Debate: US health care reform

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Is the 2010 US health care reform legislation a good idea?

Background and context

For decades, the United States has been trying to reform its health care system. In 2009, the Obama administration made health care reform its largest priority, setting a general framework for the United States Congress to pass legislation by the end of the year. With bills finalized and approved in both the Senate and House of Representatives by the end of 2009, the United States Congress is likely to go on to pass a major joint bill in early 2010. The provisions of this legislation have been hotly debated, with Republicans almost unanimously opposing them and Democrats almost uniformly in support. The main provisions have included a public option (part of the House legislation, but not part of the Senate bill), a mandate for all citizens to buy health insurance (with subsidies for those that cannot afford it), provisions to end insurance company discrimination against individuals with pre-existing conditions, and "exchanges" designed to increase consumer choice and competition between insurers among other things.

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Reform: Is the bill a major reform and step forward?

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Pro

• 2009 US health care reform is historic improvement Paul Krugman. "Pass the Bill". New York Times Op-Ed. December 17, 2009: "let’s all take a deep breath, and consider just how much good this bill would do, if passed — and how much better it would be than anything that seemed possible just a few years ago. With all its flaws, the Senate health bill would be the biggest expansion of the social safety net since Medicare, greatly improving the lives of millions. Getting this bill would be much, much better than watching health care reform fail."

• 2009 health bill is much better than nothing Joe Biden. "Why the Senate should vote yes on health care." New York Times. December 19, 2009: "The issues in the health reform bill are complicated, but the consequences of failing to pass it are straightforward. Those who would vote no on this bill need to look into the eyes of Americans who don’t have health care now and tell them they’re going to be better off without this bill — better off continuing to live without health coverage. They should explain to all those Americans who are denied coverage because they have pre-existing conditions or whose insurance ran out because of lifetime caps that they don’t need this bill. And they should tell the families who have insurance and the small-business owners who provide it that the relentless rise in their premiums without this bill will somehow make them glad it didn’t pass."

• Killing 2009 health bill would delay reform for years David Brooks. "The Hardest Call." New York Times. December 17, 2009: "The fourth reason to support the bill is that if this fails, it will take a long time to get back to health reform. Clinton failed. Obama will have failed. No one will touch this. Meanwhile, health costs will continue their inexorable march upward, strangling the nation."

• 2009 health care reform bill can be improved over time Paul Krugman. "Pass the Bill". New York Times Op-Ed. December 17, 2009: "Bear in mind also the lessons of history: social insurance programs tend to start out highly imperfect and incomplete, but get better and more comprehensive as the years go by. Thus Social Security originally had huge gaps in coverage — and a majority of African-Americans, in particular, fell through those gaps. But it was improved over time, and it’s now the bedrock of retirement stability for the vast majority of Americans."

• General statements in favor of health care reform "A clear responsibility." New York Times Editorial. September 10, 2009: "Critics of health care reform have done Americans two great disservices. They have obscured and denied the very real suffering of tens of millions of uninsured Americans and the very real danger that millions more could soon join them. And they have twisted and denied the goal of health care reform when they rail against a fictitious government takeover."

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Con

• 2009 bill does not fundamentally reform health care David Brooks. "The Hardest Call." New York Times. December 17, 2009: "The first reason to oppose this bill is that it does not fundamentally reform health care. The current system is rotten to the bone with opaque pricing and insane incentives. Consumers are insulated from the costs of their decisions and providers are punished for efficiency. Burkean gradualism is fine if you’ve got a cold. But if you’ve got cancer, you want surgery, not nasal spray."

• US health care reform is bad bargain for money Robert Samuelson. "A parody of leadership." Real Clear Politics. December 21, 2009: "Obama's plan amounts to this: partial coverage of the uninsured; modest improvements (possibly) in their health; sizable budgetary costs worsening a bleak outlook; significant, unpredictable changes in insurance markets; weak spending control. This is a bad bargain. Benefits are overstated, costs understated. This legislation is a monstrosity; the country would be worse for its passage."

• 2009 US health bill would do more harm than good Howard Dean. "Health-care bill wouldn't bring real reform." Washington Post (Op-Ed). December 17, 2009: "I have worked for health-care reform all my political life. I know health reform when I see it, and there isn't much left in the Senate bill. I reluctantly conclude that, as it stands, this bill would do more harm than good to the future of America."

• Health care bill is too large, complex, convoluted "Change Nobody Believes In." Wall Street Journal (Editorial). December 21, 2009: "An increasing roll of leaders in health care and business are looking on aghast at a bill that is so large and convoluted that no one can truly understand it, as Finance Chairman Max Baucus admitted on the floor last week. The only goal is to ram it into law while the political window is still open, and clean up the mess later."

• General statements against 2010 US health care reform David Brooks. "The Hardest Call." New York Times. December 17, 2009: "If I were a senator forced to vote today, I’d vote no. If you pass a health care bill without systemic incentives reform, you set up a political vortex in which the few good parts of the bill will get stripped out and the expensive and wasteful parts will be entrenched. [...] Defenders say we can’t do real reform because the politics won’t allow it. The truth is the reverse. Unless you get the fundamental incentives right, the politics will be terrible forever and ever."

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Uninsured: Does bill help insure 30 million uninsured?

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Pro

• Health care bill would insure 30m Americans "A bill well worth passing." New York Times Editorial. December 21, 2009: "There is a lot to like in the bill. The Congressional Budget Office estimates that it would cover more than 30 million of the uninsured and would, by 2019, result in 94 percent of all citizens and legal residents below Medicare age having health insurance. That is a big improvement from the current 83 percent."

• US health care law makes care more affordable Jonathan Chait. "Why the health care bill is the greatest social achievement of our time." The New Republic. December 24th, 2009: "Health reform solves the affordability problem [for the uninsured] by subsidizing insurance coverage, or expanding Medicaid, for low- and moderate-income families."

• 2009 health bill provides aid to those without employer insurance. For those that do not receive insurance from their employers, the 2009 health bill provides aid, to make it easier for them to buy insurance for themselves.

• 2009 health bill provides tax breaks for small employer insurance. For small businesses that will have difficulty offering health insurance to its employees, under the new mandate, the health care bill will provide a tax break to make it easier for them to provide that insurance.

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Con

• Gains of insuring 30m uninsured must be qualified Robert Samuelson. "A parody of leadership." Real Clear Politics. December 21, 2009: "To be sure, they would provide insurance to 30 million or more Americans by 2019. People would enjoy more security. But even these gains must be qualified. Some of the newly insured will get healthier, but how many and by how much is unclear. The uninsured now receive 50 percent to 70 percent as much care as the insured. The administration argues that today's system has massive waste. If so, greater participation in the waste by the newly insured may not make them much better off."

• Government-approved insurers of US health care law limits competition Jeffrey Anderson. "Give Me Liberty, or Give Me Obamacare." National Review Online. December 23, 2009: "ObamaCare would require Americans to buy government-approved health insurance. It would make it illegal to offer choices in insurance plans beyond the handful of very similar ones that the government would allow. It would become illegal to offer new and innovative plans. [...] Competition and choice would diminish tremendously. One-size-fits-all conformity would rule the day."

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Mandates: Are the mandates in the health bill justified?

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Pro

• Health insurance mandates necessary to expand risk pool Paul Waldman. "The Health-Care Ultimatum." The American Prospect. December 22, 2009: "there is simply no alternative [to a health insurance mandate]. If you're going to get everyone covered, you have to expand the risk pool so it includes everyone."

• Mandates help end pre-existing condition exclusion Paul Waldman. "The Health-Care Ultimatum." The American Prospect. December 22, 2009: "one of the core goals of this reform has always been forbidding insurance companies from denying people coverage because of their pre-existing conditions. But without a mandate, people could just wait until they get sick to sign up for coverage. If that were allowed, premiums would skyrocket to levels even more unaffordable than what we have now. It may be distasteful to deliver the insurance companies millions of new customers, but there's just no way around it."

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Con

• 2009 health bill forces buying from private insurers Jane Hamsher. "10 Reasons to Kill the Senate Bill." FireDogLake. December 21, 2009: "[The bill] Forces you to pay up to 8% of your income to private insurance corporations — whether you want to or not. [...] If you refuse to buy the insurance, you’ll have to pay penalties of up to 2% of your annual income to the IRS."

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Cost-cutting: Does the bill reduce the costs of health care?

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Pro

• Health care reform limits costs of health care Jonathan Cohn. "Andy Stern: Don't Kill the Bill. Fix It." The Plank, The Republic. December 18, 2009: "The second reason to support the bill is that its authors took the deficit issue seriously. Compared with, say, the prescription drug benefit from a few years ago, this bill is a model of fiscal rectitude. It spends a lot of money to cover the uninsured, but to help pay for it, it also includes serious Medicare cuts and whopping tax increases — the tax on high-cost insurance plans alone will raise $1.3 trillion in the second decade. [...] The bill is not really deficit-neutral. It’s politically inconceivable that Congress will really make all the spending cuts that are there on paper. But the bill won’t explode the deficit, and that’s an accomplishment."

• Health care law holds insurance companies in check Tom Bevan. "President Obama's Remarks on Senate HC Vote." Time. December 24, 2009: "The reform bill that passed the Senate this morning, like the House bill, includes the toughest measures ever taken to hold the insurance industry accountable. Insurance companies will no longer be able to deny you coverage on the basis of a preexisting condition. They will no longer be able to drop your coverage when you get sick. No longer will you have to pay unlimited amounts out of your own pocket for the treatments you need. And you'll be able to appeal unfair decisions by insurance companies to an independent party."

• 2009 health care reform bill would lower premiums Paul Krugman. "Pass the Bill". New York Times Op-Ed. December 17, 2009: "The result would be a huge increase in the availability and affordability of health insurance, with more than 30 million Americans gaining coverage, and premiums for lower-income and lower-middle-income Americans falling dramatically."

• Pilot projects of US health care reform cut costs "A bill well worth passing." New York Times Editorial. December 21, 2009: "Important elements of the bill have been strengthened during the struggle. An independent board and other new entities would be given greater powers than previously planned to test and implement cost-saving measures free of political lobbying."

• 2009 health care reform would cut deficits "A bill well worth passing." New York Times Editorial. December 21, 2009: "It also estimates that the bill would reduce deficits over the next decade by $132 billion and even more in the following decade. Despite all the exaggerated Republican rhetoric that the bill will lead to fiscal disaster, it has been carefully and responsibly drafted so that it is fully paid for without busting future budgets."

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Con

• 2009 US health care bill does not cut costs David Brooks. "The Hardest Call." New York Times. December 17, 2009: "The Congressional Budget Office and most of the experts I talk to (including many who support the bill) do not believe it will seriously bend the cost curve. [...] Over its first several years, the demand for health care will rise sharply. The supply will not. Providers will have the same perverse incentives. As a result, prices will skyrocket while efficiencies will not. There will be a bipartisan rush to gut reform."

• Health care reform would worsen the deficit Robert Samuelson. "A parody of leadership." Real Clear Politics. December 21, 2009: "the health care proposals would impose massive costs. Remember: The country already faces huge increases in federal spending and taxes or deficits because an aging population will receive more Social Security and Medicare. Projections made by the Congressional Budget Office in 2007 suggested federal spending might rise almost 50 percent by 2030 as a share of the economy (gross domestic product). Since that estimate, the recession and massive deficits have further bloated the national debt. [...] Obama's plan might add almost another $1 trillion in spending over a decade -- and more later."

• Obama has pledged health reform will not add to deficit President Obama: "I've also pledged that health insurance reform will not add to our deficit over the next decade, and I mean it."[1]

• Congress will not ultimately cut Medicare to pay for reform William McKenzie. "Senate health bill should either be defeated or rewritten." Dallas News. January 21, 2009: "we consistently have warned about during this debate: The proposal still relies upon about half of its $871 billion financing through cuts in Medicare. [...] The real problem with these cuts is that they are very, very unlikely to occur. Over the last decade, Congress has shown a distinct unwillingness to make good on cuts to Medicare. Last month, the House voted to walk on $200 billion in promised cuts."

• Taxes for health care start now; benefits begin later Jane Hamsher. "10 Reasons to Kill the Senate Bill." FireDogLake. December 21, 2009: "Many of the taxes to pay for the bill start now, but most Americans won’t see any benefits — like an end to discrimination against those with preexisting conditions — until 2014 when the program begins."

• Government health care regulations slow innovation David Brooks. "The Hardest Call." New York Times. December 17, 2009: "it will slow innovation. Government regulators don’t do well with disruptive new technologies."

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Politics: Is health care reform too political?

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Pro

• Killing 2009 health bill would delay reform for years David Brooks. "The Hardest Call." New York Times. December 17, 2009: "The fourth reason to support the bill is that if this fails, it will take a long time to get back to health reform. Clinton failed. Obama will have failed. No one will touch this. Meanwhile, health costs will continue their inexorable march upward, strangling the nation."

• Passing historic health care bill victory for Dems. Passing health care reform, the greatest social reform since the 1930s, is a great victory for the Democrats, and for any individual that supported the legislation. For those that opposed the legislation, they will have to explain why they were not willing to sign on to the first major health care reform in 70 years.

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Con

• 2009 health bill is political symbolism, not substance Robert Samuelson. "A parody of leadership." Real Clear Politics. December 21, 2009: "What it's become is an exercise in political symbolism: Obama's self-indulgent crusade to seize the liberal holy grail of 'universal coverage.' What it's not is leadership."

• 2009 health bill rushed through for political reasons Jay Cost. "Democrats Risk Another Jacksonian Moment." Real Clear Politics. December 21, 2009: "It stinks of politics. Why is there such a rush to pass this bill now? It's because the President of the United States recognizes that it is hurting his numbers, and he wants it off the agenda. It might not be ready to be passed. In fact, it's obviously not ready! Yet that doesn't matter. The President wants this out of the way by his State of the Union Address. This is nakedly self-interested political calculation by the President - nothing more and nothing less."

• US health care law is political suicide for Dems Megan McArdle. "Pass a Huge, Unpopular Bill w/Party-Line Vote?" The Atlantic. December 19, 2009: "Democrats are on a political suicide mission; I'm not a particularly accurate prognosticator, but I think this makes it very likely that in 2010 they will lost several seats in the Senate--enough to make it damn hard to pass any more of their signature legislation--and will lose the house outright. In the case of the House, you can attribute it to the fact that the leadership has safe seats. But three out of four of the Democrats on the podium today are in serious danger of losing their seats."

• US health care reform lacks bi-partisan support Megan McArdle. "Pass a Huge, Unpopular Bill w/Party-Line Vote?" The Atlantic. December 19, 2009: "No bill this large has ever before passed on a straight party-line vote, or even anything close to a straight party-line vote."

• US health care law is too unpopular Megan McArdle. "Pass a Huge, Unpopular Bill w/Party-Line Vote?" The Atlantic. December 19, 2009: "No bill this unpopular has ever before passed on a straight party-line vote. We're in a new political world. I'm not sure I understand it."

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Without public option: Is reform acceptable w/o public option?

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Pro

• Health care reform still valuable without public option Paul Krugman. "Pass the Bill". New York Times Op-Ed. December 17, 2009: "The public option was always a means to an end: real competition for insurers, an alternative for consumers to existing private plans that does not deny needed care or shift risks onto the vulnerable, the ability to provide affordable coverage over time. I thought it was the best means within our political grasp. It lay just beyond that grasp. Yet its demise--in this round--does not diminish the immediate necessity of those larger aims. And even without the public option, the bill that Congress passes and the President signs could move us substantially toward those goals."

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Con

• W/o public option, US health care law emboldens insurers Howard Dean. "Health-care bill wouldn't bring real reform." Washington Post (Op-Ed). December 17, 2009: "Any measure that expands private insurers' monopoly over health care and transfers millions of taxpayer dollars to private corporations is not real health-care reform."

• US health care law is liberal move to single-payer system Philip Klein. "Democrats Break Ground." American Spectator. December 21, 2009: "The point isn't that this one piece of legislation, on its own, will impose a Canadian-style, government-run health care system on the United States immediately. The point is that Democrats are putting infrastructure in place that will allow them to implement a government-run system over time."

• US health reform does not respond to illegal immigration Robert Samuelson. "A parody of leadership." Real Clear Politics. December 21, 2009: "The remaining uninsured may also exceed estimates. Under the Senate bill, they would total 24 million in 2019, reckons Richard Foster, chief actuary of the Centers for Medicare & Medicaid Services. But a wild card is immigration. From 1999 to 2008, about 60 percent of the increase in the uninsured occurred among Hispanics. That was related to immigrants and their children (many American born). Most illegal immigrants aren't covered by Obama's proposal. If we don't curb immigration of the poor and unskilled -- people who can't afford insurance -- Obama's program will be less effective and more expensive than estimated. Hardly anyone mentions immigrants' impact, because it seems insensitive."

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Pre-existing conditions: Is progress in this regard beneficial?

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Pro

• US health care law ends pre-existing conditions discrimination Paul Krugman. "Pass the Bill". New York Times Op-Ed. December 17, 2009: "it would prohibit discrimination by insurance companies on the basis of medical condition or history: Americans could no longer be denied health insurance because of a pre-existing condition, or have their insurance canceled when they get sick."

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Con

• US health care law still allows insurers to discriminate Howard Dean. "Health-care bill wouldn't bring real reform." Washington Post (Op-Ed). December 17, 2009: "Real health-care reform is supposed to eliminate discrimination based on preexisting conditions. But the legislation allows insurance companies to charge older Americans up to three times as much as younger Americans, pricing them out of coverage."

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Abortion: What are the pros/cons of abortion provisions in the bill?

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Pro

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Con

• US 2010 health vare law restricts abortion rights Jane Hamsher. "10 Reasons to Kill the Senate Bill." FireDogLake. December 21, 2009: "Massive restriction on a woman’s right to choose, designed to trigger a challenge to Roe v. Wade in the Supreme Court."

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Pro/con sources

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Pro

• Paul Krugman. "Pass the Bill". New York Times Op-Ed. December 17, 2009
• Jonathan Chait. "Why the health care bill is the greatest social achievement of our time." The New Republic. December 24th, 2009
• Jonathan Cohn. "Yes, I can be excited about this bill." TPM Cafe. December 18, 2009
• Jonathan Cohn. "Andy Stern: Don't Kill the Bill. Fix It." The Plank, The Republic. December 18, 2009
• Jacob Hacker. "Why I still believe in this bill." The New Republic. December 20th, 2009
• Joe Biden. "Why the Senate should vote yes on health care." New York Times. December 19, 2009
• Ezra Klein. "Still time to think small." Washington Post. November 19th, 2009
• "Health reform right now beats none at all." Chicago Sun Times. December 20, 2009
• Adam Clymer. "A Bill Fit for a Kennedy." The Daily Beast. December 19, 2009
• "Howard Dean Now Supports Passage Of Health Bill." Real Clear Politics. December 23, 2009
• Jesse Lee. "The Economic Case for Health Care Reform." The White House Blog. June 02, 2009
• "A bill well worth passing." New York Times Editorial. December 21, 2009
• Senator Sherrod Brown. "31 million reasons to support this bill." Real Clear Politics. December 24, 2009

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Con

• "Change Nobody Believes In." Wall Street Journal (Editorial). December 21, 2009
• David Brooks. "The Hardest Call." New York Times. December 17, 2009:
• Robert Samuelson. "A parody of leadership." Real Clear Politics. December 21, 2009
• Philip Klein. "Democrats Break Ground." American Spectator. December 21, 2009
• Jay Cost. "Democrats Risk Another Jacksonian Moment." Real Clear Politics. December 21, 2009
• Howard Dean. "Health-care bill wouldn't bring real reform." Washington Post (Op-Ed). December 17, 2009
• Jane Hamsher. "10 Reasons to Kill the Senate Bill." FireDogLake. December 21, 2009
• William McKenzie. "Senate health bill should either be defeated or rewritten." Dallas News. January 21, 2009
• Jeffrey Anderson. "Give Me Liberty, or Give Me Obamacare." National Review Online. December 23, 2009

See also

External links and resources