Further Details On The New Health Insurance Premium Assistance Bill

From the NYTimes:

One of the changes being pushed by the liberals would lower the age of eligibility for Medicare to 55, from 65. Another would expand Medicaid to cover people with incomes up to 150 percent of the poverty level (up to $33,075 for a family of four). The Senate bill, as it now stands, would expand Medicaid to cover people up to 133 percent of the poverty level ($29,327 for a family of four.)

A third liberal proposal would require insurers to spend a specified share of premiums — about 90 percent — on clinical services and activities that improve the quality of care. This would, in effect, limit the profits that insurers could make. [ . . .] Senator Sherrod Brown, Democrat of Ohio, is taking the lead in drafting the proposal to let people 55 to 64 “buy into” Medicare. In May, Senator John D. Rockefeller IV, Democrat of West Virginia, introduced a bill to provide access to Medicare for people in that age group. “I’ve been for that since 2001,” he said.

(Emphasis supplied.) I hope Senators Brown and Rockefeller are writing a provision that states that anyone of any age subject to the mandate (which means everyone who goes into the Exchange) will have the Medicare buy-in option. Otherwise, the mandate should be scrapped. Another possibility, it seems to me, would be to allow states to opt out of allowing their residents to buy in to Medicare. I'm sure North Dakotans will appreciate that.

Speaking for me only

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    Any-age buy-in (5.00 / 2) (#1)
    by Coral on Tue Dec 08, 2009 at 08:57:42 AM EST
    Yeah, that would be great. Anyone mandated to buy their own insurance must have access to a government-negotiated plan. I don't have the faintest hope that a bill like that will pass Congress.

    The real concern is what will happen to Democrats once the mandate kicks in and now-uninsured people begin to realize how much "reform" is going to cost them.

    It's (5.00 / 2) (#6)
    by Ga6thDem on Tue Dec 08, 2009 at 09:15:58 AM EST
    not going to have to wait until it actually kicks in. The GOP is going to remind everyone how bad this reform is and I believe it's bad enough for the GOP to ride it to the White House in 2012. It may never take effect if that happens.

    Of course, letting anyone subject to the mandate (5.00 / 5) (#2)
    by andgarden on Tue Dec 08, 2009 at 09:02:31 AM EST
    buy into Medicare is not only the public option--it's better than the public option. Naturally, that's a compromise I will accept. That should have been part of the politics of this in the first place IMO. (Who doesn't love Medicare?)

    I think (5.00 / 2) (#5)
    by lilburro on Tue Dec 08, 2009 at 09:14:59 AM EST
    in light of widely recognized student loan debt and the unemployment hitting recent college graduates in particular, it would be helpful to allow people under the age of 30 to also buy into Medicare.  Ahem...

    I imagine (none / 0) (#9)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:19:41 AM EST
    that something like that would be on the table in a few years.

    Camel's nose under the tent.


    I'm getting cold feet on that proposition (none / 0) (#11)
    by andgarden on Tue Dec 08, 2009 at 09:21:57 AM EST
    I think this is the moment were we set off the nuclear bomb of coverage. I can't foresee having a majority of this size again for some time.

    It seems logical to me (5.00 / 1) (#12)
    by lilburro on Tue Dec 08, 2009 at 09:25:19 AM EST
    to funnel healthy younger people into the Medicare buy-in.  Someone should at least suggest it.  Limit it to the exchange if you must, I guess.

    Nah, the insurance industry (5.00 / 3) (#28)
    by MO Blue on Tue Dec 08, 2009 at 09:51:27 AM EST
    wants those younger people to increase their profits. Insurance pools consisting of people under 55 and a captive audience of those 18 - 25 will do much to help their bottom line. The true story of this health insurance initiative is that whatever the insurance industry wants, the insurance industry will get.

    Of course, that's how you SAVE Medicare (none / 0) (#14)
    by andgarden on Tue Dec 08, 2009 at 09:26:02 AM EST
    well, I look forward (none / 0) (#18)
    by lilburro on Tue Dec 08, 2009 at 09:29:37 AM EST
    to learning on Fox how healthy young people are going to RUIN Medicare.

    Don't agree (5.00 / 1) (#13)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:25:39 AM EST
    I really think this is a sweet spot BECAUSE the GOP decided to defend Medicare at all costs.

    I think someone stumbled into a solution here.


    Well, if you really want to save Medicare (none / 0) (#15)
    by andgarden on Tue Dec 08, 2009 at 09:26:47 AM EST
    then you have to improve the risk pool (i.e., young people have to buy in).

    Nah (none / 0) (#17)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:29:19 AM EST
    I disagree. Make wealthier people pay more.

    This is the dirty secret no one wants to talk about.

    If wealthier people paid more in taxes, there would be no budget problem.

    The one thing I LOVE about the health care bill is how the fact that progressive taxation is being used to finance it has been completely ignored.

    Yay! for the public option for that.


    Well, I like my universal access better (none / 0) (#20)
    by andgarden on Tue Dec 08, 2009 at 09:31:54 AM EST
    than your tax increases (though they both have strong merit as progressive policy).

    I think both are important (none / 0) (#22)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:33:30 AM EST
    One is going to happen in this bill. One is not.

    I'm not willing to call it reform (5.00 / 1) (#24)
    by andgarden on Tue Dec 08, 2009 at 09:35:59 AM EST
    if it's not universal (or almost universal) access. I am especially concerned about loading up Medicare with the next worse risk pool, making it even more difficult to expand in the future (because it looks even more expensive than it is now).

    Next worst risk pool (5.00 / 1) (#44)
    by gyrfalcon on Tue Dec 08, 2009 at 10:43:37 AM EST
    is still substantially lower risk, lower cost than the risk pool Medicare covers now.  That should significantly lower the average risk/average cost per enrollee, no?

    I also doubt very much those 55-64s will pay the same rock-boottom premiums as the over-65s.  So the average per capita income to the Medicare system will also rise.

    Medicare should come out of this looking a lot better financially, then, not worse, wouldn't it?


    Maybe (none / 0) (#48)
    by andgarden on Tue Dec 08, 2009 at 10:54:36 AM EST
    I would feel much better if you also opened Medicare to the bottom brackets. And that's not just out of self interest ;-).

    Ten years of the top bracket and (5.00 / 1) (#53)
    by MO Blue on Tue Dec 08, 2009 at 12:23:13 PM EST
    ten years at the bottom would provide a diverse pool which could offer health care at the most affordable rate. Since the insurance industry wants the bottom bracket to raise their profits, that will not IMO happen.

    So would I, and it wouldn't (none / 0) (#56)
    by gyrfalcon on Tue Dec 08, 2009 at 06:06:39 PM EST
    affect me.  But the point is that opening to 55-64 isn't going to make Medicare look more expensive at all, it should do just the opposite.

    I think I stopped (none / 0) (#25)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:37:08 AM EST
    calling it reform quite a while ago.

    But Obama won't (none / 0) (#27)
    by andgarden on Tue Dec 08, 2009 at 09:39:51 AM EST
    And if we're going to call it reform, people have to LIKE IT.

    I'm confused by this passage (none / 0) (#3)
    by dk on Tue Dec 08, 2009 at 09:05:32 AM EST
    anyone of any age subject to the mandate (which means everyone who goes into the Exchange

    I thought all Americans would be subject to the mandate.  That would be a much larger group than those who qualify for the exchange under the current bill, no?

    I think you're right (none / 0) (#4)
    by andgarden on Tue Dec 08, 2009 at 09:09:36 AM EST
    You are thinking about this (none / 0) (#8)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:18:34 AM EST
    in completely the wrong way.

    You imagine a world where people will be fleeing from their employer provided insurance.

    This is the Ezra Klein fantasy world that has no relation with reality.

    I am pretty surprised to see you indulge in it.

    Memo to the Wonks - Wyden-Bennett is as likely as Single Payer right now.


    No, not at all (none / 0) (#10)
    by andgarden on Tue Dec 08, 2009 at 09:20:26 AM EST
    I think there's a simpler point: everyone is subject to the mandate. You can satisfy it through employer-provided insurance, of course.

    You WILL satisfy it (none / 0) (#16)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:27:21 AM EST
    through your employer based insurance.

    It is silly to imagine people giving up their employer based insurance as Ezra and others seem to imagine. UNLESS of course you remove the tax advantage.

    Their camel nose under the tent for that, they never admit it, is in fact the excise tax.


    How best to put this (5.00 / 2) (#19)
    by andgarden on Tue Dec 08, 2009 at 09:30:52 AM EST
    Not all employer-provided insurance is equal. I have no doubt that most people who have it will keep it, but under the status quo, you don't have the sword of Damocles (i.e. the mandate) hanging over you on the chance that you get fired.

    Nah (none / 0) (#21)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:32:45 AM EST
    I doubt anyone's big worry is the mandate of they get fired. They are worried about getting fired.

    Do not agree with you on this at all.


    I think what you're missing, and you share this (5.00 / 1) (#26)
    by andgarden on Tue Dec 08, 2009 at 09:38:31 AM EST
    with Ezra to some degree, is just how personal it is to talk about what government regulations will force you to do with respect to your health coverage.

    BTD is right (none / 0) (#30)
    by Steve M on Tue Dec 08, 2009 at 09:57:56 AM EST
    People worry all the time about losing their health insurance coverage if they get fired.  No one is saying "gee, I sure hope I retain the right to go without health insurance if I get fired."

    If there's heavily subsidized insurance available for people who lose their job, that's a huge plus.  You'll find very few people who are like, "But, but, but, there's a MANDATE for me to buy that heavily subsidized insurance."

    It is the subsidy that is make or break.  Obviously a mandate is disastrous without a public option or subsidies, no one disputes that.


    I understand the difference, but as a matter (none / 0) (#33)
    by andgarden on Tue Dec 08, 2009 at 10:07:11 AM EST
    of selling the plan, it creates a pretty crappy perception. If we're going to create a new obligation, we have to create a new benefit.

    If you have insurance (none / 0) (#31)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:59:36 AM EST
    the government will force you to do nothing.

    It is the PERCEPTION that the government will force you to do something or will do something to the insurance YOU ALREADY HAVE that stokes these fears.

    I think you are the one missing it. Ezra misses this and many other things.


    I thought that it was that if you are (none / 0) (#32)
    by dk on Tue Dec 08, 2009 at 10:03:05 AM EST
    employed by an employer who has over 10 or 20 employees, than you are forced to buy into the employer's policy (and for some people that it quite a big buy-in once you calculate the employee contributions, co-pays, etc. etc.).

    That's different from what you are saying.  What you are saying is more like what Obama has been saying, which was never particularly accurate.


    Huh? (none / 0) (#35)
    by Big Tent Democrat on Tue Dec 08, 2009 at 10:11:14 AM EST
    I do not think there is anything that "forces you to buy into your employer's insurance offerings."

    But I also think this simply does not present a realistic discussion.

    I think people may be upset about the fact that insurance is offered by their employer but rather because they wish it was BETTER.



    Well, considering that (none / 0) (#38)
    by dk on Tue Dec 08, 2009 at 10:16:43 AM EST
    1) they are forced to buy insurance due to the language in the bill; 2) by being employed by a larger employer are barred from the exchange, public option, medicare, etc.; and 3) while their employer's plan is not affordable, any other choices are even more expensive and thus not viable alternatives.  

    Thus, their choices are to buy into their employer's insurance or violate the law.


    That might be right (none / 0) (#39)
    by Big Tent Democrat on Tue Dec 08, 2009 at 10:19:04 AM EST
    to that degree, I concede your point.

    But the larger point stands, I simply do not accept your surmise that there is a big group of people who want to refuse the insurance offered by their employer.


    You're setting up a situation (5.00 / 1) (#41)
    by andgarden on Tue Dec 08, 2009 at 10:34:00 AM EST
    where big insurance can collude with big corporations to offer crappy expensive insurance, with no recourse.

    I guess we've just come (5.00 / 1) (#42)
    by dk on Tue Dec 08, 2009 at 10:39:50 AM EST
    full circle (which is fine).  I thought your larger point is that everyone who is subject to the mandate should be able to buy into Medicare.  If the details are right, I could totally go along with that.  But then you proceed to cut out most of the people are subject to the mandate.  That's what I don't understand.  

    The mandate applies to people (none / 0) (#7)
    by Big Tent Democrat on Tue Dec 08, 2009 at 09:17:16 AM EST
    who have insurance by your way of thinking.

    I think that is a silly way of thinking about it.

    A law that says you must have car insurance or health insurance does not mean much to the person who already has car insurance or health insurance.

    It is meaningful to the people who DO NOT have such insurance.

    Those people are the ones who will go into the Exchange.

    In a way, you have adopted the Village Wonk argument that having "only" 5 or 10 million people get a public option (or in this case) Medicare) is not big deal.

    It is a big deal. A huge deal. Especially for what it can mean in the future.


    The mandate applies (none / 0) (#23)
    by dk on Tue Dec 08, 2009 at 09:34:12 AM EST
    to people who have insurance not merely because I think it.  What you or I think is irrelevant.  It either does in the the bill or it doesn't.  Which is it?

    I know plenty of people who can't really afford the insurance that their employers offer (which, I understand, they are forced to purchase under the bill).  

    I don't buy the camel's nose theory.  I'm more inclined to support the idea of an expansion of medicare rather than the creation of a wholly inadequate public option precisely because Medicare has been proven to work whereas there is no evidence that the public option as crafted in the bill would be effective or economically sustainable.  Of course, the devil is in the details and likely the medicare expansion will be designed to fail.

    But the above paragraph is only opinion (as your camel's nose theory is only an opinion).  The only fact I was trying to clarify is who is subject to the mandate.  My understand is that the bill subjects all Americans to the mandate.  If that's not what it says in the bill, I'm happy to be corrected.


    Applies and EFFECTS (none / 0) (#34)
    by Big Tent Democrat on Tue Dec 08, 2009 at 10:08:40 AM EST
    are two different things.

    The laws against murder applies to you. I assume that if it did not, you would not go out and start killing people.


    Well, I guess I think that (none / 0) (#36)
    by dk on Tue Dec 08, 2009 at 10:13:51 AM EST
    plenty of people make the choice every year as to whether they can afford their employer's health insurance.  Under the new bill, those people won't have the choice.  And, none one of those employees will have the choice to go outside of their employer's plan to choose to have medicare (another precedent to exclude people from publicly administered health insurance...the camel's nose can go both ways).  So, it both applies and effects a lot more people than you are allowing for, IMO.

    You have data to support (none / 0) (#37)
    by Big Tent Democrat on Tue Dec 08, 2009 at 10:15:55 AM EST
    your surmise?

    Specifically, how many people refuse to take their employer offered health insurance?


    I have never (none / 0) (#40)
    by Steve M on Tue Dec 08, 2009 at 10:30:52 AM EST
    had a job where I was asked whether or not I wanted to accept my employer's health insurance.

    Now that I am an employer, I confess that we do not ask the employees every year whether they would just like some sort of cash payment in lieu of insurance.

    Is my experience really that unusual?


    Yes, that is unusual, I think. (5.00 / 1) (#43)
    by dk on Tue Dec 08, 2009 at 10:43:32 AM EST
    Each year I am given the opportunity to change my benefits profile at work (i.e. do I want to buy their insurance or not, do I want to add a spouse or dependent to the plan, etc.).  

    You do not ask your employees every year if they want cash payment instead of insurance, but if the insurance you offer includes a percentage to be paid by the employee, then if they choose not to buy into your plan they are effectively getting cash to use for another purpose.


    Well (none / 0) (#45)
    by Steve M on Tue Dec 08, 2009 at 10:46:25 AM EST
    if anyone is opting out just to receive a percentage of the cost of their insurance (how big a percentage are we talking about?), I suspect 99% of those people have insurance through a spouse or some other source.  I certainly wouldn't assume that they "can't afford" their employer's insurance (meaning that if they didn't have the choice to opt out... they'd quit their job?)

    I guess when I'm saying (none / 0) (#46)
    by dk on Tue Dec 08, 2009 at 10:51:14 AM EST
    "can't afford" I am saying that at minimum they are may be giving up something else that could be very important and necessary in their lives.  So even if they choose to buy into the insurance, they are still suffering in other ways.

    You just described everyone (none / 0) (#49)
    by Steve M on Tue Dec 08, 2009 at 10:58:51 AM EST
    Certainly no one is opting out because they want to take the cash home and light it on fire.  But you didn't really address my point.

    How many people - I think the answer is close to zero - are opting out of their employer's insurance when they don't have coverage from a spouse or some other source?

    I find it very hard to believe that anyone is going without health insurance altogether just so they can get a refund of 25%, or whatever the percentage is, of the amount of their premium.


    I would say (none / 0) (#50)
    by CST on Tue Dec 08, 2009 at 11:11:10 AM EST
    that percentage depends on the type and affordability of the insurance offered by your employer.  And I would say that while it is probably low, it is by no means zero.  Especially if you are a younger person whose employer offers cr@p insurance.

    I think in order to apply a mandate to these people, you have to have some minimum threshold of what quialifies under "employer insurance".  As in, if it costs more than "X" for the employee or offers less than "X" - they can buy into the "whatever government exchange/option/buy-in is available" before being subject to a mandate.

    I worked at a small company once where over 50% of the employees did not buy-in, and most were not covered under other plans, because although insurance was offered, the employer didn't cover much of the cost and the insurance offered wasn't very good, and the average age of the employees was relatively low.


    Well (none / 0) (#51)
    by Steve M on Tue Dec 08, 2009 at 11:17:21 AM EST
    I don't know what to think about the sort of person who prefers no insurance coverage at all to mediocre coverage at a 50% discount, but I'm not convinced those people should be paramount in the thoughts of lawmakers.  Again, if they get hit by a bus, who do they expect to pick up the medical bills?

    I'm also not convinced that any of those people "can't afford" insurance by any reasonable definition of the term "can't afford."


    I am just saying (none / 0) (#52)
    by CST on Tue Dec 08, 2009 at 11:50:15 AM EST
    I think we need to define "coverage" and "afford"

    Right now we're talking about hypotheticals, and you are assuming coverage and affordability are there under your definitions.  But you don't actually know what they are.  I think there needs to be a minimum threshold before we assume that people aren't choosing that option out of selfishness.


    Reasons for opting out vary (none / 0) (#54)
    by sj on Tue Dec 08, 2009 at 05:00:20 PM EST
    This link from a Walmart watch website is from 2005/2006 but I was actually surprised by this:

    According to Wal-Mart's own website, "In January 2006, the number of associates covered by Wal-Mart health care insurance increased to 46%." [http://www.walmartfacts.com]
    Nationally, 67 percent of workers in large firms (200 employees or more) receive their health benefits from their employer. More than 80 percent of Costco workers are covered by their company plan. [Employer Health Benefits 2005 Annual Survey, The Kaiser Family Foundation and Health Research and Educational Trust; New York Times, 10/24/05]

    Really?  67% of workers in large firms?  I'm kind of surprised by that.

    But I'm confused by the 25% refund data point.  I must have missed something somewhere.  Most employees who decline have other reasons.  Generally either affordability or access to other insurance (for example spouse's family plan).  Where is there a refund?


    I was employed by and retired from (none / 0) (#47)
    by MO Blue on Tue Dec 08, 2009 at 10:51:22 AM EST
    a large employer. Every year I was given the choice of selecting a plan from one or two options with a set rate per plan or a choice to drop coverage all together.

    Since confidence... (none / 0) (#29)
    by Dadler on Tue Dec 08, 2009 at 09:51:34 AM EST
    ...is the only thing that gives money any value, whatever plan is passed had better engender the confidence of the vast majority of Americans or guess what? The value of the dollar will plunge further, the cost of healthcare will skyrocket more, and the cost of any public option that survives (especially one with a risky pool) will become even more costly and less responsive.

    We still cannot stop treating money like the swallows of Capistrano. Money first, people second, that is our motto. And it is going to kill us.

    My only problem (none / 0) (#55)
    by Socraticsilence on Tue Dec 08, 2009 at 05:12:40 PM EST
    is that if this is largley succuessful it further removes incentives for private insurers to pay for preventitive care (they already feel its pointless as it basically cuts costs post-65, drop it to 55 and things like Heart Disease, and Prostate Cancer become diseases that may not be cost-effective to screen for).