HC: What Obama 'left out' about the uninsured

http://voices.washingtonpost.com/postpartisan/2010/03/what_obama_left_out_about_the.html?wprss=postpartisan

By Charles Lane

Like Fred Hiatt, I noticed President Obama’s emotional reaction when Sen. John Barrasso (R-Wyo.) advocated health savings accounts and catastrophic coverage during the health-care summit.

The president essentially shot back that this might be good for well-heeled folks like Barrasso, but not for the uninsured, who are making “$40,000” and working two jobs and are “left out.” This, the president suggested, is the typical profile of the “vast majority” of the “30 million people that we’re talking about.” Over the last year, Obama has offered three rationales for reform: cutting costs, curbing insurance industry “abuses” that undermine middle-class security, and insuring the uninsured. In his riposte to Barrasso, though, the old community organizer really seemed to be speaking from the heart. This was a case for health reform as social justice, and Obama made it with conviction.

Just one question: Does it correspond to the facts?

The actual number of nonelderly uninsured in America is harder to pin down than you might think. The Census Bureau puts out an estimate -- 45.7 million is the most recent -- but this may well overstate the policy challenge, in two ways.

First, the number includes 9.3 million non-citizens. Not all of them are undocumented aliens, but clearly a lot of them are. And neither the president’s proposal nor the House and Senate bills would make undocumented aliens eligible for subsidized coverage. They couldn’t pass if they did.

Second, the Census number fails to correct for the “Medicaid undercount” -- several million people who are actually covered by the federal government’s largest health program for the poor, but who don’t report that to the Census. It also includes some who are eligible for Medicaid but don’t enroll. Former Bush administration economist Keith Hennessey, drawing on calculations done by government experts when he was in office, puts the total of these two categories at 10.7 million

So, right there, we’ve got roughly 20 million people who are either a) presumptively ineligible for universal coverage because they’re in the country illegally, or b) already eligible for government aid under existing law.

That leaves 25.7 million people -- not 30 million, as the president said. Still, does this cohort match his description of the “left out?”

Hard to say. According to the White House, the president’s remark derives from a report by the influential Kaiser Commission on Medicaid and the Uninsured. The report estimates that “most of [the uninsured] come from working families and have low incomes,” noting that “two-thirds of the uninsured are poor or near-poor.”

Yet these statements do not appear to factor in either the Medicaid undercount or the heavy numbers of non-citizens (including undocumented aliens) among the uninsured. Non-citizens tend to be poorer than citizens.

Furthermore, young adults -- of all income levels -- are disproportionately represented among the uninsured. Hennessey estimated that 5 million of all uninsured U.S. citizens are childless adults ages 18 to 34. For these “young invincibles,” comprehensive first-dollar health insurance is not necessarily a good deal economically. In other words, it’s rational for them to be uninsured.

Another 10.1 million are individuals or families who make at least three times the federal poverty level, which is roughly the national median income, according to Hennessey.

So that leaves 10.6 million U.S. citizens with income below 300 percent of poverty, who are not on or eligible for a taxpayer-subsidized health insurance program and are not childless adults between age 18 and 34.

If anyone deserves government help, it would be this group of 10.6 million. But that is one-third, not “the vast majority,” of the 30 million figure President Obama used. And so the questions of social justice are more complicated than he let on.

This would be a more realistic summary: “We all agree that we’re going to leave out a huge segment of the uninsured because they are in this country illegally. Yes, they’re relatively poor. But, given their status, we as a country do not feel that we owe them this benefit.

“Now, we really do have a problem with about 10 or 11 million people who are working families of moderate means. What level of subsidy, if any, do they deserve, and what carrots and sticks do we have to offer others, if any, in the course of ensuring that these folks get coverage?

“In particular, should we make young invincibles buy a federally-regulated and subsidized package that probably covers much more than what they would have bought if left to their own devices -- and more than they actually need? Perhaps that will cross-subsidize older and sicker folks. But don’t forget that a lot of young adults will pay the penalty rather than sign up, and some of them may still buy insurance when and if they really do get sick, because insurance companies will have to take them.

“And is it right to subsidize first-dollar health insurance for people making at least the median national income, given that the resources devoted to them will not be available for other government purposes, including assistance to people who make less than the median?”

I don’t pretend to know the answers to these questions. But I do think they are more pertinent than sweeping generalizations about “the left out.”


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http://www.washingtonpost.com/wp-dyn/content/article/2010/02/24/AR2010022403657.html?wpisrc=nl_pmopinions

On bipartisan health care, a foundation for agreement

By Kathleen Sebelius and Nancy-Ann DeParle
Thursday, February 25, 2010; A23

Over the past year, we've had a vigorous national conversation about how to bring down health-care costs for families, hold insurance companies accountable, make health-care affordable for those who don't have it and lower the deficit. Today, Democrats and Republicans have a chance to come together, share their best ideas and unite behind reforms that will put families and small-business owners back in control of their health care.

Since this debate began, media coverage has focused almost entirely on areas of disagreement between the two parties. But as two people who have spent much of the past year discussing health reform with President Obama and other Democrats, Republicans and independents, including many of the Republicans attending today's meeting, we share the view of Rep. Charles Boustany (R-La.), who said last September: "We agree on about 80 percent of the issues right now. It's just a matter of hashing out those few areas where we disagree."

That's why we think Republicans should find a lot to like in the proposal President Obama released on Monday. It contains several ideas taken directly from Republican bills, such as letting people save on their premiums if they participate in proven employer wellness programs, a proposal supported by Rep. Mike Castle (R-Del.). Or giving states grants to evaluate medical liability models that can improve patient safety, reduce medical errors and bring down liability premiums, similar to a proposal Sen. Mike Enzi (R-Wyo.) has supported. We know Republicans will support the measures to prevent health-care fraud, such as new background checks for Medicare suppliers and real-time reviews of claims, because they're the ones who wrote them.

The president's proposal also contains insurance reforms that Republicans have supported for years. For example, it would eliminate caps on benefits, a step that has been supported by Sen. Judd Gregg (R-N.H.). Republicans including Sens. Tom Coburn (Okla.) and Richard Burr (N.C.) have backed one of the proposal's key elements: state-based, health insurance marketplaces where families will be able to easily compare insurance policies to find the one that's best for them. The president's proposal would also ban discrimination based on preexisting conditions, a change that Coburn and Burr pushed for insurance plans in these new marketplaces.

To help families afford these plans, the Obama proposal contains tax credits for middle-class families -- an expanded version of a policy that has been advocated by Enzi. It embraces the pooled purchasing options for small businesses championed by Sen. Olympia Snowe (R-Maine). It will allow Americans to buy insurance across state lines, a favorite idea of Republican House members including Paul Ryan (Wis.) and Mark Kirk (Ill.), while preserving consumer protections. And to provide immediate security for uninsured Americans who have preexisting conditions, the president's proposal creates a temporary high-risk insurance pool. That idea was proposed by Sen. John McCain (R-Ariz.) during the 2008 presidential campaign and is now supported by leading Republicans such as House Minority Leader John Boehner (Ohio).

This foundation of agreement reaches all the way down to the basic goals of reform. We all want to slow rising health-care costs. We all want Americans with insurance to have more security. We all want to make coverage more affordable. We all want to transform a system of delivering health care that former Republican House speaker Newt Gingrich has called "overpriced" and "underperforming."

With so much common ground, it would be a shame for anyone to delay needed reforms by insisting on a specific package of changes. That's why President Obama and this administration are going into today's meeting with an open mind. We're ready to hear Republicans' best ideas, and we hope they're ready to hear ours.

By sitting down across from one another with the American people watching and putting aside partisan talking points, we can have the kind of honest conversation about how to solve our health-care problems that can move this debate forward. We are ready to build on our broad areas of agreement, hash out those differences and deliver the real reform we know Americans need. Kathleen Sebelius is secretary of Health and Human Services. Nancy-Ann DeParle is director of the White House Office of Health Reform.
Thanks Aggie