Progressive Breakfast: Health Reform Passes Key Senate Vote

T'was the weekend before Xmas
And all through the Senate,
There was talk of a bill
With some health care reform in it.

With Nelson and Lieberman
Both finally placated,
All that's left, it seems,
Is for the bill to be debated.

Progressives may grumble,
But with no worries about Snowe,
Passing a bill in the Senate
Seems almost certainly a "go."

At least that's how Clement Clark Moore [1] might describe the state of affairs in Washington, where Senators wait (and complain about waiting) to vote on the health care reform bill (or what's left of it, depending on your point of view.) With President Obama back in town from Copenhagen, and Republicans unable to stop it, the Senate's health care reform bill seemed likely to pass [2] a key vote in the Senate.

And sometime after 1:00 a.m [3] on the last vote before Christmas Eve, that's exactly what happened [4].

Democrats won a major victory in their push for health care reform early Monday morning as the Senate voted to end debate on a package of controversial revisions to a sweeping $871 billion bill

.

The 60 to 40 party-line vote, cast shortly after 1 a.m., kept Senate Democrats on track to pass the bill on Christmas Eve. If it passes, the measure will then have to be merged with a roughly $1 trillion plan passed by House of Representatives in November. The Senate went into recess until noon Monday shortly after the vote.

The vote left President Obama on the cusp of claiming victory on his top domestic priority and enacting the biggest expansion of federal health care guarantees since the enactment of Medicare and Medicaid over four decades ago.

Getting (Senators) To "Yes"

OurFuture.org's Roger Hickey [5] urged passage of the bill and a continued fight for reform: "Here's my position. In these final days of the health care fight, progressives should work hard to improve the health reform bill in the Senate and in the conference with the (better) House bill. But we should support the passage of the best bill we can get — and then keep fighting for more and better reform. "

Though vowing to fight on, Republicans had little hope of stopping health care reform [6] from passing in the Senate, thanks to successful negotiations between Democratic leadership and Sen. Bill Nelson (D-NB). New York Times:

A day after Senate Democrats said that they had clinched an agreement on a far-reaching overhaul of the nation's health care system, Republicans vowed on Sunday to continue their fight while acknowledging that their chances of stopping Senate passage had faded.

...But on Saturday, Democratic leaders hailed as a breakthrough the agreement by Senator Ben Nelson, Democrat of Nebraska, to back the bill after 13 hours of negotiations.

He was the pivotal 60th vote for a measure that President Barack Obama has called his top domestic priority; it would significantly overhaul the country's health care system, extending health benefits to more than 30 million uninsured Americans.

The Senate plans a crucial procedural vote at 1 a.m. Monday and a final vote on Dec. 24, allowing scant time to review the bulky and complicated bill or a last-minute 383-page amendment that reflects the Nelson agreement.

Of course, the deal with Nelson came down to abortion [7]. Politico: "'Why don't we have two policies?' Nelson asked. 'One with and one without.' Nelson proposed that every state insurance exchange offer at least one plan that does not cover abortion, and policyholders could choose a plan with or without abortion coverage, unless states choose to ban it. Also, people who receive federal subsidies would need to write two separate checks as a way to ensure that none of the federal dollars went toward the abortion premium."

Thus, despite the perks for his state, Nelson expects a backlash [8]. NPR: "Despite the perks Nelson managed to garner for Nebraska in finally agreeing to support the overhaul bill, the backlash from those who wanted Nelson to hold a hard line against the measure was immediate. Abortion foes howled in protest. Nebraska Right to Life, which has long endorsed Nelson, issued a scathing statement that dubbed Nelson a traitor. The state's Catholic bishops followed Sunday with a statement that they were "extremely disappointed" in him. The chairman of Nebraska's Republican Party declared Nelson's decision to be the end of his political career in Nebraska, and within hours of Nelson's announcement, the state GOP launched a Web site, www.givebentheboot.com, to collect funds to oust the Democrat in the 2012 election."

He may be right. The Senate abortion compromise Not only did Nelson's compromise not pass muster with the executive director of Nebraska Right to Life, with whom Nelson spent 40 minutes on the phone explaining the deal to no avail, but it's unlikely to satisfy pro-choice activists and proponents. Daily Kos' McJoan [9] describes it as "Stupak the States":

The deal with Nelson included a permanent exemption for Nebraska from the state share of a Medicaid expansion [10] — to the tune of $45 million to be kicked in by taxpayers. In all fairness, though, the Nelson deal was not the sum total of the Senate's sausage-making on health care reform. Politico:

But another Democratic holdout, Sen. Bernie Sanders (I-Vt.), took credit for $10 billion in new funding for community health centers, while denying it was a "sweetheart deal." He was clearly more enthusiastic about a bill he said he couldn't support just three days ago.

Nelson and Sen. Carl Levin (D-Mich.) carved out an exemption for non-profit insurers in their states from a hefty excise tax. Similar insurers in the other 48 states will pay the tax.

Vermont and Massachusetts were given additional Medicaid funding, another plus for Sanders and Sen. Patrick Leahy (D-Vt.) Three states — Pennsylvania, New York and Florida - all won protections for their Medicare Advantage beneficiaries at a time when the program is facing cuts nationwide.

All of this came on top of a $300 million increase for Medicaid in Louisiana, designed to win the vote of Democratic Sen. Mary Landrieu.

Democrats dealing their way to sixty votes means that Sen. Snowe, whom the White House spent an inordinate amount of time courting, no longer mattered. As she's no longer the Senator in charge of health care reform, she's standing with her party and voting against the bill [11]. No big surprise, but Steve Benen at Political Animal notes that, after several months as the focus of the Obama administrations quixotic pursuit of "bipartisanship," Snowe had the nerve to complain about the speed of the process: "I just can't figure out what on earth Snowe is talking about. She voted with Democrats on the Senate Finance Committee reform plan, but now appears to be looking for an excuse to oppose the effort. But to sound even remotely credible, Snowe will have to do better than this. For one thing, it's a "take-it-or-leave-it package"? Democrats have been willing to give Snowe just about anything she asked for. That's the opposite of a 'take-it-or-leave-it package.' For another, nothing about this has been "rushed." Snowe has been complaining about the speed of the legislative process since July, but therein lies the point: how could this possibly get slower?"

Bending the Curve

But is it reform? That all depends on whom you ask, and even if you ask yourself you may get two different answers. Ask Time magazine's Karen Tumulty who, on Friday evening praised Reid for "putting some reform back into health care reform" [12]: "Given the drama and suspense of the past few weeks, it's understandable that the first round of commentary about the new Senate health bill would focus on the deals that Majority Leader Harry Reid had to make to bring aboard all 60 of the votes that he will need to beat a Republican filibuster... But while you might think that all this horsetrading would produce a weaker and more bloated bill, it appears that, by some measures at least, the opposite may have happened. The preliminary analysis suggests that the new bill would actually be more effective than the previous version in reining in health care costs in the long term. To use the current Washington cliche, it would do a better job "bending the curve."

Twenty-four hour's later, Tumulty changed her tune somewhat [13]: I wrote this post saying that the new version of the Senate bill does more to "bend the curve" of health care costs. I based that in large measure on the Congressional Budget Office analysis of the how effective a new independent board to regulate Medicare would be. Except CBO got it wrong, at least partly. The independent board would still act as a brake on health care costs — but not as strong a one as CBO initially estimated, not over the long run.

What threw Tumulty was the CBO's "misunderstanding" of the bill; namely, the Medicare Independent Payment Advisory board and its impact on health care costs. On Saturday, CBO director Douglas Elmendorf wrote [14]: Relative to the legislation as originally proposed, the expected reduction in deficits during the 2020-2029 period is larger for the legislation incorporating the manager's amendment. Most of that difference arises because the manager's amendment would lower the threshold for Medicare spending growth that would trigger recommendations for spending reductions by the Independent Payment Advisory Board.

The following day, Elmendorf came out with a new analysis [15]: "The Congressional Budget Office (CBO) has discovered an error in the cost estimate released on December 19, 2009, related to the longer-term effects on direct spending of the manager's amendment to the Patient Protection and Affordable Care Act (PPACA), Senate Amendment 2786 in the nature of a substitute to H.R. 3590 (as printed in the Congressional Record on November 19, 2009). Correcting that error has no impact on the estimated effects of the legislation during the 2010–2019 period. However, the correction reduces the degree to which the legislation would lower federal deficits in the decade after 2019."

Whither Reform?

Meanwhile progressives, liberals, Democrats, etc., debate whether the bill in its current form can, will, or should pass — and whether it amounts to reform.

Writing in the New York Times, Vice President Joe Biden [16] casts the bill as the next step in a history of health care reform stretching back to Theodore Roosevelt, and wants that defeat could mean losing the chance for reform for another generation:

Is America better off today because a chance at a compromise health bill was missed in 1993? For my friends on the left, the rising toll of the uninsured provides an emphatic no. For my friends on the right, the soaring share of federal spending on health care likewise provides a no. Let's not make the same mistake again.

If the bill passes the Senate this week, there will be more chances to make changes to it before it becomes law. But if the bill dies this week, there is no second chance to vote yes. What those who care about health insurance reform need to realize is that unless we get 60 votes now, there will be no health care reform at all. Not this year, not in this Congress — and maybe not for another generation.

Former DNC chair Howard Dean expressed disappointment that the Obama administration didn't fight for the public option.

Visit msnbc.com for breaking news [17], world news [18], and news about the economy [19]

Jacob Hacker [20], whose "Health Care for America" [20] plan influenced the health care platforms of Democratic presidential candidates in 2008, writes in the New Republic that he still supports the bill:

Now that the core demand of progressives has been removed from the Senate health care bill — namely, the public health insurance option — should progressives continue to support the effort?

For me, the question is particularly difficult. I have been the thinker most associated with the public option, which I’ve long argued is essential to ensuring accountability from private insurers and long-term cost control. I was devastated when it was killed at the hands of Senator Joe Lieberman, not least because of what it said about our democracy — that a policy consistently supported by a strong majority of Americans could be brought down by a recalcitrant Senate minority.

It would therefore be tempting for me to side with Howard Dean and other progressive critics who say that health care reform should now be killed.

It would be tempting, but it would be wrong.

Über blogger Markos Moulitsas [21] said on "Meet the Press" that what we've got now doesn't add up to reform.

Half a loaf or full loaf, Steve Marmel at the Huffington Post, turns the focus back on congressional Republicans and their obstructionism:

"Every single Republican has lined up against this bill. Am I supposed to believe there wasn't ONE Republican that wanted to make this work in either the house or the senate?

Forty senators cannot agree on anything. Except, of course, that they want their White House back. And that's what this is all about.

These people with the "R" in front of their name lined up in unison at the beginning of this presidency, not over fighting any specific bill — they were fighting against ALL of them. They lined up in unison because they wanted Obama to fail. Not over health care. Not over climate change. They just want him to fail. Period.

It is that simple."

Nate Silver of FiveThirtyEight [22] reminds us that the Senate bill isn't the end of the process. Far from it, in fact: "According to many sources, including the White House in their Thursday conference call, there is still highly likely to be a conference report in order to reconcile the House and Senate versions of the bill — which of course contain significant differences, including the public option. This is arguably the most likely avenue for the bill's defeat; the measure, after all, passed the House with only two extra votes, and I'd expect some liberal groups to shift their attention to the House and urge progressives to kill the bill. However, that neglects the fact that some moderate and conservative Democrats who voted against the bill the first time around will probably now vote for the compromise with the Senate, which will be significantly more moderate. It also neglects the fact that Nancy Pelosi is a significantly more skilled vote-whipper than Harry Reid. So, this is perhaps the most interesting thing to watch, but it again seems unlikely that the bill will fail to clear the hurdle."

Clive Crook, writing in the Financial Times, dismisses opposition from conservatives and (in his words ) "the loony left," and points out what the Obama administration got wrong, and what the Senate health care reform bill gets right, at the very least.

In the end, I think, everything depends on the weight one attaches to achieving security of coverage as quickly as possible. In my view, this is the overriding consideration. Abandoning the effort now might postpone that goal for another decade or more. The country should regard this as unacceptable. Once the reform is law, though, the real work begins. Getting a grip on costs will be even more urgent than it is already — especially when you recall the broader fiscal calamity that awaits the country during the next decade.

The honest case for reform along the lines of the Senate bill is not that it fixes U.S. healthcare; still less that, as the White House blithely maintains, it alleviates the country's fiscal distress. The truth is, it will create more problems than it solves. But the one big thing it gets right — the assurance of affordable health insurance for all Americans — is of surpassing importance.

Enacting this reform is not the end of the healthcare argument, but the beginning. If it does pass, it may well be looked back on as a mistake once its financial implications sink in. Yet the principle of universal coverage will have been accepted, and with luck there will be no going back. The price will be high, but is worth it.

RJ Eskow [23], on the excise tax in the Senate Bill: "The Senate's new bill won't just increase the Federal budget. We'll also pay higher premiums because we lost the public option, and face more out-of-pocket payments because the excise tax stayed in. There's an easy way for the President and Sen. Reid to disprove the Good Cop/Bad Cop Scenario, of course: They can fight like hell to win concessions in the House/Senate conference, to bring the final bill more in line with the House version. That would mean, at the very least, a public option and no excise tax."

Josh Marshal at TMPCafe [24], expressed concern about the time between passage and implementation in 2014, and what mischief insurance companies and health care reform opponents might get up to between now and then:

So here's my question: why wait so long to implement this stuff? I know stuff like this can't just be done on a few months notice. Health care is a huge part of the nation's economy. And you need frameworks of predictability, planning and transition to put such big changes into place. But four or five years seems way, waaay too long.

My impression is that some of the delays are there because it makes the budgetary accounting work better in terms of deficit neutrality. And I know the Dems would likely lose critical support without being able to show that the overall bill actually lowers the deficit. But if that's the main reason, I suspect the legislative authors may be too clever by half since they may be slitting the bill's and perhaps their own throats in the process.

So again, my question: why the wait? And how in practice what's the soonest the big reforms could be implemented? Do we really need to wait this long?

Finally, Victoria Reggie Kennedy [25] (who was present in the visitors gallery during the vote) pays homage to her late husband and "the cause of his life":

My late husband, Ted Kennedy, was passionate about health-care reform. It was the cause of his life. He believed that health care for all our citizens was a fundamental right, not a privilege, and that this year the stars -- and competing interests -- were finally aligned to allow our nation to move forward with fundamental reform. He believed that health-care reform was essential to the financial stability of our nation's working families and of our economy as a whole.

Still, Ted knew that accomplishing reform would be difficult. If it were easy, he told me, it would have been done a long time ago. He predicted that as the Senate got closer to a vote, compromises would be necessary, coalitions would falter and many ardent supporters of reform would want to walk away. He hoped that they wouldn't do so. He knew from experience, he told me, that this kind of opportunity to enact health-care reform wouldn't arise again for a generation.

Back From Copenhagen

President Obama flew home for the health care vote from the climate conference in Copenhagen, where he arrived to find chaos [26]. New York Times: "By early Saturday morning, the atmosphere at the European Union pavilion at the Bella Center had turned funereal. A group of ashen-faced European negotiators sipped beer from bottles in dim light as crews began dismantling food stalls, television monitors and giant displays of the Union's blue and gold flags. ...Brian Cowen, the Irish prime minister, had an air of grim resignation as he trudged out of that meeting shortly before 2 a.m. 'It's less than what we wanted, but the process has to go on,' Mr. Cowen said. And in what appeared to be a sharp reference to the wrangling between China, the United States and African countries that had blocked a more far-reaching accord, Mr. Cowen, as he headed for the exits, shouted: 'Certainly it's not Europe's fault!'"

Still, the president flew home with for the Senate vote on health care reform with a compromise already in his back pocket [27]. Newsweek:

Late in the afternoon on Friday, with the clock ticking down to zero, a rather dramatic scene unfolded that surprised even several top leaders at the climate negotiations in Copenhagen. In a secret meeting between Chinese, Indian, and Brazilian heads of state, the door swung open revealing President Obama, who hadn’t been invited but had arrived to crash the meeting. Several diplomats protested the intrusion, but Obama simply informed them he wouldn’t accept them negotiating in secret. He sat down and started talking.

The result of that discussion is the outcome of the Copenhagen climate talks—a political agreement that gets something on paper but lacks several of the components that many had expected to be finalized at the meeting. Under the agreement, developed nations would scale back their greenhouse-gas output 80 percent by 2050, a vague target that many who wanted stronger action see as insufficient. China’s main sticking point was that it would make domestic cuts but didn’t want to jeopardize its sovereignty by allowing international regulators inside the country, so that requirement was dropped. Another proposal sought for all parties to sign a treaty as soon as possible, but no later than the next round of climate negotiations in Mexico next December. That stipulation was also dropped, leaving a window of now until 2015 for countries to continue to review the proposal before signing on the dotted line.

Of compromise means giving something up. Noah Sachs on what's missing in the Copenhagen compact [28]: "Climate delegates finally finished two years of negotiations Saturday by "taking note" of the two-and-a-half page Copenhagen Accord hashed out Friday night. It reminded me of a marathoner who slow-walks the course, hobbles across the finish line seven hours late, and then declares victory. Yes, there was a semblance of a deal by Saturday, but it's not what any of the parties said they were coming here to do, and no medals are being handed out. The most important part of this deal is what's not in it. Crucial unresolved questions will continue to dog climate negotiators into 2010 and beyond."

Anna Field [29] at the Financial Times on why even a compromised Copenhagen compact is a victory of sorts: "Mr Obama has made tackling climate change a domestic priority, promoting clean energy technology in particular as a way to create jobs. He might have angered Europe by agreeing a hasty deal with key developing countries and disappointed environmental activists calling for bold action but, by coming home with even a wishy-washy agreement, Mr Obama has deftly given a boost to congressional efforts to limit the US’s carbon emissions."

As with health care reform, the Copenhagen compromise is seen a first step: from the New York Times:

The global climate negotiations in Copenhagen produced neither a grand success nor the complete meltdown that seemed almost certain as late as Friday afternoon. Despite two years of advance work, the meeting failed to convert a rare gathering of world leaders into an ambitious, legally binding action plan for reducing greenhouse gas emissions. It produced instead a softer interim accord that, at least in principle, would curb greenhouses gases, provide ways to verify countries’ emissions, save rain forests, shield vulnerable nations from the impacts of climate change, and share the costs.

The hard work has only begun, in Washington and elsewhere. But Copenhagen’s achievements are not trivial, given the complexity of the issue and the differences among rich and poor countries. President Obama deserves much of the credit. He arrived as the talks were collapsing, spent 13 hours in nonstop negotiations and played hardball with the Chinese. With time running out — and with the help of China, India, Brazil and South Africa — he forged an agreement that all but a handful of the 193 nations on hand accepted.

Change = Compromise?

One year into his first term in office, depending on how you look at it Obama has either delivered or disappointed on some issues central to his campaign. Steven Thomas at McClatchy [30]: "Nearing the end of his first year in office, President Barack Obama is in many ways a changed man. He's stayed the course on his highest-profile goals, still reaching for universal health care, still striving for a global pact to curb global warming. Governing has proved to be far different from campaigning, however. The world looked different once elected."