Thursday, December 24, 2009

Health Care: It's Done. For Now.

It's here. It finally happened early this morning.

In a Christmas Eve vote for the history books, the Senate early Thursday passed health care reform legislation along strictly party lines, putting President Barack Obama’s top domestic priority on a path toward passage in the New Year.

Senators filed into the Capitol before dawn after 25 consecutive days of debate that ended on the same bitterly divided tone that dominated the discussion as the final votes neared.

Republicans stood unified against the legislation, and Sen. Mitch McConnell of Kentucky, the Republican leader, vowed to continue blocking the bill he believes does not have popular support. [...]

Senate Majority Leader Harry Reid returned to the story of Caleb, a high school student in Sparks who has outgrown his prosthetic legs and has been denied new ones by his insurance company.

“How much longer can we afford to put this off?” Reid asked.

“We may not completely cure this crisis today or tomorrow, but we must start toward that end,” Reid said. “Our charge is to move forward.”

Well, at least he finally did it.

“Health care in our country is going to be defined by three Harry’s: Harry Truman, Harry and Louise, and the big guy, the majority leader,” DeParle told the Sun. She was referring to the Democratic president who led health care reform and the characters in the industry TV ads that doomed President Bill Clinton’s health reform effort.

“He drove this and he got it done. I don’t think anyone else could have done this,” DeParle said.

Sen. Richard Durbin, the Democratic Whip, said the corridors of the Senate are filled with portraits and statues of political leaders.

“But I will tell you, the contribution to this nation made by the senator from Searchlight, Nevada will become one of the shining chapters in the history of the United States Senate and our nation,” Durbin said. “He achieved what others have failed trying to achieve. And he did it with the tenacity and the strength and the determination that I’ve never seen in my time.”

Even if it's a lousy deal with plenty of flaws... Even if the lousy deal still has plenty worth passing.

Given what we think we know about the state of the legislation, I think the effort is clearly a step forward. It's not the bill I'd write if I were dictator, but it advances the cause of reform, and creates a foundation that can be built on in the future. If this bill were to fail, I suspect it would be decades before anyone even tried to improve the broken status quo. In the meantime, the effects on those suffering under the current system would get worse.

As we've talked about recently, progressives have faced this situation before. When Medicaid passed, it did very little for low-income adults. When Medicare passed, it all but ignored people with disabilities. When Social Security passed, the benefits were negligible, and the program excluded agricultural workers, domestic workers, the self-employed, railroad employees, government employees, clergy, and those who worked for non-profits. The original Social Security bill offered no benefits for dependents or survivors, and included no cost-of-living increases.

These are, of course, some of the bedrock domestic policies of the 20th century, and some of the towering achievements of progressive lawmaking. But when they passed, they were wholly inadequate. There were likely liberal champions of the day who perceived the New Deal, the Great Society, FDR, LBJ, and their congressional Democratic majorities as disappointing and incompetent sell-outs who failed to take advantage of the opportunity before them.

But the programs passed, and once they were in place, they improved, expanded, and became integral to the American experience. It took years and perseverance, but progress happened after the initial programs became law.

I'll admit that I've been struggling over this ever since the public option was dropped. Is it worth passing? Or better to be left for the killing?

Well, it passed. And once the House and the Senate iron out a compromise in Conference, we'll see some kind of health reform signed into law in 2010.

So what next? Conference is coming. There may still be a chance to fight for the public option that the House put in its bill. There still must be an effort to strip the ridiculous restrictions on women's reproductive rights inserted into both bills. There still will be plenty of negotiating on mandatory insurance spending on patients' health care, subsidies for the working poor, ending antitrust exemptions, and much more.

Basically, there is still plenty of work to do and it isn't all over yet.

So cheer up. The bill is far from perfect, but there's still a chance for a somewhat better bill in Conference. And no matter what final bill emerges, remember what Kevin Drum pointed out:

So it doesn't feel much like a victory yet. But it should. I'm 51 years old and this bill is, without question, the biggest progressive advance in my adult life. You have to go back to the great environmental acts of the early 70s to get close, and to the civil rights/Medicare era to beat it. That's four decades, the last three of which have constituted an almost unbroken record of conservative ascendency. And now that ascendancy is just days away from being — finally, decisively — broken. Warts and all, we're on the cusp of passing a bill that provides all of this:

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. (Remember how we all argued that this was a progressive feature back when John Edwards and Hillary Clinton were championing it during the primaries?)
A significant expansion of Medicaid.
Subsidies for low and middle income workers that keeps premium costs under 10% 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.

A trillion dollars in benefit for low and middle income workers. 95% of Americans insured. Medical bankruptcies on the verge of disappearing. And for the first time ever, an acknowledgement that decent healthcare ought to be universal in the United States. This is historic. This is a cause for celebration, not recriminations. As recently as 2005, I wasn't sure I'd ever see this day, and now, a mere three years later, it's here. I can still hardly believe it.

So happy day before Christmas/Saturnalia. I promise I'll have more fun stuff up later today, but I felt obligated to cheer a little, vent a little, and just talk about the obvious HUGE news of the day.


  1. Let's pick those off one at a time, eh?

    Insurers have to take all comers. They can't turn you down for a preexisting condition or cut you off after you get sick.

    ...But they'll still fix your rate to reflect your status.

    However, thou protest, sayeth:

    Community rating. Within a few broad classes, everyone gets charged the same amount for insurance.

    I'm not sure why someone entering their 50s is so thrilled with a 3:1 community rating, which is what the sub-Medicare crowd are going to get. Paying three times as much as a young person. Gee, what fun. Pre-Medicare can't really afford more than 2:1, but we wound up with 3:1 as "compromise" because Baucus wanted to charge them 4:1.

    People in the "non-group market" have about a 50% of having to pay much more because they have a so-called "Cadillac plan."

    The other mystery of community rating is that the other class is location, and nobody knows exactly how large/small these location partitions will be. If they're down to a zip code, you could see people who live in high-crime areas (both more likely to get hurt and less likely to have money, or they would have moved) paying a lot more than the people in the suburbs.

    Without the age part, community ratings might have done a fair job of equaling things out in time if the number of uninsured dropped drastically. It's difficult to predict.

    Individual mandate. (Remember how we all argued that this was a progressive feature back when John Edwards and Hillary Clinton were championing it during the primaries?)

    No longer progressive without a public option, to the contrary it's forcing you to buy from a loosely regulated market.

    A significant expansion of Medicaid.

    Well, yes, this is good. Still means that only 2/5ths of the bill's spending is going to be public spending, and it'll be going to services only available under certain conditions. The other 3/5ths are invested in private companies.

    Subsidies for low and middle income workers that keeps premium costs under 10% of income.

    Hey, people who are barely scraping by as-is, don't worry, we won't make you cut more than 10%(!) of your budget for your new health burdens.

    Limits on ER charges to low-income uninsured emergency patients

    Don't have much information on this.

    Caps on out-of-pocket expenses.

    Again, it's just that what's considered reasonable expense is way too high.

    A broad range of cost-containment measures.

    Oh? I haven't found any.

    I stand to benefit from this bill (especially now that a lot of things will happen in 2011 instead of 2014 now that the public option is scrapped) but there's no denying it's a load of crap for a lot of people.

    (also, oh hi, saw your linking to your blog on Hunter's and subscribed to RSS.)

  2. Mike-

    Thanks. I just noticed this now. Yeah, you make some valid points. That's why I'm a "reluctant supporter" of this at best.

    I'm especially with you on the public option and mandates. Without a public option, we're just forcing people to buy HMOs... And we've obviously seen how HMOs (don't) work.

    There are also other things, like the chintzy subsidies and soft "regulation" of the insurance industry, that I hope are sidelined for the stronger medicine in the House bill. Again, I'm just still holding out some kind of hope for some kind of salvageable final deal. Obama and Dem leaders really did give up too much in compromise after compromise after compromise to the ConservaDems, but I'm willing to grudgingly accept the final bill if it looks more like the House bill (sans the Stupid Stupak language).