Dead center 

Sen. Max Baucus, health care reform and the future of compromise

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Baucus's eyes widen as he reels off numbers: About 140,000 women in Montana have insurance plans that will cover such services. Nationally, it's about 47 million women, according to the U.S. Department of Health and Human Services. Once Baucus gets going, he's like an infomercial pitchman: "And that's not all!"

He ticks of a list of the law's benefits—its requirement that insurance companies cover preexisting conditions, its prohibition of lifetime benefit limits, its clause that allows parents to keep their children on their policies until the children turn 26. "Add to that the seniors who are finding they're getting a better break on prescriptions drugs than before," he says. "That's in this bill."

Baucus's staff calculates that as of July, more than 13,000 Montana seniors on Medicare were able to cut their brand-name prescription drug costs in half, saving them an average of $621 apiece.

Then Baucus explains a critical measure in the law called the "minimum medical loss ratio." If there's one problem this law has had since its passage, it's that its many parts are hard to grasp.

"Basically," Baucus says, "insurance companies have been taking too many of their premium dollars and spending it on themselves and not enough on health care benefits."

The law requires that insurance companies spend 80 percent of customers' premiums on patient care or give them a rebate. As of Aug. 1, more than 25,000 Montanans were due a check averaging $194, a total of $2.6 million. "That's a pretty big deal, when they send you a check, not a bill," he says.

Yet the law is still meeting stiff opposition in some states. Take its state-based health insurance exchanges, which will be operational by 2014. Baucus likens them to online marketplaces such as Orbitz and Travelocity.

Last year when the Montana Legislature was in session, the Republican-dominated House Business and Labor Committee killed a bill that would have created a Montana health insurance exchange. Rep. Edward Greef, a Republican from Florence and committee member, chalked that up to an "overriding sense of confusion." The committee, Greef said, figured that "if the act gets repealed or is unconstitutional, we won't have to deal with this."

Now the U.S. Department of Health and Human Services will implement Montana's exchange, assuring more federal intervention in the state's health insurance market than if the legislature had passed the bill—the very thing, it appeared, that many Republican lawmakers wished to avoid.

click to enlarge PHOTO BY CHAD HARDER

"We lose a lot of decision-making authority over the exchange," said Lucas Hamilton, spokesperson for Montana insurance commissioner Monica Lindeen, shortly after the Supreme Court ruling. "We know our market better, we live here, we actually purchase these policies ourselves."

As of Aug. 24, only 14 states and the District of Columbia had moved to establish state-based health insurance exchanges, according to the Center on Budget and Policy Priorities. Exchange legislation had failed in 27 states and bills were pending in six.

ACA's Medicaid expansion has been a tough sell, too. The law originally required that states expand Medicaid to cover everyone who earns up to 133 percent of the federal poverty level. In return, the feds guaranteed full reimbursement from 2014 through 2016, then gradually stepping down its share to 90 percent and remaining at that level thereafter. But the Supreme Court ruled that the federal government can't force states to participate in Medicaid expansion.

Gov. Schweitzer, for one, has been critical of the Medicaid expansion, worried that it could cost the state tens of millions of dollars a year. "Unlike the federal government, Montana can't just print money," he's said. But it will be Montana's next governor and its next legislature that decide.

Baucus insists that the Medicaid expansion is "wise" and "a good deal." As it happens, his view is echoed in a recent report by The Harvard Law School Center for Health Law and Policy Innovation, which argues that expanding Medicaid up to 133 percent of the federal poverty level "is in every state's interest," a position based on "strong empirical evidence that 'opting out' of expansion will have many negative implications" for health outcomes and state fiscal stability.

The report gauged where each state stands, finding that, as of mid July, 20 state governors had made public statements that were supportive or "seemingly supportive" of Medicaid expansion, with Montana being among the 12 undecideds.

Baucus laments that many of the Affordable Care Act's measures are not well understood or lack broad support. The measures' complexities haven't helped, but the greatest challenge has been overcoming Republicans characterizing the law as socialistic, even though the party's past proposals embraced key elements in the law. When Obama backed these centrist ideas—such as the state-based exchanges and insurance mandate—Republicans turned against them.

Political scientist Thomas Mann, a senior fellow at the Brookings Institution, said in a recent Columbia Journalism Review Q&A that the media "failed to inform the public of the disingenuousness of the Republican opposition and the inaccuracy of much of the rhetoric leveled against the Affordable Care Act. It was safer to cover the politics of health reform and avoid making judgments that were tougher on one party than the other."

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