Tuesday, September 29, 2009

Senate Finance Committee Rejects Public Option Amendments - So What Now?

Democrats on the Senate Finance Committee were prepared to offer three versions of the public option today (Sept. 2). Chuck Schumer (D-NY) was the sponsor of two of the alternatives - one he called the “level playing field” option. Under this plan providers would be able to negotiate reimbursement rates with the public insurer and voluntarily choose to participate in the program. This option would be required to be fully funded via premiums and even generate a reserve fund in case premiums proved to be to low. No tax dollars could be used to support it. Schumer's other amendment would have replaced the current bills plan to create insurance co-ops with the public option alread in the Senate Health, Education, Labor and Pensions (HELP) Committee's version of the bill. In that bill, the secretary of Health and Human Services would have the power to negotiate reimbursement rates. The final public option amendment was sponsored by Jay Rockefeller (D-WV), under his plan providers would be paid a rate no more than 5 percent above Medicare rates (Medicare pays less than private insurers).

Rockefeller's amendment was the first one on the block and it was defeated 15-8, with 5 Democrats joining all 10 Republicans to defeat it. The 5 Democrats were Committee Chairman Max Baucus (D-MT), Kent Conrad (D-N), Tom Carper (D-DE), Bill Nelson (D-FL)and Sen. Blanche Lincoln (D-AR). In the end, Schumer introduced his level playing field option and it was defeated 13-10 - with Baucus, Conrad, and Lincoln voting "no."

There remain three opportunities for the public option to re-emerge. 1) Once the Finance Committee reports its version of the Health Reform bill, Senate Majority Leader will merge it with the Senate HELP Committee's version - Reid could simply keep the HELP version's public option and drop Finance's co-op alternative. 2) On the Senate floor the bill could be amended to include a public option (that would require 60 votes to overcome a certain GOP filibuster). 3) If the House passes a public option and the Senate does not, the House version could be adopted in the Conference to reconcile differences between the two bills.

So three chances remain, but today's votes in Senate Finance make it clear that the public option cannot pass the Senate under normal rules of process where 60 votes are needed. The only way to pass a public option is via reconciliation - an option created in 1974 solely for resolving issues related to the deficit. NBC's First Read offers a great synopsis of the reconciliation and why it is an option of last resort - essentially, opponents could move to strike every provision in the bill not directly related to taxing and spending - the resultant bill would look like a puzzle missing half of its pieces. All of those missing pieces would be assembled into a new bill that could not rely on reconciliation and would face the 60 vote barrier. In an interesting historical side note, President Clinton and Democratic leaders considered using reconciliation to pass the Health Security Act in 1994 - but Robert Byrd (D-WV) refused, stating that such an important issued deserved a full and public debate.

The public option is not dead... but it may want to consult one of those death panels for some end of life counseling.

Evidence? We don't need no stinking evidence!

The latest meme on the Iranian nuclear program is that Iran's admission of the centrifuge facility near Qum is but the tip of the iceberg. The Times has a nice "man bites dog" piece on U.S. intelligence taking a cautious line on the Iranian nuclear program after the Iraq debacle. The story argues that European intelligence agencies are much more hawkish on the Iranian program than their American counterparts (although, this is not, as the Times reports, a mirror image of the Iraq debate). The even handedness of the Times story falls apart at the conclusion when they quote Graham Allison: “How likely is it that the Qum facility is all there is? Zero. A prudent manager of a serious program would certainly have a number of sites.” Of course, this comes from the same nuke alarmist who bet Nicholas Kristof that terrorists would explode a nuclear bomb by 2014. Over at Foreign Policy there is similar hand-wringing over the implications of the Qum facility, although the article focuses on the fact that President Ahmadinejad's statements following the disclosure of the facility are at odds with IAEA rules (insert mock shock here!). What unites both the ominous Allison quote and the equally ominous FP piece is a general aversion to providing actual evidence for their contentions. For Allison the rationale is that any descent nuclear program should have more sites. In the FP article the rationale seems to be that Iran does not follow the rules and thus there must be other facilities. Instead of relying on evidence for their claims, these authors can instead rely on general distrust of Iranian intentions to support their arguments. It is too easy for those following Iran to simply take every piece of new evidence about the nuclear program as further "proof" that Iran is trying to develop nuclear weapons. The real story is the cautiousness of U.S. intelligence on Iran, despite the cries of the nuclear alarmists. We will have to see how long evidence-based intelligence wins out over doomsday theories.

Big Day for Health Reform and the "Public Option"

Today will be a decisive day in the health reform battle. Today, the Senate Finance committee will decide whether or not to amend the Baucus bill to add a public option. The Committees 13 Democrats and 10 Republicans will consider no fewer than 4 "public option" options and at this point, no one knows what will happen. Most counts find 9 Democrats in favor of a public option and no Republicans. Max Baucus, not one of the 9, has said he supports a public option but does not believe that it can pass in the Senate (assuming a 60 vote threshold).
Blanche Lincoln, Blue Dog Democrat from Arkansas, is an unknown quantity. She is slowly inching toward the endangered senator list - like several Democrats up for re-election in 2010 her seat was once deemed to be safe, until the health care debate changed the 2010 electoral calculus. There is also the issue of Olympia Snowe and her support of a state-based public option trigger - a trigger that would only be pulled if private insurance reforms fail. At least 2 Democrats support Snowe's alternative. If the Senate Finance Committee adds the public option, in form other than Snowe's trigger, then all bets are off with regard to Democrats using reconciliation to pass the bill - they will use reconciliation. Then the battle will shift to the House where leaders will put heavy pressure on select Blue Dogs just to get the simple majority needed there. Today is one of those rare, high drama days in American politics and a day worth closely following.

The Finance committee meeting will begin at 10 AM and will likely be broadcast on C-SPAN.

Monday, September 28, 2009

The whole equation on Afghanistan

Following the release of General McChrystal’s report on the state of the war in Afghanistan, debates have broken out about the best path forward for the U.S. in a country that has not been kind to foreign powers. The struggle within the administration over the proper path forward has been well documented, with Vice President Biden seeking to draw down U.S. force levels while Secretary of State Clinton and others have pushed for a more significant commitment. President Obama, who made success in Afghanistan a cornerstone of his foreign policy as a presidential candidate, now appears less sure about increased troop commitments. At the center of this debate are two interrelated questions: can the U.S. achieve success in Afghanistan and if so, at what cost is it willing to do so?

The image of what a successful outcome in Afghanistan looks like is far from clear, and the notion that Iraq is viewed as a positive model is not particularly encouraging. But even relatively minimalist expectations for stability in Afghanistan are undercut by the large number of hurdles facing Karzai’s regime (poverty, lack of education, well-organized rebels, an unstable neighbor, mountainous terrain, etc.). In Sunday’s New York Times, David Brooks, while acknowledging choosing the right path in Afghanistan is tricky, argues “American forces have become quite good at counterinsurgency. They have a battle-tested strategy, experienced troops and a superb new leadership team.” He then goes on to approvingly site work by international relations scholars that finds counterinsurgency campaigns centered on “hearts and minds” strategies succeed 70% of the time. These numbers should give us confidence in a successful outcome, right?

Not surprisingly, as in much social science research, one must read the fine print (or at least look at all the tables). As Alex Downes points out, perhaps the more important finding for the U.S. in Afghanistan is the fact that no country that switched to fighting a “hearts and minds” campaign after eight years (the length of time the U.S. has been in Afghanistan) has ever defeated an insurgency. Of course, this does not mean that the United States is destined to fail in Afghanistan, but it does show that we need to be realistic about the odds of success, the length of time involved, and the costs.

It would be nice if we could bring findings from international relations to bear on the Afghan conflict, but the Enterline and Magagnoli dataset Brooks favorably cites contains only 66 conflicts (33 since 1946) and a significant number of these are anti-colonial wars of independence. The relatively small number of cases combined with the heterogeneity of the conflicts makes extrapolating useful information difficult. Perhaps most noteworthy is that the authors find the mean duration of a conflict after switching to a "hearts and minds" strategy is over eight years. A recent New York Times poll found that only 44% of respondents were only willing to remain in Afghanistan for more than two years.

Over the coming weeks, policymakers, commentators, and even a few academics will debate the future role of the United States in Afghanistan. While this debate will focus on the costs and benefits of an increased or a decreased commitment by the U.S. to the war, it is likely to be an elaborate sideshow. Overshadowed by this debate are two well established facts in international relations: state building is costly and time consuming and support for wars declines over time. Neither of these findings bodes well for the Obama administration putting more troops and resources into Afghanistan. At the end of the day, President Obama will have to weigh the very risky proposition that increasing troop levels will improve the situation in Afghanistan against the more predicable results for a decreased commitment. Setting the stage for an exit in Afghanistan will lead President Obama’s hawkish critics to jump all over him, but such problems are predicable and manageable. That option may be more appealing than the highly unpredictable and high stakes decision to increase troop levels.

Friday, September 25, 2009

Sometimes, Small Steps Get You There Faster...

Jay Cost at RealClearPolitics offers a great analysis of the political stakes involved in health care reform.

From Cost: "In this country, it is highly inadvisable for political leaders to pass such sweeping reforms absent a consensus that is both broad and deep. Such a consensus simply does not exist on this issue. If the President and Democratic leaders move forward with their plans anyway - despite these plainly and clearly expressed doubts - they risk reaping the whirlwind."

This lesson was learned all to well in Australia as they spent decades enacting and repealing and revising highly partisan health refrom endeavors. We do not want to repeat that here, not on an issue this important.

More from Cost: "It does not have to be this way. If the President would narrow the scope of these overly ambitious reforms, it is likely that he could formulate a broad legislative consensus on changes to the health care system. "

This bit of advice from Cost may be an especially bitter pill to swallow, especially among those of us who study health policy and understand how desperately we need substantial reform. But if the public does not accept the legitimacy of the reform, if the public rejects what is ultimately passed, the result would be a set back that would likely keep health reform off of the agenda for at least another 15 years.

And there is no reason to view a narrower piece of legislation as a defeat. In 1960, when many advocated universal health care for the elderly, partisan forces in Congress compromised and created "Medical Assistance for the Aged." It was by no means universal; rather it was a means-tested grant program that provided federal funds to states that chose to cover "medically needy" elderly individuals (essentially low income individuals in need of assistance for medical expenses).

Many viewed this program to be woefully insufficient - and it was - after 5 years only 29 states participated and they offered very limited services. But in American public policy we rarely construct fundamental new policies; rather we like to build off of existing policies. In 1965, using Medical Assistance for the Aged as a foundation, Congress created Medicare - a universal and mandatory health program for the aged, and Medicaid - a state/federal means-tested program that provides health care for low income children, pregnant women, and some low income elderly. Thirty years later Medicaid served as a model to create the State Children’s Health Insurance Program (SCHIP) to further extend health coverage for near poor children and pregnant women.

Today, over 100 million Americans receive their health care from Medicare, Medicaid, or SCHIP - one-third of the nation. The lesson of Medical Assistance for the Aged is that sometimes, a series of small steps can get you to a destination more effectively than a risky leap. At this point, trying to enact substantial health reform without firm public support, without any consensus in Congress, and via parliamentary tricks like reconciliation would be a very risky leap and could ultimately do more to harm reform efforts than help.

My advice to President Obama and the Democratic leadership is simple: Compromise, lay the foundation, and then start building...

St. Mary's College to Host Forum on Health Care Reform

The debate over health care reform in the last few months has featured plenty of yelling, a lot of finger-pointing and a shortage of dialogue.
Todd Eberly, an assistant political science professor and coordinator of Public Policy Studies at St. Mary's College of Maryland, hopes to bring some civility to the rancorous issue on Monday, Sept. 28, when three health policy experts offer diverse viewpoints at the school.

The forum, called "Beyond the Shouts: A Discussion of Health Reform in America," came about after Eberly, who spent 10 years as a health policy analyst before coming to St. Mary's, grew frustrated about the lack of conversation at congressional town hall meetings nationwide this summer.

No politicians will be on the college's panel in an effort to foster a productive flow of information and exchange of ideas. The three panelists each have different perspectives on health care reform:
  • Greg Scandlen, founder and director of Consumers for Health Care Choices, opposes President Obama's health care proposal and advocates for individual freedom and a consumer-driven health system.
  • Margaret Flowers, a pediatrician-turned-health activist who is a Congressional Fellow of Physicians for a National Health Care Program, which supports a single-payer national health system that would eliminate private insurers.
  • Karen Davenport, director of health policy for the Center for American Progress, a left-leaning think tank that supports Obama's quest for health care reform.
 Each presenter will have 10 minutes to talk about health reform before a question-and-answer session.