Conservatives have been quick to blame the administration for the slow delivery of H1N1 vaccine. Not long after Obama declared the swine flu pandemic a national emergency last month--a measure that cleared the way for hospitals to make special preparations for infected patients--Missouri Representative Roy Blunt pounced on the administration’s “onerous regulatory and legal environment” as a cause for the vaccine delays. In the Weekly Standard last week, Bill Kristol held up the swine flu response as an example of the coming “big government health care” boondoggle. “Surely this spectacle, happening in real time before us, will give even more Democrats pause. Do they really want to be known as the Swine Flu Democrats?” Earlier this month, Rush Limbaugh declared that the problem was on par with the Bush administration’s disastrous federal response to Hurricane Katrina.

But how much blame should the government really get for the shortage? Late last month, Sheryl Gay Stolberg reported on the administration’s efforts to respond to the threat of a pandemic. From the start, she reported, Obama seemed determined to put forth a coordinated plan for dealing with the outbreak, studying past government responses to flu epidemics with the help of former administration officials and adding swine flu updates to his regular intelligence briefings. The administration created a government website and public service campaign to inform the public of precautionary measures they could take to avoid the flu. And, most importantly, they moved swiftly to contract with a roster of vaccine manufacturers and got the first doses out to high-risk patients earlier than every country but Australia and China. “[T]he Obama administration left little to chance,” she notes.

One thing they didn’t fully appreciate, however, was the inherent unpredictability of the vaccine manufacturing process. Flu vaccines are typically prepared by injecting the virus into fertilized chicken eggs and incubating them until they become infected. The egg fluid is then harvested and mixed with an embalming fluid, which prevents the virus from causing illness but triggers a response from the immune system that will prevent a future infection. As Allison Bond explained in Discover, there is ample opportunity for the process to become complicated if the egg rots, or the virus grows slowly or produce a weak vaccine. (As Bond notes, HHS devoted $1 billion in funds to develop new vaccine-making technology in 2006, but those technologies weren’t ready for use when H1N1 started spreading earlier this year.)

It’s certainly been a big news week for lady parts, as some of my lady colleagues at TNR have pointed out today. But while the conservative fear-mongering about “government rationing” is an obvious political ploy, some vital questions about how much women will have to pay for preventative care in the Democratic health-care bill have yet to be resolved.

Reid’s merged Senate bill left out part of an amendment that Barbara Mikulski had successfully introduced into the Senate HELP legislation, which requires insurance companies to include women’s preventative services as part of all minimum benefit packages, for little or no cost. Mikulski argued that women of child-bearing age end up paying an average of 68 percent more in out-of-pocket costs, partly due to reproductive health needs, and often ended up delaying or forgoing care (like mammograms) because of the expense. The provision—which was in neither the House nor Finance Committee legislation—was slated to be in Reid’s bill this week, but “CBO decided at the last minute there was a problem and it was removed until that is resolved,” Mikulski spokesperson Rachel MacKnight said in an email today.

The problem, according to sources familiar with the issue, was that the Mikulski’s amendment wasn’t specific enough in terms of how it would determine which services would be covered, simply saying that it would be it up to the discretion of HHS to set the guidelines for coverage. As such, the provision was so broad that CBO ended up having to give it a very high—i.e. expensive—score, and Reid ended up leaving the language out of the bill.

Well, OK, maybe not rich. But it should mean higher wages, if it includes the tax on expensive health policies.

That's according to Jonathan Gruber of MIT, who's been studying this and just released a new memo on the subject. As he did previously, he reverse-engineered numbers from the Joint Committee on Taxation to extrapolate wage growth. His findings?

Worker wages rise by $55 billion by 2019

This amounts to almost $700 per insured household in 2019

Worker wages rise by $234 billion in aggregate over this time period

This is also a very progressive wage adjustment.  In every year, the share of wage gains accruing to those with incomes below $100,000 is about two-thirds of the total, and the share of wage gains accruing to those with incomes below $200,000 is over 90% of the total.

I'm swamped with reporting right now, so I can't really speak to the study's methodology or validty. But Gruber is certainly among the most respected and intellectually honest experts in this field. And if you'd like to draw your own conclusions, just read the full paper with the scratch-work. (Just make sure to leave me your thoughts in the comments!)

Ron Wyden will have his day and, in somewhat scaled-down fashion, he'll have his way.

Majority Leader Harry Reid, Finance Chairman Max Baucus, and Wyden just announced that they will be amending health care legislation to include a compromise version of Wyden's free choice amendment.

A press statement explains the details of the deal, which culminated weeks of hardball negotiations:

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.  The Congressional Budget Office estimates a previous version of this provision will expand coverage to more than a million Americans.

Of course, Wyden once crusaded for something much grander: Opening the exchanges to everybody. But employers and labor hated the idea, effectively killing it. That Wyden was able to get anything at all represents an accomplishment--and, perhaps, the start of something bigger, as he hinted today:

As I have long said, empowering Americans to choose the health insurance that works best for them and their family is the single best way to hold health insurance companies accountable. While this is just one step in the direction of guaranteeing choices for all Americans, it is a major step because – for the first time – it introduces the concept of individual choice to a marketplace where it has long been foreign.  This is a significant step toward real reform.

Few elements of reform are more critical to its overall success than the success of the new insurance exchanges, through which small businesses and individuals without access to affordable company health plans will buy coverage. And although the issue hasn't gotten much attention, there's a pretty stark difference of opinion over how to design them. 

The model for a successful exchange is the Massachusetts "Connector" and its management of what's known as the "Commonwealth Care" program. But, as readers may recall from a few weeks ago, not all of the bills in Congress used that model:

In the bills that passed three House committees and the Senate Health, Education, Labor, and Pensions (HELP) Committee, the exchange would be a "prudent purchaser." In other words, it would have a staff that bargained with insurers to bring down premiums--and that made sure all plans lived up to strict guidelines for coverage and customer service. In effect, any insurer that wants to offer coverage through the exchanges has to get the equivalent of a "Good Housekeeping Seal of Approval" from the administrators. This is precisely how it works in Massachusetts.

By contrast, the Senate Finance bill envisions much weaker exchanges. Instead of choosing which plans to make available, the exchange administrators would, by law, have to accept any plan that meets a relatively minimal set of standards.

Jon Kingsdale, who runs the Massachusetts exchange, calls that a recipe for "policy disaster," as consumers faced a dizzying array of more expensive, less regulated choices. "It would be like telling your grocery store they have to offer every single kind of bread baked by every single bakery. ... The exchanges would be nothing more than an automated Yellow Pages."

During the Finance Committee's markup hearings, Senator John Kerry had tried to modify the exchange proposal, so that it would more closely resemble the HELP and House models. And while he didn't succeed then, it appears that he--and his allies--have made some progress since.

The majority of House Republicans opposed the Democrats’ $210 billion physician payment bill--which passed this afternoon on a 243-183 vote--accusing the legislation of increasing the deficit by relying on federal borrowing through Medicare to pay for itself.  The “doc fix”--which will prevent steep expected cuts to Medicare payments for providers--is nothing but a “shell game designed to mask the true cost of their proposed government takeover of health care,” Representative Wally Herger wrote in a letter to the American Medical Association today, co-signed by ranking Ways and Means Republican Dave Camp. The Republican rhetoric is familiar, of course. But it was only four months ago that Ways and Means Republicans voted for an amendment that’s nearly identical to the bill being proposed today, which would stop a scheduled 21 percent Medicare payment cut next year and implement a permanent change in the payment formula for doctors.

Herger offered the Republicans’ physician payment amendment during the committee’s mark-up of the bill last July. The Herger amendment—the document is available here--was nearly identical to the language that was already in the House bill, but with a provision tacked on at the end to provide loan forgiveness for primary care physicians. As such, it was a way for Republicans to show that doctors that they supported them, even though they opposed the entire reform package. “They offered this amendment because they wanted to make sure their members could be on record specifically supporting this exact policy – the same provision that became H.R. 3961,” said Brian Cook, a spokesperson for Rep. Pete Stark. All of the Ways and Means Republicans ended up voting for the amendment--including minority whip Eric Cantor--but it was defeated 22-18 by the Democratic majority, who opposed the GOP’s political maneuver to take a symbolic vote for a provision already in the bill.

Herger and Camp--who both voted against the Democratic legislation today--took pains to explain to the AMA that they believe the Medicare payment system is “deeply flawed and urgently needs to be reformed,” saying they were only opposing the Democratic bill because isn’t financed and will increase the deficit. But, at the time, Herger’s amendment wasn’t paid for either*. Had the amendment actually made it into the bill, “it would have been paid for” through alternate means of financing that weren't in the jurisdiction of the Ways and Means Committee, says Sage Eastman, a Republican committee spokesman. “We wouldn’t have written a trillion dollar bill.”

The GOP did attempt to offer their own alternative doc fix today, which also staved off the 21 percent cut in payments next year and cut payments by 2 percent over the next four years (a financed-but-temporary fix). Mostly paid for by medical liability reform measures, they boasted their alternative was fully financed, unlike the Democratic legislation (a permanent-but-unfunded fix). But that wasn’t enough to satisfy the AMA, who sent a letter to Camp today saying the group was “disappointed” in the Ways and Means Republicans’ opposition, given their previous support for the Herger amendment--essentially trying to call them out on their flip-flop.

*Corrected explanation of why Herger's amendment wasn't financed when offered up in committee.

Senate Majority Leader Harry Reid and his allies have addressed, at least in part, a major weakness of the Senate Finance bill: The role of employers.

To review, both the Senate HELP and House bills contained relatively traditional "employer mandates." Under their terms, firms with more than 50 employees would have to offer their employees insurance coverage or pay a modest fee.

The Senate Finance committee went with a different strategy. Its bill included what's known as a "free rider" provision. The government wouldn't require companies to cover their employees. But it would assess companies that didn't offer coverage, based on the number of employees that ended up qualifying for federal subsidies to buy insurance.

The Connecticut Senator says that President Obama didn't favor a public plan when he ran for president:

It’s classic politics of our time that if you look at the campaign last year, presidential, you can’t find a mention of public option,” Lieberman said. “It was added after the election as a part of what we normally consider health insurance reform — insurance market reforms, cover people, cover people who are not covered.

Wow, that's quite an important detail! Wonder why you haven't heard it before? Because it's totally untrue. I could cite any number of sources, but how about the New York Times guide to the candidates' platforms:

Mr. Obama would strive for universal coverage by establishing a new federal health plan for the uninsured, providing benefits comparable to those offered to federal employees. .... Mr. Obama also would establish a government exchange that would allow individuals to shop for the new public plan and approved private plans.

The Politico article in which Lieberman made this false claim lets it go unchallenged.

Update, by other Jonathan (Cohn): Jonathan (Chait) is absolutely right about this. In fact, Obama proposed a public insurance option in May, 2007, on the day he first introduced his health care proposal during a speech in Iowa. From the New York Times account: 

Mr. Obama would create a new public plan open to individuals who cannot get group coverage through work or the existing government programs, like Medicaid or the State Childrens Health Insurance Program.

Second Update, by original Jonathan (Chait): Politico, to its credit, has updated its story to note that Lieberman's claim is untrue.

The Democratic Policy Committee has gathered all of the material about the new Senate bill in one place. Happy reading!

Fox News All-Star panelist Charles Krauthammer says the Senate health care bill starts collecting revenue immediately, but runs an annual deficit, so that it will explode the deficit in the long run:

In the House bill, and I'm sure in the bill that we will hear about tomorrow in the Senate, it's ten years of people paying in, and six or seven years of health care [paying out] because [the benefits] kick in later.

So that is how you make the numbers look good. But annually it runs at a huge deficit.

In fact, this is completely false. The CBO budget score of the Senate bill can be found here, on page 3. In year ten, the Senate bill would reduce the deficit by $8 billion. CBO projects that the savings would grow after that:

All told, the legislation would reduce the federal deficit by $8 billion in 2019, CBO and
JCT estimate. In the decade after 2019, the gross cost of the coverage expansion would
probably exceed 1 percent of gross domestic product (GDP), but the added revenues and
cost savings would probably be greater. Consequently, CBO expects that the bill, if
enacted, would reduce federal budget deficits over the ensuing decade relative to those
projected under current law—with a total effect during that decade that is in a broad
range around one-quarter percent of GDP.

I'm sure after learning of his mistake, Krauthammer will isue a public correction and soften his deficit-based opposition to health care reform invent a new, possibly false, reason to oppose the bill.

A few weeks ago, Capitol Hill sources began warning that the Senate leadership might decide to offer extra assistance to the middle class by taking money away from the poor. Now it looks like they've done it, albeit in a convoluted way that helps some people even as it hurts others.

It's not easy to see and, predictably, it's not easy to explain. But here's my best shot, based on conversations with analysts and experts who have studied the bill's language.

A key feature of health reform are the subsidies that the government would make available through the new insurance exchanges. Basically, the government would establish what's known as a "premium cap": If you were buying a standard policy through an exchange, the government would give you enough financial assistance to make sure the premiums didn't exceed a certain percentage of your income.

That percentage would vary depending on how much you were making. The more money you make, the more the government would let you pay premiums on your own. The less money you make, the more the government would step in to help you with them.

Other posts on the Senate health care bill:

"The GOP Flip-Flop On The Doc Fix," by Suzy Khimm

"A Change For The Better," by Jonathan Cohn

"Everything You Ever Wanted To Know," by Jonathan Cohn

"Senate Health Bill Reduces Deficit By More Over Time," by Jonathan Chait

"Peter = Robbed, Paul = Paid," by Jonathan Cohn

Legislative language for the Senate bill has been available for just over twelve hours, a preliminary Congressional Budget Office assessment for even less than that. And, already, it's clear that the fine print requires, well, some fine analysis. But before we get to that, let's take a step back and ask the simple question: Should we be happy about this bill? The answer depends entirely upon your frame of reference.

If your standard for comparison is your ideal health care reform, then of course this will be disappointing. Like every bill that's moved through Congress, this one would leave millions uninsured even after full implementation--and leave millions with coverage facing substantial, although generally not crippling, financial burdens. It would introduce some reforms to the delivery system and, according to the official cost estimates, generate budget surpluses over time. But it's not going to radically turn American health care into a paragon of cost efficiency.

Now, that sort of nirvana was never in the cards. The more relevant comparison is to the House bill. And there the verdict is more mixed. The Senate bill has the excise tax on expensive insurance policies and the independent Medicare commission, two tools that--at least in the eyes of most experts--can make a significant dent in overall health care spending. That's an advantage. On the other hand, fewer people would end up with health insurance and those with health insurance wouldn't have the same level of financial protection.