Nice post, Brady, but I'm still not convinced that Adult Basic has a serious adverse selection problem.

The theory those of us who pushed RxPA last year heard, from both single payer supporters on our left and Republicans on our right, was that Pennsylvanians get on Adult Basic when they are sick or need to have a serious medical procedure and then jump off when they are better.

Now this might happen if we actually enacted Cover All Pennsylvanians at a funding level that allowed everyone who was eligible to get insurance. But we were never close to doing that last year. Even the bill that passed the House, which was pretty good enough, was not that good.

And as currently constituted, Adult Basic has a 180,000 person waiting list and has not taken anyone off that waiting list for at least six months if not longer.

So no one can presume that they are going to be able to get on the program when they really need and jump off later. Doubling the size of the program to 90,000 won't make that possible either.

Of course adverse selection is a problem for any public health insurance program. So long as health insurance costs people something and there are no or limited waiting periods on the newly insured receiving medical care, some low income people, especially younger ones who think the odds are with them, are likely to try to jump on and off.

One solution is to require everyone to purchase health insurance. If the costs are adjusted to income, that may not be terribly burdensome although it is not politically popular.

The alternative is to build a public program good enough that lots of people want to join it. Given that the administrative costs of government provided insurance is likely to be far lower than that of private insurance, that is certainly possible. And, as a result, the costs of adverse selection will be spread around a large pool of people.

If we combine affordable insurance, minimal but not negligible waiting periods with an effort to build a large pool the problem of adverse selection can be overcome, at least at the federal level.

I think there needs to be a real discussion amongst the folks who worked on this (as well as observers) as to why healthcare reform in this state didn't pass. Not a blame thing, but a real discussion, because it's important.

I worked for SEIU. SEIU PA statewide members are 40 percent Republican. We logged thousands of phone calls by identified Republicans into Republican state house and state senate offices in favor of the healthcare bills. The healthcare effort had phones and mail and TV and grassroots and lobby days and probably the most overwhelmingly Democrat year in 20 years and healthcare still didn't pass.

Rendell might be the last Pennsylvania governor in my lifetime to make healthcare reform a major part of their platform. That is terrible enough.

But what's even worse is that as a microcosm of America, we were really a testing ground for the national effort.

And we lost.

Hannah

I was in the thick of the fight for health care reform in Pennsylvania from September 2007 to August 2008 as the Health Care Campaign Manager for SEIU and a member of the Pennsylvania Health Access Network. (Hannah Miller took over my position when I became state director of Health Care For America Now.) I’ve thought a little about why we lost and what it means. But I haven’t obsessed about it because, as I will explain below, health care politics in Pennsylvania is not really a microcosm of heath care politics in the United States. Moreover, I always knew that it would be difficult to win and thought that the effort we were undertaking was in large part a building process for what we are doing this year at the federal level.

Politics, like football, is also a game of resources, strategy in using those resources, and organization in carrying out that strategy.

The key resource is control over political office

Last year a pretty decent health care was passed by the Pennsylvania House. It never came to a vote in the Senate. Access to the Senate floor is controlled by the Republican leadership who had a 29-21 majority in the body. And that leadership blocked a vote in the Senate.

Well, couldn’t we have gotten them to bring the bill to the floor, just as we got them to bring the minimum wage bill to the floor a few years ago?

Let’s look at some of the differences between the two struggles

1. The Republican Senate leaders during the minimum wage campaign were more moderate than the current leadership. Indeed the whole Senate caucus has become much more hard right than it was just a few years ago. Both leadership and caucus were more fervently opposed to health care reform from an ideological point of view than the previous leadership was opposed to raising the minimum wage.

2. Health care policy is complicated; minimum wage policy is simple.

When it comes to the minimum wage, there are not a lot of options other than how much we raise and whether to institute an annual cost of living increase.

Health care is enormously complicated and there are all kinds of alternatives that affect various interest groups in diverse ways. That makes it difficult to find a policy proposal that attains our goals and balances the concerns of various interest groups.

As Brady pointed out, the policy we supported was opposed from the beginning by leftists who believe that we get a Republican controlled Senate to double the state income tax and add a 10% payroll tax in order to create single payer health insurance bill in Pennsylvania. I don’t think their opposition actually hurt us. But by staying out of the fight for Rendell’s program, they certainly diminished the political pressure for our proposal.

Because health care is a complicated issue, Republicans could come up with alternatives to our proposals that sounded like a serious response to the problem, even if they weren’t. The best part of our campaign, I believe, was our effort to discredit their proposals. But, they still had something to say in response to our pressure. They had little to say during the minimum wage fight.

3. Powerful interests stood in opposition to health care reform but were not that active in opposition to raising the minimum wage.

Large numbers of very small businesses were not keen on raising the minimum wage. But they were not fervent in their opposition because so many of them were paying at least some people above the minimum wage and because they knew that they would not be hurt, and might even benefit, if all businesses had to pay higher wages. Big businesses were indifferent to a minimum wage increase.

On health care, however, powerful interest groups opposed us, starting with the insurance industry which gives substantial sums of money to legislators, especially Republican Senators. The organized hospitals were opposed while the organized doctors were mostly opposed as well, until the very last moment (and then their support was mostly for PR purposes.)

In addition, the building trades opposed Governor Rendell’s health care proposals and did so quite vehemently. That was influential with Republicans. And, as a result the AFL-CIO, while part of the Pennsylvania Health Access Network, never endorsed the key bill we supported. (We have learned this lesson during our campaign this year and have a unified AFL-CIO behind us and hope to have strong building trade support as well.)

So we started off in a difficult situation, far more difficult than that we faced during the minimum wage campaign.

Our Strategy

In the face of the Republican majority in the Senate and interest group opposition, our strategy was pretty straightforward. It had two components. The first part was to bring as much pressure as we could on the six or seven more moderate Republican Senators, mostly from Southeast PA, who might support the legislation and get them to bring pressure on their leadership to allow a vote.

The second part was the Governor’s hope to pressure doctors and hospitals to support health care reform by supporting a renewal of the program that gives them substantial money for malpractice insurance only as part of a health care reform bill..

Neither strategy worked as we had hoped.

We actually were very effective in getting around 15 Republican House members in Southeast PA to vote for the bill. We targeted them precisely because they were nested in the districts of Senators whose support we hoped to secure.

And with some good organizing and media work, we got a few Senate Republicans to tell us privately that they would vote for the Governor’s bill if it came to the floor. I believe we could have gotten 26 votes in the Senate if the bill came to the floor.

But none of these Republicans would say this publicly or publicly seek a vote from their leadership.

So we had little ability to get the Republican leadership to allow a vote.

Why not? Partly leaders care about staying in office, maintaining their own position, and securing their majority. During the minimum wage fight the Senate President pro tem and the majority leader were both up for reelection. And both faced stiff primary challenges. Last year, only the majority leader was up for reelection. And his challenger was underfunded.

During the minimum wage fight, the Republican caucus was more balanced between conservatives and moderates. Last year, conservatives dominated and a Republican leader bringing our health care reform bill up for a vote could have faced a serious conservative backlash.

During the minimum wage campaign, Southeastern Republican Senators were up for reelection. As a result, they pushed the leadership to allow a vote. They were not up this or reelection year and did not push for a vote.

And the Senate Republicans, even in this overwhelmingly Democratic year, picked up a seat in the Senate. That says something about both gerrymandering and the ineffectiveness of the Senate Democratic Campaign Committee.

The second strategy didn’t work well either. The majority of Doctors get malpractice insurance from hospitals rather than paying it themselves. And many hospitals self-insure. So the malpractice money was not as much of an incentive as we had hoped. Moreover, while the hospitals and doctors were reluctant to lose their malpractice money, they thought that allying themselves to the Republicans would ultimately get them that money without losing other things they wanted.

Was there another strategy we could have used?

I don’t know of any better organizing strategy. I do think that a strong, unified health care campaign by Democratic House challengers in September might helped to bring pressure on the Senate leadership to allow a vote. And I tried, too late, to encourage such a campaign. But given how Democratic leaders think about these races, they did not warm to the idea. And it is not clear that Republican Senate leaders would have cared enough about House seats to change their mind.

A strategy that offered doctors and hospitals more carrots as well as sticks might have helped as well. But that was tough for the Governor to do because resources at the state level are so much more limited than at the federal level. We definitely should have done more work attacking insurance companies. And maybe we should have gone after hospitals as well, although they tend to be pretty popular institutions. We thought about the latter approach a few times but for reasons I won’t go into were not able to carry it off. We have learned our lesson about calling out insurance companies and that is a critical part of the Health Care For America Now campaign.

Our resources and organizing effort

I should add that the health care campaign did have far more resources than the minimum wage campaign. We had four full time organizers and got a number of local coalitions off the ground. SEIU and the UFCW Local 1776 were enormously helpful. So, from time to time, I did think that we would be able to organize enough pressure on Southeastern Republicans to force them to demand a vote from the leadership.

But we couldn’t do it. Could we have done a better job organizing our resources? Yes. There is no question that if we had gotten started sooner, resolved some internal problems in the health care coalition and in some of its component organizations, and had built more consistently on our initial efforts, we might have been able to bring more pressure where it would have been helpful. That is a lesson I’ve certainly kept in mind as I have organized our federal campaign this year.

And sure, the Governor could have done more. But he did have other concers--education and energy--and he put an enormous amount of effort into this struggle. I do think that our organizing effort might have been more effective if the administration brought us into strategy discussions earlier than they did.

But could we have done enough to make a difference and get a Senate bill to the floor? You often don’t know until you give it a try. But given that we did try a lot, and considering everything we were up against, I really don’t know if a better organized effort would have made the difference.

Wait til this year

At any rate, the Rendell health care program was never going to solve even the financial part of our health care difficulties in Pennsylvania. We always knew that we were preparing for a fight at the federal level this year. And we hoped that we would have a Democratic president and strong majorities in both houses so that we could win the fight.

That’s where we are now. And because our fundamental political circumstances at the national level are so unlike those of Pennsylvania in 2008, because we are part of a strong nationwide campaign, and because we learned a lot from last year, I’m really optimistic. This is the best chance we’ve ever had to pass national health care reform.

And it is clear that the work we did organizing around the state last year is providing the ground work for what we are doing at the federal level now. And that’s an important lesson. No organizing effort is wasted if you keep at it and keep people who care about the issue engaged in it.

As awful as Gov. Rendell has been for pushing forward the casinos, he sure does have style. Like this example from Bradys's post:

We must act now to adopt a budget that recognizes the pain we all must share, provides critically needed emergency relief, and continues to make the strategic investments that can spell the difference between productivity and panic for Pennsylvanians,"

My favorite snippets: "strategic investments" and "difference between productivity and panic."

Without digging into the details (thanks for the summary Brady!) you never really know what the Guv means. But diffusing panic is great. Of course Mayor Nutter, quite the opposite from the Guv, has actually created panic through his handling of the budget crisis. More importantly, he does not seem to share Rendell's vision for making strategic investments now.

Which brings up another one of Brady's interesting points:

House Minority Leader Rep. Sam Smith is quoted in the above article as saying we'd be better off tightening our belts than expanding the budget by 2.5%.

Brady says it above, but there is a lot of evidence that you do have to spend and invest your way out of economic crisis. And again, that is something the mayor has apparently been unable to imagine or understand. Hopefully though Rendell's proposal is good and hopefully the Mayor can learn something from it.

...more deserving of a break than, say, a barber on Frankford Avenue? Black Rock wanted a tax break until 2021 to move into a new building at the Cira Center. That's a long, long time.

I don't think that granting monopoly privileges - fiefdoms in Medieval Speak - like KOZ tax breaks is the way to go. I'd rather reduce the burden on wages first, capital second, and then get our public revenue from publicly-created value.

Joshua Vincent
www.urbantools.org
www.ourcommonwealth.org
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