Obama and Congress
The House Stimulus Bill Is Better on Health Care and Needs to Prevail
Published February 10, 2009 @ 08:52PM PT
We all need your help.
Take 30 seconds right now to send a message to your Representative and Senators, who are working to reconcile the versions of the Economic Recovery Act passed in the House and the Senate. If our lawmakers have demonstrated anything over the past week, it’s that they’re looking at the wrong thing when they negotiate on the Economic Recovery Act. Whatever could have possessed centrists in the Senate to strip or dilute the most important health care provisions from the House version of the act, it could not have been a concern over job creation, shoring up our social safety net when it’s needed the most, or using the stimulus as a down payment on urgent and budget-busting problems we need to address.
Perhaps the most symbolic example of this is the removal of $1.1 billion for a comparative effectiveness study. It creates jobs in research and analysis, it fills a desperately needed niche in determining whether the treatments we undergo at such extreme cost (more than twice as much health care spending per capita as any other country) are actually effective. It’s a sensible, data-driven approach that I wish we applied to all government spending, and could potentially yield savings down the run. It’s in the House version. It’s cut in the Senate version – and that’s just stupid.
The public health provisions are even more disturbing. Ezra Klein puts it better than I could: “The cuts came in comparative medical research, smoking cessation, HIV prevention and testing, diabetes screening and detection, pandemic flu preparedness, health information technology, and much else. So yes, in case you're wondering, the centrist compromises not only cut jobs and increased the long-term cost of health care, but also ensured the preventable deaths of thousands of people.”
Some of this are politicians trying to leave their mark on a piece of legislation, guided neither by sound principle nor by sound policy but more by a sense that they have to cut something to show that they did something.
Now it’s our turn to do something. Write to your Representative and Senators and urge them to push for the House versions of the health care provisions – and tell your friends to do the same.
(Photo credit: o paisson on Flickr.)
The Obama Public Competitor, Part 3: Red Flags
Published February 08, 2009 @ 08:24PM PT
The public competitor model embraced during the presidential campaign, and now the most likely option to be proposed in the Senate once attention turns from the stimulus package, works in theory. But as with all campaign plans, it will need fleshing out in order to work in practice. Improving the public competitor likely won’t make it into the political debate – we’ll likely spend time with the usual debate over whether we can afford to do nothing, or whether any government intervention is inherently a bad thing.
Here are my five big concerns about the practicality of the public competitor. None of them sink the idea, but all of them are cause for concern if it gets implemented. After all, the devil is in the details.
The Obama Public Competitor, Part 2: Why Might This Work?
Published February 07, 2009 @ 09:08PM PT
A public competitor as one of the choices offered to individuals without coverage through the National Health Exchange (or an equivalent) was the favored policy of John Edwards, Hillary Clinton, Sen. Max Baucus, likely Sen. Kennedy and, of course, President Barack Obama. But in the national debate, we spent more time talking about the areas of disagreement (oy, that mandate question) than why the idea of putting private insurance in direct competition with public coverage might be, you know, a good idea in the first place.
Here in part 2, I’ll give you my top five reasons why the public competitor is an intriguing solution to our quest for universal access, and in part 3 I’ll give you the five things that make me wobbly in the knees… and not in a good way.
The Obama Public Competitor, Part 1: Intro
Published February 07, 2009 @ 06:34PM PT
For our Policy Corner weekend, it’s time to finally tackle what might well be called “The Obama Plan,” but which really ought to be called “The Everybody and Their Aunt Suzie Plan.” Obama won the election, so he gets to have his name on the concept, but the daylight between what he proposed during the election and what John Edwards and Hillary Clinton proposed as their health care plans was insignificant (albeit debated endlessly). So too are the differences between Sen. Max Baucus’s vision of reform and the president’s, and presumably Sen. Ted Kennedy as well who, although once coining the phrase “Medicare for All” in the 1970s, is believed to be more or less on the same page as Baucus.
That’s a huge number of influential people who think this is a good idea – and between the president (and the two main runners up for president on the Democratic side) and the Senate Chairpersons, they’re likely to be the people who bring us universal health care legislation that has a shot of passing this year (unless something crazy happens and support for HR 676 materializes in the Senate, or Ron Wyden makes a pre-emptive strike). So it’s time to kick the tires on their idea for providing universal access.
First off, you’ll notice I’m only tackling the access leg in my “three legged stool” model of universal health care. That’s really a testament to how rich these proposals are. The full Obama Health Care Plan is worth reading, and you’ll find all kinds of proposals for wellness, prevention, coordinated care, Health IT, prescription drug reimportation, and a whole host of other ideas. The Baucus white paper kicks that up exponentially and, at 89 pages, has more ideas than it knows what to do with. But when I’m at health care discussion groups and house parties, people always want to know how the plans will cover the uninsured, and what it means for them. Hence, that's my focus for the next three posts.
So these are the rules of the road. For those who don’t have insurance through their employer or another public program (Medicaid, Medicare, SCHIP, the VA, etc.), they’ll be able to purchase coverage through a National Health Exchange. They'll apply with a single application form. They’ll be given a menu of plans to choose from, but each of those plans must be comparable in terms of comprehensive benefits, including maternity care, mental health, dental and preventative care – in short, the floor for "standard benefits" will be more comprehensive than most plans on the market for those without employer coverage. They’ll be presented a side-by-side comparison with transparency in terms of what each plan pays for. If they cannot afford the premiums, they’ll be given subsidies on a sliding-scale, based on income. Finally, among the options will be private insurance plans that meet clear standards of affordability and comprehensiveness (and with some of the more noxious business practices forbidden) and a public plan, run by the government along the model of Medicare. They'll choose which of these they want and, unlike Medicare Part D, will be able to switch from one to the other easily if they're not satisfied.
The lynchpin for this concept to work in a way that has a chance to curb the excesses of private insurance industry, control costs and promote quality, is the public competitor. It’s so essential to the model that Rep. Pete Stark in an interview declared that without it, we won’t have meaningful reform. But it’s not the brain-child of Team Edwards or Obama or Clinton. Economist and health policy wonk Jacob Hacker first proposed the idea eight years ago, and recently republished the proposal.
In part 2, I’ll give you my five reasons why this plan just might work to challenge and change the private insurance industry and providing access for all. Then, in part 3, I’ll give you the five areas that, to my mind, are still big red flags that could sink the whole enterprise.
A Letter You Wouldn’t Have Seen in 1994
Published February 06, 2009 @ 11:59AM PT
In the wake of The Downfall of Tom Daschle, there has been much hand-wringing about Daschle’s potential replacements as Secretary of HHS and as star player for the White House push on health care reform, and how badly the loss of Daschle will set back the full court press that had been scheduled for 2009. Some of you may even be having vague flashbacks to the Clinton reform push of 1993-1994, reminded of how a series of Administration missteps (from botched Cabinet appointments to the unplanned circus surrounding gays in the military) and a focus on the economy pushed health care back further and further until it had lost any and all campaign momentum. It may be that members of Congress who lived through the experience are thinking the exact same thing. That’s why the public letter to the president issued by Sen. Max Baucus, Chair of the Finance Committee, and Sen. Ted Kennedy, Chair of the Health, Education, Labor and Pensions Committee, should send one clear message to those of us working and hoping for universal health care – this isn’t 1994.
If something had come up in Donna Shalala’s vetting that made it impossible for her to be confirmed HHS Secretary in 1993, or if for some reason the Clintons had experienced a family emergency that would have prevented Hillary from taking the lead on the White House task force for health care reform, you would have seen many regretful and praiseworthy words coming from senators. But you would not have seen a letter so forcefully pledging to support the promises of candidate Clinton. For one thing, the new chair of the Senate Finance Committee, Daniel Patrick Moynihan, famously opined that there was no health care crisis and called the financing for the Clinton plan a “fantasy”... not so helpful. But for another, the expectations for the process was very different – the White House would propose and Congress would take up that proposal. If the White House was setting the tempo, there’d be no need to affirm that Congress would follow -- that would go without saying.
Clearly, this is not the process Sens. Baucus and Kennedy have in mind. Daschle or no Daschle, these powerhouses of the Senate intended from the start for health care reform to flow through them. Baucus released his white paper and began holding hearings to create the legislation immediately after the election. Kennedy has been working with aides and meeting with the players on the issue since last summer. In his unsteady health, he’s made it clear that health care is all he’s working on, even giving up his seat and seniority on the Judiciary Committee. When we have moved on from the Economic Recovery Act, you will likely see both men spring into action, whether there is yet a replacement to Daschle or not.
One of the selling points for Daschle was he was clearly a man who understood, reflected on, and internalized the process failures of 1994. As a former Senate Majority and Minority Leader, he clearly knew what works and doesn’t work in the Senate. One of the keys to success for difficult issues is that the slow, methodical, messy process of building a bill from the ground up in committee is actually healthy for major reforms – it enables you to build consensus along the way. But Baucus and Kennedy know this as well – and if we want a health care reform bill that can not only pass but pass by a convincing majority of 70 votes or more, their work is what’s going to get us there.
Daschle’s loss is really only Obama’s – with Daschle as his quarterback, the president would have had much more input into the bill that will be crafted in the Senate. But as Baucus and Kennedy’s letter affirms, the tempo of reform and reform now is undeterred just because the White House’s full attention might be delayed or distracted.
Full letter after the jump.
Public Spending Enemy No. 1: Your Health Care
Published February 05, 2009 @ 03:42PM PT
American people, you need to sit down. We need to have a talk. See, you know how Senators have been railing about the Economic Recovery Act has too much wasteful spending, that it needs to be cut and trimmed? Well, I've been listening to them and reading proposals from conservative Republicans, moderate Republicans like Susan Collins and moderate Democrats like Ben Nelson and, well, I know what they mean now. I figured you should hear it from me: anything to do with your health care is wasteful spending.
Now some of this is because spending on your health care is a "boondoggle" that's not designed to save jobs in the health care industry, create more jobs in the health care industry or help those of you hardest hit by the economy maintain coverage so much as to create an Orwellian state of control over your life (so says the always level-headed folks in the Cato Institute). That should go without saying as being wasteful to the extent that it's also potentially evidence that all government is inherently evil (and possible a plot by Darkseid from the planet Apokolips... duh).
But public health - those projects most likely to be trimmed out by state and municipal budgets under siege - that's wasteful too. Sure, administering more HIV screenings creates public health jobs, given that HIV screening and prevention has been chronically underfunded in the U.S. since 2002, a trend that's paralleled with increased infection rates over the same time. But Sen. Ben Nelson tells me that's just not stimulative and frankly, we know why - because it would help you in addition to helping the economy. Susan Collins wants to see $780 million for pandemic flu preparation. Yes, again, that would create public health jobs and our national preparedness for an epidemic like that should also be a national security concern but, see, it involves you again. Ditto smoking cessation programs -- $75 million that would create $1,500 jobs. And ditto, I'm afraid for the $1.1 billion in a comparative effectiveness on health care treatments study. Let's be honest. Aside from the researchers employed in the short-term, doing a study like that to determine which of the treatments that help build up to our more than $2 trillion in health care spending aren't even effective might, someday, cause doctors and hospitals to consider not prescribing them. It seems like spending $1.1 billion now (when we need to employ more people anyway) to save hundreds of billions later. But nope, sorry, that's just wasteful spending (or, if you prefer, a plot by Darkseid to determine which treatments to deny freedom-loving people everywhere.)
Harold Pollak makes the point, "Yet as a mechanism of economic stimulus, hiring nurses and counselors to prevent unintended pregnancies or HIV infection is no less worthy than hiring burly construction workers to build a road. Public health measures are a lot cheaper. They are a hell of a lot less likely to stiff taxpayers for an environmentally dicey boondoggle." But he's so barking up the wrong tree, American people. Karl Rove tells it like it is, "The Democrats' spending is horribly mismatched with industries that have suffered job loss... What American will be hired by a small business, factory, retail shop, hotel, restaurant or service company because of [Medicaid] spending?" (Just ignore that you health care small businesses and service companies that rely on income from Medicaid, folks. The rhetoric will go down smoother).
See, this is the thing. We want to stimulate "the economy" and that means stimulating "business" - not the "people" who work and run those businesses. And I'm afraid health care spending just does too much to stimulate people, allow you to get back on your feet, allow those of you without jobs to get decent-paying ones in research and health care services, and at the same time invest in public good that will save money down the road, either from prevented HIV infections or dodged pandemics or learning where the waste in our health care system is - well it might make economic sense, but it's too much about you. If it helps insurance companies or pharmaceutical companies, fine, no problem. We'll happily overpay for that, particularly if we use Medicare dollars. If it's your health care, any government intervention is by definition wasteful. Q.E.D.
If that sounds familiar, it's because that's all we've heard out of the halls of the Senate for 8 long years now...
(Photo credit: pmbellman on Flickr.)
If the Stimulus Goes Down, So Do Hospitals
Published February 04, 2009 @ 04:53PM PT
I’ve talked about the Medicaid provisions in the Economic Recovery Act. A lot. And a lot. And a lot. But somehow the Senate and the media have entered the funhouse mirror of public debate where we’re asking existential questions like “What is stimulus?”, “What is spending?”, “What is this ‘economy’ that you’re trying to save?” So let’s make one thing abundantly clear. The Economic Recovery Act contains $87 billion to increase the share of the federal funding in Medicaid, meaning states who are also trying to close their budget deficits can pay less for Medicaid without cutting services. It’s time to ask about consequences. What happens if the narrowest definition of “stimulus” carries the day, and either the Economic Recovery Act goes down or the Medicaid provision gets stripped from it?
Hospitals close. It’s as simple as that.
In many states, the governors and the state legislatures are playing a wait-and-see game to determine when and if more federal money for Medicaid will be forthcoming, so the details of what these cuts would look like is shrouded in speculation. Not here in New York. When the financial crisis first hit, Governor Paterson immediately offered up a package of cuts to trim down the potentially exploding state deficit – cuts in health care, education and other state spending that we already swallowed in 2008. But events have deteriorated even further, and Gov. Paterson released a proposal of further cuts with a collection of small-bore tax increases ranging from the actual useful (the soda tax) to the mere nuisance (the iTunes Tax) to the “we’re going to jack up this fee, since we can.” The target number for cuts to New York’s share of Medicaid spending? $3.5 billion.
Nice to have a number. So the Greater Hospital Association of New York worked through how those cuts would work out for each hospital in New York State. They sent the info to Crain’s NY Health Pulse, who has very exacting copyright and reproduction standards… meaning I’m hoping GNYHA self-publishes the numbers on their site soon so I can link to it. In any case, I had a normal human reaction – let’s see how the hospitals I use will be affected.
