In the past two weeks, Democratic leaders in both the House and Senate have issued their respective versions of a healthcare reform bill. Surprisingly, both bills ended up including a “public option.” In the House, this consists of a new government-regulated insurance “exchange,” where private companies would sell policies in competition with the government. The Senate bill contains a much weaker public option, with states allowed to exempt themselves if desired.

I say “surprisingly” because two competing camps have been squeezing the bills’ authors from opposite directions for a long time on this issue. Democratic liberals are adamant that an aggressive public option is essential to achieving universal coverage and controlling costs. Democrats that are more conservative insist voting for any public option would cost them re-election, with constituents punishing them over profligate government spending and promoting socialized medicine.

In the House, the main objectors are Southern Blue Dog Democrats. In the Senate, it is a group of twenty or so moderates.

Until recently, conventional wisdom assumed the concerns of moderates would hold sway. The argument ran that liberals were desperate to pass some form – any form – of healthcare reform whereas moderates would be only too happy to walk away from anything that struck them as politically toxic.

Informal vote counting suggests that, particularly in the Senate, healthcare reform proponents still lack the necessary votes to pass any bill with a public option. Does this mean Democrats are doomed to drop it before the two chambers bring their respective bills to a floor vote, let alone then attempt reconciling them in joint committee?

I do not think it necessarily does. However, the argument Democratic leaders need to apply to recalcitrant moderates is not cajoling over Party loyalty or impassioned moral pleas. The factor motivating moderates on this topic is fear. The key is to create doubt in their minds about what they ought to fear most.

The prevailing notion is that any House Blue Dog or Senate moderate will be crucified by Republican opponents over their “yes” vote on healthcare reform in 2010 or thereafter.

For House Blue Dogs in particular, the assumption that a public option is a deal-breaker may be a non sequitur. The main objection by Blue Dogs serving on the House committees writing healthcare legislation back in the summer was that bills contained insufficient reforms to control healthcare system costs. They also wanted a broader exemption for small businesses that did not have to pay penalties for failing to offer healthcare coverage to employees and fixing what they see as inequities in the current system for reimbursing rural doctors and hospitals.

In September, Democratic Representative Stephanie Sandlin of South Dakota, the leader of the Blue Dogs, said she still believed that a majority of the group would ultimately support healthcare reform “if it was reasonable and represented a consensus Democratic view.” When Speaker Pelosi released her bill, Blue Dog did not damn the public option but rather withheld support waiting to see if the Congressional Budget Office rated it as budget neutral or better.

It is true that President Obama campaigned on the promise of healthcare reform but then so did his Republican rival. So did his challengers in the Democratic primary. So did virtually every Democratic candidate in 2008. After the election, voters understood healthcare reform was not only a top priority for the Obama Administration but for the new Democratic majority session of Congress as well.

At the same time, Congressional Republicans decided to make opposition to any form of healthcare reform favored by Obama and liberal Democrats as the cornerstone of their ideological stance as well as their platform for 2010. Many Democrats hoped that Obama’s popularity would overcome voter objections. Although the Administration has effectively countered some of the harshest criticisms levied by Republicans, the President has been unable to shift public opinion on this topic.

This makes sense to me and I believe Democratic reliance on Obama to carry the day is not only overestimated but also essentially misplaced.

Much has been made of a recent Washington Post poll that shows public support for a government-funded entity offering health insurance at fifty-seven percent. Another Post poll, this time in combination with ABC News, places support as high as sixty-two percent. However, these same surveys show that if a public option caused employers to drop their current offerings and/or forced private insurance companies out of business, support for a government-funded entity plunges to thirty-seven percent.

The most recent Rasmussen poll shows that only forty-five percent of those surveyed support the current healthcare reform bills as written – or, more precisely, as best understood – and forty-nine percent would rather see no healthcare reform passed this year than the current bills become law. In spite of this, the same survey found fifty-four percent said the current healthcare system needs some major changes and sixty-one percent think it is important for Congress to pass some reforms.

Similarly, a new USA Today/Gallup poll finds that despite concerns about its high costs and the implications for the country, fifty-six percent favor passage of a healthcare reform bill.

Rasmussen looks at all these conflicting results and concludes, “Voters do not have firm opinions” on the public option or healthcare reform in general. I think it suggests that voters are every bit as much of two minds on this topic as are Democratic lawmakers. They support the idea in the abstract but easily give in to hesitation over specific proposals for reasons ranging from legitimate concerns to wild rumors to deliberate fear mongering.

Moderate Democrats are correct to believe that Republican opponents and some voters may hold a “yes” vote that turns healthcare reform into law against them. However, they are naïve in the extreme if they think a “no” vote that prevents healthcare reform’s passage will cause this issue to go away by next November. They are outright delusional if they think Republicans will not attempt to use healthcare reform as weapon against them next year.

It seems to me that voters are less likely to hold Democratic incumbents responsible for passage of legislation they favored in the abstract but retain concerns about in the concrete, especially when they will not yet have felt the impact of healthcare reform’s passage in 2010. The alternative for Democratic incumbents will be to face Republican charges that their Party first created bad legislation and then failed to solve any significant problems. This is exactly the condemnation that Democrats used to win against Republican in moderate to conservative districts in recent elections.

It is also notable that while trust for either Party remains at all-time lows among voters, most incumbents are traditionally exempted from these general suspicions by their own constituents. Voters nervous over healthcare reform and government takeovers are much more likely to be reassured by the fact that their local Representative or Senator – “one of us” – believed in it enough to vote for it than by the fact the President Obama wanted/supported it.

By voting for healthcare reform, Democratic incumbents make the race about them and their actions. Voting against it makes the election into a referendum over the Democratic Party and its ideological direction. I suspect Republicans will find the later much easier to demonize.

I suppose the correct metaphor for almost any Democratic lawmaker regarding healthcare reform is to say they find themselves between a rock and a hard place. However, House Blue Dogs and Senate moderates who find themselves so squeezed may want to consider the problem began for these particular dogs when they began barking up the wrong tree. Embracing the public option carries its share of risks but also holds potential rewards. Rejecting it is simply an admission that their Party of choice does not know how to govern – there is nothing to be gained in that for any Democrat.

Another well written and well reasoned piece here the Bell. There is also the backdrop of health insurance premiums that are expected to increase anywhere from 10 to 15% next year. That sends a sharp message that the current system is badly broken. Not mentioned is how much of that increase is to pay for the expensive lobbying by the insurance industry against reform. We know we are paying for that lobbying through higher premiums each payday.

"surveys show that if a public option caused employers to drop their current offerings and/or forced private insurance companies out of business, support for a government-funded entity plunges to thirty-seven percent".

What this particular survey shows is just how effective the unrelenting fear mongering (pull the plug on Grandma) really is because there are disincentives in the bill for any employer to keep them from dropping their current offerings. Likewise, as long as the public option is fully funded by premiums (which is written into the bill) then there is no reason to believe that private insurance companies will be forced out of business. Those kind of things have been in the bill from the beginning. Lastly, the last CBO report I saw showed the bill to be revenue neutral. The final draft will need review by CBO to assure that last minute changes have kept it revenue neutral.

It is telling that the Republicans have not and will not offer a bill of their own. That would seem to play into the hands of Democrats as they can hit hard on the theme of the Republicans being the party of no. Outwardly, it looks to me like the Republicans have overplayed their hand and will pay a price for that in 2010.

of Oregon on Rachel Maddow and Olbermann and some others shows talking about the election and healthcare reform. He makes a pretty good case for Democrats successfully framing the healthcare debate as functionally forcing everyone in Congress to say, given reform's importance to every American, what they are for, whether they like it or not. Kind of the equal opposite of Mitch McConnell trying to argue that a vote against cloture is functionally an up or down vote of the merits of the bill(s)? Republicans could be left holding the bag---an empty bag---if that Wydenesque framing is brought off.

However, that's by no means an easy task. Democrats may lose a goodly number of Senate and House seats if Republicans successfully frame the healthcare debate as a pocketbook issue first and foremost---even if simply, "Your Pocketbook Tomorrow", or "Your Pocketbook Two Months After Reform Passes". By definition, Americans wouldn't want to risk an up or down vote that signals short-term financial hardship for theoretical long-term good, even if convinced of that longer-term efficacy. Maybe if the Democrats can come off like a furniture store commercial---"No Payments Until 2013".....

Good analysis ,as always. I was never worried much about any of this. I knew the powers that be, combined with the general conservative viewpoints of most Americans would ensure that only the most necessary changes would be implemented.(like the removal of the pre-existing condition clause and a slightly more lenient Federal options trigger for the most needy via a public options clause.)... And The Free market,for insurance companies and those who want choice,would be maintained, no matter what. And so it shall be.

Yeah. Congress has to pass something--anything. So let's go for something smaller. Something simple. Something everyone will vote for and pass. We don't have to swallow this health care like an egg snake on a double whopper.

Insurance companies compete across state lines.
Tort reform for frivolus lawsuits.

That's a good start. Simple. Scrap the bill as it is now and start again with these items. Well dressed, old people will stop protesting in mobs in town halls and on busses that criss cross America. They'll love it because:

1) It's what Americans want
2) It's smart and small
3) If it passes, nobody gets the ax in 2010 elections.
4) It'll prove their president is not beholden to SEIU or other special interests like we once thought

And if that doesn't work then Washington can just throw its hands up and say, "Screw it. You states figure it out. You need to come up with something by the end of next year on a state by state basis ranging from allowing out of state insurance providers to compete in-state and maybe give them tax breaks regardless of federal mandates letting the Supreme Court decide any hurt feelings (oooo heyyyy! How do you like them apples?) to a state sized public option, to nothing at all and everything in between. Good luck and let us know. See you next year."

Peace and harmony.

Ideally, what would be happening now is that the Republicans would be presenting some kind of alternative plan and flogging the hell out of it. Such a plan would probably start with tort reform and competition over state lines. But they're not presenting an alternative plan; all they have to do is wait for the Democrats' bills to collapse, which might happen, and which would leave the status quo in place.

It's nice that the Senate bill has a token nod towards federalism with the provision to allow states to opt out of the public option. It's a pity that the bar is so high no state would actually take it.

I'm not even sure what the public option would actually get us: according to the CBO (and the liberal Ezra Klein), the public plan might actually have higher premiums than private insurance: link.

Agree.....barking up and pissing on.

Jack

Bell:

In an earlier post, I discussed my participation in a protest over Sach's bonuses, W$, and the banking system while attending “Showdown in Chicago" <link>. On Sunday night I had a brief moment with Senator Durbin while accompanying Mary Bottari, BanksterUSA http://banksterusa.org/ during her interview of him and asking questions about reinstituting Glass-Steagall. My words to him:

The Democrats have a majority in the Senate. It would be nice if the party of the majority in the Senate began to act like the Majority rather than the party of the Minority.

The Repubs would have seized the moment to ram this through and take out any defectors such as Dem in Repub skin Lieberman, etc.

In my latest post, I am negotiating healthcare insurance at my doctor or at least the lack of it in attempting to gain a price for a blood test, a urine test, and a chest x-ray. I started this venture after a battery of tests at the glamour institute of Ann Arbor. Since my insurance covers me after I am run over by a bull dozer, I asked the cost of the initial test. The second time around after the initial tests showed an elevated Sedimentation (and everything else normal) , the good doctor wanted an x-ray (turned out to be 2), a urine test, and a blood culture test to see what critters are running around in me and to see if I have a heart. Again I asked "how much?" He could not tell me and neither could anyone in the office.

The next day, I called the billing office and they told me it would be a few days before they could get a price. The billing office did suggest going outside of the system to get the tests and X-rays done as it would be substantially cheaper (40%). The X-ray were substantially more competent than the blood techs . . . one had never done the anaerobic test before . . . two small soda bottles of blood. Many have suggested, patients and people should be responsible for costs. Too this I ask how, if it takes days to get a price and you are sick? There is a serious disconnect between doctors and their business.

I would like to use one of your posts again . . .

The rock and the hard place is not so much between various policy choices, but between framing the issue in terms of politics and framing it in terms of policies. The MSM has endlessly repeated the trope that the public option cannot pass because there aren't the votes, instead of examining what are the strengths and weaknesses of the various choices.

For example, several posters here have suggested that all we need to do is allow health insurance companies to compete across state lines and tort reform. Well, okay, what are the implications of that?

Allowing health insurance companies to compete across state lines means that the state with the crappiest regulations 'wins,' and the rest of us are stuck with insurance that isn't worth a damn.

Tort reform sounds better, because there is evidence that defensive medicine drives up health care costs and the present system injects an adversarial component to the doctor/patient relationship. However, that slogan avoids the question of how we compensate those who have suffered medical injury. What recourse is available to those who have been harmed by medical practioners?

Of all the proposals wending there ways through Congress, I would say the more robust a public option is passed, the better the politics.

Why?

Because, if uninsured folks are either going to have to purchase health insurance or a pay a fine, delivering them to the tender mercies of private health care insurance will be suicidal. How do you spell g-o-u-g-e-d? When the uninsured get the bill, they will be furious and rightly blame those who put them in this untenable financial bind (some estimates have a middle-class family making $66 could end up spending 20% of their income on health insurance). Screwing the middle class has never been a great electoral strategy.

So, there has to be some mechanism to keep this affordable for the middle class. Only a robust public option with huge subsidies can do this.