Obama and Congress
-
Senate Health Bill: Less, Later, and Holy Complexity Batman (P2)
-
Does the New Senate Health Care Bill Get the Job Done?, Conclusion
-
Senate Health Bill: Less, Later, and Holy Complexity Batman (P1)
Does the New Senate Health Care Bill Get the Job Done?, Pt 2
Published November 19, 2009 @ 12:37PM PT
In evaluating the new Senate bill, I’m defining “get the job done” not through how well it does on creating the tools for serious cost control (Ezra Klein is your man for that), nor am I defining success as winning the enmity of health insurance companies, although Wall Street clearly hates this bill -- in and of itself reason to be optimistic about its effect for Main street! No, for right now I'm solely looking at the bill through the lens of whether it does enough to make health insurance affordable both to those who already have it and those currently uninsured who would get it under the Health Exchange.
In Part 1, I shared my relief at some strong changes Sen. Harry Reid had made to his predecessor bills from Senate Finance and Senate Health, Education, Labor and Pensions, causing me to say, “Woohoo!” But there are other elements of the bill that should help keep coverage affordable for the vast majority of Americans, even if they're less spectacular.
Under “Meh,” we have one bad idea from Finance that’s been kicked to the curb, provisions for Medicaid which, after much ado, are exactly where we thought they’d be, and Reid’s compromise “state opt-out” public option, which is slightly worse than we thought it’d be, although it's less because the idea is unsound and more because we're making it compete with one arm tied behind it's back.
Does the New Senate Health Care Bill Get the Job Done?, Pt 1
Published November 19, 2009 @ 01:05AM PT
Senate Majority Leader Harry Reid scheduled a press conference for this Thursday to formally unveil the long, long, LONG-anticipated full Senate bill. Which of course means it all leaked semi-intentionally Wednesday night. (Man, I’m glad the Senate isn’t in charge of keeping state secrets… oh wait…)
The initial reporting will largely focus on the sheer scope of reforms in the bill and the superficial price tag as scored by the Congressional Budget Office -- $848 billion over 10 years while reducing the deficit by nearly $130 billion. Democrats will champion the expansion of coverage to 94% of Americans and how the cost-controls in the bill reduce the deficit even more past the 10-year window. Republicans will blast the sheer length of the bill (2,074 pages, which honestly seems like a bargain considering the complexity of the issue) and their usual nonsense about government takeovers, death panels, and how cutting a single dollar from Medicare waste will make the Virgin Mary cry. And of course those not content to actually talk about reforming our morally and economically bankrupt health care system will get drawn into sideshows about Reid reverting to the same abortion language we’ve talked about all year, or the titillation of something we’ll all come to know as “the Botox tax.”
But before the madness of political punditry overtakes us, allow me to focus on one key question that will unquestionably get lost in the shuffle. Does this new Patient Protection and Affordable Care Act do enough to put quality health care coverage affordable to low- and middle-income families? At the end of the day, if we haven’t made standard, comprehensive coverage within reach of the pocketbooks of working families in America, we just haven’t gotten the job done.
How to Shame Senate Healthcare Obstructionists
Published November 17, 2009 @ 06:00AM PT
Remember Rachel Maddow announcing a 3-prong Democratic strategy to get healthcare reform passed last month? The audacious “shame them, demote them, and do an end run around them” strategy seemed lifted right out of the Tea Party sensationalistic playbook. The basic approach was to 1) do good while shaming those Congressional representatives who would deny their constituents affordable healthcare, 2) relieve obstructionist Democrats of their committee chairmanships, and 3) use reconciliation as an end run around Republican obstructionism. Well, we haven’t heard much about demotion and reconciliation lately, but the shame part is full steam ahead.
Yes, we’ve asked thousands of times for his removal, but Joe Lieberman’s Senate Homeland Security and Governmental Affairs Committee Chairmanship seems sacred to his Democratic Senate brethren. Even though Lieberman is an Independent, his obnoxious pro-filibuster stance against anything to do with a public option deserves a quick and decisive amputation from his leadership position. Ain’t going to happen, apparently.
Perhaps it’s because, if they are anything like their House counterparts, Senate Democrats knowingly have a tremendous amount of conflict of interest in their policy positions (see Change Congress’ video on Lieberman and Evan Bayh for examples.) Did you see that Genentech managed to insert its pre-scripted language into the House “debate” register via 42 Representatives? It was bipartisan representation too – 22 Republicans and 20 Democrats parroted Genentech’s positions. That’s disgusting.
4 Potential Healthcare Roadblocks in the Senate
Published November 16, 2009 @ 06:00AM PT
What can we expect on the Senate healthcare reform front this week? Besides the usual political shenanigans, I mean, like John McCain telling a bunch of his constituents to tear up their AARP cards because AARP supports the House bill (so proud to live in Arizona.) Well, here is a hint. The Senate may win one of those ‘last runner to cross the finish line’ awards, after its members take many byzantine detours along the way. After seemingly falling into a black hole last week, the Senate’s drafting and debate over its combined healthcare bill won’t be making up any time. Insiders don’t expect a test vote before Thanksgiving, making a bill before Christmas a very faint possibility. So why is that?
There are 4 big issues Harry Reid needs to negotiate around:
Lies, Damned Lies
Published November 14, 2009 @ 11:00AM PT
Many of us acknowledge that the passage of HR 3962 last Saturday was not an altogether positive thing. The bill does provide consumer protections not currently available, and will expand coverage to many currently uninsured. But it also mandates a captive market for private insurers and provides an exceptionally weak public option that’s expected to cover 2% of the population and cost more than outrageously expensive private coverage. Worst of all, Stupak's last minute amendment strikes down women’s rights as a trade-off for universal healthcare coverage. It’s ugly. Not as ugly, however, as the Republican lies that tried to defeat it.
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)
Is National Healthcare Reform Repeating Massachusetts' Mistakes?
Published November 10, 2009 @ 06:00AM PT
So where are we, as a nation, on health reform? You can compare the plans currently in play in an excellent summary here. But I can sum it up in two words: Massachusetts 2.0. Remember, MA was the first state to require all residents to have health insurance, with hardship exceptions. This was coupled with an employer mandate. It now has the highest percent insured population in the country, 97.4%. It is also drowning in healthcare costs, and looking for ways to cover them. The basis of its model: expand private insurance and use public insurance as a safety net. That has a familiar homey (or should I say House-y) ring to it, doesn’t it?
Given that Obama has studiously avoided talking about, much less praising, the MA effort, it’s ironic that Congressional efforts have mirrored this universal coverage pilot so closely. For instance, MA took the Congressional approach of tackling coverage first, and costs later. Nearly five years after its inception, MA universal healthcare is encountering steep resistance to proposed measures that would bend the cost curve, like Pay For Performance programs. As a result, insurance premiums continue to rise. They are expected to go up 10% for 2010. That’s not a good omen, as both chambers of Congress rely primarily on Medicare reimbursement cuts and pilot P4P programs to achieve cost savings.
More ominous yet, doctors in MA are cherry-picking patients based on their insurance plans. In MA as everywhere else, there is a shortage of primary care physicians. When demand is greater than supply, power shifts to those who provide the service. The complexity of the insurance behemoth wasn’t addressed during the MA overhaul, and it was in fact strengthened by a coverage mandate that did nothing to decrease insurance administrative bureaucracy. So doctors continue to pay for their correspondingly large administrative staff by preferentially seeing private plan patients. Some actually refuse to see poor patients on state-subsidized public plans.
