Pass the damn bill (#1) - Jonathan Cohn

Jonathan Cohn has long been one of the most informed, perceptive, and illuminating analysts writing about the political and policy issues surrounding the health care reform controversy. The piece below was one of his first reactions to the political bombshell caused by the Senate special election in Massachusetts. The whole thing bears careful reading.

I won't really try to summarize or excerpt from Cohn's argument. But let me just highlight two passage from Cohn's advice to a "nervous and frustrated House Democrat". First, he doesn't shy away from the bad news:

It’s up to you.

A few days ago, after a year of debate, you were on the verge of achieving a goal that’s eluded progressives for nearly a century: Creating a national health insurance program. But now the whole effort could fall apart. [....]

You’re depressed [....] You’re angry [....] And, let’s face it, you’re scared. If a Democrat can lose in Massachusetts, any Democrat can lose anywhere. That includes you. [....]

The temptation will be to drop health care, change the subject, and hope for the best. [....] The polls suggest more people oppose the plan than support it. And the right wing is having a field day with it.

[....] But in the one state that has implemented a similar set of reforms--Massachusetts, it so happens--voters support the idea by large margins. That’s why Brown went out of his way to endorse the Massachusetts system, even as he criticized its analogue on the national level.

True, shelving the bill would end the dithering. But it would also solidify the public perceptions that are destroying you now. Listen to the complaints: You’re feckless. You don’t follow through on your promises. You don’t deliver progress. Giving up on the idea that’s been your primary preoccupation for the last year--and, by the way, a primary focus of the last presidential campaign--is not exactly a way to challenge these conclusions. [....]

But there's also a positive side to being a mensch right now (something both men and women can do), in political terms as well as in terms of substantive social benefits:

[I]f you find a way to pass legislation, then you have something to show for your efforts--an accomplishment you can tout, legitimately, as making people's lives better. [....] The uninsured will benefit, for sure, but so will the insured--with a guaranteed benefits package, caps on out-of-pocket spending, cost control to slow down rising premiums, and more.

There's a problem, I know. [....] The big structural changes to health care--the ones that guarantee good, affordable coverage for all--wouldn’t happen for several years. [....] But the people who constructed this reform plan aren’t stupid. [....] Health reform is [also] full of what wonks call “deliverables”--tangible benefits scheduled to take effect mere months after the bill becomes law. Among them:

Seniors will see the Medicare “donut hole” start to shrink.

Families will get to keep kids on their policies past high school, until the kids are 26.

Preventative services will have "first-dollar" coverage, meaning you'll pay nothing out-of-pocket--that's right, nada, zilch--when you get a regular checkup.

People who are uninsurable because of high medical risks will get access to catastrophic policies, as a stopgap until full coverage becomes available in a few years.

The government will set up a website with information about different insurance plans, letting people compare benefits in standardized, plain English terms.

It will also make investments in the health care workforce--spending money to train or hire new primary care doctors, nurses, and direct care workers.

Insurers will have to fess up about how much money they divert from patient care to overhead and profits--and to set up systems for appealing coverage denials.

People will have the right to go to the emergency room--and women the right to see an obstetrician/gynecologist--without prior approval.

The list goes on. [....]

As they say, read the whole thing.

--Jeff Weintraub
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New Republic (The Treatment)
January 20, 2010
Dear Nervous & Frustrated House Democrat...
Jonathan Cohn

Dear Nervous and Frustrated House Democrat,

It’s up to you.

A few days ago, after a year of debate, you were on the verge of achieving a goal that’s eluded progressives for nearly a century: Creating a national health insurance program. But now the whole effort could fall apart.

When Scott Brown takes his seat in the U.S. Senate, the Republicans will have 41 members in their caucus--enough to stop passage of any bill if they stay united. They’ve promised to do just that when and if they get to vote on the final version of health care reform--the one that recent House-Senate negotiations produced.

You’re depressed: Brown inherits the seat that once belonged to Ted Kennedy, who had made health care reform a lifelong crusade.

You’re angry, either for taking politically difficult votes or compromising your ideals in order to move the process along.

And, let’s face it, you’re scared. If a Democrat can lose in Massachusetts, any Democrat can lose anywhere. That includes you.

Now you have a choice.

The temptation will be to drop health care, change the subject, and hope for the best. After all, the voters clearly don’t like what they’re hearing and seeing out of Washington. And health care is all they’ve been hearing and seeing for the last few months. The polls suggest more people oppose the plan than support it. And the right wing is having a field day with it.

But is it the product the voters don’t like--or the process? Truth be told, most people don’t even understand the basics of what this bill would do. (Truth be told, neither do a few or your colleagues.) But in the one state that has implemented a similar set of reforms--Massachusetts, it so happens--voters support the idea by large margins. That’s why Brown went out of his way to endorse the Massachusetts system, even as he criticized its analogue on the national level.

True, shelving the bill would end the dithering. But it would also solidify the public perceptions that are destroying you now. Listen to the complaints: You’re feckless. You don’t follow through on your promises. You don’t deliver progress. Giving up on the idea that’s been your primary preoccupation for the last year--and, by the way, a primary focus of the last presidential campaign--is not exactly a way to challenge these conclusions.

You'll have less political capital, making it hard to deliver progress on the economy or anything else. As for reelection, well, ask the congressional Democrats running in 1994 how failing to deliver health care reform worked for them.

Remember, Republicans will blame you for this bill anyway. Unless you’re among the few Democrats who opposed it on the first go-round, you’ve already voted for health care reform. And you can bet the Republicans will let voters know that come November. You’ll be the representative who voted for that awful liberal boondoggle that, thankfully, the Senate blocked at the final stages of deliberation. Or maybe you want to explain to constituents why you were for health care reform before you were against it.

On the other hand, if you find a way to pass legislation, then you have something to show for your efforts--an accomplishment you can tout, legitimately, as making people's lives better. Thanks to this bill, you’ll be able to tell people, insurance will become both more affordable and more reliable. Coverage will be there for people who don’t have it, and it will be better for people who have it already. The uninsured will benefit, for sure, but so will the insured--with a guaranteed benefits package, caps on out-of-pocket spending, cost control to slow down rising premiums, and more.

There's a problem, I know. These benefits will be abstractions when you run for reelection in the fall. The big structural changes to health care--the ones that guarantee good, affordable coverage for all--wouldn’t happen for several years. And without tangible benefits, voters will remain easy prey for Republican misinformation--the kind that nearly derailed reform over the summer and, undoubtedly, helped elect Brown on Tuesday.

But the people who constructed this reform plan aren’t stupid. They knew voters would be anxious to see results. And they designed the reform plan to produce such results. Health reform is full of what wonks call “deliverables”--tangible benefits scheduled to take effect mere months after the bill becomes law. Among them:

Seniors will see the Medicare “donut hole” start to shrink.

Families will get to keep kids on their policies past high school, until the kids are 26.

Preventative services will have "first-dollar" coverage, meaning you'll pay nothing out-of-pocket--that's right, nada, zilch--when you get a regular checkup.

People who are uninsurable because of high medical risks will get access to catastrophic policies, as a stopgap until full coverage becomes available in a few years.

The government will set up a website with information about different insurance plans, letting people compare benefits in standardized, plain English terms.

It will also make investments in the health care workforce--spending money to train or hire new primary care doctors, nurses, and direct care workers.

Insurers will have to fess up about how much money they divert from patient care to overhead and profits--and to set up systems for appealing coverage denials.

People will have the right to go to the emergency room--and women the right to see an obstetrician/gynecologist--without prior approval.

The list goes on.

You can do a lot with these ideas on the campaign trail. Visit a senior citizen home and talk about how their drug bills are coming down. Go to a community college, and chat with kids staying on their parents insurance. Shovel dirt at the construction site for new community clinics. Kiss babies while talking up the waived restrictions for OB/GYN care. Give speeches at job fairs for health care workers.

That last part should be particularly appealing--because, after all, jobs are really where you should be focusing your energy now. It’s important to pass health care but, for the political good of yourself and your party, it’s important to do it quickly. And that probably limits the ways you can proceed.

In theory, you could drag out negotiations--trying to reach an accommodation with a moderate Republican in the Senate to recapture the sixty vote majority you’d need to break a filibuster. Or you could rip up the bill, try to write and then pass a new one through the reconciliation process, figuring that whatever you got with just 51 votes was bound to be better than what you’d get with 60. If you can do that, hey, I'm all for it.

But count me as extremely dubious. There are no guarantees you’d get a better bill than what either house has already passed. In fact, given the constraints on what can and can’t be done through reconciliation, you’ll probably end up with worse. There’s no sign that any moderate Republican Senators, including the ones from Maine, are willing to start up negotiations again. The only thing certain about either of these strategies is a few more weeks of debate--which seems like certain doom politically.

But you can pass health care reform very quickly if you want. All you have to do is vote for the Senate bill, as written. Yes, I’m aware of its flaws. But it’s also far better than nothing. (Heck, if you're a centrist, you may think the Senate bill is even better than the original House one.)

Once the main bill is passed, you can always revisit it--perhaps right away, by passing a “patch” through the reconciliation process. If you're clever--and you are--you'll extract some sort of promise from the president and Senate leadership to make sure the patch gets enacted.

(Once that's done, well, maybe you can start building support for another important cause: Ending the filibuster and restoring majority rule to the Senate.)

I don’t want to mislead you: You could pass the Senate bill, which you may really not like, and still lose reelection. But passing health care reform would seem, if anything, to improve your odds of political survival. And if it doesn’t--if you’re doomed to lose anyway--enacting health care reform would give you a meaningful accomplishment in your record.

Think of everything you could do while serving in Congress. Would any single act be bigger than this? However imperfect, it will make a huge difference in people’s lives--and, quite likely, the evolution of the American social welfare state. You’ll be sparing financial or physical hardship for thousands of Americans every year, while delivering peace of mind--and safer, higher quality medicine--to literally millions of others. You’ll be saving the American economy and, along the way, helping people to stay healthy.

You can be a part of this moment in history--and, if you play your cards right, stick around in Congress long enough to enjoy it. It just takes some common sense--and maybe a little mettle.

Do you have those qualities? I guess we'll find out soon enough.