Anyway, when it comes to costs, what matters far more than the absolute size of the bill is whether there is any hope for “bending the curve.” Now I think we have a long (long, long, long) way to go in the debate over costs and “curve bending.” But this bill is a place to start. The status quo admits defeat on cost control.

Employers have to attract employees. Workers like getting a tax break on health care benefits. That will keep employers offering coverage. Anyway, if they don’t, you go to the exchange. There’s a tax inequity there that ought to be fixed but it would make employers even less likely to offer coverage if it were. This employer mandate issue really is about revenue more than coverage.

The individual penalty would be 2% of income when fully phased in. Maybe that’s not high enough for everyone. I don’t know how that figure was arrived at. The experience in Massachusetts is the penalty actually doesn’t matter much. Once it is law that you’re supposed to be covered the vast majority of folks get insured.

The details may not be perfect and I’m sure they will be tweaked over time. The basic structure is sound.

What about the physician fee fix? Without a physician fix the economics of the bill are completely mis-stated. there is a massive cost to fixing those payment rates that should be part of the CBO score. It’s misleading. I understand they pulled it out of the bill and tacked it somewhere else but it’s a $250B line item that realyl must be addressed.

Here’s a question for you on mandates. I am currenlty insuring my family of four for $6K/year and my employer kicks in another $6K. Even in the years I had children my rack rate medical expenses never exceeded (or came close to) the total of these amounts $12K. Why wouldn’t I self insure if the penalty for not carrying is $750 (or 2.5% of my AGI dependign on the bill)? Why would my employer offer coverage when the penalty for not doing so is $750? I would be happy to self insure if I knew I had guaranteed issue + ratings limited to 4:1?

Obama didn’t draft a bill and submit it to Congress because that’s exactly what President Clinton did and we know what happened to his health reform agenda (boom!). In fact, as far as managing Congress, Obama’s approach has been quite good. Where he fell down was after the bills were finalized. Then he needed to adopt the broad and common structure as his own and sell it to America. He didn’t and still isn’t.

There’s a lot more real reform in the proposals than you suggest. The individual mandate is real, though the strength of it phases in over time (in the Senate bill). The employer mandate on the Senate side has a few problems I’ve written about. But they aren’t so much an issue for coverage as for revenue. Plus, they can and likely will be modified over time. So, I view the bill (even the Senate version) as a very good start and worthy of support if one wants to see real change. That business about the Senate mandate being anti-family has been fixed. It’s fine in that regard.

In general I would caution people (not necessarily you, I’m speaking broadly here) to avoid mistaking the problems with the process for problems with the bill(s). The bills are quite good, better than many things Congress produces. One cannot expect perfect, clean legislation free of interest-group influence and political deals. That’s just how our system works. I don’t like it but to expect better right now is not realistic. Given that, I think the Senate bill deserves to be supported and the good work of some Democrats and the Administration should be applauded. But it will all be for nothing if they don’t pass it. That’s what will really tick me off.

As a healthcare analyst I want reform badly as well. However I find the most recent incarnations of the healthcare bills completely devoid of actual reform. The proposals lack strong mandates and create perverse incentives for employers to drop coverage or for families to self insure.

The blame for this can be spread evenly to both parties. But ultimately the president has shown little leadership in the construction of the bill and little follow through in terms of support. This is where my disapointment lies.