Health care reform may not be finished after all. Despite the political reverberations of last week’s special election in Massachusetts, Democratic leaders on Capitol Hill are still discussing ways of passing a comprehensive reform bill.
But it’s going to take heroic political efforts, given the number of Democrats suddenly skittish about supporting such a bill. And it’s not clear whether the Hill’s strongest reform advocates are getting the kind of political help they say they need from the White House.
According to multiple sources, the preferred option for congressional leadership remains what it was last week: Having the House pass the Senate bill, as it is currently written, and then working with the Senate to fix the bill through the budget reconciliation process.
You know the story: With reconciliation, filibusters can’t block a majority from passing legislation, so the Senate could move a bill even with “only” 59 members in the Democratic caucus. And you know the catch: Rank-in-file Democrats in the House are either spooked by the Massachusetts results, strongly opposed to elements of the Senate bill, or both. Their counterparts in the Senate, meanwhile, don't seem in any great rush to make it easier--by, say, signing a letter promising they'll support in reconciliation the same changes they had been negotiating over the last few weeks.
The White House seems to agree that passing the Senate bill and fixing it with reconciliation would be the best way to proceed. But that doesn’t mean they’re pushing hard for that option. According to the same sources, the Obama administration sent vague, sometimes conflicting signals about its intentions for much of last week--making the task for reform advocates even harder.
Even as administration staffers were indicating their support for the leadership's strategy individually, these sources noted, Chief of Staff Rahm Emanuel was calling members and soliciting their opinions on more scaled-down versions of reform. President Obama, meanwhile, said relatively little on health care reform during the first few days after the election--except to give ABC News an interview in which he talked up the less controversial areas of reform. Congressional staff and outside observers both interpreted these moves as implicit support for scaling back reform.
As one senior congressional staffer wrote in an email, expressing a common sentiment, "It is VERY frustrating not to hear from them and/or not to hear a single plan or strategy.” This staffer went on to speculate that “maybe there’s a split among advisors on what to do.”
Ohio Senator Sherrod Brown, among the Senate's most reliable and strongest progressives, expressed similar frustration last week in an interview with TPM's Brian Beutler.
It's impossible to know--or, at least, impossible for me to know--whether the mixed messages were the product of ambivalence or deliberate ambiguity. (The White House wouldn't offer official comment when contacted by TNR, except to note that Obama spoke with House and Senate leaders over the weekend.) It's also not clear the extent to which the administration was merely trying to let the "dust settle," as spokesman Robert Gibbs put it, rather than lower its ambitions.
Among other things, the president himself offered stronger rhetoric during Friday's town hall in Ohio. Towards the end of the event, Obama himself brought up health care, pointing out that severing the bill into pieces--a strategy many critics have urged and that some House Democrats have said they’d prefer--wouldn’t necessarily work:
Now, some people ask, well, why don't you just pass that and forget everything else? Here's the problem. Let's just take the example of preexisting conditions. We can't prohibit insurance companies from preventing people with preexisting conditions getting insurance unless everybody essentially has insurance. And the reason for that is otherwise what would happen is people would just -- just wouldn't get insurance until they were sick and then they'd go and buy insurance and they couldn't be prohibited. And that would drive everybody else's premiums up.
So a lot of these insurance reforms are connected to some other things we have to do to make sure that everybody has some access to coverage. All right?
Obama followed that with a stronger defense of the plan than he’d issued in several days:
This is our best chance to do it. We can't keep on putting this off. Even if you've got health insurance right now, look at what's happening with your premiums and look at the trend. It is going to gobble up more and more of your paycheck. Ask a chunk of you folks in here who have seen your employers say you've got to pick up more of your payments in terms of higher deductibles or higher copayments. (Applause.) Some of you, your employers just said, we can't afford health insurance at all. That's going to happen to more and more people. ...
Let me talk about Medicare. Medicare will be broke in eight years if we do nothing. Right now we give--we give about $17 billion in subsidies to insurance companies through the Medicare system--your tax dollars. But when we tried to eliminate them, suddenly there were ads on TV--"Oh, Obama is trying to cut Medicare." I get all these seniors writing letters: "Why are you trying to cut my Medicare benefits?" I'm not trying to cut your Medicare benefits. I'm trying to stop paying these insurance companies all this money so I can give you a more stable program. ...
We can't shy away from it, though. We can't sort of start suddenly saying to ourselves, America or Congress can't do big things; that we should only do the things that are noncontroversial; we should only do the stuff that's safe. Because if that's what happens, then we're not going to meet the challenges of the 21st century. And that's not who we are. That's not how we used to operate, and that's not how I intend us to operate going forward.
Of course, whatever clarity Obama offered on Friday faded by Sunday, when administration officials appeared on the Sunday shows and, as Joe Klein notes, offered no clear party line.
Obama will have one big chance to clarify his message this week--on Wednesday night, when he gives the State of the Union. As another senior congressional staffer puts it
State of the Union will be incredibly important for the message. It's ok to leave things vague until then. It's not ok to leave things vague at that point.
Update: Slate's Tim Noah has a terrific rundown of the various political obstacles to passage. And he's even made a reader game out of it. I also added a reference to the Sunday shows, along with Joe Klein's commentary on it. Klein seems to think the president needs to scale back or drop health care reform, given the political consequences. I think it's still better, by far, to move forward--although I agree it must be quick, leaving room for the president and the whole Democratic Party to talk about the economy. More on all of that soon...
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COMMENTS (22)
Cohn is correct, the SOTU will determine the fate of health care reform. Unfortunately, Obama's comments quoted by Cohn aren't encouraging. Unless he comes up with a better narrative by Wednesday, it's over. Obama may have the reputation as a great communicator, but when it comes to health care reform he is no better than the leadership in the Senate. The biggest selling point, ending adverse selection, is completely lost when it is coupled with comments about mandates and subsidies. Hammer away at the former and let the latter take care of itself. And stay away from talk about ending Medicare, it creates the exact opposite impression than what is intended as does talk about premium in ... view full comment
Cohn is correct, the SOTU will determine the fate of health care reform. Unfortunately, Obama's comments quoted by Cohn aren't encouraging. Unless he comes up with a better narrative by Wednesday, it's over. Obama may have the reputation as a great communicator, but when it comes to health care reform he is no better than the leadership in the Senate. The biggest selling point, ending adverse selection, is completely lost when it is coupled with comments about mandates and subsidies. Hammer away at the former and let the latter take care of itself. And stay away from talk about ending Medicare, it creates the exact opposite impression than what is intended as does talk about premium increases. No more denial or termination of insurance due to pre-existing conditions or illness, no more sick and dying children because the family cannot afford health care, no more bankruptcies or loss of homes due to illness, health insurance that will actually cover medical expenses, and everybody paying their fair share of health care costs. Who could be against that!
If there's a way to make people "against that", I think Pelosi and Reid will find it Ray.
The one thing that stands out in this mess for me is the consistency with which Democrat Congressional majorities screw Democrats in the White House. Carter had plenty of his own problems but he certainly wasn't helped by a too-left Congress which produced a probably fatal primary challenger; Clinton was sabotaged, allegedly because he slighted his Democrat Congress by doing healthcare in the back room; so Obama gave healthcare to Pelosi/Reid who took it into the back room and sabotaged him too. It seems clear that it's not their enemies Democrats in the White House have to worry about, but their "friend ... view full comment
If there's a way to make people "against that", I think Pelosi and Reid will find it Ray.
The one thing that stands out in this mess for me is the consistency with which Democrat Congressional majorities screw Democrats in the White House. Carter had plenty of his own problems but he certainly wasn't helped by a too-left Congress which produced a probably fatal primary challenger; Clinton was sabotaged, allegedly because he slighted his Democrat Congress by doing healthcare in the back room; so Obama gave healthcare to Pelosi/Reid who took it into the back room and sabotaged him too. It seems clear that it's not their enemies Democrats in the White House have to worry about, but their "friends".
There was already a perfectly good healthcare reform (the Wyden-Bennett Healthy Americans Act) which had substantial bi-partisan support, including ten Republican co-sponsors in the Senate. Anyone care to speculate why Reid and Pelosi insisted on producing the current fiasco instead?
RP: I agree about the Democratic legislatures, but I also have to say that I haven't seen much White House leadership on this issue. And, frankly, it's pretty thoroughly soured me on Obama at this point. Either he starts showing some spine, or he's a a one-term wonder, with the same historical treatment as Jimmy Carter.
RP: I agree about the Democratic legislatures, but I also have to say that I haven't seen much White House leadership on this issue. And, frankly, it's pretty thoroughly soured me on Obama at this point. Either he starts showing some spine, or he's a a one-term wonder, with the same historical treatment as Jimmy Carter.
My entry into Noah's game: Just bribe Stupak - - it's a proven winning strategy (Nelson, Landreuix, etc.). A bit tongue in cheek, but sadly a bit true...
My entry into Noah's game: Just bribe Stupak - - it's a proven winning strategy (Nelson, Landreuix, etc.). A bit tongue in cheek, but sadly a bit true...
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Hire A Repairman
Communicating and sound polling are necessary. But so is a handyman who has a manual for How Congress Works.
Since the end of July, time has not been a friend for the health care bill, Democrats position on the issue or Obama's ability to control the direction.
Yes, the economy which wasn't inspiring confidence in government, a radical right with less to lose allowed fanatics to confuse by chaos and Democrats in the senate with increasingly fragmented goals meant the dynamics against passage would gain momentum as the content-features of the bill took more hits than Favre last night.
It's not a secret that best way to defe ... view full comment
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Hire A Repairman
Communicating and sound polling are necessary. But so is a handyman who has a manual for How Congress Works.
Since the end of July, time has not been a friend for the health care bill, Democrats position on the issue or Obama's ability to control the direction.
Yes, the economy which wasn't inspiring confidence in government, a radical right with less to lose allowed fanatics to confuse by chaos and Democrats in the senate with increasingly fragmented goals meant the dynamics against passage would gain momentum as the content-features of the bill took more hits than Favre last night.
It's not a secret that best way to defeat major legislation is to stall and allow all the interests against it to suck the oxygen from from the pro side. I contained my panic but I know that more than a few experienced senate wonks understood and warned that the optimal shelf life wasn't longer than mid summer. Most of the procedures that made people dizzy should be anticipated, they're called rules.
Go check the transcripts of Lawrence O'Donnell's warnings from last Summer. He didn't have a crystal ball, he was the Chief of Staff on Finance the last time around - - - And they didn't have to rely on Democrats only. Maybe that's why (he was a writer) The West Wing emphasized the value of competent liaison and it's not a role one learns on the job. This should be a civics lesson but '93-'94 should have been good enough and it was over learned. Neither the White House nor Congress (alone) can move legislation at a pace that is sufficient rapid (unless it's war related). The names of 'facilitators' are like the best spies, unknown because they operate in the shadows and deal with both sides.
It's foolish to criticize how sausage is made if we're depending on it for our diet. Maybe we should find a guy who knows how the machine works and put him or her on the payroll? The current crew proved to be in over their heads and that we'll rely on the sausage machine for three more years. It's not too late, grab the Yellow Pages.
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I think it's crazy to be "soured on Obama" at this point. He's a much more capable politician than Carter was. He inherited the worst economic mess in decades, and by all sober accounts, has done well. Results don't come overnight.
I think it's crazy to be "soured on Obama" at this point. He's a much more capable politician than Carter was. He inherited the worst economic mess in decades, and by all sober accounts, has done well. Results don't come overnight.
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If my previous post was vague, here are a few items missing from the early '09 game plan:
1. An early deadline for committee closure. Pick off a few GOP votes on the Senate committees while Obama's support held a threat. Probably the 2nd Quarter was the latest to issue the "Sign on, or else we go public.".
2. Without the bill out of Finance, A: Lock them in for August, B: Don't let the house pass a fat target & hit the road, C: If A & B fail, Obama threatens to cancel his vacation and 'Out Town Halls them'.
3. The hope that "If only could have get 60 Democrats..." was not only not magical. It was foolish. It meant the house would have no motive to moderate, Senate R ... view full comment
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If my previous post was vague, here are a few items missing from the early '09 game plan:
1. An early deadline for committee closure. Pick off a few GOP votes on the Senate committees while Obama's support held a threat. Probably the 2nd Quarter was the latest to issue the "Sign on, or else we go public.".
2. Without the bill out of Finance, A: Lock them in for August, B: Don't let the house pass a fat target & hit the road, C: If A & B fail, Obama threatens to cancel his vacation and 'Out Town Halls them'.
3. The hope that "If only could have get 60 Democrats..." was not only not magical. It was foolish. It meant the house would have no motive to moderate, Senate Republicans wanted to be ignored so they could scream "We were ignored." and a party line vote begged outrage from people who voted for Obama and weren't crazy about most Democrats. AKA, the voters who give him his margin of victory.
Finally, 4th...Obama was (and is) the more popular brand and Democrats in Congress should have been told, "I'll ignore you before I allow you to dawdle & tarnish me. ". Not only was it not enough to believe the 'end' was unity among Democrats, it would be counterproductive because he'd be painted as courting the Washington Establishment he campaigned against. Again, he needed to put them on a clock because time was not on his side.
Someone was reporting back the the WH, "We'll have the (D) votes.", which may have been true. But this was a battle of attrition and a congressional body count was a poor gauge for success. This was a fight that needed closure before the Summer Recess. They knew they had to place the possible ahead of the perfect but didn't allow that the immediacy should take priority over the eventual.
The military revised their counter insurgency manual but Rahm appeared to be using an old copy of Congressional Warfare.
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Aren't we all tired of this debate? But the issue is so important. 45,000 needless deaths each year. I belong to a single payer group and we have just sent this to our members:
"Whether or not the current reform legislation passes in Congress, millions will remain without coverage, premiums will escalate, and high deductibles in proposed "basic" plans will keep families from needed early care. Gender and age bias will persist. The private insurance and drug industries will continue to siphon off the funds needed to expand and improve care for all.
A Kaiser Health Tracking Poll of July 2009 found that 58% favored "Having a national health plan in which all Americans would get their insurance th ... view full comment
Aren't we all tired of this debate? But the issue is so important. 45,000 needless deaths each year. I belong to a single payer group and we have just sent this to our members:
"Whether or not the current reform legislation passes in Congress, millions will remain without coverage, premiums will escalate, and high deductibles in proposed "basic" plans will keep families from needed early care. Gender and age bias will persist. The private insurance and drug industries will continue to siphon off the funds needed to expand and improve care for all.
A Kaiser Health Tracking Poll of July 2009 found that 58% favored "Having a national health plan in which all Americans would get their insurance through an expanded, universal form of Medicare-for-all?" Only 38% were opposed. Medicare, our homegrown single payer plan for seniors, is widely popular. Our job is to translate this popular support into legislation—to make what is right and just also politically possible. "
The Senate bill is modeled on the Massachusetts plan (which Scott Brown voted for). Some think that's a good plan since it has increased the numbers covered, but this morning I got an e-mail from a MA resident:
"Those in favor are not the ones who have to buy insurance under the
mandate. 50% of those find it too expensive. . . ."
An expanded and improved Medicare (properly funded) could be easily implemented--and since it would be publicly financed, it could be passed by reconciliation (which only deals with money/budget issues). We would pay a little more in taxes (progressive taxes--based on income), but we'd pay minimal or no premiums, no deductibles. We could choose our own doctors. Pre-existing conditions, gender and age discrimination, employment status would all become non-issues! And we would save our economy buckets of money.
I'm getting into the repeats responding to this blog--but dagnabbit, I'm right! And Jonathan knows it!
I must not have been clear about my point. This isn't about a better health care plan; it's about this (Senate) health care plan. After Massachusetts, neither the Senate nor the House is gonna pass health care reform unless and until polling reflects support among voters, which can only occur if the voters are convinced, by a persuasive narrative, that they will be better off (worse off) if the current version of health care reform is (not) adopted. No more denial or termination of insurance due to pre-existing conditions or illness, no more sick and dying children because the family cannot afford health care, no more bankruptcies or loss of homes due to illness, health insurance that wi ... view full comment
I must not have been clear about my point. This isn't about a better health care plan; it's about this (Senate) health care plan. After Massachusetts, neither the Senate nor the House is gonna pass health care reform unless and until polling reflects support among voters, which can only occur if the voters are convinced, by a persuasive narrative, that they will be better off (worse off) if the current version of health care reform is (not) adopted. No more denial or termination of insurance due to pre-existing conditions or illness, no more sick and dying children because the family cannot afford health care, no more bankruptcies or loss of homes due to illness, health insurance that will actually cover medical expenses, and everybody paying their fair share of health care costs. That's the current version of health care reform. The voters just need to know it, and it's up to Obama on Wednesday night and the rest of those who support reform in the critical few days following.
As has previously been pointed out, the House need not pass the Senate bill and trust that there will be adjustments afterwards. The first step could be that both houses pass a reconciliation bill making those adjustments, and the House could then pass the Senate bill _after_ the reconciliation bill passes both houses. As long as the President _signs_ the basic bill (the current Senate bill) first, and signs the reconciliation bill 5 minutes later, the effect will be as desired -- the Senate bill will be enacted, and the reconciliation bill making amendments will be enacted afterwards.
As has previously been pointed out, the House need not pass the Senate bill and trust that there will be adjustments afterwards. The first step could be that both houses pass a reconciliation bill making those adjustments, and the House could then pass the Senate bill _after_ the reconciliation bill passes both houses. As long as the President _signs_ the basic bill (the current Senate bill) first, and signs the reconciliation bill 5 minutes later, the effect will be as desired -- the Senate bill will be enacted, and the reconciliation bill making amendments will be enacted afterwards.
Reply to raylward,
You were clear enough--clearly indicating that you've been deluded. You think passage of the Senate bill means, " No more denial or termination of insurance due to pre-existing conditions or illness, no more sick and dying children because the family cannot afford health care, no more bankruptcies or loss of homes due to illness, health insurance that will actually cover medical expenses, and everybody paying their fair share of health care costs." When pigs fly!
David Plouffe, the President's spokesperson, predicts a very scaled-back version: " Parents won't have to worry their children will be denied coverage just because they have a preexisting condition. Workers w ... view full comment
Reply to raylward,
You were clear enough--clearly indicating that you've been deluded. You think passage of the Senate bill means, " No more denial or termination of insurance due to pre-existing conditions or illness, no more sick and dying children because the family cannot afford health care, no more bankruptcies or loss of homes due to illness, health insurance that will actually cover medical expenses, and everybody paying their fair share of health care costs." When pigs fly!
David Plouffe, the President's spokesperson, predicts a very scaled-back version: " Parents won't have to worry their children will be denied coverage just because they have a preexisting condition. Workers won't have to worry that their coverage will be dropped because they get sick. Seniors will feel relief from prescription costs."
Only with single payer Medicare-for-all would we get the list of meaningful reforms you hope for.
The Senate plan is a valentine gift to the insurers, but there's no heart in it!
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"They have us in their sights...nobody move!"
hmseil01 wrote, "Aren't we all tired of this debate?"
I still believe there is more risk than benefit in doing nothing. But DC is a poor place to go looking for heroic action during widespread panic. When faced with crisis, they deliberate!
So, of my many wasted words I'll repeat this: "Someone was reporting back the the WH, "We'll have the (D) votes.", which may have been true. But this was a battle of attrition and a congressional body count was a poor gauge for success.".
And the answer is yes, most are tired of this debate and Obama wasn't elected due to a fatigued electorate. No surprise there, he wa ... view full comment
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"They have us in their sights...nobody move!"
hmseil01 wrote, "Aren't we all tired of this debate?"
I still believe there is more risk than benefit in doing nothing. But DC is a poor place to go looking for heroic action during widespread panic. When faced with crisis, they deliberate!
So, of my many wasted words I'll repeat this: "Someone was reporting back the the WH, "We'll have the (D) votes.", which may have been true. But this was a battle of attrition and a congressional body count was a poor gauge for success.".
And the answer is yes, most are tired of this debate and Obama wasn't elected due to a fatigued electorate. No surprise there, he was on offense and now this bill has been sculpted so it offers more angles to attack than an unattended hockey goal.
Give me a year and I can make any 1,000 page bill look worse than the status quo. Put "$1 Billion" anywhere near it and add some mumble-mumble about Medicare and you have a debate that favors the opposition.
A Democrat who did not believe time favored the GOP doesn't deserve to hold their job. I'm not a big fan of Lou Holtz but he said "Only three things can happen when you pass and two of them aren't good". When the opposition declares they intend to defeat you by defeating this bill? I'd take that as a signal to hurry up, get it done and not wait to see if they are bluffing, capable or have the stamina.
And a week has been squandered since the last election...
If I'm correct and this battle of attrition favored the Republicans, either they won a long time ago or Democrats will waste more time & accept a greater defeat. No, I don't expect urgent action to spontaneously germinate after a year of procrastination.
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Selling any policy is like selling soap. That's my point. Do I prefer single-payer over the Senate bill? Do I prefer the House bill over the Senate bill? Well, yea, but then again I also hope all children grow up to realize their full potential. But that's not what's on the table. Selling the Senate bill is what's on the table. Maybe it's not true that the Senate bill will accomplish the four things I list. Tha's not the point. Selling the Senate bill is the point. Like selling soap.
Selling any policy is like selling soap. That's my point. Do I prefer single-payer over the Senate bill? Do I prefer the House bill over the Senate bill? Well, yea, but then again I also hope all children grow up to realize their full potential. But that's not what's on the table. Selling the Senate bill is what's on the table. Maybe it's not true that the Senate bill will accomplish the four things I list. Tha's not the point. Selling the Senate bill is the point. Like selling soap.
"I think it's crazy to be "soured on Obama" at this point. He's a much more capable politician than Carter was. He inherited the worst economic mess in decades, and by all sober accounts, has done well. Results don't come overnight."
Presidential leadership results on big issues tend to come early or not at all. And, if he's been leading on this issue, he's kept it pretty well hidden. The mixed messages since a week ago bespeak none of the discipline his compaign had, that convinced me he may know how to manage and lead. So, he may be more capable than Carter in many ways, but I certainly don't find his indulgence of Wall Street through Geithner, Summers and company, or his lack of willin ... view full comment
"I think it's crazy to be "soured on Obama" at this point. He's a much more capable politician than Carter was. He inherited the worst economic mess in decades, and by all sober accounts, has done well. Results don't come overnight."
Presidential leadership results on big issues tend to come early or not at all. And, if he's been leading on this issue, he's kept it pretty well hidden. The mixed messages since a week ago bespeak none of the discipline his compaign had, that convinced me he may know how to manage and lead. So, he may be more capable than Carter in many ways, but I certainly don't find his indulgence of Wall Street through Geithner, Summers and company, or his lack of willingness to actually take a strong position on health care, very emblematic of the type of leadership I expected from him.
I am not soured on Obama, but as someone who went door-to-door for him, I feel I can offer him my opinion. Errors were made early on. The President should have included single payer supporters from the get-go. They were blocked from testifying before the Senate. We had to wait months before Sen. Sanders was allowed to give his impressive Medicare-for-all speech.
Unless Mr. Obama can pull a rabbit out of the hat, it now looks as we'll get a skimpy version of reform--but a wholesale sellout to the insurers would be worse. The electorate of both parties realizes that.
Single payer advocates will keep on truckin' (oops mixed metaphor-- No, we won't be following Scott Brown.)
I am not soured on Obama, but as someone who went door-to-door for him, I feel I can offer him my opinion. Errors were made early on. The President should have included single payer supporters from the get-go. They were blocked from testifying before the Senate. We had to wait months before Sen. Sanders was allowed to give his impressive Medicare-for-all speech.
Unless Mr. Obama can pull a rabbit out of the hat, it now looks as we'll get a skimpy version of reform--but a wholesale sellout to the insurers would be worse. The electorate of both parties realizes that.
Single payer advocates will keep on truckin' (oops mixed metaphor-- No, we won't be following Scott Brown.)
hey lymon, I entered your idea (about forcing the vote) and if I win I will surely give you credit (not that I will ever win)
hey lymon, I entered your idea (about forcing the vote) and if I win I will surely give you credit (not that I will ever win)
If the Senate bill isn't passed (I doubt it will, but if...) exactly nothing will pass except what Repubs propose as alternative, or, if Repubs will allow some or any of the provisions in the Democrat-ic Party hosted bill to pass instead. Which means nothing will pass this year, period. Healthcare reform is dead dead dead, moreover, it is dead as the duck.
If the Senate bill isn't passed (I doubt it will, but if...) exactly nothing will pass except what Repubs propose as alternative, or, if Repubs will allow some or any of the provisions in the Democrat-ic Party hosted bill to pass instead. Which means nothing will pass this year, period. Healthcare reform is dead dead dead, moreover, it is dead as the duck.
While I still believe that the best way to move forward is for the House to pass the Senate bill and then to work on agreed changes (the Republicans will have a much weaker hand trying to obstruct those changes than they do trying to obstruct the bill itself, here's what I would have done, and what still might be done if the current bills fail.
It is important to distinguish between health care and health care finance. Our biggest problems are with health care finance and its contribution to spiraling costs and unaffordability for many even if costs were not spiraling out of control. Also, apart from some notorious and hideous compromises needed to pass the senate bill, I think the biggest ... view full comment
While I still believe that the best way to move forward is for the House to pass the Senate bill and then to work on agreed changes (the Republicans will have a much weaker hand trying to obstruct those changes than they do trying to obstruct the bill itself, here's what I would have done, and what still might be done if the current bills fail.
It is important to distinguish between health care and health care finance. Our biggest problems are with health care finance and its contribution to spiraling costs and unaffordability for many even if costs were not spiraling out of control. Also, apart from some notorious and hideous compromises needed to pass the senate bill, I think the biggest weakness of this legislation politically is its massive size. it's the same thing that killed the EU Constitution on the first couple of rounds. No normal human can understand what the thing means and that makes demogoguery easy. And it means no one can even speak authoritatively to what the legislation will and will not do. Most of what is in the bill should have been left to administrative regulation, a process in which massive details are the norm.
So, having said that, the most important steps are to eliminate the ability of insurance companies to game the system, or of people to game the insurance companies, and to create the maximum possible competition within those boundaries. This is a relatively simple matter.
1. We need regulations that specify what treatment insurances companies must pay for under what diagnostic circumstances -- national medical protocols -- and the minimums they must pay, priced out on a regional basis in a standard cost system. You don't think the government could do it? Leontieff did it for the whole damn economy during World War II using a jillion ladies and mechanical computers. Today, a single laptop has more computing power than all of that. The prices should be such as will sustain all of the necessary treatments in the country at a normal profit rate. Dispute resolution should be by independent agency, not by the doctors or the insurers. Obviously, the drafting of the protocols and the setting of rates is a task for a new regulatory agency.
2. These protocols and mandatory minimum payments would be minimums only. Any person would be free to pay more or get more. Any insurer would be free to write policies that pay more or provide more. However, any health insurer would be required to provide a "basic" policy, available to anyone at the same community rate (tied to exactly the same "communities" that the government uses to set reimbursement rates), regardless of medical condition.
3. The anti-trust exemption should be removed and the federal government should adopt regulations that enable any sufficiently capitalized insurer to do business anywhere in the country. The feds can piggy back on state insurance regulators for this purpose.
4. Everyone should receive a tax credit sufficient to buy a basic policy. This credit would be paid to the insurer of choice, not to the individual. It is in effect a voucher. Anyone who fails to elect a company would automatically be enrolled in a government pool. These pools would be bid out to insurance companies, auctioned like Treasury bills, and the price set by the auction would be used to establish the size of the credit. In that way everyone could afford health insurance, and anyone who wants to buy premium insurance can go ahead and do it.
5. The cost of the credits should be built into the tax rate structure. That way, people with low income would be paying less in taxes than the credit they receive. People with high income would be paying more than the credit they receive, but the net should be zero. This takes care of the mandate without punitive fines or anything that looks "mandatory." It is essential to do this so that people cannot game the insurance by waiting until they are sick to sign up.
6. Over a ten-year period, employers should gradually be taxed on health care benefits as necessary to recoup the losses to the Treasury in excluding this from worker's taxable income. It is unconscionable that particular individuals get the benefit of a regressive subsidy -- the tax subsidy is higher for higher income people who have higher marginal rates. This is an artifact of WWII price-wage controls and we need to get rid of it. But the transition should be slow enough for the labor market to adjust. After parity is reached, where the tax subsidy is neutralized, the tax should continue to go up until employers find it cheaper just to pay the value of the benefit in wages and finally get out of the health insurance finance business.
7. The government should supervise reinsurance pools that require insurance companies to pool their risk for "excess incidence" of medical conditions. Insurers should be required to pay into the re-insurance pools. In that manner, companies will have no incentive to "discourage" particular people from signing up as a means of gaming the system. They are going to have their share of incidence one way or the other.
8. Allow the government to negotiate with any national health care providers, including drug companies, over their rates and to lock in national rates that get built into the cost system.
9. Get all providers onto a medical information system that will give us good statistics about what will and will not work. A large datebase would also enable the government to audit against fraud without leaving its desk so to speak. it would be impossible for a cheating provider to keep his stats on incidence and outcome in line with the norm. We would also learn a lot that would allow us to adopt best practices nationwide.
Then let the market do the rest, while regulating in any way possible to lower barriers to competition in the medical industry. The charm is that the bill could be only a few pages long and would be a "patient's bill of rights." The details would be handled by regulation. Nothing mandated, nothing penalized, no rationing of care, no prohibitions imposed on either insureds or their employers. With sufficient competition, the government reimbursement rates will over time become the de facto prices and providers will rise or fall based on their ability to live within those rates. People can "shop" based on the simple question of whether the provider will or will not accept insurance reimbursement as payment in full and providers would be obliged to so disclose up front and by registration on the internet -- meaning you can sit at home and choose your provider from among those who will accept reimbursement.
Oh, and no single-payer or public option, two hot buttons that attract more political problems, in both directions, than they are worth. It doesn't matter how many insurance companies we have or whether there is a government competitor so long as competition is stiff and is on the basis of efficient administration, not the gaming of risk by denying coverage or refusing payment for necessary services.
Oh, and no single-payer or public option, two hot buttons that attract more political problems, in both directions, than they are worth. It doesn't matter how many insurance companies we have or whether there is a government competitor so long as competition is stiff and is on the basis of efficient administration, not the gaming of risk by denying coverage or refusing payment for necessary services.
Roi,
Brilliiant! Good to see Jekyll and not Hyde.
While there are some differences, Paul Ryan (R-WI) made a similar proposal in a WSJ op piece 1/27. Sorry, he's a Repub, but he is a decent and clear-thinking one. I suspect you are a libertarian at heart, and find it encouraging. Your proposal would have widespread support left, right, wherever. Shame it couldn't get a hearing. A good reason to pause? Many want reform, just not necessarily the one that is on the table.
Roi,
Brilliiant! Good to see Jekyll and not Hyde.
While there are some differences, Paul Ryan (R-WI) made a similar proposal in a WSJ op piece 1/27. Sorry, he's a Repub, but he is a decent and clear-thinking one. I suspect you are a libertarian at heart, and find it encouraging. Your proposal would have widespread support left, right, wherever. Shame it couldn't get a hearing. A good reason to pause? Many want reform, just not necessarily the one that is on the table.
Very kind of you, ds111.
No, I am not a closet libertarian; I am a pragmatist more or less of the New Deal variety (although much too young to have been around during FDR's time). Like any good American, I prefer the government that governs least -- while still accomplishing what is necessary for government to do for a healthy society because the private sector cannot. There are many things that fall into this category. One of them is market regulation, because the notion that completely unregulated markets naturally achieve an "optimal" solution, even when there is little dispute about what would constitute the optimum, is a myth. It is a myth perpetrated by the very interests that are ... view full comment
Very kind of you, ds111.
No, I am not a closet libertarian; I am a pragmatist more or less of the New Deal variety (although much too young to have been around during FDR's time). Like any good American, I prefer the government that governs least -- while still accomplishing what is necessary for government to do for a healthy society because the private sector cannot. There are many things that fall into this category. One of them is market regulation, because the notion that completely unregulated markets naturally achieve an "optimal" solution, even when there is little dispute about what would constitute the optimum, is a myth. It is a myth perpetrated by the very interests that are most powerful when left unregulated. They want us to believe that whatever happens without government supervision is the best of all possible worlds because it is the best of all possible worlds for them. Libertarians on economic matters fall mostly into this category. The would like to convince us that their devotion to unsupervised markets and whatever outcome they produce is a matter of high principle. I am not buying. Inevitably, what they prefer just happens to be very much in their own self-interest and they would like their particular successes to be immune from interference. Not only am I not buying, there is no reason at all why society should countenance this. Markets are not a virtue, they are a tool, devised by human beings to achieve their own ends. The question must always be whether they are achieving the ends that we as a society seek. That is the only value they have.
On my very first day in a superb Economics for Lawyers course at the Univ. of Michigan Law School, Prof. Peter O. Steiner said, "There are some things that markets do well and other things that markets do poorly or not at all. We are going to learn to tell the difference." That is the single most important thing I have ever learned about law, policy, and economics.
Part of pragmatism is being realistic about what politics permits and about the forces that, for their own aggrandizement, oppose and will try to frustrate change. I am well aware that the current HRC bills are far from what I would consider the policy ideal. And now you are aware too. But I am also aware that they emerged from a political environment in which the Republican party has sought to delay and obstruct purely for political advantage. I do not believe that the Republicans ever had any interest in playing the role of a constructive minority trying to shape the outcome. They have been out to destroy it from the start. What emerged is a result of those forces and the unseemly maneuvering to secure the votes necessary to overcome Republican filibuster. Had the Democrats understood from the gitgo that the Republicans were dishonest and had no intention of doing anything other than delaying and obstructing in order to exhaust Democratic political capital, I think the Democrats themselves would have shaped better bills and brought them to a vote months ago, well before the start of the next election cycle. But they were suckered by Obama's idealism, his unwarranted belief that it is possible to achieve some sort of conciliation with sworn enemies such as terrorists and Republicans.
While where we have arrived is with a bit of a pig, because it bears the scars of Republican perfidy and Obama's naïvete, my pragmatism tells me that it is the only way forward. If the senate bill is enacted into law, it will prove popular and there will be no going back. At that point, it will be possible, indeed necessary, to fix flaws and move toward a better realization of the policy objective of universal health care at a price the society can afford -- a goal we know is achievable because other industrial societies, quite a bit less wealthy than our own, have achieved it. The reason we have not, apart from the fact that there are enormous vested interests in the current system, is a feckless devotion to libertarian economics.
On the other hand, if the current effort, so near to realization despite the obstacles, lies, and smears that the Republicans have hurled at it, is abandoned, it will be a very long time before anything can be accomplished toward the goal. As well, the Democrats risk allowing this to turn into a political rout. I regard either reason as more than sufficient to finish what is virtually done.
The pragmatic way of doing things is to move forward and make progress toward an ultimate goal, not to sit and wait for the perfect opportunity. Progress not only enables people to sustain their effort, it has a unique way of creating new opportunities that were undreamt of before the journey began. As you move forward, the scenery changes, there are fresh understandings.
So, no, I am not a libertarian when it comes to the necessity of exercising the power of the federal government for the "general welfare," although I am strongly civil libertarian when it comes to leaving people alone to the greatest extent possible, particularly as to those matters where their interests are particularly private and public interference is more a matter of prurience than policy. The libertarians are libertarian in both respects; the Republicans are rhetorical libertarians when it comes to economics but never miss an opportunity to suckle from the public teat, and authoritarians when it comes to matters of civil liberty despite all sorts of rhetoric about freedom. At least I have something in common with libertarians. With Republicans, nothing at all, not with their proclaimed views, and certainly not with the utterly corrupt reality.
Response to roidubouloi:
I liked your quote from Univ. of Michigan Law School, Prof. Peter O. Steiner, "There are some things that markets do well and other things that markets do poorly or not at all. . . . "
Three 2007 Nobel prize winners in Economics said the same thing (See link below)--but we have somehow raised a whole generation of deluded proponents of unregulated capitalism.
Health care is one thing that should not depend on the market. All other democracies in the industrialized markets know this--they manage to cover all their people with some version of a single payer system. In countries that have implemented public-private hybrid systems (Germany, Switzerland), the private ... view full comment
Response to roidubouloi:
I liked your quote from Univ. of Michigan Law School, Prof. Peter O. Steiner, "There are some things that markets do well and other things that markets do poorly or not at all. . . . "
Three 2007 Nobel prize winners in Economics said the same thing (See link below)--but we have somehow raised a whole generation of deluded proponents of unregulated capitalism.
Health care is one thing that should not depend on the market. All other democracies in the industrialized markets know this--they manage to cover all their people with some version of a single payer system. In countries that have implemented public-private hybrid systems (Germany, Switzerland), the private insurers are heavily regulated. This latter point is soft-pedaled by pundits (even our favorite Jonathans) who think that the for-profit insurers will fall into line when faced with competition from a public option.
I repeat, "When pigs fly!"
Here's the link to the NY Times article by Graham Bowley about the 2007 Nobel winners (Leonid Hurwicz, Eric Maskin and Roger Myerson) who have explored the limited efficacy of markets:
http://www.nytimes.com/2007/10/15/world/16nobel.html?scp=1&sq=Bowley%20N...