Dec 23, 2009

To The Clowns

Who think this is an awesome health insurance reform bill and want to know how we could improve this one. Here.
1. Add a robust public option open to all Americans.
2. Remove the rollback of a woman’s right to choose.
3. Repeal the anti-trust exemption for private insurance companies.
4. Add early Medicare buy-in.
5. Add a real employer mandate.
6. Fix the excise tax that would reduce the quality of many Americans’ insurance. This can be done by properly indexing it so that it forever remains only a tax on “Cadillac” plans.
7. Move up the start date of reform to as soon as possible. Three years is too long!
8. Increase the affordability tax credits to individuals.
9. Expand Medicaid to 150% of FPL.
10. Reduce the maximum annual out-of-pocket limit to 5% of income.
11. Move up state waiver for innovation to 2014 and add ERISA waiver. The state waiver for innovation is a good idea, but having it start in 2017 creates a bureaucratic nightmare of putting in place one reform only to replace it a few years later. We need to fix our system now, not have states start working toward a real solution a decade from now.
12. Give states that set up “basic health programs” 100% of the money, and allow them to use the program for people above 200% of FPL.
13. Allow for drug re-importation so Americans can get cheaper drugs from Canada or Europe.
14. Give Medicare the power to directly negotiate for lower drug prices.
15. Give the government the power to negotiate for lower drug prices on behalf of all Americans (like every other industrialized country does to bring down pharmaceutical prices).
16. Create a national exchange with a strong regulation enforcer instead of state-based exchanges with weak local insurance commissioners.
17. Force all non-HMO insurance plans on the exchange (or at least on the new OPM exchange) to work with the exchange commissioners to collectively negotiate a single provider reimbursement rate for all insurance plans (as it is in Switzerland, Belgium, and The Netherlands.)
18. Add truly strong risk adjustment mechanisms to force competition based on quality instead of trying to dump sick customers (as is done in The Netherlands).
19. Increase the actuarial value of the minimum qualified plans offered on the exchange and base subsidies on the gold level (80% actuarial value) instead of silver level plan (70% actuarial value).
20. Force all insurance companies on the exchange to offer at least one precisely designed high quality insurance plan. This will allow true apple-to-apple comparisons, and make it harder for insurance companies to game the system.
21. Greatly reduce the amount of plan design leeway given to insurance companies to reduce their ability to game the system.
22. Make it illegal to sell basic health insurance for profit, like in almost every first-world country on Earth.
23. At the least, allow only non-profit insurance plans to take part in the new exchanges (or OPM exchange).
24. Reduce the community rating based on age to at most a 1:2 ratio with age rating bands. (one price for all 18-30 year olds, one price for 30-45 year olds, and one price for all 45-64 year olds).
25. Make minimum medical loss ratio 92%. (Try to do this in way to get around the CBO.)
26. At the very least, remove the MLR loophole for the individual market.
27. Allow state and local governments to apply for grants from the CO-OP program.
28. Allow the co-ops to sell insurance to anyone, not just the small group and individual markets.
29. Allow undocumented immigrants to buy health insurance with their own money on the new exchange.
30. Make all legal immigrants eligible for all public health care programs right away, instead of creating a five year wait.
31. Eliminate direct-to-consumer advertising for prescription medication.
32. Provide enough money to give every American access to a community health care center.
33. Follow the FTC recommendations and create a real pathway for biosimilars to create generic forms of the most expensive medications in this country.
34. Create a Government-run HMO option modeled on the VA system.
35. Scrap the whole bill and replace it with a single payer “Medicare-for-all” system.

And more:

1. Extend everyone’s COBRA coverage until the reform kicks in (like in the House bill).
2. Better define the term “medical loss ratio” in the bill to prevent insurers from gaming the regulation.
3. Give the IRS power and duty to enforce insurance companies’ MLR regulation.
4. Remove the six-month wait for the temporary high-risk pools for people with pre-existing conditions. If you can’t get affordable health insurance, it is immoral that the bill makes you go uninsured for six months before you get care.
5. Set up the exchange and all corresponding regulations for small business as soon as possible (a few months). They delayed the exchange because the regulations in the individual market require the expensive affordability tax credits. The small business market will not get expensive affordability tax credits, so there is no reason not to start the exchange just for the small group market as soon as possible.
6. Let insurers in the new exchange use a reimbursement rate based on Medicare plus some percent. (This idea from Jacob Hacker would have similar cost controlling effects as my previous suggestion of having the exchange commissioner force all insurers using PPO’s to negotiate one standard provider reimbursement rate.)
7. Use the OPM exchange to replicate something similar to the Swiss or German system. (Only allow only new CO-OP plans to take part. Mandate a 93% MLR, precisely define benefit packages, and have them collectively pool their negotiating power with providers and manufacturers. Make all co-ops on the OPM exchange share provider networks, reimbursement rates, and forms for PPOs plans or out-of-network charges. Create a robust internal risk adjuster and give all plans in the OPM exchange the power to reimburse at Medicare rates plus 10% for the first several years while the co-ops and OPM exchange gets off the ground.
8. Allow people below 190% of FPL, but who are not poor enough to qualify for Medicaid, to buy in to the program.
9. At least allow people who were on Medicaid but have incomes that increase just slightly above the Medicaid qualification cut off to “buy in” to Medicaid so that they can keep a seamless coverage despite minor fluctuations in income.
10. Fully Federalize the whole Medicaid program.
11. Provide serious special benefits to insurance plans that score very high on precisely defined sets of metrics (MLR, cost effectiveness, consumer reviews, survival rates, speed of claim reimbursement, easy of appeal process, customer retention, etc.)
12. Encourage states and local governments to find a way to merge their state employer insurance exchanges with the new exchange as long as it can be done in a way that does not reduce the quality or increase the cost of coverage for state employees.
13. Encourage community health care centers to work together to create new fully integrated, cost-effective health care plans to cover individuals in Medicaid, the new “basic health program,” or on the new exchange. (like the Community Health Network of Connecticut)
14. Have all insurance plans that provide coverage for young children have zero cost sharing for the health care of the child.
15. At least make all health insurance plans covering children have extremely low co-pays, deductibles, and out-of-pocket limits for the coverage of the child.
16. Have all young children in the country without insurance coverage, regardless of legal status, automatically enrolled in some form low out-of-pocket public health care program. (No child on US soil or anywhere else on Earth should ever die due to lack of access basic affordable health care.)


Anonymous said...

Let's just keep it simple for our politicians:

35. Scrap the whole bill and replace it with a single payer “Medicare-for-all” system.

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