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What's going on in the House?

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The House of Representatives is expected to vote on health-care reform Saturday. But the days before a big vote are rarely calm ones, and this week has been no exception. Democrats don't expect a single Republican to cross over to vote for health-care reform. That is to say, the Waxman-Markey cap and trade bill, which got eight Republican votes for what amounted to a tax on dirty energy paired with a bazillion (approximately) regulations on energy producers, was more bipartisan than an incrementalist health-care reform bill.

Amazing, huh?

That's left Pelosi's team mired in negotiations with three different types of Democrats who are proving restive at the eleventh hour.

First are the controversialists. This group is concerned about some of the traditionally electric issues: abortion, immigration, that sort of thing. The arguments are largely over language -- in some cases, very small differences in language, and in other cases, very large differences in language -- and most imagine that they'll eventually be finessed.

The abortion argument is centered on a pretty small, and slightly absurd, dispute: how best to cordon off federal funds. Under a compromise suggested by Rep. Brad Ellsworth, for instance, the public plan would hire a private contractor to pay abortion providers. The end result here is likely to be a complicated system in which insurers document that abortions were paid for through the funds that the individual contributed, as opposed to the subsidies. It's all a bit absurd, but it's workable.

Immigration may prove harder. The White House had a meeting with members of the Hispanic Caucus that does not look to have gone very well, with members of the caucus taking a hard line on the inclusion of illegal immigrants in the final bill.

The second group is made up of centrist skeptics. This group is rather better understood, with the final outcomes a bit more predictable. Some are from vulnerable districts and others are simply centrists, but these are the folks who think the surtax on millionaires is deeply offensive to American values, or that the public option goes too far, or that the whole thing is simply too ambitious. These are where you get most of the "hard Nos," the folks who can't be brought on with such legislative tweaks.

The final group is worried about the process. Some are concerned that the Senate isn't going to vote for three months and the House bill will simply hang out and get hammered by the right, leading to the Senate passing a substantially different, and politically safer, bill. If that's going to be the outcome, these Democrats don't want to have to defend a vote on a liberal bill that didn't even make it into law. This group isn't sure they want to vote first, and is all the more concerned given that they don't have assurances from Reid on either his timing or the language of the Senate bill.

There's overlap between these groups, of course. But even amid the last-minute chaos, fairly little is actually in play here. Twists in the language on abortion and immigration. Whether Rep. Anothony Weiner offers a single-payer amendment (he decided against it to spare some of these moderates with liberal bases more pressure and controversy than they're already facing). That sort of thing. The hope remains that the "rule" gets voted on tomorrow, and the bill gets voted on directly afterwards. Delay past this weekend isn't a death knell, but it's not a good sign, and the leadership knows that. The perception of a vulnerable process makes moderates more, rather than less, scared, which makes their demands more, rather than less, insistent.

Photo credit: By Harry Hamburg/Associated Press

By Ezra Klein  |  November 6, 2009; 2:55 PM ET
 
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Comments

"with members of the caucus taking a hard line on the inclusion of illegal immigrants in the final bill."

What does this mean? I always thought this was a made-up conservative talking point.....

Posted by: Chris_ | November 6, 2009 3:00 PM | Report abuse

Just get it done. Why isn't Rahm on the Hill twisting arms.

Posted by: maritza1 | November 6, 2009 3:00 PM | Report abuse

As I wrote on Matt's blog, just to reiterate what we have been shouting all along about this House bill, things which are wrong there:

1. Funding mechanism is wrong (funds need to come from health care system itself); very likely to fall behind medical cost inflation and it pulls out resources which otherwise could have been used for general deficit reduction.

2. Core price control is extremely weak. There is no mechanism by which national, uniform pricing is set. Unless that happens we have nothing much to go. Insurance companies in themselves (even Medicare for that matter) do not exert core control on prices. It is high prices which are dooming our health system. This bill does not address that problem.

3. Whatever MedPAC or iMAC proposals of independent commissions to control Medicare costs and other generic recommendations were there; those are diluted or outright removed. (I am not 100% sure here, so will be very glad to accept any good news here.)

4. What happens to Doc fix $250B item? Seems not included.

5. Restricted admission to exchanges.

So I think it is wrong for White House to back this bill.

Posted by: umesh409 | November 6, 2009 3:15 PM | Report abuse

The jobs data are worse than I expected. Our federal debt is ballooning.

The healthcare bill is a giveaway to the drug companies, with greater control from Washington, and with steep taxes and burden shouldered by the elderly.

The exchange doesn't fully get implemented until 2014; part of the reason for that delay is to show that the bill is "deficit neutral." We all know from Massachusetts that the CBO arithmetic has a huge error bar around its estimate.

In terms of minimizing damage to 2010 elections, either scale back the bill dramatically without a government option, or don't do it at all. Don't try to ram the House bill through because it will just invite more and more criticism for its bloated nature. TERRIBLE POLITICS! Don't the Dems realize that the last thing you want to do is to tax people with unemployment greater than 10%?


Posted by: RandomWalk1 | November 6, 2009 3:15 PM | Report abuse

It's nonsensical to take the position that surtaxes on millionaires are offensive to American values while disparities in income have risen for decades and continue to rise toward third-world levels.

In addition, there's nothing fiscally conservative, as these ConservaDems advertise themselves, about opposing health care reform legislation scored by the CBO to significantly REDUCE the deficit.

I continue to be amazed that these guys don't realize that they'd be taking a much bigger political risk by voting against health care reform than by voting for it.

To be clear, ConservaDems are not moderates, they're not centrists, and they're anything but fiscally conservative.

Posted by: cjo30080 | November 6, 2009 3:29 PM | Report abuse

cjo30080,

The CBO score leaves out the doc fix. Also there is a huge error bar around the CBO score. Even if deficit neutrality were the case, don't forget about the costs to state governments, individuals, and corporations. Fiscally prudent people might also be opposed to the burden placed on these groups.

Finally, robin hood economics is agreeable or disagreeable depending upon who gives or who receives.


Posted by: RandomWalk1 | November 6, 2009 3:37 PM | Report abuse

"In addition, there's nothing fiscally conservative, as these ConservaDems advertise themselves, about opposing health care reform legislation scored by the CBO to significantly REDUCE the deficit."

I'm asking this question in good faith -- Do you really think that the healthcare reform being offered will reduce the deficit? We're talking about a huge economic shock with healthcare reform, and I hope people aren't merely being partisan -- so, I ask again -- Do you really think it will reduce the deficit -- in other words, do you believe the CBO is working with real numbers and actual scenarios to come up with that conclusion?

Posted by: mdfarmer | November 6, 2009 3:44 PM | Report abuse

RandomWalk1,

The CBO score leaves out the doc fix because it's not in the legislation. The doc fix (i.e., repeal of Medicare payment cuts to certain specialists) will be voted on separately in the House, and in the unlikely event that it passes, it won't make it through the Senate (it already failed there).

Incidentally, state governments, individuals, and corporations will enjoy net savings from health care reform -- not additional costs.

Posted by: cjo30080 | November 6, 2009 4:05 PM | Report abuse

(1) I find it comical that Ezra continues to try to (mis)characterize the House bill as "incrementatlist" and "modest". There's nothing modest about a bill that runs for 2,000 pages, has thousands of directives and costs in excess of a trillion dollars (in just its first decade). "Transformative" and "sweeping" are adjectives that better describes this legislation.

(2) The legislative process does not approach the level of transparency that Obama promised. Remember when he claimed it would all unfold on CSPAN? Instead the wrangling over the contentious issues is occuring exclusively among Democrats and behind closed doors; the votes on the final text may well happen over the weekend, perhaps mere hours after the ink has dried on the final copy. In other words there will be no meaningful scrutiny by opposition legislators, much less the public.

(3) The Dems are being wholly dishonest about the cost of this bill. The CBO is obliged to take claims that provider reimbursement will be slashed at face value when everyone knows Congress has repeatly stayed far more modest cuts on an annual basis for many years running. And, more importantly, the most expensive benefits in the bill are backloaded and so not fully accounted for. The true cost of this bill is likely closer to $2 trillion than $1 trillion - per decade.

No bill would be better than this bill. I hope they start over and pass a genuinely incrementalist bill.

Posted by: tbass1 | November 6, 2009 4:21 PM | Report abuse


So cjo30080 we are in agreement that the Senate bill excludes the doc fix, and that is one reason why it is "deficit neutral." So when we include the doc fix, you and I should be an agreement, based on your reasoning, that healthcare reform is not deficit neutral. And there's plenty of error bar around the CBO estimate.

cjo30080, you are wrong. The net savings from healthcare reform are not there. The healthcare expansion bill (as it does not truly address fee-for-service or other incentives in a real way) is essentially a wealth redistribution package plus inefficiencies/distortions caused by taxes.

Posted by: RandomWalk1 | November 6, 2009 4:22 PM | Report abuse

The whole thing about the doc fix reminds me about the economist, telling the scientist and engineer that in order to open a can, all you need to do is to assume a can opener.

Look, let's assume away the doc fix. Lo and behold, the healthcare reform bill is deficit neutral! Now let's make further assumptions: there will be plenty of doctors out there to satisfy demand (we will double medical school enrollment and train enough foreign docs by 2014). Hey, supply will accomodate demand, great! Hey, we were wrong about Medicare costs back then, we were wrong about Massachusetts... but this time is different. We are pretty darn sure that this bill, with cuts placed to physicians which will surely never get reversed, will be deficit neutral!

Assume a can opener


Posted by: RandomWalk1 | November 6, 2009 4:36 PM | Report abuse

The House bill isn't a liberal bill. Please stop mischaracterizing government mandates and shoveling money toward unreformed health care providers as liberal policy goals. That is corporate welfare.

The millionaire's tax is fair because otherwise the new revenue for the bill comes almost exclusively from taxes on middle class benefits, while payments flow to health care providers who are disproportionately wealthy. To not include some sort of tax on high0income families in this lousy bill would be adding insult to injury.

Posted by: bmull | November 6, 2009 4:47 PM | Report abuse

RandomWalk1,

Neither the House nor Senate health reform bills are "deficit neutral" -- both bills REDUCE the deficit. Since the House has a more robust public option, it reduces the deficit more than the Senate bill.

We'd still have deficit reduction with the doc fix -- just less of it. That said, since the doc fix won't make it through the Congress, it's a red herring.

Posted by: cjo30080 | November 6, 2009 4:49 PM | Report abuse

1) Fixing the doc fix more than offsets the so-called $81 billion in deficit reduction in the Senate bill.
2) The CBO's estimate, again, has a huge error bar. Ask CBO what the 95% confidence interval is.
3) CBO analysis subject to can opener assumptions
"These projections assume that the proposals are enacted and remain
unchanged throughout the next two decades, which is often not the case for
major legislation. For example, the sustainable growth rate (SGR)
mechanism governing Medicare’s payments to physicians has frequently
been modified (either through legislation or administrative action) to avoid
reductions in those payments. The projected savings for the proposal reflect
the cumulative impact of a number of specifications that would constrain
payment rates for providers of Medicare services. In particular, the proposal
would increase payment rates for physicians’ services for 2010, but those
rates would be reduced by about 25 percent for 2011 and then remain at
current-law levels (that is, as specified under the SGR) for subsequent
years. Under the proposal, increases in payment rates for many other
providers would be held below the rate of inflation (in expectation of
ongoing productivity improvements in the delivery of health care). The
projected longer-term savings for the proposal also assume that the
Medicare Commission is relatively effective in reducing costs—beyond the
reductions that would be achieved by other aspects of the proposal—to
meet the targets specified in the legislation. The long-term budgetary
impact could be quite different if those provisions were ultimately changed
or not fully implemented."

Posted by: RandomWalk1 | November 6, 2009 5:07 PM | Report abuse


HR3961 - cost of doc fix >$200 billion
That more than offsets Senate Finance bill so-called $81 billion deficit reduction.

http://www.cbo.gov/ftpdocs/107xx/doc10704/hr3961.pdf

Game, set, match ... just kidding cjo30080, i am open to changing my mind. Just hope you are too.

Posted by: RandomWalk1 | November 6, 2009 5:15 PM | Report abuse

"No bill would be better than this bill."

Heh, this can be read two ways. In case there was any confusion, I meant to say that given the choice between this bill and no reform, I'd prefer the latter.

Posted by: tbass1 | November 6, 2009 5:24 PM | Report abuse

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