The Attempt to Terrorise Sandra Fluke - and All Women

If you've been following US news, you will be aware that yesterday President Obama placed a call to offer his support to Sandra Fluke, the Georgetown University law student who testified last week about access to birth control for women. We'll talk in a moment about the horrific things that were said about Sandra that appalled so many of us, including the President. But before we do I want to give Fluke's original testimony the prominence that it deserves. Please watch:


For those of you who can't watch videos, or who would rather scan text - the full transcript of what she had to say is below:

“My name is Sandra Fluke, and I’m a third-year student at Georgetown Law School. I’m also a past-president of Georgetown Law Students for Reproductive Justice or LSRJ. And I’d like to acknowledge my fellow LSRJ members and allies and all of the student activists with us and thank them so much for being here today.

 (Applause)

 “We, as Georgetown LSRJ, are here today because we’re so grateful that this regulation implements the non-partisan medical advice of the Institute of Medicine.

 “I attend a Jesuit law school that does not provide contraceptive coverage in its student health plan. And just as we students have faced financial, emotional, and medical burdens as a result, employees at religiously-affiliated hospitals and institutions and universities across the country have suffered similar burdens.

 “We are all grateful for the new regulation that will meet the critical health care needs of so many women.

 “Simultaneously, the recently announced adjustment addresses any potential conflict with the religious identity of Catholic or Jesuit institutions.

 “When I look around my campus, I see the faces of the women affected by this lack of contraceptive coverage.

 “And especially in the last week, I have heard more and more of their stories. On a daily basis, I hear yet from another woman from Georgetown or from another school or who works for a religiously-affiliated employer, and they tell me that they have suffered financially and emotionally and medically because of this lack of coverage.

 “And so, I’m here today to share their voices, and I want to thank you for allowing them – not me – to be heard.

 “Without insurance coverage, contraception, as you know, can cost a woman over $3,000 during law school. For a lot of students who, like me, are on public interest scholarships, that’s practically an entire summer’s salary. 40% of the female students at Georgetown Law reported to us that they struggle financially as a result of this policy.

“One told us about how embarrassed and just powerless she felt when she was standing at the pharmacy counter and learned for the first time that contraception was not covered on her insurance and she had to turn and walk away because she couldn’t afford that prescription. Women like her have no choice but to go without contraception.

 “Just last week, a married female student told me that she had to stop using contraception because she and her husband just couldn’t fit it into their budget anymore. Women employed in low-wage jobs without contraceptive coverage face the same choice.

 “And some might respond that contraception is accessible in lots of other ways. Unfortunately, that’s just not true.

 “Women’s health clinic provide a vital medical service, but as the Guttmacher Institute has definitely documented, these clinics are unable to meet the crushing demand for these services. Clinics are closing, and women are being forced to go without the medical care they need.

 “How can Congress consider the [Rep. Jeff] Fortenberry (R-Neb.), [Sen. Marco] Rubio (R-Fla.) and [Sen. Roy] Blunt (R-Mo.) legislation to allow even more employers and institutions to refuse contraception coverage and then respond that the non-profit clinics should step up to take care of the resulting medical crisis, particularly when so many legislators are attempting to de-fund those very same clinics?

 “These denial of contraceptive coverage impact real people.

 “In the worst cases, women who need these medications for other medical conditions suffer very dire consequences.

 “A friend of mine, for example, has polycystic ovarian syndrome, and she has to take prescription birth control to stop cysts from growing on her ovaries. Her prescription is technically covered by Georgetown’s insurance because it’s not intended to prevent pregnancy.

 “Unfortunately, under many religious institutions and insurance plans, it wouldn’t be. There would be no exception for other medical needs. And under Sen. Blunt’s amendment, Sen. Rubio’s bill or Rep. Fortenberry’s bill there’s no requirement that such an exception be made for these medical needs.

 “When this exception does exist, these exceptions don’t accomplish their well-intended goals because when you let university administrators or other employers rather than women and their doctors dictate whose medical needs are legitimate and whose are not, women’s health takes a back seat to a bureaucracy focused on policing her body.

 “In 65% of the cases at our school, our female students were interrogated by insurance representatives and university medical staff about why they needed prescription and whether they were lying about their symptoms.

 “For my friend and 20% of the women in her situation, she never got the insurance company to cover her prescription. Despite verifications of her illness from her doctor, her claim was denied repeatedly on the assumption that she really wanted birth control to prevent pregnancy. She’s gay. So clearly polycystic ovarian syndrome was a much more urgent concern than accidental pregnancy for her.

 “After months paying over $100 out-of-pocket, she just couldn’t afford her medication anymore, and she had to stop taking it.

 “I learned about all of this when I walked out of a test and got a message from her that in the middle of the night in her final exam period she’d been in the emergency room. She’d been there all night in just terrible, excruciating pain. She wrote to me, ‘It was so painful I woke up thinking I’ve been shot.’

 “Without her taking the birth control, a massive cyst the size of a tennis ball had grown on her ovary. She had to have surgery to remove her entire ovary as a result.

 “On the morning I was originally scheduled to give this testimony, she was sitting in a doctor’s office, trying to cope with the consequences of this medical catastrophe.

 “Since last year’s surgery, she’s been experiencing night sweats and weight gain and other symptoms of early menopause as a result of the removal of her ovary. She’s 32-years-old.

 “As she put it, ‘If my body indeed does enter early menopause, no fertility specialist in the world will be able to help me have my own children. I will have no choice at giving my mother her desperately desired grandbabies simply because the insurance policy that I paid for, totally unsubsidized by my school, wouldn’t cover my prescription for birth control when I needed it.’

 “Now, in addition to potentially facing the health complications that come with having menopause at such an early age – increased risk of cancer, heart disease, osteoporosis – she may never be able to conceive a child.

“Some may say that my friend’s tragic story is rare. It’s not. I wish it were

 “One woman told us doctors believe she has endometriosis, but that can’t be proven without surgery. So the insurance has not been willing to cover her medication – the contraception she needs to treat her endometriosis.

 “Recently, another woman told me that she also has polycystic ovarian syndrome and she’s struggling to pay for her medication and is terrified to not have access to it.

“Due to the barriers erected by Georgetown’s policy, she hasn’t been reimbursed for her medications since last August.

 “I sincerely pray that we don’t have to wait until she loses an ovary or is diagnosed with cancer before her needs and the needs of all of these women are taken seriously.

 “Because this is the message that not requiring coverage of contraception sends: A woman’s reproductive health care isn’t a necessity, isn’t a priority.

 “One woman told us that she knew birth control wasn’t covered on the insurance and she assumed that that’s how Georgetown’s insurance handle all of women’s reproductive and sexual health care. So when she was raped, she didn’t go to the doctor, even to be examined or tested for sexually transmitted infections, because she thought insurance wasn’t going to cover something like that – something that was related to a woman’s reproductive health.

 “As one other student put it: ‘This policy communicates to female students that our school doesn’t understand our needs.’

 “These are not feelings that male fellow student experience and they’re not burdens that male students must shoulder.

 “In the media lately, some conservative Catholic organizations have been asking what did we expect when we enroll in a Catholic school?

 “We can only answer that we expected women to be treated equally, to not have our school create untenable burdens that impede our academic success.

 “We expected that our schools would live up to the Jesuit creed of ‘cura personalis‘ – to care for the whole person – by meeting all of our medical needs.

 “We expected that when we told our universities of the problem this policy created for us as students, they would help us.

 “We expected that when 94% of students oppose the policy the university would respect our choices regarding insurance students pay for – completely unsubsidized by the university.

“We did not expect that women would be told in the national media that we should have gone to school elsewhere.

 "And even if that meant going to a less prestigious university, we refuse to pick between a quality education and our health. And we resent that in the 21st century, anyone think it’s acceptable to ask us to make this choice simply because we are women.

 “Many of the women whose stories I’ve shared today are Catholic women. So ours is not a war against the church. It is a struggle for the access to the health care we need.

 “The President of the Association of Jesuit Colleges has shared that Jesuit colleges and the universities appreciate the modifications to the rule announced recently. Religious concerns are addressed and women get the health care they need. And I sincerely hope that that is something we can all agree upon.

 “Thank you very much.”

 Ok.

Now, the sad duty before me is to report what has been said about Sandra by right wing extremist radio host Rush Limbaugh. The below is pretty explicit and offensive, so stop reading now if your stomach turns easily.

"A Georgetown co-ed told Rep. Nancy Pelosi's hearing that the women in her law school program are having so much sex that they're going broke, so you and I should pay for their birth control. Speaking at a hearing held by Pelosi to tout Pres. Obama's mandate that virtually every health insurance plan cover the full cost of contraception and abortion-inducing products, Georgetown law student Sandra Fluke said that it's too expensive to have sex in law school without mandated insurance coverage. Apparently, four out of every ten co-eds are having so much sex that it's hard to make ends meet if they have to pay for their own contraception, Fluke's research shows."

Can you imagine if you're her parents how proud of Sandra Fluke you would be? Your daughter goes up to a congressional hearing conducted by the Botox-filled Nancy Pelosi and testifies she's having so much sex she can't afford her own birth control pills and she agrees that Obama should provide them, or the Pope. "'Forty percent of the female students at Georgetown Law reported to us that they struggled financially as a result of this policy (Georgetown student insurance not covering contraception), Fluke reported. It costs a female student $3,000 to have protected sex over the course of her three-year stint in law school, according to her calculations.

"'Without insurance coverage, contraception, as you know, can cost a woman over $3,000 during law school,' Fluke told the hearing. $3,000 for birth control in three years? That's a thousand dollars a year of sex -- and, she wants us to pay for it." ...

What does it say about the college co-ed Sandra Fluke, who goes before a congressional committee and essentially says that she must be paid to have sex, what does that make her? It makes her a slut, right? It makes her a prostitute. She wants to be paid to have sex. She's having so much sex she can't afford the contraception. She wants you and me and the taxpayers to pay her to have sex. What does that make us? We're the pimps. (interruption) The johns? We would be the johns? No! We're not the johns. (interruption) Yeah, that's right. Pimp's not the right word. Okay, so she's not a slut. She's "round heeled." I take it back.

And despite the furore over his remarks, Limbaugh continued his attacks on Fluke in the following day's program:

This is about expanding the reach and power of government into your womb, if you're a woman. This is about the Democrat Party wanting more and more control over you. What was early feminism all about? Emancipation, individuality, freedom, liberation, all of these things. Now here comes Danica Patrick out and she says, "I'm perfectly comfortable letting the government make my health decisions for me." Well, folks, I'm gonna tell you: Right there, that's the death and the end of feminism.

When Danica Patrick can come out and say (paraphrased), "Oh, I'm perfectly fine with the government making these health care decisions for me," and that's feminism? I don't want to make these decisions! Nobody is denying Ms. Fluke her birth control pills. Ms. Fluke is approaching everybody and asking us to pay for them.

 Argh. Excuse me while I go wash my hands now. I feel dirty after quoting that.

OK. So, there are a number of things going on here, most of which are obvious, but just in case anyone is missing them, let me spell out clearly the many ways in which not only Rush, but the many other right wing commentators who have discussed this issue have gotten falt out wrong. (Leaving aside the gratuitous cruelty.)

1) This is not about sexual promiscuity. As Fluke's testimony makes clear, many women take birth control on the advice of their doctors for reasons other than contraception. And even for those who are using birth control primarily to prevent pregnancy (not that there's a damn thing wrong with that, by the way!) the overwhelming majority are married or in permanent exclusive relationships and are seeking to plan when of if they have their children.

2) Birth control costs are unrelated to sexual promiscuity. Rush seems to misunderstand this basic fact, but for the record: the cost of the pill is the same each month whether you're having sex multiple times a day, rarely, or not at all. In fact, because women't bodies take some time to adjust to the hormonal balance women are generally advised to stay on the pill consistently even if they go through a period in which they do not expect to be having sex

3) Sandra Fluke's sex life is not up for discussion here. You will notice that at no point in her testimony did she refer to her own sex life or relationship status. She spoke as a representative of other women and on behalf of an organisation, Georgetown Law Students for Reproductive Justice. We don't even know from this testimony whether Fluke herself uses birth control, is in a relationship, or is sexually active. She testified about a medical issue, siting the xperiences of other people who have been affected by it. And for her trouble she was called "slut" and "prostitute".

4) This testimony could have been given by a man. The great irony here is that when Fluke was originally denied the right to speak at the Republican-led hearing on this issue, the headlines at the time referred to the fact that this meant no women were testifying about this issue of women's health. I agree it's profoundly important to hear the voices of women about the issues that affect women. But in Fluke's case, almost nothing she said could not equally have been given as testimony by a man. But had the person testifying been male, no one could have called him slutty or suggested that his parents should be ashamed of him.

5) No-one is asking you or the government to pay for my birth control. Limbaugh's basic premise is that the free birth control provision amounts  to some sort of new welfare entitelement for women. But it's important to stress that President Obama's birth control mandate will not cost one additional dime of the taxpayers money or any additional contribution from health insurers. Offering complimentary birth control to all reduces the overal costs for insurers - thus they actually save money by providing this service. Just as other preventative health care measures (stop smoking programs, pap smears etc.) save insurers money. And they do so not only by reducing unwanted pregancies, but also by preventing medical ailments such as the one suffered by Fluke's friend. In fact, that story makes very clear how this circumstance works - free birth control pills could have prevented the formation of the cyst which eventually caused an expensive surgery followed by lifelong treatment.

So, Rush Limbaugh has literally got every single relevant fact in this situation dead wrong.

But there's something else going on here, that we need to all be aware of. Rush will pay the price for his out of order comments - already, 5 advertisers have announced that they are withdrawing their sponsorship from the show. Republican candidates have started to play the awkward Dance of Disassociation (Rick Santorum, weakly, says that what Rush said was "Ridiculous." But, ya know, he's an "entertainer" so he gets to say these things. Because gratuitous, content free personal insults are a LAUGH RIOT!) and the right wing effort in Congress to overturn the President's good work on contraceptive cover has failed.

So, no harm no foul, right? Wrong. Because, as with terrorist suicide bombings the success is not judged by the damage done to the perpetrator but by the terror imposed on the population.

Speaking up for access to birth control, or women't reproductive freedom in general, is often difficult. Like many women, I believe that my decisions about family planning and my health are private and personal, and I prefer not to discuss them publically. I have had problems in the past (in fact, I still have problems) with access to family planning services being severely constrained. And I feel a certain sense of guilt about this - that I ought to be speaking up more about this, confronting the local Catholic doctor who refuses to allow any of the 25+ doctors in his practice to prescribe birth control, complaining to the Local Council about the overcrowded, understaffed birth control clinic 2 miles away from me that is the only access women in my neighborhood have to family planning services. People are shocked by this. But BY GOD I don't want to be the public face of birth control advocacy. What happened to Sandra Fluke is exactly what in my worst nightmares I imagine might happen to me.

It takes bravery to speak up about this. Rush's attack was designed to quash that bravery in millions of women. He may well succeed. This is terrorism, pure and simple.

Not a Hypothetical Question

During the last GOP debate, there was a chilling moment when Wolf Blitzer asked candidate Rob Paul whether a hypothetical man without health insurance should be allowed to die. Someone from the audience shouted "yeah" and the audience applauded. Paul stumbled and was unable to answer.

But when we talk about whether people without health insurance should live or die, whether we should let them die, that's not a hypothetical question. It's very real, and very painful and actually applies to people here and now. People like Steve:



Our current law says that if someone shows up at an emergency room in need of urgent care, it is illegal to turn them away - whether they can pay or not. But what if they need chomotherapy for cancer? Or what if their diabetic? What if they're HIV positive - and there are expensive but effective drugs that could keep them alive.

The GOP answer is that the person should take personal responsibility for their health. But that's precisely what the Affordable Care Act calls for - it insists that if you can afford health care, you must purchase it so that your medical casts won't be an undue burden on your fellow taxpayers if (when) you need it. It says to insurance companies that they must offer insurance policies to everyone - whether they have a pre-existing condition or not. And it says to those who can't otherwise afford coverage, that the rest of us will chip in a little bit in the form of health subsidies to give you the insurance you need so that you can get preventative care and early treatment that you need to stop your health from deterioriating so that the cost to us, the taxpayers, of saving your life is as low as possible.

But in the end it says: No. You should not be allowed to die. It says, America is a country where easily preventable deaths should not take place because we simply turned our back on the suffering. It says we're all better off if we know that health care is not a luxury for the wealthy. It says that because every single one of us is at risk of losing our job, our savings and our health, we want to take some measure to protect ourselves from the consequences if that happens.

That's reasonable, it compassionate, it's economically sound. That's the Democratic policy. It's my policy.

What's yours? Ask yourself "Would you let him die?"

A "Serious Debate on Medicare"? Don't make me laugh...

Joe Nocera of the New York Times has written an interesting Op Ed about Paul Ryan, author what Nocera accurately describes as "radical vision for turning Medicare into, essentially, a do-it-yourself voucher program." Otherwise known as the budget bill recently passed by House Republicans.

Nocera is unimpressed by Ryan's plan. But he also says:

Yet I found myself disheartened as I read about the Democrats’ gleeful reaction to the victory in New York. They had a strategy now: bash the Republicans into submission over the Ryan plan. In the Senate, the Democratic leadership forced a vote over Ryan’s budget purely to force Republicans to cast a vote “against” Medicare. Clearly, the Democrats are going to make hay over the very idea that Republicans were trying to mess with Medicare, the most sacrosanct federal program of them all.

Nocera thinks that Democrats should treat the Ryan plan as a launching pad for a serious debate about how to reduce health care spending and secure the future of medicare.

It just seems so reasonable! And Democrats have been arguing for years that we'll need to bring down overall health spending as a matter of priority.

Now I'm all confused. If we agree about so much about the proposed end goal, despite our differences in approach, why exactly is it that we can't have a serious debate about medicare reform?

Oh, that's right. NOW I remember. Do you?

Do you remember when Obama talked about the importance of bending the cost curve on medicare expendiature? Remember how one of the ideas he included within the Affordable Care Act was that the government would pay for end of life counseling in which a patient would sit down with their doctor and tell their doctor how THEY wish to be cared for in the case of serious medical breakdown? Remember how this optional but compassionate option was designed so that those people who do want extraordinary measures to save their lives could make this wish clear, with the benefit of expert medical opinion, and those for whom the idea of living indefinitely as a vegetable, or dying in hospital away from their loved ones was abhorent could work with their physician to understand what level of care was right for them - would they want a focus on pain reduction and being comfortable? Who would they want to make decisions about their care if they were unable to do so themselves? Remember that this policy, a modest change to medicare's coverage options, was seen by geriatric specialists and end of life counselors as a way of eliminating UNWANTED medical spending and preventing people from being forced into heroic measures that they themselves would have seen as tortuous and undignified?

Do you remember? Would it jog your memory if I said:

DEATH PANELS!(TM)

Democrats put forward a reasonable compromise solution aimed at comprehensively reforming the existing health care system to both reduce costs and expend access to care. We pointed out that America spends more per capita on public health care alone than any other country in the world without even covering our entire population. We pointed out that medicare costs alone were skyrocketing beyond what the federal budget could sustain in the long term, and that if we made a serious effort to reform the system now, which might include modest additional tax revenue on a targetted basis, we could bend that cost curve and expand care. But that it would involve some people having to modestly trim the benefits they could expect and some others having to pay a bit more.

The Republicans acted as if we wanted to kill their grandmothers. Indeed, they outright SAID that we wanted to kill their grandmothers.

We can't have a serious debate about medicare because Republicans don't want one. They want a debate about how to reduce government spending. That's why they tried to privatise Social Security during the Bush administration. That's why Paul Ryan's plan isn't about improving the delivery of Medicare but scrapping it and replacing it with private vouchers. But when Democrats suggest that maybe there could be modest revisions to the way that Medicare operates to direct more of its expenditure towards care and less towards, for example, the profits of the private sector suppliers who have benefited from George W. Bush's medicare reform boondoggle, Democrats are demonised by Republicans for supposedly wanting cut to the program! Even though Republicans want to scrap the program entirely! Even thought Medicare itself is a Democratic policy, and one of the party's proudest achievements! It's enough to make your head explode. We're supposed to reach out to Republicans in the hope of creating a serious debate? We're supposed to use Ryan's utterly unserious proposals as the launch pad for such a discussion? It's not possible for Paul Ryan to start a debate about these issues when Democrats have been shouting into the wilderness for years.

But if you want a serious set of policies aimed at improving Medicare, Democrats have many such policies. One form of said serious policies, which, while imperfect, does in fact reduce the deficit and expand care is called the Affordable Care Act. Perhaps Paul Ryan may have heard of it?

Yes, Americans pay too much for healthcare.

And here's the source. 

Copious Republican Wrongness: I Try to Keep Track of it All

The Republican Party is so fundamentally wrong so often about so much stuff that is so important that's it's ironically easy to lose track of it all. And in recent days we've been bombarded with evidence of Republican wrongness at such a fast and furious clip that I realise I personally haven't been able to full absorb the depth and breadth of the wrong.
So let's make a quick list - based just on news stories from the past week:

1. Republicans - including John McCain back in 2008 - were wrong to insist that we should not pursue Osama Bin Laden into Pakistan if we had credible intelligence that he was there. Or rather, since one could argue that the policy might be right even if the outcome would be bad, let's say that whether this is right or wrong, Osama Bin Laden would still be threatening America today if the Republicans had won the last election.
2. Republicans - including, most notably, Dick Cheney - were wrong to suggest that Americans are less safe from terrorism under Obama than they were under Bush.
3. Republicans leaders were wrong to keep calling everything that Democrats proposed a "job killing" measure, when in fact the last three months has been the best 3 month period for job growth in 5 years. On the other hand, independent experts at Moody's have reproted that the GOP's proposed budget would result in the LOSS of over 700,000 American jobs. That's just wrong on so many levels.

4. Republicans - in particular Rep Paul Ryan - were wrong to suggest that they had a plan to cut the deficit. Ryan's so-called deficit reduction plan was based on heavy tax cuts for the wealthy plus heavy cuts to needed services for the poor (that's balanced! See! He's cutting taxes AND spending! Everything gets cut!). But even with these deep spending cuts, Ryan wasn't able to project any ability to balance the budget without his piece de resistance - a plan to eliminate Medicare and replace it with vouchers to allow the elderly to buy private health care. This proposal has been strikingly unpopular with the public, and has now been abandoned by Republican leaders - though not before House Republicans voted for it. Without the elimination of Medicare, Ryan's plan does not balance the budget.
5. Republicans in Congress were wrong to make posturing noises to suggest that they would be willing - nay! eager! - to let America default on its debt. For bizarre procedural reasons, every time US borrowing goes above a certain point, Congress must vote to allow this debt ceiling to rise. Republicans, however, had been ranting about their unwillingness to do this unless Democrats were willing to let old people die accept the phase out of Medicare. Fortunately, cooler heads have prevailed and Republicans are willing to settle for deep cuts to non-entitlement spending programs instead. Gee, thanks. The implications, if the debt ceiling were not raised, would be that the US would default on its borrowing, doing severe damage to our position within the markets, which experts believe could trigger another financial crisis. White House Economic Advisor Austen Goolsbee put it this way, "If we get to the point where we damage the full faith and credit of the United States, that would be the first default in history caused purely by insanity.”

So to sum up:

If Republicans were in charge this week, they would have left the world's most dangerous terrorist happy in his Pakistan mansion, lost 700,000 jobs instead of adding 250,000, eliminated Medicare, and cut taxes for the rich.

The one Republican achievement this week is their (apparent) willingness to reluctantly agree that they will NOT cause a financial calamity for no apparent reason.

Why does anyone vote for these guys?

Faces of Change...

Today Health Care Reform became the law of the land.

Still work to do. But a lot of good work now complete. Thanks to Nancy Pelosi, Harry Reid, President Obama and the millions of others who worked to make this day happen.

Thinking of Ted Kennedy and wishing he could have lived to see this.

David Axelrod says that Obama was more excited the moment health care reform passed than he was when he became President. I think that's as it should be - winning the election gave him the chance to do this. But he might still have failed. His Presidency might not have been successful

Now, he has something more important than a victory. He has a legacy.

This is what change looks like....

Last night, by a 219-212* vote, the House passed historic health care reform that will provide cover to more than 32 Million more Americans and make every single American more secure - noone can now be denied care because they are sick, or because they are too middle class for medicaid but denied coverage by their employer. We are all better off today than we were yesterday, including the people who right now oppose this effort.

I believe that, like Medicare and Social security, this reform will become a proud bedrock of American social protection, and will make us both healthier and more economically competitive.

This is what I and more than 52% of Americans voted for in November 2008.

* Unfortunate typo corrected....

"If it be now, 'tis not to come...

if it be not to come, it will be now;
if it be not now, yet it will come:
the readiness is all."

Hamlet, Act 5 Scene II

The House votes today on final passage of health care reform. MSNBC reports that Democrats DO have the votes to pass this bill. Passage would occur in two votes - one to pass the Senate bill as passed on Christmas Eve 2009, and the second on a package of amendments agreed with the Senate.

The United States is alone among developed nations in not offering its citizens comprehensive health care, with nearly 50 million Americans uninsured.

Although the bill before Congress does not provide universal health care, it should expand coverage to about 95 percent of Americans. It would require most Americans to carry insurance with subsidies for those who can't afford it, expand the government-run Medicaid program for the poor, and create new places to buy health care.

Even so, the reform is likely to be judged alongside the boldest acts of presidents and Congress in domestic affairs. While national health care has long been a goal of politicians and presidents stretching back decades, it has proved elusive

The readiness is all....

Yes. We (still) can.

Hello sports fans! So maybe you’ve been hearing that health care reform has gone the way of the dodo. That it’s pushing up daisies. It’s deceased, snuffed it. Has shuffled off this mortal coil. That THIS is an EX-bill!



Nonsense.

Folks like to get overexcited. Folks are excitable. But, a month on from the Dems unfortunate loss in Massachusetts, the President is uncreasingly ungently urging Congress to go just what I told you they should do.

(Yeah, Rahm’s on the phone to me all the time. “What do you think, Karin? What’s your legislative strategy, Karin? Oh help me, great guru.” It’s so annoying.)

The House is preparing to pass the Senate bill, unamended. After its passage, the Senate will pass a package of amendments to the bill that will reconcile it with the House legislation on key points.

After which, the President signs both bills into law, making for the most comprehensive reform of our health care system since, well... ever. Actually.

Every single health care bill that has ever been passed in the USA until now has failed to address the whole of the population or the whole of the industry. Don’t get me wrong, there’s been some good work done – from the creation of Medicare aimed at Seniors, to Medicaid for the poor, and SCHIP for children.

But frankly, as a childless working age adult I don’t see why I should be excluded from any improvement in the problems that affect me. (Awake, silent majority!)

Right now, if I lived in the USA I would currently be without health insurance. OR, I would be paying over $1,000 per month for basic cover as a self employed person. My mom, who is currently uninsured, was quoted $1,000 per person per month for catastrophic care only. Yeesh. Frankly, considering that I would like to keep some of my income and maybe even, heavens, buy myself frivolous luxuries – a washer dryer! A car! Imagine the luxury! – I’d rather not do this.

But fortunately, I don’t have this problem. For instead, I pay £38 per quarter as my self employed contribution towards the National Health Service, for which I get – well, whatever I need. I don’t get what I WANT, friendly and attractive staff, music pumped through the waiting rooms, unlimited on demand tests and optional services. But I guess if the NHS were willing to run up costs more than twice what they currently spend (i.e., something approximating what the US pays) they might be able to provide some of that stuff too. Meh.

I digress. Obama’s plan is utterly unlike the NHS. It’s a moderate, minimalist BEGINNING that probably won’t be enough to solve the whole problem.

What it WILL do is:

• Insure 30 million more Americans than are currently insured.

• Ban the insurance companies from denying care to the sick or at risk.

• Provide a choice of insurance plans to every American who needs it

• End“job lock” allowing people to make career decisions based on their ambitions rather than their fears.

Just, yah know. Pass. The. Damn. Bill.

I'm Baaack...

Hello loyal blog fans. I have not forgotten about you - just returning this week from an amazing 2 week vacation in the US. And Canada (Vancouver Olympics! Yay for maple leaves!).

Your regularly scheduled Obama administration and health care obsessing will resume shortly.

In the meantime, here's some tidbits for your reading pleasure:

• Is health care reform now a done deal?
• What is this "reconciliation" everyone keeps talking about?
• Why health care wouldn't stay the same without reform - but get much worse...
• Do you Vote from Abroad? Tell us about it...

Just Ridiculous

Every time I think about health care in America, I am more and furious at how diastrously wrong we have allowed it to go.

There's just no excuse for this.

Most importantly, I want everyone to understand that Americans ARE NOT HEALTHIER. If you pay twice what someone else pays for a product, you'd expect it to be better, right?

It's just crazy. And every single Republican in the US Senate has decided that this is a problem they do not want to solve. As much as the Ben Nelson's and Joe Liebermans of the world make me nuts, in the end they demonstrated some minimal sense of comapssion for the American people with their yes votes.

Republicans should hang their heads every day in shame for what they are allowing to happen. Yes, am angry.

Deep thought 2: Ben Nelson edition

A few thoughts on this:

• Ben Nelson should have just voted for it, no bribes required. (Booo hisss, bad Ben. Bad)
• Since he made it clear he WOULDN'T vote for it without a bribe, the question Americans should be asking is: "How much I willing to personally suffer in order to punish Ben Nelson?" Or in other words, "Is it OK if I'm screwed as long as I know Nebraskans are no better off?"

Thank you, that is all.

Making it Real Simple

So I had a chat today with my Dad. Dad's 1) a smart guy 2) reasonably informed and 3) favours health care reform.

So I was surprised to hear him say that he was glad that the current health care reform proposals haven't gone through. His perception was that there had been too much back room dealing, to many negotiations, to many compromises. Now bear in mind, Dad's a natural New England Republican in many ways - so it wasn't that he wanted something more radical, he's uncomfortable with government expenditure generally but recognises that health care is a problem that needs to be fixed. In many ways he's the EXACT constituency this bill was designed to appeal to.

So what's the problem? Essentially, he's been turned off by the process. No one has sold this bill to him, and a lot of folks have been talking it down. He's been hearing about the compromises with Ben Nelson, and months of wrangling and has come to the conclusion the whole thing hasn't been well considered or thought through.

So here's my message to my Dad and the millions and millions of Americans just like him: I hear you. The process sucked. It did.

But you are presented now with a simple choice. We pass this bill, which will cover more than 30 million Americans more are currently covered, will REDUCE the deficit, strongly regulate the insurance companies, and provide security to every man woman and child that they will always be able to get health insurance.

Or we do not pass it, and bankrupt Medicare within a generation, continue to pay more than twice as much for health care than any other nation on earth (without being any healthier), and still leave abotu 46 Million Americans without health insurance.

This is the bill we can pass, and it will make life in America better. Or, we can let it die and be worse off.

Everything else is... window dressing.

After Massachusetts: Where are we, and where do we go from here?‏‏

UPDATE: Center for American Progress President John Podesta has embraced my "Pass the Senate Bill and amend it through reconciliation" plan as outlined below. John's a pretty smart guy...


Dear friends,

Last week, our party suffered a massive setback by losing the Massachusetts Senate special election.

Although the Senate seat in question was universally described as "Ted Kennedy's" seat, the truth is that Teddy himself never took it for granted: he worked his tail off every year, and campaigned fiercely in every election, for the people of Massachusetts.

Whether the Republican Scott Brown will be the kind of Senator who lives up to Ted Kennedy's ideal of hard-working service remains to be seen. But he has not made a good start with his position that the moderate, bipartisan universal health care system currently operating in Massachusetts is good for citizens there, but would be bad for the rest of America. Scott Brown has vowed to reject comprehensive health care reform, leaving Democrats without the 60 votes that current Senate protocol expects for any legislation.*

So, has health care reform been defeated?

Nonsense.

We have passed comprehensive health reform through both houses of Congress. No one has ever gotten this far before - and it means we're inches away from the finish line. If we have the will to step over it.

The simplest route to passage of a comprehensive health care reform package would be for the US House of Representatives to pass without amendment the bill passed in the Senate. If House Democrats were willing to do this, we could literally have a bill on the President's desk tomorrow for signature.

Is the Senate bill everything I would hope for? No. But it is a giant step forward towards real reform. It instantly ends the most offensive and unfair practices of the insurance industry (rescission, denial for pre-existing conditions, and lifetime caps on coverage, for instance) while establishing in law for the first time the principle that every American must have insurance. It creates a national health care exchange that for the first time creates nationwide competition free from our broken system of state by state regulation. It offers tiered subsidies that fill the gap between the rich and the poor, levelling the playing field for the middle class. It?s a start. A very good start.

But House Democrats are rumoured to be saying that they won't support it.

By holding out for better, House Democrats would almost certain wind up with nothing at all. And that's not good enough. Not this time. We just can't afford another generation of delay before we get serious about solving the health care crisis.

What Can We Do?

I suggest** the following: each and every one of us should call our Congressional Representatives THIS WEEK. We should give them the following message:

• We expect them to deliver comprehensive health care reform. We?ll be very disappointed and upset if they surrender at this point.
• We understand that they may be nervous about their own personal prospects for re-election this year.
• But if they do deliver this key promise, they will have our unrelenting support. We will raise money. We will call voters. We will tell all of our friends and family how proud we are of what our congressperson has accomplished.
• In short, if you have our backs, we will have yours.

Please call your Representative today, and please e-mail me back to let me know what they say.

http://www.house.gov/

The American people need our leaders to have the courage of their own convictions. And each and every one of us needs to get busy making that happen. Break's over.

Thank you!

Karin J. Robinson

http://www.obamalondon.blogspot.com/

* Whether this supermajority standard is reasonable in the first place is the subject of another message for another day, but these are the rules under which the current bills were passed, and for the purposes of this exercise we need to assume that it will not change during the current health care debate.

** Please note, as always this e-mail is sent in a personal capacity and not on behalf of Democrats Abroad, the Obama administration or the Democratic Party as a whole. I am asking this of you as a citizen and passionate supporter of this Administration who wants it to succeed.

"You just can't go down much further than this."

There's a very useful article today in Time that explains better than I did why health care reform in bits and pieces just makes the problem worse rather than better:

That is because these kinds of well-intentioned smaller reforms create a vicious cycle:

• Healthy people, knowing they won't be discriminated against if they get sick, decide to go without coverage.
• Insurance companies, which are footing the medical bills for a lot of sick people without offseting premiums from healthy ones, raise their rates.
• Even more healthy people decide to drop their insurance.
• With an even sicker pool of people, proportionately, insurance companies raise their rates more ...

The lesson has been that, unless you have pretty much everyone covered, insurance reforms won't work. "What many people don't understand is there is a very high level of interdependence among the parts. The legislation that is in front of Congress now is incremental reform," says Princeton University public affairs professor Paul Starr. "You just can't go down much further than this."

That's true on so many levels.

Sibling Rivalry?

I've been having a very interesting Facebook discussion with my brother (say hi Tim), that I thought might be worth airing for my wider blogging public. (Both of you...)

Tim wrote:

My opinion is that the electorate is more sophisticated and independent than professional politicians give them credit for.

Lets be honest I have not even heard the Vice-Chair of Democrats abroad say that the voters made the wrong choice in MA.

I have heard much about how inconvenient the results are.

Here is a crazy idea... spend less time in defending the "Status Quo" and more time recruiting candidates that can lead and inspire the country. And damn it... why are the lawyers taking over politics and business there must be other options.

And I responded:

Tim, you haven't heard me defend Martha Coakley as a candidate because I can't. She ran a terrible campaign, she said things on the campaign trail that offended me and annoyed me. I think I understand why MA voters chose the way they did, and I don't blame them for it. iBut for the record, yes. I think the voters of Massachusetts made the wrong choice. I think they made a choice that is going to directly lead to a lot more people dying in America, cause the government's budget to explode (remember that health care reform is deficit REDUCING), and continue the unacceptable insecurity for American families. If you lose your job you should still be able to get health care. If you have a pre-existing condition, you should be able to get health care. You should be able to afford health care even if you don't have a lot of money.

The status quo in America is the opposite of that, and I hate it with a fiery passion that only groes every day. The status quo is that America is a country that pays more PUBLIC health insurance alone than most other countries, but doesn't cover more than 46 Million people, and has higher infant mortality and lower life expectancy than most countries in Europe. The status quo is that everyone lives with this as if it were somehow normal, whereas to me it's a national emergency or 9/11 scale happening a few times a year. I'm not defending the status quo, I was hoping and working, and trying very hard to change it. That may not be possible now, and I will never accept that as anything other than a terrible, terrible outcome.

Tim responds:

Amen Sister!

If the legislation under consideration was going to do all those things America would vote for it. I can guarantee it. If you can assure me that the compromise health care bill that was being jammed through the legislature was going to do those things I would fight for it.

The one concrete benefit of the bill is (was?), the elimination of selective underwriting. There is very little else I can point to as a concrete benefit. The cost benefit was not a strong case as the best anyone could hope for was to minimize the increasing costs of coverage. I am not sure even the strongest supporters of the bill want to hang their hat on those projections.

Apparently the citizens of MA do not believe that we must spend Trillions and create a huge government program to accomplish those goals.

If you want to get a proper Universal Health Care system in the United State then it should be a system that is good enough to get implemented without the level of compromise and strong handed tactics that we have seen in this process. "Super Majority or bust" is a tough way to illustrate the value of any legislation.

What is difficult to understand, or at least difficult to remember, is that those with coverage in the US are content with it. Coverage for those that have it (voters) is state of the art and it is paid by the employer (generally). That contented group is your starting point for any discussion of National Health Care. What Clinton missed and Obama has tried to circumvent is that Americans that vote... are OK with their health care coverage.

The people who do not like health coverage are business owners, the uninsured/uninsureable and to a large extent the health care system itself.

We must prove legislation can fix the major issues with health care before we trust a legislatively mandated paradigm shift. (1) Stop premium from growing at an unsustainable rate and (2) provide coverage to every American that wants to buy it. If you can show some positive results on those concerns, that would put a more comprehensive Health Care overhaul within reach. I can even offer pragmatic solutions to affect this change.

It took other countries years to get a system they are comfortable with. Why should it be any different here?

NO MORE ALL OR NOTHING HEALTH CARE PLANS!

Just thinking out loud.

And finally, here's me again:

Thanks Tim - really useful and interesting thoughts.

I think you and I are largely on the same page on all the key points. The bottom line lesson for me here is that the country's problems will ALWAYS be un-solvable if we need a 60 vote Senate majority to pass anything. It's time we all (not just Democrats) start getting serious about insisting that a majority is a majority - and if that means that in a few years time a small Republican majority can push through legislation that I don't like, then you know what? Fair enough. Democracy only works if voters can see whether the policies that their politicians advocate actually work or not. THe current situation where voters can express a clear preference for one set of policies and those policies can never be delivered just leads to stagnation and a total lack of accoutnability. In any other national parliament in the world, this process would already have resulted in a law. And frankly, a better law than the one we have.

Now, to the current health care bill. This bill (even the watered down Senate version) would have covered, by CBO estimates, over 30 million uninsured Americans. It would have put strict regulations on insurance companies that means no one can be denied insurance for a pre-existing condition (that the simple answer, by the way, to "what does this bill do for me" - the day after it passed you would instantly be protected against the common sceniaro of getting sick and then having to desperately hope that you don't lose your job or insurance lest you face bankrupcy), it would create a national health care exchange that would for the first time create real competition in the industry - right now there's 90% consolidation within each state. And finally, by adding an individual mandate and carefully offsetting that with tiered subsidies based on income, it established for teh first time the principle that every American must be covered. The Senate bill isn't perfect, but I was genuinely excited about it. It would have been a major and irreversible step forward. I still hope we might take that step. We've come so far, falling at this hurdle... well, it would be pathetic.

One further thought - to Tim's question about "no more all or nothing" health care plans...

The reality is that this plan WOULD be an incremental plan - it definitely wouldn't solve every aspect of the crisis in one go, it would just establish a framework for future tweaks and innovation. The New Yorker had a really good article recently about how health care in this sense may be like agriculture in that it will always need hands on management and constant adjustment to keep it working.
 
But, to begin solving this problem there is no way to avoid bold action, because the types of small improvments that would be superficially easy to make can cause the whole of the existing system to collapse. Most crucially, simply making it law that insurers can't deny people for pre-existing conditions - which would be the simple and fair thing to do - would massively increase costs for everyone because the incentive then would be to not buy health insurance at all until you get sick. The system only works if healthy people are paying into the system too so that it will be there for them when they get sick. That's why the individual mandate is important.
 
It's confusing and complicated and difficult. But it's vital, and I'm not prepared to give up. Ever.

Progressive should be working their TAILS off for Martha Coakley

In recent months, we've been hearing a lot of complaints from progressives who wanted a stronger health care reform (and stimulus package, and climate change legislation, and...) than President Obama has been able to deliver.

Since I'm one of the folks who would have liked more than we've got, I can sympathise with a lot of these feelings - although not with the blame pointing at Obama, who as far as I can tell has been moving heaven and earth to win progressive priorities.

But what I especially don't understand is this: those progressives who wanted a stronger bill ought to be going to the wall to prevent Martha Coakley from losing the Massachusetts Senate race. After all, if the Republican Scott Brown wins, he has promised to vote against reform in the final vote.

This would leave Democrats with two options -

1) Allow health care reform to fail. A disaster for pregressives, and for the country.
2) Pass the Senate's version of the bill unchange.

Option 2 is possible because the Senate has already voted on it, so an identical bill passing in the House would move it straight to the President for signature.

But the Senate bill is MUCH LESS PROGRESSIVE than the House bill. In recent weeks, House Democrats have been negotiating compromises to the Senate billl that would make it more acceptable to the House's more left-leaning caucus. The House compromises would add more regulation, greater access, a more progressive tax structure and stronger cost reductions. It would make it a better bill, in short. Marginally closer to what progressives have been looking for.

But without Coakley's vote, all of these improvements disappear (in a best case scenario) at least in this round of legislation, or health care reform may die out altogether - possibly for yet another generation (in the worst case scenario).

It couldn't be any more clear that the best thing progressives can be doing today to get the changes the are looking for is to obsessively help get out the vote for Martha Coakley.

Yet instead I'm hearing rumblings about "punishing" Barack for his supposed failures by withholding support. Can't my fellow progressives see that the real victim here would be themselves?

"We did it, Mr. President"

Reports are that a deal has been reached that both pro-choice and anti-abortion sides can live with. Plus a little extra cash just for Ben Nelson's Nebraska constituents.

There's an old saying that politics is like sausages in that if people could see how they are made no one would swallow it. Well, no one could say the process of passing this bill has been anything but ugly. Such is the life in our lunatic legislature.

But the passage of this bill will be a major achievement for America, for Senate Leader Harry Reid, Speaker of the House Nancy Pelosi, and for the President. A weary but fervent congratulations to them all for getting us here.

It's Now or Never

One further thought for the many people of good will out there who care about health care reform but wanted something better:

I'm not saying this bill is perfect. I do think it is good - very good even, and will leave many millions of people much better off than before. But sure, there are things in it that I would change if I were starting from a clean sheet of paper.

But we all have to understand the choice that we are making here. Our choice is not between this good but not perfect bill or another, better bill that we could pass in a year's time. It's between this or the status quo.

Remember that there isn't a single Republican in the Senate, and there is just one in the House, who is willing to vote for even this version of health care reform, let alone the stronger one that we progressives would like.

Now remember that there were nearly 40 DEMOCRATS in the house who voted against this current House bill, and there were 3 Democrats (plus Joe) who had a lot of issues voting for it. These people are not going to suddenly change their mind because progressives want something stronger. They don't LIKE PROGRESSIVES. They WANT to defeat progressives. In many cases, the best thing that they can do for their own electoral chances in their states is to be seen to anger us fighting lefties. And because health care reform doesn't exist yet, there's no constituency in their state this is benefiting from it and wants it protected. Social science proves that people are far more loathe to lose something they have than they are eager to get something better. When it comes to the conservatives in both parties who are blocking us here, we have no power over them.

Plus, we are likely to be a smaller caucus after the 2010 elections, especially if Democrats fail to achieve their single biggest domestic priority. Failing to achieve health care reform makes us look (and act!) like losers. Losers do not win the good will of voters.

But with the modified health care reform passed, a couple of things work in favor of improving and expanding it.

1. The world will not end. All the Republican scare mongering about death panels and socialism will start to look even more crazy as people look around and see none of this happening. Meanwhile:
2. A consituency is created for the Health Exchanges. People who are on it will want to protect and keep it. And the number who are on it will go up in time.
3. Insurance industry regulation will kick in right away and will make small but relieving changes to the deals people can get from their insurers.
4. All of this, plus the political bonus that comes from achieving what no other Democratic Congress or President has ever been able to accomplish before should helpt mitigate losses in the 2010 election.

Now, I know that Democracy for America is circulating a petition that shows only 33% of the public support the current bill. But I'm neither surprised by that nor worried about it. As Ezra says,

The final days of a bill are, almost by definition, the hardest. Critics have had time to mobilize. Industry has had time to lobby. Supporters have endured one painful compromise after another. Enthusiasm ebbs at the exact moment opposition peaks.


And as those who would like to see the bill fail organize, those who would like to see the bill succeed nitpick. Joe Lieberman refused to allow Medicare buy-in. Ben Nelson worries over the abortion language. Susan Collins wants to ensure access to catastrophic plans. Progressives are concerned that insurers will game the individual mandate. Name your interest group or constituency and they will name the provision, or set of provisions, that worries them. The goals of covering the uninsured and bending the cost curve remain popular, but the means are, well, more controversial.

A bill will pass. Millions will be better off. Those who oppose the bill from the left (a large number) will realise that their cause is better off now than it was before. Those who oppose it from the right will have to find a way to live with it. Either way, by the midterms people will be judging the law, not the bill - and those aspects of it that aren't working can be fixed incrementally rather than as a once and for all take it or leave it deal.

Should Progressives Oppose the Senate's Health Reform Bill?

Today I received an e-mail from Taylor Kunkle, former Chair of Democrats Abroad's Cambridge chapter and all around good guy. Taylor and I have been corresponding since early in the primary cycle, and he was a fervent and effective Obama supporter working on Barack's behalf from way back when.

So I was saddened by the despair that comes across in his message:

Greetings all,

I have come to a conclusion about the current health reform effort and I thought I would share it with you.

I now think that bill that is shaping up in the Senate should be killed. We have given up too much in order to please a hand-full of Senators and the bill as it stands will actually make the health care system in this country worse. There are two very simple reasons for this:

Insurance would be mandated and people would be forced to purchase the same crappy products offered by the insurance companies, with very little new protections against abuse and high premiums

The insurance companies would receive a windfall in taxpayer subsidies, further increasing their profits and sinking the country further into debt.

The only part of the legislation that made these two “reforms” at all palatable, was the addition of a government-run alternative to the private insurance market. With this feature now stripped from the bill, I cannot in good conscience support the bill. I have already written to the White House stating this (not that it will matter, but it made me feel better), and I am now actively working with and contributing to groups who will be fighting to kill this bill.

It is with a heavy heat that I have come to this decision, because I know it puts me at odds with a president I worked so hard to get elected. It is with an even heavier heart that I have to admit how disappointed I am in President Obama over this issue. I really feel that he did not lead the country well on this issue and I am now very pessimistic about the future, especially the 2010 elections.

I fear that if the President and the Congressional Democrats have managed to kill my spirit, then I hate to think of how many lukewarm supporters they have turned off.

I just read in the Daily Kos that a recent poll showed that over 80% of Republican plan to vote in the next election. That number is 55% for Democrats and only 39% for Democrats aged 18-29. Democrats are losing their base and this spells trouble for 2010.

I still hope that we can get good health care legislation passed, but I believe that we first need to make sure the legislation now before the Senate does not pass. Democrats should then look at bringing back the idea of Medicare for all and push such a bill through Congress under the budget reconciliation process (requiring only 50 votes with no filibuster).

I am sure you have your own opinions on this issue and you may not agree with me at all. That is fine. I encourage you to follow your convictions and stay involved in the process. We can only bring about change if we stay involved.

Thanks for listening.

Taylor Kunkle

As readers of this blog will know, I have remained a staunch advocate for this bill through all its various permutations, and I remain so now. But I am having a lot of conversations with people similar in spirit to Taylor's message, so I think it is time that I explain my reasoning in some more detail.

The Change I Voted For

As background, I should explain that when I decided to support then-Senator Barack Obama in the Democratic primary, health care reform was a very important part of the reason why I chose him over his main rival, then Senator Clinton. This is despite the fact that on the core policy area where the two of them seemed to differ - Obama's opposition to an individual mandate for helath insurance and Hillary's strong support of one - I actually preferred Senator Clinton's position on the merits.

Why? Because I read his statements on health care reform and what he seemed to be displaying throughout was an understanding that we must do whatever it takes to bend the curve of higher costs and decreased accessibility. I have a very vivid recollection of Bill and Hillary's health care fight in the early 90's, and I have always believed that the Clintons' total failure to brook compromise or negotiation in support of what they considered to be the optimal bill had horrific costs - depriving Democrats of their Congressional majority in the next election and, far more importantly, allowing many millions more Americans to become uninsured and many thousands to die for lack of coverage. What I was looking for was a President who would push very hard for the best possible deal, but would make sure AT ALL COSTS that a deal got done.

So far, Obama has lived up to my own hopes in this regard spectacularly.

We have to remember that the reason there has never been a comprehensive health care reform passed every before in the history of this country is not because Democrats are weak and ineffectual, but because there are very powerful forces in place to stop this from happening - forces of money, power, incumbency and influence certainly, but also the less sinister ones of inertia, fear of the unknown, ignorance, and people's contentness with their own care providers.

When Roosevelt passed the Social Security act, the original bill offensively excluded women and minorities. In fact, the NAACP of the time protested against the bill, describing it as, “a sieve with holes just big enough for the majority of Negroes to fall through.” Roosevelt felt he had no choice but to do this, to secure the votes of racists and reactionaries in his own party.

But once the bill had established the principle of fundamental protection for the elderly, expansion of the act to these excluded groups became possible, and in time those offensive provisions were removed. I don't think today that you could reasonably argue that the Social Security Act is harmful to minorities.

A similar story could be told about the introduction of Medicare by Johnson in 1965.

My point is that both of these programs, however imperfect they were at inception, however compromised they were from a progressive point of view, were a massive step forward for Americans, and have eben built upon and improved considerably since. At the same time, once Americans started to see the benefits of these changes, the programs became politically untouchable - no one can seriously propose to dimantle them now. A similar thing happens here in the UK, where no political party can raise the possibility of replacing the NHS for fear of political death. Once people have a benefit, they are extremely loathe to lose it.

That's why it's important to get the policy right, but it's even more important to get the policy OUT THERE.

So although I have always been willing to kick and scream and use every tool of persuasion available to me to get a better bill, the one outcome I was never willign to accept was not passing anything at all. Our system is so catastrophically broken across so many different levels (we pay twice as much, have lower life expectancy, and are spectacularly wasteful), that the most dangerous thing we could do is nothing at all. Leaving things as they are would decimate the federal budget, rapidly escalate the number of uninsured, and allow costs to rise to the point where decent care is difficult even for the affluent to afford.

Almost anything would be an improvement.

Does this Bill Make Things Worse?

But, this only holds true so long as what you are passing is an improvement, however marginal.

Taylor claims the opposite: that this bill would make the health care system in the US worse rather than better. This is an important argument, because if true that woulld be the best and only reason why progressives (and, frankly, everyone) should oppose it.

But I do not find either of the rationales that Taylor supplies here at all convincing.

To take them in turn:

1) That leaving in an individual mandate without stronger cost controls than are currently in the bill would leave consumers worse off.

Well, the first question here is whether in fact there are strong regulations in place on insurers. In fact, there are. If this bill were passed, the first aspects of it to take effect would be stringent new regulations on insurers to the advantage of consumers. These include:

• A ban on denying insurance for pre-existing conditions.
• A minimum standard of cover demanded from most plans that would preclude health related bankrupcy
• Strong penalties for insurers who practice "recission" - the diabilical practice of kicking out sick people who hold policies with the company
• "Community Rating", which helps to normalise costs across an area (this prevents insurers from charging unfairly high prices to high risk patients)
• Risk mitigation - there are a lot of boring financial reforms that prevent insurers from using the kind of risky reinsurance models that have caused so much damage to the financial markets.

There's a lot more as well. But no, consumers would not be purchasing the "same crappy products" that are being sold now. They would be purchasing slightly less crappy products.

To be specific when it comes to the amount of cover contained within a single insurance plan for an average family, "According to the CBO, the amount of coverage in the individual market would improve by between 27 and 30 percent under the Senate's bill."

But that's neither here nor there, as Tayler correctly points out, if we are then forcing people to buy insurance that is too expensive for them.

So, the simple question is - will people pay less for their insurance under this model than they would WITHOUT the bill. The simple answer to that appears to be "yes." They would pay MUCH less. (Chart is taken from this rather intemperately-titled, but highly informative Nate Silver post. Do read it!)

Now, of course the obvious thing that jumps out at you is how much of the cost savings to families comes from direct government subsidies.

So the obvious question is: does this level of subsidy threaten to increase the Federal budget deficit.

Well, every single analysis from the Congressional Budget Office (whose job it is to assess the federal budget implications of proposed legislation) has said the opposite - that on balance, the bills would REDUCE the federal deficit by a significant amount despite the increase in expenditure in some areas?

Why so? It's complicated, but basically because the current way that we pay for public sector health care is so (to co-opt Nate Silver's phrase) "batshit crazy".

But still, Taylor asks, why include the individual mandate at all? Wouldn't it be better to try and reduce costs and then encoruage people to buy in to the program, but not require it?

Well, actually no.

If eliminating the individual mandate were the cost of getting reform passed, I would reluctantly agree to it - but I would do so knowing that we were doing far more significant to the principle of cost containment than we did when we reluctantly allowed the limited version of the public option to be scrapped. Why so?

Because by requiring everyone to participate in the health insurance market, we add relatively healthier people into the system, which on the whole reduces the costs across the board. Under the current model, relatively healthy and realtively poor people can chose to not buy insurance and gamble that they won't get sick. If they do get sick, they can take emergency room visits or go into debt for critical care - and eventually declaring bankrupcy would not be unusual.

But if these individuals were driven to the market, complete with subsidies to make it more affordable, the cost savings could be shared out across all insured AND the negative economic repercussions from the small number of catastrophically ill or injured form this group would be mitigated. This principle of universality is important in understanding how to construct an effective market. We could do reform without it - just like Roosevelt had to do Social Security without covering women or minorities - but it would make the bill less universal and less cost containing. Not the improvement progressives (like me!) say they are looking for.

2) That the bill would be a profits bonanza for insurers and thus "sink the country further into debt".

It would not increase the national debt. It would decrease the national debt.  By about $130 billion.

From the CBO analysis in a letter to Harry Reid:

"CBO and JCT estimate that, on balance, the direct spending and revenue effects of enacting the Patient Protection and Affordable Care Act would yield a net reduction in federal deficits of $130 billion over the 2010-2019 period."

Would it increase insurance company profits?

Well that's a really good question! One of the things that was rumored to be in the compromise negotiated by the Democratic Caucus in exchange for dropping the public option was a provision to require that insurers must spend a minimum of 90% of their income on health care delivery. This would constrain profits without putting (effective) insurers out of business. I really liked the provision and hope it is still in there - haven't heard anything about it despite all the hullabaloo about the reversal on Medicare Buy-in.

But let's be clear - to the extent that insurance company profits are increased by bringing in lots of new customers, this is a feature, not a bug! After all, we are TRYING to increase the number of people who have health insurance!

Is it bad that they would make a profit? Well, arguably yes. Another idea from the proposed compromise that I really liked was to put in place OMB administered not for profit insurers - again, I don't know if that is still in there but I really hope it is because it was a good idea, replicating the success of the existing program for federal workers.

So I do agree that insurance company profits need to be constrained. A lot of the existing reforms are already aimed at doing that. But in the absence of a government run single payer system, if we want to expand access to health care, for profit insurers are going to play some role in doing that. And we DO want to expand health coverage! So they will make some profits. Maybe even more than before. But so long as this is happening because they are genuinely providing health cover to a lot more people, why shouldn't they?

And Finally, the Politics.

In subsequent paragraphs, Tayler says first:

I just read in the Daily Kos that a recent poll showed that over 80% of Republican plan to vote in the next election. That number is 55% for Democrats and only 39% for Democrats aged 18-29. Democrats are losing their base and this spells trouble for 2010.

And then:

I believe that we first need to make sure the legislation now before the Senate does not pass. Democrats should then look at bringing back the idea of Medicare for all and push such a bill through Congress under the budget reconciliation process (requiring only 50 votes with no filibuster).

 But he doesn't seem to see how the first one makes the second one impossible!

This is the biggest majority Democrats have had in our lifetime, or will have. And we still don't have the votes for a more progressive plan than this.

We will almost certainly lose seats in Congress in the next election. Historically, the party in power almost always does.

UNLESS, that party is see as spectacularly effective.

Failing to deliver our single biggest domestic policy priority does not equate to "spectacularly effective".

Taylor mentions the reconciliation option. I think this approach would be worth trying should all else fail - I'll try ANYTHING, honestly! - but reconciliation is a far more limited tool. First of all, any legislation passed is time limited. Secondly, there are strong limits to what you can and can't pass under this process, meaning the bill would have to be broken up and passed in increments.

Since Taylor's concerns seem to stem mainly from the absence of a public option within the insurance exchange, I'd like to propose the opposite approach.

Let's pass this bill through the full Senate process. THEN, let's pass a separate, smaller, easier bill that simply creates a public option within the exchnage. That would be completely achievable and would result in a better, more long lasting, harder to reverse health care reform than going for reconciliation on the full bill.

Plus, it would enable Democrats - rightly! - to tell Americans that they have begun to deliver on thier longstanding promise. And that Republicans fought them every step of the way.

Taylor, if you want to respond I'll gladly post your further thoughts. This is an important conversation, and I'm really glad we are having it.