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.

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.