THE TREATMENT SEPTEMBER 18, 2009
So much has been said about Max Baucus and the Finance Committee for the last few days that it's easy to forget that four other committees are supposed to have a say in the matter.
In the Senate, there is the Health, Education, Labor, and Pensions (HELP) Committee, which passed its own version of reform way back in July. HELP's bill was, admittedly, only a partial measure. Because of its limited jurisdiction, it couldn't propose changes to taxes or to Medicare and Medicaid, huge swaths of the health care enterprise. But three House committees working on health reform operated under no such restrictions. They passed full pieces of legislation, complete with financing and changes to the two giant government entitlement programs.
But even before Baucus finally introduced his legislation this week, there was a strange tendency among opinion and decision makers in Washington to dismiss both the HELP and the House bills as somehow less serious--and, ultimately, less important. Baucus' bill, by contrast, is widely considered the template upon which reform will ultimately be built--even though the measure, itself, has yet to attract much support from either side.
Why is that? One reason, I know, is a policy judgment.
The House bill is not truly deficit neutral, at least according to the Conressional Budget Office: By the tenth year, CBO says, it's paying out more than it's taking in. It also doesn't account for the cost of adjusting Medicare fees for physicians, although--as I've argued before--there's a legitimate case to be made for treating that as a separate accounting issue.
In addition, the House bill--again, according to CBO--wouldn't reduce health care spending in the long run. The Baucus bill, on the other hand, does pay for itself. And it actually reduces health care spending over the long term
Fiscal responsibility is, undoubtedly, a real strength of the Baucus approach. He and his staff deserve credit for getting that part right. And it's reason enough to make that proposal a central part of the conversation.
But fiscal responsibility shouldn't be the only thing that counts. Maybe the House bill isn't as good about paying for itself or reducing costs in the long run. But the House bill--along with its HELP counterpart--is clearly superior in one other key respect: It does a much better job of providing security. It offers more subsidies to help people pay for insurance; it guarantees better insurance coverage, thereby offering more protection against higher medical bills; and it has a public insurance plan, which advocates believe (and I agree) is ultimately more reliable than private insurance.
Is security less important than fiscal responsibilty? I certainly don't think so. And, in an ideal world, Congress would blend the two appraoches, taking the best elements of each--in effect, providing the sort of security in the House bill but in a way that's as fiscally responsbile as the Baucus proposal.
Of course, we don't live in an ideal world. We live in a world in which the U.S. Senate, with its skewed apportionment of seats, holds sway. And that brings us to the second reason the House and HELP bills don't get taken as seriously: Everybody assumes nothing close to either one of them could pass the Senate, given the need to round up at least a few centrist Democrats and possibly a Republican or two in order to pass legislation.
There's some truth here. Conservative Democrats and Republicans seem unwilling to pass legislation that contributes to higher deficits (even if, annoyingly, many of these same members didn't give a second thought to deficits when passing tax cuts and the Medicare drug benefit under President Bush's watch). This is a big reason why the White House has pushed the fiscal conservatism line as hard as it has.
But the expectation that fiscal conservatism will win out over coverage also has a certain self-fulfilling quality to it. Liberals don't have a ton of leverage right now, but they do have some. Centrist Democrats, at least, understand that failing to pass any legislation would hurt their party and that, ultimately, many of them hold the party's most vulnerable seats. And if that's still not enough to get sixty votes, there's always the reconciliation process--which carries its own political risks but can, at the end of the day, produce decent legislation.
When--er, if--legislation gets out of the Senate Finance Committee, it must be merged with the HELP bill before it goes to the full Senate. And if the Senate agrees on a package, that legislation will have to go to conference committee, to be merged with its House counterpart. The policy that process produces will be much better if the Finance bill ends up looking more like the HELP and House measures. And the surest way to make that happen is to keep reminding verybody that those HELP and House measures exist.
Update: Matt Yglesias was thinking along these same lines yesterday, and explained it with far more clever phrasing: "Curve-bending and affordable coverage are two great tastes that taste great together." I'm 99 percent sure I'm quoting that only because it's substantively correct and not because I happen to like Reese's peanut butter cups. Also, Brian Beutler lays out the road ahead nicely.