Why Obama's health reforms are in trouble
He has given Congress too much say and shifted the rationale. The electorate is over-stressed. Time for incrementalism, if Obama and the Hill Democrats can pull it off.
We are only a few days away from a reconvening of Congress and resumption of work toward, among other things, a health-care reform bill. We need to talk. This may take awhile.
The August recess has been filled with toxicity on the issue — and not just from critics of the Obama Plan which, at this late date, has not yet been fully defined. Senators and Members of Congress will return from recess with worse polarization existing than before they left.
Political and media supporters of Obama would like us to think that congressional health forums this month have been fractious and sometimes angry because of false depictions of Obama's and Democratic congressional health proposals by villains ranging from Sarah Palin to Rush Limbaugh to Glenn Beck to "right-wing extremists" to greedy insurance companies. Critics, for their part, have focused on the public costs and government controls inherent in the plans, often grossly exaggerating their statist and socialist implications. House Speaker Nancy Pelosi is their favorite poster girl.
President Obama has not helped his cause with a series of public appearances in which he often has offered his own misrepresentations or attempted to shift the subject from the substantive content of his and congressional proposals to the alleged misdeeds of insurance companies. It was painful to watch Obama attacking critics Friday at a Montana town hall during which Senate Finance Committee Chair Max Baucus, attempting to develop a bipartisan health bill, sat grimly on-stage nearby.
The White House has now renamed health-care reform as "health-insurance reform" in an attempt to frame debate as an argument between publicly-interested reformers and unpopular (according to White House polling data) insurers. Former President Bill Clinton, newly popular after his help in releasing hostages from North Korea, has been drafted into the effort to demonize insurers and is out on the stump doing so. Critics, on their side, have focused on the omission from legislation of any tort reform and demonized equally unpopular trial lawyers.
How did it come to this?
For openers, it was never in the cards that a remake of a huge part of the American economy — and one vital to the well being of most citizens — could be framed and legislated easily.
Since 1965 passage of Medicare and Medicaid, a number of attempts have been made to make major changes in our health-care system. The most recent, and successful, was President George W. Bush's proposal for a Medicare drug benefit, passed with bipartisan support. The most notable and unsuccessful was the 1994 Clinton effort, which had to be withdrawn because it lacked even Democratic congressional support. President Lyndon Johnson, seeking passage of Medicare and Medicaid, took great care to generate "consensus," which he treated as a precious concept, in undertaking fundamental health-policy change. The Clinton bill, by contrast, was developed behind closed doors by like-minded private task force members in a process which guaranteed polarization.
White House chief of staff Rahm Emanuel, an alumnus of the Clinton White House, drew the wrong lesson from the 1994 debacle. Rather than centering formulation of health legislation in the White House and executive branch, while drawing in Congressional and private-sector leaders for consultation, he concluded that content of the legislation should instead be left to Democratic committee chairs in House and Senate. Obama would campaign for the general concept of health-care reform but leave the details to Hill Democrats. Afterward, when actual legislation evolved, Obama could make it his own — or reject those parts he did not like.
That is what has happened. Obama is presently out there advocating "reform" but without any bill which is truly his own.
Meanwhile, in the House, Speaker Pelosi has responsibility for melding three committee-passed bills into one which will come to a vote on the floor. She has been in intensive negotiations with some 70-75 moderate Democrats, who want less costly and intrusive legislation, and an even larger number of progressive/liberal Democrats who want no compromise on such issues as the establishment of a public entity to compete with private insurers. In the Senate, the main game is Sen. Baucus' continuing attempt in the Finance Committee to produce legislation which can gain even a few Republican votes. The Obama White House "has not been helpful" (Baucus' words) because it has sent changing signals to both Senate and House Democrats on those provisions which it will or will not accept — especially regarding financing mechanisms.
The biggest obstacle to legislation is its cost. The White House has shifted away from its principal early argument that health reform would save public money. Congressional Budget Office and other independent estimates have indicated added costs of about $1 trillion over the next 10 years, depending on the plan's eventual content. The White House now claims that unspecified savings could be made in Medicare, thus frightening senior citizens, and that "new taxes only on the rich" would make up the balance of any financing shortfall.
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Comments:
Posted Sun, Aug 16, 2:49 p.m. inappropriate
"alleged misdeeds of insurance companies", alleged? How about "legendary", or "infamous".
Posted Sun, Aug 16, 3:04 p.m. inappropriate
A random search of findlaw "Blue Cross loses court case" brings an "alleged" example:
" BOUDIN, Circuit Judge. This is an appeal by Island View Residential Treatment Center ("Island View"), S.S.E. ("Stacy") and S.A.F. ("Sarah") seeking to recover from Blue Cross Blue Shield of Massachusetts ("Blue Cross") the cost of in-patient care furnished by Island View to Sarah, then a teenage patient. The background events are not in real dispute and, as the case turns in the end on a limitations issue, a detailed description of the medical issues is unnecessary."
http://caselaw.lp.findlaw.com/cgi-bin/getcase.pl?court=1st&navby;=docket&no;=081287
Posted Sun, Aug 16, 3:30 p.m. inappropriate
What should be understood is that Republicans have zero interest in bipartisan support of anything. GW Bush had that, Johnson had enough of it, Obama is pretending that the Republicans will participate in the general welfare of this country.
At this point he needs to take to more useful of John McCain's campaign issues, portability, and champion federal policy that would make such a thing possible (a good goal), and then let McCain vote against it.
How many blue cross companies are there? Too many. How many do we really need? One, at the most.
Commonality in will drive out the cost of having so many "providers".
Posted Sun, Aug 16, 10:12 p.m. inappropriate
"The public meetings this month have been so turbulent, in part, because voters are just plain overwhelmed by the enormity of the issues in front of them."
Substitute "politicians" for voters and you're closer to the truth. The public by a 72% supports a public option: http://www.nytimes.com/2009/06/21/health/policy/21poll.html
I wonder just how much big pharma and friends have paid out to have Obama and crew walk away from it.
Posted Mon, Aug 17, 7:09 a.m. inappropriate
It is true that the administration made deals, at the beginning of the process, with the pharmaceutical industry and medical groups in which they would drop opposition to a plan in return for White House pledges that they would remain relatively unharmed. Of course, such deals made by the White House need not necessarily be kept by the Democratic Congress.
One word of caution regarding the insurance industry: I suspect all of us have had conflicts with our health insurer, some pretty severe, over personal or family coverage. I certainly have. But it is well to remember that health insurers, as all insurers, offer benefits and
charge for their product on the same basis as other businesses do---that is, so that they can stay in business and have viable profit margins.
In some states, where government-mandated changes have made that difficult, they simply have left the market.
I have participated over the years in many exercises attempting to design an optimal system. As noted above, I long since have concluded that
consensus could be found around the notion of universal catastrophic coverage. But that idea is not presently on the table. Tort reform, also, is not on the table, even though it contributes strongly to medical-cost inflation.
While all this is happening, Medicare and Medicaid are in near-term crisis. No matter what happens in the present reform effort,
that issue must be addressed no later than next year. The unpleasant fact, here, is that benefits must be reduced or charges increased in order to restore these programs to long-term viability.
There is a problem with launching attacks on insurance companies, as presently is being done, instead of presenting reliable information
on the content of Obama/congressional proposals---which, indeed, are not yet in finished form. At a time of such uncertainty, ordinary citizens need reassurance that any changes will result in stability and certainty.
Emotionalizing the issue does the opposite.
I disagree with the comment that Republicans will oppose anything.
They supported Medicare and Medicaid. They, as well as Democrats, supported a Medicare prescription drug benefit. Congressional Republicans, just as congressional Democrats, face reelection campaigns next year in which they do not want to be typed as oppositionists.
Moreover, political history indicates that major changes---in any aspect of public policy---do not have staying power unless broadly supported at the outset across party and ideological lines.
The present financial/economic and political climates could not be more difficult but something still could evolve and be passed. The effort will depend, short-term, on the ability of congressional Democrats to agree among themselves on the final content of their own proposals.
Posted Mon, Aug 17, 8:45 a.m. inappropriate
Tort reform is not on the table because the D's are as much in the bag for the trial lawyers as they are for SEIU.
Posted Mon, Aug 17, 10:33 a.m. inappropriate
I'm not sure why we even have for-profit insurance companies; health care should not be a for-profit enterprise. Tort reform would not really be necessary if health insurance companies rose to the task of doing their jobs to help human beings rather than solely to make profits.
When we add profits into the mix, then the tension in the health insurance system is in the wrong place, emphasizing expensive overtreatment and medical "consumption" rather than sound preventive medicine and the long-term health of human beings.
This incorrect tension opens insurers up to lawsuits because, for the sake of profits, they are motivated mainly to earn money for shareholders and not to help human beings who are sick. Tort reform has no place in a for-profit market like the one we currently have; if we have tort reform, then we must have widespread availability of nonprofit insurance options for all Americans.
(Perhaps there is a place for for-profit work in the area of medical research, but even there we see profits driving pharmaceutical companies to develop and *market* new drugs similar to older ones whose patents have expired but with worse efficacy and worse side effects. I'm not sure that profit-taking here is generally in the best interest of human beings, either.)
Ideally, all health insurance companies should be nonprofits. In reality, that will never happen. But we do see countries like the Netherlands and Germany with robust private health insurance markets managing to emphasize care of human beings over profits. They do this by severely regulating insurance companies and controlling how they act and behave--which reduces their liability from lawsuits.
Another point I'd like to make is that people act like it will cost more to extend health coverage to all Americans by subsidizing it for the poor, etc.; in reality, the total cost to the American economy will be less because right now these same costs are "hidden" in jacked-up emergency room fees and what-not that we all pay in the form of property taxes, levies, and higher health insurance premiums, etc., and the inability of many Americans to understand this is half of the problem in the current "debate." Health care reform along these lines is by far the best single thing we can do to help the economy both short- and long-term.
Posted Mon, Aug 17, noon inappropriate
Mr. Van Dyk has engaged in reflexive Obama bashing ever since the President rudely gnored his advice and took on two major issues that are fundamental to the future health of the U.S. economy -- health care and clean energy reform. Now he's blasting Obama for not writing the health care bill himself, which is part of what got the Clintons in trouble. Nothing Obama does is going to please Mr. Van Dyk, who apparently still yearns for President Hillary Clinton.
But apart from that, Mr. Van Dyk doesn't understand some basics about health care economics, as the previous poster aptly pointed out. It's impossible to deal effectively with costs unless all Americans are covered under the system, because costs just get shifted around and people are receiving care too late or in the most expensive settings. And just curbing federal Medicare and Medicaid spending would simply raise costs for private payers.
Second, Mr. Van Dyk's proposal to give everyone catastrophic coverage fails to recognize that's what a growing number of Americans have now, given the rapidly rising out-of-pocket costs they are being saddled with. But having a $5,000 or $10,000 or higher deductible is simply not affordable for many Americans. It means they won't get necessary primary and preventive care, and they won't be able to dig out of the financial hole if they incur a $10,000 medical bill.
Third, insurance companies are right in saying that the insurance reforms the Democrats propose -- such as offering everyone coverage regardless of preexisting conditions -- are not viable unless everyone is required to have insurance. States that have tried such incremental reforms without universal coverage have run into big problems, which Mr. Van Dyk doesn't seem to recognize.
Finally, if Mr. Van Dyk believes Republicans will support some type of reform, he's not been reading two of the smartest conservatives around, David Frum and Ross Douthat, who both have said recently that Republicans just want to kill Obama's health reform and ride that to victory in next year's elections. Both are urging Republicans to reconsider. But there is absolutely no sign that they will. Even so-called moderates like Sen. Charles Grassley have been engaging in egregious demagogic bashing of the Democratic proposals.
--Harris Meyer
Yakima
Posted Mon, Aug 17, 6:12 p.m. inappropriate
I think Mr. Van Dyk's critics here are ignoring some large misteps by Obama and the congress. Mr. Obama started out by claiming that a major virtue of his proposal is all the money it will save. The Congressional Budget Office claims exactly the opposite. So one or the other is wrong; who is it? they have a meeting and explain the discrepancy, right? no, that never happened, at least to my knowledge. They just talk past the entire episode as if there never was a disagreement.
Mr. Van Dyk criticizes the tactic of having several committees formulate their own health care bill. Who can argue with that? we now have at least five huge, thousand page bills that may have some good things in them. Some place. How can we have a rational debate on amorphous things like that? we can't, so we call names instead.
People who think insurance companies are lavishly profitable are, of course, free to buy their stock and enjoy the fruits of high profit margins but, if you do that, you may be disappointed. To the extent that insurance companies are profitable it is more due to the good luck or good market conditions than it is to the direct relationship between premiums and outlays for medical care. Individuals who want the government to act as their health insurer (quite reasonably) believe the government will be more generous paying for treatment than a profit making enterprise. That belief is based on the expectation that other taxpayers who make more money and pay more taxes will pay enough to make medical care for this particular individual very cheap and very good. IOW, someone else will pay. Or, that the government will just borrow the money to make it work. Neither expectation is a financial or spiritual inspiration.
Posted Mon, Aug 17, 7:36 p.m. inappropriate
I agree with smacgry's questioning why we even have for-profit health insurance companies in this country. The obscenely profitable doctor-owned hospitals and high tech diagnostic clinics described in Atul Gawande's riveting article in the New Yorker awhile back are even more disgusting.
In case you missed it, you can read that article here:
www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
Students looking for bling should get MBAs or advanced degrees in math and become "quants" at Goldman Sachs and similar financial institutions instead of credentialling themselves as medical specialists who view their profession as a great way to cash in on human suffering.
Posted Tue, Aug 18, 2:42 p.m. inappropriate
This is a well thought out, objective article. That said, the author implicitly endorses the various Democrat proposals by taking the position that the party's current probems are due to bad tactics. He doesn't really address the question of their substance. He dances around the hard choices we face- we can lower costs either by lowering payments (which in all liklihood means some form of governmental rationing) or we can increase supply. While there are other tactics which would help reduce costs (better recordkeeping, tort reform etc) the country will ultimately have to fish or cut bait on the central issue.
Posted Tue, Aug 18, 2:55 p.m. inappropriate
Health care/insurance reform does not top the list of issues I feel must be addressed in order to ultimately make health care affordable and available for those who can least afford it.
For example: US auto industry leaders may list health care costs as a principle reason for their current bankrupt state, but other reasons are more to blame.
The United States is a disgrace among the world's modern nations whose standards of living place ours dead last. Our culture is degrading. We are mean-spirited misers, vicious mobs, disgruntled losers, self-absorbed pleasure-seeking illiterates and bubble-encased isolationists living in an artifically fabricated world of fear. We are no longer a nation of common interests. We are verging upon violent unrest and Civil War.
If the USA is NOT a society, should we fear socialism? If however we ARE in thousands of ways a society of 'interdependent' individuals, associations, communities, organizations and institutions, should we instead fear capitalism?
If you ask me, Wall Street is a system of organized crime committing violent acts of destruction. Follow the money...
Posted Tue, Aug 18, 4:57 p.m. inappropriate
Are you kidding me?
"The United States is a disgrace among the world's modern nations whose standards of living place ours dead last. " Dead last? Is that why people from countries all over the world are lining up to immigrate to the United States?
"We are verging upon violent unrest and Civil War." Do you have evidence of this? If so, I'm sure that Pres Obama's FBI would like to see that evidence.