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February 22, 2018

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A quick vote favors Harry Reid’s cause

Senate’s compromise deal expands Medicare and eliminates public option

To understand the next move on health care reform as the Senate cools its heels and awaits a cost assessment on this week’s proposed compromise, a quick history lesson might provide a road map.

When President Lyndon B. Johnson was trying to pass Medicare in 1965, he gave congressional allies a piece of advice once the legislation was approved by a crucial committee.

“For God’s sakes, don’t let dead cats stand on your porch,” Johnson extolled the lawmakers, in an exchange recounted by David Blumenthal and James Morone in “The Heart of Power: Health and Politics in the Oval Office.”

When a bill is ready to go, the president’s message was clear: Call it up quickly for a vote.

If the Congressional Budget Office greenlights the new provisions in coming days and Reid has the votes in hand, expect health care legislation to be fast-tracked toward passage — before the consensus that appears to have been reached slips away.

Indeed, the fragile compromise is showing its vulnerable spots.

The deal achieved by a team of 10 moderate and liberal Democratic senators this week hinges on several elements.

The public option that was a deal-breaker for several key moderate Democrats would essentially be removed, doing away with the long-sought goal of liberals in the caucus.

The public plan would have operated similar to Medicare, and supporters said it would have provided an option for private insurance and increased competition to lower costs. But moderate Democrats worried that government would be financially liable if the plan could not pay for itself, funded only by premiums.

In its place: a menu of private insurance company choices for the uninsured, overseen by the government, as well as the ability for not-quite-senior Americans to buy into Medicare, expanding the popular retiree health care program to those 55 to 64 years old.

Familiar with Medicare

Polls show this would be a popular swap: Americans are supportive of the public option — a slim 52 percent majority in Nevada want it. But they are overwhelmingly supportive of expanding Medicare.

Opening Medicare to younger Americans has been proposed several times over the years, and the Kaiser Family Foundation said Thursday that polls dating back a decade show consistently that seven in 10 Americans support an expansion of Medicare — slightly less when asked about buying in, as would be the case under this proposal.

In explaining the difference between the two, Sen. Richard Durbin of Illinois, the No. 2 leader in the Senate, said, “People understand Medicare … For many of us, this seems like a reasonable answer. It’s not a new government program. It’s one people are familiar with.”

Liberals are interested in the swap because many started this debate months, even years, ago, with the goal of universal coverage — Medicare for all.

What they would be getting is the next best thing — Medicare for quite a few more.

In fact, data from the Urban Institute show as many as 4.3 million uninsured Americans are in the 55-64 age group. Allowing them to buy into Medicare would potentially provide just as much coverage as could have been reached through the public option, which the Congressional Budget Office estimated would have been chosen by 3 million to 4 million uninsured Americans under the Senate bill.

And there lies the problem. Doctors and other health care providers consistently balk at proposed Medicare expansions, much as they fought the creation of Medicare during Johnson’s era.

Courting Sen. Snowe

Medicare pays lower rates for doctors’ services than they can get from private insurance companies — a complaint that extends from doctors to rural hospitals, which say they cannot get by on reimbursements that are not 100 percent on the dollar.

For those in Congress trying to curtail rising health care costs, reimbursing at Medicare rates is a good step toward that goal and keeping Medicare solvent. Medicare is facing its own deficit by 2017.

But for those senators whose offices are being bombarded with queries from health care providers who say they cannot afford to do business under the Medicare rates, it may lead to opposition.

Sen. Olympia Snowe of Maine, the one Republican who is being heavily courted by Democrats, said she has “serious concerns on the Medicare buy in.”

“I just think that’s the wrong direction to take,” Snowe said, suggesting she could not support the bill with such a provision.

Without Snowe, Democrats are left trying to secure all 60 votes needed to approve the legislation from their own ranks.

Sources said talks are under way on changes to the Medicare payment formula, as leaders are aware of the dissent — a sign of the continued work in progress even as the bill comes closer to resolution.

Support for expanding Medicare drops among seniors, the Kaiser Family Foundation reported, with a slimmer 56 percent majority in favor, according to its September survey. In that poll, 36 percent were opposed.

Democratic Sen. Bill Nelson of Florida, a state with a large senior population, said he is keeping an open mind on the proposal.

“I wouldn’t be surprised if the Medicare thing does not become a viable option,” Nelson said. “I think it’s going to be the lesser of the popular things.”

Getting to 60 votes

Senate Majority Leader Harry Reid of Nevada remained confident Thursday his

60-member caucus would back the proposal, even as the public math did not quite add up.

Several key senators — Joe Lieberman of Connecticut and Ben Nelson of Nebraska — have yet to give their support. Without either one, Reid would need a Republican to cross over, yet Republicans are maintaining a wall of opposition.

The Republican leader, Sen. Mitch McConnell of Kentucky, calls the health care legislation a “monstrosity” of a bill, and Sen. John McCain of Arizona suggested the proposed compromise is Reid’s “Hail Mary” effort to pass the bill by Christmas.

Democratic senators are under enormous pressure to pass President Barack Obama’s signature domestic priority from their chamber by year’s end.

One reason liberal senators may be willing to relent on the long-coveted public option is the dwindling days left to reach a deal.

“Political reality set in,” one Senate aide said. “There’s a sense of what could get to 60.”

Reid’s leadership throughout the often belabored and contorted process of bringing the health care bill to life has dumbfounded some and infuriated others.

Many have wondered if this deal could not have been reached months ago without so much public hand-wringing. But the compromise appeared rooted as much in substance as timing.

When asked if the Medicare alternative could have emerged earlier, Durbin just chuckled, noting that he raised the suggestion with the leadership and key senators four months ago and got no bites.

“It needed to evolve,” Durbin said. “It wasn’t ready.”

The other part of the compromise — the ability for the uninsured to buy private insurance on a new marketplace overseen by the government, much the way the federal employees’ benefit plan is managed — has received modest support, as neither being a tremendous advance nor a step back from what was planned.

Stephen Zuckerman, a health economist at the Urban Institute, sees promise in the overall deal, particularly with the Medicare expansion, if it sticks.

“I think this is really kind of a clever compromise,” he said. “I don’t know if it can hold.”

Lisa Mascaro can be reached at 202-662-7436 or at [email protected].

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