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If Democrats are now working on a reconciliation sidecar strategy, they should use this opportunity to make policy changes to make the health care bill more popular, or, at least, less politically toxic. One thing they could do is remove the most unpopular provisions, like the oft-denigrated excise tax on employer-provided health insurance, or the individual mandate, which is extremely unpopular. It does not matter that both ideas were once supported by Republicans–they don’t support them now, and will hammer Democrats mercilessly on them.
If you don’t think the current design of the individual mandate, with the IRS collecting the fine for not buying private insurance, is a big, easy target, just look at this picture on Rep. John Shadegg’s (R-AZ) website. There are some easy fixes to help Democrats deal with the individual mandate.
1. Drop It Completely and Revisit Later
The easiest fix is to just drop the individual mandate completely. Removing it from the bill removes the issue from the debate and the 2010 election. Even if you believe an individual mandate is necessary to make the exchanges work properly, they don’t start until 2014. Also, the individual mandate does not really get teeth until 2016. After passing the bill, Democrats would have basically six years to pass a separate bill with an individual mandate. Presumably, a year or two after most of the reforms are in place, it would be easier to sell people on the individual mandate.
2. Add a Public Alternative
Polling has shown that the option of a public alternative to the very unpopular private insurance companies makes the individual mandate much more palatable. The public alternative could be a public option or a Medicare buy-in. Both are popular and make the individual mandate less unpopular. While there has not been polling on this, it is even possible that a quasi-public/private mutual insurance company, overseen but not owned by the government, similar to Chuck Schumer’s idea of a national co-op, with a board appointed by the president, might serve the same function as a public alternative, removing some of the opposition to the individual mandate.
3. Back Premiums Penalty
If Democrats think it is very important for policy or CBO reasons to include in this bill a penalty for people who might wait to buy insurance until after they get sick, there are politically smarter options that don’t involve the fines being levied by the IRS. One option is a back premium penalty. If someone currently does not have insurance, and goes to sign up for a policy, the insurer would be allowed to charge them a penalty equal to some time period of back premiums. If the person had been without insurance for the previous two months, the insurer could charge them a penalty equal to two months worth of premiums when they sign up. There would be a maximum penalty of, say, five months of back premiums.
This could be designed to create the same type of financial incentive to sign up for insurance before getting sick, and result in the same level of people buying insurance as the individual mandate, without an “individual mandate” enforced by the IRS. A slight variation: instead of allowing the insurer to charge a back penalty, have the exchange itself charge the back premium penalty.
4. Automatic Enrollment in an Extreme Catastrophic Plan
If the goal of the individual mandate is to maximize the number of people with some form of insurance coverage, one option is automatic enrollment in an extreme catastrophic plan. Most people on the exchange will get some subsidies to help them afford insurance. The government could create a very cheap, extremely bare-bones, pure catastrophic plan, and automatically enroll anyone who does not buy insurance, but would, as a result of income level, receive affordability subsidies sufficient to pay the premiums for the public extreme catastrophic plan. Any leftover tax credits would be automatically put in a health savings account for the individual. The employer mandate could also be set to the level of average premiums for the extreme catastrophic plan to serve a similar function.
This catastrophic plan would take part in the exchange’s risk adjustment mechanisms to prevent adverse selection. Insurers would be allowed to deny people if they tried to switch from no coverage or the catastrophic plan to regular insurance anytime besides the yearly open enrollment period. This would have a similar effect of encouraging people to buy better coverage before they get sick, but still make sure people had some minimum coverage.
5. Extremely Strong Employer Mandate
Hawaii has achieved near-universal coverage with a very strong employer mandate. The Senate bill already covers the very poor and unemployed people making less than 133% of the federal poverty line automatically with Medicaid. The Medicaid expansion combined with a very strong employer mandate, requiring every business to enroll all their employees in an insurance plan, could achieve a level of coverage equal to, or even higher than, the individual mandate.
All of the Above
Democrats could go with any of the above plans for mitigating the negative effects of the individual mandate, or a combination of many of them. I would recommend using them all. Adding a public option is a popular standalone provision. The automatic enrollment in catastrophic insurance could work well in combination with the back premium penalty. It is possible that those two provisions together would do an even better job than the individual mandate at getting people to sign up for coverage. The important thing is for Democrats to not use the IRS to force people to buy private insurance. That is an act of political suicide. Most importantly, it is completely unnecessary on a policy level. Near identical goals can be achieved with much more popular policies.
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It’s important for both sides to look more carefully at automatic enrolment — some call it “libertarian paternalism” — as an alternative to a manadate to buy whatever product the health insurance industry persuades Congress to force us to buy. Medicare Part B has auto-enrolment and
It’s important for both sides to look more carefully at automatic enrolment — some call it “libertarian paternalism” — as an alternative to a manadate to buy whatever product the health insurance industry persuades Congress to force us to buy. Medicare Part B has auto-enrolment and a 95.5% enrolment rate. For background see this study. It’s a left-right way forward.
It will be quite interesting to see the rationale put forward for keeping the individual mandate. I do not believe that even the corporation loving Roberts’ court will allow Congress to give private insurance companies the means to bypass the eminent domain and equal protection provisions of the Bill of Rights for perpetuity.
After all, if Congress claims the mandate is needed to regulate commerce, then it cannot grant opt-out waivers to individual states. Additionally, since insurance companies do not directly provide a public good, how can they receive special consideration over other companies?
Will the court dockets fill up with class action suits each time an insurance company want to raise those mandated rates? Will the Youngstown decision have any bearing on limiting Congress’ and the Executive’s ability to seize the private property of citizens?
I like ideas 1-4, but I think the best idea would be the one they use in Germany, I believe. If you decide not to get health insurance, you forgo the ability to get subsidies for a significant period of time, like 5 years. Provides incentive to sign up without an Orwellian mandate.
you don’t need to go that far to see why it’s a target, democrats, progressives and everyone else hates the idea
the only people that like the idea would be the health insurance providers and I am amazed they had the republicans opose this bill since as it stood it was an incredible boon to their profit model
Insurance companies already have sections written into the policies they sell that prevent people who just bought a policy from filing a claim right away. This particular justification for the mandate is false.
Further, I don’t see how politicians can justify an individual mandate when the business mandate is dead and gone. That just seems like picking on the unemployed.
Will the court dockets fill up with class action suits each time an insurance company want to raise those mandated rates?
One can only hope.
wanna add three other popular ideas that take effect NOW and win votes?
-close the donut hole.
-offer Medicare buy-in at 55
-extend the right to COBRA for fired/laid off workers until the exchanges kick in.
need another?
-require a 90% medical loss ratio
What’s a few votes against millions in campaign contributions.
I do not believe that even the corporation loving Roberts’ court will allow Congress to give private insurance companies the means to bypass the eminent domain and equal protection provisions of the Bill of Rights for perpetuity.
This was discussed quite a bit at Balkinization with a consensus emerging around the idea that since the legislation does not mandate buying insurance, but rather imposes a tax on people who fail to have coverage, the bill is consistent with the ‘general welfare’ requirement of the constitution.
Employment based American health insurance ultimately is not sustainable when global economy will require competitive American reduced overhead loading for employers. Keeping employers as gatekeepers and agents for health insurance access and carrier duties is nonsense. It does not level access and delivery to healthcare for Americans.
AHIP and PhRMA put the fixes in to protect what they are about which was wrong a year ago and is still wrong today.
Barack Obama has proved to be a charlatan and his D Party has misread the mood of the Ameriacan voter that has earned them all the contempt American voters can display next November 2010.
Ditch the whole 2009 HCR debacle. Unlike wine it is not getting better with age. Really sick of the D Party trying to placate the Rs as that is pointless and if the Ds had real leaders instead of losers Pelosi and Reid this would have been understood a year ago.
Ditch the 2009 HCR mess. It is political malpractice and is far too much about AHIP and PhRMA getting a big wet kiss and paid for letting it happen.
AHIP in particular and it’s members such as WellPoint,Cigna and Aetna need to be cut back,pruned and staked. Sooner. Better.
It would be a major outbreak of better politics and smarter politics if the D Party would retool Medicare for all Americans.
Single Payer/Medicare For All. It is more simple. Solves the big problems and makes American healthcare coverage less complicated,more equitable and moves America towards mid 21st century.
This 2009 HCR/AHIP/PhRMA/Obama WH debacle is not worthy of more wasted time,the stupid politics and terrible policy pursuits.
I will just add a few comments to the article based on my being a retired actuary in insurance.
I like your “1. Drop It Completely and Revisit Later” – the start of 2014 with teeth in 2016 means it isn’t critical today – plus there really are other ways that pass actuarial muster that can replace it – the one that comes to mind is a combination of your 3. Back Premiums Penalty where if without ins for more than 6 months, there is a flat fee of say $1200 charged by the exchange reinsurance facility to fund a reserve build up for the exchange running a claims normalization for ALL insurers so that all have the same actual to expected ratio (the process that the life ins companies under the Mass Savings Bank life ins process used for about a 100 years). This then combined with a Public Alternative – a public option, or better yet, a buy in Medicare at adequate rates reflecting the same actuarial assumptions used for all ins companies to project claims plus 3% overhead – with the exchange reserve backstopping any year when actual to expected claims exceed 100% by paying everyone funds to bring them back to 100%, the payments paid out of the Federal budget if necessary because the exchange reserve is not large enough.
Chuck Schumer’s idea of a national co-op, with a board appointed by the president, DOES NOT serve the same function as a public alternative I see as needed, indeed the public option other than Medicare buy in does not serve the function needed, UNLESS the public option chosen has a right to the network used by Medicare and piggybacks those Medicare contracts (with payout variations by state via Medical provider requests made formally by the State but with the State forced to accept the decision of the Federal Secretary if reasonable).
Enrollment in an Extreme Catastrophic Plan does little and I do not see where you are going with this – it has no effect on the actuarial questions at hand (the paid claim far out tail is not where the money is). Affordability subsidies sufficient to pay the premiums for the public extreme catastrophic plan are nice – but so what? Helping the health destroying idea of health savings accounts is nuts (see Singapore’s price setting and backup regulations that are needed to make this work if you want to see massive gov control of the economy).
The “Extremely Strong Employer Mandate” works in Hawaii and in some countries in the EU to provide coverage – and indeed is the easiest choice, in my opinion – not the best because I see Medicare buy in at age zero with subsidies as a much better way, since the pre-existing and other ins rules that require the claims normalization or reins or mandate are not in this approach – or in the employer mandate. The problem with just an employer mandate is that it alone does nothing about cost, so those EU countries have tough price/coverage regulation.
I agree that Democrats not use the IRS to force people to buy private insurance.
all of your points have my support.
A board appointed by the President tasked to impede effectiveness in favor of Insurance Co’s bottom line – that will do it.
There is really no way around the mandate if we want universal coverage. An employer mandate simpley takes the premiums out of our checks before we see the money and while it might seem cheaper it really isn’t. If we want universal coverage then there has to be enough carrots and/or sticks to make it beneficial to purchase insurance. It also must be affordable. Yes we can use “tax incentives” but if you lose the “tax incentive” by not having insurance that is a mandate.
We don’t want universal coverage. We want universal care.
Individual Mandate: I want an individual mandate, because I want the hospitalization portion of my premium to be reduced. Hospitals are required to treat the uninsured. In exchange, they are allowed to socialize their unpaid fees in their pricing of paying patients. It is estimated that the annual premium for a family of 4 will be reduced by $1,000 to $1,200 annually if we have an individual mandate. The only make-sense exception to the individual mandate is to exempt those who are eligible for Medicaid – just sign them up when they show up for care.
Employer Mandate: I want an employer cost sharing mandate rather than an insurance mandate. The House & Senate versions have a piece requiring employers to issue vouchers to employees who are eligible for gov’t subsidies on the Exchange. Let’s open it up to all employees. Miinimum cost sharing ranges from 2% to 8% of gross earnings based on payroll size. The regulation should be modified to allow for a maximum voucher amount equal to the cost of the richest federal family plan in the exchange so employers can use vouchers to enrich their benefit packages. Another modification should allow employees to opt for vouchers even if their employer offers a group plan. Advantages: All dependents in a family will be able combine their vouchers to purchase a family policy, portable insurance, true choice, reduced hassle for employers, lower out-of-pocket costs for families, etc. This approach makes sense since the law includes a minimum medical loss ratio (MLR) of 85% for both individual and group insurance (House version) and does not allow insurers to medically underwrite (no turn- downs or pricing due to health). This all works together to make group and individual insurance pricing nearly the same – thus there is no advantage in mandating employer group insurance.
Catastrophic insurance: I am opposed to catastrophic insurance. It undermines elements of reform that work to catch things early and thus save huge life long medical expenses – think diabetes. It will increase the cost for all those who purchase comprehensive insurance because those at lower risk will select catastrophic thus increasing the risk/price of those who buy comprehensive insurance.
The Public Option: Certainly it would be great. But currently, eligibility is limited to those whose employer does not offer group coverage. Few will be eligible. Requiring employees to take the employer plan is bad because neither the House or Senate versions regulates essential benefits or affordability of group plans. Many will be trapped in bad employer plans. Add an open voucher system to the Public Option, then you have true health care reform!
Ah, reframing. Well done.
Over the last week I’ve heard at least 3 ins. spokespersons say the 40% hike here in Cal is to be s.o.p unless an individual mandate is imposed .No one even mentioned reform.Everyone here should,know there will be no public option and Obama/Rahm don’t give a fuck about dashing hopes.Obama’s corporate pimps have told him to get out there on the corner and hustle up a mandate or they will ruin his presidency via monopoly extortion of of voters.In Cal. Blue Cross has more power than politicos in toto,and everyone knows Obama has no fight in him and does nothing to threaten the elites to whom he is accountable and culturally akin .
“Automatic Enrollment in an Extreme Catastrophic Plan”
There can be other “public options” for people who WANT other things, but an inexpensive “extreme catastrophic plan” is the ONLY thing ANYONE should ever be FORCED BY THE GOVERNMENT to buy.
This is the case for POLITICAL reasons as much as for individual personal financial planning–and even with the so-called “public option.”
It might be different if you had a fully socialized system, funded in part through progressive taxation, but so long as we have this patchwork “individual responsibility” model, people need to be able to exercise some control over their own finances.
Although, personally, I’d still kill the individual mandate entirely. I repudiate the whole control fetish on which it’s based. Most people never use the medical industrial complex. If “the government” wants to do something for those who MUST use it, then let it. What else do you need?
You know, it’s always a “free market” in labor and as a result people can no longer afford things that the upper middle class considers a “necessity”– like comprehensive health insurance and a mortgage.
What this basically means is that these people are NOT going to buy comprehensive health insurance and mortgages. I don’t get why Democrats don’t get that. Everything they do is an attempt to prop up THEIR way of life on the backs of people who ARE going to basically default.
“Individual Mandate: I want an individual mandate, because I want the hospitalization portion of my premium to be reduced. Hospitals are required to treat the uninsured.”
You know what? I don’t care what you want. If you want to use the medical industrial complex, you can pay for it yourself. Your way of life is over.
The money has to come from somewhere. Money paid by employers comes from an amount included in the price of the goods sold. That means we (the consumers) are actually paying it. Legislate that companies must reduce the price of their products in the amount that they are paying the health insurance companies. Big penalties if they don’t. Competition will help in this. Goods will be cheaper for us and for foreign sales the companies will be more competitive.
Unions who have negotiated health benefits will be exempt until their contracts run out, then they can negotiate the health insurance portion back into their wages.
At this point there will be no employer provided money for the insurance.
Then-all Americans eligible for health insurance will be in a pool; everybody. The law will state what the minimum benefits shall be and how much the federal subsidy will be for each person.
The health insurance companies can then take people unconditionally (no cherry picking, luck of the draw), and sell them additional benefits (similar to Medicare advantage)to complete their coverage.
Now the money question.
Income and sales tax increases in an amount necessary to fund health care.
Obviously, lower income people won’t have to pay taxes in the amounts that wealthier taxpayers have to. So it is automatically progressive. A refundable credit for the sales tax will be available through the income tax filings. This will be progressive as well and will lessen the impact of the tax on the people least able to pay.
The nice thing about sales tax is that it will collect money from all those people who work in the underground economy, as well as all the illegals, who we know will show up at the emergency room. Since none of them file income taxes, they will not get the credit.
The tax collection mechanisms are already in place.Prices for products will be reduced. Illegals will have to pay. The health insurance companies are still in the mix with all their networks still functioning, it is in effect the public option without the government becoming an insurance company. What do you think?
Or… Stop trying to re-invent the wheel.
The rest of the western world uses risk subsidies paid to companies to make everyone’s premiums the same. This would be a hell of a lot cheaper then the subsidies in this bill and be immensely popular and make the mandate unnecessary.
Risk Equalization (check wikipedia) will have to be thought of eventually because the reg reforms are popular, the mandate isn’t and won’t pass, and without a mandate the reg reforms will be blamed for sky-high premiums.
The shame on government is that it’s not even being discussed, yet. Truly incredible.
I was not stating that the Schumer co-op would serve the same policy function, but it might serve the same political function. People don’t like the private insurance companies and want an alternative. The individual mandate is much less unpopular with an alternative.
Yes, I agree.
At a make the sale level, a national co-op would be a way to make progress.
And if they slip into the legislation a phrase that lets the co-op piggyback Medicare contracts (even at prices to be negotiated with providers) -well we get what we need!
By the way, a cat ins plan gets support above -because it does nothing and costs little and like the Schumer co-op will give cover and be an easy sale, I guess.
Likewise, the Texas pay for everything via a sales tax because then we tax illegals mindset is also above. Of course illegals pay tax under income/payroll taxes because payroll taxes are always paid and FIT withholding is hard to defeat without exposing yourself to investigation. I am surprised that the other Texas claim for the sales tax – that it allows the poor to budget better for taxes as they need to just spend less in order to pay less tax – was not brought up as a justification for health care supported by a sales tax. Of course a value added tax that is in our future for many other reasons like fiscal stability rather than fairness is just a sales tax, but I found it interesting that a sales tax to tax illegals was mentioned in this thread.
After watching Olbermann last night, I’m skeptical that any health reform legislation can pass through reconciliation. Lawrence O’Donnell stated that to get to a final vote, they still have to get past a 60 vote procedural hurdle to get there. How is that ever going to happen?
- Tom
There are tough choices made in what we want in health reform. The bottom line on the individual mandate is that it substantially lowers the cost of insurance for each individual who is insured. So…
1. Do you choose freedom from having to buy health insurance over the lives of 45,000 fellow citizens dying prematurely due to having no access to insurance, primarily due to affordability?
2. Do you choose freedom from buying insurance over paying twice what other nations pay for health care? (health care sector as a % of total economy: U.S 17.2% and growing at an alarming rate; world average 8-9% and managed to not grow). Individual average cost per capita [not per insured]: US-$7,290; World-$2,986). I want health care AND I want freedom from the rip-offs of the medical financial complex.
3. Do you want freedom from having to buy health insurance or do you want a job? Though it is hidden, this choice is being made for many Americans today.
Bottom line:
1. The individual mandate is essential to reform and reform is a moral imperative.
2. We are stupid foolish suckers to continue paying for the rip off.
A selfish, stubborn ideological resistance to reform based on “individual freedom” is just what the medical/financial complex wants in play to continue their larceny and they have paid dearly to get it in play. Honestly, do you care more about the freedom part or the not pay part? When you hide the not pay part behind your call for freedom part, you are doing just what the medical/financial complex wants, what they have paid others to gin up your passion about. Don’t be their tool! It is not in your best interest.
The chair rules the 60 vote rule does not apply – and Lawrence O’Donnell’s worry is taken care of.
Even simpler and actually more effective in providing health CARE and cutting costs:
Medicare for All…with a robust private option.
Most people are signed up for Medicare payments through their payroll taxes, most docs are in Medicare, most (all?) hospitals as well. It’s set to go now, Now, NOW! It took LBJ less than a year to start up Medicare when there barely any real computers — we’ve certainly got the computing power to sign up those not working or below working age. Fold in Medicaid, S-CHIP, other government financed health programs, etc, and we’re good to be an enlightened industrial society. (VA? Think of how easy it would be to cover returning vets if we had single payer, universal care through Medicare for All? But keep the VA as the area of expertise for the types of wounds and damage which soldiers encounter. A teaching hospital system, making ER’s better, rehab better, etc.)
People know about Medicare, they know people on Medicare, they know it works — they’ll accept Medicare.
What value do the BHIPs (Big Health Insurance Parasites) offer anyway? Big donations to politicians? Huge compensation to their execs? What’s the value added?
Oh, and Repubs have been attacking the Dems and Obama for threatening cuts to Medicare, so how could they really have standing to attack Medicare for All? Well, they don’t see any need to be actually rational….
Medicare for All! With a robust private option!
Another problem, of course, is that Obama seems to the Corporate Dem in Chief. Alas.
Why bother with mandates when universal coverage, everybody in-nobody out through Medicare for All covers all the bases, solves the problems, frees individuals and even corporations to focus on their business ideas and goals, is ready to be implemented NOW?
Why destroy the Democratic brand image built up since FDR for the sake of preserving the profitability of BHIPs(Big Health Insurance Parasites)??? Why demonstrate such great caring for the well-being of private insurers while leaving the people crumbs for coverage?
Mandates and subsidies will mean people pay not only high premiums for their insurance, they will pay in taxes to pay for those subsidies which also go to the profit line of the BHIPs. Also, many will end of with junk insurance which will offer minimal assistance toward health CARE, but will cost real money.
On Monday we may know what Obama will support (or not…), but as things stand this is the Obama BHIP-PPP. Big Health Insurance Parasite Profit Protection Plan.
Medicare for All…with a robust private option.
And, as Rep. Weiner asks, what value do the BHIPs add to health CARE??? As Sen. Rockefeller pointed out, most of the outlines of the so-called Public Option will result in extremely weak competition for BHIPs, probably no cost cutting, and a black eye for the very idea of government sponsored health CARE, while covering a very limited number of people.
Is “cat insurance” kitty care or catastrophic insurance?
I’d support Kitty Care! Even Doggie Care.
Catastrophic insurance is a way to almost force people into putting off needed medical attention and care.
Hey! Way to cut costs! Self-denial of care!
Which I’ve done, even though I have insurance. My BHIP (Big Health Insurance Parasite) charges so much per momth that when I was told I needed to go to physical therapy 3 times a week for at least six weeks, there was no way I could manage the co-pays. Toss in high deductibles and –hey!– self-denial of care. Cost cutting!
Until it’s absoutely necessary and more costly.
Medicare for All…with a robust private option.
It’s a no brainer, eh?
“This was discussed quite a bit at Balkinization with a consensus emerging around the idea that since the legislation does not mandate buying insurance, but rather imposes a tax on people who fail to have coverage, the bill is consistent with the ‘general welfare’ requirement of the constitution.
I have not had the ‘pleasure’ of following that discussion so I will ask you about it here; that idea you are reporting looks like an example of a Bill of Attainder which is also prohibited under the Constitution (Article 1, Section 9, clause 3). To wit: defining a group of people guilty of not having insurance and then passing a mandatory sentence of a tax without any of the due process benefits of a trial.
Apparently the insurance companies feel that they have to block the momentum of any health insurance and/or serious care reform now, essentially because they fear that once we get going with change it will lead to some form of single-payer and the extinction of the health insurance industry. And, I believe, they are correct. The debate taking place now has opened one of Pandora’s boxes, the one with all the data about the place of the US among industrialized nations when it comes to overall health, the data about how many US citizens die each year because of lack of health insurancem, our relatively high infant mortality, and other health statistics that shame our country’s sense of being a country that cares about something other than profits.
How can one not speculate that the tea party movement is being exploited by Republican operatives (fueled by lobbyist cash) as a distraction from this somewhat harsh indictment of how our financial institutions – in this case the health insurance industry – have failed to really “insure” us in any meaningful way.
Just look at where the Senate Minority leader gets his cash; need more be said?
Greed, still one of the Seven Deadly sins in the (true) Christian reckoning, and they ain’t lettin’ that one go easily.
Leaving your fifth aside (for brevity, it’s good), here’s one that would have big PHARMA spending so much to oppose it that they might bankrupt themselves: establish the ability of the government to negotiate drug prices within Medicare Part D. This would have some serious deficit reduction clout…
It’s pure sophistry to defend an individual mandate as a means to save 45.000 lives annually .The death toll could rise with a naked mandate. Just because it mitigates risks doesn’t mean we pay less.In fact , there would be a shareholder lawsuit if the cartel ignored its obligation to maximize profits by passing savings on to us.Relief could come only from subsidies,which means everyone pays later to underwrite extortive health care hikes via the double taxation of debt.If everyone is to pay why not have at least a public option that everyone can access.The individual mandate is not reform,it’s a shake down by the insurance protection racket and the political thugs who serve as their enforcers .