With Congress out of town for the Thanksgiving break, there’s been little to distract Washington’s prognosticators from offering their predictions over the public plan’s fate. Truth is, no one is quite sure how this saga is going to play out. Based on comments from several of the four moderates since Saturday’s vote, it’s tempting to argue that Democratic leaders will at the very least have to scale back the public plan to pass the larger bill. Then again, the way Landrieu melted Saturday at the chance to secure millions of federal dollars for Louisiana indicates that there’s much more at play here than mere principle.

With all of that in mind, Sen. Sherrod Brown (D-Ohio) offered his own optimistic take on how the drama over the public option will end, telling CNN yesterday that the historical significance of the reform vote will ultimately be enough to sway the four moderates in favor of the bill.

In the end, I don’t want four Democratic senators dictating to the other 56 of us and to the country, when the public option has this much support, that it’s not going to be in it. [...]

I don’t think they want to be on the wrong side of history. I don’t think they want to go back and say, you know, on a procedural vote, I killed the most important bill in my political career. I don’t think they want to be there on that. So I think in the end, we get them.

Under the Senate legislation as it is currently written, Americans with employer-provided coverage, whose income is below 400 percent of the federal poverty level and whose premiums are between 8 and 9.8 percent of their total income will be exempt from having to purchase health coverage but will not be able to access the exchange to qualify for government assistance to purchase insurance.  The agreed to amendment will make it possible for these individuals to convert their tax-free employer health subsidies into vouchers that they can use to choose a health insurance plan in the new health insurance exchanges.

Critics contend that the proposal will cause a flood of young, healthy workers to flee employer-sponsored plans, hiking rates for the older, sicker folks who remained. But a number of Senate Democrats had recently joined Wyden in urging adoption of the so-called “free-choice” amendment.

The Congressional Budget Office estimates that the change will cover an additional 1 million people, Wyden says.

After six weeks of drafting a bill behind closed doors, the Majority has produced a bill that increases premiums, raises taxes, and slashes Medicare by half a trillion dollars to create a new government program. This is not what the American people want. I don’t believe they think this is reform. This is not the direction to take.

It’s a little early to grasp everything that’s contained in the bill, but it’s worth noting a few things about the criticisms.

1) The primary tax increases in the Senate bill target only the wealthiest Americans. One bumps Medicare’s payroll tax from 1.45 percent to 1.95 percent for individuals earning more than $200,000 per year, and families earning more than $250,000, while another applies a 40 percent tax to insurance plans costing more than $8,500 for individuals, or $23,000 for families (excepting a number of blue-collar jobs). Those aren’t typically middle-class salaries or insurance rates.

2) The largest chunk of the Medicare cuts ($118 billion worth over 10 years) don’t target Medicare, but the private insurance plans that the government pays to cover Medicare patients. That program, called Medicare Advantage, costs taxpayers roughly 14 percent more per senior than the traditional program. The MA “cuts” actually just scale back the insurance company subsidies so that rates are more closely aligned with those under traditional Medicare.

3) Many of the proposed cuts in Medicare are designed to discourage provider behaviors that lead to needless treatments and expenses. One provision, for example, “cuts” payments to hospitals for treating conditions that were acquired after the patient arrived at the facility.

4) Many other Medicare “cuts” are not really cuts at all, but proposals to slow growth in projected spending. That is, the raise for some providers might be reduced, but it will be a raise nonetheless.

Last year, the Bush administration proposed hundreds of billions of similar Medicare “cuts.”

• $848 billion: Ten-year cost of the proposal, all of it offset by revenue increases and budget cuts elsewhere.
• $130 billion: Amount the bill would reduce budget deficits over 10 years.
• 31 million: Number of currently uninsured people who would gain coverage.
• 24 million: Number of people who would still be uninsured in 2019.
• 33: Estimated percentage of those 24 million who would be undocumented residents.
• 30 million: Number of people enrolling in exchange plans.
• 5 million: Number of those 30 million who opt into the exchange rather than accepting employer-sponsored coverage. (They’re not eligible for subsidies.)
• $447 billion: Ten-year cost to subsidize exchange plans.
• 3 to 4 million: Number of people estimated to enroll in the public plan.
• $750: Per-worker penalty for employers not offering health coverage, when employees move to subsidized exchange plans.
• $95: Penalty for individuals not complying with the insurance mandate in 2014.
• $750: Penalty for individual non-compliance in 2016.
• $36 billion: Amount the government expects to collect in penalties from employers and uninsured individuals over 10 years.
• 15 million: Ten-year enrollment increase in Medicaid and the Children’s Health Insurance Program.
• $374 billion: Ten-year cost to expand Medicaid and CHIP.
• $25 billion: Ten-year cost to states to comply with the Medicaid and CHIP provisions.
• $8,500/$23,000: The thresholds — for individuals and families, respectively — at which insurance plans will be considered high-cost “Cadillacs,” and therefore subject to a 40 percent tax. (To mollify labor unions, these thresholds were bumped up from the $8,000/$21,000 triggers found in the Senate Finance Committee’s bill.) For folks with dangerous jobs — firefighters, miners, policemen, etc. — the thresholds are even higher.
• $149 billion: Revenue generated by taxing Cadillac plans.
• $192 billion: Savings derived by reducing projected increases in Medicare’s fee-for-service payments.
• $118 billion: Cuts to Medicare Advantage program, under which the government pays private insurance companies to cover Medicare patients.

Sen. Charles Schumer (D-N.Y.) said last night that the Democrats will file for cloture today on a motion to proceed to the bill, with the cloture vote likely to come Saturday morning. The actual floor debate, however, will probably not begin until after the Thanksgiving recess, Schumer added.

The latest tally on the public option in the Senate: 50 likely supporters and 40 likely opponents, with 10 members — all in the Democratic caucus, and all necessary “yes” votes to overcome a filibuster — on the fence.

Last week, it was liberal Sen. Barbara Boxer (D-Calif.) predicting that anti-abortion lawmakers in the upper chamber wouldn’t be able to rally the 60 votes needed to pass an amendment to health reform legislation restricting abortion. This week, it’s an influential moderate Democrat warning that the health bill won’t pass without such a provision. Roll Call reports:

“What is clear is that for this bill to be successful, there can be no taxpayer funding for abortion,” Senate Budget Chairman Kent Conrad (D-N.D.) said, appearing on CNN’s “State of the Union.”

Conrad said he did not know whether the Senate would ultimately adopt the restrictive language that the House passed last week, which dictated that any new government-funded health insurance option cannot pay for abortions. But he said that some kind of abortion restriction is necessary for a bill to get through Congress.

The debate in the House is following a similar storyline, with conservative Democrats insisting that the abortion restrictions be included, and no small number of liberal Democrats hinging their support on their absence. With neither side appearing ready to back down, you can look for Democratic leaders to perform a very delicate scalpel job during conference negotiations to reconcile the two bills — something that would allow both sides to claim victory.

The $787 billion economic stimulus bill addressed the issue, providing additional federal funding for the state-federal Medicaid program. But that extra help expires at the end of next year, when unemployment rates are expected to remain near double digits. The looming expiration has left state health officials and children’s welfare advocates anxious about the effects on kids’ health care.

Enter the House health reform bill, which would provide more than $23 billion to continue the additional federal funding for six months. The Washington Post explains:

Under the Affordable Health Care for America Act, the federal government would continue to pay a higher share of all Medicaid costs — 66 percent on average, up from 57 percent before the stimulus — for an additional six months, and erase in one fell swoop a major chunk of states’ projected shortfalls for the coming year.

“It would be a huge help — critical,” said Cindi Jones, chief deputy director of Virginia’s Medicaid program, which quickly estimated last week that it would receive an extra $360 million to $380 million next year under the bill. At a meeting last week of the nation’s Medicaid directors, Jones said the group is unanimously in favor of the provision.

That provision isn’t included in the Senate’s health reform bill, but states are hoping that it will work its way into the final bill. Of course, the temporary help is no remedy to the flawed Medicaid funding formula. It’s worth asking when Democratic leaders plan to tackle that larger problem, if not in the context of the most sweeping health reforms since the program was created.

Sen. Jay Rockefeller (D-W.Va.) (Photo by Mark Murrmann/ZUMA Press)

The Democrats’ proposal to terminate the Children’s Health Insurance Program would hike health care costs for some of the country’s low-income families, likely increasing the number of uninsured kids in the name of expanding coverage, several health policy experts and state health officials warned Friday.

Under the sweeping health reform bill passed by House Democrats last weekend, CHIP would cease to exist at the end of 2013, instead shuffling those kids into Medicaid or private insurance plans on a proposed insurance marketplace, called the exchange.

Image by: Matt Mahurin

Stan Dorn, senior health policy researcher at the Urban Institute, said there are certain advantages to scrapping CHIP. Both Medicaid and exchange plans, for example, would never require congressionalreauthorization — a process CHIP is subjected to every few years, he pointed out. But due to CHIP’s affordability, Dorn said “it’s clear” that kids “are much better off” under CHIP than they would be under private exchange plans.

“It’s not even a close question,” Dorn said during a children’s health care forum on Capitol Hill Friday.

Studies suggest Dorn’s concerns are valid. One analysis, conducted by Watson Wyatt Worldwide, an actuarial research firm, found that families living between 175 and 225 percent of the federal poverty level pay just 2 percent or less of treatment costs under CHIP. Under the proposed exchange plans, researchers found, those same families would pay up to 35 percent of their children’s health costs.

Nate Checketts, director of Utah’s CHIP program, noted that the move to more expensive exchange plans would only discourage low-income families already pinching pennies in the economic downturn. “Unless there’s a mandate, I don’t think those low-income families will sign up for it,” saidChecketts.

CHIP was created in 1997 with broad bipartisan support and renewed for five additional years last February. The popular program is designed to cover children in low-income families that are ineligible for Medicaid. The House bill would both expand Medicaid and dismantle CHIP, sending some kids currently covered under the program into Medicaid plans and others into private plans on the exchange.

The Senate Finance Committee also initially proposed to terminate CHIP when it unveiled its legislation in September. However, the committee last month approved an amendment, sponsored by Sen. Jay Rockefeller (D-W.Va.), to reauthorize the program through 2019.

Supporters of the House proposal argue the advantages of centralizing control over CHIP coverage. Because CHIP is managed by states, there is a fear among some lawmakers that lean economic times could lead to sharp CHIP cuts in some spots, leaving those kids without any coverage at all. Those fears were almost realized earlier this year when California, facing a severe budget squeeze, temporarily froze new CHIP enrollment. Some health policy experts have pointed out that it’s probably not a coincidence that many House Democrats pushing the CHIP repeal are from California, including Speaker NancyPelosi, Rep. George Miller, who chairs the Education and Labor Committee, and Rep. Pete Stark, who heads the Ways and Means health subpanel.

Rep. John Dingell (D-Mich.) has also defended the plan to terminate CHIP, arguing in a recent email that “enrollment of kids increases when the entire family can be enrolled under one plan.”

Checketts agrees, pointing out the difficulties that can arise when family members’ health coverage is scattered across different programs. “It is a good goal,” he said, “to get families on a single source of coverage.”

Yet some analysts have concluded that affordability is the more significant factor to ensuring coverage.

The advantages of providing families with low-cost access to health coverage for their kids, Dorn said, “significantly outweighs the benefits of putting parents and kids in the same health plan.”

Other children’s health care advocates are agnostic. Jocelyn Guyer, co-executive director at Georgetown University’s Center for Children and Families, said Friday that, while CHIP has proven “a great success,” getting affordable coverage for kids is more important than what program provides it.

Ron Pollack, executive director of Families USA, a consumer health care group, also indicated that affordability is more critical for ensuring children have health insurance. “What are the out-of-pocket costs, and what is the care that they’ll receive?” Pollack asked, without endorsing either the House or Senate approach to CHIP.

If an analysis by the Congressional Budget Office is correct, the Senate’s plan to salvage CHIP is the more affordable option. Examining the Senate Finance Committee’s initial proposal to repeal CHIP, CBO Director Douglas Elmendorf noted last month that “some of those children would be eligible for subsidized coverage in the exchanges but would not be enrolled in an exchange plan.”

The reason, Elemndorf explained, is “at least in part to the higher premiums and higher out-of-pocket costs that they would typically face in such a plan.”

There isn’t anything wrong with it, except some people look at it as an infringement upon individual freedom. But when it comes to states requiring it for automobile insurance, the principle then ought to lie the same way for health insurance, because everybody has some health insurance costs, and if you aren’t insured, there’s no free lunch. Somebody else is paying for it…. I believe that there is a bipartisan consensus to have individual mandates.

And here’s Grassley today, raising questions about the constitutionality of those individual mandates:

For the first time in a 225- year history of the country, the federal government says you have to buy something, and if you don’t buy it, you’re going to be paying $1,500 as a family to the IRS each time you file your income tax until you get at least a minimum insurance….

And the questions raised about that — and, of course, I’m not a constitutional lawyer and I don’t — haven’t studied the law. In fact, I doubt if there’s any cases that would apply to it right now that you could call precedent…. [But] you want to assume that Congress would not pass an unconstitutional law if they knew it was unconstitutional.

When a reporter asked specifically about the difference between a federal health insurance mandate and a state car insurance mandate, Grassley had a ready answer: the 10th Amendment.

The major difference would be the 10th Amendment and what the 10th Amendment says about our federal system of government. It says something like: anything that’s not specifically delegated to the federal government is reserved to the states and the people thereof — all those rights and powers….

So states, if they want to mandate you buy something, they can do it. But that doesn’t give the federal government the right to do it.

The next question was about $50 million in emergency aid the federal government recently showered on the nation’s pork farmers — half of the assistance Grassley had requested.