As you know, the Senate passed its final bill on December 24th by 60 to 39 votes, just sufficient to overcome the Republican filibuster. Now the House and Senate leadership are working on a combined bill, designed to pass both houses of Congress, ideally in time for the President’s State of the Union Address at the end of January or beginning of February. But because there is even less “margin for error” in getting the final bill passed in the Senate, the final draft is more likely to reflect the Senate bill than the House one. There are several sources for comparing the final Senate and House bills. Here are two sources, one at a high level and the other with a lot of detail:

• Comparison in the Washington Post (note: you may find it easier to download the PDF file than tab through the comparison on the web page): (click here)
• Kaiser Family Foundation Comparison of just the Medicare provisions in the two bills (use the first link on the page): (click here)
• Kaiser Family Foundation Comparison (available as a very detailed PDF file, or you can check off only the provisions that you are interested in comparing and get a web page summary): (click here)

Not only Republicans but also some liberal Democrat interest groups and bloggers are angry with the Senate Democrats, but for different reasons of course. For example, see NY Rep. Louise Slaughter’s December 23rd article on the CNN web site “The Senate Bill Is Not Reform” (click here). These liberals are upset at two issues in particular: the failure to include a public option in the Senate bill (forcing people to buy insurance company products) and the fact that it does include a tax on “high cost” health plans provided by employers.

The House bill still has a public option in it, available only to those having to get coverage from an exchange (non-employed individuals under age 65 and those working for small employers). But as noted, the fear is that it will be “compromised” out of the final bill, as some House Democratic leaders are admitting.

We’ve discussed the public option and its potential advantages ad nauseam. But to throw in the towel in hopes of getting a future bill with the public option or getting to a single payer system in the foreseeable future in our culture is not very realistic. Those liberals who want to start over because the final bill might lack a public option or has other annoying provisions had better read Nate Silver’s “20 Questions for Bill Killers” on his well-respected politics web site, FiveThirtyEight: (click here)

Here are two of his questions specific to the public option:

Even Yale professor Jacob Hacker, who first promoted the idea of a public option, says that we need to pass a bill, even if the public option is dropped. In his December 20th article in The New Republic (click here) he says the final bill will still contain three critical reforms: the exchange(s) for individuals and small employers to compare and purchase coverage, subsidies to make coverage more affordable, and insurance reforms. We would add a fourth: health delivery system reforms, which perhaps need to be made stronger and implemented more quickly than the current provisions allow for, but which still finally put us on track to save long term dollars.

If a public option is omitted from the final bill, Hacker urges that it at least include a national health exchange, rather than the state-based ones provided for in the Senate bill, since a national exchange will give government more influence in regulating the insurance companies, and requiring financial transparency and reports.

Another and broader take on the need to pass a final bill with all its faults is found in Jonathan Chait’s December 24th article in the New Republic, “And the Rest Is Just Noise” (click here). Chait concludes:

Regarding the tax on “high cost” or “Cadillac” health plans, the debate rages on. The CNN News web site has a good article summarizing the different tax approaches that the House and Senate bills take: (click here). The Senate bill would impose a 40% excise tax on insurance companies or self-insured employers (which most large employers are) to the extent a plan’s value exceeds $8,500 annually for single coverage and $23,000 for family coverage. This value includes dental and vision coverage and reimbursements from flexible spending accounts or health reimbursement accounts, and employer contributions to health savings accounts (yes, these are three different types of accounts with varying tax rules). For example, a plan with a total value of $10,000 for single coverage would incur a tax of 40% x (10,000 - 8,300), or $680. If the insurance company had to pay it, they likely would spread it into the cost of all plans. If a large self-insured employer had to pay it, it would likely drop the plan or increase the cost-sharing provisions (co-pays, deductible, etc.) to lower the value.

The Senate bill does have provisions to increase the dollar threshold annually, but only at the rate of general inflation plus 1%. The bill also makes exceptions for high risk industries, higher costs regions, and employees over age 55. But as we all know, specific thresholds and exception rules tend to have sharp edges. Some survive and some are cut.

It is often reported that most economists don’t like the income tax exclusion given to employer-paid health coverage that is not given to others having to get coverage themselves. It’s inequitable, encourages providing rich benefits in lieu of pay, hides the real cost of these benefits, and locks them to employers rather than to individuals. But rather than start to take away this $250 billion annual tax loss, Senate Democrats tried the indirect trick of taxing the insurance companies or self-insured employers for “excessive” benefits.

Nevertheless, this approach is supported by some, like Washington Post columnist Ezra Klein and MIT health economist Jonathan Gruber, since it seems to partly redress the above problems and provides some revenue to help fund the health bill.

Gruber wrote a guest editorial in the December 28th Washington Post in support of this tax (click here). The tax is an important revenue source for helping to fund the overall bill, supposedly by bringing in about $150 billion over the next 10 years through either the excise tax itself or the higher wages that employers supposedly will offer in place of reduced health care benefits.

But New York Times columnist Bob Herbert said that’s hogwash, according to his December 29th column (click here). Employers may reduce the health benefits (or direct their insurance carriers to do so) in order to avoid the excise tax. But what’s the likelihood they will convert that to higher salaries, especially in an economy projected to have employees begging for work? Herbert cites a recent survey by the human resources consulting firm Mercer, in which only 16% of the surveyed employers said they would convert the savings from reduced health care costs into higher pay.

Health care reporter Maggie Mahar backs up Herbert in her Dec. 31st Heath Beat blog (click here). She makes a further argument that we will not save costs by increasing out-of-pocket cost sharing provisions:

Many of the individuals cannot afford high deductibles, etc. to begin with (also the reason why high deductible plan are not a good solution).
Patients generally rely on their doctors for advise on what to do, especially when it comes to deciding on further tests or procedures.
Higher cost-sharing only tends to reduce utilization in terms of filling or refilling prescriptions or going to the doctor-all of which we want to encourage, especially since most of our costs are from chronic conditions that need to be monitored and controlled.

Mahar makes a strong case that the best hope for cost control is not taxing health benefits but letting “an Independent Medicare Advisory Commission (IMAC) that uses medical evidence …encourage effective care… If Medicare follows IMAC’s recommendations, Medicare has the clout to change the way it pays for care, saving money and lifting quality by rewarding value rather than volume. Other insurers might then follow Medicare’s example.” This was the hope for the public option. Mahar sees it as also possible through Medicare itself, if empowered to change provider behavior. And to get the needed revenue, she backs the House bill’s approach of increasing taxes on high incomes, since they have made out the best with previous tax cuts and income gains over the last decade.

Finally, law professor Timothy Jost and health policy professor Joseph White echo Mahar’s ideas and suggest that if Congress wants to limit rich benefits, then they should do that by specifically defining them, rather than using a blunt instrument, like the dollar threshold (click here).

If you are eager for a recap of the flavor of the 2009 “debate” on health care reform, health care author and blogger, Maggie Mahar, reviews “The 10 Most Destructive Lies, and the 10 Most Constructive Insights, Suggestions, and Questions of 2009″ in her December 24th “Health Beat” column: (click here).

Overall, here’s one very sad lesson some of us have learned over the past year: the exponential increase in the casual willingness of so many politicians, media pundits, and average Americans to baldly lie rather than risk considering and being persuaded by others’ ideas. It used to be that democracy was about debating ideas in the hope that the best ones would emerge evident to most of us. Or if no ideas emerged with a clear consensus, then we at least give the benefit of the doubt to the will of the majority. Now politics for many is about the art of lying to put the opponent on the defensive and smearing attempts at constructive solutions without offering detailed alternatives of ones own (sorry, but “common sense” broad principles are specific legislative solutions). Even once a lie is called out, the damage is done, apologies are not made, or recants and “clarifications” are merely noted on the back of page 24. It started with discovery that dirty political campaigns work when the electorate is generally uninformed. Now it’s spread to 24/7 dirty legislative (or counter-legislative) campaigns.

Looking back at the health care reform effort in 2009, leads us to these observations:

• Grass-roots efforts work: they helped us get to the point of likely passing a version of health care reform that has stymied others for a century (if you go back to Teddy Roosevelt). Whether it was our representatives listening to us, to the Tea Party patriots, or others, Congress knows it cannot just go where the lobbyists point.
• We may each have several major or minor gripes about provisions in the draft bills that were worked out to get sufficient votes for passage. But overall, at least our two Pennsylvania Senators and Congressman Murphy showed their responsiveness and empathy to our concerns and interests. Our interaction with them and their staff proved to us that informed, specific, and reasoned arguments are more effective than shouting, sweeping generalizations, and insults.
• Because opposition will remain strong through out this year, right up through the next congressional election campaign, we will need to continue to voice our desires to see a final bill not only passed and implemented (taking several years). But we will need to stay active in:

  - Keeping the public informed of the facts and benefits of the legislation, despite the likely distortions and greater attention given to the inevitable shortcomings than to the positives. (After all, “news” is always biased towards the negative and “unexpected” problems, etc.)

  - Calling attention to shortcomings that we uncover as well, and encourage our representatives to address them in future general or “technical corrections” legislation. No major legislation is perfect the first time (or any time, for that matter).

The opposition is already testing out their falsehoods to try to deprive the Democrats of a victory and hide benefits of this major piece of legislation. Those who claim that MSNBC and its sister cable channel, CNBC have a liberal bias are wrong. Already Joe Scarborough on his “Morning Joe” show has said, without allowing others on his show to get a word in edge-wise (as is typical), that this bill does nothing to control costs but just adds another unfunded entitlement. In a CNBC interview with Republican Senator Corker of Tennessee, the complaint was that too many people would be extended coverage by throwing them into the terrible Medicaid system. All the talk shows of course pointed out the disgusting agreement to give Nebraska alone full funding of the Medicaid enhancements, as extorted by Senator Ben Nelson in order to get his 60th vote. Another theme heard is that the bill undercuts the President’s promise not to increase taxes on average Americans.

Let’s look at each of these criticisms:

• “The bill does nothing to control costs”

Baloney!  The bill actually:

• • Makes insurance markets more competitive by adding exchanges and requiring consumer protections, coverage standards, reporting transparency,
  • Mandates publishing of standard hospital fees and quality data
  • Caps the amount that insurance companies can charge for administration and profits,
  • Provides for numerous pilot innovations on delivery system reforms and bundled provider payments, that will take time to set up but can be rapidly expanded once proven,
  • Encourages states to innovate and replicate malpractice reforms,
  • Removes the 14 percent extra subsidy given to insurance companies for Medicare Advantage plans,
  • Changes the mechanism to control Medicare cost increases,
  • Puts a strong emphasis on wellness, prevention, and chronic disease management for those on Medicare, on Medicaid, in employer plans, and buying individual coverage.

Anyone saying the bill does nothing to control costs should be put on the witness stand and not let down until they say what else they would do to control costs. For years Republicans have said we need to control costs, especially Medicare (John McCain even campaigned on this last year). Now that we have bills in the House and Senate that do that, they instead try to scare seniors that Democrats are “cutting” Medicare benefits and cynically declare a seniors’ “bill of rights” to never touch Medicare.

• “Why should we give special treatment for Nebraska?”

As Presidential advisor David Axelrod said on the CNN program “State of the Union” on Sunday, most major legislation ends up with provisions benefiting specific states. “Every senator uses whatever leverage they have to help their states. That’s the way it has been. That’s the way it will always be.”  After all, for many years rural and southern Senators have dominated key positions in the Senate, and guess where most of the military bases are?  When Homeland Security money was being doled out to states in the early 2000s, guess where a disproportionate share of the money went?  Unfortunately legislation would not get done if Congress tried to ignore the extortions… er “trade-offs” required to secure key votes. Do we want to put off health care reform and ending 45,000 deaths a year due to lack of coverage, just to stand on principle against the likes of Senator Nelson?

• “The poor are being thrown into the dysfunctional system of Medicaid.”

The problem with Medicaid is that states and conservative members of Congress have underfunded it even since it was enacted. It only pays providers about 70 percent of what others pay on average because they wanted it to be a cheap program, regardless of the consequence that an insufficient number of providers are willing to take on Medicaid patients. If they now want a better system, they have to suggest how to pay for it.

• “The bill raises taxes on everyone, not just the rich.”

The bill directly raises Medicare payroll taxes on singles earning over $200,000 a year and married couples earning over $250,000 a year. There are many other fees and taxes on high cost plans, medical devices, and the like, which will affect some small portion of the population but also encourage more prudent health care spending. Likewise, there are penalties for employers and individuals who do not comply with requirements to get or provide coverage. Those are simply penalties, not taxes. If they comply, they don’t pay them. Likewise, a traffic ticket is also a fine, not a “tax.”

See a pattern here? Damned if you do; damned if you don’t. And unfortunately the TV pundits don’t bother to challenge the critics by demanding them to tell us their specific solutions. They only have time for quick sound-bites that stick in the memory like a bad commercial jingle.

The latest and final Senate bill that could pass this Thursday evening has much in common with the bill passed in the House and with the earlier Senate bill from November. The following articles and analysis provide a good summary of the key provisions and latest changes:

Senate Bill Summary (updated 12/21/09, with most-recently revised items in red), Community Catalyst (click here)

Health Bill Passes Key Test in the Senate, New York Times (click here)

Health-care reform: How the bills stack up, Washington Post (click here)

The Wonk Room, Think Progress (click here)

“For starters–and this is no small thing–the insurance company will have to sell you a policy, no matter what pre-existing conditions your family brings to the table. And you’ll know from the start that the policy will cover basic services because the government will be defining a basic benefits package. That package is going to include a broader range of services than the typical non-group policy would without reform. So when your doctor recommends a standard test or procedure, you won’t have to panic it falls into some hidden policy loophole.”

Note, the House bill offers slightly different subsidies and better protection on out-of-pocket expenses.

The Senate Democrats finally broke the health reform bill logjam on the merged committee bill at a little after 1 a.m. Monday morning by getting 60 votes for cloture to overcome the Republican filibustering and move forward to vote on their final bill. At 8 a.m. today, the Senate had its second of three cloture votes to move the Senate bill forward. The remaining procedural votes scheduled for Wednesday afternoon will clear the way for the final vote on Christmas Eve at 7 p.m. Each of these procedural votes could take place earlier if the Senate unanimously agrees to do so, but without that agreement, under the rules, they must have a minimum number of hours between the votes.

Before the vote early yesterday morning, opponents of the bill claimed to want more time to review the manager’s amendment, Senate Majority Leader Harry Reid’s changes to the Senate bill introduced in November. But then they were also strangely eager to hear a full reading of Senator Bernie Sanders’ single payer bill late last week. Plus, they tried to make the time to filibuster even a supposedly routine defense funding bill on Friday that they normally would have saluted eagerly. Their attempted filibuster of that latter bill even prompted Defense Secretary Robert Gates (a Republican) to send Senate Minority Leader Mitch McConnell (R-Ky.) a blistering letter Thursday warning of a “serious disruption” in the military’s ability to pay troops. “It is inconceivable to me that such a situation would be permitted to occur with U.S. forces actively deployed in combat,” Gates wrote. (click here).

Senator Tom Coburn, a physician and Republican of Oklahoma, showed his own version of the Hippocratic Oath by encouraging opponents of the legislation to “pray” for a Democrat (presumably 92-year-old Senator Robert Byrd) to miss the vote.

For the record, all during this year, the Republicans have shown no cooperation with the Democrats on any legislation in the Senate. According to the Dec. 21 New York Times (click here),”We have crossed the mark of over 100 filibusters and acts of procedural obstruction in less than one year,” said Senator Sheldon Whitehouse, Democrat of Rhode Island, on the floor Sunday. “Never since the founding of the Republic, not even in the bitter sentiments preceding Civil War, was such a thing ever seen in this body.”

As we write this, reports are coming out that the House is considering a swift conference committee to merge the Senate and House bills. Pressure by House leadership and the White House is being put on progressive Congressmen to accept the more conservative Senate version of the Health Care Reform bill. This acceptance decision would avoid upsetting the fragile apple cart that got the Senate bill to this point. A lot of negotiating is going on outside the formal conference process to avoid more delays. Both Houses of Congress hope to vote on the final bill by mid-January to be signed by President Obama before his State of the Union Address. Make no mistake, the politics and cover many legislators will need on their final vote on this first major piece of progressive legislation in over 40 years is still going to be played out in the coming weeks and months.

It’s been a very rough week for health care reform. So happy holidays from your favorite Congressional representatives and lobbying groups!

If it happens at all (no certainty now), it will be more modest than many people had hoped for—no public option and no early Medicare buy-in for those between ages 55 and 65. The reason comes down to a handful of Senators, as we’ve mentioned before. But the ultimate reason is due to two problems that stymie important legislation in general (and threaten America’s ability to adapt to a rapidly changing global economy and environment). One is constitutional and one legislative:

a. The constitutional one: As one person writing in response to a health care blog pointed out: the Senate gives more votes to trees than to citizens in many states. California has almost 37 million people—as many as the bottom 19 states in population. But it gets only 2 Senate votes, while they (Wyoming, Alaska, Nebraska, Idaho, etc.) get 38 votes. Thus there is a huge disconnect between popular opinion and legislation, greatly favoring rural (and generally more conservative) states.

b. The legislative one: years ago the Senate enacted the 60-vote rule to overcome filibusters, at a time when these were relatively rare. Now filibusters are used by the minority party as much as possible (according to a Washington Post columnist, “in the 2007-08 session of Congress, Republicans forced 112 cloture votes, nearly doubling the Democrats’ record when they were in the minority.”). Neither party is eager to change the rule, since it gives them some protection whenever circumstances might shift them to minority status. The Senate could change the rules and reduce the number of votes needed to overcome a filibuster and reach “cloture.” They did this in 1975, reducing the threshold from 67 votes to the current 60.

In the middle of last week, Senate Majority Leader Harry Reid thought he had found a good compromise that would get him the necessary 60 votes. Here are some very sketchy details (no written specifics are yet available):

− Scrap the government-run public option, except for still having it get “triggered” under certain circumstances,

− Allow for an early Medicare buy-in for those between ages 55 and 65 and for individual coverage only (no family policies),

− Create a private nonprofit insurance plan (possibly run by Blue Cross), to be overseen by the Office of Personnel Management (the “OPM,” the federal agency that oversees the insurance program used by members of Congress)

− Allow buy-in to the Federal Employees Health Benefits Program (FEHBP).

But the more conservative Senate Democrats and the one Republican whose vote is being courted, Olympia Snowe, are firmly or leaning against the Medicare buy-in for the following claimed reasons:

− It would further aggravate the Medicare funding deficit by likely allowing people to buy-into it at less than full cost. If people were charged full cost (estimated at anywhere from $7,000 or more per person per year!), they could not afford it, especially those who would need it the most—those who were laid off or can’t afford coverage from insurance companies.

− It would create that “slippery slope” to a single payer, government-run program.

− It pays hospitals and doctors much less than what insurance companies pay them. While those who run Medicare and many other experts say that Medicare generally pays fairly, hospital and physician associations of course would argue otherwise and expectedly are fighting hard to stop this.

− Medicare benefits are not that great anyway and most people over 65 have to buy supplements to fill in the gaps.

Those in favor of the early Medicare buy-in claim it has the following advantages:

− It would be more affordable than private insurance coverage, which many might not otherwise even be able to get, due to pre-existing conditions limits or other restrictions.

− It would save the government more money, since when the coverage is subsidized (though not planned for in the bill until 2014), it would save the government money since Medicare costs less than comparable private coverage and thus the subsidies could be lower.

− It gives Medicare more enrollees and thus more clout to encourage providers to adopt delivery system reforms.

The individual who originally proposed the public option idea, Professor Jacob Hacker of Yale, was also very skeptical of the alternatives proposed by Senator Reid this past week. The so-called national private plan that would be run by the OPM likely would be just another Blue Cross Blue Shield plan, which already has a virtual monopoly in most areas of the country— how would this save any thing if it is only “competing” against its own other plans? In a column in the online version of the New Republic (http://www.tnr.com/blog/the-treatment/public-plan-perversion), Hacker elaborates on his criticisms and reiterates the value of the public option:

“(1) it will significantly reduce costs; (2) it will provide broad, transparent coverage at an affordable price, setting a benchmark private insurers will be pressed to follow; (3) it won’t be in the business of denying or delaying needed care to people with costly conditions or shifting excessive costs onto them; and (4) it’s a vehicle for driving delivery and payment system reforms that private plans have proven unable and/or unwilling to do. Since we live in a democracy, it also seems relevant that (5) the public plan has been consistently popular with Americans (and doctors, according to a recent survey in the New England Journal of Medicine [3]), despite the unrelenting false attacks on it.”

Senator Reid got somewhat bad news on Friday from a report by the Center for Medicare and Medicaid Services, which concluded the initial Senate bill would slightly raise total public and private spending over the next 10 years by 0.7 percent (vs. doing nothing), rather than reduce it. Of course, opponents have seized on this “headline” without mentioning the more positive specifics:

− The bill would provide good coverage to most of the 47 million uninsured

− It would require better coverage to the additional 40-50 million who are “underinsured” (have lousy policies with a lot of dollar limits, high deductible that they cannot afford, or exclude many health conditions)

− The bill would help control costs after the initial 10 years during which the coverage expansions, subsidies, and cost management mechanisms are set up. The report says the initial Senate bill would extend the life of the Medicare trust fund by 9 more years.

A key problem, as we’ve noted before, is that both this governmental actuarial group and the Congressional Budget Office (CBO), which is charged with the official scoring of the bills, are very conservative in recognizing any savings for any new health delivery system reforms. But besides covering the uninsured and providing subsidies for many others to make coverage more affordable, these delivery system changes are central reason for health care reform—to bend the costs curve and get the US more in line with the rest of the advanced world economies who spend half to 2/3rds of what we spend, while covering everyone. We have no choice but to adopt these reforms before the country and more individuals go bankrupt.

In a blog on the Politico web site, health care law expert, Professor Timothy Jost, gets to the heart of the issue for the CBO and others claiming to cost projections of the legislation:

“Foster [the lead actuary drafting the report by the Center for Medicare and Medicaid Services] is skeptical of the productivity adjustments imposed on Medicare provider payments by the Senate bill, stating, “While such payment update reductions would provide a strong incentives for providers to maximize efficiency, it is doubtful that many could improve their own productivity to the degree achieved by the economy at large.” A footnote points out that productivity gains in hospitals have been “small or negligible during 1981 to 2003.” If it is impossible for health care providers to improve their efficiency and productivity, then not only is health care reform at risk, our entire economy is at risk. We simply cannot continue to expand payments for health care at historic rates if our country is to survive. The fatalistic conclusion of Mr. Foster is not acceptable.” (Politico, Dec. 13, http://www.politico.com/arena/)

See the following stories for more on the urgency of cost controls:

− “Testing, Testing,” by Atul Gawande in the Dec. 14^th New Yorker (http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?currentPage=all), which discusses why there need to be so many pilot, or experimental, programs in the legislation for delivery system reform (these provisions represent almost half of the Senate bill’s 2074 pages).

− “Finding the Nerve to Cut Health Costs,” in the Dec. 9 New York Times column “Economic Scene,” By David Leonhardt, which summarizes steps being taken by Senators and others to further expand cost controls in the legislation (http://www.nytimes.com/2009/12/09/health/policy/09leonhardt.html?_r=1&hp)

− “Business Roundtable edges away from health reform plan,” at the Politico web site on December 11 (http://www.politico.com/news/stories/1209/30502.html), which notes that the Business Roundtable group of 161 jumbo US employers is balking at the currently proposed legislation unless it does even more to control costs. The article describes several of the changes they want and are in discussion with Congress to resolve. They are also critical of some of the proposed fees that would add to their insurance costs and of the very weak individual mandate that would still allow people to waive coverage until they needed care, thus causing and driving up premium costs for everyone else. Their concerns are being taken very seriously, since they have been supporters of the reform effort so far but could turn against it if not pleased with its present direction.

The bill now being modified with these latest changes is due to get its official “score” from the Congressional Budget Office (CBO) perhaps today.

So, where are we? It partly comes down to what the House will accept from the Senate. Here are the possible scenarios:

a. If the House will also accept it (in the final joint House-Senate conference bill vote), the Senate could get 60 votes for a bill without the public option and early Medicare buy-in. House majority leader Nancy Pelosi has hinted that this might be possible and might allow bypassing the usual joint House-Senate conference resolution of the two passed bills. If a joint conference bill goes to vote, some liberal Representatives and Senators have said they will not vote for it if it does not include the public option of at least the Medicare buy-in.

b. If the House will not also accept such a Senate bill, then either:

i. The Senate needs to go back to the “reconciliation” approach talked about much earlier this year, which is a way to get around the 60-vote threshold needed to overcome a filibuster. Reconciliation can be used for financially significant bills and needs only a simple majority vote to pass. The Senate legislation then might need to be split into two bills—a predominantly financial one on Medicare reforms and subsidies and a predominantly nonfinancial one on regulatory reforms (insurance company reforms, the exchanges, etc.).

ii. Or: the Senate passes its bill without the public option and early Medicare buy-in and then one or both of these are put back in during the joint conference committee session that combines the House and Senate bill. Then the final vote would need a straight 60 votes from the Senate to pass (but not subject to any more debate on details or amendments).

In any event, time is running out. We have this week and part of next week, and then a holiday break, during which everyone goes home and gets an earful from Tea Party “patriots” and lobbyists, who speak up more than supporters of the bill generally do, fueled by fairly unbalanced cable news and well-funded TV ads running against reform running more often than pro-reform ads. According to the online news site, the Huffington Post (12-11-09), “a host of conservative groups are ramping up their efforts to derail health care reform in Congress, spending more than $3.91 million for a fresh wave of ad buys in key states, according to data provided by a Democratic ad tracker. The U.S. Chamber of Commerce is leading the charge. The pro-business group is devoting an estimated $2.78 million dollars on ads over the next week. Health care reform opponents are already outpacing proponents when it comes to television purchases—these buys seems likely to expand the margin.”

Bucks Voices members will be speaking at a number of Bucks County Senior Centers this week to highlight the proposed health care reform impact on Medicare and to answer seniors’ questions. The first panel was held this morning at Ben Wilson Senior Center in Warminster. Please come with your questions to one of the remaining panels:

Tuesday, December 8, 10:30 am
Morrisville Senior Center
Borough Annex
31 E. Cleveland Ave
Morrisville, PA 19067

Thursday, December 10, 10:00 am
Lower Bucks Senior Activity Center
301 Wood St (Wood and Mulberry)
Bristol, PA 19007

Go to the Action page of our web site and check out the full page “Health Care Security” ad Bucks Voices ran last week in the Bucks County Courier Times, Doylestown Intelligencer and the Bucks County Herald: http://www.buckshealthcare.org/hc_action.html

If you haven’t done it yet or it’s been a while, please write, email or call your senators today to urge them to pass a strong health reform bill.

One fine day, several fuzzy and tentative characters named Ben, Joe, Blanche, Mary, and Olympia-were wandering the halls of the Senate and came upon some footprints. They followed them through a thicket of disinformation about recent sightings of scary monsters from Canada and Great Britain. Olympia remarked, “This could be a very dangerous creature. I think we should at least delay it with a trigger.” Ben added helpfully, “Yeah. I’m all for triggers. I’m a member of the NRA, of course!”

As they wandered on, the footprints went past a hearing room with a Lewin Group report that said the entity could devour the private health care system, based on its many computer modeling assumptions. Blanche whispered, “We better do something to stop it!” And Mary offered, “How about we tie it up so it can’t prey on doctors and hospitals with Medicare rates and force them and insurance companies to be more efficient?” They all nodded as if that was something worthy of consideration.

Joe, whose nickname was “Eeyore,” sighed: “Some nice insurance company friends in my home state warned me to be wary of a beast that could crush them, even on level playing fields, though it would do so very inefficiently.” Joe furrowed his heavy brow, adding, “Gosh, if I come upon it, I’d just have to stab this thing with a veto pen in self-defense.”

The leaders of 100 Belly-Acher Wood, who had been taking their little public option pony out for a walk, soon heard about the serious concerns of our adventurers.  They agreed that, while the little group of pooh-poohers were likely suffering from overactive imagination glands, they should hobble their pony and change its name from “Pacer” to “Half-a-Lump,” so as not to frighten the community.

And so that is how we have now ended up with a pint-sized public option…

• that cannot use Medicare provider payment rates, but has to negotiate with all providers (good luck, when many hospitals have near monopolies in many areas!),
• that may cost more than other insurance company, as the latter do their best to attract healthier enrollees,
• that will be available only to the small number of people who buy individual coverage or work for a very small employer and thus can get coverage through a health exchange, and
• that may not be available in many states if they are allowed to “opt out” of offering it.

Senators Tom Carper, Mark Begich, and Mark Warner are trying to draft a compromise, which would call for a nonprofit insurance option to be launched in states that didn’t meet certain criteria for affordability and access. But instead of being run by the federal government, the plan would be run by a nonprofit board, and any initial government startup money would be repaid.

Still, health reform blogger Jason Rosenbaum is critical of the idea (click here to view). As he points out, and as Senator Chuck Schumer has observed, all potential conditions for a trigger are already met: health insurance premiums are already sky high and still increasing rapidly. Plus, the private insurance companies already have a near monopoly in most areas, with 94 percent of markets considered “highly concentrated” by Department of Justice standards.

Rosenbaum also is skeptical that a trigger would even be pulled to start up a public option in any state where the conditions are triggered in the future. He notes that there is a “trigger” in the Medicare Part D prescription drug program, but it has never been pulled, even though drug prices also have skyrocketed. Plus, as Rosenbaum noted in an earlier blog on September 23 (click here to view), the way Sen. Snowe’s original criterion for establishing a public option was defined ensured that it would never be triggered: