The Alan Katz Health Care Reform Blog

Health Care Reform From One Person's Perspective

Fixing Health Care Reform Harder with Pelosi as Democratic Leader

Posted by Alan on November 5, 2010

The message delivered by the 2010 mid-term election is clearly in the eye of the beholder. Some see it as a repudiation of President Barack Obama and/or Democrats in Congress. Others see it as a rejection of incumbents of all political parties. Most everyone agrees, however, that this was an election demanding change. There are other blogs that do a great job of noodling through these kinds of issues. This blog focuses on health care reform. And while I believe the Patient Protection and Affordable Care Act will be changing over the next several months, the process won’t be easy.

The difficulty is only in part because a divided Congress is a guarantee of frequent gridlock. Consider the Kabuki Theater we’ll see play out on repeal of the PPACA. My guess is Republicans in the House will push through a bill to repeal the new health care reform law. This legislation may contain language to preserve certain provisions of the PPACA, but it will be dubbed the “repeal bill.” Not that the GOP majority needs their votes, but a handful of Democrats will likely vote for this bill despite pressure by the Democratic leadership to present a unified front (Democrats aren’t nearly as disciplined as Republicans in this regard, so someone is likely to jump ship).

Democrats in the Senate will kill the bill – and will likely prevent it from coming to the floor. Either party can filibuster. Even with with a few Democratic defections (that would be Senators Joe Lieberman, Ben Nelson and Joe Manchin) the GOP will fail to garner the 60 votes necessary. So President Obama won’t even need to veto the bill as it will never get to his desk.

This script, or something much like it, has nothing to do with public policy and everything to do with politics. Each side will be playing to their base. You might even see liberal Senate Democrats put forward legislation to implement a public option or the like, safe in the knowledge that such a bill would die in the House. Again, it’s all about making partisans (and pundits) happy.

Eventually, however, members of both parties will need to focus on the substantive work of amending the PPACA. In my previous post I wrote about the need for Republicans to decide if they will seek to improve President Obama’s health care reform plan or use the PPACA as a campaign issue in 2012. In that post I also brought up the possibility that Speaker Nancy Pelosi might retire from Congress given the drubbing House Democrats received on election night. She won’t. At least not yet.

Speaker Pelosi has announced she’ll seek to become the Minority Leader in the new Congress. This no doubt delights many Republicans in the House and saddens some Democrats. As the Associated Press reports, in making the move to stay on as House Democratic leader, Speaker Pelosi “rejected pressure from moderate House Democrats – and even some liberal allies .…” Again, other blogs will dissect the broader political impact of this move. But what does it mean for health care reform?

Unfortunately, Speaker Pelosi’s decision to stay on as the Democratic leader in the House means improving the Patient Protection and Affordable Care Act will be much harder than would be the case with someone else leading the Democratic caucus. First, because Speaker Pelosi is a lightning rod for conservative anger. Speaker-to-be John Boehner will have a tough enough time getting his caucus to vote for anything short of repeal of health care reform. The GOP Caucus in the House will contain a significant number of true believers: ideologues who consider compromise a mortal sin as opposed to a natural part of the political process. And even those Republican lawmakers prone to compromise will spend the next two years looking over their right shoulder evaluating whether a vote for half-a-loaf on an issue will have career-ending consequences. Getting these compromise-shy politicians to accept a deal brokered with Minority Leader Nancy Pelosi may be asking too much.

The second reason her decision makes improving health care reform more challenging is that it means no change among the negotiators. The Big Five in Washington for the past two years have been President Obama, Senate Majority Leader Harry Reid, Senate Minority Leader Mitch McConnell, Speaker Pelosi, and Minority Leader Boehner. Assuming no challenge to the two Senators (and none seems to be emerging) and with the likelihood of the House leadership simply switching offices, the same Big Five will be negotiating health care reform for the next two years. Meaning no new perspectives, no change in tone, no difference at all (other than the relative power each holds). As anyone whose survived basic chemistry in high school can tell you, if you have combine the same ingredients in the same way expect the same results. For those of us looking for improvements to the PPACA, this is not a good thing.

Democrats in the House could choose someone else as their Leader, but Speaker Pelosi is an excellent vote counter. I doubt she’d have announced her intentions without be certain they’ll be achieved.

A lot of the Democrats defeated on November 2nd were moderates – the Blue Dog Coalition in the House will be roughly half the size in the new Congress as it was in the old one. This means the Democratic caucus is more liberal going forward than it has been in the past. And given the success of the Tea Party the Republican Caucus has grown even more conservative. The gulf between the two, consequently, is greater than ever and there a fewer bridge builders to help span it.

Changing the PPACA is important. Having the same faces among the Big 5 and more extreme caucuses in the House doesn’t mean revising health care reform will be impossible. But it does mean achieving that change will be harder.


14 Responses to “Fixing Health Care Reform Harder with Pelosi as Democratic Leader”

  1. Ann H. said

    An interesting article appeared in Kaiser Health News today, stating that HHS plans to cut premiums 20% in year 2011 for the PCIP (Pre-Existing Condition Insurance Plan) because of extremely low enrollment. It says, “Overall, the new federal Pre-Existing Condition Insurance Plan has enrolled about 8,000 people nationally, even though the Congressional Budget Office estimated that as many as 4 million uninsured Americans would be eligible and that 200,000 would be enrolled by 2013.”

    I must be ignorant. If 4 million are eligible, and the govt predicted only 200,000 of those 4 million would enroll, why does the govt think they can force enrollment of everyone in health care plans in 2014? After all, the 4 million people who are eligible MUST HAVE A PRE-EXISTING CONDITION, MUST NOT BE ABLE TO GET INSURANCE TO COVER THAT PRE-EXISTING CONDITION, AND MUST HAVE BEEN UNINSURED FOR 6 MONTHS OR MORE!!!! Out of 4 million of these eligible people, the govt only predicted 200,000 would enroll?

    Secondly, if 4 million are eligible, the govt predicted 200,000 would enroll, and only 8,000 have enrolled so far, aren’t the problems deeper than a 20% rate reduction could solve? If the govt is reducing rates 20% aren’t they guilty of overcharging premium in the first place like they claim insurance companies have done? What is their MLR?

    If only 8,000 people enrolled, wouldn’t it be wise to use professional agents to market it?

    Pennsylvania has the lowest rates by far ($283 no matter what your age), but only 1657 have enrolled in that state. Let’s do a little math. If there are 4 million nationwide, divided by 50 states, that means an AVERAGE of 80,000 eligible people would be in each state. Since Pennsylvania is reportedly the 6th largest state by population ranking, one can assume there are many more than 80,000 eligible people in that state, yet only 1657 have enrolled, even though the price is ridiculously affordable. Clearly, price isn’t the only issue.

    I’m not sure how many enrollees other states have, but there’s a hint in the article when it states, “North Carolina, where rates range from $183 to $729 a month, has enrolled 513 people, tied with California for fourth highest in the nation.”

    The article also says HHS is planning to “offer different cost/benefit options”. Am I ignorant? What happened to their idea of strictly standardizing plans in the exchange in 2014 which would strangle innovation and private competition?

    Pelosi claimed they should pass the bill and then we could find out what’s in it. We’re finding out.

    The article is located at this address –

    • Curt Cella said

      Hi Ann –

      I commented on this earlier but will do so again in response to your commentary: The reason for the utter failure of the PCIP is simply this: The government – in its usual fashion – thought they could ‘do it better’ than private industry. They crafted PCIP plans that were benefit rich but absolutely too expensive to sell. I don’t know how many indiv quotes you run but when I run them – just to amuse myself – I’ll scroll to the bottom of the roster of quotes and lo and behold there is the PCIP plan quoting some outrageous figure. Just absolutely ridiculous price that only a millionaire could afford.
      You know Ann – every liberal worth his/her salt (And you can check it out almost daily in the LA Times!) will bash the HSA up one side and down the other. BUT: They could have created health plans with more buy in from the consumer – a la HSAs – that would have ultimately come in lower and more accessible. Instead they want to be the champion of the ultra left and craft a (PCIP) plan that you and I would kill for but can NOT be afforded by just about every consumer imaginable.

      This is EXACTLY the type of thing I (& Spencer) have railed against since Day One – each and every time in history where you have people who think they know what they’re doing take control of a situation they have no business being in – you will inevitably end up with problems for one and all and an utter failure. The PCIP is just a “first taste” of what awaits. A great reason why the government should stop telling us what to do with our lives,our money, our you-name-it until they get their own house in order!

      Just a quick comment here about Pelosi decision to run for Minority leader: Mind boggling. Simply mind boggling that folks like her can not sense the message sent by the American people and do the right thing and step aside gracefully: Even more astonishing that the President has basically given his tacit approval to that ongoing train wreck and astonishingly enough that there is NOT ONE courageous MODERATE democrat that will stand against her. Mind boggling. However it did give birth to THE political quip of the year:

      “…we welcome her (Pelosi’s) decision to run for House Minority Leader based on her proven ability to create jobs for Republican lawmakers,” said National Republican Congressional Committee (NRCC) communications director Ken Spain.


    • James Thornton said

      Ann, I am a self-employed Pennsylvanian paying dearly for a policy whose terms I cannot change. If I drop this policy, I will not qualify for a replacement policy because of medical underwriting. My sins, as perhaps some readers of this blog may recall, are taking antidepressants and statin drugs, two of the most heavily prescribed pharmaceutical classes in the country. Because of these medications, both my mood and cholesterol levels are in great shape. I should mention that I am also a masters swimmer and have placed as high as 4th in the world in my age group in a number of different events in the past several years.

      Despite this, I am considered an unacceptable risk by the system that many on this discussion forum consider to be vastly superior to Obamacare (as it is so often derisively referred to–this despite its very close resemblance to the Republican plan put forth during the Clinton era.)

      I would drop my current policy and switch to the PA high risk one in a heart beat except for one problem: I have to go uninsured for six months before I can qualify for this.

      At age 58, I do not anticipate catastrophic medical problems in the next half year. But I must say that the prospect of subjecting my family to the uncertainty of “going naked” for a half year to qualify for something we can afford is a horrible choice.

      I don’t know why so many Pennsylvanians who currently do qualify for coverage don’t opt in. I can only imagine that some can’t afford even the relatively bargain basement premiums; and others figure they are immortal, invulnerable, or that if the worst happens, the ERs will still have them covered.

      If faced with a penalty for not purchasing insurance, I suspect the “opt in” percentages will climb.

      • Curt Cella said

        I run an awful lot of quotes and I’m STILL waiting for one PCIP rate to be anywhere near affordable.

        I’m sorry James but I think your commentary here is a byproduct of your age. I’m not too far off from you and the thought of going without health insurance is horrifying to me as well – but guess what? I speak to folks day in and day out who not only are going without even catastrophic coverage but also don’t seem the least bit concerned or interested in remedying the situation. And you know what, James? Plenty of these same folks aren’t getting health insurance for their children either. They simply can’t be bothered. I talk to these people until I’m blue in the face – they simply go about their lives and – I guess – think the magic insurance fairy will dab them with a wand should serious illness or injury strike. And James? We’re not talking about homeless people here: We’re talking about two income earner families who pay rent/mortgage, have cars (plural!) and the latest iPhone. These are the choices people are making James – that’s why folks like me are asking how in the world are you going to “fine” these same people into buying ever escalating insurance policies starting in 2014? The answer is you’re not.

        Combine the ‘six month without rule’ & the incredibly high rates and what do you have? Well James it turns out that when push comes to shove the bureaucrats in this country are just as “heartless” as the private insurers they rail against.

        • James Thornton said

          Curt, you raise an excellent point. What you are describing here is what social psychologists refer to as the “free rider” problem, or what we layman tend to phrase as “what should we do about deadbeats?”

          I have been researching moral psychology for an article I am writing, and an excellent resource here can be found in a TED Talk by U. Virginia’s Jonathan Haidt (you can find the talk plus an interview with him at: )

          I tend to be pretty liberal in my thinking, but this has given me some insights into the philosophy of those who take the other road. In any event, I have come to think that some form of stronger punishment for “free riders” is necessary to make everybody feel the system is operable.

          I suppose the hard core libertarians among us would say let people buy or not buy insurance for themselves and their kids, and if they get sick, they can pay for the healthcare out of pocket or go without it. ERs should, in this view, be allowed to turn people away if they have neither insurance nor an ability to pay.

          Hard core liberals would suggest that only a single payer system can fix the problems–ensuring that everybody gets healthcare at the same basic cost, paid for out of tax dollars (which I suppose means that the wealthy would pay more.)

          Most people, I suspect, pay lip service to the need for some change, but figure that as long as they have good coverage at a cheap rate (subsidized by an employer), they won’t lose any sleep over those who get screwed by the individual market, denials, rescissions, and other obviously distressing outcomes for people like me.

          Oh, well.

          What will happen will happen. I don’t see how this forum and its passionate commenters are going to amount to much of a big whoop one way or the other.

        • Curt Cella said

          Well James – libertarian, liberal, or conservative – it’s all a moot point. Our lawmakers took the “discussion” and obliterated it with the Affordable Care Act: They said everyone MUST have health insurance. The problem that we usually end up discussing here is not whether folks should have affordable access to health insurance but whether the Health Reform legislation was effective in making that happen.

          This legislation NEVER addressed the underlying cost driver in health insurance (Skyrocketing health care costs) and did a lame job of trying to “force” people into buying health insurance (The amount of the fines are utterly laughable and since it won’t be actual cold hard cash but likely just pretend money consisting of siphoning off $$ from someone’s tax return.)

          What riles most of us here (and judging from what I can read and see from other sources) is that this was such an awful piece of badly written and thought out legislation. This conversation started with Ann’s take on PCIP – and that joke of a ‘fix’ is an advance preview of the whole show that starts in 2014.

          You’re right about one thing James – nothing we say here will make a difference: How can it when the Democrats who controlled the Congress didn’t even think to include any input from Republican legislators? Heck James – if they ain’t going to listen to a Republican Senator I sure as heck know they ain’t going to listen to a taxpaying voter like me!

  2. The Democrats will likely be in a fight to hold their ground on the health reforms wherever possible and this sort of tactic will likely be used by the Republicans in their marketing to show why a Republican majority is required to get “anything” done. The Democrats, on the other hand, will continue to be poor in using the media to their advantage and will likely be hurt by their efforts.

  3. Rick said


    How many “Rick’s” are allowed on your blog? I’ve been using the name “Rick” for about 1 year and did not post that message dated November 6th at 6:57am.

    • Alan said

      Apparently WordPress allows folks to use whatever name they like. They do give them different icons — I assume assigning an icon for each email address. Unfortunately, there’s nothing I can do to control the names people use. Sorry about that.

  4. Rick said

    This development sums up my one of my biggest nightmares, the US Congress will now begin to resemble the California Legislature in that both sides will be more polarized and the net result will be gridlock. Assuming that the Tea Party members of congress take on the attitude advocated by such pundits as Rush Limbaugh will draw a hard line in the sand as will the progressives led by Pelosi with the ultimate result being the remainder of middle-of-the-road moderates (a recently adopted term of derision by both sides) staying quiet and running under the radar. My prediction is that no real improvement will be made to PPACA under this new Congress. Our only hope is that “the Silent Majority” in the voting public will become agitated enough to clean house in a general way.

    • Alan said

      I share your concern Rick. At least in California we’ve taken reapportionment out of the hands of politicians and instituted open primaries, both of which should result in more moderate candidates winning office — or at least having a fighting chance. In any event, beginning in 2012 election results in California should more accurately reflect where voters stand. If those who claim to support making government accountable to the people got behind a national movement to institute these reforms, perhaps other states would follow California’s lead on this and politics would have a chance of becoming more civil, moderate and pragmatic. That would be a nice chance.

    • Curt Cella said

      Rick – can Sacramento gridlock get any worse when you consider how long it takes these sad excuses for legislators to pass a reasonable budget (Not the quicky ‘kick the can down the street to future legislators’ types of budgets that fix nothing an ignore the monumental fiscal problems this state has?!)?

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