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The amazing disappearing bill

There's a lot of talk over whether the health-care bill should begin before 2014, and whether the long delay will give the GOP sufficient time to foment a backlash. On the one hand, the bill should certainly begin before 2014. The delay is a budget trick, an attempt to lower the 10-year cost of the bill at the expense of the very people we're trying to help. As for the backlash, I don't buy it.

Last night, on C-SPAN, a listener called in with a very simple message. "I grew up in Canada," he said. "You have no idea how terrible this will be." Some in the audience probably nodded their heads. Government-run health care is terrible, after all. Others were probably annoyed. Canada covers everyone, pays less, and gets outcomes about as good as ours. Canada is great!

In reality, the problem with the caller's argument is that Canada is immaterial. We're not passing Canada's health-care plan. We're not changing our health-care system very much at all, in fact.

Nothing happens in 2010. Or in 2011. Or in 2012. In 2014, when the bill really begins, the insurance situations of 18 million people change. A full 16 million of those people are uninsured. Aside from the small sliver of people who will pay a surtax on the final few dollars of uncommonly expensive insurance plans, the country simply will not notice this legislation.

We're reforming the margins of the health-care system. The small and non-group markets, which serve a small minority of the population. The uninsured will be the main beneficiaries, while the vast majority of Americans who get their insurance through their employers, or through the government, will see no difference, at least in the first 10 years or so.

A year after the president signs health-care reform, the country will have largely forgotten about it. That's not to say it won't be mentioned in the elections, or argued over in occasional op-eds. But what keeps it on the front page? It's easy enough to write about health-care reform when it's dominating the congressional agenda. When it's waiting to be implemented? Or when it's being implemented, and the main effect is that 16 million people without political power now have health-care coverage? I don't buy it.

The working theory appears to be that voters will blame Congress for the yearly increases in insurance premiums that will happen anyway. Again, I don't buy it. Most people don't see those increases. If they did, this would be a very different conversation. Health-care reform is very big on the scale of things that Congress normally does, but very small in comparison to our health-care system, or even our health-care problem. This bill isn't as good a bill as it needs to be, in large part because it leaves so much of a broken system untouched. But by the same token, it is not as vulnerable a bill as it could be, because it leave so much of a politically powerful system untouched. The political system will move onto other things, and the underlying policy isn't dramatic enough to hold America's attention.

By Ezra Klein  |  December 21, 2009; 10:48 AM ET
Categories:  Health Reform  
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Next: The cruel Senate


Ezra, you're speaking as a wonk. But you tend to miss the political aspect of things by a wide margin.

Democrats would be wise to make the benefits of health care reform begin much earlier than in 2014. Closing the medicare part D donut hole is a start.

Posted by: jasonr3 | December 21, 2009 11:10 AM | Report abuse

As somebody who buys insurance on the individual market and has pre-existing conditions, I'm very much aware of the annual premium increases thank you. Can you make us a nice chart showing what parts of the bill go into effect in what years?

Posted by: redwards95 | December 21, 2009 11:23 AM | Report abuse

How can you still be so ignorant of the basic economic implications of this bill? Why do you feel qualified to write about this subject? Why can't the Post hire someone that understands business and economics? I don't understand why they have a 14 year old food critic covering the healthcare debate.

You should poll all of the people that agree with you on thie blog to see how many understand the difference between revenue and profit.

Politicians have political reasons for supporting foolish policies and saying ridiculous things. You are a reporter. YOu don't have to act like a politician. You are allowed to use your brain in public.

Posted by: fallsmeadjc | December 21, 2009 11:29 AM | Report abuse

"the vast majority of Americans who get their insurance through their employers, or through the government, will see no difference, at least in the first 10 years or so".

Depends on the definition of "cadillac." Typical leftist trope - people only notice benefits, not tax increases.

Posted by: sold2u | December 21, 2009 11:32 AM | Report abuse

Don't get me wrong--I support this bill.

But in the process of reconciling the House and Senate bills, can we please change it to start earlier? 2014???

Think of it this way:

The Institute of Medicine estimates 20,000 premature deaths a year owing to lack of health insurance. A Harvard study puts the figure at 45,000. Let's say the truth is in the middle at 33,000. Waiting for four years till 2014 to start the legislation's changes thus means over 125,000 premature deaths: a decent-sized American city worth of deaths. And all for a "budget trick"? Unconscionable.

Perhaps we progressives should use whatever muscle we have left to fight for an earlier start date, not to fight for a public option -- probably no form of a public option could pass the 60-vote Senate hurdle, and even if some form could pass, it would be an absurdly weak form. Certainly it would not save as many lives as an earlier start would. And that is what this reform is about right?

(Any political wonks out there care to comment on how feasible it is to tweak the bill for an earlier start?)

From a political standpoint too, it would be nice come the 2012 election -- or better yet, 2010 -- for Dems to be able to say, "Look, we got MILLIONS of uninsured people health insurance, and helped you middle-class Americans afford it via subsidies. We're on your side. Whose side do you think Republicans are on?"

That plays better than "Just wait a few years more and fewer people will be uninsured, we promise."

Posted by: cdunc123 | December 21, 2009 11:35 AM | Report abuse

As a legislator in a small NE state, I think the next few years will be chaos for small businesses and individuals. There is plenty of time for the insurance companies to continue pursuing all their current practices to maximize profits, which has to date shown an abandonment of primary and preventive care (leaving that to be paid out of pocket by the "insured"), and to keep increasing premium rates on the older employees of small businesses, leading many more to become uninsured altogether, especially in this economy.

I think a lot of people will believe that, once the bill is past, that all those reforms will go into effect right away and subsidies will start any day. The "death panel" scare shows just how unsophisiticated the general public can be. When they find that all those reforms don't kick in for several years, there will be a whole new level of anger and frustration. Getting these provisions into effect much sooner should be a Democratic priority. And besides, the need for these people to have access to health care will still be there and just as urgent.

Posted by: jshafham | December 21, 2009 11:43 AM | Report abuse

Once again the Dems demonstrate that they are apparently clueless when it comes to really playing effective politics. They have expended tremendous political capital and crafted a bill that won't benefit the people most likely to vote in 2010.

Klein must not have taken note of the rightwing media circus which can ignite Tea Parties and transform people into foaming budget hawks after eight years of profligate spending.

The GOP has yet to really gore the Dems. They'll wait for Fox "News" to expose the deals necessary to pass the bill. They'll cite WSJ and WashPo editorials fulminating about the loss of liberty due to the health insurance mandate.

2010 will really be ugly unless the Dems implement the "nuclear option" in January and make wholesale changes the health care reform bill.

Posted by: SaltyDawg79 | December 21, 2009 11:47 AM | Report abuse

What's the point of paying premiums to insurers if the Government bankrupts the insurers? Bankrupt insurers won't be able to honor their insurance contracts.

How can you complain about the overhead expenses at private insurers while advocating legislation that will increase the regulatory compliance costs that already constitute the largest percentage of those overhead expenses?

How can you complain about the inefficiencies of private insurers while completely ignoring Federal and State Government's influence upon those inefficiencies? How is more regulation going to make them more efficient?

Why would an evil private insurer not already be as efficient as they could possibly be in the current regulatory environment to maximize their profits? Isn't that their primary concern?

Do you really think customer service is going to improve without a profit motive? Do you actually think Government bureaucrats are better at customer service?

If you don't think this bill will be noticed a year from now then you don't understand it and you shouldn't be writing about it.

Posted by: fallsmeadjc | December 21, 2009 11:52 AM | Report abuse

To his credit Josh Marshall, another pro-bill blogger, is alarmed by 2014 as the start point. Saying "I don't buy it" turns the entire moral argument for the bill into a contradictory mess. If we need to do this for Teddy, if it will save those at 150% of poverty an enormous percentage of their income, If it "is a bet that we, as a society, can solve our problems," then why isn't a big deal that no one actually gets what is now the main benefit--lower cost, accessible insurance--until 2014?

Often HCR has been defended with the moving stories of families that need coverage but can't get it. We can't make the case for this as an urgent measure that will help those most in need and simultaneously say they get their help in four years, and hey, no biggie, no one really cares about the bill doing anything in the here and now.

The House at least phased the exchanges in in 2013, conference could try for that.

Posted by: undisclosedangler | December 21, 2009 11:59 AM | Report abuse

The Government isn't competent enough to implement this bill before 2014. We're talking about unionized bureaucrats. There are no deadlines when you can't be fired and there's no incentive to be efficient when that efficiency would just reduce your piece of the budget pie.

Posted by: fallsmeadjc | December 21, 2009 12:00 PM | Report abuse

i hope it goes flaming down. it's a government plan that screws the working people for the rich. typical government stupidity. until the people can see benefits yesterday, this helps Republicans in their PR spin against the poor and working classes.

Ezra, your hopes are just that. Hopes. Fight for the truth, not some panty waist girly meme the Republicans use to scam and scare people with.

don't give the loonies ammo. they have enough fodder with the press and corporations that run our Government. are you one of them?

Posted by: BernardEckholdt | December 21, 2009 12:39 PM | Report abuse

This will be a complete joke.
It will cost far more than advertised and do far less than advertised. Hopefully when the Republicans inevitably get back in power the first item on their agenda will be to destroy this silly thing. Not modify it, destroy it.

Posted by: websterr1 | December 21, 2009 2:34 PM | Report abuse

"The delay is a budget trick..."

You are correct. An attempt to trick voters who are not watching closely.

If this bill were so good, you wouldn't have to 'trick' anyone into supporting it.

Call it what it is....a LIE and it's not the only one in there.

Posted by: WrongfulDeath | December 21, 2009 5:36 PM | Report abuse

Democrats will be ruined in red districts that didn't get sweetheart deals. My blue dog is in hiding, refusing to talk to the press. The local community is already seeing billboards that he failed us.

Don't count on keeping the house. The commercials are being made as we speak.

Oh, and hurry up, everything goes into effect in 2014 but the pork runneth over will be seen repeatedly. Stimulus redux.

Posted by: Cornell1984 | December 21, 2009 6:11 PM | Report abuse

Every one of us is going to be forced to buy the same government designed policy, and you're saying nothing much is chqnging?? There's a real difference between voluntary purchases and forced ones. The dems want to make our choices for us. They're asking for an insurrection and they're going to get one.

Posted by: hdc77494 | December 21, 2009 7:39 PM | Report abuse

From the CBO Analaysis:

An Analysis of Health Insurance Premiums Under the Patient Protection and Affordable Care Act November 30, 2009

"This discussion addresses the projected distribution of the population in 2016, using as a reference point the 162 million people expected to be covered by employment-based insurance in that year under current law."

"Specifically, an estimated 19 percent of workers with employment-based coverage would be affected by the excise tax"


For those of you without a masters degree in mathematics 19% of 162 million is about 30 million workers affected by the excise tax.

Hardly a small sliver.

You are entitled to your own opinion ... not your own facts.

(Interestingly the number affect by the excise tax is equal to the number of those newly insured)

Posted by: cautious | December 22, 2009 2:19 AM | Report abuse

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