George Miller, a gray-haired, mustachioed Democratic congressman from San Francisco, is one of the people who run Congress. He is close to Speaker Nancy Pelosi, chairs a key committee (Education and Labor) in the health-care debate, and will have great influence on the final shape of the health care reform bill, which is now quite nicely on track. So it makes sense to listen to what Miller says about the now nearing passage in the House. He worked harmoniously with fellow committee chairmen Charlie Rangel and Henry Waxman to blend their bills and listen to the myriad concerns of other members. The process included more than 20,000 public events held by House Democrats and (it sometimes felt) nearly as many private meetings. Miller described it as "the most intense negotiations in my 35 years here." Much of the bill doesn't kick in until 2013, which is only natural when we're talking about reforming one sixth of the U.S. economy. (Social Security was passed in 1935 but didn't start paying benefits until the 1940s). To provide some goodies faster, Miller worked up a list of 14 changes that Americans will feel immediately, from banning lifetime insurance caps (where chronically ill patients lose their coverage) and outlawing "recissions" (where your policy gets canceled with no explanation), to new community health clinics and improvements in Medicare. The only thing immediate and potentially big that the House failed to include in the bill is a provision for transparency in pricing, so we could all instantly access who was charging what for which pill or service. This would exert strong downward pressure on costs. The dramatic expansion of coverage of the uninsured and the end to discrimination against people with preexisting conditions are huge social advances that have been overshadowed in the national debate by the struggle over the public option, which Pelosi has decreed should henceforth be called the "consumer option."Because the word "public" is apparently so toxic that it threatens the inclusion of the idea in a final package, I'm going to go along with the Speaker on that one. So I asked Miller what he thought of a "trigger" consumer option--the proposal favored by Sen. Olympia Snowe that would allow the establishment of a consumer option only if the private insurance market was failing to hold down costs and expand access.Now you might wonder why I asked such a question. Snowe's influence seemed to have melted when Senate Majority Leader Harry Reid opted for the stronger "opt-out" consumer option, which would allow states to drop out of the public system. But with Joe Lieberman threatening to filibuster, I have a feeling the current debate may yet trigger a return of the trigger in the House-Senate conference committee that will write the final bill. The Democrats need 60 votes for final passage of the conference report (the last step before a bill goes to the president's desk) and need Lieberman and a half dozen other conservative Democrats who have been sour about a public option. Reid's opt-out might not fly. Miller, who will play a big role on that critical committee, is a strong supporter of the option formerly known as public. He says he'd be "hard-pressed" to support a trigger. "I've never seen a trigger work yet," Miller says, citing failed experiments involving triggers in immigration and other bills. "It's a substitute for not having a policy." Warming to the topic, Miller added, "A trigger is a promise that 'I'll marry you in the morning.' It's camouflage at best and a lie at worst." Miller chuckled when I told him that Lieberman had said the public option (the Connecticut senator still calls it that, of course) would cost taxpayers money, when the Congressional Budget Office and other independent analysts have said just the opposite. He pointed out that Lieberman is from Hartford, historic home of the insurance industry. One of the big questions of the next few weeks will be whether Lieberman could at least support "opt-in," where states have to actively enroll in the consumer option. This is a guy who said repeatedly when he was running for reelection in 2006 that he wanted major health-care reform. If he kills the bill because he can't stomach giving his state a choice to participate in a voluntary federal program, then he's stripped off his camouflage altogether. The House bill resolves how the consumer option would set its prices. It would be done through negotiations with providers, not pegged to what Medicare charges. That appeared to ease the concerns of small-state senators such as Kent Conrad of North Dakota, whose rural hospitals feel strangled by national Medicare reimbursement levels. But it means that the consumer option will likely be more expensive than private insurance--new proof that the critics who say it's aimed at driving private insurers out of business are simply mistaken. One reason that private insurance companies will be able to compete on price with the government is that they will no longer be able to siphon off as much for marketing, cherry-picking healthy customers (eventually to be outlawed if the bill passes) and profit-taking. Miller is proud that the House bill ends the insurance industry's antitrust exemption and requires insurers to devote at least 85 percent of the money they take in to actual health care. Under the status quo, the numbers are more like 60 or 65 percent. That's pathetic when you think about it: Forty cents of every health dollar down the drain. No wonder it's time for reform. I asked Miller why it was necessary to exclude 90 percent of the public from the public, er, consumer option. That's right--almost none of the consumers agitating for a consumer option will be eligible for it. At first, only the uninsured will be allowed to participate in "the exchange," where a consumer option would be only one of many choices. I wondered, why not let everyone have more choices? Miller says that the bill allows the government to decide by 2015 whether companies with 50-100 employees could go into the exchange instead of contracting directly with insurers as they do now. That's not good enough for me. I want to know why all Americans working for all companies couldn't go into the exchange by 2013 and choose the public option, private insurance, or something else. After all, President Obama keeps saying that the principle behind the reform is "choice and competition." This is Sen. Ron Wyden's position. He's a passionate advocate of full choice, on the grounds that it's the only way to prevent a surge in costs. He told me that if insurers jack up premiums, and Americans feel they've received nothing from health-care reform except bigger insurance bills to pay, "they'll come after Democrats with pitchforks." When I offered this scenario to Miller, he reacted sharply. "Insurance companies will do this at their peril. If we need to take action [to restrain premium hikes] before 2013, we will." I asked Wyden for the political explanation of why the consumer option wasn't available to everyone. The senator pointed to unions and human resources personnel at major corporations as the major obstacles to full choice. The unions are wrong on this, but I can at least understand their opposition. They negotiated over many years for health-care benefits instead of higher wages and don't want to part with their so-called "Cadillac plans." Gerald McEntee, head of the American Federation of State, County and Municipal Employees (AFSCME), and the White House are now at war over this.To pay for the bill, the unions will eventually have to make concessions on the tax deductibility of these plans, which are often much more generous than what white collar workers receive. The idea of them being totally tax-free is unfair and unsustainable in the current climate, as Miller and the more enlightened union leaders must surely know. But at least they have a case to make. The HR folks, who dominate the thinking of corporate America on health care (CEOs generally know finance, sales, and marketing but not benefits), are among the most selfish actors in this entire drama. They don't want the employees of their companies to have more choices when it comes to who will insure them. Why? Because it would mean less control for HR. They would lose some of the contracts with the insurance representatives they see at their golf outings and benefits conferences. That might mean--God forbid!--fewer invitations to play golf and less clout within their companies. It might mean having to do business in a different way and getting accustomed to letting their colleagues in the workplace make more of their own decisions. George Miller's not ready for that either. He and his House colleagues aren't willing to entertain the idea of making the consumer option truly available to all consumers. They think it's politically too much for the government to bite off right now. But as Obama knows, that's the best way to use competition to drive down costs and restore fiscal sanity to health care, which was a large reason why the president agreed to push this monster reform in the first place. If "House-Senate conference committee" had a snazzier name we would recognize it for the World Series that it is. House Democrats are on the verge of winning the pennant on the biggest piece of social legislation in a generation. Senate Democrats are getting closer to clinching, too. But they won't have cause for celebration until they get through Game Seven in conference, then move to final passage, maybe by Christmas.
