Things To Ponder
As I went to bed last night the following questions entered my mind.
- Which would be a greater commercial success, a book about the failure of Obama’s efforts at health reform or a book about the victory of its achievement? I think the former. (No, I’m not writing a book.)
- If health reform fails, which will be the conventional wisdom, that the Democrats over-reached or that they under-delivered? Again, I think the former. (Yet, right now I don’t think they’ve over-reached, which is not inconsistent with my thoughts on future conventional wisdom, which I expect my future self to agree with.)
Let me know what you think.
Paragraphs Worth Reading
On the near completion of health reform, from Kevin Drum (the doubly indented bit is his quote from The Hill):
Sen. Tom Harkin, the chairman of the Senate Health Committee, said negotiators from the White House, Senate and House reached a final deal on healthcare reform days before Scott Brown’s victory in Massachusetts. …
The bad news: this means that if Democrats had taken this stuff even slightly more seriously, healthcare reform would already be a done deal. Idiots. The good news: if negotiations really were complete, it should mean that creating a reconciliation deal to accompany passage of the existing Senate bill ought to be fairly easy. A few parts would probably have to be jettisoned since they wouldn’t be allowed under reconciliation rules, but that’s life. The vast bulk of the compromise would stay in place and just needs to be turned into legislative language.
Why this isn’t happening is a mystery.
On how the White House is failing to communicate, from Nate Silver:
What can Democrats do differently? Unfortunately, this is not such an easy question to answer. But from the White House’s perspective, the most obvious solution would be to behave more decisively. Don’t let policies like the public option twist in the wind: embrace them, or press forward without them, but either way, remind the House and the Senate that having a 3-month fight about the issue will leave the Democrats as a whole much worse off, regardless of how the dispute is resolved.
It all sounds so simple. The interesting question is, why are Democrats and the White House behaving otherwise? I don’t think the answer is, “Because they’re stupid.” There’s got to be more to it. To Drum I’d say that there is likely conflict in the Caucus and the Administration about whether and when to push health reform. It isn’t yet obvious to everyone that it should happen or it should happen soon. To Silver I’d say that the White House was trying to walk a fine line without knowing precisely on which side of the line the public option would fall. Moreover, they were bending over backwards not to repeat the mistakes of the Clinton approach. They let Congress be Congress. Unfortunately doing that guarantees only one thing, that it will take vastly longer to get a bill than your agenda can gracefully tolerate.
How To Listen To Politicians: Emanuel/Axelrod Case Study
How to listen to politicians: the title sounds like the start of a joke. I’ll let you supply the punchline. Meanwhile, I’ll elaborate on a meme from my take on how health reform was handled in Obama’s SOTU address. When a politician speaks she may be conveying a genuine policy preference or playing politics or both. How does one distinguish? It isn’t so easy. Even seasoned policy wonks and political junkies can disagree.
Let’s take a recent example. Over the last two days there were media reports of statements made by presidential adviser David Axelrod and Chief of Staff Rahm Emanuel about the Administration’s health reform agenda. The two gave a conflicting sense of Obama’s legislative priorities. They can’t both be right. Therefore one is talking policy, the other politics. But who is talking what?
Let’s start with Axelrod. As reported by TPM, in a briefing with reporters on Thursday he reinforced Obama’s commitment to health reform, “[W]e are working closely with folks on the Hill to develop the way forward and get this done and that’s all we’re focused on, on health care, is getting it done.” And, “We haven’t transitioned away from it … we are going to take the steps we think hold out the most promise to getting this done.”
Contrast that with Emanuel who said in an interview with NY Times reporters today that health reform was not priority number one.
Democrats would try to act first on job creation, reducing the deficit and imposing tighter regulation on banks before returning to the health measure, the president’s top priority from last year.
Ezra Klein sees this as the death knell of health reform. He explained that if health reform is really important to the Administration then
“[t]he timetable Emanuel is laying out makes little sense. The jobs bill will take some time. Financial regulation will take much longer. Let’s be conservative and give all this four months.
… The longer this takes, the less likely it is to happen. And Emanuel just said that the administration’s preference is to let it take longer. If I were a doctor, I’d downgrade health care’s prognosis considerably atop this evidence.
So who is speaking for the Administration on policy and who on politics, Axelrod or Emanuel? Jonathan Chait attempts to sort it out.
Emanuel is not necessarily speaking for the administration. Emanuel’s message is not David Axelrod’s message. And it’s not Obama’s message. But Emanuel is out there floating his [delay health reform] plan, and that’s a major problem for Democrats, not to mention the national interest.
I see two potential explanations. Either Obama doesn’t know what he wants to do, and his deputies are spreading conflicting stories in order to see what takes, in which case he needs to make up his mind pronto. Or else he wants to do what he says he wants to do, but his chief of staff is out there subverting his agenda and making Congress doubt his seriousness, in which case Obama needs to shut up Emanuel or fire him.
I think there is another interpretation and Jonathan Cohn suggests it.
[T]here’s an argument for taking health care reform out of the spotlight for a little while. It’s not good for the cause, or the people promoting it, when the political world is hanging on Evan Bayh’s every twitch. Making progress on jobs is bound to help Obama and the Democrats, which will make passing reform easier.
And the process is going to need at least a little more time–time to work through the technical elements of writing a reconciliation bill and then time to debate the bill itself.
If that’s the thinking in the White House then it would make sense for the President to have authorized simultaneous and contradictory messages. Via Rahm and to the nervous members of the Democratic Caucus: don’t worry, we’re doing popular jobs and banks stuff now. Via Axelrod and to the party base: don’t worry, we’re really going to do health care pretty soon.
If my thesis is correct then the Administration is trying to walk a fine line and satisfy their policy goals (passing health reform, among other things) and a political imperative (showing Americans they care about jobs and the economy). That suggests that Axelrod’s message is Obama’s policy goal on health reform. He wants it done. And Rahm is attempting to seize control of the politics, at the rhetorical expense of health reform.
Taking the general thrust of both messages, the best interpretation for health care reform is that the truth is really somewhere in the middle. It will get done but neither right away nor toward the end of Spring. I’m still optimistic health reform will get done, but only as long as Democrats remain convinced that failure will cost them later. If enough people lose interest in health care it will be dead. And, in that case, to answer Chait’s question, Rahm will be seen as the killer. But in truth he will have had a lot of accomplices.
Seriously Depressing News
This is not at all surprising. According to a recent Pew Research poll only 26% of Americans know how many votes it takes to pass a bill through the Senate under normal rules (h/t Jon Chait).
I consider this news depressing. The less Americans know about how government actually works (or doesn’t) the less sensible is the public’s response to what it does (or doesn’t) do and the less likely it is that anything will be done to address the structural problems that pose large barriers to important change.
As Matt Yglesias points out, obstructionism works as a political tactic in a climate of ignorance:
But I’d say the fact that people don’t understand how this [the filibuster] works is an important element of what makes it so effective. To a small slice of Americans, the GOP’s minoritarian obstructionism is a heroic stand. To another small slice of Americans, the GOP’s minoritarian obstructionism is an undemocratic disaster. But to the majority of Americans it’s completely invisible and all they see is a Democratic Party that can’t get things done.
One only needs to observe what has happened to health reform to appreciate the relevance of government structure and process. If there is one thing I wish Americans knew right now it is that the majority in the Senate can’t act like one when the minority has the power to decide what bills come to a vote.
Obama was absolutely right when he said to Republican senators in Wednesday night’s SOTU address,
[I]f the Republican leadership is going to insist that 60 votes in the Senate are required to do any business at all in this town — a supermajority — then the responsibility to govern is now yours as well.
It is a political strength to have disproportionate control over the legislative agenda. As with any powerful tool that strength can be used for good or ill purposes. What will today’s minority choose? (My guess should not be surprising.)
Where Did We Go Wrong?
The following contribution of humor to Catharsis Week (which formally ends today) is a guest post by Jim Hufford, a lawyer in Atlanta and the author of the blog Organon.
Why did everything fall apart? Was it the wasted months negotiating in the Finance Committee? Was it the August recess? Was it Martha Coakley’s colossal choke? Lieberman’s double-cross? Olympia Snowe’s snow job? Nelson’s Medicaid deal? Was it too much inside game? Too little party discipline? Was it Stupak? The recession? The excise tax? Cannibalism? Panic? Death panels? Jobs? Mammograms? Pirates?
Tempting, but no. None of these explanations can capture the truly historical dimensions of the force that now has health reform throttled in its clutches. That force finds its expression in the burgeoning activism and civil disobedience of the tea party movement. The anger of these largely libertarian conservatives began to surface in June and was clearly noticed in August. But one day in December, their movement grabbed hold of the public imagination and assumed a new prominence on the American political landscape. It was on that day that things really started going south for health reform in the 111th Congress. That day was December 16, 1773.
Let me explain. The greatest obstacles to passage of health reform legislation have been institutional and ideological forces traceable to the colonial rebellion. The original tea party, fittingly, took place in Massachusetts—a fact which adds a sort of literary depth to the otherwise meaningless and politically suicidal depression liberals are now experiencing in the wake of the Bay State’s stunning disavowal of (or obliviousness to) the centerpiece of Teddy Kennedy’s life’s work. Consider how the folklore and doctrinal innovations of the revolutionary era have shaped the healthcare debate:
First, there is our anti-tax zealotry, steeped in an ideal of heroic patriotism. The Boston Tea Party was of course an act of political vandalism in protest of a tax. It happened to be a tax on tea, but colonial agitators—like many of their latter-day namesakes—denied the constitutional authority of the government to impose any tax levied for the purpose of raising revenue without the colonists’ consent. And now members of the modern day tea party movement from Waco to Wasilla think they’re Samuel freakin’ Adams incarnate when they protest all (non-military) government expenditures—because, you see, every dollar spent is a dollar raised by taxation.
Second is our distrust of “big government” and irrational preference for state and local government, no matter how corrupt, over geographically distant, “central” government, no matter how effective.
Third is the structural bias toward small states in the Senate and electoral college. The framers’ exaltation of the arbitrary geography of statehood was one of their most profound and insidious innovations. As James Fallows recently observed, citizens of smaller states are vastly over-represented in the Senate—putting 532,668 Wyomingites on equal footing with 36,756,666 Californians. That means that individual Wyomingites have 69 times more influence in the U.S. Senate than individual Californians. (Sort of.)
Next there is a whole series of crackpot notions that took hold during the time of anti-tea hysteria: separation of powers, federalism, bicameralism, and so forth. Let me just say that, in combination if not individually, these half-baked doctrines have really screwed us. I mean, it is actually the point—not a regrettable side effect, but the point—of bicameralism to impede the legislative process and make it difficult to enact popular measures.
And then there’s the filibuster—which you can read about here, here, there, here, and, well, just about anywhere else. Now, the filibuster is not a direct product of the revolutionary era, but I would note two things: it is made possible by the constitutional architecture of bicameralism and separation of powers, and its emergence is a predictable result of bicameralism’s motivating principle of ambition counteracting ambition. (See Federalist No. 51.) Oh, and did you know that ‘filibuster‘ basically means pirate?! Arrrrggghh!
Last, but indeed not least, is the matter of the tea itself. Centuries of unease with this versatile and healthful beverage have plagued Americans as a result of the symbolism of the harbor incident. Instead we have turned to coffee and carbonated “soft” drinks. The latter’s Orwellian moniker (the stuff is basically high-fructose rust remover) has cleverly disguised the degree to which these misbegotten concoctions are contributing to an epidemic of obesity, rotting our teeth, and burning holes in our GI tracts. Conversely in Britain, as Ray Davies once observed, they have:
Tea in the morning, tea in the evening, tea at supper time. You get tea when it’s raining, tea when it’s snowing, tea when the weather’s fine. You get tea as a mid-day stimulant. You get tea with your afternoon tea. For any old ailment or disease, for Christ’s sake have a cuppa tea. [Video here.]
Nobody likes taxation without representation. Okay. But in retrospect, I think the weight of the evidence is that we totally overreacted on that one. Look what it’s gotten us: malrepresentation, an accountability crisis, holds, senators, bicameralysis, a pesky written constitution, and the procedural bizarro-world of the filibuster that lets the minority decide if the majority’s proposals get voted on. And look what we’re missing in Great Britain: tea and its aforementioned benefits, PM’s Questions, majoritarian legislative procedure, knighthood, cool accents, and…I’m forgetting something…oh yes: universal healthcare.
Therefore, it is seriously time we consider undeclaring our independence from Britain. Or we could just pass the sodding bill, already.
SOTU and Health Care: Politics vs. Policy
I’ve been hyper-busy today and not able to keep up 100% with all the SOTU spin and interpretation. Nevertheless, at the risk of repeating something someone else has said and I failed to read (yet), I’ll toss in my two cents about the way Obama handled health care in the speech.
On the one hand, policy wonks (myself included) would have loved for him to give a crystal clear signal of what direction he wants Congress to go. My preference would have been for him to say, “To the House: pass the Senate bill. To the Senate: work with the House to amend it.” That’s clear enough. That’s the policy approach.
On the other hand, there’s the political. Obama wants to (and did) set the stage for the midterm campaign claim that Republicans have brought nothing serious to the table. That’s why he said (I’m paraphrasing), “If you’ve got a good idea on health reform, send it to me.” Of course, unless Republicans are actually willing to vote for anything, all the politically feasible ideas that make any policy sense have already been offered. We know what they are. There really isn’t any other way to go from here except in the direction the House and Senate have already gone.
So, the expectation on the part of Obama and the Democrats is that Republicans won’t offer any serious alternatives, and won’t vote for anything. We all heard Obama ask for their ideas and help. If the GOP doesn’t turn up a good idea that they’ll actually vote for then that prepares the ground for accusing them of politically motivated obstructionism.
Notice, Obama can’t simultaneously invite new ideas and also command Congress to pass existing legislation. Or, he can do that but not in the same speech. In not giving the House and Senate marching orders he made a choice away from highlighting policy and in favor of the political. That’s natural given the nature of a SOTU address in an election year. A political event calls for political tactics. And that’s exactly what was delivered.
Responsibility and the Structure of Government
Continuing Catharsis Week, my colleague Steve Pizer and I wrote a Kaiser Health News opinion column that appears today. In it we note the rare demonstration of responsibility of congressional Democrats and the Administration that brought us so close to health reform. Then we explain the forces that contribute to the scarcity of responsible government and to the near collapse of the health reform effort. Just a taste:
Our system of government is designed to produce an abundance of great speeches about sweeping reforms and a pittance of actual reform delivered. So, except for frustratingly brief moments, we really have no government, just a collection of perpetual campaigners, focused on the next election and accepting no responsibility for the country’s long-term problems. In 2009 it was comforting to believe that the leaders of the majority party would use their power to govern responsibly. They tried and failed. The campaigners have taken over, again.
Please read the whole thing.
Though I agree with what we wrote, I’m still disappointed in Democrats for not (yet?) finishing the job they started. The design of our government certainly makes it far harder for leaders to govern responsibly. I get that. But I’m not willing to give the Democrats (or Republicans) a free pass. Perhaps it is because some of them certainly appeared to want to do the right thing. That gave me hope. Then it was crushed, maybe to be revived once more (I still can’t tell).
The last time I was so disappointed in a political party and a president was when George W. Bush took us to war in Iraq. Like the abandonment of compressive health reform, that too was an unnecessary and costly decision that resulted in loss of life. It is hard to forgive, and harder yet to forget, leaders who trade blood and treasure for political gain. I understand why they do it. I just don’t like that they do so. I never could. And that’s why I do what I do and not what they do.
But few of us are 100% free of responsibility and power, small though it may be. Most of us can vote. We can also write or talk to our representatives and/or their staff members. We can demonstrate, volunteer, and contribute money. In small ways we can do something toward making our dysfunctional government and the actions of our leaders ever so slightly better.
Last week I called my Democratic congressional representatives and urged them to continue to fight for health reform. (You can too. Here’s where to find contact info.) If I perceive for a moment that they are not seizing opportunities to make progress on coverage and costs they will lose my full support, and possibly all of it. The same goes for our president.
I don’t expect to have my way on every issue. I understand political realities and the limitations of our government. But I do expect my representatives to do their job within the constraints of our system. When, despite the incentives for irresponsibility, there is a chance to do the right thing, to begin to address a pressing national problem, and when the (super) majority exists to carry it out, then it should be done. On health care it wasn’t, or hasn’t been yet. Democrats defeated themselves once last week. But it is within their power to change course. If they throw in the towel for good that will be a loss for which we will all pay.
Political Feasibility is Relevant!
This post has been cited in the 4 February 2010 Health Wonk Review.
From time to time someone approaches me and asserts that another, very different approach to health reform would be better. Then they direct me to some website or a paper or just start explaining it to me. Then they want me to either agree with them or enter a debate.
One of the first things I look for is political feasibility. My would-be rival often charges that I’m only interested in what is possible and not what ought to be. The assertion, “Just because it passes doesn’t make it good,” is standard fare. I couldn’t agree more.
But that’s not my point. My point is that that which is clearly not politically feasible is not going to happen. It might be theoretically brilliant, but so is time travel through worm holes (if that is actually possible). It can’t survive the limitations of reality. Anybody pursuing it would be torn to shreds.
The point of bringing in political feasibility is that it is a relevant constraint. That which can pass isn’t necessarily good. But only that which can pass will ever happen. Ideas that are laughed out of the realm of political feasibility aren’t, broadly speaking, good ideas.
Does that mean the House and/or Senate bills are good? Well, I think they are at least good first steps toward solving many of the problems with our health care system. I don’t think they are the final bills on health reform. I do know if some variation of them does not pass we won’t see another for a long time. That they are (nearly) politically feasible is a huge plus! Moreover, that fact is not obvious from examining the bills themselves.
That’s the strange beauty of our legislative process. It certainly does weed out the political duds doesn’t it? In fact, if anything it has a high false negative rate. Whatever survives is extremely politically robust. It has to satisfy a myriad of special interest concerns and those of hundreds of legislators. It has to survive unbelievable distortions and attacks borne of insanely devious creativity. That’s not a defense of our system. That’s just the way it is.
So the next time a great new health reform idea pops into your head, ask yourself, “Would this survive a year of political scrutiny?” That’s not an easy question to answer. Few could begin to address it. But remember this, we have tried and failed at health reform many times. Very smart people were involved each time, folks that really know politics and policy. It is an exceedingly narrow needle to thread. Few ideas can make it. The current bills have made it further than any other, ever. That means a great deal.
In general anything we can conjure up that is radically different from the House or Senate bill is almost surely a dud. The sausage factory can only produce so many variations of sausage. Political feasibility is highly relevant. To ignore it is to invite fantasy. That’s just not worthwhile.
Rant Week Special: Autism Edition
There are good political and policy reasons for Congressional Democrats to pass the Senate Health Care Bill, hopefully with a reconciliation “sidecar,” but without one if need be. But I have a personal reason for my desperate wish to see the Senate Bill enacted. My daughter has autism.
In most states, including my home state of Washington, it is legal for insurers to discriminate against autistic insureds by excluding or severely restricting necessary therapy for their condition. For example, we are eligible for reimbursement of only sixty therapy visits a year under our current insurance, a fraction of the over two-hundred that our daughter needs.
Providing adequate therapy and meeting the other medical needs of her condition costs us around $20,000 per year out of pocket. This is on top of the more than $1300 monthly premium that we have been paying through COBRA for our otherwise pretty good, non-profit public-employee health plan since my wife left full-time employment with the state to work part time from home as a contractor in order to spend more time caring for our daughter.
When COBRA runs out, however, we will be in a far worse predicament. Our current plan at least covers diagnostic medical services for the team of doctors, nurses, and psychologists who help to design our daughter’s treatment and manage her medication, as well as for costly genetic screening and other testing to examine potential causes. But the group policy that my law firm provides to its employees has even more restrictive limits on therapy visits and diagnostic coverage.
And because I am a partner in my firm (and thus a self-employed part owner of the business), I would have to pay the entire $1800 monthly premium, which has been rising annually by double-digit percentages even as benefits have deteriorated. Plans in the individual market cost less, but they offer little in the way of autism benefits when they offer any at all.
The Senate Bill would outlaw autism insurance discrimination nationwide by requiring that autism coverage be included in the basic benefits package. Without it, I truly do not know what we will do when our current coverage runs out.
Encouraging News on Health Reform
This, from Igor Volsky, is the best news on health reform I’ve heard since the MA special election. Aside from the bit in the middle of the piece about Hoyer mentioning the possibility of stripping the bill down for parts (excluded in my quote below), it is consistent with other things I’ve heard today.
Reports are suggesting that Senate and House negotiators are rallying behind a strategy that would require the House to pass the Senate health care bill alongside a reconciliation package of fixes that would improve the bill and satisfy progressive lawmakers. …
Meanwhile, TPMDC is reporting that “House and Senate leaders will huddle today at 4 p.m., House Democratic leadership will meet at 5 p.m. and then House leadership will hold a caucus meeting with rank-and-file members at 7 p.m.” to “get a sense of where members stand after spending three days sounding out constituents.” …
“The overwhelming majority of our caucus wants to pass a health care bill,” the aide told TPMDC. “They can’t make a decision yet because they are still trying to work through the parliamentary procedures that are at our disposal.”
If you read the whole thing you can find bits that are less encouraging. But I think all that talk about exploring all options and so forth is nonsense in practical terms. There really is only one option and on the whole this report appears to be a sign that Democrats are discovering that fact. I think those in favor of health reform should view this as very encouraging news. More consistent doses of this for a while would be nice.
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