Obamacare and the Republicans

Centrist Matt Miller has a good article on Obamacare (he supports it) and the Republican's plan to repeat it in the WaPO.  Basically, he says that whatever plan is in place needs to both cover most people and cut costs.  Then, he adds a few interesting thoughts of his own on national health care:

Is Obamacare imperfect? You bet. I don't like the idea of micromanaging health plans via "medical loss ratios," for example. And if I were king, I'd have started with a cheaper approach that paired a funded health savings account for primary care with catastrophic coverage for every American (which capped annual costs at some fair percentage of income).

What's more, I still think the best model to emulate is mighty Singapore's, a savvy blend of private responsibility and public provision that leaves that nation with world-class outcomes at 4 percent of GDP (vs. our 17 percent). It's a breathtaking achievement that would give our overpaid medical industrial complex a heart attack.

Since being out on sabbatical leave, I've gotten a health insurance policy from Blue Cross Blue Shield that is basically what Miller recommends, a high-deductible, catastrophic coverage policy. And what's interesting is how much it's caused me to pay attention to how much the doctor's visits and prescription drugs cost. If everyone were in this kind of policy, costs would come down quickly, because everyone would be bitching about it big time!

Health Care Debacle

This article in the Washington Post illustrates why it is going to be so hard politically to reduce Medicare/Medicaid costs:

Federal officials are conducting an unusual review to determine whether the government should pay for an expensive new vaccine for treating prostate cancer, rekindling debate over whether some therapies are too costly.

The Centers for Medicare & Medicaid Services, which dictate what treatments the massive federal health-insurance program for the elderly will cover, is running a "national coverage analysis" of Provenge, the first vaccine approved for treating any cancer. The treatment costs $93,000 a patient and has been shown to extend patients' lives by about four months.

Although Medicare is not supposed to take cost into consideration when making such rulings, the decision to launch a formal examination has raised concerns among cancer experts, drug companies, lawmakers, prostate cancer patients and advocacy groups.

Our health care system is going to bankrupt us as a nation unless we somehow get the costs under control. The health reform measures recently adopted were well-intentioned in terms of extending coverage to many needy people, but they really do little to address the cost issue. In fact, by giving in to the Health Insurance industry and Big Pharma, they have made the dangers of health care overspending much worse, compared to most nations that have universal health care. For this reason, I basically view Obamacare as a failure to address the real problem.

Life has limits in everything, and so must health care.  The problem is that if 'someone else' is paying for it, most people don't think there should be any limits.

Ending the Age of Rising Inequality

This is good.

For all the political and economic uncertainties about health reform, at least one thing seems clear: The bill that President Obama signed on Tuesday is the federal government’s biggest attack on economic inequality since inequality began rising more than three decades ago.

Over most of that period, government policy and market forces have been moving in the same direction, both increasing inequality. The pretax incomes of the wealthy have soared since the late 1970s, while their tax rates have fallen more than rates for the middle class and poor.

Nearly every major aspect of the health bill pushes in the other direction. This fact helps explain why Mr. Obama was willing to spend so much political capital on the issue, even though it did not appear to be his top priority as a presidential candidate. Beyond the health reform’s effect on the medical system, it is the centerpiece of his deliberate effort to end what historians have called the age of Reagan.

Well that didn't take long

Yesterday I predicted public opinion would swing to support health care reform. I didn't think it would happen this quickly, and the more Obama campaigns on it the higher those numbers will go:

Americans by 9 percentage points have a favorable view of the health care overhaul that President Obama signed into law Tuesday, a USA TODAY/Gallup Poll finds, a notable turnaround from surveys before the vote that showed a plurality against it.
By 49%-40% those surveyed say it was "a good thing" rather than a bad one that Congress passed the bill. Half describe their reaction in positive terms, as "enthusiastic" or "pleased," while about four in 10 describe it in negative ways, as "disappointed" or "angry."

The largest single group, 48%, calls the bill "a good first step" that should be followed by more action on health care. An additional 4% also have a favorable view, saying the bill makes the most important changes needed in the nation's health care system.

This doesn't say a lot for American intelligence. But it does say that we love a winner. And it says we hate the congressional process. I can imagine that a month ago when a pollster called up someone and asked "what do you think of health care?" that person was so pissed off at congress that they said "I hate it" even if they were in fact inclined to support the actual policies.

To Life!

And now, in honor of the Health Reform victory, a great song:

Very Conservative Reform

Robert Reich provides a little bit of reality among all the exultation:

Medicare directly changed the life of every senior in America, giving them health security and dramatically reducing their rates of poverty. By contrast, most Americans won't be affected by Obama's health care legislation. Most of us will continue to receive health insurance through our employers. (Only a comparatively small minority will be required to buy insurance who don't want it, or be subsidized in order to afford it. Only a relatively few companies will be required to provide it who don't now.)

Medicare built on Franklin D. Roosevelt's New Deal notion of government as insurer, with citizens making payments to government, and government paying out benefits. That was the central idea of Social Security, and Medicare piggybacked on Social Security.

Obama's legislation comes from an alternative idea, begun under the Eisenhower administration and developed under Nixon, of a market for health care based on private insurers and employers. Eisenhower locked in the tax break for employee health benefits; Nixon pushed prepaid, competing health plans, and urged a requirement that employers cover their employees. Obama applies Nixon's idea and takes it a step further by requiring all Americans to carry health insurance, and giving subsidies to those who need it.

So don't believe anyone who says Obama's health care legislation marks a swing of the pendulum back toward the Great Society and the New Deal. Obama's health bill is a very conservative piece of legislation, building on a Republican rather than a New Deal foundation. The New Deal foundation would have offered Medicare to all Americans or, at the very least, featured a public insurance option.

What Kicks In Immediately In Health Reform?

I've been gone for two weeks, with Dad's decline and death last week.  With the historic passage of the health reform bill, which I supported (with reservations), it's time to blog again.

What were the immediate gains from the passage last night of the Health Reform bill?

Prohibit pre-existing condition exclusions for children in all new plans;

Provide immediate access to insurance for uninsured Americans who are uninsured because of a pre-existing condition through a temporary high-risk pool;

Prohibit dropping people from coverage when they get sick in all individual plans;

Lower seniors' prescription drug prices by beginning to close the donut hole;

Offer tax credits to small businesses to purchase coverage;

Eliminate lifetime limits and restrictive annual limits on benefits in all plans;

Require plans to cover an enrollee's dependent children until age 26;

Require new plans to cover preventive services and immunizations without cost-sharing;

Ensure consumers have access to an effective internal and external appeals process to appeal new insurance plan decisions;

Require premium rebates to enrollees from insurers with high administrative expenditures and require public disclosure of the percent of premiums applied to overhead costs.

Palin Loves Canada?

Oh, this is sweet!

Former Alaska Gov. Sarah Palin -- who has gone to great lengths to hype the supposed dangers of a big government takeover of American health care -- admitted over the weekend that she used to get her treatment in Canada's single-payer system.

"We used to hustle over the border for health care we received in Canada," Palin said in her first Canadian appearance since stepping down as governor of Alaska. "And I think now, isn't that ironic?"

The irony, one guesses, is that Palin now views Canada's health care system as revolting: with its government-run administration and 'death-panel'-like rationing. Clearly, however, she and her family once found it more alluring than, at the very least, the coverage available in rural Alaska. Up to the age of six, Palin lived in a remote town near the closest Canadian city, Whitehorse.

Health Care Is As Public Education

Question: should our health care system be more like the way we provide an elementary and high school education or the way we provide cars? In other words, should everyone be guaranteed a minimal amount of education, or guaranteed nothing but the opportunity to buy whatever car they can (or cannot) afford?

When you think of it this way, some kind of public, universal, guaranteed health care system becomes a no-brainer, at least for a modern civilized society.

The Truth About Health Care

Robert Kuttner, a long-time voice of sanity and basic equity in economics, writes about how to achieve true health care reform:

In 2009, total health care costs increased to 17.3 percent of GDP, with escalating premiums eating into both corporate profits and worker take home pay. The consensus among the usual policy experts is that there is no good solution. The march of technology and demography will just continue to raise health costs.

But you can reach that conclusion only by ignoring how the rest of the club of affluent countries manages to insure everyone for 9 or 10 percent of GDP, and have a healthier and longer-lived population, to boot. They do it, of course, through universal, socialized insurance.

There is no single formula. The Canadians do it with a single payer system for the insurance part, but physicians are private. The Brits have an integrated National Health Service. The Germans achieve near-universal coverage through a system of nonprofit health insurance plans.

What every other nation has in common is that they have taken the commercialism out of their health systems. As a consequence, they can direct health spending to areas of medical need rather than letting the market direct health dollars to areas of greatest profit. And with everyone covered, they can use highly cost-effective strategies for prevention, wellness, and public health. That's how you cover everyone for ten percent of GDP.  [Emphasis mine]

A Majority Will Do

Former Secretary of Labor Robert Reich on health care:

My free advice to the president: If you want to get health care enacted you must use reconciliation and quickly. Host your bipartisan gab fest at the White House on Thursday. Tell Republicans you've been eagerly awaiting their ideas for over a year, but the American public can't wait any longer. Explain to them how our current economic mess is directly related to the health care mess -- we're paying 16 percent of our GDP for health care while health insurers are hiking rates and Americans are losing their health insurance every day. Then tell the House and Senate to get to work on putting their bills together (or tell the House Democrats to enact the Senate bill and then save their disagreements for reconciliation), and tell Harry Reid you want the Senate bill on a fast track of reconciliation.

Explain to the American people you understand their impatience. The Constitution does not require 60 votes in the Senate to pass legislation. A majority will do. That's called democracy.

Pass the Senate Bill

Wendell Potter, whistleblower on the health insurance companies, just said on the Ed Show that progressives need to get behind the Senate Health Care Bill, because it's the best thing available right now, and the chance to get all this may not come again.

That's good enough for me.

White House Intention From the Start

I agree with Glenn Greenwald on this.  It's another example of the--I hate to say it, but this is the word that comes to mind--duplicity of the Obama administration.  Daily Kos and other supporters of this administration basically see it the same way.  I hope Obama knows the ill will he is engendering, because it is, I believe, going to haunt him in the very near future.

Of all the posts I wrote this year, the one that produced the most vociferous email backlash -- easily -- was this one from August, which examined substantial evidence showing that, contrary to Obama's occasional public statements in support of a public option, the White House clearly intended from the start that the final health care reform bill would contain no such provision and was actively and privately participating in efforts to shape a final bill without it. From the start, assuaging the health insurance and pharmaceutical industries was a central preoccupation of the White House -- hence the deal negotiated in strict secrecy with Pharma to ban bulk price negotiations and drug reimportation, a blatant violation of both Obama's campaign positions on those issues and his promise to conduct all negotiations out in the open (on C-SPAN). Indeed, Democrats led the way yesterday in killing drug re-importation, which they endlessly claimed to support back when they couldn't pass it. The administration wants not only to prevent industry money from funding an anti-health-care-reform campaign, but also wants to ensure that the Democratic Party -- rather than the GOP -- will continue to be the prime recipient of industry largesse.

As was painfully predictable all along, the final bill will not have any form of public option, nor will it include the wildly popular expansion of Medicare coverage. Obama supporters are eager to depict the White House as nothing more than a helpless victim in all of this -- the President so deeply wanted a more progressive bill but was sadly thwarted in his noble efforts by those inhumane, corrupt Congressional "centrists." Right. The evidence was overwhelming from the start that the White House was not only indifferent, but opposed, to the provisions most important to progressives. The administration is getting the bill which they, more or less, wanted from the start -- the one that is a huge boon to the health insurance and pharmaceutical industry. And kudos to Russ Feingold for saying so:

Sen. Russ Feingold (D-Wis.), among the most vocal supporters of the public option, said it would be unfair to blame Lieberman for its apparent demise. Feingold said that responsibility ultimately rests with President Barack Obama and he could have insisted on a higher standard for the legislation.

"This bill appears to be legislation that the president wanted in the first place, so I don’t think focusing it on Lieberman really hits the truth," said Feingold."

Let's repeat that: "This bill appears to be legislation that the president wanted in the first place." Indeed it does. There are rational, practical reasons why that might be so. If you're interested in preserving and expanding political power, then, all other things being equal, it's better to have the pharmaceutical and health insurance industry on your side than opposed to you. Or perhaps they calculated from the start that this was the best bill they could get. The wisdom of that rationale can be debated, but depicting Obama as the impotent progressive victim here of recalcitrant, corrupt centrists is really too much to bear.

Pass the Bill

After listening to Democratic Senators like Tom Harkin and Bernie Sanders, I'm persuaded that the Senate needs to pass this health care reform bill, saving the advances that it makes, and using it as a foundation for further reforms down the road.

I appreciate the sense of betrayal that some progressives have, but at this point, this is probably the reasonable way forward.  The fact that the Republicans are dead-set against the bill makes me even more sure of this.

A Little Awkward

Dana Milbank of the WaPo demonstrates another example of the discrepancy between campaign rhetoric and actual policy formulation in the Obama administration:

On the campaign trail, Barack Obama vowed to take on the drug industry by allowing Americans to import cheaper prescription medicine. "We'll tell the pharmaceutical companies 'thanks, but no, thanks' for the overpriced drugs -- drugs that cost twice as much here as they do in Europe and Canada," he said back then.

On Tuesday, the matter came to the Senate floor -- and President Obama forgot the "no, thanks" part. Siding with the pharmaceutical lobby, the administration successfully fought against the very idea Obama had championed.

"It's got to be a little awkward," said Sen. Tom Carper (D-Del.).

It's even more awkward for millions of Americans who are forced to pay up to 10 times the prices Canadians and Europeans pay for identical medication, often produced in the same facilities by the same manufacturers, simply because the U.S. government refuses to rein in drug prices.

Those favoring cheaper prescriptions amassed an impressive ideological coalition, from socialist Sen. Bernie Sanders (I-Vt.) to conservative Sen. David Vitter (R-La.). But they were no match for industry-friendly senators backed by the administration, who on Tuesday night easily voted down "reimportation," as it is called.

No surprise here: Lawmakers, and the White House, are addicted to drug money. The industry has pumped upwards of $130 million into federal elections over the past decade and is now among the top 10 donors, according to the Center for Responsive Politics. At the same time, the White House needed the industry to spend its millions of dollars in advertising money on support of the health-care legislation, not against it.

Okay, so when will our President really stand up against the big health care and financial corporations as he said he would?  We're waiting.

That's why the drug industry has been fighting for a decade against congressional efforts to allow reimportation. Obama co-sponsored one such proposal in the Senate. He also said during his presidential campaign that he wanted to "let Medicare negotiate for lower prices" for drugs. White House Chief of Staff Rahm Emanuel, when he was in Congress, also championed reimportation. Yet now, after their successful battle against it, the two are expected to fight off a similar legislative effort to allow Medicare to negotiate for lower drug prices.

Even before the vote came, it had become clear that President Obama's aides had the votes to kill the proposal Senator Obama once co-sponsored. This, said Sen. John McCain (R-Ariz.), "contributes to the enormous cynicism on the part of the American people about the way we do business here." To Dorgan, he pledged: "I will be by his side as we go back and back and back again on this issue until justice and fairness is done and we defeat the special interests of the pharmaceutical industry which have taken over the White House and will take over this vote."

Dorgan, on the verge of losing another reimportation battle, raised his voice as he pleaded with colleagues. "The pharmaceutical industry has a lot of clout. I know that," he said. "I hope the American people have the ability to expect some clout on their behalf in the chamber of the United States Senate."

To compromise when absolutely necessary is one thing.  That is pragmatic governing.  To give in almost from the beginning, as the Administration has with both the bankers and the health care companies, is another.  It is getting just a little too obvious what's going on here.  Or am I just being too cynical?

This is too much 'politics as usual' and not 'change we can believe in.'  I'm really sick of saying that, but isn't it true?

Medical Costs Rising Like a Rocket

Atul Gawande writes in the New Yorker about the problem of health-care costs:

Cost is the spectre haunting health reform. For many decades, the great flaw in the American health-care system was its unconscionable gaps in coverage. Those gaps have widened to become graves—resulting in an estimated forty-five thousand premature deaths each year—and have forced more than a million people into bankruptcy. The emerging health-reform package has a master plan for this problem. By establishing insurance exchanges, mandates, and tax credits, it would guarantee that at least ninety-four per cent of Americans had decent medical coverage. This is historic, and it is necessary. But the legislation has no master plan for dealing with the problem of soaring medical costs. And this is a source of deep unease.

Health-care costs are strangling our country. Medical care now absorbs eighteen per cent of every dollar we earn. Between 1999 and 2009, the average annual premium for employer-sponsored family insurance coverage rose from $5,800 to $13,400, and the average cost per Medicare beneficiary went from $5,500 to $11,900. The costs of our dysfunctional health-care system have already helped sink our auto industry, are draining state and federal coffers, and could ultimately imperil our ability to sustain universal coverage.

What have we gained by paying more than twice as much for medical care as we did a decade ago? The health-care sector certainly employs more people and more machines than it did. But there have been no great strides in service. In Western Europe, most primary-care practices now use electronic health records and offer after-hours care; in the United States, most don’t. Improvement in demonstrated medical outcomes has been modest in most fields. The reason the system is a money drain is not that it’s so successful but that it’s fragmented, disorganized, and inconsistent; it’s neglectful of low-profit services like mental-health care, geriatrics, and primary care, and almost giddy in its overuse of high-cost technologies such as radiology imaging, brand-name drugs, and many elective procedures.

At the current rate of increase, the cost of family insurance will reach twenty-seven thousand dollars or more in a decade, taking more than a fifth of every dollar that people earn. Businesses will see their health-coverage expenses rise from ten per cent of total labor costs to seventeen per cent. Health-care spending will essentially devour all our future wage increases and economic growth. State budget costs for health care will more than double, and Medicare will run out of money in just eight years. The cost problem, people have come to realize, threatens not just our prosperity but our solvency.

This is a HUGE problem that has to be addressed.  In the rest of his article, Gawande asserts that the Senate bill actually includes a number of different pilot projects in cost containment that could prove effective.  Let's hope so.

The Lazy Life of a NY Times Columnist

Subtitled: Being limited to 700 words a column leaves so little room for facts!

There are all kinds of lazy problems in David Brooks latest column. I'll highlight a couple of his worst points:

Early in this health care reform process, many of us thought we were in that magical sweet spot. We could extend coverage to the uninsured but also improve the system overall to lower costs.

Would Mr. Brooks like to inform us what this Magical Sweet Spot Plan was? Because I've followed the debate closely, and I have no idea what he is talking about. I suspect neither does he.

Instead of reducing costs, the bills in Congress would probably raise them. They would mean that more of the nation’s wealth would be siphoned off from productive uses and shifted into a still wasteful health care system.

Brooks is using the word "costs" deceitfully here . He is talking only about what health care "costs" the government takes on, while not including the private dollars that you and I spend on health care. But both private and public costs are part of the same health care system that is the most expensive in the world. Brooks ignores the fact that if the government spends more on health care, middle and working class costs can be reduced. For example, Brooks would say a single-payer system "costs" more. And it does cost the government more. But it costs the average person less.

But the general view among independent health care economists is that these changes will not fundamentally bend the cost curve. The system after reform will look as it does today, only bigger and more expensive.

And he quotes the Wall Street Journal. What, was Fox News busy? In fact, many economists do believe it will bend the cost curve, see Ron Brownstein's article. Back to Brooks:

In these bills, the present Congress pledges that future Congresses will impose painful measures to cut Medicare payments and impose efficiencies. Future Congresses rarely live up to these pledges. Somebody screams “Rationing!” and there is a bipartisan rush to kill even the most tepid cost-saving measure. After all, if the current Congress, with pride of authorship, couldn’t reduce costs, why should we expect that future Congresses will?

Wake up David Brooks, you might have missed something! Over to you Ezra Klein:

But Congress has made tough decisions before. The House, for instance, just voted to cut $500 billion from Medicare to reform the health-care system. The Senate is expected to cut a similar amount, and also create a new institution to make future cuts easier. Hard votes often fail, but they occasionally succeed.

Brooks also does not mention that the Senate bill creates a Medicare Commission with strong powers to cut medicare costs. Under this provision of the bill, Congress must each year vote on the Commission's entire package of reforms without getting to tweak it or add pork, with no fillibusters allowed, or Congress has the option of proposing equivalent funding cuts in other areas. That sounds about as airtight a cost-cutting system as there can be! What does Brooks want Congress to do exactly if this is not good enough for him?

Maybe Brooks would answer, "Whatever. Congress will find a way not to make the cuts." You know, Brooksy, at that point.....well, Ezra says it best:

It's possible, of course, that Congress will still reject the ideas. At that point, however, it's pretty much time to give up and go home. If there are no circumstances under which Congress will reform Medicare, there are no circumstances under which the federal government will not go bankrupt.

It seems to me that this health care bill is the best we can expect from a money-larded system in a democracy of 300 million people. And in a lot of ways it is pretty good. But its not perfect, and of course people like David Brooks will use its downfalls to try to kill the bill. But I agree with Ezra--if this bill fails, then we really are screwed. We might as well give up and go home. With the stakes so high, it seems to me a mark of partisan unseriousness to be David Brooks and so lazily and inaccurately write about this bill.

A False Choice

According to David Brooks, the current health care bills in Congress will not significantly restrain health care costs:

But the general view among independent health care economists is that these changes will not fundamentally bend the cost curve. The system after reform will look as it does today, only bigger and more expensive.

As Jeffrey S. Flier, dean of the Harvard Medical School, wrote in The Wall Street Journal last week, “In discussions with dozens of health-care leaders and economists, I find near unanimity of opinion that, whatever its shape, the final legislation that will emerge from Congress will markedly accelerate national health-care spending rather than restrain it.”

Brooks then goes on to make a very valid point:

In these bills, the present Congress pledges that future Congresses will impose painful measures to cut Medicare payments and impose efficiencies. Future Congresses rarely live up to these pledges. Somebody screams “Rationing!” and there is a bipartisan rush to kill even the most tepid cost-saving measure. After all, if the current Congress, with pride of authorship, couldn’t reduce costs, why should we expect that future Congresses will?

But then he then puts the choice before us in a very strange way.

Reform would make us a more decent society, but also a less vibrant one. It would ease the anxiety of millions at the cost of future growth. It would heal a wound in the social fabric while piling another expensive and untouchable promise on top of the many such promises we’ve already made. America would be a less youthful, ragged and unforgiving nation, and a more middle-aged, civilized and sedate one.

Decent versus vibrant? Youthful versus aged? Unforgiving versus civilized? Is that what a good health care system entails by way of choosing what kind of society we want to be?

I don't see Canada or France being any less 'youthful' or 'vibrant' because they have a single-payer health care system. Canada's economy, for example, is in far better shape than ours right now. Their banking system was recently recognized as the best, most secure banking system in the world, because it was well regulated and cautious, unlike those in the U.S. Furthermore, they have a more vibrant manufacturing sector because they don't have enormous employer health care costs like we do but a more sensible, government run, taxpayer-based health system that covers everybody.

Brooks presents a very false and unnecessary choice in our health care debate. To allow our current system to continue unchecked and unreformed is a formula for national decline, bankrupcty, and collapse. We have no choice but to reform, in a way that both expands coverage and controls cost. That is task before us. Brooks may be correct that the current efforts don't achieve this, but that doesn't negate the need for real reform.

Bending the Health Care Cost Curve

The Senate health care bill does have some people optimistic about its potential. Check out Ron Brownstein's article in the Atlantic:

"I'm sort of a known skeptic on this stuff," Gruber told me. "My summary is it's really hard to figure out how to bend the cost curve, but I can't think of a thing to try that they didn't try. They really make the best effort anyone has ever made. Everything is in here....I can't think of anything I'd do that they are not doing in the bill. You couldn't have done better than they are doing."

Mandating Private Insurance

This point of view is well worth considering, and it's why some progressives are seriously considering helping to defeat the current reform bill(s):

Of all the torrent of words that followed House passage of its version of healthcare reform legislation in early November, perhaps the most misleading were those comparing it to enactment of Social Security and Medicare.

Sadly no. Social Security and Medicare were both federal programs guaranteeing respectively pensions and health care for our nation's seniors, paid for and administered by the federal government with public oversight and public accountability.

While the House bill, and its Senate counterpart, do have several important reform components, along with many weaknesses, neither one comes close to the guarantees and the expansion of health and income security provided by Social Security or Medicare.

By contrast, if the central premise of Social Security and Medicare was a federal guarantee of health and retirement security, the main provision of the bills in Congress is a mandate requiring most Americans without health coverage to buy private insurance.

In other words, the principle beneficiary is not Americans' health, but the bottom line of the insurance industry which stands to harvest tens of billions of dollars in additional profits ordered by the federal government. Or as Rep. Eric Massa of New York put it on the eve of the House vote, "at the highest level, this bill will enshrine in law the monopolistic powers of the private health insurance industry, period."