The Wonk Room

The House Health Care Bill Makes Progress For Gay Rights

Gay rights advocates are hoping that certain LGBT-friendly provisions now part of the House health care legislation “will be incorporated into the final bill” once the Senate and House bills are “reconciled in conference.”

The House bill “ends the unfair taxation of employer-provided domestic partner health benefits,” “designates LGBT people as a health disparities population,” “allows states to cover early HIV treatment under their Medicaid programs” and “prohibits consideration of personal characteristics unrelated to the provision of health care”:

- Ends the unfair taxation of employer-provided domestic partner health benefits: While federal law allows married workers who receive family health insurance benefits to deduct the value of that coverage from taxable income, workers who are unmarried and have domestic partners are required to pay taxes on the fair market value of their coverage. As a result, “employees with partner health benefits now pay on average $1,069 per year more in taxes than would a married employee with the same coverage.” As CAP’s ‘Unequal Taxes on Equal Benefits‘ concluded, “collectively, unmarried couples lose $178 million per year to additional taxes.” The bill extends the tax exclusion to domestic partnership benefits.

- Designates LGBT people as a health disparities population: This opens up health data collection and grant programs “focused on health disparities related to sexual orientation and gender identity, enabling the government to direct funding for research and public health efforts to address those disparities.” For instance, “gay men and lesbian women are at increased risk for certain cancers (lung, cervical, breast, and anal cancer), due to a higher prevalence of smoking and inadequate risk assessment and screening by providers.” Greater research into these disparities would allow the federal government to “target the health promotion campaigns” about “smoking prevention and cessation activities” to LGBT populations.

- Provides states to expand coverage for early HIV treatment under their Medicaid programs: Medicaid “covers 55 percent of all people living with AIDS and 90 percent of all children living with AIDS who are receiving medical care.” Under current law, “individuals with HIV/AIDS who qualify for Medicaid do so because they are certified as disabled,” (which means that they will not be eligible for services until their immune systems have declined to the point of an AIDS diagnosis and/or they are no longer able to work). At this stage and is often “too sick to benefit from current therapies” and is “past the recommended point to begin treatment.” This provision, based on the bipartisan The Early Treatment for HIV Act (ETHA), would allow more HIV positive people to receive treatment at earlier stages and would “dramatically improve the quality of life for low-income people with HIV, as well as saving taxpayers money and reducing the transmission of the virus.” The Senate bill

- Prohibits consideration of personal characteristics unrelated to the provision of health care: The bill specifies that all health care and related services (including insurance coverage and public health activities) covered by this Act shall be provided without regard to personal characteristics extraneous to the provision of high quality health care or related services. Consideration of sexual orientation and gender identity in the dispensation of medical care has long disadvantaged the LGBT community.

Josh Rosenthal has more on how health reform can address the specific needs of LGBT Americans.

Why The Stupak Amendment Is A Monumental Setback For Abortion Access

Our guest blogger is Jessica Arons, Director of the Women’s Health and Rights Program at the Center for American Progress Action Fund.

Rep. Bart Stupak (D-MI)

The claim that it only bars federal funding for abortions is simply false. Here’s what the Stupak Amendment does:

1. It effectively bans coverage for most abortions from all public and private health plans in the Exchange: In addition to prohibiting direct government funding for abortion, it also prohibits public money from being spent on any plan that covers abortion even if paid for entirely with private premiums. Therefore, no plan that covers abortion services can operate in the Exchange unless its subscribers can afford to pay 100% of their premiums with no assistance from government “affordability credits.” As the vast majority of Americans in the Exchange will need to use some of these credits, it is highly unlikely any plan will want to offer abortion coverage (unless they decide to use it as a convenient proxy to discriminate against low- and moderate-income Americans who tend to have more health care needs and incur higher costs).

2. It includes only extremely narrow exceptions: Plans in the Exchange can only cover abortions in the case of rape or incest or “where a woman suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the woman in danger of death.” Given insurance companies’ dexterity in denying claims, we can predict what they’ll do with that language. Cases that are excluded: where the health but not the life of the woman is threatened by the pregnancy, severe fetal abnormalities, mental illness or anguish that will lead to suicide or self-harm, and the numerous other reasons women need to have an abortion.

3. It allows for a useless abortion “rider”: Stupak and his allies claim his Amendment doesn’t ban abortion from the Exchange because it allows plans to offer and women to purchase extra, stand-alone insurance known as a rider to cover abortion services. Hopefully the irony of this is immediately apparent: Stupak wants women to plan for a completely unexpected event.

4. It allows for discrimination against abortion providers: Previously, the health care bill included an evenhanded provision that prohibited discrimination against any health care provider or facility “because of its willingness or unwillingness to provide, pay for, provide coverage of, or refer for abortions.” Now, it only protects those who are unwilling to provide such services.

One in three women will have an abortion in their lifetime. Eighty-seven percent of employer plans offer abortion coverage. None of that will matter if the Senate takes its cues from the House. In every other way, this bill will expand access to health care. But for millions of women, they are about to lose coverage they currently have and often need.

What’s Holding Up The House Health Care Vote?

This morning, on a conference call with reporters, House Majority Leader Steny Hoyer (D-MD) warned that “action on a health care overhaul could slip past a planned Saturday evening vote into Sunday — or even Monday or Tuesday — if House Republicans employ delaying tactics.” House Speaker Nancy Pelosi (D-CA) assured reporters yesterday that “we will” have enough votes to pass the House, but press reports indicate Democrats have yet to reach agreement over coverage for undocumented immigrants and abortion.

Yesterday, 20 members of the Hispanic Caucus threatened to vote against a bill that prevented undocumented immigrants from purchasing coverage in the exchange with their own money and it’s unclear if ongoing negotiations have satisfied enough of the 40 pro-life Democrats unhappy with the bill’s restrictions on abortion funding. Reps. Bart Stupak (D-MI) and Brad Ellsworth (D-IN) have offered stronger abortion language that the caucus is currently considering.

Assuming that every Republican votes against the measure, Democrats have to peel away approximately 22 unsatisfied caucus members to pass the bill in the House. President Obama is expected to officially endorse the legislation later today and personally rally support for the measure during a visit to the Capitol on Saturday. Still, major policy disagreements could delay a House vote. Below is a table laying out the areas of disagreement:

Abortion:

Immigration:

Democrats would also have to defray likely Republican efforts to use the the motion to recommit “as an opportunity to insert a social issue poison pill, likely on abortion or immigration, that would peel off enough moderate Democrats to pass.” Republicans “could craft an abortion measure that gives pro-life Democrats little choice but to vote with the minority to change the bill. That change could make the final bill unpalatable enough for most Dems that its passage would be put in jeopardy,” Politico speculates.

Is Ronald Reagan Responsible For 1,990 Page Health Bill?

Republicans responded to the release of the House health bill by criticizing the sheer size of the legislation. House Minority Leader John Boehner (R-OH) began the Republican press conference by carrying out the 1,990 page bill and positioning the stack between the two microphones on the podium, in full view of the cameras.

“Now tell me how we’re going to fix the health care system with 1,990 pages of government bureaucracy. Now this is what the American people have been saying over the last few months, ‘enough is enough,’” he said.

Watch a compilation:

The original Medicare legislation was a mere 15 pages. Today, Congress regularly produces legislation that that is thousands of pages long. So what happened? It’s the result of the “polarization of American politics,” Congressional historian Ross Baker told the Wonk Room. In the last 50 years, “the total number of pages of legislation has gone up from slightly more than 2,000 pages in 1948 to more than 7,000 pages in 2006.”

The trend started during the 1980s, once the Regan administration began padding various committees with industry cronies and taking full advantage of the vagueness of the legislative language. Congress began writing longer bills to ensure that its intent would be properly enforced. Lesley Russell, currently a visiting Fellow at the Center of American Progress, but at the time a member of the professional staff of the House Energy and Commerce Committee, recalls how in 1987, her committee, along with Ways and Means, produced an unusually large bill governing nursing home regulations.

The Reagan administration had sought to “repeal the federal rules that governed nursing homes,” including “basic requirements that nursing homes maintain a safe and sanitary environment and respect the privacy and dignity of residents.” Congress enacted moratorium prohibiting the repeal and the Institute of Medicine was commissioned to study the conditions of nursing homes.

The report concluded that “individuals who are admitted receive very inadequate — sometimes shockingly deficient — care that is likely to hasten the deterioration of their physical, mental, and emotional health,” and Congress responded by writing “broad reform legislation, commonly referred to as the Nursing Home Reform Act.” For the first time, “the law placed a new focus on resident rights. It gave nursing home residents the right to choose a personal attending physician, to participate in planning their own care and treatment, and to be free from physical and mental abuse, corporal punishment, involuntary seclusion, and “any physical or chemical restraints imposed for purposes of discipline or convenience.”

“We knew, when we were writing this needed legislation, that it was intrinsically opposed by the administration and so we were very conscious of the need to insure that all the provisions were fully enacted as Congress intended,” Russell said. “This is my earliest recollection of Congress deliberately putting a lot of detail into legislative language,” Russell said.

Baker explained that large multi-paget bills allow Congress to hide controversial provisions, but dismissed the oft-cited argument that smaller bills would help the public better digest legislation and enhance the Democratic process. “It’s a quaint thought to think that the public would read smaller bills,” but there is really no correlation between the size of the bill and the willingness of Americans to read it, he insisted.

CBO: Public Option To Attract Only 6 Million Enrollees & Doesn’t Offer Lower Premiums

The Congressional Budget Office analysis of the recently released House health bill has concluded that the bill costs $894 billion over 10 years and reduces the deficit by $104B over 10 years.

The public option would attract about 6 million enrollees by 2019 and charge premiums that are “somewhat higher than the average premiums for the private plans in the exchanges.” This is because the public option would “engage in less management of utilization” by its enrollees and “attract a less healthy pool of enrollees,” the office concludes. Moreover, since the House bill expands Medicaid up to 150% of the federal poverty line, it’s possible that the enrollees that would have enrolled in the public option went into Medicaid instead.

Below is a comparison of the relevant provisions in the House and Senate Finance Committee legislation:

Top 10 Reasons Why Republicans Should Support The House Health Bill

This morning, Rep. Mike Pence (R-IN) characterized the entire House health care bill as a “government run insurance 2.0.” “I mean, what we are seeing here is, you know, government-run insurance, mandates for businesses, an enormous tax increase, most of which or at least half of which will be paid for by small business owners.” But Pence and the Republicans should actually read the bill before dismissing it. For while the party may oppose the bill’s provisions to tax the top 0.3% of Americans to fund reform or the new fees imposed on the pharmaceutical industry to help close the donut hole in Medicare Part D, on the whole, the 1,990 page bill is a fairly moderate proposal that incorporates numerous conservative policies.

Here are just 10 reasons for why Republicans should support the House health bill:

1. REPUBLICANS ASKED FOR – DEFICIT NEUTRAL BILL: “Do the American people believe that this almost 2,000 page bill won’t add to the deficit?” [Rep. Eric Cantor, 10/29/2009]

HOUSE BILL – DEFICIT NEUTRAL BILL: According to the Congressional Budget Office, the House bill costs $894 billion over 10 years and actually reduces the deficit by $30 billion and continues to reduce the deficit over the second 10 years.

2. REPUBLICANS ASKED FOR – REDUCE COSTS OVER LONG TERM: “Nevertheless, House Republicans recognize the need to lower health care costs.” [Rep. Mike Pence (R-IN), 9/9/09]

HOUSE BILL – REDUCES COSTS OVER LONG TERM: Encourages payment reforms that can help lower costs. Requires the Department of Health and Human Services to establish specific benchmarks for expansion of the Accountable Care Organization, Payment Bundling, and Medical Home pilot programs. The bill will also slow the rate of growth of the Medicare program from 6.6% annually to 5.3%.

3. REPUBLICANS ASKED FOR – POLICIES ACROSS STATE LINES: “Interstate competition allowing people to buy insurance across state lines.” [Sen. John Thune (R-SD), 9/8/2009]

HOUSE BILL – POLICIES ACROSS STATE LINES: Allows for the creation of State Health Insurance Compacts – permits states to enter into agreements to allow for the sale of insurance across state lines.

4. REPUBLICANS ASKED FOR – MEDICAL MALPRACTICE REFORM: “Why not bring about reasonable restrictions and limits on medical malpractice claims to end the era of defensive medicine?” [Rep. Mike Pence (R-IA), 9/9/2009]

HOUSE BILL – ENCOURAGES MALPRACTICE REFORM: The bill establishes a voluntary state incentives grant program to encourage states to implement “certificate of merit” and “early offer” alternatives to traditional medical malpractice litigation.

5. REPUBLICANS ASKED FOR – HIGH RISK POOLS: “Senator McCain has a proposal sometimes called high-risk pools at the state level…These are efforts I think we can have bipartisan agreement on and deal with the question of pre-existing conditions.” [Rep. Eric Cantor (R-VA), 9/10/2009]

HOUSE BILL – HIGH RISK POOLS: To fill the gap before the Exchange becomes available in 2013, the bill creates an insurance program with financial assistance for those uninsured for several months or denied policy due to preexisting conditions.

6. REPUBLICANS ASKED FOR – ALLOW YOUNG PEOPLE TO STAY ON PARENTS’ POLICIES: “Recognizes that not all high school and college graduates are able to find a job that offers health care coverage after graduation. By allowing dependents to remain on their parents’ health policies up to the age of 25, the number of uninsured Americans could be reduced by up to 7 million.” [Republican Health Solutions Group]

HOUSE BILL – ALLOW YOUNG PEOPLE TO STAY ON PARENTS’ POLICIES: The bill requires health plans to allow young people to remain on their parents’ insurance policy until they turn 27.

7. REPUBLICANS ASKED FOR – NO PUBLIC MONEY FOR ABORTION: “The American people will not stand for government-run insurance that uses taxpayer money to fund abortions in this country.” [Rep. Mike Pence (R-IN), 10/16/2009]

HOUSE BILL – NO PUBLIC MONEY FOR ABORTION: The bill prohibits abortion services from being made part of essential benefits package and prohibits federal funds from being used to pay for abortion (except in cases of rape, incest, and to save life of the woman).

8. REPUBLICANS ASKED FOR – PROTECT SMALL BUSINESSES: “Helps employers offer health care coverage to their workers by reducing their administrative costs through a new small business tax credit.” [Republican Health Solutions Group]

HOUSE BILL – PROTECTS SMALL BUSINESSES: The bill exempts 86% of businesses from the requirement to provide coverage. Businesses with payrolls below $500,000 are exempt while firms with payrolls between $500,000 and $750,000 would pay a graduated penalty. Small businesses would also receive a tax credit that helps cover 50% of their health care expenses.

9. REPUBLICANS ASKED FOR – PROMOTE JOB WELLNESS PROGRAMS: “Promotes prevention and wellness by giving employers and insurers greater flexibility to financially reward employees who seek to achieve or maintain a healthy weight, quit smoking, and manage chronic illnesses like diabetes.” [Republican Health Solutions Group]

HOUSE BILL – PROMOTE JOB WELLNESS PROGRAMS: The bill establishes a grant program to help small employers create or strengthen workplace wellness programs.

10. REPUBLICANS ASKED FOR – DELIVERY SYSTEM REFORM: “Uses new and innovative treatment programs to better coordinate care between health
care providers, ensuring that those with chronic disease receive the care they need and do not continue to fall through the cracks.” [Republican Health Solutions Group]

HOUSE BILL – DELIVERY SYSTEM REFORM: The bill requires the Department of Health and Human Services to establish specific benchmarks for the expansion of the Accountable Care Organization, Payment Bundling, and Medical Home pilot programs.

House Health Bill Removes Insurer Anti-Trust Exemption, Taxes Health Industry

This morning, Speaker Nancy Pelosi will unveil the re-tooled Affordable Health Care for America Act (HR 3962). (Read the bill HERE.) Coming in at around $900 billion over 10 years, the legislation will extend coverage to 36 million Americans (6-7 million more than the Senate Finance version), include a national public option that reimburses physicians at negotiated rates and require individuals to acquire coverage and large employers to provide it. The bill is paid for with a surtax on the wealthy, changes to Medicare and Medicaid, and taxes on the health care industry.

Democrats successfully lowered the price tag of the original House legislation from $1.04 trillion by expanding the Medicaid program to Americans with incomes 150% of the federal poverty line and removing the SGR fix from the bill. “A permanent doc fix will be carved out of the reform bill and introduced separately today without pay-fors,” Live Pulse reports. (Read the SGR bill text HERE)

Most of the bill’s benefits won’t start until 2013 and House leaders are introducing “a temporary government program” that would “help people turned down by private insures because of medical problems.” The Senate Finance bill includes a similar provision, a high-risk pool that would be available to Americans between 2010 and 2013.

The re-tooled House bill will also “strip the health insurance industry of a long-standing exemption from antitrust laws covering market allocation, price fixing and bid rigging” and “give the Federal Trade Commission authority to look into the health insurance industry at its own initiative.”

While Democrats are still negotiating with moderate Democrats over abortion and immigration, Speaker Pelosi hopes to have the legislation on the floor next week, with a final vote before “Veterans Day,” November 11th. At the moment, “House Democrats do not have firm commitment from enough lawmakers to guarantee passage of their bill.” One whip count has shown 23 centrist Democrats intend to vote against any health bill. Assuming that all Republicans vote against it, the bill can lose at least 38 Democrats and still pass the chamber.

House Bill Comes In At $1 Trillion, Undermines GOP Talking Points

Today, three separate House committees — Ways and Means Committee, Energy and Commerce Committee, Education and Labor Committee — released a single health care reform bill, the American Affordable Healthy Choices Act. The bill establishes “a mandate for most legal residents to obtain insurance, significantly expand eligibility for Medicaid, and set[s] up insurance “exchanges” through which certain individuals and families could receive federal subsidies to substantially reduce the cost of purchasing that coverage.” According to an analysis by the Congressional Budget Office, the legislation would cost $1 trillion over 10 years and cover 94 percent of Americans (97% if you don’t count the undocumented).

As Jonathan Cohn reports, “between savings and a new surtax on the wealthy, the bill pays for itself. In other words, it won’t inflate the deficit.” Five hundred billion comes from savings in Medicare and Medicaid and “the rest comes from a surtax on the richest 1.5 percent.”

Most importantly, the CBO coverage tables undermine the conservative claim that a public option would eliminate private insurance and erode employer-sponsored coverage. The House bill actually increases the number of people who receive coverage through their employer by 2 million (in 2019) and shifts most of the uninsured into private coverage. By 2019, 30 million individuals would also purchase coverage from the Exchange, but only 9-10 million Americans (or approximately 1/3) would enroll in the public option, the rest would enroll in private coverage.

A more detailed discussion will soon follow, but here is a table of provisions and the estimated savings:

House ‘Tri Committee’ Health Care Bill Will Fix Doc Pay

Yesterday, the House Committees on Ways and Means, Energy and Commerce, and Education and Labor released their “Tri-Committee Health Reform Draft Proposal,” an outline of essential components for a health care reform legislation.

Like the HELP bill, the House plan establishes a “new national health Exchange” to enroll Americans in affordable coverage, gives Americans the choice to enroll in a new public health insurance options, prohibits private insurers from excluding Americans with pre-existing conditions from coverage and offers sliding scale “affordability” credits to help middle class families afford health insurance. (Jonathan Cohn and Karen Tumulty break down the details here and here.)

The measure would also “replace Medicare’s ’sustainable growth rate’ method of paying physicians, who face a 21 percent cut in January unless Congress takes action.” Congress created the so-called Sustainable Growth Rate (SGR) formula in 1997 to check rising health care costs. It states that “the amount Medicare pays doctors for an average Medicare patient can’t grow faster than the economy as a whole.” As the WSJ Health Blog explains, “it’s fine if total payments to doctors go up because the number of Medicare beneficiaries rises. And it’s fine if the average payment per beneficiary rises along with the economy. But if growth in payments per beneficiary grows more than the economy as a whole, the SGR says you have to lower payments to doctors across the board to keep costs under control.”

Democrats are hoping to use the SGR-fix to win-over physician support for reform. As Ways and Means Committee Chairman Charles Rangel (D-NY) explained it, “If we don’t have the doctors on board, we’re in trouble…We have to address this in this bill.”

In 2002, once medical inflation outpaced economic growth, physicians experienced a cut in reimbursement rates, and Congress has patched every cut since. Most health care researchers argue that the formula is ineffective in holding down physician expenditures because it “does little to counter the inherently inflationary nature of fee-for-service payment” (which encourages physicians to prescribe more care) and treats every physician in every region exactly the same. As MedPAC points out, “it neither rewards physicians who restrain volume growth nor punishes those who prescribe unnecessary services.” Policy makers and physicians agree that the SGR must be reformed. In March 2007, MedPAC issued the following recommendations:

1. Repeal the SGR and allow Congress to develop incentives for physicians and other providers to furnish higher quality care at a lower cost.

2. Refine the physician fee-for-service payments and replace the SGR with a new system of expenditure targets.

One proposal would break out the services physicians provide into so-called buckets of care. The Secretary of Health and Human Services would then establish a target — based on projections of increased volume and population growth — for every bucket. Exceeding the target would trigger a pay cut.

It’s still unclear which fix the Tri Committee is considering, but the goal is to reform Medicare payments to doctors in such a way as to discourage doctors from over prescribing treatments and lower overall health care spending.