Refocusing the Health Reform Debate | Democratic Strategist

As has been the case all year, progressives are giving mixed reviews to the latest legislative step health care reform legislation, the 60-40 Senate vote-to-proceed, which is basically a preliminary cloture vote. While everyone's happy that the vote wasn't lost, there's a fair amount of angst over the threats of some Democrats to vote against the final bill, or against cloture on the final bill, unless actions unacceptable to most progressives are taken to change the bill.

And again, as has been the case all year, nearly all the focus among progressive worriers is over the public option, which Senators Lieberman and Nelson seem to be ruling out categorically.

Let's look at these two issues separately.

If, indeed, wavering Democrats who voted for the motion to proceed nonetheless conclude that they have no obligation to vote for cloture on passage of the bill unless their substantive demands are met, then we might as well start rediscussing the reconciliation strategy, because there is no version of health reform, now or at any point in recent history, that could command 60 votes in the Senate. To get to 60 on cloture (even granting that a Republican or two might still be lured across the line), it will be necessary to convert those who basically said "I hate this bill but I don't want to prevent the debate" to a position of "I hate this bill but I don't want to prevent a vote." And that will require not just moral suasion but pressure and maybe serious threats of reprisals from the Senate leadership, supplemented by a robust public campaign over the next few weeks to demonize the de facto 60-vote requirement, which much of the public knows nothing about. Keep in mind that health reform isn't the only progressive initiative that's doomed if it takes 60 Senate votes to enact anything serious on any subject, and also keep in mind that an increase in Democratic votes in the Senate in the immediate future is exceptionally unlikely.

On the second issue, the public option focus, it's as good a time as any for progressives to finally begin looking at this legislation as a whole, and as compared to what will happen if no legislation is enacted before the 2010 elections. It is entirely possible (particularly if you are a single-payer advocate) to conclude that a reasonably strong public option is more important than covering most of the uninsured, more important than the level of subsidies to make coverage practically affordable, more important than regulation to end highly discriminatory insurance practices, and more important than how and when health reform is phased in, just to mention four competing priorities. But it's equally possible--and more to the point, legitimately progressive--to consider one or more of these factors to be as important as a conventionally constructed public option--again, if you major concern is the practical effects of reform rather than setting the stage for a future single payer system. In any event, an intra-progressive debate on priorities that goes beyond the public option issue needs to happen right away.

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janinsanfran | November 23, 2009 2:11 PM | Reply

The intra-progessive debate that needs to begin is about formulating a strategy to reduce the super-majority requirement in the Senate, just as that was the necessary condition for the Civil Rights era. The current 60 vote requirement for passage of anything important is a relic of the incomplete job done in the early 60s to pass civil rights legislation -- before that the requirement was 66 votes! But as a nation, we really didn't want Jim Crow forever.

Similarly, we don't want the prejudices of 12 percent of the people in rural states to determine the direction of a rich, modern country, but that's what the current 60 vote filibuster does.

How do we move to end this without destroying all checks on short term majority enthusiasms?

Tom | November 24, 2009 4:08 AM | Reply

Okay, let us have that "intra-progressive" debate then.

I'll start. My fear is that the way this legislation is shaping up, it is going to turn out to be every bit as disastrous to individuals in need of health care as The Bankruptcy Abuse Prevention and Consumer Protection Act of 2005 -- an abominable piece of legislation that turned out to be a gift to the credit card companies and a disaster, a complete disaster, for people who are burdened with massive unmanageable debt due to medical expenses, unemployment, or other unavoidable or avoidable losses. Remember Ted Kennedy offering amendment after amendment after amendment as he stood alone on the floor of the Senate attempting to mitigate the impending disaster this abomination visited upon ordinary Americans. The legislation turned out to be so disastrous for consumers that even the credit card and mortgage banking industries decided it was too much of a good thing.

Two things: have you actually done the math with respect to premiums and co-pays and how they would impact an individual's actual take-home pay? I have, and I invite you to do it too. My math tells me that for someone earning in the neighborhood of $65,000 to $75,000 per year, with a chronic disease that needs consistent medical care, out-of-pocket expenses look to be in the neighborhood of $20-25,000 per year with the current Senate bill. Already Medicaid share-of-cost can be prohibitive in high-cost areas of the country. You think that is going to make people, i.e. voters, happy about health care reform?

Secondly, you can look to the experience in Massachusetts for how the current proposed model of HCR is going to work, and it isn't very encouraging. Trudy Lieberman over at CJR has an exceptional series on HCR that explores the impact of the Massachusetts experiment here: Health Reform Lessons from Massachusetts, Part VII : CJR. I encourage you and your readers to read the whole series.

Let's look at your priorities:

1) "covering most of the uninsured" -- in my view, any program that will (affordably) cover most of the uninsured is the whole point. Of course, a public health insurance option is the best way of doing that; we cover most seniors with Medicare; we cover most poor children and pregnant women with medicaid, SCHIP covers most children of working families who earn less than 250% FPL. Fine, but the experiment in Massachusetts shows that even with a mandate, the private insurance industry cannot affordably cover "most" of the uninsured. Instead, they opt to pay the fine for not buying it.

2) "more important than the level of subsidies to make coverage practically affordable" -- amusing that you use the term "practically affordable" -- like in hand grenades, eh? Let me ask you, why do you think that high levels of subsidies to the private health insurance industry is more acceptable -- or a better deal -- than a competing public insurance program? The public insurance program is CHEAPER for individuals and in the aggregate than high levels of subsidies. Is the point to save the private health insurance industry? We'd be better off dumping pallets of cash in their lobbies, as we did for the banks. Please look at the Healthy Families program in California for a successful public health insurance program that works.

3) "more important than regulation to end highly discriminatory insurance practices" -- if there is anything in the bill to support, it is this, of course. This kind of regulation is badly needed, let's do it. Let's do it as a health insurance regulatory bill, then. It would be easier to pass standing alone, wouldn't it?

4) "more important than how and when health reform is phased in" -- I suspect this is just a throw-in, this isn't really an issue but just nuts and bolts. Do you really think that this particular issue should take priority over the actual nature of health care reform itself? To me, it is almost irrelevant as a substantive issue, and certainly should not take precedence as a priority over the actual reform. Please explain why you think that "how and when health reform is phased in" is more important than the issue of whether there is an alternative publicly funded health insurance program available for consumers of health care.

One additional point: Please give public option advocates credit for good will. I find it patently offensive that the "pass anything" crowd dismisses us as unthinking my-way-or-the-highway rigid ideologues. If you really want to have a debate, it helps to treat the other side as if their opinions are worthy of debate. We can surely disagree on the merits of this legislation without your side being so dismissively arrogant, I would hope.

Cheers.

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