What's Next for Healthcare Reform?
This article originally appeared on The Media Consortium.
The Senate passed its healthcare bill in the early morning hours of Christmas Eve. Senate Majority Leader Harry Reid had to make major compromises to secure the votes of fence-sitters like senators Ben Nelson and Joe Lieberman. Reid sacrificed the public option to keep Lieberman on board and tightened the bill's abortion restrictions to placate Nelson.
Next, representatives from the House and the Senate will merge their respective bills in a conference committee, creating a single piece of legislation that both houses will vote on. If the conference report passes both houses, it will proceed to the president's desk to be signed into law. Conference will start after the winter recess. The whole process could be complete by late January.
Despite the Senate compromises, there's still plenty for progressives to like in the new bill. Kevin Drum lists some of the bill's positive attributes in Mother Jones:
Insurers have to take all comers: They can't turn you down for a preexisting condition or cut you off after you get sick.
Community rating: Within a few broad classes, everyone gets charged the same amount for insurance.
Individual mandate, which would require everyone to have health insurance. (Remember how we all argued that this was a progressive feature back when John Edwards and Hillary Clinton were championing it during the primaries?) On the progressive upside, a mandate would bring down costs and share risk more equitably. However, progressives realize that without a public option, it means forcing people to buy the insurance companies' crappy product.
A significant expansion of Medicaid.
Subsidies for low and middle income workers that keeps premium costs under 10 percent of income.
Limits on ER charges to low-income, uninsured emergency patients.
Caps on out-of-pocket expenses
A broad range of cost-containment measures
A dedicated revenue stream to support all this.
The House version of the healthcare bill has a public option. In theory, the public option could be added back in in conference, but even the most optimistic progressives have given up hope on that score. If the public option rose from the ashes, Lieberman could filibuster the conference report, and no one doubts he'd do it. So no matter how tough and savvy House Speaker Nancy Pelosi is, she won't have much leverage in conference. One way or another, Pelosi can probably pass just about anything that comes out of conference. Reid still has the Sword of Damocles hanging over his head.
That doesn't mean that everything is set in stone, though. J. Lester Feder of The Nation discusses what's left to be worked out in conference. Feder says the big three areas up for discussion are affordability, enforceability and financing. Compared to the House bill, Senate version offers larger insurance subsidies, but also weaker protections against high out-of-pocket costs.
Age bands are another key affordability issue: the House bill allows insurers to charge seniors twice as much for coverage, the Senate up to three times as much. The House bill calls for a national insurance exchange to drive down costs, as opposed to the Senate bill which would create state level exchanges. The smaller the exchange, the less power it has to drive down costs, which means that progressives (and hopefully fiscal conservatives) are lobbying hard for a national exchange.
As for enforceability, Feder urges progressives to watch out for a seemingly minor provision in the Senate bill that effectively guts the ban on gouging those with pre-existing conditions. Unlike the House, the Senate voted to allow insurers to offer "discounts" to customers for "wellness" That might mean that people with conditions from pregnancy to HIV could end up paying more for coverage than their healthier counterparts.
Financing is sure to be a bitterly contested issue in conference. The House wants to pay for reform by taxing the wealthy. The Senate wants to tax so-called "Cadillac" insurance plans. Currently, those who receive insurance through their employer don't have to pay taxes on the value of the coverage, as they would if they got an equal amount of money in cash. The Senate bill would tax the value of insurance coverage over a certain threshold.
The problem is that, despite the luxurious-sounding nickname, a lot of so-called Cadillac plans are pretty ordinary insurance policies held by middle-class people. For example, many union workers accepted better health benefits instead of wage increases because they seemed advantageous tax-wise. At Working In These Times, Art Levine reports on labor's attempts to eliminate the insurance tax.
Mark Schmitt of the American Prospect concludes that the bill could be improved slightly in conference by adding the House's employer mandate or improving the financing, "but everything will have to be cleared with the 59th and 60th most liberal senators." His Prospect colleague Paul Waldman is more optimistic about the prospects for improving the bill in conference. Abortion access and the public option are set in stone, but the conference committee still has power to shape the proposed expansion of Medicaid (the House is more generous than the Senate), the timeline for implementation (sooner is better for progressives), coverage for immigrants and other hot-button issues.
I predict that abolishing the filibuster will be the big progressive cause for 2010. Obama's liberal base has seen so many of its fondest hopes dashed by a Senate where sixty votes is the new fifty. If the Democrats are going to keep the "kill the bill" crowd in the fold, they'll have to channel that rage and frustration in a constructive direction. Senator Tom Harkin is proposing a symbolic bill to end the filibuster. It won't pass, of course: if Reid can't defeat one filibuster without gutting healthcare reform, there's no way he can pass a bill to abolish filibusters for good. It would get filibustered! That said, Harkin's bill is an important symbolic gesture and an opportunity to galvanize support for structural Senate reform.