Let me say up front that my disagreement with the "support the current bill" crowd is based on policy and political considerations, but I can see how reasonable people can come to the opposite conclusion. I don't think supporters of this wreck of a bill are stupid or compromised or anything like that. I'm not like Joe Klein railing against "assorted nonsense from left-bloggers", which so reminds me of his ad hominems during the Iraq War debate. How'd that turn out, Joe?
In short, there appears to be a divide between those who think the insurance industry will play nice, even with little incentive to do so, and people like me who don't. They believe that government will enforce the new regulations, people like me have seen entire industries employ armies of lawyers and lobbyists with the sole intent of undermining and avoiding such regulations. I'm a half-empty guy, others are half-full. Regardless, this is a fantastic debate. For critics who bemoaned the lack of policy discussed on blogs, this year has certainly proven that when we do have the opportunity to impact policy (i.e. a Democratic-run government), we certainly can get into the weeds on policy.
Ezra Klein takes me to task for my opposition to the mandate, pointing out that Switzerland, among other systems, have mandates that require citizens to purchase health insurance from private insurers. It's true. They do. Those countries also have strict regulatory regimes that heavily regulate those insurance companies. In Switzerland, for example, insurance companies cannot profit from the essential benefits plan everyone must purchase. That's kind of an important detail missing from the Senate's monstrosity of a bill. In addition, Switzerland also strictly regulates the price of medicines and medical devices -- something this Senate has explicitly refused to allow.
Give me those kinds of restrictions to the Senate bill, and I'll rethink my opposition.
Then there's Nate Silver and his 20 questions For Bill Killers, which I'll happily answer:
- Over the medium term, how many other opportunities will exist to provide in excess of $100 billion per year in public subsidies to poor and sick people?
The assumption here is that this bill is the only option on the table. The House still has a say in the matter. And really, the point of reform isn't to shovel taxpayer dollars to the insurance companies, it's to expand care and lower costs. I'm not willing to surrender on costs.
- Would a bill that contained $50 billion in additional subsidies for people making less than 250% of poverty be acceptable?
This betrays a simplistic view of liberals, as if our answer is to merely shovel money at a problem. What we're looking for is good policy, which in this case, would also be good politics. So no, throwing money at the insurance companies doesn't change a thing. The insurance industry would simply absorb the new subsidies just like universities have raised tuition to shovel up any increases in financial aid.
- Where is the evidence that the plan, as constructed, would substantially increase insurance industry profit margins, particularly when it is funded in part via a tax on insurers?
Where is the evidence that insurance companies would rig the system to extract record profits? I don't know. Perhaps the last decade or two might provide the answer.
- Why are some of the same people who are criticizing the bill's lack of cost control also criticizing the inclusion of the excise tax, which is one of the few cost control mechanisms to have survived the process?
Because it is a measure that would disproportionately affect blue collar workers in high-risk jobs, or workers that have given concessions on wages to preserve good benefits packages. Limit that provision to people making over X amount (say, $100K/year), and I wouldn't have a problem with it.
- Why are some of the same people who are criticizing the bill's lack of cost control also criticizing the inclusion of the individual mandate, which is key to controlling premiums in the individual market?
Because without premium caps or a public-run competitive option, there is no incentive for them to lower their premiums. They have a monopoly, and monopolies aren't in the business of unilaterally reducing their prices. There are two ways to force them to do so -- government regulation or market competition. The former is out, and the latter is inadequate.
- Would concerns about the political downside to the individual mandate in fact substantially be altered if a public plan were included among the choices? Might not the Republican talking point become: "forcing you to buy government-run insurance?"
If you start worrying about Republican talking points, you've lost the game. They're accusing Democrats of trying to kill grandma. They're not going to back off because a talking point isn't 100 percent accurate. 2010 will be the year of the "commie socialist Democrats", no matter what health care reform bill is passed.
In any case, Republicans have tried to destroy socialist programs such as Medicare and Social Security for years. If people like a program, there's nothing the GOP can do about it.
- Roughly how many people would in fact meet ALL of the following criteria: (i) in the individual insurance market, and not eligible for Medicaid or Medicare; (ii) consider the insurance to be a bad deal, even after substantial government subsidies; (iii) are not knowingly gaming the system by waiting to buy insurance until they become sick; (iv) are not exempt from the individual mandate penalty because of low income status or other exemptions carved out by the bill?
Is this argument that the mandate doesn't matter because too few people will be subject to it? If so, then strip it out. It shouldn't matter.
- How many years is it likely to be before Democrats again have (i) at least as many non-Blue Dog seats in the Congress as they do now, and (ii) a President in the White House who would not veto an ambitious health care bill?
I'm not sure how the future composition of Congress has anything to do with a battle in our current congress. This battle isn't over. But if anything, this argues for pushing for the most progressive bill possible.
In any case, most of the endangered Democrats next year are of the Blue Dog variety, while most of our (relatively meager) pickup opportunities are in Democratic-leaning districts. In other words, while our majorities will likely be smaller, it will be a more intellectually cohesive caucus. That's why all of the outright House retirements thus far have been Blue Dogs -- they're not interested in having to defend themselves in a caucus that is trending leftward.
- If the idea is to wait for a complete meltdown of the health care system, how likely is it that our country will respond to such a crisis in a rational fashion? How have we tended to respond to such crises in the past?
No, the idea is to get the best possible legislation today. We may not be able to get something with reconciliation before Obama's State of the Union Address, but I don't think something this important should be beholden to something as trivial as a speech, even one as important as the SOTU.
- Where is the evidence that the public option is particularly important to base voters and/or swing voters (rather than activists), as compared with other aspects of health care reform?
Given that the current bill only has 32 percent support, I don't think this turd of a bill in the Senate has much support of anyone, much less party activists. And the voter intensity numbers are clear -- base Democratic voters are planning to sit out 2010. And I doubt 18-29 year olds -- a key part of the Democratic base -- are going to be thrilled with a mandate. In fact, it may be the single least popular item in the bill.
- Would base voters be less likely to turn out in 2010 if no health care plan is passed at all, rather than a reasonable plan without a public option?
Nope, if Democrats gave it a serious shot, and then built campaigns around the obstructionists. Caving in to Lieberman, Republicans, and corporate interests, on the other hand, sends the message that the Democratic super majorities are irrelevant, and all the hard work from the last four years in electing them was a wasted effort.
- What is the approximate likelihood that a plan passed through reconciliation would be better, on balance, from a policy perspective, than a bill passed through regular order but without a public option?
Likelier. Seems self-evident. And really, Medicare and the VA health system shows that the government is quite capable of handling health care.
- What is the likely extent of political fallout that might result from an attempt to use the reconciliation process?
Fallout with the DC press corps? They didn't mind when Republicans used it to pass their tax cuts under Bush, but that's a different time. I'm sure they'll hyperventilate about it now. The voters? I've seen no data that suggests they care about process. Just results. Democrats would cheer, Republicans would bitch, but those guys will bitch anyway.
- How certain is it that a plan passed through reconciliation would in fact receive 51 votes (when some Democrats would might have objections to the use of the process)?
It'd be nice to find out.
- Are there any compromises or concessions not having to do with the provision of publicly-run health programs that could still be achieved through progressive pressure?
Expand medicaid, add a national exchange instead of the state one, get rid of mandate, etc.
I'm curious ... how many concessions has the other side made? Maybe it's time for a "compromise" that actually includes a compromise.
- What are the chances that improvements can be made around the margins of the plan -- possibly including a public option -- between 2011 and the bill's implementation in 2014?
I'm actually a little more optimistic about this. But here's the thing -- everyone surrenders now, the impetus for such tinkering will be gone. If people are angry and campaign on these key issues, then political pressure will be maintained for further action. The "surrender now" crowd actually makes further tinkering less likely, not more.
- What are the potential upsides and downsides to using the 2010 midterms as a referendum on the public option, with the goal of achieving a 'mandate' for a public option that could be inserted via reconciliation?
The public option remains popular, despite the year-long demonization process by insurance interests, Republicans, teabaggers, and even some Democrats. Popular enough to base a "referendum" around it? Beats me, I'd have to see more data. But if 2010 is a referendum on that current Senate bill, we're in deep trouble.
And in any case, I don't think we have much of a choice in the matter. 2010 will be all about Democratic "socialists", and HCR will be Exhibit A in the wingnut playbook.3
- Was the public option ever an attainable near-term political goal?
Yes. But even if it wasn't, perhaps we would've been better off starting with a Medicare For All approach, or at least an expansion (back when Lieberman was for it). I'm sure someone will write a book about all the tactical mistakes made during this battle. There's no doubt the Democrats blew it big time, but that's not the same as saying a desired policy outcome was not attainable.
- How many of the arguments that you might be making against the bill would you still be making if a public option were included (but in fact have little to do with the public option)?
Depends on the details of that public option.
- How many of the arguments that you might be making against the bill are being made out of anger, frustration, or a desire to ring Joe Lieberman by his scruffy, no-good, backstabbing neck?
Max Baucus caused more damage to this process than Lieberman, by slowing things to a crawl pretending that Enzi (from Wyoming!) was ever a good-faith negotiator, giving Republicans and teabaggers a chance to ramp up the hysteria and slowing whatever initial momentum the administration and congressional Democrats ever had on the issue.
I don't give a shit about Lieberman's opposition. He's just confirming everything we ever said about him. In fact, it's kind of nice seeing the Beltway and congressional Democrats start to finally understand who the real Lieberman is. But I never expected anything less from him, so pretending that this is some weird grudge match minimizes what are serious policy disagreements. Lieberman may be petty about this, but I'm not. I settle those grudges on the electoral battlefield, not the policy one.
And it's clear, we've been fighting this fight long before Lieberman decided to shine the spotlight on himself.