Health Care Reform End Game Emerges

The Obama administration and Democrats in Congress have pledged to pass a major health care reform bill by the end of the year. It will provide access to most of the uninsured through insurance reform and subsidies to help pay for coverage, bend the cost curve  in both the private insurance market and Medicare, and improve quality.

Far more likely is that at most one of the three -- improved access -- will result from passing any of the variations of ObamaCare now being discussed exclusively among  Democrats in Congress and White House officials.  Since the Democrats are far more concerned with expanding access than driving down costs or enhancing quality, all of the bills are heavily loaded in this direction.

The president has also pledged that all new spending will be paid for through taxes, fees, or reduced spending elsewhere and that total new spending will be less than $900 billion over ten years. Now, add in one more detail to satisfy progressive Democrats who long for a single-payer national health care system: there should be a “robust” public option (a foot in the door to achieving this goal). This may mean a public plan which competes with private insurers everywhere, competes only in states that “opt in," competes only in states that don’t “opt out," or will be “triggered” in all states or in some states based on what happens in the private market the next few years. And the public option will either set rates at Medicare plus 5% or through negotiations with providers.

If anyone wonders why support for health care reform is lagging, you can attribute it to skepticism about the wizardry that can produce a health reform bill that meets all of the announced three goals or to the inability to make any sense of the public option options. One does not have to be intimately familiar with the thousand-plus pages in each bill passed in the five House and Senate committees to conclude that the expansion in access  will likely drive up health care costs and reduce overall quality.

As the pubic mood on the economy and the country’s direction sours, it is not surprising that fewer Americans (only 23% in a recent Rasmussen poll) today regard health care reform as a top priority for the country. This is especially true given the rising unemployment rate, rising number of home foreclosures, and stunningly large federal budget deficit of $1.4 trillion in 2009 and projected at $9 trillion more for the next ten years.

Senate Majority Leader Harry Reid has now taken a public stand on how to meld the two differing versions of a reform bill passed by committees in the Senate  -- what he calls a public option with an opt-out provision. This, along the continuum from 90-pound weakling (a trigger, favored by Maine’s Olympia Snowe) to robust (the public option everywhere, favored by “progressives”), is stronger than an opt-in public option (favored by Delaware  Senator Tom Carper).

As soon as he announced his intentions,  two Senate members -- Joe Lieberman of Connecticut, an independent who caucuses with the Democrats, and Snowe, the only Republican to have supported any version of reform in any of the five congressional committees -- indicated their disapproval. Lieberman went as far as saying he would support a Republican filibuster if a bill came up that was similar to the one Reid described.

Two other moderate Democrats -- Blanche Lincoln of Arkansas, facing a tough re-election fight in 2010, and Ben Nelson of Nebraska -- also suggested they may go the same way. The 60 or 61 votes that seemed to be available to break a filibuster for a bill that looked like the Senate Finance Committee bill was now down to 57 to 59 for the new Reid version of the bill.

Illinois Senator Dick Durbin backed Reid, saying Reid’s hand was forced by liberals in the Democratic caucus who threatened not to support a bill without a public option. It is, of course, odd to hear Durbin describing pressure on Reid from liberals, as if to suggest that Durbin is not himself one of the most liberal members of the Senate. In any case, it seems to me very unlikely that liberals in either the House or Senate, most of whom have very safe seats, would block a bill that got them 80% of what they wanted with a reform package -- especially if such obstruction resulted in killing the chances for major reform this year and perhaps for years to come (if the GOP rebounds in the 2010 elections).