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The House's better health-reform option

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Wednesday, November 4, 2009

The health-care reform bills emerging from the House and Senate, when melded and enacted, will constitute an epochal achievement: the near-universal provision of medical care to the American people. But the House version is clearly the more epochal, as the health coverage it provides is more universal, chiefly because it's more affordable.

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For families who buy their insurance on the exchanges that both bills establish, for instance, the House bill includes more generous subsidies -- on average, $1,000 more, according to the Congressional Budget Office. The House bill also offers a lot more assistance to Medicare recipients by reducing the cost of their prescriptions. While the bill that emerged from the Senate Finance Committee renews the Bush administration's mega-bucks gift to the drug companies by continuing to prohibit Medicare from negotiating drug prices with them, the House bill authorizes those negotiations. The Senate bill reduces by half the payments that Medicare recipients must make for prescription drugs that fall into the "doughnut hole" (annual drug expenses are covered up to $2,700, and coverage kicks in again at $6,100, but for all purchases in between, Medicarians are on their own). The House bill would cover all prescription purchases by 2019.

The House bill is not only better public policy than the Senate's, it is also better Democratic politics. Seniors always constitute a disproportionate share of midterm electorates, and Democrats concerned about next year's congressional contests would do themselves a major favor by passing a bill that reduced the costs of seniors' medications. Max Baucus and Rahm Emanuel may have cut a deal with the pharmaceutical industry that limits the cost-cutting the industry will undertake (in return for the greater profits it will gain by having more insured Americans to whom it can sell drugs), but no one in the House ever signed on to it. When the two bills go to conference, the conferees should note that the House version not only bends the nation's cost curve downward but tilts the Democrats' electoral prospects curve upward.

But there's one particular in which the Senate version might be better. If the House provides better coverage to seniors, the Senate version, thanks to an amendment from West Virginia's Jay Rockefeller, provides better coverage to children. Rockefeller's amendment keeps the Children's Health Insurance Program, which provides medical coverage to otherwise uninsured children from poor families, intact. The House bill eliminates CHIP, instead expanding the number of children covered by Medicaid, which is a positive step. But children currently on CHIP whose families won't qualify for Medicaid and who will have to buy their insurance on the exchanges will get less coverage than they currently do, though the cost to taxpayers will be higher.

Unlike seniors, of course, children -- most particularly, children of non-affluent parents -- have no clout whatsoever in the political process. That's why 8.1 million of them go without insurance today, even though insuring children is cheaper than insuring any other age group, not to mention the surest investment the nation could make in its future. (We know a lot more about how to keep children healthy than we do, for instance, about how to improve our schools. For that matter, as education writers such as Richard Rothstein have pointed out, one proven way to better educational performance is to improve children's access to health care.)

Marian Wright Edelman of the Children's Defense Fund not only prefers the Rockefeller version to the one before the House but would further like to plug the holes in CHIP that make children's eligibility for the program subject to a crazy quilt of various state regulations and cut-off points. In 22 states, children in families with incomes beneath 300 percent of the poverty line are enrolled in CHIP; in other states, the cut-off is lower, and proportionally more children are uninsured. "We need to end the unjust lottery of geography," Edelman says. The 10-year cost of insuring all children whose families make less than 300 percent of poverty, according to the Lewin Group, which scored the proposal for the Children's Defense Fund, would be $110 billion. That's a real cost, to be sure, but also an investment with very real dividends, and an assumption of moral responsibility that should make it easier for us to look at ourselves in the mirror.

meyersonh@washpost.com



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