Ezra Klein

Today I looked at how the health-care law might evolve, explained the "vote-a-rama" that's happening in the Senate tonight, and looked again at the Supreme Court and health care.

Here's what I didn't get to:

1) Tom Friedman's got the right idea, but I'm pretty skeptical that changing how we vote will change how we're governed.

2) Ryan Avent is worried about the Dodd bill's approach to 'too big to fail.'

3) Hey, a free Phoenix live album!

4) Kinsley love.

Recipe of the day: Making a better matzoh ball.

I don't want to exaggerate the importance of the death threats being made against congressmen who voted for health-care reform. Nuts are nuts. But there is a danger to the sort of rhetoric the GOP has used over the past few months. When Rep. Devin Nunes begs his colleagues to say "no to socialism, no to totalitarianism and no to this bill"; when Glenn Beck says the bill "is the end of America as you know it"; when Sarah Palin says the bill has "death panels" -- that stuff matters.

I remember listening to the debate the night the House passed the Senate bill and the reconciliation fixes. There are a lot of critiques I could imagine folks on the right making of the legislation. "Regulations to define a minimum insurance benefit will impede innovation in low-deductible plans." "Congress doesn't have the will to stick to the cost savings, and until they prove able to do so, we can't pass a new health-care entitlement." "The health-care system is broken, and adding a new benefit doesn't make sense outside the context of radical reform, as it will just create a new set of stakeholders who will resist the necessary changes."

But totalitarianism? Death panels? The end of America as we know it? These critiques aren't just wrong in their description of a cautious, compromised reform that uses private insurers and spends only 4 percent of what we spend on health care in an average year. They're shocking in terms of what the speakers believe their colleagues and representatives are willing to do to the American people. Nunes, for instance, has served with Democrats for decades. He might believe them too willing to tax society's most-productive members to fund social benefits. But does he really believe them friends of totalitarianism?

And the stuff on talk radio, of course, was worse. So take the universe of people who really respect right-wing politicians and listen to right-wing media. Most of them will hear this stuff and turn against the bill. Some will hear this stuff and really be afraid of the bill. And then a small group will hear this stuff and believe it and wonder whether they need to do something more significant to stop this bill from becoming law. And then a couple will actually follow through. And one will cut the gas lines leading to house of Rep. Tom Perriello's brother after seeing a tea partyer post the address online.

Few of us are on a mountain with this stuff, of course. Many condemned me for saying that Joe Lieberman was willing to cause the deaths of hundreds of thousands to settle an old grudge with liberals when he threatened to blow up the bill if the Medicare buy-in wasn't removed. I'll stand by the math of the comment, and the analysis of Lieberman's motivations, but I certainly wish I had phrased it somewhat more delicately. The word "cause" was ill-advised.

Still, that wasn't the tone of this blog over the past couple of months, nor of most outlets. Some politicians and media figures, however, have been in the business of ratcheting up opposition by making people afraid. But you can't count on people to simply cower when they're afraid, or write letters to the editor. Sometimes, they fight. It's a dangerous emotion, and high as the stakes are, public figures need to be a lot more careful manipulating it.

Photo credit: Melina Mara/The Washington Post.

The polarizing forces of a legislative debate have a tendency to amplify the certainty of supporters and magnify the doubts of advocates. So I'd recommend Ruth Marcus's skeptical, pro-reform column. I think she actually overstates the amount of disagreement there is in the literature over whether health-care insurance saves lives (see here, here, or here for more on that), but in general, I agree with her caution.

The only twist I'd add is that the issue, in my mind, isn't so much the risk of this bill as the expectations around it. I think the cost controls are likely to work, but that's largely because they're much more modest than people realize. The bill doesn't strike me as a big "risk" insofar as the worst case is pretty much that we insure 32 million Americans and that proves somewhat more expensive than we'd anticipated. Given that the projected spending of the bill -- with no savings or revenue taken into account -- is only 4 percent of our annual spending on health care, I'd take that deal and I'll gladly sign my tax return to help pay for it. If that's the cost of a decent society, so be it.

But we're not done. Even if the bill does a better job than CBO projects, health-care costs will still bankrupt us. This is one small step for cost, one giant leap for coverage. My great hope is that the bill makes the next steps easier. But there's still no guarantee we'll take them. And the debate and difficulty Congress had passing a bill that was too small and deeply compromised has left me very pessimistic about our system's capacity to make harder decisions. The danger is not that we can't solve our problems, but that we won't. And that's the biggest risk of all.

David Min offers perhaps the clearest explanation of the "too big to fail" problem that you'll find anywhere:

“Too big to fail” is best understood as a bank panic problem, and has arisen as the result of two developments in the global financial markets over the past several decades. The first development was the tremendous growth of a “shadow banking system” operating outside of the rules that have governed depository banking since the Great Depression. This shadow banking system essentially performed the same functions as banking — attracting short-term investments and using them to finance long-term loans — but did so through the use of entities that were not depository banks, and the use of financing instruments (such as mortgage-backed securities, commercial paper, or short-term repurchase agreements) that were not deposits. Because of this nonbank, nondepository structure, the shadow banking system, which grew to an estimated $10 trillion in size, fell outside the rules and protections of the regulated banking system.

The second development was the concentration of risk within the shadow banking system, such that a small number of financial firms were and are responsible for the vast majority of its liabilities. Before the 2008 crash, the five major U.S. investment banks had a combined balance sheet size of approximately $4 trillion, and this may have understated the true level of liabilities they were holding. Witness the recent revelations about failed Wall Street investment bank Lehman Brothers, which raises questions about the extent to which shadow banks offloaded balance sheet risk through the use of dodgy transactions.

I'm a bit concerned that a lot of the public energy on financial regulation is attaching itself to the Consumer Financial Protection Agency because that's both more comprehensible and more politically useful for Democrats. But how you deal with the TBTF problem is much more important.

Now this is unexpected: In oral arguments for New Process Steel v. National Labor Relations Board, Chief Justice John Roberts and deputy solicitor general Neil Katyal got into a dispute over the three vacancies on the National Labor Relations Board. Katyal tried to explain that they're the product of Republican obstructionism: There've been holds, Katyal said, and the Senate failed to break the filibuster when it tried to vote on Craig Becker. Roberts was unimpressed. "And the recess appointment power doesn’t work why?" he asked. On that point, I share Chief Justice Roberts's confusion.

So long as I'm on the topic of the court, yesterday I argued that one reason to think a constitutional challenge against the individual mandate wouldn't work was that "the Supreme Court does not like to invalidate important laws passed by Congress." That was the consensus of most experts I've spoken to on the issue. But my colleague Charles Lane, among others, made a convincing case to me that the Roberts court has been uncommonly willing to overturn laws passed by Congress. The most recent example was Citizens United, which invalidated important elements of the McCain-Feingold campaign-finance law. So though the Supreme Court might once have been loath to interfere with legislative intent, that argument may not hold as much water as it once did.

That said, most legal experts I've spoken to think the individual mandate is easily constitutional. The brief (pdf) Simon Lazarus wrote for the American Constitution Society makes the case well. But it's a reminder that President Obama might want to be careful about getting into fights with the court: It can make his life pretty difficult if it so chooses.

Photo credit: Melina Mara/TWP.

I'm pretty skeptical that the GOP's strategy to force Senate Democrats to take embarrassing votes on the reconciliation bill will mean much in the November elections. Most voters don't follow the minutiae of congressional procedure, but nor are they stone-cold idiots. An ad saying that "so-and-so voted against a bill to stop the government from covering Viagra for child molesters" isn't going to move many voters, though it may make whoever approved the message look bad. More realistically, the attacks that say Democrats voted to destroy Medicare are going to run into two problems: First, Democrats are more trusted on Medicare than Republicans. And second, that the health-care bill has a bunch of early deliverables in Medicare, including free preventive care visits and a $250 rebate for seniors who fall into the doughnut hole.

Which gets to the Democrats' counter-strategy. The immediate benefits in health-care reform are pretty small compared with the eventual impact of the bill. But they sound good to voters. Nancy-Ann DeParle put up a list of them at the White House's blog, and this is probably the list that's going to go out to every Democratic candidate in the country. I've copied it below the fold. But before getting to that point, I'll make a prediction: If the election is about health-care reform, Democrats are going to do much better than expected. They're simply more trusted than Republicans on that subject, and they can make a more concrete argument. But if the election is about the unemployment rate, or the bailouts, or trying terrorists in civilian courts, Republicans are in better shape.

Anyway, here's DeParle's memo:

I've never forgotten Stephen Waldman's admonition that "one of the great errors in modern policy is to confuse disclosure with information." The fact that we're forcing, say, credit card companies to disclose things doesn't mean anyone can understand what they're disclosing. Here, branding expert Alan Siegel shows how we can take forms that currently confuse everyone and make them crystal clear.

The Internet is alive with the sound of health-care reform scenarios. See Douthat, Cowen, Yglesias, etc. It's difficult, of course, to predict what the system will look like in 20 years. About the only confident prediction is that there will be laws passed and decisions made between now and then that will alter the trajectory of the system. The experience of other countries suggests reforming the health-care system is a bit like eating Pringles: Once you start, you just can't stop. But here are some notes for thinking of this.

(1) When you're talking about the system, you're talking about what will happen with the exchanges. The worst-case scenario is that they become a ghetto for low-income, high-risk customers. In that world, you have a tiered health-care system: Medicaid serving the poor, exchanges serving the near-poor who don't work for large employers, and the employer market serving everyone else.

The best-case scenario is that the exchanges become the de facto health-care system as the employer market continues to deteriorate and as the exchanges prove themselves good for consumers. In this world, large employers begin entering the exchanges in 2017, as the law suggests. After a few big employers make the jump and find themselves freed from having to administrate their health-care systems and find their workers pleased with the choices (this assumes they are empowered to let their workers choose, rather than choosing for them), more follow them. This would make the system look a lot like the Wyden-Bennett proposal, and would lend itself to some conservative reforms, including the eventual abolition of Medicaid. In this world, our health-care system eventually looks like the Dutch system.

(2) Although the coverage structure of this bill might be the seed from which our next system grows, a lot more will need to be done on cost control. Of the ideas present in the bill, I'm more optimistic about implementation of the excise tax than many of my conservative friends. I'd say it's 75 percent likely to trigger in 2018, though I think there's a significant chance that it's indexed to inflation plus a percentage point or two rather than just inflation. I just don't think that the deficit politics between now and then are going to change such that you can find 60 votes to remove it entirely without finding an offset for its revenue.

I'm somewhat more skeptical than many health-care experts that flooding the system with evidence will make a big difference in spending. I think it's a good bet to increase the value of our health-care dollars -- the care we get will be likelier to work -- but it's a toss-up whether that really makes the system cheaper. Conversely, I'm more optimistic than some that the long-awaited IT revolution could save a lot of money. I'd recommend this Phil Longman article on that subject.

All that said, we're eventually going to have to face up to the elephant in the room: prices. We can't keep paying twice as much as other countries pay for each unit of care and get our costs under control. I think there's virtually no chance that this system evolves toward single-payer. But I think there's some chance that the government eventually begins setting payment rates for private payers, much as happens (successfully!) in Maryland.

(3) All that said, I have two other strong beliefs about this bill: First, in 20 years, we will be happy we passed it. It will be near to a consensus program, though like any other program, it will need continual reform and repair. Second, in and of itself, it will be much less noticeable in the system than most people think. This bill could be made very important by accelerated deterioration of the employer health-care market, but most Americans will find this reform pretty quiet once it's up-and-running -- a far cry from the debate that got it there.

"For all the political and economic uncertainties about health reform," writes David Leonhart, "at least one thing seems clear: The bill that President Obama signed on Tuesday is the federal government’s biggest attack on economic inequality since inequality began rising more than three decades ago."

A big chunk of the money to pay for the bill comes from lifting payroll taxes on households making more than $250,000. On average, the annual tax bill for households making more than $1 million a year will rise by $46,000 in 2013, according to the Tax Policy Center, a Washington research group. Another major piece of financing would cut Medicare subsidies for private insurers, ultimately affecting their executives and shareholders.

The benefits, meanwhile, flow mostly to households making less than four times the poverty level — $88,200 for a family of four people. Those without insurance in this group will become eligible to receive subsidies or to join Medicaid. (Many of the poor are already covered by Medicaid.) Insurance costs are also likely to drop for higher-income workers at small companies.

Finally, the bill will also reduce a different kind of inequality. In the broadest sense, insurance is meant to spread the costs of an individual’s misfortune — illness, death, fire, flood — across society. Since the late 1970s, though, the share of Americans with health insurance has shrunk. As a result, the gap between the economic well-being of the sick and the healthy has been growing, at virtually every level of the income distribution.

This is, in my judgment, the right way to reduce inequality. The government isn't very good at getting elbow deep in the economy and telling corporations how much they should pay their workers. It's one thing to set a minimum wage, but a whole other to decide the appropriate ratio between median worker pay and executive compensation.

The government is pretty good, however, at changing economic outcomes. And that's what's happening here. The tax code mediates between the economy we have and the society we want. The fact that the former is wildly unequal does not mean the latter need to follow along.

Graph credit: Center for Budget and Policy Priorities.

A reader gently corrects me:

Your posts today keep referring to it as the health-care reform "bill." But it isn't a bill any longer--it's the LAW! So you might want to try to adjust your mindset.

Noted.

Yesterday, the Republicans' gambit to derail the vote on the reconciliation fixes was thrown out by the Senate parliamentarian. That's not the end of their options, but it means they're left trying to slow the bill down rather than stop it altogether.

The budget reconciliation process limits debate to 20 hours, which means you can't filibuster. But it doesn't limit the number of amendments you can propose. So that's where Republicans are concentrating their efforts: As of this writing, the prescribed 20 hours of debate leading up to those amendments is ongoing, and Democrats have decided to give up their remaining seven hours to speed the process along. When that ends, the GOP has at least 32 amendments waiting, and they could introduce hundreds, or even thousands, more. The expectation is that the Senate should get to the amendments tonight (at least barring another Republican attempt to make everyone go home at 2 p.m.). At that point vote-a-rama commences.

Vote-a-rama is what happens when the Senate has a ton of amendments to deal with and not a lot of time to deal with them. Each amendments gets a minute of debate on both sides and then a 10-minute vote. They go till the amendments are finished. In this case, they're likely to go well into the night.

Republicans could try to stretch this out by proposing 600 more amendments. But someone would have to write those amendments. They would all have to be germane to the bill and friendly to the deficit. And Democrats can just keep knocking them back. The Republican strategy, however, appears to have moved from delay to embarrassment. Because Senate Democrats don't want to change the reconciliation bill and send it back to the House for another vote, they want to reject all Republican amendments. So Republicans are proposing amendments that will be embarrassing for them to reject. This strategy has reached its logical apotheosis in Sen. Tom Coburn's amendment "prohibiting coverage of Viagra for child molesters and rapists."

But embarrassment is temporary. Delay, particularly in the Senate, can be forever. So why have Republicans apparently moved away from the endless-amendments strategy?

The answer is that Obama already signed the Senate bill and Democrats already celebrated. When it seemed that the Senate bill wouldn't pass until reconciliation finished, there was energy on the Republican side to do everything possible to kill or slow reconciliation. Now that the Senate bill is finished and the Democrats are celebrating and the cameras are slowly flickering off? Well, sitting around voting on 632 amendments is no more fun for the Republicans than the Democrats, and they have families they want to see and fundraisers they need to attend. Obstruction would be no more fun for them than for the Democrats, and it might make them look petulant in the eyes of voters who want Congress to just move on from health care already.

Photo credit: Melina Mara/The Washington Post.

"There is non-controversial stuff here like the preexisting conditions exclusion and those sorts of things," Sen. John Cornyn said. "We are not interested in repealing that. And that is frankly a distraction." As Ramesh Ponnuru points out, that's basically game over for the repeal effort:

Understandably, Cornyn doesn’t want to touch the most popular element of Obamacare, the ban on discrimination based on pre-existing conditions. But unless it’s modified substantially, the individual mandate has to stay too — and therefore so do the subsidies and the minimum-benefits regs. Without perhaps realizing it, Cornyn has come out for tinkering at the edges of Obamacare.

Ponnuru is too kind, I think. Cornyn and his colleagues repeatedly said that they wanted to ban discrimination on preexisting conditions during the debate and that their argument was with all the other stuff. But all the other stuff, Ponnuru says, flows from the ban on preexisting conditions. If you're going to change the insurance market such that the sick can't be left out, you have to make sure that the risk pool doesn't become so sick and expensive that the healthy flee. That's why you do the mandate. And if there's a mandate, there needs to be subsidies to make sure people can afford what they're being asked to buy. And then of course, we need to define what they're being asked to buy, and so you get minimum benefit regulations.

If you're going to change the insurance market, in other words, you need to change the insurance market. And as Cornyn basically admits, people want the insurance market changed. If Republicans aren't willing to fight that directly, there aren't that many options for modifying it slightly. As Jon Chait says, the only way it can work is as politics. "You run on a promise to keep the popular elements and eliminate the unpopular ones.... Then, if you win, you forget about it."

"There is a little-known rule in the Senate stating that hearings can’t happen after 2:00 p.m. each day without unanimous consent," explains Amanda Terkel. "However, every day, at the start of business, the Senate generally agrees, by unanimous consent, to waive this rule and continue with the necessary business of holding hearings."

Every day, that is, until now. Republicans angry about the passage of health-care reform are invoking the dreaded half-day maneuver. Terkel explains:

Today, during a Senate Homeland Security Subcommittee hearing on transparency, Sen. Tom Carper (D-DE) announced that he had to stop the proceedings because of Republican blocks. ... The AP also reported today that Sen. Mark Udall (D-CO) had a hearing on the bark beetle canceled today “after Republicans angry over the passage of health insurance reform legislation blocked it by using an obscure Senate rule requiring a unanimous consent to hold hearings scheduled after 2 p.m.”

I could imagine a lot of smart ways to begin obstructing the chamber and making life miserable for Democrats. But declaring that you won't work after 2 p.m? Do Republicans really think the average American is going to rally to that battle cry?

Update: My colleague Paul Kane notes that this isn't specifically a 2 p.m. rule. Rather, the Senate needs unanimous consent to continue work two hours after it's gaveled into sessions. So it could be earlier than 2 p.m. And it turns out to be an old minority trick that Democrats have used too. This is further evidence, I think, that it's long past time to clean the Senate rulebook and get rid of the minority's ability to throw these procedural tantrums.

Today I wrote about why legal challenges to the health-care reform bill are unlikely to work and wouldn't much matter even if they did, looked at whether the Republican strategy of opposition to health-care reform served them well, and watched as the GOP's strategies to derail reconciliation fell apart.

Here's what I didn't get to:

1) The White House releases a year of photos chronicling their internal deliberations.

2) The allegations that Christiane Amanpour doesn't have an inside-the-beltway perspective and has angered people by taking reasoned stands on important issues makes me think she's a good choice to host ABC's Sunday program “This Week.”

3) Remembering a road trip with David Foster Wallace.

4) The administration doesn't have much of a Fannie and Freddie strategy.

5) I'll be on “Countdown” with Keith Olbermann tonight (though I think Lawrence O'Donnell is still guest hosting).

Recipe of the day: Romesco potatoes.

Republicans were using the word "repeal" a lot in the hours after the House voted to pass the health-care reform bill. But as the hours turn to days, they're talking about repeal less, qualifying it more, and even finding themselves mentioning things they like about the bill. Suzy Khimm runs through the changing rhetoric:

Sen. Scott Brown of Massachusetts, the poster boy for the conservative insurgency, said on Monday that he wasn't sure whether he'd support overturning the health care law, calling moves to do so "a little premature." As ThinkProgress notes, Rep. Phil Gingrey told CNN that he "does not want" to throw out everything in the bill, noting that there are many provisions — including health insurance exchanges, electronic medical records, greater coverage for dependents, expanded Medicaid, and increased consumer protections — that he supports. Rudy Giuliani also opposes repealing the bill. And the Chamber of Commerce — the business lobby group which often backs conservative causes and which spent some $144 million campaigning against health care reform — has said it won't support a GOP effort to throw out the legislation. [...]

Senator John Cornyn, chair of the National Republican Senatorial Committee, saidTuesday that Republicans should only focus on repealing the most controversial elements of health reform. Like Guthrie, he maintained that there are provisions worth keeping. And Senators Jon Kyl and Mike Enzi both said that partial repeal would be a more realistic goal.

So in about 12 hours, the GOP's position has gone from "repeal this socialist monstrosity that will destroy our final freedoms" to "there are some things we don't like about this legislation and would like to repeal, and there are some things we support and would like to keep."

"We always said there are things that we can all agree on in the bill," said Rep. Brett Guthrie.

At this rate, they'll be running on expanding the bill come November.

Dr. Jeff Levi is executive director of the Trust for America’s Health and a member of the faculty at the George Washington School of Health Policy. I spoke to him today about the prevention components of the health-care bill.

So tell me, as simply as you can, what this bill does for prevention.

It ensures that group-health plans offer first-dollar, no co-pay, no-deductible coverage of clinical preventive services. But there’s also a recognition that what happens outside the clinic can have a bigger impact than what happens in the clinic. There’s $15 billion over 10 years for a Prevention and Public Health Fund that will support community prevention programs that try to change the policies, the physical and social environment, that make it hard for people to make healthy choices.

Give me some examples of the types of programs and initiatives it will fund.

The focus tends to be on structural change. So anything from a national campaign to promote immunizations and a better understanding of the safety of vaccines to a narrower, neighborhood approach that puts lights in a playground or negotiates a mixed-use agreement with a school so the playground can be open after hours. It could be used to improve the walkability of neighborhoods or the nutrition standards at schools. Some of this money will go to help state and local health departments build their capacity to do this kind of prevention.

And then there are things that don't cost money, like the menu labeling initiative. Are there other policies like that one tucked away in the bill?

In normal circumstances some of the small parts of this bill would be considered huge victories. There’s menu labeling for chain restaurants, which is a huge change. There are a bunch of demonstration programs, some of them simple things that you’d think would already be the case but aren’t. Coverage of tobacco-cessation service for pregnant women in Medicaid, for instance. Incentive grants in states to do more chronic disease prevention. And the most important clinical piece is that all group-health plans offer first-dollar – no co-pays, no deductibles -- coverage for anything rated A or B by the National Prevention Task Force.

This seems a bit small to me. In the context of the bill, $15 billion isn't very much. It's hard to imagine it transforming our public health sector.

There’s not enough money to truly transform public health, if we’re honest. But if it’s leveraged right, it can be transformative. It can be leveraged as an incentive to get state governments to rethink their community health programs, and it’s a signal from Congress that this is a new direction, and some of our federal programs need to be reshaped with this program in mind.

You've implied here that part of this money is about moving prevention and public health in a different direction, that we've been doing it wrong and this is a chance to do it right. What's the new theory?

It’s thinking about a community. It could be a city, a neighborhood, or even a defined population. And you need to think about the impediments to them making healthy choices. There are parts of D.C. where you can’t walk at night or let your kids play. In those neighborhoods you could do better lighting, safer playgrounds, supervised playtime for kids. That gives them more exercise and healthier lives.

Another way to think about it is, what are the risks populations experience, and how do they contribute to other risks they take? Unsafe communities make it hard to exercise and also create stress and anxiety that comes out in drinking, in smoking, in drugs. Starting with the elements of the community that create risk and trying to change them comprehensively so you have an effect on many diseases, not just one disease.

One of the predictions that I and many others had about the health-care reform bill was that it would become more popular after passage than it was before passage. Voters like success, the media covers winners more positively than losers, and people take their cues from outcomes. The first poll taken entirely after the House vote bears that out: 50% were enthusiastic or pleased while 42% were angry or disappointed. Similarly, 49% thought this a good thing for the country while 40% thought it bad.

The poll is a Gallup poll, and as they say, that's a sharp improvement over the pre-passage numbers. On 3/9, they asked whether you'd advise your representative to vote for the bill. About 45% said yes, while 48% said no. So there's been a flip from plurality opposition to plurality support. This is, of course, just one poll, amd soon we'll know if it's a general trend.

My colleague Frank Ahrens chats with Sen. Judd Gregg about the GOP's strategy for obstructing the reconciliation package. It looks grim for Gregg. His big play was to scare the House Democrats by saying 310(g) over and again. Gregg said that the bill could be "brought down" by this budget objection. Today, the Senate parliamentarian ruled against him. That means he can't bring down the bill.

Sen. Tom Coburn admitted the reality of the Republicans' option when he was asked on CNBC whether they could stop the bill. "No," he replied. "We'll put a few holes in it, but basically it's going to come through here because they've done a good job crafting it."

More specifically, the GOP is left with two options: try and persuade the parliamentarian to strike specific provisions (creating the "holes" Coburn mentioned) or try to get Democrats to take hard votes.

In the first case, you could see the parliamentarian force small changes to the reconciliation package, which would require the House to ratify it again after the Senate passes it so that both chambers have voted on the exact same bill. That may annoy the House, but it's not a particularly big deal.

In the second case, Republicans will try and embarrass Democrats by making them vote against amendments that sound good but would hurt the bill. The first amendment, Gregg says, "will require that Medicare savings go to protect Medicare." Again, that may be annoying to Senate Democrats, but it's not some cunning gambit that will lead them to accidentally defund the health-care bill. And it doesn't sound like Republicans are planning to shut the chamber down with endless amendments of that sort (though you never know). So it looks like the reconciliation package should pass this week.

Photo credit: Chip Somodevilla/Getty Images.

When people think about the GOP's threats to repeal the health-care bill, they need to think about the actual votes that Republicans would need, and when they would take place. In the short term, they'd need not just a majority in the House and Senate, and not just a supermajority in the House and Senate, but a two-thirds majority in the House and Senate because they'd need to override the president's veto. In the Senate, that's not even a plausible electoral outcome. And as a reader reminds me, people should also remember that "now that the reform bill is the law of the land, [repeal] would increase the budget deficit relative to current law, at least in the eyes of the CBO." So if they weren't going to find offsets, they'd also need to overrule pay-go.

I'd take the talk of constitutional challenges and the talk of repeal as the necessary end point for the GOP in this debate. You can't spend a year calling something a dire threat to American freedom and then shrug your shoulders once it's passed. You at least need to assure your allies that you believed what you were saying all along. But as the days and months and years go on, it's going to be very difficult to keep up that intensity. Five months from now Republicans will be united against the Consumer Financial Protection Bureau, and a year or two after that, who knows what the issue of the day will be.

Once they actually retake the presidency, their new leader will have an agenda they're going to want to pass and problems that need to be solved, they're not going to want to spend their time picking through pieces of Obama's agenda. Don't believe me? Check out the Democrats who are about to ratify most of George W. Bush's tax cuts, even though they could let the cuts die just by refusing to act to save them, or notice that Democrats just passed a bill that strengthens the Medicare prescription drug benefit, even though many of them swore to repeal it as soon as it was passed.

And that's what I'd expect to see with health-care reform. The bill won't get repealed, but when Republicans take power, it will get nudged: Maybe they'll add low-deductible plans, or tort reform, or purchasing across state lines. Maybe they'll try to change how it's funded (though they'll have to find offsetting money somewhere else). Maybe they'll rest their argument on cost control and add more payment reforms and delivery-system changes, which would actually be a good thing. But now that health-care reform has been signed, the likely future is health-care reform reform, not repeal.

Photo credit: Photo by Chris Usher/CBS.

The president has signed the bill. I know this has confused some, but health-care reform is now law. The Senate's vote on the reconciliation fixes will modify that law, but President Obama just signed a universal health-care structure into law in the United States of America.

Photo credit: Official White House Photo by Pete Souza.

Merrill Goozner points out another little-noticed provision in the bill: "Drug and device companies will soon have to report payments to physicians in a national database, thanks to a little noted section of the health care reform bill called the Physician Payments Sunshine Act."

There were a lot of complaints about the transparency of the health-care reform process. I think most of those complaints were wrong: It's hard to identify another debate that stretched for this long, that featured this many legislative proposals and CBO analyses and interviews and op-eds and think-tank summaries and televised mark-ups, all of which were available to download on the Internet. There has simply never been a legislative debate that offered everyday Americans so much opportunity to read the primary documents and their explanations and estimations.

What got lost in this, however, is how much transparency the bill is going to bring to the health-care sector. It's not that every doctor visit will be televised, or every meeting of insurance executives streamed over the Internet. But hospitals will have to post prices. Insurance products will be presented with standardized information, consumer ratings and quality measures. The payments physicians take from drug and device companies will be in a public database. There will be independent funding for research on the relative effectiveness of different treatments. Some of these changes are small and some are big, but put together, the system is going to become a lot more visible in the coming years.

The prevention proposals in the health-care bill haven't gotten enough attention, including from me. But Marion Nestle makes a good catch here: One of the bill's provisions is a menu labeling proposal for chain restaurants with more than 20 locations. The proposal requires chains to post the caloric content of each item (and the total calories of combo meals) next to its listing on the menu, the menu board, and even the drive-through menu kiosk. This goes into effect next year, and will be one of the most visible effects of the health-care bill. You can read the provision here (pdf).

The early evidence on menu labeling has been undeniably mixed, but this is good information for people to have. In 20 years, I think we'll be baffled that there was a time when it wasn't easily available to us.

Photo credit: AP Photo/Ed Ou.

With the votes counted and the legislative battle finishing, conservatives are turning to a different branch of government to fight health-care reform: the courts. Their most promising tactic was to argue that "deem and pass" would be unconstitutional because the House and the Senate passed slightly different versions of the same bill. Previous challenges on those grounds had failed, but this is a different court and health-care reform is a different beast. But then the House rejected deem and pass and voted on the bill through the normal order. Undeterred, conservatives -- most prominently Ken Cuccinelli, Virginia's ambitious attorney general -- are planning to file suit against the individual mandate.

So is this -- or any of the other challenges being contemplated by conservatives -- likely to work? The basic answer is that the Supreme Court does not like to invalidate important laws passed by Congress. But for a more thorough look, see this article by Dave Weigel (who will soon be my colleague here at The Post!).

To put it very simply: This is good politics for conservatives but an unlikely legal strategy. And as Dave's article makes clear, the politicians pushing it know that as well as anyone. Two of the grounds for challenges that most excited conservatives ("deem and pass" and the Nelson deal) will not be relevant to the final bill, as "deem and pass" wasn't used and the Nelson deal is going to be erased in reconciliation. That means conservatives are largely left with the individual mandate -- an idea developed by the conservative Heritage Foundation and passed into law in Massachusetts by Republican presidential aspirant Mitt Romney -- and that's very unlikely to be repealed.

It's also less important if it is repealed. The virtue of challenging how the law is passed is that a successful effort could invalidate the whole thing. Not so with the individual mandate, which is a small (though important) piece of the bill. If the unlikely happened and the mandate was repealed, you could simply replace it with something like this and the bill would work very much as intended.

And as a final note, let me propose a new rule: No conservative who supports these legal challenges can complain about activist judges ever again.

Weird news out of FinReg yesterday, as a party-line vote in the Senate Banking Committee sent Chris Dodd's bill to the Senate floor after 21 minutes of consideration and no changes. Republicans are saving their amendments for later, and so, I guess, are Democrats. Dodd and Shelby continue negotiating in the hopes that they can come up with a package of amendments that will transform the bill into something both sides can support. This is pretty unusual, though.