Monday, December 21, 2009

The Day After

The Senate Democrats successfully squeaked through their key vote on the healthcare bill at about 1:15 a.m. Eastern time Monday, the 21st. Needing 60 votes to set a fixed end to debate, they got exactly 60 votes: 58 Democrats and two independents--all 40 Republicans voted against cloture.

Now that the Senate bill will gain approval (final passage expected Thursday) the bill's backers are reluctant to allow any tinkering with the delicate formula which got it through. Thus, there will be very touchy negotiations with the House backers of the bill, who will not give up the differing provisions of their bill easily. From the Senate's point of view, this means no public option, and most particularly, leaving in the deal that bought the vote of Sen. Ben Nelson (of Nebraska, allegedly a Democrat). Nelson's vote came in line in the last stages of negotiation when he got a change that suited him better regarding the wall blocking any public funds for insurance policies which could pay for abortions in "the exchange" (a change which likely stand up through final passage in both Houses), and a special dispensation on increased Medicaid costs for Nebraska (which probably will not).

Other differences can be worked out, like the source of funding for subsidies--whether taxes on the wealthy, increase in Medicare payroll taxes, or on "Cadillac" insurance policies, or, most likely, a combination of all three. The question of whether there should be one national exchange (in the Senate bill--less costly to operate) or fifty state exchanges is a tricky one. I lean toward the decentralized version, as the national exchange will be dominated by the insurance conglomerates, who have already gotten way too much.

The bill is largely a bowl of mush, but it has one essential, important characteristic: it makes access to health care a right--and an obligation--for all Americans. Progressive supporters in both Houses of Congress have reluctantly come aboard because of that virtue.

Needed: A Trigger with Teeth...

OK, it's a mix of metaphors (unless we're talking about equine dentures), but the English teachers wouldn't have approved of "Change You Can Believe In", either. Anyway, at this point, I'd accept a public option with a trigger clause. It would require only a minor outlay to prepare a public option offering or two, such as the House bill includes. The program would not be offered if coverage reached certain benchmarks and costs were contained.

For me, such a provision would be tantamount to ordering implementation of the public option, because I don't believe in the effectiveness of the mandate in the Senate bill that all must obtain insurance. There are too many people who have been mistreated by the private insurers and will never go back. Some of them will take insurance because the law says so, some will pay the fine, but more will find a way to do neither.

The trigger would also depend on the ability of the private insurers to develop low-cost catastrophic health policies for the young and low-income, a task they have not performed so far, though having decades to develop. If the coverage level neared completeness, they would have a better chance of offering it profitably, but the question is whether they will want to do it, particularly without a public option lurking over their collective shoulder.

Such a public option trigger with teeth (potwt, pronounced "Po-tweet", or, in honor of Kurt Vonnegut, "Poo-tee-weet") would be germane and consistent with a compromise between the House's public option and the Senate's absence of it. It might even get the support of a couple of Senators from the other side, if it were put to a vote. It won't be, though: too risky. It will probably be brought forward--to groans from many--in the next session of Congress.

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