I think Ezra Klein is right to argue that the leaked version of the Senate Finance Committee’s health reform legislation is somewhat of a nothing-burger. It’s not well done, it’s not rare, it’s just medium well (which, incidentally, is just how Obama likes it):

But this is what I’d term “comprehensive incrementalism.” It makes everything a bit better. It is not radical. It is not root-and-branch reform. For all the concerns about cost, there is no strong public plan able to negotiate low rates and implement aggressive reforms.

Indeed, as Klein points out, the plan institutes some important market reforms (guarantee issue, no exclusion based on preexisting conditions), but its adjusted community rating variation rate is capped at 7.5:1, which means that an insurance company can charge an older person 7.5 times the rates it charges a younger applicant. Individuals and families up to 300% of Federal Poverty Level (FPL) would receive tax credits to cover the cost of coverage and small businesses would be eligible for a temporary small business tax credit. Again, the subsidies aren’t great, but they’re better than nothing.

On the public option, the committee went with the Conrad co-op compromise and offered the new corporation some start-up seed money. Children and pregnant women below 133% of the poverty level ($28,200 for a family of four) and parents and childless adults at or below 100% of the poverty level ($10,800 per year) are eligible for Medicaid. Everyone is required to purchase coverage, but the employer role is somewhat undefined.

In fact, the “placeholder” section about employer mandate is the murkiest part of the proposal. Employers are not required to provide coverage, but employers whose workers receive Medicaid (so they are below 133% of FPL) or a tax credit in the Exchange (those at or below 300% FPL) have to pay 50% of the national average Medicaid costs on behalf of their Medicaid workers and/or 100% of the tax credit for workers in the Exchange. So employers don’t have to provide insurance if they don’t want to, but employers with a preponderance of poor workers will have to help finance their workers’ coverage. This approach preserves the employer contribution, but it doesn’t exactly preserve the system:

1) If employers are paying 50% of the national average Medicaid costs, then employers in low cost areas would be subsidizing workers in high cost areas. Employers in low-cost areas would be over-paying to provide coverage workers in high cost areas. Given this dynamic, I don’t imagine that Senators from low-cost states will find the proposal too appealing.

2) This provides employers with an incentive to not provide coverage or offer workers expensive plans, basically forcing them into the Exchange. Health reform should align the incentives so that employers and employees are all better off when the employee is insured.

The “alternatives for employer responsibility” on the last slide of the draft are no better. Option 4 is no mandate at all and the first three seem to lack an adequate penalty to encourage firms to continue providing coverage.

A higher than expected preliminary Congressional Budget Office estimate of the Senate Finance Committee’s health care reform bill — and the trouble surrounding the HELP bill — has led Chairman Max Baucus (D-MT) to postpone action on the bill until after the July 4 recess:

Committee Chairman Max Baucus said yesterday lawmakers need more time to work on bringing the bill’s cost to below $1 trillion and to reach a bipartisan compromise on it….[Sen. Kent] Conrad said the finance committee is considering a variety of ways to reduce the cost of its plan to below $1 trillion. He said the costs could drop dramatically if members limit subsidies to lower-income Americans seeking insurance.

The Washington Post’s Ezra Klein reports, “Right now, I’m told Finance is going down the road of less reform. They’re cutting the subsidies, cutting the generosity of the basic benefit package and cutting the number of people who will ultimately be insured by their proposal.” Of course, affordability and adequacy are the tents of health care reform. Progressives have rightly argued that a new public health insurance option would lower costs and insert competition into the health insurance marketplace, but hyper focus on the public option may lead reformers to miss the forest for the trees.

Health reform that fails to make insurance more affordable is at best an incremental improvement. The great irony, of course, is that a robust public option that uses Medicare-like rates would actually lower premiums and health care costs. But Democratic legislators seem unwilling or unable to stand behind a strong public option. Should they also sacrifice affordability of care in an effort to please conservatives concerned about the budget deficits, they would be placing themselves in between you and any kind of doctor.

The problem of unaffordability is most apparent for the nearly 47 million Americans who lack health insurance. The Agency for Healthcare Research and Quality found that while “15.8 percent of adults spent more than 10 percent of their family income on health care services in 1996, by 2003 the proportion of adults bearing what has historically been considered catastrophic financial burdens had increased to 19.2 percent of the population, or 48.8 million individuals.” According to the Center for Studying Health System Change, one in five Americans had trouble paying their health care bills in 2007. In fact, even moderate levels of out-of-pocket spending — spending that is well below the 5 or 10 percent of family income —created medical bill problems.

Thus, health care reform must expand safety net programs like Medicaid and SCHIP for low income families and provide help with premiums for families with incomes above approximately 400 percent of the federal poverty line. Also:

- Families pay minimum cost sharing and out of pockets expenses.

- All families should be protected from excessive premiums. The government should provide subsidies on a sliding scale. Everyone must pay their fare share and the system should gradually phase out assistance so that slightly-wealthier families don’t face a cost-cliff

- Subsidies should vary by geographical location and adjust for cost of living

During yesterday’s mark-up of the HELP committee’s ‘Affordable Health Care Act,’ Sen. Tom Coburn (R-OK) questioned the need for reform. “I think this health care is pretty damn good, I think it’s pretty dang good,” Coburn said:

I’ll tell you the other reason I think health care in this country is pretty good and good for my Medicaid patients and good for patients with no health insurance. Because when somebody gets cancer, most of the time we get them well. Most of the time we get them well. Some fall through the cracks, that’s true. But as a two-time cancer survivor, I think this health care is pretty damn good, I think it’s pretty dang good.

Watch it:

But just last month, the senator unveiled ‘The Patients’ Choice Act,’ a GOP alternative to the President’s plan, which recognized the health care crisis. “It is time to publicly admit that the health care system in America is broken…And 47 million Americans worry what will happen to them or their children if they get sick,” a summary of the bill read. Now, just a month later, Coburn, who is clearly satisfied with his own government-sponsored health care plan, has lost interest in helping Americans secure access to affordable.

In his four years in the Senate, Coburn has earned the reputation of “a fly in the soup,” abusing the senate’s hold privilege — a technique which allows senators to “object to bringing a bill or nomination to the floor for consideration” — to prevent “the Senate leadership” from bringing matters to a vote. Remarkably, Coburn’s obstructionism has even led “senate aides to now take legislation directly to Coburn’s office” to ensure “he has no objections.” Last summer, Sen. Harry Reid (D-NV) wrapped most of the non-controversial bills held by Coburn into one large measure — called the Tomnibus — in an effort to pass the mostly bipartisan legislation.

In an effort to delay the committee’s reform efforts, Coburn plans to offer numerous nuance amendments (read them all here):

- Doctor on doctor spying: To establish a demonstration project that uses practicing health care professionals to conduct undercover investigations of other health care providers in order to determine the quality of health care provided by such other providers. [Coburn, 11 & 87]

- Protecting unborn children: To provide for the establishment of an Office of Unborn Children’s Health (O.U.C.H.) [Coburn, 13]

- Toying with legislation: To clarify the intent of the prevention and public health investment fund [Coburn, 17]; Coburn To clarify the intent of the prevention and public health investment fund [Coburn, 18]; To restate the purpose of the Prevention and Public health Investment Fund [Coburn, 19]; To reduce funding and provide for a termination date for the Prevention and Public Health Investment Fund. [Coburn, 20]

Reform may be a joke to the well-insured Coburn, but for the Americans struggling with cancer, access to affordable health coverage is a very serious concern. As the American Cancer Society points out, people who are uninsured are more likely to be diagnosed with advanced cancer and too many insured Americans have a hard time affording their treatments. In Oklahoma, an average family pays $1,900 more in premiums because of the broken health care system and some 50 families “fall through the cracks” every day when they lose their health insurance.