Hurry Up and Wait

Picture this scene: At a stirring Rose Garden ceremony, President Barack Obama signs health-care reform into law, with members of Congress beaming behind him. They erupt into cheers when he puts down his pen -- hands are shaken vigorously, and even a few hugs are exchanged. Afterward, everyone speaks of how they've honored Ted Kennedy and his lifelong crusade to get every American health coverage. Over the next few days, the news media note many times that Obama accomplished what every Democratic president since Harry Truman tried and failed to do. All agree that this will almost certainly be the defining domestic-policy achievement of his presidency. Republicans grumble but know they've been beaten.

Americans watching at home are pleased and hopeful. Terrific, they say -- I can't wait for my newfound health security! And when do they get it? A little over three years from now. Because in all the versions of reform now moving through Congress, most of the provisions don't take effect until 2013. Although you've probably heard this date, it hasn't been the topic of much discussion outside the wonkiest corners of the American health-policy debate. But we should keep it in mind when we're wondering how the public will respond to reform.

As this timeline of the implementation of the House bill shows, of the high-profile provisions, only one -- the outlawing of the vile practice of "rescission," in which your insurance company cancels your plan when it learns you've been diagnosed with a serious illness -- will go into effect right away. While there are many other technical changes, the most significant features of reform -- the establishment of the insurance exchanges, the ending of denials for pre-existing conditions, and the enforcement of an individual mandate to buy insurance, along with subsidies for those with low and middle incomes -- don't happen until 2013. This is true of the Senate bills as well and will almost certainly be true of whatever bill emerges from the conference committee that will reconcile the bills that pass each house.

Why? While things like setting up exchanges and implementing an individual mandate could take some time, the real reason is money -- namely, that by delaying the implementation of the reforms for a few years, the total cost of the bill becomes much lower. That total, which will likely end up somewhere between the $774 billion plan put forth by Sen. Max Baucus and the $1.04 trillion plan passed through three House committees, is calculated by the Congressional Budget Office for a 10-year window from the point the bill is passed. Speed up implementation by an extra year, and you could add $100 billion to the cost. And since President Obama has pledged that the bill will be entirely paid for by spending cuts and new taxes, that would mean coming up with more spending cuts or more taxes, something few in Congress have a taste for.

So when reform passes, our deeply pathological health-care system will remain nearly as pathological for three full years. That's three years of people being denied care because of pre-existing conditions, three years of climbing premiums, three years of "job lock," three years of families going bankrupt when they get sick and discover all the exclusions and limits of their insurance, and three years in which millions of Americans (46.3 million at last count) go without any insurance at all. A recent study from Harvard Medical School found that 45,000 Americans die every year because of lack of health coverage, which means 135,000 will die while they wait for reform to take effect.

In his recent speech to Congress, President Obama introduced the idea of creating a catastrophic health plan right away for those who can't get insurance. If it ends up in the final bill (and depending on its details), those who can't get insurance elsewhere might get some relief. But most people will go through a midterm congressional election and the next presidential election, before they experience any of the benefits (or costs) of reform.

And you can bet that Republicans won't stop decrying health-care reform once it has passed. Once people have actually begun joining health exchanges (or even, we should be so lucky, the public option), it will become much harder for politicians to give them demagogic warnings about the coming descent into a socialist nightmare. But between now and 2013, they can still make those apocalyptic claims. If people are still uncertain about what reform means to them (and they will be), Republicans can run on repealing the supposedly awful plan no one has yet experienced.

Will it work? Some are already raising the possibility that Republicans could win back the House next year. That's possible but unlikely. But when President Obama's re-election campaign says, "We gave you health reform!", don't be surprised if his opponent replies, "You gave us death panels and a government takeover!" Because the plan won't have taken effect, many voters won't know who's right.

Nevertheless, the only thing worse than waiting for reform is knowing that reform died. Conservative Democrats in the House seem to have come to an understanding that what truly endangers them is not the passage of a health-care bill that some of their constituents might find too liberal but the failure to pass a health-care bill at all. This may explain why they've softened their opposition to the public option and have quieted their threats to kill the bill if it is insufficiently stingy toward the middle class.

If reform does succeed, analysts will write books about the Obama administration's extraordinarily intricate and dexterous political strategy. But Democrats should prepare themselves for the likelihood that people will not in fact be turning cartwheels of joy in the streets the moment the bill passes. There is too much uncertainty, too much complexity, and too much of a delay before the changes take effect for that to happen. In the long run, what matters is whether the final bill actually creates universal coverage and the security people need (and not incidentally, whether it allows for progressive tweaks in the future). But the long run doesn't really start for three years, which in politics is a long time indeed.

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