US health-care reform by numbers

We go behind the figures that have dominated debate on the Senate bill

The US Senate has voted in favour of the historic health-care reform bill today. The bill -- which some critics say has been heavily compromised and others say not enough -- must now be reconciled with a different version passed by the House of Representatives, a process that will begin in mid-January.

This landmark move follows months of political wrangling. It has been a process characterised by vicious partisan debate, wildly varying figures and exaggerated statements (remember the controversy over the NHS having "death panels"?). Here, we go behind the numbers to see what the costs will be, who stands to benefit, and what's been going on behind the scenes.

On 19 November, the Senate majority leader, Harry Reid, unveiled the health-care bill. He said that it would cover 94 per cent of the population, extending coverage to 31 million uninsured people, at a cost of $848bn over ten years.

Are there really 31 million people uninsured?

The number is actually much higher, but the question of which of these people are deserving of government assistance is hotly disputed.

According to the US Census Bureau, there were 47 million people who at some point had no insurance at all in 2009. That's more than 15 per cent of the population. However, the uninsured is a fluid group, and this oft-quoted figure includes the short-term uninsured -- those between jobs, or recent immigrants.

The non-partisan Kaiser Family Foundation found that 79 per cent of these people are American citizens (the remainder are immigrants). Two-thirds of those citizens are near or below the poverty line.

The figure of 31 million in the bill is less than the overall number of 47 million, because the bill is aimed at the long-term uninsured, and caters for US citizens only.

Republicans have disputed the figure, claiming that when you remove nine million non-citizens, about ten million covered by Medicaid or other contingency plans, five million childless adults (apparently not deserving of health insurance) and ten million who are a comfortable distance from the poverty line, the number of those actually uninsured is 10.6 million.

Where did the $848bn figure come from?

The Congressional Budget Office (CBO) cost element of $848bn given by Reid was cut down -- at least in part -- by delaying many elements of the bill from 2013 to 2014. The delayed elements include the establishment of insurance exchanges and subsidies for the poor.

But where is the money coming from?

This is a crucial difference between the bill in the Senate and the one in the House of Representatives. Let's deal with the Senate bill (the one voted on today). Most of the funding for this would come from a tax on high-end, or "Cadillac" insurance. It would be assessed for plans valued at $8,500 for individuals or $23,000 for families, with higher thresholds for high-risk workers and people living in states with costlier premiums.

There would also be an increase on Medicare payroll tax for top earners, with the rate rising from 1.45 per cent to 1.95 per cent for couples earning more than $250,000. A 5 per cent tax would be levied on elective cosmetic medical procedures.

What about the claim that health care will consume 20 per cent of GDP by 2017?

First, it's worth noting that the Centres for Medicare and Medicaid Services, which made this claim, said pretty much exactly the same thing in 2006 (slightly different figures, same conclusion).

It's not true. A study in the journal Health Affairs, published in August 2008, found that covering all of the uninsured within the existing private-based US health-care system would increase national spending on health care by $122.6bn, which would represent a 5 per cent increase in health-care spending, amounting to 0.8 per cent of GDP. It included the caveat that the details of the plan could push government spending higher.

Dr Leonard Rodberg, a US academic, gave testimony to the Congressional Forum on National Lessons for Health Reform in April this year. He argued that a single-payer national health insurance plan would not cost the US any more than it was already spending, while providing every American with comprehensive health care and building in mechanisms to contain future growth in costs.

On the subject of rising costs, the Kaiser Family Foundation found that family insurance premiums (currently paid partly by employers and partly by the employee) will average $30,800 by 2019, if increases stick to the average of the past ten years. This year, the average premium for a family policy offered at work was $13,300, up from $5,800 in 1999.

The money behind the scenes

America's lobby groups are notoriously powerful, and the health-care industry is a big hitter. It has spent hundreds of millions of dollars this year alone.

Most of this goes on donations to strategically important politicians. Senator Joe Lieberman, an independent who caucuses with the Democrats, has received more than $110,000 in donations from a single health insurance company, Aetna, this year alone.

There are six registered health-care lobbyists for every member of Congress.

Meanwhile, the Obama administration has been offering financial incentives of its own. The government will fund Medicaid, the insurance plan for the poor, in Nebraska -- led by Senator Ben Nelson, one of the most conservative Democrats -- at a reported cost of $100m.

It has also been reported that Vermont will receive $600m over ten years, while Massachusetts will receive $500m.

 

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Samira Shackle is a freelance journalist, who tweets @samirashackle. She was formerly a staff writer for the New Statesman.

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Is defeat in Stoke the beginning of the end for Paul Nuttall?

The Ukip leader was his party's unity candidate. But after his defeat in Stoke, the old divisions are beginning to show again

In a speech to Ukip’s spring conference in Bolton on February 17, the party’s once and probably future leader Nigel Farage laid down the gauntlet for his successor, Paul Nuttall. Stoke’s by-election was “fundamental” to the future of the party – and Nuttall had to win.
 
One week on, Nuttall has failed that test miserably and thrown the fundamental questions hanging over Ukip’s future into harsh relief. 

For all his bullish talk of supplanting Labour in its industrial heartlands, the Ukip leader only managed to increase the party’s vote share by 2.2 percentage points on 2015. This paltry increase came despite Stoke’s 70 per cent Brexit majority, and a media narrative that was, until the revelations around Nuttall and Hillsborough, talking the party’s chances up.
 
So what now for Nuttall? There is, for the time being, little chance of him resigning – and, in truth, few inside Ukip expected him to win. Nuttall was relying on two well-rehearsed lines as get-out-of-jail free cards very early on in the campaign. 

The first was that the seat was a lowly 72 on Ukip’s target list. The second was that he had been leader of party whose image had been tarnished by infighting both figurative and literal for all of 12 weeks – the real work of his project had yet to begin. 

The chances of that project ever succeeding were modest at the very best. After yesterday’s defeat, it looks even more unlikely. Nuttall had originally stated his intention to run in the likely by-election in Leigh, Greater Manchester, when Andy Burnham wins the Greater Manchester metro mayoralty as is expected in May (Wigan, the borough of which Leigh is part, voted 64 per cent for Brexit).

If he goes ahead and stands – which he may well do – he will have to overturn a Labour majority of over 14,000. That, even before the unedifying row over the veracity of his Hillsborough recollections, was always going to be a big challenge. If he goes for it and loses, his leadership – predicated as it is on his supposed ability to win votes in the north - will be dead in the water. 

Nuttall is not entirely to blame, but he is a big part of Ukip’s problem. I visited Stoke the day before The Guardian published its initial report on Nuttall’s Hillsborough claims, and even then Nuttall’s campaign manager admitted that he was unlikely to convince the “hard core” of Conservative voters to back him. 

There are manifold reasons for this, but chief among them is that Nuttall, despite his newfound love of tweed, is no Nigel Farage. Not only does he lack his name recognition and box office appeal, but the sad truth is that the Tory voters Ukip need to attract are much less likely to vote for a party led by a Scouser whose platform consists of reassuring working-class voters their NHS and benefits are safe.
 
It is Farage and his allies – most notably the party’s main donor Arron Banks – who hold the most power over Nuttall’s future. Banks, who Nuttall publicly disowned as a non-member after he said he was “sick to death” of people “milking” the Hillsborough disaster, said on the eve of the Stoke poll that Ukip had to “remain radical” if it wanted to keep receiving his money. Farage himself has said the party’s campaign ought to have been “clearer” on immigration. 

Senior party figures are already briefing against Nuttall and his team in the Telegraph, whose proprietors are chummy with the beer-swilling Farage-Banks axis. They deride him for his efforts to turn Ukip into “NiceKip” or “Nukip” in order to appeal to more women voters, and for the heavy-handedness of his pitch to Labour voters (“There were times when I wondered whether I’ve got a purple rosette or a red one on”, one told the paper). 

It is Nuttall’s policy advisers - the anti-Farage awkward squad of Suzanne Evans, MEP Patrick O’Flynn (who famously branded Farage "snarling, thin-skinned and aggressive") and former leadership candidate Lisa Duffy – come in for the harshest criticism. Herein lies the leader's almost impossible task. Despite having pitched to members as a unity candidate, the two sides’ visions for Ukip are irreconcilable – one urges him to emulate Trump (who Nuttall says he would not have voted for), and the other urges a more moderate tack. 

Endorsing his leader on Question Time last night, Ukip’s sole MP Douglas Carswell blamed the legacy of the party’s Tea Party-inspired 2015 general election campaign, which saw Farage complain about foreigners with HIV using the NHS in ITV’s leaders debate, for the party’s poor performance in Stoke. Others, such as MEP Bill Etheridge, say precisely the opposite – that Nuttall must be more like Farage. 

Neither side has yet called for Nuttall’s head. He insists he is “not going anywhere”. With his febrile party no stranger to abortive coup and counter-coup, he is unlikely to be the one who has the final say.