THE TREATMENT JANUARY 25, 2010
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Harold Pollack is a professor at the University of Chicago School of Social Service Administration and Special Correspondent for The Treatment.
Timothy Jost and I assembled a letter signed by 51 health policy experts asking that the House pass the Senate bill and then fix this bill’s significant shortcomings through the reconciliation process. We got a very strong group of people from across the ideological spectrum to sign on. For the most part, our letter has been favorably received in most quarters. Virtually every health supporter I know supports the general strategy we supported. Unfortunately the issue bears discomfiting similarities to the Arab-Israeli dispute. The contours of the ultimate solution seem relatively straightforward. The tactical roadmap is much more obscure.
There was one problem with our expert letter—or at least with how it was received. The House cannot move until the Senate does its part to address critically important problems in the current Senate bill. Before the Massachusetts election sidetracked public attention, House, Senate, and White House negotiators actually worked out many of these difficulties: the need to make insurance more affordable, tightening the structure of insurance exchanges, addressing union concerns over the taxation of costly health plans. Not every accommodation would move the final bill leftward. The House bill included (to my mind deeply unfair and extreme) restrictions on the financing of abortion services that must be addressed, too.
The House leadership is working hard to make something happen. House progressives have been basically good sports in swallowing compromise after compromise to secure passage of a health reform bill. This goes beyond the arena of healthcare, I’ve received surprisingly angry emails noting the number of progressive bills passed by the House that sit bottled-up in some Senate committee. I don’t think this is the fault of the majority leader. Ossified Senate procedures, combined with the systematic over-representation of rural moderates and conservatives, make things hard. Whatever the reason, there is a pretty well-founded reservoir of progressive anger and distrust that must be addressed before the House can do its part in passing the Senate bill.
Hence the obvious question. Senate Democrats, how much do you really want to pass this bill?
I hope I know the answer. Both progressives and moderates have strong reason to want this done. If this bill is chopped up or curtailed, the most obvious losers will be progressives, who will lose the opportunity to help millions of low-income or chronically-ill Americans who need help. Another important group of losers is less obvious: the large group of progressives, moderates, and even some conservatives who wish to see meaningful delivery reform.
If the House and Senate bills are abandoned, we may (eventually) win Medicaid expansions for people who need help, expanded tax credits for people who cannot afford coverage, and other measures to cover the uninsured. We may even see more stringent regulation of health underwriting and other toxic practices in the insurance industry.
We will not soon see serious delivery reforms or cost-control measures. Whether the issue is high-cost insurance plans, bundled payments, comparative effectiveness research, overpayments to medical device makers, drug companies, specialists, and Medicare Advantage plans, there will be very limited political will to match what is in the current bills.
We will not be able to get these things because we will fracture the political coalition required to enact these painful measures, because the operative lesson of last summer will be that death panel demagoguery trumps real policy argument, and because there are fewer policy levers and fewer political incentives to address these difficulties outside a comprehensive bill.
Last Friday, I and others pled with anxious House members to step up in passing comprehensive reform. Senators: Now I am pleading with you.
President Obama: Now is the time for you to step up, too. Some in your administration are starting to send good signals. Others remain unduly tentative. Fight for this thing as if your legacy is on the line--because it is. I believe you have about 48 hours to fix this up.
23 comments
Harold, I think if you look at this objectively, the problem is that there are a significant number of Democrats in the House who, like the American people, have serious reservations about the bill, but who, because of Party pressure, have gone along with the process. Massachusetts gives them an excuse to say no to Pelosi and Reid. No one is doing this publicly, but I'm sure if they thought they were anywhere close to having the votes, Congressional leadership and the Administration would be pushing much harder. The bottom line is that anything resembling either of the current bills no longer has majority support in the House and probably not in the Senate either.
- dtohmatsu
January 25, 2010 at 8:11pm
As usual, dtohmatsu, you invent facts to support your policy preference. The "bottom line" is that if there were not a requirement for 60 votes to end debate in the senate, just a majority, this would be done in a week. Indeed, it would have been done months ago. You have a bizarre understanding of what the word "majority" means.
- roidubouloi
January 26, 2010 at 5:33am
don't bother, roid. To the anti-healthcare minority, the words "majority" and "American people" mean, "those who agree with me, no matter how few." And never mind that the single most "controversial" aspect of either the House or the Senate reform bill is approved of by 22 percent more Americans than disapprove of it.
- rhubarbs
January 26, 2010 at 7:54am
Ah, if only a bunch of the great majority of Americans (+22%,according to rhubarbs) would write or call their Democratic House members and tell them to put a clothespin over their nose if necessary, stop whining about the Senate bill's inadequacies, and just vote for it and send it along to the President for signing into law with commitments to fix it later using reconciliation. Should these fastidious House members fail to do this (which seems likely), many of them will find themselves seeking new employment next year, without any sympathy from me.
- JackR
January 26, 2010 at 9:40am
Roi, Who's talking about the Senate. All it takes is a majority in the House to pass the Senate bill and it's done. So what's the problem. Like I said, they don't have the votes. And as for you Rhubarbs, talking about a poll where voters are asked about just one aspect of the bill is nonsense. Of course everyone wants the magic pony.... they just don't want to pay for it. Guys, get over it. Not only is it a bad bill, the American public knows it's a bad bill.... and Congress knows it's a bad bill.
- dtohmatsu
January 26, 2010 at 10:22am
dtoh, come on, you know the biggest hang up is the Stupak anti-abortion crowd, now if you want to argue on the merits of that one issue, fine by me, but to argue that a small minority of Democratic Congressmen represent the majority of the anything is silly. I can pretty much promise you, if the Stupak amendment had been part of the Senate bill, Congress would have passed the Senate bill. If Kennedy hadn't died, or if the Democrats had not rewritten the law and had the re-election right after Kennedy had died, or if Kennedy had done the sensible thing and retired for the 2008 election, we would be celebrating the passage of a health care bill right now. Don't pretend that this was defeat was anywhere near inevitable, Republicans simply got extremely lucky in a thousand different ways. Ah well, when Democrats stop Bush from getting absolutely everything he wants, they are accused of gridlock (and worse, traitors), when Republicans do the same they call themselves patriots, never mind the fact that the last Republican administration was an epic fail. If the American people want another lost decade, vote Republican.
- blackton
January 26, 2010 at 11:12am
I believe your claim, dtoh, was that neither bill any longer had a majority in the House or Senate. But if you re-voted today, either bill would likely pass in its own chamber. And the "conference" compromise that was being worked out would probably pass both chambers tomorrow -- if, that is, a vote were possible in the senate which it isn't because a minority is able to prevent a vote. Like I said, you have a strange view of the meaning of the world majority. There are more than enough votes in both houses if indeed the majority ruled. All the problems are a result of the fact that, in the senate, a determined minority can prevent action, even if its motivations are discreditable.
- roidubouloi
January 26, 2010 at 11:59am
Roi, I think the problem (if you're a proponent of the particular brand of HRC currently being proposed) is that neither bill would pass in the House if re-voted now. I suspect the same may be true for the Senate, but I'm not really sure. As for a determined minority preventing action in the Senate, I would not call that a problem. The protection of minority rights is one of the key elements of any liberal form of government and the codfication of those rights through the use of super-majorities is a well established and crucial mechanism for that protection. Also, while I understand why you favor the current legislation, I'm sure you don't really mean to suggest that the motivations of its opponents are discreditable. As for Blackton's comments, I think the issue for the Democrats is not just the Stupak problem (or the union problem which you don't mention), but rather the fact that there are actually a significant number of other Representatives out there who are now telling Pelosi they will no longer vote for HRC. (There is really no other explanation for the lack of action in the House).
- dtohmatsu
January 26, 2010 at 3:30pm
You have no basis for the claim that neither bill would be re-passed, and the Democratic leadership was pretty confident about the conference deal it was working out to reconcile the two bills. "Minority rights" means the political and civil rights of minorities. It does not mean that the minority governs the majority. That is anti-democratic and unconstitutional. The constitution provides for majority voting in the senate and it stretches the notion of "rules of procedure" far beyond any rational meaning to suggest that the rules can overrule the Constitution. Even a bill passed into law by both houses is subordinate to the Constitution. Surely a "rule of procedure" would not allow a the Senate to strip a given state's senators of their votes by holding them "out of order.: I mean to suggest that the motivations of Republican senators are not only discreditable but execrable. They have no interest other than in causing failure and no interest in the welfare of the nation. This has been true at least since 1932 when they did whatever they could to obstruct FDR -- solely in the hope of bringing him down -- in the midst of two of the greatest crises faced in our history. The reason for lack of action in the House is that the representatives don't like being bullied by a Republican Senate minority. The House usually thinks of itself as co-equal and in a position to negotiate with the Senate from a position of equality, not knuckle under the rapacity of Republicans. The way to find out whether the majority can adopt legislation would be for the Republicans to abandon the filibuster. Then we would find out whether there are majorities or not. I don't really believe that you believe that a law would not quickly be adopted if not for the cloture rule, even if it were slightly different than both extant bills.
- roidubouloi
January 26, 2010 at 4:52pm
Roi, Did you mean "I mean to suggest that the motivations of Republican (and Democratic) senators are not only discreditable but execrable."? Would seem more unbiased, and likely, to me, though I wouldn't subscribe to such a view either. You normally have a fair mind, and well grounded views, but this type of thinking is both inaccurate and divisive, and reflects like a mirror opposite the views on the far right. Neither is a fair assessment. The cloture rules have prevented all kinds of legislation, for better or worse, often depending on ones point of view. That's the very reason we even have such a device, to protect those not in the majority. That is not the same as minority rule. You recall that those same rules stopped many a zany idea when the Repubs had a strong senate majority, and I imagine you were rightly satisfied that even minority status had considerable power. Cloture forces consensus. We are in practice a nation of supermajority, not majority rule.
- ds111
January 26, 2010 at 5:43pm
ds111, in one sense, I wish Specter never switched parties, then from the outset Obama would have been forced to play a whole other game, either using reconciliation or incremental reform, and whichever it would have been it sure as hell would have been better than nothing.
- blackton
January 26, 2010 at 6:10pm
Roi Well obviously there is no majority support for the Senate bill. If there was, Pelosi would be pushing to get it passed in the House. As for the House bill, we will never know for sure, but given the fact that the Dems could achieve nearly everything that had been agreed to in the pre-Mass compromise negotiations through the reconciliation process, one has to wonder what the hang up is. If you have a theory other than a change in the vote calculus, I would be happy to hear it. As for minority rights, why don't we debate this after you re-read (read?) Montesquieu, Locke, Jefferson and the Constitution. I don't understand your comments about the Senate Republican minority. Until Brown got elected, the Democrats were free to pass any bill they wanted in the Senate.
- dtohmatsu
January 26, 2010 at 6:34pm
And the Democrats did. However, as is common practice, the House and Senate did not pass the identical bill. That is usually resolved in conference, a path now obstructed by the Republican refusal to allow any bill to come to the floor of the Senate for an up or down vote. dtoh, you don't even know the meaning of the word "rights." Senators don't have "rights," minority or otherwise, to be protected; they have "powers." Rights are things that attach to citizens. They are protected in the Constitution, which requires various super-majorities, of the Congress and of the States, to amend. Hence, the "rights" of minorities are protected without regard to cloture. And, no, ds111, we are not a nation of supermajority rule with rare exceptions. You, dtoh, can re-read (read?) the Federalist papers for the explanation of why not, but the short answer is so that the country can be effectively governed without being held hostage by a minority. There is nothing whatsoever in the Constitution that suggests or requires super-majorities for anything other than treaties or amendments to the Constitution itself. Ordinary legislation requires only the vote of a majority of each house, except that in the Senate it currently requires 60 votes, not even 60% of those present and voting, but an absolute 60 votes. Super-majority might be a means of forging consensus if both parties had an interest in consensus, but they don't. The Republicans have only one interest, obstruction for their own political gain of anything that might be popular with the American people, and the country be damned. If they really thought that health care reform were unpopular, they would go ahead and let the Democrats pass it and then run against them for passing such unpopular legislation. To the contrary, they obstruct because they know that it will be popular, just as are Social Security and Medicare that the Republicans now claim to defend after doing their utmost to prevent them from coming into being. That makes the Republicans execrable hypocrites and liars. I don't actually mind that so much. I know they are bunch of America-haters, outright pricks, and utterly corrupt liars, political thugs. I just wish the Democrats would free themselves of the delusion that they can ever accomplish anything without first neutering the Republicans. Negotiating with them is nothing but political suicide. Divisive, ds111? Give me a break. The Republican party is hellbent on destruction and you tell me that calling it for what it is is "divisive?" Goddamn right.
- roidubouloi
January 26, 2010 at 9:31pm
Roi, Do you really believe the bile you're spewing? Honestly, I'm curious to know?
- dtohmatsu
January 26, 2010 at 10:34pm
Damn right. I detest the Republican party, and for ample reason. These pompous, self-important assholes stole a presidential election, ignored intelligence warnings about al Qaeda just because they came from the Clinton administration, turned structural surpluses into structural deficits during a boom precipitating a colossal melt-down, stuck us in a pointless war in Iraq on the basis of outrageous lies about terrorist and WMD threats from that country, presided while Pakistan and North Korea went nuclear (despite their patriotic bombast), turned legislation over to fat-cat lobbyists, allowed, no caused, every regulatory function of the Federal government from the SEC to the FDA to the EPA to, god knows, the HSA to descend into hopeless incapacity, and clearly didn't even manage to craft effective anti-terrorist intelligence capabilities despite their purported devotion to national security -- all so that they could line their pockets and those of their buddies. They are bloodsuckers, ferocious hypocrites and liars, who are destroying my beautiful country to feed their insatiable greed while repellently proclaiming their own virtue and patriotism. Honestly. Now you know.
- roidubouloi
January 27, 2010 at 12:59am
Roi, I didn't realize you were a total nutter. What are you doing here.... I thought you all hung out at DailyKos.
- dtohmatsu
January 27, 2010 at 2:45am
For me do be nuts, dtoh, I would have to be saying something untrue, or at least exaggerating. You should read the ridiculous stuff you write here, often full of outlandish assertions that we are supposed to accept as fact. If I pulled your words out of the context in which they were written and switched a few labels so that you wouldn't know it was your own stuff, you would think you were a total nutter. I do. I just use you as a foil to make points for people who don't have such a tenuous grip on reality. Now, go play with your buddies in the "Adolph-wing of the Republican party."
- roidubouloi
January 27, 2010 at 7:57am
roi, so I take it you don't like Republicans? And dtoh, that was no rebuttal at all. Yeah, Roi was emotional, but where are the flaws in his logic? He has simply and utterly destroyed your line of thinking and your response is insult? It is like he is trying to explain evolution to you and you keep saying, nope, you are crazy, God did it, end of story, read the bible, is it any wonder he gets pissed off? I only disagree with Roi on the extent of his hatred (for instance, I think North Korea and Pakistan were going nuclear no matter who had been in power, but he is right that Bush made both situations worse). Now, you see, I rebutted a particular point, and now I can give him a chance to respond whether he agrees or not. This is how one debates. Calling him a Dailykos nutter is meaningless.
- blackton
January 27, 2010 at 11:21am
and dtoh, before you insult me by calling me a Dailykos nutter in league with roi, I disagree with him on countless issues, but it is always about the arguments. I am never afraid to admit when I am wrong and he is right.
- blackton
January 27, 2010 at 11:38am
Blackton, In your case, you're not a nutter. You logic is often flawed, but you usually avoid the hysterical rants about conservatives being evil. And... as you say, you are open to correction (albeit given your views, there is a lot that needs correcting.) Nevertheless you seem to have avoided the unfocused eyes and stiff shuffling gait that is common to the Kos crowd and North Korean political rallies. As for the point at hand..... whether there are sufficient votes in Congress to pass the progressive version of HCR..... I think I stated my belief that there were not. You and Roi obviously believe otherwise. I am not sure there is anything to rebut here....we just have a different view on the subject, but I do suppose you have noticed that Reid, Pelosi and the NYT do not share your view.
- dtohmatsu
January 27, 2010 at 12:17pm
dtoh, I absolutely agree there are not enough votes, and as I mentioned above one of the reasons is the Stupak anti-abortion crowd, who there is no finessing. I wrote on another thread that Dems. should reboot and go to the state level. Personally, I would love to see health care reform via payroll taxes and vouchers, with everyone in the state being put into a huge pool with the state negotiating with the insurance companies, with people then getting vouchers to choose which option they want. If people lose their jobs they can keep their insurance. (as part of their unemployment compensation) No more employee based insurance. I have always favored this approach, but the states have not stepped up. Now Democrats can turn there attention to the states, and blue states can actually get this done without being obstructed by pieces of shit like Jim DeMint. You can even have states that have a public option, and maybe a state that has single payer. As to the rebuttal angle, if the Senate had passed the Stupak amendment as written, I would have to rate the chances much greater than you imagine.
- blackton
January 27, 2010 at 1:07pm
Greetings Blackton, I don't particularly think that different diplomacy would have prevented either Pakistan or North Korea from going nuclear. In fact, I will concede that, more likely than not, neither could have been stopped. But that doesn't mean that Bush didn't make matters worse. There is nothing worse in international affairs than empty threats. The bluster of Bush, combined with his evident impotence, has certainly spurred Iran to both greater effort and greater defiance. If, instead of pissing on the shoes of every potential diplomatic ally, Bush had both talked to NK, in particular, while increasing international pressure (for which China was and is indispensable), then at least there would have been a price to pay that would have 1) shown the ability of the international community to cohere and 2) made it more costly for others to follow. Would it have worked? No, but the sheer, blinding stupidity of Bush's approach makes it worthy of inclusion in the list of Republican horrors, particularly since the Republicans now want to threaten military action against Iran (as Bush did with some saber-rattling) while, as usual, accusing the Dems, the only political adults in the country, of weakness. As ever, there are the Republicans exploiting danger to our country, not to relieve the danger, but for political gain. You may consider that a rebuttal if you will. I consider it a clarification.
- roidubouloi
January 27, 2010 at 1:11pm
I should have said, "Would it have worked? Not likely." I was typing too fast.
- roidubouloi
January 27, 2010 at 1:21pm