Health Reform: The End Game

For the next 2-3 weeks, Washington will be consumed by one thing -- health reform. Although the House only returned to work yesterday (and the ...
by | January 15, 2010

For the next 2-3 weeks, Washington will be consumed by one thing -- health reform. Although the House only returned to work yesterday (and the Senate doesn't return until next week), Congressional leaders have already started working on reconciling the House and Senate health reform bills. Here are the provisions to watch (or at least watch for, since Congressional Democrats have rejected requests from CSPAN and Congressional Republicans to televise the closed door reconciliation discussions).

Health exchanges. The House bill establishes a national exchange where small businesses and individuals can buy health insurance. It allows states to set up their own exchanges as well. In contrast, the Senate does away with the national exchange entirely and requires states to set up their own exchanges. In the Senate version, if states fail to establish a working exchange by 2014, the secretary of HHS can step in and establish one in that state instead. (Here's an even more detailed discussion in the New England Journal of Medicine of how the House and Senate bills implement health reform vis-a-vis the states.)

But after losing the fight for a public option, liberal Democrats seem determined to prevail on a national exchange. Influential players like Sen. John Rockefeller, D-WV, also support a single national market. States prefer the Senate version. Here's what the National Association of Insurance Commissioners had to say on the subject last week.

Bottom line: At this point, there's no information on which vision of health exchanges is likely to prevail.

The individual mandate. Supporters insist that it's necessary to prevent adverse selection and avoid a "death cycle." Detractors insist it's an onerous tax on low income Americans.

Bottom line: The mandate stays in the picture. Both the House and Senate bills have it.

What states will pay. There are interesting developments on the issue of how much states will be expected to pay too. Yesterday, Reuters reported that the White House is discussing ways the federal government can cover even more of the costs of health reform. (Currently, the Senate legislation covers 100 percent of the cost of expansion for three years and provides a 91 percent match rate for the newly insured thereafter.) States want what Sen. Ben Nelson got for Nebraska -- a full 100 percent match. Sen. Nelson, for one, agrees they should have it. However, White House officials also told Reuters they worried it would add $65 billion to an already hefty price tag.

Bottom line: States are unlikely to get the Nebraska deal.

Showdown in MA. If that isn't enough, there's another wildcard to consider -- the special Senate election run-off in Massachusetts. Republicans are hopeful that Republican state senator Scott Brown can pull off a surprise victory against state attorney general Martha Coakley. As a result, Congressional leaders seem to be stepping up the effort to settle on a deal.

Bottom line: Coakley will probably win, but it's hard to know which polls are accurate.

When will there be a deal? CQ is reporting (behind a subscription only firewall, alas) that Congressional leaders could wrap it up by this Friday. One sign of the seriousness of the talks -- so far there have been no leaks. If and when, they start, though, I'll share them here. 

1/15 Update: The White House and organized labor have reached a deal on the so-called "cadillac tax" on expensive health insurance plans. Kaiser Health News reporter Agnes Mary Carey provides a nice overview of the differences between the state-centric Senate bill and the fed-centric House bill. But the negotiations still haven't sprung a leak. Carey doesn't have any news on which position is winning out or what the compromise might be.

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