Same Old Song And Dance

Here comes the part of the health care debate where people start to talk themselves into half a loaf instead of fighting for a full one.

There are many themes in the sad and frustrating history of health-care reform. But one of the central ones is that there were many points when Democrats could have accepted a compromise and did not. Richard Nixon, for instance, proposed a plan that could have passed Congress but that liberals thought comically inadequate. It was more comprehensive than anything we will get this year. George H.W. Bush also offered a pretty good proposal but got no support among Democrats.

Opportunities at health-care reform do not happen frequently. The average between major attempts is 19.5 years. That's 19.5 years in which the uninsured stay uninsured and their ranks grow. Where a situation that is already bad gets a lot worse. This year, Barack Obama is popular, and there are 60 Democrats in the Senate and huge majorities in the House. There is no reason to believe that Democrats will be in a stronger position anytime soon. It is not like when a weakened Nixon, or a fading Bush, offered a compromise.

If reformers cannot pass a strong health-care reform bill now, there is no reason to believe they will be able to do it later. The question is whether the knowledge that the system will not let you solve this problem should prevent you from doing what you can to improve it. Put more sharply, the question should be whether this bill is better or worse than another 19.5 years of the deteriorating status quo.

Ezra Klein is not an activist. He's a health care policy wonk. And he knows that we have a very broken political system and a media that gives wide berth to out and out lies from conservatives. So he reasons that health insurance reform that gives access to coverage to 40 million Americans who don't have it will be a major improvement for many Americans, and even if that's seen as a loss in the political world, it's worth achieving. Heck, if we get community rating, forcing insurers to cover everyone with the same coverage at the same basic rate, even a jury-rigged system can be universal.

This hardly solves every problem. In particular, it doesn't do much to rein in costs. But if you combine (a) Medicare, (b) our current employer-based insurance regime, and (c) community rating along with subsidies for low-income families, you've essentially institutionalized universal healthcare insurance. Not everyone will take advantage of it — there will always be a few people who go without coverage even if it's affordable — and you still a need a few other things like out-of-pocket caps. Still, it's basically a statement that everyone in the country can and should be covered. And once that becomes a cultural norm, it will never go away.

If we end up with health insurance reform, where you have to be covered, cannot be dropped, and must pay the same rate regardless of prior conditions, and you have an exchange to buy insurance instead of being forced into a regional monopoly, people in the individual market will see the difference. Of course, problems will remain. Employers, without a mandate, will still drop coverage. The costs will continue to soar, especially without a public option that can gain a big enough following to force competition in that individual marketplace, particularly on price. The smaller tweaks of health IT and prevention and comparative effectiveness are important but may end up compromised. And without getting the real savings from stakeholders necessary to drive down costs, people will still see their premiums rise. Not to mention the fact that we're going to need millions more doctors.

The reason that liberals want to enshrine a public option, not the weak co-op alternative, is that the history of the few victories in health care and social safety net reform in this country have started with an incomplete toehold that gets expanded over time. Medicare wasn't perfect at the start. Or SCHIP. Or even Social Security. They needed to be tweaked and improved and made useful for all. I don't think it's possible for co-ops to scale up in this way. We've seen the history of them taking decades to have any measurable effect.

But Democratic leaders appear to want to give in on this one.

"We think the public option is very important," said House Majority Leader Steny Hoyer, D-Md., but "we have to see what the Senate does on co-ops, and see how it's formulated, to see whether or not it would have a similar effect."

"It's really premature for me to lay out what should be in this bill," said Senate Majority Leader Harry Reid, D-Nev., when he was asked about the public option [...]

Liberals shudder at the idea of removing a public option.

"There are rumors that the leadership is getting squishy" on the public option, said Rep. Eliot Engel, D-N.Y., a member of the House Energy and Commerce Committee, which also is trying to write a version of health care legislation.

"Some of us have pushed back hard and said we will not support a bill if it doesn't have a public option," he warned. "There comes a point where some of us will say getting a bill out at any cost is not a panacea if it's a bad bill."

When Harry Reid comes out and says what can get 60 votes beats what I want, you understand that he's laying the groundwork. This is why health insurance stocks shot up yesterday. They're on the verge of getting a forced market, lowering their administrative costs (no rescission department) and adding tens of millions to the rolls.

14 House members are so far on the record saying they'll vote against any health care reform bill that doesn't include a legitimate public option, not something that Harry Reid and the gang will try to pass off as one. And yes, at some point, the President needs to weigh in and pick a side. He sounded wobbly on this yesterday.

And the other thing that we do want to do -- now, this is controversial, and I understand some people are worried about this -- we do think that it makes sense to have a public option alongside the private option. So you could still choose a private insurer, but we'd also have a public plan that you could choose from that would be non-for-profit, wouldn't have, hopefully, some of the same high administrative costs, and would be potentially more responsive to your needs at a lower cost. I think that helps keep the insurance companies honest because now they have somebody to compete with.

And I have to say, the reason this has been controversial is a lot of people have heard this phrase "socialized medicine" and they say, we don't want government-run health care; we don't want a Canadian-style plan. Nobody is talking about that. We're saying, let's give you a choice. You can choose the private marketplace, or this other approach.

And I got a letter the other day from a woman; she said, I don't want government-run health care, I don't want socialized medicine, and don't touch my Medicare. (Laughter.) And I wanted to say, well, I mean, that's what Medicare is, is it's a government-run health care plan that people are very happy with. But I think that we've been so accustomed to hearing those phrases that sometimes we can't sort out the myth from the reality.

Nothing abut co-ops yesterday, but the move, one assumes, would be to sell co-ops as the public plan. Obama's strategy has been to get to conference and make the necessary adjustments at that time.

We'll see.

Blog Fights!

Seems to me there's been a spasm of blog fights lately. First "rational progressive" Nate Silver and "Marxist" David Sirota (I think Silver came out of that one looking really bad, BTW, and he desperately needs a special election to talk about or something). Now Jane Hamsher and Ezra Klein.

Jane has been dogged in her efforts to uncover what's going on at this "fiscal responsibility summit" next week, which may be headlined by billionaire hedge fund manager Pete Peterson. Now fortunately, House and Senate leadership have shut down the trojan horse designed to force an up or down vote on "entitlement reform" that could possibly lead to Social Security benefit cuts. But Jane noticed an interview with Peter Orszag that put "modest" benefit cuts back on the table:

Orszag’s long-running project – something that has made him the Left’s favorite Cabinet member – has been replacing talk of an “entitlement crisis” with his argument that Social Security requires only modest tax hikes and benefit cuts, while Medicare and Medicaid have much more dramatic fiscal woes.

“Social Security faces an actuarial deficit over the next 75-100 years. In the past I’ve resisted the term ‘crisis’ to describe that kind of situation,” he said. “This is not quantitatively as important as getting healthcare done.”

In steps Ezra to say that the important part of the sentence is that there is no entitlement crisis, that is, there is no thing called "entitlements" including Social Security, Medicare and Medicaid that all have the same funding problem. In fact, what Orszag has focused on all along at the CBO and elsewhere is that Medicare and Medicaid spending have the ability to destroy the federal budget, and only comprehensive health care reform can stop that. Social Security should not be in that conversation.

And you know what? They're both right! Orszag has been far more focused on health care spending as it relates to the budget, and he's absolutely right that the fiscally responsible thing to do is reform it to bring down costs (which coincidentally, would be done be eliminating the inefficiencies in delivery, namely the insurance industry). But the Diamond-Orszag plan clearly adds benefit cuts to Social Security, and Ezra's attempt to talk past that doesn't deny that reality, either. Orszag may want to end the fearmongering on Social Security by taking "entitlement reform" off the table, but he wants to do that through cutting. And that's not a liberal position. In fact, benefits ought to be increased given the collapse of the private pension system.

Jane goes after Ezra on this one.

Orszag's not running for prom king here so whether he's "one of the good guys" is not really relevant. He has been presenting his plan to cut Social Security benefits as part of the White House's efforts on "fiscal responsibility," according to people who have directly participated in those presentations. I granted anonymity in this instance in accordance with the rules followed by the New York Times, because I trusted where the information was coming from, I thought it was important to get out, and there was a valid reason (not wanting to jeopardize relationships with the administration) for requesting it.

Now Orszag confirms that reporting by doing an interview where he says he thinks Social Security requires benefit cuts. Ezra says my conclusion is "an effort to read the tea leaves to suggest that the Obama administration has a secret plan to cut Social Security benefits." I don't know what the "secret" part is.

He then goes on to tell us that what Orszag really means is that he has no intention to cut Social Security, what he really wants to do is deal with the broad question of Medicare and Medicaid as part of healthcare reform. Fair enough. But Ezra wrote a post this morning quoting anonymous administration officials on the subject wherein he granted them anonymity for no legitimate journalistic reason I can tell, because they did nothing other than give administration spin. Nobody legitimately speaking on behalf of the administration should fear retribution for doing so. Ezra transcribed this exchange with no pushback or critical scrutiny, something Glenn Greenwald has been taking Mark Ambinder to task for. If Ezra's got great sources in the administration, why is he venturing guesses about what Orszag intends? Why doesn't he go and ask them, point blank -- is cutting Social Security benefits off the table? [...]

It may be that in the wake of the horrified response Orszag got from Congressional leaders at the very thought that "fixing" Social Security has been abandoned -- these things seem to be changing by the minute. But if Ezra has valuable sources within the administration willing to speak to him about what the White House intends, there are a lot of people right now who would like to know. He should be using them to find out solid information on that front rather than float anonymous spin and then speculate about the meaning.

There are two things in conflict here - an effort to decouple Social Security with government health care spending to delegitimize the smears about Social Security, and a desire to cut benefits to put it on a path to stability (even though that's not required and an increase in the spending cap would be all that's necessary). Both of these people have enough sources inside the White House that they could get to the bottom of it. So, work the phones.

The Health Care Moment Has Its Epiphany

There's something of a consensus that Netroots Nation didn't offer enough adversarial panels and instead largely consisted of bloggers agreeing with one another. But that's not true. I personally witnessed the most adversarial panel of the weekend, and it was spectacular, because finally, both factions of the debate about health care policy on the left were able to come together and understand the political contours of the brewing fight in the Congress.

The panel was entitled "Time for Action: How the Netroots Can Lead on Healthcare Reform," and was put together by Eve Gittleson, who blogs at Daily Kos under the moniker nyceve. There's a good liveblog of the panel here, but what you need to know is that Gittleson stacked the deck. She had some great health care activists who are doing great work in different areas of the space: Giuseppe Del Priore, MD, MPH a New York cancer surgeon; Hilda Sarkisyan, whose daughter, Nataline, died after being denied a liver transplant by Cigna; Rocky Delgadillo, Los Angeles City Attorney, who is pursuing civil and criminal investigation into insurance practices; Geri Jenkins, RN a member of the Council of Presidents of the California Nurses Association/National Nurses Organizing Committee. And then Ezra Klein, associate editor for The American Prospect and a health care policy guru, appeared at the end of the panel. The aforementioned speakers were all powerful advocates. Sarkysian, whose family HAD health insurance and still couldn't get their daughter what she needed, said bluntly "This is not a good country anymore." Del Priore discussed the need for doctors and patients to handle questions of care and the need to arrest insurance executives for their crimes in denying coverage. Rocky Delgadillo outlined the schemes, like rescission (even based on spousal applications), that insurers are engaging in to maximize profit at the expense of patient care. He also mentioned how California regulators ignored a million-dollar fine to Blue Cross because they feared they would lose the case if it went to court, which is just unbelievable. And Jenkins argued that the insurance industry will play no role in reforming health care, and we need to move immediately to a not-for-profit system.

Good points all. And then Eve turned to Ezra:

Eve: Ezra, why does HCAN want to condemn Americans to this kind of system? I get confusing emails from Elizabeth Edwards and MoveOn talking about the atrocities of the insurance industry, then marginalizing the only viable solution. Can you explain this new Edwards HCAN initiative, the TV commercials, etc. . . What's it all about? What are they trying to do? It seems there are three initiatives on the table--676, Wyden and HCAN. What's wrong with Wyden and Edwards? And a follow-up...what can we realistically expect from President Obama?

I hope you don't mind that I'm sand-bagging you. I love you, really, Ezra. I just don't agree with you on this point.

This apparently startled Mr. Klein. But for him to not know the position of Eve and the CNA and an activist like Hilda Sarkysian speaks a lot to his cloistered state in Washington. Because I know all about this fight. I made one positive comment about HCAN upon their launch and took massive amounts of crap for it. I was called a defeatist and admonished for not being true to the cause. My only point was that having an organization with $40 million dollars to spend on calling out health insurers on their garbage is going to be tremendously helpful to whatever reform we get through the Congress, and furthermore I didn't see them having much of a place at the table in the policy debate. In other words they were finally an organization concerned with moving public opinion and playing the health care debate out on political grounds rather than policy grounds. And on the panel, Klein echoed the importance of politics over policy:

You can take a lot of approaches to health reform. You can emphasize policy, politics, principles, or some mix thereof. Judging from the panel, Health Care for All, and the California Nurses, could use a bit more politics in their approach. It was a panel about "health reform" -- not care or policy, but "reform" -- at a conference of engaged politicos that never mentioned the Senate, or votes, or the conditions required for presidential signature.

There was a lot of talk about "fighting" insurers and other special interests, but not much about what that fight will look like, or where it will take place, or who decides the winner. My argument, was that, for reformers, insurers aren't the real enemy. Setting them up as the opponent actually gives them too much credit. Insurers are stupid, profit seeking beasts -- the enemy is American politics, and in particular, the structural feature of the US Senate that have repeatedly killed health reform in the past. No matter what your policy preference, that's where your organizing has to be focused, because that's where the actual fight happens: In Congress. Not on panels, or on blogs, or among the Left. In the US Senate, where you have to get to 60, or at least figure out how to get rough Democratic unity for using budget reconciliation and then convince Kennedy and Carper to vote "aye" on the same bill.

This is basically the same argument Ezra makes continuously on his site, but it appeared to hit the audience like they never heard it before. And considering that it's largely the correct analysis, it was generally well-received, I thought. I spoke later with Eve, who told me that she had a conversation with someone from HCAN and "they are not the enemy." What a concept - all elements of health care advocacy on the left working together, for a change, toward a common goal.

Now granted, this week they all had a big juicy target. AHIP, the health insurance lobby, put together a fake grassroots front group called The Campaign for an American Solution. Of course, that "solution" involves funneling more cash and customers to the same broken insurance system we have now. Now, who was the very first group to coordinate a counter-attack on this front group on the first stop of their listening tour in Columbus, OH? That's right, HCAN

Well, that didn’t take long.

A day after Politico reported the health insurance industry is launching a health care reform campaign next week, the progressive reformers are firing back.

Health Care for America Now announced Friday that it plans a news conference and a rally next week to counter the insurance industry’s Campaign for an American Solution, which launches in Columbus, Ohio, on Tuesday with a roundtable discussion among uninsured locals.

“They’re pretending that the health industry represents the American public, and we need to make it really clear to them and the public that all they represent are their own profits,” said Richard Kirsch, national campaign manager for Health Care Now.

Indeed they did attend the launch, and got to ask some tough questions, confronting the head of AHIP and asking her how an insurance industry group could possibly be objective in pushing for lower rates and higher quality coverage when they are concerned solely with the profit motive. It got heated, and I'm glad they did. And all of a sudden, Daou's Triangle started closing. Rep. Pete Stark came up with a great quote:

"America's Health Insurance Plans' new 'Campaign for an American Solution' rings as true as the tobacco industry's efforts to end smoking. There is nothing grassroots about it. It is designed, financed, and coordinated through their Washington trade association with the singular goal of protecting their profits.

"I hope it is true that these companies intend to be a positive force in health reform efforts, but I tend to be cautious when the fox starts drawing up plans for a new henhouse."

HCAN called up the hotline for the Campaign for an American Solution that they set up for the public to provide input... and they got an answering machine. They've trickled this out one by one and pretty much ruined the launch of AHIP's front group. That's REALLY important for the future of health care reform. Because on the policy the views are far closer on the left than most people imagine. Everyone knows that whatever system is ultimately put forward can be paid for in a far better manner than the current wasteful, inefficient system. So expense should never be a deterrent, meaning we can build whatever system we choose and it is extremely likely to go revenue-neutral very quickly once we eliminate the shoddy budgeting of the current broken system. We know that health insurers will not jeopardize their profit margins unless they're forced to. Once you recognize these two realities, the policy goals become fairly clear. The political goals have to include attack dogs pushing back on the false memes of the right and the insurance industry, and pressuring the Senate to do the right thing.

Now Obama's plan includes some better regulation toward insurers (including guaranteed issue and community rating) and a public option to compete with the private insurance market and take the step toward a sequential single-payer. (His latest addition to the plan, a tax credit for small businesses who offer quality health care, is borrowed directly from the Clinton plan, raising hopes that eventually he'll just borrow all of it, as he should). Despite this being a fairly modest set of reforms, McCain and the right are going to denounce it as government-run "Hillarycare" anyway. So it's vital to have a broad coalition to give as good as they'll get from the right and give the lawmakers backbone to push the policy forward. Matt Stoller writes:

Coalitions are strange beasts, with multiple moving parts, but they are also the only way anything gets done. A coalition has a core of organizers behind it, and a variety of groups out in front who each take different roles. Some people can talk to Republicans, some people can talk to Democrats, some people threaten, some people cajole, some people talk to businesses, etc. HCAN is driven by labor in the form of SEIU, the NEA, AFSCME, and United Food and Commercial Workers, as well as groups primarily funded by labor such as Americans United for Change and the Campaign for America's Future. It is also driven by direct mail and Foundation based organizations, such as La Raza, Planned Parenthood, Center for American Progress Action Fund, Center for Community Change, and the National Women's Law Center.

Stoller goes on to make the point that HCAN should broaden their mandate and make this a fight about general health, and I agree. Going after convenience stores that sell fatty, sugar-laden food to kids sounds like it could be a part of their mandate. The farm bill, the transportation bill (more mass transit and more livable, walkable cities means healthier lives), and others could be brought onto the field of battle. But the larger point is that coalitions of this nature are built because they work. And the benefit is that they give lawmakers breathing space to do their job and the spine to do it right. This moment in health care demands that everyone understands the political spade work necessary to reach the desired outcome. So out of the ashes of that contentious NN panel came something pretty special. Groups across the center-left ideological spectrum working together to end the health care crisis in America and restore treatment as a basic human right.

The Ron Paul Blind Spot

Glenn Greenwald was initially a conservative. He fully admitted that in his first book. Now his views are generally associated with the left, but his takes on civil liberties and a generally non-interventionist foreign policy have a place in the Libertarian Party as well. Given that I fully understand his appreciation of Ron Paul, who as I've said is attracting so much attention because he is the only one out there offering a real critique of US foreign policy, not just as it relates to Iraq but in totality (Edwards and Obama have actually done this to an extent as well, but they're not highlighting it in the same way).

But his long screeds against anyone who dares to bring up the more unseemly parts of Paul's platform is kind of bizarre. You don't just get to pick pieces of somebody's policies when you elect somebody, and Paul comes with the paleoconservative foreign policy views AND the destruction of Medicare, the Education Department, Social Security, and practically every other social program AND the frankly weird belief in the building of a NAFTA Superhighway AND the desire to nullify birthright citizenship AND the strong anti-abortion record (which kind of upsets the whole "individual freedom" thing) AND the free coinage and abolition of the Federal Reserve AND the openly racist statements that appeal to white supremacists AND the Defense of Marriage Act. It's a whole ball of wax. And while I think nobody discounts the importance of Paul's voice in the debate, making points that would otherwise go ignored about Iraq and foreign policy forced into the national debate, these other troubling aspects of his candidacy are not off-limits.

Ezra Klein responded to Greenwald here. I really don't think they disagree all that much. But Greenwald is, I have to say, being fairly petulant. And Dana Goldstein has more.