Obama and Congress
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.
House Health Reform Passes! An Early Start to the Holiday Season
Published November 09, 2009 @ 06:00AM PT
We got an early start to the holiday season during an exciting and historic weekend. Obama reminded House Democrats that they have developed more comprehensive reform than any Congress in the last 70 years, and that it was a historic opportunity to pass it. Democrats responded by passing HR 3962 by 220-215 (two more votes than necessary) and with one Republican to make it “bipartisan”. Like Thanksgiving, though, it didn’t happen without a lot of carnage beforehand. Now the rude and boorish relatives are settling in until the New Year.
First, if you missed the Republican “debate” on the bill, you can see it at the end of yesterday’s post. Apparently acting like a bullying child in response to women exercising their right to free speech is what passes for public representation now. The GOP alternative healthcare reform “plan” was just as hollow, and following an amusing rant by Education and Labor Chairman George Miller, below (“Wanna buy it? Wanna try it? Wanna sell it? Come on America, buy this one. You're guaranteed to be left behind if you're left behind today."), the House duly rejected it 176-258.
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
House Light Hits Predatory Insurers and Complicit GOP
Published November 05, 2009 @ 06:00AM PT
Well at least one of the two manager’s amendments to the final version of HR 3962 could be useful. It addresses the “Wall Street Effect”, most obviously in a section entitled Sunshine on Price Gouging by Health Insurance Issuers. The Wall Street Effect was observed when banks and credit card companies were told regulations would be tightened the beginning of 2010 – they promptly raised rates and found all sorts of fees and penalties they could assess customers prior to that. Expecting private insurers to do the same thing when faced with health reform legislation, John Dingell created preemptive strikes to ward off predatory rate spikes.
His amendment also gives states more insurance oversight power, including up to $1 billion in regulatory grants. Insurers can also be kicked out of Exchanges for bad behavior, similar to non-profit BlueShield of California losing its risk pool participation rights next year for deliberately overcharging members. While risk pools and overcharging go together like peanut butter and jelly, Blue Shield was charging 1.5 to 3 times what the other two insurers in the pool were. This was in direct opposition to state law that premiums be no more than 125% of regular market rates. Worse, it was getting reimbursed similar to the other insurers for its supposed losses.
This sort of bad behavior has a ripple effect. You see, Blue Shield also conveniently used its inflated risk pool rates as the basis for HIPAA insurance rates (an option for those whose COBRA benefits have run out.) Since California law caps HIPAA rates at the average of risk pool rates, Blue Shield was able to milk yet more profit (oops, I mean surplus) from people with no other insurance options. Speaking of having no options, perhaps the most amusing inclusion in Dingell’s amendment is the explicit exclusion of illegal immigrants from participating in the temporary national risk pool. Like they could afford it anyway?
