COLUMBIA — House Speaker Nancy Pelosi is urging a vote on her health care bill Saturday in the hopes of forcing to a conclusion a debate that's been raging for most of the year.
After a summer of heated town hall meetings on health care reform, Missouri senators and representatives have spent the fall debating and working on various bills in the Capitol. Bills in the House and Senate have been torn apart and reassembled.
Here's a breakdown of some of the key issues and where Missouri senators and representatives stand on pieces of health care reform.
What's on the table: Originally, White House officials said they wanted a single-payer system, but they drew heavy backlash and abandoned that plan. Since then, a public option has been heavily debated and is included in the House version of the bill, which envisions a government-run option providing different levels of benefits. The House bill would also create a health exchange marketplace to compete with private insurance companies, as well as approve loans to help states start up health cooperatives. The Senate Finance Committee's bill does not include a public option. Instead, it creates private, nonprofit insurance cooperatives that would be run by consumers at the state level. The government would provide $6 billion to the states by 2012 to help create the co-ops.
- Sen. Kit Bond, R-Mo.: Supports changes to insurance-company practices that leave people without insurance, or unable to afford it. Opposes a public option.
- Sen. Claire McCaskill, D-Mo.: In favor of a limited public option, which she said could provide the competition necessary to bring down private health insurance rates. She's also open to an insurance exchange. "Providing easy-to-compare options for consumers that clearly detail what coverage you are buying for what price is important in order to inject competition in the marketplace and bring the overall costs down."
- Rep. Blaine Luetkemeyer, R-Mo.: Would like insurance companies to expand coverage to people who are uninsured, include those with pre-existing conditions. He says any government-run insurance exchange would create unfair competition with the private market.
- Rep. Roy Blunt, R-Mo.: Supports specific reforms that will "keep what works and fix what's broken," but he opposes a major overhaul. Believes any public plan would be a step toward a single-payer system. He said that a "health plan finder"— a kind of exchange — would make insurance information more accessible but that current proposals could restrict choices for patients.
- Rep. Russ Carnahan, D-Mo.: Supports a public option or an insurance exchange to compete with private insurers. He believes insurance exchanges could help increase competition and choice.
How people might be affected: The House bill would provide tax credits to people with a family income below 400 percent of the federal poverty line. The Senate Finance bill would, starting in 2013, make tax credits available on a sliding-scale basis for people and families who make between 134 and 400 percent of the federal poverty line. All of the bills on the table include an individual mandate, but the penalties and exemptions differ. The House version would impose a larger fine (2.5 percent of adjusted gross income) and exempt fewer people (those who cannot afford it or those who have religious objections). The Senate Finance bill would exempt Native Americans, people with religious objections, people who cannot afford insurance and people who pay more than 8 percent of their income for the lowest-priced available plan. The committee's bill would phase in an excise tax on people who do not purchase health insurance: $200 in 2014; $400 in 2015; $600 in 2016; and $750 from 2017 forward.
- Sen. Kit Bond, R-Mo.: In favor of lowering the costs for people who buy health insurance on their own so they receive the same tax benefits as those who get insurance through their employers. He did not comment on whether people should be required to buy insurance.
- Sen. Claire McCaskill, D-Mo.: Said that although the "ultimate goal" is to insure everyone, it's important to provide flexible options. Might be in favor of a sliding scale of subsidies based on ability to pay, while continuing to make Medicare and Medicaid available to qualified families.
- Rep. Blaine Luetkemeyer, R-Mo.: Does not support taxes or fines for people who either can't afford insurance or don't want “bureaucrat-approved” plans. Supports enhancing tax credits and benefits for people who cannot afford insurance, and said they should be allowed to pay for insurance with pre-tax dollars.
- Rep. Roy Blunt, R-Mo.: Is against all individual mandates but would support subsidies for low-income individuals.
- Rep. Russ Carnahan, D-Mo.: Believes it would make sense to "incentivize" coverage. Supports a sliding scale of individual affordability credits for those who can't afford insurance.
How businesses might be affected: According to a study by the Commonwealth Fund, only 25 percent of small-business employees had health insurance through their employer in 2007. Both the House and Senate bills would give tax credits to employers with no more than 25 full-time employees with an average annual income of $40,000. The tax credits could motivate employers to contribute to their workers' health insurance, but some people have proposed mandating employer contributions or having them pay a fine. The House bill would require employers to pay 72.5 percent of their employees' premiums or make a contribution to a fund that would help expand health coverage among the uninsured. If the coverage an employer offers is unaffordable for low-wage workers, they could choose subsidized coverage in a health exchange and the employer would make a contribution to the exchange. The Senate bill doesn't specifically require employers to provide coverage, but those with 50 or more employees would have to reimburse the government for subsidies provided. Employers with more than 200 workers would have to enroll them in a work-provided health plan, but an opt-out clause is included.
- Sen. Kit Bond, R-Mo.: Supports tax credits for small businesses so they can afford health insurance for their employees, but he opposes legislation that would require owners to cover their employees or pay a fine. "An employer mandate will hurt small businesses, kill jobs, and force employers to lower wages and drop their insurance altogether."
- Sen. Claire McCaskill, D-Mo.: Supports tax credits for businesses but wouldn't say whether she supports penalties against employers who do not cover their workers. "It’s also vital to offer exemptions to small businesses that want to provide coverage but continue to struggle with their bottom line in this economy."
- Rep. Blaine Luetkemeyer, R-Mo.: Supports small-business health plans to allow small businesses to join together and increase their purchasing power. Would not support mandating employer contributions because of his concern over the "low thresholds for penalties triggered."
- Rep. Roy Blunt, R-Mo.: Is in favor of tax credits for businesses but opposes any mandate for employer contributions.
- Rep. Russ Carnahan, D-Mo.: Said tax credits for businesses will help reduce the cost of insurance for employers. Supports mandated employer contributions, but he said tax credits of up to 50 percent and exempting that "vast majority" of small businesses (with payrolls $500,000 and below) would keep everything affordable. "Employers should have a role in providing their employees with sound health insurance."
How it will be funded: The Congressional Budget Office estimates that the Senate Finance bill would cost $829 billion and estimates the House bill would cost as much as $1.055 trillion. The legislation proposes two primary sources of funding: raising revenue through new taxes and fees and decreasing "wasteful" spending in Medicare and medical malpractice lawsuits. The House bill would create an income surtax for the wealthiest 1.2 percent of households and cut about $400 billion from Medicare over 10 years. The Senate Finance version would be funded by $13 billion in new fees and taxes on insurance companies that charge more than $8,000 for individual plans and $21,000 for family plans. The bill would also aim to cut spending on Medicare by linking payments to the hospitals' quality of performance. Another proposal to reduce spending is through tort reform, also known as medical malpractice reform. The idea is to cut back on legal claims injured people can make against medical providers as a way to reduce malpractice insurance premiums. Although some say this could help bring down health care costs, the Congressional Budget Office has estimated it would reduce national health care expenditures by only 0.2 percent.
- Sen. Kit Bond, R-Mo.: Supports cracking down on fraud and wasteful spending in Medicare, as well as reforming medical malpractice lawsuits so doctors "can stop practicing defensive medicine," as ways to cut costs and pay for insurance reform. Did not comment on increasing taxes to wealthy households.
- Sen. Claire McCaskill, D-Mo.: Believes tort reform should be decided at the state level. Supports increased taxes on wealthy households and cutting wasteful spending in Medicare. "The savings would not only go toward paying for health insurance reform but would bring down what we’re currently spending on programs like Medicare."
- Rep. Blaine Luetkemeyer, R-Mo.: Does not support increased taxes on high-income people because it might penalize thousands of small businesses that file as individuals. Said Medicare cuts could be "harmful and arbitrary." He supports tort reform: "We must also act to prevent abusive lawsuits from driving up the cost of care and driving doctors out of business."
- Rep. Roy Blunt, R-Mo.: He is against all tax increases but supports tort reform. Said the efficiency of Medicare must be improved, but cuts must be made in a "fiscally responsible manner that will not reduce current benefits for seniors."
- Rep. Russ Carnahan, D-Mo.: Believes the best way to pay for health care is by taxing the wealthiest 1.2 percent of Americans. Is against cutting Medicare costs because he believes reforming the system will make Medicare more efficient. He also said tort reform would do little to cut costs or make insurance more affordable.