American health-care reform

Presenting the bill

The stage is set for crucial vote on America’s health-care reform bill

IT’S official, or as official as these things get. The health-care package destined for a vote in America’s House of Representatives on Sunday will cost $940 billion over the next ten years. Though the Congressional Budget Office score (as the estimate is known), along with the bill's final details, seems to clear the air on what the House will vote on, the package and the process remain complicated. The House is facing a two-part vote to pass the Senate bill and also tweaks through a process called “reconciliation”. The former may be done through a rule that Republicans are saying is unconstitutional (though they have used it themselves). Procedural trickery or not, everyone in the House will cast a vote on the Senate bill plus reconciliation. Whether it passes or not is far more important than quibbles about the House rules.

The CBO also reckon that the health-care package, through savings and new revenue, will cut the total deficit over those years by $138 billion against a baseline scenario. After that, the savings get even bigger, totalling (a much more speculative) $1.2 trillion by 2029, according to some Democrats. But the sums are questionable. The CBO process has been so thoroughly gamed that the true figures could be quite different. The Republicans claim that it will cost far more and totally reject the idea that it will cut the deficit by such a sum over the second decade.

The CBO is required to score what Congress says it will do, not what it is likely will actually be done. Republicans have accused the Democrats of ignoring some spending and promising spending cuts that may never come. Revenues from an excise tax on “Cadillac” health plans may never materialise. And spending has been back loaded to disguise its scale. Nevertheless Democrats are crowing, and Barack Obama has postponed a trip to Asia to be present for the vote, the scene is set for drama.

The CBO said that it had not had time to compare fully the reconciliation proposal to earlier versions. But the Democrats claimed victory nonetheless. They see the numbers as so favourable that they have started talking about “the largest deficit reduction of any bill we have adopted in Congress since 1993” even before mentioning that it will also extend health insurance to 95% of the population. Jim Clyburn, the Democrats’ whip, said he was “giddy” over the CBO score.

This is crucial because of the number of Democrats still on the fence though the CBO’s score won a few more firm commitments of support from previously wavering Democrats. Every Republican in the House will vote against it. So Nancy Pelosi, the House speaker, must convince some who voted no to a previous House bill—quite different in many respects—to vote in favour this time. This includes deficit hawks: “Blue Dog” Democrats in conservative districts.

Another issue is trickier. Many pro-life Democrats voted for the previous House bill did so because of the “Stupak amendment”, a provision that would restrict money for abortions in the new health-care system. The Senate bill has looser, but convoluted, language. Some pro-life Democratic House members say that they are satisfied that the Senate language will not lead to looser abortion rules. Others, including Bart Stupak, author of the original House amendment, say they cannot vote for the bill. How the rest of a group of his putative allies, called the “Stupak 12”, plan to vote will be vital.

The reconciliation deal involves a few significant changes. Perhaps the biggest is the cutting of a provision letting federal regulators look out for and punish sudden and “unjustifiable” rises in private health-insurance premiums. Giveaways to favoured groups to get the bills through earlier—a sweetheart deal for the state of Nebraska on Medicaid costs, and favourable tax treatment for unionised workers—will now be extended to everyone. This added to the bill's cost. So subsidies for individuals to buy insurance will have to be phased in more slowly.

News that the president would stay in Washington this weekend, postponing a trip to Guam, Indonesia, his boyhood home, and Australia is being read in two ways. Those who think the bill is now a done deal say the White House and the Democratic leadership in Congress would not set up the president for a term-wrecking humiliation and that the bill will surely pass. Those who think the bill is still in doubt wonder why the president would not happily depart if the bill were, to use the words of his 2008 campaign theme-song, "signed, sealed, delivered". A presidency is on the line making for the most memorable Sunday in domestic politics in many years.