Hot + cold = lukewarm

I was talking with a friend last night who reads the blog, and he asked, "So, are you guys for or against the health care plan?" And others have called our reaction to the House plan "lukewarm." Well, there are good things and bad things about the two plans in the legislature now (Sal vs. Trav); here's my quick and dirty take on the components, using the Globe's comparison chart as a template. (The Globe's summary language is in italics.)

The House:

• "Cover 95 percent of the uninsured within three years." Obviously that's good. Not complete, but good.
• "Individuals must buy health insurance if they can afford it, or face a financial penalty." Problematic, to say the least. Who's to say who can afford what? The House plan does soften the blow by subsidizing lower income folks to buy insurance, but it's probably high-deductible "semi-insurance". Not so great.
• "Employers with more than 10 workers must provide coverage or face a payroll tax." Well, you've got to have a cutoff somewhere, and it'll be arbitrary no matter what, but it makes the marginal cost for adding that 11th worker pretty darn steep. Could use some tinkering.
• "About $600 million from payroll taxes and the state's settlement with tobacco companies would pay for Medicaid expansion and subsidize purchases of private insurance." Fine -- the Medicaid expansion is the best part. Big Government is frankly our friend in health insurance. If you're a single-payer fan, that simply has to be the biggest step forward.
• "The state would seek to enroll those currently eligible for Medicaid who have yet to sign up for it. But the House also would raise income limits for Medicaid eligibility, allowing an additional 205,000 people to enroll." See above. This is the best and most critical part.
• "A stripped-down private insurance plan would be offered to eligible residents for less than $200 a month; the plans may have high deductibles." Argh... can you say perverse incentives? Yes, I grudgingly accept that it's better for people to be covered for expensive cases, but in health care, the first dollar is the best dollar. You want people to spend the first dollar so they don't end up needing expensive care. (Smacks forehead.)
• "Supporters call the House plan the most ambitious of the proposals, with new government spending and new requirements on businesses. They say it would encourage employers to provide insurance and reward those that already do." Yes -- a little employer arm-twisting is frankly necessary. If employers don't want to give their workers insurance, then they can get out of the van and start pushing for single-payer. As I've said before, "Neither" is not an option. Sorry.
• "Business groups fear that the plan, because of the payroll tax, would make the state less economically competitive. Romney could veto a final bill if it contains the tax." Well, it would make our workforce healthier and more productive in the long run; take some burden off of companies that do offer insurance; and yes, put a burden on those who don't. Come on -- the correction of incentives is definitely an improvement on the status quo. We've done pretty well in this state by investing in education and other social goods; it's time to look for long-term advantages in public health.

So really, I'm very warm to certain things and very cool to others.

The Senate plan:

• "Cover half the state's uninsured in two years." Uh... hello?
• "Companies that have at least 50 employees and do not provide health insurance would be forced to reimburse the state when employees seek treatment from 'free care pool.'" Fine, but that's not the same as having insurance, i.e. first dollar (therefore preventative) coverage. Inferior to the House proposal.
• "The Senate would not require individuals to carry health insurance." Less controversial, and yet probably more costly to the already-insured taxpayer than the House mandate. Go figure.
• "The Senate plan would push to enroll 70,000 residents eligible for MassHealth who haven't signed up." Inferior to the House plan. Eligibility should be expanded.
• "The plan would also increase Medicaid rates to hospitals and doctors who treat them." Obviously important to hospitals -- I'm not well versed on this end.
• "It encourages insurers to offer low-cost, scaled-back health plans to the self-employed, small businesses, and individuals who don't qualify for Medicaid but cannot afford traditional insurance. It would be up to insurance companies to develop the plans." See my "first dollar" rant above. The insurance companies haven't come out with any such plans, so for now this is wishful thinking.
• "The Senate plan doesn't aim to cover everyone immediately, so it is considered more realistic and less heavy-handed. It has fewer requirements for employers and doesn't require individuals to buy insurance." What's this bill supposed to do again?
• "Critics worry that the Senate bill doesn't fully solve the problem of the uninsured." Ya think?

I'm also wondering what happened to the re-insurance part of Travaglini's original plan, which would make the state share costs for medical expenses above a certain level. The MassACT ballot initiative contains such a provision. A similar arrangement has lowered premiums in New York State across the board.

Health Care for All has more on the Senate bill. Ughhhhhhhhhhh...