Length of Health Care Reform Bills Silliness

It is both amusing and disappointing to see the silliness that surrounds the serious issue of health care reform.  Examples abound: calls for keeping the government out of Medicare (a government-run health plan, for those keeping score at home); claims that a government-run plan will usher in an era of lower medical premiums buying better coverage; promises of death panels; and the list goes on.

The foolishness that seems to crop up most often are criticizing the bill for being too long. Some opponents of the bill have taken to printing out the 2,074 page Senate Health Care Reform bill (even longer than the House health care reform legislation which came in at 1,990 pages) and lugging it around on their shoulder. Or taping the pages together and rolling the result down the Capitol steps. The theory, apparently, is that health care reform is such a simple problem, it should be easy to accomplish in just a few pages.

I wrote about the importance of looking at what the bill does, rather than how long it takes to do it, in a previous post. But now the Associated Press has actually put things into (numerological) perspective. Here’s what the AP reports concerning the literal size of the health care reform bills being considered by Congress.

  • The House health care reform legislation, HR 3962, is 319,145 words.
  • The Senate health care reform bill, HR 3590, is 318,512
  • The No Child Left Behind Act (supported by many of those criticizing the health care reform bills) was over 280,000 words.
  • English translations of War and Peace, which some critics has claimed is shorter than the Democratic health care reform bills, are 560,000-to-670,000 words.
  • When published in a more normal fashion than formal bills are (single spaced, normal font, regular margins) the bill comes to 209 pages.

Here’s some other meaningless statistics:

The Harry Potter series totaled 1,090,739 words. The longest: Order of the Phoenix at 257,045 words.

The Old Testament has 593,493 words; (No idea which English translation the source used).

How many words would it take to legislate the status quo? Considering the need to create Medicare, Medicaid, Veterans health care, regulate the private market, etc. etc., my guess is we’re talking about reams of paper.

Let’s focus on what matters – what the legislation does – not how many words it takes to do it. There’s plenty of substantive issues to debate. And now’s the time to do it.

Obama Administration Presents State-by-State View of Status Quo and Impact of Health Care Reform

Most readers of this blog understand the benefits and problems of the health care system status quo. And they can make an educated guess at how the various health care reform proposals will impact their world. Most voters (and much of the media, I might add), don’t have as informed a view on these issues.

Into this vacuum comes the Obama Administration with a state-by-state description of the current health care system in the jurisdiction and its view as to the benefits health care reform will deliver to the states’ residents.

Yes, the site is aimed at building support for health care reform. Still, it provides some interesting data and observations. For example, it warns that the “amount of uncompensated care provided will more than double in 45 states” by 2019 as the number of uninsured grows by at least 10 percent in every state and by more than 30 percent in 29 states.

It’s worth spending some time. You may disagree with some of what’s presented. And some of it is inaccurate — it claims, for instance, that health care reform would establish a high risk pool in California, but the state already has one. And it seems to imply that 100% of the individual market would buy through the exchange, something no one is claiming (that I’m aware of). So read it with a handful of salt. However, the reports do provide an interesting, more granular glimpse into health care in America than is usually available. And the more detailed look we all give to reform, the better.

Senate Health Care Reform Still Alive, But Likely to Change

The Senate has just spent most of today (Saturday) engaging in a debate on whether to allow a debate on comprehensive health care reform. Later this evening 58 Democrats and 2 Independents will vote to allow Majority Leader Harry Reid’s health care reform bill come to floor for debate and consideration of amendments. 40 Republican Senators will vote unanimously against allowing this to happen. Senator Reid’s Patient Protection and Affordable Care Act is still alive. It is unlikely to survive in its current form for long, however.

Don’t get me wrong. Tonight’s vote is significant, very significant.  The vote is a test of President Barack Obama’s and Senator Reid’s ability to line up enough votes to keep the bill alive.  The debate leading up to the vote has been an opportunity for Republican Senators to present their opposition to HR 3590. (Yes, the Senate has taken a bill passed by the House and moved to the Senate, gutted that language and substituted their health care reform package. Consequently, the Senate legislation has a House bill number.) And the vote to allow debate has served as an action forcing event, sort of, for Democratic moderates.

Those moderates could have sided with the Republicans killing the bill before it could be brought to the floor. Instead, they joined with their liberal colleagues and kept health care reform alive. While there are 18 moderate Democratic Senators (including Senator Joe Lieberman, who is an Independent), it eventually came down to three:  Senators Mary Landrieu, Blanche Lincoln and Ben Nelson. All three made clear they would seek amendments to the bill before voting for it. And all three are among those moderates making it clear further changes to the Patient Protection and Affordable Care Act is necessary before they’ll commit to voting for it.

We’ll learn more about the changes moderates will demand over the several weeks before a final vote on health care reform is held in the Senate.  Democratic leaders are hoping to hold that vote before the end of the year. The legislation would then move on to a conference committee that will attempt to reconcile it with legislation the House passed earlier this month.  More importantly, that conference committee, made up of an equal number of Senators and House members, will seek to fashion legislation they hope will earn the support of a majority of House members and 60% of Senators. As I’ve noted before, passage of legislation by the Senate is merely the final playoff game. The World Series — the conference committee — is yet to come.

Uniting the Democrats to allow debate on health care reform is a victory for the Obama Administration and for Senator Reid personally. That it took this much effort, however, demonstrates the challenges they yet face. Republicans appear to be uniting in opposition to the legislation. Even Senator Olympia Snowe, who voted for a health care reform bill in the Senate Finance Committee, is expected to vote against bringing HR 3590 to the floor.

I’ve written before about the power moderates have to determine if health care reform legislation will pass Congress and what the final bill will contain.  Now we’ll see that power put forward. Some of what they’ll ask for will be parochial. (That there’s a provision in Senator Reid’s bill that would send additional Medicaid money to Senator Landrieu’s state of Louisiana is neither a coincidence or accidental). But most of their demands wil concern public policy issues. Moderate Democrats tend to be more fiscally cautious than their more liberal colleagues, giving them pause to legislation that greatly expands governmental powers,  spends nearly a trillion dollars over the next decade and taxes corporations and individuals to pay for it. These are the issues on which they will focus.

Republicans will have their own pet issues, but those are unlikely to influence the outcome. Having already declared their unmoving opposition to any health care reform Democrats could claim keeps their campaign promises, the GOP has removed themselves from negotiations. (A couple of the Republicans, most notably Senator Snowe and her colleague from Maine, Susan Collins, might vote what moderate Democrats fashion. But whether they’ll be able to insert provisions without committing to voting for the bill if their amendments are accepted is unlikely. 

We don’t know yet what changes to HR 3950 moderate Democrats will demand, but the possibilities are extensive. They could eliminate a public option — or at least postpone its implementation until after other reforms have had a chance to take effect. They could  demand additional cost containment provisions. They could strengthen — or weaken — the requirement that all consumers obtain coverage. Certainly they will modify what taxes and fees are imposed to pay for health care reform.

What’s important to remember is that moderate Senators will have two shots at the bill. They’ll extract as much as they can during the current Senate debate. Then at least two or three of them are likely to agree to vote for the bill “in order to keep the process moving forward.” However, they’ll also make clear they want significant changes made to the legislation by the conference committee before they’ll commit to a vote that would place the legislation on the president’s desk. Liberals will insist they have compromised all they can, but in reality, the moderates (and the liberals) know that the progressives are likely to accept any legislation that can be called “health care reform” with a straight face. And as politicians, they have great skill in passing the straight face test.

Yes, Democrats have won the debate on whether to debate health care reform. What legislation eventually emerges from the Senate, if any, is still uncertain.

Health Care Reform’s Likely Outcome: Worse Than Promised; Not as Bad as Feared

As the Senate begins their effort to pass health care reform anxiety levels are, quite naturally and rightly rising. Health care is highly personal. For those of us working within the current framework, having politicians mess with our livelihood is a stressful to say the least. That these politicians (both Democrats and Republicans) seem to care less about the substance of the reform and more about how they appeal to their electoral base does nothing to reduce that stress.

Of course, what we’re reacting to at this stage is not the final reform legislation. The House and Senate proposals foreshadow what Congress will eventually pass (if it passes anything). The actual legislation is still to come. Put another way, we know the basic outline, but the devil resides in a suburb of the details. As I pointed out in my previous post, however, the real drafting of health care reform legislation hasn’t started yet. With the Senate taking up the issue we’re seeing the end of the legislative phase in which the parameters are defined. It’s in the upcoming conference committee that will define health care reform 2009-style (or, more likely, early 2010).

Concerning that prior post, Ron Masters, a friend and frequent reader/commenter of this blog, took me to task for writing too kindly about the current House and Senate versions of health care reform. “I’m surprised that you seem to feel that either of these bills are any good,” he write. This after a litany of shortcomings concerning the current administration, the ability of government to deliver much of anything, and the foolishness of imposing taxes and creating new entitlements in the midst of the current economic mess. And he makes some fair points.

He’s not alone. I’ve heard from a lot of brokers, readers and others who are convinced the coming health care reform will be a disaster leading to ruin and damnation for the country. I disagree. Here’s why.

As any reader of this blog knows, I don’t buy into the premises of those at the extreme. Not all government programs are good, but some are. Not all taxes are bad, but some are. Change is important, but getting change right is more important. Defending the status quo just because it is the status quo is indefensible. In other words, I’m comfortable with the gray shades of reality and uncomfortable with the black-and-whites of true believers.

I’m also comfortable with the government doing stupid things now and then. No party and no administration has a monopoly on such foolishness. (Nor has any party or administration failed to achieve some truly noble accomplishments). What’s more, no administration lasts forever. Whatever health care reform passes in the next few months will be administered by a parade of future administrations and modified by Congresses yet to-be-elected. Many people have a tendency to believe whatever Congress passes and how the current administration implements it will remain unchanged forever. It won’t. Medicare was vilified as socialistic and a fast slide toward America’s ruin when it was being created. Things didn’t work out that way. The program has survived for nearly 45 years under the administrations of Presidents Johnson, Nixon, Ford, Carter, Reagan, Bush-the-first, Clinton and Bush-the-second. Yes, it is a far from perfect program and faces significant challenges. Still, it works, it’s evolved and it will continue to do so. And the country has survived.

Another reason I’m not outright opposed to health care reform is because I believe expanding access to health insurance is critically important. It is well understood that everyone in America has access to health care. But it is also well documented that people with health insurance live healthier, longer lives. A recent study by researchers at Harvard Medical School confirmed an earlier study from the 1980’s that “uninsurance is associated with mortality.” That’s an awkward way of stating a well-accepted truism: being uninsured can be hazardous to your health.

Expanding coverage, however, is expensive. The more people who have coverage the more people who will incur medical expenses. That is after all, the whole idea and a desirable outcome. It’s also an expensive outcome. In my mind, it’s a price worth paying. Especially considering the potential return on this investment.

Those with insurance are already making heavy payments to pay for care received by the uninsured according to a study by Families USA. In 2008, the study reports, nearly $43 billion of health care the uninsured received from hospitals, doctors and other providers went unpaid. This uncompensated care results in higher premiums for those with coverage. In 2008 this hidden tax increased premiums $368 for single coverage and $1,017 for family coverage. Given the recession, this amount has no doubt gone up. Increasing the number of Americans with insurance should reduce this burden.

Early identification of potential health conditions before they blossom into serious diseases can generate tremendous economic benefits, although these savings are rarely considered in a cost-benefit analysis. Every dollar invested in preventing and treating heart attacks generates $7 in increased productivity, according to a study by United BioSource Corporation.

In other words, it’s not just the reform bills being considered in Washington that are expensive. So is the status quo. Health care costs are crippling businesses, bankrupting families and state governments, enabling fraud and abuse, increasing taxes, and failing to deliver on many of its promises. Change is inevitable – and it’s coming.

Too many in Washington believe (or at least claim to believe) that reforming the health insurance industry will reduce the cost of coverage. Far from it. The bills being considered in Congress will cause premiums to increase. Until Congress tackles the underlying causes of skyrocketing medical costs, health insurance coverage will become increasingly unaffordable. The House and Senate health care reform bills do have more cost containment provisions than is generally acknowledged. Could they be stronger and more ambitious? Yes. Are obvious cost containment opportunities missing (e.g., malpractice reform?) Yes. But they’re there. And future efforts to restrain medical costs will benefit from the seeds planted in the current reform debate.

Which brings us, I suppose, to the key question: are the House and Senate health care reform bills good? No, not really. They’re too heavy handed, using an axe when a scalpel is required. As noted, their cost containment provisions are weaker than the American people deserve. The bills reflect a misunderstanding of how health insurance works and about what drives premiums. The costs for the program are no doubt understated (few initiatives of this magnitude, whether attempted by government or business, come in under budget).

If either the House or Senate bills were the final legislation I’d be more concerned than I am now (and, for the record, I am concerned). But neither HR 3962 nor Senate Majority Leader Harry Reid’s proposal are going to be enacted, not as currently written. I believe the conference committee will need to make significant changes in order to get the votes needed for passage – if that’s even possible.

There are plenty of substantive problems with these health care reform proposals. To make matters worse, their backers and opponents are knowingly overpromising or attempting to frighten the public. Democrats claim their reforms will reduce overall health care costs, lower premiums and reduce the deficit. Wrong on all counts. Republicans claim it will destroy American businesses, annihilate Medicare, create death panels and bankrupt the country. Just as wrong.

We’ve seen this script before concerning Medicare, Iraq, and a host of other issues. Partisans on one side over promise, their opponents dredge up scenarios of doom. That both sides are equally guilty makes it no more acceptable or welcome. But it is what it is.

The main point of my previous post, and of this one, is that if reform passes, it will not be as bad as feared nor as good as promised. It will be refined sooner (by regulation) and later (by future legislation). The fight for a better health care system will continue. Only the status quo will have changed. The need to improve on it will remain.

House and Senate Health Care Reform Bills Mark the Beginning of the Endgame

Senate Majority Leader Harry Reid is unveiling his health care reform plan after it received passing grades from the Congressional Budget Office. Whether he has the 60 votes he needs to bring the bill to the floor is still an open question, but odds are he’ll have the votes when he needs it, perhaps by this weekend.

Then the fun begins. Senators will debate the bill, offer amendments, vote on those changes, and finally craft a bill. If Senator Reid and his allies play their cards well, they’ll have the 60 votes needed to allow a vote on the legislation. (Yes, before there’s a vote there’s a vote on whether to have a vote – you’ve gotta love democracy). Only then will the Senate make history and pass health care reform.

Of course, what the Senate passes and what becomes law are two different things. Just as passage by the House of Representatives of HR 3962 was only a prelude to what will be the act of drafting the “real” health care reform bill.

Many have tried, but only President Barack Obama, Speaker Nancy Pelosi and Senate Majority Leader Harry Reid have gotten this far with health care reform. What they’ve accomplished is historic and Herculean. Whether you support or oppose their bills, respect for their accomplishment is appropriate. But getting this far is not the end. Well, it’s the end of the beginning. And it brings us closer to the beginning of the endgame.

The legislative process involves several stages. In the beginning there’s a lot of sincere questions being asked as lawmakers seek information, float trial balloons, and generally get a lay of the political landscape and the issues. During this phase there are a lot of options on the tables, including the most extreme positions (e.g., do nothing or enact a single payer system).

This phase was also when it became clear that, for the most part, Republicans were as interested in defeating “Obamacare” as they were in reforming the health care system. By publicly declaring so early in the process they would oppose any legislation containing provisions dear to the Democrats, the GOP effectively removed themselves from the deliberations. Why, after all, would Democrats negotiate with a party that had made clear they would oppose anything other than their own proposals?

Of course, Republicans could ask the same question of the Democrats (and do). The difference is that Democrats are in the majority in Congress. So if the two parties go their separate ways, the Democrats could still, under the right circumstances, pass a bill. In other words, it’s their bat and ball, so if the Republicans stalk off the field, the game continues.

In the second legislative phase the House and Senate committees with jurisdiction on health care weighed in. General concepts became legislative language. Lawmaker’s inclinations became public votes. Options feel by the wayside. (This is the phase in which the possibility of enacting a single payer system was formally laid to rest).

What the committees produced generated a lot of concern, anger and raucous  objections. Apparently some folks thought someone in Washington really thought these bills would become law. Nope. What the committees were producing were negotiating positions, not laws. Everyone had their eye on the main battle to come in the fourth phase. They were setting up their arguments, gathering their support for the real showdown.

Before the showdown, however, we have to get through the current phase, phase three. In this portion of our program, ideology and public policy take a back seat to a very practical concern: what needs to be in the bill – and what needs to stay out of the legislation – in order to get enough votes to pass it.

Senate Majority Leader Tom Daschle describes this process as shoveling frogs into a wheelbarrow. Speaker Nancy Pelosi’s job: craft a bill that could get 218 members of the House into her wheelbarrow. She succeeded by cobbling together legislation that is an abomination to many of the House Members who voted for it.

Senator Reid’s task: to get 60 Senators into his wheelbarrow. To do that he’s pared back provisions (such as on a government-run plan) in ways that only three weeks ago liberals would have labeled a betrayal (and some still do. Of course, those progressives complaining about the compromises Senator Reid has made tend not be in the Senate. Because liberal Senators understand the process. If they need to accept a weakened public insurance program to help Senator Reid keep 60 frogs in the wheelbarrow, so be it.

Why do liberal House members vote for a bill they consider an abomination and progressive Senators accept compromises that were absolutely unacceptable a few weeks ago? Because this is the phase where it’s about getting something passed, not public policy.

If the Senate passes Senator Reid’s health care reform legislation, the fourth phase begins. A conference committee will be created made up of members of the House and Senate. Their task: to meld together the House and Senate proposals into a single bill for which Speaker Pelosi and Senator Reid can shovel enough frogs into their respective wheelbarrows to pass.

Think about that challenge. A single bill that can get majorities in both chambers. That won’t be easy. The process won’t be pretty. Decisions will be made based on factors outside of health care reform.

Take Senator Joe Lieberman. He’s on record declaring his opposition to a government-run health plan is a matter of conscience. His history makes clear he loves being Chair of the Senate Homeland Security and Governmental Affairs Committee. Keeping the chairmanship he loves may require him to bend his conscience a bit. Yes, who chairs a particular committee has nothing to do with the substance of health care reform. But it has everything to do with the politics of health care reform.

(By the way, I’m not saying Senator Lieberman has been threatened with losing his chairmanship unless he agrees to let health care reform come to a vote in the Senate. But if it turns out he was, no one should be surprised. Hardball is a sport played by both parties. And  the higher the stakes, the harder the ball.)

Given the nature of the issue and the politics, the conference committee will forgo public policy debates and focus on fashioning a compromise that majorities of the frogs – I mean, lawmakers – in each chamber can support. This means what the House passed and what the Senate may pass are now the extremes in the health care reform debate. Compromises, after all, tend to wind up in the middle of two poles. The Congressional leaders making up the conference committee will try to establish a middle ground on which their needed majorities can stand. Their building blocks will be what it takes to get the bill passed. That the result may be messy, perhaps even unworkable is of less concern. There will be time enough to fix those problems.

Getting reform right was for an earlier phase in the process. And by eliminating some of the more extreme ideas, by establishing the boundaries of reform, those phases assured that public policy considerations would have an impact on the final legislation. But that was then. In this final phase of the legislative process it’s is about getting reform. Period.

In short, the health care reform process to date has been fascinating and important, but it’s main purpose has been to define negotiating positions. We’ll see the end of the beginning of health care reform if and when the Senate enacts its version of reform.

Only when the conference committee convenes, however, do we move into the beginning of the endgame, the point where the drafting process of health care reform begins in earnest.

Liberal’s Approach to Health Care Reform Made Abortion Controversy Inevitable

Democrats paid a heavy toll to keep health care reform moving forward. They were forced to accept substantial and virtually unprecedented limits on abortion coverage in order to get the Affordable Health Care for America Act through the House of Representatives. This result should awaken them to the need to rethink their approach, but it assumes they learned the key lesson: where government goes, ideology follows.

Speaker Nancy Pelosi needed 218 votes to make history: passage by the House of the Affordable Health Care for America Act. Liberals got her most of the way there, but to get across the finish line Speaker Pelosi needed support from moderates and conservatives. This meant cutting a deal with the pro-life caucus. The result: HR 3962 prohibits the government-run medical plan and coverage offered through the health insurance exchanges the bill would create from covering elective abortion procedures. Liberals are furious, but to pass health care reform they had to accept this restriction as part of the package.

This post is not about the politics or morality of abortions. Readers of this blog are on both sides of this issue. This blog is about health care reform and what happened to HR 3962 concerning abortion highlights one of the greatest pitfalls in Democrats approach to reform. If they continue down the road they are on, increasing the amount of America’s health care system government directly controls and manages, the party is guaranteeing that similar defeats on similar public policy issues is all but a certainty. The issue today is abortion. In the future it could be access to birth control. Or making coverage available to domestic partners. The fact is, government-run health care does not and cannot exist in a vacuum. Politics and ideology inevitably come along for the ride.

The final health care reform bill may loosen the prohibition on abortion coverage contained in the House bill. But if the restrictions are diminished, it will be because Democrats led by Speaker Pelosi and Senate Majority Leader Harry Reid are in control of Congress and President Barack Obama occupies the Oval Office.

For now.

Eventually conservatives will be in power again. No party or ideology dominates America’s politics forever. And a conservative government will not hesitate to use the tools given to it by Democrats to push forward their agenda merely because those tools were created by liberals. 

No one should be surprised about this political reality. In a post back in August 2007 I warned single payer advocates that a government takeover of health insurance would open the door to ideology meddling by conservatives. And in August of this year I reminded liberals that while Democrats are ascendant today, politics, like a pendulum, eventually changes direction. “In 2001 the President was George W. Bush, the Senate Majority Leader was Trent Lott and the House Speaker was Dennis Hastert (just two years earlier it had been Newt Gingrich). Their view of how a public health plan should work – what it covers and who it benefits – varies considerably from the Obama/Reid/Pelosi view. Yet the greater the role liberals give the government over health care, the more control over issues like abortion conservatives like Bush/Lott/Hastert will have when they take power again – and eventually, they will.”  And I’m hardly the only observer to state this reality.

So Democrats face a critical choice. They can pursue their health care reform goals care by increasing government’s direct participation in the market or by looking to the regulations the government imposes on the market.  One opens the door wide to groups of lawmakers holding health care reform hostage to unrelated public policy issues; the other narrows this opening.

For example, lawmakers want to prohibit carriers from denying consumers coverage because of their current or previous health conditions. Creating a health insurance exchange is one method of achieving this goal, but it is not the only way. And alternatives limit the opportunity for ideological meddling in Americans’ lives.

Yes, a public plan would increase competition in the market (a primary justification for a government-run plan), but so would health insurance co-operatives. And as non-government entities, co-operatives would be less susceptible to partisan interference.

By focusing on their goals and being careful of their methodology for achieving them, Democrats can have their health care reform and limit the price they’ll pay on other issues. Or they can continue down a road in which accepting limits on abortion coverage is merely the first of many heavy and painful tolls they will pay.

House Health Care Reform Passes, But It’s Far From the Last Word

History was made on November 7th when the House of Representatives passed HR 3962, the Affordable Health Care for America Act. Yes, it was a close vote (220 in favor versus 215 opposed). Yes, only one Republican voted for the bill. Yes, the legislation leaves a lot to be desired. At the end of the day, all that matters is that the legislation passed. President Barack Obama’s health care reform initiative remains alive and is closer to reality than the efforts of his predecessors. Given the complexity and controversy surrounding the issue, not to mention the competing demands of numerous, powerful stakeholders, this is a remarkable achievement.

While historic and remarkable, however, it’s important not to read too much, or too little, into what happened. Consider:

House Passage of Health Care Reform Puts Pressure on the Senate: It’s probably hard for Republicans to understand the importance of health care reform to Democrats. I suppose it’s the equivalent of a tax decrease to the GOP. It’s a defining issue, in the sense that the issue differentiates themselves from the other side. When Republicans controlled the White House and Congress they lowered taxes. They could have made a major push behind health care reform during their years in power, but that’s not where Republicans were willing to invest the political capital in health care reform, not when it could be put behind cutting taxes. Democrats now control the Executive and Legislative branches. And they are investing their political capital where their heart is: health care reform.

Which means if you’re a Democratic Senator you do not want to be the reason health care reform fails. No doubt some members of the Senate were quietly hoping the vote in the House would fall short, letting them off the hook. No such luck. Now it’s up to Senate Democrats to keep the dream of health care reform alive.

HR 3962 is Not on the President’s Desk: Nor is it likely to ever get there.  What the Senate will pass is not likely to look a lot like the Affordable Health Care for America Act, either. The politics in the Senate are far different from that in the House. Consider the idea of the government creating – and maintaining – a health plan to compete with private carriers. Senator Joe Lieberman reiterated his threat to vote against allowing a reform bill containing a government-run plan to come to a vote on the Senate floor, according to the Associated Press. Unless his 60th vote is replaced by a Republican (think Senator Olympia Snowe) Democrats will be unable to overcome a GOP filibuster with Senator Lieberman’s vote.

Of course, as noted in an earlier post, Senator Roland Burris is threatening to prevent a bill without a public insurance plan to come to a vote. So Senate Majority Leader Harry Reid has to craft a package that satisfies a diverse and divided caucus (Senator Lieberman is an Independent, but he caucuses with Democrats in order to hold on to his committee chairmanship). Senator Reid has already submitted a proposal to the Congressional Budget Office for review. (That the CBO has yet to issue an analysis is widely taken as evidence the cost of the legislation is higher than Senator Reid is counting on, meaning adjustments will be required). Meaning …

The Senate Will Pass a More Moderate Bill. Whatever Senator Reid puts before the Senate, it will be more moderate than HR 3962. Moderates hold more power in the Senate than they do in the House. Leaving aside Senator Lieberman, passage of health care reform in the Senate will need to satisfy 17 moderate and conservative Democrats. While several of these Senators have already pledged their support to the legislation outlined (but not published yet) by Senator Reid, there’s enough hold-outs to force concessions that will disappoint liberals. Yet those liberals are unlikely to vote against health care reform and accept blame for defeating this core Democratic issue. (Senator Burris is an exception for reasons discussed in the previous post).

When the Senate Acts Will Be When Democrats Have 60 Votes:  Warner Pacific, a general agency based in California, held a series of town hall meetings last week featuring former Senate Majority Leader Tom Daschle. John Nelson, co-CEO of Warner Pacific, interviewed Senator Daschle for roughly 90 minutes and the result were numerous, meaningful insights which I’ll try to write about in future posts. But one observation Senator Daschle offered is relevant here. When it comes to passing legislation, the Senator described the role of the Majority Leader and House Speaker as shoveling frogs onto a wheelbarrow. Why did the House vote on health care reform now instead of waiting to learn more details concerning the Senate legislation? Because Speaker Nancy Pelosi had finally managed to fill the wheelbarrow with at least 218 votes and the longer she waited the more likely it was one of them would jump out.

Speaker Pelosi had a somewhat easier task than the one facing Senator Reid’s. She needed to muster a simple majority and the rules of the House gives her more power than Senator Reid enjoys in the upper house. Plus he needs to shovel a super-majority of 60 frogs into his wheelbarrow.  Once he marshals the votes, however, expect the Senate to act relatively quickly. And don’t expect a vote to be scheduled until Senator Reid is reasonably confident he will prevail. Once that happens, however, the Senate will likely pass their health care reform legislation. Then …

It’s the Conference Committee That Matters: Getting health care reform this far has required a Herculean effort by lawmakers and the White House. And it’s all aimed at getting two bills to a Senate-House conference committee. That’s where the final deals will be struck, losers and winners defined, and the political calculation made as to what single bill can be passed by both chambers of Congress.

For brokers, one of the issues to watch will be related to the health insurance exchange reform will create. In the Senate bill, at least for now, there’s a provision to require those selling products in the exchange to be licensed by their state; the House bill permits unlicensed entities to sell the products. (Ironically, the House approach, which would let DMV clerks sell health insurance in the exchange is supported by some Republicans in the Senate).

The conference committee will determine the taxes implemented to finance reform, what mandates are in place and how they’re enforced, whether there’s a government-run health plan, what cost containment provisions are included, and whether reform addresses malpractice – among other items. In other words, while everything leading to the conference committee is important, it has all been prelude.

To use a baseball analogy, think of the general discussions and hearings earlier this year as Spring Training. The committee votes were the regular season. The vote in the House was a league playoff and now we await the outcome of one more playoff series. All of this leads to the World Series, known as the conference committee. So there’s still more to come. It’s what comes out of the conference committee that, if approved by both the Senate and House, will be signed into law by President Obama. And, assuming something is passed …

Health Care Reform Will Be Worse Than Hoped For, But Better Than Feared:  A  friend from college went to the same law school I did, but a year earlier. As I approached my first day of classes I asked him what to expect. “Worse than you hope it is; better than you fear it will be,” was his reply. (And he was right). Well, the same applies to health care reform.

For example, there’s far less medical cost containment in either the House or Senate bills than most observers believe is necessary to make coverage affordable. But as Senator Daschle noted at the Warner Pacific town hall meeting – and as reader JimK has pointed out – there are some potentially significant cost containment provisions tucked away in the bills. Yes, they call for studies and regulations as opposed to describing details, but perhaps that’s the only way cost containment can make it through the political labyrinth that is Congress. They hold the potential, however, to lead to a significant bending of the cost curve. Of course, for now, it’s only a potential, but still, it’s there.

Consider: When California passed its small group reforms in the early 1990s many brokers and industry insiders feared it would harm the market. Instead that legislation, AB 1672, has been a stabilizing influence that eliminated harmful industry practices without destroying the industry in the process. Yes, there were winners and losers (the dominance of Multiple Employer Trusts in the small group market soon ended), but most brokers and their clients will agree it was a net win.

I watched some of the debate on the Affordable Health Care for America Act on C-Span Saturday. To over-generalize, Democrats made the Superman argument: the status quo was leading the country to ruin and only HR 3926 could save the day. Republicans countered with the Hell and damnation offensive: passage of the Democrat’s health care reform legislation would lead to the destruction of all America stands for.

The reality is, the Democrats are overselling what the bill does. And Republicans are exaggerating the negatives. Many of the charges leveled against HR 3962 by GOP members were similar to those their counterparts made against Medicare 45 years ago. Now the GOP positions itself as the protector of Medicare. Apparently not all slippery slopes lead to damnation after all.

What the House accomplished on November 7th is historic. It is neither all good nor all bad. Nor, significantly, is it the final word.

Comprehensive Health Care Reform Not Very Comprehensive

Once upon a time it looked like Congress and the White House would deliver meaningful, comprehensive health care reform to the American people. They certainly started down that path. The talk was of “bending the cost curve.” And of tackling issues like medical malpractice. There was even promises being made of moving toward comparative effectiveness programs and away from the costly fee-for-service provider reimbursement model of today.

Those were the days, but they’re over now. Whether as a result of the August Town Hall ruckuses, lawmaker’s ignorance, or general cynicism, those ideas are pretty much a thing of the past. Yes, there are modest efforts in the current Congressional bills to control costs. But to call them modest is kind. Politicians and pundits. will claim that what’s moving through Congress will make health care coverage more affordable and relieve the burden of medical costs on American families, but few actually believe it.

Over the past few months, the focus of health care reform has shifted to health insurance reform. And while some changes in the way health care coverage is marketed and administered are necessary, those changes will do little if anything to bring down the cost of care. On the contrary, some of the proposals being considered will, it is generally accepted, increase insurance premiums.

This shift by lawmakers from comprehensive health care reform to simply addressing marketing and distribution reform is, to say the least, disappointing. It also shows the challenge in accomplishing major change in Washington. The partisan divide is deep and cynical. The extremes within each party are in ascendancy, making compromise – the life-blood of the legislative process – all but impossible.

So instead of passing real reform, changes to the system that would restrain medical cost increases, the goal seems to have shifted to passing something – passing anything – on which the “health care reform” label can be hung. The result will do little to increase the affordability of insurance coverage or to restrain medical cost inflation. Lawmakers choose to ignore this reality – and to distract attention from it by keeping the focus on whether Congress will create a publicly run plan to compete with private carriers.

Yes, health care reform is hard while taking on the insurance companies is easy. And, as I’ve mentioned, there are some industry practices that need reforming. Given the political realities in Washington it may be that health insurance reform is all that lawmakers are capable of delivering any time soon. 

The shame of it all is that the current health care system is unable to meet America’s needs. The status quo, most objective observers from across the political spectrum agree, is unacceptable. America is the only developed nation in which medical costs bankrupts families. The cost of medical care is overwhelming state governments, threatening their ability to deliver other necessary services. Medical cost inflation is outpacing growth in wages and general inflation, resulting in increasing numbers of families and businesses being priced out of health care coverage.

Meaningful, comprehensive health care reform is critically needed. It’s what the American people desire. But Congress and the White House seem unable to deliver. The fault is not solely with the Democrats nor solely with the Republicans. This is a bi-partisan failure. And hiding behind health insurance reform won’t change that reality.

Harry Reid’s Health Care Reform Dilemma: The Myth of the 60th Democratic Senator

If asked even two weeks ago I’d have said there was an 80 percent change or greater that meaningful health care reform would be signed into law this year. Now, however, I think the chances of such an outcome are far lower – still substantial – but much less likely.

One reason meaningful health care reform may not reach President Barack Obama’s desk this year is that Senate Majority Leader Harry Reid is having difficulties in lining up the 60 votes necessary to overcome the inevitable filibuster from Republicans. Senator Reid’s problem is that while there are 60 Senators in his caucus, there are really only 59 Democrats plus Senator Joe Lieberman.

Senator Lieberman caucuses with the Democrats because he used to be one (he won re-election as an Independent in 2006) and he wants to be a Committee Chair (he chairs the Homeland Security and Governmental Affairs Committee). However, he campaigned strongly for Senator John McCain in the 2008 presidential campaign, even addressing the Republican National Convention. Senator Lieberman also has said he expects to campaign for Republican candidates in 2010. It doesn’t take much insight to predict that, were Republicans to gain a majority in the Senate, Senator Lieberman would be knocking on their door for admittance.

Senator Lieberman has pledged to support a filibuster of a health care reform bill that includes a public option.  While he recently seems to have backed off this threat, as Timothy Noah on Slate.com points out, the Senator’s position on health care reform has been … well, let’s call it a bit erratic. So let’s say Senator Reid puts forward a bill that Senator Lieberman can support, does that solve his problem?

Hardly. Remember Senator Roland Burris, he of the controversial appointment to the Senate by then-Governor Rod Blagojevich. Senator Burris is threatening to oppose any health care reform bill that does not include the public option. As Senator Rollins is a bit of pariah in the Senate (many of its members, including his fellow Senator from Illinois, having called for him to resign) the Democratic leadership has little influence over his actions. So Harry Reid is in a bit of a no-win situation. Go after Senator Lieberman’s vote and he risks losing Senator Burris’ support. Accommodate Senator Burris and there goes Senator Lieberman.

Meanwhile, Senator Reid is forced to wait for an analysis of his proposal by the Congressional Budget Office. What they have to say about his efforts to blend the Senate Finance Committee and Senate Health, Education, Labor and Pensions Committee’s differing versions of health care reform will greatly impact the votes of moderate Democrats. Since only one Republican vote, that of Senator Olympia Snowe, seems to be in play, those moderate Democrats hold the key to whether the Senate can muster the votes for health care reform.

Given that the debate in the Senate will be long, slogging through the legislation will take quite some time. While Senator Reid would like to get a bill on the president’s desk before Christmas, this is a present that may need to wait for the new year. That, of course, complicates matters considerably as 2010 is an election year. Lawmakers hate doing controversial things in an even numbered year. (Why the difference between December 2009 and January 2010 makes a difference is one of those unanswerable questions that seem to be especially common within the Beltway).

On paper, Democrats have a 60-vote majority in the Senate. That’s a myth. In reality they have a group of 60 Senators who caucus together, but don’t act together. That’s actually good for democracy (the unanimity within the Republican caucuses in Congress demonstrates stronger party unity, but a lack of individuality that is somewhat startling). But the diversity within the caucus makes being Majority Leader a lot harder.