Advocates of health care reform have often pointed to the full one-sixth of Americans who are without health insurance as a symptom of an institution in need of fixing. Foxx says the figure of 50 million is misleading because it is made up primarily of people who can either afford health care or qualify for pre-existing programs.

Foxx contends that if you take away illegal immigrants, those who can easily afford private coverage and people who qualify for Medicare and Medicaid, the actual number of “uninsurable” Americans as such is more like 7 to 10 million. She says that this is a much more manageable figure and could possibly be covered with a voucher program rather than a comprehensive overhaul of health care itself.

If Foxx is correct, her claim would certainly be worth examining in the debate over health care. But is she? Using Census data on the uninsured, even the loosest application of statistics doesn’t cut the 50 million down to 10 million.

Of the 50,674,000 who reported not having any form of health insurance in 2009 (and indeed, the numbers are likely even higher now; the 2009 figure included over 4 million more people than went without insurance in 2008), well under a million could conceivably have qualified for Medicare. There were 676,000 people over age 65 in 2009 who didn’t have health insurance.

From there, the numbers get hazier. Foxx must have based the notion that a big chunk of the 50 million are eligible for Medicaid on the fact that nearly 15.5 million Americans without insurance had household income below $25,000 in 2009. That’s hardly a good metric because it doesn’t account for household size, but it’s as detailed as the Census data gets, and it’s within $400 of 133 percent of the federal poverty line for a three-person household. Other Census data show that median household income overall is closest to median household income for families of three, and 133 percent of the poverty line is the financial eligibility criterion for most people seeking Medicaid coverage. Fuzzy math to be sure, but then, it’s very generous to Foxx’s assessment; let’s say giving her the benefit of the doubt allows it.

Another of Foxx’s categories, those who can afford it but elect not to buy insurance, correlates to the 10.56 million belonging to households earning more than $75,000. Again, for Foxx’s sake, we can go ahead and use this figure. Finally, there are the illegal immigrants. There are 9,936,000 non-citizens living in the U.S. without health insurance. If we assume that every last one of them is an illegal immigrant (though this is patently not the case), that’s a final tally of 36,656,000 Americans who Foxx might say are perfectly capable of obtaining some form of health insurance. This leaves 14 million without any type of insurance available to them, higher than Foxx’s claim of 7 to 10 million.

And yet even 14 million is surely low to an incredible degree. There may well be 676,000 seniors who should be able to get Medicare but haven’t signed up — though those who haven’t been a part of the Social Security system or worked consistently throughout their lives would be ineligible. But numbers obtained for the other categories are likely not even close. Medicaid eligibility is based not on poverty alone, but also on either having children in the household or having certain disabilities. Able-bodied adults with no children living with them must make up at least a portion of those 15.5 million.

Assuming that all households earning over $75,000 can afford health insurance is also problematic, because it doesn’t account for households that include multiple income sources, for example, from extended family living under one roof, a common configuration among many ethnic and racial minority groups. Of course, the idea that all non-citizens without health insurance are illegal immigrants rather than permanent residents cannot be accurate, and the premise that undocumented immigrants are categorically undeserving of health insurance simply goes unquestioned in the Mount Airy News article.

And all these qualifications still don’t account for overlap among the various uninsured groups. For example, many of the non-citizens without insurance likely also fall into the low-income group; many of the senior citizens must fall into both the low- and high-income groups; and so on.

Ultimately, there just isn’t enough data to tell how many uninsured Americans could conceivably qualify for some type of health insurance under our current system. It may not be 50 million, but it is certainly more than the 7 to 10 million that Foxx claims. She is sure of one thing, though: Foxx says people shouldn’t use health insurance for preventive checkups or non-emergencies. She denounces annual checkups and compares doctor visits for colds to expecting home insurance to pay for a light bulb. “That’s not what insurance was designed to do,” says Foxx. “It’s designed to do the big things.”

House Speaker Nancy Pelosi (D-Calif.), carrying the gavel used to pass Medicare in 1965, and members of the House Democratic Caucus on Sunday (EPA/ZUMApress.com)

With the last-minute support of anti-abortion colleagues, House Democrats on Sunday passed historic legislation to extend health coverage to tens of millions of uninsured Americans, protect patients from the most flagrant abuses of insurance companies, and curb runaway health care costs. All told, the $940 billion reforms represent the most sweeping overhaul of the nation’s health care system since the creation of Medicare more than four decades ago.

[Congress1]The tally was 219 to 212 in support of reforms passed by the Senate on Christmas Eve, with 34 Democrats joining every Republican in the lower chamber in opposition to the measure. An accompanying reconciliation proposal — which tweaks the Senate bill to address what House leaders considered to be inherent weaknesses — also passed, 220 to 211.

Democratic leaders were quick to place the reforms among the most significant in the nation’s history — legislation on par with that establishing Social Security, Medicare and new civil rights protections. “This is an American proposal that honors the traditions of our country,” House Speaker Nancy Pelosi (D-Calif.) said just before the votes. “We may not have chosen the time, but the time has chosen us.”

The Senate bill now moves to the White House, where President Obama will sign it shortly into law. The separate reconciliation bill then goes to the Senate, where Democrats are hoping to pass it before the Easter recess, which begins Friday. Reconciliation rules prevent upper-chamber Republicans from filibustering the proposal, meaning that Democrats need just 51 votes — not 60 — to pass it.

For House leaders, the victory didn’t come easy. Sunday’s vote capped a tension-filled week in which some Democrats who’d previously supported health care reform announced their opposition; others who’d formerly opposed reform announced their support; and party leaders were left with the delicate task of counting heads to ensure they had the numbers to pass the bill.

Quite aside from the unified GOP opposition, anti-abortion Democrats, led by Michigan Rep. Bart Stupak, had vowed to oppose the bill over language they feared would allow federal funds to subsidize abortion services — something that’s been prohibited for more than 30 years. And they had the numbers to kill the proposal. Breaking the impasse required the muscle of the White House, which stepped in Sunday to issue an eleventh-hour executive order stipulating that nothing in the reform bill would dilute the decades-old prohibition on the federal funding of abortion. The move — while blasted by abortion rights groups — caused the abortion opponents to throw their support behind the proposals.

“The real winner,” Stupak said Sunday at a press conference announcing the deal, “is really the American people.”

The rare weekend vote came after more than a year of rancorous debate over how Congress should approach health care reform. The saga first pitted Democrats against Republicans, but later — when it became clear that no Republicans would support the bill — saw liberal Democrats and their moderate colleagues doing battle over the most contentious provisions of the enormous bill. In the end, party leaders, behind Pelosi, convinced enough Democratic critics — both liberal and conservative — that the proposals would at least take steps toward fixing a health care system that all sides agree has grown dysfunctional.

“This is not the bill I wanted to support,” Rep. Dennis Kucinich (D-Ohio), the liberal single-payer supporter, said recently in announcing his reluctant support for the bill. “Hopefully” he added, it will take the country “in the direction of comprehensive health care reform.”

At the center of the reforms are a series of provisions reining in the most controversial practices of the health insurance industry. Under the reforms, for example, insurance companies could no longer deny coverage based on pre-existing conditions. They could no longer drop coverage when a patient gets sick. They could no longer hike premiums indiscriminately. And they could no longer put caps — either annual or lifetime — on coverage benefits.

Among the other major provisions, the reform bills will:

• Increase Medicaid coverage to most folks living below 133 percent of the federal poverty level ($29,327 for a family of four), while providing sliding-scale federal subsidies to  those living below 400 percent of poverty ($88,200 for a family of four).
• Require most Americans to buy health insurance or face financial penalties.
• Take incremental steps to close the coverage gap in Medicare’s prescription drug benefit — the so-called doughnut hole — by 2020.
• Hike Medicaid rates on primary care services to equal those of Medicare.
• Extend funding for the Children’s Health Insurance Program through 2015.

To fund the changes, the proposals will:

• Cut more than $500 billion from the Medicare program, largely targeting the private insurance plans that receive huge subsidies to cover Medicare patients.
• Apply a 0.5 percent hike on Medicare’s payroll tax for individuals earning more than $200,000 and families earning more than $250,000.
• Tax the most expensive insurance plans, those costing more than $10,200 for individuals and $27,500 for family plans. (That tax will take effect in 2018.)

The Congressional Budget Office, which has estimated that the bill will expand coverage to roughly 32 million uninsured Americans, said Saturday that the changes will reduce federal deficits by $143 billion over the next decade, and by roughly $1 trillion in the 10 years to follow. The analysis at once convinced some Democratic budget hawks to support the bill, and took the wind from the sails of Republican critics who have said the reforms will bankrupt the nation.

Not that it prevented GOP leaders from attacking the reforms to the last. Rep. Marsha Balackburn (Tenn.), the first Republican to speak on the floor Sunday, set the tone early, blasting the Democrats for reforms that Republicans say will steal patient choice.

“Only they see the death of freedom … as a cause for celebration,” Blackburn said. “It is their children who will pay for their greed.”

Rep. Nathan Deal, the senior Republican on the Ways and Means health subpanel and candidate to become Georgia’s governor, echoed those criticisms. He vowed that, if elected to the governor’s office, he’ll focus on nullifying the reforms, particularly the Medicaid expansion, which many Republicans have called an unconstitutional mandate on states.

“The problem with socialism,” Deal said Sunday, “is that you ultimately run out of other people’s money.”

But in the end, Republicans — while effective in slowing the pace of the legislation — were helpless to prevent its passage.

The historic nature of the vote was not lost on Democratic leaders. Pelosi, who presided over the final vote, waved the same gavel that was used when Medicare passed the lower chamber more than six decades ago. And Rep. Louise Slaughter (D-N.Y.), the head of the Rules Committee who managed part of the day’s debate, was brandishing her own copy of a 1939 letter to Congress from Franklin Delano Roosevelt, a letter urging lawmakers to include a national health care system as part of the Social Security program.

“Good health,” FDR had written, “is essential to the security and progress of the Nation.”

Seventy-one years later, Democrats are hoping he was right.

CodePink** helped organize both sit-ins, protesting Lieberman’s threat to filibuster the health care reform bill. Joan Stallard, a CodePink member who watched Tuesday as police carted off her colleagues, accused Lieberman of accepting money from the insurance industry and thus voting in the interests of those companies.

The industry itself seems to be wary of that alleged connection between donations and political favor. Although Lieberman ranks 11th among sitting senators in lifetime industry donations, this year that ranking has slipped to 62nd, according to the Center for Responsive Politics.

Editor’s note: Lieberman’s been enough of a thorn in the Democrats’ collective side that President Obama reportedly just (jokingly) offered to swap him for Israel’s hard-line foreign minister Avigdor Lieberman.

**Clarification: It was actually Mobilization for Health Care for All, a single-payer advocacy group, which organized the protest, not CodePink, as originally reported by Roll Call.

Senate Majority Leader Harry Reid (D-Nev.) (WDCpix)

Health insurance companies, for decades exempt from federal anti-trust laws, are exploiting that privilege to churn profits at the expense of patients, a number of Senate Democrats charged Wednesday. The lawmakers — including Senate Majority Leader Harry Reid (D-Nev.) — want to repeal the exemption as part of broader efforts this year to overhaul the nation’s dysfunctional health care system.

“There is no reason why insurance companies should be allowed to form monopolies and dictate health choices,” Reid told the Senate Judiciary Committee.

Illustration by: Matt Mahurin

The comments arrive during a week when the insurance industry and Democrats have been at each other’s throats over health reform — a quarrel that threatens to endure through the debate. The flames were ignited late Sunday after the health insurance lobby issued a controversial report charging that legislation passed this week by the Senate Finance Committee would hike Americans’ insurance premiums by thousands of dollars each year. PricewaterhouseCoopers, the consulting firm that conducted the study, later conceded that it had considered only a small portion of the Democrats’ strategy, ignoring, among other things, the hundreds of billions of dollars in federal subsidies designed to keep premium costs affordable.

Democrats have pounced on the report as an indication that the insurance industry, despite claims of support for the general concept of health reform, never intended to cooperate with efforts to make coverage affordable to millions of uninsured Americans. The report is further evidence, many lawmakers maintain, that Congress should create a public insurance option to compete with private companies. Repeal of the anti-trust exemption, those same voices are arguing, would be another step toward keeping the industry honest and coverage costs affordable.

“While the insurance industry hides behind its exemption, patients and doctors have continued paying artificially inflated prices, as costs continue to rise at an alarming rate,” said Sen. Patrick Leahy (D-Vt.), chairman of the Judiciary Committee. “The cost spiral is just fine for insurance companies, but it punishes patients, American businesses large and small, and taxpayers.”

Under current law, most businesses are subject to federal anti-trust rules designed to foster competition, keep costs low and preclude the rise of monopolies. But a 1945 law, called the McCarran-Ferguson Act, carves out an exception for health and medical malpractice insurers, which instead are regulated by states.

The industry argues that the exclusion bolsters competition by allowing smaller companies to obtain otherwise unknowable pricing data as they seek to enter new markets. But a growing number of Democrats and consumer groups maintain that the exception simply allows companies to feign competition while they’re really at work colluding on profit-enhancing schemes.

Separate from the broader reform legislation, Leahy has sponsored a bill that would eliminate the exemption for the most egregious anti-trust practices – those involving price fixing, bid rigging and market allocations, where “competitors” divide geographic markets among themselves in order to avoid competition. In all other cases, under Leahy’s proposal, the McCarran-Ferguson Act exemptions would remain in place.

The insurance industry argues that, not only is the Leahy bill unnecessary, but it would lead to increased costs by stifling competition. Lawrence Powell, a finance professor at the University of Arkansas who testified Wednesday on behalf of the Physician Insurers Association of America, maintained that he’s “never observed” any price-setting collusions between competing companies, “because it’s illegal.”

“All of the behaviors this bill seeks to curtail,” Powell said,” are neither apparent in the market, nor permitted by current law.”

But consumer advocates aren’t convinced. J. Robert Hunter, director of insurance at the Consumer Federation of America, told lawmakers that the exemptions simply shield the industry from the types of practices that ultimately limit competition at the expense of patients.

“They get together on claims. They get together on pricing,” Hunter said. “They do many, many things that would violate the anti-trust laws if those laws applied to them.”

Hunter urged the creation of a public option “to test the market” in order to learn the extent of the private-insurer manipulations. Today, Hunter said, there’s no indication to what extent companies are passing on to consumers the costs of, for example, advertisements opposing health care reform.

“We’ll be paying the bill,” Hunter said.

Reid agreed, testifying that the insurers’ exemption “has been anticompetitive and damaging to the American economy.”

“Insurance companies have become so large they dominate entire regions of the country,” Reid said. “What a sweet deal they have.”

Reid is responsible for weaving together the Finance proposal and another sweeping health reform bill passed in July by the Senate Health, Education, Labor and Pensions Committee. That the Senate majority leader came out so vocally in support of the Leahy bill has left supporters optimistic that the proposal could work its way into the final package.

A 2007 study lends credence to the Democrats’ concerns about the consolidation of the insurance industry. Conducted by the American Medical Association, the nation’s largest physician lobby, the survey found that, in most states, the top two carriers consume an overwhelming majority of the private insurance marketplace. In Maine, for example, the top two companies control 88 percent of the insurance market. In both Montana and Wyoming, the number is 85 percent. The lowest market concentration, AMA found, was in Florida, where the top two insurers still represent 45 percent of the market.

More recently, the non-partisan Government Accountability Office found that the top five insurers represent more than 90 percent of the market in no fewer than 23 states.

Numbers like those provide some evidence of what’s at stake for the insurance industry, which is among the most powerful lobbies on Capitol Hill year after year. Indeed, the insurance industry has contributed more than $8.4 million to lawmakers this year alone, according to the Center for Responsive Politics.

But preserving the status quo would come at a cost, according to some Justice Department officials. Christine Varney, assistant attorney general in DOJ’s antitrust division, told lawmakers Wednesday that she’s “very skeptical” that such high market concentrations don’t lead to both a reduction in competition and an increase in consumer costs.

“There is real cause for concern, when you’re reducing competition in those markets,” Varney said. “When you don’t have to compete, you can get pretty big profit margins.”

As the nation remains mired in a debate over health care reform and how to keep down the costs of expanding coverage, AAJ is trying to point out that Republicans claims that medical malpractice lawsuits are one of the big cost drivers is completely misleading. In fact, though malpractice claims and so-called “defensive medicine” does account for a small percentage of unnecessary costs, medical errors and the astronomical profits of malpractice insurers appear to be a bigger part of the problem.

AAJ’s report released today finds that the average profit of medical malpractice insurance companies is higher than 99 percent of all Fortune 500 companies and 35 times higher than the Fortune 500 average for the same time period; and malpractice insurers have seen their profit margins range from 5.9 percent to 74.8 percent, with an average of 31.2 percent. The report also finds that malpractice insurers have publicly overestimated their losses and underestimated their profits in an attempt to suggest the insurance business and medical practice in general faces a crisis that must be resolved by so-called “tort reform” — i.e., making it harder for patients to sue and to collect damages for their injuries.

“Insurance companies are gouging doctors on their premiums to mislead lawmakers,” said American Association for Justice President Anthony Tarricone, managing partner at Kreindler & Kreindler LLP, in a statement released with the report. “And today, injured patients are often left with no avenue to pursue justice, while health care costs continue to skyrocket.”

It wouldn’t have passed anyway. Aside from Republican opposition, which would almost certainly be unanimous, Sen. Jeff Bingaman (D-N.M.) said he wouldn’t support the measure either. The underlying bill, Bingaman argued, already addresses the most egregious industry abuses.

Along those lines, the West Virginia Democrat plans today to propose legislation requiring insurance companies to dedicate a minimum percentage of their premium revenues to the delivery of medical care. Rockefeller claims those companies spend too much paying salaries and rewarding shareholders, and not enough treating patients.

He has a point. The health reform bill moving through the Senate Finance Committee is a gift to the industry industry, supplying upwards of $460 billion in insurance subsidies over the next decade. Rockefeller said Congress should enact “some guarantee that these taxpayer dollars are being used to help American families get health care. … We must demand that with taxpayer dollars the health insurance companies put people before profits.”

A vote on Rockefeller’s proposal should come later today.

Yet, if today’s exchange between GOP Rep. Mike Pence (Ind.) and MSNBC political analyst Mike Barnicle is any indication, Republican leaders not only don’t have any specific legislative alternatives, but they’re also so blinded by the public option provision that they don’t seem to know what parts of the Democrats bill they support to begin compromise talks. From Pence’s interview on MSNBC’s “Morning Joe” show:

Barnicle: What, if anything, is in the bill that’s in front of the House right now, what do you like in it? What do you favor in it?

Pence: What do I favor in the bill? You know, Mike, it really is hard to look past that massive government plan, you know, the so- called exchanges with the public option. But even the private insurance elements in the exchanges, you know, are essentially government-controlled and government-dictated.

It’s, you know, what you’ve got in the vision that Democrats reported out of the Energy and Commerce Committee is just a massive expansion of the federal government’s role that I believe, as Barney Frank has suggested, would put us on a pathway toward socialized medicine.

Barnicle: Yes, but…

Pence: You know, Barney Frank said on video that if you have the public option, that’s the — I think he said that’s the fastest way to get to single payer, and I agree. So it’s hard to look past that…

Barnicle: But, Congressman…

Pence: … elephant in the room and find much there that we agree with.

So does this represent a political strategy to kill the Democrats’ health plans at all costs to deny Obama a victory? Or did Pence just not read the bill?

Hardly.

Sen. Jon Kyl (R-Ariz.) told reporters today that Republicans also won’t support the Democrats’ proposal because (1) the costs are too high, (2) the strategies to cover those costs will likely include a tax on someone, and (3) the strategy to create private co-ops is “a Trojan Horse” representing “a step toward government-run health care.” By Kyl’s telling, Republicans won’t support the Democrats’ health reform proposal unless it suddenly morphs into the Republicans’ health reform proposal. From The Hill:

Kyl said Republicans prefer a narrower approach that targets costs and the factors behind the costs, but that Democrats voted down those proposals in committee debates. The GOP would prefer to see ideas such as medical malpractice lawsuit limits, an expansion of private health care tax breaks and the abandonment of employer-mandated healthcare. The Democrat-led approach to health care also doesn’t include enough allowances for states to experiment with their own health care ideas, Kyl said.

Looks like this is destined to be a partisan bill after all.

For one thing, The Times indicates, the co-op would also need government backing in order to launch:

The government would offer start-up money, perhaps $6 billion, in loans and grants to help doctors, hospitals, businesses and other groups form nonprofit cooperative networks to provide health care and coverage.

Second, it takes a long while for co-ops to establish themselves as viable competitors to for-profit insurers:

Larry J. Zanoni, executive director of the Wisconsin plan, said: “We are a testament to the success of a health care cooperative. But it took us over 30 years to get where we are today.”

And finally, The Times reports that the co-op model hasn’t helped North Dakota, where a  co-op-style non-profit has monopolized the insurance market rather than promoting competition.

Mr. Conrad’s own state demonstrates the uncertainties surrounding cooperatives. Blue Cross Blue Shield of North Dakota dominates the state’s private insurance market, collecting nearly 90 percent of premiums. As a nonprofit owned by its members, the company would hope to qualify as a co-op under federal legislation, said Paul von Ebers, its incoming president and chief executive. [...]

Any new insurer in North Dakota would probably try to take members from the local Blue Cross plan, but that would not be easy to do.

Representative Earl Pomeroy, Democrat of North Dakota, said the proposal for cooperatives was “a very worthy idea.”

“The market here is uncompetitive,” said Mr. Pomeroy, a former state insurance commissioner. “A cooperative could provide an alternative source of insurance and some interesting competition for premium dollars. A co-op could operate at lower costs, in part because it would not need to pay its executives so generously as the local Blue Cross Blue Shield plan.”