House con­ser­v­a­tives yes­ter­day scut­tled a bill that would have denied the White House mon­ey it urgent­ly needs to imple­ment the new health reform law. But a promi­nent Sen­ate Demo­c­rat, who helped write the law, maneu­vered to deny the Admin­is­tra­tion those des­per­ate­ly need­ed funds. Mean­while, Speak­er Boehn­er and Sen­ate Demo­c­ra­t­ic Major­i­ty Leader Har­ry Reid are locked in qui­et talks to exempt them­selves and their staffs from the new law.

Got all that?

Let’s start with the House Repub­li­cans because they’re almost always the most inter­est­ing group. They are the new health law’s most stri­dent oppo­nents and also its most impor­tant enablers. Since the law’s enact­ment, they have staunch­ly main­tained that it must either be repealed entire­ly or imple­ment­ed pre­cise­ly as writ­ten. Any change to the law, they main­tain, is an unac­cept­able effort to “improve” a bad prod­uct. So they have become the Administration’s most impor­tant ally in mak­ing sure that the law they despise is imple­ment­ed on time and with as few hitch­es as possible.

Con­fused?

Let me cite the most recent exam­ple. Mil­lions of Amer­i­cans will start sign­ing up for health insur­ance cov­er­age under the new law on Octo­ber 1. They will do this through exchanges, com­pli­cat­ed admin­is­tra­tive mech­a­nisms that will enroll peo­ple in cov­er­age, deter­mine if they’re eli­gi­ble for sub­si­dies or Med­ic­aid, and then send those sub­si­dies, not to the enrollee, but to the insur­ance com­pa­ny of the enrollee’s choos­ing. The archi­tects of the law thought that states would elect to oper­ate these exchanges. But most states have decid­ed that they don’t want the headache and expense of cre­at­ing a new bureau­cra­cy to coor­di­nate with the IRS, the state Med­ic­aid agency, fed­er­al and state insur­ance reg­u­la­tors, and numer­ous insur­ance com­pa­nies, among oth­ers. So 27 states have dumped this has­sle onto the fed­er­al government

This is a respon­si­bil­i­ty for which the fed­er­al gov­ern­ment was poor­ly pre­pared. They lack mon­ey to estab­lish the exchanges. So the Depart­ment of Health and Human Ser­vices came up with the idea of tak­ing the mon­ey from a hon­ey­pot estab­lished by the health care law: a fund the depart­ment can use at its dis­cre­tion for dis­ease pre­ven­tion and pub­lic health. The depart­ment plans to take hun­dreds of mil­lions out of this fund and spend it on fed­er­al exchanges.

House Repub­li­can Leader Eric Can­tor (R‑VA) saw a polit­i­cal oppor­tu­ni­ty. Unfor­tu­nate­ly, he for­got to check with his followers.

Can­tor wrote a bill to block HHS from tak­ing mon­ey out of the fund to pay for exchanges. With­out that mon­ey, the law’s imple­men­ta­tion would be in jeop­ardy. Instead, the Can­tor bill would have shift­ed the mon­ey to anoth­er fund that was estab­lished by the health care law to help pay for insur­ance cov­er­age for peo­ple with pre-exist­ing med­ical con­di­tions.  That fund is short on cash.

Cantor’s bill would have pre­sent­ed Democ­rats with a very tricky polit­i­cal vote. The health insur­ance exchanges are poor­ly under­stood bureau­crat­ic enti­ties. The pub­lic health fund, because of its size and the broad author­i­ty it gives the Sec­re­tary to fund projects of her pleas­ing, has a bit of a bad rep­u­ta­tion in many quar­ters. So why not take mon­ey from that fund and use it to help buy insur­ance for peo­ple with med­ical needs?

Why not? Because, in the words of con­ser­v­a­tive House Mem­ber Justin Amash (R‑MI),

“We’re shift­ing mon­ey from one part of Oba­macare we don’t sup­port to anoth­er part of Oba­macare we don’t support.”

Let’s think about that log­ic.  Accord­ing to Amash, the only way to prove that you real­ly hate what he calls “Oba­macare” is to oppose all efforts to change it. Amash and fel­low House con­ser­v­a­tives, by their lights, must oppose their own lead­er­ship and side with the Admin­is­tra­tion, allow­ing it to raid the pre­ven­tion fund to facil­i­tate imple­men­ta­tion of the law Amash hates.  And he’s not alone among House Republicans.

So Can­tor, faced with sub­stan­tial oppo­si­tion from his GOP col­leagues, yes­ter­day pulled the bill from House con­sid­er­a­tion. The Admin­is­tra­tion breathed a sigh of relief, since that removed one poten­tial obsta­cle from its imple­men­ta­tion plans. Prob­lem solved, thanks to House Repub­li­cans, right?

Not so fast.

No soon­er had Can­tor sig­naled his retreat than Sen­ate HELP Com­mit­tee Chair­man Tom Harkin (D‑IA) stepped up to object to the Administration’s plan. Tom Harkin? Isn’t he a vocal sup­port­er of the health care law? Didn’t he help write it?

You bet he did. And one of the things he wrote into the bill was the pre­ven­tion and pub­lic health fund, the one that HHS wants to tap to pay for health exchanges.

So when Sen­ate Major­i­ty Leader Har­ry Reid (D‑NV) yes­ter­day sought to engi­neer unan­i­mous approval to begin Sen­ate debate on Mar­i­lyn Tavenner’s appoint­ment to head the agency that is imple­ment­ing the health reform law, he got an unpleas­ant sur­prise: Harkin object­ed.

Seems that Chair­man Harkin loves him some pre­ven­tion and pub­lic health fund. The fund lost $5 bil­lion last year as part of a deal to pay for the President’s pay­roll tax hol­i­day. Harkin wasn’t hap­py at the time, but thought he had a deal with the White House that they would keep their hands off his fund in the future.

“You’ve got to under­stand that last year, Oba­ma took $5 bil­lion out,” Harkin told Politi­co.  “That’s when I thought I had an agree­ment that they were nev­er going to do this again. Now they come and actu­al­ly — once it’s all worked out it’s about $332 mil­lion they’re tak­ing out of it this year.”

 

“I’m sor­ry to say this admin­is­tra­tion just doesn’t seem to get it,” he said. “It’s sort of like the pre­ven­tion fund is sort of an afterthought.”

By tak­ing the Taven­ner nom­i­na­tion hostage, Harkin hopes to get the White House to keep its hands off his fund. That puts the Admin­is­tra­tion in the posi­tion of hav­ing to choose between get­ting the mon­ey it needs for its health insur­ance exchanges and hav­ing its nom­i­nee to over­see the law’s imple­men­ta­tion con­firmed by the Sen­ate. Harkin believes that he can help HHS find the mon­ey else­where. His nego­ti­a­tions with the White House are expect­ed to con­tin­ue today.

But that isn’t the most inter­est­ing ongo­ing health care nego­ti­a­tion. That would be the one involv­ing the Admin­is­tra­tion, Sen­a­tor Reid and his bit­ter foe, John Boehn­er. [Boehn­er once told Reid to “go f___ your­self” after Reid accused him of run­ning a “dic­ta­tor­ship.”]  But real lead­ers nev­er let per­son­al ani­mos­i­ty impair their abil­i­ty to nego­ti­ate across the aisle in times of cri­sis. And Reid and Boehn­er face a real cri­sis: unless some­thing is done, Mem­bers of Con­gress and their staffs will have to sign up for health cov­er­age under the new exchanges.

Con­gres­sion­al employ­ees, includ­ing Mem­bers of Con­gress, cur­rent­ly par­tic­i­pate in the Fed­er­al Employ­ees Health Ben­e­fit Plan (FEHB). Under that pro­gram, tax­pay­ers pick up, on aver­age, 72 per­cent of their pre­mi­ums. But under the new health reform law, they would be kicked out of the FEHB and forced to buy cov­er­age through the health insur­ance exchanges. You know, like mil­lions of us.

But that would be, um, expensive.

“Put your­self in the posi­tion of a lot of entry-lev­el staff peo­ple who make $25,000 a year, and all of a sud­den, they have a $7,000 a year health care tab?”  Sen­a­tor Richard Burr (R‑NC) told Politi­co.  “That would be devastating.”

So, you see, law­mak­ers aren’t wor­ried about them­selves. They’re wor­ried about the staffers that they pay so poor­ly. Well, maybe. Actu­al­ly a staffer earn­ing $25,000 would receive gov­ern­ment sub­si­dies if they bought their cov­er­age through an exchange. Those sub­si­dies would reduce the pre­mi­ums in Sen. Burr’s hypo­thet­i­cal exam­ple to $1,726, accord­ing to the Kaiser Foundation’s pre­mi­um cal­cu­la­tor. That’s actu­al­ly less than the $1,960 they would pay now for cov­er­age under the FEHB, assum­ing the gov­ern­ment pays 72 per­cent of the $7000 premium.

OK, so maybe the law­mak­ers are per­haps a bit wor­ried about them­selves, since they earn too much to receive subsidies.

One dif­fer­ence between them and the rest of us is that they have the pow­er to exempt them­selves from the law’s appli­ca­tion. The oth­er dif­fer­ence is that they have to answer to vot­ers. And that is com­pli­cat­ing the nego­ti­a­tions over exempt­ing them­selves from the law. There are only two ways that this could work polit­i­cal­ly: the Admin­is­tra­tion could give Mem­bers and their staffs a waiv­er or Con­gress could over­whelm­ing­ly pass a law grant­i­ng them­selves such a waiver.

“Every­one has to hold hands on this and jump, or noth­ing is going to get done,”  a source close to the nego­ti­a­tions told Politi­co.

So there you have it: a coau­thor of the health reform law is threat­en­ing its imple­men­ta­tion after House Repub­li­cans snub a bill that would have done just that, while lead­ers of both par­ties qui­et­ly try to get them­selves out from under the law.

Just anoth­er day in health policy.