The debate in the progressive blogosphere about the merits of the health insurance legislation that will be voted on this week rages on, and passions are understandably running high.
Over the weekend I starting writing an overview of why I believe passing this bill is better than the alternative. I edited it down to the most pressing issues and concerns, and split the post into two parts.
Part 1 focuses on the bill being passed as a first step
Part 2 lays out the push for Medicare Choice For All that can and should be set into motion very soon.
There are a lot of moving parts to this. If there's something important I've overlooked, or you have a different take, feel free to let me know in the comments. I know we all share the same core values and goals here, so disagreement is always welcome.
Like many others, I still feel very frustrated with the missteps and failures of Democrats at both ends of Pennsylvania Avenue. Every bit of improvement over the status quo would matter in people's lives, and elected Dems owed it to the country to aim for the strongest possible bill.
The actions of a handful of Senate conservaDems were thoroughly pathetic and weighed down the entire caucus. The White House had it's priorities all screwed up. They chased after Olympia Snowe's vote with the Gang of Six debacle, and fetishized Beltway bipartisanship even after it became clear that voters were more interested in results than bipartisanship for bipartisanship's sake. Reconciliation was taken off the table for Ben Nelson before the Massachusetts Senate election... a loss Nelson played a key role in... which led to the revival of reconciliation out of necessity. The word "pragmatism" has been thrown around a lot in the last year or so, but what we saw all too often was "pragmatism" in name only.
Around this time last year, the Democratic Party approached a once in a generation opportunity to reassert its identity as the party of the working / middle class. Conservatives like Bill Kristol and right - wing institutions like the Cato Institute have long warned the GOP that they must do everything possible to kill, or at the very least drastically weaken any Democratic health care reform for this very reason. Our party should have really seized this moment and made a vital, winning contrast. It didn't. From the substance to the message, leading Dems didn't come at this issue from a position of strength.
All this to say, I have strong feelings about how we got to this point. But I'm making a conscious effort not to let my frustration and anger with how we got to where we are spill over into my view of the merits of the legislation itself.
Care vs. Insurance
The difference between health care and health insurance is very important in understanding where the reluctance of some progressives to support the bill comes from. Their main point is that having health insurance doesn't automatically lead to affordable, reliable, quality health care. This is a truth that we shouldn't lose sight of.
It makes sense to me to call the bill the president will sign (if it passes) "health insurance legislation" or a "health insurance expansion," as opposed to "health care reform." Health care reform won't happen unless the insurance companies face real competition. More on this in part two.
Matters Of Substance
The Missing Public Option
In the interest of accountability, here's a rundown of the most commonly cited reasons for why a public option isn't being included.
Claim: The Senate doesn't have the votes.
This doesn't seem very credible to me. If a public option were to come up for a vote in the Senate, and the president was vocally supportive of it, progressive organizations, voices, and grassroots Dems would unite behind it, and I believe it would pass. Harkin, Rockefeller, Kohl, Baucus, Begich, Hagan, Webb, McCaskill, Warner, and Byrd would support it. Carper, Conrad, and maybe even a wild card like Mark Pryor would potentially get on board once it became clear that the train was leaving the station.
I would have avoided sounding so emphatic about this if it weren't for Florida's Bill Nelson signature on the Bennet letter. His support made hitting the magic number probable.
Claim: The House doesn't have the votes.
This could be the case, but the House version included a public option, and it's hard to see what the reason for members switching their position would be. House members who voted for a bill with a public option before would face the same attacks regardless of whether a PO is included in this version. Actions of nervous members of Congress don't have to make sense. But you would think wavering members could be made to realize that they've already ensured an energized GOP base by voting for anything, so the smart thing to do is energize the Dem base and add a consistently popular element to a relatively unpopular Senate bill. Congressional Dems looking for more cover could highlight the public option's ability to cut costs, and the direct link between reform and jobs.
Claim: The White House isn't interested in a public option.
I think this is a fair statement to make. The White House trading away a meaningful public option in a deal with private hospitals and/or insurance companies has a ring of truth to it for two main reasons.
1. The Administration's general approach to reform.
2. The president's silence at key moments.
On a related note, Brian Beutler, whose coverage has been second to none, took a look at the latest death of the public option yesterday.
Influential Democrat who either opposed a public option or gave it the "meh" treatment should have caught on by now that this isn't going away.
We can see that a public option as part of this bill is almost certainly dead, but we can't see a good reason why.
Including a meaningful public option would have been a game - changer. Not only would the legislation have been stronger, it would have been much easier to defend politically. Rank and file Democrats would be energized, elected Dems would see that having a backbone pays off, and right - wing talking points against effective, responsive government would have been dealt a serious blow.
The only potential upside to the absence of a public option is that the people who kept pushing a limited public option back into the spotlight -- where it was consistently shown to be a popular idea -- can now turn their attention to something that is straightforward and much stronger in every sense of the word.
A public option would have been a game - changer.
A Medicare Choice Buy - In is a game winner.
Recent Improvements
- The Excise Tax isn't nearly as bad as it once was.
- The House is adding student loan reform to the bill. Hopefully it can survive the Senate.
- Rep. Bart Stupak's further assault on reproductive health rights (and reality) was not successful. Stupak is either desperate for attention or grossly misinformed. In either case, his actions are unforgivable. He has more than earned his primary challenge from Connie Saltonstall; a race he deserves to lose. The Nelson language in the Senate bill is also problematic. It's not as bad as Stupak, but that's not saying much.
- A national rate review authority sounds promising, but a lot depends on the definition of "unreasonable."
Where This Bill Falls Short
My criticism here will be familiar to anyone who has read the "Going Public" series.
- An individual mandate without a public choice is the glaring problem.
The individual mandate by itself is not a major problem, as long as other it comes with measures to make sure the insurance is affordable. Without a choice that the insurance companies don't control comes widespread and entirely legitimate fear that they will game the system. This is one of the main reasons why the House exemption for the individual mandate was more appealing. Now the exemption will kick in when premiums cost over 8% of income. Couples making under $18,700 are also exempted.
This falls under politics as much as policy, but the individual mandate could fairly easily become the source of visceral contempt, and soon. An individual mandate was always going to be politically tricky, though a strong public choice that would have kept insurers honest would have neutralized it. Without that check on the insurance companies, the mandate is a terrible fit for the politics of 2010. The very concept of the mandate without a choice could be enough to do tremendous damage to the credibility of this legislation, regardless of the details of the subsidies, exemptions, etc.
It seems that we're betting a lot on the regulations sinking in and crowding out the mandate.
- Michael Moore's discussion on Countdown with Lawrence O'Donnell on Monday night will revive discussion about just what enforcement of the regulations is going to look like. Howard Dean has called attention to this as well.
- There have been reports that the repeal of the insurance companies' anti - trust exemption may not make it through the Senate, even though it passed the House 406-19. This repeal is very, very popular. Any Senator opposing it is hardly a "centrist."
The Options
In the end, it all comes down to whether you think this bill does more good than harm, and whether our ability to do something better would be strengthened or weakened by its passage.
The most compelling argument against passage is that this bill will cement the insurance companies (read: the problem) into their role at the center of our health care system.
Recently I've seen an argument surface in favor of passage that strikes me as too optimistic. The argument is that one of the most important things this bill will would do is establish health care as a right. This is obviously a welcome change. But at the same time, if this falls flat, the key takeaway won't be that health care is a right, but that those who used the language of reform think people have a responsibility to give their money to insurance companies. The credibility of the very idea of health care reform is on the line.
And I generally agree with those who oppose passage that this bill will be difficult to defend politically, and it didn't have to be this way.
I think President Obama is right when he says that it's hard to tell how this plays out politically. But there is one thing I can say with confidence about the politics of all this: not passing anything would be a disaster. It would mean that we wasted a year of time and went through a process many found to be either annoying, infuriating, or downright repulsive, with nothing to show for it.
There are only two options:
Pass the bill and move with urgency to reinforce it.
or
Let the bill die and try to navigate the fallout so we somehow end up in a better position... or wait for the health care crisis to get even worse and hope this leads to a new opportunity.
Passing the bill as a first step is much more likely to get us closer to where we need to be. The second option guarantees that there will be untold suffering for people I care deeply about, at the very least for the short to mid term. There's no way I could endorse that.
This bill doesn't go nearly far enough to confront he insurance companies that are responsible for a lot of unnecessary suffering, death, bankruptcy, and strain on working people. But it does some real good in the short term, and buys us some time.
Letting the bill die would strengthen the influence of those in the Democratic establishment who are determined to learn the wrong lesson. It really pisses me off that the champions of the same conventional wisdom BS that undermined this effort would refuse to acknowledge their own costly mistakes, and instead try to rewrite history. But they would, and their spin could very well harden into the new conventional wisdom... now with extra stupid. That garbage like remains a good bet to gain significant traction underscores that we still have a huge fight for the heart and soul of the Democratic Party on our hands.
There are some good things in the bill that will give some help to people who really need it. There's just no way I could say no to that.
Pass the bill as a first step.
UPDATE:
Tuesday - 9:35 AM
Media Matters refutes right - wing spin on reconciliation.
Political Wire on the process problem and the road through the House.
Now when you start to look at the details of (Chris) Dodd's (financial reform) bill, just like with the health care bill, you will find some very good things to like, enough that a great consumer advocate like Elizabeth Warren decided to give it some modest support. Here's the problem though: if you are trying to get people excited about your reform agenda, and they are too busy debating with themselves over whether to even support the bill, you have a big, big political problem.
UPDATE #3:
Wednesday Morning
Passing this bill as a first step won't close the enthusiasm gap by itself, but it will put us in a position to start evening things out.
Progressive Ohio picked up a story that is enough to make even the most calm of us livid.
It's painfully obvious that even the most "reasoned" Tea Partier has no clue what the she is talking about. She claims the bill can't be read (this crap still? really?), that it will cost more than inaction, and that it will harm small business. These are mindless, thoroughly discredited AFP / Freedom Works talking points.
They're Having Nun Of It... but Bart Stupak is listening to James Dobson.
If you're interested in making abortion less necessary, opposing anything that could help more women get overall care makes absolutely no sense.
The upside to such a stunningly out of touch statement (with both reality and Democratic sentiment) from Stupak is that it will help galvanize support for his primary challenger, Connie Saltonstall.
Conservative Republicans are trying to co - opt progressive criticism of the bill.
This is hardly a shocker. Shadegg gave Mike Stark a preview of this line of attack a while ago. And it's a smart one to use, because as we've seen for over a year now, progressive health care policy is popular. Remember, the House vote to get rid of the anti - trust exemption for insurance companies was 406 - 19.
Here's the worst news:
Miles Mogulescu played a big role in highlighting an alleged deal the White House made with private hospitals to kill any meaningful public option.
Brent Budoswky recently expressed my views on this pretty well. It seemed about right, and would explain a lot, but I was skeptical that it could be proven.
The deal is now going to be much harder to deny. The NYT's David Kirkpatrick acknowledged that Jim Messina (White House Deputy Chief of Staff) confirmed the deal to him.
I don't think the Obama Administration fully grasps how badly this will damage their relationship with the Democratic grassroots when it's fully revealed, and make no mistake about it -- that is going to happen. This revelation isn't getting a lot of traction now, but after the bill passes (if it does), attention will inevitably turn to this deal. Sooner rather than later, Sen. Russ Feingold's statement that this legislation is what President Obama appears to have wanted all along is going to be vindicated.
You can't run the kind of campaign ran, both in a close primary and the general election, say the things President Obama often says, and then pull this crap without serious political repercussions.
Like many others, I can't stand the substance of the PhRMA deal, but at least there was a convincing argument that it was necessary for now. PhRMA has a ridiculous amount of firepower at its disposal; enough that it made sense for the Administration to evaluate what the chances were of passing anything without a deal, and look at the least bad deal they could get.
Side note: I should point out that the substance of the PhRMA deal isn't the only thing that bothers me. I could live with if it was clearly necessary, but I don't trust Team Turbo Beltway Goggles -- the worst faction inside the White House -- to go for the best deal they can get.
Making a deal with private hospitals to kill a meaningful public option crosses the line. I can understand not wanting to get in a huge fight with every big money special interest related to major legislation, but you've got to be willing to really take on somebody. If the president had put his ability and full weight behind a meaningful public option, we would have had one. Instead, he gave us... well... just words. Weak, insincere words.
This genius plan produced a bill that consistently polls a good 20 - 30% behind a public choice linked to Medicare, and contributed to a massive enthusiasm gap. Does the White House want 2011 to look a lot more like 1979 than 1995? In whose book is this "pragmatism"?
Get ready for Conservative Selective CBO - Citing Part 768,529
Brian Beutler has more on the changes to the excise tax.
Don't miss Paul Krugman on Rahm Emaneul's "vindication."
I just re - read David Kirkpatrick's NYTpiece from August regarding the hospital deal.
Here's the relevant excerpt:
Several hospital lobbyists involved in the White House deals said it was understood as a condition of their support that the final legislation would not include a government-run health plan paying Medicare rates - generally 80 percent of private sector rates - or controlled by the secretary of health and human services.
"We have an agreement with the White House that I'm very confident will be seen all the way through conference," one of the industry lobbyists, Chip Kahn, director of the Federation of American Hospitals, told a Capitol Hill newsletter.
It's impossible to tell from this whether the deal was to stop just a public option tied to Medicare rates or any public option. I'm unable to locate a transcript of Kirkpatrick's talk with Ed Shultz that Miles Mogulescu referenced.
More information to clarify what was part of the deal would be helpful, and I think we'll probably get it fairly soon. But I'm much more interested in knowing how we as a party are going to make this right moving forward.
Bart Stupak really needs to go. He thinks he's the one who is "going through hell."
Stupak's actions demanded a primary challenge even before his dismissal of nuns who support this bill. Stupak said he listens to bishops instead for no apparent reason other than bishops are dudes. Stupak also proudly stated that he was listening to James Dobson's Focus On The Family, and the anti - choice group that endorsed Fred Thompson for president in 2008.
Bart Stupak is leading a fact - free assault on women's reproductive health because James Dobson tells him to. Stupak is not "pro - life", he's pro - being reckless with people's lives.
