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Here Comes Help

The path to health care reform in the Senate runs through two committees: Finance, which is led by Max Baucus; and Health, Education, Labor, and Pensions (HELP), which is led by Ted Kennedy. 

Finance has already published three briefing papers sketching out, in rough terms, its vision for what a reform bill should look like. Now it's HELP's turn. For the last week or so, drafts of a HELP paper outlining its reform vision have been circulating around Washington. At week's end, Politico's Carrie Budoff Brown--who's been writing great stuff about the health debate, by the way--published a complete draft.

The paper is still a work-in-progress. The draft Brown got was dated May 21 and, on Saturday, language was still changing "by the hour" according to one person with knowledge of the discussions. But HELP members will need the paper when they convene in committee session this week, so a final draft can't be that far off.

Meanwhile, we know enough from the existing drafts--and what insiders are saying--to get a resaonably good picture of how Kennedy and his committee allies hope to shape the debate going forward.

One of the more encouraging signs about reform so far has been the lack of discord among key committees. Finance is the committee with the bigger portfolio, because Medicare, Medicaid, and revenue all fall under its jurisdiction, while HELP is the committee with "health" in its name and Kennedy at its helm. But the two committees have been collaborating for more than a year now. And while there have been reports of tensions, it looks like they more or less agree on the basic architecture of a reformed system.

A requirement that everybody obtain insurance, subsidies to help people pay their premiums, an insurance exchange for buying coverage outside of the group market, expansions of Medicaid for the poor, efforts to change payment so that it encourages quailty--Finance wanted all of those elements in reform and, from the looks of things, HELP does too.

Still, the latest drafts of the document also hint at some significant differences between the committees. Among them:

  • The public plan. HELP is committed to a public insurance option and, at the moment, is looking at pegging the plan's payment rates to 110 percent of what Medicare pays. (Why 110 percent? Read this.) Finance hasn't even promised to write a public plan into its bill; it's just a possibility. And several Finance members have expressed interest in setting up a "trigger," under which govenrment would launch a public plan only if private plans weren't working well enough.

  • Treatment of young and old. While both committees have indicated they want to prohibit insurers from adjusting insurance prices based on people's medical status--what wonks call "community rating"--both would allow insurers to vary rates by age. But Finance, in its paper on coverage options, said it'd allow rates to vary by up to a factor of five. In other words, an insurer could charge a 62-year-old a $5,000 annual premiums while charging a 25-year-old a $1000 annual premium for the very same policy. HELP seems inclined towards a much narrower range; in the most recent draft, insurers could vary rates only by a factor of two.

  • Regulating insurer profits. The May 21 HELP draft (the one posted on Politico) suggests that government should require insurers to spend at least a certain percentage of revenue on patient care. California tried to do this in its ill-fated reform effort. Obama endorsed a similar measure during the campaign. Finance, by contrast, hasn't raised that possibility in its documents.

Notice a pattern here? HELP is staking out the territory to Finance's left, which isn't too surprising. Look down HELP's roster and you'll see some of the Senate's most liberal members, including Sherrod Brown, Tom Harkin, and Bernie Sanders. Finance, by contrast, has prominent centrists like Kent Conrad and Blance Lincoln. The chairmen also take different approaches to legislation. Both ideologically and temperamentally, Kennedy seems less determined to pursue bipartisanship than Baucus is.

The gap between the two committees is getting attention. In Saturday's New York Times, Robert Pear described the Baucus-Kennedy break over the public plan as a "significant split." That prompted the two senators to release a joint statement affirming their determination to merge their bills eventually.

Who's telling the real story here, the Times or the two senators? Both of them, I suspect. The committees are diverging, as you'd expect at this point in the debate, but it's not hard to imagine them coming back together again through some compromise package. (Whether that compromise will make liberals like me happy is, of course, another question entirely.)

--Jonathan Cohn