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Senate Poised to Pass Health-Insurance Bill     Permalink

Sen. Ben Nelson (D-NE) got his way on an amendment banning the use of federal funds for insurance policies that cover abortion and has now said that he will vote for the bill. What Nelson wanted and got was that any woman wanting abortion coverage who also got a federal subsidy would have to write two checks: one for the base policy (subsidized) and one for the abortion coverage (not subsidized). This scheme might deter a few women from getting abortion coverage but it is hard to see how it will really reduce the number of abortions. Like so many senators, Nelson was just grandstanding so he can claim he is pro-life with no real consequences to anyone. He also got an agreement to have the entire additional cost of Medicaid in Nebraska covered by the federal government. Maybe that was his real goal and the abortion noise was just cover? Such are the ways of Congress. At this point, all 60 members of the Democratic caucus have said they will vote for cloture. That doesn't mean the bill will become law, but it is moving along.

Minority leader Mitch McConnell called the bill a "monstrosity." While the bill is 2000 pages long as currently formatted, in its final format it will be 400 pages but much of it is relatively minor and hardly a monstrosity. At its core, the federal government will pay $900 million in subsidies to private insurance companies to have them insure 30 million people who otherwise could not afford health insurance. There is no government run plan or even an expansion of Medicare for McConnell to get all steamed up about. In truth, the Republicans were faced with a choice early on: work with the Democrats and get a bill they liked or stonewall and try to hand Obama and the Democrats a massive defeat. They chose the latter and it now looks like they will get nothing. The former option was readily available in the form of the Wyden-Bennett bill which would have allowed heath-insurance companies to operate nationally with the expectation that increased private-sector competition would drive down prices. In other words, rather than fight for reform based on a private-sector solution, which Democrats would have grudgingly accepted, the Republicans put all their eggs in the "No!" basket and probably will lose their gamble.

One item in the bill that both the left and right are beginning to notice is the individual mandate. No country in the world with universal health insurance allows people to go uninsured and then sign up when they get sick. That goes against the very idea of insurance--you pay an annual premium when you don't need it so you can receive a big payout in the unlikely case that you do need it. The problem with the mandate is that for the first time ever, everyone in the U.S. would be required to pay thousands of dollars a year to a private company or face a fine. Even car insurance doesn't have this kind of mandate since you are not legally required to own a car. The bill could have gotten around an individual mandate by providing an opt-out clause. Anyone opting out would not have to buy insurance but the quid pro quo would be that if such a person ever showed up at a hospital emergency room the second question (after "Are you insured?") would be "Visa or MasterCard?" In other words, opting out would mean you don't get emergency medical care unless you can pay, even if that means you die. But that might be too much for many people to stomach, so it is not in the bill and the mandate is.

The Republicans are forcing the bill and all the amendments to be read aloud on the floor of the Senate. They are also insisting on delays between various steps of the legislative process that are normally waived, so it is now expected the final vote on the amendment bill will come on Christmas eve. In past years, senators generally spent Christmas eve doing things other than fighting with each other on the floor of the Senate, but this year is going to be different. If the Democrats had been willing to play hardball, they could have speeded up the process. For example, by recording the reading of the bill in advance and then playing it at a 5x speedup on the Senate floor. It would have sounded like Donald Duck and some Republican would have surely objected, but then the presiding officer, Joe Biden, could have ruled in favor of Mr. Duck and been sustained by a simple majority, thus de facto eliminating the "reading aloud" rule. While it takes a 2/3 majority to change the Senate rules, it takes only a simple majority to settle a dispute on the meaning of a rule.

Even if the bill passes the Senate, there are more hurdles to be overcome. The main one is the Senate-House conference. The two bills differ in a myriad of ways, such as how the $900 billion is financed, the exact wording on the abortion restrictions, when various provisions kick in, etc. There will have to be compromises on both sides and compromises that would normally be seen as part of the usual legislative sausage making will be seen this time as "abandoning long-standing moral principles." A typical issue is exactly how poor do you have to be to be eligible for Medicaid? In normal times, the conferees would just split the difference between the House and Senate numbers, but in this hypercharged atmosphere, everything will be contentious.

When the final bill emerges from conference, it goes to a straight up-or-down vote in each chamber. In the Senate, it can be filibustered, so a cloture vote is needed again and if the bill shifts appreciably leftward, some of the conservative Democrats who grudgingly said they would vote for cloture on the Senate bill may balk at the final bill. It is also possible, but unlikely, that the final bill gets 60 votes for cloture but fewer than 50 votes for the bill itself. Voting for cloture but against the bill would give people like Sen. Blanche Lincoln (D-AR) some cover in 2010, but it is doubtful that 11 Democrats will defect on the final bill.

Passage of the final bill by the House could also be iffy. The sausage presented to the House on a take-it-or-leave-it basis will be far to the right of the House bill and some progressives may choke on it. On the other hand, some Blue Dogs who voted against the original bill may happily eat the sausage. The original bill passed 220-215, so there is not much margin for error. On the other hand, Speaker Nancy Pelosi, despite her gender and dainty appearance, can throw her weight around a lot better than former Speaker Dennis Hastert (a former wrestler) or Harry Reid (a former boxer).

When all is said and done, we may have a bill, but it really doesn't reform what everyone agrees is a broken system. What it does is have the government buy poor and semipoor people insurance within the framework of the current system. The fee-for-service paradigm, which encourages doctors to do unnecessary procedures thus driving costs (and their income) up, is still fully intact. The malpractice situation, which drives doctors to practice defensive medicine by ordering all kinds of useless tests to cover their tushes in the event of a subsequent lawsuit remains the same. The fundamental lack of competition between insurance companies, most of whom have something close to a regional monopoly does not change. In short, while 30 million people will get health insurance as a result of this bill, the factors driving health-care costs ever upward will not be broken.

Politically, a health-insurance bill is likely to be a winner for the Democrats in 2010, which is why they are fighting so hard to get a bill--any bill. With the exception of the individual mandate for the small number of people who truly believe they are invincible and will always be so, most people will not experience much of a downside to the bill and will not be inclined to switch from voting Democratic to voting Republican on account of the bill. Many of the 30 million people who now get insurance will be grateful for it and little of this gratitude is likely to be showered on Mitch McConnell. But as many people have noted, by Nov. 2010, the state of the economy may still loom as the biggest issue in people's minds and the election will be won or lost based on unemployment numbers.

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