Editor’s note: Speaker Nancy Pelosi (D-CA) recently indicated she plans to use the House Ways and Means Committee version of health care reform as the base of the bill moving forward in the House. We’re reposting an analysis of what that bill looked like on the way out of committee and which amendments didn’t make it through.
Just before the August recess, the House health bill (HR 3200) cleared all three panels. The next step is House floor consideration, presumably in September.
The House Education and Labor Committee made a series of crucial health policy decisions, and on July 17, the House Ways and Means Committee completed its disposition of the bill. It took a little over 16 hours for the Committee to go through a 1,018-page bill, even though it will significantly change a portion of the economy that makes up almost 17 percent of GDP.
Ways and Means Committee members engaged in debate over several crucial provisions of the legislation, including those addressed by the two other major House committees responsible for the bill. No attempts to improve HR 3200 succeeded in the House Ways and Means mark-up. Not a single amendment, offered by a Republican or Democrat, passed the Committee.
The key items that the Committee addressed are as follows:
Waiting For Doctors’ Care. Many Americans are understandably concerned that, with the government setting benefits and filling in the details of the medical procedures that will or will not be included in health insurance, federal officials may resort to rationing care and controlling access to physicians to save money. Based on the experience of other countries, this process would result in long wait times for patients, particularly those enrolled in the public plan. To prevent such an outcome, Rep. Kevin Brady (R-TX) offered an amendment that would eliminate the public plan if its enrollees experienced longer wait times than the average wait times for enrollees in private health plans. These people would then be able to enroll in private health plans offered on the Health Insurance Exchange. The Brady amendment failed on a straight party-line vote.
Taxpayer-Funded Benefits for Illegals. The House bill, as currently structured, does not offer clear guidelines to ensure that illegal immigrants cannot access taxpayer-funded health care benefits. Rep. Dean Heller (R-NV) introduced an amendment that would use two citizenship status verification systems, the Income and Eligibility Verification System (IEVS) and Systematic Alien Verification for Entitlements (SAVE) programs, to establish an individual’s eligibility to obtain the bill’s proposed affordability credits or enroll in the public insurance option. Both programs are currently used to determine citizenship status and eligibility for public assistance programs. Safeguards to guarantee that only citizens can access federal health care benefits are necessary, considering that the US Census Bureau currently estimates that 9.6 million of the uninsured are not US citizens. The first Heller amendment failed on a straight party-line vote.
No Public Plan for Congress. President Obama has repeatedly told Americans that if they liked their current health insurance plan, they could keep it. The problem is that independent analyses of the House bill indicate that millions of Americans would lose their private insurance, particularly coverage offered by employers. Indeed, virtually all independent studies conclude that the public plan would undercut private health plans, and millions of Americans would be dumped into the public plan. Rep. Dean Heller (R-NV) offered an amendment, which would require members of Congress to enroll in the newly-created public health insurance plan. They would thereby have to forfeit their private coverage, currently offered through the successful Federal Employees Health Benefits Program (FEHBP). Even though members of Congress often say that they should follow the same rules that they impose on everybody else, the rhetoric is belied by the House Ways and Means Committee action. The second Heller amendment failed, with 21 Democrats voting no.
No Freedom to Choose Health Savings Accounts. Once again, the President has said repeatedly that if Americans like the coverage they have today, they would be able to keep it. But under the House bill, the benefits and the terms and conditions of the health benefits that are included in Americans’ health insurance would be determined by federal officials. The House bill would set conditions for what is or is not “acceptable” health insurance coverage.
Many Americans have personally chosen to enroll in high deductible plans combined with a Health Savings Account (HSA). They have chosen this option because they want to have more direct control over their health care dollars and how their health care dollars are spent. To protect consumers who currently hold these plans, Rep. Eric Cantor (R-VA) proposed an amendment that would include high-deductible plans with HSAs in the House bill’s definition of a “qualified health benefits plan.” The amendment would have prohibited the Secretary of Health and Human Services (HHS) from restricting enrollment in private health plans with HSAs. The Cantor amendment was defeated. In other words, contrary to the President’s promise, under the terms of HR 3200 Americans with HSAs could be forced to switch out of their current plans.
Likewise, Rep. Dave Reichert (R-WA) introduced an amendment that would repeal the House bill’s statutory prohibition on new enrollees into individual private health insurance plans. As currently drafted, HR 3200 prevents individual plans from enrolling new members after 2013 unless the plan is specifically “grandfathered” under the law or is transformed into a “qualified health benefits plan,” as determined by federal officials, and available through the national Health Insurance Exchange. The Reichert amendment was also defeated. This means that Americans would be prohibited by law from enrolling in a private individual health insurance plan and would be forced by the federal government to buy a different health plan in the national Health Insurance Exchange.
Government Interference in Medical Decisions. The House bill calls for increased comparative effectiveness research (CER) to determine which treatments are the most cost- andor clinically effective in handling particular medical cases. It creates a new Center for Comparative Effectiveness Research to gather the data. During a news conference from the White House on July 22, President Obama specifically pledged that health care reform would keep the government out of health care decisions. The problem is that government officials may be able to use CER to make payment, treatment, and coverage decisions. This use of reimbursement or regulation would be tantamount to using CER as a mechanism for interfering with health care decisions, something directly counter to the president’s promises. To protect patients covered by government insurance programs from this possibility, Rep. Wally Herger (R-CA) offered an amendment that would prohibit the Centers for Medicare and Medicaid Services (CMS) from using CER to make coverage determinations. The Committee defeated the Herger amendment.
Increasing the Deficit. President Obama said that he would not support health care legislation that would add to the national deficit, and wanted the health care bills to be “deficit-neutral.” In accordance with this policy objective, Rep. Patrick Tiberi (R-OH) offered an amendment that would require the Secretary of Health and Human Services to submit an annual report to the President and Congress, comparing the expected revenue and spending under the bill’s provisions for the upcoming 10-year period. In the event that projected spending under the bill outpaced revenue, the Secretary would have to reduce spending so that it would not exceed revenue. The Committee defeated Rep. Tiberi’s amendment. Meanwhile, the Congressional Budget Office director Douglas Elmendorf has expressed concerns about the projected cost of the House health care bill.
Taxpayer Funding of Abortion. The issue of taxpayer-funded abortion, as well as legal requirements on insurance coverage networks to include abortion services, have been raised in all three House committees, as well as in the Senate HELP Committee. Rep. Sam Johnson (R-TX) and Rep. Eric Cantor (R-VA) tried and failed to convince the majority of the House Ways and Means Committee not to impose such a requirement on American taxpayers. Under the proposed House and Senate legislation, there are no provisions that would prevent federal officials from mandating that health insurance plans include abortion services. Johnson’s amendment would have prohibited any federal requirements on insurance plans to cover abortions, and Cantor’s amendment would have prevented taxpayer dollars from being used to fund abortions. Both amendments were defeated. Similar restrictions were also defeated during the House Education and Labor Committee consideration of the bill.
Three major Committees of the House of Representatives have finished mark-up of HR 3200, a bill the size of a telephone book. Members of the House Ways and Means Committee have clarified their policy positions on crucial items, including the right of employee choice of coverage, the right of Americans to keep private health plans or purchase the private coverage that they like, their right to get medical care without government interference, or whether or not abortion coverage would be a matter of personal choice or government mandate. The House Ways and Means Committee has clearly answered these questions. Moreover, the Committee’s answers, in several instances, directly contradict President Obama’s oft-repeated promises to the American people.
This post was co-authored by Julius Chen.
Obamacare: Day Three of Senate Finance Committee Hearings
On Thursday, September 24th, the Senate Finance Committee continued to vote on amendments to the “Chairman’s Mark” of the America’s Healthy Future Act of 2009. As the committee continues to consider more than 500 amendments, it is becoming clear that Senators are directly undercutting the high profile promises that President Obama made to the American people in his widely broadcasted address to Congress on September 9, 2009. Consider several health policy decisions made by members of the Senate Finance Committee:
Cutting Medicare Advantage (Crapo-Kyl-Roberts Amendment D1)
The White House and Congressional leaders routinely insist that they are not going to cut Medicare benefits, only unnecessary spending or spending properly considered to be waste, fraud and abuse in the Medicare program. Senators Mike Crapo (R-ID), Jon Kyl (R-AZ), and Pat Roberts (R-KS) proposed an amendment to change the Chairman’s mark and remove provisions in Title III, Subtitle D which would result in cuts to Medical Advantage, a program which allows Medicare users to obtain coverage through private insurers. Cuts in payments to Medicare Advantage plans would result in decreased choice and competition for seniors. This amendment failed on a procedural vote (9-9).
The Ability of Americans to Keep Their Existing Coverage. (Hatch Amendment C2, Cornyn Amendment C1)
Senator Orrin Hatch (R-UT) and Senator John Cornyn (R-TX) introduced amendments to preserve Americans’ existing private health insurance coverage. This would be in accord with the President’s promise that “nothing in this plan will require you or your employer to change the coverage or the doctor you have.” Senator Hatch’s amendment would have required that the Secretary of Health and Human Services certify to Congress that the final piece of legislation would not result in more than 1 million Americans losing their current coverage. Senator Hatch’s amendment failed on a party line vote (10-13).
Senator Cornyn’s amendment also sought to guarantee that Americans enrolled in self-insured employer coverage would be able to keep their current coverage by amending Title I, Subtitle D of the Chairman’s mark. The amendment simply provided that any health insurance plan governed by the Employee Retirement Income Security Act (ERISA) would be deemed to have met the personal responsibility requirement. This amendment also failed. It was a party line vote (10-13).
A Middle Class Tax. (Bunning Amendment C3)
President Obama promised repeatedly during the 2008 presidential campaign that, “If you’re a family that’s making $250,000 a year or less, you will see no increase in your taxes.” Since that time, the President has reversed himself on the desirability of imposing an individual mandate for health insurance. In the House bill the penalty for non compliance with the individual mandate is explicitly referred to in the legislative language as a tax. In the Senate Finance Committee “Mark” , the mechanism is an excise tax: the means of enforcing the mandate, requiring Americans who do not comply with the government purchasing requirement to pay a tax, with the size of the tax dependent on their income. During the Senate mark-up, Senator Mike Ensign (R-NV) asked Thomas A. Barthold, chief of staff of the Joint Committee on Taxation, what the penalties would be if taxpayers deliberately refused to pay the tax. In a handwritten note, Barthold replied that under current law a willful failure to pay means that the taxpayer could be charged with a misdemeanor and face a penalty of up to $25,000 and not more than one year in prison. Meanwhile, Senator Jim Bunning (R-KY) offered an amendment requiring that any taxpayer requesting exemption from the personal responsibility excise tax be granted an exemption. Senator Bunning’s amendment failed (9-14).
Medicaid Expansion and State Flexibility. (Ensign Amendment C14, Crapo Amendment C2, Enzi Amendment C9)
Medicaid is a welfare program, funded by both the federal government and the states. In many states, Medicaid spending is crowding out other state budget priorities, such as education and law enforcement. States are struggling and many want relief, as well as flexibility in the administration of the Medicaid program. Senators John Ensign (R-NV), Mike Crapo (R-ID), and Mike Enzi (R-WY) introduced separate amendments to curb the negative effects of the proposed mandatory Medicaid expansion on the states. Senator Ensign’s amendment would have allowed states that experienced an increase in Medicaid spending of more than 1 percent from the previous year to opt out of the Medicaid expansion provisions as detailed in Title I, Subtitle G. This amendment failed along a party line vote (10-13).
Senator Crapo’s amendment sought to block unfunded federal mandates on the states to expand Medicaid by amending Title I, Subtitle G. The objective was to protect the states from incurring future additional and unwanted costs. This amendment failed along a party line vote (10-13).
Senator Enzi also offered an amendment that would have protected states from the Medicaid expansion if their revenues had declined for the two most recent fiscal year quarters to the date of the enactment of the bill. Senator Enzi’s amendment also failed along a party line vote (10-13).
Curtailing Choice of Medicaid Patients. (Enzi Amendment C6)
Senator Enzi (R-WY) offered an amendment to provide for additional options for Americans who qualify for Medicaid. Sen. Enzi’s amendment would allow Americans who would otherwise enroll in Medicaid also to have the option of enrolling in a qualified private health plan. The private plan would be one available through their state health exchange, a new institution created under the Baucus bill. This amendment would have increased choice for Medicaid enrollees, as well as lowering costs for the privately insured by increasing the numbers of younger persons in the private insurance risk pools. The Enzi amendment to expand patient choice was defeated (10-13).
Next week, Senate Finance Committee will continue its mark-up of America’s Healthy Future Act of 2009. Meanwhile, ordinary Americans will be able to monitor the relationship between rhetoric and reality, the gap between words and deeds, the promises and the provisions. With each passing day, as the Senators plod through their massive health care bill, the gap widens.
This post was co-authored by Kathryn Nix