How To Build The Best Health Reform Bill In Conference

If I magically had the power to build the best bill possible in conference out of only components from the House and Senate bills, this is what I would do. (Of course there might not even be a conference committee and any bill can still be filibustered by Ben Nelson, Joe Lieberman, Blanche Lincoln, etc., so the hope of building the best bill possible in conference is almost zero unless progressives in the House threaten to reject any bill that is just a massive giveaway to the insurance companies.)

House Bill

I would take the House bill as my base. In almost every way, it is a much better bill. The components which are best in the House bill and not found in the Senate bill are:

1. Millionaires’ tax instead of excise tax on employer-provided insurance.


2. National public option.


3. National exchange with national insurance commissioner.


4. Repeal health insurance companies anti-trust exemption.


5. Real employer mandate (Senate bill has only a weak “free rider” provision which will result in a net decrease in employer provided health insurance).


6. Medicaid expansion to 150% FPL (covering people between 133-150% of FPL with Medicaid is much cheaper than private insurance, saving more money. Senate bill expands Medicaid to only 133% of FPL).


7. The higher actuarial levels for qualified insurance. (In the House bill, qualified insurance must have an actuarial value of at least 70%, while in the Senate bill, it is only 60%.)


8. Applies regulations to all insurance plans, including large employer plans.


9. Medicare is allowed to directly negotiate for drug prices (though there are many problems with how this will work in practice due to the design of the provision).


10. Fully closing the Medicare Part D doughnut hole.


11. $14 billion for community health centers (the Senate provides only $10 billion).


12. Community rating of 2:1, so older people can't be charged more than twice as much as younger people. (Senate rating is 3:1.)


13. Lower annual out-of-pocket limit.


14. Earlier start date (2013 instead of the Senate date of 2014).


15. Temporary COBRA continuation until exchange starts in 2013.


16. Immediate access for legal immigrants to public health programs (Senate bill has a five year wait).


17. Allowing undocumented immigrants to buy insurance on the exchange with only their own money (Senate bill bans undocumented immigrants from using the exchange even if they are willing to pay full price with no government subsidies).

Senate Bill

The Senate bill is, overall, a very bad bill with few redeeming qualities. There are a some provisions from Senate bill not in the House bill that I would want in the final bill:

1. Better affordability credits for people between 250%-400% FPL.


2. Temporary three year reinsurance program for the new exchange.


3. State waiver for innovation (ideally with waiver date moved up to immediately instead of 2017)


4. Cantwell's basic health program for people between 133%-200% FPL (ideally, I would like to see a small change allowing states to set a limit above 200% FPL).


5. Maintaining SCHIP program after the exchange starts (saving the bill money and helping maintain better care for children).


6. Free-choice voucher for people who can't afford their employer insurance.

If I had a little bit of wiggle room, I would try to claim the $10 billion in the Senate bill for community health care centers is different than the $14 billion in the House bill, and the final bill should have closer to $24 billion total for community health centers. The money spent on community health centers is some of the best spent money in the entire bill. I would also make some slight modifications to the State waiver provision so that states could begin fully experimenting with better reform plans right away and not wait until 2017.

Conference should be where the best provisions of both bills are combined to make a better final bill. The House bill is a decent bill, and there are even some provisions from the Senate bill which would make it better. Unfortunately, due to the completely made-up and anti-constitutional 60-vote threshold for cloture in the Senate, conference is were all the best ideas from the House bill are sent to die. Ben Nelson, Blanche Lincoln, Joe Lieberman, and other senators will use their power (or people will use them as an excuse) to replace the pro-consumer protection provisions in the House bill with provisions in the Senate bill that greatly favor the insurance industry.

If Democrats in the Senate are unwilling the push through the best pro-consumer bill possible (public option, national exchange, national regulation, repeal anti-trust exemption, etc.) that favor regular Americans over large private insurance corporations, they should at least make the bill less pro-insurance company. They should remove the individual mandate that forces Americans to buy an expensive, inefficient, and low quality private insurance plan. At least then America would not be forced into a form of corporate feudalism, and progressives will have an actual bargaining chip they can use to improve the reform package sometime between now and 2014 when the full law is scheduled to be implemented.