This document provides an overview of health care reform proposals in the United States Congress in 2009. It discusses proposals for a public health insurance option, modernizing employer-sponsored insurance, expanding individual choices, and targeting the $250 billion health insurance tax break. It also notes debates around the size of insurance exchanges, expanding employee choices, omitting Medicaid reform, and ensuring any public option does not unfairly compete in the private market. The document compares different legislative proposals and argues the Healthy Americans Act proposal covers everyone with no new taxes.

1. Guide to Health Care Reform
Public
Insurance Reform Option
By Rep. Jim Cooper, July 8, 2009

3. Good Medicine
Informed, cost-conscious
individual choice

4. Get the same health
care as your Congressman
Annual, menu-based
shopping

5. Agreement on the “dog”
• Near-community rating
• Guaranteed issue and renewability
• Large risk pools
• Modernize employer-based insurance
• Shared responsibility for coverage
• Everyone gets more health insurance choices
• Purchase of private insurance should not be
included in federal budget

6. Reform is really all about coverage…

7. We are familiar with Individual and
Group Coverage…
Self-employed Company employees

8. Individual coverage doesn’t work well

9. Small group coverage isn’t much
better…

10. Why not offer large-group
coverage by state or region?

11. Everyone is invited to the party and
they wait on you, hand and foot

12. to serve your needs,
unlike their old attitudes.

13. Three figments of your imagination:
Tooth Fairy Easter Bunny Boss Claus

14. There is no such thing as employer-paid
health insurance
Only employer-sponsored.
The boss picks, but employees pay…
…by means of foregone pay raises.

15. The employer system was caused by a historical
accident in 1942
Side-effect of WWII wage & price controls;
never clearly ratified by Congress

16. Uncle Sam tried to keep lid on…
… but employers outbid
each other to get good
workers. They offered
“free” health and life
insurance and other
benefits.

17. Median cash wages have flat-lined for decades
1977-2008

18. … Sucked up by employer-sponsored fringe
benefits, mainly by health care

19. Lost pay raises are to health care like oxygen to
a jet engine
2009 pay raise 2009 insurance
2010 pay raise 2010 insurance
2011 pay raise 2011 benefits

20. We must slow down
health care spending by at least 1%!
$4.5
4.32
4.04
$4.0
3.79
3.98
Current 3.54 3.76
Trends
Trillion of Dollars
$3.5
3.3 3.55
3.09 3.35
$3.0 2.89 3.15
2.7 2.97 Trends under a reformed system
2.8
2.5
$2.5 2.64
2.33
2.46
2.32 HAA creates ten-year savings = $1.48 Trillion (4.5%)
$2.0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Lewin Group, Cost and Coverage Estimates for the “Healthy Americans Act,” Dec. 12, 2006

21. Portability: a good set of luggage
You know you can take your insurance coverage with you

22. Paying for reform
• Decision: New taxes or savings from system?
– Wasting $700 billion annually, so don’t need taxes
– New taxes would add fuel to fire
• Target: $250 billion health insurance tax break
– Unlimited exclusion for employees
– Benefits highest-paid workers at largest firms
– By far the biggest pool of savings for reform

23. How to “Cap” the Tax Break
• Slow the growth of the tax break for workers
– Soft cap at level above today’s health benefits
• $15,000 or 90th percentile benefits?
• Grandfather union health benefits? High-cost regions?
• Workers understand total cost of benefits; start to shop
– Grow cap with inflation, but not inflation plus
• CPI not medical cost index
• 1% reduction in growth solves 2/3 of entitlement issues
– No fixed cap or freeze; raises $410 billion over 10
• No one is “cut” – ratchets down growth rates

24. Why not convert boss’ benefits to cash?
Like Healthy Americans Act does?

25. Some Transition Issues
• Size of exchanges
– Surely “multiple competing exchanges” is a non-starter
– Micro-businesses of 2-10 employees too small
• Exchanges lack bargaining power, scale
• Would help with primary care physician shortage
– Ideally firms with 1,000 or fewer employees join
• Exchanges large enough, but threatens existing coverage?
– Compromise at 200?
• Expand employee choices
– Most workers today get only 1 or 2 choices
– Minimum 3 options?

26. 1st Senate Bill
• Subsidizes up to
400% of poverty
• Income of $88,000 for
family of four
• New disability
entitlement program
• Expensive employer
mandate
• HELP!

27. Senate Finance Proposal
• Leaves insurance
agents, companies,
and commissioners
in place
• 7.5x premium
variation allowed
• 100% federal
Medicaid thru 2016
for new populations
• Eliminates wait for
Medicare disability
– Buy-in at 55

28. Omiting Medicaid reform?
• 2nd Class medical care?
– Low reimbursement
– 2/3 doctors shun
patients
– Wide variation between
states
– Dominating most state
budgets
• Long-term care, end-of
life issues ignored

29. House Tri-Committee bill
-Partial bill –
-no discussion of Pay-Fors or
scoring by Congressional
Budget Office
-National exchange – how to
implement in different regions?
-Subsidize up to 400% FPL
-Weak on delivery system reforms

30. Healthy Americans Act
• Covers everyone
• Bipartisan
• No new taxes
• Scored by CBO
• Fits Obama’s 8
principles
The perfect breed?

31. Other bills to come…?

32. Obama’s Choice Matters Most

33. Big issue is the tail: public option
• Tail must fit dog
• Must not wag dog

34. Some tails look ridiculous

35. Who wants unfair competition?
Single-payer advocates

36. Schumer Option
Fair competition between dogs

37. Conrad’s Co-op Option

39. Is the HAA
radical?
No, it’s bipartisan.
The bill has 13 Senate co-sponsors:
8 Democrats and 5 Republicans.

40. No matter how great the plan, cleanup needed
afterwards