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As the health care reform debate enters what appears to be the home stretch (albeit not for the first time), what Washington is offering us (the citizenry) boils down to a choice between bad and worse. The legislation now under consideration, both the Senate bill and the slight variation on same presented as “Obama’s bill,” is the end result of a process that has methodically stripped away almost everything that made this reform effort worth undertaking in the first place. They’ve thrown out the baby and kept the bathwater.

There are still a few tidbits of worthwhile insurance regulation left in there. The bill would end coverage exclusions for pre-existing conditions, a change almost everyone agrees is a good idea. It also requires coverage for preventive care, and limits lifetime benefit caps. There are also a few tweaks to Medicare and Medicaid policy—adjusting income threshholds; saving seniors some money by closing the prescription drug “doughnut hole”; extending the Medicare Hospital Insurance tax to households with unearned income. And it cracks down on the “pay for delay” tactic Big Pharma uses to keep generics off the market.

But that’s about it, really, on the plus side. All these incremental regulatory changes could easily have been achieved without all the sturm und drang of the past year… and even cumulatively, they don’t amount to anything remotely resembling “comprehensive reform.” In any assessment of pros and cons, they’re dramatically outweighed by what the bill doesn’t do—and more importantly, by what it changes for the worse.

Fundamentally, this is a bill that strengthens the private insurance industry’s stranglehold on the American health care system, and hands it a guaranteed revenue stream at public expense. It’s so laughably far from the Republican/Tea Party charges of a “government takeover” that it’s not even in the same conceptual universe… in reality, it reflects more of a corporate takeover of government. There’s no single-payer system, of course; that was never even “on the table,” sensible as it would be. The idea of a Medicare buy-in option came and went. Even the compromised substitute, the “public option,” has been stripped away. The bill doesn’t let the government renegotiate drug prices with Big Pharma; it doesn’t let Americans reimport cheaper drugs from Canada; it doesn’t subject insurance companies to ordinary antitrust requirements. What it does do is force all of us to become customers of private insurance companies. It claims to “extend coverage” to millions more people (albeit only 30 million of the 46 million who lack it), by making premiums “more affordable”… but that affordability is illusory, since it comes not from requiring insurers to keep premiums low but rather from subsidizing (via tax credits) low-income households and small businesses to help them pay market-rate premiums. It also imposes IRS-enforced penalties on middle-class individuals and larger businesses that don’t carry coverage.

I understand the theoretical actuarial significance of getting “everyone into the risk pool” for the sake of efficiency… but doing so won’t actually achieve any cost efficiencies if it’s only a mechanism for channeling public funds to private insurers. There’s no way to ensure they won’t just adjust premiums to capture the subsidies as profit.

The bill has no serious measures to control premium growth, or to limit (much less eliminate) the co-pays and deductibles by which insurers shift costs to their policyholders. It requires a “medical loss ratio” (insurers’ quaint term for actually paying claims… as well as for every other cost of doing business and assorted overhead expense industry accountants can sneak in there) of only 85% for large-group plans and 80% for small-group and individual plans, allowing massive profit margins. (Industry MLRs have been sinking for years, to the delight of shareholders; meanwhile co-ops like Kaiser Permanente and government programs like Medicare routinely keep their MLRs well above 90%.) It claims to end rescissions, but leaves a loophole for “fraud,” which of course is what insurers already routinely allege whenever they rescind policies. And the bill does nothing to end the problem of medical bankruptcies, which have skyrocketed to over 60% of all U.S. bankruptcies in recent years (three-quarters of those from people with health insurance), since the base benefits it requires for a plan to participate in the “purchasing exchange” are so inadequate.

At the end of the day, the price for a few meager regulatory improvements is a bill that does nothing to constrain costs, nothing to improve coverage, nothing to guarantee actual access to health care… and instead of reigning in the parasitical industry that’s brought us to this pass by standing between Americans and their doctors, it rewards it with a bonanza of new customers and guaranteed profits.

It’s a bad bill. By any reasonable policy analysis, it deserves to be killed.

And yet…

It’s a Hobson’s Choice, because bad as the bill is, the alternative at this point is so much worse it’s no real alternative at all. Letting this bill die would mean letting the obstructionist Republican minority and the incoherent rabble-rousing Teabaggers claim credit for “defeating” it; letting them perpetuate the myth that reform is a “government takeover” and that “the American people don’t want it”; putting them in position to take maximum rhetorical advantage in a campaign year, quite possibly regaining control of one or both houses of Congress—and enabling them thereby to obstruct not only health care reform but any and all other policy agenda items Obama and the Democrats have planned, to perpetuate the noxious ideology that government itself is “the problem,” and thereafter to force even more destructive and reactionary policies on the country, as so vividly demonstrated by the late and unlamented Bush administration.

Not that Obama and the Democrats are any great bastion of progressivism, of course. At the moment, all they seem to be offering the country is a slow downhill slide into corporate autocracy and reduced expectations… but that’s still markedly better than a precipitous tumble into despair, deprivation, and neofascism, which is what today’s GOP has to offer. This is, no doubt, why a strong majority of members of MoveOn.org have chosen to support passage of the bill, even as-is. It’s a bad bill, yet we have to pass it:  that’s a bitter pill to force down.

Remember what Obama promised during the campaign? He supported a public option (implicitly as a first step toward single-payer); he opposed an individual purchase mandate as Hillary Clinton proposed; he opposed taxing “Cadillac” insurance benefits themselves as John McCain proposed (which unfortunately cover not only c-level corporate fatcats but also working-class union members who’ve bargained away pay increases in exchange for better benefits), instead proposing to help pay for it by increasing marginal taxes on the rich. This was something reasonable people could get behind, and on election day they did. Yet the actual bill facing us now, the one he’s beating the drum for, is the exact opposite of all of those promises.

How did the bill get so bad? And is there still any chance to improve it?

There’s plenty of blame to go around. Much of it falls to the Blue Dogs and other “moderate” (read “conservative”) Dems who have dragged their feet at every step of the process; much of it falls to more conventional members who are simply beholden to insurance industry donations.

The perfect example of the former has to be Rep. Bart Stupak of Michigan, who has obstructed the bill at every opportunity because it doesn’t do enough to block women from getting abortions, and still remains unsatisfied even though the bill has carved out an exception guaranteeing that no federal funds will be spent on abortion coverage. Stupak must be suffering a serious cranio-rectal inversion if he thinks either (as a matter of principle) that interfering with reproductive choice is a more worthy goal (or worthy at all, but that’s another discussion) than reforming the health care system, or (as a matter of practical politics) that blocking the foremost agenda item of the party with which he’s affiliated, and thus making it look ineffective and incompetent, will somehow improve his electoral prospects next fall.

The obvious example of the latter is Montana’s Max Baucus, chair of the Senate Finance Committee, who has taken in literally millions of dollars from the health care industry over the last few years…. and who personally spearheaded the shape of the bill the Senate passed last December, with virtually no regard to what the House had passed the previous summer or even what his colleagues in the Senate HELP Committee had already worked out.

Congress aside, though, the other end of Pennsylvania Avenue can’t dodge the blame either. President Obama has finally taken the gloves off, introducing a bill of his own, stumping hard for it in public, and lobbying for it on the Hill… but he can and should have done this nearly a year ago, rather than letting the House struggle with its Blue Dogs to pass a bill that was left to twist in the wind, then handing the entire issue off to Baucus to dicker and delay with his “gang of six” for the ostensible purpose of attracting Republican support that any sane observer knew would never come, even as the GOP, the Teabaggers, and Fox News revved up a campaign of Fear, Uncertainty and Doubt to undermine the entire reform effort. The most charitable possible interpretation is that Obama wanted to make sure that even the slowest members of the general public recognized that he’d extended an olive branch of “bipartisanship” that the Republicans had rejected… but that doesn’t really explain why the White House took such a hands-off approach to the issue for so long, nor why (behind the scenes) the administration cut a deal with PhRMA that left billions of dollars on the table, and an even worse deal with the Federation of American Hospitals that essentially backed off from even a watered-down public option.

That any bill survives at all after the issue’s disastrous mismanagement by the White House is remarkable. Whether the bill in its current form is really what Obama wanted all along (despite his campaign rhetoric), or whether he’s just been unduly influenced by the corporate/DLC-type advisors with which he’s surrounded himself (epitomized by the obnoxious bully Rahm Emanuel, who never saw a principle he wasn’t happy to compromise so long as it brought more money into his party’s coffers), is almost beside the point, since either way the buck stops in the Oval Office.

Meanwhile, as the legislative process nears its endgame, the past week has brought no end of buck-passing and blame-shifting from Democratic leaders in Congress, even as some commentators conclude (not unreasonably) that a cynical insurance-industry giveaway with no hint of a public option appears to have been the party’s real goal all along. What’s brought this game of hot-potato about, though, and what makes this process more interesting than it might otherwise be, is a surge of grass-roots activism significant enough that it’s had a real and undeniable impact on legislators. In a sentence: the public option isn’t quite dead yet, and we may actually beat the odds and see a halfway-decent bill make it into law.

Much of the credit goes to Adam Green and his colleagues at the year-old Progressive Change Campaign Committee (PCCC), who in late January convinced two freshman Representatives to sign a public letter urging the Senate to pass a bill with a public option (as the House had already done) using a straight majority vote—i.e., through the procedural move known as “reconciliation.” The letter quickly picked up 120 supporters in the House, and the PCCC then turned its attention to the upper chamber, getting Colorado’s Sen. Michael Bennet, who began circulating the same letter among his colleagues and attracted more than 20 supporters within a week… a number that has continued to grow, reaching 41 Senators this past week.

Of course, reconciliation is a procedure the Senate could have used to pass health care reform nine months ago, had majority leader Harry Reid had the chutzpah (and the White House support) to do so, rather than letting Baucus have his way with the bill. This was much discussed at the time, but Reid and other Dem leaders kept insisting they needed to attract 60 votes in order to avoid the implicit filibuster that the GOP has been abusing to block almost every piece of legislation that comes along… right up until Scott Brown captured Ted Kennedy’s old Senate seat for the GOP, 60 votes became literally impossible, and suddenly reconciliation became a perfectly acceptable strategy in the eyes of the leadership.

(Keep in mind, here, that health care bills have already passed both the House and the Senate. All we’re talking about at this point is what’s being called a “sidecar” bill to reconcile the differences between those two. And passing it with an up-or-down vote using reconciliation is not unprecedented or unorthodox, contrary to right-wing rhetoric… in sharp contrast to the so-called “nuclear option” the GOP threatened to get Bush’s reactionary judicial appointments confirmed a few years ago.)

So, if all we need now is 51 Senate votes (or 50 plus Biden!) to pass that sidecar, why not yank out the godawful compromises that were made to get to 60, and pass a stronger, better bill, one that includes a public option? It would make strategic sense. It would save money (according to CBO projections). And oh, yeah:  it’s really popular with voters.

That last point is key. As the bill before Congress got whittled down over the course of months to the pathetic shadow of reform described above, increasing numbers of Americans have turned against that bill, for understandable reasons—leading right-wingers to circulate the dishonest meme that people are opposed to reform in general. In reality, though, most people are upset not because Congress is trying to do too much but because it’s trying to do too little… leaving the real problem, the insurance industry, untouched. This is corroborated by the fact that even as public support for the bill has fallen, the same polls show majorities across the country and across the political spectrum have continued to support the specific good policy ideas it still contains (e.g., ending pre-existing condition exclusions)… and, as corroborated most recently by a Research 2000 poll conducted just last month, that they especially support a public option that would offer a competitive alternative to corporate insurance. Ordinary Americans know who the primary culprits are for the health case crisis, even if much of Congress is blind to the fact.

At this point, then, it has become a question of both legislative will and legislative procedure, both of which have been much-debated in the last few days. The House is reluctant to pass the Senate’s version of the original bill before a “sidecar” has been passed, since there’s no guarantee how the Senate will act after that point… so of course GOP critics were quick to insist that this is how it has to be done, that you can’t revise a bill until after it’s been passed. This was quickly debunked, yet for some reason House Speaker Nancy Pelosi seems to have acquiesced to that sequence anyway, despite the concerns of her members.

Over on the Senate side, even though Reid and the majority whip, Illinois’ own Dick Durbin, are both on the record as supporting the Bennet letter, they initially said on Wednesday that they didn’t want a public option in the sidecar and would whip the Dem caucus against it, allegedly because it would have to be introduced by amendment and any amendments to the bill would open the door to Republican shenannigans. Much public outcry ensued on Thursday, though, and they were quick to backpedal. It became clear that since the sidecar might well originate in the House, the public option could be in it anyway; and moreover that if it weren’t, any one Senator could introduce an amendment to include one, which Vermont’s Bernie Sanders promptly promised to do. At this point Durbin clarified that he would whip for a bill with a public option, provided that it came from the House that way—thus throwing the onus back on Pelosi. That same day, however, Pelosi declared that the House bill wouldn’t include one, pointing the finger of blame back at the Senate because in her view that chamber didn’t have the votes to pass it.

It’s not clear which statement came first in this tennis match, though, or whether either Durbin or Pelosi was aware of the other’s words at the time… perhaps each thinks they can leave it out while deflecting blame toward the other. But the drama continued on Friday, as the PCCC released a vote count making clear that the Senate does have 51 votes in support of a public option. The question now turned to what could pass the House, where it became clear that the leadership had given up on trying to appease Stupak and his ilk… leading to a somewhat precarious vote count on the prospect of passing anything, but also making it all the more important to attract the votes of wavering progressives who’ve become understandably skeptical of the whole bill (like, e.g., the stalwart Dennis Kucinich) to replace those of the stubborn Blue Dogs. One step quickly taken along these lines was to fold student loan reform into the proposed sidecar bill… and of course another logical one would be to reinstate the public option.

(As I’ve argued for months, progressive members of Congress have far less to lose from opposing a health care bill than do conservative Dems. Progressives tend to represent liberal districts that they can safely count on to re-elect them, even (perhaps especially) if they take a stand on principle; Blue Dogs, on the other hand, have nothing to gain by making their party look weak, since that alienates independent voters and plays right into the hands of Republican opponents.)

A final vote in the House is expected by next Friday at this point, but what exactly it will look like remains to be seen. Even a restored public option won’t make a silk purse out of this sow’s ear, but it would make it at least arguably a bill worthy of passage on its own merits rather than strictly for lesser-evil reasons. Without one, the oft-heard argument that even a lackluster bill can be the foundation for future improvement (akin to Social Security in 1935) rings painfully hollow; this would be far too likely to be seen as the outer limit of what’s politically viable, rather than just a starting point. (Imagine how Social Security would have developed if it had been started not with a public retirement fund, but with a legal mandate forcing every citizen to invest in a Wall Street brokerage account.)

Health care reform with a public option simply makes more sense: it would be more effective, less expensive, and more popular. This alone isn’t enough to guarantee Congressional support, of course, especially when industry dollars are at stake. But it’s important to get it into the bill, to submit it to an up-or-down vote, even if it gets voted down—if only so we know exactly who to hold accountable. And if Congress can muster the political will to do what’s right—with activists like the PCCC lighting a fire under their heels—and if we as voters can elect more progressive Dems rather than the centrist types (beloved of Rahm) who hobble the party today—then we just might have something we can build on with future bills. In another development this past week, after all, outspoken Florida Rep. Alan Grayson introduced a new standalone bill that would let Americans under 65 buy in to Medicare… and within 48 hours he already had 50 cosponsors.

Our national government may have been reduced to near-paralysis by decades of right-wing influence and corporate money, but it’s not entirely broken quite yet. Tempted as I often am just to give in completely to cynicism, I’m reminded that there are still good people with good ideas on Capitol Hill… it’s just that the people are still a minority, and it takes almost superhuman hard work and perseverance to get the ideas past the sausage-making machinery.

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10 Responses to “Health care is making me sick”
  1. Do NOT give up on this, Chris.

  2. insurance says:

    it is so sad that we have to fight for something which we have invested on rainy days to come, what seems clear about this agenda is that some or in fact most of the people who are in power have their own self agenda compramizing our own well being.

  3. Vamberfield says:

    This health insurance reform debate makes it really clear that we desperately need reform in the Senate. The government has been kept in a state of paralysis thanks to the arcane filibuster rule, and it’s clear that even if meaningful health care reform passes, the system is broken. Conservative Democrats like Baucus and his fellow small state Senators dominate the process, while representatives from states with actual people in them get sidelined. If you ask me the Senate itself should be limited to approving nominees for office, and let the House handle actual legislation. The filibuster has to go, and it’s abuse by the Republican party has become an unconstitutional check on majority power.

  4. Hear, hear! The GOP abuse of filibusters over the last few years is really striking. There’s some building momentum in the Senate to adjust its filibuster rules… we’ll see it it picks up any traction as the election approaches.

    In the meantime, though, let’s note that Rule 22 (which controls Senate filibusters) already allows the Majority Leader to compel the minority to mount an actual filibuster, rather than merely acquiescing to their threat to block cloture. IOW, they’d have to keep debate open the old-fashioned way, by holding the floor. That is to say, if Harry Reid had an actual spine, he could have cut a lot of these filibusters off at the pass, or at the very least made it much more clear to the public who was responsible for obstructing things. We don’t just need better rules, we need better leadership.

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