Clinton and Obama on Health Care Reform: 95% the Same

Health care reform was one of the few issues on which Senators Hillary Clinton and Barack Obama tried to differentiate themselves during their debate tonight. They acknowledged substantial similarities in their plans. Senator Obama went so far as to describe them as being “95 percent” the same. Both candidates call for the government to offer consumers an alternative to the private market, for example.

When compared to the health care reform packages offered by the Republican candidates  (which rely more on market reforms and avoids extensive government intervention) the Democratic Senators’ proposals are virtually indistinguishable. But campaigns are about choices, so they emphasized the five percent.

Senator Clinton’s proposal seeks to provide universal coverage by requiring health plans to accept all applicants and all residents to buy coverage. Senator Obama focuses on reducing the cost of health care coverage. As I’ve written before, this tension between access and affordability mirrors California’s recent health care reform debate.

The candidates described their differences in stark terms, as a seemingly irreconcilable chasm between them. In reality, while differing in emphasis, these two approaches are not really either-or propositions. They’re complimentary. Don’t take my word for it — ask my son.

He turned 13 a few weeks ago. Health care reform is not high on his list of interests. However, he’s recently gotten interested in the primary so he joined me tonight to watch the debate. As Senators Clinton and Obama went back and forth on their reform packages, he asked me what the argument was about. Thanks to the miracle of DVRs I was able to pause the debate and explain. We resumed watching and, after another couple minutes of the candidate’s throwing health care statistics around he grabs the remote, presses pause and exclaims, “This is so stupid. First you make it affordable and then you make sure everyone buys it.”

So, now that we’ve got that resolved, I’m going to have him start work on creating the Democratic party’s position on immigration. 

Pre-Super Duper Tuesday Presidential Survey Now Open

With the presidential crowd thinning and Super Tuesday on the horizon, I thought it was time for another unscientific presidential survey. And this time you get to vote in some hypothetical general election match-ups.

It only takes a minute to complete and it’s anonymous. The survey is over on the Alan Katz Politics blog, but if you want a short cut, just click here. The survey will remain available until 5:00 pst on Tuesday, February 5th.

Speaker Nunez to Put Single Payer Under ABX1-1 Microscope

Few pieces of major legislation in recent years have been subjected to the scrutiny Assembly Bill X1-1 received last week. ABX1-1, the compromise health care reform bill proposed by Governor Arnold Schwarzenegger and Speaker Fabian Nunez, was the topic of an 11 hour hearing by the Senate Health Committee on January 23rd and a thorough analysis of its finances by the Legislative Analyst’s Office. Indeed, it was the LAO report that opponents on the committee cited most in justifying their position.

Now other health care reform proposals are about to go under the same microscope. Speaker Nunez has promised nothing less. And first in line is likely to be the single-payer legislation, Senate Bill 840, championed by Senate Health Committee Chair Sheila Kuehl.

Supporters of ABX1-1 held a press conference on Tuesday to affirm their commitment to enacting comprehensive health care reform for California. During his turn at the microphone, Speaker Nunez referred to ABX1-1 as a “road map to getting the right type of health care that we need, to be a bridge between those who want government run health to those who want the private market to dictate the pace of how health care is delivered.” He pledged to continue to pursue this type of reform.

At the same time, he made clear his intent to hold proponents of competing systems — and specifically single-payer proposals — to the high degree of scrutiny to which ABX1-1 was subjected. It’s worth noting that among ABX1-1’s most vehement opponents was the California Nurses Association. They insist the only health care reform worth enacting is one that eliminates the health insurance industry and turns health care over to the government.

“I think it’s time … to have an honest conversation about single payer,” the Speaker said. “We cannot create the false sense of hope that we can do something better if it hasn’t been tested, vetted and put through the same type of scrutiny that our effort has been put through. And I intend to put each and every proposal that seeks to cover health care for everybody through that same process, because I think it’s only fair. And because I also believe that we need to be comparing any proposal not to some wishful thinking of what we might be able to do two decades from now, but to the world we live in today.”

In the past Speaker Nunez has supported SB 840. In introducing his own reform package early last year, Assembly Bill 8, he commented that while he preferred a single-payer solution he accepted Governor Schwarzenegger’s promise to veto it. Yet now he seems intent on demonstrating that SB 840 presents an even greater financial risk for the state than did ABX1-1. And that shouldn’t be hard to do.

Sacramento Bee columnist Daniel Weintraub recently commented on similarities in the risks posed by SB 840 and ABX1-1.  “[T]he single payer plan, to be financed primarily by a 12 percent payroll tax, would have run up a deficit unless its managers could have slowed the growth in health care costs to below the level of the growth in wages — an extremely unlikely prospect. To control those deficits, the commission to be put in charge of health care would have been empowered to cut benefits and levy co-payments on consumers. Hardly a risk-free undertaking.”

ABX1-1 was subjected to extraordinary scrutiny. What’s surprising is that such vetting is extraordinary. Major legislative initiatives — especially on issues that touch the lives of Californians as profoundly as health care reform — should be put under an ABX1-1-like microscope. This kind of detailed evaluation is, after all, what legislators are supposed to do. If some popular proposals are found to offer nothing more than a false sense of hope, so be it. Better to learn that now than after it’s enacted.

More significantly, it’s this approach that will help lawmakers find responsible ways to address challenging and complex issues. Ways that few might consider perfect, but that the majority can conclude with confidence, is an improvement to the status quo.

Let the scrutiny begin.

ABX1-1 Postmortems

For those distracted by — oh, let’s face it — no one could have been so distracted as tp not know Assembly Bill X1-1 died in the Senate Health Committee on Monday. The compromise health care reform package hammered out by Governor Arnold Schwarzenegger and Speaker Fabian Nunez received a single “aye” vote. Seven Senators, including all four Republicans, voted against it. Three of the committee’s seven Democrats abstained.

ABX1-1 was deeply flawed, but it also was creative and forward-looking. Many aspects of the legislation will be part of the health care reform debate — here in California and nationally — for years to come. Here’s a round-up of what folks are saying now that the year of health care reform is officially ended.

The Sacramento Bee’s Daniel Weintraub has a blunt, and on point, analysis of why ABX1-1 failed.

Frank Russo, who publishes the California Progress Report blog laments the liberal-against-liberal infighting that surrounded ABX1-1 and reminds all sides that “politics is the art of the possible.”

A sampling of California newspaper coverage from San Jose Mercury News, the Los Angeles Times, and the San Diego Union and an editorial from the San Francisco Chronicle.

And here’s how out-of-towners reported on the demise of ABX1-1 in the New York Times, the Wall Street Journal, and, from way out of town, a Chinese news outlet (why not?)

Here’s what Governor Schwarzenegger, Speaker Nunez and Senate President Pro Tem Don Perata had to say (the legislative leader’s statements were made prior to the Senate Health Committee vote). A video of a press conference held by the Governor and Speaker after the vote is on the Administration’s web site (right now it’s on the home page, I don’t know where it will be moved to later). And here’s where you can listen to Senator Perata’s press conference after the vote.

Finally, here’s a thorough review of what happened, and why, posted by the California Healthcare Foundation on its California’s Healthline web site. 

Some Lessons Learned from California’s Year of Health Care Reform

With the demise of Assembly Bill X1-1, the compromise health care reform package proposed by Governor Arnold Schwarzenegger and Speaker Fabian Nunez, California has demonstrated how difficult it is to pass comprehensive changes. The bill was attacked, sometimes viciously and not always fairly, by the right and the left. In the end, it lacked a cohesive constituency of the center to push it forward. Given the Legislative Analyst’s study showing the legislation was likely to cost the state billions of dollars more than the $14.4 billion acknowledged by its supporters, it’s doubtful any constituency could push it through.

ABX1-1 failed, but the health care reform debate that started in December 2006 did not. Governor Schwarzenegger declared 2007 to be the Year of Health Care Reform., It wasn’t, but it wasn’t a wasted effort either. California’s health care reform effort produced many innovative ideas and brought to light valuable lessons. Here’s just a few:

1. Compromise requires participation from all parties.California’s politics are unique. We’re a three party state: Democrats; Republicans; and Post-Partisans. OK, there’s only one member of the Post-Partisan party, but he’s the Governor so he counts as much as the others. Only two of the three were engaged in the negotiations that led to ABX1-1. The Republicans were excluded (whether for good reasons or bad isn’t relevant for this discussion). The result: complicated and distracting legislative and political gymnastics and a winnowing of available support for the bill.

2. It’s tough for a state to go it alone.California is a big state. A really big state, but in the end, just one state. It’s revenue raising options are few and it can’t print money. In the end, printing money was was about the only thing that could have saved ABX1-1. Without the flexibility and power inherent in the federal government, ABX1-1 lacked a credible safety net if things didn’t turn out as the authors planned. In fact, to date, no state has successfully implemented universal coverage. Some argue no state can. Health care reform may require a national solution.

3. Balancing access and affordability is key. Health care reform in California nearly died in November of last year. Negotiators had reached an impasse. Governor Schwarzenegger insisted on requiring all residents to buy coverage; Democrats argued this would could impose a financial hardship on low- and middle-income Californians.  The Administration was focused on access; the legislature on affordability.

What bridged the gap was the introduction into the dialogue of an “affordability exemption.”  Every Californian would be required to have coverage unless the cost was too great a percentage of their household income. That at least was the theory. As defined in the bill it may not have been the case. But more important than the details was the concept and how it bridged what had seemed like an insurmountable gap. It wasn’t wholly original, Massachusetts has a similar provision in its health care plan. The lesson is that until the tension between access and affordability is resolved, reforms can’t move forward. (Maybe someone should tell the Democratic presidential candidates about it — but then what would they have to argue about?)

4. It’s better to vet complicated public policy early. The Governor, Legislative Leaders and their staffs devoted thousands of hours to working through the complex issues that make up health care reform. They spoke with stakeholders of every stripe — if they had charged admission to all the meetings and conference calls they held they could have financed the bill. If you ask these insiders, the drafting of ABX1-1 was an open and inclusive process.

Only, it wasn’t. There was talk, but not always dialogue. When there was dialogue, a limited number of parties were in the smoke filled tent. In fact, the final version of the 200+ page bill was published just hours before the Assembly passed it, few if any lawmakers actually read it first.  It was only last week that the legislation got the close examination required. The Legislative Analyst’s Office (LAO) study was incredibly important and Senate President Pro Tem Don Perata was right to have demanded it before the Senate considered the bill. And the Senate Health Committee’s 11 hour meeting made sure all sides were heard on every element of the legislation. Would opening the process up in this manner months earlier have assured the bill’s passage? No one can really say, but I believe it would have inspired negotiators to fashion a more solid proposal.

5. The process worked. In their opening statements today, Speaker Nunez and Secretary of Health and Human Services Kim Belshe, gave heartfelt eulogies for ABX1-1. It was better than the status quo, they claimed. Millions without coverage would get it; millions with coverage would be more secure. Maybe. I’m sure the folks who advocated Tennessee’s ill-fated (and ill-designed) TennesseeCare felt the same way. As did the policy makers in Washington State before they had to unravel much of the reforms.

We’ll never know if ABX1-1 would have improved California’s health care system or just replaced current problems with new and potentially more devastating ones. The package was held together by optimistic assumptions and hopeful visions of how independent actors (businesses and consumers) would behave. As the LAO analysis proved, if those fragile assumptions and hopes were wrong, the resulting plan would crumble.

Concern about the risks created by the plan wasn’t the fear mongering some of ABX1-1’s supporters claimed it to be. These risks were likely and perhaps inevitable. In the end, the process allowed lawmakers to evaluate the risk and benefits of ABX1-1. And that’s what the legislative process is supposed to do.

6. It’s a marathon, not a sprint. Improving California’s health care system will take time. As flawed as it was, ABX1-1 is a good starting point for the next stage of that effort. Indeed, it’s a worthy starting point for a national health care reform effort. The legislation may have failed, but it’s legacy is likely to continue.

ABX1-1 Defeated in Senate Committee

In the end, it wasn’t even close. With just one “aye” vote, the Senate Health Committee killed Assembly Bill X1-1, the health care reform compromise bill worked out by California Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez.

It was the cost, more than anything, but Senators also criticized some of the trade-offs accepted to bring stakeholders together. But mostly it was the cost. The Legislative Analyst’s Office (LAO) report, delivered in the midst of Senate consideration of draconian budget cuts to health and human services, made the $14.4 billion program unpalitable to lawmakers of both parties.

Even Senate President Pro Tem Don Perata, a co-sponsor of the legislation, announced before the vote he could not support it in light of the LAO report.

In a letter to Governor Schwarzenegger and Speaker Nunez, Senator Perata wrote, “This bill – which is before the Senate, and the initiative, which is not – would create the third-largest program in state government, surpassed only by K-12 education and Medi-Cal.  Under any circumstances, but especially in light of the state’s $14.5 billion budget shortfall, we have the fiduciary responsibility to approve a health care coverage plan that is both self financing and fiscally sound and a moral responsibility to protect from harm those who already have health care coverage.”

The defeat of ABX1-1 is no cause for celebration. The reality is, while the health care system works well for many in the state, serious problems exist that need to be addressed. With the defeat of ABX1-1, pressure for change will continue to build. Lawmakers may succumb to the pressure to pass anything in order to have passed something.

The health care reform debate in California is far from over. The defeat of ABX1-1 is significant, but it’s not the end. Nor should it be.

Senate Health Committee to Vote on ABX1-1 at 2:00 pm

The  Senate Health Committee is scheduled to vote on Assembly Bill X1-1 today at 2:00. The chances of California’s compromise health care reform legislation moving forward are slim. At least two Democrats are expected to join with the Committee’s four Republicans to deny supporters the six votes they need.

The Sacramento Bee’s CapitolAlert web site has an excellent article on what the 11 members of the Committee have said about the bill.

Keep in mind, the vote is scheduled, but there’s a small chance no vote will be taken. If you want to listen in, it the Health Committee session is likely to be webcast. The hearing takes place in room 4203. at Stay tuned.

The Second Unscientific Presidential Survey Launched

Before the New Hampshire primary many of you participated in this blog’s first unscientific presidential survey. The results were kind of intriguing: Senators Hillary Clinton and Barack Obama tied and former Mayor Rudy Giuliani barely topped Senator John McCain.  

Since then several candidates dropped out of the race and we’ve seen results from New Hampshire, Michigan, Nevada and South Carolina. So it seems like a good time to see where your heads are at now.

This second unscientific survey is linked to the new Alan Katz Politics Blog. I hope you’ll take a minute and share your opinions (it really does take less than a minute). These surveys may be unscientific, but the results are interesting.

Thanks.

Can The Troika Pull a Rabbit Out of the Committee’s Hat?

Anyone have any idea how Governor Schwarzenegger, Assembly Speaker Fabian Nunez and President Pro Tem Don Perata are going to pull this rabbit out of their hat?

The Senate Health Committee seems poised to defeat their troika’s health care reform package, Assembly Bill X1-1. The math is pretty straightforward:

There are seven Democrats and four Republicans on the committee. Two of the Democrats have announced their opposition to the bill and none of the Republicans have ever said anything indicating they’re supporting the bill. That means the bill fails five-to-six. And that assumes none of the other Democrats decides to vote against the bill.

Seems to me there’s only three ways to turn this around:

1. Stack the committee. It’s been done before. Replace a no vote with a yes-Senator. But Senator Perata told the San Jose Mercury News he won’t do this.

2. Get a Yes vote from one of the Democrats currently committed to voting No. Committee Chair Shiela Kuehl or Senator Leland Yee have both come out against the bill. In his opening statement to the committee, Senator Perata took a none too subtle swipe at Senator Yee in his prepared statement before the start of the Health Committee hearing. “I am a little dismayed that some committee members have seen fit, or maybe one committee member, is seeing fit to pre-judge the LAO’s report without reading it. Be that as it may, I guess we all approach our work in a different manner.” As means of persuading someone to change their minds on one of the most public and publicized decisions of their political career, this approach leaves something to be desired.

More likely is that Senator Perata, the Governor and Speaker will seek a courtesy vote from one of the Democrats. Their argument could be: 1) you’ll get to vote no on the floor of the Senate; 2) we’ll owe you big time; 3) you’ll keep your office; and 4) eventually the voters will decide if they like this health care reform — why would you stand in the way of letting the people decide? 

This last argument might — emphasis on the word “might” — work. ABX1-1 is entirely dependent on a funding measure passing on the November 2008 ballot. If the initiative fails, the bill never gets implemented. So moving the bill forward can be seen as simply giving the people a chance to make the final determination. Will either Senator Kuehl or Yee buy into this? That’s a big unknown.

3. Get a Republican to vote Yes. It’s worth a try. However, the most likely GOP Senator to buck the party is Senator Abel Maldonado. He was, after all, the only Republican Senator to support the 2007-08 budget during the 52-day standoff.

However, according to someone who was there, at a meeting with constituents on Friday, Senator Maldonado expressed concern about committing the state to substantial new expenses before the state’s $14 billion deficit is fixed. As the observer described it, Senator Maldonado explained that everything he knows from his own business experience and his commitment to being a responsible elected official points to a “No” vote on Monday.

OK, there’s a glimmer of a chance that the troika can find a courtesy vote. Or they can convince Senator Maldonado to listen to their financial analysis and not that of the non-partisan and highly respected Legislative Analyst. But it’s a long shot.

Nonetheless, some Sacramento insiders, even some opposed to the bill, are convinced they’ll pull it off. The Governor, Speaker and Senate Leader simply have too much invested in ABX1-1 to let it fail this close to the finish line.

I can’t figure out how they could do it. But if any of you have a guess — or better yet, inside information — please share with the class.