The gubmint set the medical loss ratio, and now it’s time to move on to the next issue.
Even as House Republicans press to repeal the health care law, government advisers this week are preparing to wade into one of the most contentious questions raised by the legislation: What benefits must insurers cover? The answer will affect tens of millions of Americans beginning in 2014: those who buy their own insurance and those who get coverage through small employers.
This is a little more detailed:
The Patient Protection and Affordable Care Act (PPACA), signed into law on March 23, 2010, will allow individuals and businesses to purchase health insurance directly through exchanges—competitive marketplaces where buyers can compare coverage. These exchanges will offer a choice of qualified health plans (QHPs) that vary in coverage levels but meet certain standards in categories of care and limits on patient cost sharing.
The PPACA stipulates that these QHPs will cover the general categories of: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services including oral and vision care.
That’s a fairly comprehensive list, but it’s BROAD.
Further details of an “essential health benefit” package are to be defined by the Secretary of Health and Human Services (HHS) based on the scope of benefits offered by a typical employer plan.
There’s also this issue, which is huge:
Should the federal mandates on coverage offered on a state’s exchange preempt that state’s mandates?
Or, should the federal mandates be a floor, with the state mandates overlaid? Health insurance lobbyists want federal rules, but I know there’s a liberal argument for “across state lines” out there, so make it if you got it.
If the federal rules are strong enough, would that solve the race to the bottom problem (but only as to the exchanges) if we’re wanting to sell across state lines, eventually?
This is a 2009 list of what each state mandates (pdf) as far as covered procedures, providers and persons, for reference.
Republicans won’t be weighing in on these vital questions because they’re busy passing the “Repealing the Job Killing Health Care Law Act” in this new era of civility.
Ash Can
“Ration?” Even the liberal Balloon Juice…
kay
@Ash Can:
Thanks.
Dave
Personally, to your last question, I think the federal mandate should be the floor and the state should have the option to be more generous should it decide to do so. That way no matter where you go you know you are getting a baseline set of services.
Ash Can
@kay: In all seriousness, though, I’d feel guilty if I snarked on your typo and made no mention of the fact that I think your posts are outstanding. :)
Kay
@Dave:
There are liberals who say that if there were federal rules (and actual preemption) then big insurers could “sell across state lines” (eventually) and the market would be more robust.
The problem is Republicans scored “across state lines” in 2004 and it didn’t save money, but that was without an exchange.
KG
@Dave: I agree, and that’s usually how these things work, the feds set a floor and the states are free to go beyond that. The questions is whether the law was written in a way that the courts will determine that the feds tried to “occupy the field.”
singfoom
@Ash Can: I don’t want to derail the thread, but I would like to point out that all care is rationed. It always will be.
This is something that our conservative friends will never understand. This is not to suggest the idea that “Death Panels” actually exist…
But applying scientific analysis to the outcomes of different treatments for diseases will always result in a rationing of care since we can’t afford all treatments for all diseases.
And with that, I’ll stop derailing.
Kay
@Ash Can:
I sincerely appreciate the correction, and thanks for the compliment.
KG
@Kay: insurance regulation has always been a state issue. I’m not sure the feds will want to get into that, and I’m not sure the states will willingly let them.
kdaug
I haven’t heard the liberal version of across-state-lines.
I don’t see how that wouldn’t immediately instigate a race to the bottom without a federal floor.
As happened with Delaware and the credit markets, states would compete to have the least restrictive insurance regulations, and the winner gets corporate headquarters and insurance industry jobs.
What am I missing?
Kay
@KG:
I would generally agree with that. What happened with unsecured lenders scared me off “across state lines!” as a fabulous idea.
There IS some validity to the argument that what states are protecting is an insurer located within their state, not their citizens, though. It looks to me like that’s what Maine was doing, when they asked for an exemption to the MLR. They have a state-located insurer, and that’s JOBS, right? For small (population) states like Maine that’s a big deal.
Kay
@kdaug:
Well, there would be federal regs to act as a floor in the liberal version.
Bulworth
Also, too, will at least one Democrat point out that the incredibly awesome Repeal Obama’s Job Killing Obamacare legislation will again allow health insurers to kill coverage for people with life-killing Pre-Existing Conditions?
(asked in all serious civilness).
Dave
@kdaug: That’s how I see it. I think a federal baseline may actually kick off an “upwards” race, with insurance companies trying to capture upper-middle class and upper-class $$$ by offering more generous plans.
Dave
@Kay: That’s exactly right (I live in So. Maine). Losing an insurer…or anyone, for that matter, would be a big jobs hit. Does the law allow for a state to choose an insurance provider for the federal plan? That may allow smaller states to keep jobs while complying with the new law.
Kay
@kdaug:
Too, I think it’s important to remember that the fed-state rules would apply only to the exchanges, so individual and small business policies. The fed coverage mandates are a requirement to enter the state exchange, and the exchange is for individual and small business.
Kay
@Dave:
Well, the insurer is going to qualify (offer a plan that meets the coverage mandated) and then enter the state exchange.
It’s a small-ish market, though. It’s individuals and small business. Big employers have a plan, and they won’t be in this, immediately, anyway.
Lurker
In the final Affordable Care Act, each state must be comfortable with the other states’ health insurance regulations before the interstate compacts that permit selling across state lines can take place. So it does make an attempt to prevent a race to the bottom.
kay
@Lurker:
Right. But health insurance companies want to set the coverage rules (through HHS) so the state mandates don’t apply to the exchanges. Just the federal rules would apply. They want an exemption from state mandates, replacing those with whatever HHS settles on as “qualified”.
So, that would give each plan available in every state exchange (essentially) the same floor, as far as coverage. I think that somewhat moots what states are “comfortable” with, because there would then be one set of (federal) rules when the interstate compacts kick in.
El Cid
O/T, but worthy to further illustrate the high minded civic morality of the Republican agenda:
Zifnab
I’ve seen this pattern repeated with environmental regulations. The argument is that if the federal government sets a standard on clean air or water or what have you, the states are actually prohibited from improving on it.
There are a horde of reasons why this is a bad idea. First and foremost it makes state regulations virtually irrelevant. Why even have state government at all, if the feds are going to dictate everything from the top down? California regularly has to fight tooth and nail for its air quality rules. Meanwhile, Texas flagrantly ignores federal standards and just bogs the issue down in the courts.
I don’t think there is a particularly good argument for denying states the opportunity to raise their own standards.
kay
@KG:
insurance regulation has always been a state issue.
They could keep it, I think. All it would mean is they’d exempt the policies on the exchanges from their state law on coverage mandates. They could keep the other aspects of their regulatory role.
I’m not really arguing for or against. I think it could work either way, with state mandates laid over the fed mandates, or without. I just don’t think it’s all or nothing preemption, as far as the traditional regulatory role for states, because state mandates on coverage are only one aspect of that role.
kay
@Zifnab:
Martin makes a good one, but I can’t remember what it was.
Apparently, he is the (single) liberal I was referring to :)
WereBear
And if a few kids get squished, that’s not because we like squishing kids! We just can’t mess with a sacred interpretation of a document for the sake of a few lives.
/R
kay
@El Cid:
They’re going after the Commerce Clause. I’m a little shocked it’s so blatant, they used to shy away from child labor, although they’ve been leading up to this for years. They narrow the Commerce Clause all the way, and they finally, finally beat FDR. They’re really radicals.
Yutsano
@kay: And he should be around later tonight I think. He’s ebil gubmint worker like me and I don’t think this is a furlough day for him.
KG
@kay: this has been a big part of the more “intellectual” part of the conservative movement. I use to hear a lot of it during my time in the Federalist Society. I never really thought of it as much more than thought experiments, but that seems to have changed recently.
They want to undo Wickard v Fillburn where the Supreme Court said that a farmer growing wheat on his own farm for use on the farm counted as interstate commerce and could be regulated and/or prohibited. The reasoning was that while one farmer doing it might not have an effect on interstate commerce, if you looked at it int he aggregate, every farmer doing it, then it has an effect on interstate commerce.
I’ll admit to being sympathetic to their position on that particular case, but the problem is, given how different the market is today as compared to 1930, I’m not sure that overturning Wickard would actually change anything. Not to mention the fact that the change could be disastrous for the economy… imagine a nationwide company trying to deal with 50 different regulatory regimes.
JRon
We should do it like the Netherlands with a mandatory basic plan, and then we can all invest in additional packages above that. It should be a floor. Their plan covers:
Medical care, including services by GP’s, hospitals, medical specialists and obstetricians
Hospital stay
Dental care (up until the age of 18 years, when 18 years or older you are only covered for specialist dental care and false teeth)
Various medical appliances
Various medicines
Prenatal care
Patient transport (ambulance)
Paramedical care
kay
@KG:
The only time I ever seriously flirted with conservatism was over preemption, or “state’s rights”. I mean “state’s rights” in the best way, not as a cover for bigotry. It’s appealing. A laboratory of ideas! Enumerated powers! Certainty! I was never drawn to Tenthers, but I see the attraction to state law. I also love state constitutions, mine was (originally) a very liberal document.
But only in the abstract. Because that approach didn’t work, as a practical matter, and we’ve already learned that. We don’t have to keep learning it, with each new generation of conservatives. We can spare ourselves the “child labor-acceptable in certain states?” debate. We had that already. Liberals won.
KG
@kay: oh, believe me, I agree with you on this and it was one of the things that turned me off of the conservative movement. The problem is, a lot of “intellectual conservatives” want to have a pre-industrial government in a post-industrial world; I can’t see how that is a good thing. Also funny is how they like to quote Rehnquist’s line that “the constitution is not a death pact” yet seem bound and determined to make it so.
I have to admit, the political geek in me would kinda like to see what a constitutional convention would come up with today.
Omnes Omnibus
@kay: The only time I ever flirted with conservatism was over the flat tax, even then it was only on the day of my final exam for Federal Personal Income Tax in law school. I thought it would be nice to just be able to answer all the exam questions with “A flat 10% of income.”
Erik Vanderhoff
@KG: That’s how, for example, Medicaid works: certain services have to be covered to get federal matching funds. Other services (or additional categories of eligibility) can be supplemented from state budgets. And then you can bargain for certain types of services being included in different waivers or block grants that get further federal reimbursement or contributions.
burnspbesq
@KG:
But only because the Feds decided not to exercise Commerce Clause power that they unquestionably have. If you think Federal regulation would be more effective, repeal McCarran-Ferguson and have at it.
El Cid
@kay: Yes. I’ve always watched for an all-out assault on the Commerce Clause, because it’s the foundation upon which much of the modern scale national government was built, at least its ability to regulate so many issues on the state level. Goes hand in hand with the sentiment that the Civil Rights Act could not be Constitutionally enforced on private establishments. Rand Paul was just the one who was visible enough when he emphasized this point of view.
We need to go back to the days when the federal government’s Commerce Clause powers were about taking Indians’ lands and subsidizing and protecting national / multi-state railroad and telegraph companies and occasionally calling out national guard troops to shoot workers who were causing some problems.
burnspbesq
@El Cid:
If he wrote stuff like that on a Con Law exam, he wouldn’t get a very good grade.
kay
@Omnes Omnibus:
At least you took tax. I took a course on my state constitution that I loved, which is where I fell in with the federalists. That course and “natural resources law” were the only law school sections where I was fully engaged. The Commons! What’s not to love about that idea? I ended up siding with the lefties, obviously, but I’m all too familiar with this whole commerce clause ruckus.
You have to watch them every minute.
El Cid
@burnspbesq: He could get lucky and get the Supes to bring the clause back to only restraining federal interventions, like the early 1800s. Though I’m sure the right and the Tenthers would make exceptions for any intervention they actually liked.
Omnes Omnibus
@kay: I just had my first FaceBook political argument yesterday on the topic of the Commerce Clause. With a libertarian, of course. Wickard really pisses them off. So does telling them that while the interpretation of the Constitution they just expounded is an interpretation, there are others, some of which have been accepted by the courts.
burnspbesq
@KG:
You don’t have to be a FedSoc member to think that there is a line somewhere that delineates what Congress can do under the Commerce Clause and what it can’t, and that Wickard v. Filburn and Gonzalez v. Raich are one
tokestep over the line.The Framers’ understanding of what the word “commerce” meant is the subject of a long-running academic debate in which entire forests have perished, which I find to be ultimately inconclusive. And irrelevant, because I find slavish originalism to be stupid. Last time I checked, it’s not 1787 any more, and the genius of the Constitution is that its interpretation can evolve as our world evolves.
mclaren
The adamant fanaticism with which liberals deny that the so-called “reform” of America’s broken health care system is in fact no fix at all, remains at once amusing and pathological.
Evidence overwhelmingly shows that medical costs continue to skyrocket. Obama’s HCR non-reform has not changed that. On the contrary: all available evidence shows that now, with a captive market of consumers forced by the government to buy crappy overpriced private health insurance, medical devicemakers and doctors and hosptirals and health insurers have unleashed new levels of greed and gouging.
Kay’s pointless post represents yet another game of musical chairs on the Titanic that is America’s broken health care system. No matter who gets to stay in which nice stateroom, the entire ship is going down. Costs continue to explode out of control, and it doesn’t matter a damn who gets included in the exchanges or whether the federal systems represent a floor or a ceiling.
Underlying health care costs are rising so fast that no one — absolutely no one — will be able to afford medical care in another few years.
kay
@El Cid:
The problem is, if there’s a particular federal law someone doesn’t like (and there are plenty I’m not fond of), they may tend to gravitate towards libertarians/conservatives on commerce clause because it sounds GREAT to destroy the basis for that law.
No matter that you took the ground out from under all that great stuff along with it, right?
Dollared
Thanks Kay – your posts are so – so -so substantive! It’s weird, like some crazy liberal’s idea of journalism.
Omnes Omnibus
@kay: There is also a tendency to assume that laws one does not like are unconstitutional.
kay
@Omnes Omnibus:
I live in a conservative area, and we have a really small bar. We go back and forth a lot on liberal v conservative, and I’m one of two Democrats, let alone “liberals”. I have come to actually enjoy being in the minority, as far as arguing.
I had an assistant county prosecutor tell me, with real feeling, “if you knew how this country was supposed to work, you would be a conservative”.
Okay, then!
Martin
My expectation here is that the exchanges and Medicaid will come into alignment, at least as an ideal goal. Remember, PPACA was initiated to reduce the federal cost of Medicare/Medicaid, so bringing the exchanges in alignment with these plans is going to be the default attitude of HHS.
catclub
@KG: Just remember, it is commerce AMONG the several states that is in the text of the Constitution, not simply interstate commerce.
Any fair reading (ha!) would see that this power is quite broad.
catclub
@El Cid: “make exceptions for any intervention they actually liked. ”
The Fugitive slave law springs to mind.
El Cid
@kay: It wouldn’t at all be surprising for there to be shockingly inconsistent application of views on Commerce Clause limitations, allowing authority in matters conservatives want, and preventing authority in matters conservatives don’t. You are still living in the consistency-based community. That’s not how the world really works anymore.
El Cid
@catclub: The 14th Amendment got quite a bit more limited in 1883, too.
Mnemosyne
@mclaren:
It’s absolutely hilarious to me that you keep insisting you’re not a libertarian while linking to wacky libertarian organizations like the Galen Institute to support your claims.
Walks like a duck, talks like a duck, but swears it’s a hippopotamus.
Roger Moore
@Zifnab:
I think there’s a reasonable argument for having a single set of federal rules- or at least many fewer than 50 different sets of rules- when dealing with physical products that are likely to be shipped across state lines. Manufacturers don’t want to have to make 50 different versions of each product to meet 50 different state environmental standards. And some of those standards would wind up being self-defeating if it’s easy for people to dodge a strict state standard by crossing state lines to buy someplace else. The whole point of having a Federal government is to let us adopt a single standard and avoid that kind of problem.
Car emissions standards are probably the most reasonable example of allowing two sets of standards. States can either accept the federal standard or adopt the stricter California standard, but (other than California) they can’t devise yet another standard. We’ve wound up with two standards, but there are enough buyers forced to go with the California standard that the car makers can’t afford to ignore it.