Thoughts on the Summit

I watched most of the Summit but not all. There were a few moments where some clarity of discussion and differences came out, but plenty of folks just repeating their talking points carried most of the day. The people who came off the most knowledgeable on the policy issues were the President, Chris Dodd D-CT, Tom Coburn R-OK and Paul Ryan R-WI. Revised: watching some tape, Jim Cooper D-TN was also knowledgeble. Lets just say the Congressional leaders of both parties aren't so good at talking up health policy in public......

In purely policy terms, there is a deal to be had between the Senate bill and the Patients' Choice Act (co-sponsored by Coburn and Ryan, and Nunes of CA and Burr of NC). I have written a great deal about the PCA and called it the most comprehensive Republican plan. The rhetoric used by Republicans does not match the reality of the content of the Democratic bill. If only policy folks were working from these two frameworks, the compromise between Senate bill and PCA would be straightforward and it should get at least some Republican votes, but of course 218 members of the House and (presumably) 60 in the Senate plus 1 President have to agree. So, while the Senate bill with the President's tweaks and the PCA suggest a deal, the politics do not. The deal would go something like this.

Add the things they seemed roughly agree on today. More robust malpractice reform and some increased efforts at decreasing fraud and abuse.

Individual mandate. It is a fantasy to say you can have anything near universal coverage without a mandate of some sort. Some Republican staffer types have acknowledged this to me in private conversations, but note the politics of mandates are bad for Republicans. The PCA has auto enroll procedures like signing people up for cover when they get drivers' licenses and similar activities, so they are dancing all around some sort of mandate without calling it that. The President is right to insist on the individual mandate, and a great many Republicans have supported this for quite a long time until the last few months. In the end, if everyone is going to get care, the goal is to move as mean people into as big a risk pool as possible and it will take a mandate.

Insurance reforms. Banning pre-existing conditions is popular. The President needs to continue banging away that the individual mandate and these insurance reforms come together. This is the most important information job the President has in the next weeks. If you like the ending of pre-existing conditions, that comes with a personal responsibility to have health insurance because if not everyone else has to pay for your care.

The PCA has places where the text says things like 'develop mechanisms to prevent premiums from being too high and the like. They (Republicans in PCA) haven't written a lot of the necessary regulation details, but the Senate bill is solid here. They could obviously tweak the rules, but you have got to have rules to set up what insurance is so folks know what they are buying.

Level of cover. The tax credits provided by the PCA are not enough to buy comprehensive policies, and are really of the magnitude to provide catastrophic coverage only. This is where I think the President could move toward Republicans in saying the individual mandate could be for catastrophic coverage only. People could purchse more cover in exchanges, but if we could guarantee catatstropic coverage that would be a step ahead. This is the one place I think the Pres could move the most toward the Republicans if they were willing to negotiate.

Independent Medicare advisory commission. The most surprising thing of the day was Sen. Coburn banging away that 1 in 3 dollars in the system is non productive. This actually makes the case for expanding coverage via Medicare cuts.....but the PCA had a robust commission of this sort before anyone else did. The fact that such a commission is the Democratic bills is an example of a key Republican idea that has long been a part of the Senate bill. A commission of this sort is key if we will make changes to Medicare that will reduce some of the unproductive spending Sen. Coburn noted.

Financing. The PCA is actually far more radical than the Senate bill becuase it totally repeals the tax exclusion of employer paid insurance. It therefore ends the upside down subsidy (higher income get more) and equalizes the amount of subsidy (tax credit) that all Americans get to purchase private insurance. A compromise that would greatly increase the cost saving potential would be to limit the tax exclusion at a given level (say the mean). This could replace the excise tax on high cost insurance and would help orient focus on the role of patients and their use of care in driving health care cost inflation. This is probably too big a change to be realistic....I would prefer it but I think that the mix of policies to finance in the Senate bill as is is far better than the House (excise tax much preferable to income tax increase).

Medicaid. I thought the most convincing critique of the Senate bill by Republicans was talking about the 15 Million folks who would be covered via Medicaid expansions. I thought the President was also effective at making the case that Medicaid cover is preferable to not being insured and noting everyone in the room has good insurance....but I would like to see a discussion along these lines. Would the country be willing to pay more to expand coverage into private insurance? Would we be willing to pay more to move toward ending Medicaid as an acute care financing (mostly children and pregnant women). The PCA is not good on Medicaid generally for long term care/elderly as it is a block granting which is not a good idea at this point given these are the most vulnerable members of society.

So, in policy terms, there is a deal to be had. In political terms I don't think there is a deal to be had. If there is a movement toward some behind the scences compromise then great, lets see what happens, but the issues are not fine wine: ain't getting better with age.

If there is not some immediate movement toward a deal, the House should pass the Senate bill. It is good policy, and far better than the status quo. It won't take reconciliation by the way to do that, just one roll call vote. Then a reconciliation bill to enact some clean ups and tweaks that the President proposed.