Sixty. Everybody following the health care debate knows the importance of that number. Especially the progressives in the House. They get it: they can’t burden the bill with changes that will make it too heavy to leap across that barrier of sixty in the Senate. So, while they don’t want to completely knuckle under to the Senate bill, they’ll have to carefully pick a limited number of battles.

My Missouri muse on the health care reform front is Amy Smoucha of Jobs with Justice, and she pointed me toward a website called Community Catalyst, which focuses on helping activists at the state level. One of those looming battles, according to Michael Miller at Community Catalyst, is whether the health insurance exchanges will be run by the federal government, as the House bill specifies, or by state governments, as the Senate bill calls for.

Henry Waxman, D-CA, is making the case for fighting for a national exchange. But although Miller understands the reasons for that preference, he maintains that the issue is a wash and ascribes some advantages to state exchanges.

Raul Grijalva, head of the House Progressive Caucus

Sure, a national exchange would offer uniformity and perhaps lower administrative costs. And some states might do a poor job of implementation. (Indeed, with the Missouri Republican legislature’s hostility to the whole program, our state might well fall into that group.) Another reason to favor a national exchange is that it “would have somewhat better negotiating leverage with national insurance plans, at least in small states.”

But the price tag difference between a national Exchange and state Exchanges is likely less than many proponents of a national Exchange who tout a federal model’s savings believe.  The bulk of health care costs are determined by underlying local conditions, and a national Exchange will have little influence over those factors.  In addition, while it’s likely that states will vary in how well they rise to the new challenge, at least some are likely to do an excellent job.  If a future federal administration were to be hostile to health reform, the entire Exchange for the whole country could be undermined; recall that this was a problem for many executive agencies in the previous administration.

Furthermore, a national exchange is no more likely to guard us against undue influence from the health insurance industry than states are. In fact, people might be better able to resist such intrusion working at the state level. Perhaps they would stand a better chance of making their state reps listen to them than getting their congressman to hear them. Again, though, with Missouri’s Republican legislature–as ethically challenged as it often is–I’m not so sure we consumers would be able to make ourselves heard effectively.

No, what Miller would like to see the House concentrate on is keeping some of the rules that would govern the Exchange from their own bill. What matters most isn’t so much whether the states or the feds run the Exchange, but whether the rules that govern it sufficiently regulate health insurers.

So, for example, it’s important that the rules forbid any conflict of interest. No one on the governing board of the Exchange should have ties to health insurance or even to hospitals or doctors’ groups. Furthermore, the Exchange’s business should be subject to open meeting laws and provide for customer representation in their governance.

It is also important not to carve insurance markets up into distinct pieces: for instance, not to split up non-group and small-group insurance, or allow separate risk pools to operate both within and outside the Exchange.

In other words, the bill must not allow insurers to divide and conquer, or, put another way, to divide and charge more.

The bill should also empower the Exchange to exclude insurers if it is determined that they do not meet standards for providing good value.

On many of these issues, the House does in fact do better than the Senate, as well as on matters  of insurance regulation such as limiting rate variation based on age and clearly eliminating annual and lifetime limits on coverage.

Bottom line? If the House wants to fight about Exchanges, they should focus on the issues that matter most.

(photo of Grijalva courtesy of Wikimedia)