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.

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 Is Coming. Don’t Panic.

The legislative process is like Kabuki Theater. Very stylized. Clear-cut characters. Starts off slow, proceeds through several acts, ends fast and furious. The Congressional tussle over health care reform is no exception. We have the champions of the left and right pounding across the stage, striking poses, shouting out their predictable lines, scaring the bejeebies (whatever they are) out of the audience (otherwise known as constituents) and generally creating high drama. This is important work as it gives the 24 hour news stations something to talk about and this, in turn, keeps the commercials from running together in an endless loop of paid messages for help fighting the IRS, encouragement to ask your doctor about the benefits of an unhealthy number of medications, easy ways to get low cost loans and willing buyers of your excess gold jewelry.

At the same time we have numerous audience members who are quickly losing whatever bejeebies they might possess. If you are among the 470,000 Americans employed by the health insurance industry, for instance or among the tens of thousands of health insurance brokers in this country, you might feel like people are out to get you. Good catch because people are out to get you. Don’t feel too bad, though, you’re not alone. They’re also out to get doctors, hospitals, pharmaceutical companies and a host of others. 

Every health care reform idea on the table is scary to someone. Government-run plans, exchanges, mandates to sell coverage, mandates to buy coverage, taxes, cost containment. The list of proposals go on endlessly. Everybody with a stake in health care (which is everybody) has something to lose from some these reforms and someone is out there working hard to make sure these stakeholders lose it. In the health care reform everyone is an archer and everyone is a target.

So as someone with a stake in the system, but who has also spent more time than sane people should involved in politics and the legislative process, I would like to offer some simple advice to my fellow targets:

         Don’t Panic.

Don’t get comfortable, but don’t panic.

The good news is the health care reform most likely to emerge from Congress will be far more moderate than the proposals whipping around the Capital hallways today imply. This is theater — and it’s politics. Everyone in Washington is busy staking out negotiating positions, trying to score points, and auditioning for an appearance on CNN, Fox or MSNBC. Which means what they say matters, but not as much as they’d like to think it does.

In negotiations you expect to compromise so you start off asking for more than you expect to get. Every eight year old discussing bed time knows this. So do politicians. What we’re seeing at this point is primarily Democrats and Republicans anchoring their positions. In Kabuki Theater, actors will strike stances that identify their role in the story. In Congressional theater, this role is played by lawmakers. 

Which leads us to the effort of scoring points. Nothing revs up the base like lambasting opponents. The number of people who make a living by keeping a significant portion of the American population seething is significant and appalling. These people (and I use the term loosely) paint the world in terms of good and evil, black and white, us and them. Anyone who disagrees with “us” is a traitor, a fool, a liar or all of the above. They care less about moving the country forward than in adding to their power or their bank account. (Have you ever noticed how often their diatribes are followed by an appeal for cash or an advertisement?) These blowhards replace bombast for thought. They have honed the cheap shot and the stiletto implication into art forms. Fortunately there’s a cozy spot in Hell reserved for them where they’ll have to listen to themselves blather for eternity. Until then, we’re the ones stuck in their noisy hurricanes of malicious hot air. 

The subset of these sub-humans who hold public office will be especially prominent during this portion of the legislative process. Ignore them. Like the extreme positions taken by negotiators, the extreme rhetoric spouting from these Katrinas of politics are designed to rile you up, get your money and generate news clippings, not educate or move the debate forward.

The real action on health care reform is taking place in the nooks and crannies of Washington where moderates dwell. For example, keep your eye on the Senate Finance Committee. They seem to be trying to find solutions the nation can afford and that might actually work. Track the movements of moderates in the Senate, too. Senators Olympia Snow and Susan Collins are the two trendsetters on the amazing-shrinking-group of GOP moderates. On the Democratic side of the Senate moderates gather weekly in a self-described  Working Group. (Insert your own snide comment here).

The fact is, in Washington moderates win. The system is designed this way. It may not seem like it, but that’s the way it usually goes. This is the point articulately made by Jay Cost in his HorseRaceBlog over at RealClearPolitics.com. In two postings (Part 1 and Part 2) he lays out the pivot points in the legislative process and applies them specifically to the current health care reform debate. (My thanks to John Nelson for sending these my way). What he shows is that the true partisans are merely the fodder necessary to get to the number of votes needed to turn legislation into law. These pivot points vary depending on the political context.

Need to overcome a filibuster? The most powerful Senator is not the true believers who immediately vote yes or no, but the Senator who represents the 60th vote for cloture. Only that Senator can move the bill forward. The rest simply set the stage. When it comes to health care reform, watch the moderates. They are the key actors in this play because it is from among their group, along with critical  negotiators like Senators Max Baucus and Charles Grassley, from which the decisive votes will come. 

With 17 votes (maybe 18 now that Senator Arlen Specter is a Democrat) the moderate Democrats in the Senate will determine the final shape of healthcare reform. They are the ones the partisans on both sides are already seeking to persuade or, failing that, threaten (good news for television and radio stations in their states looking to sell advertising time). If these partisans are serious about passing something, however, that something will need to earn the votes of these moderates. Keep in mind, Democrats have a large majority in both chambers of Congress, but they got it by appealing broadly to the electorate. Democrats rarely are genetically incapable of group thought even when there’s just a few of them. Put 60 into one room (say, the floor of the Senate) and the chances of agreement on anything controversial is reduced to a theoretical nil.

What all this means is that the partisan posturing of the current debate is simply sound and fury signifying the hopes and aspirations of sincere partisans and cynical pot stirrers (which is which is sometimes hard to tell, but there is a difference — only the latter are despicable). Eventually the play will reach its final act. At this point the moderates take center stage and with their arrival the odds of disappointed extremists on both sides  increases(disappointing extremists is, after all, what moderates d0).

This doesn’t mean they will come up with the perfect health care reform plan. If you care about the issue you need to make your voice heard. Moderates are capable of making bad policy — and whether the truck that runs you over is driven by a true partisan or a moderate doesn’t really matter, it still hurts. Moderates are more likely, however to produce reforms that are closer to something reasonable than might seem possible appear today.

In the meantime, let the loud and boisterous actors strike their poses. It’s all part of the play.

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.

Health Care Reform is Coming, But it Won’t Be Easy

Personally, I think health care reform is inevitable. The need for change is simply too great. Too many people go without coverage, too many are insecure about the coverage they have. Controlling medical costs is a critical part of fixing the economy: businesses and state and local governments need relief. Political pressure for a solution — from across the ideological spectrum — has reached critical mass.

The reform process is well underway. President Barack Obama held a health care summit at the White House earlier this month. Several proposals are making the rounds. Senate Finance Committee Chair Max Baucus has one.  Senate Health, Education, Labor and Pensions Committee Chair Ted Kennedy and his staff have been actively meeting with stakeholders. Democratic Senator Ron Wyden and Republican Senator Bob Bennett have introduced the Health Americans Act, which is supported by several colleagues from both sides of the aisle. There’s the proposal put forward by President Obama during the campaign and embellished somewhat since his inauguration. Republicans have their plans and think tanks have theirs.

We’ve seen this before. In 1993 it looked like President Bill Clinton’s spent enormous political capital seeking health care reform. He failed. A recent Newsweek article by Katie Connolly outlined several reasons why the health care reform debate now is likely to be much different than the battles in 1993. The Clinton Administration failed in large part because their efforts were politically inept and inflexible. President Obama’s approach is much more open, inclusive and savvy.

Of course, at this stage we’re still dealing with generalities. The specifics, which is where the devil receives his mail, have yet to emerge.  When they do the hard part of the process begins. And that could be any week now.   The Washington Post’s Lori Montgomery and Ceci Connolly reported today that “House Democrats, in consultation with the White House, will give Republican lawmakers until September to reach a compromise on president Obama’s signature health-care initiative ….”  Currently, several committees in both houses of Congress are holding hearings on health care reform. These, however, are more educational in nature, allowing interested parties to provide input and begin staking out positions. With little legislation before them the hard negotiations have yet to begin. Those discussions will have to start sooner than later if Congress is to meet the House Leadership’s September deadline. Given the complexity of health care reform it will require months of negotiations to find common ground. 

Finding that common ground won’t be easy. Already Republican Leaders are identifying deal killers. A National Association of Health Underwriters’ newsletter quotes Senator Chuck Grassley, the ranking Republican on the Senate Finance Committee as identifying the Obama Administration’s call for a national health coverage exchange to compete with the private market as extremely problematic. The GOP won’t accept such a program, according to Senator Grassley, and Democrats are likely to insist on one. There may be a way to create an exchange that satisfies both parties, but that requires a lot more specifics than have emerged yet. 

(Note added 3/20/09 at 7:45 pm: the rift between Senator Grassley’s position and those favoring a government insurance plan is growing wider — and nastier. Carrie Budoff Brown, writing in Politico today, reports on “a four-day ad buy aimed at Iowa Sen. Charles Grassley, the ranking Republican on the Senate Finance Committee who is increasingly vocal in his opposition to the government insurance option.” Health Care for America Now is leading the charge against Senator Grassley. At the White House Forum on Health Care the ranking Republican on the Senate Finance Committee told President Obama that such exchanges were “‘an unfair competitor’ and could run private insurers out of business,” according to the Politico story. The article also notes that Senator Wyden found no Republican Senators willing support his bipartisan legislation if it included a government run health plan. “From a raw political standpoint, having talked to a lot of senators, I wouldn’t have any Republicans on the Health Americans Act as cosponsors if we had a public option,” he told Politico.)

There is a way for Democrats to pass health care reform without Republican votes. If a compromise fails to emerge by September, the House Leadership is pushing for a legislative process that would allow passage with simple majorities in both chambers. This would be accomplished through a process called “budget reconciliation.” Under the reconciliation rules, filibusters are not permitted enabling the Senate to move legislation forward with a simple majority of 51 votes instead of the 60 needed to end a filibuster. Democrats currently hold 58 seats in the Senate (including those of two independents who caucus with them) with one more likely to arrive from Minnesota. (Filibusters don’t exist in the House, making passage by majority vote the norm in that chamber).

But Democrats may have a tough time pulling together even 51 votes in the Senate. Senator Evan Bayh announced on MSNBC on Wednesdaythat 16 moderates in the Senate (15 Democrats and one independent who caucuses with the party) have come together to provide a united, centrist voice to issues such as health care reform. As noted in the press release announcing the group’s formation, their goal is “to pursue pragmatic, fiscally sustainable policies across a range of issues, such as deficit containment, health care reform …” and others. With 16 members, this caucus, currently dubbed the “Moderate Dems Working Group” represents more than a quarter of the Democrats serving in the Senate. If even 10 0f these centrists stick together they’ll need to be a part of any deal struck on health care reform.  (A list of the 16 Senators in the group is below).

At the same time there are liberals in Congress who would just assume have government take over the health insurance industry and create a single payer system similar to that in place in Canada and many Western European countries. At the very least they look to a greater role for the government in providing health care coverage to middle class Americans (the government is already the primary insurer for older and low income citizens).  They won’t go quietly along with a solution they feel fails to assure universal and comprehensive  coverage.

What this means is that while health care reform is coming, getting there won’t be easy. But there is a way. President Obama has long talked of the need to focus on core principles and the desired outcome instead of on how we get there. He has even said that his campaign proposal for a federal health insurance exchange (the deal breaker identified by Senator Grassley) is negotiable. As noted in the Newsweek article, the president said at  the White House summit, “If all Americans could be insured at ‘an affordable rate and have choice of doctor, have flexibility in terms of their plans, and do that entirely through market, I’d be happy to do it that way.'”

This is the approach all lawmakers and interest groups — whether liberal, moderate and conservative — need to bring to the table. The health care reform debate will be heated, passionate and difficult. But if all participants focus on the goals, the means of getting there can be found.  Given the need, it better be.

***************

The 16 members of the Moderate Dems Working Group (who, hopefully, will work on coming up with a better name) are:

  • Evan Bayh (Indiana) – co-chair
  • Mark Begich (Alaska)
  • Michael Bennet (Colorado)
  • Tom Carper (Delaware) – co-chiar and a member of the Senate Finance Committee*
  • Kay Hagan (North Carolina) — a member of the Senate H.E.L.P. Committee*
  • Herb Kohl (Wisconsin)
  • Mary Landrieu (Louisiana)
  • Joe Lieberman (Connecticut)
  • Blanche Lincoln (Arkansas) – co-chair and a member of the Senate Finance Committee*
  • Clare McCaskill (Missouri)
  • Ben Nelson (Nebraska)
  • Bill Nelson (Florida) — a member of the Senate Finance Committee*
  • Mark Pryor (Arkansas)
  • Jeanne Shaheen (New Hampshire)
  • Mark Udall (Colorado)
  • Mark Warner (Virginia)

* The Senate Finance Committee and the Senate Health, Education, Labor, and Pensions (H.E.L.P.) Committee have primary jurisdiction over health care reform legislation.