20 Responses to 20 Answers on 20 Questions.

It's been a slug-fest out there! Progressives are seemingly split almost perfectly in half on whether to kill or continue supporting the health reform legislation in the Senate. Sure, it is liberal vs. liberal, so it's been very well-mannered, but it's certainly an interesting debate -- and both sides have very valid points.

However, if you've read my last few posts, you'll see that I have fallen on the side of Nate Silver, Ezra Klein, Matthew Ygelasias, Paul Krugman, and others. And while I do not agree with people like Markos Moulitsas, Howard Dean, and Jane Hamsher, I certainly respect what they're doing, because (a) they are doing what they think is right based on a pretty decent argument and (b) I think, in the end, it will make the bill stronger.

Nate Silver (FiveThirtyEight) recently posted 20 Questions for Bill-Killers (targeted towards progressives) which was quickly followed up by with 20 Answers by Markos Moulitsas (DailyKos), so I've decided to post some responses to Markos' answers and Nate's questions -- two people who I have a lot of respect for.

The post below will look like the following:

1. Nate's Question.

Markos' Answer. 

My Response.

1. Over the medium term, how many other opportunities will exist to provide in excess of $100 billion per year in public subsidies to poor and sick people?

The assumption here is that this bill is the only option on the table. The House still has a say in the matter. And really, the point of reform isn't to shovel taxpayer dollars to the insurance companies, it's to expand care andlower costs. I'm not willing to surrender on costs.

I agree with both on this question. Nate's right that we will most likely not have another opportunity to give that many poor and sick people subsidies, but Markos is also right that the House's legislation has even more generous subsidies than the Senate. But I see that as a reason to allow this bill to go to conference, not to kill it. The subsidies should, if anything, only get stronger from this point out (assuming someone like Lieberman doesn't cut those out next, but we'll have to wait and see what happens).

I think there's a much stronger case to be made that when the pretty good subsidies in the Senate bill meet the generous subsidies in the House bill, they'll reach a happy medium.

2. Would a bill that contained $50 billion in additional subsidies for people making less than 250% of poverty be acceptable?

This betrays a simplistic view of liberals, as if our answer is to merely shovel money at a problem. What we're looking for is good policy, which in this case, would also be good politics. So no, throwing money at the insurance companies doesn't change a thing. The insurance industry would simply absorb the new subsidies just like universities have raised tuition to shovel up any increases in financial aid.

I think Markos rips apart Nate's question on this one. However, Markos doesn't seem to believe that health care reform is over for the next 10-20 years if the Senate bill is killed -- and inflation now is set to rise a 7.5% until 2016. People that have insurance now can't afford it and the poor are dying without it. The CBO estimates that a family of four making $54,000 a year would save an annual $10,000 under this legislation. $10,000 that they will have to pay out-of-pocket if the bill dies in the Senate. We can't afford to lose that.

3. Where is the evidence that the plan, as constructed, would substantially increase insurance industry profit margins, particularly when it is funded in part via a tax on insurers?

Where is the evidence that insurance companies would rig the system to extract record profits? I don't know. Perhaps the last decade or two might provide the answer.

Markos is right, but again leaves out the substance of this question. Do I, for one, wish that the insurance and drug companies should take a hit under this legislation? Yes, I do. Am I willing to allow even more people to go bankrupt and die because they're making more money? No, I am not.

Like Ezra Klein says, "[I]f I could construct a system in which insurers spent 90 percent of every premium dollar on medical care, never discriminated against another sick applicant, began exerting real pressure for providers to bring down costs, vastly simplified their billing systems, made it easier to compare plans and access consumer ratings, and generally worked more like companies in a competitive market rather than companies in a non-functional market, I would take that deal. And if you told me that the price of that deal was that insurers would move from being the 86th most profitable industry to being the 53rd most profitable industry, I would still take that deal."

4. Why are some of the same people who are criticizing the bill's lack of cost control also criticizing the inclusion of the excise tax, which is one of the few cost control mechanisms to have survived the process?

Because it is a measure that would disproportionately affect blue collar workers in high-risk jobs, or workers that have given concessions on wages to preserve good benefits packages. Limit that provision to people making over X amount (say, $100K/year), and I wouldn't have a problem with it.

Nate is dead on that the controversial "excise tax" is one of the biggest cost-controllers in the bill. Markos (and labor) are opposed to it, because it taxes all high-end health plans -- and since labor and some middle-class workers have cadillac health plans, it would indirectly be a tax on the middle class, which is why you see Markos suggesting that it only be applied to people making over $100K a year.

I would be inclined to agree with Markos if I didn't see the analysis (.doc) of the report from the Joint Committee on Taxation regarding the excise tax. It's not something that I can argue in a blip like this one, but it really does controls the costs of health care while increasing workers' wages. It is not something that can be lost.

5. Why are some of the same people who are criticizing the bill's lack of cost control also criticizing the inclusion of the individual mandate, which is key to controlling premiums in the individual market?

Because without premium caps or a public-run competitive option, there is no incentive for them to lower their premiums. They have a monopoly, and monopolies aren't in the business of unilaterally reducing their prices. There are two ways to force them to do so -- government regulation or market competition. The former is out, and the latter is inadequate.

Thank God for Ezra Klein, so I don't have to explain this one. But Ezra (and Nate) are absolutely right:

"Right now, the insurer sets the rules. It collects background information on applicants and then varies the price and availability of insurance to discriminate against those who are likely to use it. Health-care reform is going to render those practices illegal. An insurer will have to offer insurance at the same price to a diabetic and a triathlete.

"But if you remove the individual mandate, you're caught in the reverse of our current problem: The triathlete doesn't buy insurance. Fine, you might say. Let the insurer get gamed. They deserve it.

"The insurers, however, are not the ones who will be gamed. The sick are. Imagine the triathlete's expected medical cost for a year is $200 and the diabetic's cost is $20,000. And imagine we have three more people who are normal risks, and their expected cost in $6,000. If they all purchase coverage, the cost of insurance is $7,640. Let the triathlete walk away and the cost is $9,500. Now, one of the younger folks at normal cost just can't afford that. He drops out. Now the average cost is $10,600. This prices out the diabetic, so now she's uninsured. Or maybe it prices out the next normal-cost person, so costs jump to $13,000."

6. Would concerns about the political downside to the individual mandate in fact substantially be altered if a public plan were included among the choices? Might not the Republican talking point become: "forcing you to buy government-run insurance?"

If you start worrying about Republican talking points, you've lost the game. They're accusing Democrats of trying to kill grandma. They're not going to back off because a talking point isn't 100 percent accurate. 2010 will be the year of the "commie socialist Democrats", no matter what health care reform bill is passed.

In any case, Republicans have tried to destroy socialist programs such as Medicare and Social Security for years. If people like a program, there's nothing the GOP can do about it.

I'm with Markos on this one. We can't worry about the GOP. They obviously have no intention of reducing costs or covering more people. They are going to attack Democrats full-force no matter what the outcome.

7. Roughly how many people would in fact meet ALL of the following criteria: (i) in the individual insurance market, and not eligible for Medicaid or Medicare; (ii) consider the insurance to be a bad deal, even after substantial government subsidies; (iii) are not knowingly gaming the system by waiting to buy insurance until they become sick; (iv) are not exempt from the individual mandate penalty because of low income status or other exemptions carved out by the bill?

Is this argument that the mandate doesn't matter because too few people will be subject to it? If so, then strip it out. It shouldn't matter.

The individual mandate significantly matters -- even if it's only going to affect about 2.5% of the country. See my response above on the individual mandate. This also isn't to mention that most health care economists think that it's near impossible to control costs without covering everybody first.

8. How many years is it likely to be before Democrats again have (i) at least as many non-Blue Dog seats in the Congress as they do now, and (ii) a President in the White House who would not veto an ambitious health care bill?

I'm not sure how the future composition of Congress has anything to do with a battle in our current congress. This battle isn't over. But if anything, this argues for pushing for the most progressive bill possible.

In any case, most of the endangered Democrats next year are of the Blue Dog variety, while most of our (relatively meager) pickup opportunities are in Democratic-leaning districts. In other words, while our majorities will likely be smaller, it will be a more intellectually cohesive caucus. That's why all of the outright House retirements thus far have been Blue Dogs -- they're not interested in having to defend themselves in a caucus that is trending leftward.

The future composition of Congress has everything to do what what you're suggesting! If this bill is killed, it will not be revisited for probably 10 to 20 years, whenever Democrats have control of all three branches of government again.

Just like Clinton, there is no way Obama will have time to  waste another year and revisit health care again in this term or if he has a second term. We will have to wait a very long time to get legislation like this again, and Markos has to know that -- he's too smart not to. And if we wait, we will lose hundreds of thousands of lives in the process for most likely a much weaker bill.

9. If the idea is to wait for a complete meltdown of the health care system, how likely is it that our country will respond to such a crisis in a rational fashion? How have we tended to respond to such crises in the past?

No, the idea is to get the best possible legislation today. We may not be able to get something with reconciliation before Obama's State of the Union Address, but I don't think something this important should be beholden to something as trivial as a speech, even one as important as the SOTU.

Markos is suggesting that we start from scratch and use the reconciliation process. (A process that will be addressed more later.) Politically, practically, and for the country's sake, it would be insane for Democrats to start over on health reform legislation -- even if it's using reconciliation.

Is there an argument that they should have started with reconciliation from the beginning? Of course there is. But it's no reason to pretend like the Democrats in Congress (and Obama) can push off the thousand other things on their plate to start from scratch again on health care reform. Markos has to know that this will never happen.

10. Where is the evidence that the public option is particularly important to base voters and/or swing voters (rather than activists), as compared with other aspects of health care reform?

Given that the current bill only has 32 percent support, I don't think this turd of a bill in the Senate has much support of anyone, much less party activists. And the voter intensity numbers are clear -- base Democratic voters are planning to sit out 2010. And I doubt 18-29 year olds -- a key part of the Democratic base -- are going to be thrilled with a mandate. In fact, it may be the single least popular item in the bill.

I agree with Markos that we're pretty much screwed in 2010 -- especially if the bill doesn't have a public option. But what Markos doesn't point out is that we're probably screwed even more without it. And another thing that Markos leaves out is that the young adults (18-26 years-old), under this legislation, will finally be able to stay on their parents' plan. They certainly should be thrilled about that.

11. Would base voters be less likely to turn out in 2010 if no health care plan is passed at all, rather than a reasonable plan without a public option?

Nope, if Democrats gave it a serious shot, and then built campaigns around the obstructionists. Caving in to Lieberman, Republicans, and corporate interests, on the other hand, sends the message that the Democratic super majorities are irrelevant, and all the hard work from the last four years in electing them was a wasted effort.

Markos doesn't make an invalid point here, but nobody can tell if I'm right, Markos is right, or Nate is right on this. I'm still inclined to believe (looking back at 1994) that passing no bill would be worse for Democrats in 2010 than nothing.

12. What is the approximate likelihood that a plan passed through reconciliation would be better, on balance, from a policy perspective, than a bill passed through regular order but without a public option?

Likelier. Seems self-evident. And really, Medicare and the VA health system shows that the government is quite capable of handling health care.

Markos is definitely wrong on this one. One bill passed solely through reconciliation would be far worse than the regular bill. The only thing that could be passed through the budget reconciliation process are things that substantially affect the budget. So, we could have the Medicare buy-in and the public option, but we'd lose the insurance regulations, the Exchanges, new delivery reforms, and so much more.

Now, there is an argument here for whether or not two bills would be better. One for things like the public option done through reconciliation (which needs only 51 votes) and the other for things like insurance regulations and the rest (which still needs 60 votes), but like I said before, we missed our opportunity to do that. It does no good harping on the past.

13. What is the likely extent of political fallout that might result from an attempt to use the reconciliation process?

Fallout with the DC press corps? They didn't mind when Republicans used it to pass their tax cuts under Bush, but that's a different time. I'm sure they'll hyperventilate about it now. The voters? I've seen no data that suggests they care about process. Just results. Democrats would cheer, Republicans would bitch, but those guys will bitch anyway.

I'm with Markos on this. I don't think the people would have cared if we used reconciliation -- and the Republicans would attack us no matter what. But I don't think it's the "political fallout" that is the problem with reconciliation.

14. How certain is it that a plan passed through reconciliation would in fact receive 51 votes (when some Democrats would might have objections to the use of the process)?

It'd be nice to find out.

For every reason above, no it would not. Not at this point. Especially since Nate's right: There is no guarantee that even a bill would pass through the reconciliation process. Many Democrats would likely vote against it, solely because they disagree with the tactics. I'm not saying I agree with them for doing that, but it's certainly possible that the reconciliation bill wouldn't be able to muster up even 51 votes in the Senate -- and even likelier than the separate "insurance reform" bill that would still require 60 votes would fail.

15. Are there any compromises or concessions not having to do with the provision of publicly-run health programs that could still be achieved through progressive pressure?

Expand medicaid, add a national exchange instead of the state one, get rid of mandate, etc. I'm curious ... how many concessions has the other side made? Maybe it's time for a "compromise" that actually includes a compromise.

I think Markos is right to be fighting this "compromise" tooth-and-nail. It's not a compromise. We just flat-out were stripped of the public option without anything to show for it. All the progressive groups are right to be fighting against this like there's no tomorrow. There's still plenty of time to make this bill better. Even though what we have already is substantially better than the status quo.

16. What are the chances that improvements can be made around the margins of the plan -- possibly including a public option -- between 2011 and the bill's implementation in 2014?

I'm actually a little more optimistic about this. But here's the thing -- everyone surrenders now, the impetus for such tinkering will be gone. If people are angry and campaign on these key issues, then political pressure will be maintained for further action. The "surrender now" crowd actually makes further tinkering less likely, not more.

Thankfully Markos accepts Nate's point on this one, because it's big. There's substantial evidence (see Medicare and Medicaid) that this bill will grow in the future. Possibly even the very near future. Progressives can't stop fighting until we achieve quality, affordable, universal health care for all Americans. That will be far easier to do if we use this bill as a starting point, rather than having to try all over again in 10 to 20 years.

Also, with regards to Markos' post, I would like to point out that even though I'm trying to convince everybody I know that this bill is still worth passing even without a public option, I'm calling every worthwhile congressperson I can find telling them that a robust public option is essential to health care reform and encourage everybody else to do the same. Unfortunately, we lost a robust public option a long time ago, but the more we pressure Congress into supporting progressive legislation, the more likely they will be to either (a) try to fix this bill now or (b) try to fix this bill in the future.

17. What are the potential upsides and downsides to using the 2010 midterms as a referendum on the public option, with the goal of achieving a 'mandate' for a public option that could be inserted via reconciliation?

The public option remains popular, despite the year-long demonization process by insurance interests, Republicans, teabaggers, and even some Democrats. Popular enough to base a "referendum" around it? Beats me, I'd have to see more data. But if 2010 is a referendum on that current Senate bill, we're in deep trouble.

And in any case, I don't think we have much of a choice in the matter. 2010 will be all about Democratic "socialists", and HCR will be Exhibit A in the wingnut playbook.

Both guys have good points on this one. But, again -- either way -- Republicans are going to come at us hard, so we have to stop thinking about it as if they're going to take it easier or not have as much to swing at us if we don't have a public option. 

Markos is right, we have an insanely better shot at the mid-terms with a public option. But I don't think Nate is denying that. Nate is simply saying that we'll have a better shot in 2010 with a health care bill rather than without one -- which I think is true.

After all, we still have those measly 32% that will get what they want if the Senate bill is passed (since support understandably plummeted after the public option was dropped). If this legislation fails, only the Republicans will get what they want. Progressives will not be motivated by failed legislation. If this bill passes, the worst case scenario is that those 32% will still be happy. If this bill fails, almost 0% of Democrats will be happy.

18. Was the public option ever an attainable near-term political goal?

Yes. But even if it wasn't, perhaps we would've been better off starting with a Medicare For All approach, or at least an expansion (back when Lieberman was for it). I'm sure someone will write a book about all the tactical mistakes made during this battle. There's no doubt the Democrats blew it big time, but that's not the same as saying a desired policy outcome was not attainable.

I would have liked to hope it was. Like Markos, I've often thought of how differently the politics of this legislation could have been played. But, again, it does absolutely no good to dwell on the past. If we are looking ahead, the best way to have quality, affordable health care for more Americans is to use this bill as a starting point.

19. How many of the arguments that you might be making against the bill would you still be making if a public option were included (but in fact have little to do with the public option)?

Depends on the details of that public option.

Nate's point is a good one. One that I've been making for a while. It's simply that progressives flipped when we lost the public option -- at negotiated rates -- only available to 1% of the country -- that would have premiums higher than private insurance plans -- where states would be eligible to opt-out of the program -- for what? That public option was almost completely worthless. 

The only positive thing about it was sitting around waiting for it to hopefully expand as time went on. I think that Nate's trying to say that some progressives seem to have a fetish with the phrase: "public option." No matter what it is or what it does.

The bill certainly would have been better with one in, but honestly, because of how weak the public plan ended up being, not as much has been lost from the bill as you'd think. 

20. How many of the arguments that you might be making against the bill are being made out of anger, frustration, or a desire to ring Joe Lieberman by his scruffy, no-good, backstabbing neck?

Max Baucus caused more damage to this process than Lieberman, by slowing things to a crawl pretending that Enzi (from Wyoming!) was ever a good-faith negotiator, giving Republicans and teabaggers a chance to ramp up the hysteria and slowing whatever initial momentum the administration and congressional Democrats ever had on the issue.

I don't give a shit about Lieberman's opposition. He's just confirming everything we ever said about him. In fact, it's kind of nice seeing the Beltway and congressional Democrats start to finally understand who the real Lieberman is. But I never expected anything less from him, so pretending that this is some weird grudge match minimizes what are serious policy disagreements. Lieberman may be petty about this, but I'm not. I settle those grudges on the electoral battlefield, not the policy one.

And it's clear, we've been fighting this fight long before Lieberman decided to shine the spotlight on himself.

Markos makes some good points on Lieberman. I think we'd all do a lot of good if we stopped focusing on him so much (myself included), because it's exactly what he wants.

That being said, I would definitely love to ring Lieberman by his scruffy, no-good, backstabbing neck if I had the chance.