As we hyperventilate, a quiet healthcare revolution?

Healthcare wonks were understandably a-twitter yesterday over the unveiling of the first substantive "repeal and replace" legislation -- a bill from Senators Coburn, Burr and Hatch that would re-remake the individual insurance market, semi block-grant Medicaid and take a big bit out of the employer's health insurance tax deduction.

The bill is important. Some of its core provisions could be enacted within the framework of the ACA. Some of those provisions -- e.g., replacing the individual mandate with a combination of continuous-coverage protection and default auto-enrollment -- are palatable to some progressives, and others -- capping the employer's tax deduction at 65% of the cost of an average plan -- might be downright attractive to them.  Others, not so much. But as a framework for possible compromise with ACA proponents -- e.g.,  if, say, Democrats have the Senate and Republicans the House and presidency in 2017 -- it has potential.

Under the radar, meanwhile, are two bipartisan efforts that could potentially have a more profound impact on healthcare costs, and therefore on healthcare delivery, as well as on the nation's long-term fiscal outlook.  Both are attempts to move government payment for health services away from fee-for-service. Both seek to foster a combination of coordinated care and pay-for-performance (as do pilot programs in the ACA).  Significantly, amazingly, this potentially revolutionary effort has not yet taken on strong partisan markings.

The most recent effort on this front bears the imprimatur of Congress's most creative and informed healthcare legislator, Senator Ron Wyden (D-Ore.), in concert with Sen. Johnny Isakson, (R-Ga.); Rep. Erik Paulsen (R-Minn.); and Rep. Peter Welch (D-Vt.). The bill, the Better Care, Lower Cost Act of 2014, hones in on the sickest Medicare patients, a small percentage of whom account for the majority of costs.  Modern Healthcare's Andis Robeznieks explains:

Take two: Employers want to provide health insurance

Perhaps I buried my lede a bit yesterday in a post about the ACA's employer mandate. So let me try a carve-out.

Josh Barro, taking at face value some bitching about the requirement that employers with more than 50 full-time employees offer health insurance to their employees, recently charged that the mandate is a mistake and that health reform should have pushed health insurance away from the employer-employee relationship.

Defensible as that diagnosis may be in the abstract, voters at large were not the only constituency resistant to weakening the employer-healthcare bond.  Big businesses, and a not inconsiderable number of small businesses, values their role as health insurer, seeing that role as an important part of their bond with employees, as a competitive advantage, and increasingly, as an opportunity to make their workforce more productive  -- not to mention as font of a tax-free form of compensation.

Call them crazy, as Matt Miller did in October 2009 when the National Coalition on Benefits, an association purporting to represent the interests of employers covering 130 million Americans in the health reform process, helped to shoot down Senator Ron Wyden's Free Choice Amendment, which would have enabled all employees to opt out of their employer's health care plan and buy insurance on the insurance exchanges established by what later became the Affordable Care Act. The group's motto: Don't Erode What Works to Fix What's Broken. *

U.S. employers want to provide health insurance

The Wall Street Journal has a good article today, by small business reporters Emily Maltby and Sarah Needleman, about three smallish businesses grappling with the the Affordable Care Act's employer mandate, which charges employers with more than 50 employees $2,000 per employee (excluding the first 30) if they don't offer coverage.  None of the business owners opt not to offer coverage. Here's the head of a small pizza chain with 90 hourly workers:

Next year, Mr. Stark intends to offer a health-insurance plan for the first time to comply with the law. "At the end of the day, if we take care of our team members, they will take care of the guests," he says. "I philosophically believe people having health care, regardless of age, is positive."

A consultant with 93 employees adds:

Giving Ryan undue credit for Wyden-Ryan

I had a faint expression of interest in response to a letter I sent the Times a week-plus ago, responding to Steven Rattner's call for some form of healthcare rationing. Frankly I can see now why they didn't run it, as I concerned myself with a tangential point, while several letters the Times did publish went for the heart of Rattner's argument (and are well worth reading). Still, mine had some political relevance, as it took Rattner to task for giving Ryan credit for cost control mechanisms he dropped from his 2013 budget.  Here it is:

Obama corrects an expired talking point

As Republicans have doubled and trebled down on their post-truth campaign -- asserting falsely that Obama is gutting welfare reform, gutting Medicare benefits, denigrating business owners, etc. -- Obama has persisted in one misleading talking point: that Paul Ryan proposes a Medicare voucher system that, according to a CBO estimate, could raise seniors' healthcare costs by an average of over $6000 by 2030.

One big happy future family: Romneycare, Obamacare, Ryancare

On a second read of the Medicare reform plan outlined in Paul Ryan's 2013 budget, I was whipsawed by crosscurrents of irony.

I was going to lambaste the plan for its touching faith in the Competition Fairy, believed to shower her low cost/high quality beneficence on private insurance plans competing in a government-run and -financed marketplace. Then it occurred to me that the ode I was reading was virtually identical to the praises sung by Democrats for the prospective healthcare exchanges to be established by the Affordable Care Act. Indeed, the ode may have been composed in large part by a Democrat -- Ron Wyden, who coauthored a proposal with Ryan in December 2011 that Ryan's more recent plan resembles more than it departs from (notwithstanding important differences).  Here's part of the opening movement  of Ryan's Song -- emphasis (and repetition) in the original:

How Ryan duped Wyden, cont.

In my last post, I noted that

1. Senator Ron Wyden, by partnering with Paul Ryan last December in a proposal to convert Medicare to a premium-support program, seriously blurred Democrats' line of attack on Ryan/Romney Medicare reform proposals.
2. Wyden himself is having difficulty articulating the differences between that joint proposal and the Medicare reform plan included in Ryan's 2013 budget ("Ryan 2013").
3. Those differences are real, pertaining to the ways in which costs are controlled and the degree to which increased costs are passed on to seniors.

The key differences are that 1) Wyden-Ryan caps overall Medicare cost growth at GDP +1%, vs. GDP +.5% under Ryan 2013; 2) Wyden-Ryan does not abolish the ACA's Independent Payment Advisory Board, which is mandated to furnish Congress with proposals to keep costs under the cap, mainly by reducing payments to providers in various ways; and 3) Wyden-Ryan caps seniors' yearly  out-of-pocket costs while Ryan 2013 does not.

That comparison was based on a report by Kaiser Family Foundation.  I have since compared the texts of the Wyden-Ryan proposal and the Medicare reform section of Ryan's 2013 budget.  The latter comparison shows that while the differences inferred by Kaiser are real, the earlier report -- surely at Ryan's impetus -- fudges the key distinction, which is whether cost increases in excess of yearly targets can be passed on to seniors. In fact, while Wyden-Ryan emphasizes controls on payments to providers as a means to keep costs below its GDP +1% cap, it leaves the door open to increases in premiums for higher income seniors as a way to cover cost increases in excess of the cap.  Moreover, while Wyden-Ryan does not demonize the Independent Payment Advisory Board (as Ryan 2013 does at length), it does not mention IPAB at all -- and dances around IPAB's function when laying out the means of keeping costs under the cap. Wyden-Ryan also takes one Ryanesque slap at IPAB-in-absence, listing as one the authors' principles,  "Build a strengthened program around the needs of patients, not bureaucrats" (p.8 )

How Wyden muddled the Democrats' attack on RyanCare

Senator Ron Wyden, D-Oregon, is upset that people are casting the Medicare reform plan he put forward with Paul Ryan last December with the Medicare reform plan incorporated in Ryan's 2013 budget:

Flashing an anger and a willingness to counterpunch that’s rarely seen, Sen. Ron Wyden on Monday denounced suggestions that his ideas for reforming Medicare mirror those of Republican Mitt Romney and his new running mate Rep. Paul Ryan.

His protestation below strikes me, however, as a self-cancelling statement:

Wydening the insurance exchange

Senator Ron Wyden has taken a slice out of the widely respected but off-the-table Wyden-Bennett health care reform bill, which would put all Americans in a national insurance exchange, to propose now that all Americans share the opportunity to opt into an insurance exchange:

I believe there is a way to work with the present employer-based system to guarantee that all Americans have choices, and I am proposing it in an amendment to the latest Senate health care bill. My amendment, called Free Choice, would let everyone choose his health insurance plan.

It would impose only one requirement on employers — that they offer their employees a choice of at least two insurance plans, one of them a low-cost, high-value plan. Employers could meet this requirement by offering their own choices. Or they could let their employees choose either the company plan or a voucher that could be used to buy a plan on the exchange. They could also simply insure all of their employees though the exchange, at a discounted rate.

Could this widening of the exchange pool serve some of the purpose of a public option, e.g., by providing critical mass to health care co-ops? And shouldn't that partial individualizing of the health care market appeal to Republicans?

Ezra Klein reports that Obama met with Wyden and Bennett as well as with Jay Rockefeller. Could a final bill staple together Baucus's deficit-reducing funding mechanism, the bigger subsidies that Rockefeller wants (as do liberal Democrats generally), and Bennett's "privatizing" amendment? Could compromise actually improve the bill that becomes law? We can dream, can't we?