Patient CARE Act Posts

On Monday, January 27, 2014 Republican Senators Richard Burr (N.C.), Tom Coburn (OK) and Orrin Hatch (UT) released a fairly detailed outline of a new health reform plan: (The Patient Choice, Affordability, Responsibility, and Empowerment Act, or PCARE). I will aggregate my posts on this proposal in this post:

Senators Burr and Coburn (and Rep Paul Ryan and Devin Nunes) introduced the Patients’ Choice Act in May, 2009. Here are several links to that proposal (that differs in important ways from the most recent proposal)

In February, 2012 Senators Burr and Coburn introduced the Seniors Choice Act, that focuses on Medicare. The most recent proposal does not mention Medicare, nor SCA

Biggest block to a health policy deal

Maybe there is a short term CR/debt limit lift to allow time for a broader budget negotiation deal in the works, as the Republican defund-Obamacare-or-delay-key-parts-of-it in return for reopening the government argument appears to have disappeared. Paul Ryan has an op-ed that doesn’t even mention Obamacare–the original reason given for the shut down–but that lists some familiar items if you have followed the various grand bargain discussions: alter the deductible structure in parts A and B of Medicare, more means testing of the program and the like. Some reasonable policy in there, but what is still missing is a coherent Republican approach to health reform, defined as the answer to what to do about the uninsured, and how to address that while also seeking to improve quality and address costs throughout the system.

Ryan’s op-ed also doesn’t mention his own health reform plan the Patients’ Choice Act, introduced in May 2009, but not refined since. I remain puzzled that House Republicans never managed to muster an actual alternative that was carried through legislatively (pass it out of committee, CBO score, etc.) to something they claim to hate so much. And it is very hard to have a negotiation between an actual law–worts and all–and general platitudes, but no legislative details.

Title II of the Patients’ Choice Act has a general outline of issues like how to define benefits, how to enroll patients sans an individual mandate (via the use of soft mandates, or auto-enroll procedures), and at least acknowledges issues like insurance reform (though I believe ending pre-existing conditions inside state based exchanges only but allowing tax credits to flow inside and outside of exchanges, which is what the text calls for, is a fatal flaw). It is overly vague in other areas (about premiums it says exchanges shall develop methods to prevent the “imposition of excessive premiums” with no clarity as to how). It would have been hard for the Republican party to have marked up the Patients’ Choice Act, because the details are truly difficult.

It is a shame they never got around to this, as it would make a reasonable deal on health reform much more likely. Imagine if the Patients’ Choice Act had managed to outline a list of aggressive auto-enroll procedures for health coverage in exchanges that were similar in risk pooling terms to the weak individual mandate. The mandate that no one likes could be replaced, giving them political credit for a change, and letting us move ahead to implementation in a reasonable manner. The thing our country most needs for long range budget issues is to develop a way ahead on health reform that is the responsibility of both political parties, that we will actually try. What most prevents that is one side of the negotiation still being unclear about how they would address the biggest public policy dilemma of our time.

Title VIII of Ryan’s Patients’ Choice Act

I have written lots about what I consider to be the hypocrisy of Rep. Paul Ryan for criticizing the IPAB given what is proposed in title VIII of the Patients’ Choice Act (two expert boards) that he introduced along with co-sponors Devin Nunes in the House and Sens. Burr and Coburn on May 20, 2009. This post outlines the argument, and looks closely at selected portions of the text, this one elaborates on the topic given a repeal-of-IPAB-hearing held during the Summer of 2011, and this one follows up by discussing a response from Rep. Ryan’s spokesperson to my criticisms.

Keep in mind that I praised the board contained in the Republican bill in this July 24 2009 newspaper column, and said that such a board based loosely on the base closing commission could represent a bipartisan way ahead to address costs! (silly me).

Here is a link to the full text of the Patients’ Choice Act, and below I reproduce the entirety of title VIII, subtitles A, B and C, so that you can read the text for yourself.


Subtitle A–Establishment and General Duties

Read more of this post

Sen. Coburn: for unelected health boards before he was against them

Ezra Klein has an interview with Senator Tom Coburn that focuses on health care reform. Lots could be said about the interview, but I want to focus on what I see as the hypocrisy displayed by Sen. Coburn in his criticism of the Independent Payment Advisory Board (IPAB) that will be created if the Affordable Care Act is implemented. In the interview with Klein, Sen. Coburn says:

The reason I object to IPAB is you’ve got someone between the patient and the physician, and that can never be in the best interest of the patient.

The most shocking thing to me about Sen. Coburn’s consistent demonization of IPAB as a “rationing board”  is the fact that a bill (Patients’ Choice Act) that he co-sponsored and introduced on May 20, 2009 contained two unelected boards (IPAB is also quite weak; another post). That means that key Republicans supported unelected health boards a full month before the first House committee reported out HR3200. I have written tons on this issue specifically, and about Sen. Coburn’s Patients’ Choice Act generally (here, herehere, herehere, here, here, here), including some favorable things. I guess I am just naive, but this level of hypocrisy still shocks me.

Below is a post I wrote in May 2011 that focused on Rep. Paul Ryan, another co-sponsor of the PCA; just insert Sen. Coburn’s name as you read; they have behaved similarly on this issue.

Read more of this post

Me on TV talking health reform/supreme court

Here is an ~ 8 minute interview with me discussing the big picture policy context of the Supreme Court case (being interviewed by Tim Boyum of NewsChannel 14). Here are some links to the Republican Patients’ Choice Act law I noted (introduced by Sens. Burr and Coburn and Reps. Ryan and Nunes on May 20, 2009):

More on do Republicans have a replace plan?

John Goodman pushes back against arguments that Republicans don’t have a health reform replace plan as I wrote yesterday (Ezra Klein similarly, and Kevin Drum glancing off of Klein).

It is easy to write a paper in Health Affairs, a white paper, or even a draft bill that you never take into a committee to mark up and have scored (like the Patients’ Choice Act, that has been around since May, 2009). It is hard to invest political capital in pushing such a bill through the committee structure of both house of Congress and then passing it in both and getting the President to sign it. There is no historical example of Republicans driving any sort of comprehensive health reform (I would define that as something that addressed coverage expansion and addressed cost and quality). It may well be that in the future this will change, but by default we only know what Republicans are against (whatever Dems are pushing), and at some point they will have to decide what they are for and take action to implement it. Or not.

The tax rates that most Republicans claim to desire long term have no chance of producing anything near a sustainable budget without profound health reform. And health reform will require 218 votes in the House, 60 in the Senate and 1 in the White House; without this, they cannot achieve their ultimate goal. Are they the last to realize this?

IPAB repeal effort heating up again

Efforts to repeal the IPAB are heating up again in both the House and Senate (overview from KHN; link to a gated Politico Pro story this morning). I reproduce below a post from last Summer that provides a series of links on the recent history of the idea of boards to improve quality and/or address costs (shorter: boards have experts and they do good things if you appoint them; they are bureaucrats and do bad things if your opponents appoint them).

update: Energy & Commerce health subcommittee voted 17-5 to repeal IPAB (two Democrats joined all Repbulicans in voting for repeal).


I am pulling together several related posts that I have done suggesting that the Independent Payment Advisory Board (IPAB) is similar to two boards proposed in Title VIII of the Patients’ Choice Act (PCA), the most comprehensive Republican health reform plan offered in the 111th Congress. That doesn’t mean they are exactly the same, but does mean that some of the criticism levelled against IPAB by Republican critics is either uninformed about the advocacy for such boards by leading Republicans in the past, or seems hypocritical to me. It is also possible that Republicans have simply changed their mind, but then I would expect them to say that, and to lay out why they recently supported such boards, but no longer do so.

Both the PCA and the ACA proposed boards that were insulated in some manner from Congress to make health policy decisions. In this way, IPAB is a prime example of a policy idea that ended up in the Affordable Care Act (ACA) that had its genesis in a Republican sponsored bill, or line of policy thought. It is an example of something that appeared to be bipartisan in policy terms (the need for boards insulated from Congress) that became politically toxic once it appeared in the ACA.

Here are the posts I have written on the topic.

  • General argument that IPAB is similar to the boards suggested in the PCA, from May, 2011.
  • Responding to unelected bureaucrats/unconstitutional charges by showing that boards proposed in PCA were similar in structure, Monday July 11.
  • Focus on what IPAB could do in policy terms as compared to what boards in PCA were proposed to be able to do, Tuesday July 12.
  • Reaction from House Budget Committee spokesman to my blogging, and my response, Tuesday July 12.
  • ThinkProgress did a nice table comparing IPAB to boards in the PCA, Wednesday July 13.

Other relevant information.

  • Text of the Patients’ Choice Act, Title VIII p. 206-215 are the portions relevant to this discussion. Introduced on May 20, 2009 and co-sponsored by Ryan and Nunes in House; Burr and Coburn in Senate.
  • Text of the ACA, sec. 3403 p. 982-1,033 lays out the IPAB
  • Kaiser has a comprehensive overview of the IPAB
  • Column I wrote on July 24, 2009 in the Raleigh, N.C. News and Observer on the Patients’ Choice Act

Note: as stated in several posts, there are some Democrats who oppose IPAB as well.

One more thing on Seniors’ Choice Act

Even if we managed to get the details straight for Sens. Burr and Coburn’s proposal to move toward a competitive bidding/premium support approach in Medicare (my early take, Austin’s thoughts; more this morning on premium support), it is impossible to fully evaluate their proposal without knowing what they plan to do about the ACA. Their latest proposal assumes implementation of the ACA, but they continue to call for its repeal and presumably, replacement. And of course the Seniors’ Choice Act would increase the eligibility age for Medicare, making the question of access to health insurance for the near elderly even more important.

Sens. Burr and Coburn co-sponsored a proposal to address coverage for younger persons in the last Congress (The Patients’ Choice Act), but it has never been scored by the CBO. Presumably, that could change, and it would be a useful step. You cannot fully evaluate the Seniors’ Choice Act without knowing the health insurance plan for the under-65 age group that would operate along side it.


More on Butler and the individual mandate

Kenneth Thomas has a nice post on Stuart Butler’s change of heart on the individual mandate. I think he and Aaron think I was too easy on Butler, and Ezra Klein likely concurs, especially given the timing of Butler’s switch.

One point from Butler’s USA Today piece that I want to highlight and comment on:

So why the change in this position in the past 20 years?

First, health research and advances in economic analysis have convinced people like me that an insurance mandate isn’t needed to achieve stable, near-universal coverage. For example, the new field of behavioral economics taught me that default auto-enrollment in employer or non-employer insurance plans can lead many people to buy coverage without a requirement. [emphasis mine]

The thing I most hold against Butler and many other conservatives is the degree and vociferousness of their opposition to the ACA given their past positions. A reasonable, policy based opposition might have gone something like “I used to support the individual mandate, but no longer think it is the best approach. Instead of an individual mandate, we should use auto-enroll procedures to attain the needed risk pooling. The CBO should estimate how different the individual mandate is from aggressive auto enroll procedures.”

Instead, the individual mandate was painted as an unimaginable affront to the Republic, etc. etc. and this had the effect of moving us away from the policy.

Interestingly, the first comprehensive reform bill introduced into the 111th Congress (on May 20, 2009, about a month before the first version of HR 3200 was reported out of any House committee) was the Republican sponsored Patients’ Choice Act (PCA), that had at its heart the use of auto-enroll procedures to achieve risk pooling.

It was introduced by Reps. Paul Ryan and Devin Nunes, and Sens. Tom Coburn and Richard Burr. This plan proposed altering the tax treatment of employer paid insurance, providing individuals with money to defray the cost of buying private insurance in state based exchanges, and advocated auto-enroll procedures such as signing persons up by default when they renewed their drivers license or paid state income taxes. There are some big problems with this bill, however, there are similarities with the ACA that suggest that a deal could be possible in policy terms.

The PCA has never been scored by CBO. I have written that I would like to know how different auto enroll procedures would be from the weak individual mandate contained in the ACA, in terms of insurance expansions.

Given that Stuart Butler has included his interest in auto-enroll procedures as a reason for no longer supporting an individual mandate, I would love for him to join me in calling for the sponsors of the Patients’ Choice Act (one of them is my senior Senator) to provide the details necessary for the CBO to score their bill. This would provide us with some sense of the relative effect of auto enroll procedures vs. an individual mandate in expanding insurance coverage. Who knows, we might accidentally stumble upon a compromise.


Patients’ Choice Act-Title II State Based Exchanges

The Patients’ Choice Act (PCA) represents Rep. Paul Ryan’s vision for what “replace” would look like for two-thirds of all Americans (160 Million now privately insured, and 50 million uninsured) if the Affordable Care Act were repealed. I am going to write a series of posts on the various Titles, or sections, of the bill. Past posts on the PCA:

This post looks at Title II of the PCA-State-Based Health Care Exchanges (pp. 18-26).

  • Sec 202 (b) (p. 20). Benefit Parity with Members of Congress. This section does not guarantee that all Americans will get the same type of health insurance enjoyed by members of Congress, at least not at the same price. I read the text as saying that states cannot mandate different benefit levels than those enjoyed by Congress, however, there is no limit to the premium or cost sharing that can be charged for these benefits (see Sec 202 (a)(4) p. 20). Further, the amount of the tax credit provided by the PCA ($5,710 for family coverage; $2,290 for individual, p. 28) is far below the cost of a typical private insurance policy, much less what is provided to members of Congress. The federal employees health plan provides a guaranteed percentage of the premium cost for plans regardless of what they cost, which the PCA does not do. In fact, the meta point of the PCA is to move away from a guaranteed amount of insurance coverage in favor of a defined federal contribution.
  • Sec 202 (c)(1) (p.21). Automatic enrollment procedures that are designed to get persons covered by health insurance are envisioned, and the phrase “universal” is invoked on line 1 of p. 21 even if some supporters are leery of such lingo. Settings/mechanisms for auto enrollment into health insurance mentioned include ERs, submission of state tax forms, workplaces, and state dept of motor vehicles offices, such as when people renew their drivers license. This subsection lays out other procedures designed to aid in enrollment, such as having open enrollment periods and specifies that all individuals can sign up for a plan so long as they agree to pay the premiums and cost share amounts. Sec 202 (c)(5) allows individuals to opt-out of health insurance.
  • Sec 202 (c)(4)(p. 22). Limitations of Pre-Existing Condition Exclusions. This section reads in full “The State Exchange shall ensure that health insurance coverage offered through the Exchange meets the requirements of section 9801 of the Internal Revenue Code of 1986 in the same manner as if such coverage was a group plan.” This places limits on pre-existing conditions, but does not ban them for policies sold in exchanges (exclusions limited to 6 months prior to enrollment to 12 months after).
  • Sec 202 (d)(1- 2)(p.22-25). Limitation on Exorbitant Premiums. Exchanges are directed to develop ways of protecting enrollees from “imposition of excessive premiums” and potential mechanisms include risk adjustment by a state-based board, high risk pools, reinsurance and interstate compacts. To fully evaluate these proposals requires far greater detail, like what would be expected if the relevant House committees marked up the PCA which must happen for this to ever become law. Then CBO could weigh in.

The PCA is a serious proposal that remains incomplete; many details are needed to make a full comparison with the Affordable Care Act possible. Reflecting on Title II, my biggest question is:

  • how different would aggressive auto enroll procedures be from the relatively weak penalty for not being insured contained in the Affordable Care Act in terms of insurance coverage attained? I sure would like to know what the CBO thought.