Sunday, November 1, 2009

Reading list for the essential Exchange, etc.

(This is the Reading list for my previous post, entitled “The essential Exchange and the puzzling public option”.)

(This post talks about HR3962. This is the health reform bill introduced by House Speaker Nancy Pelosi on Thursday. It’s also known as the ‘‘Affordable Health Care for America Act’’ or “AHCAA”. You can download a pdf of the 1,990 page bill here. Section and page references in my post are tied to that pdf.)

Reading, lots of it, and heavily annotated:

Here’s the Wikipedia entry on the Baucus bill, aka S. 1796, aka “America’s Healthy Future Act”. (I have a friend who swears he’ll support whatever health care bill doesn’t insist on giving itself some hokey name.) Just in case you want to try to compare the two.

Ezra Klein talks about the Exchange. An excellent explanation of why this - not the public option - is the crucial element of health reform.

Ezra Klein talks more about the Exchange and describes the difference between a strong one and a weak one. (HR3962 looks to me more like a weak Exchange but I haven’t really gotten down in the weeds of the bill’s language.) At the end of his writeup Klein provides a link to “A more scholarly take”. This is a link to a paper prepared by the Urban Institute. I haven’t read the whole thing but it seems to do a good job of explaining how an Exchange works and what elements it must have to achieve “many of the nation’s most oft-state health reform goals.”

SFGate talks about how limited the Exchange is going to be, backing up Klein’s concerns about a weak Exchange. If the concerns expressed here are accurate then it sounds like the Democrats are going to end up passing a bill that doesn’t really do much to help people’s insurance situations quickly. There are high hopes that the Exchange (and the public option) will eventually bring down costs but even if that actually happens it seems unlikely it will do so before the 2010 elections.

The Heritage Foundation summarizes “Rational Alternatives to the Congressional Leadership Bills.” They do a good job of making the case that Republicans have offered alternatives rather than just saying “No” but I’m unimpressed by any of the ideas that offer. It may be that closer examination would give me a better opinion of some of them but too many of them look like they get the Federal government involved in setting up State plans. It seems like the States should be doing that on their own so a truly conservative plan would consist of getting the Feds out of the State’s business.

Time - provides a nice accessible overview of how Health-Insurance Exchanges work. HR3962 allows State-level exchanges - which the article believes is undesirable. It also (as far as I can tell) lets insurance companies sell individual polices outside the Exchange but attempts to mitigate the chance of cherry-picking by forcing insurers outside the Exchange to meet the same requirements as those in the Exchange at least to some extent. The Time article also points out that - sigh - the already existing Federal Employees Health Benefits Program is an Exchange.

The New York Times discusses possibilities and possible problems in Health Insurance Exchanges.

neo-neocon presents a few links to those on the Right who have looked at HR3962. She also links to - and has some unkind words for - Paul Krugman’s remarkably nasty presentation of the conservative position.

Movin’ Meat takes a quick look and presents some links to the bill, to the summary I referenced above, and to the Wonk Room explaining “Top 10 Reasons Why Republicans Should Support The House Health Bill”. Movin’ Meat’s first bullet point cracks me up:

Enough House moderates - citing fiscal conservatism - rejected the cheaper option which would have paid providers at Medicare + 5%, and the bill as released would require the public option to negotiate fee schedules with providers like any other insurance company. IMHO, this is better policy even though it costs more, but hypocritical Blue Dogs get under my skin.

So Movin’ Meat as a physician is being intellectually sincere when he believes negotiation is a better policy but any Blue Dog who believes the same is a hypocrite.

On the other hand I got that warm cozy feeling of tradition honored when I saw that both sides were already misrepresenting HR3962. Wonk Room says:

3. REPUBLICANS ASKED FOR – POLICIES ACROSS STATE LINES: “Interstate competition allowing people to buy insurance across state lines.” [Sen. John Thune (R-SD), 9/8/2009]

HOUSE BILL – POLICIES ACROSS STATE LINES: Allows for the creation of State Health Insurance Compacts – permits states to enter into agreements to allow for the sale of insurance across state lines.

Meanwhile RealClearPolitics (linked by neo-neocon) says:

Remember, you can purchase oranges from Florida and whiskey from Kentucky, yet you're prohibited from buying health insurance from anywhere outside your state . . . so sayeth Nancy Pelosi.

As far as I can tell, here’s the real deal:

1) Any insurance company can sell to anyone in any State via the Exchange so long as the insurance company is licensed by the State it wants to sell to.

2) Insurance companies selling via the Exchange must meet State requirements if the State has paid the Federal government to require them to do so. Otherwise they must only meet Exchange requirements.

3) States can form Interstate Health Insurance Compacts to allow insurance companies from one State in the Compact to sell insurance to residents of other States in the Compact. (Division A, Title III, Subtitle A, Section 309; page 202 on) It is not clear whether insurance companies under such a Compact would have to meet State requirements. This Section says the guidelines for such Compacts shall:

(1) provide for the sale of health insurance coverage to residents of all compacting States subject to the laws and regulations of a primary State designated by the health insurance issuer;

which seems to say that one State in the Compact will be the State whose requirements apply. But the Section also says that the guidelines for such Compacts shall:

(3) preserve the authority of the State of an individual’s residence to address -
(A) market conduct;
(B) unfair trade practices;
(C) network adequacy;
(D) consumer protection standards;
(E) grievance and appeals;
(F) fair claims payment requirements; and
(G) prompt payment of claims;

What we don’t know is exactly how these seven items will be defined. Since what many Republicans want is the ability to buy and sell health insurance across State lines in order to eviscerate State requirements, HR3962 hardly satisfies their definition of “Interstate competition allowing people to buy insurance across state lines.” So Wonk Room is wrong. However so is RealClearPolitics: people will, under certain conditions, be able to buy health insurance across State lines. Just not under the kind of conditions Republicans want.

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