Towards the Next Victory on Health Care

The passage of the health care bill is good news for President Obama and the Democrats, but it is more a case of avoiding defeat than of scoring a decisive victory. Given that the Democrats have control of almost 60% of the seats in the House of Representatives, by a margin of 257-178, and that all that was needed was a simple majority, this was not the greatest challenge facing Obama's health care reform. However, had the bill not passed the house, it would have been a stinging defeat for the president and his party.

Now the Democrats must win in the Senate. To do that, it is essential to somehow build on this initial, if unsurprising, victory in the House. However, the House and Senate are different institutions which often do not take cues from each other. Success in one far from guarantees success in the other; and momentum is an elusive, and often nonexistent issue in legislation, particularly given that it could be a number of months before the health care bill comes to the Senate floor. The issue in the Senate will not be winning a simple majority -- that should be relatively simple -- but winning a cloture vote. A cloture vote requires 60 senators voting to end discussion and bring the bill to a vote. Winning a cloture vote will be difficult, but the make or break moment for Obama.

The real partisan makeup of the Senate is now 60-40 in favor of the Democrats. This includes one nominal independent, Bernie Sanders of Vermont, who often votes with the Democrats, and one nominal Independent, Joseph Lieberman of Connecticut, who is part of the Democratic caucus but is really a Republican. Accordingly, the main focus of Obama's and the Democratic Senate leadership's aim should be to consolidate support of 60 Democrats and pick off one, or even two Republicans. The most likely candidates here are Senators Collins and Snowe from Maine. This is a different strategy than actively suiting a bipartisan bill. Doing that would require reaching out to the Republican Party and its leadership and seeking their input on the final bill. This would be a mistake because the Republican Party leadership had made it clear that their goal is to see health care, and with it the Obama presidency, fail. Reaching out to them would only make this easier for the Republican Party. Trying to peel off one or two Republicans by cutting political deals and appealing to the political realities in their home state is a distinctly different, and better, strategy.

A similar tactic should be avoiding compromising on the bill until as late in the process as possible. Obama could almost certainly get his 60 cloture votes in the Senate for a bill that is weaker than the House bill, but that trade-off would be a mistake. This is the closest we have come to meaningful health care reform in decades; if the president compromises it away too early it will be a devastatingly lost opportunity to make right one of the gravest problems facing many Americans. Rather than seeking to compromise on the bill with the misguided hope of ameliorating Republican rancor, the Democrats should seek to cut specific deals with specific legislatures when necessary, while maintaining the sound fundamentals of the bill which was passed by the house.

Winning even one Republican cloture vote will be difficult, but it may not be sufficient. Only if the Democrats hold all 59 of their votes will one Republican vote be enough. This is unlikely as there are other Democrats in addition to the already written-off Lieberman, including Blanche Lincoln of Arkansas, who is threatening to vote against cloture. If Lincoln and others do not vote for cloture it will be extremely unlikely that any Republicans will, so this is extremely important. One key tactic for attracting these votes is to make it clear, from both Reid and Obama, that there will be a big cost associated with not supporting the party on this. Offering incentives for wavering supporters will be helpful, but making it clear that no Democrat will get a free pass if they vote against cloture is essential. Democrats who vote against cloture should expect no support from Senate Majority Leader Harry Reid or Obama on future pet issues, pork or other political considerations.

These tactics will seem unseemly coming from Obama and will allow his opponents to argue that he is no different than any of his predecessors. It seems like this is a tenuous attack and one that is worth fending off if real health care reform is at stake. If Obama is unwilling to take this relatively minor political risk, and therefore lets a small handful of recalcitrant Democrats destroy our chances for health care reform, he will have failed his constituents.

 

Comments

[billy goat]

Your writing focuses on the practical and tactical approaches that need to be taken in order to move something through to passage regardless of how reformative. Truly depressing is the article written by Marcia Angell MD regarding the flaws of the house legislation and the likely outcome. Unfortunately, as a citizen, I'm not yet bouyed by the efforts of my legislators on my behalf.

[exmate]

One of the main reasons for the health care crisis in the USA is because of the ENTITLEMENTS of health care insurance companies to pimp off of health care professionals and in the process, gaining obscene profits for themselves while accepting premiums from policyholders until they become sick and coming up with bogus pre-existing conditions to cancel their policies. The government would be able to serve the same function much less expensively and much more appropriately.

[exmate]

The health insurance companies have been pimping off of health care professionals long enough. They need to be nationalized and their corporate mission changed to one of providing funds for health care instead of NOT providing health care. The CEOs and top management can keep their ill-gotten gains. They can even keep their jobs but their mission would no longer be to generate obscene profits for themselves at the expense of the patients. They should not be entitled to continue to exploit health care for their own greedy benefit. That is one entitlement that we can do without.

[Countess]

This is another step towards a theocracy as the poison of right wing religious beliefs now afflicts both political parties. Women in the United States are under attack by these despotic morons. Imagine needing the approval of a church who regularly covers up child molestation.

[jmpurser]

I agree that this bill's passage in the house can only be seen as a victory for a political party. It was certainly a major defeat for the nation.

The only good thing about the passage of this bill is we saw the fakes and liars burned away by the crucible. In the end Conyers and Weiner put party before duty and nation and voted for it. IMHO that leaves just Dennis Kucinich as the sole remaining progressive in the house. The last member on "our" side.

[Chernynkaya]

This is a political defeat—the House and Senate bills satisfy no constituency except for the insurance companies and those who think they are supporting the President by accepting this as a step in the right direction. In actuality, his most ardent supporters are leading him astray.

The bills will prove unpopular. They don’t reduce costs, they force people to buy insurance from private insurers, they all but decimate pro-choice, and they cost taxpayers without providing enough coverage. Those who are touting it as a victory live in the DC bubble.

Many liberals will stay home in 2012. Independents will either stay home or move right. Those are the two groups that helped Obama succeed in ’08. Plus, the bill won’t even take effect until 2013, so even if the effects were positive (they’re not) no one would notice. A real profile in courage would be for the President to veto the bill, but he won’t. He will try to tell us this is an historic baby step.

[theycallthewindmariah]

I don't think so. I've run into large numbers of ordinary folk who think it is a good thing.

Why does the legislation decimate pro-choice options? Does it repeal Roe v. Wade? Does it take away federal funding that I didn't know existed? Or does it say that private insurance that participate in subsidized exchanges can't include abortion coverage?

Does it forbide clinics from offering abortion on a sliding scale? Or groups like Planned Parenthood from raising funds to pay for abortions for women who can't afford them?

What's the average cost of an insurance plan now that covers abortion? I don't know because none of the plans my employer ever offered, or that I bought on the open market, ever included it.

What % of abortions now are covered by private insurance?

[Matt Osborne - Huffpost Blogger]

Here is another idea: emphasize the deficit-reduction factor of the public option. Here's another: start talking about "reconciliation," which only needs 50 Democrats to pass a deficit-reduction bill.

http://www.huffingtonpost.com/matt-osborne/reid-doesnt-need-lieberma_b_341833.html

Hold that over their heads while you discuss their pork-barrel. Put them in the dilemma: either vote for cloture, or lose everything and still lose.

[Chernynkaya]

What deficit reduction?

[jmpurser]

Under this bill we cram another 50 million people through the world's most expensive health care system that delivers the poorest results in the developed world. There is NO WAY to sell this as a fiscal "win". It's a disaster there just like it is on every other front.

[theycallthewindmariah]

No. Preventative care in doctors offices, or clinics, is alot cheaper than chronic care in an emergency room. This will lead to better "results" at lower costs.

[katooom]

The health INSURANCE bill that passed the house is NO VICTORY. It does NOTHING to address health care costs.

As for insurance - from yesterdays HP article:
"At its core, the measure would create a federally regulated marketplace where consumers could shop for coverage. In the bill's most controversial provision, the GOVERNMENT would sell insurance, although the Congressional Budget Office forecasts that premiums for it would be MORE EXPENSIVE than for policies sold by private firms."

So what good at all does this do? After we spend $1Trillion, The gov option will be MORE EXPENSIVE than private insurance? Who benefits from that! Only the insurance companies.

This bill is a travesty.

[Chernynkaya]

Fanned.

[theycallthewindmariah]

I don't think so. I'm looking forward to getting insurance that will cover my pre-existing condition.

[mergina]

A true health care victory would not involve a 2000 plus page waste of a bill. A true bill would simply LOWER COSTS ACROSS THE BOARD, ORDER PHARMA TO LOWER PRICES OR ALLOW AMERICANS TO SHOP ACROSS THE BORDER FOR THEIR MEDS, WOULD INSURE EVERY AMERICAN AND WOULD REGULATE THE INSURANCE COMPANIES AND HOLD THEM ACCOUNTABLE FOR THE DEATHS THEY ARE RESPONSIBLE FOR BECAUSE OF THEIR POLICIES.

[Decipherer]

Why do you and others repeat the line over and over again about this being a 2000 page bill? Who cares how long it is if it gets the job done? You sound like Bone'r and Can't-or, and all the other Republi-slugs from Saturday night, reading their talking points.

The things you are suggesting are simply impossible to achieve in a bill, unless you really want government to be involved in the minutiae of health care cost control.

Once I get past your ALL CAPS prose, what you are talking about at the core is a single payer system like universal Medicare, V.A., or essentially what members of Congress and federal employees receive. As logical and reasonable as that is, there was not enough support for passing that this year.

We need to do whatever we can do and get what we can get this year. We simply cannot let the perfect be the enemy of the good.

[theycallthewindmariah]

I think that repubs here have changed tactics and are trying to lower support for the House bill by pointing out it isn't "single payer", etc. Whenever they put that "doesn't control costs" or the "2000 pages" thing in, you pretty much know it is a repug.

[RepugsOut08]

There is no "victory" in this health care debate, and Obama has already let his constituents down. He should have fought for opening up Medicare for All, but he didn't even show up for the fight.
Imagine Bush deciding to invade Iraq, and then just leaving the decision totally up to Congress.
No way! Bush and his boys fought every day for what they wanted, and they got it. When a Dem was against them, they threatened them by calling them unpatriotic. They got their Dem votes for their corrupt war.
Obama turned his make-or-break issue over to Congress, and then walked away. Barely showin up in the last days of the debate, and then with no clear support for a robust public option. Do you think he's suddenly going to find his moxie now? Seriously?
I've read countless blogs over the last several months about what Obama "should do" to get health care reform passed. He didn't do any of them, and it's highly unlikely he's going to do anything helpful now. Face it. Obama has always intended an insurance industry-friendly bill. We've been had by one of the best speech-givers in history.

[Decipherer]

Why do you get off on criticizing Obama for letting Congress do the job it was elected to do as a SEPARATE branch of out co-equal, tripartite government?

President Obama set the agenda and challenged Congress to do its job. If you think, however, he is not working behind the scenes and out of the spotlight to get this and other bills passed, you are delusional.

I don't agree with everything that is going on, but for the first time in ~45 years, we have a serious chance of achieving reform.

What is wrong with that?

[RepugsOut08]

Bush didn't "work behind the scenes" when he decided to invade Iraq.
He came into our living rooms with his cohorts like Cheney, and FOUGHT for his agenda!
Day after day. Week after week. Month after month, until he got his corrupt war.
Don't you get it?
Presidents who want to be successful, don't "set an agenda," and then walk away.
They FIGHT for that agenda! That is if they want it to succeed.
So far, there's no real reform. Just an increase in insurance company customers, with no serious cost restraints.
Fight for opening up Medicare for all, and quit allowing political shills for insurance companies to make you think you've won a victory. They still hold all the cards as long as we let them.

[Conejo]

There is something very important in this health care reform debate that keeps being overlooked. The Republicans are arguing that it will raise taxes on the middle class and that it will adversely impact small businesses which are the drivers of employment.. But it won't. It will help small businesses. What they don't realize is that without health care reform, small businesses cannot hire because they can't afford to. They cannot afford the very high insurance costs for their employees. In other words the high cost of health care for small businesses is causing the high unemployment percentage. Fix health care and the unemployment percentage will come down.

[Yowsers]

Makes complete sense. If the Democrat is going to vote like a Republican, s/he would be treated like a Republican... If these Senators believe they will be given some cush with an emboldened Republican electorate, they will fail. Pair that with no Democratic money or backing, and the prospects of them surviving are nil if they don't back legislation.

Mr. President, what good are Democrats if they vote against one of your most pressing issues? Throw them out.

[Chernynkaya]

I agree. We have a majority in name only. It's a false victory.

[norwouldi]

Fanned and Faved. The Democrats who vote against this bill have just showed their true colors and have failed the litmus test of loyalty to beliefs that their supporters embraced. They are simply nothing more than career politicians that are only in Washington to collect their pension and pad their pockets. Welcome to the United States of Corporations. Government by the Insurance Companies, For the Pharmaceutical Companies and paid for by You and Me...(the lowly taxpayer). Some backing WE get for our OUR buck...Not! And Lieberman is nothing more than a whining Hyena that continues to irritate...

[gmgl]

It's simple and not difficult if one uses even a modicum of party discipline or force.

Lieberman is simple. Joe you are stripped of your committee chair if you don't vote with us. Same with Baucus. That is all that needs to be done. If you think either of those egomaniacs will let their chairs goes over this think again.

If you are a progressive you threaten not to back the bill if the party tries to bribe Lieberman or Baucus by watering down further whatever meager good things are left. They need your vote too.

I'm tired of only sticks reserved for progressives and all carrots given for pseudo blue dog "republicans" like Baucus and Lieberman.

[Yowsers]

The thing about power is that you only have it if people believe that you should have it.

[gmgl]

And very few people in the Democratic Caucus for the Senate believe Joe Lieberman should actually hold his committee chair. Last time I checked it took both Obama and Reid intervening to keep the caucus from stripping Joe of his Chair.

Exactly who do you think "believes" Joe should be in power? And what would happen if they suddenly stopped "believing". What if they "believed" someone who won't vote with the Democrats on Health Reform should not hold that nice Committee Chair gavel?

By the way, some things have power whether a person "believes" it should or not and vice versa even though I like your statement and it's profound in a way. Many people have been killed by viruses before anyone knew what they were or "believed" microbes had power.

[toggan]

Time for group think and mobilization. Reid is the "leader" right now, not a very strong one. Strong pro-reform senators will have to carry him and point him in the right direction, even baby-sit him because he gives up too easily. He is not suited to do the arm-twisting, but he will have to be encouraged continually to become more aggressive with possible defectors. I am not sure Obama is suited to do arm-twisting either; one can only hope. Reid will give away the whole store in order to keep it. Will the president? He needs to really know his party members, strengths and weaknesses. He doesn't impress me as someone who wants to get too involved. This is where his colleagues can assist him. Ideally he and the president should be on one accord on this, because this one is really too big to fail. Passage of the Health Reform bill, with the public option, is essential for his political survival as well as the president. Grass root participants should continually apply pressure on the conservative Democrats. No more concessions for Joe Liebermann, and everyone should be looking for his Achilles' heel.

[rad21]

What we have is health-insurance reform and not health-care reform. The politicians just hijacked the debate on true reform, replacing it with slogans. In fairness, the politicians main contribution is they have expanded access to healthcare insurance from about 85% to about 97% of Americans and that has been good

Faster the politicians pass this bill, quicker healthcare professionals can take over the process. And introduce true reform that will reduce the cost and increase quality of care; while eliminating over-use, under-use and inappropriate-use of medical resources.

Are the bright minds at the Ivy League institutions ready? Start by reducing the high cost of healthcare in east-coast states; where healthcare costs are nearly twice that in the mid-west. Let's stop blaming the politicians; and hold healthcare insurers and providers accountable.

[tralfas]

What are the malpractice laws in east coast states vs. mid west states? Where I live, judgments are capped at $250K for "pain and suffering," which seems to have a positive impact on keeping rates in check. I know people discount the savings from malpractice reform, but does their analysis take into effect how many unnecessary tests and procedures are done out of fear of being sued? Just look at the increase in C-Sections, which is a direct result of the rise in malpractice lawsuits.

[brklynivn]

Medicare spends the most in the Rio Grande Valley of Texas, where Doctor-Entrepeneurs charge twice to three times the amounts charged in the Northeast to freedum luvin tea-baggers on Medicare.

[eeepluribus]

below was for rad21

[eeepluribus]

Do you really believe that health insurers will begin to self-regulate and costs will go down, now that the government wants to hand them the keys to the kingdom and force everyone to be insured? People have seen their health insurance premiums rise the last decade by double and triple digits. Doctors won't be giving up their part of the pie either. What's stopping them?