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Predictions: What Will Happen With Health Reform?


These days, about one in three conversations I have includes the question, "What's going to happen with health reform?" So for ease of use, I'll just put my prediction here: I think health reform is going to go the way of stimulus.

The stimulus was a huge and important accomplishment. If you had told liberals in 2007 that they were going to pass an $800 billion dollar spending bill that made good on decades of promises about infrastructure rebuilding and comparative effectiveness research and train construction and broadband internet and green energy, they would have laughed at you.

But by the time the bill actually wound its way through Congress, most liberals were frustrated by the outcome: A few Senate moderates had lopped $100 billion in spending off of the total and done so for no apparent reason. Top economists said that the legislation, though helpful, would not be enough to close the output gap and should thus be larger. The stimulus was a historic legislative accomplishment that nevertheless left liberals frustrated because they made concessions they didn't see any reason to make and ended up with a bill that they knew would not fully solve the problem.

That, I'd bet, is how health reform will close out as well. We will spend a trillion or a bit more covering the un- and underinsured. We will regulate a fairer and more decent insurance market into existence. We will expand Medicaid and build out subsidies to at least 300 percent of poverty and create health insurance exchanges. We will fund all this through sharply progressive taxes. We may even have a public plan. In 2006, it would have been a great deal. But as the legislation winds its way through the Senate, there will be unpleasant compromises, and unconscionable omissions, and the constant knowledge that though this is progress, it is not sufficient, and the people who stand in the way of a better bill are frequently incoherent or disingenuous. And that will be terribly frustrating for supports of the effort. The result will probably be a historic win when compared to the status quo, but I doubt it's going to feel like that for supporters of the initiative.

Photo of Sen Chris Dodd and Sen. Mike Enzi by Charles Dharapak of AP Photo.

By Ezra Klein  |  June 23, 2009; 12:06 PM ET
Categories:  Health Reform  
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Next: Conrad and Schumer Nearing an Agreement?


My prediction is that we get a bill more like the Wyden-Bennett bill where we have our healthcare benefits taxed and where Medicaid is privatized instead of expanded. I also believe that MediPAC legislation will be passed further diminishing Medicare benefits for seniors and possibly raising the age of eligibility. People will be charged higher insurance premiums if they smoke or are overweight. The elderly will be incentivized to leave nursing homes in favor of home-based health care. People will go to jail if they commit waste, abuse and fraud of Medicare or Medicaid dollars. I still can't figure out if Congress will require Medicaid/Medicare recipients to have living wills as mentioned by Senator Specter a few months ago. End-of-life issues haven't been discussed that much in legislation or the news as far as I can tell. Have you heard anything on the developments of that touchy subject within the healthcare reform arena, Ezra?

Posted by: ademption | June 23, 2009 12:27 PM | Report abuse

There'll be no real reform. I'm not rooting for that state of affairs.

The money is almost irrelevant. We think we have an economy, but what we really want, and have, is a morality play. It's burnt into the pseudo-Calvininst American mythos.

If people are presented with a choice between a satisfying narrative arc, in which the good guys win and the bad guys get punished, and an actual, functioning social provision, they'll take the coherent story over the boring social provision.

A mish-mosh like the one Ezra sketches coming out of the House is a lousy backbone for a story. It'll get killed in the Senate, by a mix of superior GOP messaging, and an institution whose very DNA is designed to not do things.

I predict a collapse of support for the measure among the elderly, who a.) vote in disproportionately large numbers, and b.) whose universal care-delivery system is largely already set up.

There is no disincentive for them to not vote their prejudices, or their theories about capitalism, or their memories of how medical care was delivered when Eisenhower was in the White House. They're free to message-send to their hearts' content knowing their ox won't be gored.

Posted by: davis_x_machina | June 23, 2009 12:42 PM | Report abuse

Now, wait just a darn minute. We were told that, sure, the money would be wasted, but the point was to spend it, and stimulate the economy. And now it's being described as more trains and other good stuff?

Well, $9 billion for trains ain't diddly.

And a health care bill that doesn't establish a public option won't be diddly either. Some desperately poor people will have their co-pays reduced by $50-$100. Much more will be spent on administrators for programs telling the poor to stop smoking, and arguably, the expansion of employer-provided coverage to administrators will be the biggest expansion of actual coverage to come out of a bill with no public option.

As for the elderly, not only do they have to deal with ruinous drug costs, even with Medicare Part D, but they are acutely aware of the crisis in primary care providers. The elderly watch tv news instead of reading the internet, and AARP (an insurance company) will hit them with a perfect blizzard of anti-reform propaganda. Advertising is the bedrock of our society, so some of it will probably work. But the elderly people who are the real problem all bear the honorific of "Senator".

Posted by: serialcatowner | June 23, 2009 1:07 PM | Report abuse

"and the people who stand in the way of a better bill are frequently incoherent or disingenuous"

Precisely why the national press is so important, and why they're so overwhelmingly guilty of dereliction of duty.

Posted by: BigTunaTim | June 23, 2009 1:59 PM | Report abuse

"I predict a collapse of support for the measure among the elderly"

Absolutely. They're going to realize that the ideas about achieving cost control by limiting expensive end-of-life care are aimed at them.

Posted by: tomtildrum | June 23, 2009 5:38 PM | Report abuse

Believe it, young people are much more excited about receiving expensive end-of-life care than old people are.

Posted by: serialcatowner | June 23, 2009 7:31 PM | Report abuse

You thinnk exactly what I think. And Obama will sell it as a victory and many of us will conclude he's a sell-out. And Democrats will not get much credit -- it will seem just a natural trajectory, what this screwed up country can be expected to deliver. Disappointing.

Posted by: janinsanfran | June 23, 2009 8:58 PM | Report abuse

Ezra is the human embodiment of the weakness of the wonk.

You see, the wonk wants legislation and policy implementation, no matter what. So no bill is worse than a bad bill.

I am a citizen. I am deeply concerned that after 10 years without job growth, our country is now 20 years into a massive loss of assets and income. Central to this is our economic uncompetitiveness in value creation sectors - manufacturing and exportable services. Central to that uncompetitiveness is the fact that our labor costs are overlaid by the spending of 16% OF OUR ENTIRE GDP on health care.

IT HAS TO STOP. IT HAS TO BE REVERSED. That will take real change, real pain, and really different approaches to the whole thing.

Bottom line, as a country we no longer have the resources to overpay for health care, because the cost of health care is causing our unemployment, and if we go into long term 10-12% unemployment, we cannot fund our government, we cannot pay off our debt, we cannot educate our children, and two generations from now we will be Russia.

That is why single payer would be best. That's why the MINIMUM we can afford is 15% of our population in a well funded, aggressive as hell public plan.

In a competitive world, we can no longer afford to waste our resources on the luxury of compromising with Republicans, just so wonky folks can have new public policy toys to play with.

Ezra, you are part of the problem, and in compromising now, you are not part of the solution.

Posted by: Dollared | June 24, 2009 2:09 PM | Report abuse

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