Enemies of Reform
Michael Steele Goes Negative on Family Benefits
Published May 17, 2009 @ 06:16AM PT
It really takes some doing to simultaneously miss the point of both health care and marriage equality, but the Michael Steele era at the RNC is up for the task. The chair of the party’s latest came in what we can only presume is an unpremeditated burst of cluelessness is attempting to use the employer-based health care system as a youth-friendly talking point to explain conservative opposition to same-sex marriage. In doing so, he goes negative on family benefits with your job – the cornerstone of coverage that most of us rely on.
Let’s go right to Michael Steele’s comments in Georgia. He was talking about the need for the G.O.P. to alter its language about gay marriage to appeal to more young people. So let’s be clear, this isn’t changing the policy at all – it’s just coming up with a new way to dress up the same opposition, Frank Luntz-style. However, it’s doubtful Frank Luntz or anyone with a modicum of communications or messaging skill would have advised Steele to go with this humdinger: “Now all of a sudden I've got someone who wasn't a spouse before, that I had no responsibility for, who is now getting claimed as a spouse that I now have financial responsibility for. So how do I pay for that? Who pays for that? You just cost me money.”
I see what you’re saying, yes. Actually, wait, no I don’t. Employers suddenly having a financial responsibility for members of the employees’ family is the bedrock of our current health care system, for well or for ill. What Steele describes – “all of a sudden” getting a new beneficiary that wasn’t on the plan before – is something so familiar to most employers due to life events like marriage, births, or adoptions that it barely scratches the surface. Is Steele suggesting employers would have a right to insure only the actual employee, or demand that someone else or the government pays for the additional cost for a family plan? Is this real pain being felt by small businesses that they just grin and bear for heterosexual dependents, but would really be under severe financial pain if more dependents were in the mix? Are family plans one of the major cost drivers for small businesses in dealing with health care?
No, of course not. Not even the National Federation of Independent Businesses – hardly a progressive trade organization – will tell you dependent care is a big drain on their business. Instead, it’s the escalation curve of costs, costs and more costs. In fact, their report on health care policy is entitled “The Rising Costs of Health Care: Implications for Public Policy.” Their decidedly right-leaning take on issues of individual responsibility, increasing deductibles, additional employee share of cost, tax cuts, completely privatizing Medicare and various other remedies for the health care system mentions “restricting the number of dependents” exactly zero times. It says “government subsidies for dependents” exactly zero times. It mentions dependents at all exactly zero time. There’s a reason for that – the possibility of an increase in the number of married employees barely registers as a blip in the windstorm of skyrocketing costs for small business.
Call me crazy, but maybe Michael Steele should talk to some small business owners before he improvises on health care to bash same sex marriage. Clearly, he could even start with the most conservative small business owners. Better yet, maybe he should just stop trying to be helpful in coming up with completely false "youth-friendly" talking points that suggest the profit margin for a business is more important than love, commitment and basic fairness.
(Photo credit: ajagendorf25 on Flickr.)
"Everybody Knows" Is Not a Credible Source on Immigrant Health Care
Published May 16, 2009 @ 12:51PM PT
I’m on a “mythbusting bender” of sorts this weekend. Talk to some people, and they’ll tell you with a straight face that our poor health outcomes as a nation are related to how many immigrants we have. Immigration, we’re told, is to blame for skyrocketing costs and “over-inflating” the number of uninsured number we usually cite. Look into the numbers, though, and surprise – this “everybody knows” theory is blown to smithereens.
Look, sometimes clear falsehoods go unchallenged because people like you and me just don’t know enough. For example, a while back, I compare US health outcomes (good for infrequent but costly interventions, mediocre overall, and terrible for preventable illness) to Canadian health outcomes (pretty good on the costly stuff, very good over all, very good for preventable illness), and a number of commenters jumped on to say you can’t compare Canada and the U.S. because we have more people crossing the border. The charitable folks meant we were a melting pot. The uncharitable folks meant Canada is more “monochromatic,” shall we say (those comments were deleted, per the site policy). Now what I should have done was spend some hours researching this. I didn’t, and that’s my bad.
Luckily, the American Journal of Public Health did my job for me. Looking at the health expenditure data for immigrants and comparing it to that for American-born patients, an article printed in the most recent issue found that, “that immigrants’ medical costs averaged about 14% to 20% less than those who were US born.”
Now you might jump to the conclusion that this is because the immigrant population is disproportionately uninsured or might have complications getting insurance because of their status, and that they’re just not showing up at the hospital or doctor’s office. First, this would make them, basically, a miracle segment of the population. Your health conditions don’t disappear because you don’t have insurance, and the uninsured generally have higher per-head costs than the insured for the simple fact that if they forgo care, they ultimately have to get much more expensive treatment and interventions later on. Second, it turns out these lower cost rations are true even when the person is fully insured. In fact, try this jaw-dropping statistic out for size: “Approximately 44% of recent immigrants and 63% of established immigrants were fully insured over the 12-month period analyzed.” That makes them more at-risk – the national average for everybody is 84% with coverage – but a far cry from the “freeloading” caricature of the talking points. (Keep in mind that this data was collected in 2003 and 2004, when there was still a 5-year waiting period for legal immigrants with “green cards” for Medicaid, SCHIP and other federal health services. The recent expansion of SCHIP did away with that description.)
So that’s all immigrants, but what about the undocumented? New England Journal of Medicine has the answers in an article a few years back: “In a study from the RAND Corporation, researchers estimated that undocumented adult immigrants, who make up about 3.2% of the population, account for only about 1.5% of U.S. medical costs.” In case it’s not obvious, that means undocumented workers also make up less of our health care costs. And though there are variances state by state, undocumented workers make up about 20% of the uninsured – meaning that half of those who are in this country to work, even if they don’t have the right paperwork, do have some form of health coverage.
Immigrants as a group have often been America’s scapegoats – and I say this as an Irish-American who 100 years ago would have been told he “need not apply” for jobs. But we’re going to have to find someone else to pick on for our high-cost, underperforming health care system. The evidence doesn’t support it.
(Photo credit: Korean Resource Center on Flickr.)
Fibbing Is Not Enough This Year
Published May 15, 2009 @ 07:43PM PT
As I’ve said many times, medicine is fundamentally a science. Diagnosis and treatment is empirical – it doesn’t matter what your ideology is. Evidence is king. Yet in throughout the decades-long history of the health care debate, we tend to become obsessed with claims that are either opinion or outright lies, or some manufactured controversy that hogs the attention and makes the atmosphere for progress poisonous. But we’re starting to see, little by little, the power of fibs subside.
Let’s jump to today’s whopper – a rather preposterous claim that found its way into my inbox this morning from your friend and mine, Richard “His Hospitals Had to Pay an Unprecedented Settlement for Medicaid Fraud” Scott of Conservatives for Patients Rights. In a fundraising email, the Scott and the CPR croud claimed that Comcast had removed a response ad sponsored by the group Healthcare for America Now because it was “misleading.” In fact, they crowed, “You can try to change the subject, but you can't lie to change the subject.”
Except, it turns out, they had just lied to change the subject. Comcast hadn’t done anything. The ad campaign had run out, as it was scheduled to do, on Wednesday – a fact Comcast was happy to explain. If this were an ordinary time in our political culture, the fib would win out. Scott would fundraise off the perceived slight, and effectively change the subject from his questionable credentials as a spokesperson against reform (something even Fox is now picking up on) to the culpability of overzealous performers. It would get magnified by the noise machine, on Rush and on Fox, and everyone associated with Health Care for America Now would be asked why they were “misleading the public” about Conservatives for Patients Rights. (Just think of the abuse Acorn took immediately before the election.) This time, the fibber got nailed, dead to rights. Who knew that the only true statement in the whole email would be “you can’t lie to change the subject”?
Because throughout our history, it’s all been about lying to change the subject. No president has ever advocated for a true socialist medicine model, like Great Britain, where the government not only handles the financing, but the delivery: doctors are employees of the government and supplies are managed through some level of central planning or centralized government control. Not one president. The furthest left any of them advocated for is for some form of National Health Insurance through a single-payer – but that’s all about financing, and doesn’t touch delivery. Yet all reform-minded presidents have been accused of socialist medicine.
We constantly hear that any government intervention in health care will interfere between a doctor and a patient and automatically lead to denial of care. But what the Richard Scotts out there always do is jump to stories of denial of care in foreign lands – no need, guys. We have government-run health care here, in the form of the VA, Medicare and Medicaid. You will sometimes hear of a Medicare beneficiary not getting the exact treatment s/he wanted, but anecdotally it’s far less common than hearing the same complaint about private insurance and HMOs. And you will hear – often from the same people – that we need to clamp down on “waste, fraud and abuse” in Medicaid. Well, that actually means they’re saying Medicaid beneficiaries are getting too much care – that they’re not being denied care enough! Which is it, fellahs?
These distortions have traction only if we let them have traction. The fact that the story of the day was Richard Scott wholly failing to change the subject through lying is a promising first step – especially since we know there will be more and bigger lies coming down the pike before we know it.
(Photo credit: Runaway Wind on Flickr.)
3 Burning Health Care Questions
Published May 12, 2009 @ 08:22PM PT
There's almost too much going on in health care this week. In an endeavor to keep you up to speed (and balance out yesterday's policy-heavy posts), I bring you three burning questions on where we are in the process?
1.) Is anyone more spot-on than Rachel Maddow?
Maddow's surprise that the heavy hitter on the anti-reform front is Richard "Biggest Health Care Fraud Penalty of All Time" Scott and his madcap Conservatives for Patients Rights incredulously asks the questions that many of us are asking - when's the other shoe going to drop and some champion of the status quo with some, you know, credibility appear? Sure, we all saw the Luntz Memo, but even Luntz advises his compatriots to support health care reform (at least outwardly) while targeting Obama's specific approach. And, of course, yesterday AHIP, PhaRMA, the AMA and others just showed up for a big photo-op at the White House as allies, not adversaries. Businesses, so potent against reform in 1993, are at the White House today. These good times can't last - can they?
Anyway, Maddow's epic takedown of Richard Scott is required viewing. (As an added bonus, Howard Dean everybody!)
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2.) How long before Congress ignores Robert Greenstein?
At today's Senate Finance Committee roundtable on financing, Greenstein was representing the Center on Budget and Policy Priorities. His opening statement has been praised by Ezra Klein and Jon Cohn, and it's easy to see why. If I had the ill-gotten money of Richard Scott, I'd make an ad of Greenstein making this statement, and air it in every state where there's a so-called "moderate" in the Senate:
To finance badly needed health care reform, all sides will need to make sacrifices. Tough measures will be needed - on both the spending and the revenue sides of the budget. Moreover, the number of spending and revenue offsets that will be needed is likely to be substantial. There appears to be no single option that is politically viable and that can, by itself, produce most or all of the savings needed.
This leads to my first recommendation, in the form of a plea to the Committee. Please do not take any offset options off the table at this time. I believe you ultimately will need to put together a package that contains an array of spending and revenue offsets. The more that options are taken off the table now, the harder this will be to do.
It's easy now to make political points saying you object to this or that - and Democrats have been far more guilty of taking financing options off the table than Republicans thus far - but it just makes everything that much harder. I totally understand the notion that talk of financing may be premature until we've determined the package of reforms - but suffice to say, taking options of the table is far more premature.
3.) Who lit a fire under the president this week?
Yesterday, it was the unprecedented joint appearance with shareholders at the White House on reducing costs. Today, it's a meeting with businesses like Microsoft, Safeway, and Johnson & Johnson on wellness programs and the correlation between commitment by business owners and decreased cost for chronic disease. Tomorrow, we hear, it's a sit-down in the Oval Office to talk with Nancy Pelosi, Steny Hoyer (Dem leadership) and Rep. Rangel, Waxman and Miller - the three committee chairs with jurisdiction on health care. Is it safe to presume a meeting with Sens. Baucus and Kennedy will be announced at some point, too?
The last time we saw the president this deeply embroiled in health care every day of the week was around the time of his summits, his address to Congress and the release of his budget in February-March. Suffice to say, we were building to something then - the address to Congress and the budget not only escalated the urgency on getting health care done this year, it laid down a marker in the budget for how to get it done. But this week... well, I don't know what's out there that we'd be building to.
Is this just vitamins or does Obama have something up his sleeve?
(Photo credit: Leo Reynolds on Flickr.)
The Luntz Memo: Who Do You Trust?
Published May 09, 2009 @ 03:09PM PT
This will be my last thought on the leaked Luntz strategy memo on messaging the Republican opposition to health care for a little while. The most fascinating part for me is that, after months of hearing that private insurance is better than public, that SCHIP steals customers from private insurance, that the public plan would steal even more customers, and that private insurance has a right to the 15-20% more per beneficiary being hustled paid to them through Medicare Advantage, Luntz has a new piece of advice for conservatives: throw the insurance industry under the bus. No one trusts them.
He specially suggests Republicans represent their opposition to reform as opposition to bailing out the private insurance industry - an industry that Republicans welcomed with open arms into public coverage programs, through Medicare Advantage, Medicare Part D and privatizing part of the VA system. The why is obvious – despite what Karen Ignagni of AHIP and all the other free-market fans at last Tuesday’s roundtable at the Senate Finance Committee claim, people just don’t see the problem with health insurance as a question of insufficient regulation that can be fixed with tweaks. They see it as a fundamentally broken system:
The status quo is no longer acceptable. The overwhelming majority of Americans believe significant reform is needed – and they see Republicans (and the insurance companies) as the roadblock….
A quick scan of the polling data below shows that there is no love lost for insurance companies – primarily because of their perceived profitability, a lack of accessibility, their lack of accountability, and an excess of bureaucracy. In fact, notice how many of the top complaints involve health insurance in some way.
That’s reason number one why none of the arguments of Roy Blunt and his fellow House Republicans that private insurance must be allowed to have a monopoly and be protected from competition have made much headway. Blasting the insurance industry prompts problems other problems of credibility. After all, the 2008 RNC platform's plan for health care plan predicated on less regulation for the private insurance industry. They’ve defended the private insurance industry for so long, can they really get separation from them enough to score political points? And also, if you can’t say government will fix health care, and you can’t say private insurance will fix health care, then your solution is… what?
Reason number two is that Republicans have a credibility problem all on their own. As First Read reported yesterday:
Even with Bush and Cheney no longer heading the party, the GOP finds its favorability ratings at or near all-time lows. Despite their enthusiasm for their unified opposition to Obama (on the stimulus, the budget), they're blamed more for the lack of bipartisanship in DC.
So if Americans don’t trust private insurance on health care, and they don’t trust Republicans on health care, who do they trust? Yeah, you guessed it – that Hope guy who just won the most decisive victory in a presidential election since 1988. February’s Kaiser Family Foundation poll found that 72% trust President Obama’s judgment on health care somewhat or a great deal – a number that beat everyone else, including the 60% for doctors. (Interesting note: they didn’t ask about nurses). That number will likely go down eventually, but will it be enough for trust in Republicans trump the bully pulpit from the White House?
The most important words in Luntz’s memo are: “If the dynamic becomes “President Obama and Congressional Democrats are on the side of reform and Republicans are against it,” -- which is exactly what Obama has already started to promote -- the public will side with the Democrats and you will lose both the communication and the policy.” It may be possible for Republicans to find a way to attack the president’s plan without seeming to attack Obama, but I can’t quite see how, no matter how many scary stories of denial of care they make up dredge up. You have to trust the messenger to trust the message.
(Photo credit: tsevis on Flickr.)
The Luntz Memo: Future Fear vs. Present Pain
Published May 08, 2009 @ 04:46PM PT
Although a lively debate is now taking place as to whether the Luntz memo represents a realistic approach to defeating Obama’s as-yet unwritten health care reform or merely self-aggrandizement for Luntz, the debate misses the point. Sure, the Borg-effect is going strong in which Republican members of Congress are already being assimilated into Luntz’s language. But the real issue isn't how relevant Luntz's scare tactics are or are not for politicians. The real issue is how relevant they are to you.
A college professor of mine once opined that while you might effectively trick or distract any other sense, the brain never loses track of touch – especially if it’s pain. In words I still remember, he said, “You can easily lose track of where things are in your vision, or hear sounds coming from the wrong side, sure. But if you have a weasel attached to your arm and then step onto a nail, your brain doesn’t say, ‘Now where is that weasel?’” Oppositional political messaging – especially when, as with the GOP and health care, you can’t offer an alternative solution – is all about distraction, and the Luntz memo is no exception. But you’d have to be from a different planet in order for some of these distractions to work with the exact situation that so many Americans face today. The pain is just too real, and just too widespread.
Yes, some people have an inherent distrust of the government’s potential to interfere with their lives, but that’s not really the point today. Nor is whatever justification is used to drop the word “rationing” as a future threat. People have far less trust in and very present-tense anger at the insurance companies who are already interfering with their lives, and they’ve become all too familiar with what real rationing is. As a powerful letter to the editor in today’s NY Times reads, “As any doctor will tell you, when a private health insurance plan delays or denies a physician-recommended service, it is deciding who gets care and what kind of care people get. That is rationing.” Thanks to years of HMOs and private insurance, we know all too well what denial is. We have it now.
Yes, Luntz is able to describe a nightmare scenario of making the crisis personal, about the possibility that your own children could be denied the care they need under some hazy future government bureaucracy. But the fear of losing your health coverage is exactly the same fear, and it’s acute in this economic climate. People are losing their coverage with their jobs now. More and more companies are dropping benefits. Those that continue offering benefits may well be cutting back or asking employees to pay more of the share. Forget fear about a theoretical future we can only sort of understand – that’s immediate fear. Telling us we should be much more afraid about something else is a poor substitute when your only choice is to take or leave what your employer gives you, or take your chances on the expensive individual market. Thanks to years of skyrocketing costs, individuals, families and business owners have never paid more for premiums, never paid more for prescription drugs, never paid more for co-pays and never known so many people (possibly including ourselves) who are on the cusp of being uninsured or underinsured because of the recession. Too many people know exactly what it is to not be able to give their children the care they need when they need it. It’s called “not being able to pay for it.”
It’s almost like the Luntz memo is describing another world, one where our broken health care system is a source of annoyance rather than pain. As the Kaiser Family Foundation and Commonwealth Fund (via Jon Cohn) show, that’s just not the case. 68% have had trouble paying for medical bills in the past 12 months. 54% of chronically ill patients had trouble getting access to care this year because of cost. More from KFF’s poll: 53% found themselves using home remedies, cutting pills in half, or skipping or postponing care because they just couldn’t afford what they need. That’s the world we live in today.
The Luntz memo itself gets it: “Fully 70% of Americans consider our healthcare system to be either in a state of crisis or seriously troubled and requires significant reform.” In answer to this, though, neither he nor all those GOP-Borg adopting his language offer a solution. They just offer more things to be afraid of. And that’s where I think, for all the poll-tested language, their argument jumps off the rails. Future fear just can’t trump present pain.
(Photo credit: allistairmcmillan on Flickr.)
How Republican Borg Will Obstruct Obama's Health Care Plan
Published May 07, 2009 @ 10:32PM PT
In this age of mass political media, digestible and poll-tested talking points that can be repeated ad nauseum are the currency of the realm. Normally, you watch enough C-SPAN or read enough Op-Eds and you begin to detect a pattern – working backwards, you realize that these perfect phrasings must have been the work of hours of research and message coordination. But now that the memo from famed Republican pollster and Frank Luntz on how Republicans can best resist health care reform has leaked, we get to see this process from a new point of view. We can watch, as one by one, conservatives, talking heads, and politicians see their own speech patterns assimilated by this new anti-reform message like it was the Borg from Star Trek.
Resistance is futile.
First, you can read the memo itself or look at Time.com's summary. Now, let’s go back to Chuck Grassley’s ode to bipartisanship/lament of reconciliation from yesterday. The part that made the least sense is now much clearer through the lens of Luntz strategy memo. The weird idea that Grassley was coming up with an alternative plan to defeat the very reform bill that he’s working on with Baucus? That message is faithful to the Borg-Luntz dictum, “It’s not enough to just say what you’re against. You have to tell them what you’re for. Overt attacks on the Democratic proposals will fail if they aren’t balanced with your solutions.” When Grassley claimed that the nefarious Democrats destroying the spirit of bipartisanship were Pelosi, Reid, Rahm and a general “Democrats” and was willing to spare Sen. Baucus and President Obama from criticsm (specifically saying it’s “against the wishes” of Obama) is also playing right into Luntz analysis: “Every time we test language that criticized the President by name, the response was negative—even among Republicans…. If you make this debate about Republicans vs. Obama, you lose.”
Yes, that’s right. Chuck Grassley has been assimilated.
The House Republican task force on health care has made it known that they’ll be releasing a “Dear Colleague” letter this week. They've also made it clear that the letter uses as many buzzwords from the Luntz memo as possible. Luntz’s main recommendations are to scare people about rationing, talk about “a government takeover” of health care rather than the less scary phrase “government-run” health care, and pound away on bureaucrats disrupting the doctor-patient relationship (or, specifically, "federal bureaucrats, Washington lobbyists and out-of-touch politicians”). So check out this sentence from the House Republicans: “We know that a government takeover of health care will raise taxes, ration care, let government bureaucrats make decisions that should be made by families and doctors, and eliminate the health coverage that more than 100 million Americans currently rely on.” Eerie, right? It’s like the world’s worst drinking game.
Suffice to say, House Republicans have been assimilated. The John Birch Society, who now has a headline on its site blazing the words “Obama to Ration Care” has at least been partly assimilated (come on guys, don’t mention Obama… your poll numbers just dropped 20 points! Have you learned nothing from Luntz?) It’s sort of breathtaking to watch so many conservatives gradually adapt to the new strategy memo, transitioning their “all over the map” objections into a drone-like hive mind. And it’s also like suddenly being able to see the levers and wires that make the magic trick possible.
I’ll be writing a lot more about some of the more surprising things in this memo over the next couple of days, but I’ll leave you with this one: “Americans want solutions, not politics,” says Luntz. In another section, he elaborates, “If the dynamic becomes ‘President Obama is on the side of reform and Republicans are against it,’ then the battle is lost and every word in this document is useless.” If he's right, then the battle is lost. Congressional Republicans have had at least two attempts to articulate an alternative health care plan through their budget documents, and whiffed both times. The House working group designed to come up with an alternative has instead come up with a “Dear Colleague” letter that, for all its Luntz-inspired rhetoric, has no solutions, only a “we’re against reform” sentiment. And the Luntz memo itself, filled as it is will poll data and manufactured phrases, itself poses no solutions – just politics.
In short, the dynamic is already “President Obama is on the side of reform and Republicans are against it.” We have a memo from Frank Luntz to prove it.
(Photo credit: mharrsch on Flickr.)
