Health Reform State of Play
Stan Dorn, senior research associate at the Urban Institute, says that in the game of health care reform legislation, "We are in the playoffs."
The players are largely Democrats and the few Republicans who are not opposing reforms outright. Here is a roundup of the agreements and debates in Washington, D.C., as well as a few story ideas, which Dorn outlined in this morning's seminar with the National Health Journalism Fellows.
Consensus: Insurance reform is popular but the only way to achieve it is by mandating and subsidizing coverage.
Debate: Is it possible to reform insurance with $900 billion over 10 years?
Untold Story: Is this limit, created by what Dorn calls, "political math," an artificial ceiling that will ruin any new program?
Consensus: Legislators agree that they want to increase Medicaid eligibility to the poorest of the uninsured, those who make 133 percent of the Federal Poverty Guidelines (FPL).
Debate: How much financial responsibility will the states take for the added cost?
Untold Story: Medicaid eligibility is limited. Low-income childless adults who are not too disabled to work are ineligible. Also, what happens to the uninsured over 50 and under 65?
Consensus: Those who earn between 133 and 400 percent of the federal poverty level should receive subsidies, which should not apply to undocumented immigrants.
Debate: How much should the subsidies be and how of much of them should go to premiums versus out-of-pocket costs? Should subsidies be offerred as a tax credit or payment to health plans? How can the government prevent subsidies from funding elective abortions? Should legal immigrants qualify in their first five years in the U.S.? The Children's Health Insurance Program (CHIP) already covers the children in this income group, so what should happen to this program?
Untold Story: "But viruses don't discriminate against undocumented immigrants," said fellow Viji Sundaram of New America Media. There has been no debate in Congress on issues related to pandemic or bioterrorism. Emergency care is one place for care, "but this is a huge question," said Dorn.
Consensus: Small firms that are not currently offering employees health insurance can enter a Health Insurance Exchange that will allow workers to choose from several plan options.
Debate: Should there be a public option? Should large firms be allowed in and should it be run by the state or federal government? Is the Exchange just meant to list plans, or is its role to negotiate good rates? Can undocumented immigrants buy coverage through the Exchange?
Untold Stories: "If you build it, will they come?" asked Dorn. Reporters can investigate if people will actually join new plans. What are the differences between the Massachusetts program that is being held up as a model and the bills before Congress?
Consensus: Individuals who can afford insurance will be penalized if they do not get coverage. Employers above a certain size must offer insurance or pay a penalty to the government.
Debate: How do you define affordability? Should there be a payroll tax for employers whose workers are being subsidized?
Consensus: Health insurance companies must have minimum benefit standards. They are limited in their discrimination against consumers with high health costs.
Debate: How extensive should the standards be? Can people keep their current insurance even if they do not meet the new standards? How much can premiums vary based on age? The insurance companies can only afford these new rules if people buy insurance before they get sick, so what will happen until the individual mandate and subsidies are enacted?
Consensus: We must experiment with innovations that help control cost and shift incentives from volume to value, as well as prevention. The effectiveness of programs need to be researched and made transparent to guide informed decisions.
Debate: "One person's cost control is another person's livelihood," said Dorn. How will reform navigate everyone's interests in changing incentives?
Consensus: Health care reform will not add to the deficit because of new revenue and the slowed the growth of Medicare costs.
Debate: How much in new costs are acceptable, and how will Medicare cost growth be slowed? How will new revenue be raised?
Untold Stories: What is the impact of the uninsured? "The question of, 'Who pays?' is really what the health care system is all about," said Peter Harbage, the president and founder of health care consulting firm Harbage & Associates. The cost of the health care for the uninsured is shifted to the insured; 8 percent of the $13,200 average family premium in 2009 goes to uncompensated care, according to the Center for American Progress Action Fund. Dorn also adds that in the early 80s, our health care costs suddenly skyrocketed compared to other industrialized nations. Why did this happen?