I’m working pretty much night and day to get health care reform enacted in Washington, DC. Health care reform is, I believe, going to pass, although it’s going to be close in the House. But I just realized what passing health care reform in Washington might mean for our efforts in Pennsylvania.
State vs Federal Exchanges
It is likely, and probably unfortunate, that the bill that passes this week will have state exchanges rather than a national exchange. A national exchange, on the whole, would be better for a number of reasons. The federal government is likely to have tougher regulations on insurance companies than state exchanges. A federal exchange will have a larger insurance pool which means that costs of health care and administrative costs will be spread over larger group of people. And the state exchanges in the Senate bill will allow individual states to opt out of providing insurance with coverage for abortion
The administration is thinking about some ways to get around these problems administratively. Under the Senate bill, if the states do not set up exchanges by January 2014, or they don’t meet standards set by the Secretary, then the federal government can create the an exchange. (On some interpretations of the Senate bill, the federal government can also include a state that doesn’t set up an adequate exchange in a regional exchange.)
So one possible way to get some of the benefit of a national exchange is for the Secretary of HHS to set the standards for the exchanges so high that states won’t be able to meet them. This will force the states into national or regional exchanges.
There is another way of looking at the national vs state exchange trade-off, however. It opens up the possibility of some states going creating a state exchange with higher standards then that created by the federal government.
One state in which this might be possible is, strangely enough Pennsylvania.
The Politics of Health Care in Pennsylvania
I say strangely enough because most progressive public policy is blocked in Pennsylvania by our State Senate which is controlled 30-20 by Republicans and run by an extremely conservative Senate leadership that is elected by a Republicans delegation that has moved far to the right in the last six years. And things are particularly bad when it comes to insurance since, as I discovered when I worked to enact Governor Rendell’s health care program in 2007, the insurance industry contributes so much money to Republican Senators that it is very difficult to overcome their influence in the body.
But the Senate leadership is going to be put in a strange situation by the requirement to create an exchange in Pennsylvania. They will want to avoid a federal exchange because it is likely to be tougher than the exchange they will create in Pennsylvania. But once they bring a bill for an exchange to the floor, the possibility exists of amending it to be even stronger than the federal bill.
This possibility arises because there are five or six Republican Senators from Montgomery, Delaware, and Bucks Counties that are amenable to pressure from progressive citizens and labor unions. They come from districts that have been moving in a Democratic direction. Governor Rendell, Senator Casey and President Obama all won in these districts, sometimes by large margins. Sooner or later, these districts will be held by Democrats. But, in the meantime, we can sometimes get these Senators to support progressive legislation if, that is, we can get it to the floor.
Most of the time we can’t. Perhaps as many as five or six Republican Senators would have voted for Rendell’s health care bill, as they did for the minimum wage increase a few years before, if we could have gotten it to the floor. We found a way to get the relatively moderate Senate President Jubelirer and Majority Leader Brightbill to bring the minimum wage bill to the floor. But these two leaders were defeated in Republican primaries by hard right opponents and were replaced by Senate President Scarnati and Majority Leader Pileggi, who understood both that the primary electorate for Republicans in most State Senate districts and the Senate Republican Senate Caucus itself have moved far to the right.
How the need to create a state exchange can change health care politics
And now you can see why the requirement that the state create an exchange is so important. We health care activists may have found a way to overcome the greatest barrier to state action on health care, our inability to force the Senate leadership to bring a bill to the floor. The Senate leadership will have to bring a bill to the floor in order to create a state exchange.
And once a health care bill comes to the floor, it is open to amendment. And that means that the five or six Republicans from Democratic tending districts in SEPA, Republicans who are subject to our pressure, might be moved to vote for a Democratic amendment to the bill.
What a progressive PA exchange might have
What might it include? Well, to begin with, we will protect abortion coverage. In addition we will have a chance to create strong regulations on insurance companies.
But that is not all. We may have lost a national public option but there is no reason we can’t create a public health insurance option in Pennsylvania to compete with blues that dominate the market in Western, Northeastern and Southeastern PA here one company has 65 to 70% of the market. There are various programs the state runs that provide some kinds of insurance services. They could be expanded into a public health insurance plan that would provide an option for citizens of Pennsylvania.
And finally, there is the possibility of moving to a single payer system in Pennsylvania. I have elsewhere expressed some doubt that this is the best way to provide health care. The French and German hybrid public-private system, on the whole, seem to me to provide better results than, the Canadian single payer system. But there is no question that a single payer system has many advantages over what we have in the United States today.
Under the Senate bill, states will have the option to develop alternatives to the federal health care system starting in 2017. There is some question about whether the ERISA law stands in the way of health care reform and unfortunately a provision would overcome this problem is not found in the Senate bill. However there is some question about how big a problem the ERISA law creates and there is a line of court decisions that may overcome it.
(Chuck Pennachio has said that federal health care legislation should be defeated if it does not include a provision dealing with the ERISA problem. Given that the health care legislation did not create the problem, and that it would be so beneficial to so many millions of people, I find this very hard to understand.)
At any rate, supporters of single payer in Pennsylvania have convinced themselves that our state is closer than most to adopting single payer. I’ve been somewhat dubious about this claim, because I saw no way to overcome the barrier of the Pennsylvania Senate. Now, however, I can see a way past that problem.
We’ll have to see where we are after the 2010 election and evaluate our options. I just am writing this to point out that the need to enact a state health care exchange under the Obama health care bill might create a huge opportunity for health care reformers, one that would allow us to overcome the barrier that not only killed the Rendell health care plan but makes enacting single payer inconceivable right now, the stranglehold of the Republican leadership over floor action in the Senate.
Of course, to make this happen, we need to pass health care reform in DC now.
I’m working pretty much night and day to get health care reform enacted in Washington, DC. Health care reform is, I believe, going to pass, although it’s going to be close in the House. But I just realized what passing health care reform in Washington might mean for our efforts in Pennsylvania.
State vs Federal Exchanges
It is likely, and probably unfortunate, that the bill that passes this week will have state exchanges rather than a national exchange. A national exchange, on the whole, would be better for a number of reasons. The federal government is likely to have tougher regulations on insurance companies than state exchanges. A federal exchange will have a larger insurance pool which means that costs of health care and administrative costs will be spread over larger group of people. And the state exchanges in the Senate bill will allow individual states to opt out of providing insurance with coverage for abortion
The administration is thinking about some ways to get around these problems administratively. Under the Senate bill, if the states do not set up exchanges by January 2014, or they don’t meet standards set by the Secretary, then the federal government can create the an exchange. (On some interpretations of the Senate bill, the federal government can also include a state that doesn’t set up an adequate exchange in a regional exchange.)
So one possible way to get some of the benefit of a national exchange is for the Secretary of HHS to set the standards for the exchanges so high that states won’t be able to meet them thereby forcing the states into national or regional exchanges.
There is another way of looking at the national vs state exchange trade-off, however. It opens up the possibility of some states going creating a state exchange with higher standards then that created by the federal government.
One state in which this might be possible is, strangely enough Pennsylvania.
The Politics of Health Care in Pennsylvania
I say strangely enough because most progressive public policy is blocked in Pennsylvania by our State Senate which is controlled 30-20 by Republicans and run by an extremely conservative Senate leadership that is elected by a Republicans delegation that has moved far to the right in the last six years. And things are particularly bad when it comes to insurance since, as I discovered when I worked to enact Governor Rendell’s health care program in 2007, the insurance industry contributes so much money to Republican Senators that it is very difficult to overcome their influence in the body.
But the Senate leadership is going to be put in a strange situation by the requirement to create an exchange in Pennsylvania. They will want to avoid a federal exchange because it is likely to be tougher than the exchange they will create in Pennsylvania. But once they bring a bill for an exchange to the floor, the possibility exists of amending it to be even stronger than the federal bill.
This possibility arises because there are five or six Republican Senators from Montgomery, Delaware, and Bucks Counties that are amenable to pressure from progressive citizens and labor unions. They come from districts that have been moving in a Democratic direction. Governor Rendell, Senator Casey and President Obama all won in these districts, sometimes by large margins. Sooner or later, these districts will be held by Democrats. But, in the meantime, we can sometimes get these Senators to support progressive legislation if, that is, we can get it to the floor.
Most of the time we can’t. Perhaps as many as five or six Republican Senators would have voted for Rendell’s health care bill, as they did for the minimum wage increase a few years before, if we could have gotten it to the floor. We found a way to get the relatively moderate Senate President Jubelirer and Majority Leader Brightbill to bring the minimum wage bill to the floor. But these two leaders were defeated in Republican primaries by hard right opponents and were replaced by Senate President Scarnati and Majority Leader Pileggi, who understood both that the primary electorate for Republicans in most State Senate districts and the Senate Republican Senate Caucus itself have moved far to the right.
How the need to create a state exchange can change health care politics
And now you can see why the requirement that the state create an exchange is so important. We health care activists may have found a way to overcome the greatest barrier to state action on health care, our inability to force the Senate leadership to bring a bill to the floor. The Senate leadership will have to bring a bill to the floor in order to create a state exchange.
And once a health care bill comes to the floor, it is open to amendment. And that means that the five or six Republicans from Democratic tending districts in SEPA, Republicans who are subject to our pressure, might be moved to vote for a Democratic amendment to the bill.
What a progressive PA exchange might have
What might it include? Well, to begin with, we will protect abortion coverage. In addition we will have a chance to create strong regulations on insurance companies.
But that is not all. We may have lost a national public option but there is no reason we can’t create a public health insurance option in Pennsylvania to compete with blues that dominate the market in Western, Northeastern and Southeastern PA here one company has 65 to 70% of the market. There are various programs the state runs that provide some kinds of insurance services. They could be expanded into a public health insurance plan that would provide an option for citizens of Pennsylvania.
And finally, there is the possibility of moving to a single payer system in Pennsylvania. I have elsewhere expressed some doubt that this is the best way to provide health care. The French and German hybrid public-private system, on the whole, seem to me to provide better results than, the Canadian single payer system. But there is no question that a single payer system has many advantages over what we have in the United States today.
Under the Senate bill, states will have the option to develop alternatives to the federal health care system starting in 2017. There is some question about whether the ERISA law stands in the way of health care reform and unfortunately a provision would overcome this problem is not found in the Senate bill. However there is some question about how big a problem the ERISA law creates and there is a line of court decisions that may overcome it.
(Chuck Pennachio has said that federal health care legislation should be defeated if it does not include a provision dealing with the ERISA problem. Given that the health care legislation did not create the problem, and that it would be so beneficial to so many millions of people, I find this very hard to understand.)
At any rate, supporters of single payer in Pennsylvania have convinced themselves that our state is closer than most to adopting single payer. I’ve been somewhat dubious about this claim, because I saw no way to overcome the barrier of the Pennsylvania Senate. Now, however, I can see a way past that problem.
We’ll have to see where we are after the 2010 election and evaluate our options. I just am writing this to point out that the need to enact a state health care exchange under the Obama health care bill might create a huge opportunity for health care reformers, one that would allow us to overcome the barrier that not only killed the Rendell health care plan but makes enacting single payer inconceivable right now, the stranglehold of the Republican leadership over floor action in the Senate.
Of course, to make this happen, we need to pass health care reform in DC now.