Saturday, December 19, 2009

A Good Step

The bill is the best that can be gotten now. It uses a mixture of Medicaid expansions and setting up a private insurance market to expand coverage; 31 Million people will be insured in 10 years who otherwise would not have been. And there are significant insurance reforms which will protect consumers. I think the insurance market structures are sound and if the exchanges work well, it is easy to imagine them being opened up. We have a chance to actually set up a market for insurance, with consumers shopping for their own insurance. That is shockingly rare in such a consumerist society.

The biggest disappointment with the bill is what it doesn't do to control costs. The tax on high cost insurance is a historic de facto limiting of the tax exclusion of employer paid insurance premiums. But, we need to do much more. There is not the political will to limit the tax exclusion further at this time, but that must come down the road. And doing so will help focus the cost control effort on the end users of care--you and me. That is a huge missing piece in our culture. Everyone says that want to slow the rate of cost growth....up until it means spending less. As a society we have to grow up and face this. This is a first step, certainly not a last one.

And this has been done in a manner that CBO says does not add to the deficit, and actually reduces it a bit. If you think back to mid June when the initial CBO score came back with HR3200 increasing the deficit by quite a bit and not getting near universal coverage, you have to give credit to the Dems. They redoubled their efforts and took very seriously the need to create a bill that didn't add to the deficit.

I am glad that CLASS has survived. It is inherently uncertain trying to project disability rates into the future, but it is certain that long term care is a tremendous risk that most don't prepare well for. CLASS has the chance to stimulate the discussion and thinking about long term care before it is too late--making it a normal part of being a young adult. As someone who is 42 and will be around and in the age of needing care myself when we will know for sure whether it worked or not in stimulating better planning by helping to start the conversation, I say it is a good move.

It would be an easy call for me to vote for this. That is in large part because of what a disaster is represented by the status quo, both in terms of the human toll of being uninsured, and the inevitble effect on deficits of doing nothing. There will be unintended consquences, but also opportunities to tweak this as we move ahead over the next years and decades.

The claim that this is a rush is laughable. The basic outline of the bill has been the same since summer. Deadlines typically are arbitrary, but work also tends to expand to fill the time alloted it. Barring something unforeseen, the Senate has moved the ball down the field. Good job.

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