Democrats Could Win With a Truly Bi-Partisan Health Care Reform Strategy

Hopefully the cottage industry in health care reform paranoia can calm down now. No one in Washington is talking about strategies to short circuit the election results in Massachusetts this week in which state Senator Scott Brown, soon to be the Republican’s “41st vote,” upset the Democratic candidate in a special election. While some dismayed Democrats did consider ways of passing legislation before Senator Brown is sworn into office, there was never really a chance that would happen.

One reason Senator Brown won was a reaction to the hubris Democrats in Congress displayed over the past 12 months concerning health care reform. Favors were dealt out to key lawmakers party favors at a kid’s birthday if that’s what it took to secure their votes. A temporary exemption from an excise tax on expensive health insurance policies was crafted for unions to get their support. Deals were brokered with large pharmaceutical companies and others to get them on-board. This is politics as usual, practiced by Democrats and Republicans alike.

Engaging in politics as usual, however, was the problem: voters in 2008 expressed their desire for change. Politics as usual is exactly what the public did not want.

Given this reality, Democrats passing a health care reform bill by jamming something through would be political malpractice of the highest order. Besides, there were never enough rank-and-file lawmakers in the caucus willing to go along with such silliness. So, not surprisingly, instead of passing health care reform by manipulating the rules, Democrats are now taking a breather, gathering their thoughts and developing a strategy for moving forward.

After some reflection, Democratic leaders will realize the scope of health care reform they can pass is extremely limited. Expensive, intrusive reforms are no longer an option. This doesn’t mean they can’t pass some version of reform. It just means that the reform they can pass will need to be less expensive, less comprehensive, and less intrusive than they had hoped.

What health care reform can be passed, and how long it will take, will depend in large part on which of two strategies the White House and Congressional Leaders choose to take.

President Barack Obama, Senate Majority Leader Harry Reid and House Speaker Nancy Pelosi can either pursue health care reform that gains the vote of the fewest number of Republican lawmakers necessary or legislation that can earns support from a meaningful percentage of Congressional Republicans. Following the former strategy would see them negotiate almost exclusively with Senators Olympia Snowe and Susan Collins. Seeking truly bi-partisan reform would require negotiating with a far larger group.

The bare minimum strategy will be tempting. It requires the least amount of compromise. As I wrote the other day, they could bare the current legislation down to its cost containment provisions, health insurance reforms, and some of the less expensive ideas to expand coverage to more Americans. Such a scaled-back bill might get the support of either Senator Snowe or Senator Collins – or both. (Who knows, even Senator Brown might be supportive. He does have to run for re-election in Massachusetts in 2012. He won the special election by positioning himself as an independent and downplaying his Republican affiliation. Showing his independence from hard-line Republicans is a reasonable political strategy for him.)

The problem with the bare minimum strategy is its what got Democrats into their current mess. By pursuing health care reform that never had a chance of gaining broad support, President Obama, Senator Reid and Speaker Pelosi assured a long, politically ugly legislative process – one that required the kind of deal making that voters, especially independent voters, had voted to change in 2008.

Instead, Democrats could take the advice of House Majority Whip Jim Clyburn, who observed, “Medicare wasn’t done in one fell swoop. You lay a foundation and you get this thing done over time.” If Democrats had taken this approach from the beginning health care reform might have been enacted already. Instead months were spent battling over issues like a government-run health plan that neither Republicans nor enough moderate Democrats could support. While hanging tough for a liberal wish list pleased their base (for awhile), it was inevitable moderate Democrats would determine the final health care reform package.

To gain sufficient Republican votes, Democrats will have to be willing to accept fairly limited reforms for now. They will need to include some meaningful malpractice reform. Democrats needs not include every and any provision Republican demand. Their goal is not to pass a bill by unanimous consent. Democrats just need to offer enough to peel off a significant number of Republicans – say 12 in the Senate and 35 or so in the House. Legislation with meaningful malpractice reform and a low sticker price could do that. Is this realistic? Well, there are a number of Republicans running in moderate seats, too. Running for re-election as a candidate who “opposed President Obama at every turn” is not a recipe for job security in such seats.

If Democrats succeed in passing bi-partisan reform they’ll have laid the foundation for future health care reform efforts. But what if Republicans unify behind a strategy of blocking reform of any kind, regardless of how moderate that reform might be? Such a strategy would just confirm that the GOP is the party of politics as usual. And in 2010 that’s not an image voters are likely to reward.

Medicare Buy-in Compromise Unraveling?

Nothing lasts forever … not even health care reform compromises. The Congressional Budget Office is expected to come out with its analysis of the latest proposal – replacing a the creation of a new government-run health plan (the controversial “public option”) with a program in which Americans 55-64 could buy Medicare coverage. However, it’s looking like even if the CBO determines the idea makes financial sense, the votes to go forward with the proposal there doesn’t seem to be enough votes around for it to move forward. Which means the public option remains the big make-or-break element of health care reform in the Senate.

Only a few days ago, along with the idea of empowering the Office of Personnel Management to organize a coverage program, the Medicare buy-in compromise  seemed to be the solution to breaking the public option impasse. Now the idea seems to be losing steam.

First, doctors and hospital groups came out in opposition to the Medicare buy-in compromise, with the Washington Post reporting them as claiming the approach “would be financially untenable and would jeopardize access to health-care services for millions of Americans.”  The medical and hospital groups are concerned, according to the Washington Post, “because the program pays providers at much lower rates than private insurers, and because older Americans are the greatest consumers of health-care services.”

And then two conservative members of the Democratic caucus indicated their disapproval of the Medicare buy-in. According to the Associated Press, Senator Joe Lieberman, who had originally sounded open to the idea, now considers it “a bad deal for taxpayers and the deficit.” And the AP quotes Senator Ben Nelson as saying “I’m concerned that it’s the forerunner of single-payer, maybe even more directly than the public option.”

So while, as the Washington Post and others are reporting, the President Barack Obama and many Democrats are praising the compromise, the fact is, the Democrat’s need 100 percent buy-in by their caucus to pass any bill. (Yes, it’s possible Senators Olympia Snowe and Susan Collins might cross party lines and vote for a bill, but it’s hard to see how these Republican Senators could support any legislation conservative Democrats like Senators Lieberman and Nelson could not).

Democrats are trying to dodge a nasty choice: dropping the public option from health care reform. Liberals have made inclusion of a public option their litmus test for meaningful reform. As the liberal blog Daily Kos put it this past summer, the public option is the compromise progressives are willing to make between a single payer system and the status quo.

In the end, however, liberals will need to decide whether the absence of a public option is enough to get them to walk away from reform. Because there does not seem to be any way they will obtain 60 votes in the Senate for a bill that includes a new government-run health plan. My guess? Liberals will complain bitterly, but ultimately vote for a bill without a public option. Health care reform has been on their agenda for decades and they have moved the issue further through Congress  than ever before. To abandon it now would set back health care reform for at least a decade if not longer. Failure would hand Republicans a huge stick to use against them in the 2010 elections.

Passing reform, even reform liberals perceive as too weak, provides a foundation for future efforts. This might seem like a hollow victory for many progressives, but it would be a victory for them nonetheless. And I just don’t see them trading even a hollow victory for a hard defeat.

Senate Health Care Reform Still Alive, But Likely to Change

The Senate has just spent most of today (Saturday) engaging in a debate on whether to allow a debate on comprehensive health care reform. Later this evening 58 Democrats and 2 Independents will vote to allow Majority Leader Harry Reid’s health care reform bill come to floor for debate and consideration of amendments. 40 Republican Senators will vote unanimously against allowing this to happen. Senator Reid’s Patient Protection and Affordable Care Act is still alive. It is unlikely to survive in its current form for long, however.

Don’t get me wrong. Tonight’s vote is significant, very significant.  The vote is a test of President Barack Obama’s and Senator Reid’s ability to line up enough votes to keep the bill alive.  The debate leading up to the vote has been an opportunity for Republican Senators to present their opposition to HR 3590. (Yes, the Senate has taken a bill passed by the House and moved to the Senate, gutted that language and substituted their health care reform package. Consequently, the Senate legislation has a House bill number.) And the vote to allow debate has served as an action forcing event, sort of, for Democratic moderates.

Those moderates could have sided with the Republicans killing the bill before it could be brought to the floor. Instead, they joined with their liberal colleagues and kept health care reform alive. While there are 18 moderate Democratic Senators (including Senator Joe Lieberman, who is an Independent), it eventually came down to three:  Senators Mary Landrieu, Blanche Lincoln and Ben Nelson. All three made clear they would seek amendments to the bill before voting for it. And all three are among those moderates making it clear further changes to the Patient Protection and Affordable Care Act is necessary before they’ll commit to voting for it.

We’ll learn more about the changes moderates will demand over the several weeks before a final vote on health care reform is held in the Senate.  Democratic leaders are hoping to hold that vote before the end of the year. The legislation would then move on to a conference committee that will attempt to reconcile it with legislation the House passed earlier this month.  More importantly, that conference committee, made up of an equal number of Senators and House members, will seek to fashion legislation they hope will earn the support of a majority of House members and 60% of Senators. As I’ve noted before, passage of legislation by the Senate is merely the final playoff game. The World Series — the conference committee — is yet to come.

Uniting the Democrats to allow debate on health care reform is a victory for the Obama Administration and for Senator Reid personally. That it took this much effort, however, demonstrates the challenges they yet face. Republicans appear to be uniting in opposition to the legislation. Even Senator Olympia Snowe, who voted for a health care reform bill in the Senate Finance Committee, is expected to vote against bringing HR 3590 to the floor.

I’ve written before about the power moderates have to determine if health care reform legislation will pass Congress and what the final bill will contain.  Now we’ll see that power put forward. Some of what they’ll ask for will be parochial. (That there’s a provision in Senator Reid’s bill that would send additional Medicaid money to Senator Landrieu’s state of Louisiana is neither a coincidence or accidental). But most of their demands wil concern public policy issues. Moderate Democrats tend to be more fiscally cautious than their more liberal colleagues, giving them pause to legislation that greatly expands governmental powers,  spends nearly a trillion dollars over the next decade and taxes corporations and individuals to pay for it. These are the issues on which they will focus.

Republicans will have their own pet issues, but those are unlikely to influence the outcome. Having already declared their unmoving opposition to any health care reform Democrats could claim keeps their campaign promises, the GOP has removed themselves from negotiations. (A couple of the Republicans, most notably Senator Snowe and her colleague from Maine, Susan Collins, might vote what moderate Democrats fashion. But whether they’ll be able to insert provisions without committing to voting for the bill if their amendments are accepted is unlikely. 

We don’t know yet what changes to HR 3950 moderate Democrats will demand, but the possibilities are extensive. They could eliminate a public option — or at least postpone its implementation until after other reforms have had a chance to take effect. They could  demand additional cost containment provisions. They could strengthen — or weaken — the requirement that all consumers obtain coverage. Certainly they will modify what taxes and fees are imposed to pay for health care reform.

What’s important to remember is that moderate Senators will have two shots at the bill. They’ll extract as much as they can during the current Senate debate. Then at least two or three of them are likely to agree to vote for the bill “in order to keep the process moving forward.” However, they’ll also make clear they want significant changes made to the legislation by the conference committee before they’ll commit to a vote that would place the legislation on the president’s desk. Liberals will insist they have compromised all they can, but in reality, the moderates (and the liberals) know that the progressives are likely to accept any legislation that can be called “health care reform” with a straight face. And as politicians, they have great skill in passing the straight face test.

Yes, Democrats have won the debate on whether to debate health care reform. What legislation eventually emerges from the Senate, if any, is still uncertain.

Could Co-ops Provide Competition Where It’s Needed?

Based on what was being said on the Sunday talk shows today, the justification for creating a government-run health plan to compete with private carriers seems to be expanding. One of the fresh arguments does not seem to carry much weight, but the other might.

Some are claiming that consumers need to know they can buy the same health plan anywhere in the country. By having a public plan offering coverage nationally they would be able to change jobs, move to a different state and still keep their current coverage. Accepting that this would be a nice situation, it certainly isn’t a strong reason for a public plan given the risk that step entails. As I’ve posted before, the temptation to tip the playing field in favor of government programs is too tempting for lawmakers. Already on the table is allowing tax credits to make premiums more affordable eligible only for coverage purchased through an Exchange, for example.

The simple fact is, without a level playing field a government-run plan will eventually — not the first year, maybe not the fifth, but eventually — drive private carriers out of the market. If that’s what Congress and the Obama Administration want to do, they should just say so and try to make it happen. But if they are sincere about preserving private options for Americans, then they need to tread carefully. Creating a public plan just so consumers can keep the exact same plan when they move to a new state is simply not worth the danger.

The second justification is an amplification of the original rational for a public plan: that it would encourage competition in the market. On CNN’s State of the Union, this morning, Secretary of Health and Human Services Kathleen Sebelius brought up the lack of competition in her home state, Kansas (until her confirmation as Secretary, she was Governor of Kansas). And it is true that in some states a single carrier will have 60 percent or higher market share for medical policies sold to individuals and small businesses. In those states, additional competition should be beneficial.

Yet in other states competition is far more robust. In California, for example, there are several carriers competiting for individual and small group coverage. None, I believe, have more than 45 percent and at least three have more than 20 percent. A government venture is, arguably, unnecessary here.

If competition is sufficient in some states, but lacking in others, perhaps a national solution isn’t required. Instead, allowing the solution should be fashioned at a more local level. Senator Kent Conrad’s compromise proposal could be adapted to do just that. Senator Conrad is calling for the creation of non-profit health insurance co-operatives, much like what exists in some areas for electricity. They would be owned by local residents and businesses. They would compete under the exact same rules as private carriers. The government’s only role would be to provide seed money to get them launched. These co-ops could bring competition to places where it currently doesn’t exist. In an area where one carrier controls more than 50 percent of the market, for example, the government could assist in creating a health insurance co-operative — or several of them.

The health care reform debate is getting closer to the nitty-gritty stage every week. President Barack Obama is urging Congress to put a bill on his desk this year and Congressional Leaders are working hard to make that happen. To pass anything, let alone pass it quickly, controverseys like government-run will need to be resolved. Liberal Democrats are insisting it must be included in the final health care reform package. Republicans, including those who broke with their party to pass the Administration’s stimulus package, are adamantly opposed to it.  As the Associated Press reports Senate Minority Leader Mitch McConnell as saying, “I think that, for virtually every Republican, a government plan is a nonstarter.” Some  moderate Democrats are opposed to the idea, too.

Senator Conrad’s co-op idea may provide the needed common ground. Moderate Republican Senator Susan Collins noted, according to the Associated Press article, that the co-ops are “far preferable to the government-run plan that has been discussed by the administration. We need to better understand how it would work. But it’s certainly better than a Washington-run plan.”

The idea of a government-run plan is not the only controversey that will need to be addressed to pass comprhensive reform. But it is an obstacle. And it can serve as a template for resolving other issues. Replace targeted solutions for national ones where the problems are not national in scope. Helping health insurance co-operatives get launched in areas where there is no competition could solve local problems without creating a national one.

Reconciliation Puts Health Care Reform on Fast Track and GOP in Bind

Democrats in Congress are going to pass a budget resolution soon and, at President Barack Obama’s request, it will include reconciliation protection for health care reform. This undermines the ability of Republicans to block provisions in whatever bill emerges and would allow Congress to send legislation to the president’s desk without any Republican support.

Reconciliation protection is not new. Republicans used it when they controlled Congress over Democratic outcries of injustice. Now that the Democrats are in the majority the script remains the same, just the roles have been exchanged. The purpose of all this is to prevent the minority party using a filibuster to block legislation.

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A quick social studies refresher: It takes 51 votes to pass legislation in the Senate. However, any Senator can mount a filibuster which prevents the Senate from voting on a measure (movie buffs may remember Jimmy Stewart mounting a one-man filibuster in Mr. Smith Goes to Washington).  It takes 60 Senators shut down a filibuster by voting for “cloture“. 

Reconciliation protection means filibusters are not allowed. Democrats (and the Independents who caucus withthem) now number 58 Senators (with a 59th, Al Franken, on the way from Minnesotta). Consequently,  Democrats need only hold on to 50 votes to pass health care reform legislation. Vice President Joe Biden would be happy to provide the 51st vote. Not a single Republican vote would be needed.

And now back to our regularly scheduled post:

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Imposing a majority vote on legislation as controversial as health care reform is not common in Washington, but it has precedent. The cable news chatterboxes and talk radio will be spewing sound and fury over the injustice of it all, but that’s mostly partisan political posturing. Politics, after all, is the art of getting things done. Exploiting (or, if you’re in favor of what’s happening, “merely invoking”) the rules to achieve a goal is very much an American tradition.

Nor does reconcilliation mean Republicans will be excluded from the health care reform debate. The culture of the Senate promotes vigorous debate.  As evidence: leading Senators are referring to the expedited process as a tool of last resort. The Los Angeles Times, for example, reports Finance Committee Chair Senator Max Baucusas expressing the hope that Democrats can work with Republicans to pass health care reform.

The reason is that Democrats like Senator Baucus want to pass long lasting reform. They recognize that pendulums swing — even political ones. Indeed, given the political environment of the past few years it’s hard to see how long Democrats can sustain their large majorities in the House and Senate. Pragmatic leaders want to find common ground so the new health care system they create can withstand changes in the political tide.  “If we don’t use reconciliation, we are going to have a much more sustainable result,” the LA Times reports Senator Baucus as saying. “When we jam something down someone’s throat, it’s not sustainable.”

Republicans aren’t buying it. They claim reconciliation means health care reform will not be subject to vigorous debate. That’s not likely. The Democrats are simply not unified enough to ram something this controversial through the Senate. Instead, a group of 16 moderate Democrats in the Senate will assure that multiple perspectives are heard. And like many Republicans they’ve expressed concern about the cost of reform and the expanded government role in health care coverage being sought by many Democrats. Without the support of at least half this group, the Senate Leadership can’t move a bill forward even on a majority vote. 

Reconciliation will prevent a filibuster, not debate. That debate will be loud and vigorous. It also, however, greatly increases the likelihood that there will be a vote on health care reform, most likely by the Fall. Which puts the GOP in a bit of a dilemma.

Republicans can remain on the sidelines of the debate leaving Democrats to shape the reform legislation and inherit the blame (or credit) of whatever is signed into law. Either way, however, the GOP is marginalized and their brand as the party of “No” is solidified. Not a politically pleasant outcome.

Instead, Republicans can engage in the debate, put forward alternatives and work hard to find common ground with moderate Democrats to force some of their provisions into the final legislative packkage. Compromise, however, means they’d need to accept some provisions they strongly dislike. Further, Democrats will get the lion share of the credit for finally addressing health care reform.

Worse for Republicans, accepting any significant compromise could put them at odds with their base — and the Rush Limbaugh’s of their world who speak for that base and who apparently cannot be opposed. It’s not clear the substantive gains Republican Senators could obtain by working with moderate Democrats is worth the resulting political pain.

Unless the moderate Democrats prevent it, healthcare reform is coming, probably in the Fall. Reconciliation protection will see to that. The loss of a filibuster does not, in and of itself, mean there will be no debate. Nor does it make Republicans irrelevent to fashioning comprehensive reform.

Reconiliation cannot make Republicans irrelevant. Only Republicans can make Republicans irrelevent.