But let's discuss the merits of the respective bills, shall we? Once you drop the public option, and if anyone thinks that the public option can still be included in this bill, they are sadly mistaken, the Senate bill is in many ways more progressive than the House bill, although the House bill is more progressive in other ways. I'm going to try to attempt some comparisons, assuming that the public option is out. I want us to get out of our "he says she says" mentality and focus on the merits, and then focus on what we should be doing as progressives.
WHERE THE SENATE BILL IS STRONGER
State-based exchanges: Yup, state based exchanges. State based exchanges may well be more effective as prudent purchasers of customers and patients of the individual states. Gov. Howard Dean, who has been a progressive champion on the issue of health care, and about the only person who has actually delivered health care both on an individual (as a doctor) and a policy (as a governor of Vermont) level, demanded state-based exchanges when he slammed down the compromised senate bill that emerged immediately after Lieberman's flip flop on the Medicare buy-in:
Improvements can still be made in the Senate, and I hope that Senate Democrats will work on this bill as it moves to conference. If lawmakers are interested in ensuring that government affordability credits are spent on health-care benefits rather than insurers' salaries, they need to require state-based exchanges, which act as prudent purchasers and select only the most efficient insurers. Sen. John Kerry (D-Mass.) offered this amendment during the Finance Committee markup, and Democrats should include it in the final legislation. A stripped-down version of the current bill that included these provisions would be worth passing.And he is right. As long as we are not going to have a national public option or a single payer system, it is a bureaucratic disaster to try to have the federal government figure out which insurance companies are playing by the rules in which states and who deserves to be where. Unless we want to gut all state level regulations - current and future - of health insurance companies, which would mean California and New York and Massachusetts and Oregon would not be able to put on stronger regulations on the insurance companies. Which I don't think is a good idea, or a progressive one for that matter.
This is also an accountability issue. People in the individual states can much more easily hold accountable their state exchanges and their regulators than they can bureaucrats at the federal level. One needs not vote on things like terrorism when they choose their state officials.
While the exchanges in the senate bill are state-based, it is notable that the federal government is involved in the development and supervision of those plans via the Office of Personnel Management.
Letting States offer their own 'public options': This is not in the House bill (presumably because there is a national public option in the House bill). The Senate-passed bill allows states to experiment with their own health insurance concepts. They can, for example, take the tax breaks offered to their citizens from the federal government, and set up their own option within their exchanges (another added benefit of a state-based, rather than a federal, exchange). Katrina Vanden Heuvel wrote on December 22, 2009:
There has also been little news coverage of Sanders' fight to allow states waivers so they can move forward with their own "health insurance concepts, including single-payer." Such language is now in the Senate bill and Sanders is still working with Senator Ron Wyden to strengthen it. That is exactly how Canada developed its healthcare system, with a successful program incubated in Saskatchewan. This provision is actually stronger in the Senate bill--it didn't make it into the House version.Ezra Klein of Washington Post expands:
Section 1332 is titled "Waivers for State Innovation." But that’s a terrible name. Call it "the law for the law of unintended consequences." The idea is simple: If states think they can do better than the language and policies in this bill, and they can make a convincing case that they’re right, they can get a waiver exempting them from the legislation. They still get the money that would be owed to them, but they get to spend it their way.Credits for pointing out Ezra's article goes to "Elise" of Daily Kos, who commented on my cross-post on that site. Thanks, Elise!
Small businesses: The Senate bill does a better job for small businesses. It exempts businesses with less than 50 employees from having to provide coverage or paying a penalty, but that's not all. The Senate bill allows small businesses with up to 100 employees to buy into the health insurance exchange in their state. In other words, not only do small businesses get a break from requirements rightly imposed on Wal Mart and PG&E, they also get a break from having to negotiate with insurance companies if they do provide coverage, since their state will do it for them, and they can simply buy into the coverage provided by their state exchanges. It will give small businesses a more even playing field.
As a side benefit of this, it will strengthen the hands of the state based regulators, give small businesses an incentive to participate and monitor their state exchange regulators, and give more people a stake into the exchanges with more group buying power.
The House bill provides exemptions and reductions in penalties for business with payrolls of less than $750,000. That is alright, but for a small business with 50 employees, that's $15,000 per employee on average on the payroll. At the last Netroots Nation, Gov. Howard Dean advocated something very similar to what is now in the Senate bill for small businesses. The entire session is here. In this health care townhall, Gov. Dean actually praised the efforts of the Blue Dogs in the House.
Abortion language: The Senate bill has the Nelson language, which, by no means should satisfy any pro-choice person, but it is nothing compared to the House's Stupak language, which would ban the sale of all policies with abortion coverage on the exchange(s). The Nelson language would instead require the insurance companies to provide accounting that federal dollars are not used to pay for the abortion coverage included (if included) in a policy, and it gives states the right to ban it altogether from their exchanges. Once again, that is hardly something to celebrate, but it is not as bad as the Stupak language.
WHERE IT'S A WASH
Premium assistance at the exchanges: Both the House and the Senate bills have subsidies for people up to 400% of the Federal Poverty Level. For the poor, the House bill does a marginally better job. However, for the lower middle class, the Senate bill is superior in terms of premium assistance. A family or an individual making up to 250% of FPL would be better off in terms of premium assistance under the House bill (the poorer you are the more better off you are under the House bill). Make 300% - 400% of FPL, however, and your out-of-pocket premium cap in the exchange in the House bill is between 10 and 12% of your income, whereas under the Senate bill it is 9.8% of your income. Put it another way, an individual with income at 400% of the Federal Poverty Level (making $43,320 a year) would pay an estimated $5,198 under the House bill to purchase health insurance for a year, but under the senate bill, that same individual would pay no more than $4,245.
To be sure, I would like the House formula adapted for the lower income brackets and the Senate formula put to work for the 250-400% of FPL bracket. Nonetheless, it is, at best, a wash, and it's hardly accurate to say that the overall premium assistance is better under the House bill.
WHERE THE HOUSE BILL IS STRONGER
The public option: We would all like one. But it does not seem like it will make it into the current bill.
Medicaid Expansion: Not much to say here. The Senate bill extends Medicaid to 133% of FPL. The House bill takes it to 150% of FPL. I hope this is one place the House is able to take the lead.
Community Health Centers Expansion: As you know, Sen. Bernie Sanders of Vermont was able to secure 10 billion dollars in CHC expansions in the Senate health care bill. As he put it, it would bring a "revolution" in primary health care in America. The House bill does even better, adding $14 billion at the behest of the House Majority Whip, Congressman Jim Clyburn. Sen. Sanders and Rep. Clyburn both have expressed hopes that the House version of the CHC funding be in the final bill.
Coverage: The House bill covers an estimated 96% of all Americans, compared to 94% in the Senate bill. In real numbers, that is a 5 million people difference. The House bill will cover 36 million additional people, whereas the Senate bill will only cover 31 million more. Given that one out of a every thousand uninsured die every year because of the lack of health insurance, the House bill would save 5,000 additional lives every year over the Senate bill, even though both are dramatic improvements over the status quo.
In conclusion, we progressives have our work cut out for us. We don't have the luxury to be dismissing out of hand anything that the Bluedogs like simply because they like it. Nor do we have the luxury to cling onto our demands for the public option if we do not want to kill the bill. With the absence of a national public option, we have to work hard towards these goals:
- Expand coverage as much as possible. That means pushing for the House bill's coverage numbers.
- Ensure that the states retain the right to include in their exchanges a state-based public option, a la the Senate bill.
- Community Health Center expansion comes closer to the House version, a $14 billion expansion.
- The abortion language takes the form of the lesser of two evils, the Nelson version from the Senate.
- Medicaid is expanded to individuals and families up to 150% of FPL, a la the House bill.
- Help small businesses have a fighting chance, give them the tax breaks when they provide coverage, but don't penalize them not being able to afford to do so. Let them join their purchasing power with the state exchanges, a la the Senate bill.