President Barack Obama recently urged Congress to use "reconciliation" to enact medical reform legislation. Reconciliation rules allow legislation related to taxes and spending to be enacted by a simple Senate majority without the 60 votes needed to avoid a filibuster. Democrats no longer have the 60 votes. Reconciliation therefore appears to offer the only hope of enacting medical reforms.
There is an alternative to reconciliation, however: the "nuclear option." It seems more extreme but would be better than reconciliation in several ways. The nuclear option would have Vice President Joe Biden, presiding over the Senate, rule that the Senate is not a "continuing body." Senators would then adopt procedural rules anew for each two-year term. Rules would be enacted by simple majorities. The majority could then adopt rules that do not include a filibuster. When filibusters were rare, they allowed decisions to reflect not just how many senators were on each side of an issue but also how strongly they felt. Weak majorities could sometimes be trumped by passionate minorities. To some extent, this may have been a good thing.
Recently, though, filibusters have become the rule rather than the exception. This reflects the weakening of moderates in both parties, an unfortunate side effect of using primary elections to select party nominees. Since those voting in primaries are mainly party extremists (or "base"), the Senate has fewer moderates willing to make the compromises needed to produce the 60 votes allowing that body to vote on an issue. Before primaries, nominees were selected by party leaders and were more likely to be moderates.
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Since we are unlikely to get rid of primaries, we have to eliminate the filibuster if the Senate is ever going to be able to function again as a normal legislative body. For health care, the nuclear option would make the unseemly deals needed to pick up the votes of key senators less necessary, since no one Democratic senator could derail things. It would also allow all details of the proposed legislation to be amended, not just those related to taxes and spending. Even better, the nuclear option would allow Democrats to accept Republican demands to scrap the current bills and start drafting reform legislation all over again.
The current bills do not make a lot of sense. The most important provision prevents insurance companies from denying coverage due to preexisting conditions. For this to work the legislation also mandates that (nearly) everybody must buy insurance, but it does not back up this requirement with sufficiently strong penalties for non-compliance. The mandate to buy insurance is constitutionally dubious, at best, but even worse, it creates an unnecessarily complicated and expensive system. Instead of mandating that everyone buy insurance, why not just provide that insurance and finance it with the tax system? The savings on transaction costs alone would be enormous.
Whether we call the new system "Medicare for all" or "single-payer" or "socialized medicine" is beside the point. Socialism is a poor way to organize an entire economy, but a mixed economy with some elements of socialism might well be optimal. We should be more interested in whether something will work well, and less interested in plastering emotionally-loaded labels on it. Insurance reform by itself will not solve all of our medical problems. Something still needs to be done about the costs of the specific procedures paid for by that insurance. But no one law will do the whole job, and insurance reform would be a good beginning. Vice President Biden: It is time to push the "nuclear" button!