Making Peace With The Senate Health Care Bill

To support the health care reform bill, or not to support it, that is the question being debated across the Internet. Now that Nebraska Sen. Ben Nelson (D) has agreed to support the Senate version of the bill, it looks as if the Senate has the 60 votes necessary to pass the legislation. The new question is, "What's in the Senate bill?" I think that this is the 9th edition of the bill and it's been changed more often than Madonna has reinvented her image. After scuttling around on the Internet, I think that I reasonably understand the current content with the most recent amendments that will be voted upon at one a.m. on Monday. Of course, this all may change by the time I finish writing this entry.

Costs
According to the Congressional Budget Office (CBO), the legislation, with the proposed changes that are being offered as an amendment to the Senate's version of the health care bill would cost about $871 billion over the first 10 years. Those costs would be offset by $483 billion in spending savings and $498 billion in revenues over the period. Factoring in tax increases and lower payments to doctors, the CBO asserts that the Senate bill would reduce the deficit by about $132 billion between 2010 and 2019.

What's Changed
Elin (Mrs. Tiger Woods) and the government run insurance option (the Public Option) are gone. She may come back but the public option isn't likely to return in time for Monday morning's vote. It has been replaced with a plan to create two national or multi-state health insurance exchanges (exchanges) to be run by the U.S. Office of Personnel Management (OPM). One of the plans is to be non-profit. The CBO has stated that it is unclear whether insurers would be interested in contracting with the OPM to offer these plans. A move to replace the public option with a plan to expand Medicare to provide coverage for uninsured Americans over 55 was stopped by opposition from Sen. Nelson and other alleged Democrats and the ever present Joe Lieberman.

The Medicare payroll tax increase is 0.9% (was 0.5%) for couples with an income of  $250,000 or more and individuals earning $200,000 or more. This is a revenue raising measure. To save money, the Senate proposal cuts federal government reimbursement rates to doctors by 21% effective in 2010.

Funding for abortions has been a lightning rod in the Senate's debate about this legislation. In spite of the legal right to choose to have an abortion within certain medical guidelines and provisions, the anti-choice contingency have latched on to the health care reform legislation as an opportunity to try to make inroads in their ongoing effort to undo Roe v. Wade. The bill now includes more restrictive abortion funding language that strengthens the prohibitions against the use of public money for abortion services. The bill now separates federal funding from private funding for abortion services on the exchanges, and lets states choose not to allow insurance companies to cover abortion on their health exchanges. This change has left both pro-life and pro-choice groups unhappy (I didn't take the time to read all the reasons that both sides are upset with these changes).

Under the proposed changes, more firms would qualify for the small business tax credit for health care coverage. The tax credit would be available in 2010, a year earlier than originally proposed. The income threshold would be increased so that the tax credit will be available on a sliding scale to firms with fewer than 25 workers and an average wages of less than $50,000. Employers with 10 or fewer workers and average wages of less than $25,000 can get the full tax credit.
 What Stays the Same
Insurance Reforms to health insurance stay the same as in the first Senate bill. This means that insurers will be prohibited from denying or stopping coverage based on the cost of care or the health of the customer, or in other words, denying coverage based on preexisting conditions.

The requirement that all individuals purchase health insurance by 2014 remains the same, as do penalties for employers who do not offer insurance to their workers; however, businesses with fewer than 50 workers are exempt.

The so-called 40 percent "Cadillac tax" on high-dollar insurance plans does not change and will go into effect in 2013.

The provision remains that provides that the federal government will subsidize the cost of insurance for families who make between 133 percent and 400 percent of the poverty level.

The bill also continues to include provisions offering new federal insurance for Long Term Care.

What's next
According to the knowledgeable pundits, now that Sen. Ben Nelson has agreed to support the bill, the Democrats will have votes from 60 senators and can defeat the Republicans' efforts to filibuster the health reform bill. If all goes as predicted, the Senate will move quickly through a series of procedural votes on the bill, beginning at 1 a.m. Monday morning, and likely finishing at 7 p.m. on Christmas Eve.

However, it isn't over until it's over. Assuming that the Senate passes its bill, Democratic leaders from the House and Senate will negotiate a compromise between their competing versions of health reform. Major differences remain between the House and Senate versions, with the most significant being the creation of a public option (the House does it, the Senate does not), and who will pay higher taxes to pay for the expanded coverage. The House raises taxes on the wealthy with a five-percent income tax increase on people making more than $500,000. The Senate increases the Medicare payroll tax and creates the "Cadillac tax," which could hit middle-class workers by taxing expensive health plans.

If the conference committee reaches a compromise, the House and the Senate will both vote on the new and final version of the bill. The goal of the Democrats is for President Obama to sign the measure before his State of the Union address at the end of January.

Why a watered down bill is better than no legislation
I offer this summary because I think that it's important in this emotionally charged climate to have a clear understanding of the substance of the House and Senate bills. People that I respect and like are split on this issue, with some advocating that progressives should make our displeasure known and withdraw support for any health care legislation that doesn't include a government funded or public option. Others believe that even if the final bill is watered down, including lacking a public option, that it's better to go forward with it than to get nothing. I happen to be in the second camp.

I think that while a lot of good things have been removed in the Senate version, a lot of good things remain, most notably, prohibitions against denying coverage to persons based on preexisting conditions or charging outrageous premiums to insure those people. Even more importantly, politics is a game. It's a pretty disturbing game because the rules aren't written down and they are constantly being amended. The constants in this game are negotiation and compromise. You always ask for the moon, but you know from the outset that you're not going to get it. You leave yourself some room for compromise and negotiation.

Maintaining a facade of civility is of prime importance, unless you have had years to hone your image as an eccentric maverick and you also have acquired power through a system of favors and debts owed to you. Arguably one of the least powerful offices in the federal government is that of the president; the drafters of the Constitution designed it that way in an effort to prevent this new government from ever having the power concentrated in the hands of any single individual.

It's easy enough to call for the president to simply tell the wayward Democrats in the Senate what to do; however, the reality is that he can tell them and if they don't acquiesce, what then? He can't throw them out of the party. He could perhaps refuse to help with their reelection campaign, but chances are that their constituents don't need or want the president's input. However, this issue isn't about the president; it's about beginning the process of reforming our health care system.

That's right, reform is a process. It doesn't happen in the blink of an eye. The Senate bill cuts away far too many pieces of this bill, but the House version isn't dead. The final bill will be a compromise of the elements of both versions of the bill. However, when it comes to legislation, final doesn't mean that it's forever written in stone. More than half of the bills submitted during any legislative session aren't brand new, but rather amended versions of existing law.

If this bill dies, then chances are good that it will be several administrations in the future before the issue even makes it on the table again. The battle will have to start all over from scratch, and there is no guarantee that it will meet with any more success eight or 12 years from now. Now is the time to pass the best bill possible under the reality of the opposition and start working on the drafts of the reauthorization of the health care legislation (federal law is ripe with reauthorizations of major pieces of legislation in every legislative session). The only way that health care reform dies is if we let our righteous indignation kill it.