In a rare and strong bipartisan vote of 392-37 Thursday, the House of Representatives paved the way to a long-term solution to the “doc fix” problem, a policy glitch that Congress has kicked down the road 17 times since 2002. Each time, Congress and the president have averted steep automatic cuts in fees paid to Medicare physicians, providing short-term fixes to keep payments stable for a few months or years. On Thursday, the House adopted a 10-year, $214 billion solution: they packaged a set of Medicare cuts and new revenues that should relieve Congress of the annual drama of finding a way to forestall these cuts in payments to physicians who treat Medicare patients. Coupled with a two-year extension of the Children’s Health Insurance Program (CHIP) and new funding for community health centers, the package pays for just a third of the cost of the bill, adding the remaining costs to the federal deficit.
How was such a deal possible in an otherwise polarized and seemingly deadlocked Congress? Granted, the Senate has yet to act, but the strong bipartisan vote and support from the president will make it hard for the Senate to block enactment. Given the rarity of the House vote, I suspect we’ll soon see a spattering of headlines declaring a thaw in Congress’s deep legislative freeze, and pointing to potential new agreements on the horizon. Perhaps. But closer inspection of deal-making on the doc fix points to a set of special circumstances that likely made a bargain possible.
First, both parties had an incentive to find a long-term solution to the doc fix problem. It takes two parties to tango of course: both parties need an incentive to cross the threshold to take a seat at the negotiating table. As Frances Lee and I have argued, both parties typically ask themselves: What are the political consequences of refusing to negotiate? In this case, GOP House leaders had an incentive to remove this legislative thorn from their side, given the uphill battle for conservative votes in recent years. Last year, lacking sufficient votes to pass the fix, GOP leaders secured passage in a mere 43 seconds by voice voting the bill while most rank and file backs were turned. Similarly, Democrats had little to gain from refusing to go to the table given that the deal would potentially help to shore up the party’s priority of stabilizing Medicare. On balance, neither party leader likely saw public reward for refusing to bargain.
Second, most of the negotiations appear to have taken place out of the public eye. By one report, House Minority Leader Nancy Pelosi (D-Calif.) and Speaker John A. Boehner (R-Ohio) met to give momentum to talks in early March, but staff had been at work already for at least a month. Keeping negotiations private no doubt made it easier for each side to compromise in reaching a broader deal. Had Republicans known that Boehner had assented to paying for only a third of the deal, conservative anger might have blown up the talks. Had Democrats focused on the higher costs to be imposed on beneficiaries (AARP opposes the deal), Pelosi might have been compelled to withdraw. So long as the entire package was likely to be more favorably viewed than each of the component parts, closing the doors was essential. Lack of transparency likely fueled a bargain in the public interest.
Third, the doc fix package is a classic win-win deal. Rather than dividing up a pie of fixed size, negotiators exploited Congress’s nearly unlimited jurisdiction to combine differing party priorities into an “integrative” solution. Republicans secured long-term structural change to the Medicare program; Democrats nailed down funding for CHIP for the duration of the Obama administration. Stitching together a key priority of each party sealed a win-win deal for both House parties. (Witness Senate Democrats now holding out for a longer CHIP commitment.) Both sides get something to trumpet to their base and to the public — immunizing them from blame. In this case, the fruits of negotiating an integrative solution with the other party — rather than seeking 218 votes from within a divided conference — are clear.
Finally, the deal delivers short-term benefits while shifting costs to the future. That is, most of the “pay fors” don’t kick in for at least a decade. That allows lawmakers to earn immediate and electorally valuable credit for benefits delivered, while avoiding blame for costs imposed. Distributing costs and benefits in this way allowed lawmakers to match policy and political gains.
With these political stars aligned, leaders’ floor strategy greased the skids for an overwhelmingly bipartisan vote. Boehner and Pelosi timed consideration for just days before the deadline for passing a fix. As Matt Fuller of Roll Call reports, both Boehner and Pelosi had told their members that “the idea from the House has always been to jam the Senate by not giving them enough time for a prolonged debate.” Leaving little time for members — let alone organized interests — to fully digest and potentially mobilize against the deal helped secure the deal. Legislating in the Dark, as James Curry argues in a forthcoming book, can be essential for leaders’ exercise of power.
Does Thursday’s deal augur well for more opportunities for bipartisan dealmaking? The speaker — surely recognizing the constellation of forces that made today’s vote possibles– said it best: “When I see one, I’ll let you know.”