Too much hostage-takingThese days, it seems everyone wants to take a hostage, and everyone thinks they can. In 1994, the bar was a bit higher. Famously, Bill Clinton vowed to veto the legislation if it didn't achieve full universality. This year, Republicans and some conservative Democrats vowed to kill the bill if it contained a small public plan for the 10 percent of the population using the exchanges. This week, Joe Lieberman vowed to kill the bill if it allowed people between 55 and 64 who didn't have access to employer-based insurance to buy into Medicare. This morning, Howard Dean vowed to oppose the bill unless the state-based exchanges "act as prudent purchasers and select only the most efficient insurers." (If that was included, he said, a "stripped-down" version of the bill would be acceptable, though it's not clear what that means.)
What's so strange about Dean's objection is that the exchanges in the Senate bill (pdf) do act as "prudent purchasers," that is to say, they set limits on the plans that can enter in the exchange to ensure that people are getting good choices. The relevant section begins on page 131 of the Senate bill. "The Secretary shall, by regulation, establish criteria for the certification of health plans as qualified health plans." A couple of pages of relevant criteria follow, including marketing requirements (plans can be disqualified for focusing their marketing in outlets that would bring them uncommonly healthy enrollees), broad provider networks, coverage of options used by low-income folks (community health centers, say), quality measures, quality improvement strategies, consumer ratings, standardized benefit packages, etc.
And then, a couple of pages later, the language gets stronger. On page 143, the exchanges are given power to certify insurance plans based on whether "the Exchange determines that making available such health plan through such Exchange is in the interests of qualified individuals and qualified employers in the State." On 144, premiums, and premium increases, enter explicitly into the discussion. Any insurance plan that wants to increase premiums has to submit a written justification for their decision. It will have to post that information on its Web site. And if the exchange is not convinced, it can decertify the plan.
Don't believe me? In his op-ed, Dean names John Kerry as the senator who has been working hardest on this question. This morning, I spoke to Kerry's staff, who got me a statement from Kerry himself. "The prudent purchasing provisions in the Senate health bill will lower costs and increase affordable options for consumers," Kerry says. "It’s strong language that will allow the exchange to deliver competitive prices and offer high quality care, and I’m thrilled to see national reform honor the best innovations already succeeding in Massachusetts.”
I'm sure there's some theoretical way in which the language could be stronger. Dean doesn't say what it is, but I don't doubt it exists. But now we're talking about killing the Senate health-care bill -- with its $900 billion in subsidies and its delivery system reforms and its Medicare Commission and its Medicaid expansion and its exchanges and its regulations on insurers -- unless we make the exchanges slightly stronger prudent purchasers, when they're already strong enough to "thrill" the original sponsor of the prudent purchaser amendment?
I guess this is the logical outcome of a system in which the greatest gains accrue to those making the most credible and severe threats. But it's not healthy.
http://voices.washingtonpost.com/ezra-klein/2009/12/too_much_hostage-taking.html 
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