You’d have to change the way things have been done and that is the fact that there have been no real negotiations. There has been a bill before committee, on which I sit, the HELP committee and it was done by Democrats and no amendments were agreed to of any significance and so that’s not the kind of negotiations I did with Senator Kennedy.

Watch it:

While McCain and the other Republicans on the HELP committee tried to delay the mark-up process by offering numerous nuance amendments and complaining that the Congressional Budget Office (CBO) had not yet scored the entire proposal, the committee accepted 160 Republican amendments and spent 13 days and more than 60 hours debating the legislation. McCain objected to mark-up from the very beginning, arguing that the committee should “scrap the current bill and start over and start over in a true bipartisan fashion.”

As Slate’s Christopher Beam pointed out, “many of the GOP amendments on this incomplete list do seem pretty substantive.” (The committee even accepted several of McCain’s more substantive amendments):

- McCain 205: To establish certain policies for small group health plans

- McCain 2: Determines whether existing Federal Government sponsored health and wellness initiatives are effective in achieving their stated goals.

- Enzi 25: To impose an earning requirement with respect to enrollees.

- Hatch: Adds programs based on pain care, environment, antimicrobial resistance, oral health, wellness programs for at risk populations.

Since Kennedy’s death, a long line of Republicans have argued that “Kennedy’s absence from the health care debate prevented lawmakers from reaching a bipartisan compromise and that had Kennedy been present, agreement on health care reform would have been more likely.” But as Ezra Klein argues, “this stuff just isn’t plausible. Kennedy was around in 1994 and there was no deal. More to the point, Kennedy’s committee, the HELP Committee, has passed health-care reform. Kennedy’s staff, as you might expect, led their effort. But neither Kennedy nor his staff can make the deals for another committee. If Kennedy were in the Senate now, health care would be exactly where it is: Through Ted Kennedy’s Committee and stuck in the morass of Max Baucus’s Gang of Six. ”

Indeed, the GOP has refused to negotiate in good faith, consistantly misrepresenting the consequences of reform and fearmongering about the public health insurance option. Some Republicans are also manipulating the events of the August recess to argue that that Americans are more concerned about jobs than health care reform and are urging Congress to abandon the present effort and adopt “incremental” changes.

Describing that the HELP bill — which passed committee after 11 days of mark-up and 160 Republican amendments — as a “bipartisan, American bill,” Brown warned that if Baucus tries to satisfy “conservative lawmakers” from small states, “it means a lot of others aren’t [satisfied], including, I think, the majority of the country.” The HELP bill isn’t “bipartisan on the big fundamental issues,” like the public option and the employer mandate, Brown said, “but neither was Medicare. We would have never gotten Medicare 40 years ago if everyone had waited for the conservative Republicans to join on board”:

We had 11 days of mark up, 11 days of considering amendments in the HELP Committee. I’ve been in the House and Senate for a total of 16, 17 years now, and I have never seen a bill, in all this time that had that much attention paid to it, that many amendments, that long a period of mark up. We accepted 160 Republican amendments, this is a bipartisan bill. It’s just not bipartisan on the big fundamental issues, but neither was Medicare. We would have never gotten Medicare 40 years ago if everyone had waited for the conservative Republicans to join on board. It’s a difference in views….There is a deadline of September 15th. We need to enforce it. If Senator Baucus can’t get a deal by then we need to move forward and pass this bill. And we should use the HELP Committee bill, which is mainstream Democratic bill, mainstream American bill, and begin to move it through the Senate.

Watch it:

Passing the HELP bill through the Senate may present some difficulty. Since the HELP committee doesn’t have jursidiction over Medicare, Medicaid, or financing, lawmakers would have to add the necessary provisions in conference or on the floor, in the form of amendments. Circumventing the Senate Finance Committee, while rewarding the hard work of the HELP Committee, would certainly outrage the defenders of ‘bipartisanship’ and it’s unclear how many senators would be willing to outsource key decisions to a conference committee.

Still, the President is determined to pass a health care bill this year and yesterday, during an interview with MSNBC, he left the door open to Brown’s approach. “You know, I am glad that in the Senate Finance Committee, there have been a couple of Republicans…who have been willing to negotiate with Democrats to try and produce a bill,” Obama said, “but they haven’t yet and I think at some point, some time in September, we are just going to have to make an assessment.” “I would prefer Republicans working with us on that because I think it’s the interest of everybody. That shouldn’t be a partisan issue.”

Transcript:

BROWN: Mike Enzi represents a state of about 6 or 700,000 people

O’DONELL: Just to correct you, he represents a state of 540,000 people fewer than live on Staten Island. You represent a state of 11 million, that is more people than all 6 senators who are on the Senate Finance Committee who are behind the closed door right now combined. They all represent very small states. [...]

BROWN: We had 11 days of mark up, 11 days of considering amendments in the HELP Committee. I’ve been in the House and Senate for a total of 16, 17 years now, and I have never seen a bill, in all this time that had that much attention paid to it, that many amendments, that long a period of mark up. We accepted 160 Republican amendments, this is a bipartisan bill. It’s just not bipartisan on the big fundamental issues, but neither was Medicare. We would have never gotten Medicare 40 years ago if everyone had waited for the conservative Republicans to join on board. It’s a difference in views. I’ll accept Republican amendments when I think they’re good for my values and good for the middle class and good for my state. But these big issues like public option, like subsidies for low income people, like some of the prevention and wellness stuff. These are differences between the two parties and Senator Enzi isn’t where the majority of Americans are in these issues, I believe. [...]

BROWN: There is a deadline of September 15th. We need to enforce it. If Senator Baucus can’t get a deal by then we need to move forward and pass this bill. And we should use the HELP Committee bill, which is mainstream Democratic bill, mainstream American bill, and begin to move it through the Senate.

Throughout the mark-up process, Republicans delayed progress by offering nonsensical amendments, eliminating affordability measures for middle class families, offering non-starter alternatives, and arguing that the committee should terminate its hearings. Responding to today’s vote, the HELP committee Republicans reiterated their claims that the bill would add to the deficit, leave millions without coverage, push Americans out of their current insurance plans, and lead to greater unemployment with choreographed repetition. Watch a compilation:

Unfortunately, repeating talking points doesn’t make them true. Below is a fact check of Republican claims:

CLAIM: The bill will contribute trillions of dollars to the national deficit.

FACT: The budget framework requires a deficit-neutral health care reform bill, and the Democrats have pledged to fully finance coverage expansion from savings within the system and new sources of revenue. The Senate Finance Committee is responsible for financing the measure.

CLAIM: Force millions of Americans out of their current coverage.

FACT: According to CBO’s comprehensive analysis of the HELP committee bill, the legislation increases the number of Americans with private insurance and strengthens the employer-based system of coverage (as a result of the employer-mandate an extra 1 million Americans will have employer-sponsored coverage by 2017).

CLAIM: 34 million Americans will remain uninsured.

FACT: Since the HELP committee does not have jursidiction over Medicaid expansion, its bill officially covers an additional 20 million Americans. Republicans claim that 34 million would be left uninsured by subtracting that 20 million from the 54 million who are projected to be without coverage by 2019. However, if we assume Medicaid expansion — which the Senate Finance Committee will include in its health care bill — reform would expand coverage to 20 million additional Americans, covering nearly 97% of all legal Americans by 2019.

CLAIM: Employer mandate will tax employers and make people lose their jobs.

FACT: The bill exempts small businesses from the mandate and even offers them a credit to help make providing coverage more affordable. The madante for large employers will help pay for health care reform and, rather than resulting in “massive job losses” as Republicans claim, actually preserves the employer system of coverage. Real life experiences with employer mandates in Hawaii and Massachusetts have found no evidence of reduced employment.

As GOP pollster Frank Luntz conceded during a recent interview with the New York Times Magazine, Republicans will label the Democratic reform effort a “government takeover” of health care, regardless of the actual legislation. They are more interested in obstructing health care reform than they are in engaging in a bipartisan compromise. A new strategy memo by GOP consultant Alex Castellanos, for instance, suggested that “it is crucial for Republicans to slow down what it calls ‘the Obama experiment with our health.’”

Initially, given its limited size, a public health insurance option may have difficulty securing cheaper rates with providers. But by reimbursing providers some percentage above Medicare rates, the public option would benefit from Medicare’s ability to negotiate with providers (and given its size and national presence it can negotiate lower rates) and pass on the savings to consumers. Compelling Medicare providers to also accept enrollees from the new public option would ensure a large provider base.

Though the House bill is not perfect—it encourages providers to participate rather than compells them to—it goes much further than the Kenedy bill to take full advantage of a public plan’s market power.

Under the House legislation, Medicare providers are auto-enrolled as providers in the public option (the legislation presumes they will offer coverage unless they opt out) and their reimbursement rates, which are tied to Medicare rates for the first three years, include a 5% bonus for physicians that participate in both Medicare and the public plan.

In other words, rather than compelling participation, the bill incentivizes it and in the process secures a strong provider base that will attract more enrollees and allow the public plan to grow to a point where it can secure real savings. As the CBO notes, “on average the public plan would be about 10 percent cheaper than a typical private plan offered in the exchanges. That difference in premiums is itself the net effect of differences in the major factors that affect all insurance plans’ premiums, including their payment rates to providers, their administrative costs, the degree of benefit management they apply to control spending, and the pool of enrollees they attract.”

- Enzi 200: To eliminate subsidies for those above 250 percent of poverty
- Enzi 201: To eliminate subsidies for those above 250 percent of poverty
- Enzi 202: To provide for reductions in subsidies
- Enzi 211: To limit subsidies to those below 250 percent of poverty.
- Enzi 251: To limit subsidies to those below 250 percent of poverty
- Gregg 223: To limit subsidies to those below 200 percent of poverty.
- Roberts 203: Limiting Premium and Cost-Sharing credits to people below 200% of FPL

Watch a compilation:

In reality, millions of Americans at about 250% FPL are struggling to afford skyrocketing health care costs. A recent study concluded that medical debt contributed to 62 percent of U.S. personal bankruptcies in 2007 — and 78 percent of bankruptcy filers had health insurance but “still were overwhelmed by their medical debt.“ One in five Americans had trouble paying their health care bills in 2007 and even moderate levels of out-of-pocket spending — spending that is as low as 5 or 10 percent of family income —created medical bill problems.

Health care reform must end medical debt and medical bankruptcy, but Republican affordability measures are simply insufficient. The question of affordability is two-fold: which income levels do we subsidize and how much subsidies should the eligible families receive. While the cost of living varies widely across the country, on average, a family of three would need at least $37,919 – or about 200% FPL – to afford their basic necessities not including health care costs. So families up to 200% need to be subsidized, but who else?

Well, researchers suggest that families that spend more than 5-9% of their gross income on health care begin confronting affordability problems. As Karen Pollitz points out, “depending on what premiums are charged for qualified health benefit plans” subsidies capped above a certain level “may prove to be insufficient to ensure affordable health care for all Americans.” Congress “might consider instead a rule that no individual or family will have to pay more than 10 percent of income on health insurance premiums….cutting subsidies off entirely at an arbitrary income level can leave families vulnerable,” she says. Families at approximately 500% FPL ($110,250 for a family of four), however, can typically afford the cost of coverage.

Of course, the entire goal of reform is to slow the growth of health care costs and lower premiums for families. In this sense, subsidizing coverage — that is, making sure that every family can afford to access needed services — is a way of saving money in the long haul. After all, the billions we’re spending on subsidies is a small fraction of the $40 trillion we’re projected to spend on health care in the next ten years if we fail to slow the growth of spending.

Enzi and Hatch argued that the penalty levied on employers who fail to obtain coverage for their workers and individuals was “a new tax” that undermined “President Obama’s own commitment to not raise taxes on 95% of Americans.”

Watch a compilation:

But to characterize the employer and individual mandates as new taxes is highly disingenuous. Health reform builds on the principle of “shared responsibility,” an approach that envisions “joint contributions by the public sector, individuals and employers.” While individuals are responsible for purchasing health insurance coverage — with a waiver for those who cannot afford to do so — “firms that do not directly provide health care to their employees” would be required to pay into a public pool to help finance their employees’ coverage.

Both policies are part of a larger strategy designed to lower health care costs. The bill exempts small businesses from the mandate, offers a tax credit to help them afford coverage, subsidizes insurance for middle class Americans, and allows the lowest income Americans to enroll in the Medicaid program. All this is designed to slow the growth of health care premiums. After all, only if you have everyone in the system, can you really invest in preventive care, reduce expensive chronic disease treatments, and eliminate the cost shift from the uninsured.

Moreover, as UC Berkeley Labor Center chair Ken Jacobs and Berkeley professor Jacob Hacker explain, an employer mandate enhances the existing system of employer-based coverage, levels the playing field between employers “that provide insurance and those competing with them that do not,” reduces “crowd-out of private coverage by new public programs,” and preserves the employer contribution — an important source of funding for health care reform. And while Republicans charge that an employer mandate to provide coverage would lead to fewer jobs or mass layoffs, especially for low-wage workers, Hacker contends that “these concerns are overstated when it comes to the play-or-pay proposals currently under consideration, with their relatively modest employer requirements.”

A study of the impact of the Hawaii health care mandate, for instance, “found no evidence of reduced employment.” In Massachusetts, where employers with more than 10 employees are required to provide coverage or pay a fine, “few firms reported making changes as a result of health reform.” Moreover, “it is also important to keep in mind that health reforms with employer requirements promise new benefits for firms and workers as well as new costs,” Hacker explained in testimony to the House Education and Labor Committee. “All firms would benefit from the reduction in unpaid medical bills incurred by the uninsured. Firms would further benefit from any savings due to a reduced rate of health-care cost growth,” Hacker said.

On the whole, the consequences of failing to reform health care reform far outweigh any penalty levied on the individual or the employer. As economist Uwe Reindhardt points out, the “cost” of the health care reform bill is a small fraction of the $40 trillion we’re projected to spend on health care in the next ten years. Should we fail to reform the health care system, the cost of health insurance for a family of four “will stand at $18,000 by 2010″ or $36,000 per typical nonelderly family of four by 2020. “Millions upon millions of middle-class families will see themselves pushed into the ranks of the uninsured — and possibly into bankruptcy — unless someone helps them financially.” Currently, too many Republicans are simply standing in the way.

Transcript:

ENZI: We also need to acknowledge why the estimates of the bill are lower than the first numbers we saw. The first reason is because the bill contains a new tax on employers who do not offer health insurance to their employees. This new tax will drive down wages and cause employers to reduce the number of their employees.

HATCH: Job killing employer mandate, that is going to tax American businesses by almost 52 billion dollars?

ENZI: Most economists agree that the effect of this economic growth killing tax will fall disproportionatly on low income and minority populations.

HATCH: Now this is at a time that American families are struggling to pay their bills and keep their homes.

ENZI: With the unemployment rate now close to 10% we should be finding ways to create new jobs for Americans rather than imposing new taxes that will cut their pay and cost them their jobs.

HATCH: This is going to lead to lower wages and more job loss at a time where our national unemployment rate is at almost 10% and rising.

ENZI: The bill also reduces its cost estimate by violating one of President Obama’s campaign pledges from last year. President Obama promised that he would not increase taxes on families who made less than $250,000.

HATCH: This onerous mandate flies in the face, as the distinguished ranking member said, of President Obama’s own commitment to not raise taxes on 95% of Americans.

ENZI: But that is what this bill does. It taxes Americans who do not have health insurance. Most of those families make less than $250,000 a year. But according to the CBO under this bill they’ll have to pay 36 billion in new tax penalties over the next ten years.

HATCH: 36 billion dollars in additional tax revenue?

ENZI: There should be no doubt the American people should understand, and the Administration should understand, that this bill breaks that campaign pledge on taxes.

Here is a partial comparison of how the committee reduced the price tag (all numbers are over a ten-year period):

The most interesting saving came from the reduction in subsidies. The original language allowed for $1,279 billion in subsidies, but the new bill scored a $723 billion price tag with the CBO, a 40 percent reduction. What happened? Well, the CBO concluded that by implementing an employer mandate more Americans would retain their work-place insurance and fewer would have to purchase coverage from the Exchange. As a result, the government would have to spend less money subsidizing coverage (since the employer contribution would be preserved); employers who don’t offer coverage would pay a penalty of $750 per full-time employee, $375 for each part-time employee, that would bring in an extra $52 billion for health care reform!

The bill also saves money by reducing the subsidy eligibility from 500% FPL to 400% FPL. Now, American families of four with incomes between 400% FPL ($88,000) and 150% FPL ($33,000) would receive government assistance when purchasing insurance, but the subsidies do not kick in for a family of four at $400% FPL until they have spent more than 12.5% (or $11,000) of their gross adjusted income on health insurance — a percentage that’s substantially higher than the 6% threshold most affordability experts recommend.

The bill also finds approximately $59 billion in new revenues from premiums collected for long term care paid by individuals purchasing disability insurance through the Community Living Assistance Services and Supports (CLASS) Act, legislation currently under consideration that would create an insurance program for adults who become functionally disabled. The CLASS Act establishes “a national insurance program to be financed by voluntary payroll deductions to provide benefits to adults who become severely functionally impaired.” All working adults will be automatically enrolled in the program, unless they choose not to be.

The HELP committee does not have jursidiction over Medicaid expansion or financing of reform. Thus, its bill only covers an additional 20 million Americans and costs approximately $600 billion. However, if we assume Medicaid expansion to about 150% FPL we expand coverage, but we also add to cost, bringing the final bill to somewhere around $1 trillion over 10 years. Cohn runs the numbers for what the final results may look like:

- 20 million: Number of uninsured in 2019, compared to 54 million without reform.

- 95 percent: Percentage of Americans with coverage in 2019.

- 21 million by 2019: Additional people covered through Exchange and employer mandate.

- 20 million by 2019: Additional people covered through Medicaid expansion of up to 150% FPL.

The preliminary CBO score of the early and incomplete HELP legislation placed the cost at $1 trillion and this latest analysis suggests that the committee has been able to find savings of some $400 billion ($1 trillion – $600 billion = $400 billion). Some of that new revenue will come from the employer mandate (an AP story suggests that the mandate will generate $52 billion over 10 years), but where do we get the rest? Lower subsidies (the original version may have provided subsides at 500% FPL, now it looks like it’s down to 400% FPL)? The public option? Only the yet-to-be released CBO score can provide those answers.

But the HELP Committee’s chairman’s mark – which, for the first time includes language on the public plan and the employer mandate – does offer some new details for how the mandate and the public plan could be structured:

- Employer mandate: Large employers would have to provide coverage to their workers or pay $750 per full-time employee, $375 for each part-time employee. Businesses with less than 25 employees will receive a tax credit, on a sliding scale, based on the number of workers. Ezra Klein points out, “the CBO estimates that “a mere 150,000 will lose their coverage. That’s nothing. And it means that a lot more Americans end up insured and the government spends a lot less in subsidies.”

An employer mandate is meant to strengthen the employer-based system of coverage and reduce crowd-out into the Gateway. Crowd out (and this is what critics latch on to when they claim that Obama overstated his promise to allow Americans to keep their present coverage) is less likely if employers are required to contribute a meaningful amount “to the cost of covering their uninsured workers,” because the cost of allowing their workers to be covered through other options is not much lower.

The dear colleague letter that accompanied the new mark stated that “the completed bill virtually eliminates the dropping of currently covered employees from employer-sponsored health plans,” but some may be surprised that a modest flat fee is a sufficient deterrent to dropping coverage. The decision to charge every firm the same penalty — instead of charging firms on a sliding scale based on payroll — does not account for firm size or profitability and smaller firms and firms with lower-wage workers, could be disadvantaged.

However, it should also be noted that Massachusetts requires employers with more than ten employees to either offer a “fair and reasonable” contribution for their employees’ coverage, or “pay an annual ‘fair share’ contribution of $295 per employee.” In Massachusetts, few firms reported making changes as a result of health reform, firms reported making few changes in cost sharing or in offering more plans are a result of the mandate.

- Community Health Insurance Option: Will have to compete on a level playing field with private providers and offer competitive rates and premiums. Presumably, the plan will be able to use its administrative efficiency and its market power (assuming it is able to attract a significant number of applicants and providers) to lower premiums:

- Health care providers and individuals are NOT required to participate in the new plan, it is entirely voluntary.

- The Secretary of Health and Human Services will establish the public option in every single Gateway (whether it is regional or national) and provide the national plan with start-up funds that will have to be repaid in 10 years.

- The new plan provide coverage only for the essential health benefits, but states may offer additional benefits if they choose

- Premium rates should cover the expected costs of the plan

- The rates negotiated with providers shall not be higher, in aggregate, than the average reimbursement rates paid by health insurance issuers offering qualified health plans through the Gateway.

At the time, the New York Times had reported that the committee was considering a public plan that would reimburse providers 10 percent above Medicare rates. The outline released today doesn’t preclude that possibility, but it makes it less likely.

The new HELP framework allows the public plan to “reimburse health care providers at rates which will be no more than the average reimbursement rate paid by private plans offered through Gateways.” Under this arrangement, the new public plan would have to negotiate its own rates and play by the same rules as other private insurers within the Gateway (i.e. Exchange) — it “would follow the same rules as private plans for defining benefits, protecting consumers, and setting premiums.” What’s more, the public option would be responsible for attracting providers and would thus have to rely on competitive rates (instead of Medicare-like rates) to retain enough participants.

During its first few years of operation, the public plan would be protected from becoming a dumping ground for sicker and costlier patients. Under the outline, it would qualify for “risk corridor protections” to “offset or reclaim excessive losses and gains which could result during the start-up period (identical to those in Medicare Part D). Subsequently, its premiums would be set to make it self sufficient.”

On the whole, then, the plan follows Sen. Chuck Schumer’s (D-NY) level playing arrangement. Some of the public plan’s inherent advantages — i.e. its ability to use Medicare rates and Medicare leverage — are intentionally dulled. Still, the national option would be able, in due time, to build a strong market presence and use its size and market presence to inject competition in the insurance markets and drive down costs.

We get into this cost. We get into this repetitive word, “rationing”, “rationing.” It goes over very well with focus groups, but it has no rational here. If you go to page 323 of the actual bill, where it says ‘Incorporation.’ We absolutely prohibit that this, anything related to the Center For Health Outcomes, otherwise known as comparative effectiveness, that there “shall not be construed as mandates for payment, coverage, or treatment.” It is in the bill. Page 323, lines 5 through 7.

Watch a compilation:

Republicans relied on a three-part attack. One, ignore the existing language and offer redundant amendments prohibiting the comparative effectiveness center from mandating that doctors prescribe ‘the best’ treatments. Two — this is a somewhat more coherent strategy — argue that the Center for Medicare and Medicaid Services (CMS) could use the information to make coverage decisions for Medicare. And three, if the government uses the comparative research results to establish best practice guidelines, then doctors who don’t follow the guidelines but rather consider the individual needs of their patients, could be liable for malpractice claims.

But even the last two arguments fall apart on close scrutiny. The government isn’t mandating that doctors adopt the results of CER and it is not rationing care. Each patient has his or her unique needs and the ultimate decision for how to proceed should be left to the doctor and the patient. Currently, approximately one-third of all treatments have never been proven to produce better outcomes; CER would provide doctors with unbiased information about the most effective treatments, help doctors and patients make better informed decisions, and improve the quality of care.

Moreover, far from establishing one-size-fits all medicine or dictating treatments, properly conducted CER will actually promote faster adoption of personalized care. As Alan Garber of Stanford and Sean Tunis of the Center for Medical Technology Policy point out, “far from impeding personalized medicine, CER offers a way to hasten the discovery of the best approaches to personalization, providing more and better information with which to craft a management strategy for each individual patient.” The new CER council and CMS seek to preserve a personalized approach — that is, allow doctors to make decisions based on a patient’s history and individual needs — while eliminating truly ineffective treatments.

CER results are rarely black and white and no one study should serve as a final word on a coverage decision. But given the amount of unnecessary, redundant and ultimately harmful treatments, the government has an interest in informing health care providers about best practices– and this is what the legislation does and our doctors want. More efficient medicine is better medicine, and anyone who wants to prevent the system from wasting money is in the pockets of the medical industrial complex that is getting rich while we get sick.

After all, the “art of medicine,” as Coburn calls it, already relies on certain standards and practice guidelines and physicians often incorporate their knowledge of the patient and clinical experience to offer a patient-centered approach, as such only about half of the recommended guidelines are followed. Ultimately, however, doctors are not superheroes; they should not be ignoring “standard protocols” or attempting to re-enact the heroics of Fox’s HOUSE. They are currently driven by a set of professional standards and procedures, and as patients, it is in our interest to encourage providers to incorporate certain guidelines (derived from CER) into routine practice. After all, “the last thing most Americans want from this wise use of taxpayer funds is more published research gathering dust on library shelves.”

I’ll tell you the other reason I think health care in this country is pretty good and good for my Medicaid patients and good for patients with no health insurance. Because when somebody gets cancer, most of the time we get them well. Most of the time we get them well. Some fall through the cracks, that’s true. But as a two-time cancer survivor, I think this health care is pretty damn good, I think it’s pretty dang good.

Watch it:

But just last month, the senator unveiled ‘The Patients’ Choice Act,’ a GOP alternative to the President’s plan, which recognized the health care crisis. “It is time to publicly admit that the health care system in America is broken…And 47 million Americans worry what will happen to them or their children if they get sick,” a summary of the bill read. Now, just a month later, Coburn, who is clearly satisfied with his own government-sponsored health care plan, has lost interest in helping Americans secure access to affordable.

In his four years in the Senate, Coburn has earned the reputation of “a fly in the soup,” abusing the senate’s hold privilege — a technique which allows senators to “object to bringing a bill or nomination to the floor for consideration” — to prevent “the Senate leadership” from bringing matters to a vote. Remarkably, Coburn’s obstructionism has even led “senate aides to now take legislation directly to Coburn’s office” to ensure “he has no objections.” Last summer, Sen. Harry Reid (D-NV) wrapped most of the non-controversial bills held by Coburn into one large measure — called the Tomnibus — in an effort to pass the mostly bipartisan legislation.

In an effort to delay the committee’s reform efforts, Coburn plans to offer numerous nuance amendments (read them all here):

- Doctor on doctor spying: To establish a demonstration project that uses practicing health care professionals to conduct undercover investigations of other health care providers in order to determine the quality of health care provided by such other providers. [Coburn, 11 & 87]

- Protecting unborn children: To provide for the establishment of an Office of Unborn Children’s Health (O.U.C.H.) [Coburn, 13]

- Toying with legislation: To clarify the intent of the prevention and public health investment fund [Coburn, 17]; Coburn To clarify the intent of the prevention and public health investment fund [Coburn, 18]; To restate the purpose of the Prevention and Public health Investment Fund [Coburn, 19]; To reduce funding and provide for a termination date for the Prevention and Public Health Investment Fund. [Coburn, 20]

Reform may be a joke to the well-insured Coburn, but for the Americans struggling with cancer, access to affordable health coverage is a very serious concern. As the American Cancer Society points out, people who are uninsured are more likely to be diagnosed with advanced cancer and too many insured Americans have a hard time affording their treatments. In Oklahoma, an average family pays $1,900 more in premiums because of the broken health care system and some 50 families “fall through the cracks” every day when they lose their health insurance.

But as Sam Stein reported yesterday, it was Republicans who pushed for the incomplete HELP bill to be studied by the CBO, and “when poor results came back,” they pretended that the agency scored the entire bill. Indeed, yesterday, Reps. John Boehner (R-OH), Eric Cantor (R-VA), Sens. Mike Enzi (R-WY) and John McCain (R-AZ) criticized the committee for producing a bill that cost $1 trillion but covered only 16 million Americans, purposely ignoring the CBO’s admission that “those figures are not likely to represent the impact that more comprehensive proposals…would have both on the federal budget and on the extent of insurance coverage.”

But today, Sens. McCain and Judd Gregg (R-NH) argued that the hearing be postponed until a full cost-analysis is available. Watch it:

The delaying tactics extended into the GOP’s amendments. Rather than offering constructive improvements that could lower costs and expand coverage, a good number of the GOP’s proposed amendments do nothing to solve the health care crisis:

- Coburn 51: To prohibit the use of funds to build football stadiums.

- Coburn 111: To prohibit the Department of Health and Human Services from providing funding for fashion shows.

- Enzi 59: To prohibit the Secretary from requiring the use of best practices.

- Enzi 87: To strike provisions relating to oral health.

- Coburn 43: To rename the community health program subtitle IV – would rename it the “Federal Takeover of Local Communities.”

- Coburn 102: To limit the amount the Department of Health and Human Services may spend on conferences each year

- Coburn 29: To ensure that abortion providers are not co‐locating at schools in order to be integrated into school‐based health clinics and gain access to potential clients.

Ezra Klein observes that “the Republicans on HELP feel, or say they feel, that they were frozen out of this process. They say the bill is inadequate and its path to creation has been unforgivably partisan.” But these Republican fail to advance reform or solve the health care crisis. Rather, they preserve the current system, which, as Sen. Barbara Mikulsky (D-MD) observed during the hearing, “is a combination of Adam Smith, Darth Vader, and Invasion of the Body Snatchers.”

According to that assessment, enacting the proposal would result in a net increase in federal budget deficits of about $1.0 trillion over the 2010–2019 period. Once the proposal was fully implemented, about 39 million individuals would obtain coverage through the new insurance exchanges. At the same time, the number of people who had coverage through an employer would decline by about 15 million (or roughly 10 percent), and coverage from other sources would fall by about 8 million, so the net decrease in the number of people uninsured would be about 16 million.

But as Ezra Klein and Jonathan Cohn observe, the estimate says very little about the actual cost of health care reform. Cohn:

Imagine you were trying to build your dream house and the architect gave you a status report. The design still wasn’t finished: He hadn’t sketched out the plumbing, the wiring, and the roof. But, he said, he could tell how much it would cost to build what he’d already designed. You’d be curious about the number; it might offer some hints about how much the house would cost in the end. But you wouldn’t spent too much time dwelling on it since, after all, the final price was going to be much different. Well, that’s the same attitude you should take about the estimates of the Senate Health, Education, Labor, and Pensions (HELP) Committee bill that the Congressional Budget Office (CBO) delivered yesterday.

Indeed, in an effort to reach a compromise with Republicans, the committee omitted language about the employer mandate or the new public health care plan. Medicaid expansion is outside of the HELP Committee’s jurisdiction (that’s up to Senate Finance) and the CBO incorrectly assumed that individuals would only pay a $100 fine if they remained uninsured. As a result, the organization concluded that reform would cost “$1 trillion over the next decade and reduce the ranks of the uninsured by about one-third, or 16 million individuals.”

The CBO scored a ‘draft of a draft’ proposal. As Paul Krugman concludes, “this was a failure of communication, partly the result of an attempt at bipartisan outreach, rather than a failure of policy.”

[Read the 600+ page bill HERE or a summary HERE]

In a press release touting the proposal, Sen. Chris Dodd (D-CT) described the bill as “legislation that will strengthen what works and fix what doesn’t”:

If you like the insurance you have today, you can keep it. If you don’t like what you have today, we’ll give you better choices, including a public option for health care. This does not symbolize the end of the game or even the end of the first quarter. We still have a lot of work ahead of us and are looking forward to working with our colleagues on a bipartisan basis to resolve the remaining issues and move forward with a mark-up of this legislation next week

The bill, which does not include financing options, closely reflects the ‘draft of a draft‘ proposal circulated last week and a summary released earlier today. The legislation aims to improve access to coverage by regulating insurers — they would no longer be able to deny coverage to individuals with pre-existing conditions — expanding Medicaid and the State Children’s Health Insurance Program (SCHIP), and building state-sponsored insurance Gateways (or exchanges) to help Americans find affordable coverage. [Read an analysis of the bill HERE]

The most controversial details of health reform — the employer mandate and the structure of a new public option — have yet to be ironed out, however. According to the press release, “Democrats and Republics on the Committee will meet to discuss outstanding legislative options such as the public option and employer mandate” on Wednesday, June 10 and Thursday, June 11.” The ext of the available legislation leaves the public option and employer-mandate sections blank:

A public hearing is scheduled for Thursday, June 11 at 3 p.m. in Dirksen 430. Mark-up will begin Tuesday, June 16 at 2:30 p.m. in Russell 325.

Hatch repeated the Frank Luntz-inspired charge that a government plan would place a bureaucrat between “you and your doctor” at least four times during the segment. And he wildly misrepresented the HELP bill while pressing Democrats in Congress to track a bipartisan path towards passing health reform. Watch it:

Hatch joins a long line of conservative lawmakers who rely on poll-tested Republican talking points that are intended to stall reform rather than fix the system.

For instance, contrary to Hatch’s insistence that the bill would put a bureaucrat “between you and your doctor,” Section 2 of the draft legislation explicitly states that “a strong doctor-patient relationship is essential to the practice of medicine, and patients have a right to an effective doctor patient relationship”:

Moreover, Hatch argues that a public health care plan would “crowd out” private coverage and cites a Lewin Group study which found that 119.1 million Americans (Hatch actually rounds the number up to 120) would leave private health insurance if the public plan used Medicare payments and was opened to all employers. The draft of the HELP bill, however, specifies that the public plan would reimburse providers at 10 percent above Medicare rates and most Democratic proposals — including the President’s campaign health care plan — would likely allow only small businesses and individuals to buy-into the public plan. Under such a design, far fewer Americans “would leave private health insurance.”

All this suggests that Hatch is overstating his willingness to work with Democrats in a “bipartisan” fashion. After all, the first step towards compromise is truthfully characterizing legislation.

The legislation, called the “American Health Choices Act,” would provide universal coverage to all Americans and establish a new public health care plan to compete alongside private insurers.

As previously reported, the new public plan would reimburse providers Medicare rates plus 10 percent. Under this arrangement, the new public option would not have to negotiate its own rates, but could piggy back off of Medicare’s considerable reach. Using Medicare plus 10 rates, rather than the prevailing market rates, would lower costs and allow the plan to charge lower premium rates.

Moreover, the bill aims to improve access to coverage by regulating insurers, expanding Medicaid and SCHIP, and building state-sponsored insurance gateways (or exchanges) to help Americans find affordable coverage. Individuals and employers would be required to purchase insurance, but families earning up to 500 percent of of federal poverty line (FPL) ($110,000 for a family of four) could “buy insurance on a sliding scale with government subsidies” and anyone earning up to 150 percent of the FPL ($33,000 for a family of four) would also be eligible for Medicaid; the bill also expands SCHIP to cover people up to age 26, from age 18. Currently, an adult with no dependent children could be penniless but still ineligible for Medicaid coverage in 43 states.

Sen. Chris Dodd (D-CT), who is leading the committee’s health care effort in Kennedy’s absence, “has said he hopes to begin debating a bill in committee on June 15.”

More details after the jump:

Ensuring Adequate Coverage, Holding Insurance Companies To Account

- A group or individual health insurance plan may not impose preexisting condition exclusions

- Rates cannot vary by health status, gender, class of business or claims experience. Rates can only vary by family structure, community rating area, actuarial value of the benefit, age (rate variation shall not vary more than by 2:1)

- Insurers “must accept every employer and individual in the state that applies for such coverage”

- Insurers “must renew” coverage

- Insurers must provide value for the premiums paid (a good portion of health premiums must be used on health benefits)

- Limited cost sharing for certain preventive services, immunizations, certain screenings for infants

- No lifetime or annual limits on benefits for any participant or beneficiary

Creating State Exchanges or ‘Affordable Health Benefit Gateways’

- The federal government will provide financial aid for states to establish Gateways

- A Gateway would be required to certify qualified health plans; the plans must provide a level of standard benefits (to be established by a Medical Advisory Council) that would take effect unless Congress rejected them all at once.

- Gateways may raise funds by charging health insurance issuers a surcharge to finance the administrative and operational expenses of the Gateway.

- At the end of the year, the Gateway will redistribute funds among the plans to ensure that those with very unfavorable mixes of risk are protected.

- States can establish regional or interstate gateways; more than one Gateway could also be established in a single state.

According to news reports, “a brief, unofficial summary of the Senate health committee’s draft reform proposal circulating among Washington lobbyists Wednesday includes a public plan option that would pay providers — who would be required to participate — 10 percent more than Medicare rates.”

There is more:

- An individual and employer mandate for coverage

- The legislation would expand the Medicaid program to cover individuals earning up to 150 percent of poverty

- It would subsidize people earning up to 500 FPL to purchase insurance through state-based insurance exchanges

- Expands the Children’s Health Insurance Program (CHIP) to people up to age 26

- Establishing a “federal health reserve” type entity called a Medical Advisory Council that would assist in designing minimum standard benefits

On quick glance, this is very good news for public option proponents who were concerned that the HELP legislation would build on state-employee pools and establish fifty different plans around the country or develop some kind of trigger mechanism. This summary suggests that while providers participating in Medicare would also have to offer services in the new public option, the reimbursement arrangement would give the new plan leverage by allowing it to piggyback on Medicare’s reach. Reimbursing providers less than private insurers, but paying them more than Medicare rates allows the new public option to pass on the negotiated payment rates to consumers in the form of lower premiums.

As Lester Feder, who is covering health care reform for The Nation, explained it:

Of course, we’ll save the most money if the public plan pays what Medicare pays. But short of that, any public plan will be more effective if it doesn’t have to negotiate the rates it pays providers on its own, but can piggy back on the rates the (much much much) larger medicare program can negotiate with providers. It’s about market leverage. Let’s say I run a small chain of department stores. It’s expensive for me to negotiate with my suppliers, and if I’m not very big I won’t get great deals. So instead I say, “I’ll pay you what Walmart pays plus 10%.” Then I’m benefiting from Walmart’s ability to negotiate with suppliers.

There are some political pitfalls here — which I will re-visit– but from a cost-containment perspective, it makes sense.

The fate of the most controversial aspect of health care reform — the public option — remains a mystery, however. Over at The Nation, Lester Feder lays out the principles of a public health option, arguing, quite convincingly, that the public option must be designed in such a way that it 1) reduces health care spending 2) restores competition to health care markets 3) leads the way in improving health quality. In other words, the public option should be designed in such a way that it scores savings with the Congressional Budget Office.

But several Senators have recently endorsed a watered-down version of the public option that builds on existing state employee plans or creates a trigger (a.k.a. “fall-back public option”) that would only establish a public plan if “an arbitrary measure of market concentration were hit in a state” (the White House has also suggested that it is open to such alternatives):

Sen. Olympia Snowe, R-Maine, talked at length Thursday in a private meeting between members and staffers about the possibility of creating a fallback public option that only would kick in several years down the road if insurance companies are not doing their part to bring down healthcare costs and expand coverage, a Republican committee aide said. Snowe has had conversations with Senate Finance ranking member Charles Grassley and Sen. Orrin Hatch, R-Utah, about the proposal. From the Democratic side, Sens. Ron Wyden of Oregon and Thomas Carper of Delaware expressed interest in the idea Thursday, aides said.

State employer pools don’t have a record of lowering health care cost and as Tim Foley notes, “The problem with a trigger like this is the gun has already fired.” In other words, if a health care plan is supposed to break up concentrated health insurance markets and force insurers to negotiate the lowest prices for its beneficiaries, then what are we still waiting for? As a recent Health Care For American NOW report points out, “94 percent of insurance markets in the United States are now highly concentrated,” while premiums “have skyrocketed, increasing more than 87 percent on average over six years”:

If policy makers decide to include a public option, then they should design it in such a way that would enable it lower the nation’s health care spending. A watered-down alternative will undermine the argument of many progressives and ultimately hurt the cause of health care reform.

The debate surrounding a robust public option is one we can win, but first we must be willing to engage in it.