Action in the States- Why the Feds will not Drive Health Care Reform
I appreciate Jon's (and others) argument for "thinking big" but it's worth separating where you want to end up versus the steps to get there.
And the first, or even the second steps, are not going to come from the federal government. State reforms, "incremental" and "hybrid" as many will be, are the likely route to real reform which, when they advance far enough, will force federal changes. It's not messaging but raw power at the federal level, in the form of the filibuster, that means the federal level won't drive health care reform.
Part of peoples views on this go back to what went wrong with Clinton's proposals. Sure, Clinton made mistakes and bad comprimises but the raw reality is that the GOP decided to kill ANY plan. Bill Kristol famously issued memos in Dec. 1993 calling for no compromise whatsover (see this account):
Kristol writes that congressional Republicans should work to "kill" -- not amend -- the Clinton plan because it presents a real danger to the Republican future: Its passage will give the Democrats a lock on the crucial middle-class vote and revive the reputation of the party.
The rightwing knows that universal health care will fundamentally change the dynamics of politics in the nation, creating a basic entitlement not just for the elderly, but a benefit for every family in the country. So they will pull every political maneuver necessary to kill reform, and the filibuster means they need hold only 40-41 Senators to block reform.
So that leaves the states pushing reform. I'd love to see California pass single payer health care, as Robin Podolsky argues is possible, but California has it's own odd filibuster like problems in the form of the Gann limits on tax increases without a two-thirds vote. One reason any employer mandate looks so attractive in some state like California is that it's not legally a tax increase, so it bypasses tax limitation rules. Which is why in California, a hybrid approach is still more likely but we will see.
Decent Reforms: But there are other states where majority rules and the majority is proposing some pretty damn interesting measures. Massachusetts got more of the press last year, but Vermont passed a far better bill last year, which unlike the MA bill, actually definted and limited consumer costs:
- Health care subsidies will be offered to all uninsured up to 300% of the poverty line ($29,400 for individuals, $60,000 for family of four).
- For Vermont citizens below 200% of the poverty line and who don't qualify for Medicaid, premiums will be $60 per month.
- For those between 200%-300% of the poverty line, premiums will be $90-$135 per month.
There was a compromise that allowed the insurance to be provided by private insurers, but under these tightly controlled rules.
Covering All Kids as a First Step: But even more promising was Illinois Cover All Kids Program. While restricted to kids, the coverage is essentially universal for that age group, extending up to families making $100,000 plus, INCLUDING undocumented immigrants covered by no federal program.
Pennsylvania passed a similar program last fall, and other states are following with major expansions of coverage for kids. The political brilliance of the Cover All Kids approach was articulated by Oregon Governor Ted Kulongoski, who has recently taken his Healthy Kids Plan to the legislature, and said:
If you drive this plan into the middle class, it's not just viewed as a public assistance program. You build a base of support for the program to provide health care for all of us.
This is the flip of the Bill Kristol fears-- create an entitlement that helps every family and their fundamental orientation towards entitlements will change. If it's good enough for their kids, it's good enough for the adults as well.
Which is where both Pennsylvania and Illinois, having enacted the cover all kids approach last year, are pushing reforms this year. While not "pure" programs, the Illinois proposal is especially dramatic, with financial subsidies for families making up to 400% of the poverty line or $80,000 per year for a family of four. And premiums would be capped as a percentage of income to make sure no one gets priced out. And Illinois Gov. Blogojevich is backing his proposals with requests for $2.1 billion in new taxes and fees.
THe Federal Connection: The rightwing is really afraid of this dynamic and is mounting a counterattack. In the reauthorization of SCHIP, which partially funds some of this coverage for kids, Edwin Feulner, President of the the right wing Heritage Foundation, wrote rececently, "Congress created the program to help poor children, not to give states another excuse to shower 'free' benefits on middle-class families." Sure enough, President Bush proposed cutting off SCHIP funding for state programs providing SCHIP help to any families above 200% of the poverty line.
But what's interesting is the dynamic that led Congress to expand funding for SCHIP. States, including many Republicans ones, were so taken with the idea of expanding coverage for kids that they had overcommitted funding far beyond any federal help. So Congress was faced not with "increasing" help for kids but, given the state level actions, with a dynamic of them being in the position of "cutting" health care for the kids.
That's how states will drive federal policy-- they make the commitments to universal coverage and then pressure will build on the federal government to fund shortfalls. And once federal dollars are flowing, if insurance companies or pharmaceutical companies are leeching to large a share, that's when budget-cutting energy will drive more comprehensive changes.
It's at that point that a rightwing filibuster will mean not blocking new health care for people, but will mean cutting off health care-- a dynamic far more like the Social Security battle which the rightwing GOP leaders know they would lose.
The real question is not "hybrid" versus "single payer" versus whatever, but whether incremental steps we can take will generate new political demands by voters to keep the reforms coming. Most national health care systems around the world were not created in a single legislative act, so we should see health care reform as a multi-year process, not a "big plan" to be enacted all at once.
And my view is that the place where all of it will start-- and already is under way-- is in the states, whcih will drive reforms for the next few years.
As someone who was Hill staffer deeply involved in health reform in 1993-94, I want to say this is an excellent analysis. I agree the states will be the first movers on this as NY, PA and Florida were on SCHIP over a decade ago. It will either take a completely inequitable solution within the states or 61 Senate Dems to get this moving on the federal level.
April 11, 2007 12:16 PM | Reply | Permalink
Georgia is one of the states that expanded its SCHIP program only to be forced to contract it this year because promised federal monies were cut off. Georgia voted 70% Republican in 2004. I wonder how many Republican state legislators have figured out by now that being reliably red can have a diminshing affect on their influence at the national level.
April 11, 2007 12:53 PM | Reply | Permalink
Nathan Newman-
Respectfully disagree
I have been following the state initiatives for over two years. They really got going with the announcement of the Massachusettes "Universal Health Care Plan" announced last year followed by California, New York, Pennsylvania and others. (I wrote about each plan in my blog-see below)
The most creative plans in my opinion are from a former Governor John Kitzhaber of Oregon and, of all people, Mayor Mike Bloomberg of New York City!.
Anyway the states put bottom up pressure on the Feds to act and all current presidential candidates are defining health care reform plans.John Edwards set the first detailed mark.
The key though are the voting public who have defined this (see polls) as probably the number one domestic issue for the next president
This issue has gone beyond the states. The genie is out of the bottle and will not be forced back.
Filibuster will not work in the face of huge populous support for a national solution
Dr. Rick Lippin
Southampton, Pa
http://medicalcrises.blogspot.com
April 11, 2007 1:44 PM | Reply | Permalink
Since we are 37th in the world in the quality of our health care and since most western countries, at least, are not only ahead of us in the quality of their health care they have successful single-payer plans it would not seem unjustified to take a page from one of their health care up-and-running plans.
Is it because we are no longer a part of the western world that we can't do this?
April 11, 2007 1:47 PM | Reply | Permalink
Mr. Newman.
It seems to me it was Harry Truman who first proposed universal health care in the US - in 1948. By that measure, I think you should check your facts and offer a bit of evidence for this claim. My quick check suggests the contrary, e.g., for Canada, the UK, Cuba, and France. And France's system of universal health care is more than 100 years old, or so I've just read on its web site.
Yes. And yes also that the Republicans want to kill any attempt to create "new" entitlements. So, are you a Republican? Are they arguing your position, and if not, why must you argue theirs? Or are you simply afraid that they'll do what they've always done in such debates, i.e., not ask you what your position is, but tell you what your position is? Wouldn't be hard to do, after all, since your position is based on their principles and ideas. Aren't they?...
Let me be blunt, Mr. Newman. You're playing a losing game with this sort of rhetoric. To institute a truly socialist program in the US, it's not going to be enough to sell just that program - you're going to have to get the public past their emotional fear of the very idea of socialism. Basic entitlements? Code for socialism. And you know that.
So come on. Address the real issue. Universal health care goes through the politics of socialism vs. capitalism - don't pass GO, don't collect $200 - and you don't even want to use those words directly. Good luck getting anything at all done, if you won't even get in the game. And yes, coincidentally, Monopoly IS the name of the game.
Maybe it's just that you don't know how to defend socialism itself well enough to defend what obviously needs to be a socialist program. Well, then, learn how. Think outside the capitalist box. Stop making money a constraint on every idea. Really - stop doing it. That's playing by your opponents rules.
Try this little hypothetical game. What's the real value of money, in the US? Is it fixed? No, of course not - it changes momentarily, largely as defined by the federal reserve system. When a Republican asks "how are we going to pay for X," as if it is fixed, imagine how you might answer that in detail, beginning with something trivially simple, like, "we'll just print more money." Follow through the proposal. Offer something big, like, "we'll print enough so that each and every US citizen has at least $1M." What would be the effects of doing that? Inflation? Sure. And who would that most affect? Not those who get subsidies to reach that $1M, I can tell you.
Republicans don't want socialism because they don't want to share - anything. I say that's refusing to accept basic responsibility for citizenship in a civilized society - maintaining such societies is not free - we all have to do our part. It's high time for people like you to stop defending the gross lack of responsibility on the right, which is off the scale in moral and ethical terms, by using their ideas and principles, and start calling them on it, by getting a clue what your heart tells you your real ideas and principles ought to be.
You know in your heart what the rules of civilized society should be, Mr. Newman. Start acting like it. Please.
April 11, 2007 2:20 PM | Reply | Permalink
Bill Kristol memo in 2003 or 1993?
April 11, 2007 3:27 PM | Reply | Permalink
Well, we can't have that, can we, what Democrat would want to fundamentally change the dynamics of politics in the nation? It would be counter to the surrender strategy.
Now, if someone would please start a political party that wants to fundamentally change the dynamics of politics in the nation, I'll work my heart out for it.
April 11, 2007 3:45 PM | Reply | Permalink
Note the point-- many elected officials in the states ARE trying to pass comprehensive health care reforms. I actually wish more bloggers and other activists would pay more attention there, where they could make a difference, and less to DC where gridlock is somewhat inevitable on the issue until we elect another ten or so progressives to the Senate.
April 11, 2007 3:54 PM | Reply | Permalink
It doesn't need to be this way. It is perfectly possible to get Republicans on board with serious health care reform.
As I've argued on another thread, the key to changing the dynamic on health care is to peel big business away from the Republicans by arguing that NOTHING - not taxes, not regulatory relief, not anti-labor laws - will do more for the bottom line of most businesses than slowing the growth of health care spending and shifting the burden for paying for health care to the government and society at large.
Health care costs are a huge drain on corporate America. For the better part of 20 years, costs have been rising by double digits. The market responds with some new gimmick, like HMOs or Health Savings Accounts and costs may slow for a while. But the long-term trend continues unabated. The result is that this is now the #1 issue for HR directors and is an issue that has visibility at the highest levels of most big businesses. It also slows hiring of full-time staff and encourages the use of independent contractors, leading to less stability and security for more people. The health plan is now something that CEOs pay attention to, not just the Benefits Coordinator.
If Democrats are smart, they will do the counterintuitive thing and appeal to big business to join them in removing this drain on competitiveness. They will argue that business and consumers have an alignment of interests on this issue and that removing the link between employers and health care is a win-win. Once business leaves the fold, Republicans will come on board. Only the die-hard ideologues will continue to oppose it.
That sound you just heard was Nathan Newman's head exploding at the idea of getting into bed with business. But make no mistake: the key to getting health care reform done is to build a broad coalition of interests and business has to be a part of that coalition. As an added bonus, if business becomes even a halfway reliable Democratic constituency, it will kill off "movement conservatism" once and for all as a significant political force. That alone makes it worthwhile.
April 11, 2007 4:54 PM | Reply | Permalink
Hmm, well, that's a plan: we wait for the 50 states eventually one by one to do what there's national pressure to do. That was so effective for civil rights and medicare in the 1960s. Seriously, if there's one thing all other posts agree on, it's that the only way to bring policy in line with factors from broad public opinion to need to moral imperative is to take decisive leadership. Nathan's just running away from the issue.
John
http://www.haberarts.com/
April 12, 2007 6:50 AM | Reply | Permalink
Actually, that's exactly what happened with civil rights. Local and state governments began passing civil rights laws in the late 1940s, which propelled the issue onto the national debate even before Brown v. Board.
Hubert Humphrey was mayor of Minneapolis, where the first city civil rights law was passed and it was his speech at the 1948 Convention that helped pushed Strom Thurmond and the Dixiecrats to walk about of the Democratic Convention-- really launching the national debate on civil rights. New York and other states would follow with their own civil rights laws, building the pressure towards federal legislation.
Similar phenomenon today with global warming legislation, which is being led from the states.
April 12, 2007 7:41 AM | Reply | Permalink
But that state action was to build momentum for federal enforcement where it counted, where it was going to encounter serious resistance, and where it could lead to change. And while I applaud state action on global warming, a lot of that has involved not legislation alone but also court action to demand EPA action. And you can't seriously claim there's time to stop vast damage to the planet at this point if we don't demand the U.S. join with other nations.
In any case, you're too late: people do want health care. It's not about building momentum; it's about taking charge. It's not about choosing politically safe ground; it's about the universal in universal health care.
Until you start to stick up for everyone, and that means me, you're just sticking up for your protections. And then you want me to sympathize with the union cause. I do despite you, but you're going to have to go a lot further if you want to remain viable in the future. Otherwise, ironically, this kind of middle-of-the road position, very much like the DLC's, is going to prove the DLC right on the irrelevance of unions to Democrats. Congratulations on the farsightedness.
John
http://www.haberarts.com/
April 12, 2007 9:01 AM | Reply | Permalink
‘If Democrats are smart, they will do the counterintuitive thing and appeal to big business to join them in removing this drain on competitiveness. “
Fine, but business will be keen to know how “society at large” will pay for health care, after all they get paid to manage money.
There is little discussion of the revenue source for single payer that I can find. It seems clear that the cost must be hidden from voters in order to be politically viable. Most people get their health care from an employer and perceive the cost to be their deductibles and co pay. The single payer plan cannot simply pass the cost onto the employees as a tax representing the real cost of their health care.
So, the choices are a highly progressive tax so that a very few voters shoulder most of the cost or a business tax of some kind that is not visible to voters. Businesses will logically conclude that they are likely to bear the brunt of the tax.
April 12, 2007 11:32 AM | Reply | Permalink
there are some GOP solutions too, but with so many ideas being thrown out -- how many people are going to be able to make an educated decision? The spinmeisters work overtime on this issue, and you can make Sweden look like health care paradise or hell depending on who you listen to.
Everyone knows a change is needed -- consensus on the change is going to be a smack down.
April 12, 2007 7:17 PM | Reply | Permalink
these rankings aren't the Bible. the majority of new medical breakthroughs happen here, and we've got state-of-the art care available. Tens of thousands come here from around the world for health care, including a lot of Canadians.
We need to stop bashing the system -- it's not the problem -- the problem is access and coverage.
April 12, 2007 7:21 PM | Reply | Permalink