This morning, during a discussion about health reform with progressive bloggers, I asked House Speaker Nancy Pelosi (D-CA) if the Senate health care bill did enough to prevent insurers from jacking up health care rates between now and 2014, (when the exchanges become operational). Noting that insurers could circumvent President Obama’s proposed national rate review authority by shifting more costs into deductibles and co-payments, I pressed Pelosi on whether the reconciliation package strengthened the President’s language or included new provisions to prevent insurers from increasing rates in anticipation of the new regulations.

Pelosi explained that the Senate bill prevents insurers from excessively increasing rates in three ways:

PELOSI: The biggest lever is to prevent them from participating in the exchange. That’s what they want more than anything. Because it’s 40 million new people who will have access. By and large, mostly new people have access to health insurance, subsidized by the taxpayer. I mean, this is a big deal for them. And I think that is the biggest lever. [...] We have the rate review. We have three things I mentioned before. We have rate review, we have the depriving of the opportunity to participate, and the rate review is related to depriving them of participating, and also fining them and all that goes with that for depriving people of insurance because of a health condition, health discrimination issues that we can bring against them.

Listen:

The effectiveness of the national rate review board and the threat of excluding insurers from participating in the exchange (if they significantly increase rates in the interim period) will depend on the oversight capabilities of these institutions and what constitutes an “unreasonable” rate hike. For example, several states have used their rate review authority to avoid sudden premium increases, but it’s unclear if rate review has succeeded in significantly lowering insurer rates. In some cases, industry friendly commissioners have failed to enforce state regulations, allowing issuers to circumvent consumer protections.

This close relationship between insurers and their regulators could also undermine states’ ability to exclude insurers from the exchange. Under the Senate bill, the Secretary of Health and Human Services, in consultation with the states, will develop a plan to look for “unreasonable increases.” Insurers are required to submit “a justification for an unreasonable premium increase” to the state insurance commission authority, who then makes the appropriate recommendations “to the State Exchange about whether particular health insurance issuers should be excluded from participation in the Exchange based on a pattern or practice of excessive or unjustified premium increases.” But the legislation does not appear to set any firm standards or definitions and could allow insurers to take advantage of weak state regulators.

Today, the House Budget Committee also approved a motion (by a vote of 24-15) instructing the Committee chair to ask the rules committee to allow an amendment establishing a national rate review authority.

The Washington Post had an interesting article this morning examining the consequences of requiring insurers to collect a separate premium for abortion coverage. It turns out that when people need to send in a separate check for their abortion coverage, nobody really wants it:

In North Dakota, where insurers can cover abortions if customers pay a separate premium, the state’s largest provider says it sells no abortion policies because no one has asked to buy one. [...] “There’s not a lot to tell. We have no member who elected to have abortion riders,” said Denise Kolpack, vice president of Blue Cross Blue Shield of North Dakota, which covers about 80 percent of the North Dakota market. “We would be legally bound to provide an offering, but we have no groups that have requested it.” Similar policies are in place in Kentucky, Missouri, Idaho and Oklahoma. “It is rare that we hear in the market that an employer would request a rider for this coverage,” said Anthem Blue Cross and Blue Shield spokesman Tony Felts, whose territory includes Kentucky.

Part of the problem is that most women either don’t know that their plan doesn’t cover abortion services or don’t think they’ll ever have an abortion. Women don’t ask, and carriers don’t tell. After all, we always assume the best. A young, strapping, blogger purchasing coverage in the individual health insurance market doesn’t think he needs cancer coverage at 24 until he is diagnosed with melanoma and has to pay out of pocket for his treatments. In the same way, a young woman in North Dakota thinks she’s playing it safe by sticking to the pill and so she doesn’t bother to ask if her insurance carrier provides abortion coverage and may not be the wiser until the need arises.

In some ways, this kind of structure undermines the purpose of insurance — which we purchase to protect ourselves from life’s little surprises — and could even discourage insurers from offering abortion coverage. After all, the abortion language in the Senate bill no longer guarantees that at least once carrier in the exchange will provide abortion coverage and some health care wonks have argued that the extra administrative burden of processing a separate payment may encourage carriers to opt out providing abortion services. Plan that offer abortion services within the exchange may attract a very small clientele (because of the problem described above) or even worse, appeal to sicker women — both of which would increase costs for the carrier and dissuade plans from offering abortion services.

All of this would disadvantage poorer women. An abortion in the first trimester carries a price tag of some $400 dollars — a relatively pricey, but not prohibitive procedure for middle class women. Poorer women who don’t ask about their plans’ abortion coverage provisions, however, or can’t find affordable abortion coverage within the exchange, may be priced out their right to choose.

House Speaker Nancy Pelosi (D-CA) sounded positive and upbeat about the prospects of health care reform passing the House at this morning’s briefing for progressive bloggers, telling the eleven of us gathered in her offices, “I have no intention of not passing this bill. Let me say it in a positive way: I have faith in my members that we will be passing this legislation.”

Pelosi laid out three different routes for moving forward with reform, stressing that she preferred the third option. “The Senate Parliamentarian has said that they can only go forward with reconciliation once the bill is the law,” Pelosi said in preface. “The three options we have are…”:

1. To have a rule that sets up a vote on the Senate bill and on reconciliation, in either order.

2. The second option is to have a rule that deems the Senate bill passed when we pass reconciliation. But that would be considered a vote on the Senate bill, and members are more comfortable with the third option.

3. But we haven’t made the final determination, but the one most people like best says that we pass a rule that’s just about taking up reconciliation. On passage of the reconciliation bill the Senate bill will be deemed “passed.”

“Or the third is: the vote is on the reconciliation bill. Upon its passage, the Senate bill is deemed passed. It’s more insider and process-oriented than most people want to know, but I like it because people don’t have to vote on the Senate bill,” Pelosi clarified. House members may not want to vote for the so-called “special deals” in the Senate health care bill, but it’s hard to see how anyone will understand the distinction. Republicans will smear vulnerable Democrats with the Senate bill and every member who votes for the reconciliation package will be seen as voting for the special deals in the Senate bill. There is just no avoiding that.

It’s also unclear that the parliamentarian actually ruled that lawmakers “can only go forward with reconciliation once the bill is the law.” Republican aides quickly publicized this interpretation to dissuade House members from trusting their Senate colleagues, but the parliamentarian “reportedly clarified his position to Senate aides, saying that the reconciliation bill could be written in a way that would not require Obama to sign the Senate bill into law before the reconciliation bill is voted on.” (Which is what Democrats were hoping to do in the first place.)

All in all, none of this is terribly important. Given that lawmakers have decided to pursue the reconciliation process, the Vice President should overrule the parliamentarian’s decision (if that was in fact his decision) and allow the Senate to pass the reconciliation bill before the House votes on the Senate’s legislation. Health care reform has always been a heavy lift, but if leadership feels that it must lighten the load with arcane rules to win over (comfort) certain members, then so be it. But they’re the only ones who care.

T.R. Reid had a powerful editorial in Sunday’s Washington Post that hit at the heart of why pro-life advocates should support the Senate health are bill. It is, in the words of Mitt Romney, “the ultimate pro-life effort”:

Increasing health-care coverage is one of the most powerful tools for reducing the number of abortions — a fact proved by years of experience in other industrialized nations. All the other advanced, free-market democracies provide health-care coverage for everybody. And all of them have lower rates of abortion than does the United States.

This is not a coincidence. There’s a direct connection between greater health coverage and lower abortion rates. To oppose expanded coverage in the name of restricting abortion gets things exactly backward. It’s like saying you won’t fix the broken furnace in a schoolhouse because you’re against pneumonia. Nonsense! Fixing the furnace will reduce the rate of pneumonia. In the same way, expanding health-care coverage will reduce the rate of abortion.

It’s hard to find a direct correlation between universal health care and abortion rates, but my colleague Jessica Arons points to this Guttmacher Institute data which suggests that poorer women are less likely to abort their pregnancies when they know they’ll be able to provide their babies with needed care. “Overall unintended pregnancy rates have stagnated over the past decade, yet unintended pregnancy increased by 29% among poor women while decreasing 20% among higher-income women,” the data shows. “Between 1996 and 2000, while abortion rates for all other groups fell, abortion rates among poor and low-income women increased. Women below the federal poverty level have abortion rates almost four times those of higher-income women.” It’s a fairly logical argument that hasn’t penetrated the abortion debate: pregnant women who don’t have access to affordable health care for their babies or for themselves may be more encouraged to abort their pregnancies than woman who can meet the medical needs of their children. Similarly, women who have access to affordable health care can purchase affordable contraceptives — be taught how to use them — and prevent unintended pregnancies in the first place.

“The key,” Arons explains, “is universal coverage, where everyone knows there is a safety net for them and any children they decide to have, combined with medically accurate sex education and a healthy attitude toward sex. Because the U.S. lacks all of these, we have the highest unintended pregnancy and abortion rates of all industrialized nations.” It’s why a group of 25 “pro-life Catholic theologians and Evangelical leaders” sent a letter to Congress urging them to look past the misinformation on abortion and pass health care reform and the Catholic Health Association calls reform “‘a major first step‘ toward covering all Americans and would make ‘great improvements’ for millions of people.’” Pro-life advocates in the House should take note.

Late last night, the House Budget Committee caused a great deal of excitement when it posted the ‘‘Reconciliation Act of 2010’’ on its website. Reporters and bloggers assumed that the bill was the very package of changes Democrats had sent to the Congressional Budget Office and were surprised to find a public health insurance option, a national exchange and an earlier implementation date among the bill’s 2,309 pages. But in an indication of how complicated and arcane the Congressional process can be — even for veteran journalists — reporters quickly retracted their stories.

Upon closer inspection, the ‘‘Reconciliation Act of 2010’’ turned out to be just the old House health care bill with the student loan bill attached. As The American Spectator’s Phillip Klein first explained, the Budget Committee was using the old legislation as a vehicle to begin the reconciliation process. “Well, under the reconciliation rules in last year’s budget, any reconciliation bill would have to have been submitted to the Budget Committee by October 15, 2009. It just so happens that earlier versions of health care legislation cleared the Ways and Means and Education and Labor Committees last year. So Democrats just dusted that legislation off, and are using that as the vehicle to begin the reconciliation process.”

This afternoon, the House Budget Committee will begin marking-up the health care reconciliation package, signaling the beginning of the end of the Democrats’ year-long effort to pass comprehensive health care reform. Congressional leaders have urged members to clear their schedules for the weekend in anticipation of final up or down vote in the House, which could happen as early as Thursday. Under the Democrats’ plan, the House would pass the Senate version of the legislation, then take up a narrow package of fixes through the reconciliation process. If the House approves the changes later this week, they would go to the Senate, which would have to muster only 51 votes instead of 60.

To avoid any further confusion, below is a timeline for the best possible scenario:

1) Starting at 3pm today: The Budget Committee will report the old House health care bill, which has to be available for 48 hours before it goes to the Rules Committee. This will be a shell for the reconciliation process. The CBO will release its score of the reconciliation package today or tomorrow.

2) Wednesday, March 17th: The Rules Committee will strip the old House shell bill and replace it with the new reconciliation language. The Committee has to finalize the amendments and write a rule that will determine, among other things, whether the House takes up reform as one measure or two. Chairman Louise M. Slaughter (D-NY) could package it with the $875 billion measure the Senate passed on Christmas Eve. The package will also include Obama’s proposed overhaul of the student-loan system. At the Budget Committee markup, Democrats and Republicans will be allowed 10 motions each to instruct the Rules Committee, but the motions are nonbinding and will likely be used to score political points.

3) Thursday, March 18th or later: The bill will go to the floor as one measure or two separate bills. House will vote.

4) Senate will try to act before Easter: The Senate will do everything they can to get reform done before the Easter break, but given Republican efforts to delay the process, it’s likely that they’ll have to wait until after the break.