Could we, if only for a few paragraphs, endeavor to engage in a dispassionate analysis of health care reform? Let's take a shot.
Q: Is this, as Republicans say, “government-run health care”?
A: No. The basis of our health care insurance system will remain privately provided through private insurers and employer-based plans. But our system will become decidedly more government-regulated. That's the only way government could hope to impose a policy extending health insurance and ending cruel practices such as denying coverage for pre-existing conditions and charging people more because they're sick or capping people's benefits when they're catastrophically ill.
Government will order people to get insurance, which Republican lawyers will challenge in court, probably to no avail, on the ground that the Constitution's interstate commerce clause doesn't permit the federal government to go so far as to to reach into states and make such a mandate.
Government will create public health care exchanges comprising private insurers so that people now unable to get affordable insurance will have a place to get it. Government will subsidize low-and middle-income citizens in these exchanges, since they'll not have employer matches like many of us do.
But government will not actually “run” health care in a direct way or by the European socialist democratic model. America is famous for keeping its socialism on the margins and fashioning a hybrid public-private model.
Q: Are there, as the Democrats insist, cuts in health care costs in this bill?
A: The only ones directly mentioned are unspecified cuts of nearly a half-trillion dollars over a decade that are said to be in store for Medicare. And these, Democrats assure, I'd say dubiously, will come only from reimbursements to providers, not care for seniors, and will come from so-called waste, fraud and abuse.
I say “dubiously” because the first thing doctors and providers do when they lose Medicare money is start warning their vulnerable senior patients that they may not be able to care for them anymore — and this eviscerates any political will to follow through on the changes.
Right now, for example: For years we've had a law ordering annual automatic Medicare cuts in doctor reimbursements, and every year, including this one, Congress waives the automatic cuts and puts in the annual “doctor fix.”
Even in this very bill, the short-term expenditures on Medicare will increase — to fill part of the “doughnut hole” on prescription drugs and increase payments to rural hospitals.
It is conceivable that private insurance rates will become more competitive in these publicly created health care exchanges, and that, in time, costs of both health insurance and actual care will be brought under greater control by the broader base of insured persons. But it's entirely theoretical at this point.
Q: Does this bill make it possible to spend federal money on abortion?
A: No. The Hyde Amendment makes that illegal. It is possible for an insurer to be a part of the health care exchange offering subsidized coverage and, quite apart from that, offering wholly private-pay plans that would pay for abortion. Marion Berry didn't vote against this bill over abortion. He wanted to protect his chief of staff, Chad Causey, who seeks to succeed him in a district in which President Obama and health care reform are overwhelmingly opposed.
Q: Are the Republicans right that this will explode the already disastrous budget deficit, not actually reduce it slightly, as the Democrats say, over a decade?
A: I believe the Republicans are right. These CBO estimates of slight deficit reductions over 10 years are based on accepting at face value these political assertions of future Medicare savings. I believe the record is woefully clear that it's easier to assert future Medicare savings than actually to impose them when the time comes.
The best hope for actual Medicare savings is in these Medicare Advantage plans by which the federal government sends money to private insurers to design managed-care programs for seniors. Government can, in effect, save money in Medicare by reducing the payments for these plans and forcing private insurers to run them more efficiently or simply give up on them and send everybody back into regular Medicare.
Q: Is this, all things considered, desirable and worthy public policy?
A: Yes, except for the part about our country going bankrupt, which was happening without health care reform and is not health care reform's fault, but all our fault.