With a package of legislative changes to the health care bill on its way to President Obama, congressional Democrats have concluded work on their plan to overhaul the nation’s health care system. Republicans have said they will continue in their efforts to repeal the bill while Obama and Democrats are focused on the measure’s implementation. Kaiser Health News’ Mary Agnes Carey discusses what’s next for health reform.
JILL BRADEN BALDERAS: Good day. I’m Jill Braden Balderas and this is Health on the Hill. I’m joined by Kaiser Health News Senior Correspondent, Mary Agnes Carey, to get an update of what happened with health care reform this week. President Obama signed the bill that was passed over the weekend into law on Tuesday. The next step of the process was this reconciliation bill that has passed. So, what is in the reconciliation bill?
MARY AGNES CAREY: The reconciliation bill tried to bridge differences between the House bill and the Senate bill to make sure that health care would become law, as it has. For example, in the reconciliation package, the Cadillac Tax, that is this 40 percent tax on some of the highest cost health insurance plans, the threshold for that was increased, and it was postponed until 2018.
There were differences also on Medicaid between the chambers. In the Senate, you had something that became known as the “Cornhusker Kickback.” It was a provision for Nebraska that would have the federal government pay for the Medicaid expansion for Nebraska forever. That was taken out. In its place there was put more money to help all states pay for the Medicaid expansion that is in the package.
There was more money added for subsidies for middle income Americans to help them pay for health insurance. There was $250 placed in the package for seniors who hit something called the doughnut hole in their Medicare prescription drug coverage this year.
So again this was a package of sweeteners, if you will, to try to get House Democrats and Senate Democrats to agree to pass both the underlying bill and the reconciliation package, and as you have noted that has happened and the bill has been signed into law and the reconciliation package is headed on its way to the White House right now.
JILL BRADEN BALDERAS: So, tell us a little bit about the process of the reconciliation package. You anticipated perhaps being here through the weekend covering this, but now it is Friday morning and it is over and done with.
MARY AGNES CAREY: Exactly. So, as we know, the reconciliation package, as well as the Senate passed bill, passed the House on Sunday night. Then the drama really shifted to the Senate. What would they do? What would happen there in the reconciliation package? Republicans wanted to make major changes. They wanted to derail it. They were unsuccessful in that.
They also forced Democrats to vote on a lot of very uncomfortable provisions of the bill for Democrats, things like the individual mandate. Some Democrats may have some discomfort with it. They were forced to a vote on that.
Should you take money away from Medicare Advantage? These are private health insurance plans in the Medicare Program. All sorts of things like that, the new taxes that are in the bill, Republicans forced a series of votes on amendments. All those amendments failed. Nonetheless, they did prevail on two minor points in the reconciliation package, which went back to the House and was passed last night as we talked about.
JILL BRADEN BALDERAS: Any drama in the House?
MARY AGNES CAREY: Not so much. It was kind of anticlimactic, actually. It became evident very early in the day that House Republicans were not going to put anymore roadblocks up. They have moved on. Their message now is repeal and replace. They have made it very clear they are going to talk about things in the health care bill they think are bad, and they are going to talk about them a lot as we head to the midterm elections, so it kind of came and went pretty easily.
JILL BRADEN BALDERAS: You mentioned the Republican mantra of repeal and replace, so I want to ask you a little bit about implementation. So, we have this huge domestic policy that the Democrats have been successful in getting through.
MARY AGNES CAREY: Right.
JILL BRADEN BALDERAS: And then we have the Republican side that is basically wanting to replace it and vowing to run on that in the 2010 elections. We are not here to predict elections.
MARY AGNES CAREY: Good.
JILL BRADEN BALDERAS: But I would like to get your take on how the politics of this might actually affect the implementation of the law.
MARY AGNES CAREY: I think immediately you do have two tracks. You have the political message and then you have the implementation. There are some provisions of the bill that go into effect right away and some that will not go into effect until 2014.
So, I think the implementation process on things like the high risk pool, that is something that is supposed to be up and running within 90 days for folks who have been denied coverage from pre-existing conditions. They need help now.
CMS, the Centers for Medicare and Medicaid Services, will begin that implementation process. Same thing for the provision allowing children up to age 26 to stay on their parents’ health insurance policies. So, the implementation will move forward, both on the short and long term track, I think very separately from the political message.
We have talked about what the Republicans are going to say about the bill, Democrats and President Obama will continue to make the case. This is a good bill for the health insurance system. It is a good bill for the American public, and I think all those things just operate simultaneously.
JILL BRADEN BALDERAS: Now you mentioned a few of the elements will be implemented right away. What are some of the long term implementation issues and some of the challenges that we will be facing as this implements?
MARY AGNES CAREY: Health insurance exchanges, for example, they are going to be done on a state by state basis. They will be up and running by 2014. That will require a very extensive regulatory process and working with states individually.
You may have some challenges of state legislatures on these issues. For example, you have already got states saying we are not going to mandate that our residents have to buy health insurance, as the federal bill would do, so that is certainly a challenge.
The Medicaid expansion, that is another provision that kicks in, in 2014, that again it will be done. Some states have already gone ahead to ensure groups that are not covered by Medicaid, such as childless adults, some states have gone ahead and done that. Others have not. There is a lot of work to be done there. The subsidies that will be administered to help people afford coverage – that is another big implementation challenge in the years ahead.
JILL BRADEN BALDERAS: So, let us take a step back. Two months ago, many people were saying health care reform was all but dead, and now here we are talking about a passed bill and a reconciliation package that allowed the bill to be passed over this past weekend. So, what is your take on that? How did we get here over the past two months?
MARY AGNES CAREY: It has been an amazing ride, lots of twists, lots of turns. The election of Scott Brown in Massachusetts, who is a Republican, to replace the late Edward Kennedy, who was a Democrat – that rocked Capitol Hill. You had Senators, House members looking at that election, trying to figure it out. Was it about health care? Scott Brown talked a lot about that. Was it about the economy? What should that mean for my vote on health care, individually members looking at it that way.
And let us remember that a Massachusetts election just came two months after gubernatorial elections in Virginia and New Jersey where Republicans won. The President had campaigned for all of these Democratic candidates in Massachusetts, in New Jersey, in Virginia, and they had lost. Democrats were looking at this and thinking, again, what does this all mean?
I think there was a defining moment for the Democratic leadership on Capitol Hill and for the President, where they had to look at do you go for a smaller health care bill? Do you stay with the big package? They made the decision to go big. I think they looked at the failure of the Clinton Administration to pass health reform. That was back in 1994.
They made the case to members: if not now, when? The current system is unsustainable, and they really pushed forward. President Obama began to really ratchet up his appearances, public appearances talking about health care. He really lobbied folks on the Hill, talked to members individually, talked to them in groups to make the case that this was key for his Presidency; it was good for their individual elections.
I think Democratic leaders did the same thing in the House and the Senate, and they really pushed forward. We had the White House Summit just about a month ago, which was another defining moment. Made it very clear what Democrats thought needed to be done on health care, what Republicans thought needed to be done, and after that they pushed forward.
Let us not forget about the newest development about increases in the individual market, health insurance plans, 40 percent and higher, that was very beneficial to Democrats and to the president as they made their case. So, all that momentum, all that drive, and again pushing up against the congressional recess, it was a key moment to pass this bill for many reasons, for many pressures, and Democrats did it.
JILL BRADEN BALDERAS: Well, we will continue to follow the developments and the implementation of this law. I am Jill Braden Balderas, joined by Mary Agnes Carey with Kaiser Health News, and this is Health on the Hill.