Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Reflections on Impending Obamacare
Reform was surely needed to remove distortions imposed on medical care by its financing. The next big questions are what the Affordable Care Act really reforms; and, whether the result will be affordable for the whole nation. Here are some proposals, just in case.

Obamacare: Examination and Response
An appraisal of the Affordable Care Act and-- with some guesswork-- its tricky politics. Then, a way to capture major new revenue, even paying down existing Medicare debt, without raising premiums or harming quality care. Then, an offering of reforms even more basic, but more incremental. Finally, the briefest of statements about the basic premise.

Picking Out the Raisins From the Pudding
The Road to Nowhere

There appears no better blueprint for the 1993 healthcare reform legislation (commonly called "Clintoncare") than Jacob Hacker's 1999 book The Road to Nowhere. If President Obama did not use this same roadmap for the "Obamacare" health program, it still remains quite a good description of what he did do. His following this earlier playbook would plausibly explain much that is otherwise mysterious.

The Hacker book was originally an academic thesis written several years after the (Hillary) Clinton Health Plan experienced ignominious disappearance in the halls of Congress. By then, the Clinton episode of 1993-94 was quiet and forgotten, so participants probably felt it was safe to describe big-shot politics to a college kid writing a thesis. The resulting book was easy to follow, had a ring of authenticity, and advanced the author's career. Advanced it so much the same Jacob Hacker later became visible near Democratic policy circles, even seemingly advising political deals, even though strangely quiet, lately. The similarities between the Obama initiative and Clinton's earlier strategy in Hacker's book, are striking. However, judgment must be suspended whether to frame it as a cautionary tale, or a guidebook. In fact, the possibility that Mrs. Clinton plans to use the blueprint a third time, produces a strange fascination among even her enemies.

{top quote}
1. Pad anything into Senate and House bills. 2. Send the padded bills to a conference committee. 3. Delete all but your own ideas. 4. Ram it through. {bottom quote}
The Clinton Strategy

Boiling it down, the (Bill) Clinton strategy was to confront a House-Senate conference committee with a vast pile of often conflicting proposals, sent to a conference committee for a proposal to reconcile inconsistencies. In fact a coherent proposal could not emerge from a Clinton bill, until the President sent his list of proposed deletions to that conference committee. After trimming to its essentials, the conference committee reconciliation would then return for House and Senate approval, probably against some holiday deadline to quash objections. The process would resemble picking out the raisins from a pudding, combined with the nuisance of buying off a few soreheads, except for one thng. The Executive Branch deftly acquires more power over legislation than the Founding Fathers ever contemplated. Michelangelo's remark, that carving statues is just a matter of throwing away what you don't want, is bitterly appropriate here, especially from the viewpoint of those who thought they were elected to write laws, not follow orders. On the other hand, this approach favors a party with safe seats from concentrated urban districts, tending to be more compliant to party bosses .

In a technical sense, this process is more equivalent to a line-item veto. (A line-item veto, by the way, is something Congress repeatedly refuses to grant). It's hard to oppose an omnibus bill until its outline appears, and this Michelangelo process tends to obscure the tone and central theme of legislation until the last possible moment. From the point of Conference Committee forward, passing it back for ratification becomes a matter of rushing it ahead of criticism, and indirectly lessens the power of public opinion. Nor would be the first time a few little extra zingers, never discussed by either the House or the Senate, got slipped into a conference bill, which is typically several hundred pages in length. And the timing for release of the omnibus legislation could be selected, quite likely the day before Thanksgiving or Christmas when newsmedia were away from work. Or else after a long series of preparatory news events, building public expectations before a spectacular revelation day. But it is a mistake to focus on the press as being hoodwinked. It is the other Congressmen, the ones who ultimately don't get what they were promised.

And finally, unexpected events can intervene, as Scott Brown's Senatorial election did in this Obamacare instance. A clever scheme got suspended in mid-air by the death of Senator Edward Kennedy. The bill had been passed by the Senate, but not the House. The House bill was so different it would require reconciliation with what by then would be a different composition of the Senate, and therefore could not pass the Senate a second time. So, a bill identical to the Senate version was jammed through the Democrat-dominated House, no amendments permitted, no conference committee needed to reconcile two differing bills. Unfortunately, the original plan was to include some provisions purely for the purpose of obtaining a Senate vote or two. The original plan was to be that "deficiencies" would be remedied by some raisins tucked in the House bill, which of course never came up for a vote. Thus the resulting legislation is the pure Senate version (with all its undesirable features remaining) and we may never know what was in the unpassed House bill that might have repaired unspecified Senate flaws. After all this trickiness, does anyone wonder why so many Congressmen are dissatisfied with the result?

Looking back, it is hard to prove how much of the Clintons' original strategy was adopted by Obama, or how much influence Hacker and Hacker's book had, until someone on the inside writes another book and tells us about it. But the congressional strategy of the Obama Health Plan proposals do sound very similar to what we should probably give the name of "The Arkansas Strategy". That strategy would certainly explain a great deal of what happened; it scarcely matters how much the similarities were accidental and how much they were following the same playbook. Except, of course, if some of the participants decide to run for office in the near future, and try to do it all, a third time.

Senator Edward Kennedy

Senator Edward Kennedy's impending death, Senator Byrd's incapacity, and the contentiousness of the health reform topic always made it uncertain a 59-vote Democratic Senate leadership could assemble 60 filibuster-proof votes in favor of any healthcare proposal; one betrayal and you've lost. The Democratic Massachusetts legislature took away the right for Republican Governor Romney to fill a vacant Senate seat, and restored it for a subsequent Democrat governor. In circumstances like this, every single Democratic senator can hold a proposal for ransom, while every single Republican senator will unite in opposition. When the majority shifts Republican, which could be rather soon, the roles will be reversed in an almost certain effort to repeal whatever passed. The public was left wondering whether healthcare legislation was worth hampering our interests in Iraq, Iran, Afghanistan, Syria, immigration reform and the national debt. The Democratic Congress had to worry it was not worth the political damage from hammering it through. They might also worry that the Supreme Court might be drawn in, expressing some unwelcome Constitutional viewpoints. It's really hard to know what to wish for.

Bob Dole

Along the way, former Senate Majority Leader Bob Dole appeared on television, and revealed a different insight about Senate behavior. Senator Baucus told the press that something called a Public Option could not pass the Senate, so he was not including it in his proposal. Extreme left-wing members of the Democratic party said they would "take a walk" if the Public Option was dropped. But although it was dropped, it was included in the House version and might thus have been restored in the conference committee. This "Montana" maneuver removed Public Option from Senate debate, still hoping to preserve those 60 votes. Under the circumstances, it isn't even necessary to remember what the Public Option was, but essentially, Public Option was a proposal for the Government to go into the health insurance business itself, in order to put overwhelming pressure on the insurance industry. In 1965 this was impossible, in 1992 it was unprepared for, in 2009 it was merely chaotic.

It is widely rumored the Public Option was a punishment for the reluctance of the health insurance industry to cooperate more fully with the President, or at least a threat of what could happen if they didn't soon cooperate. Indeed, you have to question what the attitude of the Insurance Industry really was, in a proposal which would greatly diminish their control of insurance. Karin Ingaglio, the chief lobbyist for private health insurance companies, admitted to the National Journal that her group had contributed millions of dollars to the Tea Party, leaving it unclear whether she was playing both sides of the street, or else hoping to defeat the Republicans with a third-party, Tea Party, distraction. Bob Dole was a gracious, gentle old man, musing about what might be going on. You don't suppose, he mused, the Public Option might be nothing more than a red flag in front of a bull, to be surrendered with a great show of disappointment. But actually, just a feint creating an uproar, to divert attention from the real zingers in the rest of the bill, which can then pass through unnoticed. But, no, Bob Dole didn't really imagine such a thing. It was just a wild thought he happened to have.

Political observers agree that presently rancorous Congressional partisanship is the worst in a century, and it is not shared by the public. Just about everyone in the political class sees gerrymandering as the main cause. Changes in the ways voter redistricting is conducted, some say the use of computers, have made gerrymandering much more effective. When numerous safe seats arise in this way, it is only a matter of time before the Legislative seats are filled with heedless, reckless partisans, beholden to no one. But it is just as bad, if the seats are filled with party hacks, forever obedient to the unelected rulers of urban political machines (leaders of party machines seldom run for office.) The seniority system takes over, and safe-seat partisans get control over Congressional committees and party discipline. This happens to both parties because incumbents from both sides unite to achieve it. But urban districts are harder to split on party lines, so states containing large cities tend to present a permanent disadvantage in numbers for Democrats, although uniform composition makes for much greater partisanship. Contestants for the dwindling number of uncertain districts are thus forced to act more cautiously, thus tending to seem more competent by the press and the public. But even if elected, they are powerless in the face of the more unrestrained partisans who control internal power plays, and who also tend to be long-term incumbents from safe seats. As a consequence, moderates are more likely to be singled out for sacrifice in the following election.

Scientific gerrymandering has certainly coarsened and hardened the political atmosphere, considerably reducing public control of its representatives. It should also be noted that Senate seats cannot be gerrymandered, but state legislative seats definitely can be, leading to a coalition between state legislators who are almost always party hacks, and U.S. Representatives, who are increasingly so. It is said that in New Jersey and Florida, it is possible to predict the next ten years of politics with precision, if you only know how the gerrymandering was arranged. The Senate could probably devise a Constitutional amendment to fix this problem, with no chance of passing the House, or getting ratified by the States. Therefore, the present main hope for representative government lies in the national party leadership of some party, intervening into the party nominations for safe seats. Even that, would take extraordinary luck and agility. It remains to be pointed out that 2020 is the upcoming year for a census, 2022 for redistricting.

i couldn't figure out the system used to bold type some of these words---can't be all hypertext?
Posted by: bzp   |   Oct 3, 2009 9:58 AM

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