Something unusual and largely unnoticed happened last week as Democrats pushed the national health care bill through the House. In a complicated, late-night maneuver, on a party-line vote, the House Rules Committee used the health bill to pave the way for a $210 billion increase in Medicare payments to doctors, without any money budgeted to pay for it. Congress then combined that $210 billion with a measure that would force lawmakers to exercise fiscal discipline — except when it came to the $210 billion.
It was a particularly slick move, even by congressional standards. With one vote, committee Democrats managed to propose spending a huge amount of money while also claiming to clamp down on spending. More importantly, they threw a very big bone to several physicians organizations, which badly want the increased doctor payments and to whom Democrats are deeply indebted for support of health care legislation. And at the same time, they gave cover to moderate Democrats, who are under pressure to support health reform but also fear the wrath of voters concerned about overspending.
This is how it worked. Before the House can begin final debate and vote on a bill, the Rules Committee has to first pass a rule setting the terms of the process. How long will debate last? Will amendments be allowed? How many?
Normally, when the Rules Committee creates a rule, it does so for a single bill. “One bill, one rule,” says a veteran GOP Hill aide. But when it came to the health care bill, Democrats took the unusual step of combining the health bill and the $210 billion physician payment measure in a single rule; they were worried the doctor bill might fail if it were considered on its own.
The bill reverses scheduled cuts in Medicare payments to physicians. For years Congress has vowed to make gradual cuts, and for years it has put them off. All those unmade cuts would add up to a 21 percent reduction next year, unless Congress put them off again. Sure enough, bills were introduced in the House and Senate this year to cancel the 21 percent cut and replace it with an increase — what has become known as the “doctor fix.”
It's expensive. The Senate's version of the doctor fix would cost $245 billion — again, without any provision to pay for it. There was so much concern about cost that in late October, 13 Democratic senators joined all 40 Republicans in blocking it.
The House's version of the doctor fix costs $210 billion. Like the Senate's, not a penny is paid for. After the failure in the Senate, the House leadership feared Democrats might join Republicans to block it. The doctor fix might never get out of the Rules Committee.
But the fix is a top priority of the American Medical Association, which is calling in its IOU for supporting national health care. The fix is “an essential element of health reform,” AMA President James Rohack said recently. His message to the House: Get it done.
So the Democratic leadership came up with the plan to attach the doctor fix to the rule setting terms for the health care debate. When one passed, the other would, too.
But what about all those Democrats concerned about $210 billion in new spending? For them, the leadership added a clause that said when the doctor fix bill reached the final stages of House consideration, it would automatically be joined with an existing bill requiring the House to pay for the spending measures it passed — a measure called Pay-Go.
But it just happens that the Democratic version of Pay-Go contains a specific exemption for the doctor fix. So the House could approve a measure that would cost $210 billion, have no way to pay for it and still meet the requirements it has set for itself in terms of restraining spending.
It's quite a trick. “This was to keep the physicians organizations on board with the underlying monstrosity of the health care bill,” says Republican Rep. Tom Price, of Georgia, himself a doctor. “It also gives Democrats a headline that says, 'We're serious about spending,' while at the same time demonstrating that they're not serious about spending.”
The House will probably vote on it next week. It might well pass, especially because Democrats can claim it's all part of a move to impose strict fiscal discipline. And they've already set the rules: There will be just one hour of debate, with no amendments allowed.
When it comes to the doctor fix, the fix is already in.
Byron York, The Examiner's chief political correspondent, can be contacted at email@example.com. His column appears on Tuesday and Friday, and his stories and blog posts appears on www.ExaminerPolitics.com ExaminerPolitics.com