Endgame looms for health care reform battle

During this prolonged struggle, Obama and the Democratic Congressional leadership have been roundly excoriated and condemned by both the Right and the Left. From the Right they’ve been called socialists, communists, fascists, micromanagers, Big Government promoters, Tax-and-Spend Liberals, and every possible denigrating term one can conceive. From the Left they’ve been called cowards, fools, shills, sell-outs, insurance industry tools, Republicans in Dem clothing, and every other possible denigrating term one can conceive including a mocking accusation of being engaged in “11 dimensional chess.” With condemnations coming furiously from both directions, little wonder the Bewildered Middle is losing confidence in Obama as well as Democrats in general and government as a whole.

But it appears that Obama and the Big Dems are playing quite a different strategy that anything their accusers have imagined, one borrowed not from sainted political or social philosophers but rather from The Greatest boxer ever; Muhammad Ali. This health care reform exercise has been, more than anything, a classic application of the Rope-A-Dope.

For months Obama and the Big Dems have laid back, barely defending themselves, pushed up against the ropes while the opposition took swings at will. The barrage from Left and Right has been relentless and unyielding for a long time, but now the opponents are exhausted. They’ve thrown everything they have, yet Obama and the Big Dems are still standing. And not just standing, but starting to move around the ring and take some solid shots of their own.

The first indication that Obama and the Dems were changing the pace was when Obama accepted the Republican Caucus’ invitation to speak but put on a requirement that it be televised. Always before, when the president of one party addressed the caucus of another, the event was reported in the press. By moving to live television, Obama took delivery of his message out of the hands of the VRWC-controlled MSM. He took away the opportunity for Assorted Talking Heads to re-interpret his message and miss-report it to the American People. He seized control of the Media, instead of letting the Media control him.

He became the Message.

He owned the Message.

And with it, he crushed the Republicans in what was the most compelling piece of public political confrontation since the Kennedy-Nixon debates. Obama didn’t just defeat the Republicans; he sent them crying from the room with their tails between their legs, howling at the unfairness of it all and vowing to take revenge by being even bigger assholes than they had been before.

[I do not at all dismiss Universal Single-Payer advocates. We fought valiantly, but didn’t have enough power to bring anything meaningful to this battle. We should not, any of us, despair. Learning how to better frame the argument was worthwhile, and there will be another chance to make the case. Single-Payers, of whom I am one, should all take care to recognize that Obama, Pelosi and Reid are also Single-Payer advocates. We, they and you and I, didn’t have a big enough coalition this time to win. Next time – and there will be one – I am confident we will prevail.]

Now Obama and the Big Dems have picked up the pace. While the Republicans are weakened, bewildered, desperate and fresh out of fresh, Obama and the Big Dems have moved to the center of the ring and are dancing, beckoning with one hand to the Republicans and daring them to bring their best stuff on health care reform.

The last round, the Republicans led with their biggest weapons and got counter-punched until their knees turned to jelly. This round, with the venue moved to his House, Obama is already peppering them with jabs and setting them up for a knockout.

The Republicans, like all bullies, think that if they just keep charging they will prevail and so in arrogance and anger will stick out their (double) chin(s), right where Obama is waiting. And truly, thanks to maneuvering by Obama and the Big Dems, Republicans have no good choice; they either have to step up and get a very public drubbing, or slink away defeated. From here on out, with their arms exhausted and their vision blurred, they will not lay another glove on him.

With the other hand, The Big Dems have begun to move on reconciling the House and Senate bills. As a result of careful planning for what was expected to be a difficult fight, they have had multiple paths available for some time and still have options in spite of the blows thrown at them by Republicans, BlueDogs and NewDems. The so-called “new” push for a public option, in fact an objective for from the outset Obama and the Big Dems, has shifted in stance but the power is just as solid as it always was. Instead of conference and a new synthesized bill, the Big Dems will use reconciliation.

None of this emergent push for a public option through reconciliation would be happening if Pelosi didn’t have the votes to pass the existing Senate bill. Feinstein, in particular, is not one to stick her neck out if she isn’t sure she’s covered. Given the suddenness and rapidity with which this movement is unfolding, I have to believe that Pelosi has outflanked Stupak and has the votes to pass the existing Senate bill provided the Senate fixes (mostly) the House-Senate differences in funding and coverage.

As to what can and cannot be included in reconciliation, the Omnibus Budget Resolution of last spring specifically included a provision stipulating that during this session any health care reform legislation can be handled through reconciliation – without meaningful restriction. The reconciliation process is an internal Senate invention, an infinitely mutable procedural pathway and not a fixed law. Senators can do whatever they want with it, and have already decided that any – repeat, any – health care reform bill can be managed through reconciliation. Wording it cleverly to include anticipated budget balancing tricks from the already-passed Senate bill is just that, clever wording; John Yoo could knock it out in an afternoon.

(A list of the various subjects moved through by reconciliation is here.)

The very nature of the reconciliation structure will limit any attempt by opponents to obstruct, amend or strip the bill. According to rule, Reid can bring to the floor essentially any bill he deems to be health care reform related and do so by 50 votes with Biden providing the tie breaker if needed. Challenges or amendments to the bill, in contradistinction, will require both a ruling by the Parliamentarian that the challenge or amendment is proper and a 60-vote supermajority to prevail.

The current Parliamentarian is well aware that he serves at the pleasure of the Majority Leader; the last one was sacked by the Republicans when he didn’t follow their lead, and this one is not eager to follow the same path. Even if he allows a challenge or amendment, opponents must rally all 41 Republicans plus 19 Democrats to strike or add any provision. This is a nearly impossible obstacle and so, within the bounds of a 41-vote minority, whatever Reid proposes under reconciliation will prevail unchanged. A final Yes vote of 50 will be enough for passage, again with Biden presiding to cast the 51st vote should it be needed.

What was planned, with Pelosi and Reid and Obama all in agreement, was that each chamber would pass something and the differences would be hammered out in conference. Reconciliation was always on the table for Reid to use if he had to. The Brown election made the conference path impossible, leaving reconciliation as the only possibility and here we are. What is being negotiated now – between Democrats only, mind you – are the terms of the reconciliation bill, following which the House will pass both Senate measures.

Republicans are correct to assert that at this point they are no longer part of the process, except as a punching bag on the way to their defeat. They don’t have anything even plausible to offer, while Obama and the Big Dems have co-opted all of the main Republican Regressive positions and transmogrified them into sustainable, sensible and decent Liberal – if modestly so – programs. Not perfect in the whole, but far better that what we have now or will have if nothing is done. All the Republicans can do now is scream and sweat and blubber and flail with their tired and worn out proposals, while Obama and the Big Dems punch them silly. The Left at this point should be cheering, not complaining.

Pelosi and Reid and Obama have been working closely together throughout this effort, since immediately after the election. (The “Dems in Disarray” meme is a whole-cloth construct of the VRWC-MSM, sadly perpetuated by many on the Left.) All three of them want a public option. All of them wanted something stronger than the House version, but couldn’t round up the votes. They’ll go with what they can get, and should. The benefits of the total package – with a Medicare+5% public option – far outweigh the negatives.

The final-final version of the Democrat’s overall health care reform proposal hasn’t been released so we don’t know for sure what Obama will stake out at the Summit, but this outline is currently making the rounds:

The Plan will be based on the Senate bill, with adjustments to more-or-less match up with the House version.

Near-universal participation will be required, with around 20 million Americans exempted. They will not be excluded, just not mandated to participate.

Subsidies will be provided for low-income insured, on a sliding scale.

Insurance companies will be prohibited from denying coverage for any reason, from charging differentials based on risk, and from terminating coverage for use or change in risk status.

A public option will be created, providing a “bread-basket” of coverage options similar to the Federal Employee system, available to small businesses and individuals. It will be contractually overseen by private insurers, as Medicare is partially now, but with severely limited fees. Provider payments will be at Medicare+5%.

The GWBush-legacy Medicare prescription “doughnut hole” will be substantially closed.

The bribes special Medicaid subsidies for certain states will be eliminated.

The Stupak abortion restrictions will evaporate.

Overall cost will be around $1.1 Trillion over ten years, close enough for horseshoes to Obama’s $1 Trillion target; he will magnanimously “compromise” on this target by yielding to the will of Congress. Thereafter, the program should be a money-saver.

Funding will come by a mix of premiums, selective tax increases on very high incomes and some very-high-end employee-subsidized insurance plans, along with future cuts in Medicare and Medicaid coverage targeted to eliminate ineffective practices and specious treatments as well as now-rampant fraud. Elimination of fraud in those programs alone, currently a wasted cost approaching $100 Billion per year, would very nearly cover the entire program.

This “anonymous sources” release might be a feint, could be Obama and the Big Dems are holding something in reserve, but at this point with their opponent staggering and bewildered I think it is more of a solid Right lead, a crossover from a series of Left jabs, and is a set-up for a from-the-hip Haymaker of a Right Cross to be delivered on Thursday. The Republicans can see it coming, but will not be able to move out of the way in time and instead will lean into it. Face, meet Glove; Head, meet Canvas.

After this protracted engagement, many on the Left are feeling weary, fearful and unhappy and I understand; we all wished for better. But this achievement – as described above – is well more than half a loaf and we will be able to come back again in a very short time to take the remainder. If we can hold together now and pass this bill, we will have a universal single-payer system in the USA by 2020 at the latest. If the private insurers continue to raise rates as they are now contemplating, we might have it by 2015.

As always with politics, there are caveats. The margins in both chambers will be very small. Assuming Pelosi has split the Stupak coalition, she will have at most a two or three vote margin on the Senate bill. My last headcount in the Senate showed just 48 Democrats willing to back a public option; with the Brown election that would drop to 47. But Obama and Reid have been working the Dem caucus over pretty good, and they now appear to believe they can pull together the 50 votes they need. A strong showing by Obama this Thursday will help with that, but it will be a squeaker and last-minute shifts towards opposition cannot be ruled out.

Another aspect is the whole concept of bi-partisanship. Obama is, I think, sincere in his desire to try and find a way to govern with Republican participation. Their lock-step opposition to everything he wants, however, has made that impossible to achieve. Assuming the votes are as close as they appear, the only bipartisanship will turn out to be on the side opposed to the health care reform measures, where Republicans are joined by a goodly number of Democrats. Irony never goes out of fashion.

In spite of all the inadequacies, it is good to see the Democrats moving ahead with needed reform. After 40 years of getting my ass kicked on nearly every issue by the Reactionary Republicans, I am so loving this.

[Note: A last-minute search reveals that Bob Burnett sees the same analogy. Great minds, or something….]

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10 responses to “Endgame looms for health care reform battle

  1. Pingback: Endgame looms for health care reform battle « Graham Firchlis has a blog

  2. blacksheepone

    What I want is not relevant, but I really wanted to see a system that let the people who don’t have access to care get taken care of, rather than forcing insurance purchases across the board.

    • grahamfirchlis

      Now, now, what you want is as relevant as what I want, and we both know that what I want is way important so what you want must be too!

      Mandatory enrollment, including paying for it, is a key element for any universal health care system. All UHC systems, everywhere, force all residents to participate and pay a fee to do so, whether a true socialized system like the UK or a private insurance menu system like the Swiss.

      This new one of ours will provide subsidies for lower income participants, the money being provided by taxes on those with high incomes. If we had a true single-payer system, everyone would get nicked for their participation fee in various ways including income tax, sales tax, property tax, “sin” taxes, etc. and so again those with low incomes contribute less than those with high incomes.

      Can’t get to universal coverage without universal paid participation.

  3. hipparchia

    loved your description of the treatment of the republicans!

    i still think, though, that obama’s work on the illinois health justice act suggests that the dopes that are going to be roped with this ‘reform’ will be the left.

    just out of curiosity: what does your crystal ball say about [1] how soon after passing this bill will they go to work fixing its faults, and [2] what is their planned path to turn it into single payer?

    • grahamfirchlis

      Sorry, Sweetie, The Left doesn’t have enough clout to get much of anything, plus we’re disorganized by nature and prone to flailing around and chewing on each other’s butts instead of attacking our true enemies so yeah, we are an afterthought in this. The wonder is that we ever get anything at all.

      Thank the Goddess for Nancy Pelosi, because without her this would have truly been nothing but a Health Care Industry Support Act. As it is, or I should say as I expect it to be, it is still nothing more than a stopgap, a weak one, that will do very little to slow down the trainwreck we are already aboard.

      The rate increases being announced are what should tell everyone the current system is unsustainable. The insurers don’t actually make huge profits in terms of margins, and even though a lot of their income goes to marketing and admin, together those categories are not outrageous for private industry. What is driving the rate hikes now is anticipation of future cost growth.

      This is a big topic, too much for a comment, but the twin drivers for the insurance companies right now are selective withdrawal from their pools by health people dropping coverage, meaning that they are having to cover the seriously ill from a shrinking income pool, and a continued upward cost spiral for drugs and devices along with new very costly treatments. Unless that later component, the cost of health care delivery, is controlled, we will never be able to afford universal care.

      Since this bill does nothing immediate to deal with those problems, I expect the price of private insurance to continue to escalate. This rate regulatory proposal is a bandaid on a gushing artery, even if passed it will do nothing to fix the cause of the bleed. If they can’t raise rates, insurers will respond by limiting treatment coverage. Either way, private insurance becomes less and less affordable and effective.

      [1] Nobody will touch HCR until after this election, and maybe not until a second Obama term. The driver will be a continued meltdown of the private insurance sector and that will take several years to develop enough pain to be irresistable.

      [2] Planned path? Surely you jest. I say it will become inevitable, not that the higher ups will plan for that in an identifiable way. Like Jerry Brown once said, “It will emerge” and the politicians are content to let it happen that way, safer for them to follow than to lead.

      We, dear heart, you and I, need to do the planning, figure out how to frame the argument, pile up the evidence, work out the kinks, and take responsibility for making what we want a reality.

      We had a go at single-pay, and it didn’t work. If we want others to change, we need to take a hard look at what we’ve done, what worked and what didn’t, and change ourselves. Only after we change will others start to change. That is a universal truth you can bank on.

      The current path for health care delivery is unsustainable. With this new proposal, one version or another, the portion of citizens covered by one or another public pool will increase from just 50% now to 60% in three years and two-thirds or more in five years (my estimates). Meanwhile, the cost of private insurance will rise, co-pays will increase, private coverage will shrink (everyone’s estimates). The tilt is in our direction; if we are clever enough, we can help push it along to where people see that UHC is in everyone’s best interest, and not just a “handout for the welfare cheats.”

      More clever, I need to be more clever. My mantra, for a long time now.

  4. hipparchia

    ok, having read the medicare fraud article now, i have a couple of thoughts….

    $60 billion per year out of $480 billion is fraud?! 12% of the money paid out is to fraudsters?! if the task force has only found a total of $1 billion in possible fraud in 3 years of work, which adds up to maybe 1/10th of 1% of all that has been paid out over that time, how are they extrapolating that to 12%?

    i have to agree with one of the commenters on that article, this does sound like it’s meant to be a hit piece in order to convince people that govt can’t do anything right.

    • grahamfirchlis

      The estimate of $60 Billion is probably low. Between Medicare and Medicaid, the total is probably around $100 Billion anually and yes that is Billion with a “B.”

      Some of that is Mom-and-Pop fraud, some is collusion between suppliers, institutions and physicians, and some of it is organized crime. It is everywhere in the system.

      Couple of things happened. One, the payment schedule for Medicare claims was accelerated, to 30 days max. The second thing was budget cutbacks in the resources for payment processing, the result being that there is no time to scrutinize bills beyond verifying ID numbers and the planned computer system upgrades never happened so the various claims offices cannot communicate internally much less with each other. The third thing was that the budget for fraud investigation was gutted, to a tenth of what it should be.

      Net net effect of all that is fraud is easy, there is no system-wide program to identify it, there are so few investigators they are overwhelmed and can only pursue the truly foolish criminals while all the smart ones just walk way and do it again, and the systemic fraud amongst providers is so deeply imbedded it will take all-out war to excise.

      This is indeed an exercise in showing that “government doesn’t work” but not in the way you and that commentor see it. It was a deliberate assault by the Radical Reactionaries to (a) short-term maximize profit however illegally for their cronies and (b) long-term destroy the system through rampant criminalty, leading everyone to conclude that government health care specifically and government in general is incompetent.

      Blame the Radical Reactionaries who set it all in motion, not the truth tellers who are reporting the crimes.

      • hipparchia

        i blame the radical reactionaries for everything, but neither you nor the reporter are naming names and giving timelines, etc.

        who got rid of the original fraud investigators? who instituted them in the first place? were they actually finding enough fraud to make it worth keeping that many of them?

        one thing neither you nor the article mentions is that after the dead doctors scam was discovered, cms cleaned up their database and instituted an entirely new provider id number system, as well as improving their system for keeping tabs on whether drs are dead or not going forward.

        the article doesn’t mention this, which leaves the reader believing that the possibilities for this fraud to continue are still there. and that suggests that either it’s an inept job of reporting or it’s a hit piece designed to continue propagation of the ‘govt can’t do anything’ meme.

      • grahamfirchlis

        So what are you saying, h?That you won’t just take my word for it? Huh.

        I blame the Radical Reactionaries for everything because studies have shown that 99.999999999% of the time that is true. For me it is sort of like the Lottery, but in reverse; when I blame the RRs I nearly always end up Feeling Like A Winner, but there is no payoff.

        Just for you, I’ll poke around today and find the evidence trail. The Finger of Guilt is twitching in the direction of Shrub, but I’ll make certain. Check this space for further details.

        The dead docs scam has been blunted, but there are a hundred different ways to defraud Medicare as a supplier and the clever operators open up shop, run the scam for just a few months, then shut down and disappear without a trace. By the time the system detects them, they are long gone.

        But the biggest dollar amounts are “clean” fraud, flaws in the system that suppliers and providers and institutions exploit in collusion. I can give you hundreds of examples from my own experience, and tell you that by refusing to participate I cost myself boucoup bucks and eventually my career.

        That kind of fraud will be much more difficult to root out because unlike with the small crooks and organized crime who come at it from the outside, through the internal systemic approach everyone including politicians are getting a taste. They all pretend it is innocent, but I believe corruption is wrong whether or not you are likely to be prosecuted. Not everyone shares that view. Somehow, when billions of dollars a year are flowing a great many people just want their cut and never mind the morality.

  5. hipparchia

    Somehow, when billions of dollars a year are flowing a great many people just want their cut and never mind the morality.

    isn’t that the truth.

    But the biggest dollar amounts are “clean” fraud, flaws in the system that suppliers and providers and institutions exploit in collusion. I can give you hundreds of examples from my own experience,

    insider perspectives are valuable. i hope you expand on this sometime, either with or without specific examples from your own experience.

    Just for you, I’ll poke around today and find the evidence trail. The Finger of Guilt is twitching in the direction of Shrub, but I’ll make certain. Check this space for further details.

    bring us a shrubbery! awww, you’re a sweetie. i will check back.

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