Well, Ezra Klein, Republicans may not have "plan" to save insurance markets after King. But they may deal

Republican Senators Orrin Hatch Lamar Alexander John Barrasso are out today with a lightly sketched "plan" to salvage premium subsidies credited through the ACA's federal exchange if the Supreme Court rules for the plaintiffs in King v. Burwell.  The proposal closely resembles the  possible post-King negotiation that former HHS Secretary Michael Leavitt outlined to me. Here's Hatch et al:

First and most important: We would provide financial assistance to help Americans keep the coverage they picked for a transitional period. It would be unfair to allow families to lose their coverage, particularly in the middle of the year....

Second, we will give states the freedom and flexibility to create better, more competitive health insurance markets offering more options and different choices. Republicans understand that what works in Utah is different from what works in Tennessee or Wyoming. We want to give states the time and flexibility to design health-care systems that work for them, not for the bureaucrats in Washington.

People who live in states that have state exchanges will continue to be subject to Obamacare’s costly mandates and rules, along with the subsidies. But their states could also have the benefit of our solution. Every state would have the ability to create better markets suited to the needs of their citizens.

And here's Leavitt last week:

One more chilling Cohn crie de coeur

He rends my heart because he is so right and recognizes the stakes:

Now is the time to write stories about how strategically and politically insane it would be for the House to not find a way to pass the legislation.

If they fail to do so, the Republicans will be the writers of history--because the victors, not the vanquished, get the pen and the paper to do so. They will get to define what was in it and why it died. And this will have implications not just about the past but the future. Republican will say, and more effectively (but no less inaccurately) than ever, that, given the chance, the Democrats will be right back at it again with their "evil, secret fantasy to take over the health care system."  They will more successfully (and inaccurately) define "it" as being a deficit busting, government take-over that will ration care and harm seniors.

Democrats have to understand that virtually all of them have already voted for a bill that will therefore be defined by the Republicans.  As such, they--and even those Democrats who did not vote for the bill--will be linked to that party that embraced to "Obamascare." And, for those who are completing embracing a fall-back, small-ball approach, think again. That seductively tempting option won't come to pass either. Why?  Because the Republicans will work to ensure it does not.

One bitter irony in this meltdown -- one that highlights the impotence of the left generally -- is that as far as I can see there are no progressive interests groups, except perhaps the unions, pressuring House and Senate Democrats to find a way forward on comprehensive HCR.  I get emails from Moveon.org and BoldProgressives.org pushing fantasies that Democrats can somehow now be pressured to go for the full Monty - strong public option, more generous subsidies, no excise tax...as if the House is now dealing with a Senate more inclined to give the party's liberal wing what it wants instead of one empowered to block any bill other than the one they just passed, and as if their majority is not on the brink of being blown to pieces.  So we in the broad majority of Democratic voters who want the Democrats to pass an HCR bill they have the power to pass have no one sending those 'call your Senator/rep" emails with the numbers popped up right in front of you.

Paging Jonathan Cohn: ready to start a PAC?

UPDATE: Cohn hasn't started a PAC, but he's lent his Treatment blog to action by health care experts Harold Pollack (a regular Treatment contributor), Timothy Jost and 45 colleagues*:

Yesterday, Tim and I crafted a simple letter (shown below), which we emailed other health policy experts we know. Some are progressives who identify with a single-payer approach. Others are more politically moderate economists, sociologists, and political scientists. Still others identify with organized labor, medicine, or public health.

Within several hours, many outstanding scholars, activists, and practitioners signed on. Signers include Henry Aaron, David Cutler, Jon Gruber, Theda Skocpol, Paul Starr, and many others, including Anna Burger, Secretary-Treasurer of SEIU.

Read the Pollack-Jost* letter -- and call your Congressional rep (and Senators - they're punting but they could signal willingness to work on reconciliation fixes).

* Per the Anonymous comment below, I originally pegged this letter as a Cohn production. For a while, the post on TNR had his byline.  Apologies for the error.

Mean vs.Median in post-ACA health insurance

This from Princeton's Paul Starr, speaking about the rise in deductibles in employer-sponsored health plans, rang a bell:

Since the ACA, there has been no overall increase in cost sharing. There are higher deductibles, but the ACA has also eliminated most annual and lifetime limits. It has provided for more complete coverage of preventive care.
So, people actually have benefited from the ACA in some ways. But I do not think they understand that...

I think many policy analysts, looking at this objectively, would say this is actually a very good shift. That it makes sense to cover those preventive costs. It makes sense to protect against catastrophic risks. The offset to that is that people have more exposure to routine medical costs up to their deductible. 

Actually, it rang two bells. I noticed this apparent paradox myself in a 2015 Commonwealth Fund survey of underinsurance: deductibles had risen, but the percentages of enrollees going without needed care or having difficulty paying medical bills hadn't. 

More to the point, though, it reminded me of the core claim in a study by Brookings' Loren Adler and Paul Ginsburg of the post-ACA individual market: that premiums are lower than they would have been absent the ACA (and lower than forecast by CBO, even accounting for this year's spike).

Question for Fallows: Can the U.S. "muddle through" to structural change?

As someone who's mused at length over whether the United States retains its capacity for self-correction, I lapped up James Fallows' panoramic and even-handed exploration of "How American Can Rise Again" (or not). Fallows' broad points:

• Worries about American decline are a constant in our culture and a sign of societal health.
  
  
• Current problems, e.g., the structural deficits and infrastructure decay, are serious but manageable.
  
  
• More endemic and threatening than the problems that require policy solutions is our current political paralysis -- bequeathed to us by a Constitution that has not proved sufficiently amenable to amendment and that has stuck us with steadily less representative government:
  

Fallows sees no clear path to fixing the paralysis caused by the nonrepresentative nature of the Senate (where Wyoming has the same clout as California with 1/69 the population), the fiercely Gerrymandered Congressional districts, the multiple layers and local government, etc.   His conclusion is really a non-conclusion: our only hope for bringing about sufficient constructive change is to "muddle through." That is, we need leaders like Theodore Roosevelt and Dwight Eisenhower who "worked within [the system's] flaws and limits...that is the bravest and best choice for us now."

That conclusion is a bit circular, since Fallows' core question is whether the United States retains the capacity to muddle through, given the dysfunctions of the political system.  Perhaps the missing link is a discussion of whether the U.S. can "muddle through" to incremental systemic change, i.e., change in the political system.

David Brooks lambastes Democrats for agreeing with him

Never one for logical rigor, David Brooks ignores himself to a breathtaking degree in today's column.

He begins with an intriguing hypothesis: our latter day Father Coughlins -- Rush Limbaugh, Glenn Beck, Sean Hannity & co. -- command plenty of attention but virtually no votes. His evidence is probably selective, but it's an intriguing hypothesis. They are puffed up by enablers. True enough. But...

They are enabled by cynical Democrats, who love to claim that Rush Limbaugh controls the G.O.P.

Just another politically expedient lie, right? Oh, wait --

And the saddest thing is that even Republican politicians come to believe it [that the shock jocks have real power]. They mistake media for reality. They pre-emptively surrender to armies that don’t exist.

They pay more attention to Rush’s imaginary millions than to the real voters down the street. The Republican Party is unpopular because it’s more interested in pleasing Rush’s ghosts than actual people. The party is leaderless right now because nobody has the guts to step outside the rigid parameters enforced by the radio jocks and create a new party identity. The party is losing because it has adopted a radio entertainer’s niche-building strategy, while abandoning the politician’s coalition-building strategy.

The rise of Beck, Hannity, Bill O’Reilly and the rest has correlated almost perfectly with the decline of the G.O.P. But it’s not because the talk jocks have real power. It’s because they have illusory power, because Republicans hear the media mythology and fall for it every time.

To anyone who believes that democracy can't function without viable choices, it was a sad and shocking spectacle to witness a parade of Republican leaders first calling out and then kow-towing to Rush Limbaugh earlier this year. Democrats would rather have an opposition they can work with; as Paul Starr demonstrated recently, their health care bills are comprised almost entirely of Republican ideas past, but there's no one on the other side negotiating in good faith.

But in David Brooks' still partisan mind, Democrats who agree with him that the Republican party is entirely in the grip of media demagogues are "cynical." And what is Brooks? Pure-minded?

David Brooks' lazy free market fantasy

Before publishing a disingenuous parable setting up false categories of free-market versus activist government reform, David Brooks should have had a chance to read a cautionary tale of failed health care reform that appeared on the very same Times op-ed page as his own column.

Brooks spins out the reform approaches of "Mr. Bentham" (Obama Democrat) and "Mr. Hume" (free market conservative, vaguely reminiscent of Bush). Presumably these are avatars of nineteenth century reformer Jeremy Bentham and philosopher David Hume, though the affiliations are too tenuous to be worth parsing.

Mr. Bentham is a type AAA superwonk with a solution to everything; Mr. Hume is a lazy skeptic who recognizes his limitations. While Brooks takes a few swipes at "Hume," his sympathies clearly rest with him.

Mr. Bentham comes up with the Baucus bill for health care reform and the Waxman-Markey energy bill; Mr. Hume proposes in both cases to let the market work its magic. Here he is on health care:

“Why don’t we just set up insurance exchanges with, say, 12 different competing policies? We’ll let everybody choose a policy, and we’ll let people keep any money they save. That way they can set off a decentralized cascade of reform, instead of putting all the responsibility on us here.”

Yeah, why don't we just. It's really easy to estblish robust competition benefiting consumers among for-profit health insurers, and every market has twelve competitors ripe for recruitment. That's where column B, an op-ed by the former chairman of the Texas Insurance Purchasing Alliance, Cappy McGarr, offers an appropos reality check.

McGarr chronicles the failure of Texas' effort in the early nineties to establish a health insurance exchange for small businesses--a failure he blames largely on neglect from Governor George W. Bush (the quasi-model, ironically, for Brooks' "Mr. Hume," with imagery borrowed from Maureen Dowd's Boy King columns). The exchange died, according to McGarr, for want of either a public option or strict rules to prevent insurers from cherry-picking small corporate customers outside the exchange:

Most important, though, our exchange failed not because it wasn’t needed, and not because the concept wasn’t sound, but because it never attained a large enough market share to exert significant clout in the Texas insurance market. Private insurance companies, which could offer small-business policies both inside and outside the exchange, cherry-picked relentlessly, signing up all the small businesses with generally healthy employees and offloading the bad risks — companies with older or sicker employees — onto the exchange. For the insurance companies, this made business sense. But as a result, our exchange was overwhelmed with people who had high health care costs, and too few healthy people to share the risk. The premiums we offered rose significantly. Insurance on the exchange was no longer a bargain, and employers began backing away. Insurance companies, too, began leaving the alliance.

The Texas exchange failed, in other words, for want of the very types of provisions that Brooks lampoons in the Baucus bill: "He’d design a set of insurance policy regulations to make sure everybody gets uniform care"( along with various crucial experimental measures to restrict overtreatment and overbilling that Brooks does not criticize in detail).

Brooks recognizes on some level that free market fundamentalism has failed. His Mr. Hume "never could very accurately predict how the market was going to move." But he holds reflexively to his contempt for good-faith efforts to create market conditions in which health insurance competition can flourish. He won't recognize, as Paul Starr has shown, that the Baucus bill -- and indeed, all the Democratic health care bills pending in both chambers -- are comprised entirely of ideas proposed by Republicans over the past four decades. He won't consider, with Jonathan Cohn, whether an exchange minus a public option might work with strict regulation of private insurers. He hasn't engaged the tough questions driving the debate -- for example, whether the Wyden amendment opening the exchanges to all employees might foster real competition, or whether co-ops might work, or how to bend the cost curve if he doesn't like the efforts to do so that he implicitly lampoons in the Baucus bill. He prefers, with his own Mr. Hume, to whine and fantasize easy answers.

Attention, filibuster-busters: remember 2002-2006?

"I just look at this institution as really the last bastion of protecting the rights of the minority, and we should be very careful before we try and make any changes."

         - Senator John Warner (R-VA), April 19, 2005

Warner was one of a majority of 55 Republican senators when he made the statement above. He was also a member of the so-called Gang of 14 who forged a compromise over Democrats' hold on some of Bush's judicial nominees, averting a Republican move to end the filibuster specifically for judicial nominees (perhaps because they still remembered that during Clinton's presidency, they blocked far more judicial nominees than the Democrats did under Bush).

Wise men, stateswomen...today's Democrats?

Appalled by the prospect that a Brown victory in the Massachusetts Senate race could scuttle health care reform -- and Obama's presidency -- Andrew Sullivan fumes:

What you see here is the fathomless awfulness of the Democrats. Too fractured and listless to get a solid health insurance bill through both Houses in anything like the time they wanted, too disorganized to make a strong and coherent case for their proposal...

But losing Kennedy's seat is a near-epic failure. If health reform fails, it will be because of a fatal combination of Democratic hubris and Democratic weakness. They just won the presidency and both Houses. And this is what they manage? Really, who wants to belong or support a party this goddamn useless?

If you read one post on health care reform...

let it be Paul Starr's brief history, showing the extent to which the Dems' bills have incorporated Republican ideas floated over the past half century:

...the Democratic proposals are built around the ideas that Republicans used to favor -- those proposals already are bipartisan compromises. Unfortunately, they are compromises with a Republican Party that no longer exists.

This fundamental truth is not only sad but dangerous. It's no particular compliment to the Democrats to note that this country currently has only one viable political party. The Republican Party is right now neither fringe nor mainstream. It's in some volatile liminal zone between the two, a nativist, militarist, authoritarian, Social Darwinian dreamland.

Bipartisan health care reform: the sound of one hand clapping

As Paul Starr demonstrated back in September and as Obama has repeatedly emphasized recently, the Democrats' health care reform plan has a largely Republican pedigree. Plans depending in large part on subsidized private insurance were proposed by Republicans including Richard Nixon and Jacob Javits in the late 1940s, by Bob Dole and John Chafee in the early Clinton years, and again by the trio of Bob Dole, Howard Baker and Democrat Tom Daschl last year.

Ezra Klein recently documented six more contemporary Republican ideas incorporated into the current Democratic bills: an allowance for interstate compacts; the exchanges themselves, which pool risks for individuals and small businesses; a "waiver for state innovation" that allows states to structure their own plans; encouragement of state innovation on malpractice reform; the excise tax, which is a start on reigning in the employer tax deduction for health care; and the absence of a public option. 

All this conceptual bipartisanship has of course won the Democrats zero votes (okay, one House vote, to be retracted in the next round) from the present-day extremists who have taken over the Republican party. Yet the Democrats are still singing the same tune -- whether to win over the more conservative members of their own party,who largely replaced moderate Republicans, or to demonstrate their moderation to the country at large -- or both, as a centrist cast to the bill makes it easier for blue dog Democrats to justify a yea vote to their relatively conservative constituencies.

Here's Nancy Pelosi, contradicting herself in two sentences, defining the new bipartisanship in the second:

“Bipartisanship is a two-way street,” House Speaker Nancy Pelosi declares in an interview airing Sunday on CNN’s State of the Union.

“But let me say this,” Pelosi continues, “The bill can be bipartisan, even though the votes might not be bipartisan, because they [Republicans] have made their imprint on this.”

A 'beautiful bill' goes to the operating table

Before a month of Senate debates whacks all the loveliest limbs off the health care reform statue, the bill's intellectual fathers are gazing up at the pedestal with something like rapture.

Ronald Brownstein rounds up accolades for the bill's cost-control measures from "analysts from the center to the left." (And it should be noted that "the center to the left" in the U.S. healthcare debate is center-to-right in just about any other first-word democracy. Per Paul Starr, the HRC bills moving through House and Senate are a compendium of Republican ideas proposed from Congressman Nixon in the late 1940s through President Nixon in 1974 to George H.W. Bush, Bob Dole and John Chafee in the early 90s.) Brownstein:

In their November 17 letter to Obama, the group of economists led by Dr. Alan Garber of Stanford University, identified four pillars of fiscally-responsible health care reform. They maintained that the bill needed to include a tax on high-end "Cadillac" insurance plans; to pursue aggressive" tests of payment reforms that will "provide incentives for physicians and hospitals to focus on quality" and provide "care that is better coordinated"; and establish an independent Medicare commission that can continuously develop and implement "new efforts to improve quality and contain costs." Finally, they said the Congressional Budget Office "must project the bill to be at least deficit neutral over the 10-year budget window and deficit reducing thereafter."

As OMB Director Peter Orszag noted in an interview, the Reid bill met all those tests.

Positively effusive is Jonathan Gruber of MIT:

I'm sort of a known skeptic on this stuff," Gruber told me. "My summary is it's really hard to figure out how to bend the cost curve, but I can't think of a thing to try that they didn't try. They really make the best effort anyone has ever made. Everything is in here....I can't think of anything I'd do that they are not doing in the bill. You couldn't have done better than they are doing."

I find myself viewing this legislative process with what the medievals would call a "double chere" - a dual perspective. On the one hand there's the unlovely legislative process, nicely reported and themed today by Dana Milbank noting the latest concessions extracted by Blue Dog and other Democrats. Milbank spotlights the leveraging of withheld support:

After Landrieu threw in her support (she asserted that the extra Medicaid funds were "not the reason" for her vote), the lone holdout in the 60-member Democratic caucus was Sen. Blanche Lincoln of Arkansas. Like other Democratic moderates who knew a single vote could kill the bill, she took a streetcar named Opportunism, transferred to one called Wavering and made off with concessions of her own. Indeed, the all-Saturday debate, which ended with an 8 p.m. vote, occurred only because Democratic leaders had yielded to her request for more time.

Note, though, that - none of the concessions chronicled by Milbank substantively weakens the bill, and one - the Wyden amendment modestly expanding access to the exchanges - improves it. Which brings me to the second "chere": so far, the legislation is remarkably balanced, prudent, well designed to square the circle of expanding access without increasing the deficit by wringing waste out of the system and taxing in ways that won't affect productivity. If the Baucus bill's core cost-control measures substantially survive, and the final bill is leavened with more expanded access than the Baucus bill provided for, the result will look awfully like what an Obama supporter might have hoped his subtly shaping hand would have wrought.

That, of course, is a big "if." The prospect of a bill essentially like the one now brought to the Senate floor actually becoming law -- and then not being hacked to pieces by a resurgent Republican party by say 2014 -- has the giddy feel of fantasy. Certainly some pounds of flesh will be extracted -- a Stupak Amendment? a gutted public option? at least one cost-cutting pillar (excise tax?) knocked out? So breath remains bated. These are times that try one's faith that the Federal government, in the wake of a major electoral course correction, can still create legislation that improves Americans' quality of life and puts the economy on a more sustainable footing. Faith, that is, that the U.S. is still governable.