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Is health-care reform stabilizing?

It's been a bad day for health-care reform. Maybe the worst it's endured so far. A week ago, people were writing victory speeches. Today, they were trying out language for epitaphs. But by nightfall, the situation seemed to be stabilizing a bit.

Barney Frank walked back his unexpected comment that health care was dead now that Democrats only had 59 seats in the Senate. "I have realized that my statement last night was more pessimistic than is called for," he said, admitting that he had been "perhaps overreacting." Later on, he told Brian Beutler that "I'm strongly inclined to vote for the thing."

News that Barack Obama had told ABC that he wanted a pared-down bill led to instant and aggressive push back from the White House. As they pointed out, he didn't actually say that in the interview (it was a reporter's interpretation), and they released their own statement saying his preferences remain constant (though the statement is notably vague). Sources also say that the White House is letting the immediate shock of Brown's election settle, and that the president will be significantly more involved in the days to come.

Meanwhile, staffers who attended today's meeting of Senate Democrats said they were comforted that the moderates in the room wanted to see the House pass the Senate bill rather than give up on health care altogether. They also said there's a recognition that passing nothing at all is electorally unthinkable.

Consonant with that, Senator Kent Conrad, chairman of the Budget Committee, said he's open to using the reconciliation process to modify the bill, a key admission if the House is going to pass the Senate legislation.

None of this is to downplay the blow health-care reform received last night. The odds of passage have gone from extremely good to considerably worse. If the bill does survive, it is likely to be weaker, smaller and less progressive than would otherwise have been the case. Democrats have completely stopped speaking about what's important in the legislation and let process and electoral uneasiness overwhelm the conversation. But where chaos reigned this morning, something more closely related to calm is returning tonight.

By Ezra Klein  |  January 20, 2010; 6:28 PM ET
Categories:  Health Reform  
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This is proof of what I commented upon 4 months ago, which was that there was no good path to passage of this bill. What was needed at the time was to get Senators Baucus and Grassley back into the room together with Senator Snowe and pass a bipartisan bill where both parties have skin in the game.

It is just impossible to do something as big and painful as remaking the American health care system in a partisan way. It wasn't going to happen and the voters of Massachusetts were the ones who made that clear.

Posted by: lancediverson | January 20, 2010 6:45 PM | Report abuse

I don't believe a word of it. The silver lining in all this is that America's energy woes are solved. All we have to do is harness the power of Ted Kennedy spinning in his grave.

Posted by: AlanW27 | January 20, 2010 6:46 PM | Report abuse

this evening feels the way one would feel at the dinner table, after a huge betrayal of confidence by a family member.
you want everything to return to pick up where you left off...but there is still anger and blame. trusting seems somewhere way off in the distance.
people are not speaking at the table. no-one is quite sure what the other is thinking...who is staying and who is leaving. and everyone has lost their appetite.
but life goes on! there is tonight's recipe for thai cucumber salad!
so perhaps we can all cool down.

the weather out here in southern california fits the political scenario of today. dark skies and unremitting rain after tornado storms came through yesterday.

Posted by: jkaren | January 20, 2010 7:06 PM | Report abuse

"AlanW27" said best!

As events of last few days and commentary by many folks is showing; we are loosing faith in ability of 'blogs and comments' to move the needle anyways. But still we in the Base do not stop to comment. ..

However, this batch of Democrats are really whip and not having spine (even after Base is like 'battered wife syndrome') to navigate the difficulties. No one said it was easy and you cannot drop 'mission' because you are short of one Senator.

Well talk to Sen. Brown but do not allow the HCR to get hostage there.

Quicker Dems realize that let House pass Senate bill and do rest of the stuff via 'reconciliation' better will be they off this episode.

Pass 'negotiated' agreement in Senate first and then in House pass both things together (recon agreement / budget and Senate HCR bill at the same time).

Really Dems need to understand the urgency of all this.

Posted by: umesh409 | January 20, 2010 7:10 PM | Report abuse

"If the bill does survive, it is likely to be weaker, smaller and less progressive than would otherwise have been the case."

OK, I'll buy weaker and smaller, but how is the frack could it be any less progressive than this dog from the Senate? Every poor person get's a punch in the nose? (after which a free ER visit...)

Posted by: clone6 | January 20, 2010 7:21 PM | Report abuse

"his preferences remain constant (though the statement is notably vague)." Jeebus! That's been his game from Day One, and it's galling. Step up! Pretend you're the President of the United States, for f sake. Stake a position and act like you mean it. Also, I don't see things "stabilizing," what with liberals in the House telling Pelosi they won't vote for the current Senate bill. It's like the Sixth Sense: we are dead; we just haven't figured it out yet.

Posted by: randrewm | January 20, 2010 7:32 PM | Report abuse

lancediversion: "What was needed at the time was to get Senators Baucus and Grassley back into the room together with Senator Snowe and pass a bipartisan bill where both parties have skin in the game."

Didn't they try that? Wasn't concession after concession made?

What version of health care reform that is fiscally responsible and that provides close to universal coverage would Grassley vote for? What was Snowe holding out for?

Bipartisanship requires cooperation. I just don't see any from the Republican side of the aisle. This was a very moderate bill, more conservative that Clinton's proposal, more conservative than Nixon's and it still can't pick up a Republican vote. I think that should indicate how difficult the Democratic attempt at a "bipartisan" bill would be.

That's what happens when one side uses a procedural requirement for a supermajority to undermine a vote on the merits. Sad that this approach seems to be rendering the nation incapable of addressing its most important problems.

Posted by: dasimon | January 20, 2010 7:50 PM | Report abuse

The truth comes out. After all their whining the so-called moderates and their corporate backers want their bill foisted on the public. Well I think (hope) this will be a bridge too far for House progressives. We don't need this corporate crap. We need universal health care.

Posted by: bmull | January 20, 2010 7:55 PM | Report abuse

Any ideas how we can communicate to our "representatives" our disgust at the prospect of democrats pussying out on this one?

The idea that what follows is anything other than, basically: "house passes senate bill => alter bill via reconciliation" makes my stomach turn and will turn me off ever bothering to vote for democrats again (certainly this bunch)...

Stand up and play hardball - that is something that the american people can respect!!!

This bill represents the biggest legislative accomplishment in decades, as well as starts movement on fixing one of the greatest injustices of American life (oh - and hopefully will also make a start on saving the country from bankruptcy)... Passing it ALMOST seems like a no-brainer (trust dems to disprove that aphorism)

After all if they do not believe in their own principles then why should anyone else?

Posted by: lazza11 | January 20, 2010 7:56 PM | Report abuse


The answer in getting some Republican votes was through lowering the overall costs of health care by adding tort reform into the bill, and lowering the subsidies to some catagories of individuals to buy health care.

Additionally, they should have reduced the dependence on Medicaid by diverting more people into quality health insurance plans. That would have cost more money, but that would have been more than offset by the above cost reductions.

Finally, the excise tax was very important to drive down the overall cost of health care. Democrats should not have watered that excise tax down.

I believe with those modifications, many Republicans (somewhere around 10-15) would have supported the bill.

Posted by: lancediverson | January 20, 2010 8:06 PM | Report abuse

I am pissed beyond words. Two health care bills have already passed. I know, because I saw the president on television talking about the great achievement of their passage. We can't get the House bill through, but we CAN get the Senate bill through -- and then improve things from there.

But that's not the route they are going. The route they are going is to scrap BOTH bills and try again for something "pared back."

I am despondent. And btw -- how will they get Big Insurance to agree to eliminating pre-existing conditions without a mandate? And how will they get congress to agree to a mandate without subsidies? And how will they get mythical Republicans to agree to subsidies?

All these issues have already been worked through. We were down to abortion language, immigration language, and the "cadillac tax." It's absurd to believe that any reworking at this stage will be anything more than a piece of paper with the world "Health Care" on it.

Can someone please remind these people that we still have all three branches of government? The GOP is laughing at our fecklessness.

Health care is my line in the sand. If we cannot get it done with three branches of government, Dems will never see another dime from me nor another minute of my time making calls or pounding pavement. I am quite serious. I have spent more time and money than I can count in this last decade trying to get our party in power. If they don't pass this legislation, the only thing they'll ever see me do is vote.

Posted by: evietoo | January 20, 2010 8:27 PM | Report abuse

Paul Krugman has just ripped Obama a new orifice.

I too am disappointed with Obama's preemptive surrender on expanding coverage.

I think too much is being made of the Democrats alleged political incompetence. They got within two weeks of passing major health care reform. That's not chopped liver. It hurts bad right now, but I think the country's politics are moving in the right direction on health care. The third time will be the charm.

Posted by: HuckFinn | January 20, 2010 8:46 PM | Report abuse

The House should pass the Senate bill and then spend the next several months explaining what it does and why it isn't perfect yet and who to vote for to make it better. They must make a comprehensive and accurate presentation of their case. If the Dems don't pass the bill, then explain it, they are lost.

There will be no compromises coming from the Republicans for a different bill, no matter how pared-down. We've already seen that bait and switch.

Posted by: Lee_A_Arnold | January 20, 2010 8:54 PM | Report abuse

Remember when, after winning South Dakota by 22 points in 2000, the Republicans lost a statewide Congressional special election in June 2004, causing them to completely freak out about November and abandon their whole agenda? Oh wait...

Posted by: SR2006 | January 20, 2010 9:09 PM | Report abuse

There is no reason health reform has to be based on the mandate-subsidy-exchange model. Expand Medicaid to 200%FPL and have an early Medicare buy-in for those 50 and above. This puts the government in charge of the health care of most sick people, and the insurance industry is left to do what it does best: insure against risk. Add Medicare reforms and you're done. No mandate. No new middle class taxes.

Look at lancediverson's post above to see how close Obamacare is to Republican policy. Just add tort reform (a trivial issue), make the subsidies and excise tax a big stingier (why not? They're stingy as is, and neither is indexed properly to inflation). He thinks this would get 15 Republican votes. When are progressives going to stand up and say this is not what we believe in?

Posted by: bmull | January 20, 2010 9:10 PM | Report abuse

Is anyone in the Democratic Party going to take into account the fact that the American public doesn't want their "reform" bill, or does that not matter anymore?

Posted by: Bob65 | January 20, 2010 9:10 PM | Report abuse

It is out fault. We liberals and progressives who did not match the level of volume and vitriol from the other side when FNC was spreading lies and hiring angry mobs to protest town hall meetings. Where were our voices then? Where were we shouting in support of this president, like we shouted for him before he was elected to do exactly what he is trying to do--and yet somehow, the Republicans have gained the upper hand by saying to the american people that it is not what you wanted--even though you voted for it last November. It was our voices that got him elected--and it was the loud silence coming from our voices for the past 7 months--not screaming loud enough for what we want--that has done process in.

Posted by: toranto1 | January 20, 2010 9:19 PM | Report abuse

What the Democrats need to understand is that if they now fail to pass significant reform, they will have proven beyond all doubt that even with the huge majorities they now enjoy, and despite the fact that major reform has ALREADY passed both houses of Congress, failure in this effort will decisively prove to voters everywhere that the Democrats are incapable of governing. Failure now will be the Democrats' "Waterloo."

The Dems need to calm down, take a deep breath, and rapidly move forward by the perfectly sensible strategy of the House passing the Senate bill, coupled with "sidecar" budget reconciliation legislation (that will serve as a patch to correct the original Senate bill's deficiencies).

The tail in the Senate's Democratic caucus (Lieberman, Lincoln, Nelson, et al) has wagged the dog (the 51+ "real" Democrats) for too long -- it is time to stop selling out policy substance for 60 votes and/or for the bipartisan support that never materializes. Play to win, Democrats!

Posted by: Patrick_M | January 20, 2010 9:45 PM | Report abuse

Do progressives and liberals really support party leadership going behind closed doors creating programs "for the people" that merely enrich unions, bureaucrats and their own special interests?

Posted by: cprferry | January 20, 2010 10:17 PM | Report abuse

"We liberals and progressives who did not match the level of volume and vitriol from the other side when FNC was spreading lies and hiring angry mobs to protest town hall meetings. Where were our voices then?"

Speak for yourself. I spent over 4 months trying to schedule a session with one of my senators to talk about health care. No one was interested until the tea baggers started screaming in August.

The person who handle the session (business card says District Manager) was an absolute idiot; he knew nothing about any of the underlying issues. He acted as though he was doing us a favor and was disdainful of anything that didn't fit his preconceived ideas of what was important. He was there for one reason: to tell us what the Senator had already decided was the right course. When we complained that the sessions were too late, his response was that we were unrealistic to expect the Senator to work on it before since it was Baucchus' committee.

Senate Democrats allowed this to be mismanaged from the very beginning. Every Democrat in Congress should have been out in his/her district every month to *listen* to what voters wanted. Instead, they stayed in Washington entertaining lobbyists and "trying to work across the aisle". They only came out to the provinces after the Republicans had set the rules of engagement for field battle.

Posted by: Athena_news | January 20, 2010 11:20 PM | Report abuse

with a bill like this, Democrats need only pass it to finish off their death sentence. If they are that stupid and hungry to screw as many Americans by doing this, MA is just a taste of the future.

hopefully some party of libruls will coalesce from the calamity of the last 40 years of haiku. Martyr looks good on stage, and the Democratic party seems to want to play this part.

May some good come out of the errors of the last 40 years of the American tragedy. Johnson did more than enact civil rights, he destroyed the Democratic party as well. it apparently never learned ANYTHING.

Posted by: BernardEckholdt | January 20, 2010 11:37 PM | Report abuse

lancediversion: "The answer in getting some Republican votes was through lowering the overall costs of health care by adding tort reform into the bill, and lowering the subsidies to some catagories of individuals to buy health care"

I have yet to see a study that shows that tort reform would significantly lower expenses. I know it's a bugaboo for conservatives, and maybe it would help on the margins, but it's not the main driver of health care costs. My understanding is that Texas instituted tort reform and malpractice premiums did not drop significantly.

As for subsidies, I'm not sure what "categories" you're referring to, or the "diversion" of people on Medicare into "quality health insurance plans." Those plans almost certainly have far higher administrative costs than Medicare, which is one of Medicare's great advantages. If those plans require more money, then it will increase the costs of the program substantially.

Again, given the experience of the "negotiations," I simply see no serious reform proposal that would produce near-universal coverage that would get any more than one or two Republican votes. You can't have a bipartisan bill when the other side of the aisle is nothing but partisan (I'm speaking of congressional Republicans, not necessarily their constituents).

Posted by: dasimon | January 21, 2010 12:11 AM | Report abuse

"But where chaos reigned this morning, something more closely related to calm is returning tonight."

I hope this sentence also relates to you personally, Ezra. A bunch of us were freaking out about you over at Ta-Nehisi Coates's blog today. You were like the calm steady voice of reason no matter what happened to HCR over the passed year, and to see you be so seeminly demoralized as you have been today, has been sobering to say the least. Not that I blame you per se, this election really was a body blow, but it does not have to be fatal to HCR. I only hope that the Dems (and you) take a deep breath and push on through.

Posted by: silentbeep | January 21, 2010 1:39 AM | Report abuse

Money quote from Massachusetts BC/BS President Cleve Killingsworth:

"Wherever this is going," he said of the US overhaul, "the more it looks like what we’ve done in Massachusetts, the better."

By all means let's pass Massachusetts style reform that makes BC/BS happy.

Posted by: bmull | January 21, 2010 2:01 AM | Report abuse

If Obama had ever once stood up and demanded some of his platform planks on health care, even once in the process, he might have won something. Instead he sat back and let the Lieberman-Nelson Project dictate the bill with the help of DINOs while the GOP sat in a corner pouting and sucking its thumb and the vast unwashed teabagged each other in fervid response to an ever-escalating echo chamber of lunatic propaganda with no response from the President of the United States or his party whatsoever. It doesn't help that the media is right biased and false controversy addicted, but that wasn't going to change in any case.

What do you expect? Nothing in, nothing out.

Posted by: sparkplug1 | January 21, 2010 2:42 AM | Report abuse

The Democrats could still pass a progressive bill if they just get their act together. The Senate can introduce a reconciliation package to tweak the bill to the point the house can accept it. But as long as they are doing reconciliation and only need 50 votes, throw in a couple extras like a Medicare buy-in and a Medicaid funding for the states.
Otherwise, we're looking at a worst case scenario.

Posted by: philogratis | January 21, 2010 3:06 AM | Report abuse

I think Obama is playing this right. He is making noises that he hears what the voters are saying, while summarizing that it is economic uneasiness that's the basis for malcontent. Seems reasonable to me.

I agree that Brown should be seated before any further votes on HCR are done IN THE SENATE, but I don't see why the House has to wait to pass the Senate version of the bill. All they need are verbal agreements that the Senate will address their tax and subsidy issues in reconciliation, backed by the White House, and it's game time.

Posted by: ChrisNBama | January 21, 2010 7:59 AM | Report abuse

"Is health-care reform stabilizing?"
That's like asking "is the toxic dump stabilizing"! Totally misses the important point. This bill has been riddled with loopholes and unpopular measures while at the same time any systemic change and cost reducting issues have been thrown out. It's a toxic mess now! Passing it would only harm Dems. Kicking that crap into the garbage can, and simply passing a simple bill allwoing everybody to sign up for Medicare would be better, have the same positive impact on the uninsured, and could be passed through reconciliation. All it takes is the courage and the will to do it.

Posted by: Gray62 | January 21, 2010 8:02 AM | Report abuse

I'm not sure how many people will read this comment, but after a day of general despair yesterday, I have to make a general plea to anyone listening...

I believe quite strongly in Ezra's view that failing to pass a health care bill this time around will doom health care reform to sit in a drawer for another two decades. While the current Senate bill isn't perfect, it's a definite improvement on the current state of affairs. I urge all like-minded individuals to take this moment to call, write, or e-mail your Representative and Senators and make your voice heard.

There are frequent calls for this kind of action, and sometimes they are more effective than others. However, as Ezra and others have documented, many members of Congress are currently feeling nervous and uneasy in the aftermath of my state's senate election. I think right now, simply hearing a strong resolve from their constituents that we are behind them would go along way to stabilizing some of the immediate fears.

I have no doubt that this kind of action is what led to Barney Frank's retraction of his earlier statements, and I think further action focused across he country can make a big difference.

So, I urge those of you who feel that this is worth doing to contact your Reps and Senators.

Posted by: AnonymousInMA | January 21, 2010 8:51 AM | Report abuse

"I believe quite strongly in Ezra's view that failing to pass a health care bill this time around will doom health care reform to sit in a drawer for another two decades. "

The only way that would happen, would be if Democrats turned tail and gave they have every other time things got tough.

All the legislation of LBJ's "Great Society" was passed in the first 6 months of his administration. He knew what he wanted to do and was ready he got the chance.

Democrats have been bemoaning the failure of Clinton's health care effort for *15* years and yet they had no legislative opportunity when the opportunity came.

They had *15* years to educate themselves and the public about the alternative ways to deliver universal care and didn't.

They had *15* years to craft responses to the arguments of opponents and get everyone on the same page but they didn't.

Health care has been derailed now because *Democrats* haven't done the spade work with the public needed to get it done. It needn't take two decades, or even one, for them to do the work they should have been doing since the Clinton effort failed.

Posted by: Athena_news | January 21, 2010 9:30 AM | Report abuse

Well, speaking as a conservative, I'm in favor of health care reform. But this bill is totally in the wrong direction. Get rid of it and start again. This time, make it truly bipartisan, instead of pretending that including Sen. Snowe is sufficient. Sorry, but that means the bill will look very different from what you are envisioning; it will be somewhat like what we are envisioning as well. If you can't tolerate that, we won't have a bill. Skip the "obstructionist" nonsense; conservatives will only support a bill that is, well, somewhat conservative.
And, please, leave the insurance companies and drug companies out of the negotiations.

Posted by: MikeR4 | January 21, 2010 9:38 AM | Report abuse

MikeR4 , you're either naive or lying. There were already a large group of conservatives that supported the HCR bill: the conservative Dems. The bill itself, as has been pointed out incessantly, is full of conservative ideas based on what Republicans used to advocate. No current republican will vote for an HCR bill, regardless of its content. They've made the political choice to stonewall, and it's worked for them. Bipartisanship is not possible when one side doesn't want to participate.

Posted by: etdean1 | January 21, 2010 10:38 AM | Report abuse


You are right that Medicare is pretty good insurance. But I said that it is "Medicaid" that sucks! I said that a good health reform proposal must divert people out of Medicaid coverage.

As for senators on the Republican side who could be get-able if the bill was right: Voinavich, Corker, Snowe, Collins, Grassley, Alexander, Graham, McCain, Bond, Gregg, Brown, Isakson, Hatch, Enzi, and Bennett. Go get 'em! Even 5-10 would allow cover for Leiberman and Nelson and Bayh.

Posted by: lancediverson | January 21, 2010 10:54 AM | Report abuse

Grassley and Enzi were both part of the initial Gang of Six, had all the opportunity in the world to not just accept a compromise, but to create it to their standards, and chose not to. Snowe is the only Republican that's even hinted at having her vote up for grabs, and even attempts to give her exactly what she asked for weren't enough. None of those Senators are going to switch over now.

Posted by: etdean1 | January 21, 2010 11:23 AM | Report abuse

etdean1, you're just quoting Democratic spin. The conservative version of the bill would look very very different. Just because you can point to this or that feature which resembles something some Republican supported - doesn't mean that fiscal conservatives are going to be in favor of giving a trillion dollars a decade away to special interest groups in the middle of a depression. Isn't going to happen.
"MikeR4 , you're either naive or lying." Sorry, but you have no clue what conservatives think; it's too different from the way you approach things. And your response to that is to deny that they really think that way: How could they? So, some of them are lying to the naive rest of them.
But no, we have an entirely different system of thought, which you disagree with, and, apparently, can't even grasp.

Posted by: MikeR4 | January 21, 2010 11:56 AM | Report abuse

*, we have an entirely different system of thought,*

Apparently so, since it is disconnected from reality. The fix was in early, when Obama asked Republicans how many of them were willing to vote for reform if it included things like taxing high value plans and tort reform. None of them were willing. Baucus decided to work with Republicans for months to draft a plan, which came to nothing. etdean1 is repeating the facts and you are the one spouting talking points and defending yourself with a claim of, "you liberals just don't understand the reality that conservatives live in." And isn't that the problem? You all exchange a lot of strongly-believed talking points, and since you repeat them to each other, you think they're real and then get indignant when someone points out that they're wrong.

Republicans wanted NO health care reform. That was their track record in the House and the Senate. They made no efforts to pass any health reform at all. It is logical to assume that when the Democrats came to power that they would be just as uninterested in health reform in 2009 as they were from 1995-2007. What they DID have a chance was to influence how it turned out. Which they did, given the dozens of amendments they submitted and had accepted. and they opposed the bill anyway.

Posted by: constans | January 21, 2010 12:20 PM | Report abuse

Just because I can point to every feature of the Senate bill and how it has conservative origins doesn't mean that conservatives would be in favor of it? Plus, lets realize that Democrats still have a huge majority and it's only the filibuster that's standing in their way. Compromise means that the Republicans can include conservative ideas in the bill, not remove all liberal elements.

Moreover, the bill doesn't give away "a trillion dollars a decade" to interest groups during a depression.

I'm an economic conservative myself and can grasp some foundational concepts here from that side: effectiveness testing and new approaches to payment for Medicare, MEDPAC, using the existing insurance market instead of going to single payer, using exchanges as health care markets, removing or limiting the tax exemption for employer provided health insurance, and an individual mandate to prevent free riding.

Instead of just saying that the other side makes no sense, what can you show to support the idea that any Republican senator will support a health care reform bill, and what trade offs will they accept?

Posted by: etdean1 | January 21, 2010 12:41 PM | Report abuse

"You all exchange a lot of strongly-believed talking points, and since you repeat them to each other, you think they're real and then get indignant when someone points out that they're wrong." Pot. Kettle. Black. The only difference between us is that I can understand that someone might intelligently disagree with me, and you apparently cannot.
In another venue, we might discuss the facts and understanding that we are disagreeing on. Here, it's sufficient for you to just admit that just because you are sure something is true (and everyone around you is telling you you're absolutely right to be sure) doesn't mean that others, just as intelligent and well-informed as you are, might disagree.
There are, for instance, economists like Paul Krugman, and other Nobel-prize-winning economists who disagree. Probably they are as smart as you are. I doubt you're competent to decide between them; I certainly am not. I'm not even sure that it's possible given the current state of economic knowledge. People don't always agree.

"Which they did, given the dozens of amendments they submitted and had accepted. and they opposed the bill anyway." Of course, since (as I've explained) the bill is very very unacceptable from our point of view. Surely that makes sense? You may think we are dead wrong, but surely you can imagine that if we think a bill is terrible and will do harm and will cost a lot of money too (and those polls show that we do think that) - that we should oppose it.

Posted by: MikeR4 | January 21, 2010 12:53 PM | Report abuse

lancediversion: "But I said that it is "Medicaid" that sucks!"

I read too quickly. My bad.

But I still have yet to see a proposal that would accomplish substantial health care reform and provide near-universal coverage that would get more than one or two Republican votes. Snow looks like the only gettable vote.

MikeR4: "The conservative version of the bill would look very very different."

Yes, we saw it. I would cover 3 million more people. It had little if anything in the way of cost controls. In short, the conservative version would do very little and would not constitute serious reform, which is my point: I can't see a version of health care reform that actually does serious work and would get more than one or two Republican votes.

As Ezra points out in a post today, many aspects of reform have to go together. To require issuance of insurance for those with preexisting conditions, you need a mandate. To have a mandate, you need to make insurance affordable. To make it affordable, you need subsidies. To have subsidies, you need a way to pay for it.

There are many ways of paying for it, as our peer nations (all of which have mandates) have shown. But one way or another, the healthy will subsidize the ill and the rich will subsidize the poor, and there's just no way around it (again, that's what all of our peer nations do). Some conservatives object to each portion, the mandate on the ground of "freedom" and the subsidies on the ground of opposition to taxes and "wealth redistribution."

Hence, I don't see a substantial reform bill that would overcome the ideology that seems to dominate all but a couple of Republican senators. I'd be glad to be proved wrong, but the "negotiations" of the past year do not make me optimistic.

Posted by: dasimon | January 21, 2010 1:59 PM | Report abuse

"Moreover, the bill doesn't give away "a trillion dollars a decade" to interest groups during a depression." Well, I guess we disagree. Not sure why, though, since that's what the CBO says. The fact that taxes and other stuff may possibly protect the deficit doesn't change the simple fact that the money comes from taxpayers' pockets, and goes to insurance companies, unions, and other politically connected Democratic interest groups (the poor is one of them too).

As to the rest of what you said, etdean, I basically agree with you. It is reasonable for Democrats to get the lion's share of the reform bill, since they are a super-majority. However, if you need some conservative votes, you can't spend that kind of money right now, or we have to stop you. That's your decision.

And I don't know what conservatives in Congress would actually support. Maybe nothing, as you say; the two sides seem very far apart. I'm only speaking for myself - and assuming that a lot of conservatives and moderates feel this way too, which means that some Congressmen do as well.
You certainly could get support for a lot of things that Democrats would never do. Opening up the free market in insurance is a good one. Tort reform is an obvious one that conservatives think would make a big difference and is the right thing to do anyhow, and liberals don't. Then some kind of welfare-type help for the really deserving uninsured, but limited... And so on. You're probably right that it would never happen. The two sides are so different today, and we are no more likely to get a real super-majority than you are.

Posted by: MikeR4 | January 21, 2010 3:28 PM | Report abuse

I agree with you that the mandate is the key and a lot of Republicans have a logical, philosophical argument against the mandate. But the mandate is the big deal and it is the big one for liberals. So if liberals are going to get the mandate, then they have to accept a lot that they don't like in terms of size of the subsidies, Medicaid expansion, tort reform, state-based exchanges, interstate competition and the like.

And the discussions this fall were getting close but they were cut short because Obama and Pelosi wanted to meet a deadline. Do you remember when Grassley said he thought they were only a couple weeks to a month away from a deal?

Posted by: lancediverson | January 21, 2010 3:43 PM | Report abuse

"So if liberals are going to get the mandate, then they have to accept a lot that they don't like in terms of size of the subsidies, Medicaid expansion, tort reform, state-based exchanges, interstate competition and the like."

First, you can't have the mandate without healthy subsidies. If there's going to be a mandate, it has to be affordable or there's going to be considerable blowback (as well as just plain unfairness). Or if you let enough people opt-out because the subsidies aren't big enough, we'll lose the idea of universal or near-universal coverage, so why bother in the first place? Plus the people who will be "allowed" to opt-out will probably be the ones most in need of affordable coverage. As Ezra points out in a later post, you can't just "pare down" parts of the essential elements of reform without essentially destroying it since they're interdependent.

Second, as I wrote above, there's nothing inherently wrong with tort reform but I've seen no study showing that it would have a significant impact on health care costs, and I see no evidence that its addition would have garnered a single Republican vote--which is perhaps why it didn't get added.

"And the discussions this fall were getting close but they were cut short because Obama and Pelosi wanted to meet a deadline."

Is there evidence for that? I never understood the argument that things were moving too quickly. I don't know what people would have learned with more time that would have changed anyone's mind on any issue, and I don't see why well over half a year would be too short a time to reach an agreement if there was one to be had.

Posted by: dasimon | January 21, 2010 8:19 PM | Report abuse

MikeR4: "The two sides are so different today, and we are no more likely to get a real super-majority than you are."

Which is why the filibuster should go and the majority should be judged by its results. Otherwise, we are stuck with the status quo which we all agree is unsustainable.

lancediversion: "But the mandate is the big deal and it is the big one for liberals."

One more point on this. It's not that it's a big priority "for liberals." It's a necessity if one is going to prohibit discrimination based on preexisting conditions (as well as a way to keep premiums down by spreading risk across the largest possible pool). It's not a liberal/conservative thing, it's a matter of basic logic. As Ezra has pointed out, without a mandate some healthy people won't buy insurance until they're sick (the "adverse selection" problem). That will drive up premiums and prompt more healthy people to go without insurance, further driving up rates for those who are left, until only sick people are in the system and no one can afford the premiums.

A ban on discrimination based on preexisting conditions requires a mandate to make it work, which requires subsidies to make the mandate work. Once one accepts the first goal, the others follow as necessary consequences, not mere policy choices.

Posted by: dasimon | January 21, 2010 8:27 PM | Report abuse


I completely agree with you on the mandate. It doesn't make sense to do Health care reform without a mandate because of adverse selection. I don't disagree one bit.

Where we disagree is how significant a mandate is. While everyone was focused on the public option, they lost sight of the real readical change being proposed in this legislation. But the mandate is a big, big deal. It is the big deal!

You are right that you need subsidies, but they should not be too generous because people have to bear some cost for their own health care. We need other ways to drive down costs like free-market competition among insurance companies and tort reform.

Finally, you have never addressed my fundemental argument. To get something this big done, it just has to be bipartisan. This is the biggest piece of domestic legislation in decades and you have to get Republicans to believe in the good idea. You also have to get your state government partners in public health care (Republican or Democrat) to believe it is a good idea. Right now neither agree. I have suggested ways to get this thing to work. You keep wanting it to be done the hard way. Democrats keep running their heads into a brick wall. I fear nothing will get done now and the status quo (which is totally unsustainable) will continue.

Posted by: lancediverson | January 22, 2010 11:56 AM | Report abuse

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