Sunday, November 22, 2009

A 'beautiful bill' goes to the operating table

Before a month of Senate debates whacks all the loveliest limbs off the health care reform statue, the bill's intellectual fathers are gazing up at the pedestal with something like rapture.

Ronald Brownstein rounds up accolades for the bill's cost-control measures from "analysts from the center to the left." (And it should be noted that "the center to the left" in the U.S. healthcare debate is center-to-right in just about any other first-word democracy. Per Paul Starr, the HRC bills moving through House and Senate are a compendium of Republican ideas proposed from Congressman Nixon in the late 1940s through President Nixon in 1974 to George H.W. Bush, Bob Dole and John Chafee in the early 90s.) Brownstein:

In their November 17 letter to Obama, the group of economists led by Dr. Alan Garber of Stanford University, identified four pillars of fiscally-responsible health care reform. They maintained that the bill needed to include a tax on high-end "Cadillac" insurance plans; to pursue aggressive" tests of payment reforms that will "provide incentives for physicians and hospitals to focus on quality" and provide "care that is better coordinated"; and establish an independent Medicare commission that can continuously develop and implement "new efforts to improve quality and contain costs." Finally, they said the Congressional Budget Office "must project the bill to be at least deficit neutral over the 10-year budget window and deficit reducing thereafter."

As OMB Director Peter Orszag noted in an interview, the Reid bill met all those tests.
Positively effusive is Jonathan Gruber of MIT:

I'm sort of a known skeptic on this stuff," Gruber told me. "My summary is it's really hard to figure out how to bend the cost curve, but I can't think of a thing to try that they didn't try. They really make the best effort anyone has ever made. Everything is in here....I can't think of anything I'd do that they are not doing in the bill. You couldn't have done better than they are doing."
I find myself viewing this legislative process with what the medievals would call a "double chere" - a dual perspective. On the one hand there's the unlovely legislative process, nicely reported and themed today by Dana Milbank noting the latest concessions extracted by Blue Dog and other Democrats. Milbank spotlights the leveraging of withheld support:

After Landrieu threw in her support (she asserted that the extra Medicaid funds were "not the reason" for her vote), the lone holdout in the 60-member Democratic caucus was Sen. Blanche Lincoln of Arkansas. Like other Democratic moderates who knew a single vote could kill the bill, she took a streetcar named Opportunism, transferred to one called Wavering and made off with concessions of her own. Indeed, the all-Saturday debate, which ended with an 8 p.m. vote, occurred only because Democratic leaders had yielded to her request for more time.
Note, though, that - none of the concessions chronicled by Milbank substantively weakens the bill, and one - the Wyden amendment modestly expanding access to the exchanges - improves it. Which brings me to the second "chere": so far, the legislation is remarkably balanced, prudent, well designed to square the circle of expanding access without increasing the deficit by wringing waste out of the system and taxing in ways that won't affect productivity. If the Baucus bill's core cost-control measures substantially survive, and the final bill is leavened with more expanded access than the Baucus bill provided for, the result will look awfully like what an Obama supporter might have hoped his subtly shaping hand would have wrought.

That, of course, is a big "if." The prospect of a bill essentially like the one now brought to the Senate floor actually becoming law -- and then not being hacked to pieces by a resurgent Republican party by say 2014 -- has the giddy feel of fantasy. Certainly some pounds of flesh will be extracted -- a Stupak Amendment? a gutted public option? at least one cost-cutting pillar (excise tax?) knocked out? So breath remains bated. These are times that try one's faith that the Federal government, in the wake of a major electoral course correction, can still create legislation that improves Americans' quality of life and puts the economy on a more sustainable footing. Faith, that is, that the U.S. is still governable.

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