Friday in Baltimore--The Way to Actually Accomplish Something

Intentionally or unintentionally, my sense is that the White House came out of Baltimore thinking they are now on to something, and I hope the Republicans took the same lesson away.

Constructive good faith political engagement in Washington actually works.

It is just incredible that House Minority Leader John Boehner has had not direct contact with the White House for about a year. A pox on both their houses for that. The party leadership never talks to each other--save being across the table from one another on talk shows. The two sides just level charges and counter charges at each other apparently never caring whether they actually accomplish some good policy for the rest of us.

But a funny thing happened in the midst of Friday's photo-op meeting between the President and the Republican House caucus. Good faith, an airing of ideas, and a mutual respect of each other's views actually resulted in both a political coup for both sides and some very first level progress on important issues--not the least was health care.

Can you believe it? Good manners and good intentions actually have a political value!

I will suggest that the next best step is for the President to take the lead in inviting the Republican and Democratic leadership to the White House on a regular basis in an attempt to broker some real progress on the important issues. If the President wants to turn his job approval ratings around that kind of good faith leadership would take them to the stratosphere.

I am not suggesting that the very thin Republican "play book" has any big ideas for health care reform. But I do believe that many of the Democratic ideas to cover 30 million people could be embraced by lots of Republicans if the two sides could show each other some respect and not just try to jam the majorities' ideological ideas (Republican or Democratic) down the other's throat. It wouldn't also hurt the Democrats to concede some points to the Republicans.

As bad as the left has been recently in thinking they were just going to ram a health care bill their way because of the results of the last election, I saw the right do exactly the same thing when they had control in recent years. (Remember the Republican chairman of the House Ways and Means Committee who tried to get the minority Democrats arrested for boycotting a meeting?) That kind of "take no prisoners" approach to government is what is really at the heart of gridlock while the country just continues to drift downward.

Worst case, if we did see a real effort and it eventually broke down, the side that would lose would be the side that didn't behave themselves. Now that would be a political outcome we could all live with.

The State of the Union--The President Came to a Fork in the Road and He Took It

As Yogi Berra said, "When you come to a fork in the road, take it."

The President came to a fork in the road tonight on health care reform. Would he do what many liberals have demanded--push harder to pass the Democratic health care bills? Or, do as many moderate Dems and some Republicans have called for--work to get a smaller but bipartisan health care bill?

Listening to his speech he seems to be taking both forks.

Continue pushing the Democratic plans: "As temperatures cool, I want everyone to take another look at the plan we’ve proposed. There’s a reason why many doctors, nurses, and health care experts who know our system best consider this approach a vast improvement over the status quo."

Looking for a bipartisan approach: "But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know. Here’s what I ask of Congress, though: Do not walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people."

The President came to that fork in the road tonight and instead of giving the Congress a clear sense of where he was willing to put his remaining political capital he just took it.

Is he willing to put his Congressional majorities on the line in an election year to keep pushing for the now unpopular health care bills? Or, is he willing to put his political capital on the line in an effort to pull the far left in his own party to the center and call the Republicans out on their offer of bipartisanship in order to produce a modest bill?

In the wake of the President's State of the Union Address, we have no better idea just where he wants to lead his party, the entire Congress, or the country on health care reform.

Plan B—There Isn’t One—But There Could Be

As the State of the Union approaches Democrats are considering their health care policy options. There are lots of reports about “Plan B”—pushing through the Senate bill with a parallel corrections bill that could be passed in the Senate using reconciliation rules.

That’s as dead as the original House and Senate health care bills. Moderate Democrats have no stomach for such a legislative stunt in the face of Massachusetts and bad health care polls. Many liberals even question that strategy.

Everyone is awaiting this week’s State of the Union speech. Will the President:

1. Embrace the call by many on the left to Democrat-up and just ram it through?
2. Call for a scaled back bill built around modest and popular first steps that could attract bipartisan support?
3. Just jabber in a way no one can figure out which course he really supports?

My bet is on number three.

As I have said before, I think getting even a modest bill is a long shot in this election year but it is not impossible.

I like the idea of focusing on tax credits for small business as a first priority more than trying to help the individual market. The small group market is guarantee issue and government tax credits have the impact of encouraging matching funds—government money would encourage employer contributions making coverage even more affordable for the uninsured.

Add to that a modest Medicaid expansion, the albeit tepid cost containment parts of the current bills such as the pilot programs and giving CMS more authority to implement them, modest insurance reforms like ending rescission and funding for high risk pools, proving good faith with Republicans by including tort reform, and we have a bipartisan down payment on health reform.

Democrats need to erase the bad taste voters so far have for their dead health care efforts. They could do that with this kind of modest first step health care bill. Republicans also have something to prove on health care—the Democratic problems shouldn’t be confused with any sense on the part of voters that Republicans have yet to make any constructive contribution to this debate.

In my mind, the smart political move for Democrats is to call the Republicans out on their offers to be bipartisan by putting a deal on the table Republicans couldn’t refuse.

If the Republicans take the offer, the Democrats can get beyond the health care political mess they are in. If the Republicans don’t, the Dems have the leverage they need to turn the tables on the Republicans before the November elections.

They could also, coincidentally, actually help out a few million people.

Lots of folks think there is no chance anything positive can now come out of this poisoned political environment.

I am not so cynical.

A Smaller Bipartisan Health Bill? What It Could Look Like

In the wake of the Massachusetts vote, Democrats are scrambling to find a way out of the health care political mess they are in.

Right now they are in a daze standing by waiting to see if any of the "trial balloons" they have launched gain any traction. So far, ideas to ram though the now toxic Senate bill in the House in one parliamentary form or another are falling flat.

Last night, the President formally launched one of his own trial balloons--doing some kind of a scaled back bipartisan bill.

The problem with bipartisanship now is that the Republican base is not about to let any of their own Senators do anything to take the Dems off the political meat hook they are now dangling from.

Democrats could well try to create a very popular stripped down health bill with a win-win objective--if it passes they are off the hook and have something to take to the November elections and if Republicans block it they have themselves an issue on which they can try to neutralize the Republicans.

But that sounds great in principle--health care details are always problematic.

What follows is a post that I did the day after Barack Obama was elected President. In it I suggested a modest bipartisan bill was the only thing I could see passing in 2009--or 2010 for that matter.

You will note that suggestion #1 has already been accomplished--as well as some positive health IT steps.

From Wednesday, November 5, 2008:

There is Now a Real Bipartisan Opportunity in Health Care

President-Elect Obama, and about every candidate for Congress, has said he wants to change the partisan tone in Washington. Obama, the Democratic Congressional leadership, and the Republicans have a terrific opportunity to do just that on health care when they all come to Washington early next year.

As I posted earlier, I do not believe there is any chance we can see the enactment of the comprehensive Obama health plan in the near term.

But there are a number of important steps that can be taken next year and each of them have enjoyed strong bipartisan support during the past year:

1. Reauthorizing the State Children's Health Insurance Plan (SCHIP) and increasing the number of kids covered from six million to ten million. The Congress passed exactly that kind of reauthorization twice by strong bipartisan margins only to come a few votes short of being able to override two Bush vetoes of the bill. Those attempts met pay-as-you-go requirements by boosting the cigarette tax to pay for it.
2. Rearranging Medicare spending by equalizing the payments private Medicare plans get with the payments the traditional Medicare plan receives for the same seniors. The Medicare physicians face a 21% fee cut on January 1, 2010 and there are other serious cost issues for Medicare. In July, the Congress took the first step toward payment equalization with a veto proof margin of 70-26 in the Senate and 383-41 in the House. The really hard part here is crafting a new Medicare physician payment system that is desperately needed but the first step, where to get the money, has strong bipartisan support.
3. John McCain and Barack Obama had a number of similar and relatively non-controversial cost containment ideas in their health plans which would cost the federal government little or nothing. These similar proposals included the expansion of health information technology and a patient medical record; improving transparency about health care quality and costs including prices, errors, staffing ratios, infection rates, and disparities in care and costs; wellness initiatives including an emphasis on healthy lifestyles; development of best practice standards, requirements for disease management programs; requiring effectiveness reviews for procedures, devices, and drugs; and requiring providers to collect and report data to ensure standards for health quality are followed.
4. There is bipartisan support for assisting small business in providing and paying for health insurance. In 1999, 56% of employers with 3-9 workers provided health insurance to their workers. By 2007, that had dropped to 45%. By contrast, employers with more than 200 workers provide health insurance 99% of the time. The one place employer-provided health insurance is melting away is in the small employer area. A modest bill to assist the small employer enjoys support among both Republicans and Democrats.

A big $100 billion [per year] comprehensive health care reform plan like the Obama health plan is not realistic in these times of financial crisis.

But, there is already bipartisan support for a children's health insurance (SCHIP) extension and the means to pay for it, reform of Medicare provider payments and the means to pay for that, a list of commonly agreed to cost containment initiatives that would cost the government little or nothing, and bipartisan support for help to the small employer to offer health insurance.

To be sure these steps would only make a dent in the number of those uninsured and these bipartisan cost containment items will only help our cost problem around the edges.

But all of these bipartisan steps would be progress, are doable, and are affordable.

President-Elect Obama and the Democratic leadership can do what the last two Presidents did--promise bipartisanship and then quickly employ the same old partisanship out of the mistaken belief they had the majorities in Congress that would enable them to steamroll the opposition. That mistake led to the 1994 Republican takeover of the Congress in the first case and two straight election defeats, in 2006 and 2008, in the second.

President-Elect Obama, the Democratic leadership, and the Republicans have the road map at hand to truly show a bipartisan commitment to health care change and progress. They could actually break the gridlock on health care and make some modest progress.

Will they take the road less traveled or just give us more of the same?

Stick a Fork in It! The Democratic Effort to Pass a Health Bill is Dead

Tuesday’s Republican victory in Massachusetts means the current Democratic health care bills will not be on the President’s desk in 2010.

Forget the crazy talk of ramming something through—including just having the House pass the pending Senate bill.

I’ve talked to lots of people in the past few months that didn’t like the Democratic effort but conceded that the Dems won the 2008 election on a platform to do health care their way. They would say, “elections matter” and could, albeit begrudgingly, understand Democratic attempts to pass their brand of health care.

But losing Ted Kennedy’s former seat in Massachusetts with the singular issue being health care?

The game has changed. Democrats just can’t any longer spin the polls that for months have been so negative on the Democratic health care efforts.

The conclusion is now crystal clear—the people don’t want this. For goodness sakes—they rejected it in Massachusetts! On the political shocker scale this rivals “Dewey Defeats Truman” and the '94 elections.

When Bill Clinton lost the '94 elections, he went before the press the next day and took responsibility for what happened and then spent the next two years successfully rebuilding his presidency.

Obama and the Democratic leadership really only have that course in front of them now.

Defying the American people at this point with these foolish hypotheticals about how they could still thwart the obvious will of the people and pass their bill would only result in their digging themselves into an exponentially deeper political hole.

I am not sure Reid, Pelosi, and Emanuel understand this—they have proven to be incredibly politically tone deaf all winter.

But I will tell you something you can take to the bank—a lot of their House and Senate moderate Democrats do understand what this means and you can expect them to begin moving off these bills in the next 24 to 72 hours. A trickle will lead to a stampede and that will be it.

There will be no interest in staying aboard the kamikaze flight Reid and Pelosi are now piloting straight into the 2010 elections.

In the end, this was 1994 all over again. The Democrats thought they could unilaterally do health care their way and blew it just the way they did 15 years ago--out of pure political arrogance.

Let me repeat something I must have said on this blog a hundred times—health care is too big an issue to be done in any way other than a bipartisan fashion. One side simply can’t move something this big, complex, and controversial without lots of political cover from the other side. This bunch, to their peril, never understood the lesson that both Social Security and Medicare were passed by comfortable bipartisan margins.

There is no doubt in my mind that there were at least 10 Republican Senators that were ready to deal in good faith on this issue—the “gang of six” plus the Republicans who had signed on to the Wyden-Bennett bill, for example.

But when Max Baucus was given the opportunity to try for a bipartisan solution, his hands were tied—bipartisanship was defined as Republicans having to sign-on to the Democratic bills their leadership and the left wing of the party were overly confident they could pass on their own.

Health care is an easy issue to demagogue. The opposition will always do it. Republicans, including these ten Senators, did a lot of it the past few weeks. That is why the opposition needed to be neutralized in the first place with real bipartisan support.

As readers of this blog know, I have been pessimistic about this effort for more than a year. But, today I also believe there is a way to pass a substantial bipartisan health care bill that would cover at least 30 million people, reform the insurance markets very much like the Democratic bills would have, and begin a process of real systemic change. I also believe that can happen in the next couple of years. It could all be in place by the same 2014 date the Democrats had in their bill.

But for now, the overly confident and unwilling to compromise Democrats blew it again.

With their solid majorities and popular new President, whom else do they have to blame?

The only way for them to make this election-year mess worse would be to ram their bill through. There are lots of Republicans in this town secretly hoping they will at least try!

The Silver Lining in the Massachusetts Vote

The Silver Lining

by Brian Klepper and David C. Kibbe

Massachusetts voters' stunning rejection of Democrat Martha Coakley, in favor of a not-very-impressive Scott Brown, should be exactly the splash of cold water that the Democratic party - and Congress as a whole - needed. The defeat can be understood in two ways: one large and one fairly small.

First, the large one. This will probably send reform back to the drawing board. Health care is too much in crisis and too pressing to be pushed completely off the table until certain issues - including both access AND cost - are addressed.

Second, this election marks the loss of a single critical Senate seat, but it is also very loud warning shot. The mandate received at the end of 2008 was a resounding call to throw out the Republicans who for more than a decade had ridden roughshod over American values. Yesterday, the Democrats, in one of their most secure strongholds, received the same message. Whatever people in DC think, rank-and-file Americans - not those on the right or left, but the swing voters in the middle who actually determine election results - are very unhappy with the gaming that's been vividly displayed over the last year under the guise of health care reform.

The distaste expressed yesterday probably has little to do with the specific provisions of the bills, except for the largest generalities: that they expand coverage while avoiding a commitment to changes that could significantly reduce cost. But along the way, voters have witnessed -- with an immediacy and transparency that has only been available as a result of the Web -- lawmaking in its worst tradition. There was the White House's deal making with powerful corporate interests like the drug manufacturers even before the proceedings began. And the tremendous lobbying contributions by health care and non-health care special interests in exchange for access to the policy-shaping process. Or the outright bribery of specific Senators and Representatives in exchange for votes. Last week's White House deal with the unions that exempted them from the tax on "Cadillac" health plans until 2018 must have seemed like a perfectly OK arrangement to the people in the center of all this activity, but to normal people who read the paper, it was emblematic of the current modus operandi: If you have power and support the party in power's muddled agenda, you get a special deal.

The most tempting mistake now for the Democrats would be to dig in. President Obama's most appealing characteristic -- the one that got him elected -- was his embrace, his embodiment even, of approaches that would revise the traditional kinds of politics we've seen for the last year throughout the health care reform process. Of late, the most telling complaint about this Presidency so far has been disappointment that, once in office, he seemed to cave in so easily.

Undoubtedly, many Republicans are now rejoicing over the Democrats' loss and the possible defeat of any health care reform legislation. That's unfortunate. The health care crisis is real and remains unaddressed. The pressures it creates, particularly for powerful interests like business, will force Congress to return to it and develop meaningful solutions. Hopefully (though probably unlikely), Congress and particularly the Democrats, will be chastened and wiser. There's a big opportunity here to make lemonade.

There is a new, bipartisan movement in Congress, highlighted on NPR two weeks ago, that would revisit the rules around the relationships between special interests and lawmakers. This is an issue that trumps and is more important than all others, because if every policy is ultimately shaped by those with enough money to buy Congress' favor, then our democracy will be unable to hold.

The silver lining in yesterday's election was that it was a mild, if critical, reminder that, whatever DC thinks, America's center is just as displeased with the current governance as it was with its predecessors. Faced with a much larger rejection in the 1994 elections, President Clinton went on TV, took full responsibility, and then spent his time rebuilding. The good news is that today is a new day, and that, if they're interested in what's good for America over the long term rather than simply themselves over the short term, Congress has the ability to start again in ways that could please the American people and actually work to our collective advantage.

Brian Klepper and David C. Kibbe write together about health care technology, market dynamics and reform.

The Union “Cadillac” Tax Sweetheart Deal

Just when you thought you couldn’t be more cynical about the health care bill.

As I have said before, there wasn’t a lot of hope the same administration that ignored the rule of law in granting unions priority over Chrysler bondholders was going to offend them on the “Cadillac” tax.

We’ve seen the “Louisiana purchase” giving Senator Landrieu hundreds of millions for her vote, only to be upstaged by Ben Nelson’s Medicaid deal for Nebraska. Then the Democratic leadership claimed the $250 billion Medicare physician fee problem didn’t have anything to do with health care reform. Add to that a “robust” Medicare commission that can’t touch doctor or hospital costs. Or, how about six years of benefits under the bill and ten years of taxes. Or, counting $70 billion from the new long-term care program as offsetting revenue to help pay for it.

Now, the unions and public employees are going to be exempt from the “Cadillac” excise tax on high cost plans until 2018.

It will be interesting to see how proponents, or should I say apologists, for this health care effort spin the latest. I would just ask that you please, please, please, not call this mess health care reform.

There is an important election on Tuesday in the Bay State that looks to be focused on the Democratic health care effort. This kind of stunt may just be enough to push it over the edge.

A Great Summary of Where We Are

Good friend Brian Klepper has an excellent round-up of recent blog reactions to the health care bill's progress in a "Special Edition of Health Wonk Review."

It is posted on The Health Care Blog.

It is really worth your time.