President Obama's Next Step

The White House released a letter this afternoon identifying several Republican ideas that they seem to be willing to add to the President's proposal. The text, released on the White House blog is here. The President had been set to make a speech or statement regarding the way forward sometime tomorrow. It is not clear, but this could imply there have been some discussions with select Republican on different ideas, and this letter is one last chance to stimulate some final negotiation/agreements on add ons.

The items highlighted in the letter are noted in terms of Republican ideas that he is open to, or adopting. They include:

(1) Senator Coburn's waste, fraud and abuse notion of undercover 'stings' on doctors and providers. The President notes that his document of last week adopted several Republican proposals on waste, fraud and abuse, which is correct.

(2) Increasing money to states for medical malpractice demonstrations....the Pres notes his proposal has $23 Million for grants to states for medical courts, and today says he will appropriate $50 Million more toward this. He places this all in the context of agreeing with/adopting provisions of the Patients' Choice Act (PCA) which Sen Coburn and Burr and Rep. Ryan and Nunes sponsored. While I expect many will say this is not that much or not enough, it is the case that it is in line with the PCA, the most comprehensive Republican alternative. In many ways, the most puzzling aspect of the PCA was that it didn't propose more on medical malpractice. The appropriation lanugage v. authoriziation means guaranteeing these demonstration grants will be funded.

(3) Says he is open to Sen. Grassley's suggestion/worry that if expanding Medicaid by 15 Million persons, need to expand physician payment for Medicaid in a way that will make it more attractive for doctors to treat Medicaid beneficiaries.

(4) Says he is open to including language that will ensure that high-deductible plans are able to be offered in exchanges per Sen. Barrasso's comments at the summit about catastrophic coverage. The Pres says he thinks they are now allowed, but willing to clarify. This is the biggest of the developments here (more on that below).

(5) Says he will include language to end the Florida Medicare Advantage deal that Sen. McCain pointed out at the Summit. In addition, he already had included an end to the special deal for Nebraska Medicaid.

The biggest deal is #4. If there is a move to make clearer or easier a route to high deductible plans, then such plans may plausibly be more palatable to younger persons, the persons that might be most likely to not follow an employer mandate. As I noted in my last News and Observer column, a move to let an individual mandate only apply for catastrophic cover would be the likely direction of an actual negotiation on policy terms between the Senate bill and the Patients' Choice Act, for example. There is not really any evidence such a negotiation is underway behind the scences. However, moves toward making a high deductible plan more readily available in exchanges could help entice younger, healthier individuals act on an individual mandate.

The President also clearly stakes out his position that 'piecemeal reform' is not the best way forward. This stands in contrast with Sen. Alexander's notion at the summit that we don't do comprehensive well.

Next step is the President laying out the way forward, presumably tomorrow. Then, can the House find 216 votes to pass the Senate bill? At this point, based on how members of the House voted in November on the House bill, they should be 1 vote short. 220 voted yea (1 Republican, Cao who says he will vote no; Murtha died; 3 Dems who voted yes have resigned to run for other offices since) so based on how they voted in November, that is 215 for, 216 against.

The President and the Speaker have to find 1 Democrat to change their vote yes, while maintaining all those who voted yes in November. Leading candidates to switch would be 3 retiring Democrats, and Dennis Kucinich, who is a single payer guy and voted no because the House bill didn't do enough....and in his terms, the Senate bill does even less (no public option, etc). Does he prefer the status quo to the Senate bill? We will see.

Any blue dog who voted yes in November will get the full monty on being a socialist, wanting to kill your grandmother, hating America, etc. based on that vote....if they switch to no they will also get 'he was for it before I was against it' and will generally be (rightfully) understood to be wusses (this is a technical term). And the Senate bill should be much more to their liking in any event as it is more center than the House bill. So, I think those who voted yes should hold.

There are, of course the 14 Dems who voted yes and linked their vote to the Stupak abortion language. I have no idea how that plays out. I have never gotten Stupak as an actual health policy consideration, since using the logic of Stupak means that the federal government has been subsidizing abortion via the tax exclusion of employer paid insurance if one woman has had an abortion paid for by employer sponsored insurance since Roe v. Wade came into effect. I have always assumed these folks were a mixture of people who wanted to kill reform but have an excuse and/or folks who thought this was a way to advance their advocacy of their abortion position. To the extent these folks are more conservative than average in the Dem caucus, they should like the Senate bill more than the House bill.

The morning of the state of the Union, I said 5% chance of a comprehensive bill when making the case for the Senate bill. Today, I say the chance is better, because of the belief that the President can convince 1 Democrat to change. However, I am not sure of how the abortion language plays out...that is the real wild card, and the way this all goes down if it does.

Update: 8:55pm: I heard a radio report with the AP saying there are 10 Dems who voted no on the House bill in November who are considering/open to voting yes on the Senate bill. It would seem very likely 1 of these will change.....but the 14 Stupak abortion votes remain the wild card.