Moving Beyond Health Care Reform Repeal to Revision

During the 2010 election Republicans promised to “Repeal and Replace” the Patient Protection and Affordable Care Act. Having gained a majority in the House of Representatives they quickly passed a bill to do just that (joined by three Democrats). Having failed to gain a majority in the Senate the repeal process is all but over.

Senate Majority Leader Harry Reid has said he would not bring the “Repealing the Job-Killing Health Care Law Act”to the Senate floor for a vote. In response Republican Senators have promised to offer amendments repealing what they see as unpopular provisions of the law. In both the House and Senate GOP lawmakers are targeting the PPACA’s requirement that all Americans obtain health insurance coverage, malpractice reform, taxes imposed on health insurance carriers and others, denying federal subsidies (including tax deductions) for health plans that cover abortions, and permit the sale of health insurance across state lines. While Republicans know these amendments will fail, forcing Democrats up for election in 2012 to cast several votes defending President Barack Obama’s health care legislation has significant potential political benefits.

But two can play this game. So if Republicans force a vote on their measures, Democrats will require GOP Senators to vote on legislation concerning more popular elements of the PPACA. These include closing the Medicare prescription benefit donut hole, eliminating pre-existing condition exclusions for children, and allowing children to remain on their parent’s health plan up to age 26.

Then there’s the coming Republican effort to defund the PPACA. (Which creates an enjoyably ironic situation. Many in both parties, but especially Republicans, argued Democrats were arrogant to pass health care reform in the face of polls showing the public opposed their legislation. How will they respond to a Kaiser Family Foundation and Harvard School of Public Health showing 62 percent of respondents opposed cutting off funds needed to implement the PPACA?)

What all this means is that we’re in for two years of political showmanship concerning health care reform. But that doesn’t mean meaningful changes to PPACA won’t be forthcoming. President Obama declared his willingness to sign a medical malpractice reform bill. Of course there’s tort reform and then there’s tort reform. Health and Human Services Secretary Kathleen Sebelius has committed to providing “what the parameters of medical malpractice reform might be” during a hearing of the Senate Health, Education, Labor and Pensions Committee Hearing. Whether there is enough common grounds with GOP proposals to deal with medical malpractice remains uncertain until then. Meanwhile, 60 Senators have signed onto a bill to repeal the the 1099 reporting provisions contained in the health care reform law. Down the road there will be efforts to gain bi-partisan support for changes to more difficult provisions of the new reform law, including medical loss ratio requirements and the exchanges.

Yes we’ll all be subjected to the sound and fury signifying only political posturing and one-upmanship. But there will also be acts of quiet negotiation aimed at what President Obama in his State of the Union speech called “improving” the Patient Protection and Affordable Care Act. And as Politico Post describes the reaction of this language by Julie Barnes, director of health policy at the Bipartisan Policy Center, this could well be “a signal that bipartisan cooperation on health reform tweaks is on the horizon.”

One can only hope.

The Health Care Reform Kabuki Theater 2011 Style

Republicans are expected to put repealing the Patient Protection and Affordable Care Act to a vote on Wednesday. Proving yet again that Kabuki is alive and well in Washington, D.C. Which makes what is about to unfold in Congress relatively straightforward to predict with a reasonable degree of confidence.

For those who like their metaphors precise, Kabuki is a highly stylized and classical type of Japanese dance-drama. The plays, usually in five acts and sometimes lasting all day, traditionally start slowly and gain speed throughout the presentation. Characters and story lines are well-known and understood by audience – and the actors. Politics shares a lot with Kabuki and the debate over health care reform is no exception. The actual players may come and go after each election, but their roles and the story line are well understood by participants, the media and the public.

Here’s how the first three acts of the health care reform dance in Congress is likely to play out over the next several months.

Act 1: The Vote to Repeal:
Republicans are planning to bring HR 2, the “The Repealing the Job-Killing Health-Care Law Act” to the floor on Wednesday, January 19th at 10:00 am eastern time (for those wanting to TiVo C-SPAN). The debate will (hopefully) be more substantive and civil than one might have expected before the tragedy in Tucson, but there will still be a good number of outrageous claims made by both sides. After all, everyone knows the PPACA will not be repealed so this is a purely political gesture.  Republicans are fulfilling a campaign promise many of them made in the mid-term elections. Both sides will take the opportunity to throw red meat to their base (do Democrats throw blue meat?), sound bites will prevail, and pundits will be in punditry heaven.

This round will go to the Republicans. Democrats will score some hits, accusing GOP lawmakers of being in the pocket of the insurance companies, seeking to do away with those elements of the PPACA which are popular (guarantee issue, no pre-existing conditions, etc.), and more. Republicans will score their points, too, but their real win will come from the make-up of the majority that will pass the repeal bill. Republicans will be able to brag that the vote to repeal health care reform was more bipartisan than the vote to pass health care reform. And brag they will. The vote may not be very bipartisan, but it only takes one Democrat opposing their leadership to make the vote on HR 2 more bipartisan than the votes on HR 3590 and HR 4872  (the two bills that together make up the PPACA). The bipartisanship of repeal is a sound bite too sweet to ignore – it undercuts the punches scored by the other side while elevating the GOP’s hits. What’s not to like?

After passing the House, HR 2 will head over to the Senate where it may never be brought to a vote. The debate over repeal will quickly descend to playground rhetoric. Republicans will attack Democrats for playing keep-away on a vote. Given the numerous times the GOP manipulated Senate rules in the past couple of years, Democrats will use the “I’m rubber, you’re glue” defense and accuse Republicans of being hypocritical. If HR 2 does come up for a vote – or if there’s a debate over whether to bring the bill to the Senate floor – it will be because Democrats determine the political upside of doing so outweighs the political downside.

Regardless, Republicans know they cannot repeal the PPACA. Their goal in this Act is to make the effort and they’ll succeed in that regard.

Act 2: Picking Low Hanging Fruit
President Barack Obama has identified elements of the Patient Protection and Affordable Care Act that needs tweaking. So have Democratic and Republican members of Congress. Their lists have significant overlap. Both, for example, recognize the need to do away with the requirement that businesses submit 1099s to the IRS to any entity providing them products and services worth $600.

Given the realities of modern-day politics I’m not saying that these easy changes will come easily. The Senate was unable to repeal the 1099 provisions of the PPACA last November. Maybe given the public’s hunger for civility and cooperation the parties will come together on some of these no-brainer changes to the health care reform law. But that might be wishful thinking.

At the end of the day (or more likely a few weeks) Congress will make have made these amendments to the PPACA all but a certainty of passing. What will be interesting is whether the combatants decide to pass these widely supported modifications on a stand-alone basis, as a single, limited package or if as part of legislation seeking more controversial changes. Again, the decision will be based on how each interprets the politics of the situation, but my guess is that we could see most of this low hanging fruit pass relatively quickly; Republicans because an important part of their base (the business community) wants these changes done quickly and Democrats to demonstrate their commitment to civility and cooperation.

Act 3: Picking a Fight
Then it gets interesting. Republicans will vote to deny funding for some provisions of the Patient Protection and Affordable Care Act. They’ll push bills in the House to eliminate key elements of the bill (the individual mandate for sure, the exchanges and the medical loss ratio provisions possibly). Senate Democrats may push for the public option provision eliminated from the PPACA near the end of the process that produced the new law. (The public option refers to establishing a government-run health plan aimed at competing with private carriers).

These controversial changes to the PPACA will be based on both ideology and politics (as is to be expected when talking about government). Some proposals will reflect the strong beliefs of one party or the other. The parties do have valid and substantive disagreements. The parties see the role of government differently. Given the same reform they expect different outcomes. They have different approaches to problem solving. As a result much of the debate over controversial changes to health care reform will be substantive.

But not all of it. Many of the amendments, budget cuts, investigatory hearings will be politically driven. President Obama is up for re-election in 2012 as is every member of the House and one-third of the Senate. Republicans know the results of the 2010 election were more the result of centrist voters abandoning Democrats as opposed to their embracing Republicans. The GOP is on probation. They need to define themselves over the next two years in a way that earns them another term – and perhaps the White House.

That this is easier said than done may be true, but that’s a topic for a different blog. What matters in the context of health care reform is that the PPACA matters to voters. The public (and media) pays attention to health care reform. Political points can no doubt be scored by efforts to reform the nation’s transportation system, but road building lacks the appeal (or cable news attention) that health care reform gets. (This is unfortunate and I’m not condoning it, but it’s important to recognize this fact). And politicians, like actors, are expert at playing to the crowd.

Kabuki theater is highly stylized with dramatic costumes and make-up. Politics may lack the accoutrements, but it’s no less stylized. Let the curtain rise!