Knotty Issues Ahead for Insurance Overhaul

A look at what still needs to be settled

By Tom Curry
|  Thursday, Oct 8, 2009  |  Updated 11:30 PM CDT
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Next week, the Senate Finance Committee will likely approve a bill designed to overhaul insurance, putting Congress another step closer to restructuring the nation's health care system.

But unresolved issues will confront senators when that panel's bill is melded with the health committee's legislation and when Senate negotiators square off with their House counterparts.

Here's a look at some of what remains to settled:

Will the final bill ditch the Senate Finance Committee’s tax on high-cost insurance plans in favor of a tax on high-income people?
The House Democrats' bill would get some of the money needed to pay for insuring the uninsured by raising taxes on people earning $350,000 or more.

This idea seems to have public support: in a Pew Research Center poll released Thursday, 58 percent of respondents favored hiking taxes on families with incomes of more than $350,000 as a way to pay for expanding health insurance.

House Speaker Nancy Pelosi said Thursday Democrats are weighing the idea of a windfall profits tax on insurance companies. She said Monday that Congress might also levy a value-added tax on goods and services, as is common in European countries.

The Finance Committee bill takes a very different approach.

It would get much of the revenue needed to pay for insuring the uninsured by imposing a new 40 percent tax on high-cost insurance plans. The target: so-called “Cadillac” plans where the cost is greater than $8,000 for individuals and $21,000 for family coverage.

The tax, according to Finance Committee Chairman Max Baucus, D-Mont., will help curb the growth in health care costs.

And for many firms and employees, Baucus argues, this tax will never take effect.

“It doesn't go into effect till 2013; a lot of people are going to adjust,” he explained last week.

“They're not going to want to pay that,” Baucus said. “Their companies are not going to want to have insurance policies that cost that much.” He argued that, “after a while, there wouldn't be any tax, because companies just would find a way to avoid it. Find some other way.”

What other way? Trim insurance plans to keep them under the taxable threshold and, instead, pay workers more in cash.

According to the Joint Committee on Taxation, by 2016, the nearly 25 million households affected by the tax will be paying, on average, $1,000 more in taxes.

But more than 150 members of the House have signed a letter urging Pelosi to reject the tax once she starts bargaining with Senate Democrats.

It “would result in an unacceptable burden on middle-class families... who have no control over the cost of their health insurance policies,” said Rep. Joe Courtney, D-Conn., who is leading the effort to block the tax.

“That’s the thing that I find so galling — this description of ‘Cadillac’ coverage — like it’s like buying a car. It’s not,” he said.

Who would be exempt from the new 40 percent tax on high-cost insurance plans?
If Baucus is able to keep his tax on high-cost insurance plans in the bill, pressure will grow to exempt some groups from it. Sen. John Kerry, D-Mass., has proposed exempting plans which unions have negotiated with companies.

How big a penalty will be imposed on those who do not buy insurance?
The Finance Committee originally would have imposed a maximum annual penalty of $3,800 per family, but that was lowered to $750 per adult.

In the House bill, non-buyers would pay a penalty equal to 2.5 percent of their income. But the penalty could not exceed the average cost of a health insurance policy in the newly created “exchange” or electronic marketplace.

If the penalties are set too low, they won’t have the intended effect: prodding healthy uninsured people to buy coverage.

Will Congress create a government-run insurance plan along the lines of Medicare?
The Finance Committee defeated two public plan proposals, but the idea could be revived on the Senate floor, or in bargaining with House negotiators.

On the Senate Finance Committee, the Democrats who voted against the public plan came from states that Republican Sen. John McCain won in last year’s presidential election: Baucus of Montana, Sen. Blanche Lincoln of Arkansas, and Sen. Kent Conrad of North Dakota.

That pattern is likely to be seen again among House Democrats.

Will proponents of the Medicare Advantage program rally to save it from the cuts proposed in the Finance Committee bill?
The Finance Committee bill would cut $117 billion from spending on the Medicare Advantage plan from 2010 to 2019.

Medicare Advantage, a program in which private-sector firms insure about 10 million people age 65 and older, has both its critics and its champions in Congress. In some states, such as Florida and Oregon, the plans have become quite popular.

The Finance Committee bill gives some protection from the proposed cuts to Medicare Advantage plans in certain parts of the country where Medicare Advantage is less costly than the traditional fee-for-service Medicare.

But more battles are likely ahead on Medicare Advantage.

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