As I note here, implementing the new health care reform law will provide conservatives with plenty of opportunities to fear monger about health care reform, but this new scandal about Congressional staffers being exempt from enrolling in the exchanges certainly isn’t one of them. Currently, the health care law requires members and their staff to participate in the new health insurance exchanges, but Republicans are claiming that Democrats purposely excluded senior committee staffers from the mandate and will propose legislation to close the loophole:

Rep. Michael Burgess (R-Texas) announced Thursday in a “Dear Colleague” letter that he would be introducing bicameral legislation with Sen. Chuck Grassley (R-Iowa), who tried to attach a similar amendment to the reform act and the reconciliation bill. The legislation would require all Congressional staffers — and top White House officials — to buy their health plans through state-run exchanges created in the act. Currently, the reform act could be interpreted to only require Members and the staffers in their personal offices to enter the exchange, according to a Congressional Research Service memo.

“Many of my colleagues and I believe that the expansion of government control over health care was the wrong approach to take,” Burgess, who is an obstetrician, writes in the letter. “Regardless, if Congress has decided it is the right thing for our constituents, then all Members and staff, as well as the President, Vice President, and political appointees, should be mandated to be covered by plans operating in an exchange.”

I (along with Dr. Mandy Mandy Krauthamer) once debated Burgess about health care reform and for the most part, we decided that he’s a fairly thoughtful individual. So this push to strengthen the requirement (see, Republicans do love mandates!) that staffers enroll in a state-based exchange is really beneath him. First of all, the offending language was drafted by Sen. Tom Coburn (R-OK) and incorporated into the bill during the HELP Committee’s mark up of reform legislation. Democrats accepted the amendment because they thought it would demonstrate how sincere they were about their efforts, but I remember thinking that the whole thing came over as a cheap political stunt. And I still do, particularly since Republicans are now exploiting their own legislative incompetency to manufacture another scandal.

This health care law is incremental and while it provides the insured with greater security, it’s not intended to separate employees from their employer-based coverage. Congressional staffers, like all federal employees, already participate in FEHBP, the exchange that inspired these exchanges and (were it not for this requirement) could enroll in the exchanges once they open to large employers. So this particular loophole scandal is something Republicans manufactured to hold them over until they find something else to sink their teeth into.

Yesterday, Sen. Chuck Grassley (R-IA) admitted that he supported the individual mandate before he realized it was unconstitutional and now, Sen. Orrin Hatch (R-UT) has conceded that he too endorsed a policy that would have allowed the government “to tell you what you have to buy, even if you don’t want to buy it.” In 1993, Hatch, along with 20 other GOP senators — including Grassley, Bennett, and Bond — introduced a health care plan that would have required everyone to buy coverage, capped awards for medical malpractice lawsuits, established minimum benefit packages and invested in comparative effectiveness research. It was, in other words, a plan to “erode liberty.”

Last night, and then again this afternoon, Hatch was pressed on his past support for the 1993 proposal. What’s changed, CNN’s Campbell Brown and MSNBC’s Andrea Mitchell both wanted to know. Like Grassley, Hatch couldn’t come up with a very good answer. In 1993, Republicans hastily proposed the unconstitutional measure to fend off HillaryCare; nobody even understood the implications of the alternative policy, Hatch explained:

HATCH: Well, it really wasn’t. We were fighting Hillarycare at that time. And I don’t think anyone centered on it, I certainly didn’t. That was 17 years ago. But since then, and with the advent of this particular bill, really seeing how much they’re depending on an unconstitutional approach to it, yea, naturally I got into it, got into it on this issue.

Watch it:

Hatch was one of the first lawmakers to argue that the individual mandate was unconstitutional — railing against the provision during the Senate Finance Committee’s mark up of — and his conversion highlights the radicalization of the Republican party and the frivolous nature of the mandate challenges. The point has been made before that the health care law Obama signed on Tuesday resembles the 1993 Republican alternative and is far more conservative than anything Ted Kennedy or even Bill Clinton proposed in the past. The fact that Republicans are willing to embarrass themselves by walking away from ideas they’ve championed reveals everything you need to know about the sincerity of their present campaign.

Last night, in a vote of 220-207, the House of Representatives passed the Reconciliation Package of 2010, officially ending a legislative battle that has engrossed Congress for the better part of the last 17 months. President Obama is expected to sign the amendments to the health care law in the next several days and the work of health care reform now moves to the states and the various federal agencies charged with translating the bill’s 2,000+ pages into enforceable regulations.

I tried to outline what Congress can do to fine tune the bill here, but health reform faces more immediate implementation challenges. As Henry Aarons reminded us in this NEJM piece, the war isn’t over. “Passage of health care reform legislation is a cause for celebration. But supporters must not relax. They should prepare to meet the serious challenges that remain. If those challenges are not recognized and surmounted, health care reform could go the way of the Medicare Catastrophic Coverage Act of 1988“:

That bill, enacted with almost self-congratulatory enthusiasm, provoked vociferous resistance from some observers and was repealed 16 months later. If supporters of the current reform meet the remaining challenges, its course could instead resemble that of the Medicare drug bill, which was widely regarded as a case study in efficient and effective implementation.

Already, lawmakers have identified a loophole in one of the interim benefit provisions. In six months, the new law will prohibit insurers from refusing to cover pre-existing conditions as long as the child is already covered, but could allow insurers to refuse new coverage to children because of a pre-existing medical problem. HHS Secretary Kathleen Sebelius has promised to address the problem with new regulations, but it’s unclear if the protection would be in place once the benefit kicks in. Many other immediate challenges lie on the horizon:

- Establishing high risk pool program: In the next 90 days the government will have to implement a federally funded program to cover people turned down by private insurers because they have a pre-existing medical condition. But as Kaiser Health News points out, many questions remain — How much will the coverage cost? Will enrollees have a choice of plans? What medical services will be covered? What hospitals and doctors and other health care providers will participate in the networks to be created? How will the new entity interact with already established state-run high-risk pools?

- Administering small business tax credits and temporary reinsurance program: The government will provide tax credits to small employers with no more than 25 employees and average annual wages of less than $50,000 that provide health insurance for their employees. It will also have to establish a new program that will provide temporary reinsurance for employers providing health insurance coverage to early retirees between the ages of 55 and 64.

- Preventing insurers from dramatically increasing premiums: The government will have to create a process for reviewing increases in health plan premiums and requiring plans to justify increases. HHS will also have to establish a process for making recommendations to states about whether certain plans should be excluded from the Exchange based on unjustified premium increases.

And those are just some of the challenges for 2010. As we move forward many health policy wonks worry about the effectiveness of the state-based exchanges in regulating insurers and providing guidance to confused customers. Some fear that crafty health insurance executives will lure younger and healthier consumers into the less-well-regulated individual health insurance market, causing the exchanges to become populated with poorer and sicker Americans. Others argue that state-based regulators — many of whom oppose reform — will fail to effectively regulate insurers and render many of the law’s new consumer protections meaningless. There is concern that the individual health insurance mandate won’t bring enough people into the system. Free riders will continue to exploit the guarantee issue provisions to purchase coverage only after they become sick and insurance rates will continue to skyrocket.

So the road ahead will be full of speed bumps and sharp turns, and this blogger will try his best to track the progress of implementation piece by piece. After all, “[f]ar from having ended, the war to make health care reform an enduring success has just begun. Winning that war will require administrative determination and imagination and as much political resolve as was needed to pass the legislation.”