The New Republic

The three House committee chairman in charge of health legislation--Geroge Miller, Charlie Rangel, and Henry Waxman--just briefed House Democratic members on the framework and timing of a reform proposal in their chamber. The basis for the discussion was an outline, which they've made available here.

I'm preoccupied with a longer article so I don't have time for a careful read right now. My initial take, based on a skim, reveals no huge surprises but some intriguging hints about what's in store.

Here they are--although, in fine congressional tradition, I reserve the right to revise my remarks later on.

WILL THE OLD PAY MORE? It "strictly limits" premium variations based on age. As discussed previously, this is emerging as a policy flashpoint, between those who think "community rating" means everybody should pay the same rate and those who think it's ok to make older people pay far more. It's actually a bit more complicated than it might seem at first blush (including to me). Among other things, there are transition issues to contemplate, since moving to strict community rating by age would too quickly ratchet up premiums for many young people. More on this later.

WHO GETS SUBSIDIES? It would make subsidies available to people at up to 400 percent of the poverty line. That's the number most reformers have in mind, at least in the ideal. It's intersting, though, that it's lower than the figure we saw in the latest draft to leak out of the Senate Health, Educaiton, Labor, and Pensions (HELP) Committee. I've always assumed the House bill would set the outer policy boundary on the left. In this case, it would actually be a bit to the right of HELP's proposal--although, of course, HELP's bill is still a work-in-progress.

WHAT'S THE ULTIMATE PROTECTION? It "caps total out-of-pocket spending in all new policies to prevent bankruptcies from medical expenses." Although this, too, is an idea reformers have talked up, I actually haven't checked to see whether it was in the drafts/outlines we've seen out of HELP and the Senate Finance Committee. I assume it was in both, but, just in case, it's good to see this provision here. Note, by the way, the reference to "new policies." A key issue in crafting legislation is how quickly--and how aggressively--to apply new regulations to existing policies. Ideally, you'd want everybody to be subject to new regulations. But doing that inevitably means tinkering with the coverage people already have, thereby violating the first and most important political rule of heatlh reform: Assure the insured middle-class nothing will change for them if they're happy with their coverage.

WHO GETS TO USE THE EXCHANGE? The insurance exchange is open both to indivdiuals and businesses. Some critics of reform have suggested allowing only indivdiuals to buy insurance through the exchange, thereby preserving the small business market as it is. This suggests the House isn't thinking along those lines.

PUBLIC PLAN, YEA OR NAY? There's a public plan, specifics unknown. Interesting, again, that the House--which I would expect to be the far left marker in this debate--is not specifying a strong public plan. This could simply be a case of acting cagey. Or it could be a sign that, even in the House, there's strong opposition to the sort of public plan that would operate like Medicare, through the government. 

WILL GOVERNMENT REQUIRE YOU GET INSURANCE? There's an indivdual mandate, with exceptions for hardship, to be imposed "once market reforms and affordability credits are in effect to ensure access and affordability." Again, standard language for this sort of thing.

WHAT'S THE DEAL FOR SMALL BUSINESS? There's a requirement that employers provide insurance or contribute money towards coverage. Small businesses that provide coverage would receive at ax creidt. "Small low-wage firms" would be exempt from the requirement. The language, again, is important here. If you want to protect small business from a mandate--and, in general, I think that's a good idea--you can do it by the number of employees or the salaries it pays. This suggests a combination of the two strategies.

WILL HEALTH CARE GET BETTER--AND CHEAPER? There's some material at the end about fixing the delivery system--i.e., changing the way public progarms pay for treatments, in an effort to weed out waste and concentrate on the stuff that works. It's not much, but the language is broadly consistent with what we've seen from the Senate and heard from the White House.

--Jonathan Cohn 

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