Enemies of Reform
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How to Shame Senate Healthcare Obstructionists
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Lies, Damned Lies
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5 Healthcare Lessons in Possible Grocery Workers’ Strike
The Dirty Little Secret of Health Care Cost Control
Published November 11, 2009 @ 02:12PM PT
The trickiest knot in health care reform isn't immigration or abortion or even a public option. It's who's going to pay for it. We've talked a-plenty about new revenue, be it the House's surtax on millionaires or the Senate's high-cost health insurance tax. But we also need money derived from the savings that can be wrung out of our bloated $2.4 trillion a year health care system (a figure that dwarfs the measly $90 billion a year we'll spend fixing it.) Half of the costs for each of the health care bills -- and more than half of what the Obama Administration has proposed throughout the year -- are recouped by policies that "bend the curve" of our accelerating health care costs. Indeed, Republicans have made bemoaning the proposed $500 billion over 10 years of cost containment provisions in Medicare into high kabuki theater. Nonetheless, we're hearing a new "conventional wisdom" that the reform plans aren't good because they don't do enough to control costs -- and some who push this thread into hyperbole by claiming there's no cost control at all.
Here's the dirty little secret of cost control at this stage of the game: most of the politicians making the claim that the reform bills don't do enough to control costs wouldn't be caught dead voting for the ideas that really will control costs!
Don't believe me? Well, let's take Mark Warner or Susan Collins or one of the other senators now looking to poke holes in a reform plan while being secretive about what their own method for controlling costs will be. Which of the following ideas would these so-called "fiscal conservatives" actually vote for?
First, there are the elements that we know with certainty that the Congressional Budget Office would score as an aggressive way to control costs. We can start with ending the program for overpaying Medicare Advantage for-profit HMOs per customer compared to traditional Medicare -- a proposal in all the bills that the CBO guarantees will cut costs but which the insurance industry and most Republicans and moderate Democrats are fighting. Or there's the "Cadillac" tax in the Senate Finance bill, itself a somewhat lame iteration of removing the tax exemption on employer-provided insurance, a guaranteed source of revenue that also exerts downwards pressure on the cost of insurance. Or how about a public option that pays Medicare-based rates, a tool that the CBO has repeatedly scored as a cost-saver and a significantly higher cost-saver than one with negotiated rates (Warner only supports the latter, Collins supports neither of the above)?
Second, you know what else would substantially save money? Having the federal government negotiate and/or set the rates for health care services. That's how every single-payer system, from Europe to Asia to Oceana, achieves the bulk of dramatic savings. That's how hybrid public-private systems like Japan have achieved such efficiency that our per-person costs are three times as much as theirs (if we waved a single-payer magic wand tomorrow and removed the administrative costs of private insurance, we'd still have 2.5 times the costs of Japan). That's even how the conservative and wholly privatized model of Switzerland operates. And I would have a heart attack and die if I saw a single centrist Senator propose it.
Finally, there are the cost control measures that will likely save money but which the Congressional Budget Office will score as netting very little savings. These are likely the proposals a Collins or a Warner will champion. But because the CBO is doubtful that they would produce guaranteed savings, we could implement them all and still be open to the charge of "This bill doesn't do enough to control costs." For example, many -- including Bob Laszewski -- are hailing the idea of either a bipartisan Congressional commission or an independent MedPAC-like board to propose and implement cost-control tools for Medicare free from the politicking of Congress. It's a good idea, but one that the CBO is not likely to score well (interestingly, because they don't think it will generate more savings that what's already included in the bills -- natch.) Investments in prevention, primary care, coordinate care, the medical home, electronic health records -- all elements that we know save money in state Medicaid programs, closed systems like the VA, and state-of-the-art high-quality health systems like the Mayo Clinic, all likely to leave the CBO unimpressed. Reducing hospital readmissions, making adjustments for productivity changes at hospitals, and allowing trimming waste, fraud and abuse? Already in the bill, chief. Tort reform? Fuggedaboutit.
I would love it if the reform bills in Congress did even more to reform the way Medicare delivers its payment systems, blazing a path for private payers to follow. Real cost containment won't come from a single bill but from creating tools that allow us to adjust and bend the curve next year, and the year after that, and the year after that. It's not that the proposals on the table do nothing -- that I fear is about to become an often-repeated lie -- and it's not like we don't know what we can do to bend costs even further. But getting these options past the so-called fiscal conservatives who should be championing them? That's the true Gordian knot.
The dirtiest secret of all is that in health care, one man's waste is another man's profit margin... and still another's campaign contribution.
(Photo credit: http://www.flickr.com/photos/13061661@N08/ / CC BY-ND 2.0)
The Senators -- and the Yankees -- Need to Get On With It
Published November 06, 2009 @ 07:03PM PT
The New York Yankees may be World Champions, but they’re noteworthy this year for another reason: they have come up with the most obnoxious way to prolong games. All other teams in baseball have “mound conferences” -- timeouts when the catcher, the pitcher and sometimes the pitching coach meet on the pitching mound to make sure they know how to handle the next batter. But the Yankees do it with chutzpah -- all of the infielders are there discussing what pitch to throw next. I guess they think the second baseman might have a good idea on whether the hitter is thinking fastball or curve. Even that may be ok, but the Yankees also do it with shocking and excessive frequency -- including eight times in a single inning for one World Series game. The delays not only make already-long games much longer, but they’re prompting Major League Baseball to consider rule changes and disciplinary action.
I say if MLB does find a solution to the Yankees having Tupperware parties on the mound every time the score gets close, we should use it on the United States Senate.
If all goes well, the U.S. House of Representatives will vote on a historic comprehensive health reform bill tomorrow night. If all isn’t well, it may take a couple of extra days, making this the first health care deadline that the House leadership has missed in this months-long process. But the Senate is a different story. Despite a Senate Health, Education, Labor and Pensions Committee bill that was finished in mid-July and a Senate Finance Committee bill that was finished over a month ago, Majority Leader Reid still has given no clear indication of when a Senate debate is likely to start, let alone end. The same Senate health care bill process that Sen. Max Baucus once confidently predicted would be over by the Fourth of July will now be lucky to finish by Christmas -- but, the Majority Leader cautions, don’t hold us to that.
Kucinich Tries to Kill Vote on Medicare For All
Published November 05, 2009 @ 06:33PM PT
In a stunning about-face, Dennis Kucinich made a statement questioning a scheduled stand-alone vote on HR 676, Medicare For All. It was to be voted on Friday. Then he sent an email to supporters urging them to convince congressional leaders that now is not the time to vote on the single payer bill. Why would he try to kill his own baby?
It appears the House weakened the bill beyond recognition, as Kucinich says:
"... we want to offer a strong note of caution about tomorrow’s vote. The bill presented tomorrow will not be HR676. While we are happy to relinquish authorship of a single payer bill to any member who can do better, we do not want a weak bill brought forward in a hostile climate to unwittingly accomplish what would be interpreted as a defeat for single payer."
There has been no Congressional debate over HR 676. There has been no mark-up of the bill. The CBO apparently scored a weakened version of the bill unfavorably. This is of course after Nancy Pelosi inexplicably removed Kucinich's state single-payer amendment from HR 3962 after the bill had been released. She disengenuously called it a "mistake" at the time, fooling no one. Then she didn't allow it back in via manager's amendment (somehow it was okay for the Republican "plan" to get in via manager's amendment, even when the CBO thrashed it.)
Overall it seems a patented "kill switch" political trick to do a test vote on HR 676 now. Pelosi killed state single payer by playing dirty pool. Now she's trying to kill single payer, period, by forcing a phony vote on a weakened HR 676. That is why Kucinich is now calling on his support base to temporarily surrender rather than go down in flames. Sadly, it seems Congress is hell-bent upon passing weak healthcare reform, no matter what dirt it has to pull out of its bag of tricks.
You can send an email to your representative here.
UPDATE: Anthony Weiner's amendment to HR 3962, which was a substitute for HR 676, has now also been sacrificed. Nancy Pelosi convinced Weiner to accept a no-vote for the good of overall reform. Her argument is not to let perfect get in the way of pretty good. In this case it would be more accurately stated as not letting good get in the way of pretty weak.
Photo http://www.flickr.com/photos/rustydarbonne/2099154382/sizes/m/ // CC BY 2.0
Why Do We Need a Public Option Anyway?
Published November 03, 2009 @ 06:00AM PT
Political games are alive and well in Washington, D.C. First the House releases HR 3962, a disappointing bill with an optimistic and completely misleading name – the Affordable Health Care for America Act. Then the GOP decides it’s an opportune time to release its own bill, which House leader John Boehner says will lower cost and expand access by “making the current system work better” with less government intrusion into the private sector. Sounds great John, only, well, there is no system … and that whole government intrusion line? Well, that brings me to my point. Why do we need a public option again?
It seems politicians on both sides of the aisle have lobbyist-induced amnesia on that aspect. Democrats hope including a public option – no matter how weak and ineffective (a more expensive alternative to private plans that covers 2% of the population? Please!) – is all it takes to please the public, even if it’s designed to fail. Meanwhile, Republicans decry government intervention and propose tweaks around the edges of our disastrous healthcare mess that conveniently avoid touching the profit-driven culprits themselves. In other words, the US has heart disease and our D.C. representatives suggest blood transfusions, an artificial knee replacement and a flu shot.
Case in point: the central aspects of the GOP bill are tort reform, insurance pools, and inter-state policy purchases. Two of the three are already in place in many states – they haven’t budged healthcare costs significantly (tort reform achieves 10% reductions in malpractice insurance, per the CBO.) Tort reform is a good idea anyway, but not for cost curve reasons. The third proposal, while useful, doesn’t help much when insurance costs are out of control nationwide.
Douglas Holtz-Eakin, a senior policy adviser to John McCain’s presidential campaign, knows that now. The same man who touted a $5,000 insurance tax credit per family as the answer to our insurance woes now remains unemployed and his $1,000 per month COBRA is running out. He’s shopping the individual insurance market at age 51 and with a pre-existing condition that insurers cite in denying coverage. Think he’s a bit worried? All politicians should be placed in that situation; maybe they would get a clue.
Anyone familiar with T.R. Reid’s body of work on international universal healthcare systems knows that a public option isn’t a part of many of them (gives “socialized medicine” a rather hollow ring, doesn’t it?) There is a single public payer in some (Canada), multiple private insurance payers in others (Germany, Switzerland) and some countries use a combination (England.) What’s the difference then? Very simply, their ‘private insurers’ are non-profit corporations governed by iron-clad regulations: no loopholes, no kickbacks, no lobbyist favors, no profit or surplus beyond required reserves.
Why is that? Insurers are there to provide payment for the care of country residents, with no deliberate and systematized waste and no tricks. Patients are not pawns in a giant profit mill. Now, does this sound like the situation in the US? It seems like the banks and the healthcare industry own Washington, D.C. While Joe Public pays for congressional salaries and benefits (with fantastic health plan choices), lawmakers actually work for Joe Lobbyist. So whatever regulations are placed around the health insurance industry, we can rest assured they will be weak and full of holes by design.
Making sure people are covered and making sure that coverage is affordable are two different things, a distinction neither party has addressed satisfactorily. A strong public option is just one of two methods to keep private insurer prices and practices in line, regulation being the other. But if regulation is to be the answer, we need a representativectomy and a lobbyist exterminator to spray the capital. That seems unlikely. As Nancy Pelosi “mistakenly” left Kucinich’s state single payer amendment out of HR 3962 (as of scheduling this post, it hadn't been reinstated), we can’t vote with our feet by becoming interstate medical refugees. So I’m still pushing for a strong public option.
Photo http://farm3.static.flickr.com/2579/3883236444_edbc207a32.jpg // CC BY 2.0
It's Annual Enrollment Time: Brace Your Wallet
Published November 02, 2009 @ 05:00AM PT
Halloween tricks were a warm-up. While Congress argues partisan, special-interest driven healthcare reform politics these next few weeks, many employees will be faced with a stark reminder of the need for reform. Yes, November is here – annual enrollment time for 60% of insured Americans. It is rapidly becoming known as “spend more, get less” time for group health plan participation.
Now, Joe Lieberman thinks healthcare reform is going too far, that a public option is “just unnecessary” and private health plan premiums will go up. He’s threatening to join a Republican filibuster because of his “concerns.” Uh, Joe? Don’t you dare. Those premiums have already gone up, with medical costs rising three times as fast as inflation. Premiums are skyrocketing with no public option, and AHIP has promised they will continue to do so. So if you filibuster to strip the people of their power, Joe, we will strip you of yours within the Senate.
But back to reality outside the Beltway. Group health plan premiums have risen 131% in the last 10 years, according to the Kaiser Family Foundation. Employee contributions have risen 128%. Since 2006, the percentage of individual insured employees responsible for deductibles of $1,000 or more has more than doubled, from 10 to 22%. Companies still offering health benefits in 2009 downsized them – 86% now offer only one plan. That group ironically includes Blue Cross Blue Shield of Florida, whose 5,000 employees will now be offered only a high-deductible plan. Meanwhile AHIP is decrying government involvement in healthcare due to supposed lack of consumer choice.
Public Option Popularity in Limbo
Published October 22, 2009 @ 06:00AM PT
Consider this a watch list update. Things are looking rosy for a public option right now. The majority of Americans support it, up to 57% from 52% two months ago. Bipartisanship is no longer in vogue, with 51% preferring a public option to a bipartisan one. Nancy Pelosi is rumored to be inserting a strong public option in the House bill, one that may be cheaper and cover more people than the combined Senate bill. Even Harry Reid is considering including “public option lite” in the Senate bill, with a state opt-out clause. So why all the talk about the public option being in limbo, of looking for alternative ways to try and keep private insurers in check?
"Doc Fix" Shows (AGAIN) Why the House's Health Reform Bill Is Better Than the Senate's
Published October 21, 2009 @ 11:03AM PT
The last House committee to work on comprehensive health reform finished at the end of July. The last Senate committee (Sen. Max Baucus's Senate Finance Committee) finished last week. But the House has not been idle. News comes today that an initial score from the Congressional Budget Office says the House has refined its bill to only cost $871 billion over 10 years. Of course that is likely to get overshadowed by the train wreck in the Senate concerning Medicare's "Doc Fix." So many commentators are focused on the political clumsiness of pushing a separate bill in the Senate to fix the Medicare Sustainable Growth Rate (SGR) that they may miss what this Three Stooges-esque vignette tells us about the policy strength of these House and Senate bills.
Simply put, the House has its act together. The Senate's got a lot of work to do.
The SGR was an attempt to curb skyrocketing costs in Medicare which has not only failed, it's become the second-worst accounting trick in the federal budget over the past decade (the worst being leaving the costs of the wars in Iraq and Afghanistan out of the budget every year of the Bush Administration so the deficit wouldn't look so big.) A brainchild of the Gingrich Congress and an amendment to the 1997 Balanced Budget Act, the SGR is a formula intended to prevent physician compensation for Medicare from rising above the rate of growth in GDP each year. If physician fees were threatening to go higher, all doctors' fees across the board in Medicare would be cut to keep them within that limit. Not inherently a bad idea, but it has a huge flaw -- in most years, medical costs rise at several times the rate of growth in GDP whether you're talking public coverage or private insurance. The net result is that SGR would guarantee a major cut to Medicare nearly every year, at least until we get an explosive economic growth like we had in the 1990s. And we're not talking obvious waste like Medicare Advantage subsidies for HMOs or those motorized scooters you see in ads on cable TV -- we're talking doctors' fees. You know, the whole point of having health coverage.
So every year, Congress passes a one-year moratorium on the SGR. Every year, all Democrats in the Senate vote for it. Every year, almost all Republicans vote against the moratorium and for the cuts to take place (including every single one of the conservatives who are making "how dare we cut Medicare in any way, shape or form!" their rallying cry for defeating reform. Gotta love that blatant disregard for consistency.) Every year, doctors' fees in Medicare continue to rise at roughly the same "way, way over inflation" rate they do for private insurance, meaning if the cuts took place this year, it'd yield a 21% cut across the board. But every year, the cut never actually happens. It's like a bad sitcom whose punchline you can see coming from miles away. It's absurd. And it needs to be fixed.
Enter health care reform -- an obvious spot to fix it.
