22 March 2010

HCR Reax

So, at this point, it's over, except for a few housekeeping items.  Last night the House passed the Senate healthcare reform bill and the reconciliation sidecar, and this essentially ended the legislative fight over reform for this Congress.  Yes, technically, the Senate GOP could try to block the reconciliation bill in the Senate, but they are unlikely to be successful and even if they did the Senate bill itself will still be the law of the land.  So their only motivation is to try to make a little political hay.

So what is this bill?  Is it going to transform all health care instantly?  Do I need to report to the death panels this week or next?

Not so much. It turns out that despite all the hullabaloo, despite the insane level of rhetoric about the death of freedom and the destruction of the Constitution, this is a fairly limited and moderate reform bill.  It's funny -- as has been noticed elsewhere -- if, 14 months ago, you posited that the HCR bill would have been endorsed by the AMA, the AARP, the unions and the small business organization, and tacitly accepted by the insurers, you would have concluded that it must have been a pretty reasonable bit of legislation.  And it is.  It continually amazes me the frenzy which the opposition has been able to whip themselves into. 

But was this a clean win for Obama and the Democrats?

David Frum, from the Bush administration, tweeted "if HCR prevails, Republicans need an accountability moment. Jim DeMint/ Rush / Beck etc. ed us to Waterloo all right . Ours."  And from a pure political perspective he may be right.  This is a huge defeat for Congressional Republicans, and we will now see the Democrats taking a victory lap and running on the bill, which will become progressively more popular now that the ugly process articles will fade away and the benefits start to come into effect.  It's a given that the Dems will lose seats in November, but with this win under their belts it's likely that they will lose fewer than they would have otherwise.  But is it, as Drum said on MSNBC, also a policy defeat for conservatives?  I'm not so sure, and in fact I think that it's a bigger defeat for progressives, driven in part by the relentless opposition of the conservatives and the frustrating tendency of democrats to preemptively-compromise their positions.

Consider the two key policy priorities that liberals brought to the table:
Public Option (which was for many a pre-compromise down from Single Payer)
Universal Coverage

We got neither of these.  There's no publicly run insurance program at all, and the expansion of insurance coverage is incomplete at best, with a weak individual mandate and a weak employer mandate.  The insurance exchanges are state-run, not federal, and, worst of all, the implementation for most of these reforms is several years off.

Is it still a good bill?  Yes.  Is is still worth having, an improvement on the status quo?  Yes.  Is this a policy victory for progressives?  Yes, but a decidedly mixed one.  The subsidies for middle-income consumers are probably the biggest "win" for progressives, and the insurance regulations are also pretty great, though I view those as pretty consensus reforms, not progressive goals.

I'll go into the actual provisions of ObamaCare in subsequent posts.


  1. Sure. Politics is an imperfect art (like medicine), but the polarization is awe-inspiring.

    What struck me as interesting/disturbing is that NONE of the 178 GOP saw any merit in the Patient Protection and Affordable Care Act (H.R.3590). It's either that the 219 supporters are nuts or that the GOP are issuing some sort of tinted glasses.

  2. From

    Palin Facebook's 'Death Panel' to
    Wilson's spontaneous 'You Lie!' to
    Neugebauer's (age: 60) 'Baby Killer!'

    Curious what the next GOP stunt would be.


  3. Re: cost controls.

    Some of these are just silly

    1. Competitive insurance? Fine, but we both know this is only a small % of costs.

    2. The Medicare Commission? This may work but only if we ration and the law specifically forbids rationing so we will be back to these endless perverse covert rules like how the top 10% of docs who refer will be penalized the following year.

    3. Cadillac Tax? So people who pay more now will be encouraged to spend even less as they decide the plan is too expensive? To the extent it reduces plastic surgeries etc... great, but to the extent we now rob rich Peter to subsidize poor Paul, is the physician supposed to lower care for BOTH Peter and Paul after this? Or are physicians to choose "yes" on a particular course of treatment for Peter but "no" for Paul as their own value system says one is higher value economically but the other is not? And with no med mal reform? And where rationing was yet again explicitly made illegal in this bill? Are you going to be giving a pass to one of your docs in peer review when he/she says "I didn't think it was cost effective for the system", etc... Or responds similarly to a patient complaint?

    4. Bundling- So you have faith that you and your non-EM colleagues will get together and set up a series of rules to say "no" to Paul but "yes" to Peter? Or your hospital/system administrator will do this for you? And will they set up a sign in the ED front door that says: "Just FYI, we may not provide certain courses of care for you as we think someone else may be more deserving"

    ... Perhaps we will put it next to the Triage sign. ;-)

    5. Changing the politics of reform? Writing this is the will make it so? After all, the abortion issue goes away if we simply decide by fiat that it should.

    This is kidding only those with their heads in the sand and those who fail to understand the zero-sum problem fundamental to health care itself.

    Somehow we suspended the laws of economics for the laws of morality?

    We live in interesting times...

  4. OBerheard in flyover country, "Well, Obama and all his black buddies got what they wanted." Funny, isn't the House 90+% white?


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