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.

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