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.
Political Criticism ≠ Partisan
A comment on a prior post reminded me to return to an idea that has been on my mind for some time.
Readers cannot fail to have noticed that a few of my recent posts have been critical of Republican senators’ tactics with respect to health reform. At the time I wrote those posts I was aware that some might choose to interpret them as partisan attacks. They are not. There is a difference between political criticism and partisan rhetoric. It is possible to critique the conduct of Republican senators in their participation, or lack thereof, in the health reform debate without condemning all things Republican.
Of course, there is no way to prove that one is free of bias, even to oneself. Perhaps the closest thing to observable evidence is some kind of balance in one’s writing. Long-time readers will know that I’ve commented favorably on some elements of Medicare Part D legislation (passed by a Republican congress and signed by a Republican president), and I have also been critical certain elements of Democratic health reform legislation, just to give a few examples.
Moreover, I’ve been writing about a weakness in Democrats’ health reform approach that Republicans are likely to exploit. By design it does not disrupt the employer-based insurance system upon which most middle class, fully-employed individuals rely. As such, most of the ways it might improve the health care system will not be immediately apparent to middle class voters. In fact, were I to consider my own narrow interests I might not support health reform or those who championed it. If health insurance premiums do not stabilize for the working middle class it will be hard for most of them to appreciate its benefits. This is a weakness of the legislation and a source of political risk for Democrats.
Nevertheless, I do support this reform because I do not focus on my own narrow interests. My morality is of the Rawlsian persuasion. I imagine, as Rawls did, a society in which
no one knows his place …, his class position or social status, nor does anyone know his fortune in the distribution of natural assets and abilities, his intelligence, strength, and the like… The principles of justice are chosen behind a veil of ignorance.
Thus, I view the reforms we’re likely to get as favorable, despite their imperfect origins. Though it relies on an understanding of politics, this is neither a political statement nor a partisan perspective. It stems from my personal philosophy. That it shines a more favorable light on Democrats than Republicans at the moment is merely a consequence, not a motivation.
Profiles in Plausibility: The Politics of Health Reform Rollback
I still agree with Matt Yglesias and Aaron Carroll, both of whom find the my scenario of a Republican rollback of health reform provisions unlikely, even if it is more likely than repeal. The key to its implausibility is the 60 votes it would take in the Senate. That’s the nature of filibuster politics. As long as that’s still the game, I think health reform is safe. (Of course one can contemplate budget reconciliation and changes to the filibuster rules…Let’s not go there now.)
But that doesn’t mean the threat of rollback isn’t important. It is. As I wrote before, perhaps the biggest political risk of health reform’s passage is not to the statue but to the party that backed it. Republicans may not be able to repeal or rollback anything, but they can gain seats campaigning as if they can and will. Their plausible pitch, which I outlined in my prior post, is to the middle class. Wouldn’t it be better for the middle class, Republicans might argue, if they had access to cheaper insurance (never mind it would cover less) along with some tax cuts paid for by allowing the low-income subsidies to gradually erode in real terms?
In fact, as a campaign tactic, one doesn’t even need to explain how to pay for the tax cuts. A simple message of the type, “This reform doesn’t do much for the middle class. Obama and the Democrats are taking your money to pay for a new wasteful entitlement. Wouldn’t you like it back?”
On the campaign trail it may not even matter if this makes any sense. Although, the fact that it doesn’t is exactly how liberals and progressives should attack it. If health reform is debated at all, this is how I expect the debate might go.
A Plausible Threat to Health Reform
I’m in agreement with Matt Yglesias and Aaron Carroll that chances of health reform being repealed are exceedingly slim. But that doesn’t mean it can’t be watered down to a far less ambitious scale. As I wrote before, money attracts a crowd, and there’s a lot of money in health reform that some would like to use for other purposes.
What I think is more likely than repeal, though by no means certain or even highly probable, is an erosion of the low-income subsidies in real terms, perhaps tied to a change in the minimum level of coverage required. A Republican congress and president might pass such changes along with a tax cut. It is very likely that Republican candidates will campaign on it.
I could see the whole thing being spun as middle class assistance: options for cheaper insurance and a lower tax bill, albeit with subsidies for the poor that don’t keep up. Since the poor aren’t a big constituency this strikes me as at least plausible.
Another wrinkle that could make this work is a weaker mandate that includes exemptions when the premium-to-income ratio is above a threshold. Put it all together and you’ve got a gradual erosion of health reform: worse insurance, less low-income assistance, fewer individuals covered, a weaker mandate. That’s not repeal, but it would make a mockery of the hard-won reforms. Watch for it.
Consequences of Obstruction
By now the Republican strategy is clear. They will attempt to obstruct and drag out the process of moving health reform legislation every way possible. I guess the thinking is to maximize the chances of a health reform train wreck that would occur if one Democratic Senator changes his or her mind or is unable to vote (e.g. due to illness).
One of the next steps in the Republican strategy is to object to the appointment of conferees (h/t Kevin Drum). As Brian Faughan explains,
The objection will not eliminate the possibility of a conference; Democrats can resort to a fallback. They can propose a motion to appoint conferees, which is subject to filibuster. It would likely require 3 separate cloture votes to pass the motion to appoint conferees.
There is another fallback in the form of the so-called ping-pong. The House could opt to skip a conference and just vote on the Senate bill. Doing so would eliminate the possibility of making changes to the Senate bill, some of which could be beneficial. Thus, one of the consequences of the Republican strategy is to put the Senate in charge of health policy. Much of the House wrangling over the issue will have been for naught (aside from political spillover effects). So much for the two-chamber legislature (paging Founding Fathers).
There could be a few things done in conference that would improve health reform legislation. Put an emphasis on few. There really is very little political wiggle room on most things. Where there is some room it isn’t clear the likely outcome of a conference would be to dramatically improve things. (I’ll just refer back to the Kevin Drum piece I’ve already cited twice above.)
But here is one thing: the so-called Senate free-rider provision. That’s the Senate’s no-good-very-bad (and complicated) version of the House’s employer pay-or-play “mandate.” As far as I can tell it’s still in the Senate bill and the manager’s amendment [pdf] doesn’t alter it. I’ve covered it in detail in earlier posts (on both Senate and House employer provisions). It’d be a good thing if the House version prevailed. Without a conference I am not aware of any way it could.
That’s just one possible consequence of Republican obstructionism. From a tortured process comes a twisted policy. The sausage factory is replete with horrors. A few bits of grizzle end up in the links.
Fight or Flight Response to Health Reform
Circumstances that disappoint or enrage offer the opportunity for a form of fight or flight response that is at least metaphorically, if not physiologically, related to that provoked by a mortal threat. I face such situations from time to time, and I’m sure you do too: your religious or social group heads in a direction you dislike, a new policy at work disrupts a comfortable equilibrium, a neighbor disturbs the peace. How do you respond?
One choice is to disengage, to walk away. To do so would seem to offer the hope of escape, but very often it does not. It guarantees that the situation will evolve without your influence. You’ve taken away your own power, ceded it to those who are willing to do the work of improvement. Sometimes you pay a heavy price.
Take health reform. Republicans walked away relatively early and a few vocal liberals/progressives threatened to do so at the end. Ultimately, it seems many (but not all) of the latter will be on board but the former will not. (Even Olympia Snowe, one of the only Republicans who seemed to engage in good faith, wishes to kill the bill with delay.) The difference between the the left and the Republicans has been one of fight or flight. The left engaged in a fight to improve the bill. Republicans turned away.
In terms of shaping policy, the cost of Republican flight will be high. As Jonathan Chait wrote this weekend,
The Republicans eschewed a halfway compromise and put all their chips on an all or nothing campaign to defeat health care and Obama’s presidency. It was an audacious gamble. They lost. In the end, they’ll walk away with nothing. The Republicans may gain some more seats in 2010 by their total obstruction, but the substantive policy defeat they’ve been dealt will last for decades.
More galling still, the legislation the Republicans wish to defeat will provide tremendous assistance to many residents of their states. After all, uninsurance rates are highest in the South, and lack of insurance is relevant to mortality and morbidity. Republican flight has been disappointing, even insulting. It is one thing to disagree with the opposition; it is another to refuse to participate in the solution to a collective (fiscal) threat.
Meanwhile, though they did not get everything they wanted (no public option, for example), the participation of the left in the health reform debate has been laudable and significant. Ezra Klein provides one concrete example, among many:
The original Senate bill barred insurers from imposing “unreasonable” annual caps on spending. This [latest Senate] bill bars them from imposing any annual caps on spending. That’s thanks, in large part, to the left, which attacked that weakness ferociously.
Looking forward, the outcomes of future debates over the evolution of health policy will be shaped in large part by those who choose to participate. There will be much work to do, even after health reform 2009/2010 becomes law. Republicans appear unwilling to do that work. They seem committed to the political expedient of flight and will likely continue to campaign against reform. That strategy may yet work politically and for a time. The extent to and duration for which it does is up to those who’ve engaged substantively in debate so far.
As the spotlight on health reform fades, will the left fade too or keep up the fight? I hope they fight, and I hope the right joints them. Compared to flight, it’s the courageous and mature response. It’s also optimistic and necessary.
What Keeps Health Reform in the News? The Money!
To be sure health reform will not feature on the front pages (or the blogosphere equivalent) day in and out after it passes. In this I agree with Ezra Klein. He writes,
A year after the president signs health-care reform, the country will have largely forgotten about it. That’s not to say it won’t be mentioned in the elections, or argued over in occasional op-eds. But what keeps it on the front page? It’s easy enough to write about health-care reform when it’s dominating the congressional agenda. When it’s waiting to be implemented? Or when it’s being implemented, and the main effect is that 16 million people without political power now have health-care coverage? I don’t buy it.
To the extent we hear more about health reform it will be for one reason: the money. While the legislation may be internally balanced so it scores as deficit reducing, it will not be viewed as monolithic once it passes. It has both spending and savings. Could we keep the savings and gut the spending? Sure.
Who would do that, and why? Answers: Republicans, for tax cuts. While the former are out of power, that won’t last forever. And the latter are always popular. This reform will be attacked. Things may quiet down, but this is not the end of it. Money has a way of drawing attention and a crowd.
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