Matthew Holt

Snatching victory from the jaws of defeat?

Sometime pretty soon Nancy Pelosi’s team will have figured out if they have the votes and will be moving what’s basically the Senate bill onto the House floor. Those of you who remember late 2003 may remember that the last piece of major health care legislation (Medicare Part D) didn’t have the votes when it went to the floor—but The Hammer (Tom Delay)—kept the vote open for 3 hours to make sure it got done. I don’t think Pelosi’s style is quite as brutal as Delay’s but between her and Rahm Emmanuel, plus the somewhat more measured tones of Obama, it looks like enough Dems will come around. Probably.

Now whether the things gets passed by votes, proclamation or shouting doesn’t really matter. In fact some very far reaching legislation has got passed that way and had long term implications. For example in 1937 Marijuana was made illegal with no vote; the one question asked in Congress was whether the AMA was in favor of the ban. It wasn’t but the answer came back that it was, and consequently there are the better part of a million arrests a year and most of rural northern California lives off it as a cash crop. We have our weird “democracy” and Mussolini got the trains running on time.I don’t want to list all the likely long term effects of this bill here. But it is worth mentioning that most of the potentially impactful delivery system reforms in the Senate bill remain. These include the ability of CMS to launch payment pilots straight into general programs without Congressional approval, and the creation of an independent board (the IMAB) to supposedly keep public (and private) payers to specific spending targets. Will these things make any difference in long-term spending? Will CMS have the political backing to enforce its directives? Hard to say but at some point something will have to be done about costs, or else (because as Jeff Goldsmith has pointed out) we’re already seeing the impact of consumers being priced out of health care, and government is next. After all, how much longer can broke states keep promising unlimited care to public employees while cutting Medicaid?

Even after the bill passes, it’s going to be a long haul to 2014 when the exchanges are ready to go and the subsidies start to flow. And of course there are already rational, if mostly ignored, concerns about the future of insurance over the exchanges if the fines to keep the healthys “in” are too low (for more see The Anonymous Actuary’s video). But in the end we’re mandating individuals to buy private insurance, we’re having a big big Medicaid expansion, and we’re changing the way private insurance runs.

But don’t forget that many pundits—me included—thought the bill was dead and buried not seven weeks ago. So instead of forecasts about what may happen next, let’s take a minute to see how has it risen from Scotty Brown’s ashes.

First, Wellpoint was incompetent. I’ve poked fun at them saying that they were secretly playing a double bluff game in that they really wanted the extra money from the government because they realized that they couldn’t make money in the individual market any more. But as an insider told me this morning, they’re smart—but they’re not that smart. And to be fair the premium increases that poured propane on the embers of the reform fires were submitted some three months before. But there’s no question that demonizing the insurers is the one thing that works on to get the Democratic base energized. Plus it’s such good fun!

Second, the Blue Dogs need the left more than they need the independents. The Democratic base is rightly pissed. It’s seen 8 years of extreme right wing policies passed into law & war by a Republican President who lost his first election and a Congress that was barely a majority. How did that happen? Well the answer is that while the centrist Republicans have been eliminated, the centrist Democrats have hung on and actually have come back strong since 2006. If you look at any of Bush’s legislative victories that were ideological (tax cuts for the rich & invading random countries) there were always enough Democratic votes to make it bipartisan.

But here’s the rub. Independents may, and I stress may, be grumpy about health reform (as opposed to Wall Street bonuses, and everything else), but it was the lack of turnout by the Democratic base in Massachusetts which did it in for Coakley. Six weeks ago you might have said that the base (exemplified by Markos of Daily Kos, Keith Olberman, Jane Hamsher of FireDogLake et al) didn’t want this bill. More Americans were opposed to the bill from the left than the right—most thought it didn’t go far enough. But the left has mostly come around now and recognized this bill for what it is—relatively trivial health reform but a big new social program for the poor and near-poor. Dennis Kucinich’s mind change this week was emblematic of that. If the Blue Dogs want to win in November—they need the Democratic base out in force.

Third, the Democrats have been told about 1994 ad nauseum. But sometime in the last two weeks they noticed that in 1994 they didn’t pass a health care bill. And they spent until August 1994 not passing it. So rather than repeat that mistake, it looks like they might do better passing something in March and giving the electorate six months to focus on something else, while giving their base time to reflect on this being a pretty major social program victory. No guarantees and the mood in November will be brutal, but probably better to go into November with a bill than without one.

Fourth, Obama got involved this time around. He can still make a difference.

We’ll have years to describe what’s going to happen next. But before Sunday and the coming down to the wire, it’s worth reflecting that things can change quickly in politics, and that sometimes even Democrats can (perhaps) get it right.

Livongo’s Post Ad Banner 728*90

Categories: Matthew Holt

Tagged as:

18
Leave a Reply

18 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
14 Comment authors
GPExhaustedMDFat Burning Exercise ResearcherWendell MurrayMYMILLIONSITE Recent comment authors
newest oldest most voted
GP
Guest
GP

“If The States Are At 35 against and 15 Not Yet Heard From, It Would Seem That “We The People” Are More That 51% Against This Health Care Bill THIS WOULD BE A CLEAR STATEMENT THAT IF AN UP OR DOWN VOTE WAS HELD TODAY BY THE GENERAL POPULATION OF REGISTERED AMERICAN VOTERS THIS BILL WOULD NOT EVEN SEE THE LIGHT OF DAY AND ANY LEGAL ACTION FILED BY THE INDIVUDAL STATES WOULD NOT EVEN BE REQUIRED” Oh dear. Someone apparently thinks that the population of the U.S. is equally distributed over 50 states. Activate amygdala, spout nonsense. Just ten… Read more »

ExhaustedMD
Guest
ExhaustedMD

I’m just curious, Mr Holt, if this legislation does have some serious consequences for the public, some if not most that were strongly debated and just dismissed, rationalized, and projected by supporters onto the opponents as false and misleading, will you and other supporters not only admit you were wrong, but will you stand up and lead for correction? This was not a black and white issue, and yet that is all you hear from the proponents. I hope you have the courage and intestinal fortitude to watch the grandstanding tomorrow by all these democrats who will be screaming to… Read more »

Fat Burning Exercise Researcher
Guest

I think that the current discussions about healthcare are shortsighted. They do not look to the future. Healthcare initiatives to date have focussed on providing healthcare to the needy. This is good. But what about addressing the prevention of ill health. Poor personal health practices is responsible for creating the need to address healthcare at this time. It is said that it is better to teach a starving man how to fish than it is to give him fish to eat. Much has been written about the obesity epidemic. Obesity, of course, leads to ill health and exacerbates the need… Read more »

Wendell Murray
Guest

jd’s comment above seems exactly on target to me.

Wendell Murray
Guest

I agree that this is good commentary from Mr. Holt, but more or less the same as he has asserted for the past umpteenth months. As usual, Margalit offers some pithiness: “This is not about health care. It probably never was.” You can say that again. On the other hand how often are bills crafted on the basis of the fact-based merits of an issue? Rarely, if ever. Bills enacted largely reflect the influence of one moneyed interest or another with some materially large financial benefit or position of power to protect. That is certainly the case with the pending… Read more »

MYMILLIONSITE
Guest

THIS IS A PETITION TO THE UNITED STATED FEDERAL GOVERNMENT FOR A INDIVIDUAL OPT OUT REQUEST FOR HEALTH CARE We The Undersigned Wish To Convey By Their Signatures Below That They Wish To Have The Same Rights Under The Current Health Care Legislation. That Allows The Individual States That If This Would Place An Economic Burden On That State They Have The Option To Opt Out Of This Mandate. Currently Over 35 Of The 50 States Have Or Will File A Legal Action Against Washington To Claim This Is An Unconstitutional Bill. If The States Are At 35 against and… Read more »

jd
Guest
jd

I never did give up on reform passing because the electoral calculation pointed so overwhelmingly in the direction of passage. As I wrote here the night Brown was elected: “I think right now Democrats in leadership know that they have to pass this or else they are absolutely screwed. You don’t spend 9 months hyping something and making it your top priority, make compromises that turn off half the base and most independents, then fail to get it enacted. If so, those who hated it still will resent the Democratic leadership and the base will not be motivated to turn… Read more »

PGW
Guest
PGW

All this sanctimonious posturing about opposing federal funding for aborting unborn children is totally hypocritical unless you also refuse federal funding for drone attacks that might abort children after they’re born or any other war deployment. That’s what “collateral damage” is, folks. The commandment says “thou shall not kill”. It doesn’t say that unborn ones are any more protected than the born ones with families to raise.

Gregg Masters
Guest

This dude from hell is a real treat! The culture war is alive and well in the United States of Amnesia aka ‘the idiocracy’. Matt and Maggie thank you; an on point reading of the tea leaves, IMJ. My only question is whether Alex Gibney will direct Michael Lewis’s soon to be made film (rights purchased by Brad Pitt and Paramount) of ‘The Big Short: Inside the Doomsday Machine’. Listen to Lewis’s context and background piece here: http://www.npr.org/templates/story/story.php?storyId=124690424. Lewis also authored ‘The Blindside’ and ‘The New, New Thing’, http://en.wikipedia.org/wiki/The_New_New_Thing, anyone remember Jim Clark’s ambitious agenda for Healtheon, aka WebMD, aka… Read more »

Margalit Gur-Arie
Guest

“It cnnnot be “the right thing” if it is done without the permission of the people.” The people spoke in 2008 and said they want a public option, an end to escalating costs and protection from unfair insurance practices. What followed was a combination of communication errors on the Democrats side and a very successful misinformation campaign on the Republican side. As a result the people have no idea what this bill is really about. According the most recent Kaiser poll (link at the bottom), 42% oppose the bill, 46% support it and 12% are not sure. Considering the vicious… Read more »

MD as HELL
Guest
MD as HELL

So lets hear some hatred in the media and see what happens; he still thinks he is divine. It cnnnot be “the right thing” if it is done without the permission of the people. And it can be overturned with a single court case.

maggiemahar
Guest

Matthew– Thank you for such a thoughtful post. Yes, I think this legislation will pass. And while it is a flawed bill, millions of Americans will be helped. Some will be helped this year–including sick children who have been denied insurance and low-income retirees on Medicare who will no longer have to pay co-pays or deductibles when seeking preventive care (as of Jan. 1). And you are right, the fact that “the legislation lets Medicare launch payment pilots straight into general programs without Congressional approval” is key–as is “the creation of an independent board (the IMAB) to supposedly keep public… Read more »

Judy P
Guest
Judy P

Well said.

Dennis
Guest
Dennis

Oh, the bill will pass. When the CBO score came out it was a sigh of relief for supporters across the spectrum. Some of the blue dogs who the Democratic leadership let off the hook in November and were “allowed” to vote no, will this time willingly vote yes.
Others who may still be on the fence officially will agree to vote yes if their vote is needed when the clock runs down. It will pass with no Democrats to spare, just like last time.

MD as HELL
Guest
MD as HELL

Why don’t they tell us what the projected national debt will be in 10 years and in 20 years? So you cut the deficit in the 2nd ten years by 1.2 Trillion dollars. What is that compared to a national debt in 20 years of 30-40-Trillion dollars? That of course assumes that anyone is stupid enough to lend us the money.