Fixing Health Care Reform Harder with Pelosi as Democratic Leader

The message delivered by the 2010 mid-term election is clearly in the eye of the beholder. Some see it as a repudiation of President Barack Obama and/or Democrats in Congress. Others see it as a rejection of incumbents of all political parties. Most everyone agrees, however, that this was an election demanding change. There are other blogs that do a great job of noodling through these kinds of issues. This blog focuses on health care reform. And while I believe the Patient Protection and Affordable Care Act will be changing over the next several months, the process won’t be easy.

The difficulty is only in part because a divided Congress is a guarantee of frequent gridlock. Consider the Kabuki Theater we’ll see play out on repeal of the PPACA. My guess is Republicans in the House will push through a bill to repeal the new health care reform law. This legislation may contain language to preserve certain provisions of the PPACA, but it will be dubbed the “repeal bill.” Not that the GOP majority needs their votes, but a handful of Democrats will likely vote for this bill despite pressure by the Democratic leadership to present a unified front (Democrats aren’t nearly as disciplined as Republicans in this regard, so someone is likely to jump ship).

Democrats in the Senate will kill the bill – and will likely prevent it from coming to the floor. Either party can filibuster. Even with with a few Democratic defections (that would be Senators Joe Lieberman, Ben Nelson and Joe Manchin) the GOP will fail to garner the 60 votes necessary. So President Obama won’t even need to veto the bill as it will never get to his desk.

This script, or something much like it, has nothing to do with public policy and everything to do with politics. Each side will be playing to their base. You might even see liberal Senate Democrats put forward legislation to implement a public option or the like, safe in the knowledge that such a bill would die in the House. Again, it’s all about making partisans (and pundits) happy.

Eventually, however, members of both parties will need to focus on the substantive work of amending the PPACA. In my previous post I wrote about the need for Republicans to decide if they will seek to improve President Obama’s health care reform plan or use the PPACA as a campaign issue in 2012. In that post I also brought up the possibility that Speaker Nancy Pelosi might retire from Congress given the drubbing House Democrats received on election night. She won’t. At least not yet.

Speaker Pelosi has announced she’ll seek to become the Minority Leader in the new Congress. This no doubt delights many Republicans in the House and saddens some Democrats. As the Associated Press reports, in making the move to stay on as House Democratic leader, Speaker Pelosi “rejected pressure from moderate House Democrats – and even some liberal allies .…” Again, other blogs will dissect the broader political impact of this move. But what does it mean for health care reform?

Unfortunately, Speaker Pelosi’s decision to stay on as the Democratic leader in the House means improving the Patient Protection and Affordable Care Act will be much harder than would be the case with someone else leading the Democratic caucus. First, because Speaker Pelosi is a lightning rod for conservative anger. Speaker-to-be John Boehner will have a tough enough time getting his caucus to vote for anything short of repeal of health care reform. The GOP Caucus in the House will contain a significant number of true believers: ideologues who consider compromise a mortal sin as opposed to a natural part of the political process. And even those Republican lawmakers prone to compromise will spend the next two years looking over their right shoulder evaluating whether a vote for half-a-loaf on an issue will have career-ending consequences. Getting these compromise-shy politicians to accept a deal brokered with Minority Leader Nancy Pelosi may be asking too much.

The second reason her decision makes improving health care reform more challenging is that it means no change among the negotiators. The Big Five in Washington for the past two years have been President Obama, Senate Majority Leader Harry Reid, Senate Minority Leader Mitch McConnell, Speaker Pelosi, and Minority Leader Boehner. Assuming no challenge to the two Senators (and none seems to be emerging) and with the likelihood of the House leadership simply switching offices, the same Big Five will be negotiating health care reform for the next two years. Meaning no new perspectives, no change in tone, no difference at all (other than the relative power each holds). As anyone whose survived basic chemistry in high school can tell you, if you have combine the same ingredients in the same way expect the same results. For those of us looking for improvements to the PPACA, this is not a good thing.

Democrats in the House could choose someone else as their Leader, but Speaker Pelosi is an excellent vote counter. I doubt she’d have announced her intentions without be certain they’ll be achieved.

A lot of the Democrats defeated on November 2nd were moderates – the Blue Dog Coalition in the House will be roughly half the size in the new Congress as it was in the old one. This means the Democratic caucus is more liberal going forward than it has been in the past. And given the success of the Tea Party the Republican Caucus has grown even more conservative. The gulf between the two, consequently, is greater than ever and there a fewer bridge builders to help span it.

Changing the PPACA is important. Having the same faces among the Big 5 and more extreme caucuses in the House doesn’t mean revising health care reform will be impossible. But it does mean achieving that change will be harder.

Lack of GOP Support for Baucus Health Care Reform Matters, But Not So Much

After months of trying to craft health care reform legislation that would garner at least some Republican support, Senate Finance Committee Chair Max Baucus appears ready to move forward without GOP support – at least for now. According to the Associated Press, Senator Baucus will release his proposal on Wednesday without any Republican co-sponsor. The media will claim this is a huge setback for Senator Baucus and for President Barack Obama.

Maybe, but I don’t think so. First, there is a possibility at least one Republican will support the legislation when it comes to a vote in committee. Politico.com reports that “Sen. Olympia Snowe (R-Maine), who is considered the likeliest Republican to sign onto the bill, said she wants to wait to see how the committee process plays out. “’I am committed to this process,’” Snowe said. “’I want this effort to continue and I am going to work through all these issues and the committee process will advance that as well and we will continue to work together.’” While the other two Republicans working on bi-partisan legislation sounded less upbeat, they have not completely closed the door to supporting bill either.

The second reason the lack of any Republican support may not matter much in the long run is that Senator Baucus’ bill will appeal to Democratic moderates. And while Republican votes would be useful, it is moderate Democrats that hold the key to health care reform. Without the support of most of the members of the Moderate Dems Working Group in the Senate or the Blue Dog Coalition in the House, Congress cannot pass health care reform legislation. There are 18 Democratic Senators who are a part of the moderate group. At least eight of them must support legislation for it to pass. In the House, where Democrats outnumber Republicans 257-to-178, there are at least 52 members of the Blue Dog Coalition. They need at least 13 of them to support reform legislation.

Yes, there are more liberals in Congress than moderates. And some of these liberals are threatening to oppose health care reform that does not meet their litmus test of including a government-run health plan. But it’s much easier for a moderate to oppose health care reform than it is for liberals.

A moderate can stand on the floor and claim the bill is too expensive or involves too much government. Given their districts, this is unlikely to hurt them politically. In fact, it will likely help them in the upcoming election.

For a liberal to oppose one of the most important priorities of the Democratic Party because it doesn’t go far enough is a much tougher message. They must claim that millions of Americans should go without health care coverage because the bill isn’t ideologically pure enough. They must explain why insurance carriers should be permitted to continue to deny coverage to individuals with pre-existing conditions because the legislation doesn’t include a public option. In other words, liberals need to argue that the status quo is better than any reform. That’s not only a tough argument to make, it’s a foolish one.

Senator Baucus would love for Republicans to support his health care reform bill. President Obama would too. But they don’t need Republicans to support the bill. They need moderate Democrats.

Senator Baucus is pitching his proposal to those moderates. If he succeeds and if President Obama can get liberals to vote for what they will perceive is a partial loaf, then health care reform passes. If either fails in their assignment, so does health care reform.

It’s that simple. And that complicated.

Health Care Reform 2009 and the Danger of News Cycles

The campaign for health care reform is making a lot of people nervous. Every day the media is reporting on a crippling blow President Barack Obama’s reform effort has suffered or on the inevitability of passage. It’s like watching an episode of 24 or Lost every episode (or news cycle, as the case may be) a new cliff hanger. The television shows are obviously fictional. The drama of the health care reform debate is, at times, equally manufactured. And even when the situation is real, the situation is neither definitive nor long lasting.

However you get your news, the situation is pretty much the same. Every news cycle there’s some make-or-break event that requires breathless analysis. The reality is not every meeting, vote or comment is of momentous importance. It may be interesting. It may be informative. But it momentous events are few and far between. Which poses a problem for the media because they live or die on excitement.

The reason is that the need of the media to capture attention of a large audience outweighs its sincere desire to educate and/or influence that audience. The news media is a business. Like all businesses (even non-profits) it must generate revenue. For the media this means selling advertisements.  Most reporters and pundits have a want to educate and inform. Some seek merely to entertain or inflame. All of them, however, have a need to bring an audience to their advertisers. This means the stories they put forward need to excite their audiences enough so they can be exposed to the advertising that creates the revenue the media owners expect. (In this admittedly cynical view, the reporters and pundits are the equivalent of the brokers – it all begins with a sale).

In-depth stories examining the subtleties of a complicated issue like health care reform are not very exciting to a broad audience. Further, most reporters and pundits lack the expertise to examine the subtleties of health care reform. That’s not a put down as it’s not their fault. They need to be generalists and understanding health care requires specialized knowledge. Even those who truly understand the intricacies of the issue face a serious problem, especially on television: the need to break for commercials every few minutes. It’s tough to maintain a narrative when your presentation is constantly being interrupted to sell cars, prescription drugs or cleansers.

What does excite people is conflict. Which is why the media loves a good fight. Conflict requires good guys and bad guys, winners and losers. So instead of exploring the nuances of how a health insurance exchange might work (or what challenges it may face) or how the governments Medicare and Medicaid reimbursement policies increases the cost of private health insurance, the press focuses on the political maneuvering of the day. Broad statements by lawmakers go unchallenged because there’s simply not enough time (or expertise ) to challenge them. Instead, the best sound bites of the day are played and discussed in an echo chamber designed to amplify any conflict – or to create conflict where none exists.

I don’t blame the press. They have a job to do and, as I mentioned, most have a sincere desire to inform their audience as much as is possible given the restraints of their business. I do feel sorry for their audience. They can’t help but perceive the health care reform debate as a pitched battle between the forces of Light and Darkness with ultimate victory or defeat at risk each day. In short, they are exposed on a regular basis to a heightened version of reality intended to cause enough fear, relief, frustration, and elation to keep them paying attention through the commercials.

So, for example, President Barack Obama wanted each chamber of Congress to pass a bill so the two versions of reforms could be reconciled into a single bill and voted upon in the Fall. The Senate will not meet this deadline (the House probably won’t either, but they may). For the media this is great. Everyone understands due dates. Congress missed theirs so health care reform is in deep trouble and the President lost a major political battle.

Well, not quite. There’s still plenty of time to complete health care reform this year. And while the President may have missed a deadline, at the end of the day he will be judged by whether the status quo endures or not. It’s like owning stock. The price of the stock you own may change every day, but the only thing that matters is the price on the day you sell it. But the media can’t let this be known so every day’s stock price is of paramount importance..

Another example: three Congressional Committees have moved health care reform bills forward (an important milestone). Two Congressional Committees are still refining their proposals. Which ones are the most important? Given the hyperbole and attention showered on the versions that have already made it through a committee you’d be forgiven for assuming it’s the former. The odds are, however, that what emerges from the Senate Finance Committee and the House Energy and Commerce Committee are going to more closely reflect the final legislative package than anything already voted upon. The reason is that these committees are seeking to gain the support of moderates (both Democrats and Republicans) and those moderates are critical for passage.

Consider: Democrats have 60 votes in the Senate, but 18 of those are moderates. Without the support of at least eight of those moderates nothing passes in the Senate. (And this assumes only 50 votes will be needed. If 60 votes are required to move health care reform legislation through the Senate, which is more likely, then every one of those moderates needs to be brought on board).

In the House, Democrats will soon hold a 257-178 member majority (there’s one vacancy, so there are only 256 Democrats in the House today). It takes 218 votes to pass anything through the House. Without Republican support, the House Leadership can only afford to lose 39 members of their caucus. The moderate Blue Dog Coalition has at least 52 members. Do the math.

What all this means is that we have yet to see the two most meaningful health care reform bills yet. Which makes much of what’s being reported lately exciting, but ultimately, not as important as the media would have us believe. The day-to-day tumult is not what matters. Health care reform will be determined by the forces and dynamics that are not easy to explain. And they certainly don’t fit within commercials.

More Health Care Reform Proposals Added to the Mix

So many health care reform proposals are flying around the nation’s capital it’s nearly time to bring in the air traffic controllers. There are draft bills, option papers, proposals, outlines, and about any other kind of document you can name whirling around like jets over O’Hare.

Michael Johnson of Blue Shield of California and I gave a presentation on health care reform Wednesday to a group of health insurance brokers. We were reading up on one of the latest ideas issued a few hours earlier literally minutes before the panel got underway. It’s only going to get worse as some stake out (somewhat extreme) negotiating positions while others offer up potential compromises.

Here’s some of the more recent health care reform proposals to be launched — or about to be:

  1.  The web site The Hill is reporting that moderates in the House of Representatives from both sides of the aisle are meeting in private to fashioning a compromise package. Among those meeting are part of the GOP’s “Tuesday Group,” the New Democratic Coalition and the Democratic Blue Dog Coalition. Fearing retribution from party leaders, neither side is offering the names of participants. The meetings are significant not just because they are likely to produce yet another health care reform package. The negotiations also underscore the reality that while the media tends to portray both Democrats and Republicans as monolithic parties of extreme ideologies, there are a significant number of lawmakers who eschew the hardline ideology of their colleagues and search for pragmatic solutions.
  2. Former Senate majority leaders unveiled a health care reform plan they hope will provide a middle ground in debate. The plan was developed by Republican former Senators Howard Baker and Bob Dole along with Democratic former Senators Tom Daschle and George Michell. (Former Senator Mitchell is credited by the Boston Globe with having contributed to the document, although it is signed by only Senators Baker, Daschle and Dole). It weaves around the middle on a number of issues, although it does lean to the left. For example, while the proposal does not call for a creation of a federal government-run health plan it would permit states to create them. It also calls for taxing the value of health plans an employee receives to the extent it exceeds the cost of coverage provided to members of Congress. According to the Boston Globe this would amount about $5,000 for an individual and $13, 000 for a family.
  3. The House Republican leadership unveiled their health care reform plan on Wednesday, too. Among other features it would allow states, small businesses and other group to come together into “pools” to offer low cost health plans that, at a minimum, is provided in a majoirty of states. It also would offer lower-income Americans refundable tax credits they could use to purchase coverage and would make individual health insurance premiums tax deductible. It does not require consumers to buy coverage, but the GOP plan would encourage states “to create a Universal Access Program by establishing and/or reforming existing programs to guarantee all Americans, regardless of pre-existing conditions or past illnesses … access to affordable coverage.” Development of the GOP plan was led by Representative Roy Blunt.
  4. Last week the Chairs of the three House committees with jurisdiction on health care reform released a framework for reform. The Tri-Committee Health Reform Draft Proposal, put forward by House of Representative Chairs Charles Rangel of the Ways and Means Committee, Henry Waxman of the Energy and Commerce Committee, and George Miller of the Education and Labor Committee outlines the key provisions of a unified Democratic reform package. The framework calls for creation of a government-run health plan to compete with private carriers, requires all Americans to obtain coverage (with exemptions in cases of financial hardship), requires most employers to either provide coverage or pay a fee, and provides subsidies for Americans households with incomes up to 400 percent of the federal poverty level.

There will be many more proposals coming soon. As it is relatively early in the legislative process, most will stake out relatively pure ideological positions. Neither party has an incentive to offer compromise solutions yet. So House Democrats, along with Senator Edward Kennedy and his Health, Education, Labor and Pensions Committee, will anchor the left and the GOP Leadership and conservative Senators will anchor the right. As in most negotiations, the goal is to establish a starting position so far to one extreme or the other that the middle shifts in their direction.  

There will be some pragmatic proposals put forward as well. The most anticipated is that expected to be coming soon from the Senate Finance Committee. It’s Chair, Max Baucus, and its Ranking Member, Charles Grassley, seem to be sincere in their efforts to put forward a bi-partisan solution. In the meantime, President Barack Obama will keep up a drumbeat in support of getting comprehensive health care reform legislation through Congress before the end of the year. Although the White House continues to let Congress take the lead in fashioning the final reform package, the Obama Administration is beginning to get more engaged in the legislative process.

What the final health care reform legislation will look like is, as yet, unknown. It may resemble one of the ideas already put forward. Or perhaps something new to the mix will gain momentum. I’m betting that something will pass this year. The process of getting to one bill will be messy, but eventually, a consensus will form.

Not yet, but eventually.

Public Health Insurance Plan Compromise Likely When Time Is Right

The decibel level concerning whether health care reform should include a government-run health plan got a lot louder this week when President Barack Obama reiterated his strong support for the concept. Partisans on both sides of the issue ratcheted up their rhetoric several notches, drew pretty lines in the sand and retreated to reading doomsday passages from their partisan play books. Amid the clamor there were even reasonable, constructive policy discussions to be heard. All of this is to be expected. And while it can generate great anxiety among those who care about the issue, it’s important to keep things in perspective.

First, there’s no health care reform bill yet. Key House and Senate Committees are drafting them right now, but nothing “official” is on paper yet. For now everything we’re hearing comes from option papers, outlines and letters. The legislative process involves numerous steps. What people expect it legislation to look like doesn’t really matter all that much. In fact, what legislation looks like when it’s first introduced doesn’t mean all that much. It’s what the bill contains when it winds up on the President’s desk that matter. Until that version of the bill emerges, it’s all just part of the debate. 

Second, no one should be surprised that President Obama considers a government-run health plan to be important. He made his position clear during the campaign. Often. His position on the issue seems to be one of principle, not politics. He sincerely believes that, as he wrote in his letter to Senator Max Baucus and Senator Edward Kennedy, a public plan “… will give [consumers] a better range of choices, make the health care market more competitive, and keep insurance companies honest.” You may disagree with his conclusion, but he has been consistent and specific about his intent.

Third, what President Obama wants from health care reform is critical. He’s a popular president advocating popular positions. The need for comprehensive health care reform is widely accepted. The President is an extremely skillful politician (just as Secretary of State Clinton and Senator John McCain). And ultimately, he’s the one who signs the bill or vetoes it. However, the White House is only one piece of the health care reform puzzle — a big piece, but still only one piece.  Congress will write the health care reform legislation. And Congress, by design, does it’s job messily. There are three House Committees (Energy &Commerce, Ways &Means, and Education & Labor) and two Senate Committees (Finance and Health, Education, Labor & Pensions) with jurisdiction. Within each chamber, the committee chairs have all pledged to cooperate and present a unified bill. That doesn’t mean they agree on everything, however. Getting to a common bill in either the House or Senate will require tremendous work and substantial give-and-take. And any unified bill within a Chamber is only the beginning. The House and Senate bills will need to be reconciled. 

Fourth, in the end, it all comes down to votes. Democrats have sizeable majorities in both chambers of Congress. That’s a blessing and a curse. It’s a blessing because the majority, eventually, tends to rule — or at least get most of what it wants. It’s a curse because getting to a large majority means creating a big tent. The Democratic political strategy for the past several years have been to recruit and strongly support candidates who fit their districts, not who meet some test of ideological purity. Which means there are liberals, moderates and conservatives on the Democratic side of the aisle in both the House and the Senate. This, in turn, means the White House and the Congressional Leadership must negotiate with members of their own party at the same time they are negotiating with the GOP.

What all this means is that what’s being said today about a government-run health insurance plan is significant, but not determinative of what will become law. President Obamamay want a public health plan. Leaders in Congress may wanta public health plan. But in the end, they want comprehensive health care reform more. And that means bringing along the moderate and conservative members of their caucus and, if possible, Republicans, too.

Some of those moderates have made clear they have problems with a government-run plan. Consider this report from Bloomberg entitled “Health ‘Public Option’ Hits Bipartisan Resistance:  “A group of House Democrats from Republican-leaning states said any “public option” must be tightly restricted so it doesn’t undermine private industry. We cannot create a public option that stacks the deck — through rate-setting and forced participation — against a system that currently provides coverage to 160 million Americans,” said Representative Mike Ross of Arkansas, chairman of the health-care task force of conservative “Blue Dog” House Democrats.”

Senator Bill Nelson, a conservative Democrat, said this weekend that, while he is open to a public health insurance plan under some circumstance, “‘It’s a deal-breaker for me if there’s a government-run plan to replace existing insurance plans,” according to the Lincoln Journal Star. Other moderate and conservative Democratic Senators have expressed similar reservations or, like Senator Evan Bayh are, at this stage of the debate, “agnostic” about the value of a public plan.  He w3nt on to say that a public plan might be limited to serving as “a backstop, as a last resort, if the private sector has just failed to meet the challenge.”

Politics, it is often said, is the art of compromise. But it’s also a lot like poker and as the song goes, in that game you’ve got to know when to hold ’em, know when to fold ’em. The key word in that lyric is “when.”  When it comes to a government-run health insurance plan, then is not now. It’s too early for partisans on either side of the debate to compromise. That time will come soon enough. Who does the compromising will be determined the way it always has been: by whose vote is needed. Passage of comprehensive health care reform will require votes from members of the Blue Dog Coalition (House Democrats) and the Senate’s Moderate Dems Working Group. When it comes to fashioning a compromise, it’s the positions of these lawmakers that need to be closely watched.