The Speech

People like Obama, and people don't like Congress. That's generally why the President needed to give a big speech about health care instead of all 435 members of Congress having a turn ("Charles Boustany" is going to be a historical footnote right up there with Al Downing). And the President we elected is a great communicator but not instinctually a progressive. So given all that, the best that last night's speech could do is rally the public to the side of reform, and let Congress and the truly engaged members of the public do the heavy lifting on specifics of the policy.

And he unquestionably did that. He laid out in specific enough language what the policy would do: Security and stability for the insured, affordable coverage for the uninsured, and lower cost for everyone. Whether or not the actual plans can deliver on these goals remains to be seen. But everyone can agree on them. He did an extremely effective job in detailing why we need reform. There were statistics and horror stories and plain language put to use for this purpose. There was an element of shame to the data points that we're the only democracy on Earth that allows people to go broke because they get sick, that forces the uninsured to endure their hardships, that lets insurance companies deny care because it doesn't meet with their bottom line.

Then he said something that I'm sure was very reassuring to a lot of Americans not named D-Day: "I believe it makes more sense to build on what works and fix what doesn’t, rather than try to build an entirely new system from scratch." There was a gratuitous straw-man shot at single payer right before that, which I certainly didn't welcome. But health care reform lost the plot the last few months. The conservative noise machine deeply confused people and had them wondering about all sorts of radical imaginings. Having laid out the principles for a long time, he needed to reinforce that, and reject the lies being peddled by the other side. Some of these lies I wish were not lies: I think legitimate and legal medical services like abortions should be part of public health insurance coverage like any other legitimate medical service, and I think that germs don't know borders and undocumented immigrants can spread disease in the same way as anyone else, and so they should be able to get care in the most efficient way possible - and that's not going to the ER.

As to the policy, there was some actual news made here. He endorsed an individual mandate and an employer mandate; the latter doesn't appear in the Senate Finance bill, suggesting that it will not be rubber stamped. Obama endorsed the plan to tax insurance companies for high-end plans, a roundabout way of decreasing or limiting the employer deduction, a big pot of money in health care that leads to an inefficient system. He also added a concept from the McCain campaign known as "high-risk pools." In the time it takes to ramp up the insurance exchanges and eliminate denial on the grounds of pre-existing conditions, Obama would use a public program to provide catastrophic insurance to those who cannot otherwise get it right away. That will be expensive, but it will have an immediate impact on the system, which is hugely important. If we pass health care reform and nobody sees the benefits immediately, people will wonder why anyone would agree to doing it.

That high-risk pool will cost money, and Obama put the price tag at $900 billion, which isn't enough to provide affordable coverage under this framework even without the high-risk pools for four years. That's very worrying, and I hope it's not the upper bound of the possible. However, the main veto threat in the speech was a vow to nix anything that increased the deficit, so unless more revenue can be found, I don't see how that number balloons. And it needs to:

Later, Obama makes clear that health reform should cost about $900 billion. He's put that much money on the table before, but it wasn't clear whether he would try to seek more funding. Clearly he won't. On the other hand, given the current political environment, $900 billion is--just barely--what you need to reach universal coverage, or at least put us on a trajectory to it.

The test run for medical malpractice reform is a bone to the right, and if Texas is any indication, it won't work, and Republicans will be confronted by the reality of their own distortions. When medmal fails to bring down costs whatsoever, I hope Obama makes a big show of it, and we have ammunition to rebut the endless cries of "tort reform." As long as nobody gets denied justice when harmed by their doctor, I'm fine with that.

Then there's the public option. Obama kept it alive tonight, devoting seven paragraphs to it. That simply would not have happened if progressives didn't mobilize and engage on that issue. The public option also appears in the Obama plan released yesterday. Again, no way that happens otherwise. I know many of my friends are concerned that he did not make it a deal-breaker, but that's not how Obama rolls. That will be up to us. What he did was provide a solid set of arguments for it, and challenged those ideologically opposed to come up with something that provides choice in the same way - which isn't going to be very possible.

One other very important thing - Obama endorsed the Judy Feder/CAP proposal to implement "fail safe" policies that would kick in if the savings assumed by industry didn't materialize. This is EXTREMELY important for properly scoring the bill, and may allow the total funding to rise.

Health policy experts David Cutler and Judy Feder, however, have an innovative proposal for making them count. In a paper for the Center for American Progress, they argue for the implementation of "failsafe" policies — crude, surefire interventions — that will kick in if the expected savings don't manifest. Limiting the growth of Medicare payments, for instance. Increasing the excise tax on insurers. Moving the public plan towards Medicare rates.

You can think of a dozen with little trouble. But if you kept them looming behind the curtain — the Oddjob to your Goldfinger — in the event that the expected modernization savings didn't manifest, it would make the anticipated savings visible to CBO, and free up money for affordability. Moreover, it would make those savings more likely to manifest, as insurers wouldn't want more of tax on their heads and hospitals wouldn't want lower rates, and so there would be more of an incentive to implement some of the softer, gentler reforms.

But that's all policy. The emotional center of the speech was the revealing of the letter from Ted Kennedy and the explanation of his liberalism, and indeed the virtue of American liberalism. This was the part of the speech I needed to see - an uncompromising defense of the idea that we are all in this together, that we have a stake in one another, interestingly enough the themes I saw the very first time I saw Obama back in 2006. This is great rhetoric:

On issues like these, Ted Kennedy’s passion was born not of some rigid ideology, but of his own experience. It was the experience of having two children stricken with cancer. He never forgot the sheer terror and helplessness that any parent feels when a child is badly sick; and he was able to imagine what it must be like for those without insurance; what it would be like to have to say to a wife or a child or an aging parent – there is something that could make you better, but I just can’t afford it.

That large-heartedness – that concern and regard for the plight of others – is not a partisan feeling. It is not a Republican or a Democratic feeling. It, too, is part of the American character. Our ability to stand in other people’s shoes. A recognition that we are all in this together; that when fortune turns against one of us, others are there to lend a helping hand. A belief that in this country, hard work and responsibility should be rewarded by some measure of security and fair play; and an acknowledgement that sometimes government has to step in to help deliver on that promise.

This has always been the history of our progress. In 1933, when over half of our seniors could not support themselves and millions had seen their savings wiped away, there were those who argued that Social Security would lead to socialism. But the men and women of Congress stood fast, and we are all the better for it. In 1965, when some argued that Medicare represented a government takeover of health care, members of Congress, Democrats and Republicans, did not back down. They joined together so that all of us could enter our golden years with some basic peace of mind.

You see, our predecessors understood that government could not, and should not, solve every problem. They understood that there are instances when the gains in security from government action are not worth the added constraints on our freedom. But they also understood that the danger of too much government is matched by the perils of too little; that without the leavening hand of wise policy, markets can crash, monopolies can stifle competition, and the vulnerable can be exploited. And they knew that when any government measure, no matter how carefully crafted or beneficial, is subject to scorn; when any efforts to help people in need are attacked as un-American; when facts and reason are thrown overboard and only timidity passes for wisdom, and we can no longer even engage in a civil conversation with each other over the things that truly matter – that at that point we don’t merely lose our capacity to solve big challenges. We lose something essential about ourselves.

It's an annoying tic that Obama doesn't call out the enemies of the status quo by name, or that he tries to be inclusive with people who want no part of that inclusion. But this is what makes him appealing to independents - and in doing it, he brings people under an umbrella of liberalism, making the case for government as a valuable partner in our lives, making the case for good government as essential to progress, making the case for large-heartedness. And it makes his opponents look small by comparison. Daniel de Groot has a great post on this at Open Left.

Health care reform was on the ropes. It needed a champion. Obama did his job last night, and added a level of comfort and resolve to the debate. The details of the policy are where we can continue to fight. But very few people can walk away from that speech and say that nothing needs to be done. Ezra Klein has more.

Spark Of Life

Some excerpts of the President's speech tonight are now available. I will say that there's a bit of a harder edge in these remarks, particularly toward out-and-out opponents of reform, the likes of which have disrupted town halls all last month. This follows the feistiness of Obama's Labor Day speech to the AFL-CIO. Here's an excerpt of the excerpts:

But what we have also seen in these last months is the same partisan spectacle that only hardens the disdain many Americans have toward their own government. Instead of honest debate, we have seen scare tactics. Some have dug into unyielding ideological camps that offer no hope of compromise. Too many have used this as an opportunity to score short-term political points, even if it robs the country of our opportunity to solve a long-term challenge. And out of this blizzard of charges and counter-charges, confusion has reigned [...]

But know this: I will not waste time with those who have made the calculation that it’s better politics to kill this plan than improve it. I will not stand by while the special interests use the same old tactics to keep things exactly the way they are. If you misrepresent what’s in the plan, we will call you out. And I will not accept the status quo as a solution. Not this time. Not now.

Everyone in this room knows what will happen if we do nothing. Our deficit will grow. More families will go bankrupt. More businesses will close. More Americans will lose their coverage when they are sick and need it most. And more will die as a result. We know these things to be true.

That is why we cannot fail. Because there are too many Americans counting on us to succeed – the ones who suffer silently, and the ones who shared their stories with us at town hall meetings, in emails, and in letters.

"More will die as a result." That's not half-stepping it at all. And I'm glad that Obama didn't take Saxby Chambliss' patronizing advice and show "humility". From the looks of these excerpts, he won't.

And yet, this is an easy target. Teabaggers and Birthers do not have a role to play in this debate. The President might want everyone to think they do, but they don't. They don't have the votes to stop anything if the majority really wants to pass a bill. The universe of 50-60 votes in the Senate and 218 in the House, those are the ones who will enact health care reform or not. And to them, early reports show that he will be tepid and broadly receptive to whatever they might demand.

He's going to support medical malpractice reform, a sideline of the debate which has little positive value (just see the results in the states which have already enacted it) and may make it harder for patients to seek justice if harmed by their doctor. What's more, it will not change any Republican minds on the overall bill. With respect to the public option, Obama reportedly plans to endorse it, though pointedly, it appears nowhere in his excerpted remarks. What's more, David Axelrod said again today he would not draw lines in the sand and seek compromise on the provision:

He thinks that could be good for consumers, and he's going to make the case for that, but he's also going to make the point that this is not--this is an ends to a means. It's not the essence of this debate. It's a part of--it's one of the tools, and there are other ideas out there that-to-bring competition and choice that are--that are worthy as well," Axelrod said [...]

Questioned further by Wolf Blitzer, Axelrod said Obama will nod at both of most commonly suggested public option alternatives: the co-op model, and the triggered public option.

"He will acknowledge [co-ops]," Axelrod said. "There's the idea of putting trigger on the public option so it goes into effect at some date when it's clear that a market is uncompetitive. There are a number of ideas, but what is very important is that we have the kind of competition and choice that will help consumers in many states in this country."

This just seems to me like arguing from a position of weakness. You allow room for a compromise and your opponents will pounce. Olympia Snowe basically said today that the White House must give up on the public option, as she knows he'll be flexible and she can just wait him out.

A lot of people are talking about what they want to see in the speech. Jon Cohn argues that he wants some commitment to universal coverage, something that future governments would have to take away. That's good on the policy side. Drew Westen wants a simple message and draw clear lines between allies and enemies, letting the public know who is responsible for the broken system. Tim Noah doesn't want any more speeches, because with reform so close, the goal should really be pounding on moderates until they submit. Paul Krugman says that Obama should eschew details and go for the gut, laying out the personal horror stories and the urgent need for action now. Actually, I think based on the excerpts that he's going to do just that.

I think all of this is right for its own reasons, but more than anything, I actually want to see some spirit. The Republicans have clearly made a decision to destroy Obama's Presidency through endless fearmongering and fauxtrage. They started a bonfire over this Van Jones hiring and the White House let the hit squad walk all over them. This didn't appease the right but whet their appetites for more. The only way to fight such bullying, such blatant hatred, is through showing some toughness.

First of all you have to decide if you really want to win. If you just want to spend your time debating hypotheticals and dreaming of how swell things could be while weaving yourself a safety net of emergency qualifiers in case things don't go the way you planned, go get a job at the fucking Brookings Institution. But if you're gonna go to ideological war, then go to ideological war. And if you are going to fight this war you have to ask yourself "what would Dick Cheney do?"

Never apologize.
Never admit weakness.
Never concede points.
Never defend.
Always attack.

You have to remember that, in the case of the Glenn Beck conservative wing (a group of people who make the Dittoheads look like Quakers), you are dealing with a crazy salad of stupid people (and let's quit excusing them as "low information voters"...they're dumbshits), lunatics, assholes, racists, political performance artists, opportunists, and the kind of people who make eugenics seem desirable if not downright necessary.

These are not the people you need or want. You want the mushy middle and the mushy middle loves people who project strength and power. It makes them feel safe. They like being on the winning team. Power and winning intoxicates them. If they write for the Politico, it gives them boners and they'll write anything you want them to. But these people do not respond in the quite the same way to squishy papering over of defeat.

Many of those who have abandoned Obama of late are doing so because they have openly questioned his leadership and resolve. They don't know if he's willing to fight for them. They aren't so concerned with the details, but they want to know that they have a champion for their interests. So act like a winner. Show confidence and not even-handedness. Show the spark of life.

...good news: Marc Ambinder, sock-puppet for the White House press shop, reports that 100 House liberals will be the intended audience for the speech.

Bill Bradley's Model Congress

In 2000, angered by the rightward, DLC-led turn of the Democratic Party, I became interested in Bill Bradley's candidacy for the Presidency and voted for him in the California primary. Needless to say, he didn't win that year, and he retreated to the world of speeches and occasional op-eds as an eminence grise of politics. During that 2000 campaign he would say very adamantly that all Americans should have access to quality, affordable health care. It was a pillar of his campaign. Now a member of the punditocracy, he can imagine some grand compromise between the left and right on the issue.

Since the days of Harry Truman, Democrats have wanted universal health coverage, believing that if other industrialized countries can achieve it, surely the United States can. For Democrats, universal coverage speaks to America’s sense of decency and compassion. Democrats also believe that it will lead to a healthier and more productive country.

Since the days of Ronald Reagan, Republicans have wanted legal reform, believing that our economic competitiveness is being shackled by the billions we spend annually on tort costs; an estimated 10 cents of every health care dollar paid by individuals and companies goes for litigation and defensive medicine. For Republicans, tort reform and its health care analogue, malpractice reform, speak to the goal of stronger economic growth and lower costs.

The bipartisan trade-off in a viable health care bill is obvious: Combine universal coverage with malpractice tort reform in health care.

On what planet does Bill Bradley spend most of his time? Let's grant him for a second the possibility that Republicans want to reach a compromise at all on health care reform, something they have not at all shown in every single day of this debate. Mike Enzi, one of the "bipartisan" negotiators, is still referring to death panels and has been quoted as saying he's only participating in talks to stop a bill from getting passed. So you have to waive a lot to get to Bradley's notion of a model Congress.

But tort reform, which is one of those conservative buzz words which has been drained of most of its meaning, has been a state issue, at the behest of Republicans, for many years, and 38 states have enacted it in one form or another. It would be curious for Republicans to compromise on universal health care in exchange for something most states already have. What's more, given that we have this evidence from over 75% of the country, we can pretty quickly determine that medical malpractice suits are at best tangential and more accurately completely meaningless to the health care debate. Josh Richman, a very good journalist in the SF Bay Area, rounds up that evidence:

From Bloomberg News:

"(A)nnual jury awards and legal settlements involving doctors amounts to “a drop in the bucket” in a country that spends $2.3 trillion annually on health care, said Amitabh Chandra, a Harvard University economist. Chandra estimated the cost at $12 per person in the U.S., or about $3.6 billion, in a 2005 study. Insurer WellPoint Inc. said last month that liability wasn’t driving premiums."

The Congressional Budget Office in 2004 concluded that medical malpractice tort reform wouldn’t have a significant effect on health care costs:

"Malpractice costs amounted to an estimated $24 billion in 2002, but that figure represents less than 2 percent of overall health care spending. Thus, even a reduction of 25 percent to 30 percent in malpractice costs would lower health care costs by only about 0.4 percent to 0.5 percent, and the likely effect on health insurance premiums would be comparably small."

And Americans for Insurance Reform, a coalition of nearly 100 consumer and public interest groups around the country, issued a report in July which found:

• Medical malpractice premiums, inflation-adjusted, are nearly the lowest they have been in over 30 years.
• Medical malpractice claims, inflation-adjusted, are dropping significantly, down 45 percent since 2000.
• Medical malpractice premiums are less than one-half of one percent of the country’s overall health care costs; medical malpractice claims are a mere one-fifth of one percent of health care costs. In over 30 years, premiums and claims have never been greater than 1% of our nation’s health care costs.

Democrats like Bill Bradley validate conservative claims on things like tort reform despite all evidence to the contrary, then decide that honest men can strike a wonderful compromise despite having no negotiating partner on the other side.

Just in case you were wondering why Democrats lose national debates.