The Senate Votes to Open Debate on Health Care Reform

November 23, 2009

In the wake of the Senate’s vote to allow the health care reform debate to proceed to the Senate floor, Senior Fellow Henry Aaron cautions that any legislation to revamp the system must be fiscally responsible and should improve the quality of care. He says lawmakers have many long discussions ahead of them.


What is going on now, in my opinion, is a kind of political Russian roulette where successive steps hold the potential of killing the whole effort. Each survival takes us one step forward. What we now have is an opportunity for a whole range of issues to play out before the United States Senate. One is the much discussed “public option” – politically it is extremely important; substantively I don’t believe it is nearly as significant as either the opponents or the supporters believe. The abortion issue will play itself out. Again, there is a question whether the bill that passed the House could still pass the House because many of those who support abortion rights, and went along with the House bill, are really getting increasingly angry that they were forced to accept an amendment of which they disapproved. Then there is the whole issue of cost, the structure of subsidies, the nature of the mandate on individuals – these and a whole bunch of additional issues, each of which holds the potential for derailing the whole effort, are going to have to be negotiated by the Senate. If the Senate succeeds, then [it needs to be debated] by a conference committee; if the conference committee succeeds, then [it needs to be debated] once again by both the House and the Senate on bills they did not initially vote for. So there are rough times ahead. …

Clearly we are further along. We have never gotten to the stage where one House actually passed a major national health care reform bill. President Clinton did not get that far. President Carter did not even come close. Back in the 1940’s, President Truman couldn’t even get Congress to hold hearings on a national health plan that he wanted to have adopted. Before that, President Roosevelt pulled a national health reform plan from the Social Security Act. He never submitted it to Congress because he was convinced that, had he included it, the whole bill would have died. So we’re much further ahead than we have ever been before. That doesn’t mean that the remaining job is going to be easy; but each hurdle cleared makes it a little more difficult for those who are uncomfortable with some element of the bill (and may be inclined to vote against it) actually to carry through and vote against it, because things have moved so much further on an issue of such acknowledged importance (acknowledged by all the supporters, even if they disagree on important elements of the bill). …

In a way, asking about the most important parts of the bill is a little like asking what the most important ingredients in a cake are. You better get them all right because each of them is important for the final product. The individual mandate that requires people to buy insurance; the subsidies that make that insurance affordable; the requirement that businesses continue to sponsor insurance for their employees and the penalty that will keep them doing so; the additional investments in comparative effectiveness research; the insurance exchanges that will reduce the terrible inefficiencies in the marketing of insurance to individuals in small groups (and not just inefficiencies, but also unfairness such as denial of coverage and excessive premiums; the health insurance exchanges hold the potential for bringing about more far-reaching changes in the future); payment reform pilots that will try to encourage the more-efficient delivery of health care to Americans and improve the quality of the care that they receive – all of these interact with one another, I think, to produce something that will taste a lot better if we get all the ingredients in the cake than it will if we just get some. …

The Congressional Budget Office, with great courage and professionalism, produces projections of the federal budget stretching out very far into the future. Those projections indicate a very large increase in the federal budget deficit. More than all of the increase is attributable to projected growth in health care spending (federally sponsored health care spending, principally through Medicare and Medicaid). Every expert health care analyst recognizes that, in order to deal effectively with Medicare and Medicaid (which jointly account for more than all of the increase in deficit that the nation is confronting), in order to do that one has to deal with the health system as a whole. If one doesn’t do that we face a risk of reneging on what, I think, is a solemn national commitment to assure to the aged, the disabled, and the poor health care approximately like that that the rest of us enjoy. I think that is a profoundly important commitment and one we should not back away from. But if we are to honor it at an affordable price then we are going to have to do something to reform the overall health care system. That is not a job that is going to be completed by one bill. It is not a job that is going to be completed in one presidency, or even two or three. It is a challenge for a generation.