US Elections

The Affordable Care Act seeks to expand private health insurance coverage in several ways.  Most notably, all insurance companies must “offer the same premiums to all applicants of the same age and geographical location,” regardless of their health status. This is a dramatic departure from the previous system in which insurers would often charge those with pre-existing conditions substantially higher rates, or in many cases deny them coverage altogether. 

Beginning in 2014, companies with over 50 employees will be required to offer health insurance coverage to their workers or else pay a tax penalty . To facilitate access to insurance for those who do not receive it through work, states are required to set up health insurance exchanges in which consumers can compare plans.  Plans offered through these exchanges must provide a baseline set of benefits, and each exchange must offer at least two competing plans, one of which is provided by a non-profit organisation.  These plans must also offer four “predefined level of benefits".

The goal of the exchanges is to create a transparent one stop destination for small businesses and individuals who don’t obtain coverage through their employer to shop for health insurance, and to encourage market competition between insurance companies within a regulatory framework that ensures that they offer coverage to anyone who needs it.

The ACA also expands the scope of Medicaid, the government run health insurance program that is financed by a combination of federal and state funds and administered by the individual states.  Traditionally, Medicaid has been available to all children (and some parents) whose family income is below the poverty line, some pregnant women, the disabled, and seniors at a designated level below the poverty line. Citizens over 65 already receive health benefits through Medicare. Under the new law, all individuals and families with incomes below 133 per cent of the poverty line will be eligible for Medicaid. These changes are expected to extend coverage to 16 million previously uninsured Americans.

Prohibiting private insurers from discriminating against high risk applicants poses challenges though. Charging healthy and unhealthy individuals the same insurance rates creates an adverse selection problem; the sick will rush into the system while the healthy will choose to opt out. If I can purchase insurance at the same price once I get sick, it is rational to wait until I fall ill to buy it. Insurance works by pooling together the risk of individuals, but under the given rules, the pool will be flooded with high risk and expensive consumers. Since the per capita health expenditures within pools will be high, so too will the premiums that consumers pay. In order for these new regulations to work, there needs to be a way of bringing younger and healthier individuals into the risk pool.

This is where the individual mandate comes in. Under the ACA the uninsured -with the exception of select groups such as religious objectors-will be required to purchase a baseline level of health insurance coverage or pay an annual penalty of $695, or 2.5 per cent of annual income, whichever is greater. The penalty is not high enough to create de facto compliance, so it is anticipated that even with the mandate a fair number individuals will choose to opt out of coverage.

The federal government will also offer new subsidies to help offset the cost of purchasing health care.  People who are above the cut off line for Medicaid but whose income is less than four times the poverty level will be eligible for subsidies. Federal funding is provided on a sliding scale. Individuals and families with incomes 3 to 4 times the poverty level would not have to pay more than 9.5 per cent of their income for insurance, while those closer to the federal poverty level would not pay more than 3 to 4 per cent.  

Additionally, some small businesses that pay over 50 per cent of their workers health insurance costs will be eligible for tax credits.

In sum, the ACA attempts to address the affordability of health care by increasing the number of people eligible for Medicaid, preventing insurers from discriminating against those with pre-existing conditions, and increasing federal subsidies to low and middle income Americans.

The costs of the new healthcare program are financed in a number of ways. Most notably, is an additional 0.9 per cent payroll tax on individuals with an annual income over $200 000. Similarly, there is a 3.8 per cent tax on passive income, such as investments or royalties, that totals over $200 000 in a year. These taxes fund the Medicare program that provides health coverage to Americans over 65.

There is also a new excise tax on “group insurers with annual premium payments in excess of $10 200 for individual coverage and $27 500 for families.” The tax rate is “40 percent on the amount of premiums above the thresholds”

Additionally, the ACA imposes a variety of smaller fees on the “health care industry.” Among these are a 2.3 per cent tax on infrequently purchased medical devices , taxes on pay for health care executives whose companies fail to meet given government guidelines,  and an annual tax on “certain manufacturers and importers of brand name pharmaceuticals.” You can peruse the links I’ve provided if you’re interested in a fully comprehensive list of the funding mechanisms for the ACA. And here’s a good pie chart on how the bill is financed.

Estimating the total costs of the bill is not exactly a straightforward task because individuals disagree over the mechanisms used and in part because politically motivated individuals on both sides are excellent at obfuscating the issue. The Wikipedia article on the ACA provides a good summary of these areas of disagreement.

The nonpartisan Congressional Budget Office which is responsible for scoring the costs of legislation estimated in March 2011 that the act will bring in $813 billion from 2012 to2021 and cost $613 billion to implement, resulting in a deficit reduction of $210 billion dollars. At the time it was passed into law the CBO projected that the ACA will cause “national health... expenditures to rise to 19.6 percent of GDP (by 2019) as compared to 19.3 percent had ACA not been enacted.”

There’s also a final point aspect of the health care bill worth touching on. As Sarah Kliff explains:

“much of the law’s 905 pages are dedicated to... an overhaul of America’s business model for medicine. It includes 45 changes to how doctors deliver health care — and how patients pay for it. These reforms, if successful, will move the country’s health system away from one that pays for volume and toward one that pays for value. "

I’d like to tackle the issue of cost controls on health expenditures in a later post. It’s an extremely important topic, but also a pretty wonky one.   A lot of the new regulations focus on incentivizing efficiency and encouraging health care providers and insurers to keep costs down (such as the previously mentioned tax on expensive health care plans.  Ezra Klein points out that the bill implants a wide variety of potential cost control mechanisms attempting to make “reform a continuous, rather than occasional, process.”

One area of agreement amongst both defenders and critics is that, even if the ACA is upheld by the Supreme Court, this will not be the end of the health care reform process.  Simply put, while the law begins to address rising medical costs, it doesn’t contain the sort of large scale cost control mechanisms that will curb the continuously increasing expenditures on health care.  The ACA is not the cure-all for a troubled health care system, but is it an important step in the right direction or a journey down the wrong path?

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Liberals hoped that this ruling might compel even the very conservative Justice Scalia to uphold the law. Unfortunately for them, that no longer appears likely. Undeterred by the spectre of Raich, Scalia all but announced in oral arguments that he was going to vote to strike down the indvidual mandate.

Justice Kennedy was a bit less transparent. He declared that the "mandate fundamentally changes the relationship of a citizen with the government" but near the end of oral arguments seemed to entertain the idea that the consequences of the uninsured on the national health care system might make this case unique.

Reading the tea leaves in these cases is often a fruitless task, but, since I couldn't resist, I went over the transcript from Gonzales v Raich and compared the two Justice's statements from oral arguments to the votes they ultimately ended up casting. If Justice Kennedy-or perhas even Justice Scalia-appeared sceptical of the constitutionality of the law but eventually upheld it, perhaps they might do the same thing in the current health care case.

Despite ultimately siding with the federal government, Scalia did draw attention to several perceived holes in their argument.

“I mean, in these other... in these other cases, Congress presumably wanted to foster interstate commerce in wheat, in Wickard v. Filburn. Congress doesn't want interstate commerce in marijuana. And it seems rather ironic to appeal to the fact that home-grown marijuana would reduce the interstate commerce that you don't want to occur in order to regulate it. I mean, you know, doesn't that strike you as strange?”

However, far from contradicting his vote in the case, Justice Scalia's line of questioning actually makes a lot of sense given the concurring opinion he ended up writing. While Justice Stevens's majority opinion relied heavily on rationale of Wickard v. Filburn, Justice Scalia's concurrence focused more exclusively on the Necessary and Proper clause. In this context, it seems doubtful that Scalia had a change of heart between oral arguments and voting, but rather that he was trying to convince the other Justices of his own rationale for upholding the government's regulation.

At numerous other points, Justice Scalia appeared outwardly supportive of the federal government's position. He mentioned that the prohibition of marijuana appeared similar to an existing prohibition on the possession of endangered eagle feathers. In that instance, Congress had explained that there was no way of determining whether the feathers came through interstate commerce or not. Obamacare supporters who still cling to the irrational hope that Justice Scalia might uphold the mandate probably won’t take much solace in the oral arguments from Raich. Justice Scalia showed a sympathy for the Bush administration’s argument that was wholly absent from his line of questioning in the health care case.

Justice Kennedy was coyer. Many of his comments in Raich were clarifying questions, asking the lawyers to expand on statements they had made. But, the few viewpoints he did express offered cautious support for the federal government's position. Once, he reminded Bush’s Solicitor General of a case that would support their argument. He also hinted several times that the mere possession of marijuana might constitute economic activity, and that its "fungibility" made it difficult to establish whether it came through interstate commerce or not.

Kennedy voiced concern on Tuesday that the individual mandate could justify a whole host of new federal powers, but he never expressed similar worries over allowing the federal government to regulate private marijuana use within the home. All indications are that he sees the Obama adminstration's argument in the current case as at least somewhat weaker than the Bush's administration's argument for a blanket prohibition on marijuana. In Justice Kennedy’s eyes, Raich may be more or less in line with traditional congressional regulation of economic activity, while Obamacare is an unprecedented use of Commerce Clause power.

Of course, none of this means that Justice Kennedy is a sure bet to strike down Obamacare, only that he sees it representing a somewhat troubling intrusion on indvidual autonomy and state sovereignty I could see Justice Kennedy going either way. He obviously seems troubled by the idea of government mandates, but, as others have pointed out, the outcome of the case might well hinge on whether he thinks he can uphold the law and still identify clear limiting principles that would restrain the government in the future.

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If Justice Anthony M. Kennedy can locate a limiting principle in the federal government’s defense of the new individual health insurance mandate, or can think of one on his own, the mandate may well survive. If he does, he may take Chief Justice John G. Roberts, Jr., and a majority along with him. But if he does not, the mandate is gone. That is where Tuesday’s argument wound up — with Kennedy, after first displaying a very deep skepticism, leaving the impression that he might yet be the mandate’s savior.

Meanwhile, Mike Barthel thinks the politics will end up being far more important than the constitutional questions:

[T]he case you want to look to here, it seems to me, is Bush v. Gore. That case was decided on explicitly partisan grounds. The court came up with some legal logic, but then at the end of the decision they said that they weren’t establishing a principle and no one should apply this logic to any other case. They just sorta waved their hands and said “Hey, we wanted to decide this case this way, but we couldn’t really justify it, so we just decided it that way anyway and never mind why.”

The same thing is likely to happen here, I think. Of course Congress has the authority to tell everyone they have to do something. Even before reform, the health care industry in America was already so highly regulated that it looked like a Soviet grain production scheme. And the Court doesn’t have any interest in overturning that principle, not only because it would cause chaos, but because it would lessen their own authority. (The law that gives administrative agencies power to set regulation also gives federal courts the ability to adjudicate them; it’s the balance-of-powers equivalent of voting yourself a pay raise.)

And so, if they do overturn it, it’s going to be an incredibly narrow and nakedly partisan ruling.

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Harry Truman was the first American president to formally propose a universal health care system and move the issue into the forefront of the American political debate. Although his plan gained little traction in 1945, Democrats have remained committed to comprehensive health care reform, and every Democratic president since Truman has expressed support for universal health care.

Both Barack Obama and Hilary Clinton made universal health care a key issue in their 2008 presidential primary campaigns. Unlike Clinton, Obama was opposed to requiring individuals to purchase insurance as a means of broadening the risk pool and decreasing health insurance premiums, “well, if things were that easy, I could mandate everybody to buy a house, and that would solve the problem of homelessness. It doesn't.” Ironically, the “individual mandate” ended up being the centre piece of the health care reform bill.

Upon taking office, Obama put health care reform at the top of his legislative agenda. The goal was to help curb the rising cost of health care, expand coverage to the uninsured, and prevent insurers from denying coverage to those with pre-existing conditions. Both Republicans and Democrats generally agreed that these issues eventually needed to be addressed, although there was wide disagreement over the best means of doing so.

With large majorities in both chambers of Congress and the support of President Obama, Democrats were optimistic that they could pass comprehensive health care reform. However, their plans hit an initial roadblock in February 2009 when former Senator Tom Daschle withdrew his nomination as secretary of health and human services amid revelations that he had not properly reported or paid his income taxes. Before the scandal, Daschle had been set to lead the Obama’s administration’s health care overhaul. 

Initially, Obama took a passive role in the health care reform process, outlining his broad goals but allowing Congress to try and work out the details of the plan. In May 2009, Speaker of the House Nancy Pelosi vowed to have the bill signed into law by August. However, things didn’t go exactly according to plan for the Democrats. At town hall meetings across the country citizens protested against the proposed bill, and Republican lawmakers warned of the dangers of “socialised medicine” and “rationing health care.”

Democrats also had trouble convincing the more moderate members of their coalition to sign onto the legislation. In the 2006 and 2008 elections, Democrats won a large number of seats in generally conservative congressional districts. While this was obviously good news for the party, many of these new members of Congress were very moderate. These “Blue Dog Democrats” were concerned about the costs of health care reform and were reluctant to endorse government rune insurance plans. Bills have to pass through relevant committees before they can proceed to the floor for a vote, and Democrats had to appease the demands of many House Blue Dogs in order to get the bill through committee. Democrats informed Obama that passage of the bill could take longer than anticipated.

There was also much controversy surrounding the issue of abortion. The 1976 Hyde amendment prohibits federal funds from being used to pay for abortions, but there was dispute over what this should mean in the context of publicly subsidized health care. Eventually, House Democrats agreed to adopt the Stupak amendment, a proposal by Michigan congressman Bart Stupak stipulating that no federal funds be used to cover any part of a health care plan that covered abortion. Many pro-choice Democrats were upset at the compromise, but the amendment ultimately secured the necessary votes for the bill’s passage.

On November 7 2009, the Affordable Health Care for America Act was passed by the House of Representatives by a narrow margin of 220-215. Only one Republican voted in favour of the bill and 39 Democrats voted against it. The bill included a government run insurance plan, or public option, that would compete against the plans offered by private insurers. The bill mandated that all citizens buy insurance or a pay fee, and provided government subsidies to those who could not afford insurance on their own. The bill would cost $1 trillion dollars and would extend health insurance coverage to 36 million Americans.

Progress in the Senate was also very extremely slow. Senate rules required 60 votes to prevent Republicans from “filibustering”, blocking the bill from proceeding to the Senate floor for a vote. This meant that Senate Majority leader Harry Reid needed to get all 60 members of the Senate Democratic caucus to sign onto the bill. In order to appease moderate Democrats, various versions of the House bill needed to be modified. On December 24, the bill was finally passed along a strict party lines vote (60-39). It would cost $871 billion over ten years, and, notably, did not include a public option. The language regarding abortion was different as well. People receiving federal subsidies could buy health plans that covered abortion, but they had to write a separate monthly cheque for abortion coverage.

The final task was to merge the two bills into one. While there was still work to be done, it seemed fairly inevitable that the Affordable Care Act would become law. Then, the unthinkable happened. On 29 January 2010, Republican Scott Brown won the Massachusetts Senate special election to fill the seat of the late liberal icon Ted Kennedy, who had died that past August. Democrats now lacked the 60 votes to override a filibuster, meaning they could not pass a modified version of the health care bill. Massachusetts had no Republican representatives in Congress, and hadn’t elected a Republican Senator since 1972. Ted Kennedy had called universal health care “the cause of his life,” but now reform appeared in jeopardy because Democrats couldn’t hold onto his seat in one of the most liberal states in the union. In the eyes of many, this was the end of the road for health care reform. Others Democrats wanted to abandon their ambition for sweeping reform, and instead try to pass much more moderate legislation.

However, key members of the party continued to explore other options for passing the bill. Obama also refused to back down on the issue, emphasizing that Democrats couldn’t give up now after coming so close to their goal.Eventually, Senate Democrats settled on a potential solution: “reconciliation.” Reconciliation is a process generally used to modify spending in bills for the purpose of deficit reduction, and requires a simple up or down vote instead of the 60 votes required to end a filibuster. The Senate couldn’t pass an entirely new bill through reconciliation, but they could make small budget related changes to the bill they had already passed in December.

In late February, Obama and Pelosi announced that they supported using reconciliation in order to get the bill through Congress. Democrats argued that they were justified in using the procedure because given that the bill was projected to reduce deficits, it could be considered a deficit reduction measure. They also pointed out that Republicans had previously used reconciliation to pass several major pieces of legislation. Republicans accused Democrats of using a loophole to get an unpopular piece of legislation through Congress.

Speaker Pelosi was clear that she did not have the votes to simply pass the Senate Bill in its exact current form, given that House members had concerns with some specific provisions. Most notable was a guarantee that Nebraska would not have to pay any of the costs associated with the health care bill’s expansion of Medicaid. Senate Majority Leader Harry Reid had offered this deal in order to convince Senator Ben Nelson from Nebraska to vote for the legislation. Senate Democrats agreed to amend these provisions through reconciliation.

Still, there was much work to be done. Speaker Pelosi had gotten House Democrats to already sign off on one bill; now she had to persuade them to pass a bill nearly identical to the one that the Senate had already approved. Many liberal Democrats were frustrated that the Senate bill was less comprehensive than the one they had passed, but they realized that at this point it was their only option. The real difficulty for Pelosi was winning over moderate, and especially, pro-life Democrats. The Stupak amendment had been essential in getting the support of around 40 members of Congress the first time around, but there could be no such provision in the final bill. The White House and House leadership worked with these pro-life Democrats to try and find an acceptable compromise.

Then, on the evening of 21 March, Congressman Stupak and a number of other pro-life Democrats announced they had reached an agreement with the Obama administration. Obama would issue an executive order reaffirming the government’s commitment to the Hyde Amendment and also address some of the Stupak coalition’s other minor concerns, such as clear abortion restrictions on government sponsored community health clinics.

Later that evening, the House of Representatives passed the Patient Protection and Affordable Care Act by a vote of 219-212. Every Republican and 34 Democrats voted against the bill. On 23 March, Obama signed the bill into law, proclaiming that health care reform reflects, “the core principle that everybody should have some basic security when it comes to their health care." Attorney General’s in 13 states immediately filed lawsuits claiming that the bill’s individual health care mandate was an unconstitutional violation of federal powers. Two days later, the Senate passed the reconciliation bill to amend the health care legislation in accordance with the stated wishes of the House. The reconciliation bill passed the Senate by a vote of 56 to 43. Senator Nelson was amongst three Democrats who voted against the bill. The process had been a long and often frustrating one, but Democrats had finally achieved the goal that had so long eluded them.

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What would have been a better way of handling this issue? In his Washington Post column, E.J. Dionne advocates a proposal that would require religious groups to inform employees if they were not covering birth control and describe “alternative ways for enrollees to access” low cost contraceptives. Under the circumstances, I think this would have been a better solution. but there’s no denying the unfortunate and frustrating truth that it would have made it more difficult for many women to access reproductive health services.

I firmly hope that the Catholic Church changes its stance on birth control in the near future, and I remain cautiously optimistic that they will, given that the vast majority of Catholics use contraceptives. However, until they do, I’m not sure the coercive response of the Obama administration is the best course of action. It’s never easy resolving these cases in which such fundamental principles come into conflict with one another, but there are times when liberalism must be tolerant of practises that are somewhat illiberal in themselves. I believe this is one of those times.

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In previous months, these “listening sessions,” as McCarthy calls them, focused on the Republican budget legislation written by Paul Ryan and taken to the House floor in April. The initiative would shrink the percentage of federal government spending (relative to gross domestic product) to pre-Great Depression levels, convert Medicare to a sort of voucher system, shift more of the cost of Medicaid to states and preserve the Bush tax cuts for wealthy Americans ... The freshmen overwhelmingly supported what Ryan was up to — to the extent that McCarthy and the House Budget Committee chairman would murmur to each other: “Wow. We can go further on entitlements. If we don’t, these guys probably won’t even support the bill.”

Tea Party congresspeople who believe their constituents benefit if the government provides relief after natural disasters, or provides a news and weather service in a part of the country where private enterprise has not filled the gap, should ask themselves why those same constituents would not benefit from the government ensuring they have access to affordable health care. After all, if it's appropriate for government to help the small number of people whose lives are disrupted by flood, surely it should also help the significantly greater quantity of people whose lives are disrupted by illness or injury?

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• Meet Paul Bridges, the conservative Georgia small town mayor who spends his time defending the rights of illegal immigrants:

Bridges is an unlikely soldier on the front lines of the nation's immigration debate. The 58-year-old native Southerner describes himself as a conservative Republican. For years, he knew little about immigrants but didn't lack strong opinions about them: "They were just low-class people," he recalls. "They weren't even able to speak English."

• Matt Yglesias matches Republican presidential candidates with Get Up Kids songs. I have a few suggestions of my own.

• Mike Barthel says that its the parodic approach of Stephen Colbert's campaign finance stunts that makes them so dangerous:

The Times gets it wrong in saying that his super-PAC originated in a skit but “became real.” The point of parody is that there is both never a joke and always a joke, that the thing is real as soon as it becomes expressed. What the FEC has done is not make it more or less real, but legitimate.

• Fareed Zakaria argues that conservatism has lost touched with reality:

Conservatives used to be the ones with heads firmly based in reality. Their reforms were powerful because they used the market, streamlined government and empowered individuals. Their effects were large-scale and important: think of the reform of the tax code in the 1980s, for example, which was spearheaded by conservatives. Today conservatives shy away from the sensible ideas of the Bowles-Simpson commission on deficit reduction because those ideas are too deeply rooted in, well, reality. Does anyone think we are really going to get federal spending to the level it was at under Calvin Coolidge, as Paul Ryan's plan assumes? Does anyone think we will deport 11 million people?

• Brandon Soderbergh profiles a new genre of dance music invented in the DC suburbs and nurtured on the Internet:

Moombahton, a blogged-about type of slowed-up electronic dance music, began in a suburban Washington, D.C., basement in the fall of 2009. Dave Nada’s teenaged cousin asked the DJ to spin at a midday “skipping party,” wherein high-schoolers leave class early and go over to someone’s house and party. Nada, nearly twice the age of the kids, wasn’t exactly sure what to play to get them moving. He did, however, notice that they’d been blasting lots of reggaeton. So he fit the more relaxed pace of reggaeton by reducing the speed of Dutch house music ...  “The internet was crucial for its growth and it still is,” Nada says. “‘Born in D.C., bred worldwide’ is the tagline.”

• Frank Bruni outlines how gay visiblity has increased support for gay marriage:

Over the last quarter-century the love that dared not speak its name turned into a veritable motor mouth, to a point where the average American, according to an astonishing Gallup Poll last month, thinks that about 25 percent of the population is homosexual. Hardly. But that perception underscores how visible gay people have become. And familiarity changes everything.

• Ryan Adams's "New York, New York," with its video inadvertently showcasing the World Trade Center in the days before it was destroyed, has become closely associated with 9/11. The lyrics, however, say the singer "shuffled through the city on the Fourth of July/I had a firecracker waiting to blow." Let's enjoy the tune in that light. Happy Independence Day, everyone.

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One of the Republicans hoping to achieve that goal is Newt Gingrich. He's making a not very credible bid to become the Republican presidential candidate, and to coincide with his entry into the race, Mother Jones has uploaded its seminal profile of the former House Speaker. Originally published in 1984, it is a wide-ranging of the hypocrisies, immoralities, and talents of the then young Congressman from Georgia. It's definitely worth a read. What particularly caught my attention was one of the more complimentary statements about Gingrich:

Gingrich has coined a slogan to communicate his vision: a "conservative opportunity society"—the opposite, at least in language, of the liberal welfare state. Its three pillars are free enterprise, high technology, and traditional values. But unlike the Republicans of the past 50 years, Gingrich is not content simply to object to every liberal spending program; he seeks to develop a new, positive agenda for the nation. He is not antigovernment, but antiliberal. "I believe in a lean bureaucracy, not in no bureaucracy," he said. "You can have an active, aggressive, conservative state which does not in fact have a large centralized bureaucracy...This goes back to Teddy Roosevelt. We have not seen an activist conservative presidency since TR."

And this explains the GOP's problem. The party found success in strenuous opposition to a Democratic Party pushing contentious reforms to health care and governing during a period of high unemployment, but they never really came up with much of an alternative agenda. The best evidence of this lies in the party's distinct failure to even try to enact the "replace" portion of their "repeal-and-replace" promise on health care. Elsewhere, Paul Ryan's highly unpopular Medicare reforms are as unoriginal as they are unworkable. Whatever one might have thought of Republican ideas in the 1980s and '90s, or the way they implemented, there was no doubt that they had them. To improve his party's long term fortunes, 2011 Newt Gingrich might want to look back to 1984 Newt Gingrich for inspiration.

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It still is frivolous, only it now has some judges willing to heed that frivolity. Until recently I would not have thought such judges might be sitting on the Supreme Court. Not so much because I think the sitting justices are strikingly sober-minded individuals, but because in recent times, absent the rather glaring exception that was Bush v Gore, the Supreme Court had been leery of doing anything radical.

The last few years of the Rehnquist court and the first few of the Roberts one were characterized by reservation and deferral to Congress and established precedent. The court was not comfortable with bold decisions. Striking down the health care bill on an unconventional reading of the constitution would be quite outside its wheelhouse.

But of late, the Roberts court has had a lot more time for overturning well established precedent, and has been more willing to listen to novel legal ideas. This was most prominently seen in recent decisions like McDonald v Chicago, which overruled a well established interpretation of the Second Amendment, and Citizens United v Federal Election Commission, which did the same for campaign finance law. Though it is more likely to than not, considering its recent form, I can't be certain this court will uphold the constitutionality of the Affordable Care Act. Ultimately, it all comes down to what Anthony Kennedy thinks.

And even so, as Ezra Klein points out, the Hudson ruling might not be as sour for health care reform as supporters fear.

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• I describe the Washington Post article in question as having "may" misrepresented some of Newt Gingrich's comments regarding civil rights because the Post's correction is based only on emailed "clarifications" from Gingrich himself. The paper makes no indication that it concedes the reporter in question, Dan Balz, misrepresented Gingrich. Nor does Balz, in his post on the matter on the paper's 44 blog. Neither Gingrich nor Balz, to my knowledge, have offered the relevant quote in full, so it is impossible to know whom to believe; one, either, or both could be dishonest here. However, I cannot see how this squabble could justify James' sweeping condemnation of Krugman, an opinion writer who used a quote from a report that has been disputed after the fact. I do believe, though, that reading the top line results of a poll and reporting them with a link to an ideological blog suggests insufficient inquiry at best, particularly when further exploration reveals a data set contradictory to the narrative at hand.

• Republicans will gain a lot of seats in November because American voters currently loathe incumbents, and Democrats are more likely to be incumbents at the moment. This year, that loathing of incumbents looks like it will overcome the public's disenchantment with Republicans, though Republicans can undo that by reminding the public why it does not like the them. I will note that polling guru Nate Silver seems far less impressed by the post-pass bounce than I do, though he thinks it exists. He calls the data "decent, but not great" for Democrats, and speaks approvingly of a Quinnipiac poll. The Quinnipiac poll finds that voters disapprove of the health care reform 49-40 per cent. It does not indicate why they disapprove of it. It also finds that voters disapprove of attempts to challenge the constitutionality of the reform, but are more likely to vote for politicians who opposed the reform. Significantly, however, it finds that gigantic chunks of voters say a representative's vote on health care will not make them any more or less likely to vote for them in November. In fact, most voters will not be less likely to vote for a representative because of their health care vote. Americans right now, above all else, care about the economy, and the economy is still looking pretty awful.

• The Rasmussen poll James links to does show that 55 per cent of likely voters favor repealing the bill. It may well be right, even though Rasmussen has a noted tendency to elevate Republican numbers. In America, because voting is optional, likely voters and "Americans" are very different things. As Silver says:

  Rasmussen, for instance, is one of the few pollsters to already be employing a likely voter model at this point. It's not uncommon for likely voter polls to have comparatively better results for Republicans, since Democrats rely on votes from groups like young voters and minorities who turn out less reliably in midterm elections. (And, indeed, Republicans appear to have an especially significant enthusiasm advantage in this cycle.)
  

  Rasmussen may indeed be a better predictor of events in November. Congress, however, governs for all Americans, not just likely voters, and if evaluating policy approval, I see no problem with referring to a poll that includes people who are considered less likely to vote next November.

• I take polls seriously because, as my previous post demonstrated, they can drive narratives, and if interpreted incorrectly, drive them in a direction contrary to the public's actual point of view. If the only poll that mattered were indeed the one on election day, James should cast his mind back to the most recent national poll, and recall that Democrats won the Presidency, as well as increased margins in the House and Senate. And if he finds discussion of polls uninteresting, he should endeavour to quote polls less often in his posts.

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But Republicans don't need to look to even the second reported finding on a poll to discover people don't mind Obama's new health care reforms. Gallup reported a new poll earlier this week finding that 49 per cent of Americans think it is a good thing that Congress passed the bill. Only 40 per cent think it is a bad thing. 50 per cent were enthusiastic or pleased, while 42 per cent were angry or disappointed. My guess is that a big chunk of Democrats that had once been upset that the bill was not as liberal as they would like quickly realised they actually were impressed with what Barack Obama had accomplished.

When the House passed the Senate's original legislation this past Sunday, Republican Senator John McCain said, "there will be no cooperation for the rest of the year ... they have poisoned the well." If Republicans believe—and they seem to—that doubling-down on their obstructionist tactics will pay off electorally for them, they're sadly mistaken. They've confused the anger a depression-battered American public has for its government with the enthusiasm their small sliver of a base has for their own right wing ideology.

In 2006 and 2008, Americans threw their support behind the Democratic party because it had credible approaches to confront the problems with the country's health care, foreign policy, and economy. And even though the Democrats aren't as popular as they once were, the Republicans have offered no ideas to convince an American populace the GOP is better placed to solve their problems. The CNN poll I referred to above shows as much; people trust Congressional Democrats to solve major health care over Congressional Republicans on a 45-39 ratio, and President Obama over Congressional Republicans on a 51-39 ratio.

Make no mistake: right now, the American people's dissatisfaction with its government means Republicans will likely gain a lot of seats in the midterms this November. But the best way the party can prevent that from happening would be to confuse that hostility to incumbents with approval of anything Republicans are doing. Because right now, the GOP is doing its darndest to score an own-goal in what should be a mid-term cakewalk. Or do they think Americans will vote for angry, obstructionist candidates who propose to once again allow health insurance companies to reject them based on pre-existing conditions?

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One of the newer types is called a “self executing” rule; it embodies a “two-for-one” procedure. This means that when the House adopts a rule it also simultaneously agrees to dispose of a separate matter, which is specified in the rule itself. For instance, self-executing rules may stipulate that a discrete policy proposal is deemed to have passed the House and been incorporated in the bill to be taken up. The effect: neither in the House nor in the Committee of the Whole will lawmakers have an opportunity to amend or to vote separately on the “self-executed” provision. It was automatically agreed to when the House passed the rule. Rules of this sort contain customary, or “boilerplate,” language, such as: “The amendment printed in [section 2 of this resolution or in part 1 of the report of the Committee on Rules accompanying this resolution] shall be considered as adopted in the House and in the Committee of the Whole.”

So, basically, the House, by passing similar but distinct legislation (which will also have to be adopted by the Senate) is agreeing not to get into the nitty-gritty of making amendments. These self-executing rules have been around for decades, and have been used by both Democratic and Republican Congresses to enact legislation. In 2007, they were decided to be permitted under the Constitution.

I must admit, I'm not a big fan of them. My preference would be for Democrats, as well as every single Republican who think it's important to insure 30 million extra Americans and, in doing so, reduce the deficit, to merely vote for the Senate bill, then enact the House Amendments improving upon some of the worst excesses of that Senate bill.

But my preference would also be for Senate Republicans to abandon their abuse of the bizarre parliamentary procedure known as the filibuster. Let's be clear: this widespread use of the filibuster is novel to these past few decades, and can only rightly be seen as an exercise in Republican brinksmanship. America's founders, together with its populace through most of its history, did not intend for the Senate to operate with a super-majority requirement. If Republicans genuinely do not want to see the House use the self-executing rule procedure, they should agree to allow a majority-vote of the health care legislation in the Senate.

But just as filibustering any-and-everything that comes before a member is legal, but not moral; so too is playing fast and loose with House rules. If an obstructionist conservative minority will play cute with procedure, they can hardly complain when their opposition does the same. For now, I'll leave you with a list the CRS maintains of deem-and-pass rules that have been used to enact "significant substantive and sometimes controversial propositions":

• On August 2, 1989, the House adopted a rule (H.Res. 221) that automatically incorporated into the text of the bill made in order for consideration a provision that prohibited smoking on domestic airline flights of two hours or less duration.
• On March 19, 1996, the House adopted a rule (H.Res. 384) that incorporated a voluntary employee verification program — addressing the employment of illegal immigrants — into a committee substitute made in order as original text. 
• H.Res. 239, agreed to on September 24, 1997, automatically incorporated into the base bill a provision to block the use of statistical sampling for the 2000 census until federal courts had an opportunity to rule on its constitutionality.
• A closed rule (H.Res. 303) on an IRS reform bill provided for automatic adoption of four amendments to the committee substitute made in order as original text. The rule was adopted on November 5, 1997, with bipartisan support.
• On May 7, 1998, an intelligence authorization bill was made in order by H.Res. 420. This self-executing rule dropped a section from the intelligence measure that would have permitted the CIA to offer their employees an early-out retirement program.
• On February 20, 2005, the House adopted H.Res. 75, which provided that a manager’s amendment dealing with immigration issues shall be considered as adopted in the House and in the Committee of the Whole and the bill (H.R. 418), as amended, shall be considered as the original bill for purposes of amendment.

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That new timetable could see the House pass the Senate's version of health care reform as early as next week, according to the Times. The vote would be held on Thursday or Friday if the Congressional Budget Office issues its report on the legislation, and if the legislative text of the package of changes the Senate is to adopt under the reconciliation process can be written in time. 

While I must extend my utmost sympathy to Michelle, Malia, and Sasha Obama for having to miss out on this trip, and I commiserate with my fellow Australians, who I´m sure are eager to have the President over for tea and biscuits, I am glad Obama is to stay in the States. While Russell is right to say his visit to Indonesia is too important to America's foreign policy interests to cancel, Obama does not need to be visiting Australia without delay. I have little doubt that seeing health care reform through these final votes, providing 30 million Americans with insurance, and helping to control costs of a dangerously metastasising sector of the U.S. economy is a better use of Obama's time over those three days than anything he may do in Australia. And that includes crumpets with Kev.

I'm sure many Australians will be disappointed by the delay. But if it will help bring America even this small amount closer to the kind of affordable and accessable health care we enjoy Down Under, then we should gladly accept Obama's apologies. 

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We've had the Washington Post arguing, on its front page no less, that the White House is in dire straits because it doesn't listen to Rahm Emanuel enough. This was in response to suggestions the White House could pull itself out of dire straits if it listened to Rahm Emanuel less. Then there was Sunday's New York Times, which concluded the White House was in dire straits because it listens to David Axelrod too much. 

You don't even need to disdain Mark Knopfler as much as I do to tire of all this talk about dire straits and the White House, particularly when under examination, things don't look too bad for the Obama administration. True, this is not a great time for Democrats: Americans have too little patience with incumbents at the moment, probably because too many Americans are out of work. The economy is still a little too sluggish in its recovery, the deficit is a little too large for anyone's liking, and Charles Rangel's dealings appear to be a little too shady. The party can expect a tough run in the mid term elections.

But if you look a little farther afield than the Times' condemnation of Axelrod, you'll see within its pages a perfectly cogent summation of Obama's political fortunes:

Polls suggest that the public is already on the president’s side. In a New York Times/CBS News survey early last month, respondents were twice as likely to say that President Obama was trying to work with Republicans as they were to say that Republicans were trying to work with President Obama (62 percent versus 29 percent). And by overwhelming margins, they said they wanted both sides to compromise some positions “in order to get things done.”

[...]

In the New York Times/CBS poll last month, 51 percent said they view the Democrats unfavorably, the highest since November 1994, when the Republicans swept into office. But 57 percent said they view the Republicans the same way, near the all-time high of 60 percent.

The paper quotes a Democratic pollster, Stanley Greenberg:

Greenberg ... noted that the energy behind Democrats in 2006 had been building for a year, beginning with anger over President George W. Bush’s handling of Hurricane Katrina and the Iraq war. “The other side got demoralized as they watched our energy,” Mr. Greenberg said. This time, “our side is demoralized by the lack of progress. It’s almost independent of the energy on the other side.”

The Democrats have to do two things, he said. They have to show that they can govern successfully — passing some version of health care reform would be his preference — and then they have to frame the election as a choice for Democrats

Greenberg may be partisan, but his reading is accurate. This is not yet a Presidency on the ropes. For a start, as Matt Yglesias points out, Obama can lay claim to quite a few accomplishments from his first year in office. The President's approval rating, hovering around 51 per cent, is not nearly as high as it was during the heady months after he first took office, but it remains respectably positive. And most importantly, though commentators seem all too eager to elide this detail, health care, Obama's signature reform, is not dead yet. Rather than proving themselves unable to govern, Democrats are nearing the end of a long process of reform that nobody should have expected would be easy.

As my colleague Erin pointed out in an essay written for the USSC last year [PDF],  the Obama administration's approach "was not married to any particular version of health reform policy. Rather, it crafted an approach to the manner in which the policy would be shaped and political forces managed." In so doing, Erin argues, Obama has advanced this current attempt at reform closer to realisation than ever before.

Now that the Democrats have gotten over their Scott Brown-inspired shakes and realised that 41 Senate seats does not make a majority, this bill has every chance of making it as far as the President's desk. And while I would have preferred to see Obama campaigning six months ago for this legislation as hard as he is now, and while plenty of people around Washington pinpoint the length of time Max Baucus was permitted to seek the support of Senate Republicans (apparently Obama's fault), Obama has so far been reasonably successful in promoting a difficult and historic piece of legislative reform. Examining his administration's supposed failure is like complaining that, a hundred metres short of the finish line, a marathon runner has taken too long to complete the race. 

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One of the most remarkable aspects of the Medicare Part D bill is that it prohibited Medicare from using its considerable purchasing power from negotiating with drug companies to ensure lower prices.  Consequently, the cost of medication under Medicare Part D is substantially higher than under the comparable Veteran's Health service, which was able to use its purchasing power to negotiate.

And how was this expensive reform financed?  Why, using the deficit, of course.

Unlike the current health care reforms, which are not only deficit-neutral, but actually will reduce the deficit within a ten-year window, the Medicare Part D reforms were financed entirely from the deficit.  And there is strong evidence that the true costs of the bill were obfuscated: Medicare's then-chief actuary, Richard Foster, concluded the bill would more like cost $534 billion.  He was silenced by his superiors, who warned that releasing the information was illegal.  (Read Foster's account of what happened here) And so the bill passed, grossly inflating an already-enormous budget.

Where was the populist outrage then?

Perhaps the most distasteful part of this affair is the way many Republicans who voted for this bill are now voting against health care reform, and framing their opposition in terms of the deficit.  Before them is a fiscally-responsible bill that will dramatically increase the number of Americans who will have access to affordable health care, yet they raise concerns about the deficit and the cost of the bill as justification for their opposition to it.

Republican lawmakers can by all means, oppose health care.  There are many fair and genuine reasons to do so: some have to do with the role of government, some with opposition to raising taxes.

But voting for the fiscally irresponsible Medicare Part D, then against the current health care reforms because of concerns about the deficit is hypocrisy, plain and simple.

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So many presidents have tried.  Johnson was the last to succeed, but since, it's been failure after failure.  Ford, Nixon, Carter, Clinton- all tried, all failed.  Certainly, the Bush administration passed Medicare Part D (which deserves countless posts on its own), but comprehensive health care reform hasn't happened in the last 40 years.

It was remarkably fun to follow the action live: watching the debate, and reading the responses people around the United States, and around the world, were having to the occasion.  Twitter went crazy, with comments from people on both sides of the aisle.  #HCR, the official health care reform hash tag, was one of the most popular topics of the day.

In the cacophony of voices discussing the bill, some stood out.  Pundits who knew the legislation inside and out were able to offer expert commentary, explaining developments as the debate progressed.  Personally, reading the insights of noted health care reform bloggers like Jon Cohn of The New Republic and Ezra Klein of the Washington Post was invaluable.  They made the experience both more understandable, and more enjoyable.

Plus some of the snarky comments were just plain funny.

It was a communal experience.  Across the globe, we were able to witness the debate, then the vote, and participate in a conversation about it.  We could share our thoughts, excitement, outrage, concerns.  When the final vote was cast, some of the Americans I follow on Twitter spoke of toasting with their drinks, late on a Saturday night.  I toasted with my early-afternoon coffee.

It was an historic day, not merely because this was the first major health care reform to pass in 40 years, but also because we could experience it in new, digital ways.

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The vote came at the end of a long and precarious day of negotiation, stalling and deal making, and those of us who don't mind seeing the Congressional sausage factory in action got to enjoy (or endure) crucial votes on whether government should cover the cost of abortions - an amendment by Michigan Democrat Bart Stupak mandated that it should not, and in so doing garnered valuable support from anti-abortion Democrats and an endorsement from the United States Conference of Catholic Bishops. Then there was a "motion to recommit," a crafty parliamentary manoeuvre by Republican whip Eric Cantor that threatened to stall passage; that was defeated 247-187. The House even held a vote to decide whether the bill should be debated at all; it was passed 242-192, allowing the show to get under way. Thank god it did, otherwise we would have missed hearing bold declarations like that of Michigan Republican Pete Hoekstra that he was voting against the bill because "that's the vote that says ‘I love my country'."

The significance of this vote shouldn't be underplayed, but it shouldn't be overplayed either. Health care reform still has to pass the Senate, something far from guaranteed, since the 100 member chamber requires 60 votes simply to end debate and bring the bill to a vote. Senate Majority Leader Harry Reid has warned he might not be able to meet Obama's Christmas deadline for the bill. And even if the Senate can be persuaded to vote yes, their version of the legislation will not be identical to the bill the House just passed, requiring the two houses to enter the precarious process of reconciliation to come up with a single piece of legislation for Obama to place his signature on. The American system of government does well to prevent hasty and unpopular decisions - that's why the Republicans couldn't dismantle Social Security in 2005, even though they controlled both houses and George W. Bush had campaigned with it as a policy for his second term - but it does make big legislative reforms like Obama's health care plan a slog to enact.

But as laborious as the process is, America is now closer than at any point in its history to achieving health care reform. Bill Clinton got nowhere near this point with his attempt in the ‘90s. And it's a demonstration that despite the vocal Republican opposition and the suggestions that last week's gubernatorial votes in Virginia and New Jersey were a decisive rejection of Obama's policies, the political momentum is still very much with the Democrats. Bill Owens, the Democrat who benefited from the splitting of the Conservative vote in the special election in New York's 23rd district, provided a crucial Yes vote for the Health Care bill. And while the New Jersey and Virginia votes remain a real morale booster for Republicans, there's been a steady flow of opinion counter-balancing attempts to frame the votes as a resurgence of the right, pointing out that the votes in those states reflected local and candidate-related issues, not national ones, and that of the five special elections held since Obama won the presidency a year ago, Democrats have won them all. Health care reform is steadily gaining an air of inevitability that will boost its chances of passing, and while things won't be easy for Democrats in the 2010 midterm elections, getting a bill passed will help all of them, from the most leftist liberal to the most centrist Blue Dog. And considering the health care bill was accompanied by a relatively subdued Tea Party protest, it seems the outrage voiced by that niche doesn't have the widespread popularity Obama's opponents attribute to it. After a week dominated by Republican victories and a slew of stories about Obama's lack of accomplishments, this vote will be a serious boost to Democratic fortunes.

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One aspect of the American system is that party discipline is weaker than it is in Australia, meaning local voters can check on how their individual representative - as opposed to his or her party - voted on a bill. The New York Times has a map showing who voted and how.

And, speaking of sports, if you were watching the World Series last week, you might have see the jaws of some of the players masticating furiously. Perhaps you're not as ignorant as I am, but I was shocked when, a few years back, an American friend informed me they were chewing tobacco, not gum. Slate has a history of this odd practice.

Finally, new on my Glenn Beck watch: I strongly recommend checking out Jon Stewart's devastating parody of the Fox News presenter.

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It is crudely put, but Hartcher accurately identifies the outcome:

Labor believes voters on the left are pretty much captive. They have nowhere else to go. They could go to the Greens, who are calling for the 78 asylum seekers on the Oceanic Viking to be brought to Australia immediately.

But even if they were to vote Green, Labor would very likely recover their support through the preference system. So the lost primary vote from the party's left would flow back into Labor's catchment on the all-important measure of the two-party preferred count, the one that decides who wins government in the central struggle of Labor against the Coalition.

But disenchanted voters at the right-wing end of the Labor spectrum will migrate directly to the Liberal or National parties, which are still perceived to have a Howardesque tough-on-boat-people character. They are lost Labor votes that will add directly to the Coalition tally on election night.

So when the interests of the two groups, the base and the swingers, come into conflict, Rudd will almost invariably emphasise the swingers and chose the more centrist or right-leaning option.

In America, because they don't have mandatory voting, the maths is different, and this results in very real differences in the way their government works. We'll ignore for a moment that the numbers in the States don't conform to the 40-20-40 split Hartcher identifies in Australia (if that even is the split here) - a shrinking plurality of Americans identify as Democrats, a larger proportion of Americans identify as independents and more Americans identify as conservatives than moderates or liberals. The basic point is that some chunk of the population is usually going to vote Democrat, another chunk will usually vote Republican, and a third chunk in the centre is willing to go to the dance with whichever suitor shows up looking best on the night.

In this way, America is just like Australia. But unlike here, voters in the United States who would never vote for their disfavoured party have options: they can stay home and not vote at all, or they can vote for a third party. And since these voters - the base - are more likely to be politically engaged with their party, their lack of enthusiasm may multiply and cost the party more than that one voter's vote. Perhaps that voter won't volunteer to man the phones and help turn out other voters. Perhaps she won't feel like donating to the party this year, affecting the funds it has to promote its candidates. That's why, for instance, the former President George W. Bush was so eager to keep the religious right happy (even though I don't believe he did that much to advance their interests): because they devoted their time, votes, and energies to re-electing him. And that was part of the problem John McCain had against Barack Obama last year; conservatives just weren't that enthusiastic about getting him elected.

To be sure, the American maths (or, if you will, the "math") still benefits the centre. Every Democrat voter the Republicans can convince to cast a ballot for them brings a net gain of +2, because switching a vote increases the Republican tally by one while simultaneously diminishing the Democrat tally by one. It works in reverse, as well, of course. But while plucking a voter from the other side is twice as valuable as convincing a member of the base to come to the polls instead of staying at home, turning out a member of the base is still gaining a vote the party would not have otherwise received.

The real influences a voting system like this has can be seen in the health care debate. In August, the public option looked deader than dead; Democrats were singing "Danny Boy" in its honour and sending flowers to its widow. And yet, the liberal base could just not let it go, and because a hostile base will cause all kinds of electoral problem down the track, here we are in October and the discussion is not even about whether the Senate bill will include a public option, but what exact form the public option will take.

Of course, other influences were at play as well. Liberal senators like Jay Rockefeller, who aren't constrained by strict Westminster-style party discipline any more than their centrist party-fellows,  started making their unhappiness at the Democrats' concessions known, in a way that would be quite impossible for a left wing Australian Labor Party member to do outside the closed-door confines of the party room. Similarly, an Australian politician with enough ideological conviction and personal appeal can pull the country in the direction of his party's base, even while Hartcher's centre twenty percent retains its reservations - as John Howard did with the GST. But all things being equal, the American political system is set up to allow a far greater range of views to influence policy than the Australian system.

That is not to say the Australian system is without its advantages. Our moderating, mandatory-voting centre ensures energetic, well-funded and unrepresentative interest groups have a tougher time hijacking debates. Our system ensures party members have to spend less time on fund raising, because they don't have to worry about turning out the base. But there is something to be said for a democracy of the American sort, that makes its decisions by paying heed to more than just the small sliver of voters in the centre who are willing to change their minds every now and then.

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The disparities among the states that cause the differences in life expectancy are not too hard to see; people tend to live longer in states that are wealthier and live more healthful lifestyles. States with modern professional economies tend to do well, as do states that lean Democrat, though that correlation may not necessarily be a cause.

Something that obviously does correlate with and cause longer life expectancy - though even it is not everything - is health care. It should be no surprise that the long-living Hawaiians have one of the best health care systems in the country, and similarly long-lived states like Iowa, Vermont, Minnesota, Maine, and New Hampshire have comparatively cheaper, more readily available, or better quality health care systems. It's not rocket science: if it's easier for you to see a doctor, you'll probably live longer. Similarly, even though other factors like income play a significant role, states with poor health care, for instance Southern states such as Louisiana and Mississippi, have below average life expectancy rates. 

The big talk around health care reform in the States this past week or so has been Senate Majority Leader Harry Reid's endorsement of a public option, with an opt-out provision. This basically means that the government would set up a health care system, but if individual states decided they did not want to make use of that option, their citizens could not be a part of it, and the government would not offer insurance in that state. Politico describes it as "a very American idea," saying,"[o]ur founders established the notion of federalism to allow states that felt strongly about public policy to operate under different laws and procedures." As Politico goes on to explain, opting out isn't as straightforward as it sounds. It isn't clear how states would decide to opt out - should the legislature decide? The governor? The people, by referendum? If a state chose to opt out, would the sick migrate to a state that did offer public insurance? And does the government really want to create a precedent of allowing states to pick and choose which federal laws apply to them?

These are all questions that will be answered during the long process of the Senate writing, debating and approving the legislation. But one likely pitfall of the opt out provision may not be realised until it's actually in place and states actually are opting out.

Back when Congress passed a stimulus package aimed at injecting funds back into the American economy, Republican Governors like Louisiana's Bobby Jindal and South Carolina's Mark Sanford made a show of rejecting the Federal hand outs - whether for reasons of ideology, grandstanding, or both. Some, like Mississippi's Governor Haley Barbour were concerned they'd be obliged to accept welfare conditions of which they did not approve, while Jindal and Sanford were, at the time, possible 2012 Presidential nominees who had an incentive to please the Republican base.

The opt-out provision could become a similar political football, and if Governors like Jindal and Barbour are once again the ones kicking it around, citizens of the states who could most benefit from health care reform will suffer. Remember, states like Jindal's Louisiana and Barbour's Mississippi are poor states with little health care coverage that would definitely benefit from a government program.

When the stimulus package passed, a South Carolina Representative, Jim Clyburn, inserted a provision into the bill to allow state legislatures to override any Governor who rejected federal funds. (Disclosure: I will be working as an unpaid intern in Clyburn's office for a period next year.) To ensure health care remains about insuring more people, it might be a smart idea for an opt-out public option to include a similar safeguard.

Elsewhere, if you liked my post about Maine's place in America's future, you might like to take a look at Politico's profile of its senators and its political culture. It gives an excellent overview of the reasons why this odd little state is at the centre of so many of the country's big battles.

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