Health Care Nightmares

By Megan McArdle

I can't make heads or tails of the various whip counts floating around. Friends who report on politics assure me that Nancy Pelosi still has plenty of leverage to twist arms . . . but what? It doesn't seem all that likely that Ms. Pelosi is going to be in charge after November, so what exactly does she have to hand out to wavering members? And if this thing passes on some controversial procedural maneuver, the Republicans in the Senate will go into full meltdown mode, meaning that there isn't going to be any more legislation to take home to your constituents anyway. (How much pork can you cram into one financial reform bill?) 


Democratic Congressional Campaign Committee money for their campaigns, of course . . . but if you're in a district that hates the health care bill this hardly seems likely to save you. 

Meanwhile, Pelosi and the leadership have to sound 100% absolutely sure of themselves . . . because if there's any question of this thing not passing, their members will stampede for the exits. So their confidence isn't really a sign of anything. On the other hand, the conservatives claiming it's nearly impossible have equal and opposite motives. My sense is that it's at a tipping point--at this point, many of the waverers are simply holding out for more goodies, but if she loses a couple more members, the thing becomes effectively impossible. 

But I have nothing in particular to back that up . . . and as far as I can tell, neither does anyone else. 

So now I'm thinking about another political problem. Assume this passes; what happens afterward? I don't think that many people believe that the answer is "Nothing: the bill becomes law, and we sing happy smurf songs all the way to the longest life expectancy in the Western world!" Even the bill's proponents expect it will need some follow-up work. But what will that follow-up work look like? 

 Worst case scenario for Democrats: a wave of public outrage like the one that followed Cat Care, aka The Medicare Catastrophic Coverage Act of 1988 (and its step-child, the Medicare Catastrophic Coverage Repeal Act of 1989). This strikes me as quite likely, actually. If this passes, yes, you will have AARP support and a wave of positive coverage from 90% liberal media. These things did not save Cat Care from a wave of angry public protest. I mean, really angry. Who knew senior citizens could be that spry?

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That's Representative Dan Rostenkowski being attacked at a town-hall meeting with his constituents. Afterwards, he plaintively asked his press officer how long it would be before the media foofaraw  blew over. "Let me put it this way," the flack is said to have replied. "When you die, they will play that clip."

As you can imagine, congress hastened to repeal the thing. But they didn't repeal it all the way; some of the provisions remained.

My nightmare is that they repeal everything except the really popular thing, which is to say the ban on rescission and exclusions for pre-existing conditions. These are basically free, and they're by far the most popular part of the legislation, as far as I can tell.

I'm not exactly a fan of rescission, and to the extent that it is being abused by insurance companies, they deserve whatever regulatory penalties they get. But without rescission, the natural thing to do is to wait until you get sick, and then lie on your insurance application. Like bans on pre-existing conditions, this leads to the classic "insurance death spiral" where the only people who want to buy the insurance are the people who expect to need more care than the cost of the premiums, causing the pool to shrink and the prices to rise.

That's why RomneyCare actually improved premiums briefly, before they resumed their upward march: Massachusetts already had guaranteed issue and community rating, which was pushing premiums sky high. Now that they have RomneyCare . . . well, individual premiums have dropped to only the second most expensive in the country, behind New York, which still has community rating/guaranteed issue, but no mandate.

In other words, while the proponents of ObamaCare are wrong that an individual mandate actually solves all the problems with guaranteed issue and community rating, it does seem to slightly mitigate the disaster.

That seems like the not-unlikely follow up, either from terrified Dems or a brand-spanking new Republican Congress. Would Obama dare veto it? When there's no longer an unpopular Democratic Congress to hide behind? One hopes, for the good of the country. But while so far the president has been enthusiastically urging members to lean into the strike zone and take one for the team, I've seen little indication that he's willing to risk his own job.

Thumbnail credit: Tim Sloan/Getty Images

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