Comments on House Health Care Reform Discussion Draft

Jul 1, 2009

June 28, 2009

To: Representative Pete Stark, Chair, House Ways and Means Subcommittee on Health
Representative Charlie Rangel, Chair, House Ways and Means Committee
Representative Henry Waxman, Chair, House Committee on Energy and Commerce
Representative George Miller, Chair, House Committee on Education and Labor

From: Ruth Flower, Legislative Director
Friends Committee on National Legislation

Re: Comments on House Tri-Committee Health Reform Discussion Draft

Thank you for proposing a plan that is likely to meet the major criteria we have been advocating – a plan that will make high quality health care available and affordable for everyone. We offer these preliminary comments on the discussion draft; we plan to submit a full statement for the written record of the Ways and Means hearing.

1. The public plan is the linchpin of this proposal. It sets the standards and regulates the private market through competition. It is essential that this plan succeed early on. Therefore we strongly recommend that the public plan be offered to large employers from the very beginning, to ensure that


• Participants will represent a wide demographic of health care needs and will not be weighted toward those with greater needs and fewer resources


• The plan will begin operating with a strong financial base


• The per-participant cost of administering the plan would be low, relative to a plan that includes only individuals and small employers


• Health care providers will have a built-in incentive to participate in the plan.

While it is true that the federal government lacks experience with this particular type of program, it has decades of experience on which to build (VA, Medicare, Medicaid) and can observe and borrow from the experiences of privately run plans. The public plan has to succeed, and will succeed, if given a strong beginning.


2. We appreciate the attention given to preventive care and suggest that the concept be broadened to include evidence-based wellness programs that include education and nutrition support in combination with disease-management programs. According to the Milliken Institute, the combined cost of the top seven modifiable chronic diseases (cancer, diabetes, hypertension, stroke, heart disease, pulmonary conditions and mental disorders) exceeds $270 billion per year in direct care costs. A modest focus on prevention, early intervention and behavior changes can save about 80 percent of that cost annually.



3. Similarly, near the end of life, we suggest that surgical and medical intervention is not always the best choice for patients and their families. We recommend that advanced terminal patients and their families be given adequate medical information and support to enable them to consider a full range of choices, including hospice care.



4. We appreciate the wisdom of including all legal residents in the reach of this proposal. From a public health perspective, it makes sense to ensure that health care is available to everyone in our communities. Eventually, the U.S. may be able to catch up with other Western nations in offering health care even to non-immigrants who are lawfully in this country. We are concerned about the implementation of this provision in those states that have varying policies with respect to immigrant inclusion in Medicaid and SCHIP. Since immigration law is federal law, we encourage the committees to ensure that this provision applies across all states.



5. Mandatory coverage is both necessary and problematic. It is necessary because the overall health care plan will not reduce health spending and improve the health of the population unless everyone participates. It is problematic because those who don’t want to pay – both individuals and employers – don’t want to pay. The “pay or play” fines on both employers and employees are awkward and will be difficult to enforce. We propose instead a structure of truly minimal and truly universal coverage to supplement the proposals in the draft. In this structure, every person with a Social Security number is covered for preventive services that are a matter of public health, such as vaccinations, and for catastrophic care necessitated by events such as auto accidents, crime, or other tragedies. Any person can go to any hospital (or clinic) and be covered for these truly minimal services.

The cost of this truly minimal mandatory plan becomes part of every person’s tax bill. The taxpayer can obtain a credit equal to the tax by showing evidence of enrollment in a plan that meets the health exchange standards, including Medicare and Medicaid.

This relatively simple and elegant solution accomplishes three things simultaneously:

• It distributes the cost of the most expensive kind of emergency room care


• It provides a monetary incentive for enrolling in a health care plan, and reduces the threshold of that expense for individuals whose employers do not provide health care.


• It draws private health care plans toward the health exchange model, because individuals purchasing a more minimal private plan will not qualify for the credit.

Thank you again for all your work on this comprehensive proposal.