Friday, April 03, 2009

Single Payer Bills in Congress: First Impressions

By: BargainCountertenor:

You can learn something about a bill by examining its sponsors. HR 676 is a mature bill (it's been introduced in earlier Congresses) but until the current sh*tstorm didn't have a hope of passage. The usual suspects (Conyers, Kucinich, Jackson-Lee and a number of others are sponsoring this one. All the sponsors appear to be Democrats.

HR 1200 and S 703 are duplicate bills in House and Senate versions. They are currently identical. HR 1200 is sponsored in the Senate by Bernie Sanders (I would ordinarily consider that a good sign, after reading the bill I'm not so sure. See below.) The sponsors of HR 1200 are almost all also sponsors of HR 676: the exception is Congresscritter Dicks.



Both bills create single payer systems. Both bills define eligibility to broadly include US residents. Both bills limit coverage to 'medically necessary' care. This is necessary to avoid subsidizing boob jobs for strippers, etc. Both bills include dental services and vision services in their coverage.

Current systems

Both bills eliminate Medicare, Medicaid, and CHIP. HR 1200 goes further to eliminate CHAMPUS and Federal Employee programs. HR 676 implicitly eliminates Federal Employee programs with its non-competition provision.

Both bills forbid balance-billing (i.e., payment from the single payer is payment-in-full), and forbid cost-sharing (coinsurance, copayments, deductibles) generally, although HR 1200 has two exceptions. Both bills allow providers to opt for fee-for-service or capitated payments. Both bills create trust funds in the Treasury to pay for health care. The trust funds in both cases are funded by transferring current federal programs (Medicare, Medicaid, CHIP) to the Trust Fund, and add payroll taxes and income taxes. The bills differ in their specificity and in the breadth of the taxation.

Both bills anticipate cost-savings from an electronic health records system and recognize current State licensure and quality standard mechanisms.

Both bills require negotiation on fee structures with providers.
Both bills have a ban on private providers competing with the single payer system. Coverage for conditions not listed under the Acts are permissible (i.e., you could sell boob job insurance for strippers.)



HR 676 creates a national system under the Secretary of HHS. HR 1200 mandates the creation of State Health Security Programs, but allows neighboring States to band together to form Regional Programs. HR 1200 specifically excludes illegal aliens and then creates a loophole to allow illegals to be treated public health or relieve States of the burden illegals place on their Health Security Program. HR 1200 has a much more clearly defined registration program. HR 676 bans the use of SSN as the health information record ID, HR 1200 is silent on the matter.

Although both bills broadly ban coinsurance/deductibles/copayments, HR 1200 institutes 20% coinsurance for Long Term Care and 35% coinsurance for skilled nursing facilities. It reduces the coinsurance for those with family income below 200% of the Federal Poverty Level (FPL) and waives the coinsurance under 100% of FPL.

The biggest difference in the bills is that HR 676 bans investor-owned providers (e.g., an investor-owned HMO like Lovelace) from receiving payment under the system. HR 1200 is silent on the matter, which means investor-owned providers are fine under it. HR 676 allows investor-owned providers to convert to not-for-profit status to become eligible. Provider-owned group practices are not investor-owned for the purposes of HR 676.

All providers are brought in under HR 676, under HR 1200 providers can opt out, although it's not clear why anyone would want to opt out.

HR 1200 handles budgeting by adding up State program budgets and adding a little lagniappe. HR 676 handles budgeting on a regional basis. The budget structures differ significantly. HR 676 creates Capital and Operations budgets and forbids transfer between them. HR 1200 creates budgets for Quality Assessment, Health Professional Education, Administration and Operations. Capital projects are included under Operations, so there is potential for robbing Peter (actual operations costs) to pay Paul (buy capital-intensive toys like MRI machines.) HR 1200 caps budget growth at the larger of 0 and the mean increase in GDP adjusted for population growth.

Good Stuff
Both bills cover mental health care, dental services, and vision. Dental care is incredibly important. Surveys of the uninsured show that they worry more about lacking dental coverage than other things. If you can't take care of your teeth, it makes other things (like getting a job) much more difficult. If you doubt it, think for a moment about the stereotype of an adult missing several visible teeth.

My general assessment
HR 676 is not as well-defined as HR 1200. But I think HR 676 is the better bill, mostly because it does away with investor-owned health service organizations. Investor-owned HSOs are really heavily loaded with moral hazards on both sides, and my personal bias is that we are better off without them.

HR 1200 is closer to the model I would actually try to institute if I were doing it. But I don't think it's regional model idea is well-thought out. Some States (like mine, New Mexico) simply aren't large enough to run a Health Care Authority. Banding together is a necessity for New Mexico, but with whom? Texas would simply impose their system on us. Perhaps a Four-Corners Authority of NM, UT, AZ and CO, but the negotiations to get it going would be a nightmare.

So there are things I like about both bills, and things I dislike about both. Overall, I prefer HR 676 to HR 1200. But if I were a gambler, I'd lay odds on HR 1200.

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