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Too much hostage-taking


These days, it seems everyone wants to take a hostage, and everyone thinks they can. In 1994, the bar was a bit higher. Famously, Bill Clinton vowed to veto the legislation if it didn't achieve full universality. This year, Republicans and some conservative Democrats vowed to kill the bill if it contained a small public plan for the 10 percent of the population using the exchanges. This week, Joe Lieberman vowed to kill the bill if it allowed people between 55 and 64 who didn't have access to employer-based insurance to buy into Medicare. This morning, Howard Dean vowed to oppose the bill unless the state-based exchanges "act as prudent purchasers and select only the most efficient insurers." (If that was included, he said, a "stripped-down" version of the bill would be acceptable, though it's not clear what that means.)

What's so strange about Dean's objection is that the exchanges in the Senate bill (pdf) do act as "prudent purchasers," that is to say, they set limits on the plans that can enter in the exchange to ensure that people are getting good choices. The relevant section begins on page 131 of the Senate bill. "The Secretary shall, by regulation, establish criteria for the certification of health plans as qualified health plans." A couple of pages of relevant criteria follow, including marketing requirements (plans can be disqualified for focusing their marketing in outlets that would bring them uncommonly healthy enrollees), broad provider networks, coverage of options used by low-income folks (community health centers, say), quality measures, quality improvement strategies, consumer ratings, standardized benefit packages, etc.

And then, a couple of pages later, the language gets stronger. On page 143, the exchanges are given power to certify insurance plans based on whether "the Exchange determines that making available such health plan through such Exchange is in the interests of qualified individuals and qualified employers in the State." On 144, premiums, and premium increases, enter explicitly into the discussion. Any insurance plan that wants to increase premiums has to submit a written justification for their decision. It will have to post that information on its Web site. And if the exchange is not convinced, it can decertify the plan.

Don't believe me? In his op-ed, Dean names John Kerry as the senator who has been working hardest on this question. This morning, I spoke to Kerry's staff, who got me a statement from Kerry himself. "The prudent purchasing provisions in the Senate health bill will lower costs and increase affordable options for consumers," Kerry says. "It’s strong language that will allow the exchange to deliver competitive prices and offer high quality care, and I’m thrilled to see national reform honor the best innovations already succeeding in Massachusetts.”

I'm sure there's some theoretical way in which the language could be stronger. Dean doesn't say what it is, but I don't doubt it exists. But now we're talking about killing the Senate health-care bill -- with its $900 billion in subsidies and its delivery system reforms and its Medicare Commission and its Medicaid expansion and its exchanges and its regulations on insurers -- unless we make the exchanges slightly stronger prudent purchasers, when they're already strong enough to "thrill" the original sponsor of the prudent purchaser amendment?

I guess this is the logical outcome of a system in which the greatest gains accrue to those making the most credible and severe threats. But it's not healthy.

Photo credit: AP Photo/J. Scott Applewhite.

By Ezra Klein  |  December 17, 2009; 10:53 AM ET
Categories:  Health Reform  
Save & Share:  Send E-mail   Facebook   Twitter   Digg   Yahoo Buzz   StumbleUpon   Technorati   Google Buzz   Previous: Toward a better bill
Next: John Kerry's post-non-presidency


Thanks for verifying -- I thought Dean was wrong on the prudent purchaser point. He apparently did not realize Kerry's amendment IS incorporated in the merged Senate bill.

Posted by: hillgirl8024 | December 17, 2009 10:58 AM | Report abuse

Ezra -
Will there be a live chat today?


Posted by: BTW123 | December 17, 2009 11:09 AM | Report abuse

"I guess this is the logical outcome of a system in which the greatest gains accrue to those making the most credible and severe threats."

Or, in other words, the squeaky wheel gets the grease.

Where are the responsible adults in this debate?

Posted by: matthat121 | December 17, 2009 11:10 AM | Report abuse

howard dean is not very different from ralph nader.

very often, for mavericks, their egos override their good sense and clouds their judgement, and they stop operating in the real world.
to speak of killing the bill is outrageous.
howard dean is as much of an impediment now as lieberman.
that is why he was unelectable. people do see that mavericks are interesting and have their place in the political process, but they are not stable and cant provide trustworthy leadership.
ralph nader, howard dean, john mccain, sarah palin., john a greater or less degree, they cant transcend their egos...and so they cant be trusted to work in a patient, normal and constructive way with other people.
their sense of self-importance kicks in and robs them of calm and steady judgement.

Posted by: jkaren | December 17, 2009 11:10 AM | Report abuse

If you really believe the U.S. Senate can effectively deem individual consumer purchases 'prudent' or 'not prudent', you have bought into the notion of central planning.

Kill the bill. Start over. Apply ECON 101. Stop fearing private profits.

Posted by: angrydoug1 | December 17, 2009 11:18 AM | Report abuse

jkaren just wrote the most ridiculous comment I've read lately. Howard Dean is no maverick, his views are mainstream Democratic. Ralph Nader never held public office - ever. Dean was governor of Vermont for 12 years and had to deal with real problems everyday. You said he is "unelectable" even though he was elected statewide 6 times.Dean was also Chairman of the Democratic National Committee. That is also a position that requires cooperation with many people every day.

Posted by: marvyT | December 17, 2009 11:19 AM | Report abuse


i meant in bids in presidential elections.
nader, mccain, palin, edwards, dean....all exhibit similar characteristics.
their egos cannot transcend their politics.
palin also was a governor of a state, and all of these people have held some form of representation....but when i said he was unelectable, i meant for the presidency.
and why i feel that way, is because of what he is threatening right now. i am sure that john kerry and jay rockefeller care as much about the humanitarian consequences of this bill as howard dean, but they are willing to operate in the real world, the hard work, hammer away at compromises and negotiations and not put the spotlight on themselves.
they are not threatening to throw their hands up and storm away.
health care reform is not about the grandstanding of howard dean...or joe lieberman. there are others who care just as deeply and are working just as hard...
howard dean will be a footnote in all of this.....the hard work is being done elsewhere right now.

Posted by: jkaren | December 17, 2009 11:29 AM | Report abuse

I really do understand the indignation of Progressive. I share it. However, killing this bill is a terrible idea. At the very least, passage of this bill means moving the starting point from zero, where we were in 1994 which is the same as 2009, to a completely new level.

Passing the bill means that we will begin the expansion of the health care system and showing skeptics how possible it is to service everyone. After all, we do need more doctors and nurses and other healthcare workers to give everyone care.

Furthermore, we begin to change people's incentives with new payment plans and the excise tax. We curb many of the worst practices by health insurance companies. Additionally, people afraid of losing coverage will feel less trapped in their jobs. On top of that, we cover a whole lot of people who suffer silently for no good reason.

We knew from the beginning that this was a stepping stone. To say we should destroy it because it doesn't take us as far as we want, just undermines our progress.

Success of this legislation would show people that government can do good things and could serve to highlight the destructive and undesirable nature of the filibuster.

Posted by: bcbulger | December 17, 2009 11:33 AM | Report abuse

"Howard Dean is no maverick, his views are mainstream Democratic."

i dont believe his views on the health care reform bill are mainstream right now. i dont think that at this point, most democrats want to see health care reform legislation "killed."

i agree with the above post by bcbulger.

Posted by: jkaren | December 17, 2009 11:45 AM | Report abuse

I disagree with bcbulger above and support this bill for the opposite reason concerning the fillibuster. I believe the American people will see that legislation can get passed in the Senate, using existing Senate rules.

Pass the legislation, as good of health care policy changes as can reasonably be expected, and preserve the fillibuster.

Posted by: lancediverson | December 17, 2009 11:47 AM | Report abuse

Maybe Dean's playing Lieberman. Steve Benen lamented Rep Weiner's comments on the Medicare Buy-in, saying they may have goaded Lieberman into opposing it, since he just wants to kill whatever progressives like. So Dean pretends not to like the bill now, maybe Lieberman supports it.

Posted by: commercestreet | December 17, 2009 11:54 AM | Report abuse

"I guess this is the logical outcome of a system in which the greatest gains accrue to those making the most credible and severe threats. But it's not healthy."

Careful, Ezra! Not sure you want to get too jaded too soon! :-)

Posted by: JERiv | December 17, 2009 12:12 PM | Report abuse

jkaren, I don't know if this current bill is worth passing or not. Both sides have some good arguments. It certainly needs more changes. My basic point was that tarring Dean as a maverick is just plain wrong. If you read his op-ed you'd see that he has a lot of valid points criticizing this bill. He thinks that it needs more work on the cost controls and insurance regs. He also raised the possibility of using reconciliation. He did not say to kill the bill and walk away. The headlines are misleading. Also, there is still a lot of negotiating left and it's too early to just throw in the towel and accept whatever the conservative Dems demand. If the progressives don't demand improvements, we won't get any. You shouldn't stop negotiating until the very end of the process. The other side won't make that mistake.

Posted by: marvyT | December 17, 2009 12:23 PM | Report abuse

I am with Howard Dean on this. Kill the healthcare bill! The current Senate Bill is nothing but a gigantic transfer of wealth from working class Americans to the corporate elites. It is a tax increase for the benefit of the insurance industry. There is no mechanism to control insurance prices or medical costs and within ten years, the cost of insurance could double so that we are spending well over 30% of our GDP on healthcare costs. It will bankrupt the United States, destroy the middle class and turn our country into a third world hell hole. I hope this doesn't happen. The USA needs Medicare for all its people. If Americans have to buy insurance or be breaking the law they should have the best insurance...not some crapping corporate insurance from the fat cats getting $20 million dollars a year salary.

Posted by: alanwil2 | December 17, 2009 12:33 PM | Report abuse


just this morning, howard dean said that he wont vigorously work for president obama's re-election. why would he make a statement like that right now?
barack obama is the first president to be able to do anything meaningful for health care reform in decades. so why, if not for a clashing ego, would he say that this morning, making a statement indicating his disappointment for barack obama?
how much harder could barack obama have worked this year on all fronts, particularly in the effort to accomplish health care reform.
as a democrat, i am proud of this effort and accomplishment.
i dont expect miracles, when we live in a country where everyone doesnt think the way i do, and in a country that is overrun with lobbyists and omnipotent corporations.

and this is the selfish and small comment from howard dean.
he also said that he would not vote for this bill if he had a vote right now.
i think that is shocking.

i think it is outrageous that howard dean can turn his nose up at the enormous hard work and painstaking calculations that have gone into this bill by people who care just as much as he does about getting something meaningful passed.
this is what ezra klein just wrote:
"Ezra Klein: I don't believe it is. I want to be very clear on this: I think this bill will do more to help the poor and underserved than anything since the Great Society. I think it will do more to control costs, and create an infrastructure to control costs and a politics able to control costs, than anything we've ever done, full stop.

I'm not alone in this. Writers like Jon Cohn. Advocates like the Center for Budget and Policy Priorities and Families USA. Senators like Jay Rockefeller. Among the people who have really been on the trenches on this for years, there's near unanimity that losing this bill will be, and will come to be understood, as one of the most tragic and unnecessary failures in recent legislative history."

in my opinion,howard dean is grandstanding and casting disparaging comments on barack obama and the whole process is a reflection of his ego transcending his judgement.
does he think it is going to get easier if this drags on?
of course it wont. it will all fray and splinter apart.
this is the moment.
it is not constructive or helpful.


Posted by: jkaren | December 17, 2009 12:39 PM | Report abuse

Memo to the networks, and the netroots: word: hostage! It should be on everyone's lips. Axelrod came up with it and in house polling shows it to be a winner. Use it early and often in your writing about healthcare (bloggers, it should appear in 20 percent of your posts). And Joe's been taken care of. Get off his case already and keep up a steady drumbeat on Dean.

Posted by: truck1 | December 17, 2009 12:50 PM | Report abuse

It's like they always say-- to the sociopath goes the spoils.

Posted by: adamiani | December 17, 2009 12:52 PM | Report abuse

First, I think hostage-taking is not exactly the right word for someone who doesn't have veto power over anything progressing through Congress. By dint of the 60-vote majority, any senator effectively can veto the bill, as can the president, and anyone with enough Representatives committed in some mini-caucus to cover the margin of victory in the House. Howard Dean can only support or oppose the bill in public, which is what he's done. Otherwise, all due respect to Ezra and the learned commenters posting above, but correct me if I'm wrong about this:

Two weeks ago Atrios emailed Booman to suggest liberals should pretend to be dissatisfied with Medicare buy-in, lest Joe Lieberman turn on it;
One week ago Joe Lieberman came out against Medicare buy-in and said he'd filibuster it;
This week Lieberman admitted he made that decision after learning liberals, notably Anthony Weiner and Howard Dean, supported it;
This morning Howard Dean, after four years of taking no public position on controversial legislation before the Congress (as far as I can remember, although as DNC chief he probably spoke out on stuff that united the Democratic caucus), wrote an op-ed in the Post that he opposes the bill as written....

... I mean, I'm not the only one coming to this conclusion, am I?

Posted by: XPatM | December 17, 2009 12:56 PM | Report abuse

if we lose this moment of trajectory, and this opportunity to begin health care reform, we will have the likes of howard dean to thank for it.
those who will settle for "nothing less" than what they demand,may end up setting us back for years, and hurting and killling many people in the process.
they will make this into "all or nothing..." the moment will vanish, and we will be left with nothing but immense damage.
this is a moment in time.
once it is gone, it will gone for a long, long time, and where we could have had improvement and change, we will have nothing.

Posted by: jkaren | December 17, 2009 1:00 PM | Report abuse

So Howard Dean has become the Ralph Nader of health care? Not exactly what we need at this moment.

Posted by: chipjh | December 17, 2009 1:07 PM | Report abuse

I think most progressives, like me, are just angry that the president didn't use the enormous people power that he had after the election to get a much stronger, ie progressive, bill. Instead, he and his team were smarter by far by making backroom deals with the various industries represented in order to win their approval for what is for citizens, essentially, weak tea health insurance reform and is not health care reform.

Posted by: goadri | December 17, 2009 1:17 PM | Report abuse

Here in Oregon, insurance companies have to apply to state regulators before they raise rates for individual and business consumers. This is a far stronger regulation than any that Ezra praises in this post, and it still sucks. The Oregonian found that over the past 3 years, Oregon state regulators have approved every single request from the insurance industry to raise rates. In a whopping 7 out of 40 cases, regulators made them 'trim' their increase.

There is no evidence I've seen from defenders of this disaster to suggest that regulations on this industry will be enforced. This is kind of an important detail, since these regulations are about the only policy life raft left for those who think giving the insurance industry $500 billion is a good pragmatic starting point toward reform.

Posted by: andrewbaron78 | December 17, 2009 1:21 PM | Report abuse

No one is demanding "all or nothing". Until a few days ago, Howard Dean was very supportive of this bill even though it had been watered down a lot. The Lieberman cave-in was a bridge too far. The President and Reid have told the Senators that anyone who stomps their feet hard enough will get their way. The real threats to health care reform right now are some Senate Dems. Lieberman and Landrieu may have weakened the bill too much for the House to pass. Ben Nelson is still threatening to kill the bill over abortion. Howard Dean has an opinion, but he doesn't have a vote. He can't kill squat! If anyone truly wants this bill to pass you need to hammer on some senators.

Posted by: marvyT | December 17, 2009 1:21 PM | Report abuse

Sadly this is just more of the usual way things are done in the power structure of Democratic Party - when they get in trouble its time to play "attack the progressive". Dean speaks for a solid part of the Democratic base and we trust him not the DNC, DSCC & DSCC or DLC. Since that's who Ezra speaks for there is no reason to trust him either. This is just another attack on the great unwashed base of the Democratic Party by its elites.

Posted by: mwfolsom | December 17, 2009 1:35 PM | Report abuse

when they get in trouble its time to play "attack the progressive".

i would like to share my thinking with you, respecting that your opinion is different. maybe you will think this is naive...but nonetheless, this is what i think.
i myself, am sixty, and have been a democrat and worked in many democratic campaigns since i was a teenager, starting, i think with mccarthy.
after the assassinations of the kennedys, of king...malcolm x...the vietnam war..kent state..watergate...i started to realize what was possible and what was not possible.
now, i pay a fortune for my own individual health insurance, and have been for many years. i pay a thousand dollars a month for my policy, and know that my pre-existing conditions could cause me not to have health insurance at all.
but i realize now, that the president has limited power to change the system that we have now.
what is our system of government now?
pfizer, abbot, eli lilly, amgen, bristol myers~squibb, merck, amgen, blue~cross~anthem, aetna and all of the financial companies that put together their mergers and put out their buy ratings for them, and the communications companies that tirelessly play all of their ads...and every single political figure who is directly and indirectly affected by the influences and immense power of these companies and their domination on the global economy.
and then other really dangerous powers that still hold sway from the other side, like dick cheney and and part of population that despises any kind of change at all, and their minions.
i dont think that any one president or well-meaning group of people can take all of this on.
we have an opportunity to begin.
this is a really fragile moment. if we lose it, the whole thing will fray and this moment will be gone.
there will be inestimable damage that will seep into all other areas of our lives. we will not just lose health care reform. we will start losing many other things.
i was hoping for a beginning.
call me paranoid...but i didnt think more was possible.
i am grateful that barack obama has gotten this far.
perhaps others think more is possible on an attempt in the real world.

in some situations, you are better off with half a loaf.
many people right now have no loaf at all.
you are taking a big gamble with them at this fragile moment.
but there are many different ways of looking at life.
and health care reform.

Posted by: jkaren | December 17, 2009 1:56 PM | Report abuse

You're blaming Dean if the health care bill fails? Not the Republicans, not Lieberman, not Rahm Emanuel, not Obama? Good grief, are your spines so weak that you attack the one person who is fighting for the right cause instead of all those who are fighting against it?

All that fine print about "prudent purchaser" isn't going to do anything in the "real world" that so many of you are using to excuse this terrible bill. I agree with andrewbaron78 and his Oregon example. When it comes to defining "prudent" and "reasonable" and all the other code words in the bill, the insurance companies will always win and your insurance coverage will always lose while your rates go up and up.

Dean is right. Only a public option or Medicare for all will truly reform our health care system. Passing this bill merely entrenches the status quo for another generation.

Posted by: ChrisMT | December 17, 2009 2:01 PM | Report abuse

This bill is a disaster. How do you insure 30 million Americans who cannot afford insurance, force them to buy it, or pay more taxes! Beautiful strategy people, this will work beautifully. With premiums set to rise 20-25%, because the companies can no longer drop people when the get sick (a good thing), there are millions of people out there who couldn't afford insurance now REALLY not being able to afford it. Before they had to live without insurance; now they still have to live without insurance, except the get taxed an extra $2500/year. this does not bode well for the Democrats.

And for those of who think "this is the foot in the door", and later when people complain about prices Congress will make them come down...I ask you this: why would they? Yes people will be up in arms about having to buy really expensive insurance, yes they will phone their representative, and yes the Dems will want to do something about it. But they won't be able to, and the GOP won't budge an inch because every American who is being hurt by this policy is an American who will blame the Dems.

Posted by: maurban | December 17, 2009 2:04 PM | Report abuse

You're blaming Dean if the health care bill fails? Not the Republicans, not Lieberman, not Rahm Emanuel, not Obama?

if it were up to the republicans, there would be no health care reform at all.
lieberman has been deeply blamed and unvindicated for what he has done...emanuel and obama realize what is possible.
if emanuel and obama thought it would be possible to accomplish more, do you really think it wouldnt be happening?
if more were possible, i believe we would have more.
if at this point, dean becomes an instrument in derailing this fragile moment, then i do blame him.
because i dont believe we will get something better.
i think we will end up with nothing.
i think if all of this frays, it will be a catastrophe.
it will have profound consequences beyond health care.
if this were easy...if more was possible... it would never be playing out like this.
many people of evil intent are waiting for all of this to fail.

Posted by: jkaren | December 17, 2009 2:16 PM | Report abuse

To: jkaren

We really disagree -

This bill is not a beginning of a process to a better health care system but rather a full scale capitulation to the Insurance and Drug Companies. When I was knocking on doors summer of '08, stuffing envelops and asking everybody I meet to vote for and trust Obama I made a huge mistake. I really listened to what the guy said and didn't do enough analysis. I had no idea that he was lying to all of us and I am pissed! The first thing he did was sit down and sell the American People to big Pharma and then sell us to the gods of the Insurance Companies. This is the bill he wanted all along and he continues to lie to the American People about not letting the perfect be the enemy of the good. He never fought for a better bill because he didn't want one. The bill ain't good and it was never meant to be good - it was meant to dust yet another problem under the carpet while he and others rake in millions for the Insurance Companies and Big Pharma.

Its time we accepted the nasty fact - we have elected a liar and someone who has no stomach or backbone to lead to the Presidency. Now we have to deal with it.

Posted by: mwfolsom | December 17, 2009 2:40 PM | Report abuse

You throw around the term "hostage taking". Would you put Obama in the same camp for saying that he won't try again if hcr fails this time out? He set the arbitrary deadline of 2009 and now we all have to live by it or else.

Posted by: eRobin1 | December 17, 2009 2:55 PM | Report abuse

to mwfolsom,

I feel you. When I get to the point you're at, though, I ask myself how I'd be feeling right now (on any issue) with President McCain and Vice President Palin at the helm. Although it's cold comfort, I have to admit it is a reminder of why I put out so much effort in 2007-08. I have no illusions about these parties, but eight years of fundamentalists and neo-cons convinced me there is a difference. A funky Democrat is better than any Republican right now, pathetic though that difference may seem. Hang in there. Democracy with an engaged citizenry is something new and different for this country. Take care.

Posted by: kayhag | December 17, 2009 2:56 PM | Report abuse

Thank Joltin, Joe Lieberman,

He Got What He Wanted, ENJOY !!


There's No...

"Government Take Over Of Health Care"

There's Government Facilitation, Helping Private Insurance Companies Take Over The Entire Health Care Industry.

You will Not be Buying Government Health Insurance..

You'll be Buying Private Health Care Insurance as MANDATED BY FEDERAL LAW, Since You Low Life Sea Slugs, wanted Private Health Insurance...


You Got What You Wanted.

Private Insurance Companies have [[WON]]

All You Tea Party People & Republicans,

You can All Go Out and Celebrate That Fact..

The Big Insurance Companies will Get BIGGER & RICHER...


PS:Just like Auto & MotorCycle Insurance, You have it or You'll Go To [[JAIL]]

Posted by: omaarsblade | December 17, 2009 3:59 PM | Report abuse

You So Called Republicans & Tea Partiers, wanted Private Insurance, "Its The Best In The World Private Insurance"

Well Now You can Have It, But You'll be Mandated to By the Government, to Buy Private Insurance, or Face a Fine and Penalty, like when You don't have Car Insurance.

You Low Life's Wanted The Private Insurance cartels to have Control, Opposed to Government Run Health Care, well Now You have what you Wanted ..

Private Health Care Insurance, Mandated by The Federal Government.

No Government Run Health Care, You are Mandated By Federal Law to Buy & Have [[Private Health Insurance]] or Your A!! will be Fined and Possible Jail Time.

I have VA Hospitalization Coverage.

You Tea Party & Republican Party People call it...

"Government Run-Socialized Medicine"

After all, they say even without a Public Option, the bill still...

"Covers" 30 Million More Americans.

What they are actually talking about is something called the..

"Individual Mandate".

Private Insurance Cartels: That's a section of the Law that Requires Every Single American Buy Health Insurance or Break the Law and Face Penalties and Fines.

So, the bill doesn't actually "Cover" 30 million more Americans -- instead it makes them Criminals if they don't Buy Insurance from the SAME PRIVATE INSURANCE COMPANIES that got us into this MESS."

Posted by: omaarsblade | December 17, 2009 4:00 PM | Report abuse

another awesome post ezra! you got linked from huffpo, and now a bunch of people are making ridiculous accusations that show they obviously don't know the facts, because if they had been reading you for a while they would! :)

Posted by: schaffermommy | December 17, 2009 6:06 PM | Report abuse

Do not waste your time just get a degree in Health care admin and find work Check out the website

Posted by: maryken17 | December 17, 2009 11:58 PM | Report abuse

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