Come now Green lets be fair here the Interstate portion of the bill allows states to form interstate compacts with other states, So if New York and Mass. wanted to share insurance purchasng they could, thats a far cry from the bill proposed by John Shadagg (Az.) that allows from all Americans to purchase policies anywhere they choose regardless of what state that policy may be in.
There are three mechanisms in the bill that allow plans to be sold across state lines:
- National multi-state plans that can be sold in any state in the country (at least two of these must be offered through every state exchange).
- Exchanges may be multi-state if states which to merge their insurance markets.
- States wishing to enter compacts can do with with guidance and technical assistance offered by the feds.
All of those allow--at least theoretically--for greater choice and competition, all within the context of a governance structure
scaled to that enterprise. The national plans are subject to national standards. Interstate compacts would be subject to rules agreed to between states, as would multi-state exchanges.
Now, if what you're really asking for is simply deregulation (or perhaps allowing insurers to write regulations for themselves) so that insurers can shed any risks--i.e. deny or drop any coverage they please--they please and aren't subject to any meaningful standards for the products they offer (i.e. removal of any and all consumer protections for purchasers), you should say so. But you can't at the same time pretend you'd like decent coverage to be available to all since the entire mechanism for lowering costs under the proposal is to (1) keep people who need care the most
out of insurance pools and (2) significantly scale back on coverage offered.
That's just another way of asking for deregulation, as Shadegg's scheme relies on governance of health insurance policies that isn't scaled to the size of the transaction. That's why under Shadegg's bill every insurance policy now gets this lovely disclaimer:
This policy is issued by XXXXX and is governed by the laws and regulations of the State of XXXXX, and it has met all the laws of that State as determined by that States Department of Insurance. This policy may be less expensive than others because it is not subject to all of the insurance laws and regulations of the State of XXXXX, including coverage of some services or benefits mandated by the law of the State of XXXXX. Additionally, this policy is not subject to all of the consumer protection laws or restrictions on rate changes of the State of XXXXX. As with all insurance products, before purchasing this policy, you should carefully review the policy and determine what health care services the policy covers and what benefits it provides, including any exclusions, limitations, or conditions for such services or benefits.
You might shorten that to: "This insurance policy may be cheaper because it's a piece of shit offered in a state with no consumer protections. Good luck."
This is a destructive idea.
Right now insurance companies have to base themselves separately in every state they wish to sell in, obtaining a license in that state and obeying the state's law (and building their risk pool in that state separate from other states). If you go to
Anthem's web site you'll find a drop down menu of all the states they're operating in. Right now, each of those Anthem operations is segmented and subject to different rules or mandates. Under Shadegg's proposal, Anthem picks
one state to set up its national operation and call home; it's no longer based in 50 separate states.
Under Shadegg's proposal, Anthem--no longer 50 separate operations but now one giant operation--can sell in any state it likes without having to worry about being licensed or knowing their laws. Everywhere it goes, it carries a little sphere of its home state's laws around it. So if it sets up shop in South Dakota, it's free to sell insurance products in New York. And those products only have to comply with South Dakota law, not New York law.
All it has to do is find one friendly state to set up shop. And by friendly I mean "industry-friendly," a state with an extremely lax regulatory climate. A state--South Dakota in our example--can even actively entice Anthem to set up its national operation there by lowering or even eliminating its health insurance regulations. Maybe they'll even let Anthem write the legislation that does that, the way South Dakota let Citibank write its usury laws. Once they do that,
every Anthem customer in the United States, no matter what state they're in, is protected only by South Dakota's (now, in our example, virtually nonexistent) consumer protections.
The
exact same system was put in place for credit card companies after the Marquette decision in 1978: they can operate in any state but are subject only to the rules of the state they're based in. What did credit card companies do? They relocated to states that
literally let them write the legislation governing them (i.e. the elimination of state usury limits):
In an effort to stimulate the local economy, South Dakota was in the midst of eliminating its usury laws. Mr. Wriston [then chairman of Citibank] told Mr. Janklow [then governor of South Dakota] that if South Dakota would quickly pass a bill inviting Citibank into the state, he would bring 400 jobs. To preempt concerns from local banks about new competition, Citibank also promised to open only "a limited" bank. "We'll put the facility in an inconvenient place for customers and we'll pay different interest rates," Mr. Wriston recalled telling Mr. Janklow. "All we want to do is use it to issue cards.''
For Mr. Janklow, it was an easy decision.
"To me, this wasn't a credit card deal, it was a jobs deal," he said. "It was an economic opportunity for the state. I was slowly bleeding to death."
With bipartisan support and backing from South Dakota's banking association, Janklow proposed a special "emergency" bill. "Citibank actually drafted the legislation,'' he said. "Literally we introduced it, and it passed our legislature in one day."
The arrangement ultimately brought 3,000 high-paying jobs to South Dakota and a host of new suitors from banks across the country. Citibank seemed to just be the beginning.
But, you say, what about other insurers? Note that in our example South Dakota didn't create an Anthem-friendly regulatory climate, it created an
industry-friendly climate. Or as that article noted with regard to credit card companies in South Dakota: "The arrangement ultimately brought 3,000 high-paying jobs to South Dakota and a host of new suitors from banks across the country. Citibank seemed to just be the beginning." Other insurers will no doubt join Anthem in setting up their national operations in South Dakota. Or at least in states that behave in the same way to lure them in. Insurers that remain based in states like New York--with numerous consumer protections--will be the only insurers that sicker, older, or otherwise more expensive customers can hope to buy insurance from because the unregulated insurers based in South Dakota won't have any reason to take on their risk. Those regulated pools will thus become disproportionately full of expensive people, as all the less expensive customers start buying unregulated products from South Dakota. Markets like New York's then very possibly enter a death spiral or at the very least drive out those insurance companies (which creates more incentive for New York to shed its consumer protection laws).
That's why this proposal is invariably referred to as a race to the bottom. If you want to increase choice and competition through interstate sales, there are constructive ways to do that. Deregulation ala Shadegg is not it.
As for Tort reform, lets be honest here, while Tort Reform is a Rebublican Idea for the most part, there is no meaningful tort Reform in this bill , even the Presdient admits that, as well the CBO notwithstanding.
There is no national tort reform in the law. There is funding for state-based work to experiment with changes to their tort laws.
Of course this bill contains Rebublican idea's but is far from a bi-partisan bill
It's bipartisan in content. The fact that Republicans have chosen the electoral strategy they have--with its sister legislative strategy--isn't particularly interesting from a purely policy perspective.
I might add you neglected to mention the increasing to 133% of the Federal poverty level in 2014 to qualify for state Medicaid which will add about 16 million people to Medicaid. With no clear way to fund it, other than through cuts in Medicare to the tune of 500 Billion Dollars and a heavy reliance on state's that are already in trouble financially.
It's ironic, the Medicaid expansions were done because they're cheap. If we made everyone eligible for exchange subsidies (say, give the poor a voucher to buy private insurance) that would make this bill much, much more expensive. That said the "cuts" in Medicare are mostly reductions in overpayments to private insurers (turns out partial privatization actually made Medicare more expensive--who knew?) and decreases in the
growth rate of non-physician reimbursements.
Further, there seem to be this over-looking of the fact that there is no Dox-Fix in the the current edition of this bill and there is a real issue in both Medicaid as well as Medicare of providers accepting it.
Medicaid primary care reimbursements are being temporarily increased to Medicare levels (they're currently only a fraction of that) starting in 2014 to address access issues during the expansion. And the permanent SGR fix was in the House bill, unfortunately that wasn't allowed to go to conference. But it will be addressed.
So while yes while perhaps , being able to make the claim of saying we insured more people, there has been virtually nothing done to address the quality of care.
That's a bit ironic, since your primary aims for "real" reform seem to revolve around tort reform, interstate insurance purchasing, and high deductible plans, none of which have anything to do with care quality. I'm not sure why you keep repeating this point, though, as I've already pointed you to resources on the delivery system reforms that make up the bulk of the law. There's lots and lots of new support for accountable care organizations, medical homes, comparative effectiveness research, investments in wellness and prevention, incentives for discouraging re-hospitalizations and unnecessary care, performance payments, payment bundling, primary care workforce development, the CMS Innovation Center which gets to try out and rapidly implement on a wider scale new models of care aimed at improving quality and coordination, and other things I can't think of offhand.
Aside from specific initiatives (and there are dozens) the law itself, broadly speaking, is moving the system toward a new sort of systems approach: it presumes a data rich future for our system in which measuring services, quality and outcomes is the norm for evaluating and improving care. Put this together with the
HITECH Act and you have, for the first time, a real system-wide move toward quality improvement as a primary emphasis of the system.
Again this bill was an effort to get a legisltive win at all costs, and did not represent the wishes of many Americans and that is why this legislation is finding push back in the form of law-suits from many directions as well as at the ballot box.
Given
what people were saying they wanted the month the reform bills were released, I think they came pretty close to fulfilling the wishes of Americans.
