All Dem (and doc) hands on deck to get Medicare drug negotiation/ACA subsidy boosts across the finish line

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It struck my eye last week  that Doctors for America, a physician advocacy group that supports single-payer healthcare, saw fit to call on member docs (via email) to lobby for what's left of the Democrats' reconciliation bill:

This is a decisive week in Congress with the Senate poised to vote on several crucial pieces of legislation, including allowing the HHS Secretary to negotiate for Medicare drug pricing, out-of-pocket caps in Part D, and rebates for price increases exceeding inflation. There are also new provisions to make vaccines free for Medicare beneficiaries, to stabilize premiums, and expand the Medicare low-income subsidy programs.

We hope the Senate will move forward with a meaningful reconciliation package that includes the drug price provisions before the August recess. But we need to apply pressure to do so.  Remind your senators to choose #PatientsOverPolitics and pass the reconciliation bill this week, including all of the health care provisions promised to the American people. 

What to expect when Democrats are weighing single payer

Last week, Kamala Harris was asked about her support for single payer healthcare and responded, with respect to employer-sponsored insurance, "let's eliminate all that. Let's move on." Then Cory Booker was asked an imprecisely worded question  -- would he "do away with private health care" --  and gave an equally imprecise answer (no..) that left ambiguous whether health care or health insurance was under discussion. Ever since, warnings have been percolating on healthcare Twitter against framing single payer as all-or-nothing -- no more private insurance, or no Medicare for all.

Now cometh Sarah Kliff to inject some nuance. One point: "even countries we think of as single-payer still have some level of employer-provided health insurance." In Canada, everyone has "Medicare" -- fairly comprehensive insurance in which government (provincial and federal) does pay the providers. But most people also have employer-provided supplemental insurance to cover prescription drugs, dental, vision, and/or other services not covered by Canadian Medicare.

Another point: whether a transition away from private primary insurance in the U.S. is successful depends mainly on what people are asked to transition to:

Transitioning half of all Americans from one type of health insurance to another is no-doubt a huge undertaking. But whether or not it’s successful, I think, rests on what kind of coverage is on the other end. If it’s a government plan where Americans feel like they can afford to go to the doctor, then I’d expect any frustration with the transition to eventually dissipate. If it’s a government plan where co-payments and deductibles are high — especially if they’re higher than employer-sponsored coverage — then frustrations would almost certainly only grow over time.

Quite so. But I'd like to add some nuance to the nuance, on a couple of fronts.

Framing the battle for the House in New Jersey: Healthcare!

At BlueWaveNJ, I've been part of a team that's produced print handouts to frame the healthcare debate in three battleground congressional districts:

• NJ-3, where Obama admin alum Andy Kim is challenging Tom MacArthur, the "moderate" who brought the AHCA, Paul Ryan's ACA repeal bill, back from the dead with an amendment allowing states to re-introduce medical underwriting in the individual market.


• NJ-7, where Tom Malinowski, Obama's former Assistant Secretary of State for Democracy, Human Rights and Labor, is challenging Leonard Lance, a relative moderate who voted against the AHCA after voting to "repeal, defund or dismantle" the ACA (his words) more than forty times.

• NJ-11, where current House Budget Committee Chair Rodney Frelinghuysen is retiring, and Tea Party darling/state rep Jay Webber, a blood enemy of Planned Parenthood, is running against former Navy helicopter pilot and federal prosecutor Mikie Sherrill.

Of the three, Malinowski has the most detailed and thoughtful healthcare policy positions, including support for a broad Medicare opt-in plan like the Center for American Progress's  Medicare Extra plan. But the focus in each of these pieces is really on the Republican's buy-in  to Team GOP's recent attempts and current plans to dismantle existing healthcare programs -- the ACA, Medicaid, and, ultimately, Medicare -- and the Democrat's commitment to preserving what's already in place.

Below the fold, screenshots of each candidate contrast. At bottom, the front of each of these 5&8 "postcards." Going extra large for MacArthur, who's as responsible as anyone for repeal getting so close.

How Democratic candidates should talk about healthcare

The moderate/establishment candidate for the Democratic nomination in New Jersey's 7th Congressional District (a seat very much in play), Tom Malinowski, takes what in my view is an admirably substantive, focused, big-picture healthcare position:

On healthcare, Malinowski said he “does not support Medicare for all, but the idea of a Medicare option for all is worth exploring.” He said he’s spoken to many people who appreciate having healthcare options and he “would not force anyone to give up private health insurance which many Americans are happy with,” though he added that expanding a Medicare option could eventually lead to a single-payer type of system if people chose it voluntarily.

This more or less describes the Center for American Progress's Medicare Extra proposal and the Merkley-Murphy Choose Medicare Act. Those proposals in turn hark back to early versions of the public option, in which a Medicare-ish program was an 800-pound gorilla that private insurance was privileged to compete against if insurers or employers so chose. Some versions envisioned permanent competition between commercial/employer insurance and a public plan, while others expected a phase-out of private insurance (I discussed some of the variations here.)

Either way, my own view is that a public plan that employers and individuals can buy into provides a viable path either to a de facto all-payer system, in which commercial insurers pretty much have to pay similar rates to the public plan to survive, or to single payer.  And merits aside, I think Malinowski does a nice job in short space capturing both the conservative and the transformative appeal of a strong public option set alongside employer-based insurance. It's too bad that Democrats backed away from this model.

Beautiful speech, but...

I am troubled by my tribalism.

I am susceptible, in case no one has noticed, to Obama's rhetoric.  I see myself, as I once noted, in the self-mocking confession of an old graduate school classmate (I give the provenance, because grad students in the humanities are likely to be of this tribe):

I love Obama...Every time he speaks I emit a small sigh of joy, love and delight.  I know, perhaps my eyes are clouded, but he seems so completely appropriate each time he speaks, that he could be singing the national anthem in Swahili, and I wouldn't care.

So when I read Obama's historic address to the students of the University of Yangon, Burma's principal university, my heart naturally swelled in my breast,  and tears welled up. It was, as you might expect (if you're so susceptible), a beautifully constructed speech -- opening dazzling prospects of freedom and prosperity to the Burmese, applying subtle pressure at all the right points on their leaders (as I heard no less tough a judge than Human Right Watch's Tom Malinowski affirm last night), honoring Burma's dissidents, making a cogent case, as Obama always does, that America's best values are or ought to be universal values, softening the paternalism by acknowledging past American error (i.e., in Foxspeak, "apologizing").

Human Rights Watch's true-blue conservative

Early this year, David Brooks put on his Big Think cap and counterpoised against our society's alleged individualist shibboleths a communitarian ethos put forward by political scientist Hugh Heclo in a book published last summer, On Thinking Institutionally. As relayed by Brooks:

In this way of living, to borrow an old phrase, we are not defined by what we ask of life. We are defined by what life asks of us. As we go through life, we travel through institutions — first family and school, then the institutions of a profession or a craft.

Each of these institutions comes with certain rules and obligations that tell us how to do what we’re supposed to do. Journalism imposes habits that help reporters keep a mental distance from those they cover. Scientists have obligations to the community of researchers. In the process of absorbing the rules of the institutions we inhabit, we become who we are.

New generations don’t invent institutional practices. These practices are passed down and evolve. So the institutionalist has a deep reverence for those who came before and built up the rules that he has temporarily taken delivery of. “In taking delivery,” Heclo writes, “institutionalists see themselves as debtors who owe something, not creditors to whom something is owed.”

While Brooks never used the word "conservatism" he was plainly holding up this "institutional" ethic as a kind of Platonic conservative ideal. Proud professionals devote their lives to "saving" the honorable essence of institutions that themselves conserve the distilled wisdom of generations.

From this standpoint, Tom Malinowski, Washington Advocacy Director for Human Rights Watch, is a true-blue conservative. Consider his call to trust in the accumulated wisdom of core U.S. institutions in his June 9 testimony before the Senate Judiciary Subcommittee on the Constitution:

Seven years after Guantanamo opened, a stable set of rules for determining who should be detained and with what degree of due process has still not emerged.

Some of these problems are due to the inherent flaws of the system. But many are the inevitable result of creating any new system from scratch, especially one that deviates so much from standards with which US courts are comfortable and American lawyers are familiar. America's civilian criminal justice system, on the other hand, has been around for more than 200 years. The Uniform Code of Military Justice has been around for almost 60. We've had all that time to get the kinks out of the system, to establish stable rules, to train a cadre of lawyers and judges who know those rules, and to develop special procedures for special kinds of cases, including those involving terrorism.

If we try again to create a new system from scratch, if we rely again on trial and error to work out the rules, the result will again likely be more error than trial. Eventually, stable rules may emerge, after all the legal challenges and legislative re-dos are exhausted. But how long should we be prepared to wait to get to that point? Five years? Ten years? Can the United States afford more years of controversy over how to detain suspected terrorists?

To Obama, who has signaled that he wants to revamp rather than scrap the improvisations of the Bush administration - military commissions and preventive detention -- Malinowski points out that there's a kind of infinite regress in trying to reproduce the due process protections of the criminal justice system in a new regime that grants the Federal government powers the whole purpose of which is to short-circuit those protections:

Theoretically, one could design a system of preventive detention that affords detainees such a high level of due process and judicial review that it would not look like Guantanamo, or even Guantanamo-lite. But if you allow protections similar to those already provided by federal courts and courts martial, why go to the trouble of creating a new system at all?

Commentators as diverse as Andrew Sullivan, Martin Wolf and Jack Goldsmith have pointed to a kind of conservatism in Obama -- a propensity to retool rather than radically remake existing institutions, a reform impulse that aims to restore institutions to working order. With regard to treatment of detainees, Obama promises to work within our political institutions, in concert with Congress and the courts, to revamp military commissions and create Constitutional rules for preventive detention. But reforming and "conserving" Bush's radical, ad hoc exercise of this power may simply serve to codify core violations of Constitutional principles as previously understood. As Diane Marie Amann, a law professor at UC Davis, warned in the wake of Obama's May 20, speech on national security:

He signaled a plan by which they — and perhaps other detainees yet to be arrested? — could remain in custody forever without charge. There is no precedent in the American legal tradition for this kind of preventive detention. That is not quite right: precedents do exist, among them the Alien and Sedition Acts of 1798 and the Japanese internment of the 1940s, but they are widely seen as low points in America’s history under the Constitution.

President Obama promised that his “new legal regime” — words identical to those Bush Administration official John Yoo used in 2002 –- will provide an array of “fair procedures.” That ought to be a given, for the Constitution requires due process before liberty may be deprived. But no amount of procedures can justify deprivations that, because of their very nature violate the Constitution’s core guarantee of liberty.

Time will tell how "institutionally" Obama thinks about the U.S. Constitution.