The most important number in health policy is 218-51/60-1-5.
218 votes in the House
51 or 60 votes in the Senate
1 President to sign and implement the bill
5 votes on the Supreme Court to support the bill amidst political and legal challenges.
All of those elements need to be lined up for a major policy change to be embedded into our social-economic-political system.
Since March 23, 2010 major individual market changes have not had that coalition. At times, there are sufficient votes in the House plus a friendly White House and a Supreme Court that would be on board with those changes while the Senate was a vote short (Summer 2017). At other times there would be a supportive signature in the White House and no working Congressional majority in Congress (3/24/2010-1/20/17 and 10/1/17 to present) where both chambers could agree on something for the White House wants to sign.
This logic constraints my thinking.
It also appears to constrain AOC’s thinking:
AOC on likelihood of M4A getting passed: “The worst-case scenario? We compromise deeply and we end up getting a public option. Is that a nightmare? I don’t think so,” she said. (H/t @eschor) https://t.co/nbI4TBkgJI
— Alexandra Jaffe (@ajjaffe) February 13, 2020
When there aren’t huge working majorities, this creates a constraint on massive change.
So I can understand the frustration of someone like TC in a comment to a recent technocratic tinkering post:
This post is exhibit A for why the ACA is a failure. Only the nerds care anymore how if we could only tweak this and incentivize that we might be able to keep all the interests happy and make it work. Not. The rest of us know it’s the kind of cluster-fuck Rube Goldberg contraption you get when you have way too much ‘compromise’ creating a bill that should have been M4A from the start
I agree that an elegant, simple, straightforward solution is referable than a solution that is complex, messy, and counter-intuitive provided that there is an equal chance of actual implementation. But I think that implementation probabilities have to be weighed.
My big question to comments like this is HOW???
How could the Obama Administration keep on board Nelson, Nelson, Baucus, Lieberman, Lincoln, Pryor, Landrieu, Bayh, Conrad, Dorgan and MacCaskill for a bill that completely up-ends the insurance of 70% of their voters?
How could Pelosi wrangle enough votes from Blue Dogs representing a lot of districts well to the right of the median voter for an even more disruptive bill when she was able to get the ACA to pass with 3 spare votes?
How does a future Democratic administration get Medicare for All passed when the decisive vote in a reconciliation vote is either Senator Manchin or Senator Sinema?
How does Pelosi wrangle 218 votes to massively upset the status quo biases when again, her median vote is representing a district well to the right of the median voter.
How does this bill survive a Supreme Court challenge?
I have a hard time coming up with positives answers to the HOW? question in 2021 that don’t involve either pictures of multiple Senators with goats or high quality peyote.
This is a significant constraint on my thinking and it limits me to spend most of my effort within a paradigm of what is, and what is a modest displacement of the now.
By nature, I’m an incrementalist. And I have a real hard time seeing how the political stars align for Medicare for All bills to pass and survive challenges in the current political configuration.
218-51/60-1-5 rules my world.