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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18 replies »

  1. “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
    Oh dear. Someone apparently thinks that the population of the U.S. is equally distributed over 50 states.
    Activate amygdala, spout nonsense.
    Just ten states account for over 50% of the population.

  2. 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 the country, “we saved you, you just don’t know it yet!”
    Because if I and other detractors are right, all this cheerleading will cause harm and pain. Hey, if I am wrong, then what a wonderful apology I will offer sincerely and respectfully. You really think the proponents, if I am right, have the gonads to do this?
    That is if they are still in office by 2014!

  3. 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 to address healthcare.
    Why is noone talking about educating children in the subjects of fitness and nutrition in schools? Doing so would contribute to improved health in future generations and therefore diminishing pressure on the healthcare system in the future.
    In the meantime, a way needs to be found to educate the current generation in these matters . Information similar to that which is contained in the article about
    Fat Burning Nutrition needs to be taught to the general population.

  4. 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 bills on healthcare reform. Any benefit to the overall population whose interest is theoretically to be advanced is ancillary.

    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 15 Not Yet Heard From, It Would Seem That
    “We The People” Are More That 51% Against This Health Care Bill.
    If Would Seem Logical That It Should Also Be AVAILABLE TO THE INDIVIDUAL PERSON AS WELL.
    We the Undersigned Wish To Opt Out Of The Average
    $12,000.00 Per Year Price Tag
    The Current System We Have In Place by Law Already Mandates That Any Hospital Cannot Refuse Medical Treatment to Anyone That Is In Need Currently Any One Who Asks For Help Will Receive It
    This Bill Will Be Imposed By A Federal Mandate On Each Man, Woman, Child, And Even Unborn Children That Live In This The United States If This Bill Passes.
    That This Mandate Is Actually an Unconstitutional Bill in Many Ways
    The Federal Government Does Not Have the Right to Mandate that it’s Citizens Will Have to Purchase a Product Such As Health Insurance Policy.
    To Mandate That An Unborn Child Will Have To Purchase This As Well Is The Same Taxation Without Representation.
    We As Citizens Are Now Already Over Taxed the Federal Government It Takes the First 4 Months of Our Income
    The States Take Another Two Months Of Our Income.
    If You Live You Pay Sales Tax on All Purchase’s And Even More On Other Taxes Such As Property Taxes, City Taxes, Cigarettes, Alcohol, Death Taxes, And Soon Even A Carbon Tax On Breathing.
    At The Present Time With All Of The Visible Taxes And The Taxes That Are Hidden In Every Item That Is Purchased We Are Taxed At If Not More Than 50% Of Our Income’s An Additional $1000.00 Per Month $12,000.00 For A Federal Health Care Product That Once Implemented Will Only Cover 60% Of Medical Expenses After An Already High Deductable This Will Place A Large Burden On Any If Not All United States Citizen’s.

  6. 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 out. Independents will be left with a bad feeling and gravitate towards Republicans, as lunatic as they are becoming. And Republicans will be energized and optimistic, and will turn out in large numbers in November.
    The only way Democrats keep this from being a bloodbath is to pass the bill now. This will end up being more popular than Medicare Part D. And if there is a brain cell alive in the Democratic party they will present this as a step towards the reform we need, not the totality, so that they can agree with those who will be clamoring for cost control reforms and use the sentiment to press the advantage against very powerful lobbies.”
    I’d say that analysis is holding up pretty well. My biggest surprise is how quickly progressives who opposed the bill for not being progressive enough acquired pre-emptive regret and became staunch supporters. And I’m very gratified to see the Democrats are already spreading the message that this is the first major step of reform, the first big battle, and not the war. Everyone from Obama to Reid to Kucinich needs to repeat that message when they get their historic quotes upon the passage of the bill. If they stay on that theme, health care will be a net positive for Democrats in the November elections, not a negative. Only the economy (unemployment) is likely to trip them up. I’d bet not enough to lose their majorities.

  7. 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.

  8. 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:
    Lewis also authored ‘The Blindside’ and ‘The New, New Thing’,, anyone remember Jim Clark’s ambitious agenda for Healtheon, aka WebMD, aka Emdeon?
    What’s it got to do with health care and health reform in particular? Absent fundamental re-engineering of our imploding house of cards, non health system, we face the same meltdown scenario. The derivative metaphor may be, Wall Street underwriting of various ponzi schemes…anyone remember the meteoric rise and fall of the physician practice management (PPMC) industry?
    How about names like MedPartners, PhyCor, FPA Medical, Allied Physicians Group (Dallas), etc. In this run up, investment bankers made millions, while physician equity collapsed, as the ’emperors had no clothes’ realization began to take root. There just wasn’t a there, there. Further add in the influence of third party reimbursement and you enable the inflated pricing that a demand driven enterprise can create. As a result medicine, hospital and health care services in general are grossly over-valued, by virtue of a morphing (initially cost/charge based, to schedule or negotiated discount, bundled or capitated) third party buffer paradigm, much like the contribution of derivatives in the financial meltdown. What would ‘fair value’ absent this ‘derivative’ buffer, in a market based economy where the granular supply and demand for services established price? Would we witness the prevalence of massive cathedrals of medicine absent this artificial updraft?

  9. “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 campaign against the bill, and the President, I find it enlightening that there are more supporters than opposers for this bill.
    Just imagine what the polls would look like if people didn’t operate under the impression that the bill is a blue print for death panels, exploding deficits, Marxism takeover and generally the end of mother and apple pie.
    This bill is so mild and so stripped of all the lofty goals the people empowered the elected President to accomplish, including the public option, that it is almost bizarre to see the unadulterated hate and fanaticism permeating all references to liberals, progressives, Democrats and particularly the President.
    This is not about health care. It probably never was.
    Kaiser poll:

  10. 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.

  11. 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 (and private) payers to specific spending targets.”
    This gives Medicare the power to do things that it has never done before. One of the first posts I wrote for this blog predicted (or at least hoped) that Medicare reform would pave the way for healthcare reform.
    How hard will this be politically? It will be hard. But the law makes it possible for Medicare to change how it pays, what it pays for and how care is delivered. These are the sructural changes we need and Medicare reforms will ripple out into the larger system. (Private insurers also would like to rein in healthcare inflation–if Medicare will go first and provide political cover.)
    I look forward to seeing who this administration appoints as the new head of CMS. I am convinced that they have held off on this appointment not because it slipped their mind that they need a new head of CMS, but because they know their candidate will be controversial. They didn’t want to fight a battle over Senate confirmation of a strong candidate while simultaneously fighting the war over reform.
    Matthew, at one point, you almost persuaded me that it wouldn’t happen! (Your cynicism about our democratic process is only slightly greater than my own.)
    And I actually gave up hope for about ten days– before Obama came forward.
    But for most of the past 18 months, I have thought it would happen because it must.
    No legislator wants to see Medicare begin to slide toward insolvency on his or her watch. And at this point, even upper-middle class Americans are finding themselves priced out of the insurance market. If they lose their jobs, they have great difficulty covering the premiums on their own.
    That combination– high unemployment, fear of losing a job, and the fact that relatively affluent Americans are beginning to find health care unaffordable created the
    conditions that Clinton didn’t have. The recession of the early 1990s ended too quickly. This one won’t. Unemployment is going to remain high for some time to come.
    Can this legislation be repealed or undone?
    I doubt it. This is a major bill– like Social Security or Medicare. There is no turning back.
    We can only improve on it–just as we have improved on Medicare and Social Security.
    Ironically, thanks to all of the damage that George W Bush did to our economy, he brought us to this turning point in our history.
    I suspect that more and more young and middle-aged progressive will now come forward to run for office and become part of the country’s political life. For too many years– decades in fact– progressive change has seemed hopeless. There was a moment at the beginning of the Clinton administration . . . but it was extinguished quickly.
    Throughout most of the 1990s, it was hard t tell the difference between the New Democrats and the Republicans.
    Now, the differences are easy to see. Some call this polarization. I call it clarity.
    The U.S. is the only country in the developed world that puts such a high value on “bi-partisanship.” Other countries recognize the importance of debate–including debate over basic values. This is what the argument over health care reform became. And it meant that we had to think about values again, and decide where we stood.
    Admittedly, polarization means that, going foward, things will continue to be ugly. Obama will be the most hated president since FDR. He just needs to learn to say what FDR said: “They hate me and I welcome their hatred.”
    As Churchill understood, eventually Americans do the right thing. That includes American presidents. I hope Obama is learning that sometimes, being hated and doing the right thing go hand in hand.
    Finally, Matthew, thanks for providing a forum where people like George Lundberg, Nortin Hadler, Merrill Goozner, Bob Wacther, Joe Paduda —and a great many others whose names I’m not recalling at the moment– express their views. I hope they’ll continue–including many who disagree with me.

  12. 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.

  13. 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.

  14. Irony is holding a vote on a Bill which allows federal funding of abortion on the beginning of Holy Week.

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