The thing that immediately jumps out, to me, is effectively lowering the age for Medicare to 55. I get the reasoning - at that age, you'll be hard pressed to get insurers to sign up to cover even demonstrably healthy workers - but that's a huge increase in Medicare layouts without significant reforms to Medicare's payment structures... and that kind of Medicare reform, all by itself, is a huge political nightmare. If there's not a change in how Medicare pays, then I suspect the change will be in the charges 55-64 year old entrants will have to pay for Medicare Part B, and that, too, seems like a hard political piece to sell.

As an overall plan, I think, as with the general election, it's hard to see how Republicans can effectively fight it; they've got no coherent alternative (Nothing, not even Palin, is as DOA as the McCain/Bush theory of taxing employer benefits), and the kinds of things they favor - like opening theindvidual market wider - are actually in there. That's not to say there's not problems here, or that this can't be opposed; it can be, even piecemeal. And I'm curious if you can do this in pieces. It seems to me you have to buy into the whole proposal... or nothing. And that makes me a little concerned.

What is "affordable" insurance? I asked members of Baucus's policy staff, and they said that had been left up to Congress and the Health Coverage Council.

So, Ezra (or anybody), do you think this will ultimately translate into setting premiums as a percentage of income? Three hundred bucks a month might be "affordable" compared to what a lot of people are paying (or what the average employer is forking over) but there are obviously people who slip through the cracks under the status quo for whom such a sum couldn't possibly be found in the monthly budget.

Ezra,
What does this white paper mean to the Wyden plan? Is that dead in the water until this is decided or does Wyden's bill become the alternative?

Probably dead in the water. More on that later.

So there isn't anything to reduce cost of the system?

What about coverage for children?

During the campaign Obama promised to mandate coverage for all children, and last year Congress failing to override a Bush veto of sCHIPS ended up backfiring on Republicans as the public reaction was very unfavorable to them.

Also, if a child is born to an uninsured mother and is therefore not immediately covered, what happens if that child needs immediate treatment (say, a premature infant?) My guess is that there will have to be a 60 or 90 day window in which all children not otherwise covered will be covered by a fixed plan, during which the parents have time to go insurance shopping.

"It is extremely similar to the Obama plan if you added a mandate, and to the Clinton and Edwards plans if you left them untouched."

What a funny way of writing, "It is extremely similar to the Clinton plan; it differs from the Obama plan by including a mandate".

... setting premiums as a percentage of income?

if only we had some kind of system in place for levying payments from people based on their income ... but that would be socialist.

not a big fan of keeping the system employer based but the
'meaningful health insurance options are available to all' certainly leaves open the possibility of transitioning to a govt run system

Ezra: Am I correct in noting that the plan does not address Medicare Part D yet?

I salute anyone in the States who is trying to make health care a reality for all, but I can't help feeling like the States has to re-invent the wheel in an effort to sell an idea that many will immediately refuse as being "socialist"...or worse!

Wouldn't it make eminently more sense to take a very close look at what countries like France, Germany, Sweden and dare I say, Canada, are doing and use the best of those systems to craft a "made in America" solution?

But when all is said and done, it's absolutely wonderful that truly affordable health care is back on the agenda, and so fast at that. It gives one hope.

If the individual mandate is enforced through the tax system, wouldn't that let low-income people who are insensitive to tax penalties (because they don't pay much in taxes to begin with, because they lack the sophistication to tailor their behavior to tax incentives, because they work under the table, etc) fall through the cracks? How confident are you that the gov't can calibrate the "affordability" rules with sufficient accuracy to catch as many of the currently uninsured as possible? And aside from dollars and cents, I'm concerned that a complex private/public system operating under an alphabet soup of programs may not be much of a boon to people whose whole problem is that they don't perform well in complex economic systems in the first place. Maybe I overestimate how much social dysfunction is out there, but surely there's a significant number of people whom only unconditional single-payer will catch.

We'll need some way to control for adverse selection. Part D had all sorts of measures to make sure insurance companies don't cherry pick the healthiest beneficiaries and stick the rest with competitors. This can be even worse, with group plans cherry-picking and sticking the rest on the health exchange.

The non-discrimination principle is a start, but if it's not fully applied, MCOs can offer worse benefits or institute a larger burden of risk in large-group plans. To deal with this, you'd need to make plans across systems "actuarially equivalent" and have similar maximum cost sharing - a rather big undertaking.

The Democrats are saying this program is based on the one currently in place in Massachusetts. Do people know that Massachusetts has the highest per capita (person) debt amount in the nation? I saw this stat in a recent Business Week issue. I would guess this is related to the exorbitant costs associated with our mandated health care.

Private insurers haven't been able to deliver affordable universal coverage after several decades in which costs and non-coverage have both shot up. So why would another scheme depending on private insurance now be able to achieve the opposite?

We have a mal-functioning Rube Goldberg health-insurance contraption, and Democrats think they can make it work more smoothly by adding further counter-intuitive features and transposed tensions. It's crazy. Expanding rather than scrapping this contraption will just subsidize private insurers.

There is no lever you can add that will keep costs low. Ultimately costs will rise as high as insurers think the "market" will bear. And since health is not an option that people can take or leave, there is no real "market". Talking about an insurance "market" is just delusional. It's the pretense, in the face of all experience thus far, that for-profit health care will magically start to forego profits.

A politically appointed board making the tough choices in regulating the insurers? Sure, we can count on that hold the line against the industry, just as financial regulators always have come through for us.

Anyway if people over 55 deserve Medicare, then so do the rest of us.

Universal health insurance is a will-o-wisp. What we need is the real thing, not the mirage: universal health care. Baucus' plan is at 90 degrees to the direction we need to take in this country.

McCain's 180 degree plan might actually have turned out better than the Baucus/Clinton/Obama plan. By fucking up health insurance so badly, McCain might have forced a much quicker reversal back toward universal health care.

Instead, the plan under discussion appears to be an inoculation against universal health care. Just enough appearance of "reform" to dampen demands for real reform.

As Ezra says it's essentially a summary of where the Democrats are on this issue which is essentially Clinton's plan. This recognizes you are not going to be able to dump the present system for all sorts of political and economic reasons but makes bricks with the available straw. I don't see how the Republicans fight this since they literally have no viable alternative. The tax credits and taxed employer benefits were a non starter. I bet this is law by the end of 2009.

Posted by: Citizen70 | November 12, 2008 5:53 PM

Fortunately the Democrats and Obama won't be running the country based on your guesswork.

I am reading everywhere today that Obama's health plan will cost 75B$ and have a 25B$ savings projection for a net cost of 50B$ per/year.... ? If this is anywhere close why on Earth does anyone oppose this, if this is the Obama wish list? We just pissed away 700B$ into a rathole of risk and percentage games gone bad, and we cannot drop one tenth of that to get even crappy insurance with corporations? My heart aches as I just read smintheus post before me that this will kind of stop real universal dead in time for another what .... decade? How about some chatty lefties point out the AMAZING long term financial benefits of real single payer universal like the rest of the civilized world. How about restructuring the US auto industry by sweeping all the costs of employee and retiree health care into a single payer USA plan. Gee, a resurgent American industrial base where no employer ever concerns himself with the costly nightmare we live with now. Boomtime. The best part of all is that the cost per capita in every country similar to ours is drastically lower than ours. Actually solving the healthcare mess is the perfect solution to what ails us going into this recession. If only .....

Let me be honest with you. When I look at Baucus, I see stupidity. This is the face of a moron. We are supposed to put the American healthcare system in his hands? The guy has been kicked by one too many mules..

Why mandates suck (and a very nice demonstration of how policy wonks sometimes need to get out more):

http://www.dailykos.com/storyonly/2008/11/12/11410/086/271/659780

Yes, 'A Canadian Reader', those are my sentiments exactly. However, being the herd of cats that we, the United(?) States of America, are, we absolutely must do it our own way, or ELSE. Or else we wouldn't BE the United States of America. 'sigh'
Can I please move to Canada?

Canadian Reader -- You make a good point, and I think that is exactly what is going on here. Many of the European systems do rely on private insurance with mandates. I suspect many of Baucus's ideas came from looking carefully at those systems. But, this being the USA where socialism is a dirty word, we can't advertize that fact or else that will be all the brain-dead commentators will talk aboit, rather than what the plan actually intends to do.

It is extremely similar to the Obama plan if you added a mandate, and to the Clinton and Edwards plans if you left them untouched.

He may have boinked the weird New Age woman and lost the primary, but it looks like our man won the health care debate.

And that's what I really care about. Feeling proud today.

healthcare crisis and financial crisis: phony crisis, meet real crisis

I am willing to bet that there is enough money in the health care system to make health care for all a reality in the United States.

Here is a brief and not fleshed out way to do it.

First of all, use Medicare/Medicaid as the insurer for all people. Medicare would be primary and Medicaid secondary

Next, utilize insurance companies as TPAs but without a savings for denied claims, except fraud.

Now, unite the different government run health care plans under one organization. I mean Medicare, the VA and Indian Health Care. There is significant duplicate administrative, equipment and buildings.

This would allow every veteran and Native American Indian freedom of choice by allowing them to go to the provider of their choice.

Negotiate drug prices as part of the drug approval process. We are the only country in the world that does not do this, this is why we pay 40% more than Canadians for prescription drugs.

Obviously perceptions and actions would have to change, reimbursement for services is going to need to be done - but we spend 14% of GDP on health care and rank 26th overall in the health of our people.

There's plenty to pick at in the Baucus plan, but also it seems like it's the opener for discussions. The lack of serious fire against it -- including the fact that it suggests revisiting the tax treatment of health insurance a la McCain -- is interesting.

http://www.engageinhealth.com/2008/11/in_the_us_senate_finance_commi.html

Hi Jean,

Come on up!

The Baucus paln is the Massachusetts plan. In other words, it is a total scam that will make a lot of money for insurers and still leave people unable to see a doctor when they need one. Insurance is largely useless paper. The insurance industry adds nothing to the healthcare system other than cost. Insurers don't deliver care, they shuffle papers and handle the money, taking their cut, of course. If we really want universality, let's eliminate the middle men. We need a single payer system funded through an equitable payroll tax. Anything else is mere social tinkering. President elect Obama would do well to remember that the mandate was one of the reasons he was nominated rather than Hillary!

HR 676. Throw rocks for it. Now. Enough people have died. Nuff said.

I second Nico - support HR 676.

How confident are you that the gov't can calibrate the affordability rules with sufficient accuracy to catch as many of the currently uninsured as possible?
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It is a total scam that will make a lot of money for insurers and still leave people unable to see a doctor when they need one. Insurance is largely useless paper. The insurance industry adds nothing to the healthcare system other than cost. Insurers don't deliver care, they shuffle papers and handle the money, taking their cut, of course. If we really want universality, let's eliminate the middle men.

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How confident are you that the gov't can calibrate the affordability rules with sufficient accuracy to catch as many of the currently uninsured as possible?
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As for midsize and large businesses, more on that in a moment. Importantly, the Exchange is not the only space where insurers will find themselves subject to new regulation. "

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