Pointed Questions for WellPoint

On February 24th WellPoint CEO Angela Brady will appear before the House Energy & Commerce Committee. She will attempt to explain why the company’s California operating unit, Anthem Blue Cross of California, recently sought to raise rates on some individual policy holders upward of 39 percent. While the effective date of the rate increase was postponed, the hearing is not. And that it is being held the day before President Barack Obama’s bi-partisan health care reform summit with Congressional leaders is no coincidence. The Administration and others have pointed to the rate increase as one of the reasons comprehensive health care reform – or at least health insurance reform – is needed.

In preparation for the hearing, House & Energy Committee Chair Henry Waxman and Subcommittee on Oversight and Investigations Chair Bart Stupak sent a letter to Ms. Braly asking for background information. The information ranges from the general (“reasons for the premium rate increase”) to the specific (for 2005-2008, “a table listing, as applicable, premium revenue, claims payments, sales expenses, other general or administrative expenses, and profits for all individual health insurance products”) to what some might call a fishing expedition “all internal communications, including e-mail, to or from senior corporate management relating to the company’s decision to increase premium rates in California in the individual health insurance market.”)

The hearing will be closely watched, not only by lawmakers but by WellPoint’s competitors. It could provide an interesting glimpse into the rate making process employed by health insurance carriers. The information will certainly be cited by advocates – and opponents – of requiring carriers to spend a certain percentage of the premiums they take in on medical claims as opposed to administrative expenses and profits.

Ms. Braly’s testimony will also likely highlight the different ways politicians and business people view the same data. What to a member of Congress may look like profiteering could look to an executive like a prudent hedge against unknown risk.

The Associated Press has taken a balanced approach to explaining the issues behind the Anthem Blue Cross of California rate increase. The analysis is worthwhile reading for anyone following this particular controversy. Among its conclusions: rising medical costs are the main driver of rate hikes, not profits; health insurance rate regulations vary considerably from state-to-state; non-profit health plans also have large rate increases; carriers can’t, and probably shouldn’t, subsidize rates for one business line in one state with profits earned by other lines of business, especially in other states; and that there’s a lot of elements taken into consideration by carriers when they set their rates. While there’s little specifics many insurance professionals don’t already know (other than the make-up of WellPoint’s profits), it’s a very useful summary and analysis of the issues.

The timing of Anthem Blue Cross of California’s rate increase is generally perceived as constituting political malpractice. But there may be a silver lining. Ms. Braly has an opportunity to educate lawmakers on how and why carriers charge the health insurance premiums they do. If members of the Energy & Commerce Committee are willing to look beyond the politics of the rate increase, they might gain a better understanding of how health insurance works in this country.

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Health Care Reform 2009 Style

When it comes to health care reform 2009 has been an interesting year. And while comprehensive health care reform legislation will not be arriving on President Barack Obama’s desk this year, it is all but certain that will happen early in 2010. Getting to this penultimate moment has, to put it mildly, taken some doing. And the process says a lot about America and its leaders.

Health Care Reform Activity

President Obama had made clear throughout his campaign for the presidency that health care reform would be a top priority of his new administration. He lost no time making his promise real after his inauguration. Expansion of the State Children’s Health Insurance Plan, a proposal twice vetoed by then President George Bush, along with significant funding for medical technology, were a part of Administration’s economic stimulus package.

President Obama’s health care reform efforts took a serious blow in February when former Senate Majority Leader Tom Daschle was forced to withdraw his nomination as Secretary of Health and Human Services and as Director of the White House Office on Health Reform due to problems with his past tax returns. Senator Daschle is a political pragmatist who is highly regarded by lawmakers from both parties. Would the health care reform debate have been more civil had Senator Daschle led the White House reform effort? We’ll never know. What we do know is that civility quickly left the room as the House and Senate Committees with jurisdiction on the matter began their deliberations. The health care reform debate was passionate, raucous and partisan to the extreme. Neither party and no ideology is blameless for this descent into the dark side of politics. Both have benefited from it (although none as much as the 24 hour cable news channels) and both have sullied their standing with the public as a result.

Given what’s at stake when 1/6th of the nation’s economy is subjected to the legislative process, there may have been no avoiding an ugly health care reform debate. President Obama made clear in a speech in February that he wanted health care reform passed quickly. Many Republicans (and their talk show host allies) made it clear they’d rather see no health care reform rather than anything along the lines being proposed by – or that would politically benefit – President Obama. Meanwhile, the House Ways and Means, House Education and Labor and the Senate Health, Education, Labor and Pensions Committees pushed through liberal bills; anchors on the left in anticipation of the negotiations to follow. The resulting climate promoted intense partisanship.

Eventually more conservative Democrats forced the House Energy and Commerce Committee to slow done and moderate the legislation, although what they passed would still be considered “liberal” by most definitions.  All the House bills passed out of the committees without a single Republican vote. Meanwhile Senator Max Baucus was trying to fashion legislation that might gain the support of at least three GOP members of the Senate Finance Committee. (He would eventually manage to get the support of only one GOP Senator).

The difficulty of finding common ground between liberals and conservatives on health care reform was made abundantly clear during the summer of 2009. The disruption of lawmaker’s town hall meetings were reminiscent of the anti-Viet Nam War protests of the 1960’s. (I suppose it’s ironic that many of those shutting down the town hall meetings had participated in the anti-war protests more than 40 years earlier). The passion and concern of the health care reform protests were as sincere as some of the rhetoric and actions were unfortunate and despicable (death threats and swastikas are inherently contemptible and disgraceful). The protests did assure, however, that Republicans would remain united against the kind of reforms being pushed by the Administration.

Reform was being pushed by the White House even if the Administration was declining to define reform. Instead the White House broadly described the key elements they’d like to see in a reform bill. President Obama’s three core principles for health care reform called for reducing costs, guaranteeing choice and ensuring quality care for all. He would later add other conditions (e.g., reform could not add to the deficit), but the details of the bill were being hashed out in Congress by Democratic lawmakers. The result, much to the chagrin of liberals, was that over time the legislation became increasingly moderate culminating in the legislation passed out of the Senate Finance Committee with the support of only one Republican, Senator Olympia Snowe.

With all the committees of jurisdiction having staked out their positions it was time for Speaker Nancy Pelosi and Senate Majority Leader Harry Reid to pull together the pieces into bills that could pass their respective chambers. Speaker Pelosi succeeded first with the House passing a health care reform in November. The price of passage was high: liberals had to accept language dealing with abortions that sparked outrage in the pro-choice community.  It took the Senate more than a month to follow suit, but eventually they did. Now it’s up to a conference committee to pull the pieces together into one bill that can pass both the House and the Senate. Not an easy task, but with the finish line in sight it’s very doubtful lawmakers will falter now.

The Public Policy Dimension

While the activity swirling around health care reform has been … interesting, the evolution of the substance of the legislation has been even more fascinating. Not all that long ago liberal lawmakers were claiming a health care reform bill lacking a government-run health plan was no health care reform at all. They seemed to believe that a public health plan was the magic wand that would remake America’s health care system into something fair, competitive and wonderful. Or maybe they just thought the public option was a way station on the path to their promised land: a single payer system. While the House bill would create a new government health plan, the Senate legislation rejected the public option. While liberals outside of Congress continue to attack reform without a public option, liberals lawmakers seem to accept the inevitable. What emerges from the conference committee will no doubt lack a public option and liberal lawmakers will still support the reform package.

While liberals were losing a public option an unlikely coalition of conservatives and liberals were also watering down a requirement that all Americans purchase coverage. Conservatives dislike the idea as a restriction on the freedom of people to have their health care reform subsidized by higher health insurance premiums for everyone else. Liberals don’t like it because, apparently, the result is a windfall for evil health insurance companies. (OK, they offer more substantive public policy arguments against the individual mandate, but the rhetoric focuses on freedom and windfalls). Never mind that requiring health plans to sell coverage without requiring individuals to buy coverage before they incur claims is a recipe for higher insurance costs or that many states require drivers to buy auto insurance. As the legislation has moved through Congress the penalty for failing to purchase coverage has drifted toward a slap on the wrist end of the spectrum.

Other issues have taken interesting turns as well. Reimbursing doctors for counseling to seniors concerning living wills and the like was removed from the bill once the discussions were labeled “death panels.” What taxes will be imposed to pay for health care reform is still uncertain. Anti-abortion advocates have done a masterful job of inserting abortion into the debate. Both the House and Senate bills contained provisions that could “bend the cost curve” (which is apparently the new articulation of what was once called cost containment). If all the cost cutting provisions in the current bills were moved into separate legislation it would actually look like a serious effort. Mixed in with the health insurance reform dominating the current versions, however, the provisions appear weak and almost an afterthought.

Health Care Reform 2009: The Human Factor

So what to make of health care reform 2009 style?

First, that the legislative process is messy and can be downright uninspiring. Second, that tackling an issue as important and complicated as health care reform cannot overcome the need for partisans of both parties to put aside the public good for their political stratagems. Third, that the health care reform package that finally passes will be far more moderate than might have been apparent earlier this year. Fourth, criticism that Congress is moving too fast on reform are really complaints that Congress is not doing what critics leveling this charge want them to do. The health care reform bill that will find its way to President Obama’s desk in 2010 will be over a year in the making. Longer if you count the debate on health care held during the 2008 presidential election. Longer still if you include the previous health care reform efforts undertaken over the past several decades.

We elect politicians to hold office because they promise to address problems. No one has ever won a campaign on the promise to do nothing if elected. In 2008 Democrats won, and won handily, in part on a promise to solve the problems posed by America’s current health care system. They are fulfilling that promise. In the process they will create new problems.

Because the fact is we humans rarely solve problems. Instead we tend to replace existing problems with new ones. And if the 2009 health care reform process has taught us anything, it’s that the people who make up the Administration and Congress (and the general public) are only human. Anyone looking at the health care reform package emerging from Congress would find evidence of that reality.

House Health Care Reform Bill: Some Varied Perspectives

One person’s socialism is another’s sellout. At least that’s the way it seems to go when it comes to health care reform. And it certainly must appear that way to House Speaker Nancy Pelosi who today unveiled the Affordable Health Care for America Act. HR 3926 blends together provisions from the three House Committees that have produced health care reform legislation: the Ways & Means Committee; the Education & Labor Committee; and the Energy & Commerce Committee. The result is not as liberal as some on the left called for and is too radical for those on the right.

As CBS News reported, those on the left are upset that the bill would create a government-run insurance plan that would be required to negotiate rates with providers much as private carriers do. This angers liberals who want the public health plan to set rates that providers would have to accept, much as is done with Medicare and Medicaid.

Meanwhile, back on the Hill, conservatives attacked the House health care reform bill in no uncertain terms. “It will raise the cost of Americans’ health insurance premiums; it will kill jobs with tax hikes and new mandates, and it will cut seniors’ Medicare benefits,” proclaimed House Minority Leader John Boehner.

Is it socialism? A sellout? A good idea or a bad idea? Most readers of this blog can guess my answers (for those interested, my view of it is at the end of this post). Here’s how others are discussing the legislation:

The National Underwriter does a great job of identifying where some of the controversial provisions in the bill can be found. While the publication is a bit too fixated with the number of pages in the House health care reform bill (1,990), it’s still a good starting point for understanding the legislation. And it points out that the bill does nothing to prevent brokers to sell products within the Exchange, so it offers a bit of a reassuring start, too.

The Congressional Budget Office is highly regarded by lawmakers on both side of the partisan divide for its objective analysis of the budget impact of legislation– unless, of course, they don’t like the analysis. The CBO’s analysis of HR 3926 indicates it will reduce the deficit over the next 10 years by $104 billion, insure 96 percent of non-elderly legal residents in the country (18 million people).  The CBO’s director, Douglas Elmendorf, maintains a blog and summarizes the analysis in his post today. he notes that the findings of the CBO are “subject to substantial uncertainty.”

The Christian Science Monitor’s story reports on the how the liberals may call for a floor vote on a more robust public option than is in the bill in order to put Democratic and Republican members on record as to where they stand on a government-run health plan.

The Associated Press focuses on the CBO’s conclusion that the public option might actually cost consumers more than private coverage. It also notes that while Speaker Pelosi compromised on the powers of the government-run health plan to appease the more moderate members of her caucus, many of those moderates remain concerned about the overall cost.

A BusinessWeek article zeroes in on some of the taxes the House health care reform legislation would impose and how they differ from the taxes likely to be in the Senate reform bill.

Reimbursing doctors for providing end-of-life counseling remains in the House health care reform bill. Given that some conservatives described this provision as creating “death panels,” preserving this element of the bill can be viewed as an act of political courage. As I’ve posted before, the death panel claim was more of a cruel hoax on the American people than an insightful read of the legislation. But the passions and paranoia surrounding the provision was so vociferous, the easy course would have been to simply drop it from the bill – as was done in the Senate. The Oregon Congressman, Earl Blumeauer, who championed inclusion of the counseling provision in the health care reform package, says he was motivated by a talk with a Southern Minister who told him ‘It’s very important for those of us in the clergy that this provision be kept, cos’ we see situations where families don’t get the help they need, and we have to try to counsel them through.”

For those interested in reading the bill, here’s a link to HR 3926 – the Affordable Health Care for America Act. As noted, it’s 1990 pages, but there’s a lot of white space on most of the pages.

My take on the House health care reform bill is that it’s not socialism nor a sellout. It is a politically necessary step down a long road. As regular blog reader Alison noted in her comment on an earlier post concerning Senate Majority Leader Harry Reid’s efforts to forge health care reform legislation that can muster 60 votes in the Senate, “… if you start off extreme then there is more room for negotiation to where he (Senator Reid) most likely anticipates its going anyway. If you give away the farm at first you have nothing left in your hand to negotiate with. I do not believe he anticipated this to fly at all but rather offers it as a calculated starting point.”

Alison’s point applies equally as well to Speaker Pelosi’s health care reform bill.

Health care reform is a process. First there was the pre-legislation discussion of what health care reform should do. Then there were the debates in various committees in which those intentions were put into bill form. Now the leadership of each chamber are blending the work of their committees into single bills. Next will come a conference committee tasked with combining the two bills that emerge from the Senate and the House of Representatives into a single bill. At each step along the way positions harden, the rhetoric (hard to believe it’s possible) becomes even more shrill, and the compromises more plentiful. But at each stage, the final legislation becomes more clear. After all, if the House Leadership is going to push moderate Democrats to vote for a public option of any kind, a vote those moderates will need to defend at election time, they must believe it is going to be a part of the final reform package. (At least those moderate Democrats hope so).

The Affordable Health Care for America Act will look more like whatever finally emerges from Congress than the bills passed by the three House Committees. But it’s not the last word. The blended Senate bill has been described, but not seen. Both the House and Senate proposals will be evolve. We’re several weeks away from seeing the legislation that will emerge from the conference committee.

The worthiness of the result, as always, will be in the eye of the beholder.

It’s Time for President Obama to Define Health Care Reform

Now comes the fun part. With the Senate Finance Committee poised to pass its version of comprehensive health care reform we get to one of the more difficult segments of the Kabuki dance: Speaker Nancy Pelosi and Senate Majority Leader Harry Reid must now reconcile the bills passed by multiple committees into a blended proposal. Which means the time is right for President Barack Obama to publicly define what, exactly, is “Obamacare”.

First some background. In the House, different versions of health care reform legislation have been passed by the House Ways & Means, Energy & Commerce, and Education & Labor committees. To be more precise, while the legislation moved forward by Ways & Means and Education & Labor were very similar, moderate Democratic members on the Energy & Commerce committee gained significant changes in that committee’s version. Speaker Pelosi will now combine the three versions into a “Manger’s Bill.” This is the version that will be debated and voted upon by the full House.

What’s makes Speaker Pelosi’s mash-up of the House Committee’s health care reform bills important is that any changes must be imposed upon it. Her version of the bill is the “default” position. From a legislative process perspective, this puts those seeking changes to the legislative language at a disadvantage.

The same blending process is underway in the Senate. There the task is even harder. The Senate Health, Education, Labor and Pensions Committee passed a liberal version of health care reform; the Senate Finance Committee’s plan is much more moderate. The gap between them is far greater than that between the three House committee’s bills. The Associated Press describes Senator Reid’s efforts to blend two disparate health care reform bills as “mission seemingly impossible.” Given the differences in the how the two Committees addressed costs, taxes, whether there should be a government-run plan, the obligation of employers to provide coverage and other controversial items, “seemingly impossible” may be an understatement.

Unless President Obama dives deeper into the details than has publicly been the case. The White House has been engaged in Congressional health care reform negotiations for some time. According to news reports, White House Chief of Staff Rahm Emanuel, formerly part of the House Leadership, has been the Administration’s point person in these discussions. Until recently, President Obama has been willing to let Congress thrash out the thorny issues related to health care reform, setting forth broad principles. Beginning last month the president has offered more specifics, but hardly enough to clearly define what his version of health care reform looks like. At least not publicly.

With all the Congressional committees having taken a position, the time has come to get specific. Yes, the White House could leave it to Speaker Pelosi and Senator Reid to fashion compromises that can pass their respective chambers, but that only postpones the Administration’s day of reckoning. For after the House and Senate passes their differing versions of reform, a conference committee (made up of both Senators and Representatives) will convene to fashion the final bill. If President Obama waits until the conference committee convenes to publicly engage in the nitty-gritty of reform, it could be too late. Legislators will have been forced to make numerous politically challenging votes. The political payback if the White House then makes those votes unnecessary would be … ugly.

President Obama needs to make his health care reform vision known now, before those votes. He needs to say “this is acceptable;” “this is not.”  He needs to spend his political capital to define Obamacare, to give lawmakers the cover they need to make tough votes, and to rally his considerable grassroots organization behind specific legislation.

Publicly defining what he wants in the bill is a huge political risk for President Obama. His positions will anger some supporters and give opponents mounds of ammunition to use against him. Whatever changes Congress makes to the president’s reform plan will be described by the jabbering cable network pundits as a defeat for the Administration. If he accepts those changes he’ll be accused of weakness and flip-flopping. (One of the most insightful columnists around, Richard Reeves recently explained the value and wisdom of political leaders capable of changing their minds).

But the greater risk to the Administration is failing to achieve meaningful health care reform. And if health care reform does pass, the messiness of the process will be soon forgotten. The odds of President Obama getting a health care reform bill sent to his desk increases exponentially if Congress – and the public – have a clear understanding of the Administration’s legislative ambitions.

The policy and political pieces are all on the table. Selecting from among the various provisions contained in the five variations of health care reform passed by Congressional committees won’t be an easy, but it is necessary. President Obama wanted Congress to participate in the reform process. They have. Now it’s his turn.

Health Care is Local

Former House Speaker Tip O’Neill famously noted that “all politics is local.” And he’s right. He was not talking about the rules of the political game. Those are established by a national constitution and subject to state laws as well as local ones. He meant that the political dynamics of each district are what determines the ideological shading of a district.

Some examples are obvious: compare the voting record of legislators from Massachusetts and Utah. Others are less so: Republican Senator Charles Grassley had been a reasonable voice on health care reform until he remembered he was up for reelection in 2010 and saw how conservative Iowans were responding to unfounded claims of “death panels” and the like; he is now embracing aspects of the silliness.

Health care is local, too. The medical delivery system in Los Angeles looks far different from the one in Cheyenne. Even what’s considered standard treatment varies from community to community. And as Dr. Atul Gawande demonstrated in his New Yorker article, the cost of care varies greatly among localities based on medical provider’s approach to health care.

How the local nature of politics and health care interact underscores the complexity of health care reform. Because health care is local, what’s broken in the current system varies from place-to-place. Because politics and is local, acceptable solutions vary depending on locale. It may just be a coincidence, but it is worth noting that the initial advocate for community-based health insurance co-operatives, Senator Kent Conrad, hails from North Dakota where rural electricity co-operatives are common while many of those claiming only a government-run health plan will do represent urban areas.

Recognizing this dynamic, the the House Energy and Commerce Committee has described HR 3200’s impact on each Congressional District. (My thanks to Dwight Mazzone for bringing these documents to my attention). Reading through these is a glimpse of the richness and variety of America.

For example, in Wyoming (which has one Representative for the entire state) up to 19,000 businesses would be eligible for tax credits to pay for health insurance, 7,400 seniors would benefit from reducing brand name drug costs, much of the $23 million in uncompensated care hospitals and health providers face would be eliminated, and the tax surcharge to pay for reform would impact 3,120 households.

Compare this to the Los Angeles area district represented by Henry Waxman, the Chair of the Energy and Commerce. In California’s 30th District up to 14,300 businesses would be eligible for the subsidy, 5,200 seniors would see lower prescription costs, hospitals and other providers would be relieved of much of the $85 million in uncompensated care they deal with today, while 22,100 households would pay the tax surcharge.

The statistics cited come from legitimate sources, but are presented in order to muster support for HR 3200. Were the same information to be presented by House Republicans it would no doubt have a different spin. Nonetheless, the information is a treasure trove of insight into the local politics and health care that drives the health care reform debate.

These statistics should also give lawmakers demanding a single, one-size-fits-all solution to health care reform pause. As I’ve argued before, state health care reform efforts usually fail. America’s health care system is too large, too interrelated and too complex to be reformed on a state-by-state basis. States lack the tools needed to make meaningful changes work; the national government has those tools. However, the reforms themselves could benefit from local implementation. For instance, instead of creating one, national government-run health plan to compete with private carriers, enabling the creation of local health insurance co-operatives to generate competition where it is needed is more appropriate.

Finding the balance between federal and local management of health care is critical to a well-functioning medical system. It is also good politics.

Health Care Reform 2009: Even More Required Reading

Welcome to the third edition of health care reform 2009’s required reading list. (The previous editions were Health Care Reform 2009: Required Reading and Health Care Reform 2009: More Required Reading). What I try to do in these cleverly titled posts is to pull together the articles and web sties offering meaningful insights into the current health care debate. I don’t always agree with the authors facts, reasoning or conclusion, but having them available can be a useful guide to what people are saying and thinking.

1. If folks are going to argue over what’s in the House Energy and Commerce Committee’s legislation (the “America’s Affordable Health Choices Act“) we might as well all read the darn thing. And the various press releases, summaries and white papers associated with it. The Committee’s site has it all and more.
2. When the Congressional Budget Office talks people listen. (To be precise, when the CBO writes, people read — especially lawmakers, public policy wonks, the media and the political groups seeking to sway the outcome of the health care reform debate). One of their most read pronouncements concerned the impact of a government-run health plan to compete with private carriers or through a health insurance exchange under the Energy and Commerce Committee’s bill. The CBO concluded enrollment in a public plan or exchanges would be relatively modest — by 2016 they project “nearly 3 million Americans who would be covered under an employment-based plan under current law … would choose instead to obtain coverage in the exchanges because the employer’s offer would be deemed unaffordable and they would therefore be eligible to receive subsidies via an exchange…”  When part-time workers are added in, the CBO estimates that the private carriers would lose approximately 9 million people to the exchange by 2016. Estimating that a public plan would offer premiums approximately 10 percent lower than typical private plans offered in the exchange,  the CBO concludes the public plan would have a “limited effect on the the proposal’s net budgetary impact,” implying enrollment would be modest. The CBOreport is a thorough analysis well worth an investment of time.
3. When it comes to polling, trends often matter as much as the actual numbers. The Kaiser Family Foundation has been tracking the public’s attitude toward health care reform since March 2007.  Their July 29th Public Opinion on Health Care Issues finds a majority of Americans continue to believe “it is more important than ever to take on health care reform now.” While the percentage has declined since October 2008 from 62 percent to 56 percent, that’s still a striking result given the rhetoric surrounding the debate. Of course, it all depends on who you talk to: roughly 70 percent of Democrats believe this is the time for health care reform while approximately 60 percent of Republicans state “we cannot afford to take on healthcare reform right now.” Independents split 54 percent-to-42 percent in favor of moving forward with change now.
4. Just because you see it on television doesn’t mean it’s true. Partisans on the left, right and middle have a tendency to misstate the facts. FactCheck.org, a project of the Annenberg Public Policy Center is an excellent source for the real scoop. They take on liberals and conservatives with equal fervor, for instance, debunking the euthanasia claims of the right and challenging President Barack Obama’s claim that health insurance companies are raking in “record profits.” 
5. During the presidential campaign, one of Obama campaign’s most potent weapons was a site called “Fight the Smears.” It allowed the campaign to quickly respond to and debunk unfounded rumors. The White House is launching a similar site, called “Reality Check” to counter attacks on the president’s health care goals. The justifications are not surprisingly skewed to the Administration’s positions, but as a single source for President Obama’s positions on controversial issues it’s a great resource.
6. Keeping the health plans straight without a program is nearly impossible. Even with a program it’s darn tough. The National Association of Health Underwriters offers a useful comparison between the Senate Health, Education, Labor and Pensions Committee legislation and the House of Representative’s legislation (HR 3200). In fact, NAHU has a wide range of useful legislative information of particular interest to health insurance brokers. (If you’re a broker and not a member of NAHU, now is the time to join. No other organization is as engaged or effective at representing the perspective of professional insurance brokers.) The Kaiser Family Foundation ahs a great tool for comparing various health care reform proposals as well.
7. Health care reform is critical importance to state governments. They simply cannot afford the burden of increasing medical costs for programs like Medicaid (Medi-Cal in California). California Arnold Schwarzenegger made this point very clear in a letter to Congressional leaders urging them to pass health care reform, but warning against pushing the financial burden onto state governments. It’s an aspect of health care reform that is not receiving a great deal of attention, but is of critical importance. The letter does an excellent job of explaining the issue. 

Of course the most important document to read is the Senate Finance Committee’s compromise proposal. Unfortunately, it doesn’t exist yet, although there are plenty of stories on what it is likely to contain. Until it sees the light of day, however, reports on its provisions are merely conjecture, trial balloons or both. In the meantime, these sites and publications should provide some pleasant summer reading.

Progressives Will Face Tough Health Care Reform Choice

Just looking at the broad facts, liberals should be riding high. President Barack Obama occupies the White House. Democrats hold a 60-40 super-majority in the U.S. Senate and a commanding 256-178 majority in the House (with one more on the way after a special election in California later this year). Republicans are on an electoral losing streak of epic proportions and have yet to find a unified voice. It doesn’t get much better than this.

Except appearances can be deceiving and liberals will soon need to decide whether they are willing to vote for a bill that, in their view, improves America’s health care system but does not go nearly far enough or should they leave the system the way it is.

Note: This post was updated on July 30th to provide more details concerning the House Energy & Commerce Committee compromise and liberals reaction to it. Additions are presented in italics.

The evolution of health care reform legislation as it moves through Congress must frustrate progressives. It started off to their liking. Senator Edward Kennedy’s Health, Education, Labor and Pensions Committee pushed forward a bill that satisfied much of the liberal wish list. Good times continued when the House Ways & Means and the Education & Labor Committees passed equally progressive bills. That the affirmative votes on all three committee came exclusively from Democrats was not of great concern to supporters. Health care reform was coming whether Republicans wanted to join the parade or not.

Liberals were on a role, but then their moderate and conservative colleagues began to make their presence felt. And there are more of them than is generally acknowledged. While conservative talk show hosts like to brand the Democrats as a monolithic subsidiary of Mao-spouting communists, the reality is far different (actually, reality is usually different than that described by conservative talk show hosts, but that’s a topic for another day).  A party does not capture 60 percent of the Senate and 59 percent of the House by running cookie cutter candidates all pledged to the same ideology. The country is too diverse. The brilliance of Rahm Emanuel, then head of the Democratic Congressional Campaign Committee and now White House Chief of Staff, was that he discarded virtually the entire Democratic litmus test in his search for candidates. The only significant requirement he demanded of the candidates he recruited was that, once elected, they would vote for a Democrat for Speaker of the House. Meanwhile, the GOP who hewed closely to the beliefs and principles of their base. Moderates were scorned and labeled RINOs (Republicans in Name Only). They succeeded in recruiting ideologues who had no chance of winning outside the reddest of red districts.

Consequently, the Democratic caucus is chock full of moderates and even conservatives.  Which all but guarantees that liberals will be disappointed. There are simply not enough liberals in Congress to pass a bill without support from moderates.

So it should not have been a surprise when problems developed as the progressive juggernaut moved beyond some of the most liberal committees in Congress. The Blue Dog Coalition, a group of moderate Democrats in the House, objected to a host of provisions in the Ways & Means and Education & Labor bills. While they lacked the votes to hold up the legislation in those committees, they did such leverage in the the House Energy & Commerce Committee. The Blue Dog Democrats had an agenda for health care reform that differed in many respects from that of their more liberal colleagues.

Meanwhile, in the Senate, Democrats and Republicans on the Senate Finance Committee were working tirelessly to hash out a health care reform package that could garner bi-partisan support. To get there, Senator Max Baucus, Chair of the committee, was willing to jettison some of the more treasured elements of the liberal health care reform agenda.

Both the Blue Dog Democrats and the moderates on the Senate Finance Committee are making substantial progress. House Energy & Commerce Committee Chair Henry Waxman and Representative Mike Ross, speaking on behalf of the Blue Dogs, announced an agreement that will allow the full committee to begin marking up health care reform legislation. The specific changes to the bill from the versions passed by the Ways & Means and Education & Labor Committees are not yet public. But there are four major elements according to wire stories:

• Keeping the 10-hear cost below $1 trillion by agreeing to $100 billion in cuts
• Preventing a public plan from simply imposing Medicaid rates by allowing physiicans and other medical providers to negoiate rates with the government plan
• Exempting businesses with payrolls below $500,000 (86 percent of all small businesses)  from any government mandates requiring them to provide health insurance to their employees
• Postponing a full House vote on health care reform until after September 8th

At the same time, Senator Baucus and the ranking minority member of the committee, Senator Chuck Grassley, are making it known they are close to unveiling the Senate Finance Committee’s compromise. Their proposal is unlikely to include a government-run health plan. It may not include all the mandates and subsidies liberals seek. In short, they will reform the health care system, but leave much of what exists in place. Which puts progressives in an uncomfortable position.

Moderates and conservatives seem willing to defeat any health care reform legislation rather than vote for the kind of reforms liberals seek. Will liberals refuse to support legislation that does not go as far as they demand? As of now they are threatening to do just that. The Progressive Caucus is circulating a letter seeking 50 signatures (enough to defeat any bill) pledging to kill any legislation failing to contain a strong public plan.

That’s not yet known. That the compromise proposals will be attacked from both the left and the right is to be expected. And liberals are already expressing outrage at having their wishes denied. For example, the Associated Press quotes Representative Lynn Woolsey  as saying “They can’t possibly be taking us seriously if they’re going to bring this [compromise legislation] forward.”

But will liberals insist on getting their way even if it means letting the status quo stand?

Ideology and pragmatism are often hard to reconcile, but my prediction is that liberals will vote for moderate health care reform. The reason: Senator Kennedy and President Obama will eventually accept a compromise. Throughout his career Senator Kennedy has demonstrated the political wisdom of taking half a loaf now and continuing the fight for the rest another day. And, according to the Associated Press story cited above, the White House is already making clear the Administration is willing to settle for a more moderate bill.

With Senator Kennedy and President Obama’s urging, enough liberals will accept that even modest reform is preferable to the status quo. They won’t be happy with what it contains, or more accurately, what it doesn’t contain, but they will be among those applauding when President Obama signs the bill into law this Fall.

Added 9:05 pm July 29, 2009: As noted above, liberals are upset over any compromise that does not include a public health insurance plan. In a post on Politico.com, Glenn Thrush reports that “Two months ago, most of the 80-plus members of the Congressional Progressive Caucus signed a pledge that they would oppose any health care bill that didn’t contain a bona fide public option that would compete with private insurers. On Wednesday, they seemed willing to stick to their promise.”  He goes on to quote Representative Barney Frank as saying liberals might reject the House leadership’s  request to support a weakened public option. “I don’t think it would pass the House — I wouldn’t vote for it,'” the post quotes Rep. Frank as saying.  No one would cheer louder than Republicans to see health care reform fail because moderate and liberal Democrats fail to come together. Which is, to repeat my prediction from above, why I think liberals will eventually take a deep breath, vote for a moderate bill, and come back in 2010 fighting for more.

Coming Soon: Health Care Reform That Might Pass

We’re getting closer to seeing what the health care reform likely to emerge from Congress will actually look like. The Senate Finance Committee is likely to unveil its bi-partisan reform plan in the next few days. While it’s likely to disappoint members of both parties, it also holds out the greatest promise for serving as a framework for meaningful, comprehensive reform.

Some of those who will be disappointed with a more centrist approach to health care reform will be those who have created a cottage industry from highlighting the more egregious elements of the plans already passed by Congressional Committees. These proposals never had much chance of becoming law, but partisans across the spectrum embraced them as either statements of principles (on the left) or evidence of skullduggery (on the right). countless hours of heated argument, outraged accusations, misinformed attacks, and righteous indignation have been heaped on these bills. They also generated, to be fair, serious public policy debates on meaningful issues that shined a light on the complexity and trade-offs inherent in reforming one-sixth of the nation’s economy. They received all this attention in part because they were the only detailed reform plans around.

The Senate Finance Committee is about to change that. And it could be the House Energy and Commerce Committee, whose liberal and moderate Democratic members are seeking to find common ground, may also come forward with a detailed plan soon.

The health care reform proposal likely to emerge from the Senate Finance Committee will disappoint some in the White House. According to the Associated Press, it does not call for creating a government-run health plan as President Barack Obama has proposed to provide competition for private carriers. Instead, such competition would be provided by non-profit health insurance cooperatives. While the federal government would provide seed money for launching these cooperatives, they would have to survive in the market without government subsidy or management. The Senate Finance Committee is also expected to forgo requiring businesses to offer health insurance coverage to their employees, although individuals would be required to obtain such coverage on their own if their employer does not offer it.

There will no doubt be much in the Senate Finance Committee’s proposal to raise the ire of, well, most everyone. If there was a path to health care reform that triggered spontaneous outbursts of Kumbaya in the halls of Congress, it would have been introduced and enacted by now. So we get to look forward to plenty of controversy, sniping, partisan positioning and serious policy debate over the next several weeks.

The good news, however, is that all that energy will be directed to refining a health care reform plan that has the chance of actually being enacted. And that is progress.

Health Care Reform 2009 and the Danger of News Cycles

The campaign for health care reform is making a lot of people nervous. Every day the media is reporting on a crippling blow President Barack Obama’s reform effort has suffered or on the inevitability of passage. It’s like watching an episode of 24 or Lost  – every episode (or news cycle, as the case may be) a new cliff hanger. The television shows are obviously fictional. The drama of the health care reform debate is, at times, equally manufactured. And even when the situation is real, the situation is neither definitive nor long lasting.

However you get your news, the situation is pretty much the same. Every news cycle there’s some make-or-break event that requires breathless analysis. The reality is not every meeting, vote or comment is of momentous importance. It may be interesting. It may be informative. But it momentous events are few and far between. Which poses a problem for the media because they live or die on excitement.

The reason is that the need of the media to capture attention of a large audience outweighs its sincere desire to educate and/or influence that audience. The news media is a business. Like all businesses (even non-profits) it must generate revenue. For the media this means selling advertisements.  Most reporters and pundits have a want to educate and inform. Some seek merely to entertain or inflame. All of them, however, have a need to bring an audience to their advertisers. This means the stories they put forward need to excite their audiences enough so they can be exposed to the advertising that creates the revenue the media owners expect. (In this admittedly cynical view, the reporters and pundits are the equivalent of the brokers – it all begins with a sale).

In-depth stories examining the subtleties of a complicated issue like health care reform are not very exciting to a broad audience. Further, most reporters and pundits lack the expertise to examine the subtleties of health care reform. That’s not a put down as it’s not their fault. They need to be generalists and understanding health care requires specialized knowledge. Even those who truly understand the intricacies of the issue face a serious problem, especially on television: the need to break for commercials every few minutes. It’s tough to maintain a narrative when your presentation is constantly being interrupted to sell cars, prescription drugs or cleansers.

What does excite people is conflict. Which is why the media loves a good fight. Conflict requires good guys and bad guys, winners and losers. So instead of exploring the nuances of how a health insurance exchange might work (or what challenges it may face) or how the governments Medicare and Medicaid reimbursement policies increases the cost of private health insurance, the press focuses on the political maneuvering of the day. Broad statements by lawmakers go unchallenged because there’s simply not enough time (or expertise ) to challenge them. Instead, the best sound bites of the day are played and discussed in an echo chamber designed to amplify any conflict – or to create conflict where none exists.

I don’t blame the press. They have a job to do and, as I mentioned, most have a sincere desire to inform their audience as much as is possible given the restraints of their business. I do feel sorry for their audience. They can’t help but perceive the health care reform debate as a pitched battle between the forces of Light and Darkness with ultimate victory or defeat at risk each day. In short, they are exposed on a regular basis to a heightened version of reality intended to cause enough fear, relief, frustration, and elation to keep them paying attention through the commercials.

So, for example, President Barack Obama wanted each chamber of Congress to pass a bill so the two versions of reforms could be reconciled into a single bill and voted upon in the Fall. The Senate will not meet this deadline (the House probably won’t either, but they may). For the media this is great. Everyone understands due dates. Congress missed theirs so health care reform is in deep trouble and the President lost a major political battle.

Well, not quite. There’s still plenty of time to complete health care reform this year. And while the President may have missed a deadline, at the end of the day he will be judged by whether the status quo endures or not. It’s like owning stock. The price of the stock you own may change every day, but the only thing that matters is the price on the day you sell it. But the media can’t let this be known so every day’s stock price is of paramount importance..

Another example: three Congressional Committees have moved health care reform bills forward (an important milestone). Two Congressional Committees are still refining their proposals. Which ones are the most important? Given the hyperbole and attention showered on the versions that have already made it through a committee you’d be forgiven for assuming it’s the former. The odds are, however, that what emerges from the Senate Finance Committee and the House Energy and Commerce Committee are going to more closely reflect the final legislative package than anything already voted upon. The reason is that these committees are seeking to gain the support of moderates (both Democrats and Republicans) and those moderates are critical for passage.

Consider: Democrats have 60 votes in the Senate, but 18 of those are moderates. Without the support of at least eight of those moderates nothing passes in the Senate. (And this assumes only 50 votes will be needed. If 60 votes are required to move health care reform legislation through the Senate, which is more likely, then every one of those moderates needs to be brought on board).

In the House, Democrats will soon hold a 257-178 member majority (there’s one vacancy, so there are only 256 Democrats in the House today). It takes 218 votes to pass anything through the House. Without Republican support, the House Leadership can only afford to lose 39 members of their caucus. The moderate Blue Dog Coalition has at least 52 members. Do the math.

What all this means is that we have yet to see the two most meaningful health care reform bills yet. Which makes much of what’s being reported lately exciting, but ultimately, not as important as the media would have us believe. The day-to-day tumult is not what matters. Health care reform will be determined by the forces and dynamics that are not easy to explain. And they certainly don’t fit within commercials.

More Health Care Reform Proposals Added to the Mix

So many health care reform proposals are flying around the nation’s capital it’s nearly time to bring in the air traffic controllers. There are draft bills, option papers, proposals, outlines, and about any other kind of document you can name whirling around like jets over O’Hare.

Michael Johnson of Blue Shield of California and I gave a presentation on health care reform Wednesday to a group of health insurance brokers. We were reading up on one of the latest ideas issued a few hours earlier literally minutes before the panel got underway. It’s only going to get worse as some stake out (somewhat extreme) negotiating positions while others offer up potential compromises.

Here’s some of the more recent health care reform proposals to be launched — or about to be:

1.  The web site The Hill is reporting that moderates in the House of Representatives from both sides of the aisle are meeting in private to fashioning a compromise package. Among those meeting are part of the GOP’s “Tuesday Group,” the New Democratic Coalition and the Democratic Blue Dog Coalition. Fearing retribution from party leaders, neither side is offering the names of participants. The meetings are significant not just because they are likely to produce yet another health care reform package. The negotiations also underscore the reality that while the media tends to portray both Democrats and Republicans as monolithic parties of extreme ideologies, there are a significant number of lawmakers who eschew the hardline ideology of their colleagues and search for pragmatic solutions.
2. Former Senate majority leaders unveiled a health care reform plan they hope will provide a middle ground in debate. The plan was developed by Republican former Senators Howard Baker and Bob Dole along with Democratic former Senators Tom Daschle and George Michell. (Former Senator Mitchell is credited by the Boston Globe with having contributed to the document, although it is signed by only Senators Baker, Daschle and Dole). It weaves around the middle on a number of issues, although it does lean to the left. For example, while the proposal does not call for a creation of a federal government-run health plan it would permit states to create them. It also calls for taxing the value of health plans an employee receives to the extent it exceeds the cost of coverage provided to members of Congress. According to the Boston Globe this would amount about $5,000 for an individual and $13, 000 for a family.
3. The House Republican leadership unveiled their health care reform plan on Wednesday, too. Among other features it would allow states, small businesses and other group to come together into “pools” to offer low cost health plans that, at a minimum, is provided in a majoirty of states. It also would offer lower-income Americans refundable tax credits they could use to purchase coverage and would make individual health insurance premiums tax deductible. It does not require consumers to buy coverage, but the GOP plan would encourage states “to create a Universal Access Program by establishing and/or reforming existing programs to guarantee all Americans, regardless of pre-existing conditions or past illnesses … access to affordable coverage.” Development of the GOP plan was led by Representative Roy Blunt.
4. Last week the Chairs of the three House committees with jurisdiction on health care reform released a framework for reform. The Tri-Committee Health Reform Draft Proposal, put forward by House of Representative Chairs Charles Rangel of the Ways and Means Committee, Henry Waxman of the Energy and Commerce Committee, and George Miller of the Education and Labor Committee outlines the key provisions of a unified Democratic reform package. The framework calls for creation of a government-run health plan to compete with private carriers, requires all Americans to obtain coverage (with exemptions in cases of financial hardship), requires most employers to either provide coverage or pay a fee, and provides subsidies for Americans households with incomes up to 400 percent of the federal poverty level.

There will be many more proposals coming soon. As it is relatively early in the legislative process, most will stake out relatively pure ideological positions. Neither party has an incentive to offer compromise solutions yet. So House Democrats, along with Senator Edward Kennedy and his Health, Education, Labor and Pensions Committee, will anchor the left and the GOP Leadership and conservative Senators will anchor the right. As in most negotiations, the goal is to establish a starting position so far to one extreme or the other that the middle shifts in their direction.  

There will be some pragmatic proposals put forward as well. The most anticipated is that expected to be coming soon from the Senate Finance Committee. It’s Chair, Max Baucus, and its Ranking Member, Charles Grassley, seem to be sincere in their efforts to put forward a bi-partisan solution. In the meantime, President Barack Obama will keep up a drumbeat in support of getting comprehensive health care reform legislation through Congress before the end of the year. Although the White House continues to let Congress take the lead in fashioning the final reform package, the Obama Administration is beginning to get more engaged in the legislative process.

What the final health care reform legislation will look like is, as yet, unknown. It may resemble one of the ideas already put forward. Or perhaps something new to the mix will gain momentum. I’m betting that something will pass this year. The process of getting to one bill will be messy, but eventually, a consensus will form.

Not yet, but eventually.