[Note: The current HCR debate has gotten so contentious within the various 'liberal/progressive' factions that it felt important to me to amplify my position about the importance of breaking through this first barrier with an imperfect bill, and why I believe the prospects for improving it over time are stronger, not weaker, if this bill passes.]

Enacting health care legislation is like threading 3-ply thread through a tiny needle eye

In the days before the filibuster was abused with regularity, Hubert Humphrey counted the number of obstacles before a bill became law. His conservative total was 28. At any one of those 28 intersections, it could die. In fact, most do. They die because someone wants something they didn’t get, or because there’s just a fundamental philosophical difference that can’t be surmounted. When a bipartisan effort is impossible, the odds of death increase exponentially. Humphrey went on to observe this: “At each stage of the legislative highway, a few legislators lurk, like the pirates of Tripoli and take toll of the passing traffic…”

When the legislation being contemplated is major, groundbreaking social legislation that has met a stone wall of opposition for 82 years by the same institutions over and over and over again, multiply the number of obstacles by a factor of 10, and figure there’s an armada of pirates waiting to ambush.

Incremental progress lays a pathway to the goal

Looking at the progress made from 1960-1965 when Medicare finally became law is instructive, too. Everyone thinks Lyndon Johnson introduced Medicare in January and strong-armed it through by July. In fact, it progressed in incremental fragments between 1960 and 1965. President Johnson had three extraordinary circumstances on his side: sentiment, an overwhelming supermajority, and public fervor and engagement stoked over five frustrating years of effort.

1960-1965, under the magnifying glass

A bit more detail about how things progressed. I mentioned in Part 3 that insurance covering hospital, medical and nursing home expenses for the elderly had withstood a Senate vote, but not a House vote. Drilling down, I see a pathway remarkably parallel to the one we’re on now.

I. The House

• March, 1960 – Pressure mounts for the Forand bill (integration of Social Security and medical/surgical/hospital/nursing home benefits for the elderly) to be reported out of the House Ways and Means committee. It is an election year, and all Democratic candidates have endorsed the Medicare/Social Security approach to covering medical expenses of the elderly. President Eisenhower initially opposes this approach, pivots toward it, then backs away again. As a countermeasure, the administration proposes federal grants to states to subsidize private insurance premiums for the low-income elderly.
• March, 1960 – The House Ways and Means Committee is forced via procedural maneuver to an up or down vote on the Forand bill. It fails by a 2-1 margin and does not leave the committee.
• April-June, 1960 – With public pressure mounting, House Speaker Rayburn and Senate Majority Leader Johnson take a united stand for the principles in the Forand bill: that health benefits should be an integrated part of Social Security.
• April-June, 1960 – Public pressure continued to build. There were public rallies, mail campaigns to Congressmen, a great deal of public discussion and media attention in a high-profile election year.
• June, 1960 – As public pressure intensified, Wilbur Mills tried to find a middle ground. His first proposal was to give seniors an opt-in choice: higher monthly Social Security payments or medical and pension, combined. That idea was rejected. Republicans proposed an additional allocation to states for subsidizing private insurance. That idea was rejected. Finally, after working to get the AMA to agree, he settled on a plan that would expand vendor payments under the current state-run public assistance program. He proposed to create a category called “medical indigency” and was intended to help those who were not on welfare, but couldn’t afford their medical bills.

  From the Social Security history site, this step-through of the politics is instructive:

  From the point of view of the members of Congress, the Mills plan had several merits: It was more modest in cost and scope than either the Forand bill or the Republican “subsidy” plan; from a technical standpoint it was a logical first step; it was a “Democratic bill” in a Democratic Congress and was sponsored by the respected Ways and Means Committee chairman; and, not least, it had the backing of the AMA.

  In other words, a coalition could be built around a bill that fell far short of the goal but was still a victory. An incremental one, but nevertheless, a victory. It passed the House 381-23.

The Senate

Much more maneuvering took place in the Senate committees.

• June, 1960 – First, the Senate modified the Mills bill to allow the proponents of the Social Security/Health Insurance approach to add their measure as an amendment to the now-dubbed Kerr-Mills bill.
• August, 1960 – In late August, candidates Nixon and Kennedy attended a session of the Senate where all three approaches were put to a vote. Nixon argued for the Republican “subsidy plan”. JFK argued for the “social security approach”. A third group of Democrats coalesced around the Kerr-Mills bill (expanded vendor payments).
• August 23, 1960 – The Republican “subsidy plan” falls on a strictly partisan vote, 67-28. The Social Security plan was defeated by Senator Kerr and the third group of Democrats 44-51. The final bill to be voted on was the Kerr-Mills bill for expanded vendor payments. It passed 91-2 and was signed into law on September 13, 1960.

Medicare’s defeat, Round 1

Fast forward to 1961. JFK is in office, is popular, but is dealing with a mild recession, some legislative setbacks, and an increasingly vocal and organized opposition to Medicare. Kennedy’s margin of victory was far smaller than previous Democratic presidents, causing Democrats to lose 20 seats in the House. Even with a Democratic majority, he could not get the votes in the House to move ahead with Medicare in those circumstances, either in the Ways and Means committee or the full House of Representatives. Faced with that reality, Medicare is pushed back on the agenda to the midterm elections of 1962.

Meanwhile, opposition to Medicare hardens. The AMA is organized; a political action committee established, and commercial life and health carriers align with the AMA and US Chamber of Commerce. On the other side, organized labor was pressuring for Medicare, reaching out to doctors and practitioners to unite with them, while other Democrats were reaching out to the elderly and helping them get organized.

In 1962, President Kennedy begins a major push for the passage of Medicare. From the Social Security history site:

The President was said to have concluded that the issue was popular with the voters (Gallup polls showed public support running as high as 69 percent); in the fall campaign, the President was expected to make Medicare his “cutting edge issue”– the symbol of his whole New Frontier program.

In the House Ways and Means committee, negotiations were taking place around eligibility and the question of what contribution seniors would make for premiums. There were differences between the administration and the committee as to the disposition of the Kerr-Mills program, benefits covered, and qualification for benefits.

In the streets, opponents of Medicare accused the administration of using senior citizens for partisan politics rather than sincere social legislation. Terms like “propaganda blitz”, “looting the Treasury” were used routinely by spokesmen for the AMA and insurance companies. Direct mail campaigns were in full swing against it. Despite the President’s appearance at rallies with senior citizens and the still-strong public support, the vote was close.

Medicare was defeated in the Senate on July 17th by two votes: 52-48.

Watch what happened next

In the wake of the 1962 Senate defeat, Medicare partisans, searching for scapegoats, fell to fighting among themselves. Some became pessimistic and concluded that Medicare was a lost cause. Others, especially those who were closely involved, viewed the setback as only temporary; as the months went by, the arguments in favor of Medicare were growing stronger.

As time went by, insurers were beginning to see the wisdom of a government program. After they had created special products to accomodate the elderly, they were feeling the pinch of adverse selection. Support was growing in Congress, and the successful end to the Cuban missile crisis gave Democrats a gain of 4 in the Senate.

But in 1963, Medicare took a back seat to growing civil rights unrest.

And then President Kennedy was assassinated. Amidst a national tragedy, legislative resolve hardened to finish his legislative agenda. When 1965 came around, the votes, the will, and the people were in place to push Medicare into being.

2009-2010

The parallels between the early 1960s and today are clear. The same arguments, the same rhetoric, the same opposition, and the same climate exists today. Add to that a deep recession, the likes of which we haven’t seen since the 1930s, the race factor as it relates not to a civil rights debate, but the nature of our President, and the same entrenched monied interests. It’s not hard to understand why the public option became the sacrifice, nor why a national single payer system wasn’t put on the table at all.

I do not believe there is a more incendiary issue than health care in the universe of social legislation or progress, nor do I believe we can afford to ignore the leap into the future the current legislation represents. Unlike the weak and ineffective Kerr-Mills bill that covered about 88,000 people at its apex, this bill will break the pre-existing conditions barrier and establish a right for all to have access.

When Dennis Kucinich is villified for seeing and accepting political reality; when those of us who have studied the progress of legislation like this are called cowards and in-name Democrats, the larger lesson is lost. Without breaking the first barrier, there is no prospect for reaching the goal.

Alan Grayson has begun Phase II of the reform process, by introducing a bill on the House floor permitting anyone to opt into Medicare (and pay for it). He has further qualified his proposal as an “unsubsidized option”, so that anyone choosing this option will not be eligible for the subsidies given to those buying private insurance.

What progressives need to understand is this: If the current legislation fails, there is no prospect or pathway toward their larger goal. If this bill passes, we’ve established the right to health care. A door opens. Alan Grayson has extended an invitation for Congress to take the next step. Just as in 1962, this will coincide with midterm elections. Democrats, Liberals, progressives, socialists, and all others on the left need to look at how Medicare progressed. Let’s take out the national tragedy part and figure out how, after this bill passes, public support and energy can focus to elect representatives who will stand with him and agree to his proposal.

Right now, we’re on square 28 of the first round of health care reform. Alan Grayson proposes to move us to square 1 of the next round, where there will be at least 28 more obstacles. But what history proves is this: success begets success. Winning this round builds momentum for the next one. Losing this round or calling a win a loss will not take us to square 2 of the second round. Only unity and resolve does that.

A look down the timeline of social legislation is mind-boggling. Unemployment insurance, disability insurance, and retirement benefits were all in place and yet, access to health care for all Americans remains the elusive prize, even today. No matter how many years pass, arguments for universal health care are the same, as are arguments against. Here are two excerpts, both from opposite sides of the timeline.

September 9, 2009

Our collective failure to meet this challenge – year after year, decade after decade – has led us to a breaking point. Everyone understands the extraordinary hardships that are placed on the uninsured, who live every day just one accident or illness away from bankruptcy. These are not primarily people on welfare. These are middle-class Americans. Some can’t get insurance on the job. Others are self-employed, and can’t afford it, since buying insurance on your own costs you three times as much as the coverage you get from your employer. Many other Americans who are willing and able to pay are still denied insurance due to previous illnesses or conditions that insurance companies decide are too risky or expensive to cover.

President Barack Obama, to a joint session of Congress

April 25, 1928

For some time the statement has been made that only two groups of persons can afford to be ill, the wealthy and the very poor. The former are able to pay for what they get and the latter get a rather good type of service without charge.

The group that gives the greatest concern to students of the situation is the middle class. This group has been the victim of exploitation since the earliest times. It exists in one-room kitchenettes in the cities and must perforce go to the hospital in times of sickness. In the country and in the villages it is far removed from the available hospitals and pays mileage charges in addition to medical fees for medical attention. Because of its transient character it has fallen out of touch with the old-time family physician.

Morris Fishbein, “Socialized Medicine” April 25, 1928 to the American Medical Association

By 1928, most European countries had established some form of national health care, whether a state-based single payer system or a hybrid insurance private-public partnership. In the US, Theodore Roosevelt’s 1912 Progressive Party platform included this plank:

The protection of home life against the hazards of sickness, irregular employment and old age through the adoption of a system of social insurance adapted to American use;

Specific reforms embraced by the Progressive Party included:

We favor the union of all the existing agencies of the Federal Government dealing with the public health into a single national health service without discrimination against or for any one set of therapeutic methods, school of medicine, or school of healing with such additional powers as may be necessary to enable it to perform efficiently such duties in the protection of the public from preventable diseases as may be properly undertaken by the Federal authorities, including the executing of existing laws regarding pure food, quarantine and cognate subjects, the promotion of vital statistics and the extension of the registration area of such statistics, and co-operation with the health activities of the various States and cities of the Nation.

Despite the best efforts of subsequent Presidents, Congress would not cede ground on the health care issue. In 1960, federal unemployment insurance, disability insurance, and a federal pension were all in place, but health care was the sacred cow upon which Republican opponents staked their claim.

Indeed, Fishbein’s article quoted above builds the American Medical Association’s case for why socialized medicine should be avoided at all costs. After ticking off a litany of reasons why there should not be any government baseline for health care, Fishbein goes on to argue against private insurance as a way to spread the risk and costs to provide care, but he saves the deepest scorn for Great Britain’s system.

Any doctor can get on the list of those working under the act and there are in England, Scotland and Wales some 35,000 so registered. Of these fewer than 15,000 are actually doing national insurance work. About 1,000 physicians, constituting an active minority, refuse to have anything to do with the whole scheme. The number of persons insured under the act is approximately 15,000,000, so that the average number of insured persons in the care of one doctor is about 1,000.

His argument isn’t so much about the patients’ access, though as much as it is the quality of the doctors contracted to provide care. There is, in this essay, a lofty air of arrogance and elitism running through it, a tone carried through the debate in later years as well. Even though the AMA standard-bearer changed, the message was the same: We know best.

Let’s move farther down the timeline.

1943-1950: The Wagner-Murray-Dingell bill

Social Security has passed, as has unemployment insurance. Congress is bickering over disability insurance but health care is still overlooked. World War II rages on, Congress has granted some veterans’ health benefits to returning soldiers, and the debate heats up. Unions and other fraternal organizations line up behind it; the AMA organized against it. Despite Roosevelt’s past efforts to secure health care for all Americans, his reception to the actual bill proposed by the House was lukewarm, owing possibly to the ongoing war effort. He did, however, warm up to it in 1944, promising to take it up with Congress.

The bill died in committee in 1944; Roosevelt died in office in 1945. Despite Truman’s efforts to include it, and despite overwhelming public support for it (75% in favor in 1942; 59% in favor in 1943) it went nowhere.

The analysis on the Social Security site of why such a popular measure died is instructive:

The answer is that highly controversial legislation must be treated as a special case. No system of representative government can truly be equitable–nor can it survive in the long run–unless it takes into account the intensity with which opinions are held. Although the principle of majority rule is deeply ingrained in the Nation’s political tradition, Americans are equally committed to the principle that the majority must not tyrannize the minority, or deprive the minority of basic rights. As columnist Tom Wicker noted recently in The New York Times: “One of the features of the American political system, in fact, has been the restraints it exercises on ‘pure’ democracy–or what some call mob democracy. Allowing each state two senators, regardless of size and population, and interposing the electoral college between voters and candidates are only two examples.” (3)

Characteristically, our political system responds rather quickly in situations where a strong popular and interest-group consensus exists. Conversely, when there is a serious split among major interest groups, politicians tend to proceed cautiously.

The author goes on to attribute the failure of the Wagner-Murray-Dingell bill, debated over the following 5 years, to deeply divided and competing interests. He notes the following benchmarks:

• Senator Robert A. Taft of Ohio introduced a counterproposal appropriating $200 million to states to provide private health insurance for the poor. Truman would not agree to it, arguing that it would delay a program for all, and was a $200 million subsidy to the insurance industry. That angered Republicans, who united against any further effort to extend medical benefits to the elderly.
• The 1946 midterm elections centered around criticism of the New Deal programs, with the Republicans accusing Democrats of driving the country into debt.
• The AMA dug in hard, organized, and campaigned against it. They teamed up with the US Chamber of Commerce, trial lawyers, and more than 1800 other organizations.

By 1950, it was clear there was no national will to extend health insurance to all citizens. The country was distracted by the McCarthy witchhunts and the Korean war. Ultimately, the final nail in the coffin was this:

In a throwback to the early 1900’s, health insurance became entangled with patriotic issues and was pictured as un-American and “revolutionary” by the time the election campaign had begun, many candidates were shying away from taking a position on it. In political parlance, it was becoming a “pariah issue.”

And this, in a long, convoluted way with attention to the Great Disability Debate outlined in Chapter 2, brings us to 1960.

1960 – 1965 Medicare for the elderly

Despite support from the AFL-CIO and other labor players, despite voter support, it was apparent by 1960 that universal health care for all was a political non-starter. However, there was a rising movement and support for providing health care to the elderly. The American Hospital Association was looking to Congress to help them with the costs of indigent elderly patients, and unions gave the final shove to introduce a bill expanding Social Security benefits to include hospital and medical benefits for the elderly.

The AMA, however, remained adamant about any health coverage tied to a government program. Allying with the newly-formed Health Insurance Association of America, the US Chamber of Commerce and the Pharmaceutical Manufacturers’ Association, they launched a pre-emptive PR campaign against any expansion of Social Security to include health benefits.

The environment seemed right: Congress had passed a program allowing for direct payments to providers for welfare recipients, including elderly welfare recipients. After considering some incremental measures for the poverty-stricken and indigent, HR 4700 was introduced by Rep. Forand of Rhode Island. It would provide insurance against hospital, nursing homes and surgical services for OASDI recipients.

A milder bill (HR 12580) was also introduced by Republicans, which allowed for state-administered benefits for elderly patients who met a means test. Both measures failed in the House Ways and Means committee, and were never sent to the full House of Representatives.

The Senate passed Social Security amendments in 1964 which included hospital insurance provisions. The corresponding House bill did not have anything similar. In the conference committee, the Senate conferees voted 4 to 3 to include the hospital provisions; the House conferees rejected them on a 3 to 2 vote. The conference committee adjourned without sending a Conference report for approval.

After the 1964 elections, President Lyndon Johnson decided to take up the question of Medicare again as his first priority. The House began considering HR 1 on January 27, 1965, one week after Johnson’s inauguration. A shift in the makeup of the House to a strong Democratic majority gave them the votes in the Ways and Means committee to report out HR 6675 by a vote of 17 Democrats in favor, 8 Republicans against.

On the House floor, Republicans argued for a voluntary health plan with a floor funded similar to Medicaid (which would have placed most of the cost and control on individual states). During the debate, HR 7057 was introduced which provided for a voluntary system paid partly by the government and partly by the individual. Republicans fought to send HR 6675 back to the Ways and Means committee and substitute their version instead. That effort failed, and HR 6675 passed the House by a vote of 313 (65 – R, 248- D) to 115 (73 – R, 248 – D).

Meanwhile, in the Senate, major provisions of the House bill survived and it was sent to the Senate floor.

5 years after the effort began, and 37 years after the national debate began, the Senate passed HR 6675 by a bipartisan vote of 68 to 21.

Medicare became the law of the land on July 30, 1965.

Next installment: Lessons learned from historical context

1949

Fast forward our HCR time machine to 1949. World War II is in the past, a new decade is just beyond, the first Social Security benefits are being paid to retired workers, and the future looks bright.

Well, it looks bright for some, anyway. For others, not so much. President Truman has sent a budget to Congress on three occasions with expansions in Social Security coverage, addition of a medical benefit covered by a small increase in the payroll tax, and increased benefits to Social Security recipients.

Some specifics:

The amendments broadened the Social Security Act to cover roughly 10 million additional persons, including regularly employed farm and domestic workers, self-employed people other than doctors, lawyers, engineers and certain other professional groups, certain Federal employees not covered by government pension plans, and workers in Puerto Rico and the Virgin Islands. On a voluntary group basis, coverage was offered to employees of State and local governments not under public employee retirement systems and to employees of nonprofit organizations. The amendments also made benefits available to dependent husbands, dependent widowers, and, under certain circumstances, children of insured women (under the 1939 amend-
ments such benefits were not generally available to children of women workers). In addition, Congress raised benefits by about 77 percent; raised the wage base from $3,000 to $3,600; raised employer and employee taxes gradually…

The final plan didn’t look much like Truman’s original proposal, which had requested an increase in the wage base to $4,200, a disability benefit, and medical benefits for all (Medicare). The House Ways & Means committee stripped the medical benefit, lowered the wage base, and removed the lowered age for women’s eligibility (proposed at age 60 in Truman’s request).

Republicans objected, in particular to the disability benefits. Their argument:

…aid to the disabled should be limited to charity aid provided under the proposed public assistance program for the permanently and totally disabled.

Ah, the old charity argument again. Cue strains of “they can always go to the ER.”

In typical Republican fashion, they threatened to bury the bill in amendments upon amendments, causing the House Ways & Means committee to delay sending the bill to the House for a vote until they could secure a commitment from the Rules Committee to bar all floor amendments.

As you might imagine, Republicans were not amused.

On October 4, 1949, Mr. Sabath (D-Ill.) offered a resolution for four days of debate on HR 6000, with only the Committee on Ways and Means having the right to offer amendments, and with only the motion to recommit being in order.

Those favoring the resolution for a closed rule stated that the Ways and Means Committee had devoted six months to considering the bill, had heard testimony from 250 witnesses and thus knew best how to improve the program. Those opposing the closed rule said the bill was very controversial and that the whole House should settle difficult questions of policy. They said the closed rule negated the importance of other House Members and in fact usurped their rights.

In 2010, the arguments are quite similar from the Republicans. The focus is on process, the arguments shrill, stomping of feet and waving of 2000 page “monstrosities”, demonstrations on the lawn of the Capitol and a barrage of advertising day in, and day out. Today’s talk shows are filled with talk of “deeming” and “repeal”. (If you put a singsong quality to that phrase, there are lots of childhood tunes that fit.)

But wait! The Republicans were not without a plan. Here’s theirs:

The minority bill,HR 6297, introduced by Mr. Kean (R-N.J.) on October 3, 1949, held the wage base to $3,000; recommended greater coverage for domestic workers so that those who were less regularly employed would be included; exempted teachers, firemen, and policemen with their own pension systems from coverage; confined disability payments to the public assistance program; and recommended that Congress establish an independent social security system in Puerto Rico, the Virgin Islands, and other possessions rather than include them in the existing OASI program.

By today’s standards, that plan was downright liberal.

The House passed HR6000 on October 5, 1949. Now it was the Senate’s turn.

1950

The Senate, running true to form, did not take up the bill until mid-1950. It was reported out of the Senate Finance Committee without the disability benefit OR the medical benefit, and floor debate began.

Republicans in the Senate were mostly concerned with how the plan was paid for. Rather than creating and funding reserves in a trust fund, they wanted everyone age 65 to receive a flat benefit which was paid for out of that years’ budget. While their effort was defeated, they were able to secure a promise that it would be studied in the future and the Senate bill passed on a vote of 81-2.

In conference committee, the House disability benefit was dropped in favor of the Republicans’ “charity only” proposal, and the amendments adopted.

If one were to compare what President Truman requested with what he got, I believe we could say it was “less than perfect but at least 10 million more people weren’t left in the cold.”

1952

In 1952, a new round of amendments was proposed to strengthen OASI, including a reconstituted disability “freeze” integrated with state benefits, and a provision for the Federal Security Agency to make disability determinations, using their own doctors. The AMA was adamantly opposed, arguing that allowing the FSA to make disability determinations “would lead to socialized medicine.” HR7800 was defeated on that basis, sent back to committee, and brought back to the House floor in June.

An amended version of the revised bill empowered the FSA to make disability determinations, but omitted the language specifying how the FSA administrator should do so. Mr. Reed said “…let no person on this floor be deceived. You have the same old HR7800 here before you. While the socialized medicine advocates pretend to remove the specific instructions to the Administrator, they now give him more powers under general provisions of the law than he had before. You have socialized medicine here stronger in this bill than was HR 7800, heretofore defeated.*’

However, it was an election year, and the bill passed the House by a large margin.

Once again, the Senate Finance Committee took their time. Claiming inadequate time to consider the disability provisions, they stripped it from the Senate version before putting it to a vote. It passed on a voice vote, and was sent to conference committee.

If only it ended there. But in 1954, major changes were afoot.

1954 and beyond

A new Administration has taken office. One of President Eisenhower’s first acts is to send a request to Congress to expand Social Security coverage in a fashion similar to the expansion first proposed by President Truman. Congress complied, and the amendments were signed into law on September 1, 1954.

In 1956, another round of amendments lifted the disability “freeze” and added an official disability benefit to Social Security for workers “totally and permanently disabled” age 50 to 64 who met the minimum coverage requirements.

For the rest of the decade, the only changes to Social Security were increases in benefit levels. But in 1960, the debate would turn to medical benefits.

Tune in for HCR History, Chapter 3 next: The Great Medicare Debate.

I’ve been entertaining myself with a walk down memory lane on the legislative history of Social Security and Medicare for a few days. The more I read, the more familiar it all sounded. It’s a little like seeing bellbottoms and skinny jeans come back into style: fundamentally the same with small tweaks. By looking at these arguments, though, a better perspective comes through on this current effort to reform health insurance and expand access for all. From the CRS Report to Congress¹, some choice excerpts:

1935

Opponents of Social Security used the following arguments:

Some opponents maintained that the Federal Government did not have the constitutional power to create a national pension plan. Some questioned whether the system could be kept financially sound and whether adequate earnings records could be maintained for so many millions of workers. Still others criticized the program as not generous enough.They protested that it gave only partial protection and minimal benefits, and that it imposed a regressive, “soak-the-poor” tax.

In 2010, opponents of HCR argue its constitutionality, financial soundness, and on the left side, there are still protests that it doesn’t go far enough.

Turning to the legislative debate now:

When the Act was debated in Congress, leading Republicans in the House and Senate made attempts to delete the provisions creating the old-age pension system. They said they preferred to rely solely on the assistance (charity/ welfare) approach to help the aged. They argued that the payroll tax/insurance mechanism of the old-age benefits provisions might be unconstitutional and that, at any rate, it would impose such a heavy tax burden on businesses that it would retard economic development.

They contended further that the program would “destroy old-age retirement systems set up by private industries, which in most instances provide more liberal benefits than are contemplated under title II.

Can you imagine Republicans arguing that today? Campaigning on killing Social Security? Of course not, which is why they instead argue for ‘privatization’.

And yet, isn’t that exactly their argument against HCR? The mandate is unconstitutional, government shouldn’t regulate insurers, health care access disparities are just fine with them, and besides, there’s always emergency rooms.

This scenario should feel familiar. From the halls of the Senate:

On June 19,1935, Mr.Clark(D-MO.)offered an amendment to exempt from coverage under the old-age benefits system employees in firms with private old-age pension systems. This idea came from an official of a Philadelphia insurance brokerage firm that specialized in group annuity contracts. The Ways and Means Committee rejected the proposal and so did the Finance Committee (by a narrow margin), but when Senator Clark offered it as an amendment on the floor, the Senate backed him, 51 to 35, with Democrats divided and Republicans solidly in favor. In the end, the bill’s passage was dependent on deferring that particular issue.

Had this succeeded, we would have had the same weird tiered system we have for health care, where certain groups had a pension and others were utterly dependent upon their employers. Had that come to pass, the welfare rolls would have swelled as employees’ pensions were raided or simply lost to poor investment choices.

Also not lost on me: the age-old Democratic divide: Clark is a conservadem from a midwestern state, who managed to pull enough Democratic Senators with him to succeed with his floor amendment.

How was it resolved?

The conference committee reported the bill without the Clark amendments, but with an understanding that the Chairmen of the Ways and Means and Finance Committees would appoint a special joint committee to study whether to exempt from payroll taxes (and thereby from coverage) industrial employers having private pension plans and to report to the next Congress.

On August 9, 1935 the conference report cleared the Senate and was sent to President Roosevelt for his signature. Social Security was real.

Stay tuned for chapter 2, where we fast-forward to 1950 and the first benefit expansion. Chapter 3 will roll history up to the Great Medicare Debate.

¹(Major Decisions in the House and Senate Chambers on Social Security: 19354985 (PDF) )

(voice over) and now a break from politics, while I bring you the sad story of how Apple’s sterling reputation is being tarnished by their own customer service department. The Apple doesn’t fall far from the Dell tree…

Ask anybody and they’ll tell you: Apple is cool. They make cool products. The iPhone rocks. The iPod touch is awesome. We all wait to tune into the new product releases, which are so super-top secret they don’t even broadcast them. Many of us who used to use PCs have switched to Macs and for the most part, are satisfied.

For the most part. And then, there’s Jane. I’ve written about Jane before, because I so want to be her, driving all over the country, writing about it, meeting people, telling their story and telling hers. After Jane’s ancient PC died, a benevolent sponsor gave her a MacBook Pro with Apple Care and his hopes that it would be a trusted tool on her journey.

Four months later, the MacBook Pro has died. Not only has it died, Jane stands convicted of murdering it without a trial, evidence, or a chance to offer a defense.

Yet when I brought my four month-old MacBook into the Apple store, and residue was found near the hinges and fan, the guy at the genius bar insisted I must have murdered my MacBook by way of spillage. Argument was futile. He’d made up his mind — nothing but a spill could have caused the residue that was present, and there could be no other cause but spillage for the MacBook’s breakdown. The three-year warranty my donor generously purchased would not, I was informed, be honored.

Jane is more generous than I about Apple’s behavior here.

This isn’t a slam against Mac or Apple. Macs are popular for very good reason, and Apple’s customer service is generally rated high among customers. This is, instead, about my sense of disbelief and the feeling that I have been among the unlucky ones who’ve had their first Apple experience turn out badly. I don’t like being accused of something I didn’t do. It’s like being sentenced to hang for a crime I never committed, and having no way to prove my innocence short of having a CSI crime lab perform forensic tests. And while I realize that many criminals deny culpability, and that some people lie — especially if it might save them money — I’m not lying. The MacBook has rarely been out of my sight, has not been near anything wet, and has been kept in its storage bag when not in use.

When I read this, I got pissed, because I know of two other people who have replaced logic boards in their MacBook pros without spilling, too. The logic board dies. Maybe it’s flawed. Maybe the children in the factories where Apple builds their products didn’t handle it right when they were assembling it.

Maybe, just maybe Jane isn’t lying. Because, are all of these people lying, too? Look at these results, and these are just from people who post to Friendfeed. Here are some real-time Twitter results. Oh, and over here? Facebook search.

Residue or no residue, MacBooks die. Logic boards die. A customer who has a 3-year warranty in her hand and a 4-month old dead computer deserves the benefit of the doubt, Apple. It isn’t enough for your Geniuses to say she spilled. They need to prove it, and the presence of residue doesn’t prove it.

Other causes of residue

• Misapplied thermal paste at the factory
• Excessive heat (NVidia chips are a known cause)
• Defective materials in one of the chips
• Incomplete seal of the case, allowing moisture to get in

And of course, there is the possibility that we have a chicken-egg issue here. Maybe the failure of the board created the residue.

Apple has an obligation to acknowledge product weaknesses

Logic board failures on Macbook Pros are not unusual. According to MacinTouch.com, logic board failures are the most common failure on a MacBook pro. This is affirmed by the real-time search results I added above, and re-affirmed when I search on Google real-time results.

In other words, trends are clearly not in favor of this customer being wrong.

What happened to the customer being right?

Even if you’re willing to leave this as it is, the fact remains that Jane has a warranty that covers replacement of her logic board. All Apple has to do is honor it. Honoring it, even if they believe in their heart of hearts she’s lying, is the honorable thing to do, because she paid for an extended warranty.

Telling a customer they lie is not a way to build customer loyalty. Just ask Toyota about how well that worked for them.

The consequences of giving customers the middle finger…

Five years ago, I was a hard-core Dell fan, primarily because they had great reliability and customer service. Anyone who asked me got a recommendation to a Dell product, whether it was a laptop or a PDA.

Then my beloved Dell Inspiron’s warranty ran out, and the day after it ran out, the screen went black. Dell quoted me more than the cost of a new computer to fix it. By the time all of this happened, I was also aware that Dell’s formerly-stellar customer service had been offshored to call centers and the best anyone could get was a guy with a script.

I stopped recommending Dells. I didn’t tell my friends to buy Dells. I bought a Toshiba that was ok but whose keyboard I loathed and lived with it until I could find something I loved as much as I loved that Inspiron.

My white MacBook was that machine I loved more than my Inspiron. Over the past year, our entire family has moved to Macs. We have iPhones. We like them. But I’ll be honest: I haven’t had trouble with anything but one MacBook that lives a rough and tumble life in the hands of the drummer. Others, like Jane, have. And I am hearing more and more stories like Jane’s. The more stories I hear like Jane’s, the more I see in real time, the more I see Apple’s attitude toward their customers becoming one of entitlement instead of genuine concern that they are satisfied, the less likely I am to be a repeat customer.

I was set to order an iPad on Friday. I decided to wait, mostly because if I’m going to make that kind of investment, I want it to be in a company that values me as a customer and honors their commitment to their product warranties and extended warranties.

Do the right thing, Apple. Man up, repair her MacBook pro. Do it fast and you’ll give her a reason to love you again, and write about it. Just do it. You’ll be glad you did.

Related links and stories

Here’s another example of Apple calling a customer a liar re: a dead logic board. This site was created after a series of bad experiences with Apple customer service. And over here, an example of how customer service should have been handled for Jane: they replaced the logic board the same day. And here, a customer who was out of warranty suggests buying one…assuming automatically it would have been honored. Seems that there have been enough problems that Digg has an ongoing shoutout to force Apple to acknowledge the problems, too. Over here, an entire site devoted to MacBook Random Shutdown Syndrome (aka RSS)

Got more? Add them in the comments.

Just pass this right on by if you’re not in the mood for musing. I’ll totally understand. I’m not writing this for sympathy or concern or anything else. More really just to work out my own incredulity at the depth and breadth and length that people will go online to make themselves seem somehow superior at others’ expense.

I think I can honestly say without any qualifiers that while I get frustrated, I try not to make it personal. Sometimes people take things personally that I don’t mean personally, or assume that my criticism of their message is criticism of them. But I can honestly say I have never, ever said things like these about anyone else:

Ah yes, there’s [deleted], sticking up for his cum slut @karoli, and pretending like single payer is hopeless. What a LINO fucktard.

@karoli should kill herself with a dull butterknife.

I don’t like @karoli. I consider her a cancer to real change.

@Karoli On Twitter you have been an uncle Tom, as I define it.

I’m not going to mention the source of the first three except to say that the writer is a man who thinks harassing and bullying women is a sport. He deserves no more attention or mention than that.

The source of the last one, though, was a surprise. I have long disagreed with Ray Beckerman, but in the past had a great deal of respect for him as well. However, the year-long, bruising and contentious health care reform debate is about to end, with the majority of the left closing ranks around the Senate bill with a sidecar reconciliation fix. Despite accusations to the contrary, my position on health reform has been constant: pass the bill with or without a public option, because until we eliminate the exclusion for pre-existing conditions we have an inequal and discriminatory system of health care access.

In Ray’s opinion, that is “Uncle Tomism”, a term I consider inflammatory, racist, and unwarranted. Under his definition, I am an Uncle Tom for supporting passage of this bill without a public option (which is not passable in both Houses of Congress that I can see). In his mind, I’ve sold out to The Man.

Irony alert: If Ray gets his way, Sticks will have to sell out to The Man in one year by finding a job with a corporation that sponsors health insurance, because he will be ineligible to remain on our coverage that we just got this month. Instead of being a musician and entrepreneur, he will have to find some niche in some office with some health insurance and prop up their bottom lines.

Oh, now there’s a reward, Ray! Kill health care reform from the left. You show those corporations. You go. Because God knows they’ll be weeping in their profits if health care reform fails. But no matter as long as you can wear the hair shirt of purity.

Seriously. Uncle Tom? Really? Intentional race-baiting from a so-called “progressive”? From a forward-thinking, concerned about all people kind of guy? Really?

The vitriol really started pouring forth after I began to criticize Dennis Kucinich, who richly deserves what he gets, in my opinion. Kucinich is on the record as recently as Monday saying he will gladly cast the killing vote in the House. Yep, you read that right. He’d just as soon kill health care reform as pass it. Why? Well, because there’s no public option.

Keep in mind, he voted against it in November when the House bill had a public option. His excuse then was that there was no single payer. Now there’s a state single payer exception but that’s not enough for Dennis, nope. And the purists cheer while bullying those who object.

Kucinich is simply letting Stupak take the fall on abortion. Kucinich was rabidly anti-abortion until he wasn’t, and he wasn’t right around the time he decided to run for President. He claims to have gone through a transformation, but it’s interesting to note that he stands next to Stupak and is willing to own a kill on the health bill for inconsistent and inexplicable reasons.

That’s because there will never be enough for Dennis Kucinich, or Ray Beckerman, or Jane Hamsher for that matter. These are people who do not understand that their will isn’t everyone’s will. They are as dogmatic and absolute as the teapartiers are. And when someone stands up and uses their voice to show the weakness of their position, they resort to name-calling, personal attacks and flames, character assassination and even race baiting.

How progressive.

If it were happening to Ms. Dancer, I’d have no problem calling it bullying, because that’s what it is. These people are bullies, plain and simple, and they exist on the right, on the left, under rocks, in real life,in the halls of Congress and especially online.

Sadly, when it happens online it places other decent and kind people in the crossfire. That has happened more than once today. That’s the fallout of bullying. There isn’t a lot anyone can do about it other than simply block out the bully and move on. But occasionally, the ugly yellow buildup of a barrage of negative, wasted words just gets old. And tiring. It takes the joy out of interaction. As much as I remind myself that there’s no utopia in health reform or online discussion, sometimes it just needs to stop.

That’s when I close up the computer and turn off the Internet, say good night to my friends and move on to a new topic and focus. That’s where I am now. Health reform will pass in spite of or because of me and the likes of Ray Beckerman, women-bullying trolls who shall not be named on this blog, and wild-eyed flaming teapeople.

I’m all talked out on this topic. I’m moving on to some other ones. Turn the lights off when it’s done, would you?

Strains of June, 2008 play on. Back then, Barack Obama won the primary race but Hillary Clinton did not concede on cue. Speculation abounded. Would Hillary divide, or unite the Democrats? Would Barack choose her as his running mate? Every day on Newsgang Live that summer, Steve Gillmor insisted that Hillary would be VP, that she had to be VP or else Obama would lose the election.

Here we are again. At the end of a brutal year of wrangling over health care reform, everyone jockeys for position. Bart Stupak insists he must have his strict abortion language. Dennis Kucinich insists that he will vote no despite the inclusion of his state-based single payer initiative in the Senate bill. No public option, he declares, means a no vote from him. No ban on public funds for abortion, Stupak declares, means he’ll take 12 yes votes and go home.

In candidate-land, Blanche Lincoln rethinks her position on a majority vote after she is confronted with a viable primary challenger; Mr. Stupak is about to discover that he is dispensable. Alan Grayson introduces an optional Medicare buy-in for all as “The Public Option Act”, and 38 senators have signed onto some form of support for a public option, but with many caveats. Grayson’s poll numbers run higher with Republicans than the Republican candidates in his district while Lincoln’s fade and Stupak’s star plummets.

HCAN stages a mock arrest of AHIP members and the Tea Partiers bring their town halls to Washington DC. Politics, American-style. What does it all mean? Will Hillary be VP?  Will reform, even Senate-style reform, become reality? What new surprises will come tomorrow? When will Hillary be VP?

It means this bill’s going to pass. It’s probably going to involve some kind of deal for limiting women’s access to abortions, which sucks. This is because it’s easier to sell women down the river than it is to step off a high horse. It also means we will unite around it, and around the next round of reforms, too. It means that Grayson’s bill might actually become reality someday and Stupak will be blessed by a cadre of Catholic bishops.

It means 31 million people will not be discriminated against. It means kids with pre-existing conditions will have coverage right away. It means we’ll all have access to preventive care, and clinical services, and it means an end to the power of the insurance lobby as it has been for decades. It means we’ll be able to pursue dreams, like owning our own business, or being a musician, or writing the Great American novel. It means we win.

Stupak or Kucinich (and I’m guessing Stupak) will come around once the proper sacrifices have been made to the god of the moment, and we will unite.

Whether Hillary will be VP remains to be seen.

Wooooo!!!!!! I’ve been reading C&L for years and years — they’re one of my favorite blogs ever. So when they asked me to write a post about last night’s teabagger ’strategy call’, how could I resist? Go read it: Alice in Teabag-istan, complete with the mad hatter and a special appearance by our President’s cousin. (with family like that, who needs enemies?)

I see a ton of enthusiasm for the public option. I understand it. Emotionally, I agree. Intellectually, not so much. A public option is attractive on paper but has some serious and real pitfalls in my view. I understand why people don’t want to ‘let insurers win’ on this and also why they hate having commercial insurers as their health insurance choices, but there are still some very practical, non-procedural reasons to stop and think it all through.

The fight rolls on

Many, many senators have now made a public commitment to “the public option.” Notably, one of the key and vocal supporters of a public option is Senator Tom Harkin, who has not made that commitment. When asked, he answered thus:

“If we have a bill sent to us from the House that does not have the public option here, if we were to add it here, it would sink the whole bill.,” Harkin said during an interview on MSNBC, adding that he would not vote to revive the public option “if it meant that it would sink the whole healthcare reform bill.”

This statement confuses, bewilders and angers many public option supporters, I know. Jon Walker of FireDogLake, ardent public option champion and Jane Hamsher’s right-hand go-to HCR dude expressed the same sentiment I’ve seen from many others:

It is an insult to the progressive community’s intelligence to ask them to pin their hopes for a public option on Democrats taking up another health care reconciliation package to pass the public option later this year or next if it is presupposed Senate “supporters” are going to work against its inclusion in the current bill.

What we have here is a failure to communicate. Tom Harkin is arguing process. Jon Walker is arguing principle. The two are not meshing.

What public option are they fighting for, exactly?

Here’s one small process note: You really can’t start from scratch with items planned to go through the reconciliation process. Since the Senate bill, as passed by a supermajority, did not have a public option in it, that leaves the House version. So let’s review what that was, exactly.

1. A new agency, required to be self-sustaining
2. Funded with $2 billion dollars of federal money to be repaid within 10 years.
3. It would be an option available only to individuals who did not have insurance available via their employers, offered on the national insurance exchange.
4. The government would be required to negotiate rates with providers in a similar fashion to the commercial carriers.
5. Policies would be subject to the same restrictions and regulations as any other policy on the exchange.
6. The government could hire contractors to administer the plan; that is, private insurers.
7. Under no circumstances could the public option be bailed out by the government. Premiums would have to reflect the actual claims experience and administrative costs associated with maintaining the plan.

That’s the public option skeleton. The first issue that emerges is an important one, and probably why Senator Harkin is shying away: It assumes a national exchange. The Senate bill is based upon state exchanges or co-ops selling across state lines but subject to state regulation. It’s not clear how a national public option that is supposed to be sold alongside private options on state-based exchanges could actually be done. But let’s say that it can.

Why I don’t support adding this public option to that sidecar over there

Three primary reasons:

1. Adverse selection: Insurers will make even more profit with a public option because the sickest and oldest people will gravitate to the government option. This isn’t me making it up. The CBO also concurred, which is why they predicted slightly higher premiums under a public option than a private insurer option.
2. Cherry-picking: This public option would encourage insurers to price their products just a smidge higher than the public option in order to encourage those most in need to turn to the government plan and ratchet down insurers’ risks. From the standpoint of a citizen with a choice, that’s not so bad until you start realizing what it means to the financial health of a public option. Combine that with a statutory requirement for solvency and adequate reserves, and it’s not hard to see who benefits most from a public option. Not us. Insurers.
3. Duplication: I’m concerned that creating a new agency subject to the same rate structure as private insurers will slow a move to a single-payer model (or state-based single-payer) to a crawl or give incentives to privatize Medicare and move everyone to this option/system, which is less advantageous than Medicare.

Bottom line: Insurers will try to kill it with much love, merely by allowing it to exist as a repository for their castoffs, OR they will use it as a way to privatize Medicare with a weak public option for Medicare beneficiaries.

What public option is there, then?

Medicare. I have long believed that if we were to clean up the fraud and waste that is in Medicare right now, get EHRs online, shift reimbursement models toward true outcomes-based rates, a strategy emerges for expansion that goes like this:

1. Years 1-10: Expand Medicare participation on an optional basis to two groups: Ages 55-65 and 25-35, with the younger group allowed to include spouse and dependents, the older group to buy in on an individual basis. Expanding Medicare to the younger group begins to build reserves in the trust fund, since the younger participants are less likely to drive costs up. But here’s the deal: Once you buy in, you stay in, voluntarily waiving the right to shift between private and public health care plans. Employers could contribute a portion of the cost for the opt-ins based on the percentages contributed for private plans.
2. Years 11-20: Expand optional Medicare buy-in to the 35-55 group with the same terms. Opt-in, stay in. If Medicare solvency from the first group buy-in causes the trust fund to reach a certain benchmark, this group could even buy in earlier. Allow private insurance to exist alongside Medicare buy-in for all, but also permit supplemental policies or other product innovations to emerge.

In one generation’s time, the country shifts to Medicare for all, with a solvent trust fund, states are freed of Medicaid obligations, and health care access is based upon a strengthened Medicare baseline, lower cost curves, with room in the markets for private insurers to compete for other services.

Why Medicare instead of something new and shiny?

I admit that I haven’t crunched all of the numbers. I probably could, or could dig out some actuarial reports, but that’s better done by the CBO. This is what I do know: In the next 10-20 years, we hit the top of the baby boomer curve and peak enrollment in the old-age programs currently in effect. Medicare as it is today places only the most expensive group — the aging and elderly — under its umbrella, effectively creating the absolute worst-case scenario for cost containment.

Just as in private insurance, spreading the risk over a population that includes those less likely to drive up medical costs in the earlier years while including that portion of the population that will enter the system anyway within 10 years and phasing in the “middle group” over time seems like a way to smooth that bell curve of participation and cost while guaranteeing access to health care for all. It is similar to a pure single-payer model, but allows for opt-in during the phasing process; e.g. patient choice. By making the opt-in a one-time opportunity, revenues and offsets can be reasonably projected and accounted for, rather than simply having to calculate the worst-case among those who drive the highest expenditures.

This idea mirrors HR676, but smooths the shock to the system, giving time to build some decent reserves to offset current budget deficits, too. Most importantly, it utilizes a framework that, once modernized and reformed, offers the best and most efficient way to open the doors to a true, robust public option.

Why not just include it via the reconciliation process now?

Because we have not yet established the will of this country to say out loud that every citizen, every resident, every man, woman and child in this country is entitled to equal access to health care. Until we make that declaration by ending all pre-existing conditions exclusions for public and private plans alike, we can’t move to the next square. In this regard, I agree with those who argue for incremental reforms.

Establish the right to health care. Make it the law of the land. Fix what needs to be fixed inside the Medicare framework. Then throw open the doors and invite people in.

Note: @manyko2 on Twitter points out that part of this initiative would be locking down the Medicare trust fund. No borrowing. No shifting. It’s a trust fund that isn’t tinkered with. Also, @avivao pointed out that a lock-in to Medicare involves a great deal of trust. While that’s true, I think objections can be overcome by either setting benchmarks for Medicare before the lock-in happens, or allowing opt-out in certain circumstances (provider revolt, refusal in geographic location, etc.)

I realized I haven’t said anything about the Olympics. How can that be? The women’s figure skating competition was by far the most intense I’ve ever seen. Those skaters are incredible, and yes, I’m a marshmallow. I rooted for Joannie Rochette because it took an incredible piece of her heart and soul to lose her mother and still manage to get out on that ice and represent. Hearing her Canadian audience carry her over the rough spots was enough for me to turn into a blubbering mess.

Despite NBC’s insistence that I should watch nothing in real time, but should have to wait for a 3-hour time delay before seeing what people I talk to on Twitter every day have already seen and tried not to give away, tonight’s competition riveted me. I’ve seen Olympics where skaters fell on every second jump, but tonight was special, regardless of country, nationalism, and network hype.

I still love luge and bobsled, but remain convinced that anyone crazy enough to attempt the skeleton by hurtling down the luge track head-first probably deserves to be given a very large medal or simply deemed insane.

This Winter Olympics has been a lot of fun to watch, partly because of the talent and partly because the Canadian audiences have been wonderful and enthusiastic. It makes me want to go visit Vancouver, which is, of course, why we have these things. Right?

Any favorite moments? Don’t make me the sole marshmallow.