Healthier cities in the US?

December 24, 2009 will become a date to remember: today the US Senate passed its landmark health care legislation in the first Christmas Eve vote since 1895. I wrote earlier on Canada’s rough ride to Medicare, and Bill HR 3962 (the Affordable Health Care for America Act) passed in the House of Representatives in another post. It’s an electrifying issue which is exciting regardless of where you stand on this complex issue. Health care, and the delivery of health services, are crucial issues for cities in the US. While there is a lot of debate about the differences between the Senate and House bills and the numerous concessions required to pass the Senate version (Bill HR 676, the National Health Care Act or Expanded and Improved Medicare for All Act), the legislation is a particular success for the still-young Obama administration. According to the White House, the main goals of the bill are to reduce long-term health insurance costs for governments and companies, ensure a choice of doctors and health insurance, prevent bankruptcies, invest in patients and wellness, improve patient safety and quality of care, ensure quality affordable health care for all Americans, maintain coverage when people change jobs or leave work, and end barriers to coverage for people with pre-existing health conditions.

Earlier this week, the Senate narrowly agreed on Bill 676, which they endorsed 60-40 at 1am on Monday. Sixty votes are required to bypass a lengthy debate (filibuster) and the Democrats have 58 Senate seats, so they need every vote plus the two Independents. Nebraska Democrat Sen. Ben Nelson was the keystone in cementing the 60-40 vote. Critics feel the bill is too expensive (CNN’s David Frum), delivers too little, and excludes too many (Michael Moore). Republican critics maintain that health care will be “rationed” and overall patient care will suffer: House minority leader John Boehner said it “puts bureaucrats in charge of decisions that should be made by patients and doctors.” Many Democrats are still divided on the issues of abortion represented in the bill (Huffington Post’s Judy Patrick) while others say it diminishes choice by forcing Americans to buy heath insurance. Most agree that the bill was diluted significantly in order to ensure its passage, citing the exclusion of a government-run insurance option that had been included in the House bill, but as Michael Tomasky wrote for the Guardian, “Half a loaf is better than none.” Nelson, in particular, held out for concessions like a federal contribution to Nebraska’s Medicare program. The “Senate test” on Monday was said to predict the passage of the bill today.

It is somewhat troubling that US health insurance companies like Aetna Inc., Signa Corp. and Humana Inc. instantly posted stock market increases, and Democrat Sen. Joe Lieberman (CT) got major contributions from these and other insurance companies to fight the bill. While the bill is expected to cover 30 million Americans who were previously uninsured (the population of Canada, by the way) the Congressional Budget Office reported earlier this year that there were 45.7 million uninsured people in the US. Although this number has been disputed, there will still be millions uninsured in the US, since health insurance will still be tied to employment and the government option has been eliminated. But it is encouraging that the bill bans discrimination of insurers based on pre-existing conditions and mandates employers to provide health insurance, providing tax breaks for small businesses and penalties for large ones.

Today’s Senate vote required the agreement of all 58 Democrats and 2 Independents to achieve the 60-39 win. Four different administrations have tried to pass health care bills in the US. This particular bill, HR 676, was introduced in 2003 by Representative John Conyers (D-MI), and has been reintroduced in every congress since. However, the release of Michael Moore’s Sicko (2007) focused attention on the country’s inadequate health coverage, in particular discriminatory treatment of insured people and the business ethic that pervades Health Management Organizations (HMOs). American friends told stories about the aftermath of seeing the movie in the theater: afterwards, audience members lingered the lobby, saying, “We’ve got to do something about this.” The DVD release of Sicko included a segment entitled “Sicko goes to Washington” which promoted the health care bill. Although the original bill suggested a single-payer system for universal coverage, public opinion was divided: most Americans are against government-run health care, although the American Medical Association favours the option. The single payer option was dropped from in the Senate bill (it still exists in the House bill). The next step involves harmonizing the Senate and House of Representatives bills, which may take until February.

While everything in HR 676 isn’t perfect, legislation rarely is. We’re currently awaiting the proroguing of Canadian parliament (the termination of the current session) which is how our Conservative Prime Minister deals with the fact that he doesn’t have the agreement of the whole House of Commons. This would mean all bills proposed and worked on in committees would die, including the long-awaited affordable housing act (Bill C-304), which has been introduced three times already. So Merry Christmas to our neighbours to the South, and celebrate your imperfect legislation!