The Shriver Brief : Poverty Law Commentary & Insights : Sargent Shriver National Center on Poverty Law : Affordable Housing, Healthcare Reform

Co-Authored by Carrie Gilbert

[This is the sixth in a series of six articles summarizing the leading categories of issues at stake in the final stages -- the homestretch -- of the debate on national health insurance and health care reform.]

Last week the Senate released their combined bill which has been sent to the floor for debate. Many of the basic principles of the Senate and House bills are similar; however there are still major differences, including the method for paying for reform. For our final installment in our homestretch series we will compare these two proposals on how they will pay for reform and their impact on the budget deficit. 

Covering millions of previously uninsured Americans obviously has an upfront cost; however given the current state of our broken health insurance system, the proposed reforms will actually reduce the deficit. Both bills have received deficit neutral scores from the Congressional Budget Office (CBO), despite having different methods for reducing the budget.

The House bill, called the Affordable Health Care for America Act or HR 3962, proposes a combination of mandate penalties, reforms to Medicare and Medicaid and a tax on wealthy individuals to raise revenue to pay for reform.   The House bill is projected to save $426 billion over ten years by reforming Medicare and Medicaid. The federal government currently pays about $1,100 more per person to cover the same beneficiaries through Medicare Advantage, private Medicare plans, than through traditional Medicare. HR 3962 will reduce overpayments to Medicare Advantage plans.   Overall, the bill attempts to reduce fraud and waste in both the Medicaid and Medicare systems. 

In addition to extensive reforms to Medicare and Medicaid, H.R. 3962 includes a 5.4% surcharge on couples with incomes over $1 million, which would affect less than 1% of taxpayers, and amount to a moderate tax burden for these households. Some people fear that this new tax would harm small businesses that file taxes as individuals. However, the Tax Policy Center calculates that just 1.6% of taxpayers in this group would face the surcharge, and that many in this group are actually wealthy investors and not true small business owners. Ultimately, only 0.6% of taxpayers who derive more than half of their income from business sources would face this surcharge. 

The newly released Senate bill, The Patient Protection and Affordable Care Act or HR 3590, may slow the growth of health care costs over time by, for instance, imposing an excise tax on high-cost health insurance plans, decreasing overpayments that private insurers receive through Medicare Advantage, and reducing the cost of prescription drugs in Medicaid.   The new tax on high-priced health insurance policies (or Cadillac plans with yearly premiums of $8,500 for individuals and $23,000 for families) applies to self-insured plans and plans sold in the group market, and not to plans sold in the individual market (except for coverage eligible for the deduction for self-employed individuals). HR 3590 would also increase the Medicare payroll tax from 1.45 to 1.95% on individuals earning $200,000 per year and couples earning $250,000 per year. Both of these new taxes will yield considerable revenue.   

HR 3590 imposes many fees to pay for the bill, including on pharmaceutical manufacturers, medical device manufacturers and the health insurance sector. Many of these fees do not apply to companies whose sales are below $5 million and the fees are allocated across the industry based on market share. Moreover, HR 3590 mandates that non-profit Blue Cross Blue Shield (BCBS) organizations have a medical loss ratio of 85% or higher to receive the special tax benefits provided to them. This means that they have to spend at least 85% of profits on their beneficiaries’ medical care. 

Ultimately, the House bill will reduce deficits by $109 billion over the next ten years. The Senate bill will reduce deficits by $130 billion over the next ten years, and by about one-quarter of one percent of GDP in the decade thereafter, which amounts to about $55 billion in 2020 and several hundred billion dollars over the 2020-2029 period. The bill finances its expanded health coverage by redirecting existing spending and tax subsidies from less productive uses elsewhere in the health sector. Therefore, the Center for Budget and Policy Priorities’  and CBO report that the Senate Bill extends health coverage to 31 million more Americans, while keeping the total federal cost for all health care spending and tax subsidies in the decade after 2019 essentially where it would be under current law. Additionally, a group of economists sent a letter to President Obama last month advocating for many of the reforms in the Senate bill as a way to stem the costs of the health care industry. 

This does not mean that the Senate bill is the better bill. There are provisions in both bills which are worth preserving the in the final bill. Over the next several weeks, as the Senate works to pass their version of the bill and then the two bills go to conference committee, there will be several opportunities for improving the bills and producing a superior final bill. Both bills contain key provisions for slowing the growth of health care costs and paying to insure more Americans. As always, the ultimate goal is affordable quality health insurance for all Americans.

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The USDA recently released its annual report for 2008 on food insecurity in the United States. As expected in this time of recession, food insecurity significantly increased, rising from 11.1% (13 million households) in 2007 to 14.6% (17 million households) in 2008, the highest levels since the study began in 1995. Food insecure households are defined as those who, at some time during the year, had difficulty providing sufficient food for all household members due to lack of resources. One-third of these households experienced very low food security, an episode in which food intake of some household members was reduced or eating patterns were disrupted.

Access to adequate nutrition affects many aspects of a child’s life, especially their learning and future health. As the nation focuses on the rising cost of health care, it is important to recognize that a large portion of every health care dollar is spent on preventable diseases, many of which are closely linked to nutrition. President Obama pointed out the importance of this issue to our nation’s strength: “Our children’s ability to grow, learn, and meet their full potential – and therefore our future competitiveness as a nation – depends on regular access to healthy meals.”

Fortunately, several programs exist to fight hunger in the United States. They range from the National School Lunch Program to Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and include the Supplemental Nutrition Assistance Program (SNAP, formerly known as Food Stamps). By expanding these programs, increasing access to them, and reducing associated administrative burdens, we can make use of this existing framework and truly fight hunger. 

SNAP is a massive program that reaches all ages and many working families (eligibility extends up to 130% of the Federal Poverty Level, or just under $24,000 per year for a family of 3). Utilization of this program is skyrocketing across the country, having increased by more than 37% in the past two years. In fact, a new study predicts that nearly half of all children in the country (and a shocking 90% of African American children) will receive SNAP benefits at some point during their childhood.

While the federal government fully funds the benefits in programs like SNAP, states are largely responsible for the administration. And, in light of state budget crises, the front-line workers administering these programs are not getting the support they need to deal with increasing demand. This leaves needy families without benefits, and leaves millions of dollars in Washington that could be funneled into local economies. 

President Obama has declared a goal of ending childhood hunger by 2015. While it is understandable that the prevalence of food insecurity rises during a severe recession, the trend does not need to continue. We must commit to ensuring that everyone in this wealthy nation can meet their most basic needs and access an adequate diet. Improving access to our existing food and nutrition programs in a vital first step, and can go a long way toward achieving the President’s goal.

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Co-authored by Lissa Domoracki and Carrie Gilbert

[Part 2 in the Shriver Center’s series on Climate Change and Low-Income Communities]

The build-up of carbon and other green-house gas emissions in the atmosphere causes climate change. If this build-up continues, it is estimated that the average temperature in the United States could increase by as much as 9 degrees Fahrenheit by the end of this century. The negative effects of climate change are numerous: increased heat waves, increased incidence of heat-related disease and illness, increased risk of floods, droughts, and fires, rising sea levels, etc. With federal climate change legislation on the horizon, many people are talking about cap-and-trade and how it can reduce our carbon emissions. But, what exactly is cap-and-trade? 

Cap-and-trade is a simple story of supply and demand. As of now, there is no limit on carbon emissions. Power plants, refineries, and industrial plants may emit as much carbon as they want without cost. Cap-and-trade changes this, putting a price on the right to emit carbon. 

Under a cap-and-trade system, companies must turn in an allowance for every ton of carbon emitted the previous year. The number of allowances issued determines the level of or the “cap” on carbon emissions. Initially, some allowances are given to companies for free while others are auctioned off. If fewer allowances are issued, either for free or at auction, than tons of carbon currently emitted, companies subject to cap-and-trade will either have to reduce their carbon emissions or obtain more allowances.

Depending on a company’s circumstances, the company may find it more cost-effective either to reduce carbon emissions or to buy emissions allowances. Cap-and-trade systems create an open market where allowances may be bought and sold. For example, Company A may be able to very easily and cheaply reduce its carbon emissions beneath its allotted allowance level while it may be very difficult and expensive for Company B to reduce its carbon emissions at all. In this circumstance, Company A could reduce its carbon emissions enough to be able to sell its excess allowances to Company B on the open market. Regardless, carbon emissions are reduced sufficiently to meet the cap.

Over time, the number of allowances issued will decrease, lowering the cap on carbon emissions. As this happens, the purchase price of an allowance on the open market should increase. To illustrate, let’s go back to Company A and Company B. Both companies have fewer allowances allotted to them than at the onset of the cap-and-trade program, and Company A has already utilized the easy and cheap methods to reduce its carbon emissions. Therefore, if Company A is going to reduce its carbon emissions sufficiently to sell excess allowances, it must undergo more difficult and costly changes than before. In turn, Company A is only willing to sell its allowances at a higher price. Company B has made no changes, previously choosing to buy allowances on the open market.   At some point, the price of allowances on the open market will exceed Company B’s cost to reduce carbon emissions, and like Company A, Company B will make the changes necessary to reduce its carbon emissions.  

For some companies, this may mean closing a plant and shifting production to a plant that emits less carbon, constructing a new plant that emits less carbon, or ceasing operations altogether. Take, for example, the Fisk and Crawford coal-burning power plants located in the working-class Pilsen and Little Village neighborhoods of Chicago. Both of these plants, because of their age, are exempt from the Clean Air Act. As is often the case, low and moderate income people bear the brunt of the pollution from plants like Fisk and Crawford as they tend to be located in or near low and moderate income communities. According to a Harvard School of Public Health report, the air pollution from the Fisk and Crawford plants is linked to 40 deaths, 550 emergency room visits, and 2,800 asthma attacks annually. Under a cap-and-trade system, it will likely become prohibitively expensive to continue the operation of these heavy carbon-emitting plants, benefiting the low and moderate income communities situated near them.

Overall, a cap-and-trade system advances several climate change objectives. First, the cap allows for predetermined and definite carbon emission-level reductions through the issuance of a limited number of allowances.  Second, the trading of allowances provides for the reduction of carbon emissions in the most cost-effective manner by encouraging the implementation of quick and easy carbon emission reduction strategies early on. Third, cap-and-trade will make heavy polluting plants cost prohibitive to continue operating, yielding important health benefits to the low and moderate income people who tend to live near such plans. Fourth, cap-and-trade, properly structured, can accomplish yet another essential policy objective -- the protection of low and moderate income households from bearing the brunt of added consumer costs that will result from limiting carbon emissions through cap-and-trade. More on this subject in a future article in our series on Climate Change and Low-Income Communities.

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[This is the fifth in a series of six articles summarizing the leading categories of issues at stake in the final stages -- the homestretch -- of the debate on national health insurance and health care reform.]

 A recent Congressional Report initiated by Senator Jay Rockefeller found that while the insurance industry has long claimed that 87% of premium dollars go to pay for medical care, in fact, the average is 82% for the top six insurers. This five point difference equates to billions of dollars not being spent on hardworking families’ medical care. And these findings underscore the need for meaningful reform of the insurance industry. The three bills in Congress (H.R. 3962, Senate HELP and Senate Finance) include major reform to the private health insurance companies. These reforms will vastly change the way in which companies decide who qualifies for insurance and who does not. In a historic vote this past weekend, the House passed H.R. 3962, including many changes to the health insurance market.   Senator majority leader Harry Reid (D-NV) has combined the two Senate proposals and sent a couple of different versions to the Congressional Budget Office (CBO) for consideration. He is waiting on the report from the CBO before releasing a final Senate bill, which will be the version sent to the Senate floor for debate. Until the final Senate bill is released we will offer comparison and analysis on the two Senate bills (HELP and Finance).

The three bills provide for significant reform to the health insurance industry, which would greatly expand access to health insurance. As discussed in Homestretch part 4, all three proposals create a health insurance Exchange, which would regulate the individual and small group insurance plans available in the Exchange.   Benefit plans in the Exchange would be standardized. Plans would vary on the level of cost-sharing of co-pays and deductibles. Private insurance companies participating in the Exchange could not deny coverage based on pre-existing conditions. Additionally, premiums could not vary because of gender or pre-existing conditions. 

The only characteristics that are permitted to factor into premiums are age, tobacco use, family composition and geography. The three proposals set ratios for premium variation based on age and tobacco use. The Senate Finance bill limits age variation to a 4 to 1 ratio and tobacco use to a 1.5 to 1 ratio. For example, a company can only charge its oldest customers four times that of its youngest customers.   The Senate HELP bill limits age variation to a 2 to 1 ratio and tobacco use to a 1.5 to 1 ratio. H.R. 3962 limits age variation to a 2 to 1 ratio, but does not allow insurance companies to vary premiums based on tobacco use.   The insurance companies indicated they will fight the limiting ratios, because they argue that they will raise costs to younger and healthier individuals. 

The Exchange contained in the three bills would also require that insurance companies issue insurance to a consumer regardless of their health status. Additionally, an insurance company could not sell a consumer a plan that explicitly does not cover their pre-existing medical condition. Companies would have to guarantee that they will renew an individual’s policy each year.   Additionally, each proposal sets limits for annual out-of-pocket costs to policy holders.   Insurance companies would not be able to limit the amount of claims a policy holder makes either annually or in a lifetime. In other words, an insurance company could not suddenly tell a policyholder that they will no longer cover that policyholder’s claims. 

Senator Rockefeller faced significant difficulties in getting the insurance companies to voluntarily divulge what portion of the premiums goes to medical care versus profit, administration, etc. This would change under all proposals. Both of the Senate proposals require insurance companies to report how much of the revenue from premiums goes toward paying for medical services. The House proposal requires that the Secretary of Health and Human Services sets a minimum percentage of revenue that must pay for medical services.   If the companies do not meet this minimum then they must provide rebates to their customers. 

The aforementioned reform is quite similar among the three proposals, but to whom they would apply differs. Senate Finance would apply these changes to the individual and small group market (businesses with fewer than 50 employees). Senate HELP and the House bill would apply reforms to all private insurance markets, including businesses of all sizes. And the Senate Finance bill would, however, require that all new policies, both inside and outside of the Exchange, meet the standards of one of four benefit levels set forth in the proposal. 

These reforms will offer greater consumer protections and decrease insurance companies’ discriminatory practices. Some of these measures may face fierce debate an opposition in the coming weeks as the Senate sends a final bill to the floor for debate and final bill is composed for President Obama’s consideration.   These reforms will mean containing costs, creating choices, upgrading care and ultimately covering all. 

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Co-authored by: Lissa Domoracki and Carrie Gilbert

 [This is the first in a series of articles about climate change and its impact on people and low-income communities. These articles reflect the Shriver Center’s initiative to raise awareness about these issues and to advocate on behalf of these communities in the current debates surrounding federal climate change legislation.]

The images of polar bears hungry and stranded on a lone block of ice made notorious by Al Gore are heart-wrenching, but the tragedies and injustices of climate change exist here at home also. Hurricane Katrina and its aftermath put one facet of these inequalities on display and should serve as a wake-up call. Climate change affects us all, but there are several specific ways in which it will have an even greater impact on low-income communities than others:

(1)    Heat waves brought on by climate change hit low-income communities hardest. Studies show a positive correlation between the presence of heat-trapping surfaces, like black asphalt, and community poverty. These studies also show a negative correlation between tree cover and community poverty. Less tree cover combined with more heat-absorbing materials in low-income communities raise the temperature, actually making it hotter in these communities. This is known as the “heat island” effect. 
 

(2)    Low-income individuals are more likely to live in poorly insulated homes and less likely to have air conditioning or easy transportation to cooling centers to cope with these elevated temperatures.
 

(3)    Pollution is disproportionately concentrated in low-income neighborhoods and increased temperatures speed its transformation into harmful ambient ozone that aggravates respiratory conditions such as asthma. Additionally, low-income individuals are less likely to have health insurance or access to medical care, likely worsening the health problems associated with exposure to pollution.
 

(4)    Low-income communities are the most vulnerable to natural disasters. Because of climate change, these extreme weather events are expected to greatly increase in frequency and severity. Low-income people are much less likely to carry disaster insurance that would allow them to quickly rebound from the damages caused by such events. 

Climate change is a serious problem for everyone, but the consequences of climate change are even more severe for low-income populations.

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