Public Health Insurance Plan Compromise Likely When Time Is Right

The decibel level concerning whether health care reform should include a government-run health plan got a lot louder this week when President Barack Obama reiterated his strong support for the concept. Partisans on both sides of the issue ratcheted up their rhetoric several notches, drew pretty lines in the sand and retreated to reading doomsday passages from their partisan play books. Amid the clamor there were even reasonable, constructive policy discussions to be heard. All of this is to be expected. And while it can generate great anxiety among those who care about the issue, it’s important to keep things in perspective.

First, there’s no health care reform bill yet. Key House and Senate Committees are drafting them right now, but nothing “official” is on paper yet. For now everything we’re hearing comes from option papers, outlines and letters. The legislative process involves numerous steps. What people expect it legislation to look like doesn’t really matter all that much. In fact, what legislation looks like when it’s first introduced doesn’t mean all that much. It’s what the bill contains when it winds up on the President’s desk that matter. Until that version of the bill emerges, it’s all just part of the debate. 

Second, no one should be surprised that President Obama considers a government-run health plan to be important. He made his position clear during the campaign. Often. His position on the issue seems to be one of principle, not politics. He sincerely believes that, as he wrote in his letter to Senator Max Baucus and Senator Edward Kennedy, a public plan “… will give [consumers] a better range of choices, make the health care market more competitive, and keep insurance companies honest.” You may disagree with his conclusion, but he has been consistent and specific about his intent.

Third, what President Obama wants from health care reform is critical. He’s a popular president advocating popular positions. The need for comprehensive health care reform is widely accepted. The President is an extremely skillful politician (just as Secretary of State Clinton and Senator John McCain). And ultimately, he’s the one who signs the bill or vetoes it. However, the White House is only one piece of the health care reform puzzle — a big piece, but still only one piece.  Congress will write the health care reform legislation. And Congress, by design, does it’s job messily. There are three House Committees (Energy &Commerce, Ways &Means, and Education & Labor) and two Senate Committees (Finance and Health, Education, Labor & Pensions) with jurisdiction. Within each chamber, the committee chairs have all pledged to cooperate and present a unified bill. That doesn’t mean they agree on everything, however. Getting to a common bill in either the House or Senate will require tremendous work and substantial give-and-take. And any unified bill within a Chamber is only the beginning. The House and Senate bills will need to be reconciled. 

Fourth, in the end, it all comes down to votes. Democrats have sizeable majorities in both chambers of Congress. That’s a blessing and a curse. It’s a blessing because the majority, eventually, tends to rule — or at least get most of what it wants. It’s a curse because getting to a large majority means creating a big tent. The Democratic political strategy for the past several years have been to recruit and strongly support candidates who fit their districts, not who meet some test of ideological purity. Which means there are liberals, moderates and conservatives on the Democratic side of the aisle in both the House and the Senate. This, in turn, means the White House and the Congressional Leadership must negotiate with members of their own party at the same time they are negotiating with the GOP.

What all this means is that what’s being said today about a government-run health insurance plan is significant, but not determinative of what will become law. President Obamamay want a public health plan. Leaders in Congress may wanta public health plan. But in the end, they want comprehensive health care reform more. And that means bringing along the moderate and conservative members of their caucus and, if possible, Republicans, too.

Some of those moderates have made clear they have problems with a government-run plan. Consider this report from Bloomberg entitled “Health ‘Public Option’ Hits Bipartisan Resistance:  “A group of House Democrats from Republican-leaning states said any “public option” must be tightly restricted so it doesn’t undermine private industry. We cannot create a public option that stacks the deck — through rate-setting and forced participation — against a system that currently provides coverage to 160 million Americans,” said Representative Mike Ross of Arkansas, chairman of the health-care task force of conservative “Blue Dog” House Democrats.”

Senator Bill Nelson, a conservative Democrat, said this weekend that, while he is open to a public health insurance plan under some circumstance, “‘It’s a deal-breaker for me if there’s a government-run plan to replace existing insurance plans,” according to the Lincoln Journal Star. Other moderate and conservative Democratic Senators have expressed similar reservations or, like Senator Evan Bayh are, at this stage of the debate, “agnostic” about the value of a public plan.  He w3nt on to say that a public plan might be limited to serving as “a backstop, as a last resort, if the private sector has just failed to meet the challenge.”

Politics, it is often said, is the art of compromise. But it’s also a lot like poker and as the song goes, in that game you’ve got to know when to hold ’em, know when to fold ’em. The key word in that lyric is “when.”  When it comes to a government-run health insurance plan, then is not now. It’s too early for partisans on either side of the debate to compromise. That time will come soon enough. Who does the compromising will be determined the way it always has been: by whose vote is needed. Passage of comprehensive health care reform will require votes from members of the Blue Dog Coalition (House Democrats) and the Senate’s Moderate Dems Working Group. When it comes to fashioning a compromise, it’s the positions of these lawmakers that need to be closely watched.

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Health Care Reform is Coming, But it Won’t Be Easy

Personally, I think health care reform is inevitable. The need for change is simply too great. Too many people go without coverage, too many are insecure about the coverage they have. Controlling medical costs is a critical part of fixing the economy: businesses and state and local governments need relief. Political pressure for a solution — from across the ideological spectrum — has reached critical mass.

The reform process is well underway. President Barack Obama held a health care summit at the White House earlier this month. Several proposals are making the rounds. Senate Finance Committee Chair Max Baucus has one.  Senate Health, Education, Labor and Pensions Committee Chair Ted Kennedy and his staff have been actively meeting with stakeholders. Democratic Senator Ron Wyden and Republican Senator Bob Bennett have introduced the Health Americans Act, which is supported by several colleagues from both sides of the aisle. There’s the proposal put forward by President Obama during the campaign and embellished somewhat since his inauguration. Republicans have their plans and think tanks have theirs.

We’ve seen this before. In 1993 it looked like President Bill Clinton’s spent enormous political capital seeking health care reform. He failed. A recent Newsweek article by Katie Connolly outlined several reasons why the health care reform debate now is likely to be much different than the battles in 1993. The Clinton Administration failed in large part because their efforts were politically inept and inflexible. President Obama’s approach is much more open, inclusive and savvy.

Of course, at this stage we’re still dealing with generalities. The specifics, which is where the devil receives his mail, have yet to emerge.  When they do the hard part of the process begins. And that could be any week now.   The Washington Post’s Lori Montgomery and Ceci Connolly reported today that “House Democrats, in consultation with the White House, will give Republican lawmakers until September to reach a compromise on president Obama’s signature health-care initiative ….”  Currently, several committees in both houses of Congress are holding hearings on health care reform. These, however, are more educational in nature, allowing interested parties to provide input and begin staking out positions. With little legislation before them the hard negotiations have yet to begin. Those discussions will have to start sooner than later if Congress is to meet the House Leadership’s September deadline. Given the complexity of health care reform it will require months of negotiations to find common ground. 

Finding that common ground won’t be easy. Already Republican Leaders are identifying deal killers. A National Association of Health Underwriters’ newsletter quotes Senator Chuck Grassley, the ranking Republican on the Senate Finance Committee as identifying the Obama Administration’s call for a national health coverage exchange to compete with the private market as extremely problematic. The GOP won’t accept such a program, according to Senator Grassley, and Democrats are likely to insist on one. There may be a way to create an exchange that satisfies both parties, but that requires a lot more specifics than have emerged yet. 

(Note added 3/20/09 at 7:45 pm: the rift between Senator Grassley’s position and those favoring a government insurance plan is growing wider — and nastier. Carrie Budoff Brown, writing in Politico today, reports on “a four-day ad buy aimed at Iowa Sen. Charles Grassley, the ranking Republican on the Senate Finance Committee who is increasingly vocal in his opposition to the government insurance option.” Health Care for America Now is leading the charge against Senator Grassley. At the White House Forum on Health Care the ranking Republican on the Senate Finance Committee told President Obama that such exchanges were “‘an unfair competitor’ and could run private insurers out of business,” according to the Politico story. The article also notes that Senator Wyden found no Republican Senators willing support his bipartisan legislation if it included a government run health plan. “From a raw political standpoint, having talked to a lot of senators, I wouldn’t have any Republicans on the Health Americans Act as cosponsors if we had a public option,” he told Politico.)

There is a way for Democrats to pass health care reform without Republican votes. If a compromise fails to emerge by September, the House Leadership is pushing for a legislative process that would allow passage with simple majorities in both chambers. This would be accomplished through a process called “budget reconciliation.” Under the reconciliation rules, filibusters are not permitted enabling the Senate to move legislation forward with a simple majority of 51 votes instead of the 60 needed to end a filibuster. Democrats currently hold 58 seats in the Senate (including those of two independents who caucus with them) with one more likely to arrive from Minnesota. (Filibusters don’t exist in the House, making passage by majority vote the norm in that chamber).

But Democrats may have a tough time pulling together even 51 votes in the Senate. Senator Evan Bayh announced on MSNBC on Wednesdaythat 16 moderates in the Senate (15 Democrats and one independent who caucuses with the party) have come together to provide a united, centrist voice to issues such as health care reform. As noted in the press release announcing the group’s formation, their goal is “to pursue pragmatic, fiscally sustainable policies across a range of issues, such as deficit containment, health care reform …” and others. With 16 members, this caucus, currently dubbed the “Moderate Dems Working Group” represents more than a quarter of the Democrats serving in the Senate. If even 10 0f these centrists stick together they’ll need to be a part of any deal struck on health care reform.  (A list of the 16 Senators in the group is below).

At the same time there are liberals in Congress who would just assume have government take over the health insurance industry and create a single payer system similar to that in place in Canada and many Western European countries. At the very least they look to a greater role for the government in providing health care coverage to middle class Americans (the government is already the primary insurer for older and low income citizens).  They won’t go quietly along with a solution they feel fails to assure universal and comprehensive  coverage.

What this means is that while health care reform is coming, getting there won’t be easy. But there is a way. President Obama has long talked of the need to focus on core principles and the desired outcome instead of on how we get there. He has even said that his campaign proposal for a federal health insurance exchange (the deal breaker identified by Senator Grassley) is negotiable. As noted in the Newsweek article, the president said at  the White House summit, “If all Americans could be insured at ‘an affordable rate and have choice of doctor, have flexibility in terms of their plans, and do that entirely through market, I’d be happy to do it that way.'”

This is the approach all lawmakers and interest groups — whether liberal, moderate and conservative — need to bring to the table. The health care reform debate will be heated, passionate and difficult. But if all participants focus on the goals, the means of getting there can be found.  Given the need, it better be.

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The 16 members of the Moderate Dems Working Group (who, hopefully, will work on coming up with a better name) are:

• Evan Bayh (Indiana) – co-chair
• Mark Begich (Alaska)
• Michael Bennet (Colorado)
• Tom Carper (Delaware) – co-chiar and a member of the Senate Finance Committee*
• Kay Hagan (North Carolina) — a member of the Senate H.E.L.P. Committee*
• Herb Kohl (Wisconsin)
• Mary Landrieu (Louisiana)
• Joe Lieberman (Connecticut)
• Blanche Lincoln (Arkansas) – co-chair and a member of the Senate Finance Committee*
• Clare McCaskill (Missouri)
• Ben Nelson (Nebraska)
• Bill Nelson (Florida) — a member of the Senate Finance Committee*
• Mark Pryor (Arkansas)
• Jeanne Shaheen (New Hampshire)
• Mark Udall (Colorado)
• Mark Warner (Virginia)

* The Senate Finance Committee and the Senate Health, Education, Labor, and Pensions (H.E.L.P.) Committee have primary jurisdiction over health care reform legislation.