Over the weekend, the Senate voted 60 to 39 to begin debate on health reform legislation, which will begin after the Thanksgiving break. Panelists discuss what’s ahead. Watch the video or listen to audio version (.mp3). A transcript of the interview is below.
JACKIE JUDD: Good day. I’m Jackie Judd with Health on the Hill, a conversation about efforts to overhaul the nation’s health care system. Over the weekend, a major procedural hurdle was cleared when the Senate voted 60 to 39 to begin debate on landmark legislation, which will be taken up after the Thanksgiving break.
Here to discuss what’s ahead are Mary Agnes Carey of Kaiser Health News, Julie Rovner is joining us today with National Public Radio, and Eric Pianin, a long time Washington journalist. Welcome to you all. What are the major hurdles the Democrats face for members of their own party, once the debate begins? First, let’s talk about the public option.
MARY AGNES CAREY: The public option is going to be a critical part of this debate. In the Senate, states would be allowed to opt out of the public option. The House as we know does not allow that opt out permission and also has a public option. So, in the Senate you are going to have a struggle with Democratic moderates who have said they are uncomfortable with the idea of the opt out provision. They don’t like it. Ben Nelson, for example, a moderate from Nebraska, whose vote will be key on this, talks about how he would like states to opt in.
On the other side of the debate you have progressives, such as Sherrod Brown from Ohio, who say that basically from his point of view on the public option, they have compromised enough, so the idea of an opt in or another option would be the trigger option. Olympia Snowe of Main, a Republican who very much would like to vote for the Bill, under the trigger proposal you wouldn’t have a public option unless health insurance wasn’t affordable to 95 percent of a state’s residents, so this is going to be a central focus of the debate.
JACKIE JUDD: Tom Daschle, who is an unofficial but important voice in the health care reform debate, was interviewed over the weekend by NPR and talked about the option of having states come into a public system if necessary. He seemed not entirely opposed to that idea. Is that an important signal in this debate?
MARY AGNES CAREY: I think it’s a signal that they are looking for every possible option to get votes and they are trying to send a message. There is no line in the sand. It doesn’t have to be the opt in or the opt out or the trigger at this point. They are looking at everything to try to build the consensus to get 60 votes for that Bill.
JACKIE JUDD: Julie, let’s move on to another issue and that is the language regarding abortion funding.
JULIE ROVNER: Yes. When you talk about the public option, you talk about possible compromises. Very early this year, Senator Grassley talked about how everything in this Bill is probably compromisable except abortion. This is one of those issues where there really is very little gray. I think the object going in was to find language that did not really disrupt the status quo, and the status quo is that public funds, taxpayer funds are not used to subsidize abortion. How you do that has turned out to be incredibly difficult.
In the House, of course they passed the Stupak Amendment that says there will be no taxpayer funds in the public option, period. So, abortion will not be offered as a benefit in the public option and there will also be no funds offered in any plan that is subsidized within the exchange. So that means, what that has come to be accepted as the distinct possibility is that within the exchange because so many of the plans will be subsidized, that there is a distinct possibility that there will end up being no plan in the exchange that offer abortion. So even though the language of that Amendment says that a woman could buy a plan with her own money that offers abortion as a benefit, there may not be any plans that actually offer abortion as a benefit.
So, in the Senate they are working to try and find language that would allow abortion to be offered as a benefit, but not using taxpayer subsidies. The National Right to Life Committee, the Conference of Catholic Bishops say that so far the language that is in the Bill doesn’t pass that test, that there is still, even though there would be, that money would have to be kept separate, it’s still too close. There would still be a possibility that there would be taxpayer money used to actually subsidize abortion, so there will be definitely a big fight over abortion. How you get to the point where women can use their own money to buy policies that cover abortion, but taxpayer money won’t be used, it’s finding that language and so far nobody has found language that will do that, that will satisfy both sides.
JACKIE JUDD: Okay, and then Eric, finally, one of the big issues is just this general climate of the economic crisis we are all living through and the issues raised about how do we afford a Bill that, in the Senate anyway, will be $849 billion over a decade during this time of economic anxiety?
ERIC PIANIN: You are exactly right and I think the Democrats were ecstatic when they were able to get a number from the CBO of $849 billion.
JACKIE JUDD: It sounds like a bargain.
ERIC PIANIN: It sounds like a bargain, a lot less than what the House Bill would cost, which would be a little over $1 trillion over 10 years. So I think Harry Reid, the Senate Majority Leader, figured that this was an essential element in winning over some of the more conservative members of the Democratic caucus and responding to the Republican criticism that this was out of control spending.
But the reality is that as time goes by, as the economy worsens, as unemployment rises, if you look at the polls, people are, while interested in health care reform, are far more interested in jobs and doing something about the deficit, and so I think that cost is a paramount issue going into the final negotiations. Some of the moderate Republicans like Olympia Snowe are saying that is something that they are going to keep their eye on in trying to decide whether the final analysis to support the Bill, which might be very important if one or two of the Democrats or Independents drops off at the last minute.
But also I think as time goes by the Democrats have had to respond to more and more criticism about the way they are putting together this Bill and financing it, and if you listened to the debate on the floor over the weekend, John Cornyn, Lamar Alexander, Tom Coburn and others, hammering away at the legitimacy of the numbers and questioning whether some budget games were being played. I mean, for one thing they are postponing the effective date of the legislation until 2014, and yet they are going to begin collecting the taxes to pay for it well before that. People are saying that is a budget game.
There are a lot of other questions, too, about how you are going to absorb all these additional Medicaid beneficiaries into a health care system that is already ready to explode it’s under so much pressure, so I think there is a lot of economic, budgetary and practical questions that the Democrats are going to have to respond to.
JACKIE JUDD: And is it one of the general themes that Republicans will be coalescing around in terms of trying to alter or solidify in some cases public sentiment about the Bills, and that is the economic anxiety that we all are experiencing?
ERIC PIANIN: I think that is the case, and I think that in the end their minimalistic argument might resonate a little more with voters as you get closer to the final vote. I mean, they are hoping to have this thing passed by the Senate before Christmas and then they will have to go into negotiations with the House, probably some time in January we will see the final shape of this thing. I just think that the dollar sign is going to be an incredible symbol of importance in the final round of negotiations.
JACKIE JUDD: Did you want to jump in on that, Julie? I saw you shaking your head.
JULIE ROVNER: Yes I think how much this Bill costs and also how large this Bill is, you know, one of the reasons I think that a big health overhaul has never passed in all of these efforts to do it going back to Harry Truman is that when it gets close, the American people get scared. I mean, this is big. We are talking about a sixth of the economy and I think that is what the Republicans are really trying to exploit, the idea that these will mean big changes and perhaps changes that you don’t like. That was what sunk the Clinton Plan. Remember, Harry and Louise sitting at their kitchen table saying that these things are going to change and we may not like them, and that is exactly what the Republicans are going for now, that you know, maybe we should do some smaller things instead.
Of course, what has happened is the Democrats tried to do smaller things, too, in the late 1980s and early 1990s and what happens with the health care system is that it’s so interconnected that it’s very difficult to do small things. Republicans get up and say well, we could just take care of preexisting conditions. The problem with that is that you can’t really just take care of preexisting conditions because in order to do that you have to have everybody with insurance. In order to do that, you have to have a mandate. In order to have a mandate, you have to have subsidies. In order to have subsidies, you have to raise the money, so basically the smallest Bill that you could have that takes care of preexisting conditions is essentially something like what’s on the Senate floor right now, and that is how you end up where we are. So, dealing with the health care system, even if you want to deal with something small, like preexisting conditions, you end up with a fairly sizeable piece of legislation.
JACKIE JUDD: Mary Agnes, what do the Democrats do over the next month, not only to hold onto every member that they have, which they will need for the next vote, but also to help shape public sentiment?
MARY AGNES CAREY: I think they say to their members, we understand your differences, whether it’s on the public option, whether it’s on the financing of the Bill, whether it’s on the issue of abortion, we want to work with you to reach a resolution.
Harry Reid, as the majority leader of the Senate, said after the vote on Saturday night not every member of the Senate will be happy with every provision of the Bill, but they want to get that sort of cross section if you will that can bring Democratic support because they have a unique opportunity now to make changes. As Julie talked about, several times they have done smaller Bills over the years. I think with the results of last year’s election, they feel they have the mandate to go broader, to go bigger, and they want to seize the moment.
To the public, they want to reach out to people who have health insurance and people who don’t. For folks that have it, they say they want to help you keep that health insurance. They want to help control your health care costs, but there is great debate on whether or not the Bill will actually do that. And for folks that don’t have health insurance, they want to say we want to help you find a way to be covered, whether it is a subsidy to buy health insurance in the health insurance exchange or whether it’s expanding Medicaid coverage, so they are trying to touch all their bases there.
JACKIE JUDD: And over the next month, do we need to keep an eye out for pet projects being attached to this Bill? There was the Louisiana Purchase, as it’s now being called, the extra money for the state of Louisiana given to Senator Mary Landrieu for Medicaid – is it going to happen time and time again?
ERIC PIANIN: I think so. I think it’s going to be like a bazaar and people will be cutting deals left and right, shamelessly in some cases, where sort of selfish state interests will trump national interest. And Harry Reid has shown that he can play this game very well. He’s a great vote counter and he is a great deal cutter. But, eventually all these deals have to sort of bump up against the reality of limits to how much they can spend and the ripple effect of last minute changes on holding votes in both chambers. And you can cut a deal that might satisfy a couple of conservative Democrats from the south, but that may have a ripple effect over in the House with the urban Democrats who feel very differently about all that.
JULIE ROVNER: One thing I will say about the Louisiana Purchase, at least that was health related and it was germane to something in the Bill. I have seen a lot of Bills where these kinds of deals were cut that have nothing whatever to do with the substance of the Bill. So most of the deals we have seen so far, and there were a couple in the House, too, there were a couple of members who got medical schools authorized in their districts in order to get their votes for this Bill. So this is not something new that we have seen to the Senate, but this is the grease that makes the legislative process wheels go and has been. It was ever thus, so this is not exactly unique to this situation.
JACKIE JUDD: Right and speaking of the House, it’s probably a good moment to catch up on, again remind our viewers what the major differences are as we speak now between the Senate Bill and the House Bill.
MARY AGNES CAREY: One, of course, is the public option. Again in the Senate, states could opt out as it’s currently written. That is not the same in the House. It’s a public option in the exchange that is available. Abortion is going to be a very different key point, the language is much stricter in the House Bill than in the Senate Bill and so that will be a flash point.
Financing is another one. In the House there is a surtax on high income earners. Here we are talking about individuals who make $500,000 a year or couples who make $1 million. In the Senate they have chosen a different route. They want to put a tax on the Cadillac, some of the highest cost health insurance plans. They would raise Medicare taxes for some high wage earners and they would have, one of the taxes that was added was a 5 percent tax on cosmetic surgery, so they have very different approaches in those areas.
JACKIE JUDD: And the number of people who ultimately would be insured, who are now not, would also be different, right?
MARY AGNES CAREY: Yes, in the Senate you have about 31 million people who currently don’t have health insurance who would be covered at the end of the 10 year window and in the House it’s about 36 million.
JACKIE JUDD: Eric mentioned earlier that the hope is that there will be a vote in the Senate before Christmas. Do you think there will be?
JULIE ROVNER: Yes. The thing about the Senate is that they have unlimited debate. The only thing that tends to limit debate is the calendar, so they like to put big Bills up against a scheduled recess, and of course Christmas is one of those hard recesses that members tend to like to take, so I would think that would probably be a “hard out,” as they say, so I would guess that they would probably finish up right around Christmas.
JACKIE JUDD: And then it would go to conference to reconcile the differences with the House. So what does the time table look like, if we presume there is a vote before Christmas going into January?
MARY AGNES CAREY: It’s probably anyone’s best guess. Let’s say the Senate gets its Bill done by Christmas, you could have a conference in early January, some hope for a Bill on the President’s desk before the State of the Union, but I think that time table could slip.
JACKIE JUDD: Okay. You know, we’ve spent so much time now talking about the events on Capitol Hill, but in this next crucial month, what does the White House have to do? What is its role? Does it change from what it’s been doing in the past eight or ten months?
ERIC PIANIN: I think that you get varying reports on just how engaged the President and the White House is. My guess is they have been extraordinarily engaged in what is going on and from Rahm Emanuel, the White House Chief of Staff, and their top health care advisers, they are over here, over on the Hill all the time. And the President is monitoring this very closely, even when he is traveling, he’s calling members. He’s doing what Presidents do, twisting arms, and actually sometimes the further away you are from Washington, the more effective you are. I’m calling from China or I’m in Beijing right now and I really need your vote on this cloture vote.
So I think you will see an extraordinarily engaged administration pushing for this incredibly important issue. They have got to get this thing done. They have got other issues on the agenda. They have got the economy and jobs to get to. People in the House are chomping at the bit to do some more stimulus spending, so they have got to get this out of the way, and I’m sure the President wants to be able to tout this achievement at the State of the Union Address.
JACKIE JUDD: Julie, final question to you. You, as you mentioned earlier, covered the Clinton Health Initiative back in the early 90s, so I guess I would ask you to look into your Crystal Ball and talk to us for a moment or two about what you think the next several months will bring compared with the perspective of the early 90s.
JULIE ROVNER: Well, I think the good news for this Bill is that it’s ahead of where the Clinton Bill was at that point. The Clinton Administration spent all of those months in 1993 behind closed doors putting together its own Bill. This Administration has been the anti-Clinton Administration in that sense. They left everything to Congress. Everyone is now complaining they left too much to Congress and they haven’t been engaged enough. But for all the deadlines that have slipped, this Bill is still way ahead of where the Clinton Bill was, so on the Senate Floor now it’s still, the year before the election year. I think what happened to the Clinton Health Bill was that, yes it did come to the Senate Floor, but it was August of 1994, so it was just a couple of months before the election.
So I think there’s still, even though there’s this horror of going in to that election year of 2010, it will only be by a month or two, so I think that they are well ahead of certainly where the Clinton Bill was. There is considerably more momentum. Now people look at these polls and see the numbers slipping, both for the President himself, who has used an enormous amount of capital on this, and for the issue, but again we are talking about a sixth of the economy, we are talking about an enormous Bill. I don’t think this is ever going to get done with an enormous amount of popularity. It’s just too big and too easy to demagogue by people who oppose it. I’m not just talking about Republicans. I’m talking about the Chamber of Commerce. I’m talking about the people, the special interests who would be disadvantaged and there are always going to be special interests disadvantaged when you are moving around billions of dollars. So you are never going to have a Bill like this that is going to have that huge support, so I think at some point people are just going to have to hold their breath, hold hands and jump, and I think that’s what we are looking at here.
JACKIE JUDD: Okay, thank you all. Thank you. Have a nice Thanksgiving holiday, appreciate it. And thank you for joining us. I’m Jackie Judd.