Health policy consultant
Posted: February 18, 2010 08:07 PM
Next Thursday, February 25th, is a D-Day of sorts for health reform. The President has laid down a gauntlet to his own party as well as the Republicans. Come up with your ideas and solutions or STFU.
On Monday, February 22nd, the White House has said it will post online a "detailed" proposal that merges the reform ideas in the House and Senate bills that were passed late last year. Obama has encouraged the Republicans to do the same.
According to official sources:
In a letter addressed to the four top Congressional leaders, White house Chief of Staff Rahm Emanuel and Health and Human Services Secretary Kathleen Sebelius outlined the format of the scheduled February 25 health care reform meeting requested by President Barack Obama.
The meeting, to be held at Blair House, the Washington, DC, the official state guest house for the President, will begin at 10:00 a.m, and will be televised live in its entirety. Almost 50 members of Congress and the Administration are invited.
According to the letter, President Obama will provide opening remarks, followed by remarks by a Republican and a Democratic leader. This will be followed by a discussion, moderated by the President, on four topics needed in health reform legislation:
Insurance reforms--"Does it provide adequate protection against abuses by the insurance industry?"
Cost containment--"Does it bring down costs for all Americans as well as for the Federal Government, which spends a huge amount on health care?"
Expanding coverage--"Does it make coverage affordable and available to the tens of millions of working Americans who don't have it right now?"
The impact health reform legislation will have on deficit reduction --"Does it help us get on a path of fiscal sustainability?"
We will all be able to follow this on C-Span and perhaps other networks as well, and probably live streamed from the whitehouse.gov site.
So many questions and so few answers -- is this a trick by the president to force the hands of the Republicans? To force his own party to get together and make the final few agreements needed to merge the House and Senate bills in a way acceptable to both? Is it only symbolic politics and a "made for television" event to show some sort of attempt to include Republicans in the final product? Is it a brilliant strategy by the President to move health reform to the finish line? Or is it foolhardy and naive?
Only a few people know the answers to these questions and they ain't talking. What will it take to get to Monday or Thursday and what will happen after that?
To get to Monday when details are to be published online, Republicans have to decide if they want to play and, if so, to merge several of their own proposals into a consistent whole. The three main Republican issues are how to get insurance companies the right to sell their policies across state lines, how to get stronger malpractice reform that includes caps on awards, and how to help consumers assume more responsibility for their health. All of these issues are already in the Democratic bills but are weaker than the Republicans would like.
The Democrats need to resolve the final issues that divide the Senate and the House approaches to reform. Both houses have passed bills. If the House could accept the Senate bill as it is, they could send it to the president today for signature. But the Democratic House members have serious concerns about what the Senate passed, and the negotiations that have been going on are about how to "correct" the Senate bill through a process called "reconciliation" that only requires 51 Democratic votes in the Senate. Sounds easy? It is not. Some of the issues that the House Democrats object to cannot be put into the "reconciliation" framework. Only issues that have budgetary impact can be introduced in that way. So these budgetary issues are the ones that are being debated, even at this late hour.
1. How to pay for? How will we pay for the $80 to 100 billion a year price tag for covering an additional 30 million people -- should it be a tax on the rich as the House bill proposes or a tax on high cost ("cadillac") plans? The largest piece of revenue in both bills is the so-called "Tax on the Rich" in the House bill, which proposes a 5.4% surcharge on individual income above $500k and joint returns of over $1m. This raises $460 billion over ten years, nearly half the proposed cost of reforms. The Senate proposes an excise tax of 40% on the part of the premium that is more than $8500 for an individual or $23,000 for a family. That proposal raises only $149 billion. There are a dozen smaller revenue raising proposals in both bills, mainly focused on the health care industry itself, to fill out the expected cost of reform. While Labor unions have resisted the so-called cadillac tax, a new study out today by the UC Berkeley Center for Labor Research and Education concludes that a tax on high cost plans would fall equally on union and non-union plans. And 80% of the workers who would be affected by such a tax would be in non-union plans.
2. Who to subsidize and for how much? If the individual mandate to buy insurance survives the process, there needs to be some way to help people pay for coverage who can't afford it. The House bill had a higher level of subsidy than the Senate bill. Even Senator Olympia Snowe was concerned about the level of subsidies in the Senate bill, so if money can be found, look for increased subsidies in the final product.
3. Whether to allow undocumented workers to buy insurance, even with their own money. The House bill allows it. The Senate bill does not.
4. Whether to have state-based health insurance exchanges or national exchanges.. I'm not sure that the exchange issue would be allowed under reconciliation rules, so the final product may only reflect what the Senate passed -- State-based exchanges, which even allow States to opt completely out of the exchange process.
5. Whether to include a public option.. You thought the public option idea was dead? Not yet. House Majority Whip, Rep. James Clyburn (D. SC) suggests that it could still be inserted into the final bill. A public option is in the House but not the Senate bill, so the language and budgetary calculations are readily available. And many think a public option could save money.
If these and other unresolved issues can be agreed upon in the next three or four days (or if they have been agreed upon and we just don't know about it), the Democrats have a powerful tool to use in their televised health reform discussion on Thursday. They would come into the discussion with agreement, numbers to back up their proposals, and they would be days or only weeks away from putting the final bill on the President's desk.
April is another deadline of sorts -- apparently the whole "reconciliation" idea must be used before the next budget is proposed or they have to start from scratch. So if the Democrats agree on their reconciliation "fixes" and strategy, they have a month to get the House to pass the Senate bill and the Senate to pass reconciliation with 51 votes. Sounds like enough time, doesn't it? But will there be enough momentum to carry us all through yet another month of back and forth? As we dither over this, the negativity continues to increase.
Perhaps what the President is trying to do with this February 25th meeting is to tell us all that he has listened to the Republicans. He has incorporated some of their ideas, but he is not waiting for them to sign on to the Democrats' plan. If they won't, Democrats need to take a public vote on health reform. Vote it up or down. Don't just let it die and pretend it was too complicated or your state didn't get enough goodies out of it. Take a stand, dammit.
If it works, it's brilliant. If it doesn't, we all lose