For the past few months, Barack Obama and his allies in Congress have been striding towards far-reaching reform of the US healthcare system without the public paying much attention. This is changing. Interested parties are studying draft legislation to see where they stand. In spite of the Democrats’ dominance in Washington, reform will not glide through unopposed.
Using a manoeuvre called reconciliation, the administration can get reform through Congress without a single Republican vote. But the Democrats themselves are divided.
They agree on several elements. At least to begin with, private employer-provided insurance will remain the norm. “If you like your present plan”, as most Americans do, “nothing will change”. New mandates, subsidies and a regulated insurance exchange would widen coverage, as in Massachusetts. But controversy surrounds three points: what the reform will cost, how it will be paid for and, especially, what role a new public insurance plan might play.
The nonpartisan Congressional Budget Office is known for its unhelpfully honest analyses. The agency is under attack on health reform even before it has released its numbers: Democrats think these will be unduly pessimistic. Some already want Congress to ignore the CBO and use “directed scoring” instead. (Under directed scoring, policies cost what you want them to.) Even on the administration’s own estimates, reform will cost more than $1,000bn (€714bn, £608bn) over 10 years. Standards have changed lately, but it is still a lot of money.
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