THE TREATMENT AUGUST 6, 2009
President Obama just finished a meeting with the six senators now at the center of the health care reform narrative. Three Democrats, three Republicans, all of them from the Finance Committee and all of them trying, in theory, to do what four other congressional committees have already done: Report health care legislation to the floor.
The Gang of Six, as they’ve become known, have been negotiating for weeks, fighting over everything from taxes to public insurance options. And they've managed to blow through every deadline, whether imposed by themselves or somebody else. The latest one, announced last week, is September 15. If there’s no agreement by then, Chairman Max Baucus says, the committee’s Democrats may have to pass legislation on their own.
The point of today’s White House meeting was, apparently, to figure out what’s holding up the negotiations--and to figure out whether, perhaps, this whole exercise has become fruitless. It was apparently the president and members only, no staff, which is a shame. A friend recently suggested that it might have been a good time for Chief of Staff Rahm Emanuel to enforce unity of purpose in the same way that Robert DeNiro, playing Al Capone, famously did in “The Untouchables.”
For those not familiar with the reference, it involved a baseball bat and a lot of blood.
That does sound like the Rahm Emanuel we all know and love. But I think less drastic measures for moving along the committee process will suffice--like, perhaps, considering whether one of the six senators at the White House today maybe doesn’t belong.
I’m referring to Mike Enzi, the Republican senator from Wyoming. Since Wyoming is the country’s smallest state by population, Enzi is--by definition--the Senate’s least representative member. But that’s not what makes him a poor fit for these discussions. It’s his beliefs.
As Paul Krugman recently noted, Vote View ranks Enzi the chamber’s eleventh most conservative member. And on health care, he has a long history of advocating strong conservative positions--like, for example, allowing the purchase of individual insurance policies across state lines. As many experts have noted, such an initiative would undermine state health insurance regulation as all insurers relocated to the state with the least aggressive regulations, in much the same way the credit card industry decamped to Delaware and South Dakota.
Enzi, naturally, opposes the creation of a strong public insurance option--or, for that matter, any public insurance option. And while that doesn’t make him unique, his other positions are more strikingly out of step with what most reformers believe.
Consider the amendments that Enzi proposed during the markup hearings for the Health, Education, Labor, and Pensions (HELP) Committee, on which he also sits. No public list of these amendments is yet available, as they are still being compiled. But sources who followed the deliberations closely say Enzi made all of the following proposals. (I'm still awaiting final confirmation from Enzi's staff, which is going through their records, but I'm confident these are fundamentally correct.)
- Slashing the government subsidies to people who need help buying insurance. The Democrats’ HELP bill, like the House bills, would provide assistance to people making as much as 400 percent of the poverty line. Enzi wanted to cut off assistance at 250 percent. And since the subsidy levels gradually phase out with income, that would have meant less assistance for most people.
- Shrinking the minimum benefits package that all insurance policies would have to provide. Reform bills set a standard for coverage by “percentage of actuarial value”--which translates, very roughly, as the percentage of medical bills a policy will cover for the average person. (Somebody with serious medical bills would, most likely, have to pay more.) It's a crude, imperfect measure but one that gives you some rough sense of the kind of financial protection a policy offers. The HELP bill was at 75 percent. Enzi wanted to make it 60. For a sense of comparison, the standard federal employees policy is around 80 percent, the typical large employer plan is around 75, while the least generous plan in the new Massachusetts scheme is around 70.
- Scaling back regulations to prevent discrimination against the sick. All reform bills would prohibit insurers from varying premiums based on pre-existing medical condition. But they’d all make a exceptions for a few criteria, including age. The idea is to make sure young people accustomed to paying very low rates don’t face sticker shock, but if the variation is too high--and there are not generous subsidies to offset the effect--older people can be totally priced out of the market. The HELP bill, like the House bill, would have allowed insurers to vary rates for age by a factor of two. Enzi wanted to make it five.
A reform bill that included these provisions would be a pretty far cry from the kinds of reforms Obama and his supporters have been promising. With subsidies scaled down to 300 percent poverty, minimal actuarial value at 60 percent, and large age-rating bands, working and middle-class people would get very little assistance--while remaining exposed to serious medical bills.
Yet these are the positions Enzi is also pushing within the Finance committee, apparently with some success. As the Washington Post reports today, their working arrangement would now reduce subsidies 300 percent from 400 percent. Past reports have indicated the age rating bands are likely to go to five. Separately, multiple sources confirm that the latest Finance draft pegs actuarial value for minimum insurance policies at 65 percent--and that Enzi has pushed for lower than that.
Contrast this behavior with Maine Republican Olympia Snowe. She is also unhappy with the generosity of benefits and subsidies in the Gang of Six bill. But she wants to make the bill more generous--which isn’t so surprising, or shouldn’t be, because she actually has a record of working with Democrats on relatively progressive health care reform legislation.
Snowe has her differences with the Democratic leadership, to be sure--and, as far as I can tell, she's not so helpful when it comes to finding the money to pay for the generosity she supports. (Lack of financing and offsetting savings is the main reason Finance has reduced the bills' subsidies and benefits.) But, at a fundamental level, Snowe buys into the idea of what reform's architects are trying to do--in a way that Enzi doesn't.
So why is Enzi even at the table? I'm not sure. All the Finance Republicans are said to be under pressure from their party leadership just to walk away, so that suggests his interest in finding a compromise is sincere. Maybe he does sit up at night, worrying about the difficulties people face getting affordable health care. On the other hand, more than one cynic has suggested this is just Enzi's way of killing reform--i.e., through delay, diversion, and dilution.
In any event, the practical reason for Enzi's presence is the preference of ranking Republican Charles Grassley. He’s indicated he doesn’t want to be the only Republican--or, at least, the only Republican not from Maine--supporting the bill. And since Baucus is determined to keep Grassley as a partner, that means Baucus is stuck with Enzi, too.
I don't know what happened at the White House today. (I'm done reporting for a while, so it's up to Ezra or my friends at Politico.) But maybe it's time that Baucus revisit that decision--or, at least, maybe it's time for somebody to suggest to Baucus that he reconsider his position.
Enzi is entitled to his positions, which are consistent with his worldview and, I suspect, many if not most of his constituents. But they are not consistent with the basic principles of health reform--at least not good health reform. Obama and the Democratic leadership have made a good faith effort at bipartisanship, and have the engagement of Snowe (plus perhaps one or two others) to show for it. If that's still too much for Enzi, maybe it's time to move on.