Answering Nate Silver’s 20 Questions On Killing The Senate Bill
Nate Silver has 20 questions for the “bill killers”–and I have 20 answers.
1. Over the medium term, how many other opportunities will exist to provide in excess of $100 billion per year in public subsidies to poor and sick people?
Killing the current deal does not preclude passing the good parts of health reform through reconciliation. When they are forced to face passage of some of these reforms with reconciliation, or the threat of reconciliation, it is not impossible to envision Lieberman, Nelson, and Lincoln backing down on their threat of joining a filibuster.
2. Would a bill that contained $50 billion in additional subsidies for people making less than 250% of poverty be acceptable?
That money will help a few people in the short term, but, in the long run, our system built on private insurance companies is unsustainable, and will ruin our entire economy. I have zero confidence that the subsidies promised today will remain the same in the future. They might be increased by future Democrats or reduced in 2016 by a Republican Congress. Without cost controls, that money will quickly be eaten up by the ever-growing cost of health care. This reform is about trying to fix the system, not patch it with more money.
3. Where is the evidence that the plan, as constructed, would substantially increase insurance industry profit margins, particularly when it is funded in part via a tax on insurers?
The fact that the price of private, for-profit insurance stocks have gone up dramatically with each day of bad news for the public option. More importantly, the bill doesn’t need to increase profit margins to make the insurance companies more profitable. It will increase overall profits by expanding their customer base, which has be shrinking for years.
4. Why are some of the same people who are criticizing the bill’s lack of cost control also criticizing the inclusion of the excise tax, which is one of the few cost control mechanisms to have survived the process?
The excise tax is designed horribly. It’s a very weak cost control that will only reduce NHE by $100 billion by 2019. That is a 0.3% reduction. And it will only do that by encouraging employers to provide their employees with worse quality insurance policies that cover fewer procedures and have higher co-pays and deductible. Let’s say that again: the Senate bill achieves cost control by making the health insurance you already have through your employer worse so you will have fewer procedures. I support cost control mechanisms that do not hurt the quality of health insurance. The excise does not meet this important criteria. The people who told you it is a magical cost control mechanism sold you magic beans. Drug re-important alone would do a better job of bring down NHE.
5. Why are some of the same people who are criticizing the bill’s lack of cost control also criticizing the inclusion of the individual mandate, which is key to controlling premiums in the individual market?
The individual mandate only works if you have a strong social contract between people on the government. The government must promise to provide everyone with access to quality affordable health insurance, and then the people agree to an individual mandate to buy insurance. This bill fails to guaranty either quality or affordable health insurance. There is no ban on annual limits, meaning the insurance companies can now put a cap on how much they will pay out. They will still be allowed to drop their sick customers and deny claims if they decide their customers need an “unreasonable” amount of health care. And the maximum out-of-pocket limit is far too high. It will not stop medical bankruptcy if you get really sick, which makes a mockery of the whole idea of insurance.
The goal of reform is to hold down overall health care spending, not premiums. An individual mandate only holds down premiums if the premium money is used to pay for care to spread the risk. There is nothing stopping the insurance companies from just pocketing that extra money or using it to bribe providers with higher reimbursement rates to lock out competitors.
6. Would concerns about the political downside to the individual mandate in fact substantially be altered if a public plan were included among the choices? Might not the Republican talking point become: “forcing you to buy government-run insurance?”
The Republicans will say what they want anyway, but if there is a choice between public and private insurance it would not be true. And with a public option, at least you would not be forcing some people to give their money to the extremely unpopular health insurance companies — which is probably why the overwhelming majority of Americans support having that choice. Of course I’m more concerned about policy than politics when it comes to the individual mandate.
7. Roughly how many people would in fact meet ALL of the following criteria: (i) in the individual insurance market, and not eligible for Medicaid or Medicare; (ii) consider the insurance to be a bad deal, even after substantial government subsidies; (iii) are not knowingly gaming the system by waiting to buy insurance until they become sick; (iv) are not exempt from the individual mandate penalty because of low income status or other exemptions carved out by the bill?
If people are “exempt” from the individual mandate because the private insurance companies made insurance too expensive for them to buy (which thanks to the 1:3 age rating would be the older sicker people most in need of insurance) what is the point of the individual mandate? This sounds like a recipe to price out the old (nonprofitable) and force only the young (profitable) to buy insurance. The individual mandate should only be used for an “everyone in” system. This is “everyone in” except those whom the private insurance companies price out of the market.
8. How many years is it likely to be before Democrats again have (i) at least as many non-Blue Dog seats in the Congress as they do now, and (ii) a President in the White House who would not veto an ambitious health care bill?
Zero more years, because if they can’t get this Senate bill passed they will use reconciliation. Obama has decided he must pass health care reform, and if reconciliation is his only option he will use it.
9. If the idea is to wait for a complete meltdown of the health care system, how likely is it that our country will respond to such a crisis in a rational fashion? How have we tended to respond to such crises in the past?
That is not the idea at all, and completely irrelevant. The Senate bill will fail to stop the rapidly approaching meltdown of our health care system, and anyone is a fool for thinking otherwise. The CMS predicted that even if the bill passed, the cost of an average premium for a family of four will still increase roughly $1,000 a year. The meltdown is coming either way. This Senate bill is at best a very expensive band aid, and at worst a way to quicken the meltdown.
10. Where is the evidence that the public option is particularly important to base voters and/or swing voters (rather than activists), as compared with other aspects of health care reform?
Once again this is about policy for me, but there are many polls showing stronger support for the public option than the President’s health care bill. The few polls done on the matter have also shown that without a public option the individual mandate is extremely unpopular. If Democrats in Washington did not think the people cared about the public option they would have killed it a long time ago.
11. Would base voters be less likely to turn out in 2010 if no health care plan is passed at all, rather than a reasonable plan without a public option?
My goal has always been reconciliation, the use of the nuclear option, or the White House using its influence to back down conservative Democrats — something that hasn’t happened yet. I think this question is misleading because that is not the actual choice on the table. It is bad bill with regular order, a better bill with 50 votes in the Senate, or no bill.
12. What is the approximate likelihood that a plan passed through reconciliation would be better, on balance, from a policy perspective, than a bill passed through regular order but without a public option?
Extremely high. If I did not believe a much better bill could be passed using reconciliation I would not have been advocating for it for months. It is a pure myth that a good bill cannot be passed using reconciliation.
13.What is the likely extent of political fallout that might result from an attempt to use the reconciliation process?
I think it will be very small. People care more about results than process. If reconciliation results in this early Medicare buy-in starting in 2010, I think it would be a huge net political gain for Democrats by showing that reform is working.
Was there a political fallout from Bush’s tax cuts because they where done through reconciliation? I do think there was.
14. How certain is it that a plan passed through reconciliation would in fact receive 51 votes (when some Democrats would might have objections to the use of the process)?
First you only need 50 votes plus the vice president to break the tie. Second, are you really asking progressive to not stand up for better policy because there are possibly 11 Democrats who will bring down the reconciliation bill to protect their absurd Senate clubhouse feel?
The Democrats in the Senate seem were willing to give Joe Lieberman anything he wanted to get a bill labeled “health care reform” passed. If they will swallow their pride for Lieberman, they will do it for reconciliation if that is the only way the can get the “win.”
15.Are there any compromises or concessions not having to do with the provision of publicly-run health programs that could still be achieved through progressive pressure?
No. If progressive pressure cannot protect the extremely popular public option, I don’t see a single thing progressives can win on.
Progressive have zero power in Washington if they can not draw a line in the sand and say enough is a enough. Only by being willing to bring down a bad bill will they force those in power to listen to them instead of Joe Lieberman. Unless progressive are willing to play hardball, all the power will remain with Joe Lieberman (who has announced his intention to rewrite the climate change bill).
16. What are the chances that improvements can be made around the margins of the plan — possibly including a public option — between 2011 and the bill’s implementation in 2014?
If Obama does not feel a need to listen to progressive on the issue of health care reform at this moment, I don’t see how that will change between now and 2014. If anything, when people are not looking the lobbyists will go to work slowly crippling all the new regulations this bill will add. As long as we have this 60 vote myth controlling everything in Congress, all the power is with Joe Lieberman.
17. What are the potential upsides and downsides to using the 2010 midterms as a referendum on the public option, with the goal of achieving a ‘mandate’ for a public option that could be inserted via reconciliation?
I don’t know and I don’t plan to find out. We can get the public option now using reconciliation and that is what progressive should demand. It does not matter if we “win” the referendum on the public option in 2010, we already “won” the referendum on health care reform in 2008 when Barack Obama campaigned on it. If we can’t hold our elected representatives to account now it is foolish to think we will in two years.
18. Was the public option ever an attainable near-term political goal?
Yes. If Reid had used reconciliation months ago we would already have a bill passed with a public option.
19. How many of the arguments that you might be making against the bill would you still be making if a public option were included (but in fact have little to do with the public option)?
I don’t know about others but I have always argued against the excise tax. I have always said the individual mandate is only acceptable if the government provide everyone with access to decent cost effective health insurance.
20. How many of the arguments that you might be making against the bill are being made out of anger, frustration, or a desire to ring Joe Lieberman by his scruffy, no-good, backstabbing neck?
My arguments against the current bill were all made long before Joe Lieberman was empowered by Harry Reid to remove the public option. Now that the public option has been removed, the regulations have been weakened and the excise tax remains, I think the bill will do more long term harm than good when it comes to health care reform. FDL drew the line in the sand on the public option close to 6 months ago. This is not anger — this is long-term planning.