September 30, 2014

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House, Senate face huge gaps on health care

WASHINGTON — The glow from a health care triumph faded quickly for President Barack Obama on Sunday as Democrats realized the bill they fought so hard to pass in the House has nowhere to go in the Senate.

Speaking from the Rose Garden about 14 hours after the late Saturday vote, Obama urged senators to “take the baton and bring this effort to the finish line on behalf of the American people.”

The problem is that the Senate won’t run with it. The government health insurance plan included in the House bill is unacceptable to a few Democratic moderates who hold the balance of power in the Senate.

If a government plan is part of the deal, “as a matter of conscience, I will not allow this bill to come to a final vote,” said Sen. Joe Lieberman, the Connecticut independent whose vote Democrats need to overcome GOP filibusters.

“The House bill is dead on arrival in the Senate,” Sen. Lindsey Graham, R-S.C., said dismissively.

Democrats did not line up to challenge him. Senate Majority Leader Harry Reid, D-Nev., has yet to schedule floor debate and hinted last week that senators may not be able to finish health care this year.

Nonetheless, the House vote provided an important lesson in how to succeed with less-than-perfect party unity, and one that Senate Democrats may be able to adapt. House Democrats overcame their own divisions and broke an impasse that threatened the bill after liberals grudgingly accepted tougher restrictions on abortion funding, as abortion opponents demanded.

In the Senate, the stumbling block is the idea of the government competing with private insurers. Liberals may have to swallow hard and accept a deal without a public plan in order to keep the legislation alive. As in the House, the compromise appears to be to the right of the political spectrum.

Republican Sen. Olympia Snowe of Maine, who voted for a version of the Senate bill in committee, has given the Democrats a possible way out. She’s proposing to allow a government plan as a last resort, if after a few years premiums keep escalating and local health insurance markets remain in the grip of a few big companies. This is the “trigger” option.

That approach appeals to moderates such as Sen. Mary Landrieu, D-La. “If the private market fails to reform, there would be a fallback position,” Landrieu said last week. “It should be triggered by choice and affordability, not by political whim.”

Lieberman said he opposes the public plan because it could become a huge and costly entitlement program. “I believe the debt can break America and send us into a recession that’s worse than the one we’re fighting our way out of today,” he said.

For now, Reid is trying to find the votes for a different approach: a government plan that states could opt out of.

The Senate is not likely to jump ahead this week on health care. Reid will keep meeting with senators to see if he can work out a political formula that will give him not only the 60 votes needed to begin debate, but the 60 needed to shut off discussion and bring the bill to a final vote.

Toward the end of the week, the Congressional Budget Office may report back with a costs and coverage estimate on Reid’s bill, which he assembled from legislation passed by the Finance Committee and the Health, Education, Labor and Pensions Committee. The Finance Committee version does not include a government plan.

Reid has pledged to Obama that he will get the bill done by the end of the year and remains committed to doing that, according to a Senate leadership aide.

Both the House and Senate bills gradually would extend coverage to nearly all Americans by providing government subsidies to help pay premiums. The measures would bar insurers’ practices such as charging more to those in poor health or denying them coverage altogether.

All Americans would be required to carry health insurance, either through an employer, a government plan or by purchasing it on their own.

To keep down costs, the government subsidies and consumer protections don’t take effect until 2013. During the three-year transition, both bills would provide $5 billion in federal dollars to help get coverage for people with medical problems who are turned down by private insurers.

Both House and Senate would expand significantly the federal-state Medicaid health program for low-income people.

The majority of people with employer-provided health insurance would not see changes. The main beneficiaries would be some 30 million people who have no coverage at work or have to buy it on their own. The legislation would create a federally regulated marketplace where they could shop for coverage.

The are several major differences between the bills.

  • The House would require employers to provide coverage; the Senate does not.
  • The House would pay for the coverage expansion by raising taxes on upper-income earners; the Senate uses a variety of taxes and fees, including a levy on high-cost insurance plans.
  • The House plan costs about $1.2 trillion over 10 years; the Senate version is under $900 billion.

By defusing the abortion issue — at least for now — the House may have helped the long-term prospects for the bill. Catholic bishops also eager to expand society’s safety net may yet endorse the final legislation.

Lieberman appeared on “Fox News Sunday,” while Graham was CBS’ “Face the Nation.”

Differences between the House and Senate bills

House bill Senate bill
Who’s covered About 96 percent of legal residents under age 65 — compared with 83 percent now. About one-third of the remaining 18 million people under age 65 left uninsured would be illegal immigrants. The Senate Finance version covered an estimated 94 percent of Americans. Illegal immigrants would not receive government benefits.
Cost The Congressional Budget Office says the bill’s cost of expanding insurance coverage over 10 years is $1.055 trillion. The net cost is $894 billion, factoring in penalties on individuals and employers who don’t comply with new requirements. That’s under President Barack Obama’s $900 billion goal. However, those figures leave out a variety of new costs in the bill, including increased prescription drug coverage for seniors under Medicare, so the measure may be around $1.2 trillion. Senate leaders aim to keep it under $900 billion over 10 years.
How it’s paid for $460 billion over the next decade from new income taxes on single people making more than $500,000 a year and couples making more than $1 million. The original House bill taxed individuals making $280,000 a year and couples making more than $350,000, but the threshold was increased in response to lawmakers’ concerns that the taxes would hit too many people and small businesses. There are also more than $400 billion in cuts to Medicare and Medicaid; a new $20 billion fee on medical device makers; $13 billion from limiting contributions to flexible spending accounts; sizable penalties paid by individuals and employers who don’t obtain coverage; and a mix of other corporate taxes and fees. Fees on insurance companies, drug makers, medical device manufacturers. Tax levied on insurance companies, equal to 40 percent of total premiums paid on insurance plans costing more than $8,000 annually for individuals and $21,000 for families. But that number may rise to $23,000. Retirees over age 55 and people in high-risk professions may be allowed to have somewhat more valuable plans before they’re taxed. Cuts to Medicare and Medicaid. A fee on employers whose workers receive government subsidies to help them pay premiums. Fines on people who fail to purchase coverage.
Requirements for individuals Individuals must have insurance, enforced through a tax penalty of 2.5 percent of income. People can apply for hardship waivers if coverage is unaffordable. Almost everyone must get coverage through an employer, on their own or through a government plan. Exemptions for economic hardship. The Senate Finance Committee version required individuals and families to buy coverage as long as it cost no more than 8 percent of their income. Those who are obligated to buy coverage and refuse would face a fine of perhaps $100 in the first year of the program, likely to increase over time.
Requirements for employers Employers must provide insurance to their employees or pay a penalty of 8 percent of payroll. Companies with payrolls under $500,000 annually are exempt — a change from the original $250,000 level to accommodate concerns of moderate Democrats — and the penalty is phased in for companies with payrolls between $500,000 and $750,000. Small businesses — those with 10 or fewer workers — get tax credits to help them provide coverage. Not required to offer coverage, but companies with more than 50 full-time workers would pay a fee as high as $750 multiplied by the total size of the work force if the government ends up subsidizing employees’ coverage.
Subsidies Individuals and families with annual income up to 400 percent of poverty level, or $88,000 for a family of four, would get sliding-scale subsidies to help them buy coverage. The subsidies would begin in 2013. Tax credits for individuals and families likely making up to 400 percent of the federal poverty level, which computes to $88,200 for a family of four. Tax credits for small employers.
How to choose your health insurance Beginning in 2013 through a new Health Insurance Exchange open to individuals and, initially, small employers. It could be expanded to large employers over time. States could opt to operate their own exchanges in place of the national exchange if they follow federal rules. Self-employed people, uninsured individuals and small businesses could pick a plan offered through new state-based purchasing pools. Employees would be generally encouraged to keep their work-provided coverage.
Benefits package A committee would recommend a so-called essential benefits package including preventive services. Out-of pocket costs would be capped. The new benefit package would be the basic benefit package offered in the exchange. All plans sold to individuals and small businesses would have to cover basic benefits. The government would set four levels of coverage: Under legislation passed by the Senate Finance Committee the least generous would pay an estimated 65 percent of health care costs per year; the most generous would cover an estimated 90 percent. Those numbers could change.
Insurance industry restrictions No denial of coverage based on pre-existing conditions. No higher premiums allowed for pre-existing conditions or gender. Limits on higher premiums based on age. No denial of coverage based on pre-existing conditions. No higher premiums allowed for pre-existing conditions or gender. Limits on higher premiums based on age and family size.
Government-run plan A new public plan available through the insurance exchanges would be set up and run by the secretary of Health and Human Services. Democrats originally designed the plan to pay Medicare rates plus 5 percent to doctors. But the final version — preferred by moderate lawmakers — would let the HHS secretary negotiate rates with providers. Reid proposed a new federal insurance plan this week with payment rates to providers negotiated by the health and human services secretary. Unlike the House bill, states could opt out of the plan. It’s not clear the proposal commands enough votes to survive, and it could be replaced by a standby system pushed by moderates that would not go into effect until it was clear individual states were experiencing a lack of competition among private companies. The bill also would create nonprofit, member-owned co-ops to compete with private insurers.
Changes to Medicaid The federal-state insurance program for the poor would be expanded to cover all individuals under age 65 with incomes up to 150 percent of the federal poverty level, which is $33,075 per year for a family of four. The federal government would pick up the full cost of the expansion in 2013 and 2014; thereafter the federal government would pay 91 percent and states would pay 9 percent. Income eligibility levels likely to be standardized to 133 percent of poverty, which is $29,327 a year for a family of four, for all parents, children and pregnant women. States could negotiate with insurers to arrange coverage for people with incomes slightly higher than the cutoff for Medicaid.
Drugs Grants 12 years of market protection to high-tech drugs used to combat cancer, Parkinson’s and other deadly diseases. Phases out the gap in Medicare prescription drug coverage by 2019. Requires the HHS secretary to negotiate drug prices on behalf of Medicare beneficiaries. Grants 12 years of market protection to high-tech drugs used to combat cancer, Parkinson’s and other deadly diseases. Drug companies contribute $80 billion over 10 years with the majority of the money used to limit the prescription coverage gap in Medicare.
Antitrust Would strip the health insurance industry of a long-standing exemption from antitrust laws covering market allocation, price fixing and bid rigging. The bill also would give the Federal Trade Commission authority to look into the health insurance industry at its own initiative. Amendment expected to be offered on the Senate floor to strip the health insurance industry of its antitrust exemption.