Past attempts at health care reform
Past Attempts at Health Care Reform
Over the course of the last 100 years, there have been many attempts at health care reform. According to the New York Times, one of the first efforts at reform dates all the way back to Theodore Roosevelt. During the 1912 campaign, Roosevelt stated, “It is abnormal for any industry to throw back upon the community the human wreckage due to its wear and tear…and old age should be provided for through insurance” (New York Times, 1912). While Theodore Roosevelt was not familiar with the modern medical system and its vast complexities, he did recognize the government's role in protecting worker's rights. One of the rights he recognized was the need for protection of factory workers after work-related accidents. This plank from his 1912 campaign was not brought completely to fruition, but is noteworthy as the first nationwide attempts at health reform.
Series of Progressive Presidents
After the first attempt at taking the issue to the national stage, the idea saw its way through three more ‘progressive' presidents. Franklin Roosevelt pondered the idea of implementing modern medical insurance as it is known today during the new deal. However, he faced clear opposition from the American Medical Association and the attempt failed to find its way into the New Deal legislation (Goodridge, 2009). After World War II, Truman continued the push for national healthcare, but he was met with cries of “socialized medicine” from the American Medical Association (Goodridge, 2009). As history repeats itself, John F. Kennedy pushed for insurance reform that would later become the Medicare Bill under Lyndon Johnson in 1965 (Goodridge, 2009).
During the heated debate that was focused on seniors' health insurance, the question was undoubtedly raised about the viability of health insurance for all persons regardless of age. In fact, this happened during 1971 when competing plans for nationwide health insurance were introduced by Senator Edward Kennedy and President Richard Nixon. Senator Kennedy introduced “a universal single-payer health reform plan” (Goodridge, 2009). After a significant amount of debate, Richard Nixon signed the Health Maintenance Organization Act that “set aside 375 million to finance demonstration projects” (Goodridge, 2009). Both Senator Kennedy's plan and President Nixon's plan failed to push their way through congress. Therefore, in 1976, the contentious issue found its way to the fore during the election of Jimmy Carter. In fact, according to a New York Times article, there were eighteen proposals that were coming before Congress (Manolis, 1977). In fact, in a direct parallel to the current debate, the economy was in dire straights and health care reform was swept from the agenda once again.
Clinton Health Care Reform as a Case Study
While the distant past attempts at health reform are important to frame the current debate, one of the most important stage-setting events took place during the beginning of President Clinton's first term. According to a case study by the Kennedy School of Government, “fears [about health insurance] crystallized during a 1991 special election in Pennsylvania…between Democrat Harris Wofford and Republican Richard Thornburgh” (Scott, p. 4). Wofford, who was unknown, defeated Thornburgh by making health care a key provision during his campaign (Scott, p. 4). This election, carefully watched by Democratic strategists, turned health care into one of the central issues during the 1992 election of President Bill Clinton.
Vowing to make good on one of his most ambitious campaign promises, President Clinton appointed Hillary Clinton and Ira Magaziner to the “President's Task Force on National Health Reform” (Scott, p. 6). The pair split the work to a large commission that “ballooned to over 500 people” (Scott, p. 7). Throughout the tasks force's work it included many executive agencies and their personnel. However, they failed to include members of Congress during their deliberations and compromises. According to Pete Stark (D-CA), “they came over and saw us all the time, but ignored what we said” (Scott, p. 7). Thus, it seems reasonable to see how President Clinton's attempt at reform also failed from the inclusion of member's of Congress and their viewpoints. It also took the task force much longer than they had planned to formulate a plan they believed was politically viable (Scott, p. 8)
Regardless, President Clinton addressed a joint session of Congress to state, “millions of Americans who were just a pink slip away from losing their health insurance, and one serious illness away from losing all their savings” (Scott, p. 1). While President Clinton hoped to pass health reform legislation during the first part of his term, he was faced with a failed stimulus package and a tough budget to be put through (Scott, p. 8). Eventually, during congressional debate and much fervor throughout the public, the health care proposal failed to gain the needed in Congress.
Many divided factions led to the fall of the proposal, but among the most prominent were small businesses through the United States Chamber of Commerce, Health Insurers Association of America, and a tumultuous Congress. However, one of the final daggers into the heart of President Clinton's effort was the commonly cited “Harry and Louise ads” by the Health Insurers Association of America (Scott, p. 17). Further, with the 1994 midterm elections on the horizon, President Clinton was unable to secure the needed political capital to pass the plan.
With the numerous failures of past attempts at health reform, it seems unlikely that anything related to health care will ever pass through Congress. However, Democrats decisively control all avenues of public policy. If the Democrat party remains cohesive and remains far enough from the Republicans, it seems logical that health care reform should pass this fall. While this relies on many of the aspects from the Conditional Party Government theory, the Democrat party does not seem completely cohesive in the senate and threatens to be torn apart from volatile amendments like abortion funding.
Predictions about the current debate can be found in every facet of the media. One prominent prediction is from the Huffington Post. In an article by Robert Creamer, he states that “the odds are very good that President Obama will succeed in passing landmark health insurance reform legislation this fall—with a robust public health insurance option” (Creamer, par. III). He goes further to state that it is the political high ground and that Democrats cannot fail because of the upcoming 2010 midterm elections (Creamer, par. XIII). He also believes that many of the swing voters cannot stand the health insurance industry (par. IV). Also, he states that “the Obama Administration will use every ounce of political capital to win” (par. IX). His use of political capital could be attributed to the future inability to pass the rest of his agenda—something that would be detrimental to his hopes for a second term.
Following along the same lines, President Obama made many campaign promises related to health care that are still fresh on the minds of the populace. These promises are important to keep in mind when considering what the president will find acceptable to solve the health care problem. First, during the campaign, Barack Obama, promised a “new insurance marketplace” and a “public health insurance option to provide the uninsured and those who can't find affordable choice” (Obama, par. XI-XIV). It seems clear in the midst of whether or not the senate will pass a public option that this provision could be crucial to whether or not President Obama finds it acceptable to sign. However, it might be that whatever Congress puts on his desk he will sign simply to not repeat the failures of the Clinton administration and the electoral consequences that followed.
During the current debate and formulation of health care policy, it seems important to draw parallels between the Obama administration and the last attempt at health care reform—1993. It could be properly hypothesized that the Clinton healthcare failure could be attributed to the lack of involvement of Congress during formulation stages. With that in mind, President Obama has taken a completely different approach to health reform. In that, he allowed Congress to have the ability to formulate all of the health care legislation. By giving the control to Congress, he has effectively isolated himself from the debate except to urge congress to act. Now, this strategy has yet to be tested in the health care arena in modern times, which provides some more uncertainty to any possible predictions.
However, there are similarities—both methods have overly exposed many aspects of reform in the media. This over-exposure could lead to compromised public support of the current reform measures and weaken the validity of any future efforts at reform. This also leads to changes in public opinion that could threaten the viability of the rest of President Obama's agenda—weakening his chances for reelection. With the President Clinton, he attempted to insulate the reform initiatives from public opinion—a move that allowed the formulation process to remain less contentious throughout the media. With the exception of information leaks, Clinton was able to control the flow of information and at least stave off some bickering that was seen throughout the house bill this fall. It could be argued that the house leadership and senate leadership when they held closed sessions to try to reach consensus. This was clearly a move to insulate policy formation from the perils of public opinion that seemed to kill the Clinton initiative. In this, it seems simple that public opinion has perceived electoral implications. For example, the longer the health care issue remains without congressional consensus, the less likely it is to be passed. This could point to the theory that congressmen are consistently thinking about reelection. Clearly, with healthcare, policy issues are influenced by reelection goals through public opinion and the media.
Charles Grassley: Health Care
It is now important to shed some light on Senator Charles “Chuck” Grassley (R-IA) who is a key player in the Senate Finance Committee. In order to see how Senator Grassley will fulfill his role in the committee, it is important to view his past statements and beliefs. For these purposes, it is sufficient to use his press releases from his senatorial website. While these press releases are filled with political rhetoric directed at their constituents, with a proper filter, it is quite possible to find his position.
In order to properly frame his position, it should be asked, does Senator Grassley even believe that healthcare is a problem? It seems evident that he believes health care costs are a problem for American families. On November 10th, he stated in the senate, “health care costs are rising at twice the rate of inflation, straining family budgets, and making it difficult for American businesses to remain competitive” (Grassley, 11/10/09, par. V). In the same speech, Senator Grassley stated that the average worker could face “higher unemployment—more than 750,000 lost jobs; increased health insurance premiums—maybe by as much as 70 percent; lower wages—less money in your paycheck, $500 billion in higher taxes for individuals and Americans businesses…”(Grassley, 11/10/09, par. XIII). Also, he stated in a previous speech his support for small businesses when he declared them “vital to the health of our economy” (Grassley, 11/5/09, par. I). His views seem in line with the majority of the Republican Party who historically has supported small businesses with an almost special fervor. Also, Senator Grassley made a special point to mention family budgets—something that historically works well during campaigning.
Also, during some comments on the floor about the HELP committee bill, he mentioned young people as a disadvantaged entity in the legislation. He stated, “to pay for these lower premiums for elder people means much higher premiums for younger people—it's almost a hidden tax” (Grassley, 11/2/09, par. VII). Clearly he feels strongly against measures that might not be explicit taxes, but that might, in some way redistribute money. Or in other words, he would not prefer to shift costs from one entity to another entity in the market. In this sense, Senator Grassley does not favor a mandate that requires health insurance for all age groups. In the same speech, he goes further to state that he would prefer the power to regulate insurance from local officials throughout the states than to “put the power to in the hands of unelected bureaucrats” (Grassley, 11/2/09, par. VII). Additionally, down this path of ‘de-centralization, Senator Grassley said, “After reading this bill, it is clear that only one person will have a choice, and that is the Secretary of HHS” (Grassley, 11/2/09, par. IX). This statement gives a clear indication that Senator Grassley does not favor the public option and would rather this be out of the final senate bill. Part of this is due to the Congressional Budget Office's assessment that the premiums in the public option will be higher than in the private market (Grassley, 11/2/09, par. XIV). The rest of the disgust is that he thinks that the creation of a market for health insurance equates to a government takeover of healthcare (Grassley, 11/2/09, par. XVI).
Further, he dislikes the “largest expansion of Medicaid in its history” that would leave the financial burden on the states to fund (Grassley, 11/2/09, par. XV). Clearly he has the solvency of state governments in mind in these opinions. Additionally, it would seem that he favors more states rights than would typically be present in many national political debates. Also, Senator Grassley seems not to like that there are ‘tax credits' that he claims redistributes money from the government directly to insurance companies while purporting to be a tax break for citizens (Grassley, 10/29/09, par. L).
While the aforementioned things speak to the measures that he does not like about the opposition's attempt at reform, it seems important to ask what measures he would like if he was in charge of crafting health reform legislation. Senator Grassley stated that he is in favor of medical liability reform. In fact, he rebuked the Democrats and specifically President Obama on the senate floor when he said, “they refuse to even consider it (liability reform)” (Grassley, 11/2/09, par. XIX). Following along this line of logic, since he is in favor of small businesses, it seems reasonable to conclude that he would support a measure of reform that seems ‘pro-business'. For example, he clearly would not support a public option and seems to prefer options that are spending neutral from the government's point of view. For instance, he might support a measure to change the law to allow insurance companies to compete across state lines. This option produces no more government spending and relies on the market to allocate resources—something that he seemed to favor when he publicly disapproved of the public option. Also, he might eventually come to favor private-market based solutions like health savings accounts with more catastrophic coverage options from private-market insurers.
The Committee Vote
To continue to understand the current dynamics of the health care debate, it seems important to see what actions Senator Grassley took during the deliberations in the Senate Finance Committee. Much was made of the efforts of Max Baucus (D-MT) in the press to form a bill that had political viability in the senate—efforts that some, at the time, thought to be the senate's only hope of passing some form of health care reform. The efforts of Max Baucus and the Senate Finance Committee seemed to renew the vicarious debate. As ranking member on the Senate Finance Committee, Senator Grassley sought bipartisanship during the formulation process (Grassley, 10/15/09, par. X). However, he continued to state that Congress has been partisan throughout the formulation stages due to the public's general frustration of governmental actions over the previous months (Grassley, 10/15/09, par. X).
Senator Grassley expressed his opposition against many measures contained in the bill. One of the most prolific measures that he cited was the bill's propensity to raise classes on the middle class. In a speech on the senate floor, Senator Grassley cited a figure by the Join Tax Committee “that 77% of the tax increases in the Finance Committee bill would be borne by middle-class taxpayers” (Grassley, 10/29/09, par. XXV). In countless speeches on the floor, Grassley disapproves of measures that might adversely affect the middle class. Since most of Senator Grassley's constituents define themselves as middle class, it seems logical that he would want to ensure their protection during reform efforts (Grassley, 10/29/09, par. IV). Also, another general dissatisfaction that Senator Grassley expressed was the lack of bipartisanship exhibited during the mark-up (Grassley, 10/13/09, par. II). Bipartisanship is often sought on sweeping reforms simply because of the scope and magnitude of the changes to the system. Bipartisanship, in this sense, can protect the integrity of the public's image of Congress during reforms that might otherwise be unpopular among various groups like small businesses, individuals, and large corporations—basically large stakeholders.
Disfavored Aspects of the Baucus Bill
One of the first aspects that he cites during the markup of the bill was the Rockefeller Amendment (C21) “that took benefits away from children…that let children get covered through private insurance…now children in 41 states won't have access to health care and they'll be left in a grossly underfunded public program” (Grassley, 10/13/09, par. XVII-XIX). Further, he expressed discontent with the provision that requires “the Medicare commission to make cuts to Medicare forever…[and] the damage this group of unelected people could do to the Medicare program is unknown “(Grassley, 10/13/09, par. XIV). Clearly the intervention of uncontrolled bureaucratic actions was disfavored by Grassley simply because of the lack of oversight to cuts that would typically make decisions that Congress would normally make with regard to Medicare. Also, with these cuts, Grassley conveys his dislike of the negative side effects that such cuts to Medicare would do for the elderly and the disabled (Grassley, 10/13/09, par. XIII).
Another aspect that Senator Grassley expressly stated was the provision to allow illegal immigrants to apply for coverage (Grassley, 10/13/09, par. XXIII). Certainly with the contentious debate surrounding the illegal immigration issue in the past, one could see why this might be a politically popular position in a mid-west state such as Iowa. For that matter, supporting illegal immigrants through US citizens' tax dollars would be contentious for most Americans. Additionally, Senator Grassley implies that the Finance Committee bill favors insurance companies, in that, “it forces insurance premiums up and then forces individuals to buy them” (Grassley, 10/13/09, par. IX). Clearly, regardless of party status, Americans would be livid if the bill raised premiums and forced individuals that heretofore could not afford coverage to buy it. One of the strongest arguments that the Democrats have is moral suasion—citing it is the right thing to help those who cannot afford health care. If the CBO estimates are correct and the Baucus bill passes, this could damage the Democrats politically for many elections to come.
In one of the more partisan amendments, the ‘wrap-up' amendment, Grassley found himself leading the vote along party lines to prevent the “newly created Medicare Commission to raise premiums paid by senior for prescription drug coverage” to makeup for $11B in cuts to Medicare (Grassley, 10/2/09, par. II). This provision would be a quite unpopular stipulation in the bill that would resonate particularly harshly with the voting base that typically comes to the polls more consistently than any other voting bloc. While electoral concerns are probably not the only reason that Senator Grassley voted against this provision, it certainly could have been a thought in the back of his mind.
In an attempt to ensure success of the health care exchange as described in the bill, Senator Grassley proposed Amendment 328 that required “members of Congress and congressional staff [to] access health insurance through the exchange” (Grassley, 9/30/09, par. I). Senator Grassley went further to state, “the more that Congress experiences the laws we pass, the better the laws are likely to be” (Grassley, 9/30/09, par. II). This certainly was a statement that reverberated well with many voters from both parties. Surely, many would agree with this, in that, Congress should be responsible for the legislation it has previously passed. Often times, Congress only acts on a problem when there is broad public consensus that something should be done. This measure will ensure congressional accountability—an aspect most agree is necessary.
In wrapping up thoughts about the Baucus bill and Senator Grassley's position, it is important to note that even though he was a ranking member on the committee, his constant call for bipartisanship shows his lack of involvement during much of the formation process. While he was successful at getting one amendment passed, the rest of the time, he was only able to share his displeasure with the proposed measures. In the end, it seems obvious that Senator Grassley did vote no in the 14-9 committee vote (Baucus, par. I). With very few of his own provisions accepted, personal convictions, and limited amount of recourse, it seems clear that he had to vote no.
The Reid Bill: Key Provisions
While examining Senator Grassley's actions and vote in the Senate Finance Committee, it increasingly looks more likely that it will not be the bill that gets taken to the floor of the senate. Instead, Senate Majority Leader Harry Reid (D-NV) has proposed “an amendment in the nature of a substitute to H.R. 3590”—the “Patient Protection and Affordable Care Act” (Elmendorf, par. I). The reason for this change is quite complex and at this point is subjective; however, it can reasonably be deducted that this bill will make it to the floor because of the significant amount of heat and pressure that the Baucus bill received throughout deliberations. Additionally, it looks as though this bill will not even find its way through a committee markup or the amending process in committee. In fact, THOMAS, cites the bill through H.R. 3590 as the vehicle in which the bill is projected to move through Congress (THOMAS).
The provisions for this bill are immense—at 2074 pages long, the Patient Protection and Affordable Care Act looks an arduous task as any to pass (US Senate, par. I). To start, this bill includes the notorious public option, but states have the ability to “opt out” (Responsible, par. V). It also includes the previously noted exchange market and refundable tax credits for “Americans with incomes between 100 and 400 percent of the federal poverty line” with this eventually phasing out for individuals at 300 to 400 percent (Responsible, par. VII). Also, this new credit “will assit small businesses with fewer than 25 workers for up to 50 percent of the total premium cost” (Responsible, par. VII). Additionally, “beginning in 2014, most individuals will be required to maintain minimum essential coverage or pay a penalty of $95 in 2014, $350 in 2015, $750 in 2016 and indexed thereafter” (Responsible, par. VIII). The new plan will also expand Medicaid up to 133% of the Federal Poverty Line (Responsible, par. XII). It will expand the Children's Health Insurance Program by up to 23% (Responsible, XIII). The legislation will “enhance health care workforce education and training” (Responsible, XXXVII).
Congressional Budget Office Estimates
The non-partisan Congressional Budget Office estimates that the Patient Protection and Affordable Care Act will have “a net cost of $848 billion in subsidies provided through the exchanges, increased net outlays for Medicaid and the Children's Health Insurance Program, and tax credits for small employers (Elmendorf, par. VII). These costs are partially balanced by $149 billion from a tax on ‘high premium insurance plans and $100 billion from ‘net savings' from other sources (Elmendorf, par. VII). The CBO estimates that “the net cost of the coverage expansions would be more than offset by the combination of other spending changes” (Elmendorf par. VII). Additionally, the CBO estimates that enacting the provisions regarding Medicare, will lead to a reduction in direct spending by $491 billion over the 2010-2019 period (Elmendorf, par XXI). Further, the CBO states, “the coverage expansion would probably exceed 1 percent of GDP, but the added revenues and cost savings would probably be greater” (Elmendorf, par. XLI).
Senator Baucus' Bill v. Senator Reid's Bill
With the aforementioned things in mind, it should be noted that many of the provisions in the Reid bill resemble the provisions in the Baucus bill that came in front of the Senate Finance Committee with the exception of the public option. However, it still contains the expansion of Medicaid that Senator Grassley has come out against. It also contains cuts to Medicare that Senator Grassley cited as a reason for not voting for the Baucus bill. Also, the Reid proposal has the market exchange where individuals can purchase health care through on a national level just like the Baucus bill.
One stark difference that the legislation contains is the addition of tax credits to certain individuals. This one provision could entice some moderate Republicans, but Senator Grassley does not seem the type to fall prey to tax credits that are only available to certain groups of people (i.e. people between 100%-400% of the federal poverty level). This may be a strategy by Senator Reid to sway conservatives who would typically be in favor of tax credits, but it does not look to be as strong of a provision as would be required.
Senator Grassley: Yea or Nay?
One major factor that could influence the vote of Senator Grassley is the upcoming 2010 campaign season in which he is running for reelection (Hancock, par. III). Further, Senator Grassley told a local news station, “I've gotta consider I have a race and I'm gonna act accordingly and campaign accordingly” (KMEG, par. II). Such a reelection campaign would have to be factored into Senator Grassley's vote on Senator Reid's health care bill. One of the most logical places to look to see who might be influencing this decision would be his monetary supporters. During the 2005-2010 cycle, Senator Grassley collected over $500,000 from health professionals, over $400,000 from the insurance lobby, over $290,000 from pharmaceuticals/health products lobby, and over $280,000 from hospitals/nursing homes (Open Secrets, Chart). With such large amounts coming from stakeholders in healthcare reform, it would seem politically profitable to vote with the interests of these lobbies. Further, since none of these lobbies benefit from cost reduction, except perhaps the hospitals, it would seem reasonable to conclude that from this standpoint Senator Grassley should vote no.
However, campaign donations alone should not be reason enough to deny a certain percentage of the US population health care. In this case, Senator Grassley should also examine his personal convictions, which as a Republican, would point him in the ‘no' direction. Yet again, in the US, there is a notion that Congressmen should be delegates of the people. This direction is somewhat murky, but the best indicators in this situation would be public polling. In an August poll of Iowans, the Des Moines Register found that 56% of Iowans support the public option (Armbruster, par. II). However, in a Gallup poll, 49% of Americans “believe that their personal costs will get worse (Grassley, 10/29/2009, par. I). With the evidence provided by polls close to a majority in both directions, it would seem crass to base your decision on 6% of your home state—especially since it has been three months since that poll was taken.
With these facts in mind, it seems likely that Senator Grassley vote ‘nay' to the Patient Protection and Affordable Care Act. Also, this ‘nay' decision could be based off of Senator's Grassley's quote, “I base my decisions non on polls but on town meetings”—meetings where he has encountered a good deal of dissent (Armbruster, par. II). Further, the political capital that would have to be expended would be tremendous for Senator Grassley to vote ‘Yea'. For instance, it is possible that the bill could pass the senate and become so altered in conference committee that it becomes impassable in either the house or the senate. There are many provisions that could be altered in the Reid bill such as no health insurance for illegal immigrants, mandatory (without state ability to ‘opt-out'), or even the provision allowing abortions (New York Times, Chart). In other words, there are too many contentious issues that have been added to these bills to make them viable in conference committee and back through the senate and house floors.
Therefore, it is imperative that Senator Grassley vote ‘nay' and against the Patient Protection and Affordable Care Act. Additionally, because of the upcoming 2010 reelection bid, should a filibuster take place, he should not be the individual to be on the floor. Such a political risk could mean defeat should the measure become popular with the public after passage. Also, Senator Grassley should remain fervent in the debate by stating things such as, “I don't believe this bill is up to the usually high standards that the senate holds itself to” or “there are a few key provisions that I believe are not in-line with the will of the people”. With these statements he can still express his contrary views, but can do so in a way that should be acceptable to the moderate electorate in Iowa. With a ‘nay' vote, he can secure a position that allows for courteous dissent on an issue that could threaten his political future.