Early in the amendment process, the panel agreed not to hold a vote until a preliminary analysis on the legislation's cost-saving potential was available, and it appears as if the CBO will not complete its work until later in the week. That would touch off yet another delay--one that's likely to frustrate Democrats and liberal activists, who've grown impatient over the glacial pace of reform efforts.
Maybe everyone's waiting for the final CBO score. But I have a couple other theories. One is that the Committee needs some time for the White House to twist the arms of Democrats wary of approving the bill for various reasons. Jay Rockefeller and Ron Wyden are particularly upset about the fate of some of their amendments in the markup, and could take it out on the bill. If both of them refuse to support the bill, it won't pass, in all likelihood, unless Olympia Snowe votes for it.
Although Chairman Max Baucus (D-Mont.) said he has the votes to pass the 10-year, $900 billion bill out of the committee, Sens. Ron Wyden (D-Ore.) and John D. Rockefeller IV (D-W.Va.) remained undecided Sunday. If all 10 Republicans on the panel vote no, two Democratic defections would be enough to send Baucus and the Obama White House scrambling to regroup.
"More needs to be done to hold insurance companies accountable, to hold premiums down for the American people," Wyden said in an interview Sunday. "I want to continue these discussions."
Committee defeat of the bill is an unlikely scenario, but one that highlights the power every Senate Democrat -- and perhaps a few Republicans -- holds going forward in a process that could stretch beyond Thanksgiving.
I think Wyden and Rockefeller think they can improve the bill down the road. But the maximum leverage is right now, before the committee vote. So they're withholding their support until they can wring some concessions. Ultimately, Baucus will probably get his votes, but he'll need a little more time. Jon Cohn looks at the five key swing votes on the Committee - Rockefeller and Wyden, plus Bill Nelson, Blanche Lincoln and Olympia Snowe.
I have a guess that there may be another factor, however. Kent Conrad has made no secret of his disdain for the reconciliation possibility. If it did go that route, requiring only 50 votes, we may end up with a bill that, in some key parts, wouldn't even get Conrad's vote. So he's been trying to sabotage it for some time. The more the delays continue, the more that the deadline of October 15 for reconciliation comes into play. Before long, the Senate committees would have to begin that process. Conrad doesn't want that to happen. Neither does Baucus, in all likelihood, since it would lessen the power of his more centrist bill. And they've been delaying ever since. Given that there are so many issues that will need to be decided by the leadership when they merge the bills, the Finance Committee has probably already delayed the vote long enough to make reconciliation an impossibility. Mission accomplished.
Last night, Blanche Lincoln and Kent Conrad, who like to fancy themselves fiscal conservatives and whose entire rhetoric about health care has concerned "bending the cost curve" and reducing the price tag in the bill, joined with Republicans to hand up to $250 million dollars to states to teach children that sex is icky.
The Senate Finance Committee on Tuesday night approved an amendment providing tens of millions of dollars to fund abstinence education programs for teens.
The proposal, offered by Sen. Orrin Hatch (R-Utah), would provide $50 million per year through 2014 exclusively for abstinence education programs. The measure would effectively reinstate the controversial Title V program, which offered $50 million per year to states for abstinence education, but prohibited them from tapping the funds for other sex-ed subjects like contraception. The same prohibition would accompany the Hatch amendment. “Abstinence education works,” the Utah Republican said.
The vote was 12 to 11, with Democratic Sens. Blanche Lincoln (Ark.) and Kent Conrad (N.D.) voting with every Republican to secure passage of the measure.
Abstinence education doesn't work, this California Democrat says, backed up by every study ever done on the subject, including a 6-year study authorized by Congress that published in 2007. Even Max frickin' Baucus agrees, and his competing amendment on comprehensive sex ed, which also passed, wouldn't fund programs that were in his words "ineffective." Suzy Khimm has more on this.
I'm sure that giving in to Republican fears about liberated women, whether through this measure or trying to gut reproductive coverage in private insurance plans (thankfully, that amendment did fail in the Finance Committee today), will cause members of the party who don't think women should have the right to vote to flip on the bill and offer their support, right? We're just so close to consensus, and if we can just add to that 80% agreement with selling out women and futilely indoctrinating children to abstinence, we can all sing kumbaya and have a bill everyone can support, right?
Wrong. Republicans like Orrin Hatch will ask for concession after concession and offer nothing themselves. That's because they know that stooges like Blanche Lincoln and Kent Conrad will end up agreeing with them anyway, so there's no need to take ownership of the bill when you can own it by proxy.
Slightly off-topic, but this is a great story about 1,100 religious left leaders calling abortion "a moral decision" and demanding that women's rights not be sacrificed in the health care debate.
Those who have been paying attention understand that today was actually a pretty good day for the public option. We learned that Sens. Wyden, Carper and Nelson (FL) support it in some form, and that there are at least 51 votes for it in the Senate. However, yesterday Chuck Schumer did acknowledge that there aren't 60 votes at this time. Ezra Klein asks the right questions:
There are two questions here. The first is "60 votes for what?" Do they not have 60 votes in favor of a health-care plan that includes a public option? Or do they not have 60 votes against a filibuster of a health-care plan that includes a public option? If it's the former, that's okay: You only need 51. If it's the latter, that's a bigger problem. But I'd be interested to hear which Democrats will publicly commit to filibustering Barack Obama's health-care reform bill. If that's such a popular position back home, why aren't more Democrats voicing it loudly?
Second, why give up the public option now? If these moderates want to kill the measure, let them get full credit for doing so on the floor. They can sponsor an amendment to strip it out of the final legislation and go home to their districts having played a clear and undeniable role in the elimination of the public option.
The former is really the question. There are definitely 51 votes for a public option. It's unclear whether there are 60 for a final bill with a public option. And more specific than that, are there 60 to allow a vote on a final bill with a public option?
Mary Landrieu has come the closest to saying that she would filibuster a bill with a public option. Ben Nelson and Joe Lieberman are probably right with her. But I'd sure like to see them try to defy the President and doom a health care bill 40 years in the making over one provision. Reconciliation is always an option, given that you would only need 51 votes, but it's highly unlikely to get a public option that way. The main reason is that the Budget Committee would control the process, and Kent Conrad just voted against public option amendments yesterday, and would be highly unlikely to allow one to go through a 51-vote process. Heck, he doesn't want reconciliation at all. So Chris Bowers surmises that Harry Reid and the White House are the real pivot points right now, when the Senate merges the bill from their two committees:
The next step in the process does not actually involve Kent Conrad's Budget Committee, as I had previously reported (the Budget Commitee only comes into play with reconciliation). Instead, a source on the Hill confirms to me the Senate HELP and Senate Finance committees will be merged by an informal, behind the scenes process involving the four major players in the Senate: Tom Harkin (Chair of HELP), Max Baucus (Chair of Finance), Harry Reid (Majority Leader), and the White House. Together, these four will meet and decide what sort of bill to send to the Senate floor for debate and amendments.
During this process, we can guarantee that Harkin will push for a HELP or Schumer-like public option to be sent the floor, while Baucus will push for no public option to be in the bill at all. Given his recent statements, the best bet is that Reid will probably push against a public option too, and instead favor either triggers (which he has called a good idea) or co-ops (which seems to be the sort of public option he likes best). With two against and one in favor, this means that the only way a public option ends up in the bill that is sent to the Senate floor will be if the fourth major player, the White House, demands it. It is all up to the White House now. If it pushes for a public option to be included in the health care bill sent to the Senate floor, then a public option will pass as part of health care reform (at that point, all we would need are 60 votes for cloture, and from what I hear we have 57 already). However, if it allows a health care bill to go to the floor without a public option, it is pretty unlikely that a public option will pass as part of health care reform.
Bowers doesn't think any floor amendment would need less than 60 votes, and while there are conflicting reports on that, he's probably right. He also doesn't think conference committee is an option, but I'm not sure I agree there. The House will almost certainly pass a bill with a public option. So it would depend on the White House umpiring that argument in committee. And that will almost certainly be decided by what they think can pass. If the Progressive Block in the House holds firm, and looks like a higher mountain to climb than getting 3 Democrats just to flip on cloture, the White House could go the other way at any step of this process.
Instead, the very same Democrats who defeated the national program during mark-up, will likely resurrect a discarded idea floated by the New America Foundation and momentarily embraced by the White House. That compromise will create a network of public options modeled on state employee benefit plans. The proposal could be triggered by Snowe’s amendment if reform did not meet a low affordability measure, but any state-based proposal would lack the market clout to lower overall health care spending, reform health care delivery, or hold private health insurers accountable.
Today may have been the death of the public option and the birth of state-based public options.
State-based plans won't have the economies of scale to really pressure insurers, but neither would Schumer's "level playing field" public option. Therefore, given that we're going to have to improve whatever inevitably comes out of the legislation, I'm inclined to say this is better than nothing. Apparently Tom Carper has started floating this behind the scenes.
I'm not as optimistic as Robert Creamer, but I do think that the public option still has a chance to survive in some form, and can be improved after the fact.
Sherrod Brown sez that, contra Rahm Emanuel, no Democrat will vote with Republicans on a filibuster to kill the health care bill, even if it includes a public option.
Brown should go have a talk with Kent Conrad (D-ND). Ezra Klein just did, and I don't know how he got through it without banging the telephone against his ear until it hurt. That Conrad displayed an unconscionable ignorance, as well as an arrogant belief in his own falsehoods, would be normal if he were a teabagger attending a town hall. That he's a Democratic United States Senator fills me with nothing so much as fear.
Conrad raised eyebrows this week when he told the Senate Finance Committee that the health care systems of countries like France, Japan and Germany should be models for the United States because they aren't "government-run systems," even though the government intrusion into those systems is far greater than anything this country is contemplating, even with a public option. Conrad got this from a book he read over the weekend, T.R. Reid's "The Healing of America". That's right, the chair of the Senate Budget Committee, a leading voice on the Finance Committee and a member of the Gang of Six, who has been working on health care for months if not years, JUST DECIDED to look into how other countries around the world manage their health care systems.
Klein started by asking Conrad what he was talking about with respect to France and Germany:
But that runs over some fairly large variations. In France, for instance, the insurance really is government-run. The vast majority of people are on public insurance, and there's private supplementary insurance atop that. So too with Japan. They're not confined to simply subsidizing the poor.
But it's not government-run. The doctors and hospitals are private. You're right that in France there's more of a government involvement beyond providing money for those who can't afford coverage. There's a regulatory involvement in terms of what's required by the plans. But the plans themselves, the mutuals, are not government.*
You're talking about France here? Not Germany?
Both of them. The intermediaries are not-for-profits. The model is universal. Employers contribute. Reid says we are in part a Bismarck model, where employers contribute. Part which is that Beveridge model, like the Indian Health Service and the Veterans Health Service. We have a national health insurance model with Medicare. And then out-of-pocket for people with no coverage. We have a real mixed system. We really don't have a system. That's kind of what you get down to.
Klein puts an asterisk there, kindly not telling Conrad on the phone that he's totally full of it. Basic insurance in France is provided through a government program called Social Security. The mutuals only deal with supplementary private insurance.
Conrad segues into the "innocent bystander" approach to policymaking, renouncing his status as a US Senator and just marveling at how the universal "we" balk at changing the health care system:
But we decided not to change that much. The real lesson from Reid's book is that we do this badly. If the French came up with a great new medical procedure, we wouldn't say that's just some French procedure. We'd adopt it. But when they come up with a better way to do health care, we dismiss it as French, and inapplicable.
Yeah. We don't want anything to do with it. He talks about that in the book. It's an odd thing.
Sure is! If there were only a US Senator who praised T.R. Reid's book, who could draw a lesson from it about acting boldly and not getting caught up in nonsensical American exceptionalism! Wherever could we find someone?
After some talk about Medicare and the Clinton 1994 plan and the Gang of Six ("We had 61 meetings!"), Klein moves to the public option, and here Conrad reveals his true grievance:
Do you support the public option?
No.
Why?
I go back to the T.R. Reid book. I don't think a government-run plan best fits this culture. A plan that's not government-run has the best chance of succeeding in being passed into law.
Second, and this is very important to my thinking, the public option as defined by the committee of jurisdiction in the House, the Ways and Means Committee, is tied to Medicare levels of reimbursement. My state has the second-lowest level of Medicare reimbursement in the country. If my state is tied to that reimbursement, every hospital goes broke.
People say, "Just fix it." I've been on the Finance Committee more than 15 years. I've been trying to fix the unfair aspects of Medicare reimbursement all the time. We run into the House. Membership is determined by population, and the big population states write levels of reimbursement that unfairly treat hospitals in states like mine. My hospitals get one-half as much as urban hospitals to treat the same illnesses.
What about a public plan that can't use Medicare rates?
There are discussions going on about that. Obviously, it would be very important that it would be clear that it's not tied to Medicare levels of reimbursement. Those of us in low-reimbursement states would have our health infrastructure put at risk.
For all of Conrad's talk about "uniquely American systems" and "not fitting the culture," what Conrad wants is a full-on handout for providers in his state. He wants the Medicare reimbursements to go higher for North Dakota. There's probably a point where they get high enough that he can tolerate the government intrusion. He's essentially calling for a bribe.
And mind you, this is the deficit hawk chair of the Budget Committee, whose entire goal in health care reform is to "bend the cost curve." Now, raising reimbursement rates for rural areas would, of course, INCREASE HEALTH CARE COSTS across the system. But Conrad thinks it's terribly unfair to his doctors to get less than urban hospitals to treat the same illnesses. Has anyone asked Conrad about the cost of living in North Dakota as opposed to New York City?
Then, Conrad whines about that damn House of Representatives where "membership is determined by population," as if the majority should be allowed to rule or something!
Conrad, of course, is also protecting his boomer baby idea of co-ops, which he pulled out of thin air after meeting with the CEO of UnitedHealth Group. Blue Cross of North Dakota, which covers 90% of the market in Conrad's home state, would qualify as a non-profit to be a co-op and receive millions in seed money. Again, payouts are the goal here. Klein asks Conrad why the co-ops in the Finance Committee bill are so weak, leading to this incredible exchange:
I was also struck when I read the chairman's mark that the co-op option seemed shackled. It couldn't sell to large employers. It couldn't set payment rates. The co-ops are not public. But they were being prevented from competing with insurers on a level playing field. It seemed like private insurers were being protected from competition.
I think there are things I would like to see that would make certain co-ops be given the full ability to compete that others are.
So you would like to see those restrictions lifted.
I would.
Why are they there?
Because that came out of the Group of Six discussions.
I have no words.
OK, I have a couple. The Group of Six discussions FELL APART, and yet the useless co-op plan, which Conrad admits he does not like, still comes out of the language from those meetings. Why? I'd have to guess that Conrad doesn't care that the co-ops won't work, as long as Blue Cross of North Dakota gets their seed money.
Kent Conrad wants things his way. He's turning out to be as devious as anyone in the Senate. Brian Beutler reports on his effort to get the health care bill outside the window for reconciliation, which is the clear intent of this stalling tactic:
Sen. Kent Conrad (D-ND) indicated today that there may be major delays in the health care process going forward. During today's health care hearing, he told CBO chief Doug Elmendorf today that the Senate Finance Committee must be provided with a complete CBO score of the final package before the panel can hold a vote on it.
"With respect to the issue of when scoring might be available, because...it is critically important that we have scoring before a final vote is cast in the committee," Conrad said, "it is important for us to know, once there is a package, after the amendment process here, can you give us some rough estimate, in days to have a CBO score."
How long will that scoring take?
Elmendorf estimated that the full reporting could take two weeks:
"I think we can update our preliminary analysis...within a few days of the package actually being set. A formal cost estimate would require...two weeks of work by us, once the package is settled."
Conrad ultimately suggested that the committee could hold its vote on the basis of the preliminary analysis, but that two week window would presumably still apply to progress beyond the committee's vote. It would, after all, take a similar amount of time to complete a final cost estimate of the package that ultimately comes to the Senate floor.
Kate Pickert has more on this, though she curiously removes Conrad's name from it. He does appear to be the prime mover. He never agreed with the option of reconciliation, and if he can push the bill past October 15, a sort of deadline for that process, he can assure that all the legislation would have to move through a 60-vote process. Since nobody is suggesting that a public option has 60 votes in the Senate, it would essentially doom that measure, and boost Conrad's preferred co-op option, which would give millions in seed money to Blue Cross of North Dakota, which has 90% of the state market, because they could conceivably as a non-profit pass for a co-op.
It's not that Conrad really cares about the score of every item in the health care bill - after all, when the CBO produces a score he doesn't like, he's happy to ignore it.
When the Star Tribune asked Conrad if he agreed with CBO director Doug Elmendorf's conclusion that, "They seem unlikely to establish a significant market presence in many areas of the country," Conrad answered:
I do not agree with the Mr. Elmendorf's assessment on co-ops. Based on the advice of leading actuaries, we are providing enough federal seed money for these co-ops to insure 12 million Americans.
If Conrad doesn't care what the CBO assigns to his own preferred policies, why should it matter to get a complete score before voting the bill out of committee?
Conrad laid it on thick yesterday, trying to use the experience of countries like France, Germany and Japan - which do things like guarantee a baseline level of coverage for all citizens and ban insurance companies from making a profit - as proof that no government-run program is needed. But of course, Conrad's conception of health care reform bears no resemblance to those systems at all, and a public option offering baseline care at an affordable price actually does.
Harry Reid's still out there talking about reconciliation if 60 votes cannot be attained. Is it worse if he doesn't know that Conrad is pulling out the rug from him, or if he knows?
...Olympia Snowe supports this delay as well. Amazing that the two Senators with lots at stake in their own non-public option alternatives would want to delay the bill past the reconciliation window! Ezra notes that this kind of delay would be unprecedented in the history of the Finance Committee.
...This amendment was defeated. Blanche Lincoln voted with the minority, but Conrad didn't.
Boy, Max Baucus (R-MT) sure knows how to make friends and influence people, doesn't he? He bends over backwards to please Republicans and they spurn his bill. In the process he alienates Democrats, who now... hate the concessions made in his bill and don't understand their purpose, given that it brought no Republicans along. He had to stand alone to announce his bill because nobody wants to be associated with him. Not even Kent Conrad, his best bud because he included his industry-sponsored weak co-op plan, wouldn't take the dais with him. He's become such the public face for Democratic incompetence that his very name leads to boos at Democratic events:
Workers are chanting "bullshit!" at the mere mention of Baucus' name at labor events. Health care advocacy groups use his name as a punchline, if not an obscenity. He's literally gone from the most important man in the room on health care to a potentially irrelevant one.
A dealmaker needs credibility and respect on both sides, and Baucus has lost it. The Democrats on his committee don't trust his instincts or his core commitments or his legislative skill. Nor do the Democrats outside his committee. They feel he gave away too much in return for not just too little, but nothing at all. That means the Republicans on his committee have further reason to distrust his ability to make a deal, because restive Democrats are going to want to change his bill. Meanwhile, House Democrats are enraged that he left them to suffer through August, and have little interest in passing a bipartisan compromise that doesn't come with any Republican votes [...]
Even within his committee, it's not obvious he can secure the votes of the liberals, and if he does, he almost certainly sacrifices Snowe. That means the White House and the Senate leadership are going to play the primary role in both offering concessions and guaranteeing their preservation in the process. The bill remains in Max Baucus's committee, but at this point, it's largely out of his hands.
That's a good thing, on balance, for supporters of real health reform. The media still acts as if Baucus' bill is the final bill, but that's not quite the case. His bill would require substantial changes before he could even get a majority of the vote in the Senate. And there are plenty of areas for improvement:
• Subsidies. The Baucus bill is simply not affordable. Forget everything else about health care - if the coverage isn't affordable for Americans to buy into it, the reforms won't work. It won't be universal, shrinking the risk pool, and insurers will want to deny coverage or care to maximize profits in that lower risk pool. The Center for Budget and Policy Priorities tells you pretty much what you need to know. This amounts to a $140 billion dollar tax on the middle class.
One reason the Baucus bill is “cheaper” than the House bill is that it has lower subsidies. For illustration, let’s assume that the whole $140 billion difference is due to lower subsidies. Relative to the House bill, then, the Baucus bill costs the government $140 billion less; but it costs middle-income people exactly $140 billion more, since they have to buy health insurance. The difference is that in the House bill, the money comes from taxes on the very rich; in the Baucus bill, it comes out of the pockets of the middle-class people who are getting smaller subsidies. Put another way, the Baucus bill is the House bill, plus a $140 billion tax on people making around $40-80,000 per year. That’ s not only stupid policy; it’s stupid politics.
• Bad Employer Incentives. The lack of an employer mandate, replaced with a terrible "free rider" policy, is completely unacceptable. Whether you believe that it incentivizes employers to not hire low-income workers, or that it incentivizes large employers to keep wages down so they can push their employees off onto Medicaid, employers have clear, giant loopholes that they can exploit to make life for their workers objectively worse.
• No public option. The co-ops are crap. Almost worse than useless. Everyone knows it. The CBO admits it and they've been practically writing the bill with Baucus.
"Liberal Democrats fumed that Baucus had dropped the idea of a government-run insurance plan to compete with private insurance companies in favor of a national network of member-run cooperatives -- an alternative the CBO said seems "unlikely to establish a significant market presence in many areas of the country."
There is no mechanism for competition with the private insurance industry, which the President has viewed as a fundamental principle.
Now, the Baucus bill does do a couple OK things. It raises a decent amount of revenue through excise taxes on industry, a back-door way to cap the employer deduction. It reduces the deficit. And it provides for a gradual shift away from employer coverage and toward the exchanges, although that shift could happen quicker, similar to what Ron Wyden is proposing.
The fact that the President spoke with Jay Rockefeller, the leading critic of the Baucus bill and its co-ops, as well as Wyden and Bob Bennett, who hold the bill that would move away from the employer-based system, tells me that he's actually looking to improve the Baucus draft down the road in the process. As Matt Yglesias said today, this is tailor-made for the conference committee process:
Viewed optimistically, this is what conference committee is for. Each version of the legislation is audacious along one axis—committing major funds to affordability in the House, trying to take a serious whack at cost growth in Baucus—and a conference committee could meld them into a bill that does both. You could imagine a productive meeting that produces the kind of result I’m talking about that lets Mike Ross walk out and say he added tough cost controls to the bill, while Jay Rockefeller gets to walk out and say he beefed up affordability, and then Max Baucus and Henry Waxman get to congratulate each other on being masters of legislative compromise. Alternatively, of course, the whole thing could fall apart. But ultimately my point would be that both version of the legislation have strong points that could be combined into some very good legislation indeed.
Absolutely, though admittedly we don't live in a perfect world. For example, you could add back in the President's shift on charitable deductions from 35% to the 28% it was in the Reagan Administration, which would impact pretty much nobody and save $350 billion over 10 years, plow that into subsidies, and call it a day. The bill would remain fully paid for and everybody would be happy.
Ezra has some further thoughts on this. I would just add that the President knows he owns this bill, so regardless of whether or not it would make the insurance industry mad, he needs to get this right so it works for people.
When I first read this story about Kent Conrad increasing the budget window for health care reform to 20 years, I thought it would actually help the cause. Most experts predict that the savings would come in the later years, and so those could be built into the reform from the start, producing a favorable budget score. Then I thought about how the CBO was unlikely to measure savings 20 years down the road, and typically in those cases they punt and score them as zero. Which means that the outlook would appear far worse in a 20 year window than in a 10 year one. And the President has vowed deficit neutrality in the bill. So this would mean that, if the President and the Congress adhered to CBO numbers, some substantial increase in revenue or cut to the overall cost of the bill in the short term. Ezra Klein has more.
In other words, he thinks the CBO is underestimating the savings that reform will deliver, but he wants to see those savings underestimated over a longer period of time, which will make the total gap between the revenues the CBO predicts and the savings it misses appear larger. It's a bit like the restaurant review from "Annie Hall": The food was terrible, and such small portions!
The end result is likely to be a new hurdle for health-care reform: a CBO report that makes the bill's total cost sound higher, as it's measured over 20 years, and its savings seem smaller, as they're underestimated over 20 years. The Huffington Post caught up with Conrad and asked him whether this would kill the reform effort. "No," he replied, "but it makes it more challenging." The question is why Conrad wants to make health-care reform more challenging.
This is the same Kent Conrad who voted for the Medicare Modernization Act in 2003, which added $600 billion dollars to the deficit and was financed with nothing but debt.
There are three possibilities for this. One is that the 20-year projections will look bad, but not as bad in Max Baucus' bill, and Conrad is just putting his thumb on the scale for it. Two is that Conrad wants to embarrass the Congressional Budget Office in 20 years, which doesn't make sense because the CBO Director was a close colleague in the Gang of Six meetings, and also Kent Conrad isn't likely to be alive in 20 years. Three is that Conrad is just a bastard who senses health care reform slipping away from his grasp and wants to drive a stake through it.
I don't know what I vote for yet. I do know that it's time to end the tyranny of Congressional Budget Office numbers. For certain things they do a good job. For long-term projections they are admittedly conservative and uncertain, and when they don't have a clear answer, they assume zero, which distorts potential savings. The Institute of Medicine thinks the CBO is misreading the numbers and wants their numbers to take precedence.
The U.S. can cut health-care spending by $250 billion a year within a decade, a congressionally chartered panel will say this month in a bid to show costs can be contained even if all Americans are insured.
A report from the Institute of Medicine, which advises the federal government on health care, will counter “stingy” estimates from the Congressional Budget Office, said Arnold Milstein, planning chairman of the institute’s working group on health costs. The panel’s annual figure is five times the amount the budget office says the U.S. will save under a bill in the House of Representatives, according to the budget office’s July 17 letter to House Ways and Means Committee chairman Charles Rangel.
The preliminary findings from the institute, part of the National Academies in Washington, will be issued amid a growing debate over the health-care overhaul proposals that President Barack Obama is urging Congress to pass. The report will help bolster the argument that covering the nation’s 46 million uninsured won’t bust the budget, advocates of the bill say.
“The institute will make it very clear that we are right,” said Senator Benjamin Cardin, a Maryland Democrat who backs health legislation because he says it will save money. “It gives us the lift we need and the encouragement to say, ‘We’re right to do this.’”
The CBO numbers set the benchmark in Washington. But there is no balanced budget amendment, so their numbers don't carry major import. They're just what media and politicians use to identify the costs and savings in bill. It's not etched in stone, and as the Institute of Medicine shows, it can frequently be wrong.
Maybe this is part of Kent Conrad's devious plan. But more likely, he's one of these fiscal scolds who only come out under a Democratic President to thwart a progressive agenda.
John Aravosis uncovers an amazing nugget in TIME Magazine. Apparently, there are Democrats who saw Rep. Joe Wilson yell "You Lie!" at the President of the United States and thought, "that guy has a point." And they happen to be the ones writing the health care bill in the Senate Finance Committee.
The controversy over Republican Rep. Joe Wilson's shouting out "You Lie!" at the President over his claim that illegal immigrants wouldn't benefit from health-care reform apparently sparked some reconsideration of the relevant language. "We really thought we'd resolved this question of people who are here illegally, but as we reflected on the President's speech last night we wanted to go back and drill down again," said Senator Kent Conrad, one of the Democrats in the talks after a meeting Thursday morning. Baucus later that afternoon said the group would put in a proof of citizenship requirement to participate in the new health exchange — a move likely to inflame the left.
So many things wrong with this, starting with caving to an extremist. But it's worse than that on the policy end. The exchanges are just health insurance purchasing centers, like a Wal-Mart for insurance. You don't have to receive a subsidy to buy insurance on the exchanges; in fact, if your family makes over $88,000 a year, you can't be eligible for a subsidy, though you can still purchase there. What Conrad is saying is that he would make it illegal for a non-citizen to BUY something.
Not only that, but proof of citizenship laws, which we don't have in most states for voting, are onerous and disproportionately tilted away from the poor and the elderly, as well as potentially restrictive to legal immigrants with green cards, in this case. As the New York Times says today:
Should we take a harder line? Force people to prove citizenship in emergency rooms? That’s illegal, for good reason. Make verification requirements so onerous that not a single illegal immigrant slips through? Very expensive, and not smart. It would be highly likely to snag deserving citizens — like old people who don’t have their original birth certificates. And besides, we’ve tried that: A House oversight committee reviewed six state Medicaid programs in 2007 and found that verification rules had cost the federal government an additional $8.3 million. They caught exactly eight illegal immigrants.
In the case of an epidemic, like swine flu, should illegal immigrants go untreated so they can infect legal residents and American citizens?
Hard-line Republicans insist that they will fight for citizenship verification. They could, in theory, get the country to spend whatever it takes to do that and proudly report back to their voters. But there is a line beyond which antipathy to the undocumented can be damaging to those voters’ health, not to mention the federal budget. Mr. Wilson and his admirers seem to have crossed it.
Not to mention the fact that buckling to these demands will not get one Republican vote on any health care bill.
This is the Senate Finance bill, not the overall bill. But Democrats are so wishy-washy when it comes to, well, anything, that we actually could see this rotten, xenophobic, piss-poor policy in a bill supposedly designed to expand access to health care.
I know a lot of money has been flowing to Joe Wilson's opponent in 2010, but a far better use of those dollars would be to funnel them toward primary opponents for Kent Conrad and Max Baucus.
UPDATE: Conrad is now clarifying that there would be no federal subsidies, and requiring proof of citizenship would just be used to determine qualification for government assistance. Of course, you end up with the same problem, then; those without proper proof of ID would have trouble getting subsidies that could be available to them. The larger point is that there was no need to react to a teabagger yelling and screaming. This was already implicit in the bill, and allowed for the HHS Secretary to determine a best practice. This blunt instrument is not the way to do it, and makes Democrats look weak (but that's redundant).
UPDATE II: As this GAO report notes, checkpoint systems like Baucus and Conrad want were implemented under the Bush Administration to ensure undocumenteds didn't get on Medicaid, and for every $100 they spent, 14 CENTS in Medicaid savings were achieved. It's wasteful and spiteful!
The six-headed Presidential hydra, also known as the sub-group in the Senate Finance Committee, has decided to ignore everybody and keep working diligently to do absolutely nothing on the health care bill.
Senate health-care negotiators agreed late Thursday to ignore the increasingly strident rhetoric from Republican and Democratic leaders and to keep working toward a bill that can win broad support from the rank-and-file in both parties, according to sources familiar with the talks.
In a conference call, the three Democratic and three Republican members of the Senate Finance Committee agreed to redouble their efforts to craft a less costly alternative to the trillion-dollar initiatives so far put forward in Congress. They discussed the possibility of also reining in the scope of their package, the sources said.
The senators rejected the idea of imposing a deadline on their negotiations, and they agreed to talk again Sept. 4 -- four days before lawmakers are scheduled to return to Washington from their August break. The consensus, one participant said, was "to take your time to get it right." [...]
Before leaving for the month-long recess, Baucus had pegged the cost of the negotiators' ideas at less than $900 billion over the next decade. Thursday's discussions focused on driving that cost lower, the sources said.
Their draft bill was already woefully short in terms of subsidies for those who can't afford insurance. The Gang of Six wants to drive them even lower.
I'm sure the people most enamored of themselves did reject having a timeline on their circle jerk. But look who is making these decisions. Chuck Grassley has basically said he'd vote against his own bill, even if he gets everything he wants, if he cannot get more than 80 Senators total on board. The #2 ranking Republican in the Senate has already said that votes for reform aren't coming. So Grassley, one of the key negotiators here, has admitted that he won't support anything the Gang of Six does. Mike Enzi is probably stronger in that direction. Olympia Snowe admitted today that the public option was never on the table in this Gang of Six, and that co-ops are worth exploring, even though two months ago she called them worthless. Kent Conrad has been ideologically opposed to the public option for as long as anyone can remember, and came up with co-ops, in all likelihood, as a way to steal seed money for the "non-profit" Blue Cross of North Dakota, which has captured 90% of the market in his home state. Max Baucus admitted as far back as March that the public option was nothing but a bargaining chip. Jeff Bingaman hasn't been getting nearly enough heat for being part of this charade, but he has talked the talk on co-ops as well.
These six Senators, who come from states representing 2-3% of the population, have proposed ideas out of step with 77% of the public, and think they're entitled to hijack the entire process in Congress to serve those ends.
The question is what to do about this. 270,000 people listened to the President's strategy session yesterday, and over 5,600 supporters have contributed almost $350,000 to lawmakers standing up for the public option. These six lawmakers, most of whom probably want no bill at all, know that the longer they hold up the process the harder it becomes to pass anything. Harry Reid needs to use whatever means necessary to force a bill out of the Senate - discharge petitions, going around the committee of jurisdiction, whatever. At that point, we're talking about a conference committee. Which is what Obama has asked for all along. The problem is a matter of trust, as Paul Krugman put it today.
...Chris Bowers is right that this is the worst part about it - the Senate Finance Committee has decided to take two additional weeks off before meeting again. They are so bound and determined to get health care right that they'll do nothing for weeks, presumably in the hopes that health care reform will die on the vine and they won't have to do anything at all.
If you're going to create a substitute for the public option, it would be a good idea to know what it actually does before presenting it to the nation as the substitute.
The White House has indicated that it could accept a nonprofit health care cooperative as an alternative to a new government insurance plan, originally favored by President Obama. But the co-op idea is so ill defined that no one knows exactly what it would look like or how effectively it would compete with commercial insurers [...]
As the debate rages, lawmakers are learning that creating cooperatives — loosely defined as private, nonprofit, consumer-owned providers of health care, much like the co-ops that offer telephone, electric and other utility service in rural areas — will not be easy.
The history of health insurance in the United States is full of largely unsuccessful efforts to introduce new models of insurance that would lower costs. And the health insurance markets of many states suggest that any new entrant would face many difficulties in getting established.
Here's some more good news: Kent Conrad, the brainchild of this idea, admitted today that co-ops won't bring down the cost of premiums for individuals, unlike the public option. Which would be the point.
ROBERTS: What would they do to reduce costs? Because that is one of the central issues of health care reform.
CONRAD: Well, the important thing is they’d provide more competition. … Beyond that, I think it’s very important not to over-promise here. [...]
ROBERTS: So nothing really in driving down the costs of service then?
CONRAD: Uhhh, no. If you believe competition helps drive down costs, then they would certainly contribute to holding down costs.
A note on how these would affect "competition" - in Conrad's home state of North Dakota, Blue Cross Blue Shield emcompasses almost 90% of the health insurance market. And they're a non-profit that thinks they can qualify as a co-op, under Conrad's rules, making them eligible for some of the $6 billion in seed money, I presume. Amazing that Conrad's plan and the dominant insurer in his state match up almost perfectly, ain't it?
The co-op model should be seen for what it is, protection of the insurance industry. Which makes sense, considering how many Senators are in bed with those interests, in some cases quite literally. And given that the industry and their Republican representatives in Congress will STILL oppose co-ops, learning from the lesson that making a ruckus will cause Democrats like Kent Conrad to give up whatever benefit to the people can be managed in exchange for nothing, you can pretty easily see an outcome where even the weak co-ops are given no ability to come into existence, the way it happened in Iowa:
In the 1990s, Iowa adopted a law to encourage the development of health care co-ops. One was created, and it died within two years. Although the law is still on the books, the state does not have a co-op now, said Susan E. Voss, the Iowa insurance commissioner.
Wellmark Blue Cross and Blue Shield collects about 70 percent of the premiums paid in the private insurance market in Iowa and South Dakota.
Conrad keeps saying that there aren't the votes for anything but his favored idea, but no Senator has come out and said they would join a Republican filibuster of health care reform under any circumstances. Until we reach that point, 60 votes - and maybe some combination of the Maine two - remain in play. Sounds like a better scenario to me than one where 60 House progressives have already said they won't vote for anything without a public option. Mr. Emanuel, are you paying attention? Are you doing the math? Or are you reading the LA Times?
Co-Ops Are the Single Dumbest Idea I Have Heard in the Health Care Debate in Twenty Years
OK, let’s start with the notion that a co-op can do a better job of negotiating prices and protocols. But wait, on day one how many members does the co-op have? Well it has no members on day one. So, the co-op's provider relations guy goes to the doctor and hospital administrator and demands better prices and protocols. My guess is the provider’s response would go something like this, “So you are here because your stated objective is to screw my reimbursement down more than it is, you have no members now, and if I give you the rates to take members away from the existing health plans you are going to make life even more difficult for me than those existing health plans have?" My guess is that when the provider stops laughing…
Last week, we learned about astroforging, the practice of corporate lobbyists forging letters from local advocacy groups that line up with corporate goals. More evidence has been uncovered today showing the widespread nature of this practice.
Joseph Richardson received a letter from Sen. Kent Conrad (D-ND) in reply to a letter that he never sent:
Richardson never wrote such a letter, and he never would. Calling himself a “vocal member” of the North Dakota Alliance for Renewable Energy, Richardson told ThinkProgress that he is an ACES supporter and even wrote a letter to Rep. Earl Pomeroy (D-ND) calling on the congressman to support clean energy reform.
Bonner and Associates, the company nailed initially, has been engaged in this deception for well over 20 years. And as long as they got away with it, I'm sure they'd continue. It turns out that Bonner is linked to the clean coal lobby:
The Sierra Club today urged Attorney General Eric Holder to launch an investigation into the activities of a lobbying firm that has been linked to fake letters urging Rep. Tom Perriello (D-Va.) to vote against the climate bill [...]
The request stems from a newspaper report last week that Bonner & Associates sent letters to Perriello's office that were made to look as if they came from Creciendo Juntos, a Charlottesville-based Hispanic advocacy group. Perriello staffers also received similarly worded letters that were designed to look as if they came from the Albemarle-Charlottesville branch of the National Association for the Advancement of Colored People.
The letters, which urged Perriello to oppose the House climate bill ( H.R. 2454 ), used the letterhead of the two groups but were signed by individuals who are not affiliated with the organizations ( E&ENews PM , July 31).
The group American Coalition for Clean Coal Electricity acknowledged this afternoon that it had contracted Bonner & Associates earlier to perform "limited outreach," but the advocacy group denounced the firm's actions.
It's insane that Democratic lawmakers are going out of their way to label the August recess as "consequential" for health care based on the reaction of constituents in districts, when this nasty little episode shows how it's all just theater and lies.
UPDATE: Think Progress has corrected this story. Conrad's office miscategorized their response letter. The Perriello set of letters, however, are certainly real, which is to say fake. Brad Johnson has more.
In my (bungled) attempt to look at drug company advertising, I noted that the House Ways and Means Committee looked at, then discarded, the option of cutting out their deduction for advertising as a business expense to help pay for reform. One commenter rightly observed that this is a function of having to scrape for cash anywhere it can be found to pay for a policy that must remain deficit-neutral within a 10-year budget window, despite numerous up-front costs, and a completely artificial ceiling placed on how much can be spent in those ten years.
For a while now, the conversation about health care has been all about costs--in particular, the cost to the federal government. Somewhere along the line, somebody decided that health reform shouldn't involve the government sending out more than $1 trillion over ten years, even if we can provide that much money through some combination of higher taxes and savings in the medical care system.
There is no magic reason why $1 trillion should be the theshold. My colleague Jonathan Chait recently suggested that it's all because of way our bodies look. If we all had twelve fingers and toes rather than ten, he said, the magic number would be $1.2 trillion. I guess that would mean it's god's fault.
My own theory is that conservatives and centrists complaining about the price of reform don't think guaranteeing affordable coverage is really so important. I include among them a certain Democrat from North Dakota who runs the Budget Committee and keeps talking about what we can't afford to do. To be clear, Senator Kent Conrad is not god, although I wonder sometimes if he thinks he should be.
The problem is that capping the cost of the bill at $1 trillion over ten years (and by the way, in that time America will spend something around $24 trillion annually on health care) has led to fiscal scolds cutting the kinds of things out of the plan that would increase access, like lowering the subsidies that would make insurance affordable to everyone, or shrinking the benefits package so individuals would have worse coverage and higher out-of-pocket costs.
"We are very concerned that [lawmakers] have that fixed and arbitrary total dollar amount and this is it," said Stephen Finan, senior director of policy for the American Cancer Society Cancer Action Network. "Either it's not going to be enough to pay for adequate insurance or we just dumb down the level of benefits. We are concerned we could wind up with a package that is neither adequate nor affordable coverage."
Lead fiscal scold Kent Conrad gets quoted in this article too, telling us that we all "have got to be realistic about what is possible" and "We can’t do everything we’d like to do and pay for it and bend the cost curve the right way."
First off, this is actually untrue. A viable public option which didn't firewall out those with employer coverage and has a provider network and rates similar to Medicare could bend that cost curve. As could giving Americans more choices in their coverage by breaking regional monopolies through an insurance exchange. The same with expanding access and eliminating the hidden fee of paying for costly ER visits for the uninsured. And empowering an independent board to make changes to Medicare rates and structures while partially insulated from the political process. And a host of other ideas where more reform, of the kind that people like Kent Conrad don't want, can lower costs.
But this amounts to playing on the other side of the field. Americans trust Democrats on health care issues, for the most part, because they have traditionally emphasized more access to care and treatment. That's not to say that the cost issue is meaningless - it's actually in many cases complementary to the cause of access - but it's a matter of emphasis. And the moral case for health care reform has been almost entirely extinguished.
This year, however, it's not just been the opponents of the policy who have relied on the "mellifluous language of the standard economic theory of markets." It's been the advocates of reform. Ask yourself what the administration's one-line goal is on health-care reform. Is it "equal treatment for everybody?" Is it "if every American is guaranteed a lawyer, why not a doctor?" Is it even "guaranteed health care for everyone?"
No. It's "bend the curve." And the problem with "bending the curve" is that it's a broadly testable proposition. This is, in part, why the Congressional Budget Office's skeptical assessments pose such a threat to health-care reform. If the White House's primary objective was health care for every American, or guaranteed care that you could keep even if you lost your job, or choice of insurance plans for every American, you could spend a bit more on health care and say you were achieving your goal. But if you say that the point of health-care reform is to save money, and then the outfit charged with estimating such things says it won't, that strikes at the heart of the project.
Now, we're getting some better news from the CBO in the last 24 hours, as they have announced that the House bill will increase the number of people receiving employer coverage, and that a public insurance option can exist in tandem with private insurance. But the way the health care fight has played out, it has privileged these messages from the CBO. And to the media, they only matter when they matter anyway.
Somewhere along the line, Democrats in Congress and an Obama Administration obsessed with not following in the footsteps of the Clinton health care failure have forgotten to make the simple case that they support quality, affordable health care for every man, woman and child in the country. They've made a case about costs, but not a case about imperatives. There are plenty of economic arguments to make, but the moral arguments - about insurance companies denying coverage to those with a pre-existing condition, or dropping customers for the flimsiest of reasons when they ask to use their health insurance - but those have been pushed into the background. Health care is one of the more profound moral issues in public policy, and right at the moment that we're nearing a major shift in policies, we're talking cost curves and independent advisory boards. It's all important, of course, but consigning tens of millions of Americans to the horrors of no medical coverage adds a certain oomph.
If this moral case were made, a true argument about the human consequences of delay, maybe that $1 trillion dollar number inches upward. And maybe some deficits are floated within the 10-year budget window. But we turned this debate into one primarily about costs. This played right into the hands of the fiscal scolds.
Something fairly interesting happened today. It doesn't mean we will get a public health insurance option to compete with the insurance industry, but it doesn't exactly hurt. Apparently some Democrats thought that if they only watered down such a public option to nothing, they would get that vaunted bipartisan support, and everybody could go back to their districts and claim they did something when they in fact would have done nothing. But as those of us who have been observing this have known for some time, these aren't your father's Republicans, or your grandfather's, or any other relative. They are the rump conservative party, openly hostile to using government for any means other than profit-taking, and preferring to tell their constituents "good luck" instead of making any tangible difference to their struggles. And somehow, Democrats just discovered this.
Some Senate Democrats have considered nixing the public option proposal in order to win Republican support for the bill.
Schumer's role is important because he had been acting as an intermediary between liberal Democrats and moderates who are trying to strike a deal on the issue with Republicans on the Senate Finance Committee. Of the five House and Senate committees working on health care, Finance is the only one that appears to have a chance at reaching a bipartisan agreement.
Schumer said Finance Republicans had rejected several proposals designed to beef up the suggested nonprofit insurance co-ops. These included setting up a national structure for the co-ops, $10 billion in government seed money, power to negotiate payment rates to medical providers nationwide and creation of a presidentially appointed board of directors.
The Democrats tried to basically bury the public option as long as they could get any manner of support for the weak substitute. And the Republicans wouldn't budge. Like in 1993, their mission is to kill health care reform, period. Why anyone would think that any alternative would be true is beyond me, but Senate Democrats obviously needed to play Tic-Tac-Toe with the computer endlessly until they realized what a strange game it all is, and that "the only winning move is not to play."Ezra Klein comes to the same conclusion.
Republicans, (Schumer) suggests, are standing lockstep even against efforts to create a private co-op system that could offer an alternative to for-profit insurance. Their concern with the co-op plan is not that the government would be taking over the health-care system. It's that the current insurance providers would face unexpectedly aggressive competition in the marketplace. Which raises an interesting, and potentially clarifying, question: Are Republicans in this to preserve the healthy functioning of a competitive private market or preserve the profits of the currently dominant insurance companies?
Further proof of that learning experience came today from Kent Conrad, the man who devised this health co-op plan by throwing a dart against a board, as he appeared to acknowledge its limitations.
The wheels looked to be coming off with health care reform last week. But a poll showing huge public support for a public health care option and a strong bill from the House of Representatives have changed the dynamic.
Schumer and other backers of a public option insist that any plan must be national in scope, have substantial funding at the beginning from the federal government, and include national purchasing power in order to negotiate lower prices.
Conrad ticked off the areas of agreement that were reached Monday.
"National structure: I believe to be effective there has to a national entity with state affiliates and those affiliates have to have the ability to regionalize. I think his concern there can be addressed," said Conrad. "Second, he believes there needs to be national purchasing power. I think that's a good point that the national entity would be able to do purchasing on behalf of the state and regional affiliates and on behalf of the national entity itself."
Now, Schumer's vision of a public plan is a compromise from the House vision of a public plan, which is a compromise from single-payer health insurance. But things are moving in a better direction today than yesterday, when DiFi flat-out said Democrats don't have the votes to pass anything.
This teachable moment has a value for those outside the system who want to push for a real public option that can use bargaining power to force competition from insurers. Because now, as Matt Yglesias says, there's no excuse for Democrats to water down their bills in order to "seek bipartisanship" and make them durable. Republicans have revealed themselves. And given budget reconciliation and the imminent fact of 60 votes in the US Senate, Democrats have nobody else to blame. They can talk about political realities but those have essentially been voted out of existence, with respect to Republicans. Whether it's because of health industry campaign contributions or a desire to limit competition in small, rural states, a desire to get the glory for saving policy from the brink or just an ideological disinclination, individual Senate Democrats will have the collapse of any health care reform on their hands.
And yes, I mean Democratic senators. The Republicans, with a few possible exceptions, have decided to do all they can to make the Obama administration a failure. Their role in the health care debate is purely that of spoilers who keep shouting the old slogans — Government-run health care! Socialism! Europe! — hoping that someone still cares [...]
The real risk is that health care reform will be undermined by “centrist” Democratic senators who either prevent the passage of a bill or insist on watering down key elements of reform. I use scare quotes around “centrist,” by the way, because if the center means the position held by most Americans, the self-proclaimed centrists are in fact way out in right field.
What the balking Democrats seem most determined to do is to kill the public option, either by eliminating it or by carrying out a bait-and-switch, replacing a true public option with something meaningless. For the record, neither regional health cooperatives nor state-level public plans, both of which have been proposed as alternatives, would have the financial stability and bargaining power needed to bring down health care costs.
It helps to have clarity on who is blocking what the public desires. The grassroots will redouble their efforts, doing to the rest of the wayward Democrats what Change Congress did to Ben Nelson. Blue America are lining up a similar pressure Campaign for Health Care Choice on Blanche Lincoln, and you can contribute to that cause at this link.
Democrats are acting like bipartisanship matters in the health care debate, and then the Republicans have a day where they reveal a "plan" with no details, no sense of who would be covered by it and no cost estimates. It's literally a useless four-page outline.
Rep. Roy Blunt (R-Mo.), who heads a GOP health task force, said that when the details are drafted in the coming weeks, they would present a plan that “costs far less than the Democrats’ [plan] and provides better results for the American people.”
But Republicans who stayed at the press conference to answer questions — the leaders made statements but didn’t stay — could not answer whether their plan would include a tax increase to pay for such costly items as refundable tax credits for low- and middle-income workers to help pay for insurance.
1. Politicians who rail against wasteful government spending are taking action to prevent the government from reining in … wasteful spending.
2. Politicians who warn that the burden of entitlements is killing the federal budget are stepping in to block … the single most painless route to reducing the growth of entitlements.
3. They’re doing it in the name of avoiding “rationing of health care” … but they’re specifically addressing taxpayer-funded care. If you want to go out and buy a medically useless treatment, Medicare won’t stop you.
4. These same politicians are, of course, opposed to efforts to expand coverage. In other words, it’s evil for government to “ration care” by only paying for things that work; it is, however, perfectly OK, indeed virtuous, to ration care by refusing to pay for any care at all.
By the way, the "rationing" talking point is rank nonsense, but you probably knew that, based on who was promoting it.
Hell, these people have even tried to assert that health care reform shouldn't be passed because it promotes walking.
So given all of this, like E.J. Dionne I can't imagine why you would want to engage these people in any meaningful way, when they have time and again proven themselves not to be partners but unilateral adversaries.
Where did we get the idea that the only good health-care bill is a bipartisan bill? Is bipartisanship more important than whether a proposal is practical and effective? And if bipartisanship is a legitimate goal, isn't each party equally responsible for achieving it?
Most Democrats believe that fixing the system will require increased government intervention to guarantee universal coverage and to contain costs. Most Republicans oppose an expansion of government's role and believe an even more market-oriented system would pave the way to health-care nirvana.
Trying to achieve full bipartisanship by squaring those two views is a recipe for incoherence [...]
It's one thing to compromise to pick up votes, which, one hopes, is what Baucus is doing. It's another to compromise in exchange for nothing at all. The first is bipartisanship with a purpose. The second is the bipartisanship of fools.
And so we get idiotic half-measures like Kent Conrad's "throw a dart at a board" health co-ops idea, which simply does not make any reasonable sense as a substitute for the public plan unless the goal is to maintain the status quo for the sake of not angering Republicans who won't vote for the bill anyway. Health co-ops are fine at the margins, but simply could not possibly be scaled up to provide what a public plan could, which is the impetus for insurers to compete on price and quality. This is just a replay of the Bush years:
But is Conrad right about the politics? A reform proposal that doesn’t have a public plan is bound to cost more (or do less), since a public plan can save money--and save money in ways that the Congressional Budget Office will score. Get rid of the plan, and reform’s overall price tag goes up, making it harder to pass. And if reform without a public plan were to pass, it would simply not work as well, or perhaps at all. It would be more likely to run into problems because budget expenditures turn out to be higher, or implementation problems when private insurance doesn’t live up to its promises. That could sink reform before it even gets underway. In other words, maybe there’s a political risk to including a public plan. But there’s also a big political--and policy--risk to excluding it.
Strategically, Conrad’s approach is more like capitulation than compromise. Reconciliation or no reconciliation, the right political path for achieving reform doesn’t run through a minefield of endless preemptive concessions. When President Bush successfully enacted tax cuts in 2001 (through the reconciliation process, it should be noted), the question was simple: tax cuts, yea or nay? Many Democrats eventually signed on, not because they liked what Bush was peddling, but because they didn’t want to be against tax cuts. And tax cuts mostly for the rich weren’t all that popular. By contrast, there’s little question about the popularity of bold action on health care.
Memo to Congressional Dems: You. Cannot. Reason. With. Radical. Republicans. Who. Want. You. To. Fail. So stop trying, already, or else we'll have to conclude that you want no part of progress either.
While in Sacramento, the big news I never got to report was that the US Senate basically laid down the gauntlet in the fight over health care, by adding a "reconciliation instruction" to the budget conferees for health care.
That means the Democrats can pass health care reform with just fifty votes, instead of the sixty it takes to break a filibuster.
The deal was hatched late afternoon and last night, in a five-hour negotiating session at the office of Senate Majoriy Leader Harry Reid. A trio of White House officials were there: Rahm Emanuel, Peter Orszag, and Phil Schiliro. Also present, along with Reid, were House Budget Chairman John Spratt and Senate Budget Chairman Kent Conrad.
The reonciliation instruction specifies a date. That date, according to one congressional staffer, is October 15. (The original House reconciliation instruction had a late September deadline.)
In other words, the House and Senate each have until that day to pass health care legislation.
If they haven't, then both houses will consider health care under the reconciliation process, which is relevant primarily for the way it affects the Senate. There will be a limit on the time of debate. Republicans won't be able to filibuster it.
This really changes the dynamic of the health care debate, from one where the Republicans can simply sit back and oppose, to one where they have to engage in the debate or risk getting shut out entirely. The President's changing perspective with regards to bipartisanship reflects the fact that he knew he had to change this dynamic. And emboldened by it, the Senate Majority leader can now apply the pressure.
In order for this bipartisan process to take root, Republicans must demonstrate a sincere interest in legislating. Rather than just saying no, you must be willing to offer concrete and constructive proposals. We cannot afford more of the obstructionist tactics that have denied or delayed Congress' efforts to address so many of the critical challenges facing this nation....
Make no mistake - we are determined to reform health care this year. Our strong preference is to do so by working alongside you and your caucus. The health of our citizens and our economy are at stake; neither will be able to recover if we do not....
We look forward to hearing your ideas and working with you. The budget we will vote on this week gives us nearly six months to work together toward a comprehensive reform bill. Let's use that time to work together in our common interest rather than against each other and against the interests of the American people.... There is a seat for you at the table; we hope you take it.
This doesn't completely ensure health care reform; there's the question of how you pay for all this, for starters. But it does force compliance in a way that was not possible before. And with Republicans flailing about, I'd say reform is much more likely.
However, there had to be some sort of bargain to Conservadems like Kent Conrad and Blue Dogs like Allen Boyd, both members of the budget conference committee, in exchange for the reconciliation instruction. Jon Cohn speculated that PAYGO rules would become law, which you can see as good or bad. I'm much more concerned that Social Security reform was put on the table as part of the deal.
One outstanding question is what Conrad may get in exchange for not standing in the way of reconciliation provisions.
“Would I want things? Yeah,” Conrad said.
Conrad and Judd Gregg of New Hampshire, the ranking Republican on the Senate Budget Committee, have long pushed for creating a task force that would write policy prescriptions for the government’s long-term budget problems that Congress would have to vote on.
When asked if this proposal could in some way be part of a potential deal on the budget resolution, Conrad only would say that many things have been discussed.
Obviously, we cannot allow Social Security, a successful program, to be altered in any way that cuts its already meager benefit. So we'll have to see how this plays out.
...I should note that ending the privatization of the student loan process was also tagged for reconciliation, and that should go through much more smoothly, because it closely reflects the spirit of reconciliation, which is used for cost-cutting and deficit reduction. Great decision.
Last week saw a paroxysm of opposition to Barack Obama's budget plan from leading Senate Democrats. Evan Bayh formed his moderate working group, and Kent Conrad whittled down the budget proposal (in many respects by reinstating helpful budget fictions that make the deficit look smaller). And opposition to the Administration-supported cram-down proposal may scuttle that piece of the housing bill.
The last Democrat who held the White House, Bill Clinton, saw the core of his domestic agenda come to ruin, his political support collapse, and his failure spawn a massive Republican resurgence that made progressive reform impossible for a decade to come. The Democrat who last held the White House before that, Jimmy Carter, saw the exact same thing happen to him [...]
George W. Bush came to office having lost the popular vote, with only 50 Republicans in the Senate. After his disputed election, pundits insisted Bush would have to scale back his proposed massive tax cuts for the rich. Instead, Bush managed to enact several rounds of tax cuts that substantially exceeded those in his campaign platform, along with two war resolutions, a Medicare prescription drug benefit designed to maximize profits for the health care industry, energy legislation, education reform, and sundry other items. Whatever the substantive merits of this agenda, its passage represented an impressive feat of political leverage, accomplished through near-total partisan discipline.
Obama has come into office having won the popular vote by seven percentage points, along with a 79-seat edge in the House, a 17-seat edge in the Senate, and massive public demand for change. But it's already clear he is receiving less, not more, deference from his own party. Democrats have treated Obama with studied diffidence, both in their support for the substance of his agenda and (more importantly) their willingness to support it procedurally.
I'm of two minds on this. On the one hand, no co-equal branch of government SHOULD be a rubber-stamp (certainly the Hastert/DeLay/Frist Congress under George W. Bush shouldn't be emulated), and Congress has every right to carry out their legislative agenda under their own terms. At the same time, the endless whining from Democratic "moderates" to modify the Obama agenda, not out of any principle or belief that a middle course makes the most sense from a policy standpoint, but because they have been seduced by the high Broderist idea that the middle distance between two points is a virtuous end in itself, is both grating and irresponsible. The moderates use selective outrage - we must close the deficit, but we can't cap subsidies to wealthy agricultural interests to save money, just to use one example - to frustrate progress and make recovery more difficult.
However, Ezra Klein argues that the peculiar structures of the Senate are a far greater obstacle than the glory-seeking Senate moderates:
Which isn't really to argue with the substance of Jon's article: The Senate is a broken branch. If we don't properly respond to the financial crisis or avert the crushing blow of rising health costs or slow the advance of catastrophic climate change, it will be because the institution is no longer capable of governance. But that is not, as Chait would have it, a purely Democratic problem. It's an institutional issue. The local obsessions that Chait attaches to Conrad and Nelson are similarly prevalent among Republican Senators. The tremendous power of swing senators is as undeniable and capricious when Republicans rule as when Democrats hold power. The allure of obstruction is an compelling to minority Democrats as minority Republicans (the early Bush accomplishments were actually more bipartisan than Obama's, though that was because Democrats controlled the chamber rather than because Bush was the gracious and cooperative type).
I don't argue this point to be churlish. You can understand the problems of the Senate in two ways. The first is that it's a problem of party discipline. The second is that it's a problem of rules. If you think it's the first, the answer is to put resources and effort into mounting a primary challenge against Ben Nelson. If you think it's the second, then the answer may be to put time and energy into repealing the Byrd Rule, or lowering the filibuster limit, or making it easier to replace chairman, or otherwise transforming the structural incentives that makes legislative success such a delicate and unlikely outcome and thus allows individual Senators to exert so much control over it. Moreover, if you think it's the second, you can actually make something of a bipartisan argument, rather than a purely partisan one. The Senate, as currently composed, doesn't work for Republicans any better than it works for Democrats. And it really doesn't work for the country. And that's probably an easier argument than trying to convince Nebraskans that Ben Nelson's incredible power isn't good for them.
We have already seen and may yet see more progress from this Congress - the ConservaDem backlash to using budget reconciliation, for example, may just be a pose to force Republican compliance. But I think I lean more toward this being a structural problem requiring structural solutions, particularly in the Senate. The country really cannot afford a set of rules that tilt so heavily in favor of the status quo, especially in this time of profound challenges. In fact, the resultant reaction we've seen continually by the executive branch is to usurp the power of the Congress in the name of getting something done, which is unadvisable. Only by empowering Congress to actually act can we really have equal branches of government.
You have to be something of a Kremlinologist to decipher the true meaning of Senate Democratic statements these days. In all of these matters it helps to focus on actions. For example, Kent Conrad (D-ND). As the chair of the Senate Budget Committee, he has been the most vocal about the widening deficit, the new CBO scoring showing that deficit widening even further, and how President Obama's plans are simply too ambitious for words. Sounds like the old fiscal responsibility thing, right? Well, the actual budget summary from Conrad is entitled "Laying Foundation for Long-Term Economic Security With Investments in Energy, Education, and Health Care," and the proposals do track the President's major long-term goals. And the supposed "cost-savings" in his budget plan are mainly derived from a bunch of gimmicks.
...someone who was genuinely alarmed by the fact that the CBO scored Obama’s plans as leading to large deficits in the final years of his ten year budget would not have “solved” this problem by abandoning Obama’s ten-year budget window switching to a five-year window. Similarly, re-inserting the “let’s pretend will use the AMT to raise taxes on the upper-middle class and then not actually do that” approach to budgeting, though now a time-honored trick of the Bush years, is not an actual deficit reduction measure.
Long story short, Senator Conrad cares about the deficit and is taking some action to make it smaller. But he also cares a great deal about being seen as a deficit hawk, the kind of guy who’s not afraid to take an axe to the president’s proposals. And in this instance the administration rather smartly eschewed a lot of this kind of pain free “virtual” deficit reduction, thus making it possible for interested Senators to deploy favored accounting patches on their own initiative and take credit for more reduction than they actually produced.
The White House seems to have no problem with the changes made, because the changes for the most part are made of air. And in some sense, Conrad actually enhanced the prospect of health care reform, by offering revenue-neutral space for a reform fund and allowing that particular budget item to be scored on a 10-year timeline, so that the savings in the later years can allow for an up-front deficit. And while Conrad deleted reconciliation for health care and energy proposals, because they exist (at least for health care) in the House version, they can be imported at a later date, meaning the threat can still be held over the heads of Republicans.
So Conrad appears to me to be someone who wants to appear like a centrist while facilitating the needs of a progressive budget, in direct contrast to Evan Bayh, Tom Carper and Blanche Lincoln, who want to appear like supporters of the President while obstructing and hacking up his agenda:
We formed our working group because we recognize both the difficulty and the urgency of accomplishing a huge and ambitious agenda. We must act quickly and decisively to repair our financial markets and start to turn the economy around. In addition, we believe that President Obama is correct when he says that we cannot afford to wait any longer to fix health care and transition to a clean-energy economy.
These are titanic and complicated tasks, and we believe that many worthwhile policy solutions can be found in the practical center -- ideas that also have the benefit of appealing to vast segments of the American electorate. Unfortunately, the Republican leadership has basically decided to stay on the sidelines to let the Democrats carry the load of reform alone.
As moderate leaders, it is not our intent to water down the president's agenda. We intend to strengthen and sustain it. Moderation is not a mathematical process of finding the center for its own sake. Practical solutions are practical because they offer our best chance to make a difference in people's lives today without forcing our children to pick up the tab tomorrow.
The stakes are too high for Democrats to fear a policy debate. Such debates produce better legislation. On nearly all important votes, a supermajority of 60 senators will be needed to pass legislation. Without Democratic moderates working to find common ground with reasonable Republicans, the president's agenda could well be filibustered into oblivion.
It's really not possible to take these people seriously. The whole "practical solutions are great because they are practical" part really gives you the sense of who you're dealing with here. They live in a magical pony and fairy land where they, only they, can bring the nation together, despite all evidence to the contrary, by just clicking their heels and magically finding those "reasonable" Republican votes for anything but the most watered-down policy. They are also very worried that if Obama passes the agenda on which he ran, moderates who voted for him will be very upset and will throw Democrats out of office in 2010. That's really their response. And none of them, just like their partner in crime Susan Collins can actually name anything they'd cut, or explain why a 51-vote majority is undemocratic:
"I'm very concerned that the levels of debt that the president's budget would entail are simply unsustainable and would pose a significant threat to the health of our economy," said Sen. Susan Collins, a Maine Republican who plays a pivotal role in Senate negotiations. "I've had conversations with several centrist Democrats who have exactly the same concerns I do."
Well, what would you cut? "One of the areas I would look at are the huge agricultural subsidies," she said. Those farm payments are one of the few cuts Obama has already proposed, which Collins added was "to his credit."
Anything else? "I thought I did pretty well coming up with one right off the top of my head," she said [...]
Sen. Mary Landrieu (D-La.) said she leans no on Obama's budget because of its size but is open to being convinced. She's not looking forward to cutting it, however. "That's always the problem. How to cut back and what to cut back," she said.
Yet the main change that Landrieu would like to see highlights the political contradiction at work. Tax hikes on independent oil and gas producers, many of whom operate in the Gulf, she said, are a "non-starter." Removing that tax hike, though, increases the deficit [...]
"Reconciliation should not be used to impose a major policy change. It's unfair to those who hold a minority view," Collins added.
Isn't that undemocratic? Collins was asked why she and a handful of senators should wield so much power over the nation's policy.
"I don't really think I have all that much power but I'm glad you think so," she said, laughing.
"I don't think it has anything to do with the power structure of moderates," she added. "People want to see healthcare reform, want to see us deal with major issues, but not in an undemocratic fashion. I think people want to see fuller debate and deliberation and more involvement by the minority."
But isn't the need for 60 votes undemocratic? Didn't the nation have a full debate, followed by an election in which people voted for major change?
"I disagree totally with that," said Collins. "I do not believe the American people voted to short circuit debate and prevent people with a minority view on both sides of the aisle from having the ability to amend a bill."
Behold the reasonable, responsible moderates who will save us from this crisis and return America to glory again.
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