Stimulus and Health Care

HR 5140 in 2008

HR 1 (the Obama Stimulus)

Stimulus estimate chart from Obama transition team (with annnotations)

The real author of contemporary health proposals

In the 2008 campaign, Senator Obama expressed reservations about a mandate. By mid-2009, he changed his mind.

Ross Douthat neatly explains the interest group universe:

The mandate offered the interest groups what all entrenched industries desire: a fresh and captive market for their products. For the insurance companies, it promised enough new business to offset the cost of covering Americans with pre-existing conditions. For the health care sector as a whole, it guaranteed that disposable income currently being spent on other goods and services would be spent on its instead.

This explains why the health care bill was ultimately backed by so many industry lobbying groups, from the Pharmaceutical Research and Manufacturers of America to the American Medical Association. It explains why the big insurers, while opposing the final legislation, never attacked it as vigorously as they did Bill Clinton’s ill-fated reform effort.

By 8/1, Energy & Commerce and HELP approve bills. CQ summary:

Two health care overhaul bills — HR 3200 and a draft Senate bill approved by the Health, Education, Labor and Pensions (HELP) Committee — are similar. Both bills would require employers to provide health insurance to workers and individuals to enroll in an employer-based, private or government health care insurance plan or face penalties. But there are differences in the details.
Employer Insurance Mandate
HR 3200: The bill would require employers that do not offer coverage to pay a payroll tax equal to 8 percent of their payroll costs. Certain small businesses would be exempt.
Senate Committee Draft Bill: For employers that do not provide coverage, the bill would assess a fee of $750 per worker per year, or $375 for part-timers. Businesses with 25 or fewer employees would be exempt.
Individual Mandate
HR 3200: The legislation requires individuals, by 2013, to buy coverage or pay a fine of 2.5 percent of their income — but the fine would be capped at the cost of the average plan in their area. It offers a hardship exemption.
Senate Committee Draft Bill: The bill would make individuals pay a fee of $750 a year if they fail to obtain coverage. As with the House version, it exempts those who have not qualified for any affordable coverage.
Subsidies
Both versions would offer subsidies to those with an income below 400 percent of the poverty level (about $88,000 for a family of four and $43,000 for individuals) down to the eligibility threshold for Medicaid coverage. 

The political climate changes:

• Overall approval rating
• The Tea Party arrives

In the fall, House passes one version, with public option.  The Senate, rather than use the House-passed health bill, instead uses an unrelated tax bill (HR 3590) as the shell for its version.

Scott Brown's election prompts a different kind of procedure:  passing the Senate version, with agreed-upon changes in the reconciliation bill.

The final legislation.

Nourse and Schacter on bill drafting:

Staffers’ drafting choices seem to be driven not by issues of legal dexterity but by the demands of a competing set of virtues—what we  are calling “constitutive virtues.” The interpretive virtues are the  virtues, generally, of courts: precision in drafting, consciousness of interpretive rules, discovery of meaning in past precedent, and detached reflection on the language of particular texts. Constitutive virtues, by contrast, tend to prize the institutional values of legislatures: action and agreement, reconciling political interests, and addressing the pragmatic needs of those affected by legislation.

Over and over again, staffers explained their choices in terms of constitutive virtues—that deliberate ambiguity was necessary to “get the bill passed,” or that statutory language was drafted on the floor because a bill was “needed” by a particular senator, by the leadership, or by the public. Even staffers’ reliance on lobbyists was an attempt to understand how the bill would “affect” people in the world. It was not that the staffers did not know the rules or recognize the interpretive virtues; it was that those virtues frequently were trumped by competing virtues demanded by the institutional context of the legislature. In an ideal world, the staffers seemed to say, they would aspire to both clarity and agreement, but, if there were a choice to be made, the constitutive virtues would prevail.