Paul Krugman: A little closer to universal coverage

This good news in Paul Krugman's report on the initial Senate vote has stayed good--yesterday both House and Senate overrode Bush's veto on Tuesday by wide margins. This column originally appeared in the July 11th New York Times

It was the worst of days, it was the best of days. On Wednesday, Senate Democrats capitulated to the Bush administration on wiretapping — with Barack Obama joining the coalition of the craven.

Later that day, however, those same Senate Democrats won a huge victory on Medicare.

News reports stressed the cinematic quality of the event: Ted Kennedy, who is fighting a brain tumor, made a dramatic appearance on the Senate floor, casting the decisive vote amid cheers from his colleagues. (Only one senator was absent: John McCain.)

But the vote was bigger than the theatrics. It was the first major health care victory that Democrats have won in a long time. And it was enormously encouraging for advocates of universal health care.

Ostensibly, Wednesday’s vote was about restoring cuts in Medicare payments to doctors. What it was really about, however, was the fight against creeping privatization. Democrats finally took a stand — and, thanks to Senator Kennedy, seem to have prevailed.

The story really begins in 2003, when the Bush administration rammed the Medicare Modernization Act through Congress, literally in the dead of night. That bill established large de facto subsidies for Medicare Advantage plans — plans in which Medicare funds are funneled through private insurance companies, rather than directly paying for care.

Since then, enrollment in these plans has been growing rapidly. This has had a destructive effect on Medicare’s finances: the fastest-growing type of Medicare Advantage plan, private fee-for-service, costs taxpayers 17 percent more per beneficiary than Medicare without the middleman. It also threatens to undermine Medicare’s universality, turning it into a system in which insurance companies cherry-pick healthier and more affluent older Americans, leaving the sicker and poorer behind.

What does this have to do with cuts in doctors’ fees? Well, legislation passed a decade ago makes such cuts automatic whenever the growth in Medicare spending exceeds an unrealistically low target. This year, the automatic cuts would have reduced doctors’ payments by more than 10 percent, a pay reduction so deep that many physicians would probably have stopped taking Medicare patients.

In previous years, payments to doctors were maintained through bipartisan fudging: politicians from both parties got together to waive the rules. In effect, Congress kept Medicare functioning by expanding the federal budget deficit.

This year, the Democratic leadership decided, instead, to link the “doctor fix” to the fight against privatization and offered a bill that maintains doctors’ payments while reining in those expensive private fee-for-service plans. Last month, the Senate took up this bill — but Democrats failed by one vote to override a Republican filibuster. And that seemed to be that: soon after that vote, Senators Max Baucus and Charles Grassley had another bipartisan fudge all ready to go.

But then Democratic leaders decided to play brinkmanship. They let the doctors’ cuts stand for the Fourth of July holiday, daring Republicans to threaten the basic medical care of millions of Americans rather than give up subsidies to insurance companies. Over the recess period, there was an intense lobbying war between insurance companies and doctors.

And when the Senate came back in session, it turned out that the doctors — and the Democrats — had won: Senator Kennedy was there to cast the extra vote needed to break the filibuster, a number of Republicans switched sides and the bill passed with a veto-proof majority.

If the Democrats can win victories like this now, they should be able to put a definitive end to the privatization of Medicare next year, when they’re virtually certain to have a larger Congressional majority and will probably hold the White House.

More than that, however, advocates of universal health care, like Health Care for America Now, the new group headlined by Elizabeth Edwards, have to be very encouraged by this week’s events.

Here’s how it will play out, if all goes well: early next year, President Obama will send his health care plan to Congress. The plan will face vociferous opposition from the insurance industry — but the Medicare vote suggests that this time, unlike in 1993, Democrats will hold together.

Unless Democrats win even bigger than expected, however, they won’t have the 60 Senate votes needed to override a filibuster. What the Medicare fight shows is that the Democrats could nonetheless prevail by taking their case to the public, daring their opponents to stand in the way of health care security — so that in the end they get some Republicans to switch sides, and get the legislation through.

A lot can still go wrong with this vision. But the odds of achieving universal health care, soon, look a lot higher than they did just a couple of weeks ago.