Health Care, Abortion, and the Foot in the Door

"If one doesn't have access to Health Care at all, the question of whether it pays for abortion or not becomes moot."

Thanks for another timely and incisive piece, Al.

I wish I could cheer on this plan, but I can't. The insurance mandates are terrible on a policy level, and crippling on a personal level.

I can't help but look at it this way:

1. I voted for a candidate who promised he wouldn't support insurance mandates.

2. This bill contains insurance mandates, forcing uninsured people to buy (generally) private insurance or pay a penalty.

3. Private insurance doesn't pay for effective treatments unless they're approved by Pfizer, Merck or the AMA.

4. Obama supports a bill that would force me to pay these bloodsuckers more money, taking money away from effective treatments that I'm currently paying for out of my own pocket.

Voting for Obama doesn't seem like such a smart idea right now.

Erick - The Massachusetts health care law (signed by Mitt Romney when governor) had mandates. They've proved completely unenforceable. I very much doubt that the federal plan is going to be able to effectively make people pay penalties. And in the event that it does, an outcry will rise up across the land that may force Congress to change that policy. I don't think mandates are sustainable.

Under the checks and balances of the US Constitution, the president doesn't get to decide what Congress passes. He can push and prod - and he's done plenty of that - but in the end he can only sign (or not) what Congress puts on his desk. The election of a president didn't change that Congress is so subservient to special interests. It seems to me that your expectation was that it would. I certainly never had that expectation. Nor do I blame the legislative branch's shortcomings on the executive. If we want a different Congress, we accomplish that by targeting them, not by changing the president.

Trying to kill off the insurance companies in one go would be akin to trying to eat an elephant in one bite.  The insurance companies wield too much influence currently for it to be realistic for us to pass a healthcare bill that didn't include them.  We need to keep pressure on our elected officals to produce the best bill possible now, get the bill passed and then start fighting anew to make it better.

If we fail to pass something now, we won't have another shot for decades.  Are you willing to condemn those without access to medical care to that fate for decades more because mandates are passed.  That seems like cutting off ones nose despite their face.

Eliminating recision, pre-existing conditions, are huge deals for many people.  The bill is far from perfect, but on the whole I think it does more good than bad.

Having Voted for Obama seems like a bad idea?  You think McCain's/Clinton's healthplan would be better?

The question the hardcore single-payer or nothing folks (especially those who think Hillary would have magically given it to us by now) can never really answer is:  "If the public option is so worthless, why are the Republicans, the Blue Dogs, and the insurance companies that feed both groups so dead set against it?"

The reason they can't answer it is, of course, because the public option isn't worthless -- it is the foot in the door (or as the Cons prefer to call it, the "Trojan Horse") that leads to single-payer.

I know there was some discussion on stripping health insurance companies from their long standing exemption from Federal anti-trust laws.  An October 2009 AP article quotes Senator Leahy as saying such a move would put an end to "price-fixing, bid-rigging and market allocation in the health and medical malpractice" insurance areas, said Sen. Patrick Leahy, D-Vt., chairman of the Senate Judiciary Committee. Leahy said he would seek a vote on the plan when the Senate debates health care legislation in the next few weeks.  http://www.msnbc.msn.com/id/33414313/ns/politics-health_care_reform/

Does anyone know if the anti-trust provision made it through the House version?

In my opinion Ezra Klein is the go-to person for understanding from a liberal standpoint what's in this bill, that is all the esoteric funding, coverage, limitations, etc and he is high on the bill.  Ezra has a column in the Washington Post and TAP.

In his 11/19/09 Post column Ezra claims the bill "would be the most important cost control bill ever considered by the U.S. Congress" by putting controls on Medicare, "value based purchasing" and other details.  Ezra states the Senate version pays for itself while leaving 94% of the country insured by the second decade.

The savings from Medicare and Medicaid, paired with the excise tax (which CBO says "is effectively a reduction in the existing tax expenditure for health insurance premiums") and a handful of other changes, leaves the government spending no more on health care than it otherwise planned to. That's impressive stuff given that some 94 percent of the country has health insurance.  http://voices.washingtonpost.com/ezra-klein/2009/11/health-care_reforms_grand_barg.html

Maybe you are right that the thing can be improved over time and will be too popular to repeal. But comparing this bureaucratic monstrosity to Medicare is not reassuring considering that was single payer, i.e. sensible, coherent, and understandable, and this is not.

I see the mandate issue in its best light as well-intended "liberal" public policy that looks good on paper but burns up upon contact with the street. You can't prohibit free-will, a lesson that our policymakers should learn with respect to the drug war as well.

But I do see a blowback benefit from a health-insurance mandate being enacted that might seem far askew, yet I bet it serves as a bass beat for a better tune.

If you are going to mandate that everyone in the country have health insurance for the benefit of public health and the fiscal health of the system, because those are the arguments, ultimately, then how do you exclude millions of so-called "illegal immigrants" from that equation and keep intact any logical argument that the rest of us must have health insurance or the system will not work?

Now, you can come down a lot of ways in arguing the resulting points, but for me, I see the most persuasive argument being that if a mandate applies to one person in this country, then it must apply to all. So legalize everyone who isn't "legal" to assure the mandate is for real, or drop the pretense of the mandate.

Of course, there is the more Nazi-leaning viewpoint out there, prevelant among a lunatic fringe, that we should empower insurance companies and health care providers to report anyone presenting for care who does not have health insurance, and then use that as a pretext for deportation roundups.

But I suspect that way of thinking will do more to destroy our health care system -- and assure bad public health outcomes -- than the more rational approaches of assuring "everyone" has access to health care if it is "mandated," or getting real about the nature of free-will, a pretty fundamental American value.

Just my two cents and I wouldn't mandate it on anyone.

 I am so grateful you decided to write about this hotly contested debate. As you may know, I was one of the Rorschach testees who was furious by the house vote.  I was ready to walk away from the Dem party and politics all together. It took a few days, many cuss words and lots of reading to get over my gut reaction anger. Then I recognized any HCR bill containing a public option and other long overdue reforms that reaches the Presidents desk is as you say a "foot in the door". Am I happy with either bill entirely? Hell no! There are many reasons both bills are crappy, but at this moment in time something is better than nothing.

So, I am looking forward to 2010-organizing a network of progressives to help primary dems who voted for the Stupak Amendment in districts where Democrats have a good shot of winning. Pitts in PA, Leiberman, Bachmann and probably Blanche Lincoln will also be targeted.

 Just when I thought I could sit back and relax for awhile after health care reform passed.. I am now a woman on a mission.  My anecdotal evidence that you are absolutely correct on this subject.

that  won't have much support from many progressives, but after watching the health care debate, I understand a bit more about the mandates.

One of the arguments for them is that, with the elimination of pre-existing conditions as a way to deny coverage, the system can't afford to let people wait until they are seriously ill to buy insurance - which is likely what many otherwise healthy young people without employer coverage would do.

And secondly, with the elimination of denials for pre-existing conditions and recision, the pool of insured that the health insurance system (including the public option) will take on increases the costs of the risk pool tremendously. We need to pool to be larger in order for that to be sustainable.

I don't like the idea of mandates any more than anyone else. But with an insurance system - the bigger the risk pool - the cheaper the overall costs to everyone. That's one of the main reasons why single payer is so much less expensive. And while mandates are an ugly part of this incremental approach to that final goal - I can see why they might be necessary.

And on the abortion issue - my hope is that Stupak highlighted the need to get rid of the Hyde Amendment. That's what it did for me personally, so I hope I'm not the only one.

On the one hand, I agree that any health care plan is a foot in the door, better than nothing (in some cases quite a bit better), yada yada yada, and in the end I'll support it, even though I think that Congress's approaches threaten long-term reform by failing to create anything that will control costs across the system.  But like many other feminists, the Stupak amendment caught me by surpise--by shock, actually.

The fact that the amendment won't affect most women (just the ones who really need the coverage--and by the way, who the hell would buy an abortion rider because she plans to need an abortion?? Huh??) isn't the real shocker.  It's the direct and casual assault on women's bodies, as though we were just another special interest group who wanted our particular condition covered.

Women, like people of color, are discriminated against because of the fact of our bodies, not because of our practices or beliefs or identity or who we are as persons.  Gay or straight, rich or poor, we're paid less, considered unreliable, and easily objectified into doll-like distortions of desire and denigration.  People joked about McCain's age and cluelessness, but when they joked about Clinton they commented on her sexless pantsuits and middle-aged body.  You didn't have to be a Clinton fan to be offended.

So when some of us--not just women, thank heavens--are furious about the amendment, please at least acknowledge that, for those who fought for it, abortion is not only an issue of medical care; it stands for women's rights.  Anti-abortion forces hate it unequivocally for the same reason they hate affirmative action and the ERA--because they will defend the special rights of white men against those of us whose bodies betray what they percieve as vulnerability.

There.  I feel a little better.  Now I'm going to see if there's a chance someone could unseat Matheson.  His seat might as well be filled by a Republican; except for wilderness issues, he votes exactly like one.  He's just there to make his largely non-Mormon, non-native, left-of-Bishop-or-Chaffetz constituency feel better about living in Utah.  Perhaps a Republican would force them to be honest about their politics.  And as we've seen, a Democratic majority means absolutely nothing when you have economic and social right-wingers among them.

One thing I have never heard thought through regarding mandates is the really long-term. What I mean is, if they don't work or are unenforceable as Al and Bill suggest, haven't mandates gone at least part way towards an overall public shift in the sense that it takes some sort of near universal buy-in (or force-in) to get near-universal care? In other words, mandates to me act as a kind of tax (a la Europe) that allows in the short and medium term a near-majority to access health care. While Obama's own campaign idea was to lower costs and let people choose to opt-in to affordable care, the mandates may be a step in that direction in the sense that they prime the populace to presume that it takes all of us with (mandates--or higher taxes) to get to the end-goal of fully universal and ultimately fully public health care. If you take away mandates down the road, you have to pay for the health care somehow. A conversion of the mandates to some other incentive-based approach coupled with an increased accessibility of a public plan and the end of the insurance industry's anti-trust status, plus countless other regulatory tweaks would seem to be the direction the whole might be headed 10-30 years out, especially after the public had gotten used to the idea that it takes some form of near-universal involvement to get universal care.

Any thoughts?

Actually Medicare does have a sort of mandate.  When I turned 65 I applied for Medicare Part A (hospitalization) but since I'm still working and my employer based coverage is better than Medicare Part B, I did not apply for it.  However, SSA cautioned me when I do retire there is a form I will need to have my employer complete proving I was covered under another insurance program or I would have to pay a 10% surcharge for each year that I was Medicare eligible and did not apply.  That means if someone waits until they're 70 and are not covered under any other insurance, their monthly Medicare Premium would be 50% higher, twice as much at age 75, etc and that higher cost remains as long as the person is in the system.  The Medicare premium is deducted up front from the person's Social Security retirement check.  Obviously the system needs the relatively healthy 65 year olds included with the 95 year olds.

With Lincoln now on board for the procedural vote tonight, she is declaring no PO at all. With Schumer working on a trigger deal, do folks think that no PO (triggers + mandate) is a real foot in the door still? I suppose it is because of all the insurance reform and the exchange being set up, but the trigger idea is just so repugnant. I can't see how a trigger is not in the cards.

USE LEGISLATIVE RECONCILIATION

Sacrifice GOP hurt feelings, not women and civil rights:  A Political Plea

AL KEEPS HIS PROMISE TO POST ON WOMEN'S ORGANIZING AND AS ALWAYS DELIVERS THE MOST THOROUGH AND INCISIVE POLITICAL ANALYSIS ON A SUBJECT:

Al, thanks for tackling this difficult issue like you said you would.  We readers and supporters can always count on you to be true to your word, and to democracy, and to offer incisive political analysis, which you again deliver, more clearly than I have seen elsewhere.  It's very cogent and helpful, yet I do have a counterpoint, which I hope to coherently elaborate on below.

ON THE POSSIBLE SUPERIORITY OF USING THE LEGISLATIVE RECONCILIATION PROCESS VERSUS UNNECESSARILY SACRIFICING HALF THE POPULATION'S CIVIL AND HUMAN RIGHTS; LET US ORGANIZE AROUND THAT: 

The fight around the Stupak amendment should not be a political fight.  It is a civil rights fight, and sacrificing women's civil rights today for political horse trading down the road that realistically may or may never happen is not only highly risky, it will be literally life-threatening for many thousands of women every single year.  It's not a matter of who pays for an abortion or how few or many are affected.  It is a matter of not having to unnecessarily sacrifice one single citizen of the United States in order to move this nation forward:  Are we a people who practice human sacrifice?  Well, er, with our nasty habit of starting unnecessary wars and such, maybe we are, but in the case of safe available reproductive services, it need not be the case.

To me, who admittedly is far from omniscience or infallibility (way far from), a more telling metaphor to use in this national-health-care foot-in-the-door debate might be the Stupak amendment's camel's-nose-under-the-women's-tent metaphor.  Women's reproductive rights have been in danger ever since they were first 'granted' by Roe.  The Stupak amendment is the sneaky culmination of the decades-long violent and slanderous pushback against women, employing murder, physical intimidation, propaganda, and scapegoating, but characterized also and especially by weak-kneed political accommodation and electoral cowardice, which all combined has all but removed available access to safe reproductive care for most women in most non-urban areas.  Further accommodation and political cowardice must stop now.  Are women to be sacrificed because of political habit, and political convenience?

Though, as I infer that you say, letting the Stupak amendment slither into the final legislation could bring better politics into play years later, which would in turn result in better legislation more years later, there is no guarantee of even this.  Further economic or terroristic catastrophe, the regressive Supreme Court, and the continued erosion of women's rights due to the pre-existing example and inertia of its current neglect plus the acceptance of the Stupak 'compromise', could prevent what would otherwise be an American natural progression toward greater rights for women and for all, personal rights and economic rights included.  Stopping Stupak could be the most effective way to staunch the ultraconservative cultural counterrevolution in this and other civil rights and other issues of importance.  I see Stupak not only as injurious and wrong, I see it also as quiet linchpin, a subliminal crossroads.  Indeed, how much democracy do we want?

NOW, FINALLY, MY EMBARASSINGLY MODEST ARGUMENT FOR USING LEGISLATIVE RECONCILIATION TO SAVE THE DAY - WE HAVE THE VOTES (AND NOBODY DIES):

The more politically courageous, more effective, and more worthy political answer, to me, is to use reconciliation (a fully legal procedure, with precedent!) to draw the bright line now, and not sacrifice women to the pathetic god of an anemic national health-care bill, or to the mere hope for one in the future.  Stand firm now for women and draw the line bright also for a better health-care bill overall as well.  Use reconciliation to do both.  We have the votes for it.  All the years of organizing and campaigning that's come before has led us to this point.  For all we know, today may be the high-water mark for progressive possibility for a generation to come.

What kind of nation do we want to be?  Well, whatever that means to progressives, we don't have to wait.  We can be it and have it now.  Use the power of reconciliation.  In the immortal words of Seals & Croft:  "We  may never pass this way again".  Seriously, women's rights are EVERYONE's rights.  Cut that Stupak nose off to spite his sniveling patriarchal face (so much for civility and debating rectitude, but have ya seen the guy?!).

Sincerely,

Funktilius, Your Servant and Admirer

______________________________

You've articulated what I've felt for a long time.  It's important to get something done now.  Fine-tuning can be made later, but as long as the bill has something of value, it's better than nothing.

It reminds me of a scene near the end of the movie 1776, when Adams and Franklin are discussing whether to remove the anti-slavery clause from the Declaration of Indpendence in order to get South Carolina's vote:

"First things first, John.  Independence, America.  If we don't secure that now, what difference will the rest make?"

Couldn't a nationwide referendum be done to "validate" the public option and subsequently the Senate bill?

I mean, the GOP claim American voices weren't heard last night when Dems managed to reach the magic 60. If the public said loud and clear they wanted a public option, then that rationale would fall apart and thus allowing room to reconciliation.

Otherwise, reconciliation may be a shot on the foot and conservative democrats could be pissed...

from The Providence Journal:

Kennedy: Barred from Communion

“The bishop instructed me not to take Communion and said that he has instructed the diocesan priests not to give me Communion,” Kennedy said in a telephone interview.

http://www.projo.com/news/johnmulligan/KENNEDY_COMMUNION_11-22-09_7PGHOL...

They love human beings so long as they're still in the womb.

But when the fetuses are born, only the sons (and not the daughters) of rich ones count.  (See also: Honduran coup.)

How interesting...didn't the uncle of Patrick, Pres. J.F. Kennedy, assert during his campaign that the Catholic Church would not call the shots during his presidency?  How interesting...that the only time we are so close to health reform, the church is willing to allow so many to die in the name of "life"?  How interesting...that the son of the champion of Health Care for all, Ted Kennedy, would be denied communion just months after his Dad's death?  How interesting...that Pope John Paul 2 condemned the Iraq War but Catholic politicians, who voted to support this war, against the Pope's declaration, continue to receive communion.

Hypocrites.  Jesus said it best:  White washed graves, full of dead men's bones.

After the vote last night, there is plenty of work ahead.  I'm ready.

"And in the event that it does, an outcry will rise up across the land that may force Congress to change that policy. I don't think mandates are sustainable."

Al,

You might be right, I honestly don't know what to think about this health care bill. It has some major improvements, yes ... but at the cost of feeding tens of millions of new customers to the private insurance companies.

I guess where I think the line is crossed is around the point where the government mandates that uninsured people buy private insurance. I think a mandate like this would piss off a lot of Obama voters (including myself).

"If we fail to pass something now, we won't have another shot for decades."

Paul,

I'm not sure if I believe this argument, because the status quo simply can't continue. Heallth care costs can't continue to rise at 2-3x the rate of inflation for much longer, simply because their customers won't be able to afford it anymore. The money to pay for insurance actuaries, doctors, hospitals and drugs will dry up.

Is this a good solution? No, it's a horrible 'solution'. But I'm not sure that propping up a top-heavy health care system by feeding it hundreds of billions of dollars is a very good solution either.

It's quite a gamble:

Will mobilized pro-choice voters make up for the demobilized Bam supporters who've become disillusioned on any one of several issues?

Given that the public won't feel any positive effects of the bill until 2012, and that costs will continue to rise, will healthcare bill post-passage expansionists be able to convince a still suffering public that the solution is to continue the expansion?  Or will the Right be able to capitalize on the misery and point to Democrats experiments with "socialism" as the cause, thus justifying rollback or neutering?

Will progressive cheers of victory seem hollow and self-congratulatory to a public that continues to be immiserated? Will insurance companies, strengthened by their new subsidy, sharpen their short- and long-term survival strategies?  Will it be easier for insco's to block expansions of the bill since the less-public terrain of those dealings play to their lobbying strengths?

How long can people sustain themselves on hope without seeing some tangible effects?  And how long can the clownishness of the Right keep them out of power?

We need jobs.  We need healthcare.  Even if the bill passes,  we won't be getting any of that anytime soon.  Being impressed by political ju-jitsu and 11th dimensional chess does not put food on the table.  The clock is ticking, and if past is prologue economic distress really helps Right wing demagogues.

The immediate benefits of the HCR bill will start shortly after it passes. The prohibitions of denying for preexisting conditions or recission will go into effect at once. That will enable thousands to purchase insurance. A temporary high risk pool will be started for at least some of those who are not now covered. There are funds to extend subsidies for COBRA policies.

Even more funds are in this bill than in the stimulus bill to be made available for Community Health Centers, both for additional staffing and more centers. These serve many people with good quality team centered health care and take Medicare, medicad, private insurance and self pay. No one is turned away for lack of money; fees are scaled and payments are modest to none. The CHCs are already seeing an increase in patients.

Increased funds for Medicaid will allow millions more to be covered as soon as the bill passes.

And I think requiring insurance companies to cover children up to 26 on their parents policies will give a boost to many young adults just starting out and not earning princely sums.

There is ever so much more: funds for training more primary care doctors and more nurses; for electronic records which will decrease errors and duplication as well as reducing fraud, will take a few years to show up but need to be started now. There is more.

HCR is not all about the public option. Even single payer, without dealing with the underlying problems in the provision of health care, would be doomed to failure.  Medicare itself will fail with out the rest of the reforms in the bill.

@Sam:  Where are you getting your information?  Do you have any numbers, even rough ones, about how many more people will be getting healthcare and over what timetable?