Dear History,
I write to you today from the middle of a battle. I don't yet know whether I am explaining our ultimate defeat (and, if so, to what end) or providing colorful detail to help illuminate our victory. It may be something in between; it usually is.
I started this letter on Thursday, Dec. 17, 2009, four days after Senator Joe Lieberman betrayed party and principle by demanding that every concession to progressives be taken out of the health care bill to win his support. At that dark moment, my vision of our plight came from an old kids cartoon. (I have no particular one in mind, but I'm sure that one exists.)
In this cartoon, a giant speeding locomotive, representing the Democratic Party, speeds towards a cartoon character (let's imagine that it's Droopy Dog) standing on the tracks. There is anticipation ... collision! ... smoke ... and when the dust clears, the train is crumpled and derailed and the cartoon dog remains intact, brushing a speck of dirt off his shoulder, Physics be damned.
Our task had been how to keep the train from being derailed by Droopy Dog. (It's been such a week, though, that even last Monday seems far away.)
So, here is a report on how this battle looked to us at the time.
In the few days since, Ben Nelson received his own ransom, Harry Reid introduced his manager's amendment, and establishment Democrats from across the spectrum have coalesced in at least grudging support for more or less Reid's bill. We progressive activists have settled into customary camps: those who think that this reform is as good as we can get and those who think that we have compromised too much.
The latter accuse the former (with some force) of making it too easy for our opponents to better us in negotiations; the former reply that when politicians say that "we have nowhere else to go" in these situations, it's because we really don't.
The former accuse the latter of being willing to abandon the Democratic Party and let the thieves, thugs and torturers retake control of our government; the latter reply that what they do personally is less the issue than what the broad swath of American voters, by far most of whom are far less interested in politics than anyone posting here, will do.
You'll note, History, that not one of the arguments presented above is dumb. We can err here both by commission (passing a bad bill) and omission (passing no bill) and no polling snapshot of where the public stands right now can truly tell us which outcome will be worse. We'll never know, either, because we can only take one path; whoever loses out will always argue that things could have been different, could have been better.
Because people will, invariably, say that their opponents were stupid and shortsighted, I want to take a few minutes to explain why -- excitable as people on both sides can sometimes get -- that isn't really so.
Our Choice
My hope had been that the choice we make now could have been postponed to a later stage in the process, after a conference committee in which we could present the swing voters with a Hobson's Choice that we could hope turned into a fait accompli. I had hoped that we'd just concede whatever was necessary in order to get the 60 Senate votes to get a bill into conference committee, with the understanding that our concessions were not necessarily going to shape the final bill. But, when you have three Senators who can plausibly provide your last two votes, they get a lot of say in when the final battle takes place, and they wanted the final battle now. So, as battles sometimes do, it has come earlier than was optimal.
Explaining the debate over the bill is mostly explaining the reactions of progressive critics. The case-in-chief of progressive advocates is simple: this is the best we could get out of the current Congress, the is the height of our power to act, the bill does a lot of good despite its deficiencies, so take the victory while we can.
This story can be embellished: “This will be the foundation for our future healthcare system. If the bill we pass is popular, we may pick up support in the Senate (and, less likely, the House) and be able to do something better in the 112th Congress. If we pass no bill, however, we're likely to lose seats (for similar reasons to those applying in 1994), and then we'd be even less likely to pass a decent bill.” But all of this is basically reiterating four words familiar to anyone who has ever engaged in negotiations: “Good enough. Take it.”
Those opposing the bill do so on three grounds: policy, politics, and what I'll call pride.
The policy argument against the bill.
The policy argument of the bill is broken into two parts: that the bill is a deficient policy and that we can improve on it.
That the bill is deficient is the easier argument to make. The bill fails to ensure that competition, or to sufficient regulations, can hold down the cost of premiums. (This is generally believed by progressives to be intentional.) There are existing and potential additional holes in the “insurance reform” provisions of the bill. The provision on abortion funding is a horrific insult to both women and progressives. And so on.
Various counters to these arguments are possible, but they seem to fall into three categories of which I'll skip the first: “no, it isn't true,” “we'll see,” and “we can fix it.” Addressing these abstruse arguments would make an already overlong diary ridiculously so; you can read Nate, Josh, and couple of Kleins, and others if you want them. It's the last two responses than interest me here.
“We'll see” is in most cases here the truly honest answer. We've got models, the models contradict, and we don't really know what will be true. (In other cases, “we'll see” is unnecessary; we know, for example, that if there's a clear loophole present in the bill, the insurers will make use of it. That's the stuff that we truly do need to work out in conference. Yes, they will try to make more loopholes, and maybe we will end up playing “whack-a-mole” with them, but the spotlight will be hotter on them than it has been previously.) If we're creating a machine with a thousand moving parts like this – or, for that matter, like single-payer – we just don't really know what the output will be. The questions to ask are whether we'll be able to identify the problems and whether we can fix them once we do.
I don't know, History, if we'll be able to identify the future problems that occur – but it seems to me to be more likely after passing a bill than it is now. Progressives, who read nyceve's writings, already know about problems in the present system, but that hasn't translated into widespread public awareness of them (something about which I think we here have fooled ourselves at times.) Once we have a system in place that is supposed to work, though, it seems likelier to me that we can identify that this loophole or that lack of subsidies or those policies are the problem – and that we can then more likely fix them.
But can we fix them if we identify them? That will probably, if it happens at all, involve either passing “wedge issue” bills using the normal process – making imposition of universal mandates contingent on reasonable affordability would be one such measure (and I'd like to see Republicans block that one!) – or passing reconciliation bills with a 50-vote majority.
The big unknown here, the thing that kept me on the fence for a long time, is the question of whether the reconciliation process would really work here. (Yes, Bush was able to do it. Bush had to win over a few Democrats who think like Ben Nelson. Democrats have to win over a few Republicans who think like – oh, maybe Chuck Grassley. Which is easier?) The answer here, again, is that except perhaps for Harry Reid, Dick Durbin, and Chuck Schumer, we really don't know.
This turns out to be important. While those favoring progressive reform don't know that it would really work, their confident predictions notwithstanding, those opposing reform don't know that it won't work. The threat of reconciliation has apparently been credible enough to get Ben Nelson, especially, to make a deal he didn't want to make -- a victory for the progressive critics. But what if we dropped (or even sidelined, as I recently suggested) the normal legislative process to try reconciliation first (and for the main structure of reform, instead)? Well, to oversimplify, either we win or we lose. If we win, great. (It will, we're told, lead to even worse relations on Capitol Hill, but seriously, unless the Republicans are going to start shooting people they've already pretty much maxed out on being vicious lying obstructionists.) But if we lose? Well, if we lose on reconciliation, then we probably lose this bill too. Once Lieberman and Nelson know that that threat is a hollow one, they can do even worse to the bill, partially out of spite.
Now there are two sorts of bill opponents who want to use reconciliation. Some think that reconciliation is better than passing nothing and that passing nothing is better to passing this bill. The above scenario creates no problem for them.
Up until recently, I've been the other sort: one who would be interested in seeing what we could achieve through reconciliation, but who would then favor the present bill over passing nothing. For us, the problem of “shooting and missing” with reconciliation is a huge one. We don't want to fail to pass a bill that – admit it, people – does contain a lot of good insurance reforms. My solution to this is to try to reconciliation process after we pass the bill. Yes, that's right: pass the bill, establish it as a “base camp,” and then try to scale the mountain using reconciliation. This may involve reneging on assurances made to Lieberman and Nelson that we won't do that. Ask me how I feel about betraying them. If public pressure (that's us!) pushes Harry Reid to say “sorry, but the base is upset and we have to give them their swing at using reconciliation; we understand that you'll vote no, and we accept that,” then Joe and Ben will just have to accept that. We won't need their votes because we'll already have had their votes. (If they want to repeal the bill, they'd better have their own 60 votes!) So that's my approach – get the bird in the hand, then immediately set out after the birds in the bush.
I do want to give the first sort of bill opponents their due here: they argue that this bill simply isn't worth having -- that the foundation it establishes is lousy. There's much to be said for the argument, but it hides a contradiction. On the one hand, it is certainly likely that the pro-insurer elements within the Democratic Party, combined with a shamefully united Republican Party, are so awful and craven that they just will not allow the health insurance industry to be harmed. (It's worth noting that that industry a higher personal stake on this issue than anyone else, as single payer would largely put it out of business and a well-run public option might, if it doesn't turn into a dumping ground for the sickest patients, cut their profits down to the bone.) The problem is that once you decide that the Democrats are too compromised by the insurance industry, you also concede that you may not have the votes to push a better plan through reconciliation either.
Notice how the parties switch sides. Proponents who assert that if we don't pass a bill now we won't pass one for decades say “sure, once there's a system in place, it's easier to adjust it.” Opponents who assert that we can pass a bill next year through reconciliation or even thereafter say “no, once we've passed a bill, we're not revisiting this issue for decades.”
I'm with proponents on this one. I think that social programs like Social Security and Medicare, and initiatives like the Civil Rights Acts and Voting Rights Act, show that the first step of putting some program in place is the hardest to achieve. Then, if the program seems worthwhile, it's easier to say “let's change it” than “let's start an entirely new program.” (Health care itself is an example of the difficulties of the latter tack.) I certainly don't dismiss the argument that our political leaders won't want to revisit health care soon, though.
So my ultimate answer as to whether we can fix them is: “it depends.” I love that answer, because largely what it depends on is our political pressure. In other words, the existence of even a deficient program not only invites, but relies upon, our continued political activism. We'll have to get better at PR than we have been – why can't voters recite the stories nyceve tells the way that they can the contestants on American Idol and Dancing With the Stars? – but if we keep track of and trumpet our successes, we can convince the public that we've done something good, much as we did with Social Security and Medicare.
A final word, before leaving policy, on the abortion issue. Abortion is one of my top issues. And yet I, like Barbara Boxer and Bernie Sanders, would ultimately accept this regulation (and then try to roll it back once the “base camp” bill is passed.) It's rotten, insulting, and maddening – but it's not a betrayal.
If this bill did reduce access to abortions, then I would probably say “sorry about your health care reform, but I'm getting off the bus.” But it does something different. It creates an “opt-out” for states on including insurance-based funding for abortions within their states. You can still pay for abortions. You just can't use government insurance for them.
This sucks, no doubt about it. The comparison to treatment of Viagra would be funny if it weren't so sad. But it leaves us pretty much where we already are with the Hyde Amendment banning Medicaid funding for abortions, which was declared constitutional in Harris v. McRae. This bill isn't making the system bad; it's continuing a bad system.
Our initial position was: this bill shouldn't change the status quo regarding abortion funding. The problem with that plan, it becomes evident, is that the bill does change the status quo, because it introduces a new category of funding that didn't exist before: funding for women who seek abortions through plans being set up through this legislation. These women have, until now, largely been uninsured; as such, they had the right to have abortions but (obviously) could not get insurance to pay for them. Those women in anti-abortion states gain nothing here, but they also lose nothing. Those women in pro-choice states gain something. I don't like the former one bit, but accepting it as the cost of passing an otherwise acceptable bill is not a betrayal. (Meanwhile, I'd like to see NARAL or NOW or Planned Parenthood set up mutual insurance, where for $100/year people could get funding for an abortion if and when they need one. Set the premiums high enough to make a little money. Depending on the rates, I'll buy a policy even after it's no longer personally necessary.)
The political argument against the bill
The other main argument made against the bill is that it will kill the Democratic Party and usher in years of horrific Republican rule. Given the stakes, I take the argument seriously. Note, though, that if you make this argument at the same time as your saying that you will personally abandon the Democrats, you sound foolish.
Could passing this bill harm the Democratic Party? Absolutely. History, you don't give us any assurances, I know. It is perfectly possible that Democrats will be blamed for every denial of coverage forever after; Republicans will certainly try to arrange that. It is possible that mandates will drive people to the point of revolt and that their ire will be trained solely on Democrats. The downside goes very far down.
How does one analyze this, then? Well, first, we have to recognize that we can only make a choice between alternatives. The alternative is: trying for a better bill and failing. Proponents argue, with substantial force, that that would put the Democrats in even a worse political position. Failing to pass a bill not only undermines the Democratic Party as a vehicle for change, but it also reinforces the meme that Democratz iz teh Weak! These are known dangers, significant dangers, and the danger of commission had better be one hell of a lot larger than the danger of omission in order to outweigh them.
So: how big is the political danger of passing a bill? My belief is that it's appreciable, but smaller than the danger of inaction – especially when the party has coalesced around it as it has now.
This argument (certainly as I have made it in the past) largely involves mandates, especially as applied to young voters. To them, this is (or at least feels like) a new tax. They will blame the Democrats for having to pay it, just like they blame Democrats for having to pay Social Security Insurance taxes that they may never be in a position to use.
(Wait – young voters don't blame Democrats for that? Well, maybe there's a clue.)
First, let's not overestimate the number of people who will be subject to this new … let's call it a “payment.” It won't be huge: only those people not currently insured who prefer not to be insured are being “forced” to do this, and most of them are at income levels where they will be subsidized, and most of the rest can afford it well enough that even if it's a black mark against Democrats it's unlikely to be a decisive one in determining their votes. That the money goes to private insurers is bad, but we may be able to fix that.
Second, this is a problem that is fixable. Here's a proposal that you probably haven't heard: instead of fees, assess young people (or maybe all people) liens against their future income, such that the government will take an additional 5% off the top of any income they make over $40,000/year until their “back insurance payments” are paid off. There: political problem solved, and not at a huge cost to the government, either. (The money will come in, after all – unless someone never makes enough money, in which case it turns into an appropriate retroactive subsidy.) Or, if you don't like that, just increase subsidies straight out. It will be a great opportunity for pandering. That drives the Republicans nuts, as a bonus!
The “political fallout” argument also rests on the argument that people will resent being forced to pay money to private interests. (Frankly, I think that this overestimates the political sensibility and sensitivity of American voters, who embrace plenty of governance by private actors, but whatever.) I simply don't think that this is decisive, but it does lead us to the third category of argument against the bill: pride.
The prideful argument against the bill
I don't use the term "pride" to be pejorative. I consider this a real and substantive argument: that this bill is an assault on our dignity as individuals and as a nation. The idea is this:
The insurers are bad, they are parasites, they are perverting the political process with their contributions and their lobbying, and any bill that leaves them standing is unacceptable. We have to get them out of our medical care in order to have a system that we can be proud of.
You get past the policy deficiencies and you get past the alleged political impact and I think this is where a lot of political activists end up: that compromising with these parasites is just wrong. It is demeaning, insulting, a national embarrassment.
I hear you. I wanted these bastards gone too, or at least relegated to offering the equivalent of Medigap insurance. If you look through a lot of the comments on diaries such as this one, you'll see a consistent theme of simply not wanting to be complicit with a bill that leaves our society structured in this way.
I'm not going to say that this is immature. I think this is a healthy instinct – but like all instincts, it may sometimes have to be suppressed. The question is: is the failure to achieve the banishment of the health insurance industry a good enough reason to kill the bill? I think that it is not.
Here's why: I see what we're doing as part of a larger struggle. I have no problem with accepting “complicity” at one stage if I think it leads us towards a stage where we can eliminate that complicity entirely.
I've used the phrase “we can fix it” above. There's another, perhaps better, way, that we can describe this: “we can build on it.” The great, beatific, wonderful Senator Tom Harkin said just recently that this health insurance is like a starter home that we can build on.
OK, I like the metaphor. I'll call this bill “Tom's House.”
The question I ask is: are we better able to reach where we want go if we stand on the platform that this bill provides or if we go back to standing on the ground?
I think that it's obvious that we are better off making future progress if we establish Tom's House as a base camp.
Furthermore, I think that the Republicans think so too – which is why they have fought so hard to stop it. They're less afraid of this bill then of next bill, where we improve this bill. In Civil Rights terms, one reason they don't want the Civil Rights Act of 1964 is that they really don't want the Voting Rights Act of 1965.
I think that the insurers think so too – but that they're being sort of quiet right now because they don't want to provoke us into making the bill worse – for them.
Think about what our stance has been so far. We've been, paradoxically, playing defense. We've set up a program and had to try to defend it against all attacks. It has not been jolly work.
Now, the program goes into effect. It's deficient. The Republicans would like to eliminate it, but they know that even if they have two successful election cycles, they won't have the 60 votes they'd need. So this bill becomes the new status quo, that is better from our perspective from what we had but worse than what we want.
The Republicans now have to be the ones who defend it, to keep us from improving it. We become the guerrillas then – except we're guerrillas equipped with the advantages of power. We can attack this bill all over, from every angle, at the times of our choosing, to make points with the public about how Republicans defend its deficiencies and to get changes through because Republicans don't want to defend them.
We have a lot to do and we are equipped to do it. The first thing we have to do is to get President Obama to say something like this as he signs the bill:
This bill is a great achievement, but it has been the product of much political compromise, much of it painful for much of the Democratic Party. Like all new initiatives, it is far from perfect – but we will build on it. In fact, we will start to build on it this year, this month. While we have other priorities that I don't want to get lost, we are going to try to fix some of the deficiencies in this bill. I believe that when the spotlight is on single provisions that the public will want to see changed in this legislation, we'll find that many of our Republican colleagues, and their supporters, will find that it makes sense for them to vote with our party and with the hopes and desires of the American people.
(And yes, when we says the word “supporters,” I want him to cast a meaningful glance at Senator Joseph Lieberman.)
We'll need to push Obama hard to do anything like this. Some of his advisors may believe that this bill is just peachy as it is. We'll have to produce the polling data that documents the political dangers we face, studies that show the policy dangers. We'll have to argue that we need a system that makes us proud. We'll need to remind him that he needs to rally his base -- and that the stakes of doing so are enormous -- and that, if he is at his best, he can do it with a single arched eyebrow.
That's why I see our future as being if this bill passes. Life won't be perfect by any means, but this bill, over the long term, may well usher in a Golden Age of activism, one in which we're not hampered by the need for 60 votes, but in which we can experience the joys of being on offense with a fair expectation of victory.
I want to see that up-or-down vote on repealing insurers' antitrust exemptions. I want to see who votes no.
I want to see a vote on a bill that simply ties the mandate to affordability.
I want to see a vote on a Medicare buy-in for those who have reached age 55.
I want to see plenty of other votes, on programs popular with the public that will create wedge issues for Republicans, as well.
I want to build many new rooms onto Tom's House.
And that is why, Dear History, I and many others like me -- with respect for those who think otherwise and fully recognizing You may prove us wrong -- will support this bill. You have hinted that better times may come.