President Obama has won a first, though hardly decisive, victory in the health care campaign, with the passage of HR 3200, the Affordable Health Care Act 2009, through the US House of Representatives.

Passage of the bill is the first stage in reforming the US non-health care system. Importantly, it contains the all-important “public option” — a state-owned health insurer which can offer coverage at lower rates than the private carriers, thus forcing their exorbitant premiums down.

Other provisions within the 2000-page bill include a ban on excluding people with pre-existing conditions from health insurance, new controls on provider (ie doctor and hospital) charges, huge funds for integrating and computerising health care records across the country, and much more.

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The bill seeks to limit the ballooning cost of health care by making cutbacks in “Medicare” — the open-ended 65+ public care which half of the “Obamahitler” protestors are covered under — and bringing in some controls on the ludicrous amounts big Pharma can charge the government for drugs.

However the bill only just squeaked through the House, with a majority of 5.39 Democrats voted against it, and only 1 Republican — a Vietnamese-American from Louisiana, pretty much the unhealthiest state in the Union — voted for it.

While getting any sort of a majority is seen as a triumph for speaker Nancy Pelosi — the vote occurred on Saturday night after a week of near round-the-clock arm twisting — there were serious misgivings about some of the deals that had to be made.

One in particular, which excluded abortion from public insurance or from any subsidies to private insurance, was an exceptionally bitter pill. Since non-emergency abortion is scarcely available under public provision currently, the amendment does not make coverage any worse, but it now makes termination an even more “special” case than hitherto.

Others are whackier still — an amendment (supported by Republican Orrin Hatch and previously by the late Ted Kennedy, for negotiating purposes) that allows public funding for spiritual healing — ie Christian Science intercessionary prayer at $20 a pop.

Mad stuff, but the bill is through, and as Mark Steyn notes — ruefully — that’s the important thing. To get something passed in the House is further than Bill and Hillary Clinton’s 1993 bill got.

Now however, there’s the Senate. Pelosi had about 38 Democrats she could lose (with a 77-seat House majority), and some of them were released from the whip, so that their Big Insurance backers can be assured they got their moneys worth, but the Senate is on a knife-edge.

Ted Kennedy hasn’t been replaced yet, and slimy Joe Lieberman, who usually votes with the Dems on social issues, has indicated he won’t support a bill with a public option in it. He won’t even support “cloture”, the vote that prevents a filibuster, and allows the bill to go to a simple majority vote.

That leaves the Democrats with, at most, 58-41, against a filibuster, and needing a 60-40 split. Their best bet is to convince Maine’s moderate Republican senator Olympia Snowe over, and one or two others from godknowswhere.

But that presumes a 100% Democratic whip, and that looks unlikely, with a half-dozen “blue dog” Democrats having already vowed to vote against a public option.

Should they be able to persuade the Blue Dogs to vote for cloture, and then against the bill, the bill will come to a majority vote and pass around 53-46, and the Blue Dogs’ blushes will be spared.

But if they can’t get them to yes on that, the Democratic leadership has another option, which is to make them perform an actual filibuster.

Currently, all you have to do to filibuster — ie to prevent the bill from coming to a majority vote — is for 41 senators to indicate that they would filibuster it if required.

That removed the need for senators to stay on their feet reading from cookbooks, Dickens, etc, with a series of explicit rules governing their behaviour (no leaning on surfaces, no physical support by other senators, no toilet breaks).

The automatic filibuster dramatically changed the nature of American governance, but by stealth — the Senate became a de facto supermajority chamber, an inherently conservatising option.

However, at any time, by a simple majority vote, the automatic filibuster can be removed — and the minority opposition would have to talk the bill out to the end of the current Senate session.

The advantage of this is that the US public would see the filibuster for what it is (the word comes from a dutch word for pirate or ‘freebooter’), a mad obstruction tactic being executed by people desperate to hold back change.

Will the Dems go there? Or will they observe what has become a sort of collective Senate alignment against the House – that it is in the interest of all Senators to keep the automatic filibuster, and hence their vastly increased power within the bicamera.

The look-out is that they won’t even let the bill come to the floor before the Senate breaks for ‘the holidays’, as the Christmas season is very multiculturally called. This will allow the Democratic leadership to craft a complex “trigger option” — one where there is no public option immediately and lowcost health care is provided by non-profit insurance co-operatives effectively, big insurers pool resources to offer more basic coverage at cheaper prices, on a sliding scale that ensures near universal coverage of some description.

The problem with co-ops is that they would have no power to affect the prices health insurers set for their regular premiums so individuals and businesses continue to pay a mozza for cover. Worse, as Alexander Cockburn pointed out in Counterpunch, this would be combined with a mandating system, similar to car insurance, where you would be required to have health insurance — effectively the state would be holding the gun while Big Insurance picks your pocket. Only in America.

The trigger option would allow for a rollout of a public option if, after three-five years, average premiums had not come down to set levels. Since they wouldn’t, this is a public option by stealth. It would allow Republican Senators Snowe and Collins from Maine to support it, and one or two others, while able to save face with their constituents and soft-money corporate donors.

Should that fail, there is a final option, which is to abandon HR 3200, and roll it into the 2010 budget bill as a series of provisions — it is then subject to a “reconciliation” vote, which is a straight majority in both houses, and guaranteed to pass. The White House could then argue that the will of the people was expressed in the HR 3200 and the Senate obstructed it — reconciliation is then in the spirit of the original vote. Indeed, that may be the overall game plan.

Whatever the case, HR3200 is an enormous victory, the first serious universal health care bill to get through a House of Congress ever. The Senate will be tough, if not insurmountable, but this has months to run. Quite aside from the manifold improvements any sort of serious bill will offer in American life, it will give Obama a victory he can go back to his base with, and fire them up anew for the Herculean labour of making change in America.

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Peter Fray
Peter Fray
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