Health Care Reform

The Supreme Court Overturns History

Every 80 years, the Supreme Court has decisively entered a sharply divided political process to provide its own answer to the fundamental question of American politics: what is the scope and purpose of government?  Each time, it has attempted to reinforce the generational and party alignments of a previous era in the face of challenges from the beliefs and partisan preferences of an emerging civic-oriented generation like today’s Millennials (born 1982-2003). But this time, as the eighty year cycle came full circle, the US Supreme Court’s decision to uphold the individual mandate in the 2010 Affordable Care Act (“Obamacare”) under the taxation powers of the Congress surprised everyone.  

As in the past, the generational and partisan composition of this Supreme Court reflects an earlier era. Five of the justices, including a majority of its conservative bloc (Roberts, Thomas, and Alioto) are Boomers (born 1946-1964). The rest are members of the even older Silent Generation (born 1925-1945). A majority are Republicans. Yet in this case,  Chief Justice Roberts   bucked history and his generation’s preference for ideological confrontation in order to preserve the institutional reputation of the Supreme Court. 

Perhaps the Court understood the historical and generational trends any ruling to overturn the Affordable Care Act would have had to fight against. Two-thirds of Millennials wanted the Affordable Care Act either to be expanded (44%) or left as is (23%). By contrast, clear pluralities of Boomers (44%) and Silents (46%) wanted it repealed. Millennials, however, represent the wave of the future. They now comprise one-fourth of all eligible voters; by 2020 more than one out of three adult Americans will be Millennials. And that Millennial-dominated future is now likely to arrive much sooner as a result of the court’s decision. 

Because this large cohort is bringing a new “civic ethos” to American democracy, the Court’s decision is likely to have far reaching effects on the future relationship between government and its citizens. Millennials believe that social rules are important but that everyone should have the freedom to choose how to abide by them. They see government as a parent, setting the boundaries of behavior but not dictating it. Two key elements of the Court’s decision today  reinforce this approach.   One upholds the right of the federal government to tax behavior of which it does not approve (in this instance, not buying health insurance). The second denies Congress the right to dictate to the states what they must do with regard to Medicaid. The Millennial civic ethos will use democratic processes to determine national priorities and rules for permissible behavior by both individuals and states, even as it provides incentives for greater individual and local initiative.  

With the Court’s affirmation of the constitutionality of the Affordable Care Act, the country is likely to see this framework used to resolve many of the other policy challenges the country faces.  June 28, 2012, will be remembered as the day the Millennial Era arrived in the nation’s legal principles as it did in its electoral politics four years ago.  

This blog appeared first in the Huffington Post.

The President's Reforms and the New Politics of Health Care Costs

The health care reforms enacted this week are an unequivocal political triumph for President Obama. He turned back the most intense and dogged partisan campaign to stop a piece of legislation seen in this era, enhancing his own popularity and power until at least the next setback. More important, the reforms as passed constitute the most serious social-policy achievement in two generations. They not only provide a clear and secure route to insurance coverage for two-thirds of the Americans who don’t have it. The President’s reforms also end a sheaf of abhorrent insurance practices – most notably, preexisting condition clauses and lifetime coverage caps – which withhold payment for care when, as it happens, people actually need it most. The open question, however, is whether the reforms also will make the country’s health care system more sustainable by slowing its trajectory of cost increases. 

Without reforms to do so, those prospects are at once scary and unsustainable. A few months ago, I calculated how much an average, middle-class family should expect to spend on health care in 2016: The answer is fully one-third of the family’s real annual income – a level that’s unsustainable both economically and politically. 

Here’s how I figured it out. The Congressional Budget Office tells us that an average family will earn $54,000 per-year in 2016, when moderately-priced family insurance coverage will cost $14,700. Most people’s employers will pay much of that bill; but those payments come out of people’s wages, not the company’s profits. Taking this into account, a middle class family’s earnings in 2016 should come to $68,700 ($54,000 + $14,700), of which $14,700 or 21.4 percent will go for health insurance. That’s not all. Experts figure that their co-payments and other uninsured expenses, on average, will come to another $5,100 in 2016. They’ll also pay taxes to help cover other people’s health care – 2.9 percent of their cash wages for Medicare ($1,566), plus perhaps $1,500 more in federal and state income taxes for Medicaid and for Medicare costs not covered by the 2.9 percent payroll tax and for the subsidies for the uninsured under the new reforms. Add up all of that, and it comes to $22,766 or 33.3 percent of the middle-class family’s adjusted income of $68,700.

As Harvard health care expert David Cutler and others have concluded as well, the new reforms provide a credible beginning for what will still be a long and arduous process to control cost increases. Here’s how. To begin, the insurance exchanges should reduce costs in the individual and small-group insurance market, while the investments in IT should help slow costs across the system. In the largest and fastest-growing part of health care, treating the fast-rising numbers of older Americans, the reforms also include significant cost reductions in Medicare.  Perhaps most important, Medicare will move from volume-based payments to reimbursements based on the value of the treatments. In addition, the reforms create a new Medicare advisory board to propose new ways to cut costs or save expenses, tied to a process for fast-tracking the recommendations through Congress; and there are also cuts in overpayments for Medicare Advantage and other supplemental Medicare plans, as well as new measures to reduce Medicare fraud and abuse. Finally, there’s a new emphasis on prevention programs, which could significantly reduce future costs. 

All of this will help, but it won’t reduce the share of our average family’s income going to health care by more than a percentage-point or two. To make a bigger difference, each party will have to accept much more difficult changes advanced by its rival.  So, Democrats will have to live with taxing a good share of the value of employer-provided coverage – the only tax increase conservatives will swallow these days – along with malpractice reforms more far-reaching than the limited state-based experiments enacted this week. For their part, Republicans will have to accept a public option, the only way to introduce real competition for insurers in areas where one or two of them now constitute an effective monopoly or duopoly.

Happily, the passage of the President’s reforms this week will make such hard steps much more likely politically, if not any easier. The reason is that with these reforms, the federal government, for the first time, has accepted overall responsibility, and ultimate accountability, for the nation’s health care system. When costs continue to rise sharply, as they will, voters across the country will have Washington as a focus for their displeasure, and the next election as an effective way to express it. That political prospect will drive much more stringent steps to contain costs, as it has in every other advanced country in the world. Only it’s coming later here, which is why we now spend so much more than other countries on health care.

Broken No More?

There is a new breeze blowing through Washington this week. Yes it has hit 70 degrees outside. Spring is in the air, and it has lightened everyone's step a bit. But the real change is what is happening in the governing party and in the Capitol. The people's business is starting to get done.

It has been a remarkable few weeks here in DC. A payroll tax cut for small businesses to help provide a modest boost to the economy was signed into law, passing the Senate with 11 Republican votes. A serious bipartisan immigration reform plan outline was advanced. The final financial regulatory reform package is taking shape. The President offered up a thoughtful vision on how to improve the nation's education system, and is about to pass a major overall and expansion of the college student loan program. The FCC released a powerful vision for the future of broadband and the internet in the US.  Competitive - and what we all hope were fair - elections were conducted in Iraq. And of course, the big one - modernizing and improving our health care system - is close to passage. 

After a fitful first year, the Democrats are learning, however clumsily, to become the governing party. None of the three Democratic leaders - Obama, Reid, Pelosi - have ever been in their position when the Democratic Party was in such a strong position with the public, or had so much power in Washington. Democrats have more seats in Congress and received a higher vote share in 2008 than in any time since the 1960s. Barack Obama was not yet age ten the last time Democrats were in a similar position in DC, and frankly, the years of conservative ascendancy, which kept the Democrats on the defensive and largely out of power, left an entire generation of politicians more used to challenging the power of others than wielding it themselves. And it has shown over the past 14 months.

This new day for Democrats - huge Congressional majorities, a country tempered by failed conservative policies, a significant Party ID advantage, and a powerful and growing majority coalition - is unlike any time we've seen in Washington in at least 40, if not 70 years. The Democrats have clearly needed time to learn how to be a governing party, to align their interests, manage complex legislation, bring along a lot of new staff, Senators, Members of the House, and a young President into a coherent team. It has been a bumpy process - no big surprise - but there are signs this week that this new 21st century Democratic Party is finding its way, learning how to manage the new circumstances, do what is required to move the nation forward.  It is learning how, after the end of the conservative ascendancy, to become a governing party.

In 2007, Peter Leyden and I wrote an article called The 50 Year Strategy, which argued that the failure of conservative politics and the emergence of a "new politics" of the 21st century offered the chance for the progressive movement to build a new and durable progressive era, and usher in a re-alignment in American politics.  I still believe, deeply, that this opportunity is very much present today. With strong leadership and the courage to tackle the nation's most important problems, it is still very much within the center-left's grasp. And in many ways this question - could the Democrats seize the historic opportunity they had to realign politics, and usher in a new era of reform and progress? - has been, and remains the single most important question in American politics today.  This morning, the chances of the Democrats seizing the moment - and the conservatives continuing to make equally historic political miscalculations - seems ever more possible.

Steven Pearlstein has a nice reflection on all this in the Washington Post this morning.

It may not be morning in America just yet, but today it certainly feels a lot more like spring - a time of hope and of possibility - for Washington and for the 21st century center-left.

Update: See our recent report on the changing coalitions of the two political parties to learn more about the current state of the Democratic Party's emerging majority coalition.

Obama's Evolving Health Care Pitch

In his press conference yesterday the President talked about this goals in reforming our health care system which demonstrated a clear evolution of thinking and narrative.  Take a look:

During our meeting we also touched briefly on how we can move forward on health reform.  I've already announced that in two weeks I'll be holding a meeting with people from both parties, and as I told the congressional leadership, I'm looking forward to a constructive debate with plans that need to be measured against this test.  Does it bring down costs for all Americans as well as for the federal government, which spends a huge amount on health care?  Does it provide adequate protection against abuses by the insurance industry?  Does it make coverage affordable and available to the tens of millions of working Americans who don't have it right now?  And does it help us get on a path of fiscal sustainability?

What is encouraging about this langauge is that as NDN has suggested for some time the true test of any proposed health care reform is whether it can get costs down over time while maintaining quality and accelerating innovation.  It makes sense that to achieve another important goal - creating universal coverage - that one must first figure out how to make the system less expensive.  For as President Obama said repeatedly during the 2008 campaign, people do not have health insurance today because of its high cost.  Creating a more competitive, intelligent, effecient, less expensive and patient-driven system needs to be the primary goal of health care reform, and there is no way to do this without sacrificing one of the other stated goals of the 2009 debate - making sure everyone can keep what they have. 

My own take is that the adoption of that rhetorical goal - letting everyone keep what they have - was a critical moment in driving health care reform off the political rails.   For how can one have "reform" if everyone gets to keep what you already have? Where is the reform in that? And if your basic argument is that the system is terribly broken, and needs to be fixed - in fact it is an urgent national priority - then how can you then say but you, the American people, get to stay in the old broken system and not join the effort to reform?

In fact what is required for true reform and the construction of a 21st century health care system in the US is for everyone to in fact leave behind the current, inadequate system and move to a better system.  Rhetorically the President needs to tell those who are satisfied with their insurance today that in fact the new system will actually not allow them to keep what they have, but will offer them something fundamentally better (the idea you get to keep what you have was also dramatically undermined by the idea of the excise tax on "cadillac plans").

As the President's language suggests above, he is rhetorically and intellectually moving beyond the theory of the bills which passed in 2009.  I am not sure how this evolution of the President's thinking will effect what happens with health reform in 2010, but the tests the President offered yesterday are the right tests which all reform must be measured.  At the core of this new pitch must be that the new system will be better for everyone, and that everyone has a stake in making it happen.

President Obama Focuses on Health Insurance Reform as Piece of New Foundation

In his weekly address, President Obama discusses the struggle that everyday people have been and are currently going through, and how health insurance reform is a key piece of a new foundation. He specifically focuses on reforms that will take effect in the first year after reform passes. Take a look:

How to Sink a Three-pointer Today - Part II

Last week, I offered up some advice for President Obama on how to shape his speech to the joint session of Congress today. Here are a few more pointers, based on the numbers:

Demonstrate that reforming health care will aid or at least not hurt individual Americans or their families. Surveys conducted by both Pew and the Henry J. Kaiser Family Foundation have consistently indicated that at least a plurality of the public (albeit a declining one) believe that current health care reform proposals would help the country as whole. At the same time, voters are not as sanguine about the impact of health care reform on themselves and their family. The recent CBS News survey indicates that 31% believe that current congressional health care reform proposals would hurt them personally, while only 18% say they would help. More specifically, voters are more likely to believe that these proposals would raise (41%) rather than reduce (20%) their health care costs; worsen (34%) rather than improve (19%) the quality of their health care; and, make it harder (37%) rather than easier (13%) for them to see a doctor. Similarly, clear pluralities perceive that these proposals would hurt the middle class (43%), seniors (36%), and small businesses (46%). As has occurred so often during the past four decades, Republicans and conservatives, with Democratic assistance, have managed to define a Democratic initiative as a social program that would aid others to the detriment of average Americans. Given this, it's surprising that the public is not more strongly opposed to what it perceives to be President Obama's and Democratic health care reform proposals than it already is. If he does nothing else, the president must use his speech to inform and convince the public that his health care reform proposals will benefit, or at least not hurt, middle class Americans.

Recognize that he and his party are dealing from a position of relative strength, even on the matter of health care reform, than Congress as a whole or the Republican opposition. Even though President Obama's overall job approval score and his marks for handling health care have trended downward over the past several months, they remain well above those of the other actors in this drama. In the most recent Daily Kos tracking survey, only Barack Obama was rated favorably by at least a plurality of voters (52%). By contrast, only a third have favorable impressions of the two Democratic congressional leaders, Nancy Pelosi (32%) and Harry Reid (31%). Less than one in five are positive about the two GOP leaders in Congress, Mitch McConnell (19%) and John Boehner (15%). Only 39% are favorable toward the congressional Democrats as a whole, while just 18% feel that way about the congressional Republicans.

And, with regard specifically to health care reform, the CBS News survey indicates that by a greater than 2:1 margin (50% vs. 23%) voters believe that President Obama has better ideas than Republicans. This margin has remained consistent throughout the summer.

Moreover, the Democratic Party is clearly the majority party both inside Congress and within the electorate, although some reporters seem to forget this. In commenting about President Obama's speech on the Today Show, Chuck Todd said that the setting on Wednesday evening would be odd because "half of the members will be applauding wildly and the other half will be sitting on their hands." Actually, Democrats comprise about 60% of the members of each House and that 10-percentage point difference is of more than academic importance. Democrats not only have enough members in Congress to make more noise than their GOP counterparts, but their edge is sizable enough to control the legislative process if they are willing and have the courage to use it. 

Meanwhile, out in the country, according to both Pew and Ipsos, about half of the electorate identifies with or leans to the Democratic Party. By contrast, only somewhat more than a third say that they are Republicans or lean that way. This is a far different pattern than it was in 1994, the last time Congress considered health care reform, when equal numbers (44%) identified with each party. This Democratic majority is bolstered by the party's disproportionate strength within emerging and growing demographics-Millennials (voters 18-27), Latinos, Asians, and African-Americans-as well as women, who comprise a slight majority of both the population and electorate. These groups underpinned the president's decisive victory in 2008 and continue to support him, his legislative initiatives (including health care reform), and the Democratic Party to a substantially greater extent than other groups.

Stemming from its status as America's majority party, voters continue to have a far more favorable image of Democrats than Republicans on most issues and government management matters.


Democratic Party

Republican Party



Can do better on issue of...












Health care




Foreign policy




The economy
















Budget deficit








Terrorist defenses




Which party...




More concerned about disadvantaged




More concerned about people like me




Can bring needed changes




Selects better candidates




Governs in more honest/ethical way




Can better manage federal government




More influenced by lobbyists




More concerned about needs of business




Obviously, Congress is constitutionally equal to the executive branch. The president cannot simply dictate to or command it to act in order to win a congressional majority. It would also be a plus if at least a few Republicans supported Democratic health care reform initiatives, although seems increasingly unlikely, something that may ultimately force the president and his party to go it alone. Some compromise will likely be necessary to obtain either or both of those ends. But, in his negotiations to achieve those goals President Obama, his staff, and congressional Democrats should recognize that they do some advantages, among them majority status in Congress, a majority coalition within the electorate, and a far higher level of public favorability than the Republicans. This means the president and Democratic congressional leaders should not have to completely roll over to achieve meaningful health care reform. They will not have to do so if they recognize and work from their current position of strength.

A recent Los Angeles Times article maintains that whatever ultimately happens with current healthcare reform proposals, President Obama has taken the matter further than did Bill Clinton, the last president to make such a concerted effort-or indeed any president has since Harry Truman proposed a national health care program six decades ago. What Barack Obama says next Wednesday and does in the weeks that follow will go a long way toward determining whether he will have to be satisfied with the moral victory of simply exceeding his last Democratic predecessor or go on to win final victory. Clearly and forcefully stating his goals and being willing to take advantage of his political and institutional strengths will put him in position to, at long last, win the health care championship.

How to Sink a Three-pointer Next Wednesday - Part I

In spite of a slight uptick in Barack Obama's job performance score in the Real Clear Politics index over the past day or two, the overall picture in the month-end polls is a continued decline in the American public's attitudes toward the president, Congress, and both political parties, especially the Democrats, and a tightening in the generic congressional vote since the beginning of the year. These same surveys also point to the increased importance over the past several months of health care reform to voters relative to other issues. For these reasons President Obama's speech to a joint session of Congress next Wednesday is crucial to the fate of his presidency and his party. Just how should the president shape this key speech to win the day next week and beyond?

Most obviously, recognize the clear importance of health care reform to the electorate. A late August Pew research survey indicates that health care has almost caught the overall economy in importance to the American public. Twenty-percent now say that health issues are the major problem facing the country today. That's about seven times higher than in January. By contrast, while a plurality still perceive the economy is most important, the number saying that fell from 53% in January to 27% currently. In addition, the number rating unemployment as primary dropped from 31% to 19%. Concern for the financial system also has been cut in half (from 16% to 7%). Overall, the percentage citing any economic issue has dropped from a near unanimous 80% at the start of the year to a bare majority (55%) now. In part, the increased perceived importance of health care reform is a self-fulfilling prophecy: if the media, the punditry, and the political community, including President Obama, say an issue is important, the public eventually catches on. As a result, the number claiming in the Pew research that they have heard "a lot" about Congressional efforts to reform the health care system increased from 41% in July to 53% in late August. This increased level of importance makes the outcome of the effort to reform health care crucial to the Obama presidency, its legislative initiatives in other arenas, and to the results of the 2010 mid-term elections.

Failure to properly address that issue in 1993, at least in part, cost the Democratic Party control of Congress and could do so again next year. Once the GOP took control of Congress in 1994, President Bill Clinton was forced to severely scale back his efforts to change other aspects of American society and eventually announce that the "era of big government is over." President Obama's speech to Congress on September 9 is an important first step in redefining the health care reform effort and setting the tone for the rest of his presidency.

Don't hesitate to take credit for perceptions that the economy has improved. There is another reason for the increased public concern with health care reform and the decline in concern with economic matters. Recent evidence suggests that the economy has improved recently. For example, U.S. productivity has achieved its highest level in years and studies indicate that the TARP policy, harshly criticized as a "bailout" for Wall Street, is actually making money for the federal government.

While few believe that the economy is completely out of the woods, the public has tentatively begun to detect these economic "green shoots." An Ipsos/McClatchy poll indicates that the number believing that the U.S. economy has "turned the corner" has increased from 3% in March to 11% in late August while the percentage perceiving that the "worst is yet to come" fell from 57% to 35%. Instead, a plurality (49%) says that the economy has "stabilized, but not yet begun to improve." Similarly, a CBS News poll indicates that more than a third (36%) believe that the national economy is "getting better," while only 25% say it is "getting worse." Most important, the percentage saying they are very concerned about a job loss in their household is down from 44% in April to 26% currently. Such Obama and Democratic policies as the Economic Recovery Act, the auto and financial industry loans, and the "cash for clunkers" program have played a part in these early signs of recovery. The president should not be shy in taking some credit for these economic gains.

Emphasize that the desire for health care reform is in the American mainstream and not something "radical," "socialist," or "Nazi." In spite of charges over the past several months by Republicans, conservatives, and gun-toting tea-baggers that reforming the health care system is somehow un-American, the CBS News poll indicates that a clear majority of the electorate favors either fundamental changes (55%) or a complete rebuilding (27%) of the U.S. health care system. There is surprisingly little partisan variation in the perception that the health care system should be reformed fundamentally or rebuilt. This is a long-standing concern; these numbers have changed very little over the past two decades. Moreover, in spite of the belief that the Medicare program is the "third rail" of American politics, most Americans also believe that it should be fundamentally changed (52%) or rebuilt (16%). Nearly half of seniors (46%) concur in this assessment. President Obama should make it plain that his call for health care reform simply reflects what most Americans have favored for many years.

Clearly explain, perhaps for the first time, what his and Democratic health care reform proposals will and will not do. The CBS News survey indicates that not even a third of Americans (31%) clearly understands the health care reforms currently under consideration by Congress. Two-thirds of all voters (67%), including 58% of Democrats, 69% of Republicans, and 74% of independents, say these proposals are confusing.

While the media and health care reform opponents bear some responsibility for the muddied waters, President Obama and his allies deserve their fair share of criticism. And, American voters are more than willing to give them blame. Less than a third of the electorate (31%) and only half of Democrats say that the president has clearly explained his plans for health care reform. With four or five different health care reform bills before Congress and the president's surprising reticence, before now, to strongly involve himself more than sporadically in the issue, the public's confusion about what health care reform entails is certainly understandable. To date the president has largely let others carry the ball in the effort to reform health care and his opponents have taken full advantage of the vacuum. The president's address to Congress next week is a big opportunity to fill that void by clarifying and simplifying what he and his congressional allies are proposing.

Provide a clear list of the specific benefits of his health care reform proposal. Letting others define his health care reform policies has been very damaging for the president. Since June, according to CBS, the number that disapproves of his handling of health care matters has increased from 34% to 47% while the percentage who approve has fallen from 46% to 40%. As a result, Pew says a plurality now oppose (44%) rather than favor (38%) the health care proposals now before Congress. And, yet as a late July Time Magazine survey indicates, when pollsters present voters with a listing of the specific elements of the health care reform package, solid majorities support most of them.





Provide tax breaks to small businesses to make healthcare coverage for their workers more affordable




Require healthcare insurance companies to offer coverage to everyone who applies, even those with pre-existing health conditions




Provide coverage almost all Americans, even if the government needs to subsidize healthcare for those who can't afford it




Raise income taxes on those earning more than $280,000 annually to help pay for healthcare for those who can't afford it




Create a government sponsored public health insurance option to compete with private health insurance plans




Create a national single-payer plan similar to Medicare in which the government would provide healthcare insurance for all Americans




Require all but the smallest businesses to provide health insurance to their employees or pay a penalty




Tax employer-provided health insurance to pay for the additional cost of expanding healthcare to those who can't afford healthcare now




Peter Hart and Bill McInturff combined most of these specific elements in a single question in their July survey for NBC and the Wall Street Journal and described it as "the health care plan that President Obama supports." A clear majority (56%) of the public said they favored the plan. Only 38% were opposed. These numbers were virtually unchanged since the question was first asked in April. When poll respondents clearly hear and understand the specific aspects of President Obama's health care reform initiative, most favor those elements individually and when they are combined. Next week the president should take advantage of his opportunity to provide the same clarity to the entire American public.

Hais, Winograd Pen Roll Call Op-Ed on Health Care Reform, Political Generations

Prolific NDN Fellows Hais and Winograd have a timely op-ed running in the print and on-line editions of Roll Call today.  It begins:

Millennials, Americans younger than 28, provided President Barack Obama most of his popular vote margin over Sen. John McCain (R-Ariz.) in 2008. Millennials are not interested in letting ideological posturing stand in the way of “getting stuff done,” as Obama likes to say, especially in an area as crucial as health care.

Like the members of other generations, almost all millennials (90 percent, according to a Pew Research Center poll in May) believe that it is time that health care is made more accessible and affordable for all Americans. However, only a third of millennials, in contrast to about half of those in older generations, are concerned about the impact of greater governmental involvement in the health care system (36 percent vs. 47 percent). And millennials are far less likely than older generations to prefer once again deferring health care reform to avoid higher taxes or larger deficits.

The fundamental question that Members of Congress from older generations will need to answer during this summer’s health care debate is just how much they want to accomplish as opposed to scoring political points or pursuing ideological agendas.

For the whole piece visit here.   We will be publishing a longer version of the essay later today, so check back this afternoon for more.

The CBO Weighs In

The Congressional Budget Office, powerfully, weighed into the health care debate yesterday:

Congress's chief budget analyst delivered a devastating assessment yesterday of the health-care proposals drafted by congressional Democrats, fueling an insurrection among fiscal conservatives in the House and pushing negotiators in the Senate to redouble efforts to draw up a new plan that more effectively restrains federal spending.

Under questioning by members of the Senate Budget Committee, Douglas Elmendorf, director of the nonpartisan Congressional Budget Office, said bills crafted by House leaders and the Senate health committee do not propose "the sort of fundamental changes" necessary to rein in the skyrocketing cost of government health programs, particularly Medicare. On the contrary, Elmendorf said, the measures would pile on an expensive new program to cover the uninsured.

Though President Obama and Democratic leaders have repeatedly pledged to alter the soaring trajectory -- or cost curve -- of federal health spending, the proposals so far would not meet that goal, Elmendorf said, noting, "The curve is being raised." His remarks suggested that rather than averting a looming fiscal crisis, the measures could make the nation's bleak budget outlook even worse.

Elmendorf's blunt language startled lawmakers racing to meet Obama's deadline for approving a bill by the August break. The CBO is the official arbiter of the cost of legislation. Fiscal conservatives in the House said Elmendorf's testimony would galvanize the growing number of Democrats agitating for changes in the more than $1.2 trillion House bill, which aims to cover 97 percent of Americans by 2015.

A lot of Democrats want to see more savings, said Rep. Mike Ross (D-Ark.), who is leading an effort to amend the bill before next week's vote in the Energy and Commerce Committee. "There's no way they can pass this bill on the House floor. Not even close."

Going to be interesting to see how the White House and the Congressional Leadership respond over the next few days to the new information from the CBO.  Given the continued weakness in the economy, and the worsening long term fiscal picture that follows the recession caused decline in government revenue, those promoting health care reform will have to be persuasive that reform will both help create jobs and improve the long term fiscal prospects of the nation.  Given how weak the economy is now, until it improves I worry that any health care bill which can be painted as one that could push us further into recession now, or help drive us further from solvency in the future, will be a hard sell.

Rob Shapiro makes a similar case in his weekly column yesterday.

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