Two Steps Forward, No Steps Back

It's not the size that matters

Today President Barack Obama will unveil health care proposal Part VII. The new House bill, according to Speaker Nancy Pelosi, will be "much smaller" than previous efforts. After surveying the brutal political conditions facing them, Democrats, it seems, believe that if they lay claim to more modest legislation, they lay claim to a less horrid bill. If only that were true.

Though a political victory is a must for the Obama presidency, those who are invested ideologically in the promise of government-run health care understand that even a small victory today can be an enduring one. Once Washington gains a toehold -- and considering government controls 49 cents on every health care dollar spent, by "toehold" I mean "bearhug" -- it is an inescapable reality that whatever it comes up with will be expansive and expensive.

That's the message Pelosi was telegraphing to her allies when -- in addition to pointing out how itty-bitty the bill will be -- she added that it will be "big enough" to put the country on a "path" toward sustainable health care reform. The righteous "path," naturally, ends at the gates of a single-payer system. The infrastructure to reach this objective -- price controls, new entitlements and wide-ranging mandates -- will be set in place once Democrats use reconciliation to pass the bill, deal with the short-term electoral consequences and let history work itself out.

You know how it goes: Did you hear about the appalling conditions those children are living under? Gotta expand it. How about the old lady who has 12 prescriptions when she only needs eight? Gotta control costs.

A minor victory for liberalism today also would be a colossal triumph tomorrow because it's improbable -- implausible, actually -- that Republicans ever would have the fortitude (or the votes in Congress) to repeal most of Obamacare should they regain power.

Remember that state participation in Medicaid is voluntary. What governor would pull out of that or any entitlement program? Remember that Congress estimated Medicare's cost at $12 billion for 1990 (adjusted for inflation) when the program kicked off, in 1965. Medicare cost $107 billion in 1990 and quickly is approaching $500 billion. Who's going to stop it? The template is used over and over again. Government is a growth industry.

When you unwrap today's health care reform legislation, nearly every Democratic initiative, small or large, is designed to affect the choices people make through some mechanism of top-down control. On the flip side, so far, reform legislation has been devoid of any meaningful market-based solutions that would spur a healthier private-insurance sector, guaranteeing consumers will see rates rise and Democrats will have a boogeyman to point to as they "fix" the bill down the road.

I remember asking liberal Rep. Diana DeGette of Colorado -- after she, for the umpteenth time, claimed that Republicans had presented no ideas in the health care debate -- what she thought of the GOP bills in the House at the time. She replied that they were too small and not "comprehensive" enough to really matter.

Now, apparently, small is OK. Why? It never has been an issue of how comprehensive a plan is, but how invasive it could be. And no matter how many iterations of health care "reform" are foisted on the nation by Democrats -- or what the exact dimensions of those iterations may be or how many public relations angles are deployed to sell them -- the core issue has not changed. Though, it is clear, the tactic of incremental "progress" has been relearned. Don't be fooled. The endgame has not changed.

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Obama considers GOP health bill input

President Obama said Tuesday that he is considering adding four Republican ideas to his health overhaul plan, a bipartisan overture that Republicans said still does not get at the root of their objections with the bill. The move comes a day ahead of Mr. Obama's expected announcement on how to move the plan through Congress, which many lawmakers expect will include the use of reconciliation - a complicated procedural tool to circumvent a Republican filibuster in the Senate.

In a letter to congressional leaders, Mr. Obama said he's interested in several Republican suggestions, including: allowing private "health savings accounts" into the insurance exchanges; addressing disparities among the states in Medicaid reimbursements to doctors; authorizing another $50 million in medical malpractice grants to the states; and using undercover investigators to ferret out waste in the Medicare and Medicaid programs. "I said throughout this process that I'd continue to draw on the best ideas from both parties, and I'm open to these proposals in that spirit," he wrote.

Mr. Obama's letter merely said he is exploring the policy ideas, which Republicans outlined in the White House's bipartisan health care summit last week. But minority lawmakers said Tuesday that added provisions wouldn't change the bill's underlying new taxes and cuts to Medicare funding.

"Unless you're going to attack the cost of health care, which those bills obviously don't - they increase the cost of health care and they spend more money when we should be spending less - you haven't solved the underlying problem," said Sen. Tom Coburn, the Oklahoma Republican who proposed the medical malpractice grants and the anti-fraud measures.

The other proposals came from GOP Sens. Charles E. Grassley of Iowa, Richard M. Burr of North Carolina and John Barrasso of Wyoming.

Mr. Obama also said he would remove from the final health overhaul plan extra Medicare Advantage funding for Florida and extra Medicaid funding for Nebraska - two provisions targeted by Republicans, including his 2008 presidential rival, Sen. John McCain of Arizona, as "sweetheart" deals designed to buy the support of wavering lawmakers.

Instead, Mr. Obama said his proposal would gradually reduce Medicare Advantage payments across the country and provide more federal funding to the states to help them with their Medicaid bills, which would grow under the Democrats' plan.

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Yes they can (and will)

On last night’s podcast, I argued that Democrats in Congress will indeed pass something called “health care reform” even if the bill doesn’t accomplish almost anything they claimed it would. For close to a century, government-controlled health care has been the holy grail of the statist set, and they aren’t about to pass up the best (and perhaps last) opportunity they have to see that goal through. Andy McCarthy admonished Republicans to keep this in mind when counting unhatched Senate and House seats from this Fall’s elections:

Today’s Democrats are controlled by the radical Left, and it is more important to them to execute the permanent transformation of American society than it is to win the upcoming election cycles. They have already factored in losing in November — even losing big. For them, winning big now outweighs that. I think they’re right.

I hear Republicans getting giddy over the fact that “reconciliation,” if it comes to that, is a huge political loser. That’s the wrong way to look at it. The Democratic leadership has already internalized the inevitablility of taking its political lumps. That makes reconciliation truly scary. Since the Dems know they will have to ram this monstrosity through, they figure it might as well be as monstrous as they can get wavering Democrats to go along with. Clipping the leadership’s statist ambitions in order to peel off a few Republicans is not going to work.

I’m glad Republicans have held firm, but let’s not be under any illusions about what that means. In the Democrat leadership, we are not dealing with conventional politicians for whom the goal of being reelected is paramount and will rein in their radicalism. They want socialized medicine and all it entails about government control even more than they want to win elections. After all, if the party of government transforms the relationship between the citizen and the state, its power over our lives will be vast even in those cycles when it is not in the majority. This is about power, and there is more to power than winning elections, especially if you’ve calculated that your opposition does not have the gumption to dismantle your ballooning welfare state.

Bruce thinks McCarthy is being overly generous with respect to the courageousness of congress members, and that in the end the House will not have enough votes to pass the Senate bill, and thus start the reconciliation process (which Keith Hennessey describes quite well). Enmity between the two houses of congress, in particular the House’s distrust of the Senate to pass a new bill “fixing” the first bill, may make passage of the first bill impossible. Making the task of passing a reconciliation bill even more herculean are some procedural quirks that potentially allow an infinite series of amendments to be offered during the vote-a-rama process in the Senate, and the great likelihood that much of the bill will violate the Byrd Rule, which negates provisions that do not deal with the budget (for a great explanation of both, once again, visit Mr. Hennessey). To top it all off, if the reconciliation bill increases the long-term budget (more than ten years out), then the whole thing automatically gets scrapped (again, see Hennessey). That’s quite a lot to overcome.

However, I think the Democrats, and especially President Obama, are bound and determined to pass something regardless of the high hurdles to be faced in the process or the eventual political costs. This is Obama’s legacy, after all, and the only thing he’s really spent any time on during his presidency. If there is any way that Congress can pass something resembling a health care bill, they will do it. The Senate has already done it’s job on this score, and voting weaknesses in the House virtually ensure that Nancy Pelosi can wrangle assurances from Harry Reid that the Senate will pass the reconciliation bill. The final version may be swiss cheese, and the Byrd Rule is likely to knock out several provisions that are necessary to get votes (think “Stupak amendment”), but in the end I believe that the Democrats can cobble something together that will garner majority votes in both houses and be sent to the president for his signature. This issue is simply too important to the left to let go.

Something else to keep in mind, with respect to vote counting, is that any Democrat congress member who has decided to “retire” ahead of this Fall’s elections will have no repercussions from voting for either the Senate bill or the reconciliation bill. The seats of these lame-duck congressmen are viewed by Republicans a potential pick-up’s for the next congress, when they should be worried about how the lame ducks will be voting.

In the end, I think that Reid and Pelosi deliver something in the way of a public option with tax hikes and that Obama will declare victory when he signs the bill into law. There’s certainly no virtue in this process, but then, there’s really no virtue left in Washington, so that should come as no surprise.

UPDATE: “The Biden Situation”

According to Norman Ornstein, of AEI, and Robert Dove, former Senate parliamentarian, the unlimited amendment tactic during vote-a-rama may not be all it’s cracked up to be [HT: AllahPundit]:

Should passing health care reform come down to the use of reconciliation — and all signs point that way — Vice President Joseph Biden could play a hugely influential role in determining not only what’s in the bill but whether or not it passes.

Two experts in the arcane rules of the Senate said on Monday that, as president of the Senate, Biden has the capacity not just to overrule any ruling that the parliamentarian may make but also to cut off efforts by Republicans to offer unlimited amendments.

“Ultimately it’s the Vice President of the United States [who has the power over the reconciliation process],” Robert Dove, who served as Senate parliamentarian on and off from 1981-2001, told MSNBC this morning. “It is the decision of the Vice President whether or not to play a role here… And I have seen Vice Presidents play that role in other very important situations… The parliamentarian can only advise. It is the vice president who rules.” [...]

“The vice president can rule that amendments are dilatory,” Norm Ornstein, a fellow at the American Enterprise Institute and one of the foremost experts on congressional process, told the Huffington Post. “That they are not serious attempts to amend the bill but are designed without substance to obstruct. He can rule them out of order and he can do that on bloc.”

“There are time limits,” Ornstein added. “It is not that they can keep doing it over and over again.”

How ironic that the same man who famously mangled the VP’s constitutional role in the Senate might possibly wield that very power to foist ObamaCare on us. Well, I guess it’s no more ironic than the “Kennedy seat” busting a filibuster-proof majority that was depended upon to deliver Kennedy’s life-long dream of government-run health care.

Just the same, I wouldn’t count on ObamaCare being dead and gone just yet.

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ObamaCare's Partisan peril

A recurring theme struck by defenders of ObamaCare has been that it is similar to previous measures expanding the welfare state. On ABC's "This Week," in an interview with guest hostess Elizabeth Vargas, Speaker Nancy Pelosi had this to say:

Vargas: What do you say to your members, when it does come to the House to vote on this, who are in real fear of losing their seats in November if they support you now?

Pelosi: Well first of all our members--every one of them--wants health care. I think everybody wants affordable health care for all Americans. They know that this will take courage. It took courage to pass Social Security. It took courage to pass Medicare. And many of the same forces that were at work decades ago are at work again against this bill.

Later, interviewing Sen. Lamar Alexander, Vargas made the same comparison, and the Tennessee Republican hinted at why it is flawed:

Vargas: You also said in your remarks at the summit that Republicans have come to the conclusion that Congress, quote, "doesn't do comprehensive well," that our country is too big and too complicated for Washington. But Congress has passed many historic and sweeping and comprehensive bills in the past: Medicare, the civil rights bill, the Americans with Disabilities Act. Are you saying that this Congress is uniquely incapable of doing something sweeping and massive and dramatic?

Alexander: Well, the answer's yes, in that sense.

Vargas: That's not good.

Alexander: But no--but let me go back. You mentioned the civil rights bill. I was a very young aide here when President Johnson, who had more Democratic votes in Congress than President Obama had, had the civil rights bill written in Everett Dirksen's office. He was the Republican leader.

He did that not just to pass it. He did it to make sure that, when it was passed, it would be accepted by the people and there wouldn't be a campaign as there will be in health care to repeal it from the day it's passed.

All of the laws Pelosi and Vargas cited--the Social Security Act of 1935, the Civil Rights Act of 1964, the Social Security Act of 1965 (which created Medicare) and the Americans With Disabilities Act of 1990--were passed when Democrats held majorities in Congress. But all had substantial Republican support (including, in the case of the ADA, from a GOP president).

By contrast, at this juncture not a single Republican in Congress supports ObamaCare. Why should they, given that the public overwhelmingly opposes it? That's why ObamaCare now cannot be enacted without a combination of partisan bullying and procedural flimflam.

This leads us to doubt the common assumption that ObamaCare would be irreversible if passed. Not that we want to put it to a test, mind you: Repeal would require an enormous effort, and would almost certainly be impossible before 2013 (with 42 Senate seats held by Democrats not up for re-election this year, a veto-proof GOP Senate majority is not even a mathematical possibility in the next Congress).

But there is no precedent for a massive, unpopular expansion of the welfare state that has support only within one party. It's possible that Americans would grudgingly come to accept it anyway. It's also possible that they would hate it even more once it had been imposed upon them. It may turn out that Obama and Pelosi not only are trifling with their party's short-term prospects, but are putting at risk its long-term viability, and perhaps even the political stability of the country.

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Budget deficits cause third of British hospitals to cut number of operations performed

One in three hospital trusts is having to make cuts in the number of operations it performs because they are in the red, according to new research. Casualty departments are also facing the axe because primary care trusts are over budget and running a deficit – despite a record Department of Health budget of around £100 billion this year.

A new study by the think tank Civitas of figures provided at the public board meetings of 100 trusts has found that health service overspend is set to hit £130 million. And last night the health think tank the King’s Fund warned that one in three hospital beds in London could face the axe as spending cuts bite.

The Department of Health has warned trusts they cannot enter the new financial year and hospitals that don’t get their budgets back in balance will have to hand back money from next year’s budget or find themselves subjected to central control. The study found that GPs in Hertfordshire were told to get ‘approval’ before recommending hysterectomies, tooth extraction and the removal of 'skin lumps and bumps'. In a memo to doctors, hospital managers warned: ‘It is usually better to wait to see if symptoms resolve themselves.’

The primary care trust in Enfield, North London, was the worst affected in the survey. There hospital bosses are £17.5m in the red despite a budget of £450m. Trust chiefs have decided to axe an accident and emergency department at Chase Farm hospital in Enfield and replace it with an urgent care centre that is only open for half the day and will not take blue light ambulance cases.

The findings are particularly stark since they suggest that hospitals cannot live within their means even during a time of record growth in spending—making cuts all the more likely when the taps are turned off by the next government. The last public spending review in 2007 decided that health spending will rise from just over £90 billion in 2007/08 to £110 billion in 2010/11. That is a real terms increase of 4 per cent year on year.

The Tories have pledged to give the NHS continuing real terms rises and Labour have promised to protect ‘frontline’ health services. But whoever wins the election the rate of growth in health spending is expected to be cut dramatically after a decade that has seen the NHS budget treble in real terms.

Analysts say that simply leaving the NHS to make do with rises that keep up with inflation will lead to an NHS shortfall of £20bn by 2013, rising to £38bn by 2016. James Gubb, head of health policy at Civitas, said: ‘If financial control cannot be exercised in times of plenty, it does not bode well for times of famine. ‘With billions to effectively be cut from the NHS we are looking at huge productivity improvements to maintain today's standards. Prudent organisations would be looking to set money aside to invest for such times.’

John Appleby, chief economist of the King's Fund, warned of drastic cutbacks: ‘In London there is a plan to close a third of hospital beds that is being floated by the NHS. It's not out in the open yet and already it's attracted huge opposition,’ he told the Guardian.

Health trusts say the deficits are the result of increased demand as a result of swine flu, the coldest winter for decades and record numbers of emergency admissions. [No mention of the ever-expanding bureaucracy?]

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Musician dies after fall at troubled British hospital

A talented musician died after falling from a trolley where he had allegedly been left untreated for hours in the accident and emergency unit of the shamed Stafford hospital, it was claimed yesterday. Andy Stubbs, 41, who had a three-year-old son, died last August after being admitted to the hospital with a head injury following a fall at his home. According to his family Mr Stubbs, who was bleeding profusely from a head wound, suffered two further falls while in hospital but was not given a brain scan until the following morning, by which point it was too late to save him. He died as a result of a cardiac arrest after suffering bleeding on the brain.

Last week Stafford hospital was the subject of a damning independent report which catalogued a litany of patient neglect and abuse over a four year period. The Francis Inquiry unearthed evidence of elderly patients not being washed for several weeks, being deprived of food and water and left to lie in soiled sheets for hours at a time. The report also heard evidence from patients who had been misdiagnosed and others who were ignored for hours after being admitted to A&E.

Mr Stubbs's death came six months after the shocking details of the hospital's failings were first uncovered and during a period when they were supposed to have begun to put their house in order. An inquest into his death, held yesterday at Cannock Coroner's Court, ruled that he had died as a the result of an accident.

But his father Bernard Stubbs, speaking from his holiday home in Portugal said: "How can it be accidental death when they have allowed him to fall in hospital. He went into A&E at 4pm and was still there four hours later. "I left him and when I came back I was told he had fallen twice. He did not receive a scan until the following morning when they said to me, 'It's too late, there is nothing we can do'." He added: "If he had received a scan when he first arrived, he may well be still be with us today."

Mr Stubbs from Stone in Staffordshire, had just received a writing credit on the latest Robbie Williams album and was a well respected pop composer and musician. A family friend said he had been undergoing some personal difficulties after splitting from his girlfriend and had battled alcoholism. But the friend added: "The coroner said Andy was intoxicated when he was admitted to A&E. He had been having some problems and was upset about the break-up of his relationship but that is not an excuse for him not being treated properly in hospital. "He was a loving kind gentle man who adored his son Ruben. Now a little boy is going to grow up without his father and yet again with the Stafford hospital no one is being held to account. His death has left a huge hole in a lot of people's lives."

A spokesman for the Mid Staffordshire NHS Trust said: "I would like to offer our sincere condolences to Mr Stubbs’ family for their sad loss. "Mr Stubbs’ death was reported as a Serious Untoward Incident in accordance with the Trust’s policy and a full investigation into his care and treatment was carried out. "The recommendations from the investigation have been implemented and actions will continue to be monitored. Patient safety is our priority and it is extremely important that we learn from incidents to improve care for other patients."

Earlier this month a jury inquest returned a verdict of accidental death on 58-year-old Christopher Wooley who died after falling from a trolley in the A&E department of Stafford hospital.

Julie Bailey, founder of the Cure the NHS campaign group said: "This is the second incident of a patient dying after a fall in the A&E department of Stafford hospital, you would hope they might have learned the lessons after one tragedy. It is a depressingly familiar story of vulnerable patients being left alone when they ought to be being looked after and treated. "We need a public inquiry in order to find out the truth of what has been happening."

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