The Never Ending Story That is Health Care Reform Continues

President Barack Obama is scheduled to announce his final health care reform package tomorrow (Wednesday). This is the version of reform the President hopes Democrats in Congress will embrace and enact through a process that would side-step the inevitable Republican filibuster of health care legislation. Passage is far from assured. There are still several parliamentary maneuvers available to the GOP to slow the legislative process down. And it’s unclear whether Democrats can muster a majority behind any single bill to pass health care reform even if no super majorities are required.

Yet there are indications Democrats could be successful. For example, the House passed its health care reform bill by the slimmest of margins – 220-215 – last November. Only one Republican voted for the bill and he has indicated he won’t bolt his party again. Given that 218 votes are need to pass legislation in the House, this doesn’t give Speaker Nancy Pelosi much room for error. However, according to the Associated Press, “at least nine of the 39 Democrats” who voted against the health care reform bill in November are now “undecided or withholding judgment until they see Mr. Obama’s final product.”

That same Associated Press story also reports that the President is thinking of incorporating four Republican proposals raised during the bipartisan health care reform summit last week. These are: 1) using investigators disguised as patients to uncover fraud and waste; 2) increasing payments to Medicaid providers; 3) strengthening and expanding Health Savings Accounts; and 4) expanding the medical malpractice reform pilot programs already in his bill.

It’s not that the President thinks including these provisions increases the likelihood of any Republicans supporting his health care reform legislation. But it would provide Democrats with a useful talking point during the firestorm that would follow passage of reform legislation by a simple majority vote in the Senate. Democrats will be able to say something along the line of “We met with Republicans and had an open mind, even incorporating some of their cost saving ideas into the final package. And our package already included several provisions Republicans had supported now or in the past. Their unanimous opposition, consequently, obviously reflects politics more than policy so we had to find away around the filibuster. What we did was fair, legal and within the rules.” Or something along those lines.

What all this means is that there’s still several chapters to go in the never-ending story that is health care reform.

  • Will Democrats find a way to bring health care reform votes to the floor of the Senate?
  • Will the House vote first or wait until after the Senate takes action (if it ever does)?
  • If a vote is taken, will there be sufficient votes to actually pass a bill?
  • If Congress does enact health care reform legislation, how soon after the President signs it into law will it take before the first law suit is filed?
  • Which party will suffer at the polls this November for the the procedural games both have played?

And on and on. Stay tuned.

Health Care Reform Effort Will Continue, But Fate is Uncertain

With the bipartisan health care reform summit history, President Barack Obama is turning to the future of his push to revamp America’s health care system. Here’s a simple way for President Barack Obama to demonstrate a commitment to cost containment and bi-partisanship. As he said in his weekly address this morning, “I am eager and willing to move forward with members of both parties on health care if the other side is serious about coming together to resolve our differences and get this done.”

He also made clear, however that he would move forward without Republican support if that was necessary. “I also believe that we cannot lose the opportunity to meet this challenge,” he said, concluding, “It is time for us to come together.  It is time for us to act.  It is time for those of us in Washington to live up to our responsibilities to the American people and to future generations.  So let’s get this done.”

The other day I wrote about the three step process Democrats are likely to use to attempt to pass comprehensive health care reform. To summarize: House Democrats would pass the health care reform previously passed by the Senate. The Senate would pass a clean-up bill (which I’ve also heard referred to as “sidecar legislation”) that makes fixes the House and President Obama want that impacts costs and taxes. The House passes the clean up bill. The President signs both bills and health care reform, Democratic-style, is the law of the land.

Turns out this gambit, while legal and within Congressional rules, doesn’t play out as cleanly as I’d first surmised. John Nelson, a regular reader, brought to my attention that there are various ways Republicans can slow this process down to a crawl. The GOP could not filibuster the sidecar legislation because it is being considered under what’s called the reconciliation process. However, they may not need to. Under the rules governing the reconciliation process Republicans can introduce an almost unlimited number of amendments. While in theory the reconciliation process limits debate to 20 hours, the amendments could stretch out the debate for weeks.

As President Obama accurately noted during the health care reform summit, most Americans care more about the substance of health care reform than the process. However, it’s equally true that the legislative procedures used to push the issue this far have created a cloud over the substance of reform. Republicans have artfully used the messy give-and-take typical when drafting major legislation and cast it as a reason to oppose what was drafted. Some of these criticisms, such as the deals cut to favor specific states, are valid; others, such as condemning the legislation because the bills themselves are large, are spurious. But what’s undeniable is the drumbeat of criticism concerning process has undermined the substance of the bill (of course the serious problems with the substance of the bill hasn’t bolstered it’s popularity either).

If the Democrats could accomplish their legislative maneuvers quickly attention would shift to he substance of the legislation long before the November elections. In other words, like yanking off a bandage, the political pain generated by the process would be over quickly. If Republicans force Democrats to spend weeks mired in process, however, the political pain becomes increasingly greater – and perhaps unbearable.

What all this means is that the odds of comprehensive health care reform passing have improved considerably since the election of Scott Brown to the Senate from Massachusetts and the subsequent loss of the Democratic caucus’ 60 vote, filibuster-busting majority. But those odds haven’t increased as much as a I thought when I wrote about the three-step process Democrats would likely use to enact the reform legislation.

There are smart people on both sides of the issue. There are passionate people on both sides. The effort to pass – and to defeat – health care reform will continue. How it ends is anyone’s guess at this point.

Democrats Now More Likely to Move Health Care Reform Forward On Their Own

Well, so much for a breakthrough. The health care reform summit was fascinating political science. But it certainly does not seem to have generated a clear direction for anything close to bipartisan health care reform. Which means President Barack Obama and Democratic leaders will put forward a bill for an up-or-down vote, most Democrats will vote for it and no Republicans will. The only questions remaining are: 1) will Democrats invoke a rule that will allow them to move forward with a simple majority or will they permit the GOP to prevent the legislation from coming to a vote; and 2) will Democrats make any changes to the legislative proposal put forward by the President to reflect issues raised by Republicans during today’s health care reform summit. This post addresses the first question; the next one the second.

Reconciliation: My guess is that Democrats will use reconciliation as a means of bringing health care reform legislation to the floor of the Senate for a vote. As NPR has reported, it would not be the first time reconciliation led to substantial changes to America’s health care system. As Sara Rosenbaum, chair of the Department of Health Policy at George Washington University, notes in the NPR story, “In fact, the way in which virtually all of health reform, with very, very limited exceptions, has happened over the past 30 years has been the reconciliation process.”

She’s not just talking about arcane legislation, either. COBRA, the provision that allows workers to continue their coverage after leaving an employer, was passed through reconciliation. In fact, COBRA stands for the bill in which this health insurance extension was included, the Consolidated Omnibus Budget Reconciliation Act of 1985. Reconciliation is the “R” in “COBRA.” In 1997 the Children’s Health Insurance Program, which along with Medicaid now covers one in every three children in the United States, was passed as part of a budget reconciliation bill. As the NPR story reveals, the list literally goes on-and-on. It seems health care reform simply can’t wend its way through the Senate with a super majority. is this because, as the Center for Public Integrity reports, there are eight health care lobbyists for each member of Congress? Whatever the reason, reconciliation is commonly used to pass health care reform.

It’s likely Democrats will keep this streak going. Yes, Republicans will cry foul, but at the end of the day, it’s a perfectly legal process. And while not every provision of the President’s reform package is likely to be eligible for reconciliation, enough will be to enable Democrats to declare victory.

Assuming, of course, they can muster majorities for comprehensive health care reform legislation. The earlier House bill passed with two votes to spare – including one from a Republican who is now saying he’d vote against the bill. And while the Democratic caucus numbers 59 members, there are 18 members of a the Moderate Dems Working Group. Whatever bill comes before the Senate will need to hold onto nine of those moderates – and that’s assuming all other Democrats are willing to go this route. Some liberals, including Senator Jay Rockefeller, have expressed reluctance to to invoke reconciliation. In the end, the President is likely to muster enough support for a bill – he only needs 50 votes in the Senate as Vice President Joe Biden could cast the decisive vote there. The vote will be close in the House, but Speaker Nancy Pelosi has repeatedly demonstrated her ability to muster a majority when needed.

President Obama needs a vote on health care reform. Politically he needs to demonstrate to his base and moderate independents that his commitment to hang tough on the issue – even if it means he’s the captain going down with his ship. If Republicans (and some Democrats) defeat the legislation, he’ll have shown he’ tried. America doesn’t like quitters (former-Governor Sarah Palin being the most prominent exception). They do like fighters. Politically, moving forward on health care reform is a necessity.

It also makes public policy sense. The health care status quo is untenable. Change is needed. Even if his ambitious reforms fail, the effort will set the stage for more modest reforms – modest reforms that could be introduced and voted upon before the November elections.

In an upcoming post I’ll discuss whether the bipartisan health care reform summit makes it more likely the President will moderate his health care reform proposal.

Health Care Reform Summit May Be Substantive

Will the February 25th health care reform summit merely be political theater? Or will it serve as an inflection point that leads to passage of health care reform legislation? I haven’t seen any polls on the matter, but a quick search on the topic certainly creates the impression that many believe the summit will be six hours of politics with nothing substantive emerging.

I respectfully disagree.

Yes, the bipartisan health care reform summit President Barack Obama is convening will have more than its fair share of politics. That’s inevitable when that many politicians are in the same room. And given that it is in the electoral interest of Democrats to produce health care reform and in the electoral interest of Republicans to deny Democrats this victory, that politics will pervade the proceedings is to be expected. Nor should the political facets of the summit be criticized or denigrated. America’s legislative system is political. Unlike other country’s in which the ruling party is expected to rule (thus Prime Ministers are the leaders of the legislative majority), in America we set up a system that would inevitably be adversarial.

Of course, one could argue (and I do) that this adversarial relationship has gone too far. Today’s political climate is poisoned by an unwillingness or inability by one side to recognize anything of value put forward by the other. Opponents are not simply wrong, they are evil. It’s as if the prevailing logic has become: “Reasonable people cannot disagree because anyone who was reasonable would agree with me. Ergo, people who disagree with me are unreasonable.” That this is a both foolish and unhealthy, both for the individuals involved and the Republic, doesn’t seem to matter. That radio talk shows and cable news channels (especially during prime time) pour fuel on this fire – usually embellished with misunderstood or downright erroneous facts – only makes the matter worse.

Which is a long way of saying that those who claim the bipartisan health care reform summit will fail to rise above political gamesmanship have the odds in their favor. But at the risk of being naive, I think it will lead to something more substantive. Here’s some reasons why:

  • It’s hard to be political for six hours straight (even with an hour off for lunch). The participants know they’re engaged in a bit of Kabuki theater. But staying in character that long is tough. These folks do have sincerely held beliefs. Even those who stifle those beliefs in favor of scoring political points are likely to let a ray of substance shine through during the course of the day.
  • And each side has an incentive to seize that ray of sunshine (to butcher the metaphor) and ratchet it up a bit.
  • For Democrats, the incentive is to get on record the specific provisions Republicans demand to see in a health care reform bill and identify the ones they can live with. By expanding the Obama health care reform proposal to include as many GOP ideas as possible, the Democrats assume a no-lose situation. If including those provisions gain Republican support for a bill, they win by passing health care reform legislation. If Republicans remain united against a bill that includes ideas they profess to support, the Democrats get to paint the Republicans as obstructionist.
  • For Republicans, they need to re-position themselves as something other than the Party of No. Not that their base wants them to do anything other than oppose whatever bill the Democrats put forward. But Republicans won’t win elections this November just appealing to their base. It’s independent voters who decide elections. In Virginia in 2008 those independent voters helped send a Democrat to the White House. Those same independents last year put a Republican in the Governor’s mansion. By offering substantive proposals Republicans in Congress can demonstrate they’re serious about solving problems. They can then claim to withhold their support for whatever legislation the President puts forward on the grounds that they cannot support rate regulation, or Medicare cuts, or new taxes or something. But they need to show they care about fixing America’s health care system. And that means putting ideas on the table that reduce costs and expand coverage.
  • Which leads me to believe President Obama’s health care reform plan will be modified subsequent to the summit. And because it will likely incorporate ideas from a broader spectrum than participated in the drafting of the current plan, the result is likely to be a better proposal.
  • At the very least, the summit will allow Democrats and Republicans to explain to the American people the “why” behind their positions. Which will liberate Democrats to move forward with legislation regardless of whether Republicans support it or not.
    • If the Republicans have used the summit to seize the high ground, the resulting legislation will be much more moderate than what the President is proposing today.
    • If Republicans fail to put forward meaningful ideas, the proposal will be poorer for it, but will move forward nonetheless.

    At the end of the day, I believe both chambers of Congress will vote on a comprehensive health care reform bill – something that has not happened in recent memory despite decades of effort. If Republican Senators filibuster the President’s health care reform bill, Democrats will turn to the reconciliation process (which allows them to pass legislation with a simple majority, not the super-majority overcoming a filibuster requires.) They’ll claim they gave bipartisanship a try and that they are playing by the rules (which permit circumventing filibusters in certain circumstances) and by American principals (what’s more American than “the majority rules?”)

    That’s my educated guess. What’s hazier to me are two additional and critical questions.

    1. Will the legislation voted on by Congress be health insurance reform or will it be real health care reform that tackles the need to control costs?
    2. Will they be able to put forward a single bill capable of obtaining majorities in both the House and Senate?

    But first things first. And first is the summit. Will either size, neither or both engage in a substantive debate? I think so. And even those who are skeptical of this result should hope so.

    Why Liberals Will Be Disappointed By The Health Care Reform Summit

    Americans’ views of the upcoming bipartisan health care reform summit will differ greatly: their ideologies and existing opinions concerning health care reform will color how they view what unfolds at Blair House on February 25th. Those in the center and right will hear talk of new government agencies and programs, new federal rules and the regulations, and wonder why those on the left are so disappointed. Isn’t what President Barack Obama proposing an unprecedented incursion by the federal government into health care? What more could the left want?

    What liberals want is a single payer system. Often couched as Medicare for All, liberals hoped last year the new Administration would move forward with a complete remake of America’s health care system. Not they had much basis for such wishful thinking. Candidate Barack Obama made it clear that he would not be pushing for a single payer system if elected. After the election he made clear the private carriers would be a central part of the country’s health care system (single payer advocates would do away with health insurance companies).

    In short, a single payer was off the table pretty early. But that doesn’t mean it was forgotten. I was watching Senator Bernie Sanders call for Medicare for All on one of the news stations earlier this week.

    As we approach the Amidst the accusations that President Barack Obama is refusing to compromise on his health care reform package, it’s worthwhile  intention to lead a government takeover of health care in the United States Dr. Quinten Young, national coordinator of Physicians for a National Health Program, attacked both the House and Senate health care reform bills as “disastrous.” In a Huffington Blog posting, Dr. Young called on President Obama to “lay out the facts to the American people and provide energetic leadership for this eminently rational proposal.”

    Not going to happen. Consider the current status of Medicare’s finances. Representative Paul Ryan, writing in Newsweek magazine this week, notes Medicare “is short $38 trillion of what it promises to provide your parents, you and your kids. In five years, the hole will grow to $52 trillion. Your family’s share: $458,000.” It’s also worth noting that the single payer bill recently passed by the California State Senate (and likely to be passed by the State Assembly then vetoed by Governor Arnold Schwarzenegger) has a price tag of roughly $200 billion. As noted: it’s not going to happen.

    Which explains why liberals are so dismayed when President Obama’s health care reform plan fails to include a government-run health plan to compete with private carriers. Unlike moderates and conservatives who see this (to varying degrees) as a compromise, liberals view the lack of a public option as the elimination of a compromise they already agreed to. They want a single payer system. They were willing to accept a public option. Now that’s off the table, too?

    People feel passionate about health care. The issue is personal, political and policy all wrapped into a complex mix of laws, regulations and history. Which is why many observers believe the bipartisan summit will be little more than political theater (I disagree for reasons I’ll put in another post later today). And people will naturally interpret what happens tomorrow based on their own view of health care reform policy and politics. The perspective for liberals seeking a single payer system will be that of an ever shrinking loaf, leaving them with little to celebrate – in their view.

    As noted, however, the left’s disappointment is unsurprising, and the fault of their own misinterpretation of election night 2008. Democrats increased their majorities in both chambers of Congress. Democrats won the White House. Progressives interpreted these results as the triumphs of liberalism. They were not. They were triumphs of the Democratic Party – a party that includes moderates and conservatives. Just as all Labradors are dogs, but not all dogs are Labradors, most liberals are Democrats, but not all Democrats are liberal.

    No one knows for sure what will emerge from the health care reform summit. But a safe guess is that liberals will be further disappointed.

    Bipartisan Health Care Reform Summit Changes Health Care Reform Dynamic

    In politics it’s often easy being in opposition to the party in control. Since your ability to pass laws is limited, at best, the goal shifts from legislating to point making. Minority parties tend to introduce bills to bolster their base and embarrass the majority. They get to rail against the inevitable hypocrisy that is a part of governing in a democracy while ignoring their own double standards back in the days when they were in charge.

    In Washington this game is clear and obvious. The Democrats, control of both chambers of Congress and the White House, try to muscle through their priorities. The Republicans unanimously oppose them. In California the game plays out a bit more subtly. Democrats have large majorities in the legislature, but a Republican occupies the Governor’s office. This allows Democrats to shift between the role of the party in control and the opposition. The result: Democrats back a bill that would establish a $200 billion single payer program in the state, safe in the knowledge that it will never become law. If a Democrat becomes Governor next year single payer legislation will still be on the table, but it will be vetted and debated far more thoroughly than this year’s bill.

    Now that Democrats have lost their filibuster-busting majority in the Senate, the dynamic in Washington changes substantially. Republicans have been unified in their opposition to the Democrats health care reform proposals. With 60 votes Democrats could ignore them. The debate was all within the Democratic caucus and took place between liberals and moderates. Reduced to 59 votes, Democrats face a new reality: Republicans matter.

    President Barack Obama gets this. His appearance at the House GOP conference was a masterful stroke. The give-and-take can be viewed differently depending on the partisan glasses one wears, but the political picture painted at the event unarguably favored the White House. The mere presence of the Democratic president at a Republican meeting was a victory for the Administration. Most of his questioners read from prepared documents (one from a huge book). President Obama answers were note-free. This made it seem like the Republicans had mapped out how to trap or embarrass the President while President Obama was there to simply talk.

    Worse, the Republicans could not help but couch their questions in loaded, political terms. (“When will you stop being a socialist” kind of thing). President Obama not only called them on this behavior, but focused his remarks on substance and the need for bipartisanship. Because the questions were politically laden, even when the President responded in kind he won – self-defense is a valid excuse in the eyes of most non-partisans. The best evidence the President benefitted from attending the event: Republican leaders admit, off the record, that televising the question and answer session was a mistake.

    Now President Obama is taking the dialogue to a new level and Republicans are in danger of being cornered again. Think of it as the “Be Careful What You Wish For Gambit.” Republicans have been accurately complaining they’ve been excluded from negotiations concerning health care reform. That’s about to change.

    On Sunday President Obama announced he would convene a bipartisan health care reform summit with legislative leaders to be televised live. The New York Times quotes President Obama as stating “I want to come back and have a large meeting, Republicans and Democrats, to go through systematically all the best ideas that are out there and move it forward.” The paper goes on to say that “Mr. Obama challenged Republicans to attend the meeting with their plans for lowering the cost of health insurance and expanding coverage to more than 30 million uninsured Americans.”

    This move has the potential to actually move health care reform forward. Democrats could be forced to defend some of their more tenuous proposals. Republicans might have to explain how their reforms stack up against the Democrats’ ideas. Republicans could use the opportunity to pin Democrats down on some of their favorite ideas (e.g., medical malpractice reform) while Democrats could question their GOP counterparts on how requiring carriers to accept all applicants regardless of pre-existing conditions can work without requiring all Americans to obtain coverage. In other words, there’s an opportunity for a meaningful, substantive debate that would educate the public while identifying common ground among the Congressional combatants.

    And then there’s the political theater of it all. If Democratic or Republican participants use the opportunity to score political points rather than solve problems it will be apparent for the world – and their constituents to see. You can bet that President Obama will avoid this mistake. Instead this is an opportunity for him to present himself to voters – especially independent, moderate voters – as a thoughtful, serious leader focused on finding solutions to serious problems. There’s no more politically potent place for a politician to stand than above politics.

    Of course, there’s no guarantee this summit will take place. Republicans are insisting that the legislation passed by the House and Senate be shelved before they participate. While I appreciate their concern about giving credence to the Democratic plan, the reality is that any discussions need a starting point. And the Democratic legislation is what’s before Congress. Taking into account that many of the provisions of the bills are non-controversial, starting with the current bills makes sense from a practical standpoint. Further, politically it’s to the Republicans advantage to force Democrats to defend their proposals. Especially given rifts within the Democratic party within and between each chamber, defending the existing bills would put Senate Majority Leader Harry Reid and House Speaker Nancy Pelosi in an extremely awkward position.

    However, instead of turning the President’s summit idea into an advantage, Republicans seem to be deploying the tactics that made them a minority party in the first place. Consider Republican Representative Darrell Issa. According to the Associated Press he said that the first question Republicans should ask President Obama is “Did you lie about moving forward on malpractice reform?” Yes, this feistiness is red meat to the Republican base, but elections are won among moderates – and moderates are tired of politics-as-usual. Representative Issa could have made the same point by suggesting the first question be “How can the GOP help President Obama keep his promise to move forward on malpractice reform?” That’s the approach most independent voters are hoping to see. (Granted, some independents are well to the right or left of the mainstream, but the ones that decide elections tend to be moderates.)

    President Obama’s call for a bi-partisan health care summit is subtle and significant.  At best it leads to passage of health care reform albeit at the political price of rewarding Republicans for being partners in reform. At worst the summit proves no health care reform is possible, but in the process shows that it is Republicans who are unwilling to take substantive action.

    For President Obama this is a win-win situation. For Republican it is a dangerous one. If they rise above politics it could cement their standing as the alternative to the current Congress.  That’s their win. If they follow Representative Issa’s example, however, they’ll make their base happy, but undermine the electoral momentum they’ve gained in the past year. That would be their loss.