reconciliation and healthcare - the R in COBRA

Have you ever had COBRA health insurance coverage? It's the stopgap insurance coverage you get after you leave a job, intended to fill the gap in your coverage until you find a new job (and doesn't last forever, which is why extended unemployment still leaves people uninsured. This in a nutshell why single-payer/Medicare for all is a better system than our employer-provided insurance model, and why since we are stuck with employer-provided insurance, why we need universal insurance coverage reform.)

As NPR - exclusively - reminded us today, the "R" in COBRA stands for none other than budget reconciliation, the very process currently being painted as a "nuclear option" by establishment Republicans desperate to stop the health reform train. In fact, as it turns out, budget reconciliation has a long history of being used for health care legislation:

health care and reconciliation actually have a lengthy history. "In fact, the way in which virtually all of health reform, with very, very limited exceptions, has happened over the past 30 years has been the reconciliation process," says Sara Rosenbaum, who chairs the Department of Health Policy at George Washington University.

For example, the law that lets people keep their employers' health insurance after they leave their jobs is called COBRA, not because it has anything to do with snakes, but because it was included as one fairly minor provision in a huge reconciliation bill, she says.

"The correct name is continuation benefits. And the only reason it's called COBRA is because it was contained in the Consolidated Omnibus Budget Reconciliation Act of 1985; and that is how we came up with the name COBRA," she says.

It's not just COBRA - children's health insurance has also been implemented via reconciliation:

The expansion of health insurance coverage for low-income children is a prime example.

"In 1980, children who were living at less than half the poverty level in the United States could not get a Medicaid card in half the states if they had two parents at home," she says.

But via a series of budget reconciliation bills, beginning in 1984, Congress began expanding Medicaid coverage. In 1997, also in a budget reconciliation bill, it created the Children's Health Insurance Program, known as CHIP. Today, says Rosenbaum, who helped write many of the children's health provisions in those bills, Medicaid and CHIP together cover 1 in every 3 children in the United States.

"So literally we've changed everything about insurance coverage for children and families, and we've changed access to health care all across the United States all as a result of reconciliation," she says.

What about Medicare? Yup, also via reconciliation:

Budget reconciliation has also been an important tool for changing the Medicare program.

"Going back even close to 30 years, if you start say in 1982, the reconciliation bill that year added the hospice benefit, which is very important to people at the end of life," says Tricia Neuman, vice president and director of the Medicare Policy Project for the Kaiser Family Foundation.

Over the years, budget reconciliation bills added Medicare benefits for HMOs, for preventive care like cancer screenings; added protections for patients in nursing homes; and changed the way Medicare pays doctors and other health professionals.

Because the point of budget reconciliation was usually to cut the deficit, the huge Medicare program was nearly always on the chopping block.

NPR even provides a helpful list summarizing all the health-care legislation over the past 30 years that was passed via the reconciliation process - see below. The bottom line is that reconciliation is a valid legislative process - one used by every President, including Presidents Bush, Clinton, and Reagan, and health care reform qualifies because it is fundamentally about a government outlay and thus well within the boundaries of the Byrd Rule.

Kudos to NPR. Then again, its not a surprise, given that NPR listeners are the most well-informed of any broadcast news audience. That's the value of public broadcasting in an era where the mainstream media are forced to lay off hundreds of staff by their entertainment industry conglomerate owners.

A History of Reconciliation

For 30 years, major changes to health care laws have passed via the budget reconciliation process. Here are a few examples:

1982 - TEFRA: The Tax Equity and Fiscal Responsibility Act first opened Medicare to HMOs

1986 - COBRA: The Consolidated Omnibus Budget Reconciliation Act allowed people who were laid off to keep their health coverage, and stopped hospitals from dumping ER patients unable to pay for their care

1987 - OBRA '87: Added nursing home protection rules to Medicare and Medicaid, created no-fault vaccine injury compensation program

1989 - OBRA '89: Overhauled doctor payment system for Medicare, created new federal agency on research and quality of care

1990 - OBRA '90: Added cancer screenings to Medicare, required providers to notify patients about advance directives and living wills, expanded Medicaid to all kids living below poverty level, required drug companies to provide discounts to Medicaid

1993 - OBRA '93: created federal vaccine funding for all children

1996 - Welfare Reform: Separated Medicaid from welfare

1997 - BBA: The Balanced Budget Act created the state-federal childrens' health program called CHIP

2005 - DRA: The Deficit Reduction Act reduced Medicaid spending, allowed parents of disabled children to buy into Medicaid

(List reproduced from "Health Care No Stranger To Reconciliation Process" by Julie Rovner on NPR's Morning Edition. Here's the story transcript and audio.)

Related: An explanation of how the budget reconciliation process works, also at NPR.