THE TREATMENT JANUARY 25, 2010
Harold Pollack is a professor at the University of Chicago School of Social Service Administration and Special Correspondent for The Treatment.
Timothy Jost and I assembled a letter signed by 51 health policy experts asking that the House pass the Senate bill and then fix this bill’s significant shortcomings through the reconciliation process. We got a very strong group of people from across the ideological spectrum to sign on. For the most part, our letter has been favorably received in most quarters. Virtually every health supporter I know supports the general strategy we supported. Unfortunately the issue bears discomfiting similarities to the Arab-Israeli dispute. The contours of the ultimate solution seem relatively straightforward. The tactical roadmap is much more obscure.
There was one problem with our expert letter—or at least with how it was received. The House cannot move until the Senate does its part to address critically important problems in the current Senate bill. Before the Massachusetts election sidetracked public attention, House, Senate, and White House negotiators actually worked out many of these difficulties: the need to make insurance more affordable, tightening the structure of insurance exchanges, addressing union concerns over the taxation of costly health plans. Not every accommodation would move the final bill leftward. The House bill included (to my mind deeply unfair and extreme) restrictions on the financing of abortion services that must be addressed, too.
The House leadership is working hard to make something happen. House progressives have been basically good sports in swallowing compromise after compromise to secure passage of a health reform bill. This goes beyond the arena of healthcare, I’ve received surprisingly angry emails noting the number of progressive bills passed by the House that sit bottled-up in some Senate committee. I don’t think this is the fault of the majority leader. Ossified Senate procedures, combined with the systematic over-representation of rural moderates and conservatives, make things hard. Whatever the reason, there is a pretty well-founded reservoir of progressive anger and distrust that must be addressed before the House can do its part in passing the Senate bill.
Hence the obvious question. Senate Democrats, how much do you really want to pass this bill?
I hope I know the answer. Both progressives and moderates have strong reason to want this done. If this bill is chopped up or curtailed, the most obvious losers will be progressives, who will lose the opportunity to help millions of low-income or chronically-ill Americans who need help. Another important group of losers is less obvious: the large group of progressives, moderates, and even some conservatives who wish to see meaningful delivery reform.
If the House and Senate bills are abandoned, we may (eventually) win Medicaid expansions for people who need help, expanded tax credits for people who cannot afford coverage, and other measures to cover the uninsured. We may even see more stringent regulation of health underwriting and other toxic practices in the insurance industry.
We will not soon see serious delivery reforms or cost-control measures. Whether the issue is high-cost insurance plans, bundled payments, comparative effectiveness research, overpayments to medical device makers, drug companies, specialists, and Medicare Advantage plans, there will be very limited political will to match what is in the current bills.
We will not be able to get these things because we will fracture the political coalition required to enact these painful measures, because the operative lesson of last summer will be that death panel demagoguery trumps real policy argument, and because there are fewer policy levers and fewer political incentives to address these difficulties outside a comprehensive bill.
Last Friday, I and others pled with anxious House members to step up in passing comprehensive reform. Senators: Now I am pleading with you.
President Obama: Now is the time for you to step up, too. Some in your administration are starting to send good signals. Others remain unduly tentative. Fight for this thing as if your legacy is on the line--because it is. I believe you have about 48 hours to fix this up.