[What follows is an editorial post I wrote for the Courier-Post Community Editorial Board]
As the House prepares to vote on the Senate version of health care reform (and the Senate prepares for the arduous reconciliation process to follow) I am left thinking how much of a Catch-22 this bill is politically and policy-wise–both for politicians and for individuals who want to see reform take place.
On the one hand, few would argue that our current health care system is not in need of reform, particularly when it comes to access and cost. Polls strongly reflect this across the ideological spectrum. However, while the current bill will seek to cover millions of Americans that, for whatever reason, do not have access to health care (as well as ensure that in the future citizens cannot be denied coverage due to pre-existing conditions) it remains to be seen if this is the most effective way to guarantee such coverage. However, in order to achieve this the bill leverages a number of provisions that are both controversial politically and not guaranteed to be effective in practice.
For example, let’s take a look at pre-existing conditions. While the bill would ensure that people cannot be denied coverage due to pre-existing conditions it will require an insurance purchase mandate in order to keep premiums from skyrocketing. This is one reason why many (including myself) were calling for a public option or single payer. A public option provides people denied coverage elsewhere a safe haven. However, with a public option you still require a mandate since both the government plan and private insurers run the risk of having their risk pool skewed significantly in the wrong direction (since more sick people would be opting in than healthy individuals). Single payer goes even further, since it would remove the problem in its entirety of mandates and pre-existing conditions. Covering everyone by law eliminates mandates and ensures the widest possible and least-skewed risk pool. A compromise could have been to at least include a public option trigger. This would have created some additional pressure on insurance companies to lower their prices and extend coverage without directly increasing the deficit. This bill simply doesn’t bring any such pressure. The bill also lacks any market-based mechanisms to increase competition which, in theory, may also expand coverage and lower costs.
An additional problem is that while the CBO has scored the bill as a deficit reducing measure 10 years out one major cost issue related to health care is not addressed in this bill: the so-called “Doc-Fix”. While the bill does include ~$500B in Medicare savings and cuts, it does not deal with the massive financial issue of the looming rate increase to doctors who treat individuals under Medicare. It is a complex matter, but at the end of the day this could require an additional $250B dollars over ten years to cover costs.
One argument for passing the current bill is that it is a start–get a foundation in place and then tweak and add provisions as necessary. The argument against this approach is that it assumes that current conditions and incentives continue past November. From a Democratic perspective, it assumes that the Democrats will be in a position to get additional health care measures passed. Both history and current poll numbers indicate that the make up of both the House and Senate will look very different than today. Additionally, and related to politics, it is hard to imagine surviving Democrats sticking their necks out to pass further health care measures after witnessing the fallout from the November vote.
Politically, the President and congressional Democrats have effectively trapped themselves with this bill. While it clearly appears to be a bill that various factions within the party do not like, they’ve sunk so many costs into its crafting and passage that it is hard to imagine a scenario where they decide not to proceed and instead offer a different bill up for debate. The cost/benefit analysis here is inconclusive: passing a flawed bill could be viewed as a major legislative victory leading up to the midterm elections. And while many of the party faithful will not be overjoyed with its provisions, it may be seen as an improvement over what previously existed. Not passing health care reform could be viewed as a betrayal. This will not only have a negative impact on individual members of Congress, but on President Obama’s ability to move other parts of his agenda forward over the next few years.
However, it could just as easily trigger disappointment from many in the base, demobilizing those who would be key to what is sure to be a tough November election. Additionally, Republicans will certainly run against the bill and given how independents have polled on this issue are likely to make significant congressional gains as a result. Moreover, the vast majority of Americans will not experience any direct benefit from the bill early on, which is likely to trigger disappointment and anger–at the very least, they won’t be very impressed by its passage, making it harder for Democrats to secure reelection in contentious areas and for Obama to utilize public approval to move additional pieces of legislation forward.
Moreover, by using self-executing rules and reconciliation in order to gain passage, the view is developing that this will make the bill less legitimate in the eyes of voters. Rightly or wrongly, the fact is that process here is having a negative impact on public opinion. And when you combine that view with the fact that most will not experience direct benefits for some time it creates an even more hostile election environment for Democrats going forward.
Finally, as mentioned above, passing the current bill and hoping for incremental improvements is unlikely given the likely altered composition of Congress after November and the fear that many remaining Democrats will have in taking up such measures after many of their colleagues are shown the door. Furthermore, President Obama is not likely to keep health care reform at the top of his legislative agenda after this current battle concludes. In order to win reelection, the President will need to run on the strength of a diversified portfolio of political accomplishments. This likely means he will take on new issues, such as financial regulation, economics and job creation, etc. After the current battle over health care I cannot imagine he and his advisers would choose to revisit the issue two years out from the general election.
My personal view is that from a policy perspective the bill should not pass. I would much rather see a bill with a public option or, at the least, a public option trigger. However, politically this would leave the Democrats and President Obama with little to run on come November. I would argue, however, that other Presidents have recovered from failed major policy initiatives prior to midterms–midterms where their parties lost majorities. One recent example is President Clinton who was able to recover and have a productive presidency that spanned two terms. While it will be a roll of the dice either way, the country and the Democrats may be better off taking their chances with another bill.