We Interrupt This Visit To Russia To Bring You A Statement On Health Care

Or -- why hasn't the White House figured out a clearer way to say what it wants to say?

White House chief of staff Rahm Emanuel, in an interview with the Wall Street Journal:

" 'The goal is to have a means and a mechanism to keep the private insurers honest. ... The goal is non-negotiable; the path is' negotiable."

Barack Obama, in a statement released from Mother Russia:

"I am pleased by the progress we're making on health care reform and still believe, as I've said before, that one of the best ways to bring down costs, provide more choices, and assure quality is a public option that will force the insurance companies to compete and keep them honest. I look forward to a final product that achieves these very important goals." [emphasis added.]"

Translation: a bill that expands access and cut costs is a higher priority than a bill that does both and includes a public plan. That said, a bill must contain some way to pressure the insurance industry to keep costs down and improve quality. The political realities in Congress right now preclude the president from being more specific. Also: given that the public plan question is one of several unresolved debates, the White House wants to save its political capital for other questions, like payment reform, taxing health benefits (i.e., capping the exclusion), employer/individual mandate penalties (pay or play) and more. 

Background: The White House is sensitive to three counter-pressuring forces. One: a health care bill probably won't pass the house without a public plan option. Two: a health care bill probably can't attract 60 votes in the Senate with the version of the public plan that passes the house. The White House, here, is looking at the conference negotiations -- the end game. They're letting the House be the House and the Senate be the Senate. A White House intervention in favor of a robust, competitive public plan would doom the bill in the Senate. Three: what Obama wants. The President wants a bill with a public option and which has the support from --and buy in from -- all stakeholders. If given the option of having a bill with a strong public plan and no support -- indeed, intense opposition from -- the insurance industry, or a bill with a weak public plan and plenty of industry support (and Republican votes), Obama would choose the latter. Critically, though, Obama and the White House are relying on Karen Ignani and others to build Republican support for the bill. If the industry can't bring along any Republican votes, it makes no sense to give them a veto option on a public plan. 

The "mechanism to keep private insurers honest" is the goal, of course, of a universally available and government-subsidized public plan. When the public (a big majority of the public) tells pollsters they support a public plan, they're saying they support a "mechanism There are other ways to achieve this goal: government regulations, hybrid public-private plans, experimental public plans, cooperatives (maybe). To be clear, one of the problems is etymological. There is so thing as a "public plan." It is a concept that requires details: who would get access to it? Would providers be forced to participate? How much would they be compensated? Would the government subsidize it? When would it kick in? And would it work as promised? If it's poorly written, it'll simply shift costs to the public, something the White House won't tolerate. If it's used along with Medicare and Medicaid to experiment with payment reforms, maybe they will. Last week, former Sen. Tom Daschle issued a warning of sorts to the insurance industry: Democrats will be less willing to play ball if Republicans refuse to meet them halfway. The message: the insurance industry needs to get Republicans on board, or else Democrats will, when writing the final bill, be tempted to write legislation that the industry will not only be unable to support but will find quite distasteful. 

The big question mark is reconciliation. Senate Majority Leader Harry Reid and Budget chairman Kent Conrad say that the anti-filibuster process simply isn't applicable to most health care legislation, and because reconciled provisions would sunset after five years, the reforms would be impermanent and probably not enforceable. If Democrats need only 50 Senate votes, then they don't need to worry about the President's language now. But if they need 60 votes in the Senate, they do. The House will pass a bill with a strong public plan. The Senate HELP committee's public plan will be strong; the Finance Committee's public plan will be weaker. There will be a fight about amending one of the bills to include the public plan of the other; it will be nasty, brutish and short. Arguably, the President might choose to intervene at that moment. Obama's language on the public plan has been stronger in recent weeks, which may reflect his belief that (a) there inevitably will NOT be a strong public plan in the final bill, so he can be less cautious (but still somewhat cautious), or, (b) he calculates that his support for the concept is enough to make sure that something strong enough to serve as a mechanism to hold insurance industries accountable is included.