My letter to the Senate Finance Committee about ACA repeal legislaton

Topher Spiro, veep for health policy at the Center for American Progress and a forceful ACA advocate on Twitter (@topherspiro), got hold of a letter from Senate Finance Committee Chair Orrin Hatch to healthcare "stakeholders," inviting their input by May 23 on Republican senators' efforts to write an ACA repeal bill. Hatch asked that letters be sent to HealthReform@Finance.Senate.gov.

Since the Republican senators' bill-writing process is as secretive and rushed as the House's, Spiro seized the opportunity to encourage non-privileged "stakeholders" -- all of us -- to send their two cents to the email address provided. He has offered to tweet any letters tweeted at him, with a screenshot.

Here's mine:

Dear Members of the Senate Finance Committee:

As a constituent, husband and father of two adult children, son and son-in-law of four aged parents, member of a community and citizen of a nation with many people who lack affordable, reliable access to health insurance or are at risk of losing newly obtained insurance, I urge you

• not to eviscerate Medicaid by imposing per capita caps on federal funding or imposing a block grant formula; 
• not to phase out the ACA Medicaid expansion or reduce the enhanced federal funding that enables it;
• not to end income-based subsidies for premiums and out-of-pocket medical expenses that render individual market coverage and actual healthcare affordable to millions of low-and moderate-income Americans; 
• not to compromise the ACA's ban on medical underwriting or mandating of guaranteed issue or requirement that health plans provide Essential Health Benefits; and 
• not to repeal the ACA taxes that have enabled some 20 million Americans thus far to gain insurance coverage.

Olympia Snowe, put up or shut up on healthcare reform's flaws

In George Packer's long dossier of Senate dysfunction, Olympia Snowe repeats for the umpteenth time that she voted against the healthcare reform bill because she was shut out of merging the Finance Committee bill, which she help forged and voted for, with the HELP Committee bill:

Snowe also voted for the Finance Committee’s health-care-reform bill last October, the only Republican to do so. But in December, at the pivotal moment, she voted against the version that went before the full Senate. “I wasn’t interested in expanding this program beyond the Finance Committee version—it grew by a thousand pages,” Snowe said. She wasn’t included in the negotiations with White House officials that took place in an elegant conference room across from Reid’s suite of offices, and said that the Democrats “did not accept any of my proposals. As I said to the President, it was all windup and no pitch.” 

Snowe here resorts to the Republican fallback position of ridiculing numbers of pages rather than specifying what she didn't like in substance.  The enacted health care reform law is similar in its essentials to the Finance Committee bill -- about which Snowe had this to say to Ezra Klein on October 16, 2009:

David Leonhardt tries to do Obama's job for him, part II

David Leonhardt continues to do yeoman's work explaining the stakes and outlining the means of health care cost control. Today he compares cost control measures in the House bill, which he finds wanting, with those in the Senate Finance Committee bill, which are stronger. His main theme: that the true test of the Obama Administration's leadership comes now, in the endgame, in the skill and force with which they push for the most promising cost control measures.

Perhaps the single most telling flashpoint, according to Leonhardt, will be the fate of the so-called "MedPAC on Steroids," a commission empowered to make a yearly package of Medicare cost control recommendations to Congress, which Congress would have to vote up or down as a package. Leonhardt calls a commission thus empowered a "Fed for Health" to emphasize the need for political insulation. "Whether one ends up in the final bill," he writes, "will be a good test of Mr. Obama's endgame leadership."

Obama would seem to agree with Leonhardt. Back in July, he highlighted the commission as a a potential guiding light for cost control over the course of years and decades, telling Fred Hiatt:

At this point, I am confident that both the House and the Senate bills will contain what we've been calling MedPAC on steroids, the idea that you continually present new ideas to change incentives, change the delivery system, understanding that because this is such a complex system we're not always going to get it exactly right the first time, and that there have to be a series of modifications over the course of a series of years, and we have to take that out of politics and make sure that an independent board of medical experts and health economists are providing packages that are continually improving the system. So I think there's general consensus that that is one of two very powerful levers to bend the cost curve.

As for the second "lever":

Now, the second idea, which is the one that got more attention, even though Elmendorf, I think, has emphasized the benefits of a MedPAC board, as well, was the elimination of the tax exclusion [on employer-provided health insurance]. And I've been very clear on my position that I think to add additional costs to families right now when they're already seeing their premiums doubled is not the kind of health reform that I'd like to see, but I believe that there may be ways of getting at the same principle.

For example, you could conceivably set up an index of some sort that makes sure that health care inflation -- or to make sure that the exclusion only accommodates a certain amount of health care inflation -- as opposed to 8 percent or 9 percent, or what have you -- without burdening current plans, but over time assuming -- if we're assuming that health care inflation is going to continue to be a problem, that you could get at the problem in that way.

Hiatt: A kind of cap, but one that doesn't hurt anybody --

Obama: Currently.

Hiatt: -- at the current level?

Obama: Exactly. You're also seeing, I think, some interesting discussions in the Senate Finance Committee about a variation that goes after the insurance companies, as opposed to directly taxing the benefits.

That "variation that goes after insurance companies" is in the Senate Finance Committee bill, in the form of a surtax on plans that cost more than $21k per family and $8k per individual. "Along with the Medicare commission," according to Leonhardt, "this tax is the biggest single difference between the Senate and House versions. "

So Leonhardt has highlighted the degree to which the White House is in sync with Senate Finance on cost control, and the key cost control omissions in the House bill.

On the other side of the ledger, the House bill provides more generous coverage than the Senate Finance bill. Many who embrace the basic architecture of the Democrats' health reform efforts dream of a bill that combines House coverage with Senate cost control. Deep pessimism about the way Congress works in this era leads many to supsect that we'll get the opposite. I would bet on a mixed scorecard - maybe 1-for-2 on the excise tax and MedPAC, or both surviving in weakened form, and somewhat more generous subsidies with a stiffer coverage mandate than the Finance bill provides.

If a bill passess at all. The abortion pound of flesh extracted in the House, the weak majority with which the bill passed, Lieberman's grandstanding on the public option...all have made me wonder.

See also: David Leonhardt tries to do Obama's job for him (Part I)