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GOP Senators Slam Launch of Health Overhaul Bill

By Jane Norman, Drew Armstrong and John Reichard

June 9, 2009 -- Just as the Senate Health, Education, Labor and Pensions Committee Democrats unveiled a 615-page bill Tuesday in preparation for a scheduled June 16 markup by the panel, Senate Republicans mobilized by elevating the issue of process in health overhaul debate.

Underscoring GOP complaints that Democrats are trying to move health overhaul legislation too hastily, Republicans on the two key Senate committees handling overhaul bills joined in sending a letter to their Democratic colleagues Tuesday urging a thorough airing of the proposals and their costs before markups begin later this month.

Republicans generally stuck to polite language in urging that the process follow three steps before any markup in order to produce sound legislation: committee members should be given 7 to 10 days to review legislation; they should know the price tag of proposals by receiving cost estimates from the Congressional Budget Office and the Joint Committee on Taxation; and Democrats should "identify the offsets used to pay for heath reform."

"We are committed to working together with you to develop a bipartisan health reform bill," they wrote in the letter to Senate Finance Committee Chairman Max Baucus, D-Mont., and to Chairman Edward M. Kennedy, D-Mass, and Sen. Christopher Dodd, D-Conn., of the Senate Health Education, Labor, and Pensions Committee.

But the letter advised that "while expedience can sometimes be a virtue, it cannot be placed above the need to implement sound, well considered policy." And in a press briefing Tuesday afternoon, a senior aide to Michael B. Enzi, Wyo., the top Republican on the Senate HELP Committee, was far more unvarnished in his criticism. He singled out the HELP committee's Democratic leadership in particular for mishandling the legislative process, contrasting it to the more bipartisan process followed by the Senate Finance Committee.

"We weren't involved in the drafting of this product," said the Enzi aide. "My boss was very disappointed by what we saw today." Republicans were called in only occasionally to be briefed on the bill's contents, but given no input whatsoever, the aide said. "It's been frustrating." Nor were there any substantial interactions between Kennedy himself and Republicans, said the aide. "We've only interacted with Sen. Kennedy's staff. Sen. Kennedy has not been around because of his health reasons...All of our discussions have been at the staff level."

The aide said the process was a stark contrast to what the Senate Finance Committee had done by holding a series of public hearings and private member briefings over several weeks where Republicans were given a chance to offer input on the bill and learn about the proposals in private. "There are still huge outstanding issues there, but Senator Baucus is at least going about it the right way," said the aide. "In contrast, the HELP Committee is going to try and shoehorn that entire process four days before a committee mark. It's unlike any process that I've ever seen that leads to a bipartisan bill."

Beyond the process used to draft the bill, the aide said Republicans were upset both with the proposals included in the bill, and also with what was missing. "We have no idea . . . how the Democrats are going to pay for any of this," said the aide. His comments weren't confined to process considerations; the aide also slammed the Kennedy proposal for a government-run insurance option, employer mandate, Medicaid expansion, and federal health board.

Some New Details and Lots of 'Options'

The bill text follows the outlines of a draft bill circulated earlier but adds some details on health prevention, mandated nutrition labeling at chain restaurants, increasing the health care workforce, attempts to combat health care fraud and abuse, and development of follow-on biologics.

However, an analysis of the bill prepared for senators also offers a smorgasbord of options that apparently could yet be considered to change the way in which delicate issues such as the public plan, employer mandates, subsidies for the uninsured and more are handled. A statement from the committee says that "key outstanding issues" will continue to be discussed by Democrats and Republicans.

The "Affordable Health Choice Act" is intended to restructure the U.S. insurance market in all 50 states. It would place mandates on individuals to obtain insurance and employers to provide it. It would establish so-called "Gateways" in the states that would serve as marketplaces for consumers to obtain insurance, set up a public plan alternative, extend subsidies to families to assist in the purchase of insurance and bar insurance companies from using pre-existing conditions, age, gender or other conditions to set insurance rates. Children could remain on parents' policies until they are 26. No policy could include lifetime or annual benefit limits.

However, final language on a public plan option and the employer mandate apparently could still be open to change, and other sections as well. The committee said in a statement that Democrats and Republicans will meet Wednesday and Thursday to "discuss outstanding legislative options such as the public option and employer mandate." A public hearing is scheduled for Thursday and a markup will be launched June 16 and is expected to take as long as three weeks. The bill will eventually be folded in with a measure under development by the Senate Finance Committee that is expected to be announced as soon as next week.

Three options for the public plan—likely the most controversial piece of the bill—are under discussion, according to a section-by-section Senate analysis obtained by CQ HealthBeat. The first would be a public plan operated by the government, using a payment schedule based on Medicare rates and set in law. The second option would be a plan contracted out by the Department of Health and Human Services but operating under the same rules as private market insurance carriers. The third option would be to drop the public plan entirely, the approach which would be favored by most Republicans.

A separate section of the analysis defines a public health insurance option as a plan approved by HHS that offers payments for items and services at Medicare rates plus 10 percent; another option is to strike that definition.

On the question of subsidies for individuals who need help buying insurance, the committee lists three options for the "premium credits" that would be extended through the Gateways. The first option would be to allow them for families earning up to 500 percent of the federal poverty level, or about $110,000 for a family of four. The second would be sliding scale subsidies up to 200 percent of poverty level, and the third would be a tax credit tied to average premiums in a service area.

Options for discussions also are presented for the individual mandate. One suggestion is to instead provide subsidies or tax credits for individuals who enroll in health insurance; another is to automatically enroll low-income people and/or those who have been offered employer insurance, with an option to opt out or change plans, with late enrollment penalties.

Five possibilities are listed for the employer mandate, including just dropping it entirely. One would be "pay or play," meaning that all but small employers would have to offer health insurance meeting certain standards to employees or pay a fee. Another approach would be to avoid mandates but make employers pay back any portion of Medicaid coverage provided to workers. Under another, if the employer doesn't offer affordable coverage and the worker has to enroll in a publicly subsidized plan, the employer would have to make a payment to the government equal to the employee's coverage. A fifth option would allow employers to offer incentives for employee behavior, perhaps through changes in the gift tax.

The committee statement says that the bill will include five principles—that consumers will be able to keep the coverage they have now if they like it; reduction in health care costs; better disease prevention; health system modernization; and long-term care and services.

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