Mandate

The New York Times had a gloom and doom story (which also compared apples and oranges, but we are getting ahead of ourselves) over the weekend about how New York's experience teaches us that national health reform will make insurance unaffordable because it will require insurers to cover sick people. It left out, or glossed over, dozens of ways in which New York's version of piecemeal insurance reform is different from the comprehensive national health reform plan.

This doesn't mean that we shouldn't pay attention to, and learn from, New York's experiences. (Or Massachusetts, Vermont, Minnesota, Wisconsin, Hawaii etc.) Of course we should. But we shouldn't assume that history is going to repeat itself, particularly when some of the lessons -- like the need for mandates -- have already been absorbed.

While some of the more significant features of the bill won’t kick in until 2014, a lot will happen between two days ago and six months from now. The Huffington Post put together a great slideshow, highlighting the “Top 18 Immediate Effects.” (My colleague, Julie Barnes, told you about most of them last week, but never hurts to look at the pictures, too.) These provisions range from small business tax credits to donut hole rebates to allowing young adults to stay on their parents’ plans until age 26. Check it out. Here’s a convenient implementation schedule, courtesy of the American Medical Association. And the New York Times put together a great graphic that shows how reform will affect different types of people.

Health reform will certainly be a “bear to implement,” said Donna Shalala, the Health and Human Services secretary during the Clinton administration, because in many respects, the work just begins now.  And while it's federal reform, the bulk of the work is left to the states. "In essence," explains Anthony Wright, executive director of Health Access California and regular contributor to the Treatment, "the bill spurs 50 different health reforms." Which means it's smart to get going.

The bipartisan health care summit may be so last week, but before we move on (to reconciliation and House vote counting?) we wanted to just pull out three pieces of the transcript which made an impression on us. Here's President Obama explaining why he came around to believe in the individual mandate. It's important partly because it gets to the essential point of why we have to do comprehensive reform -- piecemeal just doesn't have the answers.

Here's Obama (and no, we haven't seen any comment from Secretary of State Clinton...):

Now, on the mandate, though -- because the mandate issue is connected, and so I'm just going to mention this real quickly, and then I will move on. When I ran in the Democratic primary I was opposed to the mandate.

(We are updating this with a few comments made at the summit, and a little more explanation of how the Senate Democratic bill's approach to "across state lines" would work.)

We expected a few issues to be stressed at today's health reform summit -- among them, buying insurance across state lines and malpractice reform. We were right. We've been tweeting all morning, but here are a few thoughts and a guide to some work we've done in the past on these topics.

Across State Lines. Republicans are still pushing the idea of letting people buy insurance across state lines -- an idea we've pointed out doesn't work, at least not how they have historically constructed it. Here’s our report (and also the executive summary) published back in 2008. Our study indicates that allowing insurers to sell across state lines, in the way the Republicans have and continue to propose, would make it harder and more expensivefor many Americans to access quality health coverage. It may benefit some of the young and healthy, but it would have a devastating impact on the insurance market for everyone else (and none of us will be young and healthy forever). It would gut many of the patient protections and state rules now in place, and as President Obama put it, risk creating a '"race to the bottom."

However, the Senate bill does allow states to pool enrollees and form insurance "compacts" (check out the Kaiser side-by-side for more details) permitting the sale of insurance across state lines -- but with oversight, regulations and a mandate. As Senate Finance Committee chairman Max Baucus commented at the Blair House earlier today, "We do allow for that [across state lines]. But not exactly the way some would." Once the exchanges are up, Baucus added, people could buy insurance across state lines and benefit from competition. But there would be rules -- that strengthen patient protections. When the Senate Finance committee first developed its "states' compact" approach, Len Nichols wrote on our blog that it would ensure that insurance market rules would be uniform across state lines, "ensuring that every insurance package provides access to necessary services and protects consumers' health and financial needs."

The latest study released by the insurance industry, while better than the one that came before it, is riddled with flaws. The recent report produced by Oliver Wyman (an management consulting firm with an actuarial services arm) for the Blue Cross Blue Shield Association (BCBSA) is more reasonable than the PriceWaterhouseCoopers study issued by America's Health Insurance Plans (AHIP), but it, too, is designed to scare Americans into accepting the status quo rather than comprehensive health care reform.

Lets' be clear here: some of the best plans in the country are Blue plans, and we need all of them to get better post-reform. It's worth noting that the two things the Blues have been lobbying about most vigorously are the same positions that Wyman's analysis supports: (1) prevent the melding of the small group and individual markets, and (2) keep the insurance exchange as small as possible.

The report gets one thing right: reformers must make sure insurance coverage is affordable and that the mandate to buy insurance is enforceable so that most Americans get coverage. Otherwise, requiring insurers to sell to any customer who wants to buy (guaranteed issue) will risk the stability of the risk pool in the exchange. On this much we (and many others) agree.

What I cannot agree with is the attempt to sway the reform debate with data that cannot be checked and assumptions that seem to be designed to produce the results BCBSA wants us to believe. On many points Wyman and BCBSA could be correct. But since their data are not public, it is impossible to check.

These are the report's weaknesses:

Robert Greenstein over at the Center on Budget and Policy Priorities finds plenty to like about the bill the Senate Finance committee has approved -- and much that still needs work. With his usual mix of progressive values and budgetary common sense, here's how he balances it out:

Last time I ran into Bill Frist, he was sounding distinctly nonpartisan on a panel discussion about preventive care and social determinants of health. We then talked about comparative effectiveness research at Vanderbilt, where he is affiliated, and he was so enthusiastic that he took my notebook out of my hands and began sketching diagrams of DNA molecules (at least I think that's what they were.) I asked him why he didn't write on op-ed about this, given that the research has been so controversial among his fellow Republicans. As far as I know, he hasn't written that an op-ed -- but he just penned an endorsement of an individual mandate to purchase health insurance.

The mandate is a lynch pin of effective insurance market reform and it's coming under increasing Republican attack. Some state legislators are even talking about amending their constitutions -- a largely symbolic conversation among conservatives -- to ban such a requirement.

In his guest column for U.S. News and World Report, Frist called for an individual mandate. He wants to begin smaller than the bills currently being considered in Congress, recommending a mandate for catastrophic coverage as "an appropriate place to start." But he defined catastrophic coverage as good enough to protect people from bankruptcy from medical bills, and made clear that he favors expanding coverage as the economy improves.

The White House has posted President Obama's letter to Senators Ted Kennedy and Max Baucus on health care reform. He reiterated his vision (and ours) that reform is an economic as well as a moral imperative. And he added a few points (and $$$) we hadn't heard before:

The health insurance industry, in what was widely seen as a step toward consensus on health reform, has said it would stop charging sick people higher rates as part of a comprehensive health reform plan that required everyone to have insurance.

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