House vs. Senate: How healthcare proposals compare

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House vs. Senate: How healthcare proposals compare

As the political bargaining moves into the final stages, lawmakers will address the key issues: rising insurance costs, the uninsured, protecting the insured, quality of care and Medicare.

September 8, 2009

Returning from their summer recess, congressional lawmakers are facing a climatic showdown to the yearlong struggle over healthcare. At issue are scores of competing provisions scattered through half a dozen bills. And no final decisions have been made on any of them.

In the House, Democratic leaders are synthesizing the proposals of three committees, but floor debate has not begun. In the Senate, a bill close to the expected House blueprint has been approved by the health committee formerly headed by the late Sen. Edward M. Kennedy (D-Mass.). But a less liberal version is being developed by the Senate Finance Committee, where moderate Democrats are negotiating with a handful of Republicans.

So far, President Obama has not put forward concrete proposals of his own -- preferring to outline basic goals and leave the details to Congress. That's likely to change in the weeks ahead.

Keeping in mind that significant changes can be expected as the political bargaining moves into the final stages, here are the major issues in play and how the House and Senate are likely to approach them:

Rising insurance costs

House: Create a government-run "public option" plan to compete with private insurers. Not everyone would be eligible to choose the government option.

Also, set up state insurance pools or "exchanges" that would give individuals and small business more leverage to buy coverage -- presumably at lower prices.

Senate: Likely to reject the public plan in favor of establishing private cooperatives, initially backed by government funds, to compete with private insurers.

Also create state insurance pools to help individuals and small business buy more affordable insurance.

Cost: The Congressional Budget Office estimates the increased coverage element of the House bill would add $65 billion to the federal deficit over 10 years.

Argument for: Supporters think the public option would be the most effective way to push prices down. Advocates of cooperatives believe they can compete with large insurers because of smaller administrative costs.

Argument against: Critics worry that employers will stop providing coverage and push workers into an ever-growing new bureaucracy with out-of-control costs.

Critics of co-ops say they will founder unless they are very large.

Insuring the uninsured

House: Expand eligibility for Medicaid to include more low-income workers. Make regular medical insurance more affordable to moderate-income individuals through the exchanges or the public option.

Senate: Expand Medicaid eligibility. Possibly open Medicare, which now serves only the elderly, to younger people. Insurance pools and co-ops could also help make coverage within reach for more people.

Cost: The CBO estimates that Medicaid expansion could cost, in a "broad range," $500 billion over 10 years. The option to open Medicare to younger people is being considered in the Senate Finance Committee; no cost estimate yet.

Argument for: Costs of treating the uninsured are often shifted to those with insurance in the form of higher premiums.

Argument against: Medicaid and Medicare are already draining the federal coffers, and expanding the programs would only exacerbate the problem.

Protecting the insured

House: Forbid insurance companies from refusing coverage on the basis of preexisting conditions. Outlaw annual or lifetime caps on benefits.

Senate: Same.

Cost: A ban on preexisting condition exclusions would cost insurers some, but if coupled with a mandate requiring everyone to buy insurance, insurers would probably gain financially.

Argument for: Insurers often use preexisting conditions as a reason to deny coverage, making the purchase of a plan on the open market difficult.

Argument against: Without adequate protection for insurers, people would buy coverage only when they are seriously ill, some fear.

Improving the quality of care

House: Establish a federal center to study the effectiveness of healthcare services. Promote the use of electronic medical records. Offer incentives for more efficient delivery of care. Require the disclosure of financial ties among doctors, hospitals and other medical providers.

Senate: Same, except may not require financial disclosure.

Cost: As part of the stimulus package, Obama set aside $19 billion for health information technology, mostly to promote electronic medical record-keeping.

Argument for: Lack of comprehensive, easily accessed information on patients contributes to higher costs and lower-quality care.

And knowing what kinds of treatment are most effective is even more important for making care cheaper and better.

Argument against: So-called effectiveness research is the first step toward rationing care and giving the government control over personal medical decisions, some say.

Changes in Medicare

House: Expand the prescription drug benefit by eliminating the so-called doughnut hole coverage gap. Reduce or eliminate geographic variation in reimbursements. Reduce extra payments to Medicare Advantage to lower overall costs. Use bundled payments where possible to increase system efficiency.

Senate: To be determined, largely on the basis of what the finance committee agrees on.

Cost: The House bill provisions are estimated to reduce federal spending by $219 billion over 10 years.

Argument for: The doughnut hole is a financial hardship on many seniors, and the government can save money without reducing coverage by ending regional disparities and the extra reimbursements for Advantage plans.

Argument against: Closing the prescription gap takes money, and Medicare is already heading for financial trouble.

Many seniors like the Advantage plans, which offer them free services other Medicare recipients can't get. And regional payments reflect real cost differences.

The total cost of legislation

House: An estimated $1.04 trillion over 10 years, according to the CBO. To be paid for through savings in Medicare and Medicaid payments and a tax on wealthy individuals and families.

Senate: Negotiators have pledged to keep the cost of the Senate's plan under $1 trillion, but the final bill has yet to be negotiated.

The finance committee is still exploring revenue-raising mechanisms, but could tax high-end health insurance benefit programs that are currently tax-exempt.

Sources: House and Senate committees, the Congressional Budget Office, the Kaiser Family Foundation