Monday, July 20, 2009

Monday Morning Health Care Roundup

"A Real Win for Single-Payer Advocates" (John Nichols):
Canada did not establish its national health care program with a bold, immediate political move by the federal government.

The initial progress came at the provincial level, led by the Co-operative Commonwealth Federation's Tommy Douglas when he served from 1941 to 1960 premier of Saskatchewan. The universal, publicly-funded "single-payer" health care system that Douglas and his socialist allies developed in Saskatchewan proved to be so successful and so popular that it was eventually adopted by other provinces and, ultimately, by Canada's federal government.
For his efforts, Douglas would be hailed in a national survey as "The Greatest Canadian" of all time. But Douglas' regional initiative also offers a lesson for Americans.

Those of us who know that the only real cure for what ails the U.S. health care system is a universal public plan that provides health care for all Americans while controlling costs recognize the frustrating reality that there are many economic and political barriers to the federal action that would create a single-payer system. This makes clearing the way experimentation at the state level all the more important.

And, remarkably, the forces of real reform have won a congressional victory on that front, a victory that ought not be underestimated.

By a 25-19 vote, the House Committee on Education and Labor on Friday approved an amendment to the House's health-care reform bill allowing states to create single-payer health care systems if they so choose.

"There are many models of health care reform from which to choose around the world – the vast majority of which perform far better than ours. The one that has been the most tested here and abroad is single-payer," explained Congressman Dennis Kucinich, the Ohio Democrat who proposed the amendment. "Under a single-payer system everyone in the U.S. would get a card that would allow access to any doctor at virtually any hospital. Doctors and hospitals would continue to be privately run, but the insurance payments would be in the public hands. By getting rid of the for-profit insurance companies, we can save $400 billion per year and provide coverage for all medically necessary services for everyone in the U.S."

Votes for the amendment came from progressive Democrats who favor single-payer -- such as Congressional Progressive Caucus co-chairs Lynn Woolsey, of California, and Raul Grijalva, of Arizona -- as well as conservative Republicans who have no taste for single-payer but want states to be able to set their own agendas.

Opposition to the amendment came mainly from Democrats such as committee chair George Miller, of California, who have resisted moves to create more flexible, innovation-friendly legislation.

The Education and Labor Committee -- one of three in the House with jurisdiction over health care -- then apporved the amended America's Affordable Health Choices Act, H.R. 3200, by a vote of 26-22.

The campaign for to add the amendment was advanced by a number of groups, in particular Progressive Democratic of America, which mounted a last-minute campaign to sway Democratic members of the House committee. PDA Tim Carpenter is right when he says: "This is a victory for single-payer advocates. Our job in the ensuing weeks will be to ensure that this amendment does not get stripped from the final legislation."

And they will have powerful allies who will fight to preserve the amendment.

After the committee vote, Rose Ann DeMoro, the executive director of the California Nurses Association/National Nurses Organizing Committee, said, "This is a historic moment for patients, for American families, and for the tens of thousands of nurses and other single-payer activists from coast to coast who can now work in state capitols to pass single-payer bills, the strongest, most effective solution of all to our healthcare crisis."

De Moro gets it.
Allowing states to do what is necessary to provide high-quality yet affordable health care for all -- even as a federal plan falls short of that goal -- opens up vital new avenues for promoting, and actually implementing, single-payer systems.
"Why Obama Likes His Odds" (E.J. Dionne Jr.):
It was not the soaring rhetoric that is Barack Obama's signature, but he recently offered the sound bite that may define his presidency: "Don't bet against us."

There are reasons to believe that his confident words -- they were about health-care reform but have broader application -- were not the bombast of a bluffer exaggerating the strength of his hand. They reflect the high cards that Obama holds and has only now started to play.
Of course, no one ever thought passing a health-care bill would be easy, and the effort hit some bumps last week over costs and how to cover them.

But Obama doesn't quite see things the way his more nervous Democratic allies do because he missed the years in Washington during which his party was beaten down. Many Democrats had their perceptions of political reality shaped by the failure of Bill Clinton's health proposal, the 1994 Republican revolution and the GOP's triumphalism during President Bush's first term.

That world, however, turned upside down in 2005 -- the year Obama arrived in Washington. Bush's power dissolved in the failure of his Social Security privatization proposal, the Hurricane Katrina backlash and rising disillusionment with the Iraq war. By the end of 2006, less than two years after Obama's arrival, Democrats had seized control of both houses of Congress.

The paradox is that Obama's limited experience under Republican sway makes him more comfortable than many of his allies are with wielding the power that comes from large Democratic majorities.

And it's real power. Nothing made that clearer than the trajectory of Judge Sonia Sotomayor's Supreme Court nomination battle -- or non-battle.

It has often been said that Republicans have not put up much of a fight against her, but the reason for their pacifism is rarely mentioned: Republicans were severely constrained simply because they lack numerical clout.

Had the Senate been more closely divided, the GOP might have mounted a more aggressive campaign that, if nothing else, could have raised the cost for moderate Democrats of supporting Sotomayor. But knowing they'd never get the votes to stop her, Republicans decided to wait for a more opportune moment to pick a real fight.

The numbers work Obama's way on other issues. Much was made of the 44 House Democrats who defected from the president's position by opposing the cap-and-trade bill last month. The more important fact is that Democrats have such a big majority that they could lose all those votes and still prevail, even if narrowly. The same numbers give Speaker Nancy Pelosi significant room to maneuver in selling the House health-care bill.

And with 60 votes in the Senate, Democrats can, in principle, work their will on health care without any Republican support. Obama is bound to make compromises, partly to bring along moderate Democrats. But the size of the Democrats' Senate majority means they won't be able to blame the Republicans if health reform dies. This increases the pressure on moderate Democrats to get something done.

There is thus an irony to the game Obama must play. He will continue to speak in bipartisan terms to keep open the possibility of picking off Republicans if they're needed -- Sen. Olympia Snowe (R-Maine) already seems inclined to work with him -- and because such an approach appeals to moderate Democrats whose sensibilities he must soothe.

The open-to-the-other-side style also helps him hold support from political independents around the country. He needs them to preserve his good approval ratings, which are themselves a form of political capital.

But Obama must simultaneously convince Democrats that they are not living in the Republican congressional eras of 1995 or 2003 -- that if it's necessary, they have the strength on their own to win. This was the implicit message Obama conveyed to Sen. Max Baucus (D-Mont.) to push him to conclude his frustratingly protracted health-care negotiations with Republicans in the Senate Finance Committee.

Getting Baucus to move this week is essential to maintaining momentum. If Obama seems likely to win, interest groups will be more forthcoming, his own party will be more likely to hold together and more Republicans will be inclined to cut a deal.
And that, finally, is why Obama wants to make sure his party bets with him, not against him. His core message to fellow Democrats is that the only things they have to fear are the fears and insecurities bred into them when they were a battered minority. Obama is free of those doubts because he never knew them.
"President Is Set to 'Take the Baton'" (WaPo):
Six months into his presidency, Barack Obama may have no greater test of his ability to translate personal popularity into a successful legislative agenda than the upcoming two weeks.

With skepticism about the president's health-care reform effort mounting on Capitol Hill -- even within his own party -- the White House has launched a new phase of its strategy designed to dramatically increase public pressure on Congress: all Obama, all the time.
Senior White House aides promise "an aggressive public and private schedule" for Obama as he presses his case for reform, including a prime-time news conference on Wednesday, a trip to Cleveland, and heavy use of Internet video to broadcast his message beyond the reach of the traditional media.

"Our strategy has been to allow this process to advance to the point where it made sense for the president to take the baton. Now's that time," said senior adviser David Axelrod. "I don't know whether he will Twitter or tweet. But he's going to be very, very visible."

Another senior White House aide added: "It's time to raise the stakes on this."

But even as Obama returns to full-time campaign mode, he is facing increasing calls to show that his presidency can manage the tough, nitty-gritty of lawmaking by cutting deals with his allies to keep his health-care legislation moving in the House and Senate committees.

Conservative Democrats in the House are promising to vote against reform as it now stands, and are preparing two dozen amendments, including measures aimed at lowering the effort's long-term cost. In the Senate, members from both parties are urging the president to break his campaign promise to preserve the tax-free status of health benefits. And a chorus of weary voices from Capitol Hill is urging him to abandon his demand for passage of bills in the House and Senate by Aug. 7.

"I don't think we should be bound by a timetable that isn't realistic," Sen. Olympia J. Snowe (R-Maine), a key swing-vote on health care, told Obama last week as she reminded him that President Lyndon B. Johnson took 1 1/2 years to pass Medicare.

Obama has not officially budged on the timetable, although he and aides notably have not mentioned the August deadline in recent remarks. But he is quietly working with conservative, Blue Dog Democrats in the House on an amendment to create an independent panel to govern Medicare reimbursement rates that could help reverse crippling health-care inflation.

Most difficult for Obama is the pressure to accept a tax on health benefits as a way of financing the massive insurance reform he wants.

Speaking on "Fox News Sunday," White House budget director Peter Orszag would not rule out support for the benefits tax, but he continued to promote Obama's preference for limiting deductions for wealthy taxpayers.

Some Democrats close to the negotiations say they think it is only a matter of time before Obama backs off. One proposal that has emerged would tax insurance companies, as opposed to beneficiaries, and is considered a potential compromise approach that he may be able to embrace.

Aides said Obama and his team plan a rapid response to new developments, as they did Thursday with a quickly arranged conference call to rebut assertions by the Congressional Budget Office that health-care costs would go up, not down, if the Democratic bills pass.

The effort began Friday with impromptu remarks by Obama from the Diplomatic Room, even as groups allied with the White House launched political ad campaigns this weekend aimed at wavering lawmakers. On Monday, his advisers say, he will do a round of interviews to drive the narrative for the week. Private meetings with lawmakers will become more frequent and urgent.

The decision to vault Obama to the front carries huge risks.

The decades-long drive to reform the health-care system now rests largely on Obama's ability to quell revolts among Democratic allies, many of whom have spent the past several weeks picking at pieces of his proposals.

If conservative House Democrats succeed in sowing fear of rising deficits, it will be seen as Obama's fault that he could not rein them in. If Democrats in the Senate do not agree on financing, Obama must explain the failure despite his party's majorities in both chambers.

The health-care debate was at the center of private discussions at the annual summer meeting of the National Governors Association over the weekend. The health-care legislation under consideration in Congress envisions a significant expansion in eligibility for Medicaid, whose costs are shared by Washington and the states. Their budgets squeezed by the recession, governors fear a costly mandate to cover the newly eligible. The governors devoted most of a private lunch to the issue Saturday and earlier voiced objections to Senate Finance Committee Chairman Max Baucus (D-Mont.) over funding plans.

Obama's top strategists, including Axelrod and Chief of Staff Rahm Emanuel, have repeatedly defended the administration's ambitious agenda by saying that success breeds success -- each legislative victory makes the next one easier to accomplish, they insist. The flip side, then, is that a health-care failure could doom the rest of Obama's agenda.

Obama's advisers express confidence that the setbacks of the past week can be overcome, and they insist they have spent "no time" discussing the impact on his political fortunes if health-care reform does not pass this year.

"We don't do doom-and-gloom," Axelrod.

But the president's top advisers also recognize that the sense of optimism about health-care reform that existed in Washington several months ago has largely evaporated.

Cable news programs repeatedly declare the president's health care program is "teetering" or "embattled," despite a week in which Obama's proposals were endorsed by the doctor and nurses associations and committees in both legislative chambers passed major bills.

"We're swimming upstream against a culture of failure on health care in Washington," said one adviser, who spoke on the condition of anonymity to discuss the administration's strategy.

The White House decided early in the year on a hands-off approach to health-care legislating.

"Had we put a plan out, the entire debate would have been changes to the plan," said Emanuel, a veteran of the failed Clinton health battle. "It would have been how the president is failing or succeeding."

But even as he shifts into a more active role, Obama must be mindful of his legislative allies. Rather than strong-arming these old bulls, the White House must tiptoe around them.

Baucus was a veteran lawmaker in 1994 when the Clinton plan ran aground. House Energy and Commerce Chairman Henry A. Waxman (D-Calif.) is a leading health-care expert. Senate health committee Chairman Edward M. Kennedy (D-Mass.), who is battling brain cancer, voted to create Medicare in 1965.
For health-care reform to succeed, Obama will have to carefully navigate between paying the appropriate respect to those men while exerting the leadership that many are demanding.

"It's getting hotter, and there are bumps, but we are closer to health-care reform than ever before," Emanuel said.

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