I’ve been ruminating on the observation by an OTB commenter I mentioned the other day, that in the PPACA the Pelosi-Reid Congress enacted the “least disruptive meaningful change” to the system of healthcare insurance, trying to reconcile that observation with my own view of the law. Here’s what I’ve come up with.
I think it depends on how you define “meaningful”. I think that the Congressional Democrats defined meaning in terms of a list of buzz words, e.g. “guaranteed issue”, “community rating”, “market-based”, and so on, and their idea of meaningful resulted in the neoliberal mare’s nest of the PPACA. I don’t buy the apologist’s “60th senator” explanation. I think the PPACA is exactly what the Congressional leadership wanted.
I think the PPACA is exactly what the Congressional leadership wanted.
Candid? Harsh? Strongly stated? I’m kind of surprised…….
” I think the PPACA is exactly what the Congressional leadership wanted.”
This is so bizarre I am not sure how to respond.
Steve
I think the leadership could’ve gotten any bill they wanted passed. And, steve, if you think that the Democratic Congressional leadership really wanted single payer but had to back away from that to get Olympia Snowe’s vote, please submit some evidence. Acceptable evidence would be a bill implementing single payer that was making the rounds. I think it’s a pretty high hurdle since they didn’t get Olympia Snowe’s vote.
IMO the best explanation of why they adopted elements of a plan produced by Heritage Foundation twenty years previously is that Congressional Democrats had been persuaded over that period that they needed to include “market-based” elements. I don’t see any real evidence that they wanted Republican votes.
The president’s saying “well, if we were starting over…” does not constitute evidence that the Congressional leadership wanted single payer.
Mare’s nest? I think shit storm captures the reality better.
Has anyone followed the money? Throughout the whole nasty sausage making of PPACA it seemed to me that the Democrats had decided on this approach because it was lucrative for them to get in bed with the insurance companies, and they dealt with the pushback from leftist ideologues by claiming political necessity (clearly a lie for the reason Dave mentions- they didn’t get any GOP votes so why would they have needed to appease?)
Is there any reason to believe that this gut level impression of mine was inaccurate? Seems like it would be fairly easy to look at campaign contributions but I haven’t taken the time to check.
CStanley,
Dems first get into bed with the insurance companies, then they deride them, and now they are passing the buck back over to them to take the heat for this thing not working. It’s all part of the playbook they employ to win.
1) I dont understand the obsession with single payor. Most countries with universal care dont have single payor. Germany, France, Singapore, Japan, Australia, etc. You should know this. They are all viable models even if they all have problems. So does single payor. A true single payor like the Canadian or UK plan has zero political viability. Every Senator and Congressperson from a swing state/purple state loses their seat. Any bill they wanted? They couldnt even get the public option. If they really are socialists, and if there is anything they should have wanted if their goal is govt takeover, they should have wanted the public option. An IPAB with teeth. Strong exchanges rather than the weak ones they got. ETC.
2) There were any number of articles and books that were written about why Clinton, a capable politician (more talented than Obama), couldnt pass health reform. Pick one and read it. May I suggest Daschles book? I think it safe to say the consensus was that their plan was too radical. That it cut out Congress when they were the ones who would pay the price. That it didnt have buy in from the industry. Remember Harry and Louise? So, they started with ideas that were accepted by the GOP (Romneycare, the Heritage plan) and modified it. I think their idea was to pass a bill. Your idea seems to be that they should have failed again by trying to pass a better bill. (The health care industry has nearly always dominated predominantly to the GOP, 2008 being the real exception.)
3) I ask again, what could they possibly have included that would have gotten a GOP Senator to sign on. Just sharing one’s name on a bill was enough to get primaried.
Steve
Health sector donations.
http://www.opensecrets.org/industries/indus.php?Ind=H
@steve:
The charts at that link don’t capture the trend of health insurance company donations and lobbyong though. Looking at health field in general is different than examining how much cash flowed as a result of the choice to make healthcare reform all about health insurance reform, and getting that “buy in” you mentioned.
I think you are correct about the political inviability of single payer, but that was a bipartisan problem. It was moderate Dems in non-safe seats who had to be placated, not the GOP.
steve, you’re digressing. If you don’t think what was passed was the Congressional Democratic leadership’s preference and you don’t think that single payer was their preference, then what was?
I think the available evidence supports the idea that the PPACA was, indeed, what they wanted and the “60th senator” or “getting Republican support” excuses are just that, excuses. There is no practical way to bring legislation to the floor in the Congress without the support of the leadership. If they didn’t want the PPACA, they could have damned it at any time. They didn’t, so they wanted it.
I think it was pretty clear that their goal was insuring the uninsured. They campaigned on health care reform and they won. However, Clinton also promised health care reform and couldnt deliver. They wanted to cover more people and they didnt want to fail this time. They knew that if the health care industry opposed them they probably couldnt pass a bill. They knew that if it looked too much like govt run health care (NHS) it would be too easy to demagogue and get shot down. They knew that they couldnt risk insuring illegals or immigrants, so they had to exclude them.
In short, they had to design a bill that could pass. It couldn’t put the Senators from swing states into too much jeopardy. That meant incremental modification of our existing system.
I dont know what leadership though an ideal bill would be. Maybe Medicare for all, maybe not. I actually doubt that they were fixated on a particular reform. I think they wanted a politically viable bill that would cover as many people as possible. They gave up a lot of things they clearly wanted, like the public option, to get it passed. I think you can say they preferred the ACA over no reform bill. To say this was the bill they wanted all along is absurd.
Steve
I am going to have to side with Steve on this one. I think Dave’s argument would be much stronger if they hadn’t spend so much time and effort in corralling the cats towards something else (Public Option).
Something like single payer may have been preferred by many in congressional leadership. I’m not sure. I do suspect, however, that not much time, effort, and thought was put into plans that were pretty clearly never going to happen. Instead they wanted the public option, and absent that what we eventually got.
Basically, you’re agreeing with me, Trumwill. The Congressional Democratic leadership might have preferred what we got plus the “public option” in the abstract but they weren’t willing to pay the price for it so we got the PPACA as-is. That was their preference.
Except that, unlike Single Payer, they really did try and were willing to pay a price for Public Option. It’s just that the 60th senator wasn’t willing to.
That said, the 60th senator was a Democrat. Attempts to blame the final product on Republicans are… problematic. I say this as someone who wishes that the GOP had actually tried to influence the legislation instead of doing what they did.
I think the ACA is clearly what Obama wanted. Ezra Klein, a few days before the Senate voted out the ACA:
“The health-care bill that looks likely to clear the Senate this week is not very close to the health-care bill most liberals want. But it is very close to the health-care bill that Barack Obama promised.”
He then quotes the Obama campaign white paper:
“The Obama-Biden plan provides new affordable health insurance options by: (1) guaranteeing eligibility for all health insurance plans; (2) creating a National Health Insurance Exchange to help Americans and businesses purchase private health insurance; (3) providing new tax credits to families who can’t afford health insurance and to small businesses with a new Small Business Health Tax Credit; (4) requiring all large employers to contribute towards health coverage for their employees or towards the cost of the public plan; (5) requiring all children have health care coverage; (5) expanding eligibility for the Medicaid and SCHIP programs; and (6) allowing flexibility for state health reform plans.”
The main difference Klein observed is that “the exchanges look likelier to be run by states or regions than by the [federal] government.” Hillary Clinton’s plan was also a guaranteed issue plan, with the main controversy being an individual mandate, which Obama campaigned against. Much is made of the public option, but Obama himself said “I didn’t campaign on the public option.”
I think Congressional leadership generally gave form to Obama’s proposal. I don’t know if its what they wanted, but I think they believed they had a mandate for something close to what Obama campaigned on.
@Trumwill, when Obama denied he ever campaigned on a public option, there were a number of fact-check articles that I think concluded that it depends on what you mean by “campaigned” and by “public plan.” He actually rarely mentioned the public plan and its not clear what it was. What emerged were authorizations for national (or local) co-ops.
I think what happened is that most liberals believe that all smart people favor a single-payer. Obama and Hillary are smart people, so they do too. But they had to propose guaranteed issue as a compromise with moderates, who are not very smart, but venal and easily scared by conservatives. When a strong public option did not emerge, it felt like the Democrats were needlessly compromising with themselves.
As to Republicans, McCain’s proposals were built around eliminating the tax-break for employer-sponsored health-care, then high-deductible healthcare plans, portability to different states, HSAs, and tax credits to the needy. This is a very different direction.
PDS, I am making a distinction here between “public option” and “single-payer system.” Obama definitely never campaigned on the latter. I think you’re absolutely right that a lot of people assume that HRC and BHO really supported it. There was a private quote where Obama said as much, I think, though I’m not sure how verified it is. I actually think it’s true, but since he never said it publicly and never campaigned on it, I can’t disagree with someone who thinks otherwise.
The public option, though, was very heavily debated. The PO being “We’ll still have insurance companies and all that jazz, but we’ll let the government run an insurance company for those who can’t find insurance elsewhere or prefer it. There were some – I think precisely the sort of people you are talking about who assumed single-payer was and is the goal, as well as Obama-haters – who thought that the public option was a backdoor into single payer. But I’m referring specifically to the less-ambitious-than-single-payer-but-more-ambitious-than-PPACA Public Option.
Truth be told, whether Obama really supported that or not I don’t know. I honestly (and uncharitably, I’m afraid) think that Obama was purposefully vague on what he wanted other than something to call his own health care plan. I give Pelosi credit for pretty much everything. Pelosi, either speaking for herself or for her caucus, was very vocal about the public option for a while, and I think it was her preference, until she gave up on it.
Trumwill, I think you are misremembering when and how the public option was debated. When the Senate bill passed in 12/09 without a public option, Obama was asked about his promise of a public option and he said the Senate bill contains everything he campaigned on, and “I didn’t campaign on the public option.” This unleashed the fact-checkers, who discovered that “public option” was almost never mentioned in the campaigns, and if was his statements were not very clear.
Examples:
“We looked in our Obameter database for a promise the public option and couldn’t find one. We were surprised at first. After all, in recent days it feels like we hear the term “public option” a million times. ”
http://www.politifact.com/truth-o-meter/promises/obameter/promise/518/create-public-option-health-plan-new-national-heal/
“Obama never made the public option the focus of his health-care ideas, in the primaries or in general election. In fact, he never uttered the words “public option” or “public plan” in his big campaign speeches on health care.”
http://firstread.nbcnews.com/_news/2009/09/09/4436723-first-thoughts-obamas-three-audiences
After the election, Obama and others stepped up references to the public option (and it may have become important with the individual mandate reversal), and it was extensively debated among pundits and in the blogosphere. A public option certainly wasn’t important to Obama.
To say this was the bill they wanted all along is absurd.
What is absurd though is that the bill they passed was about as viable as Bernie the corpse, and had to be dragged across the line. If they were going to cut every backroom deal and use every arcane parliamentary move possible, why not do that for a more principled plan? I’m a conservative and definitely do not want single payer but at least it is something that makes sense and could actually ‘work’ ( if not in the fashion I prefer.)
Thanks, PD. More evidence of the point I made: the Congressional Democratic leadership got the healthcare reform bill that they (and the president) wanted.
That was precisely the question I asked in posts here when the bill was enacted. I don’t think the bill could be explained as an attempt to gain Republican votes. They didn’t notice that they didn’t have any Republican votes? I don’t think the bill could be explained by the need to attract the 60th senator. if Max Baucus had written the bill, do you think he would have criticized it as harshly as he did after he voted for it? What makes a lot more sense is if his arm had been twisted to vote for an obviously bad bill and he had buyer’s remorse.
The leadership could have blocked the bill at any step in the process if they hadn’t liked it.
That’s how I came to the conclusion I did. When you eliminate the impossible whatever remains, however improbable, is the truth.
Some interesting history: The House version did not trust state exchanges, and wanted national exchange primacy. When the Senate version replaced that concept with state exchanges, Progressives saw this as a major disagreement to be resolved in conference. Only a national exchange was seen as having the power to check the insurance industry.
“The single biggest weakness in the Senate bill is its reliance on states to implement the exchanges,” [Diane Archer] writes. “The federal government should implement the law in a uniform way and relieve the states of the burden of setting up whole new insurance markets and regulatory structures — unless they choose to and demonstrate their ability to — as the House bill provides. And, we need the will, skill, resources and power of the federal government to ensure that the insurers behave. ”
. . .
“It’s hard to imagine how Ben Nelson would get on board with national exchanges,” said one health care reform activist. “The states rights/every state is different argument” is an impediment.”
http://www.huffingtonpost.com/2009/12/30/latest-public-option-conc_n_407369.html
Its funny how the wheel turns. Today, the state exchanges were supposed to relieve the national government of an insurmountable task. Thanks, Ben Nelson?
@ CStanley
“Seems like it would be fairly easy to look at campaign contributions but I haven’t taken the time to check.”
Took me one minute. See, Insurance.
According to that site, the Republicans are the winners in the Who Gets the Insurance Company BigBux Sweepstakes.
I think my cite answer’s the question CStanely raised for Steve @ November 15, 2013 at 5:11 am.