Religious exemption for contraceptive coverage: who pays when the employer is self-insured? (cont.)

When the administration announced its compromise regarding the requirement that all health plans offer free contraception -- i.e., that if an employer objected on grounds of conscience, the insurer, not the employer, would pay -- I wondered immediately how that would work in the case of the large number of employers whose health plans are self-insured. Who would pay in cases where the employer is the insurer?

My guesses included the third party administrator (TPA) usually hired to run such plans. But that did not seem entirely to make sense, because a) not all self-funded plans use TPAs, and b) the TPA, by definition, does not fund the services provided.  Requiring them to pay for contraception would be a little like requiring outsourced payroll-handling services to pay for, say, ergonomic chairs.

Yesterday, HHS Secretary Kathleen Sebelius rendered an answer of sorts. The Times' Robert Pear reports:

Has the administration caved on contraception?

Last Friday I wondered how the administration's contraception compromise, which mandates that health insurance companies, rather than the employers who hire them, pay for contraception, would apply to self-insured health plans, where there is no outside insurer, only a third-party administrator (TPA) and sometimes a stop-loss insurer to cover highly expensive treatment. 

Now HHS Secretary Sebelius says that self-insured plans will be "exempted." What exactly does that mean? Here's the Washington Times*:

The earth beneath their feet: Obama recasts health care reform

Reading the Obama Administration's letter setting out the terms of the Feb. 25 health care summit, it struck me that the obvious has crept up on us by inches. It's this: moving in his own deliberate fashion, President Obama has doubled down on health care reform.  Rather than gather his Democratic flock in the immediate aftermath of the Massachusetts debacle, he has moved the political ground beneath them as well as the Republicans.  He has issued a put-up-or-shut-up to the whole Congress. Of course, he knows that only the Democrats have something to put up. But he is going to make them put it up -- even if they vote it down. 

Look at how the work order, so to speak, is framed (the letter is under the signature of Rahm Emanuel and Kathleen Sebelius):

We have seen again in recent days that when it comes to health care, the status quo is unsustainable and unacceptable. The proof is right in front of us: just last week, a major insurer, Anthem Blue Cross, announced plans to increase premiums for many of its policyholders in California by as much as 39 percent on March 1.

As the President noted this week, if we don’t act on comprehensive health insurance reform, this enormous rate hike will be "just a preview of coming attractions. Premiums will continue to rise for folks with insurance; millions more will lose their coverage altogether; our deficits will continue to grow larger."

Now is the time to act on behalf of the millions of Americans and small businesses who are counting on meaningful health insurance reform. In the last year, there has been an extraordinary effort to craft effective legislation. There have been hundreds of hours of committee hearings and mark-ups in both the House of Representatives and Senate, with nearly all of those sessions televised on C-SPAN. The Senate spent over 160 hours on the Senate floor considering health insurance reform legislation and, for the first time in history, both the House of Representatives and Senate have approved comprehensive health reform legislation. This is the closest our Nation has been to resolving this issue in the nearly 100 years that it has been debated...[snip]

"Healthcare reform is entitlement reform," cont.

Re the Obama budget team's mantra,"healthcare reform is entitlement reform": one soundbyte strategy for getting this across is to portray the projected 75-year social security shortfall as a bite on the ass of projected Medicare deficits.

In today's Times Jackie Calmes channels one such comparison from the Obamites:

Adding to the pressure, Republicans are back to attacking Democrats as tax-and-spenders. Yet they have not proposed how to pay for their own, more modest health care proposals. Nor did they offset the cost of creating the Medicare prescription drug benefit six years ago when they controlled Congress and held the White House. Its projected deficits exceed the shortfall for all of Social Security over the next 75 years, according to the program’s 2009 trustees report.

Among the trustees issuing that report: Geithner, Sebelius, Solis.

Compare Peter Orzag in last week's FT:

Our fiscal future is so dominated by healthcare that if the US can slow the rate of cost growth by just 15 basis points a year (0.15 percentage points), the savings for Medicare and Medicaid would equal the impact from eliminating Social Security’s entire 75-year shortfall.

Imagine...a rhetorical strategy based on fact.