[Posted by Karl]
As the Democrats’ attempted government takeover of the US healthcare system moves into the back rooms for a bit, it seems like a moment to take a step back from the trees and look at the forest.
Bob Laszewski (who reminded me of how important the CBO would be in this debate back in May) recently summed up this debate as “the coming convergence on Capitol Hill of three extraordinarily powerful, and contradictory, forces”: (1) the Democrats’ near-religious fervor on this issue; (2) the public’s anxiety — leaning toward disapproval — of the effort; and (3) the fact that the Dems still do not have a bill that can become law. Currently, I would say that (1) trumps (2) — though that could change once bills start emerging from those back rooms. Accordingly, it is (3) that is crucial.
Moreover, I tend to agree with Laszewski that “[t]he big issue is going to be money — just whose taxes are going to get raised to the tune of $500 billion to pay for it.” If the Baucus vapor bill’s tax on “Cadillac” insurance plans is unacceptable to Big Labor, and the House’s surtax on “millionaires” is unacceptable to moderates in both chambers (Democrats are the “party of the rich,” y’know), it is far from clear that those babies can be split — but then what?
This yawning chasm is why the Senate is going to try to pay off the AMA by fixing the Medicare Sustainable Growth Rate (SGR) fee cut problem off-budget and (ostensibly) separate from ObamaCare. But even if the Dems can clear the procedural hurdles to that shell game, they will have closed only about half of the gap.
The Dems also have to face the the Pushmi-pullyu of “affordability”, otherwise known as mandates and subsidies. The Baucus vapor bill gutted the fines for enforcing the individual mandate, but still requires insurance companies have to get rid of medical underwriting and pre-existing conditions provisions. That creates a “death spiral” for insurers, which is why they have belatedly leapt into opposing ObamaCare. Liberal wonks may want to dismiss the insurers, but the insurers’ studies and campaigns can fuel the pre-existing public opinion that ObamaCare will increase costs and decrease quality. Amping up that public anxiety would make it more difficult for the Dems to maintain the unity necessary to pass a bill.
Keith Hennessey also raises the potential for a fight over regional disparities in the subsidies, if they follow the approach in the Baucus vapor bill. For example, similar families would get a $6,365 subsidy in Las Vegas, Nevada, but only $3,220 in Portland, Maine. In contrasting high-cost vs. low-cost areas of the nation, I am sure it was coincidence that Hennessey picked the home states of Sen. Majority Ldr. Harry Reid and swing RINO Sen. Olympia J. Snowe.
If I have any disagreement with Laszewski, it is here:
The public option, employer mandates, a turbo-charged MedPAC? These are not the biggest issues. The White House will take any deal they can get and will quickly pressure liberals to back off wherever necessary.
These may not be the biggest issues, but the “public option” has become something of an article of faith on the Left, which is why we see House Speaker Nancy Pelosi trying to get centrists to sign on to a strong “public option,” just days after suggesting that liberals consider a watered-down “public option” — and why we see Sen. Maj. Ldr. Harry Reid and Sen. Chuck Schumer exchanging barbs over Reid’s not-so-veiled reluctance to include one in the merged bill in the Senate. If the “public option” is seen as dead or neutered too soon in the process, the Dems’ near-religious fervor likely cools a bit, making it harder to pass a bill.
Moreover, there are issues missing from Laszewski’s list that certainly will register with Congress. Subsidizing abortions and coverage of illegal immigrants may seem like sideshows to health policy analysts, but they are hot-button, high-intensity issues with voters, so attention should be paid. And there are the cuts to Medicare and Medicare Advantage that will antagonize seniors, who make up a disproportionate slice of the electorate, especially in midterm elections.
Given this set of issues, it is not surprising that despite Pres. Obama’s frequent declarations that the time for debate is over, House Maj. Ldr. Steny H. Hoyer says that Congress will probably be in session until mid-December and possibly even later. As time runs on, the Democrats may be tempted to exploit the budget reconciliation option they have been quietly keeping on the table. However, as Rick Weissenstein, a health care analyst for Washington Research Group, told CBS:
“I think it would be perceived, certainly by Republicans and moderates, as a last ditch effort to pass something that didn’t have popular support,” he said. “If you’ve gotten to that point, in some ways you’ve kind of lost the war.”
Indeed, with only 24% of voters nationwide saying Democrats should pass ObamaCare on a partisan basis, it is entirely possible that trying to pass the bill alone would sink it entirely.