Starting Points: Congress

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Dec 27, 2009

After health care, we need Senate reform

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By Ezra Klein
Sunday, December 27, 2009; B01

On Dec. 8, 1964, Mike Manatos wrote a letter that explains what's wrong with the Senate in 2009. This wasn't, of course, the subject of his letter. Manatos was no futurist; he was Lyndon Johnson's liaison to the Senate, and he was writing to update his bosses on Medicare's chances in the aftermath of the 1964 election. Surveying the incoming crop of senators, Manatos counted a solid majority in favor of the president's effort. "If all our supporters are present and voting we would win by a vote of 55 to 45," he predicted.

That letter would never be written now. In today's Senate, 55 votes isn't enough to "win," or anything close to it; it's enough to get you five votes away from the 60 votes you need to shut down a filibuster. Only then, in most cases, can a law be passed. The modern Senate is a radically different institution than the Senate of the 1960s, and the dysfunction exhibited in its debate over health care -- the absence of bipartisanship, the use of the filibuster to obstruct progress rather than protect debate, the ability of any given senator to hold the bill hostage to his or her demands -- has convinced many, both inside and outside the chamber, that it needs to be fixed.

This might seem an odd moment to argue that the Senate is fundamentally broken and repairs should top our list of priorities. After all, the Senate passed a $900 billion health-care bill Thursday morning. But consider the context: Arlen Specter's defection from the Republican Party earlier this year gave Democrats 60 votes in the Senate -- a larger majority than either party has had since the '70s. Democrats also controlled the House and the presidency, and were working in the aftermath of a financial crisis that occurred on a Republican president's watch. This was a test of whether a party could govern when everything was stacked in its favor.

The answer seems to be, well, not really. The Democrats ended up focusing on health-care reform's low-hanging fruit: the bill the Senate ultimately passed does much more to increase coverage than it does to address the considerably harder problem of cost control, it strengthens the existing private insurance system and it does not include a public insurance option. And Democrats still could not find a single Republican vote, which meant they had to give Nebraska a coupon entitling it to a free Medicaid expansion and hand Joe Lieberman a voucher that's good for anything he wants. If the Senate cannot govern effectively even when history conspires to free its hand, then it cannot govern.

To understand why the modern legislative process is so bad, why every Senator seems able to demand a king's ransom in return for his or her vote and no bill ever seems to be truly bipartisan, you need to understand one basic fact: The government can function if the minority party has either the incentive to make the majority fail or the power to make the majority fail. It cannot function if it has both.

In decades past, the parties did not feel they had both. Cooperation was the Senate's custom, if not its rule. But in the 1990s, Newt Gingrich, then the minority whip of the House, and Bob Dole, then the minority leader of the Senate, realized they did have both. A strategy of relentless obstruction brought then-president Bill Clinton to his knees, as the minority party discovered it had the tools to make the majority party fail.

Unfortunately, both parties have followed Gingrich's playbook ever since. According to UCLA political scientist Barbara Sinclair, about 8 percent of major bills faced a filibuster in the 1960s. This decade, that jumped to 70 percent. The problem with the minority party continually making the majority party fail, of course, is that it means neither party can ever successfully govern the country.

Jeff Merkley, a freshman Democratic Senator from Oregon and former speaker of Oregon's House of Representatives, spoke to this issue in an interview last week. "When you use the word filibuster," he said, "most of us in America envision it as the ability to speak at length and even delay progress by taking hours. I count myself among those Americans." He sighed. "But it's not a filibuster anymore. It's a supermajority requirement. And when that becomes commonly used, it's a recipe for paralysis."

Tom Harkin, the veteran Iowa Democrat who chairs the Senate's influential Health, Education, Labor and Pensions Committee, was even more dismayed by recent events. His efforts to curb the filibuster began in the 1990s, when he was in the minority. "People say I only worry about this because I'm in the majority," he said Tuesday. "But I come at this with clean hands!" Back then, his partner in the effort to reform the filibuster was Lieberman. "The filibuster," Lieberman said at the time, "has become not only an obstacle to accomplishment here, but also a symbol of a lot that ails Washington today." Lieberman has since stopped worrying and learned to love obstructionism. But Harkin hasn't.

This isn't just a Democratic concern, though Democrats, being in the majority, are the ones raising it now. In 2005, Senate majority leader Bill Frist nearly shut the chamber down over the Democratic habit of filibustering George W. Bush's judicial nominees. "This filibuster is nothing less than a formula for tyranny by the minority," he said at the time.

Potential solutions abound. Harkin would eliminate the filibuster while still protecting the minority's right to debate. Under his proposal, bills would initially require 60 votes to pass. Three days later, that threshold would fall to 57. Three days after that, 54. And three days after that, 51. Merkley has some other ideas. One is to attract Republicans to the project by phasing the filibuster out six or eight years in the future, when we can't predict which party will initially benefit.

There is real promise in Merkley's approach. The danger of reforming the Senate is that, like health-care reform before it, it comes to seem a partisan issue. It isn't. Members of both parties often take the fact that neither Democrats nor Republicans can govern effectively to mean they benefit from the filibuster half the time. In reality, the country loses the benefits of a working legislature all the time.

But members of both parties have become attached to this idea that they can block objectionable legislation even when they're relatively powerless. This is evidence, perhaps, that both parties are so used to the victories of obstruction that they have forgotten their purpose is to amass victories through governance. Either way, a world in which the majority can pass its agenda is a better one, a place where the majority party is held accountable for its ideas and not for the gridlock and inaction furnished by the Senate's rules.

Law professor Lawrence Lessig often compares the dysfunctions of the Congress to the woes of an alcoholic. An alcoholic, he says, might be facing cirrhosis of the liver, the loss of his family and terrible debt. Amidst all that, the fact that he drinks before bed at night might not seem his worst problem. But it is the first problem, the one that must be solved before he can solve any of the others. America, too, is facing more dramatic problems than the Senate rules: A coming budget crisis, catastrophic climate change and an archaic and inefficient tax system, to name a few. But none will be solved until we fix the dysfunctions of the Senate.

Ezra Klein reports on domestic and economic policy for The Washington Post and blogs at washingtonpost.com/ezraklein. The full interviews with Sen. Jeff Merkley, Sen. Tom Harkin and political scientist Barbara Sinclair can be found there. Klein will be online to chat with readers on Monday at 12 p.m. Submit your questions and comments before or during the discussion.

Dec 22, 2009

Nurses Say Senate Bill Entrenches Chokehold of Insurance Giants

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by John Nichols

Want to know what's wrong -- really wrong -- with the health-care "reform" bill being pushed through the Senate by Majority Leader Harry Reid?

Ask a nurse.

"It is tragic to see the promise from Washington this year for genuine, comprehensive reform ground down to a seriously flawed bill that could actually exacerbate the health-care crisis and financial insecurity for American families, and that cedes far too much additional power to the tyranny of a callous insurance industry," says National Nurses Union co-president Karen Higgins, RN.

"Sadly," adds Higgins, "we have ended up with legislation that fails to meet the test of true health-care reform, guaranteeing high quality, cost effective care for all Americans, and instead are further locking into place a system that entrenches the choke-hold of the profit-making insurance giants on our health. If this bill passes, the industry will become more powerful and could be beyond the reach of reform for generations."

The 150,000-member NNU, the largest union and professional organization of registered nurses in the U.S., condemned Reid's bill -- which is expected to gain Senate approval this week -- as a deeply flawed measure that grants too much power to the nation's largest private and for-profit insurers.

Specifically, the union that takes in the powerful California Nurses Association, cited 10 fundamental flaws in the Senate bill:

1. The individual mandate forcing all those without coverage to buy private insurance, with insufficient cost controls on skyrocketing premiums and other insurance costs.
2. No challenge to insurance company monopolies, especially in the top 94 metropolitan areas where one or two companies dominate, severely limiting choice and competition.

3. An affordability mirage. Congressional Budget Office estimates say a family of four with a household income of $54,000 would be expected to pay 17 percent of their income, $9,000, on healthcare exposing too many families to grave financial risk.

4. The excise tax on comprehensive insurance plans which will encourage employers to reduce benefits, shift more costs to employees, promote proliferation of high-deductible plans, and lead to more self-rationing of care and medical bankruptcies, especially as more plans are subject to the tax every year due to the lack of adequate price controls. A Towers-Perrin survey in September found 30 percent of employers said they would reduce employment if their health costs go up, 86 percent said they'd pass the higher costs to their employees.

5. Major loopholes in the insurance reforms that promise bans on exclusion for pre-existing conditions, and no cancellations for sickness. The loopholes include:

· Provisions permitting insurers and companies to more than double charges to employees who fail "wellness" programs because they have diabetes, high blood pressure, high cholesterol readings, or other medical conditions.

· Insurers are permitted to sell policies "across state lines", exempting patient protections passed in other states. Insurers will thus set up in the least regulated states in a race to the bottom threatening public protections won by consumers in various states.

· Insurers can charge four times more based on age plus more for certain conditions, and continue to use marketing techniques to cherry-pick healthier, less costly enrollees.

· Insurers may continue to rescind policies for "fraud or intentional misrepresentation" – the main pretext insurance companies now use to cancel coverage.

6. Minimal oversight on insurance denials of care; a report by the California Nurses Association/NNOC in September found that six of California's largest insurers have rejected more than one-fifth of all claims since 2002.

7. Inadequate limits on drug prices, especially after Senate rejection of an amendment, to protect a White House deal with pharmaceutical giants, allowing pharmacies and wholesalers to import lower-cost drugs.

8. New burdens for our public safety net. With a shortage of primary care physicians and a continuing fiscal crisis at the state and local level, public hospitals and clinics will be a dumping ground for those the private system doesn't want.

9. Reduced reproductive rights for women.

10. No single standard of care. Our multi-tiered system remains with access to care still determined by ability to pay. Nothing changes in basic structure of the system; healthcare remains a privilege, not a right.

In fairness to Reid and his fellow Senate Democrats, most of the flaws in their bill are also present in the House bill. And that's the really depressing part.

While members of the Obama administration and key senators claim that the legislation should be enacted because it seeks to expand coverage, places new regulations on insurers and might be improved in the House-Senate conference committee, NNU co-president Deborah Burger, RN, offers a more realistic diagnosis:

"Those wishful statements ignore the reality that much of the expanded coverage is based on forced purchase of private insurance without effective controls on industry pricing practices or real competition and gaping loopholes in the insurance reforms."

Dec 21, 2009

Passing health reform could be a nightmare for Obama

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By Robert Samuelson
Monday, December 21, 2009; A19

Barack Obama's quest for historic health-care legislation has turned into a parody of leadership. We usually associate presidential leadership with the pursuit of goals that, though initially unpopular, serve America's long-term interests. Obama has reversed this. He's championing increasingly unpopular legislation that threatens the country's long-term interests. "This isn't about me," he likes to say, "I have great health insurance." But of course, it is about him: about the legacy he covets as the president who achieved "universal" health insurance. He'll be disappointed.

Even if Congress passes legislation -- a good bet -- the finished product will fall far short of Obama's extravagant promises. It will not cover everyone. It will not control costs. It will worsen the budget outlook. It will lead to higher taxes. It will disrupt how, or whether, companies provide insurance for their workers. As the real-life (as opposed to rhetorical) consequences unfold, they will rebut Obama's claim that he has "solved" the health-care problem. His reputation will suffer.

It already has. Despite Obama's eloquence and command of the airwaves, public suspicions are rising. In April, 57 percent of Americans approved of his "handling of health care" and 29 percent disapproved, reports the Post-ABC News poll; in the latest survey, 44 percent approved and 53 percent disapproved. About half worried that their care would deteriorate and that health costs would rise.

These fears are well-grounded. The various health-care proposals represent atrocious legislation. To be sure, they would provide insurance to 30 million or more Americans by 2019. People would enjoy more security. But even these gains must be qualified. Some of the newly insured will get healthier, but how many and by how much is unclear. The uninsured now receive 50 to 70 percent as much care as the insured. The administration argues that today's system has massive waste. If so, greater participation in the waste by the newly insured may not make them much better off.

The remaining uninsured may also exceed estimates. Under the Senate bill, they would total 24 million in 2019, reckons Richard Foster, chief actuary of the Centers for Medicare & Medicaid Services. But a wild card is immigration. From 1999 to 2008, about 60 percent of the increase in the uninsured occurred among Hispanics. That was related to immigrants and their children (many American-born). Most illegal immigrants aren't covered by Obama's proposal. If we don't curb immigration of the poor and unskilled -- people who can't afford insurance -- Obama's program will be less effective and more expensive than estimated. Hardly anyone mentions immigrants' impact, because it seems insensitive.

Meanwhile, the health-care proposals would impose substantial costs. Remember: The country already faces huge increases in federal spending and taxes or deficits because an aging population will receive more Social Security and Medicare. Projections the Congressional Budget Office made in 2007 suggested that federal spending might rise almost 50 percent by 2030 as a share of the economy (gross domestic product). Since that estimate, the recession and massive deficits have further bloated the national debt.

Obama's plan might add almost an additional $1 trillion in spending over a decade -- and more later. Even if this is fully covered, as Obama contends, by higher taxes and cuts in Medicare reimbursements, this revenue could have been used to cut the existing deficits. But the odds are that the new spending isn't fully covered, because Congress might reverse some Medicare reductions before they take effect. Projected savings seem "unrealistic," says Foster. Similarly, the legislation creates a voluntary long-term care insurance program that's supposedly paid by private premiums. Foster suspects it's "unsustainable," suggesting a need for big federal subsidies.

Obama's overhaul would also change how private firms insure workers. Perhaps 18 million workers could lose coverage and 16 million gain it, as companies adapt to new regulations and subsidies, estimates the Lewin Group, a consulting firm. Private insurers argue that premiums in the individual and small-group markets, where many workers would end up, might rise an extra 25 to 50 percent over a decade. The administration and the CBO disagree. The dispute underlines the bills' immense uncertainties. As for cost control, even generous estimates have health spending growing faster than the economy. Changing that is the first imperative of sensible policy.

So Obama's plan amounts to this: partial coverage of the uninsured; modest improvements (possibly) in their health; sizable budgetary costs worsening a bleak outlook; significant, unpredictable changes in insurance markets; weak spending control. This is a bad bargain. Health benefits are overstated, long-term economic costs understated. The country would be the worse for this legislation's passage. What it's become is an exercise in political symbolism: Obama's self-indulgent crusade to seize the liberal holy grail of "universal coverage." What it's not is leadership.

Dec 2, 2009

Afghan Plan Faces Sharp Questioning From Senators

By ELISABETH BUMILLER and BRIAN KNOWLTON

WASHINGTON — Defense secretary Robert M. Gates, Secretary of State Hillary Rodham Clinton and the nation’s top military officer laid out a muscular defense of President Obama’s decision to send 30,000 additional troops to Afghanistan on Captiol Hill on Wednesday, but members of Congress of both parties objected to major parts of the new strategy.

At a crowded hearing of the Senate Armed Services Committee, Senator John McCain, the Arizona Republican who last year ran against Mr. Obama for president, sharply questioned Mr. Obama’s plan to begin withdrawing the additional American forces by July 2011.

Senator McCain said it was “logically incoherent” to say that the withdrawal would begin that summer, “no matter what,” but also say, as the administration does, that the exit date would also depend on conditions on the ground.

The answer, after a sometimes tense back-and-forth with Mr. Gates and Adm. Mike Mullen, the chairman of the Joint Chiefs of Staff, was that the administration would review the situation in Afghanistan in December 2010 and then “evaluate,” as Mr. Gates put it, whether it would be possible for Mr. Obama to begin withdrawals in the summer of 2011.

“Then it makes no sense for him to announce the date,” Mr. McCain retorted. In short, he said, “that gives the wrong impression to our friends, it’s the wrong impression to give our enemies.”

Later in the session, Senator Jack Reed, Democrat of Rhode Island, said, “It strikes me as that the Taliban has been emboldened quite aggressively the last several years without any type of deadline.”

Senator Carl Levin, the Michigan Democrat who is chairman of the committee, questioned whether sending so many additional troops might keep the Afghans from building up their security forces on their own.

“Where I have questions is whether the rapid deployment of a large number of U.S. combat forces, without an adequate number of Afghan security forces for our troops to partner with, serves that mission,” Mr. Levin said.

Mr. Levin is recognized by members of both parties for his expertise in military matters. So is Mr. Reed, a West Point graduate who served 12 years in the Army, and another panel member, Senator Lindsey O. Graham, Republican of South Carolina.

Two committee members, Mr. McCain and Senator Jim Webb, Democrat of Virginia, fought in the Vietnam war. And another member, Senator Daniel K. Akaka, Democrat of Hawaii, is one of the few World War II veterans still in the Senate.

In his opening statement, Mr. Gates, who pushed for the 30,000 additional troops and was singled out by the White House as influential in Mr. Obama’s decision, sharply differed with some of Mr. Obama’s advisers who have argued that the United States should focus on rooting out Al Qaeda from Pakistan, and that the Taliban in Afghanistan do not present a serious long-term threat to the national security of the United States.

On the contrary, Mr. Gates said, Al Qaeda and the Taliban are inextricably linked.

“While al Qaeda is under great pressure now and dependent on the Taliban and other extremist groups, for sustainment, the success of the Taliban would vastly strengthen al Qaeda’s message, to the Muslim world, that violent extremists are on the winning side of history,” Mr. Gates said.

“Put simply, the Taliban and al Qaeda have become symbiotic, each benefiting from the success and mythology of the other. Al Qaeda leaders have stated this explicitly and repeatedly.”

Senator Joseph I. Lieberman, the Connecticut independent who heads the Senate’s homeland security committee, said he was convinced that “there is no substitute for victory over the Islamist extremists and terrorists in Afghanistan. A war of necessity must not just be fought; it must, of necessity, be won.”

Mr. Gates sought to dispel any notion that the United States is being dragged into a conflict without end, and that Washington is motivated by naïve idealism.

“This approach is not open-ended ‘nation building,’ ” he said. “It is neither necessary nor feasible to create a modern, centralized, Western-style Afghan nation-state — the likes of which has never been seen in that country. Nor does it entail pacifying every village and conducting textbook counterinsurgency from one end of Afghanistan to the other.

“It is, instead, a narrower focus tied more tightly to our core goal of disrupting, dismantling and eventually defeating Al Qaeda by building the capacity of the Afghans — capacity that will be measured by observable progress on clear objectives, and not simply by the passage of time.”

Mrs. Clinton said America’s military efforts in the region will be complemented by realistic and practical moves to improve the lives of Afghan civilians.

“It’s a cliche to say we have our best people in these jobs, but it happens to be true,” she said. “We will be delivering high-impact assistance and bolstering Afghanistan’s agricultural sector, the traditional core of the Afghan economy. This will create jobs, reduce the funding that the Taliban receives from poppy cultivation, and draw insurgents off of the battlefield.”

In response to a question from Mr. Webb, Admiral Mullen said his visits to Afghanistan as well as discussions with American military leaders had convinced him that the Afghan people as a whole are “very tired” of war, and not particularly loyal to the Taliban.

Mr. Levin said he was troubled by the numbers being floated. In the vitally important Helmand Province, in southern Afghanistan, he said, the current ratio of American to Afghan troops is 5 to 1. “Doubling the number of U.S. troops in the south will only worsen a ratio under which our forces are already matched up with fewer Afghan troops than they can and should partner with,” he said.

In general, the other senators set off few political fireworks, and the event had little of the drama that marked other Capitol Hill hearings on the war in Iraq. At one point Senator Evan Bayh, Democrat of Indiana, offered his congratulations to Mrs. Clinton on the recent engagement of her daughter, Chelsea.

There was more emotion later in the day when the three appeared before the House Foreign Affairs Committee, where Representative Dana Rohrabacher, a California Republican who opposes the war, asked: "What is different about what the president said? Even today, I don’t hear anything that different. Maybe it’s a different facade.”

In the Senate hearing, Mr. Gates offered a dire picture of Afghanistan, should the United States not succeed.

“Failure in Afghanistan would mean a Taliban takeover of much, if not most, of the country and likely a renewed civil war,” He told the committee. “Taliban-ruled areas could in short order become, once again, a sanctuary for Al Qaeda as well as a staging area for resurgent militant groups on the offensive in Pakistan.”

When pressed by Senator Susan Collins, Republican of Maine, why the United States had to invest so much military power and money in Afghanistan when Al Qaeda still had the ability to establish safe havens in other countries, Mr. Gates replied that Afghanistan was unique.

Not only was it the place where the 2001 attacks against the United States were launched, he said, it “is still the wellspring of inspiration for extremist jihadism everywhere.”

He said that the “guidance and strategic leadership” for Al Qaeda comes from the group’s leaders who are in the border area with Pakistan, and that there is an “unholy alliance” that has developed in the past year between Al Qaeda, the Taliban in Pakistan and the Taliban in Afghanistan.

“And these people work off of each other’s mythology, off of each other’s narrative, and the success of one contributes to the success of the other,” Mr. Gates said.

He added, “If anything, the situation, I think, is more serious today than it was a year ago because of the attacks of the Taliban in Pakistan on Pakistan, and the effort of al Qaeda in collusion with the Taliban in Pakistan to try and destabilize Pakistan itself.”

President Obama, speaking on Tuesday before cadets and senior military officers at the United States Military Academy at West Point, announced that he would dispatch 30,000 additional troops to Afghanistan in the coming months, but he vowed to start bringing American forces home from Afghanistan in the middle of 2011, saying the United States could not afford and should not have to shoulder an open-ended commitment.

Promising that he could “bring this war to a successful conclusion,” Mr. Obama set out a strategy that would seek to reverse Taliban gains in large parts of Afghanistan, better protect the Afghan people, increase the pressure on Afghanistan to build its own military capacity and a more effective government and step up attacks on Al Qaeda in Pakistan.

Administration officials said that they were hoping to get a commitment for an additional 5,000 to 8,000 troops from NATO allies — perhaps as early as Friday at a foreign ministers’ meeting in Brussels — which would bring the number of additional troops in Afghanistan to close to the 40,000 that Gen. Stanley A. McChrystal, the American and NATO commander in Afghanistan, was seeking.

Sheryl Gay Stolberg reported from West Point, and Helene Cooper and Brian Knowlton from Washington. Reporting was contributed by Peter Baker, David E. Sanger, Mark Mazzetti, Carl Hulse and Mark Landler from Washington, and Carlotta Gall from Kabul, Afghanistan.

Nov 20, 2009

Obama faces congressional anger about economy - washingtonpost.com

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ECONOMIC WOES TAKING A TOLL
House Republicans call on Geithner to resign

By Brady Dennis, Zachary A. Goldfarb and Neil Irwin
Washington Post Staff Writer
Friday, November 20, 2009

Growing discontent over the economy and frustration with efforts to speed its recovery boiled over Thursday on Capitol Hill in a wave of criticism and outright anger directed at the Obama administration.

Episodes in both houses of Congress exposed the raw nerves of lawmakers flooded with stories of unemployment and economic hardship back home. They also underscored the stiff headwinds that the administration faces as it pushes to enact sweeping changes to the financial regulatory system while also trying to create jobs for ordinary Americans.

President Obama's allies in the Congressional Black Caucus, exasperated by the administration's handling of the economy, unexpectedly blocked one his top priorities, using a legislative maneuver to postpone the approval of financial reform legislation by a key House committee.

Two buildings away, at a session of the Joint Economic Committee, Republicans escalated their attacks on Treasury Secretary Timothy F. Geithner, including a call for his resignation.

"Conservatives agree that as point person, you failed. Liberals are growing in that consensus as well," said Rep. Kevin Brady (R-Tex.). "For the sake of our jobs, will you step down from your post?"

Rep. Michael C. Burgess (R-Tex.) took a different tack. "I don't think that you should be fired," he told Geithner. "I thought you should have never been hired."

Even Sen. Charles E. Schumer (D-N.Y.), a friend of the administration, suggested that Geithner had been inconsistent in addressing China's practice of keeping its currency low against the dollar.

And Rep. Peter DeFazio (D-Ore.) said Wednesday on MSNBC that he thinks Geithner should step down, pointing to his handling of the aftermath of American International Group's meltdown.

Across Capitol Hill, senators signaled their opposition to rushing regulatory reform. While some Democrats voiced reservations about parts of the bill, Republicans went further, faulting Sen. Christopher J. Dodd (D-Conn.) for pushing ahead before the roots of the crisis were understood.

Perhaps most troubling for the administration was that one of the few measures to succeed Thursday was an amendment by Rep. Ron Paul (R-Tex.) that would subject the Federal Reserve to unprecedented scrutiny. The amendment, which won bipartisan support in the House Financial Services Committee despite the reservations of administration officials, would allow the Government Accountability Office to audit all of the Fed's operations, including its decisions on interest rates and its transactions with foreign central banks.

Paul and allies in both parties -- more than 300 members of Congress have endorsed the measure -- are looking to increase oversight of an institution they consider partly to blame for the financial crisis. Federal officials and many private economists worry that the amendment could make future central bank policymakers reluctant to take unpopular steps to prevent inflation or support the economy for fear of second-guessing by Congress and government auditors.

The House committee had been set to vote to send the final piece of its regulatory reform package to the House floor after months of debate. That is, until the committee's chairman, Rep. Barney Frank (D-Mass.), told a shocked committee room that passage of the bill would be delayed until Dec. 1 because the Congressional Black Caucus wanted the administration to do more to help African American communities suffering in the economic decline.

Frank told committee members that black lawmakers were "frustrated by the response to the economic situation by the administration." He said the caucus had no issues with the legislation itself. "They want obviously to continue to have some bargaining power with the administration," he said after the hearing.

The caucus itself did not publicly detail its concerns Thursday, but one member, Rep. Maxine Waters (D-Calif.), issued a statement: "The recession has created a unique systemic risk that threatens all parts of the African-American community, including the poor and the middle class."

The caucus began discussing its concerns with Frank and the administration several weeks ago. Frank hosted a meeting Monday night between caucus members, Geithner and White House Chief of Staff Rahm Emanuel.

"You're talking about people whose constituents have been badly hammered by this," Frank said. "Given the nature of this recession, there needs to be some more conversations."

Frank said the caucus had concerns about whether minorities were being fairly represented in helping carry out Treasury's bailout programs and other federal efforts to resolve the financial crisis. The government has contracted out much of the work to Wall Street firms.

Congressional aides said the caucus's concerns are similar to those of the Democratic Party's liberal wing. Caucus members are pushing for legislation that would directly lead to new jobs by providing tax benefits, for example, that would provide incentives for home renovations and funding for new infrastructure projects. They also want to extend health-care and unemployment benefits.

Meanwhile, Geithner was taking a beating as he urged Congress to pass regulatory reform as quickly as possible, arguing that delay would create uncertainty for businesses across the country. Lawmakers sharply criticized him for his role in the crisis during the tense Joint Economic Committee meeting. They were particularly critical of his involvement in the decision, as president of the New York Fed, to bail out AIG.

But Geithner pressed forward: "To ensure the vitality, the strength and the stability of our economy going forward, we must bring our system of financial regulation into the 21st century. Nobody in my job should ever be in the position again of having to come into a crisis like this without those basic authorities."

Dodd, chairman of the Senate Banking Committee, chose the marbled Caucus Room in the Russell Senate Office Building -- site of past hearings on Watergate, Pearl Harbor and the Wall Street abuses during the Great Depression -- to open debate on a massive draft bill designed to achieve the most ambitious reworking of the financial system in decades.

"This is one of those moments in our nation's history that compels us to be bold," Dodd said.

But soon, ranking committee Republican Richard C. Shelby (Ala.) took the floor, and for 18 uninterrupted minutes he opined that nearly every element of Dodd's bill was misinformed, uninformed, unnecessarily rushed or just plain flawed. "This committee has not done the necessary work to even begin discussing changes of this magnitude. Nevertheless, you have laid a bill before the committee," Shelby said. "I will be opposing this legislation. Not because we disagree on its ends, but rather on its means."

Shelby said Dodd was wrong not to conduct an investigation into the causes of the recent financial crisis before pushing forward with legislation. He said rather than ending the problem of institutions that are "too big to fail," the current bill expands the government's ability to bail out big banks. Shelby apologized for the length of his critique, expressed his hope that the two men might "yet find some common ground," and yielded the floor.

"Well," Dodd said in the morning's only moment of levity, "I thank you for the endorsement."

Staff writer David Cho contributed to this report.

Nov 16, 2009

Immigration looms as sticking point in health-care legislation - washingtonpost.com

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Immigration and health House measure omits Senate panel's legal test

By David Montgomery
Washington Post Staff Writer
Monday, November 16, 2009

The 31-year-old woman creeping gingerly into Adventist HealthCare's free-standing emergency department in Germantown was obviously in pain, and physician Orlee Panitch quickly diagnosed the problem: gallstones.

The case wasn't an emergency -- yet -- but the woman, who is an illegal immigrant, didn't know where else to go for care.

"Her inability to access care is a problem," Panitch said. "At some point, untreated, she'll need emergency surgery to deal with this."

That question of access to care for some immigrants, and who should pay for it, could well become one of the most contentious sticking points in the coming weeks as members of Congress sit down to reconcile the health-care bill passed by the House on Saturday with the yet-to-emerge Senate version.

The controversy centers largely on whether illegal immigrants should benefit at all under a revised health-care system. Democratic leaders had vowed that only legal residents would receive subsidies to buy insurance. And after Rep. Joe Wilson (R-S.C.) famously shouted "You lie" at President Obama when he made that vow to Congress, both the White House and the Senate Finance Committee went a step further. They pledged that undocumented workers would be barred not only from receiving subsidies but also from buying insurance through federally sponsored exchanges -- even if they used their own money.

Last week, when some House Democratic leaders pressed to match the Senate Finance Committee version, Hispanic lawmakers threatened to revolt and ultimately prevailed: Under the bill approved by the House, illegal immigrants would not be barred from the exchanges.

That stark debate, however, has largely obscured the distinct challenge raised by immigrant families as reformers try to provide coverage to as many Americans as possible. Because so many of the nation's 38 million immigrants -- legal and illegal -- live in households that include both categories, families must often rely on a patchwork of care and funding. And while the legislation could have a significant impact on how millions of immigrants obtain care, it is clear that large gaps in coverage will remain, not only across immigrant communities but also even within individual families.

Maria Salmeron, for example, is a legal resident from El Salvador who has insurance through her job in the kitchen of a nursing home. But her husband, a construction worker who is trying to legalize his status, has no insurance. Their youngest child, Isabella, a 2-year-old citizen in pigtails, requires a ventilator to breathe. Her medical needs are covered by state and federal programs.

On a recent fall day, Salmeron took Isabella to a pediatric clinic in Falls Church, where a bilingual pediatrician, Albert Brito, checked her for a cold and helped her mother make an appointment with a kidney specialist for the child.

Meanwhile, the nurse who comes to the family's home to help take care of Isabella has no insurance. J. Katan, a legal resident from Nigeria, said she cannot afford the premiums for the plan offered by her nursing agency.

"If I need to see a doctor," she said, "I go myself, and I pay."

Locally and nationwide, roughly two-thirds of working-age immigrants who are legal residents are insured, and more than one-third of illegal immigrants also have insurance, according to a new study by the Migration Policy Institute, a Washington think tank. The group estimates that as many as 2.8 million uninsured legal residents of working age could benefit from reform, by qualifying for expanded Medicaid or proposed subsidies to purchase insurance. Nearly 1 million uninsured legal immigrants also work at firms that could be required to provide insurance. And 1.8 million uninsured illegal immigrants work for firms that may be required to provide insurance, according to the institute.

Even as lawmakers remain divided over how far to extend the new safety net, some health providers already have fashioned multi-layered systems to match care with the mixed needs of immigrant families.

The Falls Church pediatric clinic that treated Isabella was created by the Inova Health System, part of a cluster strategy that includes a maternity clinic for uninsured women, a nutritionist, a low-cost pharmacy, a lab, classrooms and social workers to help families navigate the system.

"We're basically a community safety net as well as a medical safety net," said Geoffrey DeLizzio, director of the clinics.

Ramiro Herbas, who came from Bolivia eight years ago, recently brought his son, Demothi, 2, for a checkup and a flu shot to the Falls Church pediatric clinic. American-born Demothi qualifies for Medicaid. Herbas said he has a work permit, but his construction jobs don't offer insurance. If he gets sick he visits a doctor's office in Seven Corners, where discount practices cater to immigrants, $40 a visit.

For some, the emergency department will remain the only option -- especially for patients like Susy, the illegal immigrant with gallstones, who would be excluded from subsidies.

"The pain is strong," said Susy, a babysitter who came from Peru six years ago. Because of her immigration status, she spoke on the condition that her last name not be published.

As Susy lay on a bed, Marcos Pesquera, executive director of Adventist's center on health disparities, picked up the phone and made an appointment for her with a surgeon, who, two weeks later, removed her gallbladder at Shady Grove Adventist Hospital.

Susy said she was initially asked to make a deposit of $3,500 to the hospital. Ultimately she made a deposit of just $100, she said, but she added that she may be asked to pay more.

The surgeon declined to comment, but his colleague, Jason Brodsky of Inpatient Surgical Consultants, said in an e-mailed statement: "We are pleased to provide this care regardless of a patient's insurance status."

Most of the cost of Susy's care will end up being absorbed by Adventist.

Like Inova, Adventist HealthCare, a $1.2 billion nonprofit provider, has stitched together services on its Germantown campus with a cluster of clinics and emergency care, paid for by an array of public and private players.

Next door to the emergency department where Susy was treated, Monica Peñaherrera, 53, sat in an examination room at a clinic operated by the nonprofit Mobile Medical Care. Peñaherrera is an American citizen but has had no health insurance since her husband's construction business declined. When she felt a pain in her breast recently, she came to the clinic she had heard about at her church.

"I'm comfortable here," Peñaherrera said after she was examined by nurse practitioner Marylynn Gonsalves. "I think of her as my family doctor."

For Peñaherrera's visit, she pays $30. Montgomery County pays $62. "That is way less than half what our costs would be," says Bob Spector, executive director of Mobile Med. The rest comes from cash and diagnostic support from Adventist, plus Mobile Med's own fundraising and reliance in some cases on donated medical expertise.

The patchwork of services is also paid for by taxpayers and people with insurance.

"We have to try to cover for those who can't pay or won't pay with the revenues that come from people who can and do pay," says Bill Robertson, president of Adventist HealthCare, which provided about $51 million in uncompensated care -- to poor, uninsured patients like Susy -- in their two local hospitals last year. The hospital covers the gap with money from other patients' insurance plans that pay more than cost.

Downstairs from Mobile Med is a maternity clinic for uninsured women, where Socorro Almejo, 38, an immigrant from Mexico, brought her 17-year-old daughter, Reina, who is pregnant, for a routine prenatal exam. Reina is receiving a full range of pregnancy checkups for $450 through a county-subsidized program. Almejo herself has no insurance and goes to another clinic when she is sick. "I'm glad at least my children have [coverage], even if I don't," she said.

Dianne Fisher, the county health department's nurse administrator for women's health services, said the goal was to ensure healthy pregnancies and births. "Otherwise," she said, "they would show up in the emergency room, with more problems."

Nov 14, 2009

Obama presses Congress to rework immigration laws - washingtonpost.com

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By Spencer S. Hsu
Washington Post staff writer
Saturday, November 14, 2009

The Obama administration expects Congress to begin moving to overhaul the nation's immigration laws early next year, Homeland Security Secretary Janet Napolitano said Friday, adding that improved border security and a drop in migration caused by the economic downturn make such changes "far more attainable" than in 2007.

"When Congress is ready to act, we will be ready to support them," said Napolitano, President Obama's "point person" on immigration policy issues. "The first part of 2010, we will see legislation beginning to move," she said.

Napolitano's speech, delivered at the liberal-leaning Center for American Progress, was aimed at Latino advocates who have expressed skepticism that Obama would fulfill a campaign pledge to push for a "comprehensive" immigration package.

Napolitano reaffirmed Obama's support for a "tough but fair" path for legal status for an estimated 12 million illegal immigrants.

"We will never have fully effective law enforcement or national security as long as so many millions remain in the shadows," Napolitano said.

At the same time, Napolitano sought to reframe the debate from past years, saying lawmakers' earlier demands that the government improve "enforcement first" have been met. She argued that the time to work on immigration issues is when a sluggish economy is dampening illegal migration.

In recent years, the U.S. government has built more than 600 miles of fencing and pedestrian barriers on the 2,000-mile border with Mexico, and more than doubled the ranks of the U.S. Border Patrol, to 20,000 officers, Napolitano said. Meanwhile, because of a shrinking job market and increased enforcement, Border Patrol arrests last year were less than half the 2005 level of 1.2 million.

"These are major differences that should change the immigration conversation. . . . We have gotten Congress's message she said. "Trust me: I know a major shift when I see one, and what I have seen makes reform far more attainable this time around."

Republican critics say that changing laws to allow more foreign-born workers is foolhardy at a time when U.S. unemployment is nearing 10 percent.

"It is ironic that a poor economy is their justification for amnesty," said Rep. Lamar Smith (Tex.). "How can they claim that enforcement is 'done' when there are more than 400 open miles of border with Mexico, hundreds of thousands of criminal and fugitive aliens and millions of illegal immigrants taking American jobs?"

Immigrant advocates said they were pleased the administration is approaching "the moment of truth" for a debate, but said they were still watching to see it and Congress commit real political capital. Congressional watchers also say the issue faces a crowded calendar in the Senate, which is set to take up health care and climate legislation.

Nov 12, 2009

Rep. Kennedy and Bishop in Bitter Rift on Abortion - NYTimes.com

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By ABBY GOODNOUGH

Representative Patrick J. Kennedy of Rhode Island was to meet Thursday with Thomas J. Tobin, the Roman Catholic bishop of Providence, and perhaps start healing a bitter rift over whether health care legislation now before Congress should restrict abortion coverage.

Instead, they postponed the meeting, and Bishop Tobin stepped up his public rebuke of Mr. Kennedy, accusing him Wednesday of “false advertising” for describing himself as a Catholic and saying he should not receive holy communion because he supports using taxpayer money for abortions.

“If you freely choose to be a Catholic, it means you believe certain things, you do certain things,” Bishop Tobin said on WPRO, a Providence radio station. “If you cannot do all that in conscience, then you should perhaps feel free to go somewhere else.”

The United States Conference of Catholic Bishops has lobbied forcefully against including federal financing for abortion in the health care legislation, and Bishop Tobin, who has led the Catholic Church in Rhode Island since 2005, has been a vocal participant.

His conflict with Mr. Kennedy — an unusually personal example of the pressure Catholic bishops are bringing to bear on the health care debate — started last month, when Mr. Kennedy, a Democrat in his eighth term, questioned why the church had vowed to fight any health care bill that did not explicitly ban the use of public money for abortions.

In an interview with Cybercast News Service on Oct. 21, Mr. Kennedy said he could not understand “how the Catholic Church could be against the biggest social justice issue of our time,” adding that its stance was fanning “flames of dissent and discord.”

The next day, Bishop Tobin called the comments “irresponsible and ignorant of the facts” and Mr. Kennedy “a disappointment” to the church.

Mr. Kennedy, a son of the late Senator Edward M. Kennedy, then agreed to meet with the bishop, but said his discord with the church hierarchy “does not make me any less of a Catholic.”

When the House approved its version of the legislation last Saturday, Mr. Kennedy voted for the bill but opposed an amendment, ultimately adopted, that restricted abortion coverage.

Bishop Tobin, in a letter publicly released Monday, called Mr. Kennedy’s support of abortion rights “a deliberate and obstinate act of the will” that was “unacceptable to the Church and scandalous to many of our members.”

“It’s not too late for you to repair your relationship with the Church,” he wrote, “redeem your public image, and emerge as an authentic ‘profile in courage,’ especially by defending the sanctity of human life for all people, including unborn children.”

Mr. Kennedy declined an interview request, and on Tuesday he told reporters in Providence that he would not comment on the bishop’s letter.

“I had initially agreed to a meeting with him,” Mr. Kennedy said, “provided we would not debate this in public in terms of my personal faith. But unfortunately he hasn’t kept to that agreement, and that’s very disconcerting to me.”

The battle is being waged nearly three months after Mr. Kennedy’s father died of brain cancer and received a Catholic funeral despite his longtime conflict with the church over abortion rights and other issues. After the senator’s death, his family made public a letter he had written to Pope Benedict XVI. “I have always tried to be a faithful Catholic,” he wrote.

In Wednesday’s radio interview, Bishop Tobin said he still hoped to have a private conversation with Representative Kennedy, who, he said, has a chance to win the church’s acceptance.

“It’s not too late for the congressman to redeem his image,” the bishop said, “and to embrace the church and the teachings of the church.”

Initially waved off, Hispanic advocates jump into health debate - washingtonpost.com

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Effort centers on ensuring reform doesn't shortchange immigrants

By Krissah Thompson
Washington Post Staff Writer
Thursday, November 12, 2009

After trying to carefully balance their interests in health-care reform and immigration, the nation's Hispanic lawmakers and largest advocacy groups are scrambling to develop a strategy to counter what they see as efforts to shortchange immigrants in health bills on Capitol Hill.

They had tried to keep the two issues apart, concerned, they said, that immigration would distract from health care. But other lawmakers and activists have inserted the immigration issue into the middle of the health-care debate, causing a collision between what Hispanic leaders call their two top policy priorities.

Many of them believe that a health-care overhaul is vital to their community, which is disproportionately uninsured and suffers from a host of chronic illnesses. But with the current bills excluding more than a million Hispanics -- mostly legal immigrants -- the debate runs into the issue of immigrants' rights.

"In every policy debate, as long as immigration remains unresolved, there is going to be a question of what happens to immigrants in this country," said Jennifer Ng'andu, deputy director of health policy at the National Council of La Raza. "One of the reasons that there is so much concern is that our nation's leaders have not dealt with these issues."

Under the health bill passed in the House on Saturday, illegal immigrants would be allowed to buy insurance on a newly created exchange with their own money and without government subsidies. The bill expected in the Senate would bar illegal immigrants from the exchange altogether. In both the Senate and House, all legal immigrants are eligible for government subsidies to buy insurance on the exchange, but immigrants who have been in the country for less than five years would remain barred by existing law from enrolling in Medicaid and Medicare.

At a meeting in May with Hispanic groups and members of the Congressional Hispanic Caucus, activists pushed for dealing with immigration reform within the health-care debate, recalled Elena Rios, president of the National Hispanic Medical Association.

"They told us, 'Don't you dare,' " she said of lawmakers. " 'Don't distract. This is about health-care reform and eliminating health-care disparities.' I thought that was smart. We realized that wasn't the focus."

Now, however, she says she is worried that the health-care bills moving through Congress will not do enough to help immigrants and alleviate health-care disparities in the Latino community.

Similarly, a September meeting with White House policy advisers included a "warning" against confronting the health-care barriers immigrants face because of "fears that conservatives in the Senate could use the issue to kill the bill," Rios wrote on her Web site.

Immigration has become a major political hurdle, regardless.

"We assume the Republicans are prepared to offer any number of immigration-related amendments to slow down the process and score political points," said Jim Manley, a spokesman for Senate Majority Leader Harry M. Reid (Nev.).

The issue isn't clear cut among Democrats, either. Tensions have emerged between the Hispanic Caucus, the White House and Senate Democrats.

After Rep. Joe Wilson (R-S.C.) shouted "You lie!" when President Obama pledged that the reforms he proposed "would not apply to those who are here illegally," the White House promoted language barring undocumented immigrants from the exchange, which was adopted by the Senate Finance Committee.

Members of the Hispanic Caucus balked, saying that rule was more restrictive than current policy. According to the Pew Hispanic Center, about 40 percent of illegal immigrants have some form of health insurance.

"I am not going to vote for a health-care bill that includes provisions that exclude people using their own money to go to the exchange regardless of their immigration status," said Rep. Luis Gutierrez (D-Ill.). "It is silly and stupid. If we do not allow them to purchase it, their communities will suffer. Their children will suffer."

On Saturday, House leaders worked to satisfy the concerns of Hispanic lawmakers after a majority of their 22-member caucus pledged to vote against a bill that did not allow all immigrants access. Leaders of the caucus have also met with the White House and Senate leadership in recent days to outline their concerns.

In the Senate, advocacy groups are looking to Sen. Robert Menendez (D-N.J.), who pushed in the Senate Finance Committee to allow undocumented immigrants to buy health insurance on the exchange without taxpayer subsidies. But he has not decided whether to introduce similar amendments when the Senate's floor debate begins, an aide said.

Several Republicans in the committee, including Sen. Charles E. Grassley (R-Iowa) and Senate Minority Whip Jon Kyl (R-Ariz.), introduced immigration-related amendments. The Federation for American Immigration Reform, an advocacy group that supports limiting immigration, is encouraging them to push for barring illegal immigrants from the exchange and denying tax subsidies for health care to legal immigrants who have been in the country for less than five years.

"The Senate is going to have to deal with these red hot issues right at the start of their process, otherwise it is going to dog them during the debate," said Bob Dane, a spokesman for the group. "We see the health-care bill as having been hijacked and reshaping immigration policy."

Some Hispanic activists believe their early cautious stand may have backfired, and they are turning up their advocacy, said Lillian Rodriguez Lopez, president of the Hispanic Federation.

Recently, the largest advocacy groups, including the Federation, La Raza and League of United Latin American Citizens, launched a lobbying campaign focused on removing the five-year ban for legal immigrants and on getting coverage for all families, even families in which the children are legal immigrants and the parents are illegal.

The groups applauded the House's passage of its bill last week, but stressed that they want more coverage for the 4.2 million legal immigrants who are uninsured, according to a study by the Migration Policy Institute, and consideration for the estimated 7.2 million illegal immigrants who do not have health insurance.

"We feel that our community is not being fully represented in the conversation and needs to be more aggressively represented," Rodriguez Lopez said.

Letter of concern

Ten Hispanic organizations sent a joint letter to members of Congress on Wednesday to express their concern about pending health-care legislation. Led by Hector Barreto, who served as a chief of the Small Business Administration under President George W. Bush, the groups said the bill passed Saturday by the House would place unfair mandates on Hispanic small businesses and families.

Barreto, now chairman of the Latino Coalition, said in a statement that "the House vote illustrated Congress's refusal to come up with a bipartisan solution on real health-care reform. We will not support a bill that creates an inefficient and ineffective government-run health care system for America."

Other groups that signed the letter include the Virginia Hispanic Chamber of Commerce, U.S.-Mexico Chamber of Commerce and the Hispanic Alliance for Prosperity Institute.

Nov 11, 2009

Ezra Klein - The $900 billion mistake

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by Ezra Klein

Barack Obama has not given much in the way of specifics for health-care reform. Few policies have been nonnegotiable and virtually none have been dictated. The exception is a number that was neither nonnegotiable nor dictated, but was received on the Hill as if it was both, and has come to dominate the health-care reform process: $900 billion.

The number sprang from Obama's September speech laying out his own plan on health-care reform. "Add it all up," he said before a joint session of Congress, "and the plan I'm proposing will cost around $900 billion over 10 years." The plan he proposed, however, did not mention the price tag, and the president did not include any specifics about how that price tag was reached. Nor did the president's language actually set a hard ceiling. "Around $900 billion," when you're talking about internal modeling for a plan that the Congressional Budget Office hasn't seen, is not the same thing as a $900 billion limit.

This was not like Bill Clinton waving his pen and promising to veto any bill that did not reach universal coverage. But that's how it was understood on the Hill. "It made things complicated," sighed Rep. George Miller. "We were working off of one track and then we had to switch." The Senate isn't having an easier time of it. Reid's office is waiting for the Congressional Budget Office to return an official score of their health-care reform bill. If it's under $900 billion, they will move forward with it. If it's over $900 billion, they will revise it, and send it back to CBO for a new, and hopefully lower, score.

There are three questions here. The first is how the Obama administration came up with the $900 billion estimate. The second is why they included it in their speech, after so relentlessly avoiding specifics until that moment. And the third is why the Hill embraced it as a hard limit rather than a general proposal.

The answer to the first is a mixture of policy and politics. Health-care reform was embattled. The Gang of Six was breaking apart. There were those in both the White House and the Senate who wanted to radically scale back the ambitions of the bill. Amidst this, members of the White House's policy team managed to model a plan that they considered pretty good and that came in at about $900 billion -- a bit lower than what the House had proposed, but a bit higher than what the Senate Finance Committee was considering. Further, there didn't look to be support for revenues that reached much beyond $900 billion, at least in the Senate. This wasn't a new limit so much as an articulation of a boundary that already existed.

It was, they hoped, something of a political sweet spot. It calmed some moderates by showing that the White House was willing to push back on the ambitions of more liberal members of Congress and pleased some liberals by showing that the White House wasn't letting the chaos of August distract them from the need for an ambitious bill.

But once that number entered the process, it began guiding the process. Sources on the Hill aren't really clear how the sum transformed from an estimate of the president's plan to a hard limit for their plan. Few recall that the original language included the qualifier "around." Even so, the number stuck. It strengthened the hand of moderates in both chambers and allowed them to create a ceiling. It also seemed clear that if the White House was comfortable with $900 billion, then it wasn't going to fight to protect the spending in any bill that exceeded that cap, so there was no point in the liberals bothering to push the issue.

The problem is that the number, which was chosen at a point of political weakness for health-care reform and the Obama administration, is too low. Most experts think you need closer to $1.1 trillion for a truly affordable plan. Limiting yourself to $900 billion ensures that the subsidies won't be quite where you need them to be, and means that virtually every spare dollar has to be spent strengthening them. If you want to add $30 billion to the bill creating coordinated care teams across the country -- a project that could transform chronic care in this country and eventually save many times its start-up cost -- there's little budgetary flexibility even if you could find the revenue, because each dollar is in a zero-sum competition with each other dollar so the entire plan comes in under the limit.

The second problem is that it's not clear what the number includes. Obama's plan, for instance, didn't say a word about the Medicare payment fix, which will cost more than $200 billion, and which many commentators argue should be included in the cost of the plan (I don't agree with them, incidentally). It didn't include specific delivery system reforms. It didn't show its own modeling, so it's hard to say whether the subsidies it envisioned were sufficient, or whether CBO would score the proposal at a higher, or lower, cost.

The reason for this ambiguity is that the limit was never really a limit. It wasn't attached to a plan that was scored by the Congressional Budget Office. It didn't refer to an actual number, or define how big of a boundary was meant by the qualifier "around." It didn't specify what it included. But to the detriment of the bill, it has become a hard ceiling, reducing both the potential affordability of the legislation and the flexibility of Congress to add delivery system reforms that could save money or improve health in the long run. For that reason, Congress should go back to Obama's original speech and follow the president's original lead. A process working towards a bill that's "around $900 billion" is a lot better than a process that's arbitrarily decided to produce a bill under $900 billion.