Dana Goldstein

The Baucus Health Plan, on Abortion and Immigration

Max Baucus released his Senate Finance Committee health reform plan today, and there are no huge surprises. As Ezra writes, low subsidies and high premiums mean health care costs will continue to cause personal bankruptcy for many unlucky Americans. The better news is that Baucus expands the health insurance exchanges to large employers; in the House bill, only small companies can participate in the exchanges. And of course, the expansion of Medicaid to childless adults is a major progressive victory.

Abortion and immigration are two issues that divided the bipartisan Gang of Six until the bitter end, so I took a close look at where Baucus came down. On abortion, his mark-up is clear: The basic health care package he envisions does not cover most abortions:

Federal funds continue to be prohibited from being used to pay for abortions unless the pregnancy is due to rape, incest, or if the life of the mother is in danger.

Private insurance companies can choose to offer plans that provide additional, elective abortion coverage -- as 87 percent of employer-provided plans already do -- but they must "segregate" public funds from paying for the procedure. This means that if an insurer wants to cover abortion, it must create a special fund to do so, made up of money garnished from premimums and co-pays. Government-provided affordability credits will not be able to contribute toward the cost of abortions. This is a bureaucratic headache for insurers, and it certainly has the potential to dissuade abortion coverage. The House bill continues to be much more progressive on reproductive health, as it sets up a public plan that would most likely include abortion as part of primary care.

On immigration, Baucus requires a confirmation of legal status before receiving health care subsidies, through a check of Social Security numbers. He also denies affordability credits to anyone whose legal resident status is set to expire in less than a year, which seems unjust -- especially if future immigration reform provides more paths toward legality.

cross-posted at TAPPED

Paulites, Progressives, Health Reform...and the U.S. Constitution

The United States Constitution has taken on major significance in the health reform debate, with grassroots "teabaggers" calling universal health care -- and indeed, much social spending -- unconstitutional. In a piece for the Daily Beast, I reported on how this Constitutional originalism is borrowed from the Ron Paul campaign. (Ironically, many Paulites and teabaggers, while complaining that the Constitution doesn't explicitly provide for a universal health care system, would like to amend it to ban abortion. They can't seem to decide if the document ought to be interpreted strictly or loosely.)

Considering the current foment around Constitutional interpretation, it was poignant to see the House of Representatives pass yesterday, on a voice vote, a bipartisan resolution recommending that every high school in America devote one week each fall to teaching seniors about the Constitution. Resolutions, of course, are non-binding and mostly symbolic. And who doesn't support exposing students to their government's foundational document? What's more surprising is the partnership between the two co-sponsors of the resolution: Ron Paul and freshman Democrat Alan Grayson, a member of the Progressive Caucus who recently hired Netroots blogger Matt Stoller as a senior policy adviser.

Grayson and Paul agree on some issues. Both are staunchly opposed to Obama's policies in Afghanistan and Iraq. Paul told me several weeks ago, "You can’t keep expanding a war in the Middle East and pretend you can come up with a $2 trillion medical-care program." In a Vanity Fair interview last May, Grayson said, "What I care about is our surviving these difficult economic times, and when I’m asked to vote for $100 billion to extend occupations that fundamentally served no purpose that could not be accomplished any other way—in lieu of spending for the things that human beings need...I have to say, 'No, there’s a better use for that money.'”

On health reform though, the two politicians are polar opposites. Grayson's press secretary, Todd Jurkowski, says Grayson has hosted four health reform town halls in his Florida district, and that at each one, the congressman was confronted by health reform opponents waving the Constitution. Like Ron Paul, Grayson carries a copy of the Constitution with him. He is a graduate of Harvard Law School and clerked on the D.C. Circuit Court of Appeals before going into business.

"The Congressman knows the Constitution," Jurkowski says. "From the Congressman's point of view, the preamble itself is one justification for health reform," since it vows to "promote the general welfare" of the American people. "So is the interstate commerce clause," Jurkowski added, which allows for national markets such as the proposed health insurance exchanges.

If more students read the Constitution in school, perhaps some will come around to Grayson's way of thinking. But in the end, debates over the Constitution and health care are less about logic and the law than about activist attempts to paint the concept of universal health care itself as un-American and "socialist."

cross-posted at TAPPED

Reproductive Health in the Baucus Plan

After heath reform, who will decide what medical services insurance companies must cover? The House and Senate HELP committee bills empower an independent council of medical experts to make coverage recommendations to the Health and Human Services secretary. This is the group that would make controversial decisions about whether abortion, infertility treatments, or certain experimental procedures should be covered in basic health plans.

The White House plan released yesterday stays silent on the question of who decides coverage specifics -- and that is likely because there is now an alternative in town. Sen. Max Baucus' Finance Committee plan articulates broad areas of coverage that must be included, such as preventive care, primary care, hospital stays, and maternity care. But Baucus would allow insurance companies themselves to define what services each of those areas include, without government interference. Insiders say Baucus left the independent council out of his plan because moderate Republicans don't like the idea of restraining the private market in this way.

What does Baucus' compromise mean for reproductive health coverage, which remains a source of debate as Congress discusses reform? Advocates are cautiously optimistic. "Services like contraception, STI testing and treatment, and Pap tests can and certainly would fit into many of the other categories," such as preventive care, says Adam Sonfield, senior public policy associate at the Guttmacher Institute. "Reproductive health services, including contraception, would likely be covered in almost every plan, because that’s the way coverage is today. ... It makes financial sense for insurance companies. Contraception is very clearly cost-effective."

Under the Baucus plan, abortion coverage would likely remain unchanged; there is no public option, and private insurance companies would determine individually whether to cover the procedure, as they do now. Eighty-seven percent of current employer-based insurance plans do provide some abortion coverage.

cross-posted at TAPPED

Health Reform Better for Poor than Middle Class. How Did We Get Here?

Matt Yglesias notes the Wall Street Journal is reporting that in his big speech to Congress tonight, President Obama will reaffirm his commitment to a public option -- a dinky public option. This awesome chart from Nick Beaudrot shows exactly how dinky it is; the pink boxes represent the public option. But it also demonstrates something else about health reform that you won't hear any Democrat say: It does more to help the destitute poor than the working or middle class.

Even Max Baucus' compromise plan, which contains no new public insurance option, expands Medicaid to all Americans below 133 percent of poverty. Currently, Medicaid is open only to pregnant women, children, single mothers, and the disabled. After reform, healthy, single adults will be eligible. That's a major progressive victory, and it's possible because insurance companies aren't interested in this segment of the population, which can't afford to enter the private market. Government can choose to expand here without undue corporate pressure.

But what's going on in this plan for the working and middle classes? At 300 percent of poverty -- $66,150 for a family of four -- Baucus requires a family to spend 13 percent of its income on health care before government subsidies kick in. That's a burdensome $8,600. For sure, this is better than said family going completely bankrupt under the current system, should they get into a catastrophic car accident with insurance that caps hospital expenditures. But middle-class Americans -- voters! -- may not see exactly what is in this plan for them. Politically, this is a very hot potato. There's still time to strengthen protections for the middle class in negotiations between the White House and Congress. But such efforts won't work if the administration is willing to neglect the issue of subsidies in favor of defending the public option.

cross-posted at TAPPED

Kennedy's True Legacy on Abortion and Disability

In his column this morning, Ross Douthat sets up a dichotomy between Ted Kennedy and his also recently-departed sister, Eunice. Ted was a Bad Kennedy and a Bad Catholic because he was pro-choice; Eunice was a Good Kennedy and a Good Catholic because the cause of her life was disability rights, and she supported anti-abortion rights organizations such as Femnists for Life, the Susan B. Anthony List, and Democrats for Life.

But Kennedy's legacy on abortion and disability is actually far more complex than Douthat acknowledges. In 2005, Kennedy co-sponsored a bill -- the Prenatally and Postnatally Diagnosed Conditions Awareness Act -- that expanded federal financing for support programs for expectant and new parents who receive a Down syndrome diagnosis. Research shows that doctors delivering such a diagnosis often share very little information about living with the disease, and presume that the patient would prefer to terminate her pregnancy. Indeed, about 90 percent of couples who receive a prenatal Down syndrome diagnosis do choose abortion. But enriched by his sister Rosemary's life, Kennedy sought to link expectant and new parents with mentor families already raising a child with Down syndrome, as well as create a national registry of families willing to adopt disabled infants.

Kennedy's partner on the bill was conservative Catholic Sen. Sam Brownback, who regularly compares abortion to slavery. During negotiations between the two offices, Kennedy held fast to his belief that the law must go further than just dissuading abortion; he wanted to be sure the legislation offered funding to improve the lives of disabled people and their caretakers. Last October, the bill was signed into law by President Bush. In a testament to Kennedy's coalition-building genius, it was even supported by NARAL President Nancy Keenan, who said it offered women choices without undermining their right to an abortion.

Only Ted Kennedy could bring NARAL to the table with Sam Brownback. And that's because he knew, in his heart, that there was no contradiction between being deeply pro-choice and deeply pro-disability rights.

For more on the moral complications of genetic testing, disability, and abortion, check out my 2007 In These Times feature, "Genetic Disorder."

cross-posted at TAPPED

On the Radio, Discussing Circumcision and HIV

One of the great things about being a magazine writer is that it allows you to develop quirky areas of expertise. And indeed, I've been covering the HIV/circumcision story on and off for over two years, since I first wrote for In These Times about Mayor Bloomberg's attempt to encourage circumcision among gay men of color in New York. (Incidentally, that article was my first for editor Phoebe Connelly. A few months later, we both joined the Prospect.)

With the Times reporting this week that the CDC is considering recommending routine circumcision of American infants, the issue is gaining wider media pick-up. My boyfriend reports that he saw talking heads debating the topic on MSNBC. And this morning, I was a guest on the BBC/Times NPR show "The Takeaway," alongside Dr. Roy Gulick, chief of the Division of Infectious Diseases at Weill Cornell Medical College. You can listen to the segment, which is about 10 minutes long, here. It's a good introduction to the current research and public health debate around circumcision.

If you've been reading me periodically, you know I'm skeptical about whether circumcision is the right HIV-prevention strategy within the United States. After all, the United States already has the highest circumcision rate in the developed world -- 79 percent -- and also the highest HIV-infection rate. That's why advocates have been focusing on a message of "condoms, condoms, condoms" for three decades. I worry about promulgating the misconception that circumcision is a miracle cure against the AIDS epidemic, especially in communities -- such as among immigrants and the poor -- where encouraging regular condom use is already an uphill battle. And especially because gay men were not included in the most promising circumcision/HIV studies.

When Takeaway producer Molly Webster called me yesterday to discuss coming on the show, she asked me how I got interested in this topic -- one that raises a lot of people's eyebrows, and can lead to very heated arguments in families and between partners. (Joseph O'Neill wrote a wonderful short story for Harper's dealing with the question of whether to circumcise a son.) There are a few reasons. First, I've been living for over three years in Washington, D.C., the city with the highest HIV-infection rate in the United States -- 1 in every 20 adults. That horrific number inspired me to follow more closely the HIV/AIDS research coming out of Africa. I was excited and encouraged to read that among heterosexual men, circumcision can decrease HIV contraction rates by as much as 60 percent.

But that news came at a time when, on a more personal level, I was questioning the practice, especially since I am Jewish and it is considered an absolute give-in -- even among totally secular Jews -- that baby boys will undergo the procedure. Why is it that even as Jews have assimilated and rejected many religious practices, such as strict Kashrut, we continue, as a community, to cling to circumcision? In large part, it's because of the understandable desire for sons to look like their fathers, especially on a part of the body that carries so much psychological weight. But there's also a deep emotional tie to circumcision; a feeling of pride that Jews are physically marked as such -- that a Jewish man can never totally escape his Jewishness, because it is inscribed on his body through circumcision. During the Holocaust, this was one way in which Jews were identified by the Nazis. We Jews are rightfully attached to that history. One of my friends, who is studying to become a rabbi, recently told me he considers circumcision the single most important Jewish religious obligation.

There have been discussions about circumcision in my own Jewish family, as intermarriage and new births forced some of the older members of the clan to question the practice for the first time. I don't have a firm conclusion on any of this stuff. Public health and cultural concerns need to be balanced with the reality that circumcision is surgery without consent, and that it removes a natural, though not totally essential, part of male anatomy. I suspect that circumcision rates, after declining over the past several decades, will go back up. After all, most parents would like to give their children any weapon they can to fight disease. In any case, those are my thoughts on all this, since I'm often asked why I write periodically about this topic.

Explaining Health Reform, On TV

Here's my half-hour segment on "Washington Journal," with host Robb Harleston. It was a lot of fun taking calls from viewers. It's interesting that although professional journalists usually ask about the political process of reform, regular people are really just concerned about coverage -- how they'll get it and and how much it will cost. They really are engaged on the policy level, if not particularly informed.

I was also on MSNBC yesterday, talking with David Schuster about the political side of health reform. I'll post that when I get the video.

Update: And here it is.

Visit msnbc.com for Breaking News, World News, and News about the Economy

Who's Who in Health Reform? And Does it Mean Liberals Will Lose?

A blockbuster A1 story from the New York Times this morning, by David Kirkpatrick, gives progressives more heartburn on health care reform. Rahm says:

"We have heard from both chambers that the House sees a public plan as essential for the final product, and the Senate believes it cannot pass it as constructed and a co-op is what they can do. We are cognizant of that fact."

More each day, it sounds as if the White House is willing to give the Finance Committee a free pass on the public option and other progressive goals, such as extending insurance subsidies to those with incomes up to 400 percent of the poverty level -- $88,200 for a family of four. Kirkpatrick reports:

Industry lobbyists and moderate Democrats in both chambers, though, argue that the White House’s actions behind the scenes show a recognition that the finance panel’s anticipated compromise is the most likely template for any final legislation.

Why do Finance and its health industry-funded chairman, Max Baucus, enjoy such privilege, even as one of the committee's key Republican negotiators, Chuck Grassley, tells Americans they "have every right to fear" fictional death panels? To be sure, since the grassroots anti-reform movement hit a fevered, almost violent-pitch last week, the White House -- which is shaken by the development -- is probably more eager than ever for health reform to have a "bipartisan" imprimatur, even if the only Republican who votes for the legislation is a true outlier, such as Olympia Snowe.

But there are other factors. Last year, during the thick of campaign season, Ezra Klein and I wrote a cover story for the Prospect on Barack Obama's vision of Democratic party-building and legislative success. One of the most surprising things about Obama's electrifying campaign, we reported, was that it was led not by insurgents unschooled in the ways of Washington, but by Congressional insiders, many of them "veterans of the party's impotent era" during the mid-1990s. These are men who worked for Dick Gephardt, Tom Daschle, and yes -- Max Baucus -- tempering liberal goals when Republicans held a firm majority. Jim Messina, the White House deputy chief-of-staff known as "Rahm's Rahm" -- in other words, an enforcer -- is Baucus' former chief-of-staff, and is likely to see thing's Baucus' way, extending the Montana senator's influence into the highest levels of the administration.

To be fair, the White House also employs high-level staffers who've worked for Congress' pre-eminent liberals. Melody Barnes, head of the White House Office of Domestic Policy, is a Ted Kennedy alum. Legislative aide Phil Schiliro, who reportedly represented Team Obama in key House negotiations, used to work for Henry Waxman, who is widely trusted by liberals. But at this point in the game, there is little doubt that the Senate is where the action is, and that hard-nosed, realist compromisers, like Messina and Rahm, are likely to be leading the way.

cross-posted at TAPPED

On Health Reform, Uncertainty Breeds Peril

Many supporters of health reform believe that systemic questions, such as whether or not reform will include a public insurance option, should inform the congressional and public debates. But the truth is that Americans, unsurprisingly, seem to be most concerned about coverage specifics. After reform, what procedures will and won't be covered? Will my array of choices expand or contract?

Those fears have been artfully exploited by the increasingly enthusiastic and radical conservative anti-health reform movement. In response, today the White House launched "Health Insurance Reform Reality Check", a website modeled after "Fight the Smears," a campaign season effort to dispel rumors about Barack Obama's background and positions.

The new site is built around a simplified, eight-point explanation of how consumers will benefit from health reform. Using this messaging, the administration plans a public relations push during the congressional recess, with a focus on drumming up grassroots support via the Obama's team's email list and outreach to the liberal blogosphere. But given the intensity of anti-reform protests over the last week, there is little doubt that the president seems to be on the defensive. The continued lack of one, concrete, completed health reform bill means that opponents of reform can grandstand on a number of hypothetical issues. For example, both the House tri-committee bill and the Senate HELP committee bill create an independent council of medical experts to advise HHS on what services will be covered in the new health exchanges. Conservatives have suggested that the council -- which, of course, does not yet exist -- will prevent terminally ill patients from receiving life support or continuing care, or will mandate abortion coverage.

Both of those outcomes are completely improbable. Neither are on the White House's agenda. But by kicking some tough choices on coverage down the line, to after reform passes, Democrats have opened the door to this kind of scare-mongering. Uncertainty is uncomfortable, and opponents of reform -- along with skeptical moderates -- are exploiting that simple truth.

Nowhere is this more apparent than in the abortion debate. None of the health reform proposals in Congress threaten the Hyde Amendment, which currently prevents the federal government from funding abortions. But anti-choice legislators are not satisfied. Many women will receive government subsidies to buy health insurance after reform, and Republicans -- including some senators in the all-powerful "Gang of Six" -- would like those women to be banned from accessing abortion with those funds, whether they are covered through private insurance plans or a potential public option. This would be a significant curtailing of reproductive rights, since most private insurance plans currently do offer some abortion coverage.

In this case, the current reform proposals actually do maintain the oft-heralded "status quo:" Medicaid won't cover abortion, but private insurance plans will. It is reform opponents who are pushing to change the way health care is delivered, by curtailing women's ability to access abortion coverage in the private insurance market. This morning, a senior administration official, speaking on background, told me that some moderate Republicans are choosing to understand health insurance subsidies as tax credits, and thus, from a libertarian point of view, might support a woman's right to access any health procedure she wishes with that "tax credit," including abortion. And yet, this official affirmed that abortion is among the issues holding up the Senate Finance Committee -- right alongside long term cost containment and debates over whether the federal or state governments will pay to expand Medicaid.

In other words, almost everything about health reform remains up in the air. Stay tuned.

cross-posted at TAPPED

The Abortion Ad Wars

None of the health reform bills before Congress mandate abortion coverage in a potential public plan. Rather, they kick that ball down the field, allowing a council of experts -- after reform passes -- to advise the Health and Human Services secretary on what procedures should and shouldn't be covered.

Yet continuing its campaign to use the abortion issue to kill health reform, the Family Research Council will be airing this TV ad in five states with swing senators: Pennsylvania (Arlen Specter and Bob Casey), Arkansas (Blanche Lincoln), Alaska (Mark Begich), Louisiana (Mary Landrieu), and Nebraska (Ben Nelson).

What this ad doesn't tell you is that behind the scenes, religious right groups are lobbying Congress to ban all abortion coverage within the health insurance exchanges, even abortions covered by private insurers. Another tactic of abortion opponents is to use health reform as a vehicle for cutting off federal funding to Planned Parenthood, which currently uses tax dollars to provide basic preventive gynecological care, contraceptives, and sex-ed to poor women and girls. (The group is already banned from using federal funds to pay for abortions.) So Planned Parenthood has been running its own national TV ad:

Sadly, the Planned Parenthood ad just doesn't pack the same punch, because it doesn't tell viewers Planned Parenthood's mission is under threat in the health reform debate -- or ask them to do anything.

cross-posted at TAPPED