Analysis: What Happens Next?
By Elliott Gorelick
Politics Editor
House Speaker Nancy Pelosi’s smile was absolutely genuine as she took the gavel and declared, “This bill is passed.” President Obama noted the historic moment, but also noted that more work was needed to get to the goal when he stated simply, ““Now it falls on the United States Senate to take the baton.” Senate Majority Leader Harry Reid planned to bring his version of health-care reform to the floor for debate this week.
Ultimately, if reform passes, significant changes in health insurance would occur, but the health-care delivery system (which is the focus of UCSF) would only change through secondary effects. The major features of the House bill include the creation of health insurance exchanges with a government sponsored plan as one of the possibilities – the so-called public option. Those individuals or small businesses unable to obtain health insurance through standard means would shop at these exchanges. Health insurance coverage would be required for everyone with subsidies provided for lower income individuals and tax penalties for those who did not purchase a plan. Other important technical details include premium leveling for age groups and no denials for preexisting conditions.
In order to secure passage of the bill, the Democratic leadership allowed an amendment which broadly restricts insurance for abortions except in limited circumstances. The amendment was offered by a Democrat, Bart Stupak, and passed handily with 240 votes. One indication of the importance of both votes is that all 435 members of Congress were present for the vote on both the Stupak Amendment and the final bill.
Given the history of abortion in the United States, it is not surprising that this would be a controversial point. On the other hand, the public option is deceptively controversial. Large numbers of Americans are already covered by public insurance – Medicare and Medicaid. Also, many states have additional public insurance programs for high risk pools and/or low income assistance. In addition, many of those most vehemently opposed to a public option are those politicians who claim to be most concerned about controlling costs. Every analysis has concluded that a public option would save the government money. Ultimately, the opposition is political theater revolving around the easily played-upon fear of government making health-care decisions for everyone.
In bringing the bill to the floor, Reid claimed he still hopes to pass it by the end of the year. Procedural obstacles in the Senate mean that, at some point, 60 votes will be needed to move the bill forward. Whatever form of the bill emerges from the Senate will then need to be reconciled with the House version in conference where both the abortion restrictions and the public option will be hotly contested. With breaks for Thanksgiving and Christmas, it is unclear if this can really be accomplished before the end of the year although the threat of keeping Congress in session could provide some leverage. Health-care reform is the centerpiece to Obama’s legislative agenda, so something will pass eventually or expect the Democrats to suffer significant midterm losses in the 2010 election. (With a large chance that the economy will still be in the doldrums throughout next year, this is a risk regardless, but a failure on health-care reform will guarantee Republican victories.)
Even if a bill gets enacted, there will be tens of thousands of pages of rulemaking and commentary before the final details would be worked out. Things to watch for in order of their timing: 1. What compromises will need to be incorporated into the Senate bill? 2. What will emerge from the conference for the final up and down vote? 3. How will the final bill and the subsequent rulemaking process implement any abortion restrictions? 4. What effect will the availability of a government run exchanges in encouraging businesses to drop employee sponsored health insurance? 5. How much will insurance costs increase or decrease for different demographic groups? 6. What will the long-term impact be on the actual delivery of health care?
It is a good bet that something will pass in the next few months; the political stakes for the Democrats are just too high. But like the passage of the House bill, it is only a single step in a long process – a process that might be said to have begun 64 years ago today when President Harry Truman sent a message to Congress proposing a national health insurance plan.
Elliott Gorelick is a third-year pharmacy student.
This article appeared in the November 19, 2009 issue of Synapse.
