The past couple days have been difficult ones for most of us. After months of activism, the jig is up. Health care reform will not include even a minimal public option or Medicare opt-in. Instead, we get something remarkably close to the Baucus Bill we all trashed months ago.
One thing I thought I'd bring up is that it's possible to believe multiple things about this. It is possible to believe
both that
the bill is worth passing, and
that it could have been much better.
And given that much of the blame is falling to the President, I think it is possible to believe both that
yes, getting even a more modest health care bill through is a substantial achievement, considering the fact that every other president before him failed at this and he could probably have fought harder for a few things, such as the Medicare buy-in.I.
Kill the Bill: Yea or Nay?On the issue of whether we should kill the bill, I come down firmly
against. As great as the Medicare opt-in idea was, it was still going to affect a relatively small portion of people. The major components of this bill remain intact. It will dramatically expand Medicaid, shore up the employer-based system (at least in the interim), end major insurance company abuses, and allow the individual and small group markets to get insurance at group rates, with strong protections, choice of plans, and generous subsidies. It also, for the first time, enshrines the principle that access to health care is a right, not a privilege.
The key argument against this is that, small as they were at the outset, the expansion of Medicare and the public option were the real long-term keys to this bill. Most progressives wanted - with a lot of justification - for us to at least be able to move towards a public-plan-dominated health insurance system: if not single-payer, then at least, a hybrid, quasi-single payer plan. Although the bill never quite got that far, at least the existence of a public plan seemed to put that firmly as a long-term possibility. Without it, that hope remains completely unrealized.
Still, I think it would be foolish to kill the bill with the public plan out. The public plan as structured, as well as the Medicare buy-in, would have needed successive legislative expansions over the next several years and decades for them to even approach what progressives were hoping they would be. The impact of this bill on most people remains almost exactly what it was before Joe Lieberman's latest shenanigans.
I would also ask the kill the bill crowd why the seriously believe that killing health care reform now will improve its odds in the future. Every single time health care reform has died in the past we wound up with something less ambitious the next time health care reform was tried. Truman's proposal (single-payer) was more radical than Nixon's, which was more radical than Clinton's, which was more radical than Obama's. Killing the bill would only mean that we're re-fighting all the same battles again, over some similarly byzantine and probably less ambitious plan, just to get to a starting point. And it would probably delay health care reform another 12-16 years, till the start of the next period of Democratic control of the White House.
I would argue the better plan is to simply
pass the fucking bill. Then work immediately to pass a Medicare opt-in and a Medicaid/SCHIP federalization through reconciliation. Of course, it's doubtful, given the legislative calendar, and given the leverage of the conservadems over the regular bill, that such a Medicare expansion could pass in
this Congress. (The conservadems would probably block the regular bill.) But that is something that could be put through the 50-vote process in the next Congress or the one after that.
The "Kill the Bill" crowd would argue that "fix it later" will never happen. I can't blame their cynicism. But how do they square their cynicism that Congress won't "fix the bill" later, with their confidence that Congress will be able to
start all over again later?
II.
Should we just go for a Medicaid/Medicare expansion Through Reconciliation?This is Howard Dean's proposed idea. I think there's some merit to it, but I think it's entirely unrealistic at this point. This may, in hindsight, have been a better strategy from the outset - get some major public plan expansions in through reconciliation, cover about half the uninsured, and then go for the less controversial reforms later. But at this point, doing this would basically mean no health reform of any kind this Congress, and possibly not at any point this presidential term. The bill would take several months to get rewritten, and even if it could pass the Senate through reconciliation, it might not pass the House (remember that the health care bill only barely passed that body).
So I still think it's better to pass it now, fix it later. With the caveat that the only way we will fix it later is if we make this a continuing issue. If the base continues to be an activist about this, if we continue to press this, and if it remains a major part of the agenda.
In the meantime, I'd refer people to
Paul Starr's proposals in the NYT from a few weeks ago, in which he raised several other issues besides the public plan that need to be improved. Focus on that for now, to make this bill better. Then work to expand Medicare and Medicaid later.
III.
Blame the Prez?Lastly, what role does the President play in all of this? I do think that when this is all said and done, the expansion of coverage will count as a major achievement. FDR failed to get health care reform. Truman failed. Kennedy failed. Johnson didn't even try (settling for Medicare and Medicaid). Nixon failed. Carter failed. Clinton failed.
At the same time, while I do think the bill is worth passing, and while I do think Obama deserves some important credit, I wouldn't let him off the hook here. People like Ezra Klein and Matt Yglesias have argued that the White House has a lot less leverage over recalcitrant senators than outside observers think. Generally, I they're correct. But in this case, I think they're being a little too charitable to the White House. I agree that the President couldn't have gotten single-payer by simply beating his chest. And I'm not even sure he could have gotten a regular public option. But the Medicare opt-in compromise had
59 votes.
Yes, Ben Nelson and a couple others were somewhat tentative in their support, but they negotiated it and were probably going to support it. It's not at all clear to me that the White House couldn't have gotten this passed had they been willing to play some hardball for that extra single vote. Maybe Lieberman was a lost cause, but was Olympia Snowe? She hinted she was a no, but unlike Lieberman, who clearly is negotiating in bad faith, Snowe seemed to actually want the bill to pass; besides, her "trigger" idea was included, Medicare opt-in was hardly revolutionary, and you could have appeased her by expanding the exchanges, maybe agreeing to delay it a couple of weeks, etc.
In other words, as a usual defender of the White House, I do feel that if they have a weakness it's that too often they'll settle for 70% of what they want if they have 0% chance of defeat, when they probably could have gotten 80% of what they wanted with a 10% chance of defeat.
That's one major aspect of the context behind Rahm telling Reid to give in to Lieberman. The other aspect is simply that, at this point, the White House just wants this thing done with. This was supposed to finish in September. This being stalled in the Senate is blocking every other item on their agenda. The jobs bill. The education bill. The college loan reform bill. Cap and trade. Financial reform. The transportation bill. Immigration reform.
Those are all things Obama has pledged to tackle before the mid-terms. ALL of those things were supposed to be in process right now. None of them are anywhere close to the floor because the Senate has let this health care bill twist there for months.
That's why Rahm gave Lieberman everything he wants. But while I understand why they did it, I still don't really agree with it. No, the Medicare opt-in wasn't everything, which is why I'm willing to let the bill pass. But it was still a good idea that could probably have gotten a 60th vote if they really tried for it.
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