With Congress coming back today from the July 4 recess, time will be short and work will be long as the proposed deadlines for completion of healthcare reform legislation mark-ups loom. In the House, July 31 is the target date; in the Senate it's August 8.
Can they make those deadlines?
In the House, key issues—including a public health insurance option, health exchange, and caps on out-of-pocket spending—have been included in a draft bill approved by three House committees. The big questions now on the table: How much will it cost, and how to pay for it?
In the Senate, the costs have had the focus. Before he left town for the recess, Sen. Max Baucus (D-MT), chair of the Senate Finance Committee, announced that the panel's reform package now had "options" that the Congressional Budget Office (CBO) said "would cost under $1 trillion [over 10 years] and would be fully paid for." These options, though, were not specified, but are thought to include lowered insurance subsidies for lower- and middle-income Americans.
The Senate Health, Education, Labor and Pensions Committee went back to the budget drawing board and came up last week with a bill that was scored by the CBO at just over $611 billion over 10 years—a vast drop from the $1 trillion score a week earlier, according to a letter by Sen. Edward Kennedy (D-MA) and Sen. Christopher Dodd (D-CT), who is chairing the committee as Kennedy continues to deal with a brain tumor.
So now come the details. Especially in the Senate, the committees likely will be focused on several key areas—many of which have seen strong disagreement:
Public insurance option: Not surprisingly, topping the list, is a government-operated public insurance option. In their letter last week, Kennedy and Dodd said that they "will not shy away from this challenge . . . we must not settle for legislation that merely gestures at reform."
In the House draft, the public option would be operated within an insurance exchange, would be financed only by its premiums—not by requiring additional government funding—and would be subject to the same regulatory requirements as private plans.
However, GOP opposition appears strong against any type of public plan. Sen. Charles Grassley (R-IA), the ranking minority member of the Senate Finance Committee, said Sunday on CBS, "I am going to make sure we are not going to nationalize health insurance, and a public plan is the first step to doing that."
Employer Mandate. Under a "pay or play" provision in the HELP Committee bill, employers that do not offer their workers "adequate" coverage will be charged an annual fee $750 for each uncovered full-time employee and $375 for each part-time employee. Firms with fewer than 25 employees would be exempt from the mandate. Last week, Dodd called this "a modest cost."
"Such an employer mandate would put businesses out of business," Grassley said. "It would have the same faults that the Clinton bill had 15 years ago, and that's going down the road of not getting healthcare reform."
House GOP leader John Boehner (R-OH), speaking Sunday on Fox television, said the employer mandate—plus the public option—were "deal breakers" with his fellow Republicans. The approach to mandate health insurance through employer and individual mandates would "lead to higher costs, rationing, and lower quality healthcare delivery," he said.
National Health Insurance Exchange. Creation of a new health insurance exchange would make "a transparent and functional marketplace" for individuals and small employers to comparison shop for insurance among public and private insurers, according to the House draft.
The exchange idea, though, has received a wary eye at the state level. For instance, last month, one group of state legislators called the proposed insurance exchange a "federal takeover" of the states' role in regulating health insurance.
Health Co-operatives. In an attempt to reach bipartisan support, the creation of nonprofit health co-operatives has gotten second and third looks in the Senate Finance Committee. Under the proposal made by Sen. Kent Conrad (D-ND) last month, co-ops would initially receive federal startup money but operate independently from the federal government.
However, Sen. Charles Schumer (D-NY), also a member of the Senate Finance Committee, has said that a co-op is not a substitute for a public plan and would be too decentralized to bargain for the best values for insurance buyers nationwide. He did admit, though, Sunday in an interview on CBS that a patient owned cooperative system could serve as a possible point of agreement among committee members on both sides of the aisle.
Comparative Effectiveness Research. The House draft calls for funding a comparative effectiveness trust fund from fees on insured and self-insured health plans.
However, the topic of comparative effectiveness research remains a sensitive issue among Republicans. Just last month, Senate Minority Leader Mitch McConnell (R KY) and Sen. Jon Kyl (R AZ) introduced a bill (S. 1259) to prohibit the use of data obtained "from comparative effectiveness research to deny coverage of items or services under federal healthcare programs."