“Gee, I hope this works”

Ruth Marcus BELIEVES in the new health care reform law.  But she points out that no one knows exactly what it will do:

If I were a member of Congress, my floor speech before casting a yes vote would have boiled down to:

Gee, I hope this works.

One of the astonishing aspects of the health-care debate is how little is actually known about the implications of a change this far-reaching. Everyone has a theory, and a model to match, but even some of the most fundamental questions remain the subject of debate.

On the most basic of all — does having health insurance lead to better health? — the evidence is solid but not unanimous. The Institute of Medicine, reviewing the literature in 2009, found that “the body of evidence on the health consequences of health insurance is stronger than ever before. . . . Simply stated: Health insurance coverage matters.”

But a study that same year by Richard Kronick, a former health-care adviser to President Bill Clinton, found “little evidence to suggest that extending insurance coverage to all adults would have a large effect on the number of deaths in the United States.” . . .

To take another example, one common assertion has been that the uninsured end up getting health care — just more expensive health care, in emergency rooms and when conditions have worsened, with the costs passed on to the rest of the population. The notion that the tab is being picked up one way or another makes intuitive sense.

A new National Bureau of Economic Research paper by Michael Anderson, Carlos Dobkin and Tal Gross questions this assumption. The researchers examined health-care consumption by 19-year-olds who had just been dropped from their parents’ coverage. They found that not having insurance resulted in a 40 percent reduction in emergency room visits — “contradicting the conventional wisdom that the uninsured are more likely to visit” the emergency room and a 61 percent drop in hospital admissions.

“Overall, these results suggest that an expansion in health insurance coverage would substantially increase the amount of care that currently uninsured individuals receive and require an increase in net expenditures,” the authors write. Emergency room visits could increase by 13 million annually, and hospital admissions by 3.8 million, they project. . . .

Will younger adults, who account for about half the population of uninsured non-elderly adults, sign up for coverage — or will they pay the fine instead? How will that decision affect premium levels and the adequacy of federal subsidies?

Will the expansion of coverage create a shortage of health-care providers and result in higher prices, or will, for example, higher Medicaid payments for primary-care doctors stem an exodus of doctors from the program? Will employers add coverage because workers facing the mandate to obtain insurance will press for it, or will they drop it because it will be cheaper to pay the penalty and let employees fend for themselves?

Will increased coverage of preventive care save money because diseases will be caught earlier — or will the added cost of widespread screening exceed the economic benefits? The Congressional Budget Office has concluded that, “for most preventive services, expanded utilization leads to higher, not lower, medical spending overall.”

via Ruth Marcus – A generous dose of caution on health reform – washingtonpost.com.

We don’t even know the regular consequences of this new health care system.  Let alone the unintended consequences.

The health care bill passed

In a straight up vote (not using the “deem and pass” dodge), the final tally was 219 for to 212 against. It took 216 to win.

The difference was the 6 pro-life Democrats who agreed to vote for the bill if the President would sign an executive order forbidding federal money in the program going to pay for abortion. (See post below.)

Now the Senate must pass some reconciliation elements, but since the House passed the Senate bill and since the President will sign it, this is essentially a done deal.

Did you watch the debate? What I saw was quite telling. What did it tell you?

What’s in the Health Care bill

For a useful summary of the provisions of our new national health care system, see  A look at the health care overhaul bill – washingtonpost.com.  Here are some highlights:

COST: $940 billion over 10 years, according to the Congressional Budget Office.

HOW MANY COVERED: 32 million uninsured. Major coverage expansion begins in 2014. When fully phased in, 95 percent of eligible Americans would have coverage, compared with 83 percent today.

INSURANCE MANDATE: Almost everyone is required to be insured or else pay a fine. There is an exemption for low-income people. Mandate takes effect in 2014.

INSURANCE MARKET REFORMS: Starting this year, insurers would be forbidden from placing lifetime dollar limits on policies, from denying coverage to children because of pre-existing conditions, and from canceling policies because someone gets sick. Parents would be able to keep older kids on their coverage up to age 26. A new high-risk pool would offer coverage to uninsured people with medical problems until 2014, when the coverage expansion goes into high gear. Major consumer safeguards would also take effect in 2014. Insurers would be prohibited from denying coverage to people with medical problems or charging them more. Insurers could not charge women more.

MEDICAID: Expands the federal-state Medicaid insurance program for the poor to cover people with incomes up to 133 percent of the federal poverty level, $29,327 a year for a family of four. Childless adults would be covered for the first time, starting in 2014. The federal government would pay 100 percent of costs for covering newly eligible individuals through 2016. A special deal that would have given Nebraska 100 percent federal financing for newly eligible Medicaid recipients in perpetuity is eliminated. A different, one-time deal negotiated by Democratic Sen. Mary Landrieu for her state, Louisiana, worth as much as $300 million, remains.

TAXES: Dramatically scales back a Senate-passed tax on high-cost insurance plans that was opposed by House Democrats and labor unions. The tax would be delayed until 2018, and the thresholds at which it is imposed would be $10,200 for individuals and $27,500 for families. To make up for the lost revenue, the bill applies an increased Medicare payroll tax to the investment income and to the wages of individuals making more than $200,000, or married couples above $250,000. The tax on investment income would be 3.8 percent. . . .

EMPLOYER RESPONSIBILITY: As in the Senate bill, businesses are not required to offer coverage. Instead, employers are hit with a fee if the government subsidizes their workers' coverage. The $2,000-per-employee fee would be assessed on the company's entire work force, minus an allowance. Companies with 50 or fewer workers are exempt from the requirement. Part-time workers are included in the calculations, counting two part-timers as one full-time worker.

SUBSIDIES: The proposal provides more generous tax credits for purchasing insurance than the original Senate bill did. The aid is available on a sliding scale for households making up to four times the federal poverty level, $88,200 for a family of four. Premiums for a family of four making $44,000 would be capped at around 6 percent of income.

This seems like we’ll be spending an awful lot of money for not all that much. We go from 83% of Americans with health insurance to 95%, a gain of 12%? More people will be getting government money. Does a family of four making $88,200 really need a subsidy? Isn’t that a really good salary? (Most college professors don’t make anywhere near that, and yet they do OK.) I’m curious what percentage of Americans will go on at least a partial dole. Quite a lot, I’d think.

And it doesn’t go into effect until 2014! So why all the urgency in the rhetoric and in the push to get this passed?

Other thoughts about what this bill would do?

Passing Health Care without voting for it

Our Democratic leaders are resolved to pass the health care reform bill no matter what.  Even if it doesn’t have the votes.  Here is the latest strategy:

After laying the groundwork for a decisive vote this week on the Senate's health-care bill, House Speaker Nancy Pelosi suggested Monday that she might attempt to pass the measure without having members vote on it.

Instead, Pelosi (D-Calif.) would rely on a procedural sleight of hand: The House would vote on a more popular package of fixes to the Senate bill; under the House rule for that vote, passage would signify that lawmakers “deem” the health-care bill to be passed.

The tactic — known as a “self-executing rule” or a “deem and pass” — has been commonly used, although never to pass legislation as momentous as the $875 billion health-care bill. It is one of three options that Pelosi said she is considering for a late-week House vote, but she added that she prefers it because it would politically protect lawmakers who are reluctant to publicly support the measure.

“It's more insider and process-oriented than most people want to know,” the speaker said in a roundtable discussion with bloggers Monday. “But I like it,” she said, “because people don't have to vote on the Senate bill.”

via House may try to pass Senate health-care bill without voting on it – washingtonpost.com.

Destroying the Senate

The “Christian Science Monitor,” not a conservative publication, has a piece by Mark Sappenfield entitled Reconciliation: why healthcare reform ‘nuclear option’ is deadly. It discusses the tactic of evading the filibuster rules so as to pass the Health Care Reform bill with a bare majority, rather than needing 60 votes. The author is referring to a “Face the Nation” appearance by centrist Republican Lindsey Graham and centrist Democrat Evan Bayh:

To many senators, including Graham, these procedures are not roadblocks to effective governance, they are the building blocks of it. The Senate is generally the last word in American legislative politics partly because it is seen as being more collegial and collaborative than its congressional cousin – and these seemingly arcane rules are the reason it is so, some would argue.

What is the significance of requiring a bill to win 60 votes or face a filibuster, after all? It is, at least on one level, an inducement to find compromise – to cross the aisle, to build coalitions.

To Graham, using reconciliation to pass healthcare reform circumvents the very mandate for consensus-building that makes the Senate unique.

Of course, reconciliation has been used before by both parties. But Graham noted that other cases involved at least some cross-party consensus. In this case, not a single Senate Republican voted for the healthcare reform bill.

If Senate Democrats used reconciliation to make changes to their healthcare bill, Republicans would pull out every stop to bring work in the Senate to a halt between now and the November elections, both Graham and Senator Bayh conceded.

Analogies

I love analogies.  Here is one from Charles Krauthammer on a conundrum in the health care reform bill:

Obama was reduced to suggesting that his health-care reform was indeed popular because when you ask people about individual items (for example, eliminating exclusions for preexisting conditions or capping individual out-of-pocket payments), they are in favor.

Yet mystifyingly they oppose the whole package. How can that be?

Allow me to demystify. Imagine a bill granting every American a free federally delivered ice cream every Sunday morning. Provision 2: steak on Monday, also home delivered. Provision 3: a dozen red roses every Tuesday. You get the idea. Would each individual provision be popular in the polls? Of course.

However (life is a vale of howevers) suppose these provisions were bundled into a bill that also spelled out how the goodies are to be paid for and managed — say, half a trillion dollars in new taxes, half a trillion in Medicare cuts (cuts not to keep Medicare solvent but to pay for the ice cream, steak and flowers), 118 new boards and commissions to administer the bounty-giving, and government regulation dictating, for example, how your steak is to be cooked. How do you think this would poll?

Perhaps something like 3 to 1 against, which is what the latest CNN poll shows is the citizenry’s feeling about the current Democratic health-care bills.

What are some other analogies that might help us understand current issues?

(This is not a thread about the health care bill, as such. Challenge the aptness of Krauthammer’s analogy, if you wish, but what I’d like to see are more analogies.)


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