Tuesday, December 15, 2009

Health Care: Who Should Liberals Believe?

As both Greg Sargent and Steve Benin write this afternoon, there's a split developing on the left about whether liberals and those to the left of liberals should support the bill that's appears to be emerging from the Senate. Both of them characterize the debate as wonks vs. activists...here's Greg:
The bloggers who are focused on political organizing and pulling Dems to the left mostly seem to want to kill the bill, while the wonkier types want to salvage it because they think it contains real reform and can act as a foundation for further achievements.

In the former camp are bloggers like Markos Moulitsas, former House candidate Darcy Burner, and the Firedoglake crew. They mostly deride the bill as a giveaway to the insurance companies that does nothing for consumers. A quick rundown of their opinions right here.

In the latter camp are wunder-wonk types like Ezra Klein, Jonathan Cohn, and Nate Silver. They all make expansive arguments that the current legislation contains real reform and indeed represents a fairly immense progressive achievement. A quick rundown of their opinions here.

Note that Howard Dean is now joining the anti group. He's neither wonk nor activist; he's a pol trying to secure the support of activists.

So, the question is: if you're a liberal, should you listen to the wonks or the activists?

Regular readers will no doubt know that I'd advise liberals to support the bill. But rather than just give that advise, I think a more helpful thing to do is to generate some questions to ask of activists who oppose a health care bill without a public option. So, The Big Questions I think undecided liberals should want answers to:

First category: the first order effects of the bill.

1. Does the bill help or hurt the uninsured compared to no bill at all?
2. Does the bill help or hurt insured poor and middle class American compared to no bill at all?
3. Does the bill help or hurt the long-term prospects for Medicare, compared to no bill at all?
4. Does the bill help or hurt any special group that you're particularly concerned about (the poor, women, cancer survivors, the disabled, Latinos...you name it) compared to no bill at all?

Notice what I don't ask about: whether the bill helps or hurts insurance companies (or doctors, or other interests); also, whether the bill punishes or rewards the various pols (Lieberman, Reid, Rahm, Nelson, whoever) for their real or imagined sins against liberals. In my strong opinion, neither of these should be nearly as important as how it affects the bulk of Americans.

Next category: is a better bill available, short or medium term:

What's the path to a better bill?

5a. For a comprehensive bill through reconciliation, can you identify 50 Senators who would support a strong public option available through the exchanges imposed via reconciliation. If not, can you identify 50 Senators who would support a weak public option (available through exchanges only), with an opt out, imposed via reconciliation?
5b. Can you describe the elements of the bill that would be lost, or would risk being lost, through reconciliation? How do they compare to the answers to question 5a?

6. If the better path is through beating the filibuster, how is that feasible, even though the political scientists who study this stuff say it isn't? If through repealing the filibuster altogether, how is that going to happen in the near or medium term?

7. Another option is a less comprehensive bill -- I heard Woolsey say that on MSNBC this afternoon, and Dean says: "go back to the House, start the reconciliation process, where you only need 51 votes and it would be a much simpler bill." Question: what exactly would be in the "simpler" bill, what would be left out of the bill that appears to have 60 votes in the Senate now, and why is the "simpler" bill better for the groups in questions 1-4?

Notice what's not relevant here: mistakes, real or imagined, by bill proponents to date. Whether Obama, Reid, and Pelosi would have been better off with different strategies and tactics is not important to the question of what's available now.

Last category: Long term effects of failure.

8. Will Democrats do better or worse in the 2010 elections if the current bill passes?
8a. Will "progressives" have more or fewer votes in the next Congress if this bill passes?
9. Will Obama's approval ratings rise or fall if the current bill passes?
10. Will the liberal agenda -- climate, jobs, etc. -- be helped or hurt if this bill passes?
11. On health care specifically, what is the path to getting a better bill in the next ten years if nothing passes in this Congress?
12. On health care specifically, what is the path to getting a better bill in the next ten years if the current bill passes in this Congress?

Now, I know what my advice to public option supports would be.

I think the wonks make an excellent case that the answers to the first four questions are all helps, not hurts.

On questions five and six, I think all of us who study Congress would conclude that at this point, in this Congress, there's no better (that is, more liberal) bill to be had. The votes simply aren't there. I'll go back to question seven at the end.

On the political questions, eight through twelve, I think there's no question at all but that it's better for Democrats, and for liberals, if this bill passes. For what it's worth, so does Chris Bowers, from the activist camp.

That leaves question seven. Is there some minimal bill that (1) could pass, and (2) could get enough of the benefits of the current bill that it would be worth doing? I really can't see it, but perhaps there's something there. My advice to liberals who are tempted to oppose the bill would be that there's a lot riding on exactly what this minimal plan might be, what the chances of actual passage would be, and how it compares to the bill moving through the Senate now.

Granted, on all of these, there might be counterarguments. Read the arguments of the kill-the-bill group. See what Howard Dean and the other activists have to say -- not generalities about some theoretical better bill, or vague claims about "real reform," but specific alternatives, and how exactly they can happen. How would they answer these questions? What's their argument? Their evidence?

I don't think they have a case.


  1. I'm going to disagree a bit with respect to 8 through 12.
    8) Looking only at 2010 seriously underestimates the negative impact, electorally, this bill could have. The mandates do not kick in until after 2010, so by selecting that as your evaluation point, you've biased the answer.
    8a) Same as above with respect to time horizon.
    9) Obama's approval may tick up slightly, but there is no reason to believe there will be persistence of effect.
    10) The liberal agenda has been kneecapped by this process. Blue Dogs in the House and ConservaDems in the Senate are just getting started on emasculating the liberal agenda. Their victory in denuding health care is only going to embolden them. (see, for example, past few months of Nelson and Lieberman)
    11 & 12) Let me turn this one around on you-- what is the plan to improve this bill in the next ten years if Congress passes it? if Congress fails to pass it?

  2. Seth -- Thanks!

    Heterodox --

    Interesting comment. I'll reply at length...

    On (8): if you think that individual mandates with subsidies would be unpopular, I think that's a fair reason to oppose this bill. I think the evidence leans the other way, though. My guess is that people who currently want insurance but can't get it (because of cost, but especially pre-existing conditions) will be very happy with the results; people who don't want insurance will be somewhat unhappy with it. OTOH, assuming it fully closes the donut hole, which I expect the final bill will, then it's clear that Medicare people will be very, very happy with it, despite being solidly against it now. I'll grant, however, that anyone who is unhappy with health insurance/health care may blame the bill & the Dems, even if their problems have nothing to do with the bill (but that may also be true if the bill fails). Then, also, there's the shorter term factor about the party & Obama keeping their promises. Put it all together, and I think it's solidly a net plus for Dems to pass it.

    Oh, and the time horizon that matters most is 2010, mostly because it'll tend to fade as an issue regardless, but also because the consequences of a bad election for Dems in 2010 will affect later elections.

    On (10), I strongly disagree. What hurts the liberal agenda is lack of liberals in Congress (and the rejectionist GOP strategy in the Senate). But overall, a president with a reputation for getting things passed is going to find it easier to get things passed.

    On 11 & 12: that's pretty straightforward. If the Liebermanned bill passes, liberals can start agitating the next day for putting a public option into reconciliation in 2010 or (more likely) 2011 (I think reconciliation in 2010 is going to be for cap-and-trade). Also, I'm pretty sure that opening up the exchanges could be done through reconciliation...even if it can't, it's pretty easy to imagine expanding the exchanges as a rider to something else.

    But if this thing fails, it's very hard to see Obama trying again. Ever. We'd probably get S-CHIP expansion, and maybe a little other stuff, but it really would be 1994 all over again.

  3. ... but, very rarely it politivs hold it;s purity.
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