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:

"MedPAC on steroids" is toxic to many...

Hey, we're having a real debate about controlling healthcare costs.

Some "responsible" conservative commentators, a.k.a. New York Times op-ed writers, who expressed queasiness about Paul Ryan's plan to convert Medicare into vouchers of ever-shrinking value nonetheless praised Ryan for opening up discussion of how to control Medicare costs specifically and healthcare costs generally. The same is true of Obama's counter-proposal, a centerpiece of which is strengthening the mandate of the Independent Payment Advisory Board (IPAB) created by the ACA to limit the prices Medicare pays for various treatments.  A strong IPAB was one of Obama's chief priorities in the legislation. He would not fight for a public option, but he fought for IPAB.

Surprise surprise: the Wall Street Journal editorial board does not like IPAB:

Mr. Obama, by contrast, is relying on the so far unidentified technocratic reforms of 15 so far unidentified geniuses who are supposed to give up medical practice or academic research for the privilege of a government salary. Since the board is not allowed by law to restrict treatments, ask seniors to pay more, or raise taxes or the retirement age, it can mean only one thing: arbitrarily paying less for the services seniors receive, via fiat pricing.

DeLay of de land in Congress

Tom DeLay may be a mean, corrupt extremist thug whose chief mission while in power was to sell sell legislation to lobbyists. But that doesn't mean he doesn't know the legislative process:

"The Democrats will do exactly what we always did, rewrite the bill over and over until they give all the members what they need to get to 218 votes. The Senate will do the same thing." It will, he predicts, be a straight party-line vote, and "maybe a few Republicans voting for it, but not many."

Right on cue, the Times today reports that Senator Bill Nelson, Democrat of Florida, is getting hammered by seniors up in arms about planned cuts in subsidies to Medicare Advantage providers, and is in turn holding out to have those cuts eliminated or scaled back. The Times' Robert Pear notes the likely effect if Nelson succeeds:

Approval of the amendment could invite other Democrats to ask for similar deals that might make the bill more palatable to their constituents, but more costly as well.

So we'll see what happens to all those lovely cost-saving measures in the Baucus bill that led the CBO to score it better than deficit-neutral.

The Times article also highlights the many channels of corporate influence. Nelson has received substantial contributions from the insurance industry, health professionals and pharmaceuticals -- a total of over $1.6 million, putting him at about #14 among Democratic senators. But he's being pressured also by seniors in Medicare Advantage programs (remember, he represents Florida), put up to it by their insurers (e.g., Humana), who are scaring them with letters that the Obama administrations calls "misleading and confusing." Ah, democracy...

As a footnote, one under-reported element of the health care debate is the performance and value (or lack thereof) offered by Medicare Advantage programs. The subsidies paid to Advantage providers have been targeted and denounced. Some programs have been flagged for misleading representations of benefits. Obama has implied that Advantage programs provide nothing of substance that seniors can't get from traditional, fee-for-service Medicare. At the same time, the programs should at least have the potential to implement many of the cost-saving measures touted by the Administration - global payment systems, preventive and wellness care, teams of doctors that communicate with each other. I'm going to see what I can scare up on the topic.