The expected Christmas Eve Senate vote to pass a health care reform bill will be a remarkable, historic event. Given the power of the economic forces that have been hell-bent on stopping health care reform dead in its tracks, it is extraordinary that Democratic Majority Leader Harry Reid could cobble together 60 votes - every Democrat - to pass a health care reform bill.
That vote opens the curtain on the last act in this drama. The House and Senate bills will now be merged and a final product will - hopefully -- pass and be signed into law. But like most dramas, the last act - more than any other - will tell us how the story turns out.
Seven key points:
1). The odds are not good that a public option - or Medicare buy-in - will be part of the merged bill. That is a shame. To change the power structure - and the economics -- of the health insurance industry in America, a public option of some sort is a must. Two weeks ago we came very close to getting at a "Medicare buy-in" provision for people between 55 and 65 years old. That deal would have opened the door to allowing everyone to "buy in" to Medicare - which in my view is the absolutely best alternative for the future of health insurance in America.
That, of course, is precisely why Senator Joe Lieberman betrayed the other members of the Democratic caucus and his original support for the Medicare buy-in. The insurance industry thought that - this time at least - they had the cards to prevent any form of public option. For the short term, they are likely to be right. But don't bet against the public option being off the radar for long.
In a system where everyone is required to buy health insurance, the pressure will grow to assure that people have a choice other than the private insurance industry. I predict that before the health insurance exchanges in this bill go into effect, a public option of some sort - and preferably the option for everyone to buy into Medicare - will be one of the choices.
2). Even though a public option is not likely to be part of the final bill, the bill will represent an incredibly important step forward for our country and especially the millions of ordinary Americans who have no health care coverage, or teeter on the brink of losing their health care coverage every day.
Among other things the final bill will almost certainly:
· Make health care a right for every American.
· Eliminate the insurance industry's ability to deny coverage to those with pre-existing conditions.
· Eliminate the insurance industry's ability to cut people off once they get sick.
· Create a requirement that insurance companies spend at least 80% to 85% of their revenue on providing medical care - not administration, advertising and profits and CEO salaries.
· Make the health insurance market more competitive - and reduce the ability of the insurance industry to make massive, semi-monopoly profits.
· Put in place a whole battery of consumer protection regulations that will help rein in the health insurance industry.
· Eliminate almost a half-trillion dollars of taxpayer subsidies to insurance companies that manage so-called "Medicare Advantage Plans" -- subsidies that the government has paid over and above the cost of providing these same services directly through Medicare.
· Provide subsidies to millions of Americans who cannot currently afford health insurance.
· Control health insurance premiums. The Congressional Budget Office has estimated that all of these provisions will begin to bring down health insurance premiums for many Americans.
3). The House/Senate negotiations will determine just how good the bill is at achieving these goals. It will determine in particular how affordable health insurance is for tens of millions of people, and whether companies have a responsibility to contribute to provide coverage to their workers.
4). Most crucial, the House/Senate negotiation must solve two problems that will determine whether huge blocks of Americans think health care reform is a success or a failure.
The first of these problems is a Senate provision that would tax so-called "Cadillac health plans." The notion that the best way to control health care costs - or pay for the bill - is to tax the insurance premiums of ordinary workers makes no sense whatsoever.
Some believe that this health care "excise tax" would somehow "bend the cost curve." In fact, it would simply shift who pays for health care from employers to employees by encouraging companies to scale back their health insurance plans and leave larger gaps for individual employees to cover on their own.
The very notion of "Cadillac plans" make no sense. The quality of these plans is being measured by price - not by the coverage offered. Washington Post business columnist Alan Sloan noted last week that members of the Senate are currently covered under the Federal Employees Health Benefit Program, where the average age of a policyholder is 46 years old. It costs $6,971 for individuals and $16,124 for families in 2010. That's well below the current proposed threshold of $8,500 for individuals and $23,000 for families in so-called "Cadillac Plans," which would be subject to an "excise tax." And while it is a good plan - it isn't a "Cadillac." It is about the same as the run-of-the-mill plan currently offered by many employers to their employees. Maybe a fancy Chevy.
But what if the Senate - average age of 63 - had to buy coverage like many other groups of 100? Then the same coverage would cost about $14,000 for individuals, and $32,000 for families - and would be taxed as a "Cadillac Plan." The Chevy miraculously becomes a "Cadillac" just because the people covered get older. You could actually argue that the "excise tax" is an "older-sicker-workforce" tax.
Truly "bending the cost curve" requires eliminating the massive waste of insurance company profits, marketing costs and the millions paid to CEO's and other executives; cutting the cost of pharmaceuticals so that Americans don't continue to pay much more than everyone else in the world for the same products - and changing the health care delivery system so that it pays to keep people well, not for every procedure or patient visit.
No, the last thing we need to do is to raise the cost of health care for many average Americans by taxing their benefits. And from a purely political point of view, if this health bill taxes the benefits of a large number of ordinary Americans, the Republicans will make that the signal issue that they pound home in swing Democratic districts next fall.
5). The second critical problem to be solved centers around women's reproductive rights. No one expects the final health bill to reinstate public financing for abortion. But it cannot do anything to strip women of their hard-fought right to pay for abortion through private health plans. The current House version of the bill is actually more restrictive than the Senate version. But the final version must been carefully drawn so that it does not curtail a woman's right to obtain insurance that covers reproductive health.
It is one thing if we don't get everything we might want out of the health reform bill - if, as Senator Tom Harkin says - it's a starter house that can be expanded. It would be quite another of large groups of everyday Americans actually lose ground - either through having their benefits taxed, or because their reproductive rights are compromised.
6). In the weeks ahead the Republicans, the insurance industry and Chamber of Commerce will make a last-ditch effort to kill reform. They will launch a fusillade of advertisements and mobilize their Tea Party allies to frighten swing Members - especially in the House. Progressives have to brace to defend Democratic members from these attacks, or there is still a very real possibility that the effort to pass health care reform will be stopped just feet from the finish line.
Just remember the last scene in the classic film Fatal Attraction where the Glenn Close character lies unconscious - and apparently drowned in the bathtub - but suddenly springs from the water and almost does in Michael Douglas and Ann Archer. It ain't over 'til it's over.
7). I think it would have helped President Obama's standing with his political base - and swing voters - had he more forcefully advocated for a public option throughout the last months. But I don't agree with those who think the shape of this bill would have been materially different. He could have chosen to pass a narrower bill - that might have included a public option, but no insurance regulation or exchanges - through the process of budget reconciliation. That would have allowed him to pass a bill in the Senate with 51 votes. But to pass comprehensive reform through the regular Senate order - given the archaic 60-vote filibuster rule - his more vigorous advocacy for the public option would have made little difference.
It was Joe Lieberman that ultimately called that shot, standing firmly for the private insurance industry -- standing against the majority of Americans, Democratic Caucus and the President -- and betraying his fellow Democrats. That, by the way, is why the rules of the Senate that empowered Lieberman must be changed.
And those who are critical of the President need to remember two other things. First, it appears that he will actually pass health insurance reform - a monumental achievement that has eluded Presidents for more than half a century. It's easy to criticize. It's not so easy to actually get things done.
Second, he didn't have to take on this big challenge - or any of the other fundamental issues on his legislative agenda. Barack Obama believes in making fundamental change and though some Progressives may question his strategy or tactics at any given time, it is hard to imagine success for the progressive cause that does not also require that Barack Obama be successful as well.
Robert Creamer's recent book: "Stand Up Straight: How Progressives Can Win," available on amazon.com.