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Still time to think small

This is a good bill. Not a great bill, but a good bill. Imagine telling a Democrat in the days after the 2004 election that the 2006 election would end Republican control of Congress, the 2008 election would return a Democrat to the White House, and by the 2010 election, Democrats would have passed a bill extending health-care coverage to 94 percent of Americans, securing trillions of dollars in subsidies for low-income Americans (the bill's $900 billion cost is calculated over 10 years, but the subsidies continue indefinitely into the future), and imposing a raft of new regulations on private insurers. It is, without doubt or competition, the single largest social policy advance since the Great Society.

Not bad, huh?

This bill is likely to pass the Senate on Christmas, and head to the president's desk before the State of the Union. It will be hard to change big things about the bill between now and then. But it will be fully possible to change small things. An example came in the manager's amendment. The original Senate bill barred insurers from imposing "unreasonable" annual caps on spending. This bill bars them from imposing any annual caps on spending. That's thanks, in large part, to the left, which attacked that weakness ferociously.

There are a lot of pages in this bill. A lot of sentences. A lot of loopholes and weaknesses (alongside a lot of strengths and improvements). Not all of them will be caught between now and passage, or even between now and implementation. But some of them can be. And some small things can be added, changed or tweaked. But first, they have to be noticed and publicized. Both the underlying bill and the package of amendment can be downloaded and scrutinized here.

By Ezra Klein  |  December 19, 2009; 3:23 PM ET
Categories:  Health Reform  
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Next: The Senate begins to pass health-care reform


" It is, without doubt or competition, the single largest social policy advance since the Great Society."

a cause for celebration!!!
for many people, this bill will be a godsend!!!!

all those who worked so hard for barack obama, should take a measure of joy in this. this was the change that was possible, under formidable circumstances, and in less than a year, it has been accomplished.

we are on a good road.

Posted by: jkaren | December 19, 2009 3:52 PM | Report abuse

Don't count your chickens ...

We're on the road, but aren't there yet.

Posted by: fuse | December 19, 2009 4:00 PM | Report abuse

Taxing health care benefits is bad policy and even worse politics. Middle income workers can't be the ones stuck with the bill for health care reform. That's the Senate's bill in a nutshell.

Huge mistake. See CWA's report for real numbers on what taxing benefits does, not more self-justifying garbage:

The Senate bill does lots that's good, but if it leads to labor unions sitting on their hands in the mid-terms, it could all get swept away along with the dem majority. Kicking the base in the teeth is not such a good strategy, particularly when it's bad policy.

Posted by: PeteSikora | December 19, 2009 4:00 PM | Report abuse

Many fear this bill will inflate the health care industry into something so big no future government will be able to control it. This bill may not be just a start, it may be final. This is it. You wanted reform? You got it, stop complaining.

It may mark the end of the debate of single payer, or a public option apart from Medicaid and Medicare. This bill may represent the loss of the opportunity to install any cost controls.

Perhaps the threshold from which government no longer had a handle on the industry was already crossed and that is why this Senate bill has become what it is. Perhaps this is in fact a bipartisan agreement, appearances to the contrary.

Both parties agree, cost containment is a non-starter. Cue the strains of Kumbaya.

This is not about "good but not great", about flaws that can be tweaked at some later date. This writes force fed, country-wide health care profiteering into federal law. The only chance for regulation of health care effectiveness, access and efficiency at the local level will be moved to Washington's K street. Good luck with that America.

People, we don't live in a tiny rich country like Holland, Switzerland, Sweden, or Norway. This country is the third largest in the world behind China and India. Do you know what that means about the cost of universal coverage combined with forced inefficiencies?

After our population comes Indonesia, Brazil and so on. So lets drop the bs about Shangrila's health system. This is the most expensive piece of legislation ever, ever in world history.

It moves the colossal American economy further into health care as its central economic activity...with no cost control mechanism, just a few fig leafs and some things that are good and right, like more FQHCs.

Posted by: shrink2 | December 19, 2009 4:10 PM | Report abuse

Before 2014, there can be a "restricted annual [benefit] limit" on essential health benefits. Sec. 10101 [sec. 2711] sub. (a)(2), pp. 2-3. And annual limits can still be placed on benefits that are not essential health benefits (sec. 10101 [sec. 2711] sub. (b), p. 3).

Posted by: Policywonky | December 19, 2009 4:15 PM | Report abuse

"It's good enough, it's smart enough, and dog-gone it, people like it." --Ezra Think Smalley

Posted by: bmull | December 19, 2009 4:41 PM | Report abuse

P.S. Before waxing poetic about the 'historic' nature of this bill, consider that FMLA is way more valuable to middle class families than this bill will ever be.

Posted by: bmull | December 19, 2009 4:48 PM | Report abuse

Yes, eliminating women's reproductive health rights under private insurance is certainly 'historic.' Who could have imagined, in 2004, that returning Congress to Democratic control would result in this kind of upending of abortion rights?

Kill the Senate bill.

Posted by: TeddySanFran | December 19, 2009 5:18 PM | Report abuse

Thank you, Ezra, for providing some real good sense and especially good perspective. This is one hell of achievement for Barack Obama, and it's time to admit it.

Posted by: impikk | December 19, 2009 5:35 PM | Report abuse

Thank you for your hard work on helping all of us make sense of this process. I ahve been in favor of a single payer system for oh so many years. This is a far from perfect product. However, given the dysfunction of our congressional system, esp. the senate, we need to see this as a win, a step in the right direction. There are many good things in this bill. Despite the respect I have for many liberal dissenters, e.g., Howard Dean, I believe it's now or never. Health insurance will never happen under a republican administration/congress.

Posted by: bosic0 | December 19, 2009 5:40 PM | Report abuse

Mr. Klein is a hypocrite. He very harshly criticized Senator Lieberman, in for journalists at this paper, an almost unprecedented tirade, for preventing a Medicare buy-in for persons between fifty five and sixty four. Klein said Lieberman's opposition would result in the needless deaths of tens of thousands of uninsured people.

Yet he supports a bill that will have such tragic, unnecessary results. Tens of thousands of human beings will die because of lack of health care insurance within the next ten years. His hypocrisy is indefensible.

Posted by: Aprogressiveindependent | December 19, 2009 5:51 PM | Report abuse

It is so typical of Ezra that in all his exuberance, he would not talk anything about cost containment in the bill. I was looking at the CBO report and here is what caught my eyes:

"The legislation also would establish an Independent Payment Advisory Board, which would be required, under certain circumstances, to recommend changes to the Medicare program to limit the rate of growth in that program’s spending. Those recommendations would go into effect automatically unless blocked by subsequent legislative action. Such recommendations would be required if the Chief Actuary for the Medicare program projected that the program’s spending per beneficiary would grow more rapidly than a measure of inflation (the average of the growth rates of the consumer price index for medical services and the overall index for all urban consumers). The provision would place a number of limitations on the actions available to the board, including a prohibition against modifying eligibility or benefits, so its recommendations probably would focus on:
• Reductions in subsidies for non-Medicare benefits offered by Medicare Advantage plans; and
• Changes to payment rates or methodologies for services furnished in the fee-forservice sector by providers other than hospitals, physicians, hospices, and suppliers of durable medical equipment that is offered through competitive bidding."

What this means is the Board would not recommend changes in lot many cases as Medicare Expenses would not increase faster than 'average of consumer price index of medical services and general CPI growth'. I believe originally it was only 'CPI of medical services' which is improved further to include average with general CPI as well. But the most desired proposition is it should be only 'general CPI'. This is because general growth rates are highest for Medical Services, then for Medicare and then for general CPI in decreasing order. To bend the curve means to bring the Medicare growth rates more aligned to general CPI. There is no reason to have any correlation with growth of Medical Services overall. In this particular example it is not clear whether Lieberman-Rockefeller amendments in this regard is accepted.

Posted by: umesh409 | December 19, 2009 5:54 PM | Report abuse

I'm curious as to why you think this will be passed in final form by both houses before the State-of-the-Union. The Senate and House bills rely on wildly different funding sources, and so far there's no indication that the two sides will enter reconciliation even close to agreement. Unless the House is willing to back down from the steep income tax surcharge in its bill, I don't see this getting done before Obama delivers his SOFTU address.

Posted by: stratman1 | December 19, 2009 6:19 PM | Report abuse

Even if one grants this happy summary assessment, hard not to wonder about and wish for what might have been possible if our President had drawn some lines and made some strong statements: his "we must all get along" line is wearing soooo thin,
and the more so for women who will find their reproductive health rights set back by decades at least.

How much more of what will lost in days ahead to the empowered Boll Weavils, Christian fundamentalists/Catholic Bishops, and the Connecticut Conman hard
to predict and harder not to fear.

Posted by: esthermiriam | December 19, 2009 6:38 PM | Report abuse

It is, without doubt or competition, the single largest social policy advance since the Great Society.

Not bad, huh?

Umm. Ezra. The degree to which the policy is advanced is not how we measyre success. If the policy is bad, for example, a large degree of advance would be a bad thing. Now spare us the cheerleading. David Brooks gave an honest analysis of the drawbacks. If you continue to trumpet the gains without discussing either the costs or the possible negative impacts, then you are not analyzing, you're promoting.

Posted by: lostinthemiddle | December 19, 2009 6:50 PM | Report abuse

I agree with you Ezra - a healthcare reform bill is better than no bill. If you don't have your health you have nothing. Why anyone would not want Universal Healthcare coverage is absolutely ridiculous. If you have a chronic condition like diabetes and no health insurance (due to loss of job, or being dropped by your healthcare insurance by no fault of your own) - good luck (that's the Republican soluion). You have to ask yourself why? Why are these Republican senators in the Senate trying to deny a right that they have? Great healthcare Insurance. Merry Christmas Y'all.

Posted by: sunnyside1 | December 19, 2009 6:55 PM | Report abuse


This is not over.

Americans cannot true Sen. Ben Nelson (D-Big Pharma), Sen. Bob Casey (D-Rome, Italy), or Sen. Joseph Lieberman (C-Israel).

Lieberman's people have already spread the word on the Hill that he will scuttle the bill - with money from Sheldon Adelson, Michael Milken, and Henry Kravis - unless the Obama Administration endorses an immediate blockade on Iran, a formal military attack on Baghdad by June 2010, the institution of a loyalty oath throughout Israel by March 2010, and the abolishment of the Palestinian Territories by September 2010.

For Sen. Lieberman, it's all Likud all the time. And don't you forget it.

Posted by: MarkinJC | December 19, 2009 7:09 PM | Report abuse

The Bill is good, but I still believe we need a stump, an idea like the Public Option in it, that is the landmark in the public psyche, the bill maybe good but it is too wonky.

So the choice is clear for the fiscal hawks and conservatives,

Public Option or Tax increase? they cant have it both ways.

Posted by: FebM | December 19, 2009 8:00 PM | Report abuse

Still time to think small


Indeed, and Ezra Klein doesn't disappoint. Again.

One only has to recall his verbose - and utterly wrong, as it turns out - discussions of why the Iraq surge was a bad idea to appreciate his prattle on health care legislation.

We give far too much credence to these dime a dozen pundits.

Posted by: JamesSCameron | December 19, 2009 8:01 PM | Report abuse

Ezra, thank you for all your hard work & help, knowledge & good will through this extremely stressful process. It's been a lifeline.

BTW I learned last week that the small non-profit I work for is paying $35k for my insurance in 2010. Which means I couldn't pick it up on COBRA if I wanted to. And I need that insurance due to expensive chronic illness.

Posted by: JaneG | December 19, 2009 8:53 PM | Report abuse

Ezra, I have a question about that graphic on the WP home page, comparing the House and Senate bills. It says the Senate Bill would increase the deficit by $132 billion. I was under the impression from reading the CBO score that it would decrease it. Is the graphic incorrect in that regard?

Also, just looking thru it, it seems to me that the House bill has a lot of provisions that the Senate bill ought to include: for example: removing the anti-trust exemption for insurance companies. why do they have this in the first place? Does it make them immune to federal investigators of fraud and money laundering, etc?

Posted by: caramel3 | December 19, 2009 9:13 PM | Report abuse

I think the Democrats can do one thing to this bill that would shut Republicans up and make them look hypocritical to their members: they Democrats should adopt the Republican's amendment on tort reform if they offer to put it up for consideration. The CBO has said that the tort reform proposal will worsen care, increase revenues and cut spending. For the Democrats, it would give them ammo to say that Republicans voted against something that they were pushing for as the golden cure to health care costs.

Posted by: ATLGuy | December 19, 2009 9:17 PM | Report abuse

Ezra, I bet you are smirking now thinking you have won a great victory. Well, let's see what happens in the mid-term elections. This bill is offends voters on both ends of the political spectrum. Enjoy your presumed victory while you can. A storm is gathering on the horizon. 2010...WITHOUT DOUBT, VOTE THEM OUT!

Posted by: my4653 | December 19, 2009 10:53 PM | Report abuse

For those who lack forsight -- In Time..., A public option or single payer will come....., that is if we can just get our foot in the door!

Posted by: wdsoulplane | December 20, 2009 7:51 AM | Report abuse

I just watched MTP and was treated to Markos and Tavis Smiley joining hands with Ed Gillespie and Joe Scarborough, skipping down the road together in near complete agreement. I got all warm and fuzzy seeing Markos and Scarborough teaming up to beat up on our democratic president. Now that is bipartisanship.

I think Tavis said the one thing that gets to the heart of this. He said something like we should have stood on our principals. I saw it as an admission that it would have been better to lose on our principals than compromise with centrist democrats to pass something. Principals seem to be way more important than all those millions of people who are going to benefit from this bill. Sure, they could benefit a lot more "if only" it were better, but something is better than nothing. I wish those progressives would look in the mirror and admit, "I care more about my principals than people's lives."

Posted by: LiberalForReal | December 20, 2009 10:21 AM | Report abuse

I just love it when the disgruntled left (I'm way left but not disgruntled, a little bummed, but not disgruntled and vengeful), I just love it when they threaten in their veiled way about voting against democrats in 2010 or 2012. Really, your going to vote for some teabag candidates, Sarah Palin in 2012? Really? :) These are the same voices that said they wouldn't vote for Obama after Hillary lost, the same voices who from the beginning of Obama's presidency have been carping at him, impatient, undercutting their own party's leader. What is says to me is that their is a whole segment of the "Democratic" party that really don't support their party. They are not liberals or progressives, they are consumed by their own self interests, scorched earthers. I see so-called liberals, and I won't name names, almost gleeful that Obama is down in the polls, they trumpet every little thing that isn't right in American and place the blame at the feet of Obama. They seem giddy that a democratic president is not popular, attacking him with some sort of enjoyment...really, read between the lines. Everything they post is through a filter that proves that Obama is a terrible president, skewing everything to confirm their prejudice. Sickening. I chalk a lot of it up to those scorned Hillary supporters, their is a huge correlation between former Hillary supporters and those who are his fiercest critics, look for yourself.

Posted by: LiberalForReal | December 20, 2009 10:41 AM | Report abuse

A previous poster said you're not analyzing, you're promoting. No kidding. That's been going on here from the beginning, with good personal results for Mr. Klein, if not for the country as a whole.

Posted by: truck1 | December 20, 2009 10:54 AM | Report abuse

It didn't have to be this way. From Atrios:
Total spending on health care, per person, 2007:
United States: $7290
Switzerland: $4417
France: $3601
United Kingdom: $2992
Average of OECD developed nations: $2964
Italy: $2686
Japan: $2581

Posted by: AuthorEditor | December 20, 2009 11:41 AM | Report abuse

Hate to be too snarky, but if you're going to stand on your "principals" better ask her first....

Good to remember that whatever the House tries to do in conference, it has to be able to pass the shaky 60 votes in the Senate. So not likely anything big will be put back into the Senate bill. Small things, perhaps. Tweaks, yes. But we have to be realistic, yes we do.

As for the OMG shock that there was horse trading on this bill -- does anyone remember that this has been going on since time immemorial? The Louisiana purchase, huh? The Bill of Rights? Horse trading is how things get done. Some people get better horses than others so stop being shocked about this.

Posted by: LindaB1 | December 20, 2009 1:27 PM | Report abuse

LindaB1...Sorry to inform you but after conference, the Senate requires only a simple majority! So.....those of us against this awful bill are screwed!!!!!!! Ten senate dems are not going to change their minds! Congress has no problem with 60% of the public wanting this to be defeated. Some change!!!!!!!!!!

Posted by: my4653 | December 20, 2009 9:12 PM | Report abuse are you going to be screwed if this passes? Do you have health insurance, will you still have it when it's a law?

A hell of a lot of people who are currently screwed will be unscrewed when this takes effect. Woo hoooo, children, sick people, poor people and the working poor all will have a chance to get affordable health insurance. Not so bad, considering the state of politics today.

Posted by: LiberalForReal | December 20, 2009 9:40 PM | Report abuse

"I chalk a lot of it up to those scorned Hillary supporters, their is a huge correlation between former Hillary supporters and those who are his fiercest critics, look for yourself."


i couldnt agree with you more.
remember how hillary clinton and john edwards promised to work to bring us the moon?
committed with all of their hearts to health care?
hillary clinton could have owned this health care debate....but she chose to abandon it completely... though it was supposedly her deepest humanitarian concern and passion.

and nothing further needs to be said about the other candidate who bled for the "other america."

but barack obama takes the rap.

Posted by: jkaren | December 20, 2009 9:48 PM | Report abuse


many (not all) of the people who are shouting the loudest against this bill are the ones who do have health care.
if this bill fails, and i was one of the people supporting its demise, i would not have the courage to sit down with someone who lost the opportunity for health care that they could have had, and tell them all about why i was against the bill.
it is easy to talk about principles when you are not sick or hungry.
this bill will not save everybody....but many who could be helped will not have that "right," if it is destroyed.
that will be a terrible shame.

Posted by: jkaren | December 20, 2009 10:00 PM | Report abuse

"It is, without doubt or competition, the single largest social policy advance since the Great Society." - Ezra

I don't see it. There is no health policy here and no social committment to healthcare as basic human need. What we have is a conflation of health with the finance industry that has led people like you to equate health insurance with care. Absent an actual health policy, the insurance mandate is little more than support program for industry.

" Why anyone would not want Universal Healthcare coverage is absolutely ridiculous." -- sunnyside1

That anyone would call this "universal health coverage" is ridiculous. It is neither universal nor does it guarantee care. What it does is reinforce a bad financing model that stands between citizens and care. It protects those whose insurance is paid for by someone else and penalizes individuals who are already paying 100% of their own care.

Posted by: Athena_news | December 21, 2009 9:21 AM | Report abuse

"Principals seem to be way more important than all those millions of people who are going to benefit from this bill." -- LiberalForReal

Excuse me, but I strongly disagree with your arguments. Health care reform has been my number one policy issue for almost a decade. I supported Barak Obama because I honestly believed that by doing so, I would be helping the nation get on a path to universal care. I did not advocate either single-payer or a public option, I asked for a sustainable universal care option similar to what I had seen experienced in other countries.

I am one of the largely ignored individual subscribers. Under no circumstances would anyone consider me wealthy; I work for my living and I pay for my insurance with what should be going to retirement savings. My insurance premiums will increase considerably over the next 4 years and it's highly unlikely that I'll ever qualify for subsidies.

I have no problem with the idea of social insurance that covers everyone. What I don't understand, is why people like me have to bear the brunt of fantasies of people like you and Ezra. Until your health benefits are taxed or mine exempted, you have no business criticizing those of us who oppose the outcome of this particular non-debate as bad policy.

Posted by: Athena_news | December 21, 2009 9:36 AM | Report abuse

LiberalForReal....How am I screwed, you ask! Well, my Medicare benefits will be cut; the cost of my supplement plan will go up; my premiums for Medicare will go up (but the benefit for 2010 was frozen); service providers will be more reluctant to accept Medicare patients; and more taxes will be imposed on business and YOU! Please pull your head out of your butt regions and smell come fresh air!

Posted by: my4653 | December 21, 2009 9:57 AM | Report abuse

Top 10 Reasons to Kill Senate Health Care Bill

Forces you to pay up to 8% of your income to private insurance corporations — whether you want to or not
If you refuse to buy the insurance, you’ll have to pay penalties of up to 2% of your annual income to the IRS.
Many will be forced to buy poor-quality insurance they can’t afford to use, with $11,900 in annual out-of-pocket expenses over and above their annual premiums
Massive restriction on a woman’s right to choose, designed to trigger a challenge to Roe v. Wade in the Supreme Court
Paid for by taxes on the middle class insurance plan you have right now through your employer, causing them to cut back benefits and increase co-pays
Many of the taxes to pay for the bill start now, but most Americans won’t see any benefits — like an end to discrimination against those with preexisting conditions — until 2014 when the program begins.
Allows insurance companies to charge people who are older 300% more than others
Grants monopolies to drug companies that will keep generic versions of expensive biotech drugs from ever coming to market.
No re-importation of prescription drugs, which would save consumers $100 billion over 10 years
The cost of medical care will continue to rise, and insurance premiums for a family of four will rise an average of $1,000 a year — meaning in 10 years, your family’s insurance premium will be $10,000 more annually than it is right now.

Posted by: obrier2 | December 21, 2009 10:34 AM | Report abuse

jkaren, how was clinton supposed to campaign for healthcare as secretary of state? obama took her out of the senate and put her in his cabinet. in a non-healthcare department.

Posted by: kidlacan | December 21, 2009 12:52 PM | Report abuse

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