Health Care Bill: The Public Option and Senate Markup

Lori Montgomery
Washington Post Staff Writer
Friday, October 2, 2009; 12:00 PM

Washington Post staff writer Lori Montgomery was online Friday, Oct. 2 at Noon ET to discuss the progress of the bill that would overhaul the nation's health-care system. A Senate panel has twice voted down proposals to create a government-run insurance plan, dimming the prospects for a so-called "public option."

The Senate panel has also quashed plans to tax senior citizens with catastrophic medical expenses and defeated Republican amendments on abortion and immigration. The panel aims to bring the bill before the full Senate within two weeks.

A transcript follows.


Lori Montgomery: Good morning, health care fans. It was a late night at the Senate Finance Committee, which finally wrapped up work on its massive package of reforms at 2:08 a.m. The sausage is still being ground, but I'll do my best to bring you up to speed. So let's get right to it.


Wokingham UK: Do you expect that when this is all over the cost curve will be bent - and in which direction?

Lori Montgomery: This is an excellent question, and one that is very hard to answer. Right now, the best information available suggests that only the SFC bill would bend the cost curve -- and by this, I mean federal spending on health care -- downward, mainly because of the tax on high-end health insurance. But if you're asking whether the bill will lower the cost of health care in general, well, THAT, I think, is anyone's guess.


Richmond, Va.: Carefully done polls of U.S. Citizens and their physicians (Robt. Wood Johnson Foundation, 9/09, show BOTH groups support a Public Option by 60+ per cent.

Why isn't Congress listening to its employers?

Do we need to march on Congress?

Lori Montgomery: Whether you march on Congress is up to you, of course. But the reason the SFC is not listening is because it has many conservative Democrats who are hesitant to expand government's role so dramatically. The issue is not dead, however, and could be revived in Harry Reid's office next week....


Rockville, Md.: What about a turn around in the Conference Committee? Or is that a process only for bills that do not get much publicity?

If the President has a plan, it seems to depend on the Conference bill to fix it.

Lori Montgomery: Let's be clear: This bill will be written in conference committee. Regardless of what passes the House or Senate.


New York, NY: Hi, Lori. Hope you can help me understand this crazy situation. House leaders last week released CBO estimates for liberals' preferred version of the public option that showed $85 billion more in savings than for the version the Blue Dogs preferred. In total, a public option based on Medicare rates would save $110 billion over 10 years. That is $20 billion more than earlier estimates. Can you explain this to me? If the public option actually saves taxpayers $100 billion over the Blue Dogs' proposed plan, why are these so-called "fiscal conservatives" against it? Are the Blue Dogs just pretending to be "fiscal conservatives" as a ruse to get elected?

Lori Montgomery: The Blue Dogs are mainly from rural states, which get screwed under current Medicare rates. Their docs and hospitals are generally paid much lower than the national average. So many Blue Dogs and other rural lawmakers want to see a change in the Medicare formula before they would be willing to support yet ANOTHER big insurance system based on rates that hurt their providers.


Questions on Filibuster: Given how much reporters write about the need for 60 votes to break a filibuster, it's pretty stunning that you guys never get around to asking Senators whether they'll vote to sustain or end a filibuster. Isn't it long-past time for reporters to start asking Senators if they will filibuster the public option -- not just whether they "support it," or "think it has enough vote," but "will they filibuster it"? Has the Post reported on this and I've just missed it?

Lori Montgomery: I've asked this question, too. Sen. Ben Cardin D-Md. told me he thinks Democrats ought to make the Republicans filibuster on health care. Make them do a real 24-hour gabfest. But the Senate can't operate without cooperation between the parties, so the SOP is to negotiate bills onto the floor.


Fairfax, Va.: Is there any chance at all that there will be a public option of some sort in the final bill?

Lori Montgomery: See above. Less than 50 percent, I'd say, but still quite possible.


Carlsbad, Calif.: We need incremental change not revolutionary change.

Institute changes that will facilitate tort reform.

Allow private organizations to manage insurance exchanges, including retailers such as Wal Mart, Target, Costco, K Mart; clubs and fraternal organizations; credit unions

Allow insurance companies to sell health insurance across state lines

Eliminate requirement differences from state to state.

Eliminate pre-existing condition issue

Require companies that provide health insurance to their employees to allow employees to bring their own insurance with them with the company paying an amount equal to the premium the company pays for its own group health insurance.

Lori Montgomery: OK. That's a thought.


Friendship Heights, Md.: Assuming the major elements of the Baucus bill become law I am having a hard time seeing what the major insurance companies would object to.

Sure they finally have to cover pre-existing conditions and they will have less leeway to deny claims. But the bill will force (and subsidize with Federal money) a significant number of mostly healthy Americans who currently don't have any health insurance into the system. And they will be forced to buy into bloated rates sold by extraordinarily profitable health insurance companies.

What I see is more and more Americans being forced to participate in a system that is mostly a big rip off - we pay a lot for poor service and poor outcomes. Why would insurance companies object to this bill and why would the average American who is fed up with the current system support it?

The only way the Baucus bill would make sense is if the Federal Government were to step in and heavily regulate these private insurance companies so their prices are fairer and their services better. But I don't see that happening right now. Am I missing something?

Lori Montgomery: Well, there is a substantial amount of insurance regulation in the bill. it would end the pre-existing condition thing, as well as recissions and annual and lifetime caps on coverage. It would require everyone to buy minimum creditable coverage that limits out of pocket expenses to a far greater degree than most individual policies do now. And SFC last night tried to slap a cap on pay for insuranced executives. so there are a number of changes for the industry, but whether they bring prices down is a whole different matter


Silver Spring, Md.: Note to Harry Reid and Nancy Pelosi:

If the Public Option is dead, the Democratic Party is dead to me. I'll go back to voting third party until you rid the Democratic Party of Blue Dogs.

What's the use of a supermajority if you refuse to use it? Lead or get out of the way.

Lori Montgomery: OK, but why? That seems a little short-sighted.


Houston Tex.: Who do you think might be on the conference committee?

Lori Montgomery: Leading members of the committees that passed the bills.


Using reconciliation?: Any more insight on whether the use of the reconciliation option is still on the table? The GOP used it several times to push through their preferred agenda. Why not the dems?

Lori Montgomery: Reconciliation is not likely to be needed. The Democrats have 60 votes now. If they can pull together and win over Olympia Snowe, they'll be in good shape. Besides, the reconciliation process is so fraught with danger, I never thought it was a likely option


Princeton, N.J.: A public option is a big error. We need a government run universal plan like HR676 (only 70 pages long) which simply gives an improved Medicare to every man, woman, and child in America. This is supported by margins of 2 to 1 in many polls including the Post - ABC poll.

The main reason that it is far better to extend Medicare to everyone is cost. Private insurance companies waste about $400 Billion each year in high overhead and physician and patient compliance costs. There is another $100 Billion wasted on high drug prices to companies that spend 3 times as much on "marketing" as on R & D. This $500 Billion each year can be used to pay for the extension of Medicare to everyone. If you simply add a public option and keep for profit insurance, you are leaving the $500 Billion on the table. You are simply adding cost. This is not smart .

Lori Montgomery: Many people would agree with you. But they don't have the votes in Congress.


Cambridge, Mass.: I am appalled at the terrible coverage of health care in the last 4 or 5 years, before single payer was "taken off the table". As Ezra Klein of the Post has reported he has attended many meetings where single payer advocates were polite, informed, and dominated the questions, but "The media hasn't shown the slightest inclination to cover their presence at event after event after event."

To this day I have never seen an article, column, or editorial that analyzed the waste in private insurance and drug company marketing which many believe totals $500 Billion every year. Now, when it it way, way, way too late, we get a few article examining how other countries get better health care at half the cost.

Health care reform represents a triumph of special interest over the good of the American people, and the media has contributed to this failure of democracy by not not only supporting the lack of consideration of the best ideas, but also preventing even discussion of these ideas.

Lori Montgomery: Single-payer was off the table before the Congressional debate began. That's why you don't see most policy reporters wasting time on it.


Chantilly, Va.: If Blue dogs are worried about the rates that would be paid to providers in their states and hence not supporting a public plan, why don't they offer a public plan with some features which would address this problem. Hundreds of amendments have been offered. Or have they won seats with thin majorities and are worried there might be some kind of backlash from some independents who voted for them in the past which would result in their losing their seat in the next elections?

Lori Montgomery: They have. It's the alternative public plan based rates negotiated with providers. But liberals don't like THAT option.


Princeton, NJ: I don't think Carlsbad has looked at the data.

"Eliminate pre-existing condition issue" - if you do this without more regulation, people will wait until they get sick to get insurance.

"Allow insurance companies to sell health insurance across state lines" - Think about the credit card cos all of which are in SD or DE. If we do this we will get even more useless policies.

"Institute changes that will facilitate tort reform." - The CBO has a couple of definitive studies that show tort reform saves NO money. It merely prevents people from seeking redress for their ills.

Lori Montgomery: Good points, as well


HELP me understand: The only committee to put forth a bill without a public option has been the Finance Committee. By contrast, both the HELP and House bills were actually voted and passed by full committees before the August recess and both include a public option. Why does the Finance Committee's bill trump the others?

Lori Montgomery: Because it more closely mirrors the Senate politically. The Baucus bill was essentially drafted by three moderate Democrats and three Republicans. It is a centrist package that Senate leaders hope will win over the caucus. And this debate is all about what can pass in the Senate. The assumption is that Nancy Pelosi will be able to rally the House to do its job, whatever the outcome in the upper chamber. Though that's been looking less certain lately!


Fairfax, Va.: Since Obama has for all practical purposes given up the public option that he supported as a candidate, what is the likelihood that it will survive the conference committee negotiations?

Lori Montgomery: Like I said, less than 50-50. Unless they come up with some variant that can win broad support in the Senate.


New York, NY: We understand the 60-vote "supermajority" is fantastic and all. But it's meaningless without full and complete Democratic support. So I must ask again: Will any of the 60 democrats filibuster the health care bill if it includes a public option? Have you asked them this simple question yet? Has anybody?

Lori Montgomery: No. Democrats are not going to filibuster their own bill. But they could have the same impact by refusing to vote for it.


DC: We really should stop calling it a public option, because if it was put in place, I, as a taxpayer, would have no choice when its bailed out for under-pricing risk. It is like saying that I had the option of having my mortgage bought by Fannie Mae or not...sure but I'm still paying the cost of the bailout. Name me one federal insurance program that over the long run hasn't lost money. The politics are always toward under-pricing, whether its mortgage insurance, flood insurance, social security, etc.

Lori Montgomery: Health care fans?


single payer was off the table before the congressional debate began.: But was it always "off the table"? Maybe it was put off the table because it got no coverage.

Lori Montgomery: I don't think media coverage had much to do with the political calculation that the nation was not ready for single-payer. The implosion of hillarycare had a greater impact, I'd say


Southern Maryland: Whatever the faults or merits of the public option, it's misleading to claim that it would amount to a "government takeover of health care." How much of that claim is simply a scare tactic, and how much comes from fear or a lack of information?

Lori Montgomery: This is a republican talking point that democrats are clearly afraid of.


but they don't have the votes in congress : Why not? Because the reps were bought?

Lori Montgomery: Um, no. Because our fine representatives in Washington believe the people they represent would not be happy with the result. Not everything in the world is a vast conspiracy.


Rockville, Md.: " Let's be clear.."

I wish others would be so clear. It seems that they avoid the topic.


Lori Montgomery: Happy to oblige!

Less happy about the prospect of long hours staking out those conference committee meetings, though...


essentially drafted by three moderate democrats and three republicans.: Come on! At most ONE of those 3 Republicans support it. And she may be the only one in the whole Senate!

Lori Montgomery: Yes, but they all helped to draft it. And that's why you saw so few dramatic changes during the markup over the past two weeks.


Arlington, Va.: Isn't it still in the best interests of the Republicans to prevent a bill from coming to a full vote by using the rules of the Senate to require 60 votes from the Democrats? It sounds like at least a few Democrats would vote with them, negating a handful of Republican defectors. It would seem like scaring the electorate into dooming any type of health care reform bill would be their best path to retaking the House and Senate next year. Voters never seem to know or care who's at fault for things that happen or don't happen in Washington - they simply blame the party that's in power.

Lori Montgomery: Yes, it seems clear that the GOP leadership would like to see this bill fail. But Democratic leaders are about to embark on a big horsetrading session to make sure their reluctant members come on board and the 60 votes needed for passage are happily united.


"republican talking point": Yes, Lori. We know it's a scary GOP talking point. The question is whether it's true, or not. Is it valid to say that the public option is a "government takeover" of healthcare? Yes? No?

Lori Montgomery: Personally, no, I don't think offering a public insurance plan as an option amounts to a "government takeover" of health care. But I'm not sure my opinion matters much. Republicans keep saying it, and seem to think it's effective.


Washington D.C.: Does the health insurance industry have any input into the legislation? And why?

Lori Montgomery: Of course, they do. Because, like you and me, they are American citizens, too. Believe it or not!


I, as a taxpayer, would have no choice when its bailed out for under-pricing risk.: And I as a taxpayer have no choice when my tax dollars are used for faith-based programs, abstinence-only programs, etc.

Lori Montgomery: There you go.

By the way -- why so much focus on the public option here? Isn't anybody here concerned about what I think is a much bigger issue: the prospect that many people could be required to buy insurance they can't afford? These bills have a MANDATE, people. with FINES attached. Anyone?


the implosion of hillarycare had a greater impact, : But in 2003, well after Hillarycare, the Post - ABC poll asked:

"Which would you prefer: the current health insurance system in the United States, in which most people get their health insurance from private employers, but some people have no insurance, OR, a universal health insurance program, in which everyone is covered under a program like Medicare that's run by the government and financed by taxpayers?"

62% favored Medicare for All; 33% were opposed. That's pretty decisive. A more recent NY Times poll had support at 72%. A Pew poll showed doctors supported it by 59%.

Lori Montgomery: Unfortunately, polls do not necessarily control votes in the U.S. Congress.


Bellevue - The hospital, not the city!: I keep seeing people in these chats quote a 60-80 percent support for a public option. I think polls that show this are very problematic in their phrasing. To the extent that Americans know what they want, I think the figure cited is very misleading if not inaccurate.

Lori Montgomery: Bellevue, you ain't crazy. I think you're right.


you and me, they are American citizens, too.: But you and I did not give Baucus and friends millions of bucks. We do not spend $1.4 million a day to get quality health care in the US as the insurers spend to protect their scam.

Lori Montgomery: As American citizens go, they have a disproportionately loud voice.


New York: I do not see any provisions to guarantee that "cost to service" is assured. As there is no provision in the bill to assure a minimum level of service at a regulated rate. There is no assurance that insurance companies will lower their rates based on an increase in market size. Their ability to limit risk is being limited which will only make a case for higher rates not lower or more affordable rates. I see this as a short sighted effort which will result in families having to choose between feeding their children and making sure to "stay out of jail" by paying what, in effect, is an informal health tax.

Lori Montgomery: This is pretty much the Republican argument. And several democrats on SFC are also worried. Last night, you saw the committee adopt several amendments to ease the impact, including a clear statement that no one will go to jail for failing to buy insurance or pay the fine.

I think affordability is going to be a huge issue as this debate moves forward.


the prospect that many people could be required to buy insurance: Look, you have to have something like this if you are going to cover pre-existing conditions. It's a no-brainer.

For Bellevue - I quoted a question. Did you find it misleading?

Lori Montgomery: Bellevue?


Manassas, Va.: I don't think anyone will FORCE anyone to take the public Option. Look the way insurance works is people who stay relatively well, and pay their premiums are essentially, helping to support those who are sick or have chronic conditions. This is because they don't need or use their benefits as much as those who have diabetes, or cancer or whatever condition. All that I heard is that Obama wants the public option to be run the same way.

I have a question for those who are against the public option. Uh, do you accept Medicare? Its a public option. Do you accept Medicaid, its a public option. I've been off of health insurance. Sometimes my doctor visits are slightly cheaper than what my co-pay would be. Who's providing the difference right now? Uh, the public! And Congress doesn't want a public option?!

Lori Montgomery: !


You don't need supermajority to pass a bill: They don't need 60 votes for passage. They just need 60 votes to head off a filibuster. Once it gets to the actual vote, don't they just need 51 votes? You said before that none of the Dems would vote to filibuster... that means it's going to the floor. Right?

Lori Montgomery: There seems to be little doubt that the bill will go to the floor. and Democrats seem quite confident that they can unite the caucus and avert a filibuster (60 votes). When all that's done, you're right: 51 votes to pass.


Beaumont, CA: In my opinion, Chairman Baucus' "mark" was a very responsible and balanced proposal that will serve our country well. His masterful leadership during the past couple weeks demonstrated an in depth knowledge of the unbelievable complexities of the health care issues that I found very, very reassuring. I am a supporter of President Obama's "urgency of now" need to change the way our Federal democratic republic works and the importance of addressing our broken health care system. I just wish he had not put people like Baucus in such an awful box when he declared months ago that you can keep your present medical insurance if you want, and it will not cost you anything more in taxes to do so. That silly promise was used by the Republicans to hang around poor Senator Baucus's neck during the last two days. In truth, their are millions of American's today who pay practically nothing for their Cadillac type plans; this is totally unfair and inequitable. Health insurance must be treated like other national priorities and everybody must be in it from birth to death. They must include premiums in their yearly budgets just like they plan for the costs of food, shelter and car insurance. Those millions not spending anything today for health insurance are going to have to pay more through taxes and fees. I think Senator Baucus kept us focused in that direction!

Lori Montgomery: Here's a different point of view. You aren't Max's mom, are you?


Mandates: Why are there still mandates, if there may be no public option? If there's no real reform, why gift the insurance industry with millions of new customers?

Lori Montgomery: The democrats would argue that their bill does contain real reform. The public option is not the only path forward.


SF, CA: "single payer was off the table before the congressional debate began. that's why you don't see most policy reporters wasting time on it."

I'm so tired of hearing this lame argument. Journalists are NOT supposed to be stenographers for the people in power! They are supposed be be advocates for the public. Sometimes the real story is about WHY something is "off the table". Remember the Iraq War?

Lori Montgomery: And sometimes the real story is what your representatives actually plan to do to you, which is where most of us are focusing our attention right now.

Look, if single payer advocates had been able to rally support among the various constituencies pushing health care this time, it would be on the table. They didn't. That is not the fault of journalists.


Washington, DC: I just don't understand the obsession with the public option. Many European countries provide health care for all with private insurers and self-employed doctors. In fact, some of those countries have most successful plans in Europe. It just seems to me that "public option" has become a mantra to the left-wing without regard to the facts. Republicans must be quite happy to read these posts about "no public option, no votes for the Democrats."

Lori Montgomery: Are YOU Max's mom?


Princeton, NJ: People keep avoiding the main problem. Competition, the free market just doesn't work for health insurance just as it didn't work when we had for profit fire departments. The reason all this stuff is so complicated and messy is because the core is rotten. If the first principle of health care reform is to preserve the obscene compensation of insurance executives and the high returns to their wealthy stockholders, no matter how many pages long your bill is, it just won't work.

No other country has a health care system based on the free market; it has failed spectacularly in the US.

HR676 is just 70 pages long and gives everyone decent coverage for less than we are now paying. It is simple.

Lori Montgomery: Friends?


So... are they gonna get 50?: Before you seemed to be saying that it's going to be difficult to pass a bill with a public option, then you said the dems won't filibuster and the bill (even with a public option included) and it will therefore make it to the floor for a simple-majority vote. Do you think there won't be at least 50 democrats voting for it if there's a public option, out of the 60? Who are these 10+ recalcitrant Democratic Senators, then?

Lori Montgomery: Look, here's the math: to take a bill to the floor, they need consent. That means nobody objecting to it. Then they have to be sure they can avert a filibuster. That means 60 votes. Then they need 51 people who are willing to vote for the thing. weakness at any point creates an opening for the opposition to block the bill.

But the political reality behind the numbers is that the Democrats have to satisfy pretty much their ENTIRE caucus. That means compromise.


To Washington:: "Many European countries provide health care for all with private insurers and self-employed doctors."

Name one European country that relies SOLELY on private insurers? France? Nope -- they have a public plan that is supplemented by private insurance. Germany? Wrong again! So where are these countries you're talking about?

Lori Montgomery: Washington?


various constituencies pushing health care this time: Who are these constituencies I didn't write letters to or call up or !@#$%-&-&-%$

Health insurers? Big Pharma? Who?

Lori Montgomery: There are loads of groups on the health care bandwagon, including labor unions, the AARP, small and large business groups, etc.


Washington, D.C.: Why not collapse Medicare, Medicaid, S-chip, Tricare and others into one health care program? Forge towards universal health care.

Lori Montgomery: Yikes. You think the screaming is bad now?


Polls are skewed: Asking people if they support insurance for all doesn't delve into the question of how much they are willing to pay for it. And if you are someone like me, with decent private coverage that will likely be subject to the "Cadillac" plan tax, your support may dwindle. A lot of middle class people, already bearing the brunt of the uninsured financially, would again pay for the leveling of the playing field.

Surveys are largely useless when the respondent doesn't have the entire picture.

Lori Montgomery: You must be very sick or very well insured. The Cadillac plan tax, as currently written, hit less than 15 percent of policies nationally.


To Max's Mom: LOL... even France and Germany both have "government-run systems." And the government intrusion into those systems is far greater than anything this country is contemplating, even with a public option. And don't even start with U.K. and Canada, which are single-payer government run in their entirety.

Lori Montgomery: Here you go, Mom.


Name one European country that relies SOLELY on private insurers?: Switzerland & perhaps the Netherlands, but in Switzerland, the government writes a basic policy that all insurers have to offer, the government sets the price, and the cos can make NO profit on it.

Lori Montgomery: Insight from across the pond


Costs UP?: If the reason most people who don't have health care is the cost, it seems counter intuitive to ask them to buy insurance which (being of plainest vanilla type) may not be very useful. There are likely lot of people outside of the categories which would be subsidized under the reforms who are in this situation. What specific measures are in the bills to bring down the cost? Refusal to provide insurance for pre-existing conditions, removal of caps all seem likely to push up costs than down.

Lori Montgomery: There are a lot of provisions in the bill that would seem to increase costs. But democrats are hoping that they will bring costs down for most people by pushing young, healthy folks into the pool, and by encouraging competition in the exchanges. There is also the very optimistic belief that pilot programs to reform Medicare -- the nation's largest insurance plan -- will encourage providers to practice more efficient medicine, bringing costs down for everyone.


labor unions, the AARP, small and large business groups: Labor unions support single payer. AARP is an insurance company. Many business groups do support single payer. Only the ones driven by ideology don't and you can't change a closed mind.

Lori Montgomery: So where are they? I guarantee you that labor has a very loud voice at the table right now.


Argh! I don't get it!: You wrote: "...they have to be sure they can avert a filibuster. that means 60 votes." But you already said no Democrat would vote against cloture, didn't you? That means 10 Senators would have to defect during the actual floor vote. I'm asking, if you really think there are 10 senators who would actually vote against a final bill (whatever it includes)? (Btw, I say 50, because we know that Biden would vote as the 51st, in a tie-breaker).

Lori Montgomery: No, I didn't say that no democrat would vote against cloture. I said no democrat would filibuster. There's a bit of a difference.

The whole idea, though, is to write the bill so you're sure that all 60 democrats can support it. Again, that means compromise.


Rockville, Md.: What are the chances for a government run malpractice system - much like crop insurance or flood insurance?

Lori Montgomery: Bad.


polls do not necessarily control votes in the U.S. Congress. : You keep dancing around the question. Why don't our representatives vote for the best plan when it is what the people want?

Lori Montgomery: Because the people want different things!


We need a public option: The insurance companies have not done a good job "insuring" people. This has been stated in many stories, and I know I've had to fight them on some basic things myself. We do need a public option so it's fairer for people who can't afford to spend the money on insurance for their families. I am totally appalled that so many people are too concerned about the insurance companies and are worried about the "cost" of the public option, but they don't seem concerned that a teacher who is single but has kids has to pay an additional $200 a month for insurance - and that doesn't include co-pays, what's not covered, etc. The insurance companies have been making far too big of a profit, and I'm totally disgusted with the Democrats and the "Blue Dogs" for caving in to them. I'm really glad I didn't contribute my time or $ to any of them.

Lori Montgomery: Well, public option will have to have the last word. My time is up. Thanks for joining us here in the Wapo chatroom.


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