Cantwell Amendment Passes

It's not much, but for people making between 133-200% of the federal poverty level it's a good start.

Senator Maria Cantwell (D-Wash.), taking a page from a program originating in her home state of Washington, has successfully maneuvered an amendment through the Finance Committee that comes close to a public option while not quite getting there.

The program, which made its way into the finance committee bill by one vote, would affect those above the 133% of the federal poverty line (those below this threshold are currently covered by Medicaid) up to 200% of the FPL. This would include a family of four earning up to $44,000.

Rather than handing over the $6500 health insurance subsidy that these people would have qualified for under the initial Baucus plan, that money would be handed over to the states to create a negotiating fund to be controlled by the state.

Participants would not get their insurance from the state through some sort of state operated public insurance option. Rather, the state would combine all this federal subsidy money and use the clout of controlling this large sum of cash to negotiate with private insurers on behalf of participants in order to get them the best deal.

It’s something of a collective bargaining approach for those in a low income bracket, with the state functioning as the local labor negotiator.

I wouldn't call it "close to a public option." It's a good policy to bundle federal monies together and allow states to bargain with it, and it will allow for competition at that low end. Of course, insurers might have to raise prices on everyone else to compensate for either lower rates on that pool, or missing out on having them in their systems. But there are caps for that, theoretically, and I would have expected those insurers to push to the max of those caps anyway. So overall, this is a good policy, and I'm glad Cantwell got it through.

Among Democrats, only Blanche Lincoln voted against it.

What's In A Name?

What's In A Name?

by dday

Harry Reid is now saying there will be a "public option" in any final health care bill. I'm sure nobody knows precisely what he means by that.

U.S. Sen. Harry Reid, D-Nev., said today there will be a "public option" in whatever health insurance reform bill comes out of Congress.

"We are going to have a public option before this bill goes to the president's desk," Reid said in a conference call with constituents, referring to some kind of government plan.

"I believe the public option is so vitally important to create a level playing field and prevent the insurance companies from taking advantage of us," he said.

Tom Harkin said almost exactly the same thing today - and he said that Republicans wouldn't be at the table when the two Senate bills get merged together.

Here's the good news about this. Reid is acknowledging that he absolutely cannot get away with having a final bill without something he can call a "public option." And progressives have done a good job of very specifically separating out triggers and co-ops as something that would not fit that definition. This is almost entirely due to grassroots activism. The public option would have been thrown out months ago if nobody was advocating for it from the bottom up. It was certainly not the intention of anyone in Washington to go into October with this issue still up for grabs. They were perfectly content to jettison it to protect insurance industry profits.

That said - there is no definition here for what public option means. And if you asked Sen. Reid point-blank, I'm sure he wouldn't give you a definition. He wants something that he can call a public option so the grassroots can be satisfied. What will that be? Probably not co-ops or triggers because they've been too well-defined by the grassroots. There are other alternatives coming in their place.

Tom Carper is pushing the idea of giving the states the ability to create a public option, which states could then link together for increased bargaining power. They wouldn't be able to use Medicare bargaining rates and they wouldn't have Medicare's provider network. And being state-based, they wouldn't have much leverage to gather the client base necessary to force a lot of competition with the private market. Of course, a lot of the "public options" out there offer weak, "level playing field" provisions similar to Carper's amendment. Jon Cohn says that actually, this is already in the bill:

One interesting question is whether the proposal is already redundant, thanks to an amendment that another member of the Finance committee, Ron Wyden, introduced that Chairman Max Baucus accepted before the hearings even began.

It's Wyden amendment C8, which appears on page two of the modified bill Baucus introduced formally for markup:

Amend Title I, Subtitle A to allow a State to be granted a waiver if the state applies to the Secretary to provide health care coverage that is at least as comprehensive as required under the Chairman’s Mark. States may seek a waiver through a process similar to Medicaid and CHIP. If the State submits a waiver to the Secretary, the Secretary must respond no later than 180 days and if the Secretary refuses to grant a waiver, the Secretary must notify the State and Congress about why the waiver was not granted. – Insert at the end of b)(1) ―and with citizen input through a referenda or similar means;‖ – In b)(2) strike ―a‖ and insert ―this‖ – Insert b)(4) ―the State submits a ten-year budget for the plan that is budget neutral to the Federal government.‖ – Insert at the beginning of c)(2) GRANTING OF WAIVER.— The Secretary shall approve the plan only if it meets criteria consistent with that of the America’s Healthy Future Act, including that it shall lower health care spending growth, improve the delivery system performance, provide affordable choices for all its citizens, expand protections against excessive out-of-pocket spending, provides coverage to the same number of uninsured and not increase the Federal deficit.

What does the gobbledygook mean? Wyden's staff says it's designed to encourage state experimentation. I haven't yet gotten an official reading from Finance Committee staff on their interpretation.

But my own reading, which I've run by a few analysts, is that it gives states the ability to implement coverage schemes that bolster coverage, control costs, and improve quality at least as well--and hopefully better than--the Senate Finance bill. That would include creating a public option. (You could even read it to allow a state-based single-payer plan.) So it's the Carper amendment, but without the restrictions.

Cohn notes that the HHS Secretary would have to rule, in the Wyden Amendment, on whether any state proposal met the proper criteria. Which means that, under a Republican Administration, you could see nothing helping people allowed to go through, or even scale-backs to benefits (though there is presumably a federal floor).

Still, maybe this is what Reid will determine as a "public option." Or maybe he'll dump Wyden's amendment and pick up the Carper idea and call that a public option. Or maybe Maria Cantwell's proposal, which allows states to negotiate on behalf of the uninsured below 200% of poverty level for a basic plan, will fit the bill, even though it sounds like a good policy but in no way a substitute for the public option.

The point is that all the activism and advocacy has gotten us far further than we would normally be in this debate. But there are still plenty of compromises out there that politicians will call "the public option" as an escape valve. It will be important to see these policies for what they are, instead of applying the name and being done with it.

Finance Committee Follies

So how's that Finance Committee doing on health care?

Well, they did manage to beat back a requirement that people show a photo ID to use the exchanges or access subsidies, though the enforcement requirements in the bill still deny undocumented immigrants the ability to but insurance on the exchanges, which is pitiful, and restrict LEGAL immigrants from doing the same for five years. So it's a win without a victory.

In better news, Max Baucus continues to be pushed to the left on affordability.

In a push to lock down votes, Senator Max Baucus, the Montana Democrat and chairman of the Senate Finance Committee, is pulling together a last-minute package of changes to his health care legislation aimed at addressing the chief concern among his fellow Democrats: that health insurance be made as affordable as possible for moderate-income Americans.

“There’s an effort to solve people’s problems,” said Senator John D. Rockefeller IV, Democrat of West Virginia, who has been a critic of the bill. “How far that’ll go, we’ll see.”

Among the proposals under consideration is an amendment by Senator Maria Cantwell, Democrat of Washington, that would create a “basic health plan” for Americans earning less than 200 percent of the federal poverty level, or $44,100 for a family of four. The proposal would let states develop or expand various existing insurance programs that now typically cover people who qualify for Medicaid. Small states could develop plans jointly.

The Baucus bill would already expand Medicaid to Americans earning up to 133 percent of poverty, and Ms. Cantwell’s proposal would effectively expand it further. But because her plan is expected to be cheaper than providing subsidies to those low-income people to buy their own insurance, it could save money that could be used to make other provisions of the bill more generous.

The Cantwell Amendment sounds pretty good at first blush. While not a public option, it's a proven idea (Washington state has this) that would reduce costs up to 200% FPL that can be used to increase subsidies above that level. UPDATE: Ezra Klein has a good interview with Cantwell about her proposal. She claims it would hit 75% of the total uninsured.

But I really like what Jay Rockefeller's cooking up - a legitimate floor for what insurance companies must spend on treatment and care.

This is delectable politics. Fresh off a meeting with Ob-Rahma, Jay Rock has come back to the Senate and demanded 90% loss ratio for any coverage the subsidies pay for. "Loss ratio" is insurance-speak for what they actually have to spend providing actual health care. That means the insurance companies can't steal 20% of our tax dollars to pay for executive salaries. They get 10%.

They're peeing their pants right now.

But I suspect Jay Rock has offered this as an outcome of his meeting with Ob-Rahma. I'm sure at that meeting they said, "Jello Jay, We'd like you to pitch other ways to save money. We'd like to come up with a way to keep costs down."

And voila!!! 90%!!! Insurance companies have to actually provide health care without gobs of executive subsidies. We're actually going to demand a certain amount of health care in exchange for the half trillion MaxTax!!!

There's no way to vote against this and still claim that you are on the side of the people instead of the insurance companies. With the cost savings in the bill, not to mention the ease of using the exchange to advertise services, insurers should easily be able to spend 90% of all premiums and still make a health profit. The only problem with this is enforcement, and how you get compliance from insurers who lie about loss ratios currently.

The Finance Committee will consider all these amendments and have a final vote on the bill next week, with Harry Reid bringing a merged bill to the floor the following week. We now know the schedule - time to make sure the best bill gets out.

I Can't Improve On That

Atta J. Turk with the definitive post on the end of the streak of Republican sex scandals, as a staffer in Democratic Senator Maria Cantwell's office is picked up for trying to arrange sex with a minor.

'Course, the scoreboard still reads 53-1, but I'm sure that won't matter to those who read the scoreboard with one eye closed.