Health Care Reform: Could it have gone differently?
In the wake of the all-but-certain collapse of health care reform legislation, there has been a lot of analysis about how this could have gone differently. Was there a different path that would have resulted in success? I thought I’d throw my two cents in for what it’s worth.
First of all, I think it’s important to note that if Congress had succeeded in getting a health care reform bill onto the president’s desk before January 19th, the press would probably have proclaimed Obama a legislative genius who had succeeded where many other presidents had failed. For the press—as for many of us—nothing succeeds like success.
At the beginning of Obama’s term, there were a few voices—Bill Galston outside the administration and Vice President Biden within it—who counseled the president to postpone consideration of health care reform until the economy had recovered. David Brooks offered similar counsel, suggesting that Obama would have to rebuild trust in government before he would be able to move such a large initiative forward.
It’s not clear, though, that postponing consideration of reform until later in the president’s first term would have increased the likelihood of success. Even without the blowback from the reform debate, the Democrats would almost certainly have lost seats in both the House and the Senate in the 2010 elections, decreasing the odds of reform passing in the next Congress. Members of Congress would have resisted making hard votes in the run-up to that election, making reform a harder sell in 2010 than it was in 2009.
A second set of voices suggests that the President should have embraced more incremental reforms as a way of building broader support for the bill among Republicans. It should be remembered, though, that majority leader Harry Reid spent several months trying to hammer out a consensus among the Gang of Six, a group of moderate Democrats and Republicans.
That work, though, began to unravel after the Tea Party movement began to put pressure on Republican lawmakers to oppose reform. Two of the three Republicans on the group, Mike Enzi (R-WY) and Chuck Grassley (R-IA) began to distance themselves from the reform discussions. Grassley, in particular, suggested at one point that the public had “every right” to be afraid of the end-of-life language in the House bill, which had been characterized by grassroots GOP activists as “death panels.” While it was probably reasonable to give Grassley some room to shore up relations with his base, many Democrats in the Senate thought Grassley had clearly crossed a line. They began to fear that the Republicans were simply dragging out the negotiations to inflict political damage on the Democrats. By the end of the summer, there was increasing pressure on Reid from his caucus to go it alone if necessary.
Politics aside, one wonders whether a durable agreement could ever have been reached that would have garnered more than one or two Republican votes. The reality is that the Republicans’ favored reforms—caps on non-economic damages in malpractice suits and allowing insurers to sell policies across state lines—would only have had a minimal impact on health care costs and virtually none on coverage. The latter was also opposed by state insurance regulators since out-of-state insurers would not have had to comply with the insurance regulations of the new states where they were operating. While one suspects that technical problem could have been solved, the solution would probably have involved federalizing insurance regulation, an ironic outcome for a party generally committed to defending the prerogatives of state government.
The reality is that private health insurance is very expensive and, even under the most optimistic scenarios, it is going to remain very expensive. There is no way to insure 30 to 40 million people through private health insurance without spending a very large amount of federal tax dollars. Paying for that is going to require new revenues, i.e. taxes. The number of Republican lawmakers likely to sign on for this was always going to be small, and as time went on those lawmakers were under increasing pressure to stand with the rest of their caucus. Democrats, for their part, were simply not going to accept a bill that did not provide coverage to a large portion of the uninsured.
There has been some discussion about whether it would have been possible for the Democrats to get the vote of Olympia Snowe (R-ME) if they had been willing to compromise more. In some ways, she was more deeply engaged in the details of reform than Democratic senators like Ben Nelson (D-NE) and Joe Lieberman (I-CT). Snowe, though, did not seem to have a strong sense of urgency about getting the bill done, and that raised questions about whether she was really willing to commit.
With the current reform bills going down in flames, we face the question of whether there is anything that can be salvaged. Some have suggested that the Congress should pass the pieces of reform that have bipartisan support, such as insurance reform. The problem is that the pieces of reform are designed to work together. If you are going to use private insurance to insure the uninsured, you have to require them to take everyone regardless of health status. But if you do that, you create a risk that only the sick will buy insurance. One of the reasons for the individual mandate is to bring the healthy into the risk pool to balance the sick. But if you are going to mandate that uninsured families buy policies costing several thousand dollars, you need a system of subsidies to make it affordable. If you do all that, there is almost no way to avoid having a very large, complex and expensive bill.
There are also some thoughtful conservatives and liberals wondering why Obama didn’t just propose a simple Medicare buy-in for those 55-65 and a broader Medicaid expansion for poor families. I have to say that it is somewhat ironic to see this idea being floated by conservative thinkers like Ross Douthat and Reihan Salam. But liberals like Ezra Klein like this too, particularly since it could probably be done through the Reconciliation process and only require 51 votes in the Senate. Whether any actually existing Republican officeholders would support this remains to be seen, however.
I could go on, but I think you get the idea. There was never going to be an easy path to reform. All conceivable paths to reform legislation that cover a large number of people will cost a lot of money and gore more than few sacred cows. This particular effort came closer to passage than any other in the last 60 years. I am having a difficult time imaging an alternative approach that would have improved the prospects for success.
There are two final ironies in the collapse of this particular reform effort that I want to highlight. The first is that the bills rejected by the Republicans this year contained policies that many of them supported back in 1994, including an individual mandate, group purchasing arrangements, and tax subsidies to help individuals purchase coverage. Of course, that also implies that things the Democrats found unacceptable in 1994 they are now willing to accept! In any case, both parties have arguably moved in a more conservative direction since then. These bills were hardly “socialism.”
The second—and related—irony is that the Republicans success in using the Senate filibuster to kill the current round of reform may ensure that future efforts to expand coverage rely on public programs like Medicare, Medicaid and CHIP rather than private insurance. There are reasons—which I may elaborate on another time—why I am not necessarily sure that is a good outcome. But if pushing reform through Reconciliation becomes the only way to get any reform at all, I suspect the Democrats will ultimately embrace it.
Ross Douthat a conservative? I Douthat.
Perhaps now Obama will heed Biden’s advice about getting the economy on track.
A very fine analysis, Peter. Thanks for pulling it all together. Your read makes great sense. I’m not sure what else really could have happened, barring Ted Kennedy staying alive.
There is an argument to be made that Obama should have been more active in pushing for it, but I’m not sure that would have worked, and would likely have led to a backlash or have carried with it a political cost. One always has to keep in mind that the first and last responsibility for this failure falls at the feet of the Republicans; I sometimes lean towards Andrew Sullivan’s description of the GOP as nihilists, except I think they believe opposing everything will somehow work for them. Maybe it will.
But I think Obama dislikes “politics,” that is campaigning and the war room mentality that Bill Clinton and Karl Rove loved. I think he wants to govern, to allow Congress to do what it should, and to attempt to show that government can work. Thus governing would be his version of campaigning. It is a virtuous approach, I think, and one that is sorely needed. But I suspect it is also Obama’s way of avoiding the unpleasantness (for him) of barnstorming and startegizing constantly.
Yet being more of a politician might have helped win the crucial p.r. battle that the GOP and Tea Partiers won, and that took Massachusetts, where it all went south.
Now he’ll have to be more Clintonian, as we’ve seen with the budget freeze proposals. It may work. But much would be lost.
None of the above constitute the true irony of the healthcare debate.
Here’s what does:
In 1973, President Nixon proposed a universal health care insurance plan.
Senator Edward Kennedy originally opposed it on the basis that…well choose your commentator…but most agree that it was because Kennedy was convinced that Nixon was only offering something that benefited insurance companies.
He wasn’t the only one who opposed the universal health care insurance plan – the AFL-CIO were onboard the opposition wagon too.
However, and much to his credit, Kennedy did decide eventually to a compromise deal with Nixon. The Nixon-Kennedy compromise would have produced what it is that you all crave – and more.
But it was too little too late as Watergate crested national attention and swamped the new President Ford, who despite a valiant effort, was unable to get anywhere with the legislation.
Kennedy is on record as describing this lost opportunity as his greatest political regret.
Kennedy is also on record as describing universal healthcare as his greatest political goal.
Less than six months after his death – even though it came in the midst of a new healthcare bill with a Democrat President, and a resurgent Democrat Congress, Ted Kennedy’s most important political goal is as dead as he is.
Now, THAT is irony.
DG – There is an argument to be made that Obama should have been more active in pushing for it, but I’m not sure that would have worked, and would likely have led to a backlash or have carried with it a political cost.
Ken – President Obama should have come down off his perch, developed his own healthcare proposal, rolled it out and explained it to the public, and guided it through Congress. As for political cost, the president is much more popular than anyone in Congress; he could have afforded to use his political capitol if he had really wanted to.
DG – One always has to keep in mind that the first and last responsibility for this failure falls at the feet of the Republicans; I sometimes lean towards Andrew Sullivan’s description of the GOP as nihilists, except I think they believe opposing everything will somehow work for them. Maybe it will.
Ken – You must be joking. The Democrat-controlled Congress had all year to pass this. They had filibuster-proof majority in the Senate and a very solid control of the House, they did NOT need Republican votes – at all – and they knew it. That is why last summer Reid and Pelosi so freely snubbed their Republican counterparts. Then it seems, Democrats lost the courage of their convictions, and decided they would not (all the while bleating that they could not) go it alone. If Democrats were so sure of their plan, why did they not pass it when they had the votes? I guess it does not matter; now they do not have the votes and the whole thing is DOA.
DG – But I think Obama dislikes “politics,” that is campaigning and the war room mentality that Bill Clinton and Karl Rove loved.
Ken – This is hilarious. President Obama, or any president for that matter, by definition Loves politics. What are you thinking? President Obama lives and breathes politics.
DG – Yet being more of a politician might have helped win the crucial p.r. battle that the GOP and Tea Partiers won, and that took Massachusetts, where it all went south.
Ken – President Obama should have come down off his perch, developed his own healthcare proposal, rolled it out and explained it to the public, and guided it through Congress. As for political cost, the president is much more popular than anyone in Congress; he could have afforded to use his political capitol if he had really wanted to.
I think President Obama should have simply proposed fixing Medicare and Medicaid programs, and expanding them to cover the 30 million uninsured folks that everyone was wringing their hand about in the first place.
And for those who will surely wail that “Medicare and Medicaid are broken” I would only say that if the government cannot run these two relatively small national health programs, why in the world would we trust government with a much larger national health program?
If the government is going to be in the health business, it needs to learn how to run a national health program. Medicare and Medicaid are good programs to start with.
Once the government gets good at running Medicare and Medicaid, then we can consider expanding those two programs to gradually cover more people.
“There are also some thoughtful conservatives and liberals wondering why Obama didn’t just propose a simple Medicare buy-in for those 55-65 and a broader Medicaid expansion for poor families.”
I thought this would be a good deal, too, until I looked into it.
Estimates I read indicated that the Medicare buy-in for those 55-65 would be about $300 per month per person if the system were to remain self-sustaining (i.e., I presume without adding new taxes to the public at large). And most Medicare recipients have supplement insurance to pay for hospital stays, meds, and diagnostics that Medicare doesn’t cover.
You can buy private insurance for that amount of money–which, if you multiply that by two uninsured people over 55–would be about $700 per month–and way beyond my means.
This could be a good plan if buy-ins could be placed on a sliding scale, but that would mean more tax subsidies to keep Medicare going. Or maybe a reduction in spending elsewhere. Fer instance, anyone else wonder about that first-time home buyer rebate?? Those of us without insurance need the kind of lobbyists the realtors have!
Highever, I think the health care/insurance reform issue is a dead duck, and it’s clear that those who have insurance view those of us who do not have it as whiny-assed “Boombers” who think the government should shuck out $$ so we can live in Strawberry Fields Forever, lalalala.
Your fellow citizens and their elected representatives aren’t going to help you, so you better do what you can to stay healthy, and, if not, die quick so you don’t leave your family with debt that’ll force ‘em into bankruptcy. See my nine-point plan for the uninsured elsewhere on this blog.
Ooops, one too many “la’s” in Strawberry Fields. Imagine how John Lennon would be ashamed of me.
“Your fellow citizens and their elected representatives aren’t going to help you”
We can write and call our representatives and senators and tell them, “Don’t let health care reform die!”
I’m up for another populist movement. The Tea Partiers have already claimed tea, but coffee and beer are still available. Coffee Klatschers for Healthcare Reform? But no Starbucks cups – too elite.
To Catherine Harding’s recap of political history, I would add: in the wake of the 2004 presidential election, when the economy was strong, unemployment was amazingly low, and President Bush claimed a mandate, he floated ideas for both healthcare reform and Social Security reform. The key ideas of Republican healthcare reform were expanded health savings accounts and much higher annual deductibles. The theory was that health insurance distorts the healthcare market by shielding consumers from the effects of rising medical prices. Consumers who feel the pain of paying for more of their own treatment are more likely to shop around, and the resulting competition would drive prices lower. Democrats would have none of it, for pretty much the samre reason that Republicans would have none of so-called “ObamaCare”: Democrats can’t countenance a market-based solution, and Republicans can’t countenance a government-based solution.
Btw, Social Security hasn’t gotten financially healthier in the ensuing six years, either. Neither Social Security nor current government-funded healthcare programs are on the path to self-sustenance, and the recession has brought the “day of reckoning” closer because government revenues fall during a recession.
The parties need to figure out a way to work together on both issues. Each has ensured that the other can’t claim credit for major legislation. Now is the time for some bipartisan cooperation. We have a leader in the White House who campaigned for just such a post-partisan moment. If ever there was a time for him to step forward, it’s now.
And as it happens, he’s making a major speech tonight. Sieze the damn moment, Mr. President.
Jim, the bill is dead. Lawmakers are backpedalling away from it as fast as they can. Write your legislators and behold the waffle you’ll receive back.
Viz activism and galvanizing the party base, Kathleen Hall Jamieson, IMO an incredibly well-grounded thinker, has pointed out that conservative talk radio (nutbars like Rush excluded) has been able to lay out a clear ideology that gives the conservative movement cohesion and unity.
There is no equivalent on the liberal side that has been able to galvanize people in the same way. We can argue about why that might be so, but I think it’s one reason the health care bill became the mess it did and is the reason no Democrat really wants to pull it out of the toilet now. (Like Will Rogers said, “I don’t belong to no organized political party; I’m a Democrat.”)
It’ll be interesting to see what Obama says about it tonight. Lamarr Alexander said yesterday that if the Prez talked about terror, jobs and the deficit, he could make more friends with the GOP. On the one hand, I was astounded that a Republican would think that a Democratic president with a majority in both houses needs to make nice with the GOP. What’s more astounding, however, is that it seems to be true.
” Lamarr Alexander said yesterday that if the Prez talked about terror, jobs and the deficit, he could make more friends with the GOP.”
I expect to hear a lot tonight about fiscal responsibility.
I suspect that a main reason there are no liberal radio stars is because big- business owns the media, and that’s the last thing. Ig busumess wants.
[By the way, Comcast is lobbying Congress to let it buy NBC. We reslly do have to do something about the continued weakening of Old Media. It's not long for this Earth.]
Okay, if health care reform is dead, how many years will you live in the wilderness without universal coverage before someone, maybe a gay, Catholic, female, president tries again (he says tongue-in-cheek)?
I suspect that a main reason there are no liberal radio stars is because big- business owns the media, and that’s the last thing. Ig busumess wants.
The only thing that counts with business is audience ratings, which converts to ad revenue and thus adds to the bottom line. Any liberal who could pull in listeners as Rush Limbaugh does would be welcomed with open arms.