The Alan Katz Health Care Reform Blog

Health Care Reform From One Person's Perspective

Health Care Reform a Question of Trust

Posted by Alan on March 10, 2010


In the end, health care reform may come down to a question of trust: does the House of Representatives trust the United States Senate enough? Yes, majorities in both chambers are  comprised of Democrats, but that is far from sufficient. We’re talking about political careers here. We’re talking about overcoming the animosity said to exist between House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid. We’re talking about politics, fear, egos and legislation that will impact every American along with one-sixth of the nation’s economy. During a recession. In an election year.

This is epic stuff going on here.

Let’s review. In order to enact President Barack Obama’s health care reform package Congress must execute a three step legislative dance:

Step One: the House passes the Senate’s version of reform – a bill most oppose, but could accept with some changes. Once passed by the House, the legislation would go to the President’s desk for his signature and become law.

Step Two: The Senate passes legislation to make the changes House members (along with Senators and the President) want. These changes would all relate to government spending or taxation, enabling this so-called “side-car” legislation would be passed by through the reconciliation process. In other words, the clean-up bill could be passed by the Senate with 51 votes instead of the super-majority of 60 votes requires for most legislation now days.

Step Three: The House passes the Senate’s side-car bill, sending it on to President Obama for his signature. Taken together, the Senate bill and the clean-up legislation becomes the Democrat’s health care reform package.

The problem is that before they can amend an existing law, that existing law has to exist. Meaning the House has to pass the Senate’s health care reform bill before they know whether the Senate can and will pass the clean-up bill. No one in Washington actually likes the Senate bill as it is chock full of provisions House Democrats neither support nor wish to defend in this election year.

Without complete confidence that Senate Majority Leader Harry Reid can and will push through the side-car legislation, asking House Democrats to pass the unloved Senate bill (without any support from Republicans) is a huge risk. What if Senate Democrats refuse to enact the remedies House Democrats expect and demand? What if Senate Republicans succeed in blocking passage of the clean-up legislation? A lot can go wrong. Given the only three laws that seem to  apply within the beltway (those being the laws of Gravity, Unintended Consequences and the one named after Murphy) something is all but guaranteed to go wrong.

Not surprisingly then, as I’ve talked to legislative staff and others here in Washington a lot of creative thought is being devoted to bridging the trust gap. One rumor was that Speaker Pelosi was demanding that Senator Reid deliver two letters. The first would put in writing his commitment to pass clean-up legislation satisfactory to House Democrats. This letter would also guarantee that the Senate Parliamentarian (who ultimately will decide what provisions can be passed through reconciliation and which can’t) will permit these remedies to be approved with a 51-vote majority under reconciliation rules.

The second letter requested by Speaker Pelosi was rumored to be one signed by 51 Senators pledging their support of the side-car legislation. 

If true, the Speaker’s demand for written assurances is highly unusual, to say the least. And not all of the guarantees are within Senator Reid’s power to offer. For example, he has no ability to commit the Senate Parliamentarian to any specific decisions. The Senate Parliamentarian is an independent, non-partisan referee. The current Parliamentarian was appointed by Republicans when they controlled the Senate. No one has questioned his fairness during his service since (although some Republicans are now setting the stage to attack him if any of his decisions work to the advantage of Democrats). Senator Reid cannot control what the Parliamentarian will decide.

Another rumored solution to the Democrat’s dilemma would be one in which the Senate’s health care reform bill would be deemed passed by the House only if the side-car legislation was also passed. In the House, votes are subject to “rules” which specify everything from how much time a measure can be debated to how many amendments may be considered. The theory is that a rule could be passed that would, in essence, make enactment of health care reform clean-up legislation a pre-condition for the vote approving the Senate health care reform bill being considered binding. Or official. Or something. OK, I’m not sure how the rule would be worded, but the goal would be to prevent health care reform from passing without the provisions of the side-car bill also passing.

What to make of all this? First, that Democratic Leaders feel a great sense of urgency to enact health care reform. The longer voters sees Congress  struggling through procedural mazes, the less they support the legislation. Some have reported that President Obama has asked to have a bill ready for his signature by Congress’ Easter recess (if he’s going to use holidays as markers I would suggest April Fools Day just to demonstrate the White House still has a sense of humor, but that may just be me. The Associated Press story cited above says the Administration is hoping to see health care reform legislation passed by the end of next week when President Obama is scheduled to start foreign travel.

The second takeaway from all this pretzel-making is that Democrats are anxious to make the legislation more acceptable to the American people. The side-car legislation will contain several provisions put forward by Republicans. It is likely to eliminate the sweetheart deals favoring specific states. Democrats know they’ll be attacked this November if they pass health care reform legislation or if they fail to do so. Given this reality their best strategy is to pass a defensible bill.

What all these rumors also imply is that whether health care reform passes all comes down to whether Speaker Pelosi and Senator Reid can trust one another. If they can, health care reform is likely to move forward. If they cannot, health care reform in its current form is most likely doomed.

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13 Responses to “Health Care Reform a Question of Trust”

  1. Nosedoc said

    This just surfaced on Yahoo:

    http://news.yahoo.com/s/ap/20100312/ap_on_bi_ge/us_health_care_overhaul

    Is Nancy Pelosi flying the airplane drunk, blindfolded or both?

    • Nosedoc,

      Thank you for that link.

      It can take time to read through all of the machinations being employed to pass this thing; in doing so I found this:

      “Obama tried to soothe the feelings of two generally liberal constituencies — Congress’s black and Hispanic caucuses — in separate White House meetings Thursday. Some black lawmakers say the health legislation doesn’t do enough to help poor people. Many Hispanic members say it mistreats illegal immigrants trying to buy insurance with their own money.”

      Well pardon me, but we have enough problems in this country now with Health Care. And Illegal Aliens (they aren’t immigrants if they aren’t here legally, as came my father, aunts and uncles who escaped Hitler, my wife’s father and uncle who immigrated from the Philippines, and many Hispanic friends of ours who immigrated here from Cuba, Spain, and Mexico; all Legally) consume a huge amount of our national health care bill yet have NOT paid into our system.

      It is illegal for any US Employer to hire an Illegal Alien, any. Should they be found out, they can be prosecuted, and if found guilty fined a lot of money and be imprisoned. A contractor friend in Palm Springs unwittingly had hired an Illegal who provided false identification, including a phony CA Driver’s License, a phony Social Security #, and when ICE caught up with him and deported him and his wife he had the audacity to call our friend and ask him to send him $9,000 to pay the “Coyotes” to smuggle him and his wife back to PS. When our friend said, “No way, Jose” (his real name…so he said) Jose’s family members, here Legally, stomped to his office an demanded that he help their criminal relative. Had our friend not been able to prove that he acted in good faith (and was paying CA State Unemployment and State Industrial) he could have been arrested and could have lost his life’s work!

      If it is illegal, as it should be, for an employer to hire an Illegal, then it should be illegal for any company or agent or broker to provide these Illegals with any form of insurance.

      The Employers who hire these “Coyotes” to bring the Illegals here should be tried, and if convicted, tossed in the clink for many years, their businesses sold and the funds dispersed to Health Care Agencies to help those here Legally. These Hispanic Leaders who demand that we should insure and “baby” Illegal Aliens need to get their heads clear, and begin worrying about the members of their community who need to be properly educated so that they can compete in an ever growing difficult economic time, and should not be advocating for our country to violate the law in a show of obvious disdain for the Rules of Law that govern this, and most other countries in the Free, and not free world.

      • Nosedoc said

        You did not mention EMTALA, the federal law that requires hospital emergency rooms to treat all comers, regardless of immigration status or ability to pay. This places a tremendous financial strain on every American hospital and the health professionals that provide services there.

        • Doc,

          You’re correct. I meant to do so, but didn’t. Thank you for reminding me, and all of the readers of this blog.

          Many years ago (well, to me), maybe 15, I presented a number of Group Health Docs a Long Term Care insurance group plan that had been approved for their staff (Group Health Coop, aka GHC, an HMO). The many docs (no offense meant by the term “Docs”, my dad was a Cardiologist) who I insured routinely complained about the numbers of Illegal Aliens and Welfare cases that expected to receive top dollar care surprised me. They were truly “pissed”.

          As an agent trying to do my best with this group I was nonetheless surprised. Perhaps I expected a more “understanding” response, especially from HMO docs. However, I felt it refreshing that they were so honest about their repulsion in having to give those who didn’t give a hoot the same quality of care they gave to the working poor, but contributing members of the Co-op, to those who weren’t here legally, and to those who didn’t care to contribute, even when they could. I fear that the many really great, and good physicians, who give their hearts and souls, after having given their hard earned dollars and years of education to their (your) chosen profession to Help people, will be so harmed by this irresponsible legislation, that they, as are many Medicare docs already, will decide to retire, or find another field in which to give their service. No one has a constitutional mandate to go broke.

          A good friend of mine, a neurologist, no longer will work with Medicare. He either charges the patient what they can afford, or writes it off. He had a “write up” in Newsweek. He has performed millions of dollars in pro-bono work rather than subject himself to government interference.

          It occurs to me that you walk in those same heart filled and caring shoes.

        • EvoRev said

          I’m not certain where I saw the story now, but I just saw a report that talked about how if the reform bill passes there is concern that we will lose a large number of physicians.

          I wish I had more time to focus on what they were saying. I’m not certain how passing this bill would translate into fewer physicians but that was certainly the assertion.

          One factor, I suppose, would be income. If a physician believes he or she can no longer earn enough to A) pay back student loans and B) pay for malpractice insurance then I suppose there comes a point where it simply isn’t viable from a business standpoint.

  2. I just saw this video of a comment made by Nancy Pelosi that should trouble anyone who thinks that this HCR action should be passed into law:

    And this woman is the Speaker of the House? I find it difficult to believe, though I have often observed her complete arrogance and condescending manner toward the electorate, that her staff allowed her to make such an off the charts comment.

    • Nosedoc said

      Well, it’s the same staff that is allowing this woman to try to lead all the lemmings off the proverbial cliff.

      You liked the last metaphor, Spencer, so I came up with another one.

  3. Alan,

    As usual, an excellent commentary!

    While under the current Democratic Majority in both Houses of Congress, unnecessary to passage of any iteration of HCR, the question I think perhaps even more important is, “Does the American Electorate trust either the House, the Senate, or the Administration?”, and given what I have been reading, hearing and observing, the answer by a large majority of Americans would be, “No.”

    And that should strike anyone reading this blog as a very sad commentary on the state of Politics in this country.

  4. Nosedoc said

    Would the President sign the Senate bill without the clean-up legislation? If he were to do this, then he, not Harry Reid, would become Lucy pulling away the football at the last split second, sending Charlie Brown (every Democratic Congressman) flying. This would be a betrayal of trust of monumental proportions, and would establish a disgracefully unethical precedent.

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