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Working In These Times

Monday, Oct 5, 2009, 6:28 am

After Grayson’s Attack: In Search of…A GOP Health Plan

BY Art Levine

Republicans reacted wtih outrage last week after Rep. Alan Grayson (D-Fl.) offered a blistering attack on the nearly-invisible Republican healthcare proposals: "The Republican health care plan is this: Don't get sick, and if you do get sick, die quickly."

But SEIU's Andy Stern and other progressive leaders have noted that Grayson, despite his hyperbolic rhetoric about "die quickly" and a "Holocaust," was correct about the impact of inaction on health reform: 44,000 people die each year because they lack health insurance. Indeed, Stern said at an Atlantic Magazine-sponsored conference last week:

"[Republicans] have no healthcare plan and they are letting people continue to suffer," he said. "That is an issue and they should be held accountable."

Yet during the President's healthcare speech before Congerss last month, many Republicans were shown holding up copies of their 37 House bills to counter the well-deserved notion that they're the "Party of No," dedicated to obstructionism.

But even some Republican proponents of their own legislation quietly concede that the Republican leadership hasn't seriously pushed their own alternative healthcare plan. One Republican staffer, when asked about the Republican over-emphasis on attacking Democratic plans, told In These Times, "I don't disagree...There hasn't been enough attention to the ideas in [our] plan."

So what's the real story about Republican health plans?

Republicans have actually offered various bills, almost all emphasizing combinations of tax incentives, individual subsidies and vouchers that supposedly give individuals more control over their healthcare and promote portability of insurance, but they haven't united behind a single bill or set of core principles.

It's been well over 100 days since House Republican leader John Boehner  and other House GOP leaders promised to introduce their own legislation.

The upshot of all the various plans, however, remains basically as Grayson described it: "Certainly from what I've seen of the 37 bills, the lesson is still 'Don't get sick,'" says Dr. Lesley Russell, a Fellow at the Center for American Progress who specializes in health policy. Indeed, as Think Progress summed up the view of progressive experts:

A close look at the GOP's so-called "principles" shows that they would break-up employer-based coverage, endanger the coverage of Americans with pre-existing conditions, and drive-up health care spending.

On top of that, several of the basic ideas in the various bills have been around for over a decade and could have been introduced in the Bush administration, if the GOP cared to do so. As one Center for American Progress memo noted, according to the Wall Street Journal:

Eight of the ideas have already been incorporated into Democratic legislation; five lie outside the jurisdiction of the relevant committees; and five have been around for more than a decade, so Republicans could have enacted them when they were in power.

In fact, as Russell found, despite complaining that Democrats have ignored their ideas only five provisions from the 37 bills were even offered by Republicans as amendments in any of the three House committees considering the Democrats' health bills.

Even if they're not serious about pushing for their own health reform agenda, American Progress's Wonk Room has highlighted their ostensible goals (as opposed to a possible hidden agenda of simply enriching health insurers):

These [GOP] alternatives claim to expand access by giving Americans a tax credit to purchase health care coverage outside of the employer-based system and control health care spending by capping awards for malpractice claims, and eliminating “waste, fraud, and abuse” from the system.

But perhaps one reason they haven't been pushed forward is that they could easily draw fire and raise alarms for potentially destroying employer-based care and wiping out Medicaid coverage for mothers and children.

Critics say they essentially force many workers and Medicaid recipients to fend for themselves with relatively modest tax grants that apparently don't cover even half the cost of premiums, nor effectively ban insurers' restrictions on pre-existing conditions.

On the House side, the most sweeping Republican proposal is the "Empowering Patients First Act," introduced by Rep. Tom Price (R-Ga.), chairman of the Republican Study Committee. (Price also introduced a resolution condemning Gray's "breach of decorum.")

Experts at the Center for American Progress, Center on Budget and Policy Priorities and liberal advocacy groups point to a range of potentially dangerous flaws in Price's bill and related proposals. They offer an average tax credit of $5,000 for a family of four, while the real-world costs are at least $13,000 for premiums—assuming the insurers would accept them with pre-existing conditions, which they're not required to under Price's proposal.

So how does Price's bill deal with the issue of pre-existing conditions? It promotes the use of expensive, voluntary "high-risk pools" for the sickest people by the under-regulated state governments.

As Wonk Room's Igor Volsky observes:

All of these proposals break up the employer-pool by encouraging younger workers to opt out of their current coverage and purchase insurance elsewhere. The departure of healthy workers from employer insurance pools would drive up average health costs, forcing more workers to opt out entirely. This unravels employer health insurance for Americans who prefer it...

Uninsured Americans or those who opt out of their employer-sponsored coverage could either purchase insurance through voluntary state based exchanges, associations, high risk pools or across state lines (presumably in the individual market). Unfortunately, none of these options provide viable alternatives for the 56 million non-elderly Americans struggling with diseases like cancer and diabetes who are now covered through their jobs.

Under the Republican plans, insurance companies could still “cherry pick” only those individuals for coverage who do not have costly health conditions.

On the Senate side, physician Sen. Tom Coburn's plan, "The Patients' Choice Act," bills itself as attempting to deal with pre-existing conditions by creating a complex method for penalizing companies that  "cherry pick" patients more than others, while offering only other modest protections for patients who enroll in private health insurance-dominated exchanges.

Most strikingly, the plan aims to use "auto-enrollment" for the uninsured to sign them up in the untested private insurance exchanges (they could opt-out, though) and completely ends tax breaks for employer coverage for workers. This is more radical than even capping the tax breaks, and, in turn, many experts and advocates say, will likely spur employers to drop coverage since employees could in theory get coverage elsewhere with the new tax credits -- while raising workers' overall taxes.

It's just as troubling to critics that it would requires about 45 million non-disabled mothers and children to leave Medicaid and enroll in private insurance.  "Our plan transforms Medicaid!" one Republican staffer boasts.

Indeed, it does, but not in ways likely to appeal either to Medicaid recipients or those who care about public health or the needs of the poor. As the Center for Budget and Policy Priorities (CBPP) warned:

Plan Would Jeopardize Needed Care for Tens of Millions of Medicaid Beneficiaries

The bill’s failure to make coverage affordable for many low-income people is especially serious because the bill would also eliminate Medicaid coverage for low-income children, parents, and seniors, pushing tens of millions of vulnerable people into the private insurance market. Low-income Medicaid beneficiaries tend to be in poorer health and are more likely to have chronic illnesses than people enrolled in private insurance; if forced to purchase coverage on their own, many likely would find the premiums unaffordable.

In addition, low-income seniors who are eligible for both Medicaid and Medicare would face substantially higher costs, because under the bill as drafted, Medicaid would no longer pay their Medicare premiums and cost-sharing.

In addition, unlike those enrolled in employer-plans, patients in Medicaid auto-enrolled in private health insurance exchanges apparently couldn't return to Medicaid if they wanted to: they'd have to choose between private insurance companies in the exchanges and other companies outside the exchanges.

As their prescriptions and doctors' visit dry up during the inevitable snafus of waiting to transfer to coverage by for-profit private insurers, they'll graciously be offered "counselling" on their choices.

From the Republican perspective, this plan—which has already been rejected when offered as an amendment in the Senate health, education and labor committee—isn't a Dickensian effort to rob impoverished mothers and children of affordable, accessible healthcare. Its announced goal is not just to put Medicaid on a sound fiscal path, but to "take the Medicaid stamp off their foreheads," as one staffer describes it, and allow recipients access to a broader range of care since as many as 65% of physicians don't participate in Medicaid.

The miracle of the free market would then be set into motion—although this plan doesn't limit cost-sharing for the ex-Medicaid recipients or set meaningful minimum benefit standards tailored to the needs of low-income families and children. 

But can't they just remain with their clinics and doctors in Medicaid? "They're not allowed to stay [in Medicaid]," a Republican staffer points out, excepting the disabled and the aged in long-term care. So much for the much-vaunted freedom in healthcare promoted by Republicans.

Senator Coburn and his co-sponsors, though, had a far sunnier view of their legislation when they introduced it in May:

Earlier today, U.S. Senators Tom Coburn, M.D. (R-OK) and Richard Burr (R-NC) and U.S. Representatives Paul Ryan (R-WI) and Devin Nunes (R-CA) introduced health care reform legislation that delivers on the shared principles of promoting universal access to quality, affordable health care, and does so without adding billions of dollars in new debt or taxes.

“The Patients’ Choice Act of 2009,” transforms health care in America by strengthening the relationship between the patient and the doctor; using choice and competition rather than rationing and restrictions to contain costs; and ensuring universal, affordable health care for all Americans. “The Patients’ Choice Act” promotes innovative, State-based solutions, along with fundamental reforms in the tax code, to give every American, regardless of employment status, age, or health condition, the ability and the resources to purchase health insurance.

The CBPP's January Angeles has a far darker assessment:

Plan Fails to Create a Viable Alternative for People Losing Employer Coverage

Of particular concern, many of the people who would lose employer-based coverage would likely be unable to find affordable, comprehensive coverage on their own. The bill fails to address the significant shortcomings of the existing individual health insurance market that make it difficult for individuals who are older or have various medical conditions to obtain coverage...

Conclusion

The Patients’ Choice Act is deeply flawed. It would likely cause many people who now are insured — including millions of workers who are in below-average health and currently are covered through their employer, as well as millions of poor children and parents — to lose their current coverage. In many cases, these people would end up uninsured, paying substantially more for insurance than they now do, or purchasing insurance that provides inadequate coverage and has high cost-sharing. The bill also would sharply increase costs for many low-income elderly individuals...

In other words, as Rep. Grayson said, it amounts to..."Don't get sick."

Art Levine, a contributing editor of The Washington Monthly, has written for Mother Jones, The American Prospect, The New Republic, The Atlantic, Slate.com, Salon.com and numerous other publications.

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