While others seem ready to declare health care reform dead, Henry Aaron explains why reformers must stay the course in the most recent issue of the New England Journal of Medicine. They have everything to lose, and nothing to gain if they abdicate their responsibilities now. More importantly the nation will be left with a health care system that fails society while threatening our economy.
While others flail about, the Brookings Institution Senior Fellow makes his case in calm, lucid prose, reminding us that nothing has changed over the past month. The House and Senate have, in fact, managed to pass two very similar bills. If you explain the legislation to the public, the majority of Americans favor reform. All that remains to be done is to reconcile those bills—which in the end requires a simple majority.
Aaron begins: “The course of health care reform in 2009 resembled the silent movie series ‘The Perils of Pauline’ in which each episode began with a threat to the heroine’s life but ended with her salvation. Despite repeated near-death experiences, reform legislation passed both houses of Congress. After so many obstacles had been surmounted, the remaining task of reconciling the House and Senate bills seemed doable.”
Then, Scott Brown won in Massachusetts, and although that election was not a referendum on healthcare reform “ it . . . caused something approaching a panic attack among White House and congressional Democrats.” There was no need to lose sight of the goal, Aaron argues, the task ahead was clear.
“The 2009 budget resolution instructed both houses of Congress to enact health care reform. The House and the Senate have passed similar but not identical bills. Since both houses have acted but some work remains to be done to align the two bills, using reconciliation to implement the instructions in the budget resolution follows established congressional procedure.
“Furthermore, coming from Republicans, objections to the use of reconciliation on procedural grounds seem more than a little insincere. A Republican president and a Republican Congress used reconciliation procedures in 2001 to enact tax cuts that were supported by fewer than 60 senators. The then-majority Republicans could use reconciliation only because they misrepresented the tax cuts as temporary although everyone understood they were intended to be permanent — but permanent cuts would have required the support of 60 senators, which they did not have.
“The more substantive objection to the use of reconciliation for passing health care reform derives from the fact that, according to polls, more Americans oppose than support what they think is in the reform bills. It is hardly surprising that people are nervous about health care reform. Most Americans are insured and are reasonably satisfied with their coverage. In principle, large-scale reform could upset current arrangements.
If public perceptions of the intended and expected effects of the current bills were accurate, democratically elected representatives might be bound to heed the concerns. Because the perceptions are inaccurate, reform supporters have a duty to do a better job of explaining what health care reform will do. When participants in focus groups are informed about the bills’ actual provisions, their views become much more positive. The prevailing views have clearly been shaped by opponents’ misrepresentations of the reform plans, which supporters have done little to rebut. Opponents have described as a “government takeover” plans that would cause tens of millions of people to buy insurance from private companies. They have told people that a plan deemed by the Congressional Budget Office to be a deficit reducer is actually a budget buster. They have fostered the canard that end-of-life counseling would mean the creation of “death panels” (a claim that PolitiFact.com labeled “the lie of the year”). They have persuaded Americans that their insurance arrangements would be jeopardized by plans that would in fact leave most coverage untouched, add coverage for millions of Americans, and protect millions of others from cancellation of their coverage and from unaffordable rate increases in the event of serious illness. . . “
[Here it is worth noting that, according to Washington Post/ABC polls released yesterday, when asked whether Congress should keep working to pass comprehensive health-care reform two-thirds of Americans said “yes”—including 88 percent of Democrats 56 percent of independents and 42 percent of Republicans.—mm]
Aaron continues: “Health care reformers in the administration and Congress have a powerful case to make and, on an issue of such enormous importance, a duty to make it. In addition to reminding Americans that reform will protect, not jeopardize, coverage by preventing insurance companies from canceling coverage or jacking up premiums for the sick, reform advocates should remind them that the proposed legislation will bring coverage to tens of millions of currently uninsured Americans and protect it for scores of millions of others. Reform advocates should explain the legislation’s legitimate promise of cost control and quality improvement.
“President Barack Obama has announced a bipartisan meeting on moving the reform process forward. It is an opportunity for all sides to present ideas for improving the bills that already have been passed by both houses of Congress. If modifications are identified that will command the support of simple majorities in both houses, they should be adopted through reconciliation. Then the House should pass the Senate bill.” [It really is that simple. The majority just needs to remember that it is the majority, that it has the support of the public, and that the party must stop negotiating with itself. mm]
Aaaron concludes: “Other strategies, in my view, have no prospect of success. Abandoning the reform effort is the worst strategy of all — not only for reform advocates, but for the nation. Reform advocates are already on record as supporting reform. Voters who oppose reform will not forget that fact come November, and those who support it will find little reason to make campaign contributions to or turn out to vote for lawmakers who were afraid to use large congressional majorities to implement legislation that would begin long-overdue efforts to extend coverage, slow the growth of spending, and improve the quality of care.
“The start-from-scratch and piecemeal-legislation strategies are invitations to time-consuming failure. The Senate would need 60-vote majorities for every component of such reforms. To be sure, lawmakers could craft a different bill that would extend coverage to fewer people than the current bills do. But they could not institute serious insurance market reforms without assuring a balanced enrollee pool — or assure such a pool without mandating coverage. Nor is it politically possible or ethically fair to mandate coverage without offering subsidies for low- and moderate-income people. And it is not possible to prevent those subsidies from increasing deficits without tax increases or spending cuts, which reform opponents won’t support and which would require 60 Senate votes. The call to start anew is naive at best. At worst, it is a disingenuous siren song, luring health care reformers into a political swamp.”
If you believe as I do that the current system is unsustainable and already unfair, then putting off reform is tantamount to Nero fiddling while Rome burned. The short term benefits of such a “system burn” strategy can only accrue to a few narrow minded and greedy souls. To me, it is mainly the rules and non-population proportional constitutional makeup of the Senate that keep forcing our society to ignore critical beneficial changes for the many while keeping in place a system that is unsustainable and unfair.
I am curious how most people can be satisfied with their insurance while also wholeheartedly supporting health reform?
In addition, I am concerned about subsidizing private insurance, because the plans entail protection people either are unwilling or unable to afford.
Isn’t that why we have the National Flood Insurance Program and the Pension Benefit Guaranty Corporation?
Don Levit
Don, NG
Don– Most pepole are happy with the employer-sponsored insurance they have — but worried that either a) their employer might cut back on or eliminate the insurance or b) they might lose their job.
In addition, some American are concerned about others– the many uninsured people who, in some cases, are their brothers, sisters, children, neighbors. Other Americans worry about the less fortuante whether or not they are related to them.
NG–
Yes, this is Congress “fiddling” while
the U.S. health care system burns. .
The GOP’s threats if reconciliaton is used is specious. They used reconciliation for the 2001 Bush tax cuts with less contention over those than for health care reform (62 senate ayes – 12 were democratic votes).
The Dems should use reconciliation and let the chips fall where they may. They should target those who vote against reform in November but start as soon as the votes are in and never let up right up to the election.
r.l. sauer–
Welcome to the blog.
You wrote: “The Dems should use reconciliation and let the chips fall where they may.”
I agree completely.
Note thatthe poll asked if citizens were in favor of “healthcare reform” – and they are.
“Health Insurance Reform” is not “Healthcare Reform”
I am always amazed to hear that so many people are satisfied with their current private company insurance. Maybe they seldom have to use it. I used to be satisfied with my insurance, Medicare; then my former employer switched me to a Medicare Advantage program. Now most of my doctors will no longer take my insurance, and I’m constantly having to look for new doctors. What a crazy non-insurance system we have in this country!
Personally, I think starting from scratch is the best option. I do not like the current legislation, along with most people I’ve spoken to.
I’d rather have them pass a bill that will work, rather that just any bill, so that they can say they are doing their job.
” but worried that either a) their employer might cut back on or eliminate the insurance or b) they might ose their job” -MM
Those people have good reason to worry. 40% of large employers are not confident that they will offer health benefits in 10 years and 70% are disatisfied with their current insurance arrangements. Fewer than half of small businesses can afford to offer insurance today.
How then does a strategy that seeks to reinforce the primacy of employer-provided address the legitimate concerns of people such as you describe?
The issue should not be how to buy more of a failed model for the uninsured, it should be how we can get on a path that will provide everyone with the medical and financial security enjoyed elsewhere.
I’m 100% in favor of actual health care reform. That’s why I am opposed to the currently proposed legislation.
Athena:
You make several good points.
Employer-provided insurance is temporary, lasting as long as the employee’s tenure at the company.
The government has attempted to extend the coverage by providing significant subsidies for COBRA continuation.
With the potential legislation, if the person starts working for a new employer who does not offer insurance, he is provided the opportunity of purchasing insurance through an exchange, again with significant subsidies.
The fact that subsidies must be extended for COBRA and exchange policies tells me the present system is not sustainable.
Are these subsidies intended to make insurance more affordable?
I think not.
Don Levit
First of all, there is little chance that the House and Senate bills will become the essence of health care reform. The wind is no longer at the Dems’ backs. You are correct that the public is very skeptical.
You commented: “If public perceptions of the intended and expected effects of the current bills were accurate, democratically elected representatives might be bound to heed the concerns. Because the perceptions are inaccurate, reform supporters have a duty to do a better job of explaining what health care reform will do.”
This is interesting. Does this mean if the public disagrees with your position that they must not be sufficiently informed and have been duped? If they had agreed with you, would they be considered Mensa material?
http://www.MDWhistleblower.blogspot.com
Mr. Aaron blames the bill’s critics for misleading the public. But give the public credit. They/we understand that Medicare has a $40 trillion unfunded liability, and is approaching insolvency. They also understand that Medicaid is swallowing the federal and state budgets. And they understand that private insurance cost increases are unsustainable – much of it due to cost shifting from Uncle Sam.
The proposed “reform” that calls for massive tax increases is not viewed as a solution. The CBO is not credible when is says it reduces the budget. The public will not swallow this reform in the context of trillion plus deficits for the foreseeable future – and a stimulus bill that is not popular.
No politician can coherently explain the plan. This is because it is so complex and does not significantly address runaway costs.
Laying the entire problem at the feet of Republicans and an ill-informed electorate is nonsensical. The uninsured is a symptom of the problem. Address spiraling costs, avoid massive taxes and the public will follow – as will the GOP. And we will be able to get more people insured.
Bill:
I agree with everything you said.
One area of contention people may have with your statements is regarding the deficit for Medicare.
How can Medicare have a deficit if we are taking in more money than we are paying out in benefits?
The reason is that the asset of Medicare is its revenues, and the liability is its current expenses.
The accounting for Medicare is on a cash basis, not an accrual basis.
The same is true for Social Security.
Many of us know that it takes 40 quarters to be fully insured for Social Security.
If Social Security was stopped today, and we continued to pay those who had accumulated 40 quarters, their benefits at their retirement age until their deaths, we would be about $10 trillion in the hole.
But, the government doesn’t consider one being fully vested under Social Security. Regardless of whether he has contributed for 40 quarters, he is vested only for the current fiscal year. Thus, poof, we aren’t $10 trillion in the hole.
We are actually at a surplus.
Don Levit
Government continues to talk in circles about healthcare reform. Healthcare reform can be re-hauled, but the answer is through the private sector. It’s time to quit beating our heads against the wall and rethink our approach to the system. Our fee-for-service model is broken and it’s time that we stopped focusing on how to afford the healthcare system we have and focus on how to make healthcare affordable.