It’s finally happened. The health care reform has at last officially passed into the Twilight Zone. How else to explain the idea under serious consideration in the Senate to make student loan reforms a part of the health care reform package. Yes. Really.

Follow this down the rabbit hole:

The Obama Administration wants to remove banks from the student loan process. This would apparently shift money in the program that currently goes to overhead and/or bank profits to tuition payments, helping more students for the same amount of spending. (I’m surer the issue is far more complicated than this, but this is a health care reform blog so this description will do). Legislation to implement these reforms has passed the House, but has stalled in the Senate due to a Republican filibuster. Sound familiar? The way around this dilemma is for Democrats to pass student loan reform through the reconciliation But to do that appears to require combining the student loan and health care reform bills into a single piece of legislation.

A fair question at this point might be, “Huh?”

Reconciliation, you’ll recall, allows passage of spending and tax bills with a simple majority. Reconciliation is the path the Senate will take in passing the clean-up legislation the House is demanding in exchange for passing the Senate’s health care reform bill. And there’s the rub.

It seems the reconciliation process can be used but once per year (or maybe session – I’ll edit this post once I find the answer). Which means that if reconciliation is used to pass the health care reform clean-up bill it would no longer be available to get the student loan reform legislation through the Senate. Or vice versa. So the solution is to combine the two into one bill.

This legislative mash-up may make sense from a parliamentary perspective, but it makes no sense to the general public. Instead, it will smack  of legislative trickery, something that has already soured much of the population on the current  health care reform bill. By adding to the through-the-looking-glass surrealism of the legislative process, combining student loan and health care reforms will only confirm to voters the feeling they have that Washing, D.C. is a reality-free zone.

Of course, such Carroll-esque lawmaking has been done before. The law that allows employees to keep their employer’s coverage after they leave the company is referred to as COBRA – which stands for the Consolidated Omnibus Budget Reconciliation Act (of 1985). In the past I’ve focused  on the “R” in COBRA standing for reconciliation. But it appears the “O,” for omnibus, is just as significant. That legislation addressed more than continuity of medical insurance coverage. Which means there’s precedent for asking one reconciliation bill to carry disparate legislative burdens.

Just because there’s precedent, however, doesn’t mean this strange development to an already strained legislative process is any less, well, strange.

Filed under: Barack Obama, Health Care Reform, Healthcare Reform, Politics Tagged: reconciliation, student loans
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This is the part of the national roller coaster ride more commonly referred to as reforming America’s health care system where the twists and turns come fast and the responses are increasingly furious.

Yesterday’s post described attempts to deal with the lack of trust between Senate and House Democrats. To summarize: House Democrats don’t want to approve the Senate’s version of health care reform without guarantees that the Senate will and can pass clean-up legislation changing that legislation. House Democrats fear a failure by the Senate to pass the clean-up bill will leave them forced to defend a vote for a clearly flawed bill.

Well, the challenge of reassuring House Democrats the clean-up legislation will pass just got tougher. According to David Drucker of RollCall.com, the Senate Parliamentarian has ruled that the Senate’s health care reform legislation must become law before the Senate can consider clean-up legislation. And the only way the Senate bill can become law is if the House passes it – as is. One might think this means President Barack Obama’s health care reform legislation is dead.

One might be wrong. Senate Majority Leader sent a letter today to Senate Minority Leader Mitch McConnell that formally informs Senate Republicans that the Senate will consider the health care reform clean-up bill under the rules of reconciliation (meaning it takes a simple majority to pass the bill). This can be taken as a show of confidence that Senator Reid believes the House will be passing the Senate’s health care reform bill.

House Speaker Nancy Pelosi is also expressing confidence that Democrats in her chamber will pass health care reform. And based on the optimistic statements made by several participants and reported by the Associated press after a meeting between the Administration and House Democrats today, progress toward passage of health care reform is, indeed, more likely today than yesterday. No one is saying it’s a done deal yet, but clearly the effort is intense and continues.

A critical development will be the Congressional Budget Office’s analysis of changes proposed to the Senate Bill (what will become the content of the clean-up legislation). The CBO report will have a substantial impact on those Democrats on the fence about the comprehensive health care reform package put forward by the Administration.

But more twists and turns await.

• Can the House Leadership find a procedural path that would allow the House to pass the Senate’s version of health care reform but make it’s enactment subject to passage of the clean-up bill?
• How many Democrats who voted for health care reform when it passed the House will now vote no because the Senate’s abortion language will prevail in the final product?
• Will liberals insist on a public option as a price for their vote?
• Will moderate Democrats who voted against the House bill vote in favor of the more moderate Senate version of reform?
• What will be the impact of the inevitable demonstrations House Democrats will face during the upcoming Easter recess?

And the list goes on. The only thing for certain is that no one knows for sure, after all the twists and turns, where we all wind up.

Filed under: Barack Obama, Health Care Reform, Healthcare Reform, Politics
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In the end, health care reform may come down to a question of trust: does the House of Representatives trust the United States Senate enough? Yes, majorities in both chambers are  comprised of Democrats, but that is far from sufficient. We’re talking about political careers here. We’re talking about overcoming the animosity said to exist between House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid. We’re talking about politics, fear, egos and legislation that will impact every American along with one-sixth of the nation’s economy. During a recession. In an election year.

This is epic stuff going on here.

Let’s review. In order to enact President Barack Obama’s health care reform package Congress must execute a three step legislative dance:

Step One: the House passes the Senate’s version of reform – a bill most oppose, but could accept with some changes. Once passed by the House, the legislation would go to the President’s desk for his signature and become law.

Step Two: The Senate passes legislation to make the changes House members (along with Senators and the President) want. These changes would all relate to government spending or taxation, enabling this so-called “side-car” legislation would be passed by through the reconciliation process. In other words, the clean-up bill could be passed by the Senate with 51 votes instead of the super-majority of 60 votes requires for most legislation now days.

Step Three: The House passes the Senate’s side-car bill, sending it on to President Obama for his signature. Taken together, the Senate bill and the clean-up legislation becomes the Democrat’s health care reform package.

The problem is that before they can amend an existing law, that existing law has to exist. Meaning the House has to pass the Senate’s health care reform bill before they know whether the Senate can and will pass the clean-up bill. No one in Washington actually likes the Senate bill as it is chock full of provisions House Democrats neither support nor wish to defend in this election year.

Without complete confidence that Senate Majority Leader Harry Reid can and will push through the side-car legislation, asking House Democrats to pass the unloved Senate bill (without any support from Republicans) is a huge risk. What if Senate Democrats refuse to enact the remedies House Democrats expect and demand? What if Senate Republicans succeed in blocking passage of the clean-up legislation? A lot can go wrong. Given the only three laws that seem to  apply within the beltway (those being the laws of Gravity, Unintended Consequences and the one named after Murphy) something is all but guaranteed to go wrong.

Not surprisingly then, as I’ve talked to legislative staff and others here in Washington a lot of creative thought is being devoted to bridging the trust gap. One rumor was that Speaker Pelosi was demanding that Senator Reid deliver two letters. The first would put in writing his commitment to pass clean-up legislation satisfactory to House Democrats. This letter would also guarantee that the Senate Parliamentarian (who ultimately will decide what provisions can be passed through reconciliation and which can’t) will permit these remedies to be approved with a 51-vote majority under reconciliation rules.

The second letter requested by Speaker Pelosi was rumored to be one signed by 51 Senators pledging their support of the side-car legislation. 

If true, the Speaker’s demand for written assurances is highly unusual, to say the least. And not all of the guarantees are within Senator Reid’s power to offer. For example, he has no ability to commit the Senate Parliamentarian to any specific decisions. The Senate Parliamentarian is an independent, non-partisan referee. The current Parliamentarian was appointed by Republicans when they controlled the Senate. No one has questioned his fairness during his service since (although some Republicans are now setting the stage to attack him if any of his decisions work to the advantage of Democrats). Senator Reid cannot control what the Parliamentarian will decide.

Another rumored solution to the Democrat’s dilemma would be one in which the Senate’s health care reform bill would be deemed passed by the House only if the side-car legislation was also passed. In the House, votes are subject to “rules” which specify everything from how much time a measure can be debated to how many amendments may be considered. The theory is that a rule could be passed that would, in essence, make enactment of health care reform clean-up legislation a pre-condition for the vote approving the Senate health care reform bill being considered binding. Or official. Or something. OK, I’m not sure how the rule would be worded, but the goal would be to prevent health care reform from passing without the provisions of the side-car bill also passing.

What to make of all this? First, that Democratic Leaders feel a great sense of urgency to enact health care reform. The longer voters sees Congress  struggling through procedural mazes, the less they support the legislation. Some have reported that President Obama has asked to have a bill ready for his signature by Congress’ Easter recess (if he’s going to use holidays as markers I would suggest April Fools Day just to demonstrate the White House still has a sense of humor, but that may just be me. The Associated Press story cited above says the Administration is hoping to see health care reform legislation passed by the end of next week when President Obama is scheduled to start foreign travel.

The second takeaway from all this pretzel-making is that Democrats are anxious to make the legislation more acceptable to the American people. The side-car legislation will contain several provisions put forward by Republicans. It is likely to eliminate the sweetheart deals favoring specific states. Democrats know they’ll be attacked this November if they pass health care reform legislation or if they fail to do so. Given this reality their best strategy is to pass a defensible bill.

What all these rumors also imply is that whether health care reform passes all comes down to whether Speaker Pelosi and Senator Reid can trust one another. If they can, health care reform is likely to move forward. If they cannot, health care reform in its current form is most likely doomed.

Filed under: Barack Obama, Health Care Reform, Healthcare Reform, Politics Tagged: Harry Reid, Nancy Pelosi, reconciliation, side-car legislation
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Someone should do a poll. The question: should politicians base their votes based on polls or on their own judgment and belief? There was a time when I think the general consensus might have been in favor of politicians standing for something in spite of the prevailing wind. Now it’s clear that the answer is whatever the politician wants it to be at the time.

Exhibit One: I’m at the National Association of Health Underwriters Capitol Conference in Washington, DC. This morning the general session featured lawmakers (from both parties) including Representative Mike Pence, part of the Republican Leadership in the House. Representative Pence, a former radio talk show host, is articulate and bright.

One of his arguments for why President Barack Obama’s health care reform package should be defeated, however, was that polls show Americans oppose the health care reform the legislation. This point has been made frequently and consistently by many Republicans and opponents of the President’s reforms.

Interestingly, this line of reasoning was not brought up when, late last year, during the debate over reforming how banks and other financial institutions are regulated. The financial reform bill passed without a single Republican vote. I assume Democrats made the argument during the debate that Republicans should support the legislation because polls show the public supports such reforms. (Interestingly, when individual components of the health care reform package are surveyed, voters tend to favor them).

So apparently many politicians believe lawmakers should cast their vote in accordance to the polls when the polls coincide with the pre-existing position of the politicians, but should vote their conscience when the polls disagree with their pre-existing position. (Note: a pre-existing position is different than a pre-existing condition. Just so we’re clear).

Legislating by responding to polls is a dangerous path. It subjects legislating to the passion of the moments. The Founding Fathers were aware of the dangers of this approach, consciously creating layers of checks and balances to prevent this outcome (a fact Representative Pence noted in arguing for subjecting health care reform to a 60-vote super-majority in the Senate). If our representatives in Washington are simply supposed to cast their vote in accordance with the latest polls we could save a lot of money by simply replacing all 535 members of Congress with the folks at the Gallup Organization.

But that’s not what most Americans want most of the time. Instead, Americans expect their representatives to debate, deliberate and use their best judgment. After all, we generally consider those who stand by their principles statesmen; those who base their votes on the latest survey results we consider mere politicians.

There’s a lot wrong with President Obama’s health care reform plan. Opposing it because of the latest survey results is a lousy reason. Instead, lawmakers who determine the package will do more harm than the status quo, should vote against it. Representatives who conclude the reforms are an improvement over the status quo should vote for it.

It’s really as simple as that. No polling required.

Filed under: Barack Obama, Health Care Reform, Healthcare Reform, Politics Tagged: Mike Pence
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Just some random thoughts while we see if the Democrats can muster enough votes to enact health care reform. None of them are worth a separate post (and may not be worth being in any post), but I thought I’d clear the decks before the real fun starts over the next few weeks.

It’s Franken’s Fault: If health care reform fails I blame Senator Al Franken. Elected by a mere 206 votes, Senator Franken became the 60th Democratic vote, the super-majority the caucus needed to overcome, in theory, any Republican filibuster. This enabled President Barack Obama and Democratic leaders in Congress to treat health care reform as a Democrats-only endeavor. Yes, Senator Max Baucus tried to work out a compromise with a few Republicans (and actually got one of them to vote for the Senate Finance bill). But liberals in the party and in the land of pundits were constantly and consistently pushing reforms to the left.  For example, Democrats insisted health care reform include a government-run health insurance plan far longer than would have been the case if they lacked a super-majority. Want proof? The public option fell to the wayside within 58 hours of the loss of their super-majority.

Of course, liberal Democrats had already made the mistake of believing that all Democrats think alike. Proud to be the party of inclusion, they forgot that they had included moderates and conservatives into their ranks. They somehow thought they could get Senators Ben Nelson, Joe Lieberman, Blanche Lincoln and other centrists to go along with the liberal wish list for health care reform. Having a super-majority masked this illusion. So if 104 Minnesotans had voted the other way, who knows, health care reform might have passed months ago.

Republicans Will Vote to Keep the Sweeteners.  Republicans hate being called the Party of No, but they’ve earned the epitaph. They seem to have adopted a political strategy that Democrats can achieve no victories. Whether that’s to embrace the Tea Party advocates who want the federal government to go away, acquiescence to Rush Limbaugh who is on record saying he wants President Obama to fail, or, who knows, a sincere expression of their public policy beliefs, the outcome is they act in near lockstep to defeat any proposal with the Administration’s finger prints on it. Which may create an interesting spectacle: Republicans voting to preserve the Cornhusker Kickback and the Louisiana Purchase.

These are among the legislative sweeteners added to the Senate health care reform bill to gain the support of Senators Ben Nelson and Mary Landrieu. And to deprive President Obama of a victory on health care reform Republican may need to defeat legislation to repeal them. Here’s why:

Under the legislative dance Democrats are likely to use to pass health care reform, the House will pass the Senate’s version health care reform bill. Since the Senate bill already passed that legislation – with a super-majority no less, House passage sends it directly to the President’s desk for his signature. At the same time Democrats will introduce legislation aimed at modifying the Senate legislation to, among other provisions, repeal the sweeteners, bribes, backroom deals, whatever you want to call them. Among those “other provisions,” by the way, are a number of items on Republican’s health care reform wish list. To deny Democrats the a victory on health care reform, Republicans may have to defeat the clean-up legislation – a vote to keep the sweeteners and to defeat their own reform proposals. The word “ironic” comes to mind – along with many others.

Politicians Need an Asterisk Projector. President Obama likes to say that “If you like your current health insurance you can keep it.” Well, in theory maybe. For awhile perhaps. But even in the short-term there’s a huge caveat: there’s no guarantee you can keep your health insurance in the current health insurance system and the reform bills do nothing to change that. When employers changes coverage, their employees change coverage. Whether they want to make that change or not. If a carrier drops a particular health plan in the individual market, insureds have to choose another plan. So when President Obama makes this pronouncement, he should project an asterisk over his head to cover these contingencies.

When Republicans condemn Democrats for even thinking about using the reconciliation process to pass the health care reform clean-up legislation discussed above they should project an asterisk. That’s because they were very happy to pass tax cuts a few years ago using the reconciliation process. So what Republicans mean when they oppose reconciliation is that they’re for it when it’s helpful to them and they think it’s un-American when it’s not.

For a Rookie He’s Gotten Pretty Far. Regardless of what you think of President Obama’s ideas or his tactics, you have to give him credit for getting further with health care reform than any of his predecessors. Pretty impressive for someone who was a State Senator just five years ago.

Whether It’ll Make Things Better or Worse is A Guess. Of course, it would be nice if the health care reform package he may get through was better than what will emerge from Congress, but let’s face it: no reform proposal would be popular. This is one of those issues in which there are no popular options. Everyone recognizes the status quo can’t endure. Everyone knows every proposal to fix the system is gravely flawed.

My first political mentor, Cathy O’Neill, used to say, however, “The test of whether to vote for something is not whether it’s perfect, but whether it’s better than what we’ve got.” When it comes to health care reform, however, there’s no way to know if a particular bill will make things “better” or not. The system is too complex. The opportunity for unintended consequences is too great. It’s likely only comprehensive reform can fix the system, but there’s no way to truly understand what comprehensive reform will accomplish until well after it’s implemented. Not a reassuring prospect, but it’s reality.

We’ve Only Just Begun.  Let’s say health care reform passes. That’s just the start. States and regulators will need to interpret and implement the reforms. Future Congress’ may seek to change or repeal the bills. Yogi Berra is supposed to have said, “It’s not over until it’s over.” When it comes to health care reform, “It’s not over even when it’s over.”

Filed under: Barack Obama, Health Care Reform, Healthcare Reform, Politics Tagged: Ben Nelson, Blanche Lincoln, Mary Landrieu, Max Baucus, Senate Finance Committee
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File this under “Better Late Than Never” but the drum beat aimed at focusing attention on the need to constrain medical costs in America continues.

Earlier this week I wrote about Sacramento Bee columnist Daniel Weintraub’s posting a reality check for California lawmakers that all the insurance carrier bashing they’re enjoying will do little to address the rising cost of health care. That post also reported on Warren Buffet’s advice to the president to do much more to rein in costs.

Then, yesterday, President Obama indicated he’ll be incorporating into the legislation he’ll be proposing later today some of the medical cost cutting ideas put forward by Republicans during last week’s bipartisan health care reform summit.

And the beat goes on. CNN has been reporting this week on extraordinary and wasteful costs in America’s health care system. $140 for a single Tylenol pill? $1,000 for a toothbrush anyone?

Some of the unnecessary expenses are mistakes made by the hospital that slip past health insurers’ claim examiners (a Georgia patient billed for 41 bags of IV solutions for an emergency room visit that lasted two hours in which just one bag was used). But some of the outrageous expenses are intentionally designed “to make up for lower payments the government pays through Medicare and Medicaid.”

The CNN report goes on to cite, however, a Pricewaterhouse Cooper’s Health Research Institute finding that $1.2 trillion of health care spending in the United States – roughly half – represents waste. This analysis includes in the definition of waste defensive medicine, preventable hospital readmissions, medical errors, and unnecessary emergency room visits. (The Congressional Budget Office has estimated that 30 percent of America’s health care spending is wasted or spent on low-value services using a less broad definition of waste.

There hasn’t been this much talk focused on the need to reduce medical costs since Dr. Atul Gawande wrote about the difference in Medicare spending experienced in two Texas cities, McAllen and El Paso. That was right before attention shifted to the misbehavior of demonstrators during Congressional Town Hall meetings and the debate in Washington pivoted to health insurance reform rather than health care reform. And I am not suggesting that the need to focus on medical cost containment undermine efforts to reform health insurance company behavior where that’s necessary.

Nor am I saying that the health care reform bill the President will put forward today does enough to attack skyrocketing medical care costs. But it will be a start. And it will do more than the proposal he unveiled last week or those previously passed by the Senate and House of Representatives. And that’s a good thing. Let’s just hope it’s the beginning of the effort to reduce health care costs and not the end of it.

Filed under: Barack Obama, Health Care Reform, Healthcare Reform, Politics Tagged: Atul Gawande, Daniel Weintraub, medical cost containment, Peter Orszag, Warren Buffet
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President Barack Obama is scheduled to announce his final health care reform package tomorrow (Wednesday). This is the version of reform the President hopes Democrats in Congress will embrace and enact through a process that would side-step the inevitable Republican filibuster of health care legislation. Passage is far from assured. There are still several parliamentary maneuvers available to the GOP to slow the legislative process down. And it’s unclear whether Democrats can muster a majority behind any single bill to pass health care reform even if no super majorities are required.

Yet there are indications Democrats could be successful. For example, the House passed its health care reform bill by the slimmest of margins – 220-215 – last November. Only one Republican voted for the bill and he has indicated he won’t bolt his party again. Given that 218 votes are need to pass legislation in the House, this doesn’t give Speaker Nancy Pelosi much room for error. However, according to the Associated Press, “at least nine of the 39 Democrats” who voted against the health care reform bill in November are now “undecided or withholding judgment until they see Mr. Obama’s final product.”

That same Associated Press story also reports that the President is thinking of incorporating four Republican proposals raised during the bipartisan health care reform summit last week. These are: 1) using investigators disguised as patients to uncover fraud and waste; 2) increasing payments to Medicaid providers; 3) strengthening and expanding Health Savings Accounts; and 4) expanding the medical malpractice reform pilot programs already in his bill.

It’s not that the President thinks including these provisions increases the likelihood of any Republicans supporting his health care reform legislation. But it would provide Democrats with a useful talking point during the firestorm that would follow passage of reform legislation by a simple majority vote in the Senate. Democrats will be able to say something along the line of “We met with Republicans and had an open mind, even incorporating some of their cost saving ideas into the final package. And our package already included several provisions Republicans had supported now or in the past. Their unanimous opposition, consequently, obviously reflects politics more than policy so we had to find away around the filibuster. What we did was fair, legal and within the rules.” Or something along those lines.

What all this means is that there’s still several chapters to go in the never-ending story that is health care reform.

• Will Democrats find a way to bring health care reform votes to the floor of the Senate?
• Will the House vote first or wait until after the Senate takes action (if it ever does)?
• If a vote is taken, will there be sufficient votes to actually pass a bill?
• If Congress does enact health care reform legislation, how soon after the President signs it into law will it take before the first law suit is filed?
• Which party will suffer at the polls this November for the the procedural games both have played?

And on and on. Stay tuned.

Filed under: Barack Obama, Health Care Reform, Healthcare Reform, Politics Tagged: filibuster, health care reform summit, Nancy Pelosi, reconciliation
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That health insurance carriers were ascending to the throne of political piñata in the health care reform debate has been apparent for some time now. Last July President Barack Obama began referring to health care reform as health insurance reform. A couple of weeks later Speaker Nancy Pelosi described insurance companies as “almost immoral” for opposing the creation of a government-run health plan. That insurance companies were to be cast as the villains was pretty much inevitable. People like and trust hospitals and doctors much more than health insurance carriers. And pharmaceutical companies, while profiting far more from health care than medical carriers are a bit removed from people’s daily experience. The reality is the only group Americans trust less when it comes to health care reform than insurance companies are Republicans in Congress.

Compounding the situation the health insurance industry has had atrocious timing. America’s Health Insurance Plans (AHIP), the industry’s trade organization, released a report warning that health care reform plans being considered by Congress would dramatically increase medical insurance premiums for many Americans. The message was hardly welcomed by Congressional Democrats, but what infuriated them was the timing. The Senate Finance Committee was about to vote upon the closest lawmakers had come to a bipartisan agreement (meaning at least one Republican voted for it. The vitriol the report inspired went far beyond its substance.

Then there’s the timing of recent rate increases in the individual health insurance market. While Anthem Blue Cross’ individual market increase first captured the public – and lawmakers’ attention – it’s now clear several carriers have levied double-digit premium increases in multiple states in both the individual and small business market segments. Many political observers believe that these rating actions breathed new life into flagging reform efforts.

But the 24-hour news channels and other media along with their innumerable pundits need fresh meat. Their job is to keep people watching (or reading) so the commercials don’t run together. There’s only so many ways you can use “insurance company” and “venal” in the same story before it gets old. Insurance company bashing will continue, but there are signs that serious attention may be given to aspects of America’s health care system reform beyond insurance markets.

Consider: Daniel Weintraub is one of California’s most respected journalists. In addition to reporting for and providing opinion pieces to the Sacramento Bee he maintains an excellent blog on health care issues, HealthyCal.org. In the past, Mr. Weintraub has been hard on insurance carriers. Nor is he a fan of the health care status quo in this country. So it must have been a surprise to even him when he wrote a post that makes clear that bashing health insurance companies is not the same as enacting meaningful health care reform.

Mr. Weintraub begins his post citing the political travails California insurance companies face in the state today, ranging from separate investigations by Attorney General Jerry Brown and Insurance Commissioner Steve Poizner to a host of legislative hearings led by lawmakers who, like the Attorney General and Insurance Commissioner, are seeking higher office in this election year.

While noting the entertainment value of this spectacle and recognizing that “it might actually produce information relevant to the health care debate,” Mr. Weintraub makes clear that “health insurance company profits and administrative costs remain a relatively small factor in driving the cost of coverage skyward. The biggest reason that health insurance is getting more expensive,” he continues, ”is that health care is getting more expensive.”

The post includes a useful pie chart describing national health expenditures as broken down by the US Centers for Medicare and Medicaid Services. Of the $2.3 trillion on health care Americans spent in 2008, $159 billion (approximately seven percent) “went to private insurers after deducting all the costs they pass through to the doctors, hospitals and other health care providers.” Put another way: “health care costs nearly doubled between 1998 and 2008, increasing by 96 percent. If we had eliminated private insurance companies in 1998, and assuming they provide no benefit in managing costs, health spending still would have increased by 83 percent during that decade.”

None of this means that health insurance companies and their behavior should be ignored nor their misdeeds forgiven. But as Mr. Weintraub notes, “when this election year is over and the current political bash-fest comes to an end, the core costs of health care will still be there, and chances are they will still be rising.”

That a respected journalist is noting that attacks on health insurance companies are diverting attention from other serious issues with America’s health care system is significant. But he’s not alone. According to Politico.com, Warren Buffett is advising President Obama “to scrap the health care bill and start over” because the legislation “does not focus on controlling costs.” (He went on to say that he’d vote for the Senate bill as opposed to maintaining the status quo).

President Obama and his allies will argue that their legislation does attack rising costs – and they have some evidence to back their claim. But few could honestly say it goes far enough. And while good starts are important, the question is whether the Administration and Congress have the political will to follow-up with meaningful cost containment measures.

Attacks on the health insurance industry will continue. Every drama needs a villain and in this particular theater, carriers are the bad guys. But that folks like Mr. Weintraub and Mr. Buffet are calling out politicians for failing to more fully address the most critical issue undermining America’s health care system – runaway medical costs – is an encouraging sign.

Filed under: Barack Obama, Health Care Reform, Healthcare Reform, Politics Tagged: Daniel Weintraub, government health plan, HealthCal.org, Jerry Brown, medical cost containment, Nancy Pelosi, Steve Poizner, Warren Buffet
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With the bipartisan health care reform summit history, President Barack Obama is turning to the future of his push to revamp America’s health care system. Here’s a simple way for President Barack Obama to demonstrate a commitment to cost containment and bi-partisanship. As he said in his weekly address this morning, “I am eager and willing to move forward with members of both parties on health care if the other side is serious about coming together to resolve our differences and get this done.”

He also made clear, however that he would move forward without Republican support if that was necessary. “I also believe that we cannot lose the opportunity to meet this challenge,” he said, concluding, “It is time for us to come together.  It is time for us to act.  It is time for those of us in Washington to live up to our responsibilities to the American people and to future generations.  So let’s get this done.”

The other day I wrote about the three step process Democrats are likely to use to attempt to pass comprehensive health care reform. To summarize: House Democrats would pass the health care reform previously passed by the Senate. The Senate would pass a clean-up bill (which I’ve also heard referred to as “sidecar legislation”) that makes fixes the House and President Obama want that impacts costs and taxes. The House passes the clean up bill. The President signs both bills and health care reform, Democratic-style, is the law of the land.

Turns out this gambit, while legal and within Congressional rules, doesn’t play out as cleanly as I’d first surmised. John Nelson, a regular reader, brought to my attention that there are various ways Republicans can slow this process down to a crawl. The GOP could not filibuster the sidecar legislation because it is being considered under what’s called the reconciliation process. However, they may not need to. Under the rules governing the reconciliation process Republicans can introduce an almost unlimited number of amendments. While in theory the reconciliation process limits debate to 20 hours, the amendments could stretch out the debate for weeks.

As President Obama accurately noted during the health care reform summit, most Americans care more about the substance of health care reform than the process. However, it’s equally true that the legislative procedures used to push the issue this far have created a cloud over the substance of reform. Republicans have artfully used the messy give-and-take typical when drafting major legislation and cast it as a reason to oppose what was drafted. Some of these criticisms, such as the deals cut to favor specific states, are valid; others, such as condemning the legislation because the bills themselves are large, are spurious. But what’s undeniable is the drumbeat of criticism concerning process has undermined the substance of the bill (of course the serious problems with the substance of the bill hasn’t bolstered it’s popularity either).

If the Democrats could accomplish their legislative maneuvers quickly attention would shift to he substance of the legislation long before the November elections. In other words, like yanking off a bandage, the political pain generated by the process would be over quickly. If Republicans force Democrats to spend weeks mired in process, however, the political pain becomes increasingly greater – and perhaps unbearable.

What all this means is that the odds of comprehensive health care reform passing have improved considerably since the election of Scott Brown to the Senate from Massachusetts and the subsequent loss of the Democratic caucus’ 60 vote, filibuster-busting majority. But those odds haven’t increased as much as a I thought when I wrote about the three-step process Democrats would likely use to enact the reform legislation.

There are smart people on both sides of the issue. There are passionate people on both sides. The effort to pass – and to defeat – health care reform will continue. How it ends is anyone’s guess at this point.

Filed under: Barack Obama, Health Care Reform, Healthcare Reform, Politics Tagged: bipartisanship, filibuster, health care reform summit, reconciliation
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President Barack Obama repeatedly tried to get the bipartisan summit on health care reform to focus on policy rather than process. Now that the summit is over, however, process is rightfully back on the table.

As I noted in my previous post, many of the major health care reforms of the past few decades have been accomplished through use of the reconciliation process. But how exactly would it be used this time for this reform?

Let’s review where reconciliation fits into the wonderful whacky world of the U.S. Senate. As you’ll recall, 41 Senators can invoke a filibuster and consequently prevent a bill from coming to the floor.  Only if 60 of their colleagues vote to close debate (by invoking cloture) can a bill be voted upon by the full Senate. (For an interesting history of the filibuster and cloture, check out the Senate’s web site). There is an exception, however. Since 1974, budget and tax related items can be brought to the floor of the Senate through a process known as “reconciliation” and no filibuster can stop it. So a key issue is, what matters are eligible for the reconciliation process?

Enter Senator Robert Byrd the widely acknowledged master parliamentarian of the U.S. Senate. He created what is known as the Byrd rule to help determine what is outside the reconciliation process. Put simply, the Byrd rule defines as “extraneous matter” items that do not impact government outlays or revenue in a substantive way. (It’s more complicated than that, but that’s the gist of it).

New taxes, and the health care reform process has plenty of them, are clearly within the purview of the reconciliation process. Preventing carriers from excluding pre-existing medical conditions from coverage is not.

What this means is that the Senate can not pass comprehensive health care reform through the reconciliation process. But hang with me here, because the fact is they don’t need to pass comprehensive health care reform through the reconciliation process because they already have. Remember? It was only a few weeks ago, on December 24th, 2009 to be precise. The Senate passed a comprehensive health care reform bill on a party-line 60-to-39 vote. yes, I know. It seems like ages ago, but it has only been a couple of months. And that affirmative act still stands.

So here’s the legislative three-step Democrats are likely to use to pass comprehensive health care reform.

Step One: The House votes on and passes the Senate version of health care reform.
Step Two: The Senate, using the reconciliation process, passes legislation to “fix” certain aspects of the health care reform it passed in the Senate.
Step Three: The House passes the Senate’s ‘clean-up” bill.

Both the Senate health insurance legislation and the clean-up bill arrive on the president’s desk. He signs them both into law.

What you may (and should) ask, would be in the clean-up bill? As previously predicted here, the follow-up bill is expected to remove state-specific funding elements such as the special treatment currently in the Senate bill favoring Nebraska, Louisiana and a few other states. The clean-up is also likely to change the criteria of a “Cadillac health plan” subjecting fewer policies from being subject to the proposed excise tax. Other fees and taxes would also likely be a part of the second bill. In other words, the clean-up bill would only relate to the budget and/or taxes, meeting the test of the Byrd rule.

I haven’t come up with this on my own. This legislative dance to enact health care reform was discussed at length on “Hardball with Chris Matthews” on MSNBC (the relevant discussion starts at about 3 minutes, 10 seconds in this clip, although he refers to it as a two-step process). What’s significant, however, is that it’s a strategy that makes sense (if your goal is to pass health care reform). Republicans will object that it’s ramming health care through Congress, but the GOP can’t claim the three-step violates Senate rules.

Many thought President Obama’s health care reform bill died with the election of Scott Brown to the Senate from Massachusetts on January 19, 2010. The odds are: they were wrong.

Filed under: Barack Obama, Health Care Reform, Healthcare Reform, Politics Tagged: cloture, filibuster, reconciliation, Robert Byrd
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