Obama and Congress
Rep. Grayson and the Face of Uncompromising Reform
Published September 30, 2009 @ 10:35PM PT
If you’ve been watching C-SPAN 3, you’ve seen a Senate Finance Committee compromising away affordability, compromising away shared responsibility, compromising away the public option, even compromising the notion that we should only heavily invest in peer reviewed and evidence-based teen pregnancy prevention programs. But Rep. Alan Grayson’s back-to-back impassioned speeches from the House floor on health care reform gave me a reason to flip back to C-SPAN 1.
I hadn’t planned to write about the comments made by Rep. Grayson at all. As witty as his diatribe about the complete absence of a Republican plan for universal health care was, it was still a diatribe. Somewhat predictably, the same minority party which had rushed to defend Rep. Joe Wilson’s breach of decorum, and who had filled up the House record with fear-mongering and baseless flights of rhetorical fancy about how the public option would “kill people,” and how health care reform would “put seniors in a position of being put to death by their government,” and how the health care bill told seniors to “drop dead,” now rushed to demand an apology against Grayson’s own hyperbolic flourish. We’ve seen this picture before. If we’re lucky, it would become a tit-for-tat. If we’re unlucky, it would be a capitulation. In any case, it would be a distraction.
It may yet prove to be -- but it's not tonight. Say what you want about Grayson, but he gets what this debate is really about. Tonight he took the floor to apologize, not for the feigned injured pride of thick-skinned politicians looking for a partisan advantage, but for those who truly deserve an apology: the Americans who we fail year in and year out because we haven’t fixed health care reform, the Americans who have no other choice but to go bankrupt when they get sick, and the 45,000 Americans who die every year for no other reason than we lack health insurance.
Health care isn’t just a political football. For many, it’s life and death. And it’s about time one of our elected officials stood up and said so!
The Good, the Bad, and the Stupid in Yesterday's Public Option Debate
Published September 30, 2009 @ 12:01AM PT
Yesterday was public option day in the Senate Finance Committee mark-up, as amendments by Sens. Rockefeller and Schumer that would have created public health insurance options for the Baucus bill were debated for hours before going down to defeat. Outlets like Huffington Post and the Politico promised everything short of actual bloodshed in a Democrat vs. Democrat battle royale. But that didn’t even remotely happen. Instead, we got an honest-to-God debate. But senators will be senators, and there was some inanity to be had as well.
These were weighty issues, and they got the consideration they deserved. From Sen. Rockefeller’s impassioned arguments that private insurance companies have treated the American people so badly that they need and deserve the security of a public option; to Sen. Grassley’s stern admonishment against introducing a player into the marketplace who could come to dominate it; to Sen. Schumer being the first politician I’ve heard yet make the argument that those already with insurance would see lower costs due to the competition from a public option, there was much matter here.
For a sampling, check out Sen. Rockefeller’s argument and questions for the Senate Finance Committee policy staff:
Good stuff! Tough questions! And no willful ignorance in sight. Sadly, the whole day did not match this level of erudition. Also demonstrated during the proceedings is that some of our senators aren’t quite masters of reading comprehension.
Sen. Kent Conrad had to go and ruin the erudition when, once again, he held up France as an example of universal health care that works even though it’s not government-run. Conrad seems to have preposterously newly gotten this observation from T.R. Reid’s new book, which he read just a few weeks ago. To which I say, Senator, please stop skimming! (Regular readers of this blog will remember that French citizens are covered for public hospitals and most doctors through the government-run program Sécurité Sociale, which the supplement with complimentary private insurance on top). Weirdly, this complete misreading of the French system served as the basis for Conrad voting against both public option amendments, even when his initial complaint of too-low Medicare rates for the Rockefeller version was sated by the Schumer version.
Similar, opponents of the public option constantly cited a study that suggested that millions -- no, tens of millions -- no, hundreds of millions would sign up for a public option, leading to the crumbling of private insurance. Of course, this was not the projection of the Congressional Budget Office, the authoritative estimated numbers which Sen. Kyl later referred half-jokingly as “our holy grail.” The CBO projects only 10, maybe 15 million people would sign up for a public option, were it offered alongside equivalent private insurance plans in the Health Exchange for individuals and small businesses.
No Sens. Grassley et al. were quoting the Lewin Group’s analysis of a public option, which dramatically estimated 103.4 million people would enroll in it, with 83.4 million leaving private insurance to do so. There’s a huge problem here -- well, two, really. That Lewin Group model presumes the public option would be available to everyone, but it’s not. Only small businesses and individuals can sign up for it. It also presumes that the public option pay providers based on Medicare rates -- something the Rockefeller version would do for two years only, and the Schumer version would never do. In short, the entire model does not apply to what they’re talking about. You won’t hear Grassley or Hatch or Ensign or anyone else quote the other set of numbers from the Lewin Group -- the ones that more accurately model the proposal in the amendments and conclude 78% of people in private insurance now would stay right where they are, with a modest 33.6 million enrolling for the public option. This despite the fact that it’s in the exact same report!
Oh, and by the way, I’ve made this plea before, so I may as well copy it verbatim: “please, please, for the love of God, please find someone else to crunch your numbers. The Lewin Group is a wholly-owned subsidiary of Ingenix, the database company that provides information on provider rates for most of the major insurance companies, and is itself a division of UnitedHealth, the nation’s largest insurer.”
Yesterday’s Senate Finance Committee showed several members at their best. It also showed several members flunking basic reading comprehension.
So let me ask you -- how nervous should we be that the latter group of senators were the ones who successfully voted down the public option amendments?
The Public Option: Wanted, Dead or Alive
Published September 29, 2009 @ 05:28PM PT
If you could pick one day to stay home from work for the purposes of watching C-SPAN, today should have been it. For five hours, the members of the Senate Finance Committee considered two amendments that would have added a public health insurance option to the Baucus bill, one by Jay Rockefeller (WV) and one by Charles Schumer (NY). Both amendments failed, but there are at least three other opportunities for a public option to come out on top. And the inescapable fact is that more and more Democrats are facing their do-or-die moment -- and choosing the public option.
The box score: Rockefeller’s version, which would have used Medicare rates for providers and hospitals for two years to jump-start the plan, and then segue to negotiated rates like any other insurance plan, failed by an 8-15 vote. Schumer’s version, which uses negotiated rates from day 1, similar to what’s in the Senate HELP bill and the most recent version of HR 3200, failed by a 10-13 vote. No Republicans vote for either amendment, and neither did Sens. Blanche Lincoln (AR), Kent Conrad (ND), or Chairman Max Baucus (MT).
Meanwhile, in the non-Beltway version of the United States, Kaiser Family Foundation released yet another poll which showed that not only is the public option remain popular among the American people, it’s slightly more popular than health care reform in general. For months now, this tracking poll asks if people would favor “[c]reating a government-administered public health insurance option similar to Medicare to compete with private insurance plans.” In this latest poll, 58% responded in the affirmative. When asked if they think it’s “more important than ever” to reform health care, 57% say yes. Not bad for a public option that has been declared “dead” just about every week this summer.
Actually, the public option is less popular in Kaiser than in other polls, if you can believe it, including the New England Journal of Medicine poll which found 63% of doctors favored it -- a poll frequently cited by the Democrats on the committee today. Republican Senator John Ensign at one point asked why, if the public health insurance option was so popular, Democrats were having such a time getting to 60 votes. It was a confrontational question. But for all of its bravado (and his completely lame follow-up that “maybe it isn’t popular after all” -- you’re a senator; don’t tell me you’re not obsessively checking the polls, buddy), it’s the right question. Why excuse did the Democrats on the committee have for voting against it?
Well, Baucus, whose white paper on health care advocated a public option and who praised it today, still voted against it using the argument that he didn’t believe that it would pass in the Senate. It’s kind of a brilliant self-fulfilling argument, if you think about it. The next time I can’t finish a project on time, I’m going to try telling my boss, “I’m not going to finish this project because I believe it won’t be finished.” Conrad seemed most worked up about the fact that the public option would be government-run. He even went so far as to praise, once again, the French health care system for being entirely private -- a description sure to startle the French. As for Senator Lincoln, God only knows. She didn’t even attend the debate, and voted by proxy.
But I wasn’t surprised by any of those no votes. I will admit I was quite surprised by both Nelson (FL) and Carper (DE) voting for Schumer’s amendment, scarcely a few weeks after both suggested they’d only vote for a public option with a trigger. Bingaman (NM) was part of the “gang of six” who delivered an option-less bill, but he voted for both amendments. Two months ago, I would have put Cantwell (WA) in the “probably no” column. Today she was a co-sponsor of Schumer’s amendment. And my biggest surprise of the day is the announcement by Sen. Tom Harkin, new chair of the HELP committee, that he had the votes to “comfortably” get a public option passed in the Senate (if not yet enough to defeat a filibuster.)
We’ll see another round of “is the public option dead or alive” punditry after the events of today. But the one point that seems indisputable is it doesn’t matter what the Senate Finance Committee does or does not do -- the public option is necessary, it’s popular in Congress, popular in the White House, and popular across the country. As such, it can’t be counted out until the final vote is tallied.
(Photo credit: http://www.flickr.com/photos/jaytamboli/ / CC BY 2.0)
"I Think Your Mom Probably Did": The Best of the Weekend
Published September 27, 2009 @ 10:46PM PT
Every weekend, I share my three favorite videos or stories that helped enhance my own understanding of the health care debate. In Washington, the focus is almost entirely on the machinations of the Senate Finance Committee, the House’s preparations for a full floor debate, and the looming question of what package can or will survive in the Senate. But with such a focus on the politics, there’s not quite enough on the policy. Luckily, the first two articles helped me fill in the gaps.
1.) Kaiser Health News, “Canadian Doctor: Dutch Health Care System Could Work In U.S.”
Dr. Robert Ouellet, until recently the president of the Canadian Medical Association, was also recently on a fact-finding mission to several European countries to assist the Canadian government in finding ways to improve their own universal health care system. This interview really has it all – musings on where the American health care system needs to go, comparisons to the Netherlands and several other countries, and myth-busting about the much-maligned Canadian system.
As mentioned before, those looking to blacken the name of Canadian medicine need to spend more time talking to Canadian doctors.
Q: In the United States, we’ve heard a lot of negative things said about the Canadian health care system. How do you respond?
A: First, people are not dying on the streets in Canada. I think there is a lot of exaggeration in what we have seen in the ads in the United States about the Canadian system. We have a problem of access and we want to fix that, that's for sure. We're not denying patients care because they don't have money. We have good quality. Many doctors, I am one of them, went to the United States for training. So it's not fair to say our system is so bad. That's not true.
Q: Would the United States be well-advised to adopt some of the Canadian ways of doing health care?
A: I think so. The most important thing for us is to keep our system universal. If it is one value that you want to import, that's fine. But it doesn't mean you need to import all [of our system] because it won't work in the States. And it's the same for us. You have good things in your system. But we don't want to have your system here in Canada. This is why we went to some European countries, to look at something different. And the first value we were looking for is universal access.
Read the whole interview at Kaiser Health News.
2.) The New York Times, “Medicare Scare-Mongering”
If we’re having a health care debate, then it must be time for someone somewhere to be darkly warning that Medicare is about to face massive debilitating cuts! If I was a senior citizen, I'd be ticked that my presumed gullibility had become such a political target. As this New York Times editorial illustrates, the reality is that a major goal of health care reform is to strengthen the Medicare program to increase its solvency and quality.
What the Republicans aren’t saying -- and what the Democrats clearly aren’t saying enough -- is that in important ways, coverage for a vast majority of Medicare recipients, those in traditional Medicare, should actually improve under health care reform.
The House legislation, the only bills in near-final form, would reduce and ultimately eliminate a gap -- the so-called doughnut hole -- in Medicare drug coverage that currently forces more than three million beneficiaries to pay for drugs entirely out of their own pockets once they hit specified spending levels. That would also benefit many other beneficiaries who pay high premiums for coverage in the gap that they never end up using.
The House bills would also waive deductibles and co-insurance for preventive care that can head off serious illness, expand eligibility for programs that assist low-income beneficiaries and provide incentives for doctors and hospitals to coordinate care, improve quality, and lower costs. All that should benefit many if not most Medicare beneficiaries. And delivery system reforms should benefit the private plans as well.
Read the full editorial at New York Times.com
3.) Stabenow Replies To Kyl: You Don't Need Maternity Benefits, 'But Your Mother Did'
My favorite video from the Senate Finance Committee mark-up (with a big h/t to Igor Volsky over at Think Progress). Once again, a conservative member of Congress is making the case that legislatures should not create minimum standards for coverage (a la, a mandate). I don’t buy that argument, but if you’re going to make it, I’d avoid citing a class of medical care that half of the population had an excellent chance of needing at some point in their lives.
Plus, it’s basically a video of a United States Senator making a “Your Mama” joke. What’s not to love?
When It Comes to Laws, Understanding Is Better than Reading
Published September 27, 2009 @ 06:23PM PT
“Read the bill” was a common refrain at congressional town halls throughout August. I agreed with the general principle -- members of Congress should understand what they’re voting on before they vote on it. Regular folks should also be paying attention to the political process, if for no other reason than to learn whether their representative is putting their interest first. But reading the text is no guarantee that you’ll understand what you’re reading, as many frustrated American citizens also learned this summer. Reading the bill isn’t a good in and of itself. It's only a good if it yields understanding.
In fact, there are three distinct areas where the focus on "scripta sola" -- only the text of the bill -- actually harms our understanding of what’s going on in health reform.
1.) What the hell are they talking about, anyway?
I’ve lost count of the number of people who’ve said or written to me that “this is the worse legalese that I’ve ever read.” I’m always tempted to ask, “How many bills have you read before, exactly?” Legalese might not exactly be like reading another language, but it’s at least like reading Chaucer or Shakespeare -- if you’re used to reading or hearing it, it’s not that difficult. But as many a seventh grader has learned, getting to the “used to the language” stage can be a true pain.
That’s why we’ve seen so many viral emails spreading misinformation – it’s almost too easy to make your standard bill language sound vaguely menacing. Context clues are not much help when you don’t know the context in the first place.
2.) The text of the bill is only one part of the debate
The "read the bill" flare-up erupted this week into the debate that took up entirely too much of the first day of mark-up in the Senate Finance Committee. Traditionally, no matter if the chair is a Republican or a Democrat, he submits a “Chairman’s mark” for a bill. This presents the full content of the bill in plain English (or as close as they can get), and helpfully also highlights how these provisions are or are not different than current law. The amendments are similarly presented in plain English, argued in plain English, and adapted. After the process is over, the bill is translated into legal language. If there are any discrepancies, the plain English version prevails.
CBO Estimates for the Gazillionth Time that Public Option Saves Money
Published September 25, 2009 @ 11:05AM PT
OK, this is just getting plum silly.
You don't hear as much these days about how giving people the choice of enrolling in a government-administered insurance plan based on Medicare as one of many options in the Exchange marketplace will cause the end of private insurance as we know it (the Congressional Budget Office score predicting only 10-15 million people would enroll in a public option certainly put the damper on that myth). But you do hear all the time from Republicans and so-called moderate Democrats that "we can't afford a public option." They're playing on the confusion that "the public option" is the entirety of health reform, which it certainly is not. In fact, the public option is a net cost-saver. The Congressional Budget Office confirmed for the umpteenth time today that having it as part of health reform saves money for all of us.
To review, the CBO scored the Senate Health, Education, Labor and Pension Committee bill twice -- once with an employer mandate and public option and once without. They found that a health care package with employers sharing responsibility and including a public option cost $400 billion less one that didn't have those items. Then they scored just the public option in the initial draft of the House bill and found that having it saved money -- $150 billion less -- vs. not having it.
Still, the so-called "fiscal conservative" Blue Dogs have made the public option one of their chief complaints. They don't want to see the public option use reimbursement tied to Medicare rates and prefer that it negotiate rates directly with providers like any other insurance plan. In fact, they made this their major demand back in July when they held the House Energy & Commerce mark-up hostage. Ultimately, Rep. Waxman relented, the public option was modified in the way the Blue Dogs wanted, and the mark-up continued. Of course, as we move towards a full floor debate in the House, some prominent Blue Dogs like Mike "Take my pharmacy -- please!" Ross are saying they now won't vote for a bill with a public option regardless. Speaker Pelosi in turn has declared she'll submit her own amendment to reinstate the original version of the public option, including piggybacking off Medicare rates. Today, I see on Congress Daily that CBO has not only scored the public option again, but we can now compare whether the Pelosi option or the Blue Dog option save more money. The answer: the Pelosi option, overwhelmingly ($110 billion vs. $25 billion for the Blue Dogs).
OK. We get it! Using Medicare rates for the public option makes the whole package some $85 billion cheaper. But why should we care? Well, first of all, the public option, like any private insurance plan, is paid for by premiums from its customers combined with tax credits for low- and middle-income individuals and families that enable them to afford said premiums. As Ezra Klein points out, "the $85 billion reflects reduced federal spending on subsidies because premiums in the public plan will be lower. Savings to individuals and businesses paying lower premiums will be much larger than $85 billion, and politically, much more important." It's not just that it's cheaper for the government, it's cheaper for the customers -- and that's likely to have an influence on the costs for everyone in the Exchange by forcing the costs down for private insurance as well. That's what we mean by competition. Competition is not just an abstract good. It's good because it forces these insurance monopolies to give you a better deal.
It's not a surprise that CBO scores much better savings with a public option than without, and with a stronger public option than a weaker one, all while maintaining the number of people enrolling in the public option will remain modest. What is a surprise is that anyone is continuing to listen to the anti-public option rhetoric from the increasingly inappropriately named "fiscal conservatives" in the Democratic party. Put another way, when the hell did it become "fiscally conservative" to stubbornly insist that one of the most popular elements of health care reform cost more?
(Photo credit: http://www.flickr.com/photos/pixelspin/ / CC BY-ND 2.0)
Immediate Help for Pre-Existing Conditions in the Baucus Bill
Published September 24, 2009 @ 11:25PM PT
If you’ve read this blog lately, you know I’ve been tough on the Baucus bill. Other bloggers have been inclined to give it a fair shake and have pointed out some excellent features (most of them paralleling features in the House and Senate Health, Education, Labor and Pensions bill). So in the interest of fairness, it’s worth point out a feature I initially was initially skeptical of but am now very encouraged by, even though it's not present in any other bill: setting up immediate high-risk pools for those currently excluded from affordable insurance on the basis of pre-existing conditions.
Denying a health insurance plan to someone because they’re likely to need medical care crosses the line between thrifty business and cruelty. Most Americans are understandably repulsed by the practice. America’s Health Insurance Plans, the industry organization for insurers, haven’t even made an attempt to deny the practice and instead have merely tried to trade it for an individual mandate requiring everyone to buy coverage. Every progressive bill on the table would add new regulation on the insurance industry to outlaw the practice. Just as good, they would also prevent insurers charging someone more because of a pre-existing condition (because the difference between denying a policy outright and pricing it so high that you can’t afford it is academic). If we get any reform bill passed, this odious practice will change once and for all.
The problem: in the Baucus bill and the House bill, the Exchange -- the “one-stop shopping” marketplace for comprehensive plans with tax credits to make them affordable to individuals and small businesses -- doesn’t open for business until 2013, and the insurance regulations don’t kick in ‘til then.
Baucus’ solution is to create high-risk pools for those intervening three years. That immediately tripped my “sucky idea” alarm. After all, we have these state-based high-risk pools for those refused insurance now. As the NY Times notes, 200,000 people are already enrolled in them with decidedly mixed results. John McCain plugged them heavily in his presidential campaign health care plan as an alternative to regulating insurers (of course). He called it “GAP” for Guaranteed Access Plan. But the trend in the states is for these types of plans to not be widely used because they’re not affordable. You just can’t get a lower deductible than $1,000, and most of those plans have monthly premiums in the range of $650-$1,300. A high-risk pool plan in Chicago, for instance, will run you over $10,000 per year for an individual. Sure, they don't turn you down, but who can afford it?
But to paraphrase Obi-wan Kenobi, “These aren’t the high-risk pools you’re looking for.” Baucus’ bill instead creates an option that’s more like a pre-cursor of what will be available in the Exchange. Although some of the details aren’t fully fleshed out, the bill calls for a high-risk pool plan that’s as comprehensive as the most affordable insurance plan in the Exchange (the so-called “Bronze plan” which covered primary care, hospitals stays, mental health, you name it). There won’t be an increased price on the basis of your health status, and the premium will be “100 percent of the standard premium rate for a Bronze plan.” There’s no mention of subsidies, which is the other element that makes plans in the Exchange affordable for those who are middle- or low-income. But still, that’s a much better option than exists today. The cost would be a mere $5 billion to create these pools in each state (or possibly supplement existing ones).
Even $5 billion dollars won't help everyone. Without subsidies, they’d presumably have to be able to afford a market-rate standard plan, which is about $5,000/year for an individual. But considering many people with pre-existing conditions have zero options today, even this would be a help to bridge the gap between now and 2013.
(Photo credit: http://www.flickr.com/photos/colorloose/ / CC BY 2.0)
