Healthcare roundup: countdown to cloture

            A few things about healthcare reform, now that all the bribes have been distributed and the Senate is about to end the madness (at least, until January):

          First, even though the bill disadvantages low-income women and is way too lenient towards the pharmaceutical and insurance industries, the fact that it was hijacked by moderates in the final weeks is not worth crying over.  Sen. Ben Nelson (D-Neb.) may have been the voice of unreason in wanting to match the House’s strict language on abortion, but imagine what the bill would have looked like if he and the other conservative Democrats were not even at the table.  If a rank-and-file Democrat ran for the Senate in Nebraska, rather than a Democrat who matched the constituency, that would have opened the door for a Republican to take Nelson’s place.  Then there would be 41 Limbaugh-lites running around—none of whom would be even receptive to sitting down and negotiating like Nelson was.

            Second, what is it with the Senate’s penchant for allowing states to partially opt out of reform?  First it was the public option, now it’s abortion coverage (states can opt out of allowing plans that cover abortion on the exchange).  I am pretty sure that Roe v. Wade does not read “Women have the right to an abortion, unless their Republican governor or legislature says it’s not cool,” so why are low-income women in conservative states being disadvantaged here?  Members of the House are rumbling that this provision might not be constitutional, I could only presume on grounds of full faith and credit—nevertheless, whatever the justification, it is unfair.

            One other abortion comment: the proposal to mandate everyone to write two separate checks, with the intent of segregating private abortion coverage from premium payments that may be subsidized by the government, is acceptable in principle, but practically is a headache-and-a-half.  For instance, say that my monthly premium is $60 and my insurer charges $1 per month in case I need an abortion (with the other $59 going to routine checkups, money in case of an organ transplant, etc.).  I would have to write one check for $59 and one for $1, which seems to me like it has the potential to increase administrative costs.  However, looking at the access aspect, I don’t believe that many abortions are elective procedures, like cosmetic surgery.  And I think it’s unfair to charge women for the operation above and beyond what they’re paying for other medical services.  If all the Nelson compromise does is slice off a portion of the premium to be accounted for separately as going toward abortion coverage, rather than imposing a surcharge on abortion insurance, I feel that is acceptable.

            Finally, there is nothing the media loves like a good poll showing bad news.  A majority of Americans disapproves of the way Obama is handling healthcare and disapproves of Congress’s bills.  I cannot speak for every respondent to these polls, but had I been polled at any point during this year, I invariably would have registered my disapproval, too.  Does that mean I’m jonesing for a Republican takeover of Congress in 2010?  Of course, not—and I imagine many people taking these polls feel the same way.  My disapproval has stemmed from news like the exorcism of the public option from the bill, the disgusting display of fealty that representatives from both parties show toward the healthcare industry, and the president’s inability to discipline his party.  It would be like taking a person to a slaughterhouse, having him watch a cow being butchered, and asking, “Do you approve of the way your hamburger is being prepared?”  This is what happens when the president does not dictate policy and the legislature is actually allowed to do its constitutional duty: it’s messy; feelings get hurt; but what matters is the result, and no poll at the moment can get a sense of what that will be.

Let’s opt out of the “opt-out” idea

            Senate Majority Leader Harry Reid’s (D-Nev.) announcement that the healthcare bill for his chamber will include a government-run option is a double-edged sword.  On the one hand, it is a relief to liberals who consider the public option to be the next-best (and only) alternative to a single-payer system but at the same time it puts moderates of both parties (well, Democratic moderates plus Sens. Collins and Snowe) in an enormous position of power.  Every senator who could potentially vote for this bill is needed and must be accommodated in the search for sixty votes.  It’s an undemocratic system that gives disproportionate advantage to rural states, but that is the way our Constitution works, for better or worse.

            The small state senators have a legitimate point with a public plan which is linked to Medicare, in that doctors already receive lower per-patient reimbursement by the government than by private insurers in their states or by Medicare payments to other states.  In part, this is due to the different costs of living throughout the country, but also it is attributable to formulas which have historically penalized efficient, rural providers such that they cannot afford to take on a good number of Medicare patients and still meet operating costs.  So, from their perspective, private insurers would better compensate doctors.

            Still, the formula can be altered.  What’s more, the people who do not have insurance currently are treated either at neighborhood clinics or in emergency rooms, so all that this legislation is doing is shifting the costs around.  The goal of healthcare reform is to bring down the cost of providing care overall, so the combination of new customers, reduced premiums, lower drug prices, and patient-centered care will, in theory, increase the number of patients that doctors see while decreasing the amount of billable-hours treatment people receive for their illness.

            I am concerned about this new “opt-out” aspect of the public option.  If states are allowed to forgo participation, how will the people currently uninsured find an affordable plan, especially if there is a mandate on individuals to purchase insurance?  Plus, the greater the number of people that participates in the public option, the more the costs of treatment will be spread between healthy and ill people, lowering premiums not just for people in the government plan, but for its competitors.  If half of the states choose not to make the public option available, what will that do to cost estimates which base premium prices on a certain level of participation?

            Lastly, there is a civil rights question here: if states are presented with a means of insuring those who are sick but choose not to make that path available to citizens, is the state liable for every ensuing preventable death?  Will public plan-based insurance be valid if a person seeks medical treatment in a state that has opted out?  And if states opt out, should they have to find another way to ensure that at least 95 percent of their legal residents have insurance or face some penalty, such as being denied funding for highways?

            The top map in this graphic is from Gallup, and I colored in the bottom section with the electoral results from last year’s election.

There seems to be a slight correlation between the percentage of insured adults per capita and the political leanings of the state.  Of course, this map does not indicate which party is in charge of the state legislature or the governor’s mansion.  For instance, even though Virginia voted Democratic in 2008, we will very likely have a Republican governor and legislature when the healthcare bill takes effect.  So, we can say that generally, state governments controlled by Republicans (who will be most likely to opt out) tend to have higher rates of uninsured adults.

            What it comes down to is this: I am worried that the ability to opt-out of the public option will fail to help people in states that most need an alternative method of procuring affordable insurance.  The senators from states such as Arkansas, Nebraska, and Louisiana should look at the 19 to 27 percent of constituents who lack insurance and explain why they were loathe to support a plan that will ensure their wellbeing.

Children’s book author Ted Kennedy, dead at 77

Kennedy, a federal government employee, published his well-received children's book in 2006.

            Noted children’s book author Edward M. “Ted” Kennedy died on Tuesday night at the age of 77.  Kennedy, who worked in the District of Columbia, was best known for his 2006 book My Senator and Me: A Dog’s-Eye View of Washington, D.C.  The story is narrated by a Portuguese water dog named Splash, who takes the reader on a journey through the city and explores the functions of the federal government.

            The 56-page fiction book, published by Scholastic Press, cemented Kennedy’s reputation as one of the most-admired contemporary children’s writers.  In a press release, Scholastic praised how Kennedy “rose from relative obscurity to pen a unique and touching story that is also an educational lesson” for young Americans.

            Kennedy’s writing style was both humorous and earnest, with the main character telling readers that, “If you want a friend in Washington, get a dog.”  Kennedy’s collaborator, Caldecott Medal-winning illustrator David Small, said that “If he is only known for one accomplishment, I’m glad that it is this.”

            While best recognized for My Senator and Me, Kennedy lived quietly, working for the federal government for many years.

Prepare for healthcare reform without the GOP

            President Obama has always been very clear on what he wants to see in healthcare reform: 1.) ensure that all Americans have insurance that will provide them with the care they need. 2.) Make reform deficit neutral.  And 3.) bring down the costs of healthcare expenditures for families, businesses, and the government in the long term.  Being a pragmatist, Obama has remained open to different methods of accomplishing these goals.  If the answer lay in a single payer system, he would probably support that; if the answer required as little government intervention as possible, that would be acceptable to him also.

            However, there came a point at which universal healthcare has turned into “incremental” healthcare—out of concern for fiscally conservative Democrats and Republicans.  But now, each passing week that the Senate Finance Committee cannot come up with an outline for a new system is time in which town hall protestors, Fox News commentators, and the general dynamics of next year’s midterm elections may prevent reform from occurring at all.

            Obama has given the Finance Committee negotiators until September 15 to come up with a bipartisan bill, at which point he presumably will press for action without the Republicans.  While I worry that imposing such a deadline may alienate any GOP senators who are thinking of supporting reform, there comes a point at which thoughtful deliberation turns into purposeful obstruction.  There is no point in watering down reform in order to meet Republicans at some imaginary middle point where they will say, “Okay, that’s good enough for us.”

            That point probably lies somewhere to the right of insurance cooperatives—a proposal that the small-state senators in charge of the negotiations have proposed in lieu of a public option.  Critics on the left say that co-ops will be too small to be effective competition and will have to negotiate rates with healthcare provides like private insurers.  Critics on the right, like Sen. Jon Kyl (Ariz.) are calling co-ops a “Trojan horse” that are just disguising a planned government takeover of healthcare.

            If GOP senators feel that even a concept as weak as a cooperative is too much government intervention, then I think that it is time to pull the plug on bipartisanship and return to the public option commitment.  The public plan is a compromise that liberals made after a single payer system was taken off the table.  What exactly have conservatives compromised?  The fact that they seem not to be willing to support anything other than the status quo is hardly a commitment to improving the healthcare system.

            To be fair, some Republicans are taking the reform effort seriously.  Sen. Olympia Snowe (Maine) was the only Republican on the Finance Committee not to draw a line in the sand in opposing a public option.  Like the president, she remains open-minded on the means to the overall end of accomplishing the three key goals.  Sens. Susan Collins of Maine and George Voinovich of Ohio may also be open to the Democrats’ plan.

            Realistically, the Democrats have 60 senators; they do not have 60 votes, however—meaning support from GOP moderates is key.  But in looking at the record of the current Congress, the most important votes were taken with almost solid Republican opposition: the Lilly Ledbetter Fair Pay Act in January, the stimulus package in February, and Sonia Sotomayor’s confirmation in August.  Although I don’t believe in the helpfulness of drawing strict lines, President Obama should seriously enforce the September 15 deadline.  Otherwise, he may not have another opportunity to build momentum to pass this crucial legislation.

Healthcare reform: tyranny of the minority?

            Some fundamental questions about the nature of the democratic process have revealed themselves over the course of the healthcare debate.  For example, how does one reform the system, as President Obama wishes to do, while still telling people that they can maintain the medical and insurance networks that they have now?  Or, why are lawmakers holding town hall meetings now to receive either affirmation or criticism from the public—after the key decisions have already been made?

            Or, why is a group of senators that represents 3 percent of the population crafting 20 percent of the healthcare bill?  That is the question The Washington Post addressed last week in looking at the Gang of Six on the Senate Finance Committee—Max Baucus (Mont.), Charles Grassley (Iowa), Kent Conrad (N.D.), Olympia Snowe (Maine), Jeff Bingaman (N.M.), and Mike Enzi (Wyo.)—who are tasked with finding a way to pay for the new system.  The potential problem is that these folks—while attempting to inject moderation between coastal liberals who yearn for a single-payer system and southern conservatives who seem perfectly satisfied with the status quo—really have the interests of a totally unrepresentative sample of the American public in mind.

         Is this fair?

 

         Let’s have a little history lesson here.  James Madison, who drafted the Virginia Plan prior to the Constitutional Convention as a broad outline of an effective national government, wanted to limit the influence of states on the types of responsibilities that would fall to the federal government in three ways: 1). He wanted the House of Representatives to elect senators (a “dilution” to pick the wise and stable men who would act as a check on the tumultuous lower chamber).  This was scrapped relatively early and relatively unanimously by people who thought that—our republic representing both the people and the states—the state legislatures should be the most appropriate electors of senators.

         2.) He wanted a federal veto on state laws that, by either being bad or volatile or just plain improper, would be overridden by the national government.  He more or less got this, though not explicitly, in the form of the supremacy clause and the fact that federal courts can declare state laws as violating federal statutes.

         3.) Madison wanted proportional representation in both houses of Congress.  This was crucial, and it took him several weeks of vocal opposition to come to terms with the fact that this would not happen.  Small states threatened to walk out and one delegate from Delaware took Madison aside to tell him that if small states could not have their interests represented equally in at least one chamber, they would have to find comfort in foreign hands.  A counter-proposal by the small states called the New Jersey Plan was never seriously considered (even small states recognized that the national government needed to be stronger; consequently the only real difference between the two plans was a unicameral vs. bicameral legislature), but it was leverage the smaller states used to make their concerns heard.

            It’s not that Madison did not respect the concern about a “tyranny of the majority.” He just felt that small states’ fears were misplaced.  He asked, what could Pennsylvania, Massachusetts, and Virginia possibly have in common that would cause them to ally against the smaller states?  In his mind, divisions would be regional—North v. South.  That was where differences in economy, lifestyle, ethnicity, and, of course, slavery would arise.  Naturally, he was correct.

          Fast forwarding one hundred years of so, we can thank the composition of the Senate, for better or for worse, for the shape the nation began to take.  As Manifest Destiny took hold in the 19th century, our continent was still inhabited by the French, Spanish, and British.  What was to keep American settlers loyal as they headed west, far from the seat of the federal government—or any government for that matter?  It was the incentive that they would receive outsize influence in the Senate should they decide to apply for statehood once the population reached a sufficient size.

         The bottom line is that the way the Senate is structured is the same double-edged sword that the Founders anticipated.  Is it fair now?  No.  Was it fair then? No.  Has the Senate augmented its own importance and magnified its own dysfunctions since 1789?  Absolutely.  Is there a fix?  Only if small state senators use their disproportionate power for the greater good—that is to say, they realize that they are the beneficiaries of a two hundred year old compromise and cannot fairly impose the beliefs of a small minority on the majority.