Can You Say "Tipping Point"?

Abstract number two.

President Bush plans to weigh in on the healthcare debate tomorrow during his state of the union address. Hillary Clinton is proposing legislation to expand the federal health plan for children. And of course, Schwarzenegger is doing his best to pass his own pet insurance plan.

But, as you probably know, these are not the ground breakers.

Way back in the day, 1989 to be exact, Oregon had a plan: the Oregon Health Plan or OHP.

Basically, the Oregon plan expanded Medicare to cover more of the state's uninsured. They started out by providing enrollment in managed healthcare plans to residents that earned 100 percent of the federal poverty level. But in order to expand the number of people they covered, the plan limited the services provided. When the OHP budget was drawn up, all the treatments would be prioritized and then the line was drawn.

“Every two years the state legislature would literally draw a line in the list, with Oregon Medicaid paying for all services above the line and no services below it,” Jonathan Oberlander wrote in his study on the failure of the plan.

None of the current state proposals have this rationing built in. But the plan didn't fail because of the controversial line drawing, instead the state tried to enlarge the plan even more in the beginning of this decade. However, complicated enrollment rules, changes in co-pays and deductibles and substantial premiums for the new members, caused many people to drop out of the program. Add an extreme economic slump and the OHP stopped accepting members in 2004.

The message to states going down this path is a basic one: don't change a bunch of things all at once (also, don't provide a tax kicker, but that's another story).

Other States
The newest plan on the horizon is from Gov. Ed Rendell of Pennsylvania. This plan is so new the legislation hasn't been written yet, but it has a couple of shiny new ideas tucked inside.

Rendell noticed what a lot of other governors are noticing these days: uninsured people use medical services anyway and the state ends up paying, a lot. So since the state's already paying, let's reduce the cost of medical care.

The proposal suggests saving money by reducing medical errors, preventing hospital-based infections, outlawing smoking in the workplace and increasing the tasks that can be performed by nurses. And that's just the "cost-cutting side." On the "where will this money come from side," we have an increase in the cigarette tax and a payroll tax for businesses that don't provide health insurance to their employees.

I haven't seen the details yet, but Bush's plan sounds awfully confusing to me. It goes something like this- we will make people who pay a lot for health insurance pay even more by taxing their plans and then we will use that tax money to subsidize the purchase of less expensive insurance for others.

I get that part where money from rich is supposed to go to poor (except that most people who work and get insurance through their employer don't have a lot of choice in coverage). But this is also supposed to be some kind of mechanism that will reduce the average price of insurance over time. Hmmm. Well, if we assume that the most expensive plans are purchased through employers that don't offer options to employees and probably switch providers once in a decade, I really don't see how this will work.

Massachusetts, the first state to require that residents purchase health insurance has had their plan in place since April 2006. Residents earning less than three times the federal poverty level can get a subsidized plan with no deductible (that includes dental!).

I'm excited about dental because dentistry is neglected by many insurance plans and many, many people visit the ER with dental issues.

California is still in the midst of the heath insurance battle. Schwarzenegger proposed, the assembly passed but the senate is on the fence on the $12 billion dollar plan. One of the fights is whether the money will come from taxes or fees. Fee are the magic word here, if you say TAXES, Schwarzenegger will have gone back on campaign promises.

The Robert Wood Johnson foundation is tracking state plans.