Category: Health Care

The Importance of the Underlying Bill

There has rightly been a lot of attention given to the New York Times article, in which anonymous senior Senate aides float the idea that Harry Reid will not include the public health insurance option in the combined bill that is brought to the floor for a vote. Reid’s office has denied that this is the case, but the proof will be in the pudding. We will likely know in the next week or two what the bill Reid brings to the full Senate for consideration is and the contents of that bill will almost certainly be determinative of its outcome.

The reason for this is that we are approaching the point in time where substantive changes to the content of the legislation are able to be made. The big ticket item is obviously the public health insurance option, though there is no doubt the fate of provisions relating to access, affordability, and employer responsibility will be determined by the contents of Reid’s bill, too.

The reason that Reid’s decision is so crucial is that any amendment on the floor to controversial parts of the bill will likely require 60 votes to pass. This is not because it is in the Senate rules that controversial provision take 60 votes. It is not. But what has been the rule since Lyndon Johnson’s tenure as Majority Leader is that unanimous consent agreements are used to set ground rules for debate, amendments, and voting. To make a deal so things move forward, anything controversial like amendments which would add or remove the public health insurance option, will require 60 votes. And such, any amendment is almost certainly doomed to failure.

Chris Bowers highlights this in a run-down of the legislative state of play on health care reform:

No good strengthening amendments will pass on the Senate floor. If there is no public option in the bill that passes through Kent Conrad’s Budget committee, don’t expect one to emerge from the Senate via amendments. The 60-vote culture will be in effect for all amendments to the health care bill when it arrives on the Senate floor, and so there won’t be enough votes for the public option–or any other significant strengthening amendment-if it is not included in the bill that comes out of the Budget committee.

Republicans will not find 20 Democratic votes to strip the public option and while there are certainly more than 51, it is doubtful there are 60 votes to insert the public option in via an amendment.

The Times article reports on Reid’s decision making process:

“None of these decisions are going to be made without significant presidential input,” said Jim Manley, a spokesman for Mr. Reid.

And so, it is up to Harry Reid and, on the tough calls, President Obama. They will determine what the Senate votes on later this year. If the public health insurance option is in the bill, it is because Reid and Obama have decided that they want it to be, for they will know that it will not be stripped via amendment. And if it is not, it is because Reid and Obama expressly decided that they do not want it to be part of health care reform legislation. It is that simple.

What’s worse is the inevitability of it all. The inevitability of Reid and Obama refusing to wrangle conservative Senate Democrats to force them to stand up for the party and this presidency…and the expressly right policy. The inevitability of advocates of the public option trying to put a bright sheen a bill without it. I can see Schumer, Rockefeller, Brown or Dodd saying now, “We will get a chance to vote on it via an amendment and that’s the best we could have hoped for.” As if leadership could not have made a different choice…

At the end, though, there’s something reassuring about this process. If it goes as predicted above, with the public option sent by Harry Reid and Barack Obama to die the death of a failed amendment to a crappy bill then I will know exactly what I can expect when it comes to leadership from Obama and Reid. But if they do the right thing, if they push for policies that will literally affect every single American, then I can look forward to having a real Democratic presidency, after all. As I keep saying, time will tell.

Dodd on the State of Health Care Reform

Via CT Blogger of My Left Nutmeg, here’s Senator Chris Dodd talking about the state of health care reform. Of particular note is Dodd’s take on the notion that the Democratic Party has been unable to maintain caucus discipline generally and the importance for their to be caucus discipline on the procedural vote to move to debate whatever legislation comes forward in the Senate. Dodd suggests that all 60 members of the Democratic caucus should vote for cloture to overcome the expected Republican filibuster of health care legislation. Dodd says he’s repeatedly told the caucus that is unique. He tells his colleagues that “you may not get another chance to do something as significant as you will in the next fifteen weeks.”

We shall see if Senate Democrats follow Dodd’s lead and stand as one to give the Senate the chance to debate health care reform.

The Coming Trigger War

Mike Lux is right, courting of Olympia Snowe’s support for health care legislation by the White House has the potential of starting a war within the Democratic Party over what reform will look like and who has the power to determine it. If Snowe comes at the cost of a trigger for the public health insurance option — constructed to be so weak that it will likely never be triggered — then it will surely cost liberal votes in both the Senate and the House. It will effectively put the Democrats in Congress in a position that pits their ideology against the President. This is an awful place to be, but more importantly it is an avoidable place to be.

What would instead make more sense would be for the White House to make the cloture vote in the Senate on whatever legislation comes to the floor a party line vote that will be scored by leadership. That is, if you don’t vote in favor of ending debate and getting the legislation to a majority wins situation, you will raise the ire of the White House, the Senate leadership, and the DSCC. In this way, it doesn’t matter how Olympia Snowe will vote – because the 60 members of the Democratic caucus will be sufficient to pass cloture and get to a simple majority-rules vote. On final passage, the White House will signal that members can take a walk if they don’t like the bill.

So much media attention has been given to needing 60 votes to pass a bill in the Senate. But this just isn’t true. 60 votes are needed to overcome the Republicans’ filibuster – a procedural vote that does not necessarily relate at all to the content of the legislation. To wit, we’ve seen the GOP walk away from  provisions they have previously supported with the sole principle involved being “Delay, delay, delay.”

If the White House demands it and if Harry Reid demands it, the cloture vote on health care legislation can be a party-line vote. Rather than moving to 51 votes to pass something under reconciliation, this would allow 51 votes to pass something under normal rules. A public option would be possible, as would any other provision. And Olympia Snowe would not be in a position to divide the Democratic Party.

It’s really a question of leadership. Will Snowe be the fulcrum that the Democratic Party is broken in two on? Or will President Obama show some muscle and demand support from the Senate to simply get to a majority vote? We shall see.

Gutierrez Rips Admin on Immigrants’ Health Care

Rep. Luis Gutierrez (D-IL) was the first Latino Congressman to endorse President Obama in his  campaign. Now that the administration is looking amenable to assuaging the concerns of Joe “You Lie!” Wilson regarding access to health insurance for immigrants, Obama is at risk of losing support from Hispanic members of Congress. Gutierrez is pushing back hard against Obama and the fundamental misplacement of priorities when it comes to how available insurance will be for immigrants in any reform plan.

“What is the administration’s answer?” asked Gutierrez. “To give him exactly what he said from this hatred. Because now, the administration has told us that if we’re going to have reform of our health care system … all those that go to the private sector in order to get their health care, that they will verify them. They will verify Social Security; they will verify their status in the United States of America.”

“So, and remember, we’re not talking about government health care, we’re talking about everybody is going to be required to get health care insurance,” said Gutierrez. “And so as we go to this big store, right, where everybody is required. And this exchange, the health care exchange, where if you don’t have health care you are required to go purchase it. When you go and attempt to purchase it, what does the administration say? The administration says, ‘You will have to prove that you are legally in the United States and have a Social Security number and a right to that.'”

Yesterday Matt Yglesias had an important post that highlighted how wrong it is from a policy standpoint to have an immigration status check as part of the delivery of health care and health insurance. In short, because most immigrants tend to be younger members of the work force, they are healthier and thus require less care. As a result, their participation in the pool of the insured lowers the risk and thus lowers the cost of health insurance for everyone. In short, excluding immigrants from the health insurance exchange or barring the ability of undocumented immigrants to buy insurance at all is bad policy driven by spite and xenophobia, not any actual grounding in health care economics. It makes reform more expensive and puts a much greater risk on the system by driving people to use expensive emergency room care as their primary doctor. It’s reckless, stupid, and inhumane…and both the Obama administration and Democrats in Congress need to change their course.

Update:

I now see that the New York Times Prescription blog is reporting that Baucus, Conrad, and the White House all agree that undocumented immigrants should not be allowed to buy health insurance through the insurance exchange.  All presume that there will be some other way for them to buy insurance, but it’s not clear what would exist outside of the exchange.

Absolute Bunk

There’s really no other way to describe this post from Chuck Todd of NBC.

*** Fixing the public option fetish: But the speech also will be a failure if progressives — Obama’s second audience tonight — are still obsessing over the public option a week from now. We’ve said this before and we’ll say it again: Obama never made the public option the focus of his health-care ideas, in the primaries or in general election. In fact, he never uttered the words “public option” or “public plan” in his big campaign speeches on health care. But there is no doubt that the public option has fired up the left, and how he sells them near-universal coverage and lower costs — even if it means no public plan — could very well be the trickiest part of tonight’s speech. Indeed, that the White House allowed this to become the be-all, end-all on the left (“Public option or die!”) remains a mystery. On TODAY this morning, White House Press Secretary Robert Gibbs said that “there can be no reform without adequate choice and competition,” but didn’t say that choice and competition had to come from a public option.

First, I don’t know of anyone on the left who is campaigning for the public option in a “Public option or die!” context. There is no “die”, merely the desire by a very large number of House progressives to have health care legislation that includes a public health insurance option, something that the President spent seven paragraphs of his speech last night arguing in support of.

Second, Todd is clearly trying to set up a metric in which a week from now he can turn around and the President’s speech was a failure because progressives still want the legislation to include a public health insurance option. There are two things fundamentally wrong with this. To start, Obama never, ever said that the goal of the speech was to stop progressives from supporting the public option as a priority in the bill. To the contrary, the content of the speech clearly shows that he was doing no such thing. He spoke eloquently in support of a public option, though he stopped short of making it a required element.

But perhaps more importantly, it is not Todd’s job to score the process based on whether or not a a particular contingent of the Democratic Party continues to have a specific policy goal. This speech was not an argument against progressives nor was it an argument against the public option. It wasn’t even a plea by Obama to progressives to stop arguing passionately for the public option. Or at least, the speech I’ve watched and read twice wasn’t. Maybe Todd had a different “First Read Only” edition of it that was delivered directly from the floor of the House to Todd’s noggin.

Progressives are not standing in the way of change. Progressives are not blocking the President’s plan for health care. Conservative Democrats and pretty much all Republicans are. Is it possible that the progressive bloc in the House will decide that what is moving forward is unacceptable (eg for its lack of a public option) and as a result will oppose it? Of course. But that is not the scenario now. And, in fact, up to this point the press, the Senate, and the White House all seem to be acting with great certitude that the House is incapable of stopping whatever legislation comes out of the Senate, even if it does not have a public option.

Todd’s bizarre and offensive post does a number of things that no one has done before: cast progressives as key roadblocks to change, set the speech up as Obama’s moment to beat down progressive policy goals, and make clear Obama’s opposition to the public option. Nothing preceding the speech nor during the speech gives Todd any ground to stand on. He’s just making things up and, conveniently, every single bit of his fictional analysis is either a slur on progressives or something that can be used to undermine Obama’s political capital in coming days. What more do you need to know about Chuck Todd and his allegiances?

Krugman vs The Anti-Public Option Crowd

Paul Krugman has a must-read blog post pushing back on the self-described liberals, namely Joe and Ezra Klein,  who are criticizing the continued inclusion of the public option as an essential piece of healthcare reform. His entire post is important, but his conclusion is particularly apt in the relevance of supporting the public option as a mark for support for liberal political philosophies writ large.

Let me add a sort of larger point: aside from the essentially circular political arguments — centrist Democrats insisting that the public option must be dropped to get the votes of centrist Democrats — the argument against the public option boils down to the fact that it’s bad because it is, horrors, a government program. And sooner or later Democrats have to take a stand against Reaganism — against the presumption that if the government does it, it’s bad.

Indeed.

As Duncan Black pointed out yesterday, there is no chance “centrists” in American politics today would support the creation of Social Security, let alone public education or the US Postal Service.

The point is we’ve moved away from “there are just certain things government does well and should do” and over to “maybe government should do some stuff for the poor but that’s about it.” It’s a problem, both from a policy perspective, as there are certain things the government should do, and from a political perspective, as benefits-for-other-people never gets wide support.

Yet if we look around, there is no question that government is the best way to ensure a firm social safety net and communal services are efficiently delivered. To think otherwise is to ignore what has worked over the history of our country in favor of the very recent Republican dogma that reached its persuasive pinnacle from the mouth of Reagan.  It was then embraced by the Democratic Leadership Council and Democrats were told that in order to win, they had to sound like Republicans. This is a dynamic that the progressive blogosphere has been working against as a central narrative strain since its earliest days.

Opposing the public option is opposing the compromise that it represents – that in order to get something done, liberals had to surrender their pursuit of a Medicare for All-type system. More to the point, opposing the public option is tantamount to opposing the pursuit of what liberals believe in. That is a central point both Krugman and Black are making. It’s not just that the public health insurance option is a good idea from a policy standpoint, it is an idea that arises from a purely liberal political basis.

Now there may be political arguments against the public option. We don’t have the votes in the Senate. The administration won’t spend political capital to get these votes. There are risks to Democrats in red districts for supporting a government health insurance program. Et cetera. But these are temporary postulations that could easily be challenged and redefined, especially through principled leadership that showed a commitment to the efficacy of liberal ideas.

Looking forward to tonight’s speech by President Obama to a joint session of Congress, the question at hand is whether Obama will exert leadership in support of meaningful reform that includes the public option. I don’t know what he will say, but I hope he takes the largest microphone in the world and proudly stands up for both what he believes in and the intellectual history from which he comes.

Not To Be Mistaken for Leadership

Matt Yglesias has a sober post about the Baucus proposal for healthcare reform legislation. While much of the blogosphere has been furious about its timidity, Yglesias sees value in that it would move the ball forward and improve the healthcare system in the United States. He justifies this, in part, by saying that while Massachusetts and Switzerland aren’t ideal models we should use to shape reform policies, they are notably better than the healthcare system elsewhere in America.

Sure. Fine. Whatever. No one who has been has an active advocate for massive reform (be it single payer or a public option) has ever said that it wasn’t possible to put together some package of changes that would constitute an incremental improvement of the healthcare system in America. It’s not surprising that the Baucus proposal would reduce the number of uninsured America and do some things to provide a higher degree of regulation of the insurance industry than we currently have. But this is not to be mistaken for leadership and therein lies the real critique of Baucus as I see it.

The challenge wasn’t for Baucus to take his position as chair of the Senate Finance Committee and create legislation that produces marginal change. The challenge to Baucus, and in reality to all members of Congress and the President, was to produce legislation that essentially solves the crises of the healthcare system: coverage, affordability, access, and quality care.  The needs for reform exceeds the benefit of incremental change.

So when I look at the Baucus compromise, which I would concede is better than I thought it would be and has a likely price tag of a couple hundred billion more than DC conservatives want, I am stunned by the refusal of Baucus to attempt to solve the healthcare problem by showing, at minimum, a comparable level of leadership to Chris Dodd and the three House committee chairs. Yglesias is right that the Finance proposal would make the healthcare system in the US a bit better than it currently is. But we need leadership, not incrementalism. And right now it will take leadership to overcome incrementalism put forward by Baucus.

Update:

There’s also the question of while conceding that the Baucus plan is an incremental step, it may not be a step in the right direction.  That seems to be Chris Bowers’ take. Obviously there is danger in pushing a piece of legislation that lowers the quality of coverage, increases risk, and is a handout to insurance companies. Whether or not this incrementalism is positive or negative, it is clear that it is nonetheless not leadership.