In Search of Plan “C” for Health Care Reform?….Stick With Plan “A”
The Washington Post has an editorial this morning that doesn’t exactly oppose the President’s health reform proposals, but gives the President a rap on the knuckles for not being more aggressive controlling costs. They are particularly aggrieved that the President proposes to delay the implementation of the “Cadillac tax” on high-cost health plans to 2018.
“Count us among the worriers. The tax is key for two reasons. It would raise revenue needed to pay subsidies to the currently uninsured; Mr. Obama chose the politically easier option of extending the Medicare tax to unearned income of the wealthy, thus making it more difficult down the road to prevent Medicare from going bankrupt. And, by discouraging expensive plans, such a tax would be the single most effective tool to reduce the cost growth that threatens the nation’s well-being”.
This editorial is one of the more exasperating documents to appear during health reform.
I happen to favor the “Cadillac tax,” though I wish it were more explicitly limited to affluent taxpayers. This is a sensitive issue. Workers have made wage concessions to expand or to preserve generous health benefits that might be affected by the new policy. I see nothing inherently wrong with giving unions and firms more time to adjust collective bargaining agreements in light of new tax policies.
Especially perverse is the Post’s criticism of proposals to raise Medicare taxes on the wealthy. Viewed outside the context of health reform, this provision provides one needed corrective to the regressive tax cuts enacted during the Bush years. The idea that it is simple political expediency to raise taxes on capital income of the wealthy comes as a great surprise to anyone who has followed American tax policy over (say) the past 30 years. Three other issues are especially irksome in the Post’s editorial.
First, President Obama proposes many features designed to reduce the level and growth of medical spending. He has gotten little political credit for these complex and controversial measures, but they are there.
Insurance exchanges will reduce administrative and marketing costs in the markets for individual and small-group coverage. This idea enjoys wide Democratic and Republican support. The President would reduce significant overpayments to Medicare advantage plans. He supports bundled payment models and other innovations designed to improve quality and cost-effectiveness of care. He supports greater use of comparative effectiveness research to provide an evidence-base for improved resource allocation decisions.
Over considerable opposition from within his own party, the President supports an Independent Medicare Advisory Board modeled after the commission that recommends military base closings. The Congressional Budget Office gave the President little credit for this in the scoring numbers. Yet this change could have a potentially revolutionary impact on Medicare policy–which is exactly why so many pharmaceutical and medical device manufacturers, many medical specialties, and many elected politicians are unhappy with this measure.
Some of these measures are buried in the fine print. Others were included despite deep opposition from self-avowed fiscal conservatives whose concern for the federal budget precisely stops at the boundaries of their own states or their own favored constituencies. (The most powerful cost-control measure, a strong public option, was brought down by Republicans, insurers, and virtually the entire supply-side of the medical economy, but that is another story.)
These obvious realities underscore the second reason why the Post’s argument is so irksome. Although the House and Senate bills include many specific elements favored by (for example) officials in the last Bush administration, Republicans have made a basic strategic decision to filibuster and to vote in lockstep against the signature policy initiative of the Obama Presidency.
As a result, President Obama needed to corral every single Democratic vote to pass the signature measure of his presidency. The President was willing to deal on tort reform and other difficult matters. Although the gang of six talked interminably, no Republicans were willing to deal.
Proposed piecemeal, the cost-control measures already contained in the President’s proposal would command little public or interest-group support. These measures would command little enthusiasm from a Congress freed from the fiscal constraints required to pass a comprehensive bill that simultaneously provides critical benefits to millions of people.
The Post seems oblivious to the fact that defeat of the President’s comprehensive reform would damage any future cost-control effort. Interest groups that oppose specific measures–certainly including the “Cadillac tax” –would cite this defeat in discouraging politicians from supporting similar efforts. They would cite the success of crudely demagogic “death panel” rhetoric to deter serious measures to improve the quality and economy of Medicare services.
Progressive politicians desperate to help millions of uninsured people would learn from this episode that the smart move is to propose a politically attractive package of benefits without offsetting spending reductions or taxes to pay for it. I would hardly blame them.
Then there is the third reason. The Post writes: “We think that it is not asking too much, given the dire fiscal straits, for Washington to show that it can swallow distasteful medicine while, and not after, it passes out the candy.”
No candy is being distributed here. The bill whose survival is at stake is not some pork-barrel agriculture or weapons bill. After decades of failure, this bill would provide critical protection for 50 million uninsured people. It would help millions of others facing medical bankruptcy because they are underinsured or because they have serious illnesses leading them to exceed lifetime insurance caps that would be immediately ended under the President’s proposal.
This very morning, our local Catholic church presented an appeal from a family whose infant son was diagnosed with Hemophagocytic Lymphohistiocytosis, a rare and deadly disease. As the costs of his care approach $1 million, the family has established a website appealing for help. They have no plan B. There is no plan B for states, either, which desperately need this bill to avoid even more dire fiscal difficulties than are projected for the federal government.
The President has spent the past year, and has risked much of his presidency, to address these critical needs. After this bill is passed, he and the Congress should pursue further serious cost-containment efforts. The current bill provides the best platform to do this.
There is a moral urgency to passing this bill. The President, House and Senate leaders might have done more to cut costs if they had even secured one or two moderate Republican votes. They had to cut some messy deals to get this done. There were good reasons to do so. Against heavy odds and several decades of failed efforts, President Obama and his allies are close to getting this done. By fetishing a single imperfect aspect of the President’s proposal, the Post mischaracterizes the policy dilemma. The Post also misses the magnitude of what is at stake.
By: Harold Pollack- the Helen Ross Professor of Social Service Administration at the University of Chicago and a Special Correspondent for The Treatment-The New Republic, March 7, 2010
How to Make Something Controversial
People say the media is more viscerally sympathetic to Democrats than Republicans. But working in the other direction is the fact that Republicans understand the media much better than Democrats do. Take the reconciliation process. The media is giving blanket coverage to this “controversial” procedure being used by the Democrats. But using reconciliation for a few fixes and tweaks isn’t controversial historically, and it’s not controversial procedurally. It’s only controversial because Republicans are saying it is. Which is good enough, as it turns out. In our political system, if Democrats and Republicans are yelling at each other over something, then for the media, that is, by definition, controversy. This is something Democrats did not understand when George W. Bush was in power.
The Senate reconciliation vote occurred on May 23, 2003. In the month of May, only one New York Times article so much as mentioned the use of reconciliation for the tax cuts — a May 13, 2003, article that devoted a few paragraphs to wrangling over whether Senate Republicans could assign the bill number they wanted (S.2) to a bill approved via reconciliation. The Times also used the word “reconciliation” in a May 9, 2003, editorial, but gave no indication whatsoever of what it meant.
And that’s more attention than most news outlets gave to the use of reconciliation that month. The Washington Post didn’t run a single article, column, editorial, or letter to the editor that used the words “reconciliation” and “senate.” Not one. USA Today, the Los Angeles Times, and the Associated Press were similarly silent.
Cable news didn’t care, either. CNN ran a quote by Republican Sen. Chuck Grassley about the substance of the tax cuts in which he used the word “reconciliation” in passing — but that was it. Fox News aired two interviews in which Republican members of Congress referred to the reconciliation process in order to explain why the tax cuts would be temporary, but neither they nor the reporters interviewing them treated reconciliation as a controversial tactic.
And ABC, CBS, NBC? Nothing, nothing, nothing.
And why was there nothing? Because Democrats weren’t complaining. The tax cuts might have been controversial, but they weren’t creative enough to polarize the procedure the Bush administration was using to pass them.
But some of the credit for that has to go to the Bush administration, which took seriously the need to institutionalize reconciliation when they were strong and popular rather than weakened. When Bush came into office, he used reconciliation for his first tax cuts. That was a sharp break with precedent: Reconciliation had never been used to increase the deficit, and the process was so poorly suited to the purpose that the Bush administration had to let all of them sunset after 10 years. It was a bizarre, bizarre bill. But by using it for his popular first round of tax cuts, Bush normalized it such that Democrats couldn’t really complain when he used it for his much more controversial second round of tax cuts.
By Ezra Klein | March 5, 2010; 9:53 AM ET
The GOP’s Astonishing Hypocrisy on Health Care and ‘reconciliation’
For those who feared that Barack Obama did not have any Lyndon Johnson in him, the president’s determination to press ahead and get health-care reform done in the face of Republican intransigence came as something of a relief.
Obama’s critics have regularly accused him of not being as tough or wily or forceful as LBJ was in pushing through civil rights and the social programs of his Great Society. Obama seemed willing to let Congress go its own way and was so anxious to look bipartisan that he wouldn’t even take his own side in arguments with Republicans.
Those days are over. On Wednesday, the president made clear what he wants in a health care bill, and he urged Congress to pass it by the most expeditious means available.
He was also clear on what bipartisanship should mean — and what it can’t mean. Democrats, who happen to be in the majority, have already added Republican ideas to their proposals. Obama said he was open to four more that came up during the health-care summit.
What he’s unwilling to do, and rightly, is to give the minority veto power over a bill that has deliberately and painfully worked its way through the regular legislative process.
Republicans, however, don’t want to talk much about the substance of health care. They want to discuss process, turn “reconciliation” into a four-letter word, and maintain that Democrats are just “ramming through” a health bill.
It is all, I am sorry to say, one big lie — or, if you’re sensitive, an astonishing exercise in hypocrisy.
All of the Republican claims were helpfully gathered in one place by Sen. Orrin Hatch, R-Utah, in an op-ed in Tuesday’s Washington Post. Right off, the piece was wrong on a core fact. Hatch accused the Democrats of trying to, yes, “ram through the Senate a multitrillion-dollar health-care bill.”
No. The health-care bill passed the Senate last December with 60 votes under the normal process. The only thing that would pass under a simple majority vote would be a series of amendments that fit comfortably under the “reconciliation” rules established to deal with money issues.
Near the very end of his article, Hatch concedes that reconciliation would be used for “only parts” of the bill. But then why didn’t he say that in the first place?
Hatch grandly cites “America’s Founders” as wanting the Senate to be about “deliberation.” But the Founders said nothing in the Constitution about the filibuster, let alone “reconciliation.” Judging from what they put in the actual document, the Founders would be appalled at the idea that every major bill should need the votes of three-fifths of the Senate to pass.
Hatch quotes Sens. Robert Byrd and Kent Conrad, both Democrats, as opposing the use of reconciliation on health care. What he doesn’t say is that Byrd’s comment from a year ago was about passing the entire bill under reconciliation, which no one is proposing to do. As for Conrad, he made clear to The Washington Post’s Ezra Klein this week that it’s perfectly appropriate to use reconciliation “to improve or perfect the package,” which is exactly what Obama is suggesting.
Hatch said that reconciliation should not be used for “substantive legislation” unless the legislation has “significant bipartisan support.”
But surely the 2001 and 2003 Bush tax cuts, which were passed under reconciliation and increased the deficit by $1.7 trillion during his presidency, were “substantive legislation.” The 2003 dividends tax cut could muster only 50 votes. Vice President Dick Cheney had to break the tie. Talk about “ramming through.”
The underlying “principle” here seems to be that it’s fine to pass tax cuts for the wealthy on narrow votes but an outrage to use reconciliation to help middle-income and poor people get health insurance.
I’m disappointed in Hatch, co-sponsor of two of my favorite bills in recent years. One created the State Children’s Health Insurance Program. The other, signed last year by Obama, broadly expanded service opportunities. Hatch worked on both with his dear friend, the late Edward M. Kennedy, after whom the service bill was named.
It was Kennedy, you’ll recall, who insisted that health care was “a fundamental right and not a privilege.” That’s why it’s not just legitimate to use reconciliation to complete the work on health reform. It would be immoral to do otherwise and thereby let a phony argument about process get in the way of health coverage for 30 million Americans.
E. J. Dionne, Jr-Syndicated Columnist-March 4, 2010
Summited Out: The GOP Wants Capitulation, Not Compromise
Who won? It’s the exact same question people asked in 2008, after each of the presidential debates. I didn’t like it then and I don’t like it now. What’s “winning”–scoring more debate points, making fewer gaffes, or simply appealing to more voters? And aren’t all those judgments pretty subjective anyway?
But if Thursday’s event didn’t produce a winner, it was clarifying.
Health care reform, as I’ve said many times now, is really about achieving three basic goals: Making sure everybody has insurance, making sure coverage is good, and making sure that, over time, medical care will cost less. Thursday’s discussion revealed the stark differences between the two parties–not just over how to pursue these goals but also over whether they are even worth pursuing.
Making sure everybody has insurance is primarily a matter of providing access to policies, regardless of medical status, and then guaranteeing that people can pay for them, no matter what their income. The former requires re-engineering the insurance market–in particular, organizing the non-group market into insurance exchanges, through which insurers will sell regular policies at regular prices even to people with pre-existing conditions. The latter requires providing subsidies, based on people’s incomes, which in turn requires raising some money.
The Republicans made clear on Thursday they rejected both ideas. Re-engineering the insurance market requires too much government, they said, and providing subsidies requires too much money. The best they could offer were “high-risk pools,” which would provide thinner coverage–at higher prices–to people who couldn’t get insurance on their own. This means expanding coverage to only 3 million people, rather than 30 million, but the Republicans hardly seem to care. When Obama asked Wyoming Senator John Barrasso to speak to the problems of the uninsured, Barrasso responded by saying he wanted to talk about … the already insured. Not that Democrats mind talking about the already insured.
Reform’s second goal–making sure everybody’s coverage is good–is primarily for the benefit of people who have insurance today. Many of these people have coverage that won’t meet their needs, although they may not know it yet. Only when they get sick will they discover that their plans have loopholes, allow for exorbitant out-of-pocket costs, and leave them with little recourse if there are disputes over what’s covered. The Democrats propose to fix this by establishing a minimum set of benefits that all plans must cover, limiting the amount of out-of-pocket expenses insurers can pass along, and creating appeals mechanisms for consumers upset about denials.
This approach, too, is one the Republicans rejected on Thursday. Over and over again, Republican representatives and senators said the problem wasn’t insufficient regulation. It was too much regulation. They called for allowing people to purchase insurance across state lines–and allowing small businesses to form associations that would be exempt from existing state regulations. The effect of such changes, as the Congressional Budget Office has noted, would be to erode benefits–to weaken, not strengthen, the protection from medical expenses insurance now provides. Senator Tom Coburn praised this transformation, suggesting the great exposure would turn people into smarter consumers. Well, it might do that. Or it might simply mean people with medical problems face even more onerous financial burdens.
And what about making medical care less expensive? The Democrats’ approach is to try a combination of approaches: Eliminating waste, redirecting Medicare payments so that they reward efficiency, altering the tax treatment of insurance, and so on. They admit it will take time and that they are not sure which approaches will work best. But these efforts get at the root causes of rising medical costs–not just profit or administrative inefficiency, but also the tendency towards unnecessary over-treatment.
Republicans in theory should support many of these ideas, but, as usual, they had nothing good to say about them. Instead, they continued to pound the Democrats for cutting Medicare, even though the Democratic reductions are calibrated to make the program more responsive–and even though the Democratic reductions are far smaller than the ones Republicans have championed over the last 15 years (not to mention the ones Representative Paul Ryan still supports).
Instead, the Republicans’ great hope for reducing cost lay in de-regulation–which, again, succeeds only by shifting medical expenses back onto the people with medical problems–and malpractice reform–another idea that Democrats support but that, according to CBO, doesn’t actually account for that much spending.
The Republicans have their justifications–and, to be fair, if they are convinced government spending and regulation will do more harm than good, then they are right to hold these many views. But it is not as if their alternatives even come close to solving the problems Democrats would. Instead, Republicans seem to believe these problems are fundamentally unsolvable, at least in any manner they would find acceptable.
And this explains the message Republicans delivered over and over again on Thursday: Rip up the bill and start over. That’s not a plea for compromise. That’s a demand for capituation. And it frames the choice for Democrats pretty clearly. Either they will act alone, or they will not act at all.
By: Jonathan Cohn, Senior Editor- The New Republic Feb. 26, 2010
Obama To GOP: It’s Over
Obama listened politely for six hours, with occasional flashes of temper, but in the end, the message was clear: It’s over. We’re moving forward without Republicans.
Whether Obama and Dems will succeed in passing reform on their own is anything but assured, to put it mildly. But there’s virtually no doubt anymore that they are going to try — starting as early as tomorrow.
That was the subtle but unmistakable message of Obama’s closing argument. After hours of hearing Republicans repeat again and again that only an incremental approach to reform is acceptable to them, Obama rejected that out of hand.
Here’s the key bit from Obama:
I’d like Republicans to do a little soul searching to find out if there are some things that you’d be willling to embrace that get to this core problem of 30 million people without health insurance, and dealing seriously with the pre-existing conditions issue. I don’t know frankly whether we can close that gap.
And if we can’t close that gap, then I suspect Mitch McConnell, Harry Reid, Nancy Pelosi and John Boehner are going to have a lot of arguments about procedures in Congress about moving forward.
Unless I’m misreading that, Obama is saying that unless Republicans support comprehensive reform as Obama and Dems have defined it — dealing with the problem of 30 million uninsured and, by extension, seriously tackling the preexisting condition problem — they will almost certainly move forward with reconciliation.
What’s more, Obama also essentially accused Republicans of approaching today’s summit in bad faith — after they had sat there with him for six hours. He said that even after the public option was taken off the table, Republicans continued to use the same “government takeover” slur.
“Even after the public option wasn’t available, we still hear the same rhetoric,” Obama said. “We have a concept of an exchange which previously has been an idea that was embraced by Republicans before I embraced it. Somehow, suddenly it became less of a good idea.”
This accusation, combined with his assertion that Repubicans need to do some “soul-searching” on whether they wanted to join Dems in tackling reform as they have defined it, amount to an unmistakable vow to move foward without them.
Democratic aides are already interpreting Obama’s remarks along these lines. As one senior aide emailed: “We may make one last effort to try to get a Senate Republican.”
In terms of who “won” today’s debate, I tend to think Republicans actually accomplished much of what they needed to do today. It seems likely that some Congressional Dems will be just as skittish tomorrow as they were yesterday about moving forward alone via reconciliation. That means Dems still have an enormously difficult task ahead.
But Obama’s message to Dems and Republicans alike today was that barring some kind of major change on the GOP side, this is exactly what he and Dem leaders are about to attempt.
Update: To clarify, this was a call to Dems, perhaps more than anyone else, that the time has come for them to stiffen their spines and move forward with reconciliation, which Republicans, and even some nonpartisan observers, have repeatedly characterized as akin to marching off a cliff.
Also: This summit was always about laying the groundwork for Dems to go forward alone, barring a major capitulation from Republicans. As noted here repeatedly, Dems will find themselves in exactly the same position tomorrow as they did yesterday: Confronting the enormously difficult task of passing ambitious reform on their own.
Update II: A GOP aide emails the Republican take: “They badly needed a win today and they didn’t get it. Not even close. Republicans were prepared. The President was pedantic and peeved.”
Greg Sargent-The Plum Line Feb 25, 2010
Contrary to Greg’s take on who won today, my take is that the American people won. Delay, deny and obstruct was on full display by the GOP today. That was transparency that even Stevie Wonder could see!
Raemd95
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