Health Reform: An Online Guide

Links to everything you need to know about the Patient Protection and Affordable Care Act of 2010.

Legislative Text:

Thehealth care law is actually two laws.

The first, the Patient Protection and Affordable Care Act of 2010, is the bill as passed by the Senate, 60-39, on Dec. 24, 2009, and by the House,  219-212  on March 21, 2010 (section-by-section analysis here). It was signed into law on March 23.

The second, the Health Care and Education Affordability Reconciliation Act of 2010, consists of changes to the first made under Senate reconciliation rules in order to prevent a filibuster. The first  part comprises the bulk of the reconciliation act (section-by-section summary here). The second  part is a manager’s amendment (summary here). The third and final part consists of two minor changes concerning Pell grants that were made by the Senate. The first two chunks of the reconciliation act passed the House, 220-211, on March 21. All three parts passed the Senate, 56-43, on March 25. The third part passed the House, 220-207, on March 25. The reconciliation bill was  signed into law  on March 30. A section-by-section summary of the entire reconciliation act is available here, and a summary of both laws (minus the parts concerning student loans) is available here, here  and here.

More detailed summary information about both laws is available here and here. On March 20 the Congressional Budget Office issued its final estimate  on the two bills’ cost. CBO calculated the legislation would save $143 billion over ten years while extending coverage to 32 million of the 45 million uninured.

Consumer and Provider Information:

The American Medical Association (which endorsed the final bill) has an FAQ for consumers here  and a summary for doctors here.

The Kaiser Family Foundation has a tool for calculating health care subsidies  under the new health reform laws. Katharine Seelye of the New York Times explains how to use it here. Kaiser also has a good timeline of when key provisions of the laws take effect.

The New York Times published a handy interactive chart  on March 21 showing how health reform will affect the insured and the uninsured.

Comparison Charts of House, Senate, and White House Bills/Proposals:

The Kaiser Family Foundation  has a superbly detailed chart, updated March 23, comparing the House- and Senate-passed bills from Oct. and Nov. 2009 with the final bills signed into law in March 2010. You can also create your own comparison chart, choosing to highlight various topics as treated in various proposals.

The Commonwealth Fund’s chart is nicely interactive and fairly detailed. Updated March 18, it covers the House- and Senate-passed bills and also the House reconciliation bill. A separate chart  that details the bills’ insurance provisions also covers these.

Pro Publica has a side-by-side chart, updated March 21, showing precisely how the House reconciliation bill (including the manager’s amendment) changed the legislative language of the Senate-passed bill. Not for dilettantes!

The Wall Street Journal’s chart, updated March 22, includes the House- and Senate-passed bills from oct. and Nov. 2009 with the final bills signed into law in March 2010.

The House committees on Ways and Means, Education and Labor, and Energy and Commerce created a comparison chart on Dec. 29, after versions of the bill had cleared both the House and the Senate. It ‘s pretty detailed, but it doesn’t cover changes made in 2010.

Congressional Budget Office:

May 2010 letter to Rep. Jerry Lewis, R.-Calif., calculating “discretionary spending” costs relating to health care reform at $115 billion over the next ten years. These costs are associated with administering the law through the health and human services department and the internal revenue service and providing grants newly authorized under the law. A previous CBO estimate in March calculated discretionary costs at $50 billion. Of the $115 billion, roughly $86 billion  is already included in the budgetary baseline, i.e., it’s being spent already. So the new discretionary spending necessitated by Obamacare would really be about $30 billion, assuming congressional appropriators choose to spend it all (which would be unusual). On the other hand, the $30 billion in new spending does not include funding for a number of new grants created under the law whose cost the CBO finds itself unable to calculate because the bill language offers no guidance beyond the boilerplate “such sums as may be necessary.”

March 2010 letter to Rep. Nancy Pelosi scoring the reconciliation bill as saving, in combination with the Senate-passed bill, $138 billion over the next ten years and extending coverage to 32 million of the 45 million people who are currently uninsured.

March 2010 letter to Sen. Harry Reid scoring the Senate-passed bill three months after the vote (and before the planned final vote via budget reconciliation of modifications by the White House and the House of Representatives). CBO now says the bill saves $118 billion over the next ten years and extends coverage to 31 million of the 45 million people who are currently uninsured. This estimate does not take into account any changes that will be in the reconciliation bill. The RAND Corporation ran some numbers  on the president’s Feb. 22 proposal.

December letter to Sen. Harry Reid scoring his “manager’s amendment” (which secured the vote of Sen. Ben Nelson, D.-Mont., who is believed to be the 60th vote for a filibuster-proof majority) as saving an additional $2 billion over ten years and extending coverage to the same 31 million of the 45 million people who are currently uninsured.

November letter to Sen. Evan Bayh estimating the effects of the “blended” Senate bill on private health insurance premiums. CBO calculates that in 2016 the bill would increase premiums in the nongroup market by 10 percent to 13 percent, but that among those purchasing nongroup policies in the new exchanges, fully 59 percent would be paying substantially less than sticker price because they would qualify for federal subsidies. For those receiving subsidies, the bill would lower premiums 56 percent to 59 percent. CBO calculates the bill’s effect on premiums in the employer-based market to be virtually nonexistent.

November letter to Sen. Harry Reid scoring his “blended” Senate bill as saving $130 billion over the next ten years and extending coverage to 31 million of the 45 million people who are currently uninsured. As with the Pelosi “blended” bill, CBO estimates that premiums for the public option would be higher than those for private insurers, not lower, as anticipated before CBO’s analysis of the Pelosi bill was released. Somebody must’ve told CBO chief Douglas Elmendorf that they’d slap him if he called yet another CBO’s analysis “preliminary,” because this analysis is not billed as preliminary.

November letter to Rep. John Dingell scoring Speaker Pelosi’s “blended” House bill as altered by Dingell’s manager’s amendment as saving $138 billion over the next ten years. It took CBO three tries to arrive at this number. Its first estimate put the amended bill’s ten-year savings at $129 billion (compared to the earlier $104 billion savings prior to the manager’s amendment; see October letter to Rep. Charlie Rangel, below). Then, after the manager’s amendment was revised, CBO altered its ten-year savings estimate downward, to $109 billion. The $138 billion savings figure was arrived at after CBO realized it had made a mathematical error.

November letter to Rep. John Boehner scoring the GOP’s proposed substitute for the Pelosi bill as saving $68 billion over the next ten years and extending coverage to three million of the 45 million people who are current uninsured. “Three million” is not a typo. The GOP bill would save significantly less money than the Pelosi bill and would leave “the share of legal nonelderly residents with insurance coverage” essentially unchanged. This analysis is “preliminary,” apparently the only kind CBO is making these days.

October letter toRep. Charlie Rangel scoring Speaker Pelosi’s “blended” House bill as saving $104 billion over the next ten years and extending coverage to 36 million of the 45 million people who are currently uninsured. The bad news for Pelosi’s compromise “level playing field” public option (see page six) is that its premiums would be higher than those for private insurers, not lower, as anticipated. This analysis, like CBO’s analysis of the Baucus bill (see below) bills itself as “preliminary.”

October letter  to Sen. Max Baucus forecasting that the finance committee bill as amended during markup will save $81 billion over ten years and extend health coverage to 29 of the 45 million people who are currently uninsured. The analysis, produced in collaboration with the Joint Committee on taxation, is “preliminary.”

September letter toSen. Max Baucus forecasting that his chairman’s mark will save $49 billion after ten years and extend health coverage to 29 million of the 45 million people who are currently uninsured.

September letter to Sen. Mike Enzi forecasting that a “public option” government health insurance program would exert competetive pressure on private insurers “to a small degree,” and that public-option premiums would end up being “roughly comparable” to premiums in the private market. That’s because the public option would likely “attract enrollees who, overall, are less healthy than average,” a problem arising in part from restrictions in the various House and Senate bills on how aggressively the public option could negotiate prices with doctors and hospitals. Although the public option would be risk-adjusted (i.e., the sicker its enrollees, the larger a share it would receive of government funds), the CBO predicts that such risk-adjustment wouldn’t likely be sufficiently precise to keep premiums low. (The Princeton sociologist Paul Starr, a veteran of the Hillarycare wars, has been  predicting this scenario  for some time.)

August letter to Rep. Dave Camp about the House health reform bill’s impact on drug spending by Medicare beneficiaries. The CBO calculates that while average premiums would increase 5 percent in 2011 and 20 percent by 2019, out-of-pocket costs for drug purchases would decline due to the bill’s creation of a rebate program for Medicare beneficiaries who are also enrolled in Medicaid (about one-quarter  of the total) and to a phasing-out of the “donut hole,” a gap in coverage for seniors who spend more than $2,700 annually on drugs but less than $6,154. (These amounts change from year to year.)

August letter to Rep. Nathan Deal arguing that preventive care typically “leads to higher, not lower, medical spending overall.”

July 2009 letter toRep. Dave Camp estimating that six million people would purchase health insurance through the House bill’s proposed health insurance exchanges, and that two million of these would select the public option. The CBO disputes an estimate by the Lewin Group (see “The Cost and Coverage Impacts Of A Public Plan,” above) that more than 100 million people would enroll in the public option if all employers were given access to the exchanges. (Under the existing bills, only small employers are) The CBO does not give a figure of its own, but says its estimate would be “substantially smaller.”

July 2009 letter to Rep. Steny Hoyer scoring savings from the White House’s proposed Independent Medicare Advisory Council, a Federal Reserve-type agency that could impost cost reductions on Medicare with minimal interference from Congress, at a measly $2 billion over 10 years, thereby dashing White House budget director Peter Orszag’s hopes that the IMAC would be a political “game-changer.” The CBO believes “the probability is high that no savings would be realized … but there is also a chance that substantial savings might be realized,” and that after 10 years the IMAC “would generate larger but still modest savings on the same probabilistic basis.”

July 2009 letter to Rep. Charles Rangel scoring the House bill as costing a whisker over $1 trillion over ten years. This doesn’t take into account the bill’s proposed measures to raise money, which include a surtax on high incomes.

July 2009 letter  to Sen. Ted Kennedy scoring his bill as costing $597 billion over 10 years and halving the number of uninsured Americans. Jonathan Cohn of the New Republic writesthat this does not take into account a planned expansion of Medicaid that does not fall under the Kennedy committee’s jurisdiction. That would increase the bill’s cost to at least $1 trillion, Cohn estimates, but would very nearly eliminate the ranks of the uninsured.

June 2009 letter  to Sen. Ted Kennedy scoring his bill as costing $1 trillion over 10 years and extending coverage to only 16 million of the 45 million uninsured. The cost is high and the coverage is meager because the estimate assumes no “pay or play” provision for employers, no public option, and no “individual mandate” requiring all Americans to purchase health insurance. Kennedy’s HELP committee is still trying to hammer these out.

June 2009 letter to Sen. Kent Conrad on budgetary impacts of health reform. Reviews various policy options.

Key Issues in Analyzing Major Health Insurance Proposals,” December 2008.

Centers For Medicare and Medicaid Services (studies by chief actuary).

Rick Foster, chief actuary for the Centers, has been more pessimistic  about health reform’s potential for cost savings than CBO. Click here for his Nov. 13 letter about Medicare cuts proposed in the House bill, which he considers problematic. Click here for his less-publicized Oct. 21 letter projecting that the House bill would reduce federal spending by 2 percent over 10 years. Click here for his Dec. 11 letter projecting that the Senate bill would increase slightly the percentage of gross domestic product dedicated to health care spending. Click here for his Dec. 11 letter about the Senate bill’s Medicare provisions repeating the concerns raised in his Nov. 13 letter.

White House:

White House Web Page on Health Reform. This site appears to exist only for the purpose of propaganda; for hard information you’re much better off going to the main White House Web page. Click here for President Barack Obama’s compromise proposal, released Feb. 22 in advance of the televised Feb. 25 bipartisan meeting at Blair House. C-span archived video of the entire seven-hour meeting (morning session, afternoon session). Warning: It’s dull. You’re better off skimming the transcript (morning session, afternoon session). Click here for the March 2 letter that the president sent congressional leaders after the Blair House meeting, incorporating some Republican ideas into his Feb. 22 proposal. Click here for a version of same as annotated by Slate.

The rationale for the Obama plan’s proposed price controls on health insurance premiums (later tossed out to accomodate the Senate parliamentarian) was spelled out Feb. 18 in  this Health and Human Services department memo. In a blog post, the Congressional Budget Office said it lacked sufficient detail to calculate the proposal’s budgetary impact. The RAND Corporation made its own calculation, though. Click here for Slate’s glossary of health reform jargon and slogans.

Click here for Obama’s Sept. 9, 2009 speech to Congress. Click here for the text of an earlier White House plan (really just a sketchy outline) unveiled that same night. Click here for Obama’s July 22 press conference on health care. Click here for Obama’s June 15 speech to the American Medical Association. Click here for “The Economic Case For Health Reform,” a report by the White House Council of Economic Advisers. Click here for candidate Obama’s health plan during the 2008 campaign. (This last is not on the White House Web site.) Click here for a handy compendium of all Obama White House statements relating to health care.

The text of President Obama’s St. Crispen’s Day-style remarks to the House Democratic caucus prior to the Nov. 7 floor vote on health care reform (“We’ll look back and say that was our finest moment”) was not released, but Politico had a reasonably detailed account. A second St. Crispen’s Day-style speech prior to the March 21 House vote is available on video.

White House Office of Management and Budget. OMB chief Peter Orszag’s blog is frequently about health care reform. Click here for Orszag’s entry touting the Independent Medicare Advisory Council, a proposed Fed-like body that could impose cost reductions on Medicare with minimal interference from Congress. Click here for Orszag’s subsequent defense of the IMAC after the Congressional Budget Office concluded that Orszag’s “game-changer” would save only $2 billion over 10 years (see CBO’s July 2009 letter to Rep. Steny Hoyer, below). The IMAC idea is fleshed out in this July 17 letter  to House Speaker Nancy Pelosi, and in this draft bill  submitted by OMB.

House of Representatives:

House Speaker Nancy Pelosi. The House passed the Senate-passed bill (see below) March 21, 219-212. This vote guaranteed health care reform would become law. Click here for the text of the seemingly meaningless  executive order on abortion that won Rep. Bart Stupak’s vote.

Also on March 21, the House passed a reconciliation bill, 220-211, that made some changes to the Senate-passed bill. The House had to pass reconciliation again on March 25, 220-207, to accomodate two minor changes concerning Pell grants that were made by the Senate.

Click here for the reconciliation bill modifying the Senate bill that was unveiled March 18, here for a manager’s amendment modifying the modificiations slightly, and here for the two additional minor changes made to accomodate the Senate. Click here for a section-by-section summary. Click here for the March 18 Congressional Budget Office score (later revised slightly; see CBO section).

Click here for the text of the health care reform bill as passed Nov. 7 on the floor of the House of Representatives, 220-215 (roll call).

This “blended” health care bill was assembled from versions that cleared three committees (see below). Click  here for the bill text as released by Speaker Pelosi on Oct. 29., 2009;  here for a Nov. 3 “manager’s amendment” from Rep. John Dingell (the bill’s lead sponsor) that made a few minor changes;  here for last-minute modifications to the manager’s amendment; and here for an amendment sponsored by Rep. Bart Stupak, D.-Mich., and adopted on the House floor, 240-194 (roll call), barring virtually any insurer participating in the exchange from offering coverage for abortions. (The Stupak amendment didn’t make it into the final bills passed in March 2010.) Click here for a log of all actions taken on the blended House bill.

Click here for a summary of amendments submitted to the House rules committee, listed alphabetically by sponsor. Click here for the rule on the House vote, which passed, 242-192 (roll call). The rule set the terms for the floor debate and, most significantly, allowed for a vote on the Stupak anti-abortion amendment, on whose passage the U.S. Conference of Bishops conditioned support  for the House bill. Click here for why the Stupak amendment was a crummy deal.

Click here for a nifty New York Times chart listing the 39 House Democrats who voted against the bill on Nov. 7, with additional information about their background and their districts. One of the 39 nays came from Ohio Rep. Dennis Kucinich, a stalwart single-payer advocate (he later supported the bill in the final March 2010 votes). Kucinich opposed the bill because he thought it was too kind to private insurers. The rest came from mostly conservative members. Thirty-one of them represent districts that went for McCain; 22 are from southern states; 14 are freshmen; and 12 of them represent districts where 20 percent of the nonelderly or more lack health insurance. (Special shout-out to Oklahoma Rep. Dan Boren, who voted nay even though 29 percent of his nonelderly constituents lack health insurance. Boren opposed the bill because “the worst thing we could do during a recession is raise taxes” and because “the public option would ultimately lead to a single-payer health care system.”)

Click here for a statement from the sole Republican who voted in favor on Nov. 7, Louisiana Rep. Anh “Joseph” Cao. This was achieved partly by an apparent promise from President Obama to consider boosting Louisiana’s Medicaid payments and forgiving its community disaster loans. Passage of the Stupak anti-abortion amendment (see above) also helped win Cao’s vote. (Cao opposed the bill in the March 2010 votes.)

Click here for major changes in the blended bill compared to the bill as introduced. Click here for a short summary, here for a more detailed summary,  here for a section-by-section summary, and here for an implementation timeline. Click here for some details on the public option, here  for some details on the tax provisions, and here for some details on how, contrary to PhRMA’s White House deal, the House bill allows the government to negotiate drug prices. More summary details available here, here, and here.

The Congressional Budget Office estimates the Pelosi bill’s cost here  (updated here  to include the manager’s amendment, which lowered the bill’s ten-year cost by $25 billion; updated a second time here, to incorporate modifications to the manager’s amendment, which bumped the cost back up by $20 billion; and updated a third time, to correct for a CBO error, lowering the bill’s cost by $29 billion, for a final ten-year score of $138 billion in deficit reduction). The Centers For Medicare and Medicaid Services flag a potential problem with the bill’s Medicare cuts here. Changes to the tax provisions are scored here by the Joint Committee on Taxation.

House Ways and Means Committee. Here is the text of the bill as passed by the Ways and Means committee on July 17, 23-18, and here  is a summary of Ways and Means’ specific changes to the original bill (text, summary) as introduced by Ways and Means, Education and Labor, and Energy and Commerce prior to markup. For an early “discussion draft” of the tri-committee bill prior to the House bill’s introduction, click  here. For an even earlier outline, click here.

House Education and Labor Committee. The bill cleared the Education and Labor committee on July 17, 26-22. Here (scroll to bottom) are the 42 amendments that Education and Labor committee voted on, of which 23 were accepted.

House Energy and Commerce Committee  On July 31, after extended negotiations between chairman Henry Waxman and conservative Blue Dog Democrats, the bill was passed by the Energy and Commerce committee, 31-28. The committee posted an admirably detailed, day-by-day record of its six-day markup.

Day One (July 16): transcript; chairman’s mark (i.e, the working draft as altered by Waxman in various minor ways): text, summary).

Day Two (July 17): transcript; amendments: summary, texts. Six offered, four passed.

Day Three (July 20): transcript; amendment texts. Nineteen offered, 10 passed.

Day Four (July 30): amendment texts. Thirty-two offered, 18 passed.

Day Five (July 31): amendment texts. Forty-one offered, 22 passed.

Day Six (supplementary markup, Sept. 23): amendment texts. Fifteen offered, three passed. Click here to watch the morning session, here to watch the afternoon session.

House Republican Conference. Click here for its Web site skunking health reform, and here for its “reading guide” to the blended House bill. House Republican leader John Boehner introduced a GOP version alternative to Obamacare (text, summary). On Nov. 7 the House voted it down, 258-176 (roll call). Click here  for the Congressional Budget Office estimate of the bill’s cost. Click here for Slate’s explanation why it’s a dumb proposal. Click here for an earlier iteration.

A much-discussed alternative proposal offered by Rep. Paul Ryan, R-Wis., would eliminate Medicare.

Names of the Dead. The slightly-unhinged  Rep. Alan Grayson, D.-Fla., set up this Web page to collect testimony from friends and family of people whose deaths can be attributed to a lack of health insurance. Grayson identified which of these people lived in Republican districts and recited their names  on the House floor, along with the names of their representatives.

Senate: Majority Leader Harry Reid.  Click here, here, and here for the text of the final reconciliation bill as passed March 25, 2010 on the Senate floor, 56-43. Click here for a summary of the health- and revenue-related provisions of the reconciliation bill and the earlier bill passed in Dec. 2009.

Click here for text of the health reform bill as passed Dec. 24, 2009 on the Senate floor, 60-39. This was the bill the House voted into law on March 21, 2010 before making some changes in the reconciliation bill (which it passed the same day).

Sen. Reid  introduced a “blended” Senate bill (text, summary), assembled from bills passed by two committees (see below), on Nov. 18, 2009. A short summary is available here. A summary of provisions that would take effect immediately is available here.

On Dec. 19 Reid introduced a “manager’s amendment” (text, brief summary) including changes made to the bill to win the support of Sens. Ben Nelson, D.-Mont., Joe Lieberman, ind-Ct., and other moderates. Most notably, the public option was removed from the bill and language was inserted allowing states to remove abortion coverage. The Congressional Budget Office (analysis; blog summary) estimated that Reid’s amendment would add $2 billion in budget savings to the $130 billion it earlier projected over a ten-year period. Before the manager’s amendment was added, the Centers For Medicare and Medicaid Services projected here that the Senate bill would, over ten years, increase health care spending slightly as a percentage of gross domestic product.

Detailed summaries are available of key provisions of the Dec. 2009-passed bill regarding  subsidies for the purchase of insurance and other topics. More information on the bill can be found here. (Note: Key information here will be out of date, as the bill was later modified by the March 2010 reconciliation bill.)

On Nov. 22 the Senate voted to begin debate on the bill, 60-39 (roll call) For Slate’s cumulative amendment scorecard, click here.

Click here for Slate’s leak-based description of a compromise alternative to the public option that Reid never unveiled because he couldn’t win enough support for it.

Senate Republicans. Sen. Judd Gregg, R.-N.H. (who, during the minute and a half  when he was going to be President Obama’s Commerce secretary, said: “This is not a time for partisanship. This is not a time when we should stand in our ideological corners and shout at each other”; video here) offers tips to obstruct health reform on the Senate floor in a Dec. 1 letter  to fellow Republicans.The Senate GOP skunks health reform in a Senate Doctors Show starring Sens. Tom Coburn, M.D., and John Barrasso, M.D. The first episode  had a Wayne’s World-style charm, but subsequent episodes boast distressingly slick  production values. Click here for Coburn’s slightly-unhinged Senate floor statement to seniors: “I have a message for you: You’re going to die sooner.” (For a Democratic counterpoint, see “Names of the Dead,” below.) Click here to read a transcript in which the good doctor tells the wife of a brain-injury victim to suck it up.

Senate Finance Committee. Chaired by Max Baucus, finance completed markup on the bill in the wee hours of Oct. 2 and passed it on Oct. 13, 14-9. Reid subsequently blended it with the Senate health committee bill (see below). Click here for a plain-English text of the finance bill as amended. Click here for the text in legislative language. The Congressional Budget Office estimates the bill’s cost here.

Click here for a summary of amendments adopted by the committee during markup, and here for more detailed descriptions of each one.

The unamended ”chairman’s mark” is also online, along with a version incorporating certain proposed amendments that was made public on Sept. 22 (text, summary). Proposed committee amendments to the bill are posted here. Slate’s Chris Wilson assembled them into this sortable spreadsheet.Click here for Sen. Jay Rockefeller’s Sept. 16 letter to Baucus making a highly persuasive case against health cooperatives as an alternative to a public option. Click here for a similarly scathing Rockefeller letter from Nov. 2 about the insurance industry’s “medical loss ratios,” i.e., the portion of the premium dollar spent on health care. (Many thanks to Talking Points Memo and the New York Times for archiving these important documents, which have disappeared from the Senate Commerce committee Web site.)One week before Baucus introduced the chairman’s mark he released a ” Framework For Comprehensive Health Reform.” For an earlier “draft proposal” (presented to members as a slide show) click here. Click here for Baucus’ initial 98-page white paper on health reform, here for the financing options initially under consideration, and here for the coverage options initially under consideration. Click here to watch hearings.Click here for a summary of provisions in the unamended chairman’s mark that would take effect right away. Click here for a finance committee staff memo explaining the discrepancy between the Congressional Budget Office’s cost estimate for the unamended bill ($774 billion over ten years; scroll down for link) and the finance committee’s ($856 billion over ten years). Click here for a finance committee staff memo explaining (sketchily) how the unamended bill’s expansion of the state-federal Medicaid program to enroll 11 to 12 million more people would affect the states. Click here for an analysis of the unamended bill by the Joint Committee on Taxation.

Senate Health, Education, Labor, and Pension Committee. This is the committee that was chaired by the late Ted Kennedy. Sen. Chris Dodd led it during Kennedy’s illness (click here to watch markup sessions), and with Kennedy’s death the chairmanship passes to  Sen. Tom Harkin. The bill (text, summary) cleared the committee July 15 in a party-line vote, 13-10. For some reason, the health committee took two months to make public the bill as amended during the July markup.  Here is a partial list of committee amendments (mostly Republican) and whether they passed or failed. Here is an earlier iteration of the Senate HELP committee bill prior to committee markup.

The Senate health committee bill, unlike the Senate finance committee bill, contains a public option, and Senate majority leader Reid included that in the blended bill he sent to the Senate floor, albeit somewhat weakened and with a provision allowing states to opt out. There’s some doubt as to whether Reid can assemble a filibuster-proof majority (60 votes) to support even a watered-down public option, barring a decision to pass the bill through the budget “reconciliation” process, which requires only a majority (50 votes plus Vice President Joe Biden). Reid says he won’t choose that route.


The Treatment. (New Republic health blog). For analysis of the health care debate, this is the best single source available online, largely because of its principal author, New Republic Senior Editor Jonathan Cohn. Cohn is the author of Sick: The Untold Story of America’s Health Care Crisis—and the People Who Pay the Price,which is the smartest and most readable survey I’ve seen of America’s centurylong failed experiment with market-driven health care. Cohn is thoughtful and judicious (occasionally to a fault), and he stays on top of important developments.

Ezra Klein. (Washington Post blog; for posts prior to May 13, see his American Prospect blog). Klein writes on a variety of economic topics, but he’s developed a particular expertise on health care. Like a lot of younger bloggers, Klein can write in a tone that’s irritatingly narcissistic and self-aggrandizing. But Klein is extremely knowledgeable and well-sourced. He frequently scoops the Post’s newspaper staff on important health care stories, and his arguments are usually sound.

The New Health Dialogue Blog. The New America Foundation’s health reform blog is much more interesting than its deadly name would have you believe.

Matthew Yglesias. Yglesias majors in foreign and economic policy but minors in health reform, and is worth reading on all three. The site is sponsored by the Center For American Progress, a liberal think tank.

Igor Volsky.Lotsa smart, newsy stuff on health care reform (and other topics). This site, too, is sponsored by the Center For American Progress.

Gooznews. Smart analysis from the left by Merrill Goozner, a former economics reporter for the Chicago Tribune, with an emphasis on Big Pharma.

Robert Reich. The policy entrepreneur and former labor secretary has emerged as a leading critic from the left. Occasionally a little sloppy with the facts, Reich nevertheless stays on top of developments and offers characteristically sharp analysis.

Megan McArdle.The Atlantic’s libertarian economics blogger, imported from the Economist, opposes health reform.

Health Affairs Blog. Health Affairs, a peer-reviewed journal about government health policy, devotes much of this Web page to expert commentary from a variety of perspectives. Kind of blah, but I keep hoping it will get better.

The Health Care Blog.Informed insider commentary from Matthew Holt and others. Not for dilettantes.

News Sites:

Politico Health Care Page. Politico has stayed on top of breaking developments and takes the trouble to provide readers direct access to documents of interest. The Web site can be a bit lazy about updating its health care page, so if you want to be certain not to miss its latest offerings on the reform bill try the home page.

Talking Points Memo/Health. TPM is looking less like a blog these days and more like a news site. Brian Beutler’s coverage has evolved from good to indispensible.

Kaiser Health News. A news agency started by the Kaiser Family Foundation, a  nonprofit cousin  of Kaiser Permanente, the pioneering health maintenance organization. (The common ancestor is Henry J. Kaiser. There is no current affiliation, financial or otherwise, between the Kaiser Family Foundation and Kaiser Permanente.) It claims and has thus far demonstrated independence from any financial interests; the executive editors, Laurie McGinley and Peggy Girshman, are veteran journalists for the Wall Street Journal, Congressional Quarterly, and National Public Radio, and the scrupulously nonpartisan Len Downie, former executive editor of the Washington Post, chairs the advisory committee. Kaiser Health News has quickly established itself as a comprehensive news source on health care reform. The site is updated throughout the day, but not quite enough, and often only with summaries of other news organization’s scoops.

New York Times Prescriptions.  Love the name! David Herszenhorn, the principal author, is an excellent reporter, and in a few short months this site has gone from being ho-hum to being clearly superior to the Washington Post’s Daily Dose and the Wall Street Journal’s Health Blog (see below).

The Huffington Post still looks mostly like an aggregation of blogs, but Sam Stein  and Ryan Grim have been delivering health-reform scoops there.

C-span Health Care Hub.  Video of floor debate, congressional hearings, press conferences, etc. related to health reform.

Daily Dose. The Washington Post’s health reform blog. Less interesting than Ezra Klein’s Post blog, which is a little embarrassing because Klein is only one person, whereas Daily Dose has multiple authors. The Post doesn’t seem to be putting much energy into the site. Still, worth a glance.

Health Care Reform 2009. The New England Journal of Medicine privides expert commentary from many different points of view.

Wall Street Journal Health Blog. Less focused on health reform, but what’s there is usually very good.

Columnists: Paul Krugman. The Nobel Prize-winning economist’s New York Times column (scroll down) often slices through conservative cant about health reform. So does his blog.

Karen Tumulty. Intelligent reportage from straight down the middle. Tumulty doesn’t surprise, but she does inform.

Steven Pearlstein. Washington Post financial columnist increasingly preoccupied with health care; smart liberal-centrist analysis.

David Leonhardt. New York Times columnist who writes frequently and intelligently on health care.

Robert Samuelson. The Newsweek columnist has emerged as a leading critic from the right.

Timothy Noah. Modesty forbids.


Uwe Reinhardt. Links to publications by America’s leading health care economist. Click here for Reinhardt’s recent posts to the New York Times’ “Economix” blog.

Jacob Hacker. Links to publications by the political scientist who created the “public option.” Click here for Hacker’s December 2008 report, “The Case For Public Plan Choice in National Health Reform.” Click here for Hacker’s April 2009 report on how to structure such a plan on a “level playing field” with private insurers. Click here for other Hacker writings on health care.

Jonathan Gruber. Links to the MIT economist’s op-eds on health reform.

Caveat emptor: In early January Politico revealed that Gruber received $297,600  the previous June from the health and human services department to assess various health reform proposals. (Click here for the documentation.) This brought mild embarrassment to journalists Jon Cohn  of the New Republic and Ronald Brownstein  of the Atlantic, both of whom have relied on Gruber heavily yet were unaware of his financial ties to the Obama administration. (Add me to the list of those who were somewhat less embarrassed because we’d relied on Gruber somewhat less; henceforth I will try to flag Gruber’s financial ties whenever I quote him.) Gruber’s priorities have long been in pretty obvious alignment with the Obama administration’s, but for what it’s worth my sense is that the influence runs from Gruber to the White House rather than the other way around. In at least one instance (his misplaced enthusiasm  for the excise tax on “Cadillac” health plans) that influence has contributed to bad policy. Overall, it’s fair to say that Gruber is a cheerleader for health reform, and that his economic reasoning is likely influenced by his political preferences. That said, Gruber remains respected by his academic peers as a leading expert on the economics of health care.

Click here  for his paper (revised Nov. 27) arguing that, contrary to a health insurance industry study (and a later CBO study), the “blended” Senate bill would lower health premiums in the non-group market. Click here for his analysis of the tax on “Cadillac” health plans, which he argues will raise wages. Click here for his Nov. 2 testimony before the Senate health committee arguing that health reform would help small businesses.

Think Tanks and Public-Policy Consultants:

Center on Budget and Policy Priorities. A nonprofit dedicated to calculating the impact of pending legislation on low-income people, CBPP has an excellent reputation for scrupulous, in-depth research. Click here for its health page, here for its review of whether Congress’s previously enacted Medicare cuts were realized (short, counterintuitive answer: yes), here for its critique of the subsidy structure in the Senate bill, and here for other reports on health reform.

Rapid Response: The Obama Health Plan. Heritage Foundation Web site dedicated to terminating with extreme prejudice the Obama health care plan. (It failed!)  Here’s the right-wing solution Heritage prefers.

Health Care Cost Monitor. The latest research on health care costs, an issue that the White House and Congress have placed at the center of the health care debate, from the Hastings Center, a bioethics think tank.

Is The Public Plan Option a Necessary Part of Health Reform?”Yes,argue John Holohan and Linda Blumberg of the Urban Institute. They predict the insurance industry “would survive at about the same size but be more efficient and more effective in controlling health care spending.” A later paper  by the Urban Institute’s Robert Berenson, John Holahan, and Stephen Zuckerman despairs of enacting a strong public option now and proposes that instead the health care bill include a trigger enacting a strong public option down the road.

The Lewin Group. Widely respected in the past, since 2007 Lewin has been owned by the insurer UnitedHealth, which may have undermined its objectivity. Click here for its report forecasting financial catastrophe for health insurers if a robust “public option” is included in health care reform. (Say it with me: Not my problem!) Click here for Lewin’s budgetary evaluation of the Senate finance bill (summary findings here), and here for a similar evaluation of the House bill as passed by the Energy and Commerce committee prior to its being blended with two other versions of the bill (summary findings here). These last two studies were commissioned by the fiscally conservative Peter G. Peterson Foundation, whose president, former Comptroller General David Walker, drew on their findings in this somewhat gloomy Nov. 9 speech.

Commonwealth Fund. A frequent source for health journalists of research related to health reform.

Henry Aaron.Links to publications by Brookings’ smartest expert on health reform. Brookings also has a Center for Health Care Reform  led by Mark McClellan, former Food and Drug Administration commissioner and administrator of the Centers for Medicare and Medicaid Services under President George W. Bush (and older brother to prodigal White House press secretary Scott McClellan).

Other Data and Documents:

Health Insurance and Mortality in U.S. Adults.” This study by six Harvard-affiliated physicians calculated that between 35,000 and 45,000 annual deaths among the nonelderly can be attributed to a lack of health insurance.

Side-by-Side Comparison of Health Care in U.S. vs. Other Industrialized Nations. From NPR. Read it and weep.

Health Systems: Improving Performance.” This is the 2000 report by the World Health Organization made famous by Michael Moore’s Sicko. It ranks the world’s health care systems. France is no. 1. The U.S. is no. 37. But hey, that’s still two notches ahead of the impoverished island nation of Cuba! (For rankings, go to Page 152.)

The Language of Healthcare 2009.” The Republican game plan  for killing health reform, as outlined to House members in May by “Dr.” Frank Luntz. (No, not that kind. Luntz has a Ph.D. in political science.) Herr Doktor Luntz’s prescription owes some debt to William Kristol’s 1993 memo about how to kill Hillarycare. Kristol recently updated the latter, advising Weekly Standard readers: “Kill It, and Start Over.” (In the intervening years Kristol has learned it’s bad form not to pretend to want to start over.) See also Celinda Lake’s strategy memo  for Democrats on how to sell health reform this year.

Lobby Groups:

U.S. Conference of Catholic Bishops.Amazingly, this interest group wielded more clout than any other as the vote on final passage approached (though in the end it lost). That’s because the bishops opposed the Senate bill’s language on abortion. If health reform hadn’t passed, you could have done worse than blame the pope’s chief pro-life lobbyist in Washington, Richard Doerflinger. With breathtaking hypocrisy, the bishops kept sending  pious letters to the Hill urging members to set aside their petty differences and pass the bill. For an antidote, read this March 17 letter  from the heads of more than 50 U.S. Catholic women’s religious orders. The nuns disputed the bishops’ claim that the bill would fund abortions with taxpayer dollars and urge its passage. Priests are Republicans, the late Robert Kennedy  often noted, and nuns are Democrats.

Health Care for America Now!A coalition of labor unions and other liberal groups lobbying for universal health care.

Campaign for an American Solution. The insurance lobby. Click here for its Oct. 12 study, released on the eve of the Senate finance committee vote, alleging that over the next decade the bill would raise the cost of the average family health insurance policy by $4000. The study does not take into account “the impact of the new subsidies on the net insurance cost to households. Also, if other provisions in health care reform are successful in lowering costs over the long term, those improvements would offset some of the impacts we have estimated.” An underappreciated aspect of the study is the industry’s admission that even without health reform health premiums will nearly double. A more succinct case for the public option can scarcely be imagined. Click here for the group’s Oct. 20 attempt at damage control on the Washington Post op-ed page.

The American Medical Association. The doctors lobby. Click here to read its endorsement of the final bill as passed in March 2010. Click here to read its endorsement of the House bill as introduced. Click here to read the endorsement letter it sent to House Ways and Means committee chairman Charles Rangel.

The American Hospital Association.The hospital lobby. It favors the Senate finance bill, though “we remain concerned about the need to further expand the level of coverage.”

Physicians for a National Health Program.The single-payer lobby. Excellent ideas, zero influence.

Journalism and Essays of Lasting Interest:

The Health Care Crisis and What To Do About It” by Paul Krugman and Robin Wells in the New York Review of Books (March 23, 2006). The best introduction to why we need significant government intervention in the health care industry.

The Cost Conundrum” by Atul Gawande in The New Yorker (June 1, 2009). Illustrates why Medicare costs vary dramatically in different parts of the country. The critique of doctors’ overspending will be familiar to readers of Shannon Brownlee’s Overtreated, but the piece is well-reported and deftly written, and it made a big impression  on President Obama. (Health researcher Daniel Gilden argues that Gawande overlooked the degree to which Medicare costs are out of control in McAllen, Tex., where the story is set, because the population there is “sicker and poorer.” To read Gilden’s critique, along with critiques of his critique, click here. To read Gawande’s replies to his critics, click here and here.)

The Best Care Anywhere” by Phillip Longman in the Washington Monthly (January 2005): The remarkable success of socialized medicine at the Veterans Administration. Later expanded into a book. (Full disclosure: I wrote the foreword. I didn’t get paid and won’t get paid if you buy the book, but you should buy it anyway.)

The Health of Nations” by Arnold Relman in the March 2005 New Republic. Later expanded into A Second Opinion. Relman lays the blame for the present health care crisis on the advent of a culture of entrepreneurship abetted, ironically, by the creation of Medicare and Medicaid in 1965, which greatly expanded the medical marketplace. Another contributor, Relman says, was the 1975 Supreme Court decision Goldfarb v. Virginia State Bar, which applied antitrust law to the professions, including medicine. The ruling prohibited as anticompetitive medical-society fee recommendations and advertising bans and promoted instead the notion that market economics would serve medical consumers.

Uncertainty and the Welfare Economics of Health Careby Kenneth Arrow in the Dec. 1963 American Economic Review. Influential article (abridged here) explaining why market economics doesn’t serve medical consumers.

A System From Hell” by Kate Michelman in the Nation (April 8, 2009). A harrowing first-person narrative by the well-known abortion-rights activist about how medical costs brought about her financial ruin.

The American Way of Dentistry by June Thomas in Slate (Sept.-Oct. 2009). A seven-part series on a medical crisis that’s hiding in plain sight.

How American Health Care Killed My Father” by David Goldhill in the Atlantic (Sept. 2009). An essentially libertarian view. The best libertarian analysis typically displays virtuoso clarity in describing a problem and childlike simple-mindedness in proposing a solution. Goldhill’s essay conforms to this pattern. But purely as a diagnostic exercise, the piece is quite good.

Health Care for All“: NPR series on how the Europeans do it.

Sick Around the World“: PBS Frontline series on same. Correspondent: T.R. Reid of the Washington Post. Reid is author of the forthcoming The Healing of America.

The Obama Administration’s Options for Health Care Cost Control: Hope Versus Reality” by Theodore Marmor, Jonathan Oberlander, and Joseph White in Annals of Internal Medicine, April 7, 2009. A skeptic’s guide to projected cost savings.