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Health-care: E.J. Dionne on the final bill and the case for reform

E.J. Dionne Jr.
Sunday, March 21, 2010; 1:00 PM

Washington Post columnist E.J. Dionne Jr. discusses the final vote on the bill to reform the health-care system, why he supports an overhaul and what's next for proponents of the bill.

At 2 p.m., Megan McArdle discussed why she opposes the reform bill.

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Deming, N.M.: Could one draw a parallel between the efforts of Rep. Stupak to further restrict use of federal funds for policies that might pay for an abortion and the federal government restricting the rights of federal employees from using their federal wages to pay for an abortion?

E.J. Dionne Jr.: First, welcome everyone and thank you for participating. This is a very exciting day, a momentous day in our history. It's good of you all to join one of the most important arguments we've had in many years. As many know, I am hoping that we will take a large step toward universal health coverage by passing a bill that would insure 32 million of us. We will know soon. I believe it will pass.

On this question: I is already the case that none of the health plans available to Federal workers cover abortion. They are prohibited from doing so. Rep. Stupak and his allies believe the same sorts of rules should apply to the Federal exchanges. My own view is that the Senate bill contains language that bars Federal funding for abortion that is sufficient for abortion opponents to support this bill.

And I want to use this question to make a broader point. Because I have been writing a lot recently about the arguments inside the Catholic Church about the health care bill, I thought I would get some questions on this. I prepared this answer in advance that I will use as a reply now to all subsequent questions on the subject that it could cover. I will post as many of those questions and comments as I can, so participants can have their say on this issue.

As many readers know, the U.S. Conference of Catholic Bishops oppose the Senate bill up for a vote today because they believe it breaches the principles of the Hyde Amendment, which prohibits federal funding for a abortion. The Catholic Health Association and a large group of leaders of women's religious organizations support the bill. The CHA and the nuns believe the bill does not include any funding for abortion.

I believe the CHA and the nuns are correct, both on the specific issue of abortion funding and in their support of the bill, which would extend health coverage to 32 million Americans.

On the specific issue of whether the Senate bill contains funding for abortion, I thought PolitiFact.com had the simplest and clearest answer. Responding to Rep. Daniel Lipinski's assertion that the bill "allows taxpayer money to pay directly for abortion in federal community health centers funded in the bill," Politifact wrote this:

Could the money be used for abortions? It doesn't seem likely based on the comments from the White House, Sebelius, the Congressional Pro-Choice Caucus and the umbrella organization for community health centers. But neither can we say definitively that the scenario laid out by the Lipinski and the National Right to Life Committee could not happen. If you focus on the technical possibilities -- which is an entirely legitimate thing to do -- who can say whether a court might rule that without a specific prohibition, abortions could be permitted? You can't fault organizations like the National Right to Life Committee for raising concerns about potential loopholes, even if they seem unlikely. And perhaps language will have to be added to remove any doubt. A White House official saying the president would work with Congress to draft language to make clear that federal funds for community health centers should not be used to fund abortions certainly sounds like an acknowledgment that there is at least room for interpretation.
But we think the issue looks more like a political dart than a legitimate concern. That's especially true in light of the track record of community health centers. They have never in their 45 years provided abortions. They did not even before the Hyde Amendment was enacted. They have not even when they got $500,000 from the economic stimulus to expand their services (essentially coming the same way as proposed through Senate bill). They have not even though federal funding limited by the Hyde Amendment comprises just 20 percent of their annual budget now (and they'll still be getting that appropriations money, with its strings). Given all that and the public pronouncements from the White House, the Congressional Pro-Choice Caucus and Sebelius that the money could not be used to provide abortions, we think it's highly misleading to state definitively, as Lipinski did, that if the Senate bill passes then federal dollars will start flowing to community health centers to provide abortions. We rule Lipinski's statement Barely True.

(My emphasis added)
http://www.politifact.com/truth-o-meter/statements/2010/mar/09/daniel-lipinski/lipinski-says-senate-health-bill-allows-taxpayer-m/

I believe that to reach their conclusion that the bill does fund abortion, the Bishops have to make a series of assumptions that I believe are highly questionable. The single best commentary on this question I have seen appeared in Commonweal magazine, the liberal Catholic publication (with which I have had a warm association for over 30 years). Commonweal ran an excellent editorial under the headline "Crying Wolf." Here is a link to the editorial. http://commonwealmagazine.org/crying-wolf I will quote key portions here:

One needs a good reason to oppose a bill that would cover 30 million uninsured Americans and greatly improve insurance for those who already have it. If the Senate bill did clearly authorize the federal government to pay for elective abortions, prolife Americans might have such a reason. To conclude the bill does this, however, requires one to believe that every ambiguity-every possible complication the bill doesn't explicitly address-is a ploy by prochoice politicians to sneak abortion funding into the system. President Barack Obama and his party's leadership have promised the bill won't be used in this way. Their critics instruct us to presume that they're lying….

Critics also claim that the money the bill appropriates for community health centers is not subject to the Hyde Amendment. No doubt the bill would be strengthened with the addition of language that clearly imposes the Hyde rule on any federal money given to health centers. But since such money will in any case be channeled through the Department of Health and Human Services (HHS), where the Hyde Amendment obtains, there is no good reason to suppose that it will be exempt from the amendment's constraints. Besides, if HHS really could spend any part of the new funding on elective abortions, it wouldn't matter that the Hyde Amendment keeps it from using the rest of its money for this purpose: as the bill's critics never tire of telling us, money is fungible-the Hyde Amendment works only if it covers everything HHS spends. It's also worth mentioning that none of the existing health centers, which provide care to one in eight children born in the United States, has ever offered abortion services.

My bottom line on this came at the end of a blog post I put up yesterday. I'll share part of it here: http://voices.washingtonpost.com/postpartisan/2010/03/the_nuns_the_bishops_and_healt.html#more
Catholics are divided over the health-care bill. I believe passionately, as does Sister Carol, that it would be an enormous mistake to miss this opportunity to extend health coverage to more than 30 million Americans. I also share her view that the Senate bill, as written, does not provide for Federal funding of abortion. Cardinal George and the Catholic Bishops Conference believe just as passionately that the bill is not clear enough on the abortion question and should therefore be opposed. As a Catholic, I am deeply disappointed that the Bishops have taken this position, and I disagree with their reading of the bill, even as I also think that they are acting from good will and sincere belief. I hope that this afternoon's talk of an executive order to satisfy the concerns of abortion's opponents will allow those who believe in the cause of life to find a way of supporting this health care expansion because it will reduce the number of abortions in our country while also preserving and enhancing lives.
I'd like to offer the last word to my former Washington Post colleague T. R. Reid. In his excellent book, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, he wrote:
Those Americans who die or go broke because they happened to get sick represent a fundamental moral decision our country has made. Despite all the rights and privileges and entitlements that Americans enjoy today, we have never decided to provide medical care for everybody who needs it. In the world's richest nation, we tolerate a health-care system that leads to large numbers of avoidable deaths and bankruptcies among our fellow citizens…
All the other developed countries on earth have made a different moral decision. All the other countries like us-that is, wealthy, technologically advanced, industrialized democracies-guarantee medical care to anyone who gets sick. Countries that are just as committed as we are to equal opportunity, individual liberty, and the free market have concluded that everybody has a right to health care-and they provide it.
We should, too. And today, I think we will take a giant step toward doing so.

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Kensington, Md.: Dan Balz's piece putting the pending health care reform legislation into historic context notes that other major changes (Social Security and Medicare) were passed with bipartisan support. He seems to imply that the lack of such support for the current HCR push is necessarily a statement about the legislation in question. Why is this situation not a statement about how ideologically extreme and politically-obsessed the out-of-power party (GOP) has unfortunately become? And why do you think the media does not stop to ever consider this angle? It's mystifying. Millions without health insurance, all they can say is "no", but they get a free pass from the press.

washingtonpost.com: The Take: Historic win or not, Democrats could pay a price

E.J. Dionne Jr.: Thank you. I admire (and enormously like) Dan Balz, whom I worked with closely i the 1990s. I have not read his piece yet.But I agree the underlying point you're making: The Republican Party of today is a much more conservative Party than the Republican Party in the days when Social Security was passed in the 1930s or Medicare was passed in the 1960s. Think about the liberals who were Republicans in those days: George Norris and Bronson Cutting and Fiorello LaGuardia in the 1930s, Mac Mathias, Jacob Javits, Ed Brooke, Clifford Case, Brad Morse, John Lindsay, Ogden Reid -- I could go on and on -- in the 1960s. Many who used to be moderate or liberal republicans switched to the Democratic Party (just as many conservatives, particularly in the South)switched to the Republican Party. So I think that you are right: Alas, the only way to pass comprehensive health insurance reform at the moment is with Democratic votes. The odd thing, as I mentioned in a blog post published in the paper today, is that this bill is Republican in many of its core ideas. It is very market-oriented. It resembles a bill proposed in the 1990s by the Late Senator John H. Chafee of Rhode Island, and is also like Mitt Romney's Massachusetts plan. Maybe this will change someday and there will be progressive Republicans again, but we have to act in the world as it is, not in the world we wish existed. Thanks.

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Chadds Ford, Pa.: I support the bill because it will increase coverage of those unable to get health insurance. It does not appear to have meaningful controls on costs, like a public option. My question: little has been said about how it will be paid, eg, the mix of taxes. (I would prefer the tax be on the affluent.)

E.J. Dionne Jr.: Thanks. I don't want to spend too much time detailing taxes. There is some good material in the paper over the last few days on this. There are taxes on the wealthy in this bill. In particular, the Medicare tax will be extended to investment income for the wealthiest among us. There are taxes on device makers, and some other levies. The tax on so-called Cadillac health plans will hit some in the middle class, though the reconciliation bill, if it clears both houses, will cut that tax back and delay its full implementation. The short answer is that this is financed more by the better-off than by the less well-to-do.

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Silver Spring: Mr. Dionne, assuming this all passes, how successful will the Republicans' repeal efforts be? Do you think the bill is good enough that most Americans will say "Gee, this isn't bad after all?"

E.J. Dionne Jr.: In Australia, the Australian Labor Party pushed through a comprehensive health system and t was repealed by the next conservative government. Labor came back to power and passed it again, and now it is so popular that the conservatives there accept it -- just as they do in Britain, Canada and all other democratic nations that have established universal systems.

My hunch: This will not get repealed. Assume for the sake of argument that the Republicans take over the Congress in this fall's elections -- I don't assume that, by the way, but will do so just for the sake of this question. Even if they had the votes to repeal it, President Obama would veto the repeal. We then get to 2013. If I had to guess, I'd guess Obama is re-elected. If Republicans had full control of the government, they might repeal it. But by then, I think too many people will be anticipating the benefits which kick in the next year.

So my short answer is: Possible? Yes. Likely? No.

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Salinas, CA: E.J., just before the House was gaveled into session, C-SPAN reported that Rep. Stupak has announced that he will vote yes on the HCR bill. Game over?

E.J. Dionne Jr.: That's huge news. I haven't seen it because I have been doing this chat. But if Stupak is a "yes," then it is game over. It will pass. The last holdouts were the Stupak group of right-to-life Democrats, a number of whom had already switched to yes. Thanks for sharing that with us.

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Summerfield, Fla.: We hear politicians in the Senate declare that they know what the American people want. What I would like to know is: how many of the American people do the 41 Republicans and the few democrats who oppose the health-care bill really represent? Most seem to come from sparsely populated areas. Could someone please remove the smoke and mirrors from this question and certify where the real majority of Americans are on this issue?

E.J. Dionne Jr.: Amen. The Senate is a very troublesome institution. It is not representative of the country. When Wyoming, Idaho and the two Dakotas have as many votes as California, New York, Florida and Texas, there is a problem for democracy. (I am fond of the small states I mentioned; I am just talking about unrepresentative nature of the Senate.)

The last poll I saw in the Wall Street Journal showed the country split whether the overall bill should pass. (Someone can correct me but I believe 46 percent said yes, 45 percent said no.) So the public is split. And many of the particulars in the bill are very popular (such as not permitting pre-existing conditions from blocking people from coverage). I think the bill's standing in the polls was hurt by the very messy and at times ugly process that legislative systems create. So everyone just should vote their conscience.

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Scottsdale, Ariz.: Hi from warm and sunny Arizona.

State lawmakers here(large majority Republican, as you probably know) eliminated the State and Federally funded Kidscare which serves over 38K children thru age 18. Asthma, cancer, shots, any illness? Supporters said they had "no other choice" AZ Republic today. Tough choices here, eh?

Would the health care bill pick up these 38+ thousand Arizonans?

E.J. Dionne Jr.: Greetings. This sort of thing is exactly why we need a national system. It is tragic. As a parent, I have thought a lot of what it would mean to be without insurance when one of my kids got sick.

I don't think it will take effect quickly enough to pick up all these people right away for the reasons I explained above. The Feds already cover most of the costs of he State Childrens' Health Insurance Program. This does not sound like a good choice by your legislature, though I am at a great distance and don't pretend to know all the details.

By the way, it's pretty warm and sunny here, too. My warmest wishes to Arizona.

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Washington, D.C,: While I've ready with interest your coverage of the debate about this bill in the Catholic Church, I have to ask -- why should the Church's views really impact a bill that's going to cover 30 million people from a variety of religious/moral/ethical backgrounds?

E.J. Dionne Jr.: Fair question. The Church's views matter only because its views have influence on some key members of Congress who are strong opponent of abortion. Because a group of about a dozen House members are, at the same time, (1.) supporters of health care reform and (2.) abortion foes, they became swing votes in the House. Speaker Pelosi needed them to form a majority. While I have disagreed with the Bishops on this one, I think faith traditions have a right to influence the direction of policy just as other groups of Americans do -- the unions and the Chambers of Commerce and the trade associations. Our religious groups often bring a moral voice to the debate on issues such as torture, immigration, welfare and help for the third world. Religiously inspired groups that do extraordinary work on behalf of social justice causes that progressives believe in include Bread for the World, Religious Action for Reform Judaism -- Rabbi David Saperstein is one of my heroes. The Catholic Bishops are usually on the side of helping the poor and the marginalized. That's why (as a Catholic) I was disappointed in where they stood on today's vote -- especially since the Catholic Church has, historically, been a strong supporter of universal coverage.

So: No religion can or should dictate what the government does. But all religious people and religious groups have a right to enter the public square, make their arguments,and try to influence policy. Does that make sense to you?

Thanks for the question.

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Princeton, NJ: EJ, you mised the point of the first question. If a woman soldier uses her pay to get an abortion, is that using federal funds to pay for an abortion?

If it is not, then there should be NO restrictions on the kind of insurance one can buy with the federal subsidies in the bill.

E.J. Dionne Jr.: She can use her own funds from her salary. Sorry that I missed your point. The studies I have seen suggest that most abortions are not paid for by health insurance, though there are some competing studies with different findings. Thanks

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Indiana: I don't understand why the conventional wisdom is that this is going to be an albatross for Democrats in the next election. If you're a Democratic candidate who can't find people in your district you can point to and say "Jane Doe lost her insurance because of an unrelated pre-existing condition after she was diagnosed with breast cancer. We have made it so that kind of injustice will never happen again," well, then, you're just not a very good politician. That's not the bill's fault.

E.J. Dionne Jr.: I agree entirely. Indeed, I think that if they do not pass the bill, the House members and Senators who voted for one or the other bills last year would still be stuck with their "yes" votes, but have nothing to defend. I think with a new system in place, those who voted for it will have something to defend, and it will not look like the monstrous mess that critics described. If you look at it for a moment just from a political point of view, I think Democrats are better off passing a bill and showing they can govern than putting in all this effort and emerging with nothing to show for it. Voters would not like that. Democrats would look like they cannot govern. This is one reason why I believe the bill will pass. It's important, however, that Democrats put in a lot of time explaining and defending what's in this bill. As I mentioned earlier, many of its specific provisions are popular.

So you are right and the conventional wisdom is wrong -- though in truth, I think a lot of people who form the conventional wisdom (whoever they are!)actually agree with you. Republicans are saying passing this bill would be a disaster politically. But then they are trying to kill the bill, so it's a perfectly natural thing for them to say. Thanks for the thought.

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Princeton, NJ: There is a health care economist, Uwe Reinhardt, at our University who is generally regarded as a world authority on health care systems. We have had a number of discussions on single payer systems. Although he agrees that these are vastly more efficient on any system based on competitive for profit insurance, he says, "Americans are not mature enough to learn from other countries." (He is a Canadian, born in Germany.)

Is he correct?

E.J. Dionne Jr.: He is a brilliant man, but I disagree with him on our maturity. I think we are a pretty mature people. My view is slightly different: All health system reforms start from where a country finds itself at a particular moment. The British health system was created right after World War II and was influenced by the way Britain provided health care during the war, when lots of people left the cities to escape bombing and the government had to play a major role. Other countries (Switzerland, for example) built on private systems. Getting from where we are to single payer in one step would be a huge leap. We will have a mixed system, with a version of single payer in place for Medicare and Medicaid and subsidized private insurance for the non-elderly and those who are not poor. And we will evolve from there.

By the way, the seed of this thought -- that each country evolves the health system that fits most naturally -- was planted by a brilliant physician from Boston in a lecture I heard last year. I cannot for the life of me remember his name.

On the point of our maturity: I actually think we're pretty good at learning from others. Our own social insurance systems drew on experiences in Europe. Our Progressive movement was in a rich dialogue with New Liberals in Britain and Social Democrats on the continent (Christina Democrats, too). An excellent historian named James Kloppenberg wrote a book on this. I think all countries should be open to good ideas from other countries.

Thanks for your thoughts.

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Lexington, Ky.: I currently have what I take to be good health coverage with my employer. If I change jobs in the next few years what new options will I have because of the Health Care Bill, or what currently common options might I lose? Might I be able to choose between a government health care option, and a private option?

E.J. Dionne Jr.: The best thing about this bill, besides the subsidies to help low- and middle-income people afford insurance, is the creation of insurance exchanges that will allow individuals to bargain for insurance. If you lost your job now and had to buy insurance, you would be bargaining as an individual and have a very hard time getting a decent deal, especially if you are middle aged or older. The exchanges pool everybody together and bargain with insurance companies on behalf of all members. They are like a cooperative. If your new employer had insurance, you would probably do exactly as you do today and pick one of his or her plans. Over time, I have a hunch the exchanges will be opened to everyone, even people whose employers provide insurance. That's Sen. Ron Wyden has been trying to get done.

In any event, I think the creation of these exchanges is a good thing and a big deal.

Thanks for you question.

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Overland Park, Kan.: Why are we assuming that Republicans don't know what the people want, and Democrats and the President do? Why don't we put it to the American people to vote on? We are still a democratic society and the voice of the American people should be heard.

E.J. Dionne Jr.: Glad you came in to the discussion. I am not assuming that. As I said earlier, I think opinion is split on this. Even though I disagree with them on a lot of things these days, I know that the Republicans speak for a lot of Americans. (Even in defeat, John McCain got 46 percent of the vote.) I think members of Congress should vote their consciences. And then we'll have an election in which we will argue out whether passing this bill was a good or a bad idea. (We'll obviously argue about other things, too.) The only thing I object to is the inconsistency of people who say, for example, that former President George W. Bush was brave and right to surge troops into Iraq, even though public opinion was against it, but that Democrats should now follow public opinion and vote against the health bill, whatever they believe. (The same inconsistency would be wrong in the reverse as well.) But human nature being what it is, we tend to cite public opinion when it seems to be with us and seak of the importance of courage when public opinion is aganst us.

Thanks for your thoughts.

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Winnipeg, Canada: As a Canadian who was live when medicare came into effect, I can tell you that there was a lot of opposition here, too. Doctors went on strike in Saskatchewan (the first province to adopt medicare) and there was much wailing and gnashing of teeth by conservatives about the move to communism that medicare represented. Now Tommy Douglas, premier of Saskatchewan when medicare came into effect, is widely regarded as our greatest Canadian, and the medical association has honored him with a a sculpture.

When my kids got sick, I never thought twice about taking them to the doctor or hospital.

Like the man says, "try it, you'll like it."

And the naysayers who are so noisy now will quietly try to forget how silly they sounded.

E.J. Dionne Jr.: Just wanted others to see your comment. I think this is a good point. Thanks

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DC: Does the Post have any plans to actually explain what the bill contains. The paper and most of the mainstream media (not to mention the right wingers) have done a real disservice by not highlighting what's in the bill. The public favors elements that the bill contains, but obviously doesn't know that they are in there.

E.J. Dionne Jr.: I am sure they will. They have published a lot of things of this sort already. But if the bill passes, look fr this tomorrow.

Thanks

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Arlington, Va.: What happens next, assuming the bill is passed? Can you walk us through the timeline of when it becomes law, when we start paying for it, when the benefits go into effect, etc.?

E.J. Dionne Jr.: I apologize. I wrote a long answer to your question earlier and it got gobbled up by my computer (or maybe I hit the wrong key). In brief, certain things (such as letting adult kids stay on their parents' plan through age 26 and a ban on recissions by insurance companies) take effect immediately or very quickly. The full plan won't be in effect for four years. I am sure the paper will have a lot about this.

Thanks.

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E.J. Dionne Jr.: Thanks to all for your thoughtful comments and strong views. Now we can watch history be made -- and then we can have our great debate about whether this was the right thing to do, and where to go from here. I hope I can join you all again for that debate and discussion. Have a great Sunday.

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