Thursday, March 25, 2010

the bipartisan health care reform law

I agree with Vice President Biden that this week's enactment of historic health care reform legislation was a big ... er, deal. It's an achievement the whole country should be proud of.

In my post last week ("president romney's first year"), I imaged a parallel universe where Mitt Romney won the 2008 presidential election and how the policies and performance of President Obama's first year might have been perceived had they been those of Romney instead. As it turns out, Berkeley economist Brad DeLong had the same thought:

Over in that alternative branch of the quantum-mechanical multiverse in which Mitt Romney was elected President in November 2008, this health-care bill ... passed the House of Representatives 352-83 and passed the Senate 79-20, with near-solid Republican support. Left-wing Democrats whined that it was not real
reform. The David Broders and David Brookses of the world trumpeted it as an
extraordinary victory for American bipartisanship.

Instead, we are here -- where a nearly identical plan appears very, very

We truly live in a weird world.

DeLong has lately taken to calling the new health care reform law "RomneyCare" to highlight the fact that the health care reform bill that President Obama signed into law this week follows the same basic contours as Mitt Romney's successful and popular Massachusetts plan (
you can read a good history of that plan here).

It is basically the same plan that
Republican's proposed as an alternative to the Clinton health care plan in 1993 (follow that link for a good comparison of the '93 plan with the new law).

In other words, Democrats just passed the Republican health care reform plan -- without a single Republican vote.

Bear in mind, the bill that was signed into law this week was endorsed by the AMA (which has never before supported any health care reform effort), the AARP (I'm pretty sure they're not out to "kill granny"), the American Hospital Association, the American Nurses Association, the Catholic Health Association, a group representing 59,000 Catholic nuns, and way too many other groups to list. But it didn't get a single Republican vote out of 198 Republicans in the House and 41 Republican Senators.

Among those who helped
design the Romney plan was the conservative Heritage Foundation. It's principal architect was MIT economist Jonathan Gruber, who also advised the Obama administration. Although Republicans are now decrying the "individual mandate," it was the centerpiece of Romney's "Personal Responsibility" plan. Here he is in a 2006 Wall Street Journal op-ed touting his new law:
... I proposed that everyone must either purchase a product of their choice or demonstrate that they can pay for their own health care. It's a personal responsibility principle.

Some of my libertarian friends balk at what looks like an individual mandate. But remember, someone has to pay for the health care that must, by law, be provided: Either the individual pays or the taxpayers pay. A free ride on government is not libertarian.

The Romney plan also covers abortions. (Babykiller!!)

This week Republicans have taken up the theme that the individual mandate is not just bad policy ... but unconstitutional. Among those leading the torch-and-pitchfork crowd against President Obama's health care act is none other than ... Romney himself, who on Monday called the bill that garnered 60 votes in the Senate and a majority in the House, "
an unconscionable abuse of power." Romney has also joined the Republican chorus claiming the act is unconstitutional -- although he has so far inartfully dodged all questions on whether the thinks the individual mandate is constitutional. But that is the focus of the Republican attorneys general of 13 states (including Washington State's ambitious Republican attorney general) who this week filed a lawsuit claiming the individual mandate is unconstitutional. Most serious legal scholars consider that suit nothing more than frivilous partisan grandstanding -- unless the current radical majority on the Supreme Court decides to overturn a few generations of court precedent (as they did in the Citizen's United case that overturned a century of restrictions on corporate money in our electoral system). Republicans apparently were against "judicial activism" and "frivilous lawsuits" before they were for them.

Among the current Republican senators who co-sponsored the 1993 Republican alternative, which included an individual mandate, are Kit Bond (R-MO), Robert Bennett (R-UT), Orrin Hatch (R-UT), Richard Lugar (R-IN), and Chuck Grassley (R-IA). Republican Senators who have
co-sponsored another bill built around an individual insurance mandate include Lindsey Graham (R-SC), Mike Crapo (R-ID), Judd Gregg (R-NH), and Lamar Alexander (R-TN). And Olympia Snowe (R-ME) actually voted for the Senate bill in committee. Apparently, all were for a Romney-style "Personal Responsiblity" plan before it became an unconstitutional OUTRAGE.

The plan that was passed into law this week is also essentially the same as the proposal put forth last summer by the the
bipartisan Bob Dole/Howard Baker/Tom Daschle group. As Jonathan Cohn describes it:
Earlier [last] year, a group of former Senate majority leaders--Republicans Howard Baker and Bob Dole, along with Democrats Tom Daschle and George Mitchell--showed how that might be accomplished. After negotiating with each other for more than a year, as if they were still in office and representing their two parties, the group (minus Mitchell, who had since joined the administration) unveiled a fully fledged health care reform proposal in June. They released it through the Bipartisan Policy Center, a think tank they’d establish precisely to advance proposals like these. And, at least on paper, it looked like the kind of scheme members of both parties could support in good conscience.

The Center’s proposal had the same basic architecture as the plan Obama put forward in his presidential campaign and that congressional committees have been debating this year. Everybody would have to get insurance; in exchange, government would make sure everybody could get insurance, by subsidizing the cost for those who needed financial assistance--and by creating a marketplace in which people without access to employer policies could get coverage regardless of pre-existing conditions.

The major point of departure between the various Republican plans and Democratic proposals earlier in this process had been the inclusion of a "public option" in the Democratic plans. But as we all know, the public option was dropped along the way (thanks, primarily, to Joe Liebermann and Ben Nelson). So, as it turns out, the bill that passed Congress was actually more conservative than the Dole/Baker/Daschle plan, which included state-based public options and a triggered public option at the federal level:
Instead of a single public-insurance plan into which people could enroll, the Center’s proposal would have given states the option of creating independent insurance plans to compete with private insurers; it allowed the federal government to step in with its own plan only if, after five years, there was evidence the system needed more competition.

Yes, former Republican Senate leaders Dole and Baker were willing to go further than Congressional Democrats. Who knew Dole and Baker were totalitarian socialists?

Now repealing health care reform is joining taxes, abortions, guns and gays among the list of Republican "lithmus tests." But as people learn what is really in the new law (e.g., no "death panels", "free health care for illegal immigrants" or "federal funding of abortion") they are finding out that there are a lot of pretty cool things in the bill.

Among the provisions that kick in this year:

NO DISCRIMINATON AGAINST CHILDREN WITH PRE-EXISTING CONDITIONS: Prohibits health insurers from denying coverage to children with pre-existing conditions. Effective 6 months after enactment. (Beginning in 2014, this prohibition would apply to all persons.)

ENDS RESCISSIONS: Bans insurance companies from dropping people from coverage when they get sick. Effective 6 months after enactment.

EXTENDS COVERAGE FOR YOUNG PEOPLE UP TO 26TH BIRTHDAY THROUGH PARENTS INSURANCE - Requires health plans to allow young people up to their 26th birthday to remain on their parents insurance policy, at the parents choice. Effective 6 months after enactment.

SMALL BUSINESS TAX CREDITS: Offers tax credits to small businesses to make employee coverage more affordable. Tax credits of up to 35 percent of premiums will be immediately available to firms that choose to offer coverage. Effective beginning for calendar year 2010. (Beginning in 2014, the small business tax credits will cover 50 percent of premiums.)

BEGINS TO CLOSE THE Medicare Part D Donut Hole: Provides a $250 rebate to Medicare beneficiaries who hit the donut hole in 2010. Effective for calendar year 2010. (Beginning in 2011, institutes a 50% discount on brand-name drugs in the donut hole; also completely closes the donut hole by 2020.)

NEW, INDEPENDENT APPEALS PROCESS: Ensures consumers in new plans have access to an effective internal and external appeals process to appeal decisions by their health insurance plan. Effective 6 months after enactment.

ENSURING VALUE FOR PREMIUM PAYMENTS: Requires plans in the individual and small group market to spend 80 percent of premium dollars on medical services, and plans in the large group market to spend 85 percent. Insurers that do not meet these thresholds must provide rebates to policyholders. Effective on January 1, 2011.

IMMEDIATE HELP FOR THE THOSE WITH PREXISTING CONDITIONS (INTERIM HIGH-RISK POOL): Provides immediate access to insurance for Americans who are uninsured because of a pre-existing condition - through a temporary high-risk pool. Effective 90 days after enactment.

COMMUNITY HEALTH CENTERS: Increases funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years. Effective beginning in fiscal year 2010.

INCREASING NUMBER OF PRIMARY CARE DOCTORS: Provides new investment in training programs to increase the number of primary care doctors, nurses, and public health professionals. Effective beginning in fiscal year 2010.

And that is not even remotely a comprehensive list.

Given all the popular stuff in the act, it's not surprising that some Republicans are already starting to back away from calls for total repeal (except when talking to their crazy base and the tea party crowd). Yesterday,Senator John Cornyn (R-TX), the chairman of the National Republican Senatorial Committee, said:

"There is non-controversial stuff here like the preexisting conditions exclusion and those sorts of things. We are not interested in repealing that. And that is frankly a distraction."

So now Republicans, like Cornyn, are FOR the really popular stuff, like the ban on preexisting condition exclusions. Their argument is with all the "other stuff" (for example, how you go about paying for it -- Republicans don't like to pay for our government). But all the "other stuff" flows from the ban on preexisting conditions.

If you say the sick can't be excluded from the insurance market, then people will just wait until they get sick to buy insurance. That will make insurance more expensive and cause more healthy people to drop their insurance, which will further raise rates and cause more healthy people to drop out, further raising rates, in what is known as the "insurance death spiral." That's why if you eliminate preexisting conditions, you have to include an individual mandate -- what Mitt Romney called "personal responsibility" when he was selling his Massachusetts plan. And if there's a mandate, there needs to be tax subsidies to make sure people can afford what they're being required to buy (just like in Massachusetts). And then of course, you need to define what they're being required to buy, and so you get minimum benefit regulations.

There you have it -- the basic structure of the health care reform that just passed Congress. It also happens to be the approach to health care reform that has long been advocated by Republicans as an alternative to a single-payer system (like the hugely popular Medicare system which
Republicans now consider sacrosanct -- except when they are trying to kill it) or other more government-oriented approaches. Near universal coverage achieved entirely through private insurance companies and private health care providers. Just like RomneyCare and the 1993 Republican plan.

But, of course, everyone knows what's been going on here. Republicans have been very open about it. Their lock-step obstructionism was never driven by the specifics of the health care reform plan -- or the details of any other particular legislation. It started in the very first days of the Obama administration -- at a time of a national economic crisis. The New York Times last week had a good piece on
Senate Republican leader McConnell's strategy of obstruction:

Before the health care fight, before the economic stimulus package, before President Obama even took office, Senator Mitch McConnell, the Republican minority leader, had a strategy for his party: use his extensive knowledge of Senate procedure to slow things down, take advantage of the difficulties Democrats would have in governing and deny Democrats any Republican support on big legislation.
In the process, Mr. McConnell, 68, a Kentuckian more at home plotting tactics in the cloakroom than writing legislation in a committee room or exhorting crowds on the campaign trail, has come to embody a kind of oppositional politics that critics say has left voters cynical about Washington, the Senate all but dysfunctional and the Republican Party without a positive agenda or message.

But in the short run at least, his approach has worked. ...

On the major issues — not just health care, but financial regulation and the economic stimulus package, among others — Mr. McConnell has held Republican defections to somewhere between minimal and nonexistent, allowing him to slow the Democratic agenda if not defeat aspects of it. He has helped energize the Republican base, expose divisions among Democrats and turn the health care fight into a test of the Democrats’ ability to govern.
The strategy that has brought Senate Republicans where they are today began when they gathered, beaten and dispirited, at the Library of Congress two weeks before Mr. Obama’s inauguration. They had lost seven seats in November, another was teetering, and they were about to go up against an extraordinarily popular new president and an emboldened Democratic Congress.
As the year went on, Mr. McConnell spent hours listening to the worries and ideas of Republicans, urging them not to be seduced by the attention-grabbing possibilities of cutting a bipartisan deal. “I think the reason my members are feeling really good,” he said, “is they believe that the reward for playing team ball this year was the reversal of the political environment and the possibility that we will have a bigger team next year.”
Mr. McConnell is credited with a very effective run over the last 15 months — though being minority leader has distinct advantages over being in charge of making the Senate function.

“Throwing grenades is easier than catching them,” acknowledged Senator John Thune of South Dakota, a fellow member of the Republican leadership.

McConnell's stategy has been effective because many voters (aided by media coverage that treats all policy debate like a sporting event) base their judgments on whether a policy is reasonable by the level of bipartisan support. Lock-step partisan opposition sends the signal that legislation is extreme. As McConnell explained in the New York Times piece:
“It was absolutely critical that everybody be together because if the proponents of the bill were able to say it was bipartisan, it tended to convey to the public that this is O.K., they must have figured it out,” Mr. McConnell said about the health legislation in an interview, suggesting that even minimal Republican support could sway the public.

McConnell made the same point to National Journal:
Then as the year unfolded -- whether it became the stimulus, the budget, Guantanamo, health care -- what I tried to do and what John [Boehner] did very skillfully, as well, was to unify our members in opposition to it. Had we not done that, I don't think the public would have been as appalled as they became ... Public opinion can change, but it is affected by what elected officials do. Our reaction to what they were doing had a lot to do with how the public felt about it. Republican unity in the House and Senate has been the major contributing factor to shifting American public

Democratic attempts to craft bipartisan legislation, by definition, cannot succeed as long as Republican opposition is unified. So Democrats could adopt RomneyCare or the 1993 Republican health care alternative, and Republicans who co-sponsored that earlier bill would still vote against it -- making it, by definition, a partisan Democratic bill. Or they could enact the largest two-year tax cut in US history, and every Repubolican would still vote against it -- making it partisan Democratic legislation. Or they could attempt to set up a bipartisan deficit reduction commission, and seven Republican co-sponsors would still vote to successfully filibuster it. And then Republicans accuse Democrats of enacting partisan legislation. Or, if the Demcrats are unable to overcome the opposition, they are accused of being ineffective. So far, that strategy seems to have been working for Republicans (if not the American people).

Senator Jim DeMint (R-SC)
famously said early in the health care process, "If we’re able to stop Obama on this it will be his Waterloo. It will break him." The goal was to "break" the Obama presidency. Had they succeeded in defeating health care reform, they would have done so.

On the other hand, if they had sought to get a bill more to their liking, they could have easily achieved that goal. President Obama was desperate for any Republican support. Senate Finance Committee chairman Baucus, with President Obama's encouragement, went to ridiculous lengths over months to get Republican support, even long after those with whom he was dealing, like Chuck Grassley, were picking up the "killing granny" and "free health care for illegal immigrants" themes and otherwise making it clear they weren't going to break with their party's obstruction. In return for even half a dozen Republican votes, Democrats almost certainly would have agreed to gut their bill.

That was especially true after the Massachusetts election when Congressional Democrats were running for the hills and even President Obama was making noises about a scaled down effort. Had Republicans come up some kind of pathetic, soggy, half a loaf, defeatist Democrats would have jumped at it. Even if it only succeeded in dividing the Democratic caucus, it would have killed the bill. But, as it turns out, Republican insistence on total defeat of the health care reform effort, with no compromises, ended up leaving Democrats with no option other than to go ahead with the bill that had passed the Senate with 60 votes on Christmas Eve.

Former Bush speechwriter, David Frum, has been among those faulting Republicans for their strategy on health care, saying (in a
widely cited blog post) that they ended up creating their own Waterloo. (Matthew Yglesias notes that the whole "Waterloo" metaphor is historically inapt.) But Frum makes the mistake of assuming the Republican goal was to come up with better health care reform legislation. Rather, the goal was to create partisan division and discredit the Democratic effort. And they largely succeeded at that.

Frum also makes the point that Republicans had worked their base into such a crazy rage over the last year that they couldn't back down. How do you compromise with "totalitarianism" or a "socialist takeover of the country" or "death panels"? The Glenn Beck/Rush Limbaugh/Sarah Palin crowd is now calling the shots. As Frum
observed, "Republicans originally thought that Fox worked for us, and now we are discovering we work for Fox."

Republicans now seem to be doubling down on the partisan division and obstruction. There is the whole phony "repeal" effort (Republicans would need 67 votes in the Senate to overcome a presidential veto which they couldn't achieve even if they won every Senate seat up this year). Then there is the frivilous litigation challenging the constitutionality of the act. But my favorite is John "Hey Kids Get Off My Grass!" McCain's
threat, "There will be no cooperation for the rest of the year." As opposed to all that Republican cooperation before. And what has made McCain more churlish than usual? Democrats overcame a Republican filibuster with 60 votes in the Senate. An OUTRAGE!

Jonathan Chait
makes a good point regarding McCain's threat:
[I]f we believe McCain [and other Republicans], they're saying that there are areas in public policy where Republicans would help make legislative changes that they believe would make the country a better place, but they are refusing to do so out of pique ... In other words, their own claim is that they are deliberately choosing to create suffering -- not merely preventing legislation the Democrats want, but preventing legislation they agree would help people and would otherwise support -- in order to punish the Democrats. This sounds like something the Democrats would accuse them of doing, not something they'd boast about.

This is the guy whose presidential campaign slogan was "Country First."

Senate Republicans are already acting on their threat of total obstruction by invoking an
obscure Senate rule to prevent any Senate committee meetings from taking place after 2pm. (In sympathy with their cause, I call on all Americans to join Senate Republicans by heading home from work every day at 2pm.) Seriously.

You couldn't come up with better material for a Gail Collins column if you tried -- and she has a
great one today. As she reminds us:
[F]eel free to remind Rush Limbaugh that he promised to move to Costa Rica if health care reform gets implemented. Once you’re done, you can go back and remind him that Costa Rica has national health care.

For that alone, we should all be grateful that health care reform was finally signed into law.

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