THE TREATMENT JULY 14, 2009
The three House committees writing health care legislation have just released the full text of their bill. And my immediate, admittedly tentative reaction is strongly positive. Once fully implemented, this reform plan will accomplish most of the goals on my mental checklist:
- Generous subisidies, available to people making up to 400 percent of the poverty line
- Expansion of Medicaid to cover people making less than 133 percent of the poverty line
- Guarantees of solid benefits for everybody, with limits on out-of-pocket spending
- Strong regulation of insurers, including requirements that insurers provide insurance to people with pre-existing conditions without higher rates
- An individual mandate, so that everybody (or what passes for everybody in these discussions) gets into the system and assumes some financial responsibility
- A public plan, one that appears to be strong, although I'll reserve judgment on that until I hear from the experts
- Choice of public and private plan, at first just for individuals and small businesses, but later for larger businesses and--possibly--eventually for everybody
- Efforts at payment reform, if not necessarily as strong as they could be
- Investment in primary care and prevention, which is not sexy but potentially important for general health .
The Congressional Budget Office score? Their initial estimates have it covering 94 percent of people living here and 97 percent of legal immigrants, for net outlays of just over $1 trillion over ten years. That figure includes the offsetting effect of the employer mandate, which--at a healthy 8 percent of payroll for larger companies that don't insure workers--would generate $30 billion a year by the end of the decade-long planning window. (Smaller businesses would be exempt.)
I've not yet seen assessments for the new revenue and offsetting savings; I believe everybody is still waiting on numbers from the Joint Committee on Taxation, which does official estimates for revenue. But my House sources say they expect that between savings and a new surtax on the wealthy, the bill pays for itself. In other words, it won't inflate the deficit.*
I do have one, not minor concern: It will be a while before people see the best stuff. Most of the major elements--the insurance exchange, the subsidies, the insurance regulations, the public plan--won't come online until 2013 or later. This is, I believe, also true of counterpart bills in the Senate.
There's a sound policy rationale for going slow; it takes a lot of work to set up exchanges, regulations, and the like. But four years is a long time. And I suspect money has a lot to do with the pace. Slower implementation makes it possible to keep the price tag to around $1 trillion.
On the bright side, some provisions--filling in the Medicare drug donut hole,
bolsteirng the primary care workforce, among others--would start in the next two years.
at least one key insurer regulation would kick in right away: Come 2010, insurers could no longer yank coverage from people retroactively because they've uncovered new evidence of pre-existing conditions. This practice, known as "rescission," is among the most patently unjust features of our health care system.
So, no, it's not perfect. I gave up on perfect quite a while ago. And I'm sure more flaws will emerge as we all have time to give this more scrutiny. (Expect more analysis, here and elsewhere, in the next day.) But within the existing political constraints, it's hard to do imagine a much better bill than this.
An implementation timeline, along with those initial CBO assessments, appear below.
*Update: A source just passed along the revenue estimates from the Joint Committee on Taxation. As expected, JCT projects that the reforms would raise $580 billion in new revenue over ten years, the vast majority from an income tax surcharge affecting wealthy Americans.