The 2014 State Of The Union Address

Boehner SOTU

The State of the Union address (transcript here) was rather modest, considering the limitations Obama faces in dealing with Congressional Republicans who have had the policy of opposing Obama’s agenda on political grounds since the day he took office. The few policy proposals had already been released, such as an executive order regarding the minimum wage at companies receiving government contacts. There were a few moments during the speech worth noting. He began with what was basically a defense of his record on the economy:

The lowest unemployment rate in over five years. A rebounding housing market. A manufacturing sector that’s adding jobs for the first time since the 1990s. More oil produced at home than we buy from the rest of the world – the first time that’s happened in nearly twenty years. Our deficits – cut by more than half. And for the first time in over a decade, business leaders around the world have declared that China is no longer the world’s number one place to invest; America is.

That’s why I believe this can be a breakthrough year for America.

Of course, in what is essentially a disproof of trickle-down economics, he recognized that problems remain:

Today, after four years of economic growth, corporate profits and stock prices have rarely been higher, and those at the top have never done better. But average wages have barely budged. Inequality has deepened. Upward mobility has stalled. The cold, hard fact is that even in the midst of recovery, too many Americans are working more than ever just to get by; let alone to get ahead. And too many still aren’t working at all.

This sure makes the right wing claims that Obama is a socialist sound ridiculous. Plus there is his support for small business:

Let’s do more to help the entrepreneurs and small business owners who create most new jobs in America. Over the past five years, my administration has made more loans to small business owners than any other.

While it may or may not be wise, I always wish that Democrats would do more to directly take on the absurd positions held by many Republicans. Unfortunately I’m not sure that showing Republican denial of science would be politically successful in a country with such vast scientific illiteracy. At least we did get this:

But the debate is settled. Climate change is a fact.

He is right about climate change, but the debate is only settled in terms of the scientific knowledge. Climate change is a fact. So is evolution. And the earth is round. Try to convince the Republicans.

Obama also defended his record on health care:

Already, because of the Affordable Care Act, more than three million Americans under age 26 have gained coverage under their parents’ plans.

More than nine million Americans have signed up for private health insurance or Medicaid coverage.

And here’s another number: zero. Because of this law, no American can ever again be dropped or denied coverage for a preexisting condition like asthma, back pain, or cancer. No woman can ever be charged more just because she’s a woman. And we did all this while adding years to Medicare’s finances, keeping Medicare premiums flat, and lowering prescription costs for millions of seniors.

Obama said little about the problems caused by Republican obstructionism, but did mention the “forty-something votes to repeal a law that’s already helping millions of Americans.” I believe the exact number is forty-seven votes to repeal the Affordable Care Act.

Among the lines which got the most attention of the night, when discussing equal pay for equal work:

It is time to do away with workplace policies that belong in a “Mad Men” episode.

The official Republican response was rather empty, and there were also two Tea Party responses. The bulk of the opposition I saw to Obama on line (and in an op-ed by Ted Cruz)  has been to the use of executive orders, ignoring how much fewer he has used than his predecessors. Where were all the conservatives now complaining about Executive power during the Bush years, when Bush went far further than Obama is contemplating?  I doubt their complaints will receive much sympathy from swing voters (the few who exist). As I pointed out recently, voters are realizing that the Republicans are responsible for gridlock, even if the media often overlooks this in their efforts at appearing objective by treating both parties equally when they are not mirror images of each other.


All in all, the address was liberal but hardly ground-breaking. The Monkey Cage has compared every SOTU address since 1986 based upon ideology. This year’s speech was placed around the middle of previous addresses from Obama and Bill Clinton. What I really found interesting about this chart was how far the Republicans moved to the right under Bush. State of the Union addresses are hardly an exact measurement of the ideology of a president, but it is interesting that Ronald Reagan and George H. W. Bush are far closer to the two Democratic presidents compared to George W. Bush. George W. Bush Started out comparable to the previous Republican presidents in his first speech, then moved significantly to the right. Maybe this was the result of 9/11.

If nothing else, I was happy that it wasn’t Mitt Romney giving the speech. I’m imagining Mitt Romney spending the evening going up and down in his car elevator. I couldn’t resist staring with the above picture which captures John Boehner, even if he isn’t orange enough. I did feel that his green tie did clash with his orange face.

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A Tale Of Two Countries: Health Care In Red Versus Blue America

ObamaCare Enrollment

The United States is increasingly dividing into two countries, a Blue America and a Red America. Blue America is becoming a more free country, while Red America increasingly has states which intrude more into the private lives of individuals, and use government to enforce the views of the religious right. Blue America is a more prosperous America, while Red America is more dependent upon money from Blue America, taking in more federal tax dollars than they pay. As much as they hate to admit it, Red American is the America of takers. Now we are seeing yet another division. People in Blue America are more likely to receive health care coverage than people in Red America.

Jonathan Cohn has two charts which demonstrate this. The first compares people who have enrolled in private health plans through the Affordable Care Act. Note how heavily tilted this is towards the blue states. There are some exceptions. Massachusetts has low enrollment because most people in the state already had health care coverage under their plan. Kentucky is a notable exception of a red state with relatively high enrollment because of having a Democratic governor who has been heavily supporting the Affordable Care Act. There are also some  blue states such as Oregon which had difficulties with their state exchange. Enrollment should pick up as this is fixed.

There are probably a couple of reasons for this divide. The most significant is probably the degree to which the state governments are supporting and promoting the Affordable Care Act. There is also probably a cultural difference. People in the red states are generally less well informed–if they were not they would not vote Republican. They are more likely to listen to the misinformation about the Affordable Care Act from sources such as Fox. They are also more likely to listen to conservative leaders who are telling them not to purchase ObamaCare coverage. Independent thought is not a strong point among the low-information Republican voters in the red states.

The second chart compares expansion of Medicaid. It should come as no surprise that the working poor in the blue states are far more likely to have this available than those in the red states.

I can’t help but wonder how long the political leaders in the red states can continue to fool so many of their citizens. Sooner or later they will realize how people with Democratic state governments are benefiting. Some might even decide that it is more important to worry about health insurance than whether two gay guys can marry, or whether women use birth control and possibly even have an abortion.

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Medicaid Is Not The Route To A Single-Payer Plan

Corrente is a far left blog which I generally have little interest in, but there are bound to be times when our interests overlap. Today I must say they are right while Paul Krugman and several other liberal writers/bloggers, who I would generally side with over Corrente, are wrong. Paul Krugman and some other liberal writers have been praising Medicaid expansion as if it is a path towards a single-payer plan. A writer at Corrente counters with a post saying that Paul Krugman is wrong about Medicaid.

The writer describe some of their negative experiences in a Medicaid program and concluded:

This is not the system Krugman imagines. He’s not alone; most Democrats and many people who describe themselves as progressive are celebrating the Medicaid expansion under Obamacare as an extraordinary advance. In terms of coverage, they’re right. In terms of steering the country toward health care equity, they’re wrong. Medicaid patients are too often treated as second-class citizens, and the problem is likely to worsen without the kind of drastic reform I mentioned earlier.

There are at present about 150 million Americans being served by at least a half-dozen single-payer systems. We need to take the most popular of those systems and expand it to provide cradle-to-grave coverage for everyone in the country, and improve it to achieve the health care equity that Americans deserve and that President Obama has described as a basic human right. We need Medicare for all.

Medicaid, as the author acknowledged, varies from state to state and even within different parts of states. Some people will have better or worse experience, but the fact remains that in general Medicaid patients are second-class citizens in the health care system. Access to care does vary, but is far different from the health care experiences of most Americans who have insurance or are covered by Medicare. My office receives quite a few calls each week from both people on Medicaid who do not have physicians and from those who desire to get away from the second-class care they often receive in the clinics which will see them. While better than no coverage, to those who have better coverage Medicaid would represent all the horrors of government run health care which the right has been crying about.

I bet that Krugman, and those who echo his views, would change their minds very quickly if they had to give up their private physicians and obtain all their care through Medicaid clinics.

The blogger at Corrente is also correct that, while Medicare is not perfect, Medicare for all would be a much better model for a single-payer plan. It is far better than Medicaid, while still keeping costs down.

I must conclude by also pointing out that Medicaid expansion is not without benefits. Having Medicaid is still far better than having no coverage, despite misinterpretations being spread by conservatives regarding studies of Medicaid expansion in Oregon. I previously discussed this topic here. When the Affordable Care Act was being considered in Congress while the Democrats technically had sixty votes, there weren’t sixty votes for either a pubic option or even a Medicare buy-in, due to opposition by Joe Lieberman and Ben Nelson. With limited money to expand health care coverage, and the impossibility of a single-payer system based on Medicare getting through Congress, Medicaid expansion was an understandable compromise to provide some coverage to the working poor. That does not make it a desirable model for moving to a single-payer plan.

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Misunderstanding Of Medicaid And Emergency Room Use

There has been a surprising amount of attention to a recent study showing that if you give people Medicaid coverage they will go to the Emergency Room more often than if they did not have coverage. That should hardly come as a surprise. If someone has to pay, they will be far more reluctant to go to the Emergency Room where they will build up a huge bill.

Much of the attention is coming from conservative sites who misunderstand the issue (or are intentionally engaging in distortion), and claim that this shows a fault in Obamacare.

Discussion of Emergency Room use in the past was often centered around the conservative claim that the uninsured poor are not without health care coverage because they can go to the Emergency Room when sick. The usual response is that ER care is far more expensive than other out-patient care and is a poor source of treatment for chronic medical problems. Plus the poor cannot really go to the ER on a routine basis without running up a huge debt.

Provide Medicaid or private insurance, and use of the ER will increase. Many patients with both private coverage and Medicaid abuse the ER for a variety of reasons. There is certainly no reason to believe that Medicaid patients will be any less likely to do so.

Reducing over-use of the ER requires additional measures. To some degree this should improve as more of those with newly-received Medicaid become better established with primary care physicians. Simple educational measures and Medical Homes would bring about a further decrease in ER over-use. A study such as this of people who only recently received Medicaid would be expected to show greater 0ver-utilization in early years.

These simple measures will not eliminate over-utilization of emergency rooms for non-emergency visits. If this is the goal, Medicaid programs would need to utilize further measures often used by insurance companies to reduce over-utilization. This might include significantly higher co-pays for ER versus other out-patient visits, either for all visits or for only non-emergency visits. A more extreme practice used by some plans is to require prior-authorization from either the insurance company or the patient’s primary care physician before an ER visit before the visit would be covered. (Of course exceptions need to be made for true emergencies. We do not want people with chest pain to have to waste time getting approval before seeking medical attention, and insurance companies cannot deny payment because someone is unconscious and unable to seek authorization.)

Long run there are potential cost savings in providing Medicaid coverage which ultimately leads to people seeing primary care physicians and receiving preventative care as opposed to episodic care from Emergency Rooms. However it would take years to see the benefit from this. The goal of Medicaid expansion is to provide care to those who are not receiving care, not simply to save money. Denying medical care and letting people die younger might save more money, but is not a desirable public policy agenda.

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Expanding Medicaid Coverage Is Beneficial (Ignore Those Conservative Bloggers Arguing Otherwise)

A study in The New England Journal of Medicine comparing people with and without Medicaid in Oregon provides an excellent example of how the right-wing blogs can take data and cherry pick the information which supports their views while ignoring the full set of information. The study does not provide evidence against expanding Medicaid through the Affordable Care Act, despite their spin. This is a topic which I wish I had more time to devote to tonight, but only have the time for some brief remarks.

The study shows that with some measures of medical care those receiving Medicaid coverage did better than similar adults who did not receive Medicaid coverage in Oregon’s lottery but there was not a large enough sample for the differences to be statistically significant. The most significant differences were reduced rates of depression and financial strain:

In particular, catastrophic expenditures, defined as out-of-pocket medical expenses exceeding 30% of income, were nearly eliminated.

Reducing financial strain is a rather significant benefit of having medical coverage. That’s also a key reason why so many people are concerned about receiving health care benefits from their employer and having Medicare coverage after they retire.

Showing improvements in measures of chronic diseases in a two year study, but not enough to be statistically significant yet, really comes as no surprise. It takes time to see major improvements in diabetes care, and the improvements shown in this study are a real start.

The results could be better. When I receive new diabetic patients who are poorly controlled I will see them every two weeks, and have them in for blood sugars in the time between these appointments. A new diabetic appointment will be well over an hour, and not uncommonly two hours. The glycated hemoglobin levels used in the study provide an average measure of blood sugar over the past 3 months. (It is a test of the effects of elevated blood sugars on red blood cells and provides an average based upon the life span of red blood cells). With intensive treatment of uncontrolled diabetics it still takes several months to see a statistically significant change.

I generally do see greater drops in glycosylated hemoglobin over the first year of treatment than this study is showing in two years. Of course this is not with Medicaid patients. No doctor could afford to do this with what Medicaid pays. The study shows that a poorly funded program provides some benefits. Giving the same people coverage at the level of private insurance, or at least Medicare, would probably result in even better outcomes. This study is not evidence that providing Medicaid doesn’t provide benefits, but it could be argued that to provide better results we should be putting even more money into health care benefits. I would also expect to see more impressive  improvement over a longer period of time.

I am surprised that they used HDL level as a measurement in the study as, while improving it will decrease the risk of heart disease, it is very difficult to change HDL levels regardless of medical intervention. Having Medicaid coverage would not be expected to affect this.

Two years is not long enough to meaningfully evaluate changes on chronic diseases. An evaluation of treatment for acute problems would be more meaningful over this time period. Kevin Drum’s impressions on this are correct:

The study suffers from the usual problem of measuring “outcomes,” and suffers especially because it measured only a very limited set of outcomes (primarily chronic conditions like blood pressure, cholesterol, and diabetes). This has long been one of my pet peeves. The problem is that there are lots of things that improve your quality of life but don’t show up as an improvement in either mortality rates or glycated hemoglobin levels. If I have an infection, for example, a course of antibiotics is a godsend. More than likely, though, the infection would have gone away eventually on its own. Does that mean the medication was useless? Of course not. Ditto for arthritis meds, a better pair of glasses, a new hip, a root canal, or fixing a broken ankle.

The truth is that if you take a narrow view of “outcomes,” it’s hard to find a significant effect from most of our healthcare efforts. Nonetheless, improved access to Medicaid produces plenty of improvement in acute problems; better use of preventive care; and far better financial outcomes. This is all worthwhile stuff even if controlling chronic conditions remains a challenge.


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Expanding Medicaid

Although ten Republican governors have pledged not to accept the Medicaid expansion funds in the Affordable Care Act and 22 other governors are also considering turning down the money, Think Progress explains how these funds save money for the states:

1. Under Obamacare, states no longer have to finance health insurance for people above 133 percent of the federal poverty level. Many states fund health insurance programs which cover residents living at more than 133 percent of the federal poverty level (FPL). Obamacare makes residents at higher than 133 percent of the FPL eligible for subsidized health insurance through state insurance exchanges at no cost to states. For example, Idaho would no longer have to fund health insurance for its 63 percent of uninsured residents who are above 133 percent of the FPL, reducing its $47 million annual uncompensated care cost to $17.3 million.

2. Under Obamacare, states pay billions less to cover people below 133 percent of the federal poverty level. States pay billions in health insurance programs for residents living at less than 133 percent of the FPL. After five years of Obamacare, the federal government will cover 90 percent of insurance costs for state residents making less than 133 percent of the FPL. For the first three years of the expanded Medicaid program, the federal government will cover 100 percent of Medicaid costs. The surveyed states will save $4.2 billion (100 percent of their uncompensated care costs) annually for the first three years, and $3.0 billion annually starting in 2019. For example, Michigan pays $212 million annually in uncompensated care costs. After five years of Obamacare, Michigan would have to pay only $68 million annually in the expanded Medicaid program.

3. By making health insurance universally available, Obamacare slashes the “hidden tax” states pay in health insurance premiums. States pay a “hidden tax” in the form of higher insurance premiums to account for the cost of covering the uninsured. “By greatly reducing uncompensated care,” the Council explains, Obamacare works to “reduce this hidden tax.” For example, North Carolina would see its annual $58.6 million insurance premium “tax” reduced to reflect a much smaller number of people without health insurance.

A modern industrialized nation should really be able to do even more for the working poor than to place them on Medicaid. I wish that the entire idea of expanding Medicaid would disappear and instead there was more money to assist more people in purchasing real insurance through the exchanges (perhaps made more economical with a public option). At least the Affordable Care Act also increases payment for primary care services temporarily, but unless this is made permanent those on Medicaid will continue to receive second class care. It is unrealistic to expect physicians to see more Medicaid patients at a loss.

Unfortunately at present expanding Medicaid is the most likely means of extending health care to the working poor. Ultimately I expect that most red states will give in and take the federal funds to provide this coverage, but many people might continue to suffer until this happens.

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Study Verifies That Poor Do Benefit From Medicaid Coverage

Medicaid provides poor health care coverage compared to Medicare, or to private insurance plans which do provide coverage, but is still far better than no coverage at all. This sounds incredibly obvious, but  a significant number of conservatives deny reality on this (as with most other) matters. Therefore it is worthwhile to link to a report that shows that yes, poor people are better off when they have health care coverage from Medicaid. The New York Times reports:

When poor people are given medical insurance, they not only find regular doctors and see doctors more often but they also feel better, are less depressed and are better able to maintain financial stability, according to a new, large-scale study that provides the first rigorously controlled assessment of the impact of Medicaid.

Among the findings:

In its first year of data collection, the study found a long list of differences between the insured and uninsured, adding up to an extra 25 percent in medical expenditures for the insured.

Those with Medicaid were 35 percent more likely to go to a clinic or see a doctor, 15 percent more likely to use prescription drugs and 30 percent more likely to be admitted to a hospital. Researchers were unable to detect a change in emergency room use.

Women with insurance were 60 percent more likely to have mammograms, and those with insurance were 20 percent more likely to have their cholesterol checked. They were 70 percent more likely to have a particular clinic or office for medical care and 55 percent more likely to have a doctor whom they usually saw.

The insured also felt better: the likelihood that they said their health was good or excellent increased by 25 percent, and they were 40 percent less likely to say that their health had worsened in the past year than those without insurance.

The study is now in its next phase, an assessment of the health effects of having insurance. The researchers interviewed 12,000 people — 6,000 who received Medicaid and 6,000 who did not — and measured things like blood pressure, cholesterol and weight.

This is not the type of situation where you can normally have a control group for comparison, but the conditions for the study were set up by an unusual situation in Oregon:

The study became possible because of an unusual situation in Oregon. In 2008, the state wanted to expand its Medicaid program to include more uninsured people but could afford to add only 10,000 to its rolls. Yet nearly 90,000 applied. Oregon decided to select the 10,000 by lottery.

Economists were electrified. Here was their chance to compare those who got insurance with those who were randomly assigned to go without it. No one had ever done anything like that before, in part because it would be considered unethical to devise a study that would explicitly deny some people coverage while giving it to others.

This helps verify that the aspects of the Affordable Care Act which expands access to Medicaid will be of benefit. It would be even better if instead these people are  given access to actual health care insurance through the exchanges or through a public option modeled on Medicare.

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Arizona Governor Proposes Fining Medicaid Smokers

I’m not saying I’m advocating this, but I’m also not terribly upset by one Republican effort which I’m sure someone somewhere in the liberal blogosphere sees as another effort to take money from the poor. Arizona Governor Jan Brewer has proposed a $50 per year charge for Medicaid recipients who engage in unhealthy life styles such as cigarette smoking. ABC News reports:

Childless adults who are obese or suffer from a chronic condition and who fail to work with their doctor to meet specific goals would be charged $50 annually. The $50 annual fee also would apply to all childless adult smokers.

“If you’re not going to manage those things and take some personal responsibility, and in turn that costs the state more money, then you need to have some skin in the game,” said Monica Coury, assistant director of Arizona’s Medicaid program.

Obviously seeing the details of such a plan would be important. There is no question that tobacco smoking leads to far greater medical expenses and it is reasonable for an insurer to want people it is covering to discontinue this habit. Medicare pays for tobacco cessation counseling during an office appointment on top of the usual payment for the office call. Many private insurers also base their rates upon habits. The policy which covers my employees has a lower rate for those who participate in a wellness program.

I would be more cautious about using a government program to try to regulate personal behavior. However a $50 charge for cigarette smoking hardly sounds like a draconian act by Big Brother (although I’m sure Republicans would be claiming this if it was part of “Obamacare.”) I would also have concerns about charges which Medicaid recipients might have difficulty paying, but if someone is buying cigarettes regularly they certainly are spending far more than $50 per year on items beyond true necessities.

I am just speculating, but I assume that the limitation in the proposal to childless adults is to make sure that the $50 doesn’t come from money which might otherwise be spent on children who have little control over the habits of their parents. (Or maybe not limiting to the childless would occasionally work. I can imagine the nagging: “Daddy, quite smoking already so we can  buy a Wii.”)

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House Passes Extension of Medicaid Match

The House passed legislation to extend higher federal government matches for Medicaid through mid-2011. The Senate passed the same bill last week and Obama is expected to sign this afternoon. The federal government has been paying an extra 6.2% to assist states hurt by the poor economy.

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AARP Joins Physician Groups In Blasting Congress For Inaction On Medicare Payment Fix

The failure of Congress to act on the Medicare “doc fix” has led to protests from medical organizations and the American Association of Retired People who have pointed out the harm this will do to the Medicare program and people dependent upon Medicare for their health care. The American Academy of Family Practitioners has called on Congress to stop harming patients and do their job. The American College of Physicians has blasted Congress for causing “Irreparable damage to Medicare” as seniors and military families face loss of access to health care. AARP sent the following letter to every member of Congress urging action on Medicare, warning that their inaction “threatens access to physician services for millions of Medicare beneficiaries.”

On behalf of millions of AARP members, I urge you to immediately pass legislation that ensures seniors have access to their physicians, and provides much needed fiscal relief to the states and to unemployed individuals.

Regrettably, given Congress’s failure to reach timely agreement on a Medicare physician pay package, the Centers for Medicare and Medicaid Services has now been forced to implement a draconian 21.3 percent reduction in their reimbursements.  This cut threatens access to physician services for millions of Medicare beneficiaries – especially those living in rural and other underserved areas.

While Congress continues to debate temporary patchwork solutions, people on Medicare are growing increasingly anxious about whether they will be able to find a doctor when they need one.  Seniors, who have paid into Medicare their entire working lives, deserve the peace of mind of knowing they will be able to find a doctor who will treat them.

AARP urges Congress to act immediately to stabilize doctor reimbursement rates for as long as possible until a permanent solution can be found.   For nearly a decade, Medicare patients and the doctors who treat them have been held hostage by short-term patches to an unworkable Sustainable Growth Rate (SGR) formula.  In the months to come, we look forward to working with Members of Congress from both sides of the aisle to repeal the SGR formula and replace it with a permanent physician payment system for Medicare that rewards value and ends the uncertainty for patients and providers alike.

In addition, enhanced Medicaid funding to states to assist them with the added costs of providing health coverage to low income individuals and for home and community based services must be extended.

Finally, we urge the extension of unemployment benefits for those unable to find jobs during this economic downturn.

AARP members are counting on you to address these critical issues immediately to protect their health and economic security.

Congress Plays Chicken With Medicare

Medical blogs have been protesting the failure of Congress to resolve this problem. For example, Dr. Rob warns that Congress is playing “a great big game of chicken.”

  • The house is playing chicken with the senate.
  • The Democrats are playing chicken with the Republicans.
  • They aren’t in the cars themselves, we are.  Doctors and patients are careening toward destruction in the name of political gamesmanship.

Surely they will flinch.  Surely someone will understand the consequences of the crash.  But you know what?  Sometimes each side expects the others will be the ones who flinch.  Sometimes nobody flinches.  Sometimes the cars crash and people are killed.

There are two potential ways to resolve this deadlock. The quickest would be for Nancy Pelosi to go along with Senate Majority Leader Harry Reid, House Majority Leader Steny Hoyer, and Rep. Robert Andrews (D-N.J.), the Chair of the Education and Labor health panel, and allow the House to vote on the temporary fix passed in the Senate last week.

Nancy Pelosi has been insisting on a different course by attaching the Medicare “doc fix” to other unrelated legislation. The Senate is attempting to pass legislation which includes some of Pelosi’s goals, but it is questionable if the Senate could pass such legislation without watering it down to the point where Pelosi would not find it acceptable.

For Nancy Pelosi to be the one who, at present, is blocking passage of this legislation might be political suicide for the Democrats, risking turning over control of Congress to the Republicans in November. The Democrats are already on shaky ground with seniors. As Ezra Klein pointed out earlier today, health care reform has become more popular since passage–except with seniors. The Democrats cannot afford to further alienate the senior vote, which tends to turn out more heavily in off year elections than the younger voters who are more likely to stick with the Democrats.

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