How Do We Keep the Senate from Running Away on Health Care?

by Tim Foley

category: Obama and Congress

Published June 18, 2009 @ 03:16PM PT

Let’s go back to my first post for this site, where I came up with this far from revolutionary definition of universal health care: "Universal health care means giving coverage to every American, reducing the costs of our wasteful system to make care affordable for every American, and ensuring the care we receive has the best quality.”  Notice what’s not on this list:  keeping Chuck Grassley happy, trying to duck the insults of John McCain, and making sure we don’t need to use a decimal point in the final price tag for the reform package.  This is the health care fight, folks.  Will we stand and fight and stick to the package that can do some good, or will we be scared away by a price tag?

I’ve already talked about the Twitterer and the Maverick, so let’s focus on this last point.  Most of the time, we figure out what we want and then figure out the price for it.  Sen. Max Baucus and the Senate Finance Committee are now going in reverse – they’re figuring out how much they want to spend and then will figure out what they want based on that.  Their initial package looks like it will wind up in the range of $160 billion a year, or $1.6 trillion over 10, as scored by the Congressional Budget Office.  That’s not a huge shock – that smart prediction has been at $1.5 trillion for months now, and President Obama on Monday paved the way by saying:

Making health care affordable for all Americans will cost somewhere on the order of one trillion dollars over the next ten years. That sounds like a lot of money - and it is. But remember: it is less than we are projected to spend on the war in Iraq. And also remember: failing to reform our health care system in a way that genuinely reduces cost growth will cost us trillions of dollars more in lost economic growth and lower wages.

Bold words.  But the Finance Committee had the opposite reaction:  “Run away!”  Rather than move the bill forward or improve it, Baucus is determined to get that number down to an even trillion.  I suppose this makes sense.  After all, Baucus has been the one unnaturally obsessed with the employer tax exclusion – meaning he was focused less on what would go in the bill or how much it would cost but on how to pay for it.  But it doesn’t make any sense if your eyes are on the goal of comprehensive health care reform.  Ezra Klein makes the point better than I can:  “It is, for one thing, an arbitrary target. Why $1 trillion? Why not $1.3 trillion or, for that matter, $700 billion? And it's an arbitrary financing target. It's not $1 trillion with coverage expanded to 40 million people. Just $1 trillion.”

This is the exact same cart before the horse thinking that has led Congress to propose the SGR fix to Medicare, which arbitrarily and somewhat unthinkingly cuts physician reimbursement by a set amount this year, rather than systematically reform fee-for-service to focus on chronic conditions, coordinated care and primary care, and away from just doing more procedures.  Even if the SGR fix was implemented – Congress always votes to delay it – it wouldn’t solve the problems of Medicare reimbursement.  It would just cut it.  You’ve heard of the expression we use to need a scalpel, not a handsaw?  Congress historically doesn’t even use a handsaw – they use a baseball bat.

The thing is, the CBO is not being opaque about how to get a good score.  In a letter to Kent Conrad (I can’t wait to see the health care co-op get scored, by the way), CBO Director Elmdorf lays out exactly what would get a good price tag:  “For example, if the growth rate of federal health care spending was trimmed by 1 percent per year during the next 20 years, the savings would roughly match the cost of an expansion of insurance coverage by the end of the decade and would exceed that cost in the next decade.”  Translation:  covering everyone won’t pay for itself, but we can afford to cover everyone if we can get costs under control.  To that end, CBO lists a number of options that score very high, from moving away from fee-for-service and towards “account care organizations” where providers would get a bonus if the demonstrate they’re delivering high-quality care and holding down costs; bundle payments to hospitals for episodes of care; conduct and disseminate comparative effectiveness research; expand the use of prevention, wellness and primary care; and, of course, remove the tax exclusion on employer-provided benefits.  All sensible ideas worth doubling down on.  And with people losing their coverage every day, coverage and cost are worth standing and fighting for.

But how much do you want to bet that the Finance Committee will read this and say, “It's time to run away more”?

(Photo credit:  Center for American Progress on Flickr.)