As a candidate for the late Sen. Edward Kennedy?s seat, Scott Brown campaigned against the health care reform proposal winding its way through Congress. Now that Massachusetts voters have elected Brown, President Obama no longer has the 60-vote majority he needs in the Senate to push through the current package. We asked Kathleen Stoll, deputy director of the nonprofit Families USA, and health economist Brad Herring, an assistant professor at the Johns Hopkins Bloomberg School of Public Health, what Brown?s upset victory means for the legislation?and for the future of health care reform in general.
iVillage: Now that Scott Brown will take over Sen. Kennedy?s seat, is health reform dead?
Kathleen Stoll: I don?t think in any way, shape or form that Scott Brown?s victory is a death knell for health reform. The Massachusetts election didn?t change the dynamic of what the tough issues are.
Brad Herring: I wouldn?t say it?s dead, but it definitely has been dealt a huge body blow. It?s safe to say the chances of passing health reform have diminished greatly; there are several options on the table, though none look particularly attractive.
iVillage: What are those options?
Herring: The House moved a little quicker than the Senate in passing a bill last fall and their version is more liberal, whereas the Senate?s is more centrist, though both had virtually no Republican support. Moving forward, you?ve got to reconcile those different bills and have both passed in the House and Senate before the final bill goes to President Obama. Because Brown will become the 41st Republican, that allows the GOP to maintain a filibuster and prevent a final bill from being considered.
The safest bet among the different options is for the House to pass what the Senate passed?for them to hold their nose and take their medicine. In a process called reconciliation, a companion bill could be passed shortly afterwards that makes changes to the Senate bill. That companion bill would only require 51 votes in the Senate?50 senators with Vice President Joe Biden breaking the tie?not the ordinary 60 that are needed with other proposed measures.
Another option would be to go back to square one and write new legislation that?s passed under the reconciliation rule that only requires 51 votes in the Senate. The concern with that option is that certain provisions would have to get stripped to meet the rules of the reconciliation process, which requires that legislation be germane to the budget. So it would be a big bill, but a little smaller than what exists now, because certain things?such as the requirement that health status not be a factor in determining premiums or being eligible for a policy?probably can?t be included in the reconciliation process.
Reconciliation is something Democrats have been pushing all along. But reconciliation is risky for the Democrats because of the appearance they?re sidestepping Senate rules. There?s already the perception of there being discussions about health reform in secret and kickbacks to special interests, so the approach of doing this in two rounds just doesn?t look good for the Democrats. But they?re faced with alternatives, all of which are bad, so their goal is to try to find the least-bad solution.
iVillage: Reconciliation is an option being talked about by Families USA and other groups. What parts of the bill would be negotiated during this process?
Stoll: One issue is whether there should be a national health exchange?a national marketplace of plans offered across country?or if states should have their own exchanges. The premise of the House bill is that there will be a national exchange. Then if a state showed Health Secretary Kathleen Sebelius that it could set up an exchange that follows all the national exchange rules, they could substitute that. The Senate bill assumes that each state sets up its own exchange and gives states options to come together in regional pools. If a state doesn?t do those things, the federal government could then come in and provide insurance options to residents of that state.
An issue for unions is whether there should be a tax on high-cost plans?so-called ?Cadillac? plans. The House version doesn?t have that tax at all, while the Senate bill does. The problem is that over the years, unions have negotiated better plans at the cost of not getting wage increases. If we tax those union plans, that?s seen as an unfair situation by union leadership. What is being negotiated is whether the surcharge would hit fewer plans.
The abortion issue [whether to allow abortion to be covered under government-subsidized plans] has been controversial.
Another issue I?d put at the top of the list is affordability?how many subsidies the government provides to help people purchase coverage through a tax credit, and what kind of protections there are on out-of-pocket costs once they have that coverage. That?s a key issue for members of Congress because it affects how voters will perceive the bill. It?s a personal pocketbook issue and many Americans will view the bill through that lens.
iVillage: Besides reconciliation, what other directions might health reform take?
Herring: The second-most-likely scenario is for this to all die because there are irreconcilable differences.
The last and least likely option is to move the bill to the right and make it more bipartisan. That could range from trying to pick up two more votes from Republican Sens. Susan Collins and Olympia Snowe from Maine, or to create something more consistent with the Wyden-Bennett Act, a proposal that?s been circulating for more than two years. In my mind, that might produce the best bill, but I suspect it?s very unlikely because the appetite for starting afresh is really, really low.