House narrowly passes health care bill
Associated Press
Rep. George Miller, D-Calif., walks to the House of Representatives floor with Speaker Nancy Pelosi before the House approved passage of the Democratic health care bill.
Associated Press
Published: November 7, 2009
WASHINGTON — In a victory for President Barack Obama, the Democratic-controlled House narrowly passed landmark health care legislation Saturday night to expand coverage to tens of millions who lack it and place tough new restrictions on the insurance industry. Republican opposition was nearly unanimous.
The 220-215 vote cleared the way for the Senate to begin debate on the issue that has come to overshadow all others in Congress.
A triumphant Speaker Nancy Pelosi likened the legislation to the passage of Social Security in 1935 and Medicare 30 years later.
“It provides coverage for 96 percent of Americans. It offers everyone, regardless of health or income, the peace of mind that comes from knowing they will have access to affordable health care when they need it,” said Rep. John Dingell, the 83-year-old Michigan lawmaker who has introduced national health insurance in every Congress since succeeding his father in 1955.
In the run-up to a final vote, conservatives from the two political parties joined forces to impose tough new restrictions on abortion coverage in insurance policies to be sold to many individuals and small groups. They prevailed on a roll call of 240-194.
Ironically, that only solidified support for the legislation, clearing the way for conservative Democrats to vote for it.
The legislation would require most Americans to carry insurance and provide federal subsidies to those who otherwise could not afford it. Large companies would have to offer coverage to their employees.
Both consumers and companies would be slapped with penalties if they defied the government’s mandates.
Insurance industry practices such as denying coverage on the basis of pre-existing medical conditions would be banned, and insurers would no longer be able to charge higher premiums on the basis of gender or medical history. In a further slap, the industry would lose its exemption from federal antitrust restrictions on price gouging, bid rigging and market allocation.
A cheer went up from the Democratic side of the House when the bill gained 218 votes, a majority. Moments later, Democrats counted down the final seconds of the voting period in unison, and and let loose an even louder roar when Pelosi grabbed the gavel and declared, “the bill is passed.’
From the Senate, Majority Leader Harry Reid of Nevada issued a statement saying, “We realize the strong will for reform that exists, and we are energized that we stand closer than ever to reforming our broken health insurance system.”
The bill drew the votes of 219 Democrats and Rep. Joseph Cao, a first-term Republican who holds an overwhelmingly Democratic seat in New Orleans. Opposed were 176 Republicans and 39 Democrats.
Nearly unanimous in their opposition, minority Republicans cataloged their objections across hours of debate on the 1,990-page, $1.2 trillion legislation.
United in opposition, minority Republicans cataloged their objections across hours of debate on the 1,990-page, $1.2 trillion legislation.
“We are going to have a complete government takeover of our health care system faster than you can say, ‘this is making me sick,“’ jabbed Rep. Candice Miller, R-Mich., adding that Democrats were intent on passing “a jobs-killing, tax-hiking, deficit-exploding” bill.
But with little doubt about the outcome, the rhetoric lacked the fire of last summer’s town hall meetings, when some critics accused Democrats of plotting “death panels” to hasten the demise of senior citizens.
The legislation would require most Americans to carry insurance and provide federal subsidies to those who otherwise could not afford it. Large companies would have to offer coverage to their employees.
Both consumers and companies would be slapped with penalties if they defied the government’s mandates.
Insurance industry practices such as denying coverage on the basis of pre-existing medical conditions would be banned, and insurers would no longer be able to charge higher premiums on the basis of gender or medical history. In a further slap, the industry would lose its exemption from federal antitrust restrictions on price gouging, bid rigging and market allocation.
At its core, the measure would create a federally regulated marketplace where consumers could shop for coverage. In the bill’s most controversial provision, the government would sell insurance, although the Congressional Budget Office forecasts that premiums for it would be more expensive than for policies sold by private firms.
The bill is projected to expand coverage to 36 million uninsured, resulting in 96 percent of the nation’s eligible population having insurance.
To pay for the expansion of coverage, the bill cuts Medicare’s projected spending by more than $400 billion over a decade. It also imposes a tax surcharge of 5.4 percent on income over $500,000 in the case of individuals and $1 million for families.
The bill was estimated to reduce federal deficits by about $104 billion over a decade, although it lacked two of the key cost-cutting provisions under consideration in the Senate, and its longer-term impact on government red ink was far from clear.
Democrats lined up a range of outside groups behind their legislation, none more important than the AARP, whose support promises political cover against the cuts to Medicare in next year’s congressional elections.
The nation’s drug companies generally support health care overhaul. And while the powerful insurance industry opposed the legislation, it did so quietly, and the result was that Republicans could not count on the type of advertising campaign that might have peeled away skittish Democrats in swing districts.
Over all, the bill envisioned the most sweeping set of changes to the health care system in more than a generation, and Democrats said it marked the culmination of a campaign that Harry Truman began when he sat in the White House 60 years ago.
Debate on the House floor had already begun when Obama strode into a closed-door meeting of the Democratic rank and file across the street from the Capitol to make a final personal appeal to them to pass his top domestic priority.
Later, in an appearance at the White House, he said he had told lawmakers, “to rise to this moment. Answer the call of history, and vote yes for health insurance reform for America.”
Participants also said Obama had referred to this week’s shooting rampage at Fort Hood, Texas, in which 13 people were killed. His remarks put in perspective that the hardships soldiers endure for the country are “what sacrifice really is,” as opposed to “casting a vote that might lose an election for you,” said Rep. Robert Andrews, D-N.J.
It appeared that a compromise brokered Friday night on the volatile issue of abortion had finally secured the votes needed to pass the legislation.
As drafted, the measure denied the use of federal subsidies to purchase abortion coverage in policies sold by private insurers in the new insurance exchange, except in cases of incest, rape or when the life of the mother was in danger.
But abortion foes won far stronger restrictions that would rule out abortion coverage except in those three categories in any government-sold plan. It would also ban abortion coverage in any private plan purchased by consumers receiving federal subsidies.
Disappointed Democratic abortion rights supporters grumbled about the turn of events, but pulled back quickly from any thought of opposing the health care bill in protest.
One, Rep. Jan Schakowsky, D-Ill., detailed numerous other benefits for women in the bill, including free medical preventive services and better prescription drug coverage under Medicare. “Women need health care reform,” she concluded in remarks on the House floor.
A Republican alternative was rejected on a near party line vote of 258-176.
It relied heavily on loosening regulations on private insurers to reduce costs for those who currently have insurance, in some cases by as much as 10 percent. But congressional budget analysts said the plan would make no dent in the ranks of the uninsured, an assessment that highlighted the difference in priorities between the two political parties.
It was a theme of Obama’s remarks to Democrats at midmorning.
The president said Democrats have a 70-year history of creating and defending programs like Social Security and Medicare, Andrews said afterward, adding Obama had said the day’s vote “is going to define the difference between the Republican and Democratic parties for decades.”
Associated Press writers Phil Elliott, Alan Fram and Erica Werner contributed to this report.
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Reader Reactions
Tyates,
Part of me fears the worst as you do, but the patriot in me is optimistic. I refuse to allow my father’s death in service to this country to be in vain, and I will fight to the death if necessary to keep this country from descending further into the abyss of socialism.
That said, I must again commend David for his well reasoned and obviously well researched comments.
I will say that I have had the same family physician for nearly 14 years and have had many discussions with him regarding the already outrageous and burdensome bureaucratic red tape involved in running his practice. He has indicated to his employees that if obama’s health care plans are implemented he will have to let some of them go, but my fear is that he will just quit practicing as many physicians have indicated that they will do. Many physicians are opposed to these plans and are outraged at the AMA’s support of them. If that doesn’t throw up some red flags nothing will. Doctors are already under great stress to abide by the ridiculous rules and paperwork required by insurance providers such as BCBS, and the government run Medicare and Medicaid programs. I personally am offended and angered at the gall of BCBS’s attempts at telling my doctor how to treat his patients. I can only imagine how much worse it will be if the inept fools in DC are allowed to place even more restrictions and guidelines for care on the hard working physicians of this nation.
This health care bill is the wrong thing at the wrong time. Our country cannot afford it. Plain and simple.
americangenie,
From reading a number of your posts, I understand our Constitution and its interpretation is a key focus, the argument of living vs. original views are interesting. I have enjoyed the Scalia/Bryar over the years.
My interpretation of the “Democratic Republic” comment was not a prima facie challenge to our constitutional republic, but was to emphasize that within the rule of law we democratically elect certain representatives to reflect our interest, respecting the intent to avoid mass populace rule.
You and many others raise an interesting point about “moral hazard” or perverse incentivizes, of course this is true with healthcare as well.
If our healthcare delivery is organized in silos of individual interest, we can’t reasonably expect an integrated result.
At this point, it seems of value to clarify a fundamental decision; what ever reason, do we think it is in our best interest to have a base line level of health care for everyone?
If the answer is no, then no comprehensive health care delivery system will appear reasonable. If we do decide universal healthcare, at some level, is in our best interest, there are some basic concepts that we should be able to concur.
If we choose to move towards any cost/coverage solution, below are some considerations:
Symbols, “free market”, “big government”, and “my doctor” seem to be eclipsing discussions concerning healthcare access and delivery. The discussion continues primarily as a well marketed “group identity” litmus test propagated by the industries with an interest.
The concept of healthcare service and technology providers, or underwriting interest working to reduce ROI while increasing accountability, ignores basic human behavior. In other words, issues that are bigger than any given corporate interest have to be regulated by broader interest.
Although very distasteful for some, the federal government is the only entity that transcends each silo in the context of a common interest.
Capitalism is terrific for innovation, and productivity, however, its incentives are limited to the immediate interest of the investor, which is not a bad thing, its simply a limitation we must be aware of.
There is no inherent “evil” within the healthcare industry or government, there is a obsession of revering or demonizing the symbols of both rather than embracing the concepts that each symbol represents.
If electorate can agree that it’s better to at least provide a level of care equal to what we now provide in emergency rooms across the country; the discussion is reframed to; will we choose to provide additional basic coverage and how to deliver the level agreed?
To review, the US doesn’t have a “health care delivery system” period. We do generate some of the most advanced technology and highly trained providers. Integration of these elements into a system, require comprehensive incentives consistent with collaborative behavior.
Lambasting physicians, hospital administrators, insurance executives, and CMS employees concerning, greed, inefficiency, fraud and incompetence is not solving the problem.
-Physicians are primarily paid to provide individual services within the context of a social compact, “make people well”.
-Although hospital payments from the CMS in traditional Medicare are generally case priced within MSDRG’s (Medicare Severity Diagnosis Related Groups) in-patient, and APC’s (Ambulatory Payment
-Continued-
Classification) out-patient, hospital charges and cost reporting used in the rate calculations significantly diverge the payments from consideration of broader market realities.
-Underwriting success is maximized by minimizing CLR’s(claim loss ratios) and in the case of MA (Medicare Advantage) plans, maximizing the bid and benchmark system which does not allow for decreases. The current MA premium to FFS is running about 114% for 2009.
-CMS employees are generally retained based on demonstrated ability to implement and maintain defined processes.
If we choose to build an “integrated health care delivery system”, government payments to physicians must be, acuity adjusted, longitudinally based and outcome measured.
Hospitals payments must significantly further the current shift towards payment for reasonably controllable metrics.
With or without a government option, underwriting must be community based, with universal participation, otherwise adverse selection and preexisting condition rationing will continue.
If there is a government option, it must include fair cost of capital constraints and judicial oversight for fair private sector access to the courts concerning anti-competitive claims.
CMS employees must be rewarded for process results, as measured at the program level for financial, customer service, and outcome metrics.
Rationing is, and will be, part of healthcare delivery with or without system integration, the question becomes, on what basis? The private sector will continue to have financial incentives to provide a plethora of boutique services for those with the resources.
The vast majority of care will continue to be rationed financially by some combination of the government and private sector. Clinicians can today, or under any plausible health care reform measure, recommend a myriad of treatment options.
Under any healthcare reform scenario, health care is rationed by provider willingness to deliver specified health care for an agreed price.
A candid discussion can begin when the bills in the House and Senate, are deficit neutral, currently, the Senate is, the House is. The Obama administration must accept CBO scoring and deliver final legislation accordingly.
Most importantly, I suggest, as a community, we rise above calling people stupid that don’t agree with us; the hallmark of intelligence is recognition that our way is not the way. If my comments in the Auburn Opelika News can at least encourage a modicum of civility in how we think about each other, it will be well worth the effort.
americanangie,
well writen…unfortunatly, I believe we have went past the point of no return. Either party really offers no true, long term, and realistic solutions.
We are now “subjects” not citizens. Subjects have little or no rights, except what is acceptable to the King(Goverment).
This has been coming since the days of Bush Sr. who often spoke of a “one world order”. The difference now is Obama, Pelosi, Reid and the rest, both republican & democrat, have shifted things into high gear towards a socialistic/dictatorship.
This country has been eroding away since Bush Sr. was in office…really as far back as the Johnson administration in the 60’s.
The thing I hate most is my children, grandchildren and future generations will be under even more weight by the King(Government). And, for those who died for liberty, their blood shall have been in vein!
What was, is no more! I, being an optimist, can see no true hope on the horizon…From now on, whom ever is in the White House and in Congress will only be members of a beuracratic system controlled by the handfull of a few! To me it appears to be a cross between Marxism & Nazism. Both of the forementioned started as “labor parties/unions” who took it upon themselves to make all things equal in theory…But we have seen the end result of their theories. People can say what they want, history does have a way of repeating itself. The people of this country have grown ignorant and become entitlement minded.
The worse the economy gets the more the “subjects” shall look to the King(Government) for help/entitlements!
With all this said, as I posted earlier, the pinion of Socialism is Socialized Medicine…everyone wants good affordable healthcare, especially if the King is going to tax more and spread the wealth! Call me crazy if you want, but I won’t call you stupid if you disagree with my views. One thing Ron White said is TRUE…“You can’t fix stupid!“ 
David,
Thank you for your well informed and articulate comments they are much appreciated by me.
I do have a question. I am 54 years old. I was taught and I believe this nation was founded as a Constitutional Republic. When did it become a Democratic Republic?
No true democracy has ever lasted as long as this nation has survived because once the masses figure out they can vote for and receive benefits from the public coffers that is exactly what happens.
When the populace is so indebted to the government for their care they are no longer citizens. They quite simply become subjects who are ruled rather than governed.
Every piece of legislation that this so-called president and his lackeys in Congress have rammed through has brought this nation closer to a socialist dictatorship than it has ever been. It’s as if they are trying to cause a revolution. They arrogantly believe that the masses of people who voted for this so-called president are going to stand up and fight to be subjugated.
They are mistaken because these are the same people who expect the government to solve all their problems for them and as such they will just sit back and let the government handle it. It won’t be pretty and in the end it will be the citizens who save this nation not the sheep who are being herded to slaughter by this ill conceived administration.
Americangennie, we need your input, I already know what I think, my knowledge grows much more by faster by understanding the perspective of others.
The recent AJPH (American Journal of Public Health) peer reviewed study considered mortality related to insurance coverage and took place between 1988 and 1994. One of the criticisms of the study was that perhaps most of the uninsured are illegal or undocumented people.
During the study period, the undocumented population was ~eight million (2000 Census bureau), considering this, and other illegal population data are suspect, perhaps we can agree that relative to the (88-94) period, this number errors significantly on the high side.
The national median age overall is about 36.7 years (United States – Age and Sex, 2007 American Community Survey)
The national median age for non documented people is around 30 (Median age 28 (Michael C. LeMay 2007; 25.5, Social Contract Journal Fall 1992)
56% of undocumented people are uninsured (Center for Immigration Studies March 2005)
It seems unlikely to suggest that most of the survey population was composed of 44% of 8 million people with a median age ~ 30.
Today we have larger numbers, however, it stands to reason that currently, and during the last two decades, most folks coming to this country illegally are doing so to work, probably are not generally on deaths doorstep although they probably are more likely to incur injury, as has been pointed out in this forum.
Offering coverage across state lines will improve the lack of competition at the state level. There are over 1300 companies, however, for example, in the small group market (generally 2-50), in over 40 states, the median market share of the largest carrier was about 47% in 2008. The market share ranged from about 21% in Arizona to approximately 96% with BCBS of Alabama(including out of state business, GAO report February 2009). The lack of existing competitive networks in place will translate into far less national competition than we might initially expect.
Although actual malpractice payout totals less than .5% of annual healthcare cost there is a defensive medicine cost beyond the direct amount. How does this compare with other cost? Data reported by the CBO 2004 and Medpac 2009 suggest a far larger expense is driven by perverse incentives generally related to fee per procedure payments and more specifically to self referral caused by physician ownership of imagining equipment.
Malpractice insurance is influenced by claims in combination with the insurance cycle. For example underwriting losses increased $3.1 billion between 1996 and 2001. In addition to claims increasing from $5.1 billion to $9.5 billion, carrier Investment income dropped from 30.2% to 19.1% during the same period. By 2007 the industry claims loss to premium ratios were favorable resulting in $1.4 billion surpluses. (A.M. Best)
Tort reform in terms of capping non economic and punitive damages and reforming the legal definition of “informed consent” is logical and has a modicum of support on both sides of the a aisle, however, in terms of net impact relative to a $2.5 trillion healthcare industry, we are staring at a grain of sand while missing the beach.
As for the constitutionality of the commerce clause’s applicability in this case, there are certainly serious minded discussions as to how the courts should interpret this, but not about how thee courts will ultimately rule. By focusing on the legal reality we actually have to work with helps avoid becoming stuck in how we feel, to the exclusion of what realistically is achievable, within a legal/social fabric.
I hope that you and others continue to comment, focusing on specific aspects of proposed legislation to fuel a thoroughly thoughtful discussion.
estoy2u’s comment seems particularly apropos relative to our greatest challenge “Without knowledge of basic civic responsibility, a democratic republic is lost”
David
The Constitution does not provide for many things that the “government” is involved in. Regulations and the welfare of a nation are broad based. One can imagine that if the “health” of a young nation would have been a concern, perhaps somewhere it might have been specifically spelled out. Just as the ‘founders’ had no inkling that the ‘right to bear arms’ would eventually lead to someone wanting to own an automatic assault weapon rather than a musket, there was no inkling for some cushion for medical costs. The House bill or any, for that matter might not be the ‘right’ thing to do according to the Constitution. So then, what are the alternatives? Should the Constitution be amended as it has over the years to fit and mesh with a growing AND STILL EVOLVING DEMOCRATIC REPUBLIC. THIS NATIONS HEART BEAT (THE CONSTITUTION, A LIVING DOCUMENT) requires infusions from time to time…the key word…“time”...so with time it grows and changes, by the will of the people, and so it should. But the people have lost control; big business, special interests, self interest, partisan interest, and greed appear to be the players of the day. Without knowledge of basic civic responsibility, a democratic republic is lost. Whatever happened to ‘HS Civics’ along with ‘US Government’ requirements. Talking radio and TV heads are not the answer to a well informed public.
David,
It is sad that taxpayers have to shoulder the burden for so many who do not have insurance, but you and many others are missing the point.
If our country took the immigration laws on the books seriously & got rid of the many illegals of every persuasion in this country there would be a huge drop in the number of freeloaders feeding off of hardworking taxpayers.
If welfare recipients were forced to look for jobs instead of new ways to take advantage of the system costs would also likely come down.
If tort reform came before unconstitutional government mandates & people were allowed to shop for insurance across state lines the business would become more competitive & most likely costs would come down.
This won’t happen as long as the sheep of this nation keep electing & re-electing trial lawyers as representatives of the people. They don’t represent our interests. They only represent the lobbyists who pay for the representation.
Once again - it is not in the federal governments job description as laid out by the Constitution to take care of us in this manner.
Why this is so hard to understand defies all logic. Read the Constitution, for Heaven’s sake. Nowhere does it guarantee the right to medical care. If you find it in there please let us know & I will gladly shut up.
Would 5% equal a take over of healthcare; what about 78%?
Tyates36854 represents many that are concerned about mandates, a point to keep in mind is that we are paying ~ $1,140 each for those that don’t have insurance. Unlike driving which is optional, if we get sick or seriously injured, health care will be delivered, the key question is whether we spread the cost or allow people to “free load” on those of us with insurance or are providers of care. Can we afford not to insure everyone, at least at the current cost level?
Thates26854, specifically, how are any of the bills in question socialized medicine? Is a government seeded option estimated by CBO to cover ~10, million by 2019 a government take over? If so, how?
Currently in 36 states, 3 insurance companies control at least 50% of the market (Health Affairs, Volume 23, No. 6, Nov. /Dec. 2004, Exhibit 1.), BCBS of Alabama maintains between 75% of 78% of the market within Alabama. Is this near monopsony and monopoly competitive? If so, how is it functionally different from your vision of a public option?
David
The core pinion of socialism is socialized medicine. I hope Lindsay Graham is right, that this bill will be DOA when it hits the Senate!
I beleive every American who wants to be insured can be, but we don’t have to have “pork” loaded programs to do it and it does not need to be shoved down our throats!
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