The Alan Katz Health Care Reform Blog

Health Care Reform From One Person's Perspective

The Congressional Health Care Reform Three-Step

Posted by Alan on February 25, 2010

President Barack Obama repeatedly tried to get the bipartisan summit on health care reform to focus on policy rather than process. Now that the summit is over, however, process is rightfully back on the table.

As I noted in my previous post, many of the major health care reforms of the past few decades have been accomplished through use of the reconciliation process. But how exactly would it be used this time for this reform?

Let’s review where reconciliation fits into the wonderful whacky world of the U.S. Senate. As you’ll recall, 41 Senators can invoke a filibuster and consequently prevent a bill from coming to the floor.  Only if 60 of their colleagues vote to close debate (by invoking cloture) can a bill be voted upon by the full Senate. (For an interesting history of the filibuster and cloture, check out the Senate’s web site). There is an exception, however. Since 1974, budget and tax related items can be brought to the floor of the Senate through a process known as “reconciliation” and no filibuster can stop it. So a key issue is, what matters are eligible for the reconciliation process?

Enter Senator Robert Byrd the widely acknowledged master parliamentarian of the U.S. Senate. He created what is known as the Byrd rule to help determine what is outside the reconciliation process. Put simply, the Byrd rule defines as “extraneous matter” items that do not impact government outlays or revenue in a substantive way. (It’s more complicated than that, but that’s the gist of it).

New taxes, and the health care reform process has plenty of them, are clearly within the purview of the reconciliation process. Preventing carriers from excluding pre-existing medical conditions from coverage is not.

What this means is that the Senate can not pass comprehensive health care reform through the reconciliation process. But hang with me here, because the fact is they don’t need to pass comprehensive health care reform through the reconciliation process because they already have. Remember? It was only a few weeks ago, on December 24th, 2009 to be precise. The Senate passed a comprehensive health care reform bill on a party-line 60-to-39 vote. yes, I know. It seems like ages ago, but it has only been a couple of months. And that affirmative act still stands.

So here’s the legislative three-step Democrats are likely to use to pass comprehensive health care reform.

Step One: The House votes on and passes the Senate version of health care reform.
Step Two: The Senate, using the reconciliation process, passes legislation to “fix” certain aspects of the health care reform it passed in the Senate.
Step Three: The House passes the Senate’s ‘clean-up” bill.

Both the Senate health insurance legislation and the clean-up bill arrive on the president’s desk. He signs them both into law.

What you may (and should) ask, would be in the clean-up bill? As previously predicted here, the follow-up bill is expected to remove state-specific funding elements such as the special treatment currently in the Senate bill favoring Nebraska, Louisiana and a few other states. The clean-up is also likely to change the criteria of a “Cadillac health plan” subjecting fewer policies from being subject to the proposed excise tax. Other fees and taxes would also likely be a part of the second bill. In other words, the clean-up bill would only relate to the budget and/or taxes, meeting the test of the Byrd rule.

I haven’t come up with this on my own. This legislative dance to enact health care reform was discussed at length on “Hardball with Chris Matthews” on MSNBC (the relevant discussion starts at about 3 minutes, 10 seconds in this clip, although he refers to it as a two-step process). What’s significant, however, is that it’s a strategy that makes sense (if your goal is to pass health care reform). Republicans will object that it’s ramming health care through Congress, but the GOP can’t claim the three-step violates Senate rules.

Many thought President Obama’s health care reform bill died with the election of Scott Brown to the Senate from Massachusetts on January 19, 2010. The odds are: they were wrong.


13 Responses to “The Congressional Health Care Reform Three-Step”

  1. Rosy said

    I am guessing that anyone against the health reform.. HAS and can afford insurance… I am an American.. I pay taxes… My husband is out of work… and I can only find part time work… My husband has a Masters degree… I only a Bachelors… BUT.. hey… I am working at a Church’s Chicken place to pay the bills…
    We live in a real home… 4 bedrooms, 3 baths, 2 car garage… Pool… BUT… being self employed… as I am… I have to purchase insurance out of the STANDARD that all of you “Nayer’s” pay.

    Here is the breakdown for ME and my family:

    I am on two types of anti-depressants… (Un-insurable)… my husband has High blood pressure (Un-insurrable). So we have to go to the best we can find out there for self-employed people with health issues…

    Lowest cost we have found that gave us any type of coverage… COST to us monthly… $3,200.00. AND what does that cover…??? Last March I was in the hospital for a heart problem… of my $9,600.00 bill… THIS GREAT insurance paid $100.00 of my bill…

    That is what many AMericans are dealing with… IT gets to the point that I feel I can not afford to LIVE in America…


    AND I see all you fighting to take the right to live away from me… Can I afford it… CAN YOU? Without insurance or assistance…???

    SO… I guess we should just let all the self-employed… un-insurable people DIE…

    SO if you vote against the health reform..

    KNOW THIS… YOU ARE PLACING DIRT ON MY GRAVE… and the GRAVE of my husband… Some really good people… just not employed where the boss pays most of the bill…

    So I say…


    We are in the minority… BUT WE ARE REAL LIVE PEOPLE… and we deserve to LIVE…


    • EvoRev said

      Rather than looking at why we (who oppose the bill) are “placing dirt” on your grave, I think the more relevant topic should be why the cost of your medication, the cost of your hospitalization is so high. As someone with some insight into how the insurance industry works as well as the healthcare billing system for most major hospitals… I can promise you, they are charging you that much because they can. I can promise you, if you were able to get more insurance options (by allowing insurance companies to offer policies across state lines!) those costs to you would come down. It’s called competition. Right now there is none.

      And as a side note…the fact that you can only find work part time at a fast food restaurant seems to me a bigger issue for the vast majority of citizens. I am in the majority…and I consider this focus on health care reform secondary in importance to the economy and jobs in particular.

      I found your jab “I am guessing that anyone against the health reform.. HAS and can afford insurance” particularly ironic since you have a 4 bedroom house, 3 baths and 2 car garage…oh yeah, with pool. You see, I live in a 1 bedroom apartment and I try to live within my means.

  2. There is a unity lost between Governing Parties that is needed to help the people feel secure. The moral building block for Health Care.
    To see the true Health Care Tax forum you must stop thinking in 3-D,This multi tax forum is against a $100 Trillion Dollar system.. …
    To force pay into another system of failures within Health Care Insurance Groups.
    This economy will not balance with this concept of a tax forum against the Health Care System. The issue of how to force pay into this system of Health Care may have worked but I am still troubled over the progressive tax forum within this Bill. It covers so many items and Countries that it only forces the system to adjust itself. In some areas, increases against the people and the troubled economy, and in other areas, less effects will be felt.
    But this is my big problem, Government Officials seek help and they are to proud to ask us, “the true working force of Government.” It is understandable they have failed the People and within the United States Of America all we ask is to see us as who we are and not try to bring us into this world of the intellectual. I guess our Prime Directive is that of Star Trek, so it must be understood that for millions of people we are just as happy as can be making $13.00 per hour and we have no interest in this world of politics, and how to be a Enstine. Government Officials must understand that there is a level of people within different parts of this Country, that seek to be only that they find to make them happy.
    As for this economy well, it is said that the U.S.A. Arms Division has created enough arsenal to destroy every last creature in the world 2 times over,built with tax dollars. This would be funny if not for the irony of it. And now as time has passed Government Officials keep failing. Before 9/11 all the way to today.
    As it is in a world of a system, when employees continue to fail, one or two things happen, one; you get fired, two; if you see into a person a good, then it is political correct to implement a penalty or roll back in pay. But this implement of penalty is more favored in the course of action in the Federal Employment World. So how to fix the economy and unite it with the Health Care issue. It would be in the Countries best interest to implement a 10% per cent penalty against every State, County and Government Official within this Matrix of failures. Hey what is that old saying, what is good for the Goose is good for the Gander. I am serous about this, it is past due to show that our Government Officials they have failed, their system failure reaches into this world of warnings that they brush aside as if the information is not worthy noting. From Pearl Harbor to 9/11/2001 to 3/07/2010 of our tax system and Health Care Reform. This 10% per cent penalty should go into the Health Care Forum.
    The big problem that Government Officials have is that they have no street credit. President Obama still has some but if he does not take his family and step away from these dueling Parties, that fight over this Health Care Dollar, and stand with Us he will lose all credit from the streets to the county.
    President Obama, I would say to you, you have one last chance to regain the hopes and dreams of the American People. To reach out in a concept that states, if there is 250 million people in trouble because of these failures, I would give all my money to them and then I would say to all that I gave money to, “I have no money left, would you all please give me $1.00 back and then I would have $250. million dollars to start all over again.”

    As for this $100,trillion dollar in site………….
    Results 1 – 10 of about 685,000 for net worth of medicine development industry
    Just to show how deep this Health Care Tax split petition reaches. The term split petition is used because of the Tax factor plan that is not seen because of the intent not to show a capital Taxing of close to a $100 trillion dollar package, a yearly system income, not profit…..

    Some have stated that I clam to have spiritual in site or something of the sort. I assure you this is not true, so when I state that I asked God to help, it is my way of saying hey Bobby show me how to work on theses Chevy engines. But I do thank you for the consideration. Consider me a cross of Jethro Bodine from the Beverly Hill Billies with my 10th. Grade education and Vin Diesel from the move Pitch Black.
    So drop on by and see page 100 at our site and follow the blue pill link

    Health Care within a moral value, is to ,


    Henry Massingale
    FASC Concepts in and for Pay It Forward on google. yahoo, and
    please take the time and visit all my new friends on the net and if you wish to post with FASC Concepts you will be most welcomed. So join us and share your ideas as one in one voice.

  3. “But you will see an entirely different class getting blackballed.

    Self employed writers like me, contract workers that save corporations from paying benefits or SS contributions, the whole second class tier of citizens.

    Why can’t we start our own club?

    Why do you conservatives hold all the licenses>”

    Actually, Jim, we don’t. Of course, I am a Fiscal conservative to moderate, and Socially very liberal. An independent, so perhaps I don’t fit the mold to which you are referring.

    Regarding Jews, I am one, and I can tell you that while things aren’t as bad as they once were in the US, there is still a lot of room for improvement (A Methodist Minister who I insured actually said, “How much? It’s gotta be a lot, because there IS a Jew here.”). And that’s only a small taste of what we in my tribe can and have experienced.

    Self-employed “Any-ones” can experience a certain level of discrimination, damned if I know why. My S_I_L is a self employed computer writer, was employed by WaMu for a lot of bucks, and has been laid-off since they went belly-up, and can’t get a job, period. Times are usually tough for those of us who really run the engine of this country, and they are worse now. When the economy picks up, and people are doing better, you’ll see that “discrimination” ease up. When the economy began “going south”, I told my wife, “Just watch the anti-Semitism” in this country increase; the Jews are always the first to be condemned for bad times…and many Jews are writers, as are you.

    No, you won’t see signs telling anyone to “stay away”, it’s too easy to sue those creeps today, and win. That doesn’t alter the fact that any minority of people, and self-employed are considered to be in the minority though in fact we’re in the majority, will suffer more than others in times of economic downturn.

    I just wanted to offer a bit of a different way of seeing these things.

    Jim, you said, “Well, Alan, thanks to you, Spencer and I are almost getting along! It’s been at least a week since I suggested he might have a severe proctological problem.”

    I saw my proctologist, asked him to please remove my head from my ass, and he did. And what is this, “Spencer and I are ALMOST getting along”? Damn, Jim, I thought we were really becoming friends! I still do! 🙂

  4. Thanks once again, Alan, for a wonderful explication of complexity.

    I think you should consider running for office. Your keenness of mind and decidely even-handed approach is what is needed. People tend to castigate all politicians as inept liars and bribe-takers, but I have got to believe there are many who really do want to do the right thing.

    You could be one of them! Why don’t you move to Pittsburgh and challenge Jason Altmire, former healthcare lobbyist and blue dog Democrat with big, blow-dried politician hair, for his seat?

    Then I could vote for you.

    • While I don’t believe that the “refreshed” Senate Bill, absent language giving discriminatory favors to those who sold their souls for a few (million) bucks, would be good legislation to pass, I must admit, Alan, that I agree with Jim.

      Having worked with you on the Legislative Council of NAHU, seen the good works you accomplished as NAHU President, and knowing that you were awarded the NAHU Harold R. Gordon Memorial Award (NAHU’s Person of the Year) in 2003, I think you wold be eminently qualified to run for Congress, preferably the Senate, and lend your “balance” to an otherwise seemingly self-interested group…with one caveat…while Jim would envision you as a simply liberal Democrat, I would prefer to see the “Blue-Dog” preface on that title. I do think that the Blue dogs bring more of a balance to their positions, or at least are s’pose to, than their more liberal counterparts.

      In seriousness, you do lend balance, and it is my belief that you would not be able to “be bought”, by anyone. I agree with Jim that you are a man of honor.

      Just a thought…I’m sure as hell never going to do it. I wouldn’t last ten minutes before I’d knee-cap someone, and shoot, that would be the end of my career. 🙂

      Oh, BTW, Jim, I felt that I had to give you another “Thumb’s Up” on that one! You earned it!

      • James S. Thornton said

        Thanks, Spencer. The fact that we would both like to vote for Alan shows that the gulf between the various factions on this issue does not always have to be insurmountable!

        In fact, I think if we could all just take some of the various elixirs Aldous Huxley appeared to endorse in the dotage of his career, we might come to believe we inhabit a benevolent pantheistic universe where lions lie down with lambs.

        For those of you who may have been following my own personal private insurance travails, I just received this year’s notification of rate changes for next year.

        Our policy is going up from $1711.50 per month to $1865.50 a month–not quite such a travesty as Anthem’s proposed increase, but then again, they could have upped it to a million dollars a month for all I can see. If you don’t have the money to pay, you can’t pay.

        Here’s a question for Alan. If, as Anthem and many private insurers maintain, there is hardly any profit in the private market, what is the tremendous resistance to just ceding this portion to the government?

        Why can’t we just say something a la: if you are a business with 500 or more employees, a big enough pool to get some kind of reasonable rate per person, you are obligated to provide insurance for your employees.

        If you are self employed or work for a small company, you have the option to buy private insurance, or obtain a bare bones policy through the government, or do some kind of mix and match form of both these options (bare bones policy from govt PLUS supplemental from the private market.)

        Why does AHIP fight this tooth and nail while simultaneously maintaining there is little, if any, profit in the individual market?

        We suffer; apparently they suffer, too. Why not make it so everybody has reduced pain?

        • Alan said

          The individual can be a solid business. It’s extremely difficult now because of the economy. Healthy people drop out of the market to save money; those who need the coverage don’t. Utilization can skyrocket in a short period of time. The carriers are now trying to get in-front of the train. It’s a messy system.

          I don’t think anyone argues the individual market works well as is. The question is how to fix it. Personally, I prefer a system where carrier have to accept all comers and all consumers have to buy coverage (or, if that’s politically unacceptable, allow carriers to impose a penalty on folks who don’t purchase coverage until after they need it). But as the health care reform summit demonstrated, there’s a diversity of opinion on the matter.

        • Alan,

          I KNEW you’d be the right person for us to send to Congress!

          I completely agree with your comments, 100%. You are “spot on”!

          So…when would you like Jim and me to get started on forming a feasibility committee? 🙂

        • Alan said

          Normally I’d send the overly flattering and way too kind comments by you and Jim to the trash bin, but: 1) most are mixed in with substantive comments; and 2) my mother reads the blog and she loves them. But she and I do thank you guys for the nice words.

        • Alan,

          LOL! Alan, you’re welcome, and actually, and I beg to disagree, our comments are not really overly flattering…you do evidence the kind of balance and thought too few in our largest governing body do. Professional politicians have always struck me as being a bit too taken with themselves, and we KNOW how much they love that money. I imagine, were you to accept our challenge to run, you’d take a rather substantial cut in pay…and we can’t really ask you to do that, your family might object.

          I’m delighted that your mother reads your blog (Hi, Alan’s mom!)! She has a lot of reasons to be proud of you.

          Okay, I can feel my own sugar level rising. I’ll stop…so, Alan, when should we get that feasibility study going? LOL 🙂

        • Well, Alan, thanks to you, Spencer and I are almost getting along! It’s been at least a week since I suggested he might have a severe proctological problem.

          What again is the rational against allowing freelance writers or other common groups of self employed people pool together to create a significant number of folks to pool their risk and enjoy the rights and protections enjoyed by governmental group insurance or Fortune 500 Corporations?

          I just don’t get it. AHIP complains about the administrative costs and relatively low profits associated with dealing with so many individuals. Small groups tend to be more vulnerable to death spirals.

          I feel like the nation is a series of High Class Country Clubs that you need to be invited to join. The Republicans love this, because many of them are born into the right clubs. (Oh, Daddy got me my first job at Goldman, I started out as a president and had to work my way up to CEO.) Meanwhile, unlike the Country Clubs of the 60s, you won’t see the racist and antisemitic signs on the entrace to the Health Insurance clubs. No x or y admitted! Stay away!

          But you will see an entirely different class getting blackballed.

          Self employed writers like me, contract workers that save corporations from paying benefits or SS contributions, the whole second class tier of citizens.

          Why can’t we start our own club?

          Why do you conservatives hold all the licenses>

        • Thank you, Jim, for the nice comments. I truly believe that those, whose perspectives may seem to be far apart, can in fact, work together to achieve a common goal. Compromise and negotiation are important arts to learn if we expect to move forward and not just “tread water”.

          OMG, Jim! My wife has lately been asking me if I’m ever going to grow up. I’ve said, “No, I’m having too much fun”, and in looking for a good quote for you from Huxley found this, which I’ll show to my wife: “A child-like man is not a man whose development has been arrested; on the contrary, he is a man who has given himself a chance of continuing to develop long after most adults have muffled themselves in the cocoon of middle-aged habit and convention.” ~ Aldous Huxley. “Take that, Fran!” LOL

          I found reading your personal insurance experiences to be “educational”, but more important, and from a human level, startling, especially this: “Our policy is going up from $1711.50 per month to $1865.50 a month–not quite such a travesty as Anthem’s proposed increase, but then again, they could have upped it to a million dollars a month for all I can see. If y ou don’t have the money to pay, you can’t pay.” Too true…a few years ago we were paying $800 and change for major medical, a plan with very high deductibles and co-pays. It is now $1,400 and change per month. We have a $2,500 medical deductable and a $3,000 per year cap on Rxs. Unfortunately, a couple of my Rxs can wipe that out by midyear. No dental, vision, yada, yada, and we carry a LTCi plan that we bought when we were 48 (Good benefits, good rates). I go on Medicare this July (23rd) and my wife goes on Medicare in November. For one (silly) moment I thought our costs would decrease. Then I did the math. With Part B, Part D, and a Med Supp Plan F, we will pay $541 per month each, and $1,082 per month for both. The LTCi is in addition, obviously.

          Several brief comments: Frankly, I think that we should be paying more for Medicare Part B (Part A is covered automatically). We can afford it, though my wife is now choking since I told her a moment ago what we will pay. Medicare Part A is fantastic coverage and we in the USA have literally been giving it away since its inception. It should be paid for on an income means tested basis (during our working years as well as when retired), and wouldn’t now be broke. Medicare Part B has only recently been charging a more equitable premium, and is means tested, though the levels of income aren’t high enough, IMO. Part D is relatively inexpensive, and with the inclusion of the “donut holes” should be inexpensive. A Medicare Supp Plan F (the highest in coverage if also carrying Part D) is expensive. It should not be, as the liability to the companies offering it are relatively low…before I retired I specialized in LTCi and Medicare Supps and was always surprised at the small return from them except on really outrageous physician’s bills. The public does “nickel-dime” the companies with Med Supps and I’d like to see better options with deductibles offered to those who can handle the 1st dollar 1st day crap.

          Enough of my “brevity challenged” post. I can only hope that in some way this information may help other readers of this blog. Perhaps it is now more clear why I have a very hard time with those who would remove $500Billion from Medicare funding. Everyone working pays into the Medicare Trust funds, as do every employer for each employee. Should the government need to raise the contributions to make it work, do it. Should they need to do a far better job enforcing the existing regulations against abuse, do it. But don’t penalize the average working American who has done what they were asked just to pay for a national health system, or a public option. That is simply unconscionable.

Sorry, the comment form is closed at this time.

%d bloggers like this: