We won't know who in the political firmament are the winners and losers in the health-care wars until the 2010 election, but it is easy to identify the logical winners: the Arkansas Democrats who will vote for the final bill in late winter. That is likely to be both senators and all three Democratic congressmen.
The heavily compromised Senate version, which is expected to pass this week, is closest to the eventual bill because the Senate and House conferees will have to accede to the tightness of the vote in the Senate, where there is not one spare senator. Since there will be no public option, Rep. Mike Ross, the only Democratic holdout on health-care roll calls, should vote for it. He would have to manufacture a fresh excuse to vote no.
Republicans are counting on a big backlash from Arkansas voters, who have been hammered with the biggest propaganda campaign in the state's history, which continues to tell them that their taxes will be raised, their relations with their doctors impaired, their medical care rationed, their Medicare slashed, their aging parents euthanized and federal budget deficits sent into the stratosphere.
But here is why logic favors the Democrats, especially in Arkansas. This state may be the biggest single beneficiary of the reforms or at least one of the top three or four. Fewer of the new taxes and fees that are to pay for the reforms will be collected on Arkansans than on the people of almost any other state because Arkansas has fewer families earning more than $250,000 a year who would pay a Medicare payroll tax increase and fewer union workers with Cadillac health plans that would have a portion of their premiums taxed.
On the other hand, the per-capita benefits — the net cash flow into the state for medical care — may exceed those of every other state. It depends on the final language on cost sharing between the state and federal governments on expanded Medicaid eligibility.
Can Sen. Blanche Lincoln and Rep. Vic Snyder, the two Democrats who are apt to have tough opposition, brag about that? Probably not. The Bible may encourage us to care about the poor but it is not politically merchantable. Still, they could talk about the economic impact of a huge and permanent infusion of cash into the state, dispersed first through all the medical providers and then flushed through the economy.
The health bills do many things that ought to make nearly every Arkansan except a few business owners happy, and most of the owners should be relieved that they can finally provide health coverage to their workers at an affordable price. Insurance companies will no longer be able to shed people who get chronic illnesses or deny coverage to people owing to old injuries or a disposition for some illness. People with modest to high incomes will be expected to buy insurance — not at the low rates that a public option would have provided or caused but at better prices than are available in the current market. The elderly and disabled will get nearly all their prescription drugs covered. The bills attempt to impose some limits on insurance profits by requiring 85 percent of their premium income to be spent on medical services, which might hold down premium increases. There will be a number of pilot projects, which might one day show the way to controlled health spending.
But for Arkansas the big deal in the health bills is federal assistance to help low-income people obtain insurance through the government or private plans. We have a bigger ratio of those folks than nearly every state and we now do less for them than nearly every state.
Actually, there are two big deals.
People who do not have insurance will be able to buy it through exchanges where presumably the insurance companies will offer competitive prices through one big risk pool. The federal government will extend refundable credits on a sliding scale to help those earning up to 400 percent of the federal poverty line (about $88,000 for a family of four) pay the premiums. The House and Senate bills do it in different ways.
Adults who earn under 133 percent — 150 percent in the House bill — of the federal poverty line will be covered by Medicaid, which already serves 26 percent of all Arkansas citizens. Some 170,000 Arkansans could get medical coverage for the first time. Oh, but it will bankrupt the state government, which must match federal grants, the Republicans say. The federal government will pay all the costs from 2013 through 2016 and more than 91 percent of the costs after that. Arkansas will be affected more than any other state because it now offers coverage to adults earning up to only 17 percent of the poverty line, the lowest threshold in the country.
Sure, the state will have to ante up a share of the cost in a few years but it will be minuscule when you calculate the fiscal impact of a couple of billion dollars of outside cash flowing annually through the medical system and beyond.
Voters may not thank the Arkansas delegates for their votes in 2010, but as with Social Security and Medicare, they will some day.