that the Senate is unlikely to pass one, but have always held that the public option is not more important than guaranteeing access to affordable, comprehensive coverage for all.  It’s possible to accomplish the latter without the former, as Uwe Reinhardt points out, other countries have done.

As others have pointed out, even the flawed health reform bills on the table will provide the most meaningful social justice reforms for low- and moderate-income Americans in 40 years. Here’s the big picture:  a progressively financed system of comprehensive care that is accessible not only through a job and is affordable at every income level will enable many more families in poverty to attain middle-class income and assets.  Unlike food, shelter, transportation, and education, the cost of needed health care varies wildly across otherwise similarly situated families.  A family with serious chronic condition, illness or injury may need hundreds of thousands of dollars in care in a year, while one with routine preventive and primary care needs may need relatively little.

There are no shortage of provisions in national health reform that will greatly benefit Texans and that we could not pass on a state level anytime in the foreseeable future, including a prohibition on discrimination based on pre-existing conditions and expanding Medicaid to all people living in poverty, just to name two.

Nothing that emerges from a legislative process is ever perfect, and the Senate process in particular moderates legislation and forces compromises.  But moving forward in the Senate is the best alternative.  Getting the strongest bill possible out of the Senate, out of the conference committee, and signed by the president is just the first step in health reform.  As the legislation progresses, we’ll continue to point out how it can be improved.  And once it is passed, we’ll continue to work with everyone else who wanted more from reform by advocating for strong implementation of the bill, and over the years ahead, improvements that get us closer and closer to ideal health reforms.

In my opinion, the biggest thing missing from this House Republican party proposal and the stated positions of  Republican officials on health reform in the current debate is that covering all Americans, or even making coverage affordable for all Americans, is never mentioned as goal.  All that is mentioned is reducing the cost of coverage (or the rate of cost increases).  This can’t get America anywhere near coverage for all, because the $12,000 a year average cost of family premiums (not even counting other out-of-pocket costs) is simply too big a share of total income for too many low-income full-time working families.   Also missing from the House Republican bill are other hallmarks of insurance market reform, such as ending wild unregulated premium variations based on age, gender, health status, and occupation.

I hear daily from a wide range of national groups, from wonky analysts to pro-reform organizers.  In recent days, calls are coming in from all quarter for continued pressure on Texas Congressmen Henry Cuellar (our one avowed Blue Dog), Chet Edwards, Solomon Ortiz, and Ciro Rodriguez to get on board with the House bill.  I can’t begin to explain to you whether or why they are either genuinely wavering or widely perceived to be so, but we want to make sure the word is out on that topic.

TVHR was happy to assemble 21 organizations to sign a letter supporting affordability priorities in health reform; Texas AFL-CIO also submitted a separate but coordinated letter.  It is hard to get everyone in the room, on the phone, or reading their email when you need to coordinate a consensus draft, and ultimately there were 3 major statewide groups who only bowed out because of one provision in the letter.  Guess which one?  You got it—the public option.  The letter pitched that option as a key cost-saving measure, noting that the lower the cost, the more low-income uninsured folks can be helped from the same limited pot of money.  How many of us would have predicted a year ago that this would be the lightening rod issue is has become? 

I continue to believe that the biggest lift of all is establishing in law the goal of making decent coverage affordable for all.  I remain hopeful that we are about to make the biggest step in U.S. history toward that goal.

You can read all over the web about all the ways the votes may play out on this.  But what would Texas do in an “opt-out” scenario?  The answer, as usual:  it depends.  We don’t know yet what specific process would be required for a state to opt out.  Will Governors decide?  Must the state Legislature pass a bill opting out, and if so will any special vote margins be required to do that?  Will there be any penalty for a state to opt out?  Any affordability standard to meet, as with the Snowe trigger?  Will voters who cannot afford insurance tolerate their Legislators voting to opt out?  If residents in neighbor states can access affordable comprehensive care from a public plan and Texans cannot, will that situation last very long?

The Center for Public Policy Priorities and TVHR have not made the public option central in our work, but without a public option success at getting affordable coverage for every American will require strong insurance reforms applying to a majority of the market, robust funding for premium subsidies, and strong bargaining powers by health insurance exchange(s).  Every compromise that whittles away at these, makes a public option more important.

The inclusion of a robust public option will provide small businesses and qualifying individuals with the opportunity to purchase affordable and high quality coverage. A public option would also increase competition among private health insurance providers, and ultimately lower the costs of premiums, reduce out-of-pocket expenses, and decrease the long-term costs of health reform.

Insurance companies have responded to the renewed support for a public option by claiming it could prove the end of the private insurance industry and lead to additional increases in premiums.  This isn’t exactly what insurance executives are saying in private.  At an industry meeting held last month, senior vice president for underwriting, pricing and health care economics at UnitedHealthcare, Richard Collins disclosed to investors:

“I believe the private system is important because it brings innovation, it brings energy, it brings change, it brings ideas that are often used in the public sector system as well,…I think we can have both a public and private system.” -Richard Collins, senior vice president for underwriting, pricing, and health care economics, UnitedHealthcare

With the increasing public support for more affordable health care options, it sounds like the same old scare tactics are being employed by the insurance industry.

We would agree with some of the health insurance lobby’s concerns, though certainly not their tactics. In this health reform process, all of us should be suspicious anytime we hear a group say, “we don’t like X” without also stepping up and saying, “and here is exactly what we want Congress to do to fix the bill.”

The House version of health reform (and the Kennedy HELP committee version) provides much of what the insurance industry says they want: stronger premium assistance and out-of-pocket caps for consumers, and has stronger individual and employer responsibility mandates. So, why is the industry not pointing to the House bill as the preferred option? Perhaps because the House also favors inclusion of a public option to be sold alongside for-profit plans in the new health insurance exchange.

Penalties for those who don’t buy insurance can only work if affordable coverage is available, and affordability must encompass both premiums and out-of pocket costs. It is only fair and reasonable to impose a penalty for the uninsured if comprehensive coverage at a fair affordable price is a reality. This is where the Finance bill is weaker than the House.

Large numbers of folks choosing to pay a penalty because they can’t afford the premium and staying uninsured is the outcome to be avoided. A few folks making this choice is inevitable in a system that offers that choice.