Monday, September 21, 2009

Health Care Monday

Ezra Klein: The Patient Is in Stable Condition and Improving Rapidly
The Atlantic Politics team asks the question on somebody's mind: "Can President Obama's media blitz – appearances on five Sunday talk shows this weekend – save health reform?"
Save health reform from what? Consider the recent developments: Two weeks ago, four of five committees had passed their bills, and one committee was tangled in an interminable and opaque process. Last week, that committee produced a bill that, though not perfect, is pretty close to the other bills on the table. On Friday, the committee chairman and the crucial Republican have both announced that the subsidies need to be raised, which addresses the main problem liberals have with the legislation. Later this week, the Massachusetts Senate is expected to allow an interim replacement for Sen. Ted Kennedy, giving Democrats their 60th vote.
Obama's weekend blitz wasn't meant to save health-care reform. It was meant to push it those final 10 yards. He could fail in that effort, but that's where we sit: incredibly, incredibly close to the finish line. Closer, by far, than we have ever been before.
 Most, but not all, of the talk in the political world is that the public option in health care reform is in some trouble. President Obama presented a defense of the proposal during his joint-session speech two weeks ago, and polls continue to show national support for the idea, but for a few too many lawmakers in the Senate, it's out of the question.
We learned yesterday, however, that the president, at least publicly, does not think the provision is dead.
Obama maintained that while the centerpiece of his healthcare reform effort, a public (or "government-run") option, is absolutely not dead, it also is not the "silver bullet" that would instantaneously repair the nation's healthcare system.
"I absolutely do not believe that it's dead," Obama told Univision's "Al Punto" of the public option's fate. "I think that it's something that we can still include as part of a comprehensive reform effort."
But the president still signaled that the public option, a key reform for which he has pushed for months, would not serve as a panacea for healthcare problems.
"What I've said is the public option, I think, should be a part of this but we shouldn't think that, somehow, that's the silver bullet that solves healthcare," Obama said on NBC's "Meet the Press" with David Gregory, rejecting the idea that he'd effectively told liberals that the public option will not be included in reform.
I'd just add that the president has been fairly consistent on this since his big health care speech on Sept. 9. Obama talked up the public option in Pittsburgh last Tuesday, and promoted the idea again in College Park, Maryland, on Thursday.
Time will tell what's possible in the Senate, but talk that the White House would abandon the public option when things got tough has not come to fruition, at least not yet.
 This was one of the livelier exchanges between President Obama and George Stephanopoulos on today's ABC News' "This Week."
The host argued that an individual mandate would force people to spend money, which necessarily makes the idea "a tax." The president disagreed -- strongly.
OBAMA: Well, hold on a second, George. Here -- here's what's happening. You and I are both paying $900, on average -- our families -- in higher premiums because of uncompensated care. Now what I've said is that if you can't afford health insurance, you certainly shouldn't be punished for that. That's just piling on. If, on the other hand, we're giving tax credits, we've set up an exchange, you are now part of a big pool, we've driven down the costs, we've done everything we can and you actually can afford health insurance, but you've just decided, you know what, I want to take my chances. And then you get hit by a bus and you and I have to pay for the emergency room care, that's...
STEPHANOPOULOS: That may be, but it's still a tax increase.
OBAMA: No. That's not true, George. The -- for us to say that you've got to take a responsibility to get health insurance is absolutely not a tax increase. What it's saying is, is that we're not going to have other people carrying your burdens for you anymore than the fact that right now everybody in America, just about, has to get auto insurance. Nobody considers that a tax increase. People say to themselves, that is a fair way to make sure that if you hit my car, that I'm not covering all the costs.
STEPHANOPOULOS: But it may be fair, it may be good public policy...
OBAMA: No, but -- but, George, you -- you can't just make up that language and decide that that's called a tax increase.... What if I say that right now your premiums are going to be going up by 5 or 8 or 10 percent next year and you say well, that's not a tax increase; but, on the other hand, if I say that I don't want to have to pay for you not carrying coverage even after I give you tax credits that make it affordable, then...
At that point, Stephanopoulos referenced Merriam Webster's, to try to nail down a precise definition of a "tax." The president responded, "George, the fact that you looked up Merriam's Dictionary, the definition of tax increase, indicates to me that you're stretching a little bit right now. Otherwise, you wouldn't have gone to the dictionary to check on the definition."
The host added, "But your critics say it is a tax increase."
Obama replied, "My critics say everything is a tax increase."
And here endeth the lesson.
  •  Aravosis suggests that Maybe an individual mandate is a tax cut  Stephanopoulos tried to argue today that by requiring all Americans to get health insurance, President Obama was imposing a tax increase on those Americans who don't have insurance - because he's requiring them to pay money for something (an odd argument, since by that definition, shopping for food, or buying a CD, is a tax increase). But in any case, if one wants to argue that making someone pay a monthly fee for insurance is a tax increase, then lowering the monthly premiums for the rest of us - which supposedly Obama's plan is going to do - would be a tax cut for the rest of us. And considering more of us are insured than uninsured, that would mean most of the country would be getting a pretty large tax cut. So there.
Ezra Klein: Good Manners and the United States Senate
The Massachusetts Senate seems likely to follow the House and approve legislation appointing a replacement for Ted Kennedy, but they're not comfortable with it. It makes them feel dirty. After all, in 2004, when John Kerry was running for president, they worried that Mitt Romney would appoint a Republican -- or himself -- to fill the seat, and passed legislation to ensure all open Senate seats are filled by special election. Now that Kennedy has died and the next five months seem crucial for health-care reform, they want to allow Gov. Deval Patrick to appoint an interim replacement until the special election is held. Reversing course seems like the rawest form of partisanship.
But this vote could be the difference between finally achieving the thing that Ted Kennedy said he went to Washington to do, and failing once again. In light of that, Kevin Drum retorts, "do you think the Texas legislature would hesitate even a few hours to do the same thing in reverse? Or any other Republican state legislature?"
The broader point is that we don't need to be here. There's no law that Republicans have to press their advantage in the wake of Kennedy's death and mount a filibuster of health-care reform. If one of Ted Kennedy's many Republican friends in the Senate announced that he could not support a filibuster if 59 Democrats voted to move forward, as that would just be ghoulishly taking advantage of Sen.Kennedy's passing and would also void the will of the voters, who elected 60 Democrats that would be that. Massachusetts could relax and wait for the special election, content in the knowledge that Kennedy's absence would not thwart health reform.
If I were a Massachusetts Senator, I'd remember that fact next time I felt a pang of conscience about replacing Kennedy.
 Chait: TRB: Left-Handed Compliment
If health care passes, will it be a grand historical achievement, or a crushing disappointment? The answer, I predict, will be both. The American health care system is an indefensible morass of waste and cruelty. The distance between the status quo and the ideal is therefore so vast that we could—and probably will—end up with a reform that massively improves the system, while coming nowhere close to the ideal.
Which basis of comparison will prevail? In the long run, obviously, the substantive merit of the legislation is what counts. But, over the next few years, President Obama’s political capital will hinge in part on whether Americans see health care reform as genuine progress or a political fig leaf. And his biggest foe in the perception battle seems to be the liberals.
That’s what happened in the aftermath of the economic-stimulus package. Indeed, the contours of that episode strikingly resemble the health care debate. Obama began with hopes of winning broad bipartisan consensus for a sweeping overhaul. But staunch GOP opposition and the fecklessness of moderate Democrats forced him to scale back both his political and policy ambitions. Ultimately, he eked out a partisan bill, which moderates scaled back for no coherent reason other than to burnish their own centrist credentials.
As a matter of policy, the stimulus still represented a major success. The law signed by Obama is massive. Yet a bizarre disconnect has opened up between economists and everybody else. As numerous articles have shown, economists believe almost unanimously that the stimulus has provided a significant boost. Polls, though, show most people think it either has done nothing or has hurt the economy. Republicans have pounced, waving around proposals to cancel the stimulus.
Why did Obama’s substantive triumph turn into a political liability? One reason is that the Keynesian intellectual basis for the stimulus is harder to explain than the intuitive (but wrong) gut reaction that when times are tight, the government should tighten its belt, too. Another is that joblessness has continued to rise, and explaining that it would have risen more quickly without the stimulus is tricky.
But, surely, a third factor came into play: the almost total lack of approving commentary. Liberals like Paul Krugman and, um, me devoted nearly all of their efforts to demanding a bigger and better stimulus. That sort of constructive criticism is necessary. It’s certainly cathartic as well, given the maddening stupidity of the centrist compromises, which removed the most effective parts of the stimulus for the sake of meeting arbitrary round numbers. Yet this left a landscape in which one side was attacking the stimulus as a socialistic outrage, and the other was attacking it as a feeble half-measure. No wonder the public turned against it.
Health care, alas, seems to be following the same track. My liberal friends seem convinced either that Congress will reject health care reform, or that it will pass a meaningless palliative. The main exception among this admittedly unrepresentative sample consists of liberals who study health care reform for a living and those (like me) who regularly communicate with them. These wonks (and wonk acquaintances) all think Obama will sign a historic health care bill. Sadly, the wonk cohort is starkly outnumbered.
So, it’s worth pointing out that, for all the flaws of the process, Obama appears to be on track to sign one of the towering social reforms in American history—the most important change in our social contract since at least 1965, or (I’d argue) even longer. Even the most conservative of the bills working its way through Congress would regulate the health insurance market to prevent the discriminatory practices that ruin the lives of the sick and make vulnerable workers fear to change jobs or strike out on their own. It would start to rationalize the practice of medicine and slow the explosive growth in costs that have gobbled up any growth in wages for many years. (The establishment of the Independent Medicare Advisory Commission, charged with targeting wasteful practices, would constitute a massive reform on its own.)
And, of course, every bill would establish a practical entitlement to health care. The extent of the coverage remains weak. But remember that the original Social Security Act not only offered meager provisions and no disability benefit— Got hurt in the factory and couldn’t work? Tough luck—it also excluded nearly half of the working population, including most women and African Americans. The important point was setting a new societal expectation of what constituted basic economic rights, which, over time, would be filled in so that the reality met the promise. Fifty years from now, the notion that people would die from lack of access to medical treatment, or lose their homes and life savings because they got sick, will seem as barbaric and foreign as the notion of the elderly dying in poverty did after the establishment of Social Security.
So why are liberal activists, bloggers, and even members of Congress so sullen? First, they think anything that has the support of the insurance industry must be bad policy. And, while it’s true that the interests of insurers and the interest of good policy work at cross-purposes, they aren’t mutually exclusive. Insurers want government to cover the uninsured, and they are willing to cut some fat from their profit margin to tap into that new customer base.
Second, liberal health care activists have come to fixate on the public option as the end-all, be-all of reform. “If Barack Obama’s health care plan gets changed to exclude a public option like Medicare, then it is not health care reform,” insists Howard Dean. “Legislation rises and falls on whether the American public is allowed to choose a universally available public option or not.” It’s worth recalling that Dean’s own health care plan from 2004 did not include a public option. Most liberal health care wonks think a public option is helpful but not vital. Maybe they’ve all been bought off by the insurance industry, but I doubt it. If anybody sees Jonathan Cohn tooling around in a new Bentley, let me know, and I’ll reconsider.
Liberal Democrats in Congress understand that they won’t have any leverage unless they can credibly claim to vote against reform that falls short of their ideal. This requires them to say things like “health care reform without a public plan is not reform.” It becomes a problem if enough people actually believe their own bluff.

1 comment:

  1. Nice review of articles. It is necessary to know all possible points of view. I'm curious what will be the result. Health care reform is one of the most important issues because the current state can't last forever. Lucky are those countries that have it done. Canada could be seen as a model. Here are some facts: USA spends over 15% GDP, while at least 15% of the population is not covered at all. Whereas Canada spends only 10% of its GDP, covering 100% of its population. Best regards, Lorne.