The Health of the Nation

So the House passed a landmark health care bill, and everyone's trying to figure out what it all means.  Is passage of a substantial reform now near-inevitable, as the White House seems to be claiming?  Or was this the peak, as the Republicans claim?

I don't think you can deny that this adds momentum to the campaign (unless health care reform's favorables, now well below the unfavorables, slip still further).  It certainly demonstrates that Nancy Pelosi is a hell of a speaker, whatever you may think of her personality or politics.

I know that Amy Sullivan thinks that she and the leadership committed something close to malpractice by not getting the pro-lifers involved sooner, and thereby setting up the caucus for a deal which banned the use of federal funds to buy any insurance that covers abortions.  But I'm not sure that even that charge really sticks.  The fact is, on a pooling basis--and that's the level at which the federal government operates--giving someone money to buy insurance that covers abortions is exactly the same thing as directly paying for their abortions.  The original compromise, segregating the funds so that the federal subsidy wouldn't pay for the abortion part, was a transparently ineffective gimmick.

How transparently ineffective?  If it really was just her money buying the coverage, the rider/segregated funds distinction wouldn't matter.  Obviously, the reason it does matter is that funds from some other party--possibly a pro-life party--would be helping to pay for the abortions, either through the fungibility of tax transfers, or premium pooling.

I don't see how anyone ever thought this was going to fly; there are (as we just saw) more pro-life members of the House than pro-choice, and they're not actually total idiots.  I knew this was coming two years ago, and not because I'm sort of amazing prognosticator.  Medicaid in most places covers abortion only in the cases of rape, incest, and the life of the mother because, well, when the government provides your health care, the procedures that are covered will be determined politically.  I had thought that Democratic feminists understood the trade off they were making, and believed that it was worth it.  But many of them seem to be genuinely surprised that health care rules will be written with respect to the opinions of the National Right to Life Committee.

I think Pelosi did about the best she could with what she had--maybe a little better, even.  The core question now is what happens in the Senate.  Every time this project goes through another iteration, its price tag goes up--the cost of buying support from recalcitrant lawmakers.  But the mechanisms used to pay for those costs are pulling father apart:  excise tax versus income tax, strong public option or no.  Normally the senate just trims down the more extreme House provisions, and the price tag.  But at this point, every provision is attached to a dug in and very motivated interest group.

Moreover, the reason the House pushed this so fast is that it's getting politically tougher.  The favorables on health care are falling, the unfavorables rising, and unless the passage of Saturday's bill reverses this trend, it's just going to get harder to pass anything.  I don't know if it's actually true, as I've heard Republicans claiming, that Pelosi scheduled the vote on a Saturday because she didn't want any more Democratic lawmakers going home and talking to upset constituents.  But whatever the reason, keeping Congress in town over the weekend to vote on a bill that doesn't take effect until 2013 doesn't signal a really healthy initiative.

The one thing I think we can say definitely is that the gross cost of the bill is going to stay on an upward trend.  The problems are being papered over with special gifts to whatever interest groups wavering legislators most favor.  That's also going to mean the cost control will be underwhelming.