The Alan Katz Health Care Reform Blog

Health Care Reform From One Person's Perspective

Senate Health Care Reform Still Alive, But Likely to Change

Posted by Alan on November 21, 2009

The Senate has just spent most of today (Saturday) engaging in a debate on whether to allow a debate on comprehensive health care reform. Later this evening 58 Democrats and 2 Independents will vote to allow Majority Leader Harry Reid’s health care reform bill come to floor for debate and consideration of amendments. 40 Republican Senators will vote unanimously against allowing this to happen. Senator Reid’s Patient Protection and Affordable Care Act is still alive. It is unlikely to survive in its current form for long, however.

Don’t get me wrong. Tonight’s vote is significant, very significant.  The vote is a test of President Barack Obama’s and Senator Reid’s ability to line up enough votes to keep the bill alive.  The debate leading up to the vote has been an opportunity for Republican Senators to present their opposition to HR 3590. (Yes, the Senate has taken a bill passed by the House and moved to the Senate, gutted that language and substituted their health care reform package. Consequently, the Senate legislation has a House bill number.) And the vote to allow debate has served as an action forcing event, sort of, for Democratic moderates.

Those moderates could have sided with the Republicans killing the bill before it could be brought to the floor. Instead, they joined with their liberal colleagues and kept health care reform alive. While there are 18 moderate Democratic Senators (including Senator Joe Lieberman, who is an Independent), it eventually came down to three:  Senators Mary Landrieu, Blanche Lincoln and Ben Nelson. All three made clear they would seek amendments to the bill before voting for it. And all three are among those moderates making it clear further changes to the Patient Protection and Affordable Care Act is necessary before they’ll commit to voting for it.

We’ll learn more about the changes moderates will demand over the several weeks before a final vote on health care reform is held in the Senate.  Democratic leaders are hoping to hold that vote before the end of the year. The legislation would then move on to a conference committee that will attempt to reconcile it with legislation the House passed earlier this month.  More importantly, that conference committee, made up of an equal number of Senators and House members, will seek to fashion legislation they hope will earn the support of a majority of House members and 60% of Senators. As I’ve noted before, passage of legislation by the Senate is merely the final playoff game. The World Series — the conference committee — is yet to come.

Uniting the Democrats to allow debate on health care reform is a victory for the Obama Administration and for Senator Reid personally. That it took this much effort, however, demonstrates the challenges they yet face. Republicans appear to be uniting in opposition to the legislation. Even Senator Olympia Snowe, who voted for a health care reform bill in the Senate Finance Committee, is expected to vote against bringing HR 3590 to the floor.

I’ve written before about the power moderates have to determine if health care reform legislation will pass Congress and what the final bill will contain.  Now we’ll see that power put forward. Some of what they’ll ask for will be parochial. (That there’s a provision in Senator Reid’s bill that would send additional Medicaid money to Senator Landrieu’s state of Louisiana is neither a coincidence or accidental). But most of their demands wil concern public policy issues. Moderate Democrats tend to be more fiscally cautious than their more liberal colleagues, giving them pause to legislation that greatly expands governmental powers,  spends nearly a trillion dollars over the next decade and taxes corporations and individuals to pay for it. These are the issues on which they will focus.

Republicans will have their own pet issues, but those are unlikely to influence the outcome. Having already declared their unmoving opposition to any health care reform Democrats could claim keeps their campaign promises, the GOP has removed themselves from negotiations. (A couple of the Republicans, most notably Senator Snowe and her colleague from Maine, Susan Collins, might vote what moderate Democrats fashion. But whether they’ll be able to insert provisions without committing to voting for the bill if their amendments are accepted is unlikely. 

We don’t know yet what changes to HR 3950 moderate Democrats will demand, but the possibilities are extensive. They could eliminate a public option — or at least postpone its implementation until after other reforms have had a chance to take effect. They could  demand additional cost containment provisions. They could strengthen — or weaken — the requirement that all consumers obtain coverage. Certainly they will modify what taxes and fees are imposed to pay for health care reform.

What’s important to remember is that moderate Senators will have two shots at the bill. They’ll extract as much as they can during the current Senate debate. Then at least two or three of them are likely to agree to vote for the bill “in order to keep the process moving forward.” However, they’ll also make clear they want significant changes made to the legislation by the conference committee before they’ll commit to a vote that would place the legislation on the president’s desk. Liberals will insist they have compromised all they can, but in reality, the moderates (and the liberals) know that the progressives are likely to accept any legislation that can be called “health care reform” with a straight face. And as politicians, they have great skill in passing the straight face test.

Yes, Democrats have won the debate on whether to debate health care reform. What legislation eventually emerges from the Senate, if any, is still uncertain.


12 Responses to “Senate Health Care Reform Still Alive, But Likely to Change”

  1. Dave Wood said

    The amazing thing to me in this whole debate is that finally people are truly looking at this mess we call American health care and realizing its shortcomings. Sadly Obamacare only EXPANDS the wasteful, inefficient, and unfair system we have.

    The main problem with American healthcare is that there are TOO MANY chiefs running TOO MANY smaller systems ie. Medicare, medicaid, SCHIP, states programs, private plans, AARP, Governors, The executive branch of govt and the HHS, 532 congressman, and on and on. The problem is that the chiefs of each of these legs of our health care system each DO NOT have the ability to authorize major change, or in the case of the congress, the lack of will. Thus we get small changes to a system that is rotten to the core with waste, dysfunction, and bad management. We truly need a do over, but instead will get tinkering and expansion on the existing system.

    Thus on each and every decision, whether its lowering prices for drugs, end of life expenses, prevention, inner city disparitys, rural health care, emergency room closings, shortages of family doctors, and on and on, we lack the ability for any of the above chiefs of these systems to truly change the system where change is needed.

    In Europe the single payer govt ran systems are able to make changes when needed and they then face the voters in the next election. Europeans get accountability and changes when needed. And they get everyone covered for about HALF what we pay per capita. In France, they get to see ANY doctor at ANY place at ANY time… free choice.

    Our system is flawed to the bone. We need state based single payer systems over seen by the Congress but self ruling, self taxing, and independently ran by a locally elected authority. And we need a state based private insurance based system for our conservative friends that would also be over seen by the congress, yet self ruled and self taxed by a local authority. In this way we could see liberal Vermont vote in a single payer system and the rest of the states could watch and see how it goes. Likewise we may see conservative Oklahoma vote in a private insurance based system with true more choice and more competition as the Republicans like Newt Gigrich preach about. Without the Federal govt spending one dime. In this way we get accountability and changes where needed.

    I call this dual system the TWO BILL SOLUTION. What say you?

  2. Alison said

    For me the Louisiana “purchase” was nothing short of a bribe and puts the driving force behind this bill on a whole different level. Integrity not only fell on the floor but someone swept it under the couch.

    • James S. Thornton said

      I agree with this, Alison. However, to appear shocked that bribery is just now rearing its ugly head seems to me either naive or disingenuous. To me and many other victims of the current AHIP-dictated status quo, lobbying is not just a synonym for bribery; it threatens to replace the term altogether.

  3. Ron said

    yes, we need healthcare reforms. But Obama and congress should focus their energy on JOBS first. If we had jobs we can afford health care. health unemployed people are useless. Congress get your head on straight. thanks for the article.

    • James S. Thornton said

      Ron, this argument of yours seems to me yet another of the bullet points endlessly fashioned by opponents of reform.

      Yes, reform is necessary but…

      Then put any kind of reasonable excuse for delaying it right here.


      * but jobs are right now a higher priority
      * [when and if employment returns to more historic norms] but people have good jobs now and can finally afford healthcare, so why rock the boat?
      * but cutting taxes is a higher priority
      * but the national security must come first
      * etc.

      Can you describe ANY scenario where healthcare would EVER be something you’d think needs to be fixed NOW?

  4. Mark Goodman said

    Like many others I was disappointed that Health Insurance Reform will continue to move on the floor of the senate. I would be much happier if a Health Reform debate was moving forward. It became apparent during the summer that the President and Congress had the courage and or gumption to truly get after the problems.

    A young physician was interviewed Saturday afternoon in front of the capital and talked about the need for a public plan to keep insurance companies from raising rates. I thought about that and wondered why no one suggests a public oil company so the oil companies wouldn’t raise my price at the pump. If it works for health insurance companies than why not any other commodity whose prices rise?

    This week the New York Times had an article about how pharmaceutical companies were raising prices 9-10 percent to help pay for their contribution to the coming reform. Perhaps the insurance companies should say that additional cost shouldn’t be covered. My guess is people wouldn’t be too happy.

    Intellectually people can understand the issue and even hypothesis solutions. That is until something happens to them and they want ever test, drug therapy treatment and consult available. Believe it or not want it or not we will be rationing care just as Europe has done so for years.
    Like everything else in this discussion rationing has many faces and means different things to different people, companies and government. Rationing doesn’t mean better or worse but different.

    • James S. Thornton said

      Did you happen to see 60 Minutes this past Sunday? I know it is an old story, but the amount of spending on people’s healthcare during the last 2 months of life is outrageous.

      A 90 year old dying of cancer who develops a heart arrhythmia cannot, by law, be turned down for an implantable pacemaker and defibrillator, and Medicare must pay for it.

      Most people say they do not want their deaths prolonged by technology, and would much rather die at home or under hospice care. But the system is set up to funnel them into the ICU’s, where hospitals, specialists, equipment makers, pharmaceutical interests, etc. make a fortune on the end game.

      Then the Republican Party suggests that any attempt to be rational about this is “pulling the plug” on grandma, regardless of what grandma wants.

      Pulling the plug is one thing. Inserting dozens of plugs in every orifice of grandma’s body and exposed vein is yet another.

      Hospitals will fight tooth and nail to keep their beds filled and their test apparatus running and their doctors operating.

      So much for death with dignity. We are all moving to an end game where we become peri-corpses from which money (our own and the tax payers) is siphoned out by an efficient and ruthless corporate suction system.

      • Mark Goodman said

        This is where rationing should start. As difficult as it is for people to let go of loved ones at some point “care” needs to have a deeper meaning.

        Other countries have systems in place to deal with this situation.

  5. We see bills (ie: stimulus package) that at the last minute get a bunch of pork rolled into it fueled by last minute deals, lobbyists, and interest groups and all in the name of democracy and compromise? We should avoid huge bills of any kind because of this. I believe in the core principle that great things comes to pass through small and simple things. We have this huge bill coming to the floor for debate. Votes will be a matter of picking and choosing what you believe in and as long as you get that, then you are willing to put up with the rest? How much bad is going to be rolled into the good? Our health care issues can be addressed singularly and decisively if we try to solve them one at a time and not in one big massive bill that few can wrap their heads around.

    I believe in the KISS principle- Keep It Simple Stupid!

    KISS principle

    “Keep It Simple, Stupid.” A term which simply indicates that the simplest solution or path should be taken in a situation. This principle can be applied to any scenario, including many business activities, such as planning, management, and development.

    Health Care Reform is complicated indeed but the best path to reform is through small and simple steps in the right direction. Fix what needs to be fixed and leave everything else alone.

    • Nosedoc said

      By tackling health care reform before immigration issues or Medicare Reform, Congress is already in violation of the KISS Principle.

    • James S. Thornton said

      The problem with healthcare reform is there are now small and simple solutions.

      You can’t force insurers not to rate people (the pre-existing conditions bugaboo everyone hates) if there is no mandate to buy insurance. Otherwise, you can wait till you feel the crippling chest pains before

      1) chewing an aspirin
      2) calling an ambulance
      3) logging online and getting insurance

      This is not a simple matter to overcome, and it’s just one of the many matters in our system that are incredibly complex, morally, financially, ethically, and philosophically.

      Is life sacred? Some say yes, that it should be preserved via the best technology as long as humanly possible. Others say no, let people die with dignity.

      Are people free to make their own decisions in life? Some say yes, don’t make me wear a helmet when I ride my chopper, don’t try to regulate my drug use, etc. Others say, fine, but if you get in an accident or develop cancer, don’t expect my tax dollars to pay for your treatment at the ER.

      But what about the kids of such rugged individualists? Is it fair for a baby to be born in our country and left to fend on its own because the parents don’t want to buy health insurance?

      None of these things are easy.

      If you listen to those who say that some ideology has simple cures (the market will right all things; Jesus will provide; etc.), you are listening with the wrong lobe of your brain–the reptilian part where greed and hope and fear are untroubled by rationality.

      • Your right, you can’t force people and that is what FREEDOM is all about. People do have their free agency and consequences come with that or else what is freedom? I like my democratic freedom that gives me the right to choose. I don’t want the government dictating to me my health plan, my schooling or my job responsibilities.

        However, life isn’t fair and people aren’t always dealt a fair hand so our government should enact legislation to protect the rights of the less fortunate like children who don’t have health insurance (ie: CHIPS texas medicaid for children).

        For those who choose not to buy health insurance then the consequences are that you might not get the best of care if and when something happens and you will be in debt for a very long time.

        For those who buy health insurance, even deductibles are hard to pay.

        Health saving accounts- save your money in a tax protected account for your deductible. Or if you like the co-pays, start saving to cover your deductible.
        Buy insurance to cover your deductible. I know there are accident and critical illness policies that will cover the deductible.

        For those who cannot afford health insurance or qualify for it medically then we need solutions.

        Low income = Medicaid (Improve it)

        Pre-Exisiting Conditions = State run risk pools that are subsidized to a small degree by insurer profits so the costs are brought down.

        Low income + pre-existing conditions = state run risk pools + government subsidy.

        High Costs of Health Care = tort reform + incentives (tax breaks) to buy health insurance + rewards for living health life styles + more focus on preventive care.

        Don’t punish the insurance companies, the doctors or our citizens through taxes or penalties.

        The smart way to tackle health reform is through enacting solutions that will make our health care system stronger (lower costs and greater coverage) and thereby protect the lives and pocket books of our citizens.

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