Democratic Platform and the Senate health bill

You can throw a dart at the left-ideological blogosphere and if you aim it roughly for health care reform, chances are you are going to hit a post about how the Democratic party is violating its own platform with the Senate bill.  Horror!  Of course, you can look at the right wing lunatic blogosphere and they are screaming about Socialist Communist Kenyan (TM) takeover of health care reform.  But I'm planning on examining the claims of this serious violation of the Democratic platform today.  After all, Democrats are in power in the White House, the House and the Senate.

First let me introduce you to the 2008 Democratic National Platform.  As you will see, it divides each policy area into subsections about what the Democratic platform says about that policy area.  I am going to list them and assign points based on a rather simple idea: I wasn't at the platform discussions.  I don't know what was given the most weight and what was given the least.  So each goal under the main health care umbrella will get the same amount of points assigned, and each sub-goal within it will divide up those points equally.  Sound fair?  Ok.  So let's find out how the Senate health care bill stacks up against those goals.

Before I go on though, because I'm a Democrat, I'd like to begin with a reminder to my fellow Democrats about this President and this Democratic Congress' commitment to health care and children.  The platform, in the health care section, starts off this way, highlighting the importance of health care reform among Democratic delegates:
If one thing came through in the platform hearings, it was that Democrats are united around a commitment that every American man, woman, and child be guaranteed affordable, comprehensive healthcare. In meeting after meeting, people expressed moral outrage with a health care crisis that leaves millions of Americans – including nine million children – without health insurance and millions more struggling to pay rising costs for poor quality care.
The President and the Democratic Congress moved swiftly after Obama's inauguration to drastically reduce this number.  On February 4th, 2009, the President signed into law a big expansion of SCHIP, covering 4 million additional children, cutting the number of children uninsured by nearly half.  That is in addition to 7 million children previously covered, bringing the total number of children covered by SCHIP to 11 million.

Work on health care indeed began before the current legislation.  The Recovery Act dedicated more than $145 billion to investments and reform of health care systems, including $87 billion to states in just the next couple of years to maintain Medicaid programs, $25 billion to help laid off workers buy COBRA, $19 billion for Health Information Technology (HIT) deployment, and $10 billion in additional funds for the National Institute of Health.

Now let's move on to the particular sections for health care in the 2008 Democratic platform.  Each category, except one one-liner, will be worth 20 points.  First up:

I. Universal coverage and insurance options - 20 points possible.
Covering All Americans and Providing Real Choices of Affordable Health Insurance Options. Families and individuals should have the option of keeping the coverage they have or choosing from a wide array of health insurance plans, including many private health insurance options and a public plan. Coverage should be made affordable for all Americans with subsidies provided through tax credits and other means.
From here, point distributions:

Coverage, 10 points possible (100% coverage possible)
The Senate achieves 94% coverage, so it gets a 9 (House bill would get a 10, with 96% coverage).

Health care choices: 10 points possible - 5 for public plan, 5 for affordable choices.
Senate bill does not have a public plan.  Zero for that.  Health insurance choices are alright, costs are largely a wash with the House bill, although it could always get more subsidies.  So it gets 4 out of those 5 points.  So 4 out of 10 here.  (House bill would get a 9).

Category I Score: 13/20.

II. Shared responsibility - 20 points possible.
Shared Responsibility. Health care should be a shared responsibility between employers, workers, insurers, providers and government. All Americans should have coverage they can afford; employers should have incentives to provide coverage to their workers; insurers and providers should ensure high quality affordable care; and the government should ensure that health insurance is affordable and provides meaningful coverage. As affordable coverage is made available, individuals should purchase health insurance and take steps to lead healthy lives.
The platform sure sounds to me like it's at least quite open to a mandate.  Given a whole lot of delegates (Clinton and Edwards delegates) were pledged to candidates who openly campaigned for a mandate, this is a reasonable assumption. The Senate bill has a mandate - an affordable one, as I have discussed before - with a hardship exemption.  The Senate bill provides employers with incentives to provide coverage, with small business tax credits for health insurance going into effect immediately.  The Senate bill does as good as the House bill to ensure high quality care - with both reforms in care delivery and defined minimum benefits.  It puts an onus on the insurers to come up with coverage with value given the 85% Medical Loss Ratio (MLR) requirement - i.e. insurers spend that much on health care or cut you a check at the end of the year - coupled with an excise tax on high-premium employer plans discouraging unnecessarily expensive but not necessarily more effective policies.

I give Shared Responsibility on the Senate bill its full 20 points.

Category II score: 20/20.

III. End Insurance Discrimination (pre-existing condition) - 20 points possible
An End to Insurance Discrimination. Health insurance plans should accept all applicants and be prohibited from charging different prices based on pre-existing conditions. They should compete on the cost of providing health care and the quality of that care, not on their ability to avoid or over-charge people who are or may get sick. Premiums collected by insurers should be primarily dedicated to care, not profits.
The Senate bill eliminates discrimination (all discrimination, including in price, not just in acceptance) based on pre-existing conditions, although not until 2014, when the exchanges start.  Pre-existing condition discrimination against children is banned immediately.  The Senate bill ends recessions if you get sick or injured, and bans annual or lifetime caps (lifetime caps for existing policies are grandfathered, but you can switch easily since no discrimination is allowed based on health conditions when you choose a new plan, and new policies are forbidden from having a cap).  The Senate bill also allows insurance companies to charge older people 3 times as much.  That'll cost some points.  Largely because of this, I'm giving it a 15 in this category.

Category III score: 15/20.

IV. Insurance Portability - 10 points possible
Portable Insurance. No one should have to worry about losing health coverage if they change or lose their job.
I know I said 20 points each.  But this is pretty bare knuckle and short.  Not any components.  10 points is good enough for this.  Portability is basically achieved through the exchanges, which are present in the Senate bill.  Some will quibble that insurance on a national exchange is more portable than insurance on state based exchanges, and even though I disagree, I don't want to belabor the point.  Fine.  9 points.

Category IV score: 9/10.

V. Meaningful Benefits - 20 points possible.
Meaningful Benefits. Families should have health insurance coverage similar to what Members of Congress enjoy. They should not be forced to bear the burden of skyrocketing premiums, unaffordable deductibles or benefit limits that leave them at financial risk when they become sick. We will finally achieve long-overdue mental health and addiction treatment parity.
Well, the Senate bill's minimum coverage isn't quite what Congress has, but the basic package is modeled after it.  No junk insurance.  Affordability and cost control measures include the exchange (marketplace), the ability of state and federal regulators to monitor premiums and kick out insurers from exchanges, the 85% MLR requirement and the excise tax only for high-priced for group plans, dis-incentivizing costly plans that don't deliver better insurance.   Mental health is covered.  Premium assistance is available for people up to 400% of poverty; Medicaid is extended to people up to 133% of poverty.   Out-of-pocket expenses are limited on a sliding scale (as are premium caps) for people up to 400% of poverty, and above that, to $5,950 for individual plans and $11,900 for family plans.  The mandate is inoperative unless you can find insurance that will costs you 8% or less of your income in premiums.

But both the Senate and the House does a disservice in terms of abortion coverage - although the Senate bill is lesser of the two evils on that.  I do believe abortion is a "meaningful benefit."  Although this next point is not considered in grading, I do caution you that Vice President Biden's Violence Against Women Act is up for re-authorization next year.  Do we want Republicans be in control of Congress for that?

So, take a few points off the top for the imperfections (lack of abortion coverage, mainly), 17.  That's a B.  Sounds fair to me.  The House bill would lose more points on abortion coverage, and stand at about a 15.5 for me.

Category V score: 17/20.

VI. Prevention and Wellness - 20 points possible
An Emphasis on Prevention and Wellness. Chronic diseases account for 70 percent of the nation’s overall health care spending. We need to promote healthy lifestyles and disease prevention and management especially with health promotion programs at work and physical education in schools. All Americans should be empowered to promote wellness and have access to preventive services to impede the development of costly chronic conditions, such as obesity, diabetes, heart disease, and hypertension. Chronic-care and behavioral health management should be assured for all Americans who require care coordination. This includes assistance for those recovering from traumatic, life-altering injuries and illnesses as well as those with mental health and substance use disorders. We should promote additional tobacco and substance abuse prevention.
This thing is on steroids in the Senate bill - what can be done as part of a health insurance package is, anyway.  Preventive care is free after your premium - i.e. no copay or deductible for preventive care.  Since pre-existing condition is gone, people with chronic care will be able to get health insurance and get proper care.  The Senate bill (being set apart from the House bill) also allows employers to provide employees with premium discounts, reduced cost sharing or additional benefits when an employee participates in a wellness program and meets certain health related standards.  To ensure it does not unfairly leave people behind, employers must provide alternative standards for those for whom it's unreasonably difficult to meet those standards.  This reward initially reaches up to 30% of cost of coverage, and may be increased to 50% in appropriate cases.  (Source: KFF - check 'Senate bill' in the top box, and then 'Wellness' in the bottom one, and then click 'generate comparison.')

Mental and behavioral health are included, including substance abuse care, as noted above.    Electronic medical records will help make you not go through the same test five times.  And let's not forget the $10 billion Community Health Center expansion in the Senate bill, thanks to Sen. Bernie Sanders, something he characterized as revolutionizing primary care (which is also preventive care).  Sanders has also already increased funding for CHC's in the Recovery Act.  Women's preventive care is well-covered.

This bill does as well as can be done with legislation on prevention and wellness.  Full marks.

Category VI score: 20/20.

VII. Modernized system that lowers cost and improves quality - 20 points possible
A Modernized System That Lowers Cost and Improves the Quality of Care. As Americans struggle with increasing health care costs, we believe a strengthened, uniquely American system should provide the highest-quality, most cost-effective care. This should be advanced by aggressive efforts to cut costs and eliminate waste from our health system, which will save the typical family up to $2,500 per year. These efforts include driving adoption of state-of-the-art health information technology systems, privacy-protected electronic medical records, reimbursement incentives, and an independent organization that reviews drugs, devices, and procedures to ensure that people get the right care at the right time. By working with the medical community to improve quality, these reforms will have the added benefit of reducing the prevalence of lawsuits related to medical errors. We should increase competition in the insurance and drug markets; remove some of the cost burden of catastrophic illness from employers and their employees; and lower drug costs by allowing Medicare to negotiate for lower prices, permitting importation of safe medicines from other developed countries, creating a generic pathway for biologic drugs, and increasing use of generics in public programs.
We don't know how much families will save with this bill.  It's not entirely clear.  But consider this: in 2008, the average family health plan cost $12,298, or about 18% of the median income for a family of 4 that year, $67,019.  If you are a median family, with let's say the primary policy holder about 45 years old, the Kaiser Health Reform Subsidy calculator estimates your premium to be $11,080 under the Senate proposal.  You would be eligible for subsidies, and the federal government would pay $4,512 of that cost.  That leaves your family with $6,568 in premiums.  So to you, the drop in cost is well over the $2,500.  (This is obviously if you are purchasing coverage in the individual market and not obtaining through your employer.)  But it might not be as much for families that aren't eligible for subsidies.  Overall though, with the help of the subsidies, that goal is pretty much met.

Electronic medical record and technology upgrades?  Check, a whole lot was already there before the debate even started, in the stimulus bill.

Independent board to find out what works best and the most effective care?  Check, at least for Medicare (waiting for Sarah Palin to start screaming 'Death Panel!' anytime now).

Removing cost burden of catastrophic illness?  Sure, if you consider most people will be required to get coverage, widening the pool and thus spreading out the cost of catastrophic illness.  Until the exchanges open, here is also a high risk pool set up in the Senate bill.

Now the Senate bill doesn't let Medicare negotiate drug prices, and points are coming off because of it.  But, it does, over time, completely close the Medicare drug benefit donut hole.

The Senate bill also fails to allow for drug re-importation.  Something will be taken off the top here.  I will note that the White House has promised to work with Sen. Byron Dorgan to enact a separate drug re-importation measure.

The Senate bill protects brand-name biologics drugs for 12 years, but in fairness, so does the House bill.  The Senate bill, however, slaps $2.3 billion in annual fees on brand name biologics makers.  So it might actually be doing better in this respect than the House bill.

Overall, I'm giving this modernizing system to improve cost and quality category a C.  That's a 15.

Category VII score: 15/20.

There are a few other areas of the health care platform, but legislatively, they are generally addressed in different areas, and thus would not make sense to include here.  These are:
  • Building a strong health care workforce through incentives and training (primarily addressed via education policy and legislation. A quick note that Sen. Bernie Sanders, through the Recovery Act and this bill, also secured the largest increases for the Health Services Corps, in addition to the CHC's.)
  • Commitment to eliminating ethnic, gender, sexual and other discrepancies in health care (can't be addressed in direct insurance coverage legislation, primarily addressed through access in existing programs, and of course, the Senate bill outlaws discrimination based on any of those factors.  The thing to work on now is regional discrepancies, since markets vary, and so does the customer base's makeup.)
  • Public health and research (primarily funded through NIH and CDC).
So from the 7 areas above, I don't think I have been particularly generous in scoring.  As you saw, a total of 130 points were possible: 6 areas with 20 points each and one with 10.  My scores, in those 7 areas, total 109 points.  That's 84%.

In other words, we are getting about 84% of the Democratic health care platform in the Senate bill.  84%.  That's pretty damn good!  Maybe that's why two staunch proponents of the public option, House Majority Whip Jim Clyburn and Sen. Al Franken agree that the Senate bill is a 'very good' bill.  Now we can sit here and squabble about the other 16%, we can hold or we can make sure that we get this bill passed and get the 84% of the health care platform of the Democratic party - and possibly more!

To do that, you need to make a few calls - even if you have already made those calls.  First, call the Capitol switchboard and ask for your member of the House.  Tell them politely but firmly that you expect your member to vote for the Senate health care bill as is so that it can be signed by the President.  Then urge them to follow up with a reconciliation bill to fix it (or find your member at House.gov).  Call the Capitol switchboard back and ask to speak to your Senators (you can also find your Senators on Senate.gov).  Tell them you expect them to follow through on the House's reconciliation bill.  Call Harry Reid also if you like, as well as Speaker Pelosi.  Here are the toll-free numbers:
  • 1-866-338-1015
  • 1-866-220-0044
  • 1-866-311-3405
Finish the job on health reform.