Even if the bill does a better job than CBO projects, health-care costs will still bankrupt us. This is one small step for cost, one giant leap for coverage. My great hope is that the bill makes the next steps easier. But there’s still no guarantee we’ll take them. And the debate and difficulty Congress had passing a bill that was too small and deeply compromised has left me very pessimistic about our system's capacity to make harder decisions. The danger is not that we can’t solve our problems, but that we won’t. And that’s the biggest risk of all.

via Ezra Klein – The risk of health-care reform.

There’s no constituency and little reward for tough choices in Washington. It breeds a town full of cowards. Our legislative branch is broken.

A short while ago on Fox News I saw a segment that included one “expert” who claimed that healthcare reform would do something “unprecedented,” namely, requiring citizens to purchase some commodity.

Unprecedented? Really?

Let's start with the direct part. I would encourage anyone who believes such claims to pull out his or her most recent paycheck. Someplace on there you will see FICA deductions that (in theory at least) are set aside to fund Social Security (OADSI) and Medicare programs. These are the two biggest government-sponsored insurance programs administered by the feds, and two of the largest line items in the federal budget. These paycheck deductions are not optional, and for all but the self-employed they are taken out immediately.

Put another way, you are already required by law to buy the commodities we might simply call “retirement insurance” and “medical insurance.” You can't opt out of either program and you can’t delay the payments–which we may as well think of as “premiums”–until April 15 each year. (I suppose you can opt out of taking the benefits later.) Moreover, you only see in your paycheck the true impacts of half your premiums, because the other half is hidden by being “contributed” by your employer–although this also ought to be considered lost income and thus a mandatory direct tax because employers account for this tax obligation when setting salaries or wages. Although there’s no payroll deduction for unemployment insurance, employers also must consider these “premiums” when setting those wages and salaries, so let's classify that a mandatory but indirect tax.

As for mandatory, although there is some debate about whether the insurance mandate will actually be enforced–and strong evidence that it won't be because there are no criminal penalties for people who fail to buy insurance–it is clearly less mandatory given that it requires citizens to actively go out and buy it instead of having it taxed automatically from their paychecks.

In sum, the newly legislated insurance tax is at least as indirect as unemployment insurance, more indirect than either Social Security or Medicare taxes, and less mandatory than any of the three. And yet it will be challenged as unconstitutional on mandatory direct tax grounds? One’s head spins.

Now, the kicker: In a related segment moments earlier, Fox News’ Bret Bair was reporting on how the healthcare reform would entail “raiding” Medicare to pay for the new healthcare programs. That is, there was an attempt to scare seniors by alluding to the possibility of touching a mandatory health insurance program that comes with a mandatory direct tax provision–but without so much as a pause to consider whether that programs fails the very constitutional standard raised in the next segment about the new healthcare law.

via FiveThirtyEight: Politics Done Right: Constitutionality of Mandatory Insurance.

The rest seem dead on, as sad as they may be. In particular 3, 5, 6, 7 don’t bode well for our system of government. click through to the original piece to get the explanation for each.

FiveThirtyEight: Politics Done Right: What We Learned.

Putting the policy and its implications aside, what political lessons can we takeaway from the past year? Plenty, some of them rather disconcerting.

1. Non-incremental policy change is never easy.

2. The presidential pulpit doesn’t bully by itself.

3. Misinformation is more easily disseminated than debunked.

4. Have an Administration bill.

5. Proxying process for policy works.

6. It pays to hold out.

7. Bipartisanship is a waste of time—except as a tactical feint.

Some of these guys will lose their jobs for voting yes. There may be a modicum of courage left in Congress.

Update: 216 votes with 1:42 to spare. The final vote is 219 to 212, with 2 no votes from Republican members.

What the New Health Care Legislation Will Mean to Consumers’ Wallets

The elderly:   $599 billion (Medicare)

The poor:      $333 billion (Medicaid)

The workers: $250 billion (Tax subsidy for employer provided benefits)

Veterans:       $39 billion (The VA)

Military:         $50 billion (combined TRICARE and direct costs)

That´s not counting some smaller bits and pieces like federal employee health costs, payments and subsidies at the federal and state levels for charity care. The total spending was about $2.3 trillion So we´re talking about adding perhaps $100 billion per year more to this. The government already controls about 1/2 of health care expenditures in the US. It´s an incremental step, not wholesale adoption of communism, socialism or totalitarianism. It may eventually make some dent in the tens of thousands of US deaths every year attributable to a lack of insurance coverage. On the down side, it doesn´t do enough to control costs and it preserves a stupid employment based system. We can learn and adopt from other examples among wealthy nations who seems to spend much less while covering all (or the great majority) of their citizens.

This would form a floor for benefits, with an opt out for those who have other coverage. A mandate is a must. Spend more on effectiveness research, the Pharma lobby and medical device makers be damned. We need to know what actually works best, not what’s most profitable. Couple that with medical education reform that encourages people who actually want to practice medicine to go into primary care specialties like family practice and pediatrics, by relieving them of 6 figure student loan burdens. Begin slowing the growth of reimbursement to expensive sub-specialties.

Some years ago I worked at a small community hospital in St. Pete. I thought it interesting that an ophthalmologist would come on surgery days twice week and line up eight cataract cases, spend about 15 minutes each and get over $1000 each before lunch.

On another floor we’d have elderly patients in heart failure and diabetics with uncontrolled blood sugar. Both can easily be prevented by relatively inexpensive in-office care and regular follow-ups. We need to spend more on primary care and reimburse less to the guys like the ophthalmologist example.

But I digress, back to the flawed real world plan. Here’s the take I thought the most realistic on it’s chances:

And so Democrats in Congress find themselves facing an uncomfortable but clear choice. Although they may not reap political advantage from the legislation, most of them recognize that failing to pass it would be worse. The devastating aftermath of their party’s inability to act on health care in 1994 remains a vivid, cautionary lesson.

via Will It Pass? The Odds on Health Care – Room for Debate Blog – NYTimes.com.

Pass the plan or you democrats get it, death by circular firing squad. If they had anything remotely similar to party discipline, the whole thing would be a boring fait accompli. At least they keep drama going and going and going.

Read it yourself, Reid puts the GOP on notice that they will in fact use reconciliation to complete health care reform. Let the screaming from the right begin, now!

I suppose this means that Harry Reid does in fact have balls.

…the Democrats’ bill more closely resembles Richard Nixon’s health-care proposal—the one that Ted Kennedy went to his grave regretting he hadn’t embraced—than it does Bill Clinton’s, to say nothing of Harry Truman’s. Nor are all its Republican features archeological. “Our bill contains over a hundred and forty-seven distinct Republican amendments,” Senator Tom Harkin, of Iowa, reminded his summit colleagues. The health-care reform bill—which, despite everything, is still alive—is an ambitious piece of legislation, however modest it may be by the measure of the rest of the developed world. Ideologically and substantively, it is centrist. It has Republicans, and Republicanism, in its family tree.

via Bipartisanship and your health : The New Yorker.

The GOP caucus simply wants to block reform by any means necessary. It’s not about the relative merits of reform proposals or who came up with them. It’s not about tens of thousands who die annually because they delay care for a lack of coverage. It’s not even about wild shrill, misused accusations of socialism or fascism. It’s about electoral politics, pure and simple. If they can deny Obama a victory, they feel like they’ll do better in the mid-terms. If thousands more die, well they probably didn’t have the money to contribute to their campaigns anyway.

Democrats will finish their health reform efforts within the next two months by using a majority-vote maneuver in the Senate, Majority Leader Harry Reid (D-Nev.) said.

Reid said that congressional Democrats would likely opt for a procedural tactic in the Senate allowing the upper chamber to make final changes to its healthcare bill with only a simple majority of senators, instead of the 60 it takes to normally end a filibuster.

via Reid: Dems will use 50-vote tactic to finish healthcare in 60 days – The Hill’s Blog Briefing Room.

I just hope it’s not yet another Charlie Brown getting the football yanked away type moment. The would benefit electorally from actually getting something substantive done.

There’s been a profound sense of disappointment in the Obama Administration’s inability to do what they promised. The effort has lacked leadership from the White House. This needs to change. He needs to get in there and twist arms and apply leverage to his own caucus to get them lined up behind the legislative agenda.

Sen. Michael Bennet’s effort to revive the public option in the reconciliation process is gaining steam, with almost 20 senators signing on to the idea. Among them are Dianne Feinstein and Chuck Schumer, who are not, shall we say, possessed of a whimsical or quixotic temperament.

Of course, you don’t need almost 20 senators. You need 51, or more. And complicating that project is that the question here is not simply “public option: yes or no?” It’s whether you want to jam a public option into a bill that Senate Democrats already passed without a public option. Not only are you throwing out any hope of appearing even slightly bipartisan, but you’re also increasing internal dissension and adding unpredictability into a process that’s collapsed into chaos already.

via Ezra Klein – Is the public option making a comeback?.

Op-Ed Columnist – Do the Right Thing – NYTimes.com.

A message to House Democrats: This is your moment of truth. You can do the right thing and pass the Senate health care bill. Or you can look for an easy way out, make excuses and fail the test of history.

This fantasy that there are Republican votes for a more moderate bill really needs to end. There are no Republican votes for healthcare reform, no matter how moderate or conservative it is. They’re opposed to healthcare reform. They’ve always been opposed to healthcare reform. They’e Republicans! There’s nothing wrong with them being opposed to healthcare reform. And they are. Full stop.

Going down this path would be dangerously delusional. It would waste time, piss off voters even more, and accomplish nothing. It's time for House liberals, labor unions, lefty activists, Blue Dogs, Democratic pro-lifers, and fence-sitting centrists to all face reality: the only way to pass healthcare reform of any kind is for the House to pass the Senate bill as is and then work to improve it later during the budget reconciliation process. It's not perfect, but it will work. Nothing else will.

via Facing Reality | Mother Jones.

I think he’s dead on, pass the Senate version of HRC and fix what you can in reconciliation and with future legislation. There’s really no point or percentage in it for Democrats to abandon the entire project when the goal line is literally in sight. They’ll lose a considerable amount of support from progressives and the Democrats can’t win based on the president’s ever waning popularity or his leadership.

Obama has not led on any of this. He’s been the careful centrist he always was.  Let’s not get all wobbly over the loss of one seat in the Senate, that’s 1% of 1/2 the legislative branch, which is 1/3 of the 3 branches of government (to paraphrase last night’s Daily Show).

As for the intra-party food fight over who’s to blame for Coakley’s loss of what should have been an easy win, there’s plenty to go around. She was an awful candidate, but no worse than many an empty suit currently existing in Congress (editors note, I considered “working” instead of “existing”, but that seemed to bit of a stretch). The national part didn’t seem to pay any attention to the special election in Mass. until the final week and that was just too little and waaay too late. The president didn’t do much until the last minute either. Plus, there was absolutely no message prepared in case of a lose, just a lot of surprised people winging it. They’ve yet to recover balance.

Krugman tries to talk sense to reflexive Euro-bashers.  Adopting a more humane attitude by taking steps to ensure everyone in the richest nation on earth has access to health care isn’t going to turn us into some kind of socialist dystopian nightmare. And the idea that Europe is economically stagnant because workers get certain mandatory benefits like vacation and (GASP!) sick leave and health benefits just isn’t true. It sticks in the craw of conservatives who prefer what feels true to what’s actually true.

Flashback: ‘The Night The Clocks & Scoreboard Stood Still’ | Fired Up! Missouri. (h/t Ezra Klein)

Note that it was, and still is, completely unfunded and added 100% to the deficit.  Furthermore its ten year costs are about a $1 trillion vs roughly $900 billion for current reform package.  The health reform bills now before Congress actually reduce the deficit by $100 billion. Explain to me again which party is the party of fiscal sanity and responsibility?

If you hear anyone complaining about the process, show them that link and ask them to justify those tactics. If you hear any bitching about how this effects 16% of the economy, point them to this bit from Ezra Klein:

…this idea that the health-care bill affects “16% of GDP” is inane. That 16% of GDP captures people in private insurance, Medicaid, Medicare, and assorted other arrangements purchasing medical care. This bill will not stop them from purchasing medical care nor will it change the way they purchase medical care nor is it likely to change how much medical care they purchase.

To put this even more clearly, in 2008, the country spent $2.3 trillion on health care. In 2016 — so, after implementation — this bill will spend about $150 billion helping people buy health care. Assume that national spending that year will be about $3 trillion, then the health bill is accounting for about 5 percent of our spending that year. The idea that this bill, which is going to cost fairly little in the scheme of things and do virtually nothing to people who are already insured, is somehow transforming the provision of 16 percent of GDP is misleading at best.

After a long day of acid, partisan debate, Senate Democrats held ranks early Monday in a dead-of-night procedural vote that proved they had locked in the decisive margin needed to pass a far-reaching overhaul of the nation’s health care system.

via Health Bill Passes Key Test in the Senate With 60 Votes – NYTimes.com.

Something is better than nothing. While this bill lacks a great many things, the insurance reforms and subsidies are extremely important.

It is odd to read things like this:

The Republican leader, Senator Mitch McConnell of Kentucky, lashed out at Democrats in his closing speech, charging that they were defying the will of the American people, and that Mr. Obama was breaking numerous campaign promises. “If the people who wrote this bill were proud of it, they wouldn’t be forcing this vote in the dead of night,” he said.

It’s odd because if not for a long series a parliamentary maneuvers designed to delay things by the Republican minority, it would have long since been done. He’s complaining about votes in the middle of the night when their tactics are what necessitates it. It’s the same disingenuous bullshit that’s marked the GOP approach to the subject of health reform from the beginning of the process. Their standard process is to simply lie about things, stamp their feet and act like badly behaved 2nd grade children. Good luck with that.

The gist from Kevin Drum  is that something is better than nothing and defeat would set things back years if not decades.  I add that with each attempt, from Truman to Johnson, Nixon and Clinton the goal was a little less ambitious. Where would that leave it if Obama fails? The insurance reforms alone are worth the price and shockingly overdue. Complete failure consigns perhaps tens of thousands of Americans to death for the want of health insurance over the next ten years. How many more will become disabled and unemployed or go bankrupt?

This doesn’t mean that I forgive Lieberman for doing his best to destroy it. I’d still like to see him stripped of his chairmanship and kicked in the nuts on the way out the door (see my previous post).

Update:

A TPM reader shares the same view I hold. It’s insane to throw out the baby with the bath water. We need what’s left in the bill, to say otherwise is ridiculous. We want more and should work for more, but if this is what we can get right now, so be it.

Update 2:

Krugman grudgingly agrees

Nate believe the blue dog type conservative democrats staked out their ground during the summer and stuck to it. The votes were never really there to get a public option. Leiberman gave it a swift kick in the nuts on the way out the door, it’s effectively dead. The result is a weaker bill that will cost more money, have less effective cost controls and cover fewer people, perhaps that’s what the opposition was after all along.

I’m of the opinion that after Lieberman’s opposition to the Democrat’s top domestic priority and after having campaigned for McCain/Palin during the last election cycle he richly deserves being stripped of his committee chairmanship. He desperately needs another well financed primary challenger from the left-center next time around. There’s probably a few of his colleagues who’d like to line up to give him a swift kick in the nuts on the way out to door.  Democrats don’t need him if he’s unwilling to support the party’s priorities. Either you caucus with Democrats and support the party’s initiatives or you find yourself another party willing to put up with all the maverickiness. Party discipline anyone?

Serious students of health care have known for a long time that the magic of the marketplace doesn’t work in health care; the United States has the most privatized health-care system in the advanced world, and also the least efficient. The pale reflection of this reality in the current discussion is that reform with a strong public option is cheaper than reform without — which means that as we get closer to really doing something, rhetoric about socialism fades out, and that $100 billion or so in projected savings starts to look awfully attractive.

It has also been clear from international evidence that universality is cheaper than leaving a few people expensively without care. That’s reflected now in the projected savings from a strong employer mandate.

The point is that reality is pushing for a more progressive reform than the Baucus bill. Truly, the facts have a liberal bias.

via The facts have a liberal health-care bias – Paul Krugman Blog – NYTimes.com.

Most support public option for health insurance, poll finds – washingtonpost.com.

A new Washington Post-ABC News poll shows that support for a government-run health-care plan to compete with private insurers has rebounded from its summertime lows and wins clear majority support from the public.

A clear majority of 57% supports a public option, despite a massive disinformation campaign. Support has been firming up since bottoming out in August at 52%. I believe the ONLY reason there isn’t broader support, particularly among Democrats in Congress, is because of the money being spent by lobbyist to defeat meaningful reform. Congress seems much more interested in protecting the interests of insurance companies than they are in protecting you from bankruptcy from medical expenses or death from a lack of access to timely care. People die because of our distorted priorities:

Nearly 45,000 people die in the United States each year — one every 12 minutes — in large part because they lack health insurance and can not get good care, Harvard Medical School researchers found in an analysis released on Thursday.”We’re losing more Americans every day because of inaction … than drunk driving and homicide combined,” Dr. David Himmelstein, a co-author of the study and an associate professor of medicine at Harvard, said in an interview with Reuters.

It’s a national shame. We can do better. We deserve better. Timidity will allow people to die, it’s just that simple.