Dear Nate Silver...
Nate Silver, over at FiveThirtyEight.com has 20 questions for people who are coming out against the health care reform bill currently pending before the Senate.
Over the medium term, how many other
opportunities will exist to provide in excess of $100 billion per year in
public subsidies to poor and sick people?
Subsides don’t make coverage
affordable nor do they guarantee access. The penalty for noncompliance – that
is, for not obtaining coverage – in some versions of the bill have been
significantly lower than the cost to actually buying a plan. Baucus tried to
get round this by including a “young invincible” plan since it is critically
important for risk-spreading that young healthy people become part of large
insurance pools. The “young invincible” plan morphed into the “catastrophic
plan” (Section 1302(e) in the Senate bill) and would be available to those aged
30 or younger. Nevermind that this is when preventive care is most important
and this plan limits it to three visits.
2. Would a bill that contained $50
billion in additional subsidies for people making less than 250% of poverty be
acceptable?
At this point, real health reform
would be acceptable. The federal poverty measure is a joke. It hasn’t been
retooled in decades and $55,125 for a family of four isn’t a lot of money,
particularly when you consider that under some provisions in the bill, a family
could be stuck paying 3:1 for older members, 1.5:1 for tobacco
users, etc. And the subsidies would reduce the cost of insurance to 2% of
income for those at 100% of the FPL but could be as much as 9.8% of income for those at 400%
of the FPL.
And the deductible for small employer plans could be as much as $4000 (Sec. 1302(2) of the Senate bill). That’s almost 10% of the above family’s income.
3. Where is the evidence that the plan,
as constructed, would substantially increase insurance industry profit margins,
particularly when it is funded in part via a tax on insurers?
Well, I don’t know about profit
margins but I do know the CBO said in a November 30 letter that “CBO and JCT
estimate that the average premium per person covered (including dependents) for
new nongroup policies would be about 10 percent to 13 percent higher in 2016
than the average premium for nongroup coverage in that same year under current
law. About half of those enrollees would receive government subsidies that
would reduce their costs well below the premiums that would be charged for such
policies under current law.” And this: “In sum, the greater actuarial value and
broader scope of benefits in the legislation would increase the average premium
per person in the small group market by about zero to 3 percent (with other
factors held constant). Those requirements would have no significant effect on
premiums in the large group market.”
Profits? I dunno. But more money would be going to insurance companies overall, either from premiums that citizens would pay or that would be subsidized by taxpayers.
4. Why are some of the same people who
are criticizing the bill's lack of cost control also criticizing the inclusion
of the excise tax, which is one of the few cost control mechanisms to have
survived the process?
I’m not. I think an excise tax on excess benefits is awesome. I’m a progressive, prochoice liberal who is (GASP!) for rationing. Yup, I wrote it. We simply cannot have everything all of the time. We do fabulously well in emergency and critical care in this country and we, frankly, suck at primary and preventive care.
5. Why are some of the same people who
are criticizing the bill's lack of cost control also criticizing the inclusion
of the individual mandate, which is key to controlling premiums in the
individual market?
Again, not me. I am for an
individual mandate but one that is truly affordable. And to make it so, we need
a public plan and an employer mandate with some strong enforcement mechanisms
and steep noncompliance penalties.
6. Would concerns about the political downside to the individual mandate
in fact substantially be altered if a public plan were included among the
choices? Might not the Republican talking point become: "forcing you to
buy government-run insurance?"
Well, since lots of people have
Medicaid, or Medicare, or SCHIP, or Tricare, or use the VA, I think we could
successfully counter that message. Would it be hard? Yes, it would. But there
are some terrific companies out there that I bet could make it work.
Also, how many of the Republicans with that talking point are Medicare enrollees? And of those, how many use FEHP? (Easy answer to the 2d question: More than 90%, I’d guess. And while FEHP isn’t government-run -- it doesn't employ the doctors and hospitals -- the government does run the payment system to get them some very, very good insurance).
7. Roughly how many people would in fact
meet ALL of the following criteria: (i) in the individual insurance market, and
not eligible for Medicaid or Medicare; (ii) consider the insurance to be a bad
deal, even after substantial government subsidies; (iii) are not knowingly
gaming the system by waiting to buy insurance until they become sick; (iv) are
not exempt from the individual mandate penalty because of low income status or other
exemptions carved out by the bill?
Hmm, good question. I don’t think
anyone has completed such analysis but I can say that the penalty for
noncompliance is quite low: $95 in 2014,
$350 in 2015, and $750 in 2016 and indexed thereafter. An additional
penalty equal to half the penalty amount is imposed for each uninsured
dependent of an individual up to 300% of the normal penalty.
Take for a minute the much-touted high-risk pools that would be created for people who have been uninsured for at least six months and who have a pre-existing condition. These plans would be required only to not exceed current HSA-linked high-deductible policies (currently $5,950 for an individual, $11,900 for a family), and premiums that do not exceed those charged for a standard insurance policy. The penalty for noncompliance is SIGNIFICANTLY less than buying into a high risk pool.
8. How many years is it likely to be
before Democrats again have (i) at least as many non-Blue Dog seats in the
Congress as they do now, and (ii) a President in the White House who would not
veto an ambitious health care bill?
Well, I take issue with ambitious.
It was ambitious back in the spring. Now it is merely looking for the
gentleman’s C.
But how long? I don’t know. But is it going to be ages now because when this praises-sung-to-rafters bill rolls out, many people – including many people desperately in need of coverage – won’t notice anything new. Sure, in 2014 they might think it is a great idea but that is one midterm and one presidential election from now.
9. If the idea is to wait for a complete
meltdown of the health care system, how likely is it that our country will
respond to such a crisis in a rational fashion? How have we tended to respond
to such crises in the past?
Badly. We’ve responded badly. But
we did manage to create a single-payer mechanism for Medicare. And you know
what LBJ said when he signed it into law in Missouri
“It
was a generation ago that Harry Truman said, and I quote him: ‘Millions of our
citizens do not now have a full measure of opportunity to achieve and to enjoy
good health. Millions do not now have protection or security against the
economic effects of sickness. And the time has now arrived for action to help
them attain that opportunity and to help them get that protection’…. And just
think, Mr. President, because of this document--and the long years of struggle
which so many have put into creating it--in this town, and a thousand other
towns like it, there are men and women in pain who will now find ease. There
are those, alone in suffering who will now hear the sound of some approaching
footsteps coming to help. There are those fearing the terrible darkness of
despairing poverty--despite their long years of labor and expectation--who will
now look up to see the light of hope and realization. There just can be no
satisfaction, nor any act of leadership, that gives greater satisfaction than
this.”
When you read that quote, can you honestly envision Obama giving such a speech about this bill? I can’t.
10. Where is the evidence that the
public option is particularly important to base voters and/or swing voters
(rather than activists), as compared with other aspects of health care reform?
I don’t know. But I know that that base voters and swing voters went the polls with hope for change in their hearts. Instead, we’ve gotten a compromised-to-the-point-of-near-irrelevancy bill. The Prevention and Wellness Trust and Fund in the bill are awe-inspiring. For the first time ever, a mandatory stream of funding for real, difference-making medicine. Too bad too few people will be able to reap the rewards.
11. Would base voters be less likely to
turn out in 2010 if no health care plan is passed at all, rather than a
reasonable plan without a public option?
The party in power almost always loses seats in the
midterms. If no health care plan is passed some might sit it out. But will they
sit it out if a health care plan passes that will affect them beginning in
2014?
12. What is the approximate likelihood
that a plan passed through reconciliation would be better, on balance, from a
policy perspective, than a bill passed through regular order but without a
public option? 13. What is the likely extent of political fallout that might
result from an attempt to use the reconciliation process? 14. How certain is it
that a plan passed through reconciliation would in fact receive 51 votes (when some Democrats might have objections to
the use of the process)?
A bill passed via
reconciliation would be nightmarish. See this: Wonk
101: A Camel is a Horse Designed By (Conference) Committee. Also: How the
Senate Parliamentarian Might Be King.
15. Are there any compromises or concessions not having to do with
the provision of publicly-run health programs that could still be achieved
through progressive pressure?
Like what? At this point,
if the bill passes in the Senate form (or close to), about the best we can hope
for is Madame Secretary using her regulatory pen to require the inclusion of lots
of stuff in the very open definitions of preventive care services. There will
be plenty of lobbying at the executive branch level but Lieberman has spoken
with regard to legislative action.
16. What are the chances that
improvements can be made around the margins of the plan -- possibly including a
public option -- between 2011 and the bill's implementation in 2014?
Very bad. See the Taking, the National Economy. See also, Midterms, Party in Power.
17. What are the potential upsides and
downsides to using the 2010 midterms as a referendum on the public option, with
the goal of achieving a 'mandate' for a public option that could be inserted
via reconciliation?
Upside: We get rid of
DINOs. Downside: We get rid of DINOs. But reconciliation is a HORRIBLE idea so
why am I even answering this question?
18. Was the public option ever an
attainable near-term political goal?
Perhaps if the Democrats
were a little more spine-having. We’re thinkers but not so good on the
party-whip issues.
19. How many of the arguments that you
might be making against the bill would you still be making if a public option
were included (but in fact have little to do with the public option)?
Well, since my arguments
center around access to good care at affordable rates, my opposition would be
significantly softened were the public option reinserted.
20. How many of the arguments that you
might be making against the bill are being made out of anger, frustration, or a
desire to ring Joe Lieberman by his scruffy, no-good, backstabbing neck?
I lived in the Nutmeg State
Has anyone sent this to Nate Silver? Because really, you should.
Posted by: Glennia | January 08, 2010 at 09:43 AM