A Sensible and Politically Feasible “Paring Down”

For reasons explained well by Krugman in his column yesterday, it isn’t possible to pare down or chop up health care reform and still end up with something that will hang together (read it if you don’t get why). Yet something that seems smaller is precisely what frightened Democrats seem to be casting about for. Small, incremental changes to existing programs and law is one way to go, but they won’t do much to address the big coverage and cost problems we face.

But there’s another way. It’s politically sneaky and it relies on the fact that Americans mostly don’t understand how CBO scores bills. Health reform seems big in part because of its price, on the order of $900 billion. That’s the cost over ten years, which is what CBO estimates in its budget analysis of bills. The idea is to bring that cost down by slowing down implementation of reforms and a few other tweaks.

By delaying implementation of exchanges (and the individual mandate and subsidies that go with them) the 10-year price would come down. It would also come down if more folks are covered by Medicaid. So another tweak is to use the House’s cutoff (or higher) for eligibility for that program. Maybe there are a few other ways to nibble at the edges of things to cut a few billion here and there. Suppose doing all this brought the ten-year cost down to, I don’t know, $750 billion. All this could be done under the budget reconciliation process, requiring only 51 votes in the Senate, provided the House passes the Senate bill, as many experts are urging.

So, here’s the Democrats’ message to America:

We heard you. You want something smaller that doesn’t change things too quickly. We can get that done for you. We can do it soon. We have a brand new approach to health reform that is cheaper for taxpayers. It will achieve the goals you sent us here to accomplish, but cost far less.

You can’t expect Democrats not to spin this as new because that’s what they are seeking. But, really, the only way to achieve what they set out to do is to pass the Senate bill, and the only way to make it seem new and different is to tinker with it under reconciliation. If they can get it to actually cost a lot less (over the next 10 years) and move a bit more slowly, they can satisfy the necessities of both politics and and policy. Right now I don’t see any other way to do that.

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