HEALTH INSURANCE: "Across States Lines" is Back -- And It Still Won't Work

The idea that we can solve our health care problems by allowing people to buy an insurance policy "across state lines" sounds tantalizingly easy. Unfortunately it's not true. It will make our problems worse and be devastatingly risky for many Americans. Yet the idea has been resurrected in bills proposed by the Republican Study Committee (RSC), Congressman John Shadegg (R-AZ), and Senator Jim DeMint (R-SC).

Don't be fooled: without significant and nationwide market reforms (like those put forth by the committees of jurisdiction in both the House and Senate), selling health insurance across state lines will lead to less-comprehensive insurance packages, higher costs for families, and reduced access to care. It is a step backwards for not only our insurance markets, but also, and more importantly, for the American people who struggle every day to secure quality, affordable coverage.

Last year, New America published a detailed explanation of why this policy is an unviable solution. Our paper and two-page summary can be found here, and previous blog posts can be found here, here, here, and here. But this is the bottom line:

COST: Medicaid Crunch Time

We all know that as the economy plunged, the need for Medicaid swelled.

The Kaiser Family Foundation gives us a clearer picture of exactly what that meant in all 50 states as the country went into its worst recession in decades.

The foundation's latest report revealed a steep increase in Medicaid enrollment -- an average of 5.4 percent in the fiscal year 2009, far exceeding predictions. Total Medicaid spending grew by 7.9 percent -- quite a bit higher than the 5.8 percent that had been projected. 

The signs for the current fiscal year indicate anticipated enrollment will outpace budgeted spending increases. 

"The recession has shown the importance of Medicaid as a safety net for millions of Americans who have lost health coverage when they have lost their jobs," said Diane Rowland, executive vice president of the Kaiser Family Foundation and executive director of the Kaiser Commission on Medicaid and the Uninsured. "But it also has shown the challenges for states of maintaining coverage when state revenues drop during times of economic crisis."

COST: The Secret Life of Medicare Computer Tapes

Security was tight as NPR's David Kestenbaum entered the inner sanctum. Six staffers hovered around him.

It wasn't the CIA. Or a secret air base. Or Fort Knox. Not even the Playboy mansion. It was the closely-guarded Medicare databank in Baltimore.

The databank is enormous, petabytes of data (a petabyte is a 1 with 15 zeros after it, Kestenbaum explains). The rows and rows of shelves, a half-million cassettes of computer data, so vast that a robot is required to navigate it. The library holds medical records of decades of Medicare patients. And their doctors. It could potentially tell us much about quality and performance and efficiency of just about every physician in the United States.

Except it's a secret. Some researchers and consumer advocacy groups have fought to open it up (not the patient records, but the doctor data). And doctors have fought to keep it closed.

Arnold Milstein, a physician and researcher who has advised the White House on health care economics, wants it open. Doctors don't even know how they stack up against their peers, against standards. The database could tell them.

COST: The High Price of Failure

As Congress debates the details of health reform, it may be valuable to recap the high cost of doing nothing

A new Urban Institute report examines the likely impact of another health reform failure on insurance coverage and government, employer, and family spending in all 50 states. In The Cost of Failure to Enact Health Reform: Implications for States, the Urban Institute uses the Health Insurance Policy Simulation Model (HIPSM) to project cost and coverage implications for the worst case, intermediate case and best case scenarios.

As you might expect, even the "best" case scenario is none too good. Under any scenario, the status quo would significantly add to the financial burdens of Americans of all income levels. Middle-class families would fare the worst.

Let's take a look at a reform-less United States of America in 2019:

HEALTH POLITICS: Poll Shows Increase in Public Support for Health Reform

Every slide comes to an end, and the latest Kaiser Health Tracking Poll finds that public support for health reform increased from August to September.

As with previous polls, a majority of American's continue to support health reform, with 57 percent of respondents saying it is more important than ever to address the issue -- a 4 point increase from August's survey. The percentage who said their family will be better off also increased six points (42 percent vs. 36 percent in August), as did the share of those who think the country will be better off if health reform passes (up eight points from up eight from 45 percent in August to 53 percent).

Democratic support for reform remains steadily high (77 percent favor tackling reform now), and the shift in polling reflects a softening in opposition from Republicans and independents. The percent of respondents who felt they would be worse off if reform past fell by 12 points from August to September for Republicans and by 10 points among independents.



QUALITY: More Getting Primary Care From Community Health Centers

A growing number of Americans rely on federally qualified health centers for care, reports The Wall Street Journal. Last year, community health centers, as well as migrant and homeless health centers, served approximately 18 million people. That number is expected to hit 20 million this year, according to the WSJ and the National Association of Community Health Centers.


COST: Forging Ahead on Affordability

As we noted in our wrap up of last week's Senate Finance proceedings, one of the biggest issues for health reform going forward is the question of affordability. Over at the New York Times Prescriptions blog, David Herszenhorn weighs-in:

Democrats proposing an overhaul of the American health care system have gotten themselves locked in a box around the question of affordability.

This is not the question of whether the proposed health care legislation is affordable for taxpayers and the federal government -- an issue that seemed to be answered when the Congressional Budget Office said the Senate Finance Committee's bill would eventually help reduce federal budget deficits.

The affordability question vexing Democrats is whether those with moderate income will be able to afford health insurance, even with the subsidies the legislation would provide and all sorts of new rules aimed at controlling costs.

Herszenhorn suggests that so-called curve bending provisions of the legislation -- the stuff that will lower rates of health care inflation and reduce overall costs -- will take too long, while raising the subsidies would cost too much. He thinks one option available to Democrats is to lower the affordability threshold for the individual mandate so that more individuals and families would be exempted from a requirement to purchase insurance. (Currently, individuals and families would be exempt if the cheapest option available, with subsidies, cost more than 10 percent of their income.)

While Herszenhorn's piece is certainly to attune to the political challenges of health reform, we think his take on the policy options available is a bit too glum.

COVERAGE: Triggers For A Public Option Can Work

With the Senate Finance Committee still to debate how (or if) to include a choice of public health insurance plan or co-op in the new insurance marketplace, it is a good time to clarify the implications of a public plan that takes effect when competition is lacking or prices are too high, the so-called "trigger" option. Senator Snowe (R-ME) is expected to introduce a version of this idea in an amendment to provide a "safety net fallback plan to ensure access to affordable coverage."

The amendment (Snowe Amendment # 1 - Coverage, p. 207) would establish a non-profit government corporation to offer a competing plan in any state where 5 percent or more of its residents do not have access to "affordable" coverage (with affordable defined consistently with the original Chairman's Mark on a sliding scale between three percent and 13 percent of income for individuals between 133 percent and 300 percent of the federal poverty level (FPL). Chairman Baucus has since modified his mark, moving the sliding scale affordability test to between two percent and 12 percent of FPL. More than likely, Senator Snowe will modify her amendment accordingly. 

Some have argued that a "trigger is an excuse for not doing anything." This assertion is simply wrong. It should not get in the way of serious consideration of this viable option.

QUALITY: Creating Incentives for Wellness Through Health Reform

This post appears on the National Journal's Health Care Experts Blog where you can also see what other health policy analysts have to say about ways to promote wellness through health reform.

This is another example for which both God and the Devil are in the details. No one disputes that some behavioral choices -- smoking, diet, regular exercise, age and condition-appropriate screenings -- affect health status, expected health costs, and therefore, our collective average premiums. It seems perfectly reasonable, especially to economists and to those who make good choices already, to use incentives to encourage socially responsible choices and to discourage those that impose costs on others. At the same time, smoking is addictive and extremely hard to quit for some people who really want to, obesity can be caused or exacerbated by genetics and often comes with co-morbidities like depression that make financial incentives ineffective, and some people can only afford to live in neighborhoods with no stores that sell fresh fruits and vegetables and with little safe walking space. So how to reward good behavior without punishing the unlucky?

HEALTH POLITICS: Mark Me Up Buttercup

During mark ups of the America's Healthy Future Act in the Senate Finance Committee yesterday afternoon, Senator Chuck Grassley asked Chairman Baucus if he should book a plane ticket home or if they would be their all weekend.

It looks like the ranking Republican from Iowa got his wish, as the Senate Finance Committee adjourned at 12 pm Friday. The Committee will resume markups next Tuesday, when, as Politico reports, they are expected to take up amendments related to the public health insurance option.

So while we wait patiently for what may be the most closely watched debate in C-Span 3's history, here's rundown of some of the major changes to the chairman's mark, as well as some outstanding issues going forward: