At Least You Have Your Healthcare

President Obama and the Democrats scored a big victory this week with the passage of the healthcare bill. Other people(Ezra Klein and Jonathan Cohn are my go to people) can talk about the substance of the bill better than I can but I want to focus on some of the political aspects.

The passage of this bill means the Democrats will maintain their majority in 2010. Various historic and political trends will mean Republicans gain congressional seats but since they did not defeat Obama and congressional Democrats then they will not gain the majority. Unlike in 94, Democrats have a success to blunt the Republican criticism and popular items they can use to attack Republicans for opposing.

Republicans know this and know the magnitude of this defeat. They also know they lost to an African-American and a woman and many conservatives can't stand that fact either. The world is changing and the old guard is giving way to the new. The healthcare bill demonstrates that the new guard can do what they said they were going to do and that they will be around for a while.

So, Kudos to President Obama, Speaker Pelosi, Sen Harry Reid(who may well have sacrificed his seat) and every Democrat who voted for the bill for achieving the biggest legislative advancement since the Great Society and hopefully ushering an area of more progressive governance.

Why the Healthcare Bill Needs to be Passed

I work at a hospital, and lately I have noticed flyers around my office advertising a benefit for a fellow employee. The benefit is to help with medical costs for the employee and the employee's family. I do not know this person and do not know any details about the illness.

I think that what the hospital employees are doing is admirable and deserves to be commended. However, it points to the biggest weakness in out healthcare system. A hospital employee with good benefits is still in financial straits due to a major medical problem. In the richest and most powerful country in the world. this is unacceptable and needs to change. Yet the U.S. system of employer based private insurance is no longer sustainable.

The House of Representatives could change this tomorrow if would pass the Senate healthcare bill. The Senate could help if it would produce a reconciliation bill. The President could help if he would signal what he wants done.

The bill is not perfect and it is not what I would dream of having but it is a good bill. It makes sure that people will always have insurance. It makes sure that the government will help people who have have trouble affording insurance buy insurance, and it sets the groundwork for controlling medical costs. The healthcare bill will do a lot of good for a lot of people and a little bit of good for a lot more.

Pass the Damn Bill.

Mass Reax.

Last night in Massachusetts Republican Scott Brown defeated Democrat Martha Coakley to win the special election to fill the U.S. Senate seat most recently held by the late Sen. Ted Kennedy(D-MA). I feel obligated to share some of my thoughts about this development.

1. Congratulations are in order to Senator-elect Brown. He ran the better campaign; he diagnosed the mood of the electorate better, he ran a more disciplined campaign, and he was quick to pounce on Coakley's many gaffes. Sometimes in politics the person who does a better job is rewarded.

2. This is a setback for President Obama and the Democrat's agenda but it is only any insurmountable obstacle if Obama and the Congressional leaders allow it it to be one. I have long thought that Obama spent most of his political capital cleaning up the mess the Bush administration left. However, I thought there was still enough capital to pass the healthcare bill. All the the other major agenda items are probably of the table; except for economic and job issues that can be addressed through the budget and reconciliation process. Still with helathcare added to the mix this would be a substantive first Congressional session for Obama.

3. There is a Senate helathcare bill that the House can pass tomorrow if it wants to and there is still an empty healthcare reconciliation bill that can also be used. The House needs to pass that bill and then come back and use the reconciliation bill to pass the compromises the White House and Congress are currently negotiating. Morally this has to happen because people need to have access to healthcare and they need to know they will always be able to have health insurance. Politically, this bill has to pass because Congressional Democrats and President Obama cannot afford to not have this bill pass. If this bill fails then it will be the end of Democratic power in Washington for a long time. Also Democrats need to change the narrative. Right now the narrative is that the Democrats are in disarray and their agenda is possible. If healthcare passes then the narrative changes to Democrats fight and overcome setback to pass healthcare bill.

I have been watching Democrats for too long to think they will choose the obvious path. However, I hope they soon see that this is only real path they have.

The Difference Between a Moderate Republican and a Conservative Democrat

However much it stinks to high heaven, and it stinks a whole lot, there was a deal that could get Sen. Ben Nelson to vote yea on the healthcare bill. With her refusal to back the healthcare bill because she feels the bill is being rushed, Sen. Olympia Snowe(R-ME) makes it clear that no deal could be reached to earn her vote.

The incentives(political, partisan, and individual) were always structured in a way that Sen. Nelson would feel pressure to support the bill but Sen. Snowe would feel strong pressure to oppose.

The difference between a conservative Democrat and a moderate Republican is the difference between finding a way to get to yes and finding a way to get to no.

Saved by the Moderates?

The Senate begins debate on the healthcare this week, and the quality of the bill might depend on the stubbornness of a group of Senate moderates. This group of moderates includes Sen. Mary Landrieu(D-LA), Sen Joe Lieberman(I-CT), Sen. Blanche Lincoln(D-AR), and Sen. Ben Nelson(D-NE). All 4 of these Senators currently outright oppose or are skeptical of a bill including a public option. Each of the 4 senators have their own reasons and it might be difficult to appease all of them.

However, the opposition of these 4 might provide a a means for strengthening the bill. A new report from the Urban Institute says that a public option with triggers would be better then the public options currently in any of the legislation before Congress. There is also talk in the progressive community about the weaknesses of the public option. The problem with the public option is that it is not tied to medicare rates and it has limited eligibility. With these limitations, the public option could very likely become a dumping ground for uninsurable; which would make the public option more expensive.

A public option with a strong trigger might be able a better bill and might be able to pass the Senate because of the support of Maine's Olympia Snowe and Susan Collins. I also think that a bill that jettisons the public might be a very good bill if it includes increased subsidies and increased access to the insurance exchanges.

There are good reasons to continue to fight for a public option. A successful public option would help liberals make the case that an increased role for government actually helps people's lives, and it would be easier to fix a weak public option then it would to create one at a later date. Those are both good reason to continue to fight for a public option but if those moderate senators are willing to increase subsidies and increase eligibility for the exchanges then I would be willing to make a deal on the public option.

Elections Have Consequences

The Senate joined the House and today passed the Matthew Shepherd hate crimes legislation. The bill was attached to a defense appropriations bill and 58 Democrats and 9 Republicans voted for the bill. Russ Feingold(D-WI) opposed the bill because of elements relating to Afghanistan in the defense appropriations section and Robert Byrd(D-WV) was not present to vote.

Also from the hill today comes word that the healthcare bill that goes to the Senate floor will probably have a public option. Most moderate Democrats appear mollified by the knowledge that they will have a chance to vote to strip the public option provision. If a public option is in the bill then its opponents need 60 votes to strip it out of the bill, and if it is not included proponents need 60 to insert it. This news makes it very possible that the final bill will include some form of a public option.

This is good news and a reminder of why many of us worked, contributed money, and voted for President Obama and the Democrats.

Why Healthcare Reform is So Hard

Rep. Mike Ross(D-AR-4), who is the leading Blue Dog healthcare spokesman, received a sweetheart deal from an Arkansas based pharmacy chain to sell a piece of commercial property. Oh, and the health industry donated $342, 475 to Rep. Ross. The practice of legalized bribery is alive and well in Washington.

Healthcare Reform to the Max

Sen. Max Baucus(D-MN) finally is circulating his idea for healthcare reform and moderates appear to be gathering around a public option with a trigger that would go into effect if insurance companies fail to meet certain targets.  It now appears that the outlines of a healthcare deal appear to be in place.  After the craziness of August it is hard to believe that we are close to some type of deal but Jonathan Cohn explains how August affected the the political situation and how the odds of a bill being passed are unchanged and perhaps more likely.

Based on my studying of the issue, this is my guess as to what will happen.  A bill with a public option that has a trigger will pass.  The bill will increase Medicaid eligibility and will include an individual mandate.  To help people pay for the mandated insurance there will be subsidies of about 350% of poverty level.  There will also be an employer mandate and some type of insurance exchange that will allow individuals who don't get insurance from their employers, and small businesses, to have access to reasonably priced insurance.

I am not the first to suggest this but President Obama strikes me as someone who uses conservative means to achieve progressive ends.  As The American Prospect pointed out earlier this summer, Obama maintains a strong belief in the ability of American institutions to solve our country's problems.  As far as I can tell this belief includes the medical establishment in the U.S. 

The current reform proposals seek to keep the basics of our the employer based health insurance system but it wants to make the system achieve universal coverage and do it in a more efficient manor.

This is a far from perfect bill and it feels like a colossal disappointment when compared with what seemed possible at the beginning of the debate.  However if a bill like the one described above passes then it will be the most progressive legislation in a generation.  More important a bill that is successful and popular will set the stage for further progression towards public based universal healthcare.

The reality is that not all Democrats are liberal progressives.  Even though the Reagan era looks over, the Democrats are still struggling to posit a positive message about governments role in our society.  The most important thing this bill might do is to reverse the "government is the problem" mentality that marked the last 3 decades of political debate and restore the public's trust in the government's ability to pursue collective action for the public good  If the bill does that then it will be easier to move from this bill to an even more substantial reform of our healthcare system.  

The Moral and Political Case for Healthcare Reform

Nicholas Kristof wrote a column this week that tells a heartbreaking story of a couple forced to divorce because our healthcare system made it impossible for them to stay together and still afford the treatment for the husband's early onset dementia.  The moral case for healthcare reform is that in a civilized and just society this would not happen.  Working people would be able to have access to health care.  Middle income people would have sufficient resources to get care and not face going broke when they realize their insurance is not sufficient to pay their medical bills.  And there would not be insurance companies making obscene profits while people go broke or can't afford the care they need.

Despite our pretensions, we don't really live in a civilized and just society.  Working class people can't afford healthcare.  Middle income people often find their insurance is not sufficient and they go broke.  All the while insurance companies make profits.  The reason for this is we have politicians that fine with this reality.  Rep. Lynne Jenkins(R-KS-2), who recently said the Republicans need a "Great White Hope" to go after President Obama, held a town hall this week.  A single mother said the she has trouble getting medical care for her child because she can't afford the insurance.  Rep. Jenkins laughed off the woman's concern.  The political case for healthcare reform is that people like Rep. Jenkins need to be kept far from power.  The better the health care is then the more likely the forces that profit off our dysfunctional system, and their political minions, will continue to be in the political wilderness.

What Exactly is a D.C. Moderate?

Of my states two Senators I have met one of them.  The one I have met is Sen. Chuck Grassley(R-IA) who is the ranking member of the Senate Finance Committee and the leading Republican negotiator for the health care bill.

When I met Sen. Grassley it was last spring at a townhall meeting in my home of Red Oak.  He covered all the issues of the day, and he held the most conservative positions possible.  He was, for example, firmly against Sen. McCain's(who was his party's Presidential nominee at the time)immigration reform ideas.  In his Senate career he not shown himself to be anti-war like former Sen. Lincoln Chafee(R-RI) or to hold pro-choice views like Maine's current GOP Senators Susan Collins and Olympia Snow.  Unlike Sen. George Voinovich(R-OH) or Sen. Lindsey Graham(R-SC), Grassley did not support Justice Sonia Sotomayor's nomination to the Supreme Court.  Sen. Grassley did not support the Lily Ledbetter act, did not vote for the stimulus, or the most recent cash for clunkers bill.   There is nothing in his record to indicate that he is anything but a conservative Republican.

Except that Sen Grassley is the most powerful Republican on the Senate Finance Committee, and when the GOP was in control Grassley served as the chair.  The Senate Finance Committee, as explained here, deals with matters of government revenue and programs funded by the Federal Government.  This is only anecdotal evidence but everything I know about Sen. Grassley is that he takes good care of his constituents and is willing to his use his access to federal funds to help local programs.  I find nothing wrong with this because I believe there are matters of local importance that can only be funded with the help of federal money.  It looks like Grassley's reputation for moderation comes from his willingness to assist fellow Senators to access federal funds for their locally important projects.  This is fine work but just because Sen. Grassley helps a Senator access federal funds does not mean that Grassley agrees that Senator politically.

Reports like these make it clear that Sen Grassley, for both idealogical and bare-knuckled political reasons, is not really interested in a health care reform bill.  The question is whether or not President Obama and Finance Committee chair Sen. Max Baucus(R-MT) realize that Grassley doesn't want a deal.  If Obama and Baucus continue to hold to some D.C. establishment idea of moderation they are damned fools and the healthcare bill will reflect their foolishness.

This Sh*t has got to Stop

Former Alaska Governor Sarah Palin said that Obama's "Death Panel" could decide to kill babies who, like her son, have Down's Syndrome.  The former governor is an ignorant and loathsome fool who appeals to the worst in American political culture, but sentiments like hers could do real damage to the ability of people to receive end of life care.

According to the National Hospice and Palliative Care Organization and the National Hospice Foundation only about half of the people who are currently eligible to receice hospice care actually get it, and that 10% of families who receive hospice care believe that the care stated to late.

 

There are some other facts about hospice and palliative care that need to be acknowledged.  People on hospice are still followed by their local doctors and a not a panel of bureaucrats in Washington D.C.  People can still receive various types of chemotherapy, radiation, dialysis, or other types of treatments while on hospice.  People can still be treated for their health concerns while on hospice.  For example, if a person on hospice care with terminal lung cancer slips and falls on an icy sidewalk then they can go to the ER and still have their broken arm treated.  People can voluntarily come off hospice care at any time they choose and people on hospice are routinely checked to see if hospice is the best level of care or if another level of care would be better suited to the meet the person's needs.  Again, making this decision is not a group of government folks from Washington but local doctors, nurses, and other medical professionals who work with patients and families to find a way to keep providing the care that best meets the person's needs.

Susan Collins, a Republican Senator from Maine, understands what hospice is about and how so many more people would benefit from receiving hospice care.  So, she inserted the language in the health care bill to ensure that more people are made aware of the benefits of end of life care.  This ignorant demagoguing from the likes of Sarah Palin just makes more people afraid of end of life care and keeps many people who would benefit from hospice from accessing the care hospice provides.  Real people might needlessly suffer because the words and actions of the vile and the foolish.  

This sh*t has got to stop.

Max Baucus, Point Man

The focal point of the health care debate is focused on the Senate Finance Committee chaired by Sen Max Baucus(D-MT).  After reading a couple of profiles of Senator Baucus, I have thought about him and the process, and this my guess as to why we are where we are in the debate.

Senator Baucus has made a career of straddling the middle.  He supported the Bush tax cuts and the Iraq War.  When the Republican passed the Medicare drug bill the only two Democrats allowed into the room during negotiations were Sen. Baucus and another moderate Democrat Sen. John Bruex(D-La).  However, Baucus led the way when congressional Democrats successfully fought Bush's plans for Social Security.

As I look at this record my sense is Baucus is a conservative in the traditional sense.  He doesn't want radical change but he will fight tooth and nail to protect what already exists.  The questions then are does health care reform require radical reform, and is the electorate calling for change?

The article from the Missoula Montana paper quotes a former Baucus aide saying, "I think we've reached a juncture, probably in history, where there's a difference between hard work and leadership.  And Max needs to show that... he can get a good bill passed through leadership, not just hard work.  If he wants to be remembered he needs to provide the leadership to solve this problem."

I 'm not sure that a person whose instincts are conservative can bring the required leadership for health care reform.  Even though the proposal is not very radical because it still keeps the anachronistic employee based health system, it still contains the seed to grow into a radical change of our health care system.  Baucus either cannot see this or wants to bring reform reform through tweeking the current system.  

However, the path of the current system is unsustainable.  More people will become uninsured and more insured people will be risking bankruptcy if they should have a major medical need.  Businesses will offer health insurance that covers less and less and continue to provide stagnant wages because health benefits eat the compensation packages.  The current proposals are a compromise from progressives desires for a single payer.  The current proposals do provide a way for more progressive options to be visited at a later date.  

Baucus' instinctual conservative view means he sees tweaking the current system is the answer, which would make harder to grow his plan in more progressive direction  and one day might require a more extensive overhaul.  Also, Sen. Baucus's conservative political instincts means he is misreading the political winds.  He cam of age in a era of Republican ascendency but is in an era of Democratic ascendency.  His sidelining of the more liberal members of committee means he risks losing big and bring the whole package down.  Chairman Baucus even locked the chair of the Health sub-committee Sen Jay Rockefeller out of the negotiations. 

Baucus' method of leading a group of centrist Democrats and Republicans means he misread the situation.  He should have led negotiations beteen more liberal Democrats and centrist Democrats to get a bill that could be supported by every Democrat in his committee.    He negotiated with those he didn't need to and left out those whose votes count.  A gentlemanly move but one that fails basic leadership.  He has attempted to lead those who he cannot and ignored those who could help him.

However, it is not too late.  The big thing now is to get the bill out of committee and onto the floor.  The other bill from the Senate HELP committee and the House bills are substantially more progressive.  Baucus can show real leadership by help combining the two bills and being willing to support the final product if it is more liberal than his original bill.  He can also show leadership by siding with his Democratic colleagues against any filibuster attempt and leading the centrist Democrats to siding with the party on the procedural votes even if some of them vote against the final legislation.  It will mean that Baucus will need to go against his every political instinct.  I realize that is hard but real leadership means being able set aside your instincts on those rare occasions when real and lasting positive change can happen.

Health Reform Blogging

Last night I was talking to my friend Legs about the health reforms bills that Congress is working on.  I felt like I was having trouble explaining the bill and so I refreshed my memory today.  What follows is a summation of what I found out today.

Both the House and the Senate HELP committee have released their plans, and both are pretty similar.  The underlying goal is to keep the existing employer based health system for those who are in it but find a way to maker it more efficient.  The plan also wants to cover those people who care currently not covered by health insurance.  To that end both bills include an individual mandate which would make having health insurance mandatory.  The key then is too make that mandate affordable.

Both bills include a strong public plan which would compete alongside plan from private insurers in a health insurance exchange.  The exchange would be a place where individuals and businesses would use their large numbers as leverage to choose among competing health insurance plans.  In the House bill there are various types of plans that vary based on much the the ratio of cost sharing.  The insurance exchanges in both bills are nationally run, but states can opt opt out if they agree to certain conditions.  

In addition there are subsidies for people and families to buy  the insurance and cap on how much a person will be forced to pay out of pocket for insurance.  The subsidies are based on a sliding scale that goes up to 400% of the poverty line.   There is also an increase in Medicaid eligibility that increases coverage to include up to 133% of the poverty line and also sets the stage for a potential complete federal take over of Medicaid.

The real issue then is how to pay for this bill.  The Congressional Budget Office has scored the bills to be in the neighborhood of 1 trillion dollars over a 10 year period.  About half the bill will be paid for by making Medicare and Medicaid more efficient.  Both bills also include a marginal surtax on incomes above $350,000.  The President has proposed eliminating some tax deductions and raising the marginal tax tates to Clinton era level, and some in Congress are considering some type of value added tax(VAT). 

There is still some concerns about how the bill will control costs, which is way the Senate Finance Committee has not presented their bill yet.  The major concern for the Finance Committee is how to contain costs.  What the Finance Committee wants to do is cap the tax exemption for employer based health care but nothing is definite.

I did most of my research by looking at the House Education and Labor website and by reading Matthew Yglesias and Ezra Klein.

Harry Reid, Occasional Leader

Senate Majority Leader Harry Reid(D-NV) told Senate Finance Committee Chair Max Baucus(D-MN) to "stop chasing Republican votes on a massive health care reform bill."

I have not understood Sen. Baucus' fetish for a bi-partisan bill.  Perhaps, in the some odd-chance someone who understand the interpersonal relationships in the Senate reads my blog, someone could explain why Senator Baucus could not sit down with Sen. Charles Grassley(R-IA) the Ranking Member of the Finance Committtee and say, "Senator Grassley I can't compromise without bringing down all sorts of fury on my head and the same goes for you.  I will keep us from having to go through a painful series of compromises.  I have the votes to pass health care reform out of the committee.  Democrats will vote for it and Republicans will vote against it.  That way everyone knows who is responsible for the success or failure of health care reform and they can act accordingly at the ballot box."  

Nancy's Victory

This week the Senate efforts on health care reform resembled a keystone kops movie.  Mark-ups began in the Senate Health Education Labor and Pensions committee on a bill that did not include a public option and was preliminarily scored by the Congressional Budget to cost more and covered fewer people than hoped.  Over in the Finance Committee, the 1st draft of their bill does not include a public option or employer mandate but it does include reduced Medicaid coverage, an individual mandate, and instead of a public plan it included health co-ops.  The most charitable description of the Finance Committee's draft was that it represents "comprehensive incrementalism." 

Then yesterday the House presented its health care proposal.  In an effort to reduce turf battles, the Ways and Means, the Commerce and Energy, and the Education and Labor Committees all combined to produce a joint bill called "tri-committee" plan.  This bill is much more in line with progressive goals.  It includes a public plan, increased Medicaid Coverage, and a insurance exchange.  The House has now staked out a progressive position and Speaker Pelosi declared that she is committed to a public plan.

If a progressive healthcare reform bill passes then it will be a victory for liberals in the House.  People like Speaker Pelosi, Ways and Means chair Charlie Rangel, Education and Labor Chair George Miller, Commerce and Energy Chair Henry Waxman, Rep. John Dingell will have done most of the work to get health reform passed.

Yes, That's the General Idea

From Steve Benen I learned about this article detailing Republican's frustration that President Obama announced his desire that health care reform should include a public option.  Apparently Republican senators believe a public option would kill off any possibility of a bipartisan health bill.

The Senate can pass a health care bill without a single Republican vote.  In fact, Democrats can afford to have some of their own members vote against health reform.  The big rub is on whether to include a strong "public option" as part of the bill.  A public option would allow people to have the option of buying health insurance directly from the government.  The fewer Republican votes then the stronger the public option.

Bi-partisanship is a means to an end and not an end itself.  The end is a health care bill that provides affordable health care for all Americans.  A public option is a major component of that goal and Democrats have enough vote to get some form of public option passed.  President Obama's letter made it more likely that the public option will be a strong one.  There is no need for the Democrats to weaken a bill to gain GOP votes that are not needed just to satisfy the false demand of bipartisanship.  Sacrificing the idea of a bipartisan bill to achieve a bill with a strong public option is a price that should be easily and willingly paid.