Health Reform - The Problem is the Senate

I’m hearing from a lot of my liberal friends a great deal of frustration over the fact that health reform is facing a serious uphill battle when the 08 election pretty clearly demonstrated that a majority of the voting public wants some significant policy change in the US. And a common thread is the typical self-hating kvetching that I’ve come to loathe from liberals: “Obama made a bunch of a tactical and marketing mistakes”; “We liberals are just too nice; we need to scream and rant like the righties”; etc etc etc.

But here’s the thing: if we ignore all the “optics” then health care reform is facing difficulties for only one real reason: the fucked up rules and constitution of the US Senate. The Senate is so anti-democratic in makeup, and the cloture rule is so ass-hatted, that the Senate is preventing the majority of actual voter representation from passing policies.

Here’s a good Yglesias column on point. Here is the main quote:

If you attribute to each Senator half the population of the state he or she represents, then the Democrats’ two Senators from California, two from New York, one from Florida, two from Illinois, two from Pennsylvania, one from Ohio, two from Michigan, one from North Carolina, two from New Jersey, two from Virginia, two from Washington, two from Massachusetts, one from Indiana, one from Missouri, and two from Maryland together represent 51.125 percent of the American people. That’s just 25 Senators.

In other words, 25 (Democratic) Senators represent a majority of the US population, and the remaining 75 Senators, which includes every single Republican, only represents a minority of the US population. When you combine that with the cloture rule, you get what is essentially a minority rule house of Congress. THAT is the key problem. There’s a lot to scream about, but the hard numbers are simple: if we had a Senate that more reasonably represented popular sovereignity with a majority rule vote and process system, we’d have major health reform right now.

Note: Despite the above, there is one Dem self-hate criticism that is merited: Harry Reid is just completely ineffective. Even with the crazy Senate rules, the Dems did in fact have the 60 votes (for a while) to get things done, and nothing got done. So bash on Reid all you like. The rest of the arguments are just window dressing on the core problem: our Senate is a sad beast.

Uh, you do realize that’s by design, right?

More worrying to me is the way legislation can get blocked in some subcommittee because the chairman won’t let it past without stuffing it with his or her pet amendments.

Isn’t more the problem that more and more polls show that people don’t want liberal heatlh care reform? More and more people are turning against it. Median voter theory tells us that we shouldn’t expect health reform that differs signficantl from what the median voter wants.

The problem for health care is that a lot of voters don’t want the reform that’s currentl being touted. The centrist position is well to the right of what liberal bloggers want.

OK, but have any of the proposed plans to this point actually been liberal plans per se? I mean all of them are MORE liberal than we have now (which is basically no plan for most Americans), but that’s not the same as being full on liberal plans. The liberal bloggers seem to want a single-payer plan, but I haven’t seen such a plan proposed.

So I still think a lot of the problem is that it’s being sold as a liberal plan, perhaps because of who the President is, perhaps because it’s a Democrat plan, or perhaps because some of the Republicans have labled it a liberal plan.

Not really. Unless there is an effective public option, then what has been proposed is simply health insurance reform. It isn’t health care reform. Obama is trying to push a plan through that also caters to big pharma. That is what is discouraging to a lot of liberals. Single-payer wasn’t on the table from the start. It was never even considered as an option.

Personally I’d like to see a truly socialist health care system enacted, similar to Britain’s. It won’t happen here though, as our government seems to be too easily swayed by corporate lobbying.

So I still think a lot of the problem is that it’s being sold as a liberal plan, perhaps because of who the President is, perhaps because it’s a Democrat plan, or perhaps because some of the Republicans have labled it a liberal plan.

You are correct here. The Obama plan is being sold as liberal, and Republicans are trumpeting that it is liberal and even socialist (obamacare!). In reality, the plan is quite conservative and corporate friendly.

Quick problems: The house plan is significantly farther left that most people want. Also, a lot of the moderate House Dems already took a bad vote for them on cap and trade. They’re leary of another vote after stimulus, cap n trade. So those are your problems in the House.

The President also made a big strategic error by immediately focusing on cost controls. That led to the rationing argument being very effective. It also made the “death panel” argument stick more. For example, having doctors discuss end of life arrangements in the context of a bill that is saving money, particularly on end of life care. It’s not irrational to connect the dots and see that these dicussions are a way to encourage seniors to opt for “Do not recussiate” orders. That and the natural fear of having less money spent on them is why a lot of seniors don’t like the bill, despite the AARP pushing it.

I also think the Dems argument fails in the initial logic test. People(and CBO) don’t see how you’re going to expand coverage and save money. People who already have insurance think they’re going to pay more and get less. Makes them want the devil they know.

Yeah. By design.

It was done precisely because small states didn’t want large states just railroading them and dominating the government. Regional differences were a lot more important back then, and they’re still very important now and the Senate serves the same function today as it did 200 years ago.

No Senate = No United States.

We wouldn’t even be here having this discussion if we hadn’t gotten a Senate.

Why do they think this though? Isn’t it because we are told it will raise taxes without realizing that taxes are not our only expense? I’ve said this in several threads now, so I’m sure I sound like a broken record, but the fact that our taxes will increase does not in itself prove that our costs will increase (for the average citizen). Much depens on what plan is proposed/passes, obviously. I actually think a single-payer healthplan would be the most cost efficient ultimately, but that seems unlikely to happen. As a result, I have no idea how the costs will turn out, and I suspect very few Americans do. Maybe that’s what you mean by the ‘devil they know’? That uncertainty could be the issue. But I think they are just hearing the tax bogeyman part of the equation and not thinking about savings elsewhere, or even what those increased taxes would buy.

It’s funny to me that very few Americans had a problem with increased spending under Bush in order to protect our security from terrorists that barely harmed any Americans (as a percentage of our total population) and likely lack the ability to do so. But they are unwilling to throw money at healthcare, which affects every single American at some point.

In 1790, the biggest state (Virginia) was 20x the size of the smallest (Tennessee, which had just been established). Excluding Tennessee, it was 12x.

In 2008, the biggest state (California) is 69x the size of the smallest (Wyoming, which isn’t alone at the bottom of the population contest).

This is interesting, but not really the problem.

Keep in mind that the Senate’s rules are all artificially generated outside the constitution. The “raise the bar to 60 votes to pass anything and need a committee to approve it first” mechanic are due to internal rules. It’s a nuclear option to actually just throw a bill at the Senate floor for a straight 50/50 up/down vote, but at some point, someone’s going to do it to clear the cruft out of the Senate.

In regard to the polls, one of the serious problems is that many voters right now don’t understand the actual debate which is occurring. Specifically, the actual proposals that are at issue are a combination of insurance reform for all citizens and subsidies for the poor, with an additional issue of having a public option in some plans but not in others. That’s it. However, many poll responders seem to be responding as if the proposals were a complete government takeover of health care, along the lines of a British or in the lesser form, a Canadian system. Nobody in major league politics is proposing either a Canadian or British system, so the poll responders are off base to a pretty substantial degree. This is a good example of why the founders set up the country as a representative government instead of direct democracy.

My problem is that the system of representation is problematic due to the combination of the fact that the Senate is not proportionately representative, combined with the extremely anti-majoritarian cloture rule. If you change either of those things (representation proportions in the Senate, or the cloture rule), we would right now have significant health reform.


You are correct in terms of the origin of the Senate but I disagree with you in two ways. First off, I disagree that “the Senate serves the same function today as it did 200 years ago.” The size differences between the states are significantly larger now, and we also have an extremely unusual cloture rule, a rule created by the Senate (it’s not in the Constitution), which means that a very small piece of the country can derail the large majority. Mathematically, you need 41 Senators to prevent cloture, and if you take the 41 Senators from the 21 smallest states, it would come to about 15-20 million people total, about 5% to 6% of the overall US population. So I think that between population changes and the cloture rule, the Senate has become a much greater barrier to legislation that it was intended to be. Basically, 5% of the people can deny the other 95% a chance to even vote on a proposal. That, IMO, is a serious miscarriage of democracy.

Second, I think that because of 225 years of change, it’s time to rethink the core design of the Senate. As you say, the Senate was originally designed to prevent large states from overpowering small states. This was done as an incentive to entice the small states to join the union. However, now all 50 states are so deeply interwoven into the national culture and economy that IMO we don’t need state by state equivalency to keep states in the union. Additionally, the value of voting and widespread participation has increased: at the founding, a relatively small portion of citizens were eligible to vote due to property and wealth requirements. Since then we’ve become a mass democracy and the principle that every vote should count equally has become very important. That means that the fact that I as a Californian have 1/70th the representation in the Senate as a Wyoming resident or an Alaskan is a problem.

So I think the time has come to discuss revising the structure of the Senate. But that’s a big deal and shouldn’t be done hastily. There is one thing we can do now which would help: repeal cloture.

I definitely think the cloture rule needs to be repealed. It’s a historical descendant of the filibuster rule, which was created at a time when Congress was seasonal and travel times were a big time sink. Now Congress is essentially year round and Senators can travel via air so I think the need for a filibuster is gone. And the cloture rule was always a weird bastardized riff on filibuster and was IMO never intended to be used the way the Repubs are using it. So lets get rid of that.

Without cloture the Senate would still be undemocratic but at least it wouldn’t allow for 5% of the population to hold 95% hostage.

Not really. People have no idea what’s actually in the health care reform bills. The Democrats are explaining it poorly and the Republicans are outright lying. Also, what the American people want in terms of healthcare reform depends vastly on who does the polls and how they’re worded.


Unless there is an effective public option, then what has been proposed is simply health insurance reform. It isn’t health care reform. Obama is trying to push a plan through that also caters to big pharma. That is what is discouraging to a lot of liberals. Single-payer wasn’t on the table from the start. It was never even considered as an option.

Of course Single Payer was considered as an option. I work with some of the people working on health care reform, and they’re smart, principled people who put everything on the table, everything from everywhere. And then they started moving towards the possible. Single payer would have never, ever, ever, ever passed. People who argue it could have, in this place and time are wrong. Period.

Even trying to put it forth as a head fake or a negotiating boundary would have done more harm than good right out of the gate. I consider myself to be as liberal as the next guy, but people who argue that single payer “should have” been proposed irritate me, because there’s a difference between sacrificing political capital to win a tough fight (public option), and utterly stabbing the good in the face in pursuit of the perfect.

The same with the deal with big pharma. A calculation was made that this was going to be an incredibly tough fight, and the choice was between pharma and the insurance companies. They decided to not take on both at once, and given how brutal it’s been as it is that was a smart choice. Again, these are people who are forced to deal with the possible.

I have to agree with this point. And it’s not that single payer is “too liberal”. There is a specific reason why single payer was not put on the table: the tax “cost” would be WAY too high. This ties in with Robert (no relation) Sharp’s point: to make single payer work you would have to take the approximately 750 billion $$ per year that employers pay for health care and convert that into tax revenue. If you did it right, it would not have much net impact on individuals, but (and this is the big but) it would the biggest line item in the tax budget, pretty much ever. In terms of the way it would be accounted by GAO and reported by the mainstream press, it would be the biggest tax increase in history, by a big margin. And so the idea is dead. Dead as the proverbial Norwegian Blue.

This is a very sad truth, because, as Robert has pointed out, it’s not a real net increase in cost to the taxpayer, but it would portrayed and perceived as one.

The problem with the senate is not the proportion of population represented per senator, but lies instead in the concept of the “State” from where they are elected.

I agree with you on the Cloture rule definitely. Not as much on any other revisions.

Not really. As with most polling, it’s all in the questions.

When asked stuff like what they think of “Obama’s healthcare bill” or “The healthcare bill in Congress” or some shit, people don’t like it. They don’t like it because nobody likes to see the sausage get made.

When you describe the features of the healthcare bill (e.g. “Would you like a bill that does x, y, and z?”) the bill’s popularity goes up a bunch. Nate Silver at writes about this stuff a ton; go check him out for more.

People need to remember that the makeup of the senate was a compromise that sat alongside the 3/5th’s compromise which was not exactly the highlight of American Civics. If you ignore the historical context and just look at what it does today it’s really just a bad case of gerrymandering and serves no real purpose. If we just can’t do without bicameralism than there are better ways to set that up.

But hey, we’ve been down that road before. Expect a lot of, “OMG, it’s in the Constitution, it cannot be questioned”. Also, there’s no way this will ever be changed, sadly, so it’s just something we have to live with. Cloture, as you point out, just makes it worse and is probably something that could be looked at as a partial solution.

Anyway here’s a good read on the Senate discussing the many imbalances its makeup has caused and discussing, in depth, the issue of bicameralism, it’s advantages, and why the Senate doesn’t actually accomplish these.