Sunday, March 21, 2010

House Approves Landmark Bill to Extend Health Care to Millions, For Consumers, Clarity on Health Care Changes


Published: March 21, 2010 The New York Times

WASHINGTON — Congress gave final approval on Sunday to legislation that would provide medical coverage to tens of millions of uninsured Americans and remake the nation’s health care system along the lines proposed by President Obama.

By a vote of 219 to 212, the House passed the bill after a day of tumultuous debate that echoed the epic struggle of the last year. The action sent the bill to President Obama, whose crusade for such legislation has been a hallmark of his presidency. Democrats hailed the vote as historic, comparable to the establishment of Medicare and Social Security and a long overdue step forward in social justice. “This is the civil rights act of the 21st century,” said Representative James E. Clyburn of South Carolina, the No. 3 Democrat in the House.

After a year of partisan combat and weeks of legislative brinksmanship, House Democrats and the White House clinched their victory only hours before the voting started on Sunday.

They agreed to a deal with opponents of abortion rights within their party to reiterate in an executive order that federal money provided by the bill could not be used for abortions, giving the Democrats the final votes.

Democrats said that in expanding access to health coverage for uninsured Americans, they were creating a new program every bit as important as Social Security and Medicare, while also putting downward pressure on rising health care costs and reining in federal budget deficits.

Republicans said the plan would saddle the nation with unaffordable levels of debt, leave states with expensive new obligations, weaken Medicare and give the government a huge new role in the health care system. The debate on the legislation has highlighted the deep partisan and ideological divides in the nation and set up a bitter midterm Congressional election campaign, with Republicans promising an effort to repeal it or block its provisions in the states.

Representative Marcy Kaptur, Democrat of Ohio, said the bill heralded “a new day in America.” Representative Doris Matsui, Democrat of California, said it would “improve the quality of life for millions of American families.”

But Representative Paul D. Ryan, Republican of Wisconsin, denounced the bill as “a fiscal Frankenstein.”

Representative Lincoln Diaz-Balart, Republican of Florida, called it “a decisive step in the weakening of the United States.”

Representative Virginia Foxx, Republican of North Carolina, said it was “one of the most offensive pieces of social engineering legislation in the history of the United States.”

The passions swirling round the bill were evident Sunday on the sun-splashed lawn south of the Capitol. Hundreds of protesters chanted, “Kill the bill” and waved yellow flags declaring, “Don’t Tread on Me.”

They carried signs saying, “Doctors, Not Dictators.”

The health care bill would require most Americans to have health insurance, would add 16 million people to the Medicaid rolls and would subsidize private coverage for low- and middle-income people, at a cost to the government of $938 billion over 10 years, the Congressional Budget Office said.

The bill would require many employers to offer coverage to employees or pay a penalty.

Each state would set up a marketplace, or exchange, where consumers without such coverage could shop for insurance meeting federal standards.

The budget office estimates that the bill would provide coverage to 32 million uninsured people, but still leave 23 million uninsured in 2019. One-third of those remaining uninsured would be illegal immigrants.

The new costs, according to the budget office, would be more than offset by savings in Medicare and by new taxes and fees, including a tax on high-cost employer-sponsored health plans and a tax on the investment income of the most affluent Americans.

Cost estimates by the Congressional Budget Office, showing that the bill would reduce federal budget deficits by $143 billion in the next 10 years, persuaded some fiscally conservative Democrats that they should vote for the bill.

Democrats said Americans would embrace the bill when they saw its benefits, including some provisions that take effect later this year.

Six months after the legislation is enacted, many plans would be prohibited from placing lifetime limits on medical coverage, and they could not cancel the policies of people who fall ill.

Children with pre-existing conditions could not be denied coverage.

Health insurers, for example, could not deny coverage to children with medical problems or suddenly drop coverage for people who become ill.

Insurers must allow children to stay on their parents’ policies up to their 26th birthday.

Small businesses could obtain tax credits to help them buy insurance.

And within three months of the law’s taking effect, people who have been locked out of the insurance market because of a pre-existing condition would be eligible for subsidized coverage through a new high-risk insurance program.

That special coverage would continue until the legislation’s engine kicks into a higher gear in 2014, when coverage would be extended to a wider part of the population through Medicaid and new state-run insurance exchanges. Those exchanges, or marketplaces, are meant to provide much more competitive, consumer-friendly online shopping centers of private insurance for people who are not able to obtain coverage through an employer.

In 2014, people with pre-existing conditions could no longer be denied insurance, all lifetime and annual limits on coverage would be eliminated and new policies would be required to meet higher benefit standards.

Even sooner, in 2013, affluent families with annual income above $250,000 would be required to pay an additional 3.8 percent tax on their investment income, while contributing more to the Medicare program from their payroll taxes.

And eventually, the most expensive insurance policies would be subject to a new tax.

Here is a look at some of the main ways the health care overhaul might affect household budgets.

The Uninsured

Although most Americans who do not obtain health insurance would face a federal penalty starting in 2014, many experts question how strict the enforcement of that penalty would actually be.

The first year, consumers who did not have insurance would owe $95, or 1 percent of income, whichever is greater.

But the penalty would subsequently rise, reaching $695, or 2 percent of income.

Families who fall below the income-tax filing thresholds would not owe anything. Nor would people who cannot find a policy that costs less than 8 percent of their income, said Sara R. Collins, a vice president at the Commonwealth Fund, an independent nonprofit research group.


Medicaid, the federal health insurance plan for the poor, would cover lower-income individuals under the age of 65. Under the new rules, households with income up to 133 percent of the federal poverty level, or about $29,327 for a family of four, would be eligible.


Most other uninsured people would be required to buy insurance through one of the new state-run insurance exchanges.

People with incomes of more than 133 percent of the poverty level but less than 400 percent (that’s $29,327 to $88,200 for a family of four) would be eligible for premium subsidies through the exchanges.

Premiums would also be capped at a percentage of income, ranging from 3 percent of income to as much as 9.5 percent.

The basic plan would cover 60 percent of the cost of the benefits. The proposal would limit out-of-pocket costs at $5,950 year for an individual and $11,900 for a family.

The exchanges would offer three other benefit plans, covering 70 percent to 90 percent of costs.

A plan for catastrophic coverage would be available to people up to the age of 30 and those who are exempt from the requirement to obtain insurance.

People with pre-existing conditions who have been turned down for health insurance could sign up for a high-risk insurance pool that would be available within 90 days and remain available until 2014.

Within six months, insurers would be prohibited from denying coverage to children based on pre-existing medical conditions, from placing lifetime dollar limits on coverage and from rescinding coverage when a person becomes sick or disabled.

The ban on exclusion based on pre-existing conditions would be extended to every one when the exchanges are operational in 2014.

Premiums for older people cannot be more than three times the premium for young adults.

Insurers competing in the new exchanges would be required to justify rate increases and those who raise prices excessively could be barred from the exchanges.

Insurers would be required to spend more of their premium revenues — between 80 to 85 cents of every dollar — on medical claims. According to a recent Senate Commerce Committee analysis, the largest for-profit insurance companies spend about 74 cents out of every dollar on medical care in the individual market.


The exchanges would also help people who lose their jobs, quit or decide to start their own businesses. “If you lose your employer-related insurance, you will be able to move seamlessly into the exchange,” said Timothy Stoltzfus Jost, a professor at the Washington and Lee University School of Law.

Moreover, people of any age who cannot find a plan that costs less than 8 percent of their income would be allowed to buy a catastrophic policy otherwise intended for people under age 30.


People who receive coverage through large employers would be unlikely to see any drastic changes, nor should premiums or coverage be affected. But almost everyone would benefit from new regulations, like the ban on pre-existing conditions that would apply to all policies come 2014.

There might even be cases where people would be eligible to buy insurance through an exchange instead of through their employer, Professor Jost said: those who must pay more than 9.5 percent of their income for premiums, or those whose plans do not cover more than 60 percent of the cost their benefits.


One of the biggest changes involves the Medicare prescription drug program. Its unpopular “doughnut hole” — a big, expensive gap in coverage that affects millions — would be eliminated by 2020. Starting immediately, consumers who hit the gap would receive a $250 rebate.

In 2011, they would receive a 50 percent discount on brand name drugs.


Starting in 2018, employers that offer workers pricier plans — or those with total premiums of $10,200 or more for singles and $27,500 for families — would be subject to a 40 percent tax on the excess premium, said C. Clinton Stretch, managing principal of tax policy at Deloitte.

Retirees and workers in high-risk professions like firefighting would have higher thresholds ($11,850 for singles, or $30,950 for families), pegged to inflation. Although the taxes would be levied on the insurer, experts expect the assessment to be passed on to the consumer in the form of higher premiums or reduced benefits.

The Democratic effort to secure the 216 votes needed for passage of the legislation came together only after last-minute negotiations involving the White House, the House leadership and a group of Democratic opponents of abortion rights, led by Representative Bart Stupak of Michigan. On Sunday afternoon, members of the group announced that they would support the legislation after Mr. Obama promised to issue an executive order to “ensure that federal funds are not used for abortion services.” Mr. Stupak described the order as a significant guarantee that would “protect the sanctity of life in health care reform.”

But supporters of abortion rights — and some opponents — said the order merely reaffirmed what was in the bill.

The procedural vote on Sunday, approving the terms of debate, had put the House on track to approve the health care bill that was passed by the Senate on Dec. 24, on a party-line vote. That bill will soon become the law of the land, the White House said.

House Democrats were also poised to pass a separate measure that would make significant changes and corrections to the Senate bill. That measure would go to the Senate, where the majority leader, Harry Reid, Democrat of Nevada, has promised to take it up in short order. Mr. Reid said he had the votes to pass it, though he faces resistance from Republicans.

The House galleries were full, and the floor was unusually crowded, for the historic debate on health care. Passage of the bill would be a triumph for Mr. Obama and Speaker Nancy Pelosi. Working together, they revived the legislation when it appeared dead after Democrats lost their 60th vote in the Senate and with it their ability to shut off Republican filibusters.

Republicans said they would use the outcome to bludgeon Democrats in this year’s Congressional elections. The White House is planning an intensive effort to convince people of the bill’s benefits. But if Democrats suffer substantial losses in November, Mr. Obama could be stymied on other issues, including his efforts to pass major energy and immigration bills.

The campaign for health care overhaul began as a way to help the uninsured. But it gained momentum when middle-class families with health insurance flooded Congress with their grievances. They complained of soaring premiums. They said their insurance had been canceled when they got sick “It’s not just the uninsured,” said Representative Jim McGovern, Democrat of Massachusetts. “We also have to worry about people with insurance who find, for crazy reasons, that they are somehow going to be denied coverage.”

Lawmakers like Representative Tammy Baldwin, Democrat of Wisconsin, sustained the drive for universal insurance coverage. Adding urgency to the debate were the strident complaints of employers, especially small businesses, who said they were being crushed by the cost of employee health benefits.

In the end, groups like the United States Chamber of Commerce and the National Federation of Independent Business tried to stop the bill, saying it would increase the cost of doing business. But other groups, including the American Medical Association and AARP backed it, as did the pharmaceutical industry.

The Lawmakers agreed that Sunday’s debate was historic, but they were poles apart in assessing the legislation.

Ms. Pelosi said the bill would free people to pursue their dreams without having to worry about being bankrupted by medical bills or losing health insurance when they switch jobs. “It’s liberating legislation,” Ms. Pelosi said. “It’s to free Americans to live their passion, reach their aspirations without being job-locked because they have to have health care, especially if they have someone in their family with a pre-existing condition.”

Representative Rodney Alexander, Republican of Louisiana, said, “You cannot expect to expand coverage to millions of individuals and to curb costs at the same time.”

Republicans said the picture painted by the budget office was too rosy, because the new taxes and fees would start immediately, while the major costs would not show up for four years. Moreover, Republicans said Democrats would pay a price for defying public opinion on the bill.

“Are you so arrogant that you know what’s best for the American people?” Representative Paul Broun, Republican of Georgia, asked the Democrats. “Are you so ignorant to be oblivious to the wishes of the American people?” Lawmakers spoke with deep conviction in explaining their votes.

“Health care is not only a civil right, it’s a moral issue,” said Representative Patrick J. Kennedy, Democrat of Rhode Island, who invoked the memory of his father, Senator Edward M. Kennedy, Democrat of Massachusetts, a lifelong champion of health care for all.

With this legislation, 32 million currently uninsured Americans will gain health insurance coverage, this is a good start on universal healthcare, but we are far from finished here, with 22 million people still left uninsured.

Everyone in the United States of America, the wealthiest nation in the world, deserves basic healthcare coverage.

Women should not be denied access to abortion coverage, the right to choose should not be only for the wealthy.

The rich and the large corporate entities need to pick up a much larger share of the cost of America’s social safety net.

In our life time we have seen an extraordinary expansion of democracy, corporate power, and corporate control of the media as a means of protecting corporate power against democracy.

This country can never be the land of the free for any of us unless we make it the land of the free for all of us.

There is no freedom for those who endure abject poverty, only despair, and there is no salvation for those who ignore the plight of the hungry and homeless, when they have the means to eliminate it. - Bob Daraio

No comments: