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Five ways the House and Senate could negotiate out a better bill

chummyreidpelosi.JPGI'm going to skip the beginning of this column because, well, you guys don't need to sit through the wind-up. Suffice to say this appeared in the Sunday business section, and it's my wish list for the House and Senate health-care negotiations.

From the House

The subsidy scheme: This one's really a no-brainer. The House's legislation makes insurance more affordable than the Senate's does. And really, that's what this process is all about. The House would expand Medicaid coverage to households with incomes of up to 150 percent of the poverty level, rather than the 133 percent proposed by the Senate. And between 150 percent and 300 percent of the poverty level, the House's subsidies are stronger, helping people buy better insurance, at a lower cost, with less out-of-pocket risk, than the Senate bill. For decades, Democrats have worked to ease the plight for folks who can't afford insurance. To come this far only to choose the less generous subsidy scheme would be like building a grand house only to decide to save a few bucks by not putting locks on the doors.

National insurance exchanges: The exchanges are the new marketplace -- complete with regulations on insurer behavior and consumer ratings -- where people will buy insurance. At the beginning, they're only for very small businesses and the uninsured. Over time, larger employers will enter the fold, and the exchanges could prove the future of our health-care system. The Senate bill hands them over to the states, and it separates the exchanges for small businesses and individuals. The House bill lets the federal government run them unless the states specifically seek the authority, and it combines the small business and individual markets into one. Bigger exchanges with stronger regulators are better exchanges with more protections for consumers. Go with the House version.

Employer participation: The original sin of the American health-care system is that a tax quirk meant to prevent profiteering during World War II ended up routing health-care insurance through employers. That's bad for all sorts of reasons, not least that it drives up costs because individuals don't know the real cost of their insurance. But employers like controlling their worker's benefits, and so they've prevailed on Congress to leave it unchanged. Fine. The House bill forces employers with more than $750,000 in payroll to provide insurance to their employees or pay a fine. This gets people covered and raises more than $130 billion from employers that choose to pay the fine rather than cover their workers. If employers decide they don't like this arrangement, then maybe we can finally strike a deal to get beyond the employer-based system once and for all.

From the Senate

Excise tax: Keep the tax for expensive, employer-provided insurance. The House bill taxes the rich. The Senate bill taxes extremely expensive insurance plans. If that were all there was to it, the House bill would be better. But the Senate bill's tax also controls costs: By making extremely costly insurance even more costly, it gives a big advantage to insurers that manage to keep costs down. It also begins to redress our system's insane and regressive decision to tax wages but not employer-provided health benefits. Most economists think this one of the most promising cost-control ideas in the bill. It's also one of the riskiest: If the legislation doesn't control costs, the tax will begin to hit more and more plans as time goes on. But cost control is going to be hard to do. At some point, we have to muster the courage to try.

Independent Medicare Commission: The reaction most Americans had to watching the health-care bill wind its way through the Senate was disgust. Disgust at the partisanship, at the power of special interests, at the cynical use of the filibuster, at the senators who extorted last-minute goodies and concessions and bribes. Oddly enough, the Senate itself agrees. The Medicare Commission is an effort to remove continuing reform of Medicare from the Senate's clutches. An independent body of experts would propose reforms that bring Medicare in line with spending targets. Those packages could not be amended or filibustered or ignored. The House bill doesn't have this provision, possibly because the House is less dysfunctional. But the Senate is right: The Senate is terrible, and it needs to be removed from the process to the greatest extent possible.

There's much more that you can imagine being improved in the bill: Regulations on insurers could be stiffened, the start date could be moved from the 2014 envisioned by the Senate to the 2013 preferred by the House, more could be done to move Medicare away from paying for volume and toward paying for quality. It's a big bill, with a lot of moving parts. So much of the effort in past weeks was getting it ready for passage. Congress shouldn't waste this opportunity to get it ready for America.

Photo credit: Bill O'Leary/The Washington Post.

By Ezra Klein  |  January 11, 2010; 5:00 PM ET
Categories:  Health Reform  
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Next: National exchanges vs. state exchanges


It begins with bi partisanship. If politicians actually tried it they would discover it not only works but that it works well! The American public would truly be ecstatic!

Posted by: joe100821 | January 11, 2010 5:32 PM | Report abuse

Is there anything in your House wish list that you think Ben Nelson might find objectionable? He's been threatening to bail if the conference bill goes too far left. Could a national exchange get in the way of his version of the abortion compromise? I'm also worried that anything stronger than the Senate's terrible employer faux-mandate will draw his ire.

Posted by: cog145 | January 11, 2010 5:51 PM | Report abuse

Ezra, I do think you fail to take into account how important the rating rules, the minimum actuarial value, and the individual mandate are -- and on all three, the House bill is demonstrably better than the Senate bill. I think these affordability provisions are far more important than the employer mandate.

Posted by: BradGabel2002 | January 11, 2010 7:07 PM | Report abuse

Richard Trumka had a great quote today on the Cadillac tax. It pits the middle against the poor. That's not progressive and I will continue to vehemently oppose it no matter what hypothetical benefits supporters contrive. It's not like we've tried everything else. There are other options.

Posted by: bmull | January 11, 2010 9:36 PM | Report abuse

On his way out the door, retiring Senator Chris Dodd (D-Conn) has some bad news for health reform advocates still cheering the late December Senate vote.

"Health care reform is 'hanging on by a thread,'

Posted by: obrier2 | January 12, 2010 9:18 AM | Report abuse

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