Health care reform: Politics and substance

Source: The health care mess

With health care reform reduced to a sporting event – or as Hendrik Hertzberg calls it in the latest New Yorker, a brawl — I sometimes find myself wishing I lived in a benevolent dictatorship. (Just kidding.)
As President Obama pointed out in his press conference on health care last week, his political opponents see the derailment of health care reform as a big political win for the Republicans. He quoted Republican Senator Jim DeMint: “If we’re able to stop Obama on this, it will be his Waterloo. It will break him.”
Why does Obama continue to pursue Republican votes?

The politics: Is bipartisanship worth it?

Adam Nagourney, veteran political journalist for The New York Times, has an excellent article that addresses this issue. Here are some points to consider:

• Unlike the bipartisan support that passed Social Security in 1935 (16 of 25 Republican senators) and Medicare and Medicaid in 1965 (81 of 102 Republican representatives), bipartisan support seems unlikely in the current political climate.
• Bipartisan support today means fewer than 10 Republican Senators and less than that in the House.
• Obama has pledged to end partisan infighting, but is it worth giving up options, such as a public insurance plan, for so few Republican votes?
• Giving up on bipartisanship reduces Obama’s appeal with independent voters, who dislike partisanship.
• If the health care plan turns out to be ineffective and there was no Republican support, this could be risky for Democrats and Obama in the elections of 2010 and 2012.
• Passage of a health plan with only Democratic votes could establish a polarizing pattern that will make it difficult for Obama to follow through on the remainder of his agenda in the next three years.
• Bipartisanship is especially important on major welfare-state proposals, since they might otherwise unravel in the coming years.
But then there’s the problem of the nature of the Republican Party these days.

[I]t is hardly clear that a bipartisan agreement on health care is even possible. A string of Congressional defeats has recast the Republican Party, leaving it smaller, more conservative and more combative. …
Senator Evan Bayh, Democrat of Indiana, … said he still believed it [bipartisanship] was important, but added, “The Republicans are reduced to a core, so there aren’t that many pragmatists left to work things out.”
James A. Thurber, the director of the Center for Congressional and Presidential Studies at American University, said that 30 years ago, about one-third of Republicans in the House and Senate were moderate.
“In the last 30 years, we continually lost the middle, ideologically,” he said. “And the loss of the moderates makes it very difficult to get bipartisanship for major policy changes.”

In the opinion of David Axelrod, a senior adviser to President Obama, “Ultimately we are going to be measured by what we do, and not by the process. Process can’t be more important than the outcome of the legislation.”
It appears we won’t know the outcome of this standoff anytime soon.

Health care: The substance

The same issue of the Times had an unsigned editorial with an excellent, extensive summary of what the current legislation looks like, with an emphasis of what’s in store for those for already have insurance.
Legislation is likely to include a health insurance exchange, which would be phased in gradually.

Under the House bill, the exchanges would start operating in 2013. They would be open initially to people who lack any insurance; to the 13 million people who have bought individual policies from insurance companies, which often charge them high rates for relatively skimpy coverage; and to employees of small businesses, who often pay high rates for their group policies, especially if a few of their co-workers have run up high medical bills. By the third year, larger businesses might be allowed to shift their workers to an exchange. All told, the Congressional Budget Office estimates that 36 million people would be covered by policies purchased on an exchange by 2019. …
The House bill … would require that all new policies sold on or off the exchanges must offer yet-to-be-determined “essential benefits.” It would prohibit those policies from excluding or charging higher rates to people with pre-existing conditions and would bar the companies from rescinding policies after people come down with a serious illness. It would also prohibit insurers from setting annual or lifetime limits on what a policy would pay. All this would kick in immediately for all new policies. These rules would start in 2013 for policies purchased on the exchange, and, after a grace period, would apply to employer-provided plans as well.

Who won’t be happy with the plan? Healthy young people who feel they don’t need insurance. They will be required to purchase insurance by a federal mandate.
What if I already have good coverage? The advantage of the plan is that it provides greater security for those who wish to change their employer or who risk losing their job.
Will insurance cost less?

Two factors could help drive down the premiums for those who are insured. In the short-term, if reform manages to cover most of the uninsured, that should greatly reduce the amount of charity care delivered by hospitals and eliminate the need for the hospitals to shift such costs to patients who have private insurance. One oft-cited study estimates that cost-shifting to cover care for the uninsured adds about $1,000 to a family’s annual insurance premiums; other experts think it may be a few hundred dollars. …
In the long run, if reform efforts slow the growth of health care costs, then the increase in insurance costs should ease as well. And if the new health insurance exchanges — and possibly a new public plan — inject more competition into markets that are often dominated by one or two big private insurance companies, that, too, could help bring down premiums. But these are big question marks, and the effects seem distant.

What about rationing and the quality of care?

Critics have raised the specter that health care will be “rationed” to save money. The truth is that health care is already rationed. No insurance, public or private, covers everything at any cost. That will not change any time soon.

The editorial also discusses the impact of the plan on older Americans.
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