Moving up the Pace of Reform
When Congress passed Medicare in 1965, it went into effect one year later. In contrast, the major provisions of the health-care reforms now before Congress would not go into effect for three years (January 1, 2013, under the House bill) or four years (January 1, 2014, under the bill being voted on by the Senate).
The House's timetable is bad enough, but the Senate's timetable is, to put it bluntly, nuts. A four-year delay in delivering benefits from reform would give rise to widespread disappointment and confusion during the intervening years, and it would expose the entire program to the risk of being overturned in the 2012 election, if not in 2010.
When I worked at the White House in 1993 on the Clinton health plan, one of my responsibilities was to think through the "phase-in"--the series of steps that would be required to put the legislation into effect. I haven't been involved this time, but I don't think it's a deep mystery as to what is motivating the decision to delay the program, though it seems to me to invite more problems than it avoids.
The most important reason for the delay is the effort to keep the projected ten-year costs below the $900-billion ceiling that President Obama set in his speech to Congress on September 9. Obviously, the ten-year costs will be lower if expenditures don't begin until the fourth or fifth year, and by starting up some of the taxes earlier than the expenditures, the legislation can help reduce the federal deficit. Fiscal concerns--or at least fiscal appearances--have thereby driven decisions with potentially disastrous political consequences.
Second, any program that centrally involves the states as well as the federal government necessarily has a longer timeline than one involving the federal government alone. Not only must federal agencies translate the law Congress passes into specific rules--a process that can consume up to three years or longer. The states must also enact corresponding legislation, work out their own regulations, and, under the Senate bill, establish new organizations--the health insurance exchanges. (The House bill would set up the exchanges under federal authority, which would move things along faster and avoid foot-dragging or outright resistance by Republican-controlled states.)
Third, the House's January 1, 2013 date for implementation may raise worries that if states are conducting their first open enrollments in the new insurance exchanges in the fall of 2012, any bugs in the program's start-up could create political problems for the president's re-election.
Assuming the health-care legislation goes to House-Senate conference, one of the priorities should be to address these concerns and provide for a faster timetable than the Senate's. One possibility is to abandon the idea that the program has to be implemented on the same date in every state across the nation. Instead, states might be given incentives (though not yet full funding) to come into the program early, perhaps even during 2011. A state like Massachusetts, which already has a functioning insurance exchange, might be able to move that quickly. Other states might follow during 2012, with a final date for implementation and full federal funding coming in mid-2013.
Staggering the start-up dates would enable states that acted later to learn from those that moved first. By fall 2012, under this approach, President Obama and the Democrats who had voted for reform could point to areas of the country where the program was already in effect. And even if Democrats lost the 2012 election, it would be difficult to undo the program and take insurance coverage away from the millions who had gained it.
There is one final possibility. Even if the House-Senate conference adopts the slow Senate timetable, the proposal for accelerated implementation in "early-action" states could still be passed separately in a subsequent budget-reconciliation measure (which requires only 51 votes in the Senate). One way or another, Democrats need to find a way to speed up the pace of reform.
I feel so stupid - If it doesn't go into effect for 4 or 5 years - How many people will go bankrupt over medical expenses? How many will not be able to get insured over "pre-existing conditions?" How many millions of emergency room visits will the uninsured have? What's wrong with this picture? Honestly, if AIG and Citibank can be bailed out literally overnight, then why do ordinary people who don't have collateralized debt obligations to other fat cat counterparties, who only are just going to lose their homes and life savings to medical bills, have to wait 5 years? Why?
Public Option 2010
I was hoping lying had ended with Bush.
December 21, 2009 10:09 AM | Reply | Permalink
Why do the people whose work keeps this empire running have to wait for years to receive their crumbs? We're not as important. We don't have the same rights as the ruling class. We should shut our mouths, enjoy our place and be thankful the Lords haven't shipped us off wholesale to the moon.
The only way any of this will change is if we rise up as a collective and take power from them. Unions, social movements, radical civil disobedience in the form of general strikes are the tools. Unfortunately, we're too comfortable typing comments on blogs, myself included.
The rulers will only give up power when forced, never sooner.
December 21, 2009 10:33 AM | Reply | Permalink
if the political environment changes markedly, Obama may find it advantageous not to veto a repeal bill that crosses türkçe çizgi film izle ben 10 izle his desk even if he is reelected (or perhaps to enhance his ben 10 izle chances of reelection). But these scenarios bakugan izle strike me as highly improbable. türkçe çizgi film izle That's in large part why the Republicans are pushing so hard to defeat, derail, or at least delay reform. bakugan izle
August 5, 2010 1:32 AM | Reply | Permalink
The naivety is strong in this one, my lord.
December 21, 2009 2:45 PM | Reply | Permalink
Professor Starr -- these are great points. I'm really baffled as to why there has been no discussion of doing a follow-on bill via budget reconciliation.
It seems to me there is little reason why administration and congressional leaders could not agree to "ping-pong" the current Senate bill through the House, unaltered, to the President's desk for passage by the end of the year. And then push through a reconciliation bill in January with all of the "fixes" they can possibly get with 50+Biden votes in the Senate. Importantly, the planned cloture vote on December 24 would be the last one ever on the HCR packages.
December 21, 2009 10:28 AM | Reply | Permalink
When we purchase insurance, whether its health insurance, home owners, or for the car, we pay up front. To some degree, isn't this what's happening with this reform, we pay up front to get the pool of money needed to pay for the benefits that come online in 5 years?
Just a guess.
December 21, 2009 10:55 AM | Reply | Permalink
We do and there's often a waiting period before you can make a claim. But it's not usually a 5 year waiting period!
December 21, 2009 11:03 AM | Reply | Permalink
destor,
agreed, but in this case we're talking about millions of people.
I'm not arguing that I'm right, I'm just putting forth a view.
As to the bill itself, whatever comes out of conference will be controversial and we won't know what really is in store until we're maybe 18 months to two years into the program.
December 21, 2009 12:42 PM | Reply | Permalink
Does anyone wonder if the health insurance profits will also be delayed for five years?
.
December 21, 2009 3:42 PM | Reply | Permalink
Johann,
heh, not in this universe.
December 21, 2009 7:55 PM | Reply | Permalink
would expose the entire program to the risk of being overturned in the 2012 election, if not in 2010.
subsidies and enforcement may be at risk, but they all ready are. I guess implementation of the exchanges could be knocked around, or slowed.
But I doubt the GOP will go against the lobby and try to take away mandates, or subsidies all together. I'd bet the industry would lobby pretty hard against that. The GOP might make it all even sweeter for the industry, like we've seen them do in regards to Drug prices and medicare. Or reduce what little regulation there is.
But now they can hang all premium increases around the neck of the Democratic party. I'd bet they'd rather tug on that noose for awhile. It'd be hard to make the program more privatized!
December 21, 2009 11:03 AM | Reply | Permalink
We have a "can't do" mentality in our nation now. We just can't do anything that might benefit ordinary citizens, without taking long enough to do it that the GOP can reverse what steps have been taken when they next gain control. We can't do changes in the laws governing "too big to fail" banks until we bail them all out a few more times. We can't do carbon emission reductions needed to help slow down global warming.
The only things we can do now are things that transfer massive amounts of national wealth to the bank accounts of obscenely wealthy individuals. Those are a slam dunk. And, the Afghanistan Fiasco is one of those things.
December 21, 2009 11:08 AM | Reply | Permalink
Maybe we've got a 'can't do' mentality and maybe we're just too dumb to figure out a 'can do.' I'm serious. Other western nations have figured out how to provide universal health care for their citizens, but for us it seems to be rocket science.
Of course we could do what tiny Taiwan did, go around the world studying other in-place systems, take the good home while discarding the bad, and then build an efficient system of their own based on the good ideas of others. (Of course for us that would mean admitting that there are a hell-of-alot of much smarter people in the world than there are collecting paychecks in DC.)
December 21, 2009 2:23 PM | Reply | Permalink
While I share this concern that Josh has brought up, I don't see any reason to push the panic button. Two to four years is a political eternity and there is plenty of time to make adjustments, tweaks and improvements to the effort, after this bill becomes law and provides the momentum.
December 21, 2009 11:17 AM | Reply | Permalink
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December 16, 2010 4:38 AM | Reply | Permalink
A small suggestion: After the final law is passed, bring up a government insurance plan [aka pub opt] under reconciliation process and enact THAT on 1/1/11.
December 21, 2009 11:20 AM | Reply | Permalink
I don't understand the reasoning behind the delay of implementation. Perhaps there are technical reasons certain things can't be done much sooner, but whatever...
I would say that presuming a bill is signed, repealing it before it takes effect will not at all be easy. The very same filibuster that made it so hard to get agreement would need to be overcome to repeal the law, and while I fully expect the Democrats to lose senate seats in 2010, and quite possibly 2012 as well, to protect the bill they'd need to keep just a 40 vote caucus together. If Obama wins reelection in 2012, then the need is just 34 votes to uphold a veto.
I wouldn't say repeal is impossible. Maybe the Democrats do lose 20 Senate seats and the presidency in 2012. Even if the Democrats lose "only" 15, they may not be able to keep 40 votes in line to sustain a filibuster. Or if the political environment changes markedly, Obama may find it advantageous not to veto a repeal bill that crosses his desk even if he is reelected (or perhaps to enhance his chances of reelection). But these scenarios strike me as highly improbable. That's in large part why the Republicans are pushing so hard to defeat, derail, or at least delay reform.
Because if it actually does pass, it will be *very* hard to undo.
December 21, 2009 11:51 AM | Reply | Permalink
Using reconciliation for accelerating some changes actually does make sense. One point I'm not seeing too many reconciliation proponents address is that reconciliation bills automatically expire. Paul Krugman noted the oddity of the disappearing, and then resurrected "death tax" is because the original tax cut bill was passed via reconciliation. The GOP extended it once, but the Bush tax cuts are now set to expire after 2010 because even that extension was also passed via reconciliation.
While I would certainly have preferred a far stronger bill (why Obama never even put single payer on the negotiating table, if he truly believed it to be a better system, still baffles me), passing HCR via reconciliation, even with a public option, would risk having it simply expire. At some point you'd eventually need to get past a filibuster to make the law permanent, and it's far from clear that would be easier, or even possible, in the near future.
But to use reconciliation to accelerate parts of a permanently enacted bill makes sense: by the time the reconciliation bill had to sunset, the permanent bill would take effect.
December 21, 2009 11:59 AM | Reply | Permalink
The delay is motivated in part by the need to have reform budget neutral. People wanted reform but many were unwilling to make any personal sacrifices upfront to see the uncovered get covered. Had there not been the stimilus package and a bad economy we might have seen something better.
December 21, 2009 12:16 PM | Reply | Permalink
Kill Bill: http://bit.ly/7cLnHF. "Sometimes bills can be improved later" and "sometimes we later realize we missed an opportunity" are not, contrary to Krugman and Reich, good enough reasons to support this Frankenstein. Kill the Senate bill. There is still time to do this much better.
December 21, 2009 12:44 PM | Reply | Permalink
Too late...the wheels have been set in motion. The pigs get to feed at the trough first before anything else happens as thousands more Americans die needlessly.
Big man, pig man, haha, charade you are...
December 21, 2009 1:06 PM | Reply | Permalink
In my conversations with people about the health care bill, the issue that seems to have the most impact on the lives of people who already have health insurance is the new rule about pre-existing conditions. But if people are waiting years, the politics are reversed: "all this work to pass a health care bill, and I still can't get (or change) insurance."
December 21, 2009 2:59 PM | Reply | Permalink
I'm more cynical about politicians than Mark Twain ever was, but I guess I'm also a romantic. I bet my bottom dollar that Obama foregoes a second term before allowing his baby to be repealed. I actually believe the man puts his principles above reelection.
As of this morning the bill is now almost certain to pass. Eventually we will all learn what the White House did behind the scenes to help make it happen. On Thursday it will became law. On Friday I'll be able to start supporting some of those who are dissatisfied with the new health care laws, one issue at a time, one shortcoming at a time.
December 21, 2009 9:42 PM | Reply | Permalink
I just want to know -- has there ever been a law passed before that required Americans, simply existing as adult citizens, to enter into a contract with a private company?
December 21, 2009 9:51 PM | Reply | Permalink
I can't think of any such instance, but it might possibly have happened before. I have to doubt that the mandatory purchase from a private, unregulated industry is even constitutional. If we had a normal Supreme Court I know it would be declared to be unconstitutional - Congress cannot delegate their constitutional responsibilities, for example, and this is delegating it to private industry.
A very good amendment to a military budget, for example, would be eliminating the insurance exemption from anti-trust laws, and setting up price controls on health insurance. The latter is even ideal for reconciliation passage. My objection to being required to buy a product from a private company would be greatly lessened if that company was subject to price controls.
December 21, 2009 10:24 PM | Reply | Permalink
I think you've got the current Supremes' attitudes bassackwards.
Begin with the fact that no one is required to buy health care insurance nor are opt-outers being taxed (fined) for not buying insurance. They are being taxed in order to recover the cost their free-riding imposes on the government (once the government starts subsidizing health insurance costs).
The Federalist Society Four -- Roberts, Scalia, Alito, and Thomas -- would likely hold the bill unconstitutional as an unreasonable restraint on their free market ideals (substantive due process as in Lochner). But I doubt they could drag Kennedy along with them.
December 21, 2009 11:10 PM | Reply | Permalink
Third, the House's January 1, 2013 date for implementation may raise worries that if states are conducting their first open enrollments in the new insurance exchanges in the fall of 2012, any bugs in the program's start-up could create political problems for the president's re-election.
Bugs? What percentage of Americans are actually going to be eligible for participation in these state-based exchanges? What's going to happen when people see the deductions (and deductibles) for their employer-based plans going up, the level of service going down, and then realize four or five years from now that they are not even eligible for the vaunted exchanges, but have been indentured to their employers? What happens when folks in some states realize that folks in other states get to buy cheaper policies through the latter's state's exchanges?
The cheerleaders for this plan don't seem to have grasped the fact that while many people will benefit from it, others will be hurt significantly. Some of the noisiest noise hasn't happened yet because most people don't know much about what is actually in the plans. But there is going to be a lot of political hell to pay once the components of the plan are implemented. No wonder the Democrats are keen to delay the implementation on the most unpalatable parts of the plan until after the election. For one thing, there is going to be a whole spate of stories about various "Joe the Plumbers" going out of business once the employer mandate kicks in.
December 22, 2009 12:12 AM | Reply | Permalink
As to why the reforms are held off for four to five years, I know the principal actors will say it's to give time to the states and insurance companies to set the stage for the change. Cynics say it's due to the election cycle.
I have an itch though, that won't go away. I suspect these changes will have a non-trivial impact on the economy. It's my belief that the lead-in is in hopes that the economy will have recovered before these measures take effect. Whether this is true, or just my paranoid nature, I don't remember seeing any discussion of effects on the economy.
Here's just one for-instance. Has anyone seen a treatment of what the effect of the mandate will have on consumer spending?
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Moving up the Pace of Reform
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December 8, 2010 3:01 PM | Reply | Permalink
I agree with you that there is one final possibility. Even if the House-Senate conference adopts the slow Senate timetable, the proposal for accelerated implementation in "early-action" states could still be passed separately in a subsequent budget-reconciliation measure (which requires only 51 votes in the Senate). One way or another, Democrats need to find a way to speed up the pace of reform.
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December 22, 2010 3:24 AM | Reply | Permalink
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