Saturday, August 29, 2009


One of the effects of the exaggerations, misinterpretations, distortions, and downright lies about Congressional health care reform proposals—mostly from far-right politicians and their hangers-on—has been to deter more objective analysis.

In fact, two key features of the current Senate and House bills—the insurance exchange structure, and the controversial public plan option—need much closer examination, and possibly considerable revision.

FIRST, the insurance exchange structure. It’s a reasonable concept: if insurers were to compete via an exchange for individual and small group business, they would offer highly competitive rates to attract as much business as possible.

Unfortunately, as a Health Affairs blog piece by the former managers of the PacAdvantage exchange makes clear, it isn’t as simple as that. PacAdvantage, which served some 150,000 California small business employees, ultimately collapsed and closed its doors in 2006, a victim of adverse selection. As the PacAdvantage managers explain, having insurers also marketing directly to small groups allowed them to cherry pick the best risks, leaving the less-good risks in the exchange. As adverse selection continued its work, the exchange went into a death spiral with worsening exchange risk leading to higher rates, leading to the least-bad risks leaving the exchange, leading to even higher exchange rates, and so on.

The obvious way to avoid this problem in national reform is to require that ALL individuals and ALL small group employees be included in each regional exchange. Unfortunately, health reforming politicians have adopted “you’ll be able to retain your existing coverage” as part of their reform pitch. It’s understandable, since forcing groups to switch to an exchange is not going to help the prospects of legislation that’s already in trouble, but it instantly opens the door to cherry-picking by insurers, with the prospect of failure of every exchange.

Is there a solution? Rather than imposing an additional mandate on businesses, current bills could be modified to require that all insurers participate in the exchange, and that their exchange rates be no higher than those offered directly to any insured group, thereby forcing insurers to treat exchange and non-exchange insureds as part of the same pool and avoiding the adverse selection effect.

SECOND, the public plan option. So far, the political controversy has focused on the obvious arguments for and against the public plan: it would force insurers to offer better rates, but it could push millions of Americans out of private coverage into a government program.

A close look at data from Medicare Advantage, in which private plans compete with the traditional government option, indicates that both arguments are questionable.

MA’s private coverage alternative is indeed more costly than traditional Medicare, by some 13 percent—more than $11 billion in 2009. However, most of the difference is due to the additional benefits offered. The private plans’ 2009 base bids to CMS—excluding the cost of additional benefits—averaged 102 percent of FFS rates, with HMO and PPO bids averaging just 99 percent of FFS.

These base bid rates include profit and administrative costs, in contrast to the FFS rates which exclude both administration and financing costs. Even the most conservative estimate of these additional costs would put fully-loaded FFS rates above those of the average private plan.

The comparison of Medicare FFS and MA plans is further skewed by the MA bid process. Not only do the ridiculously high “county benchmarks” used in payment setting favor high bids, but the payment formula (which discounts the difference between the base bid and the benchmark, but not the base bid itself) encourages excessive loading of profit and administration into the base bid. In other words, in a more rationally designed competitive environment, average private plan costs should be significantly below those of traditional Medicare.

In terms of the current Senate Health and House bills, with proposed payment rates higher than Medicare, the public plan looks even less competitive. While there would undoubtedly be some who would opt for a government program over a private plan, the vast majority are likely to choose the lower cost option, with the public plan more likely to increase health care costs than decrease them.

Are there compromises that might satisfy liberal politicians’ desires for a public plan? One possibility is to build a “trigger” into the bills that would allow creation of public plans only where private plans fail to meet cost control benchmarks.

Another possibility is to build on the existing public plan for the non-elderly: Medicaid. Congressional committees are already proposing Medicaid expansions, while simultaneously proposing subsidies to make exchange participation more affordable for non-Medicaid eligibles, leading to an anomalous situation in which one family may receive free Medicaid coverage, while a second family whose income is only a few dollars greater is forced to pay a significant part of the exchange premium in order to comply with an individual coverage mandate.

A less costly and unfair approach might be to allow individuals to buy-in to Medicaid. Since average per capita Medicaid costs are approximately $2000, compared with estimated subsidy costs of close to $4000 (based on CBO estimates, in 2009 dollars), this would eliminate both the anomaly and the need for subsidies, with a potential dramatic reduction in the ten-year cost of reform of some $770 billion.

Thursday, August 6, 2009


Five congressional committees and their staffs, plus numerous Obama administration officials, have been working on health care reform for more than three months, with no immediate end in sight. Is health care reform legislation getting closer, or is its likelihood actually receding? What’s the state of play?

In the House, three versions of HR 3200, “America’s Affordable Health Choices Act,” have been passed by the three responsible committees (Ways and Means, Education and Labor, and Energy and Commerce). The Energy and Commerce version differs significantly from the other two in several respects following the refusal of Blue Dog Democrats to support the original version: it reduces Medicare payment disparities between urban and rural areas, it modifies the public plan provision to require that payments be negotiated with providers rather than tied to Medicare rates, and it shifts some of the cost of Medicaid expansion to states. Preliminary CBO scoring puts the ten-year federal cost of the various versions of HR 3200 in the $900-$1,100 billion range, with minimal impact on overall national health care cost trends.

The next step, following the August recess, will be for the full House to debate the various versions and then to vote on a single bill. Given that conservative Democrats have insisted on the public plan payment negotiation provision, while liberal Democrats have been equally vehement in condemning the requirement (and no Republican support is expected for any version), the bill’s fate is uncertain. However, since any possible final legislation will also depend on Senate action (and therefore can be blamed on the other chamber), a compromise seems probable.

In the Senate, a draft bill—the Affordable Health Choices Act—has emerged only from the Health, Education, Labor and Pensions Committee. Generally, this bill follows the pattern of HR 3200 (insurance exchanges, insurance reform, individual and employer mandates). The CBO has estimated that the ten-year federal cost of this bill would be some $600 billion, but this number excludes the cost of Medicaid expansion. (Note that the CBO’s ten-year estimates include only about six years of full implementation.)

The Senate Finance Committee is attempting to craft a bill to attract some bipartisan support, with committee negotiators from the two parties continuing to meet. Whether the negotiators will be able to resolve their differences is far from certain, especially with the Republican members of the group coming under fire from their own party for trying to work with the Democratic majority.

With the House already enjoying the August recess and the Senate also closing down for the remainder of the month, what’s likely to happen next?

A lot depends on Senate Finance. A breakthrough in negotiations there would presumably produce a bill that could attract at least the magical sixty votes (despite their nominal sixty members, the critical illnesses of Senators Kennedy and Byrd make it unlikely that Democrats could produce a filibuster-proof majority without some Republican support). In turn, Senate Finance’s actions will influence House members. A bipartisan Senate bill will likely encourage Blue Dog Democrats to push hard for inclusion of its more conservative provisions in the House bill. Alternatively, failure of Senate Finance negotiations may result in a more liberal House bill, since Democrats will see less reason for compromise. Also, without a bipartisan agreement in the Senate, Democrats may be forced to use the reconciliation process in order to sidestep the need for sixty votes.

Assuming that reform bills do reach the point of a vote in each chamber, what are the chances of passage? It looks like a toss-up. On the one hand, Democrats—liberal and conservative—have expended enormous energy in pushing for reform; failure to pass any reform legislation would be a huge defeat for the party, and a threat that might cause even the most doctrinaire members to compromise. On the other hand, momentum has been lost, opponents are energized, the public is confused, and—given the difficulty of making changes to our complex health care system—health care costs will continue to increase and the number of uninsured will continue to rise for some time even after passage of a bill before any improvement becomes apparent. At least some erstwhile supporters of reform may choose to avoid being blamed for voting for something that is going to take even longer than the economic stimulus to produce results.