Holy shit. This is actually happening. The goal that evaded Teddy Roosevelt, FDR, Truman, Johnson, Nixon, Carter, and Clinton.
From everything I can tell, the pieces are set and a vote in the next 4-5 days on comprehensive federal health reform is likely to be successful. Ezra has a good run down of the particulars of the bill:
Legislation that covers 32 million people. A world in which 95 percent of all non-elderly, legal residents have health-care coverage. An end to insurers rescinding coverage for the sick, or discriminating based on preexisting conditions, or spending 30 cents of each premium dollar on things that aren't medical care. Exchanges where insurers who want to jack up premiums will have to publicly explain their reason, where regulators will be able to toss them out based on bad behavior, and where consumers will be able to publicly rate them. Hundreds of billions of dollars in subsidies to help lower-income Americans afford health-care insurance. The final closure of the Medicare Prescription Drug Benefit's "doughnut hole."
But wait...there's more!
But you also get the single most ambitious effort the government has ever made to control costs in the health-care sector. According to the Congressional Budget Office, the bill cuts deficits by $130 billion in the first 10 years, and up to $1.2 trillion in the second 10 years.
That deficit reduction piece is absolutely crucial for a whole host of reasons.
There are some people out there pretty furious about this legislation. I hear talk that it doesn't really control costs (still haven't figured out how comparative effectiveness research and bundling aren't important parts of controlling costs) or that it forces people to buy terrible insurance (the same terrible insurance that it monumentally improves and that so many of us currently fight like hell to hold on to despite rate hikes).
Anyways, I've been working off-and-on on federal health care reform since late '06. This just feels damn good. One more vote to go in the House. One more in the Senate. A signature from the President.
Health care reform is entering the final stretch in Congress. All sorts of stories will be written in the next few days, but the bottom line is that the Congress is about to pass the most significant economic justice legislation in 40 years and the most fundamental rewrite of our social contract since the New Deal and Social Security.
Like Social Security, Medicare, and, well, everything, this bill is a process, not an end-point. But the expansions of Medicaid, the creation of health insurance exchanges paired with meaningful regulation to make insurance function more like a regulated utility than the ferocious beast it has become, and the subsidies to make insurance affordable are all huge immediate gains for low- and middle-income Americans.
Combine all of those moves with the strong attempts to control costs -- bundling of prices, comparative effectiveness research, etc. -- and we've got something that just may keep people insured for the long term while also being the single biggest piece of deficit reduction legislation passed in the history of this country.
Damn. I know there are a lot of complaints out there, but we stand at a major turning point of American history. The future will build upon this point in a few ways:
Creation of a public option. Count me skeptical that we'll get it in this bill. But the public option is an easier thing to pass in the future than the framework in which it would live and, over the long-term, it is important, but nearly as important as the insurance market regulations and subsidies that will make insurance fair and affordable. We can get back to this and probably in better form than the compromised version we'd get today.
State experimentation. One of the amendments that both Ron Wyden and Bernie Sanders helped insert allows states to take the revenue streams under the bill and implement alternate models of reform, so, yes, California, New York, or even Montana could pass, for example, a single-payer plan and use the federal funds to make it happen.
Implementation of further cost control. This last piece will be the hardest, but it may prove the best. Focusing especially on bundling and comparative effectiveness research, which both create the opportunity to cut costs while increasing quality, we may be able to significantly restrain health care spending while improving health outcomes.
The wonderful people at Families USA, a progressive outfit that has been working on health reform for something like 25 years, put out a report on the effect of health reform on Montana. Over 100,000 Montanans will get insurance. Pre-existing condition discrimination will be a thing of the past.
Good news on the health reform front, where the President announced on Super Bowl Sunday that he plans an open meeting at the White House with Congressional leaders from both parties and cameras from C-SPAN for a conversation about improving and passing the health care bill.
If they want to take a pass on being able to provide input, let them pass. Hold the summit, ask for their ideas, let the President outmatch them once again, and pass the Senate bill and a corrective bill through both chambers, on party lines if need be.
I continue to see people screaming bloody murder over the health care legislation moving through Congress. I don't have the numbers handy, but a poll (CNN, I think) recently found a narrow plurality opposing the House legislation, with a notable portion of those opposing it for being too conservative (worth noting, of course, most opposition was actually from the right or was self-described non-ideological).
The Senate bill, by most accounts, is a more conservative bill. It is financed primarily not by an explicitly progressive tax, but by an excise tax on health plans that will hit Goldman Sachs executives for sure, but will also hit a lot of working class union members who have negotiated health benefits for years.
The subsidies for purchasing coverage in the Senate bill are lower than I would like, meaning near-term affordability isn't what I would hope (of course, it also means less of a public transfer to private insurance companies, which I suppose is OK).
With all that in mind, people have been asking me a lot lately why I'm still supportive of the bill. For me, it really cuts to a few things:
The underlying structure of the bill -- subsidies, insurance exchanges, insurance market regulations, etc. -- are the right underlying reforms to make a public/private system work. They also may take us a bit closer to single-payer and certainly do not move us further away (e.g. single-payer supporters may not get what they want in this bill, but it does not foreclose victory down the road, which is important).
There are some very smart political incentives built in. For example, members of Congress get thrown into the exchanges with a lot of the rest of us, helping guarantee that the incentive down the line is for them to maintain high quality and affordability (relatively speaking on the affordability, a lot of members of Congress happen to be very rich and all are higher income than the majority of Americans).
The biggest point of all is that the Senate bill is extremely serious about costs over the long-term. What should worry just about everyone in the healthcare debate is how completely unsustainable the current system is. It isn't just that it is expensive or that administrative costs run too high. Those administrative costs don't even begin to explain the wild inflation that occurs in America's healthcare sector. You simply cannot have costs in 17% of your economy rise at rates 5-10% faster than the economy as a whole in perpetuity.
My friend Jay Stevens wrote a while ago that his problem with the excise tax was that it penalized spending on healthcare and that we should be happy to encourage people to spend more on healthcare. If healthcare actually improved health, I'd be inclined to agree that it is worth subsidizing. But the correlations are relatively weak (and the odds that hospitalization can hurt or kill you are unfortunately high). Under these circumstances, reducing healthcare spending and allowing ourselves to spend more money on other things (perhaps sporting equipment or healthy local food, both of which can be expensive but would do more in general to improve health than more heart surgeons) would be a good thing.
Does the Senate bill do this? We don't know. But it does everything it can to "bend the curve." Is that good for progressives? Depends on what you mean by progressive, but anyone concerned that health insurance is too expensive for low-income people and tthe middle class should hope that the low- and middle-income people of 20 years in the future have better choices. That requires bending the curve. And by all accounts, the Senate bill works harder to bend the curve than the House bill.
The Senate bill isn't just deficit neutral. Over the next twenty years, by CBO's (rough) estimates, it will reduce the deficit by three-quarters of a trillion dollars. That, as they say, is real money. It does that by long-term holding federal spending on healthcare steady even as massively expanding federal assistance to help low-income and middle-class Americans purchase insurance.
Even better news: CBO has at times been known for being woefully pessimistic. They overestimated the cost and underestimated the impact of tradeable permits for reducing SO2 pollution (which helped clean the air in my (and Dennis Rehberg's) hometown of Billings -- maybe "cap and trade" ain't such a bad idea, Mr. Rehberg). They overestimated the cost of Medicare's prescription drug benefit. And they routinely admit that they can't "score" the cost of key provisions of health care bills that may further reduce spending because these are experiments and folks like CBO approach experiments conservatively.
A couple months ago, a "meme" flew around Facebook as millions of social networkers changed their status to read "No one should die because they cannot afford health care, and no one should go broke because they get sick." Both the Senate and the House legislation accomplish these goals. If we want to establish additional corollaries, such as "No insurance executive should make money" or "No brain surgeon should make more than $250,000 per year," we could have done that. But those goals aren't really as important, either policy-wise or politically.
Soon, we'll pass a bill that should effectively end medical bankruptcy in America and guarantee baseline health care access for all citizens (too low a bar, I agree, for a variety of reasons). Over the long-term, this bill will likely ensure that we need not ever turn back on that promise and that we may even expand on it, just as we did over time with the promises of the civil rights acts and Social Security.
Mike Dennison has a good and informative story out this past weekend with the short version of what health reform will do for most Montanans in difficult situations: make their lives better even if it is hard to know precisely what will improve until 2013.
For some folks, this is another major black eye for an already deeply flawed bill. For many of us, though, this is simply another foreseen frustration inevitable with major system changes in a huge sector of the economy.
The health care bill will have a handful of immediate changes. Although the structure of the national high-risk pool is currently unclear, it should provide some near-term help for the currently uninsurable. In the slightly longer term, the exchanges and the subsidies and insurance regulations should make coverage affordable for basically everybody and near-universal coverage will be the standard in the U.S. And we'll also put some key systems in place to actually bend the cost curve on health care -- which eventually will mean fewer procedures, devices, and drugs that aren't improving our health.
What marked me most about the Dennison piece wasn't the sadness of the young woman at the end when she hears that no help is coming for three or four years, it is that based on these five (representative?) stories, help is actually on the way. It's been a long time since anyone could say that on the health care front.
Here's some heartening news for Montanans: Max Baucus, who had voted against two public option amendments in committee for fear that they would induce a filibuster, is back on board coming out of the negotiations he participated in with Senators Reid and Dodd and the White House:
I included a public option in the health reform blueprint I released nearly one year ago, and continue to support any provision, including a public option, that will ensure choice and competition and get the 60 votes needed to pass the Senate. Success should be our threshold and I am going to fight hard for the 60 votes we need to meet that goal this year.
As Talking Points Memo notes, this statement leaves Max some wiggle room. But Max has always been the negotiator creating wiggle room on this stuff. That's been his job -- to make sure the bill passes.
Right now, we're on track to get a bill passed with a public option while overcoming a filibuster. I know there are still naysayers in comments (and as I wrote below, I still want improvements on the employer provisions and the affordability) because the Eeyore wing of the progressive movement is alive and well, but this is a victory.
What's more, it is a victory that would not have been possible without this whole insane hand-holding process. How do we know that the White House and Max bent over backward far enough seeking GOP support? Newsweek's Howard Fineman is calling it pointless. When the conventional wisdom becomes that Republicans obstructionism is worthy of being dismissed, we're in good shape.
We're closer now than we've ever been to passing systemic health care reform. It's a massive down payment on fixing this system. I, like many others, have gotten frustrated during this process, but damn if we don't keep getting the ball down the field at the crucial moments.
Interesting story this morning as negotiations have apparently wrapped up in the Senate. Multiple outlets are now reporting that the Senate bill moving to the floor will have a national public option with a state opt-out clause. Interestingly, this is happening despite apparent reservations from...the White House.
So Harry Reid and Nancy Pelosi appear to be showing some decent spine in the last couple weeks.
On a worse front, the bill appears set to feature an employer pay or play provision that penalizes the hiring of low-income individuals by small businesses. It also isn't clear what subsidy levels will be like.
But still, we've got some progress.
Update - Two other thoughts:
I'd prefer no opt-out clause. with what is happening in the House, we may get a straight national public option -- that'd be good.
Still, worth keeping in mind that Medicaid is actually an opt-in program -- and all 50 states have Medicaid.
Ezra Klein today reported that Harry Reid was very close to including a national public option into the healthcare reform bill that would be voted on in the Senate. Until...
...Max Baucus held a meeting.
Here, stories begin to diverge. Depending on who you talk to, Baucus either held a routine, informational meeting telling the Senate moderates and members of the Senate Finance Committee what's going on, as he's been doing fairly regularly, or he held a meeting in which he tried to rally Senate moderates to change Reid's mind. Or maybe there's no difference between the two. The first to really speak out after the meeting was Sen. Ben Nelson, and, as one staffer pointed out, Nelson didn't need Baucus to remind him that he was opposed to a national public option. Soon enough, Olympia Snowe was also making firm statements against the public option, and threatening a filibuster.
Sort of astounding for a Senator who claims to support the public option. In fact, right now, we have to assume that Max Baucus is actively working against the public option.
This week, George Ochenski wrote a pretty d*mning op-ed in the Missoula Independent, accusing state Democrats of lining up to praise Baucus' efforts on healthcare and his bill because of money. Campaign money. Oodles and oodles of cash. And you know what? He's got a point.
But money isn't everything. Votes matter, too. And I guarantee they can't have both Baucus' money and widespread support among voters, especially those of the Democratic base. Because this bill, without a robust, widely-available public option, is going to affect a majority of Montanans' not one single bit, except to raise their premiums. Many, if not most, voters will wake up the day the bill goes into effect, and still find rejected claims due to preexisting conditions in their mailbox along with a stiff little premium hike to cover those the insurers will be forced to cover. (You know how they'll frame it, too. Those "shiftless""irresponsible" ones, the "parasites" who don't take care of their health.) And a lucky few union families will find a nice fat tax hike in their pay stub, too.
The bill without a robust public option is a kind of welfare program for the poor. Which is fine. But it's been framed as healthcare "reform." And when people hear "reform," and want "reform," and you give them something else that's definitely not "reform," you know what their reaction will be.
It will destroy the Democratic party.
So. Montana Democrats. You either stick with Baucus and drive off a political cliff, or you ditch him and find another way to raise money. H*ll, if you come out strong and hard against Baucus and for the public option, raising money probably won't be an issue.
And, frankly, Baucus isn't the only one who appears to be against us. Also from Klein's piece:
On Thursday night, Reid went over to the White House for a talk with the president. The conversation centered on Reid's desire to put Schumer's national opt-out plan into the base bill. White House officials were not necessarily pleased, and they made that known. Everyone agrees that they didn't embrace Reid's new strategy. Everyone agrees that the White House wants Snowe on the bill, feels the trigger offers a safer endgame, and isn't convinced by Reid's math. But whether officials expressed a clear preference for the trigger, or were just worried about the potential for 60 votes, is less clear. One staffer briefed on the conversation says "the White House basically told us, 'We hope you guys know what you're doing.'"
Frankly, I hope the White House knows what it's doing. Because from here, it looks like they're pushing for the clusterf*ck.
The New York Times: "In the debate over health care reform, no issue has produced more fury and sound bites than the question of whether to include a government-run insurance plan. It is not indispensable, and its role would be limited. Even so, we strongly support inclusion of a public option - the bigger and stronger the better. That is the best way to give consumers more choices, inject more competition into insurance markets, hold down the cost of insurance policies, and save money for the federal budget."
Open Congress put up S.1796 - the Senate Finance Committee's health care legislation - on its site.
Max Baucus thinks a "watered down" version of the public option could get 60 votes in the Senate:
"This issue is alive and we are looking at it to see what makes the most sense," the senator declared on a conference call with reporters. "The major overall goal here though is to get health care reform that passes the Senate, gets 60 votes, and I just don't know if there is 60 votes for the most pure kinds of the public option. There may be 60 votes for the less pure kinds."
The less pure kinds, Baucus explained, were co-ops, a public plan triggered by economic conditions and an insurance structure that allowed states to opt in or out of a public option. He seemed to find the last option the most intriguing.
A. Co-ops and a trigger are not a public option, even "watered down."
B. Why does anyone care what Max Baucus thinks anymore? Frankly, he shouldn't be involved in the creation of the final bill the Senate votes on. His role now is to vote for cloture on whatever bill the leadership crafts.
Be sure to check out "This American Life" and its two-part series on healthcare reform: "Someone Else's Money," on the health insurance industry; and "More is Less," on the reasons behind the rising cost of health care in the US.
Here's the SNL sketch where the "Rock Obama" makes Max Baucus bark like a dog, and then throws him out the window:
I have to admit, I enjoyed watching the Rock rip off Mitch McConnell's arm...heh heh.
In case you missed it, a lot of interesting things happened this week, a lot of them deserving their own posts. But, sadly, there's only so much time in the day...
Just when you thought the issues around the Flathead Lake Boat Crash couldn't get any more asinine, they do.
James Conner has the details of that night's incident - apparently Barkus thought he was heading in the opposite direction than he actually was, and was pulling a u-turn at 45 mph in the dark in treacherous waters when he struck the lake bank. Dan Testa, too, has a good roundup of that night's events - two scotches and an unknown amount of red and white wine for Barkus. Just the thing for a chilly night out on the lake.
Now Barkus' lawyer is challenging the .16 BAC results - which, I know, is his right to do and probably a smart legal maneuver. But Barkus is also planning on finishing out his Senate term, as if nothing's happened here, as if he hadn't just boozed up and almost killed himself and four others on Flathead Lake.
The crash was a good sign he's got a problem, eh? I mean, for most of us, this would be a kind of, I dunno, a wake-up call, wouldn't it?
That's the way I'd see it if it were me. I'd be apologizing my *ss off to the friends and family of those I injured through my loathsome behavior, I'd cooperate with the authorities and plea bargain my way into a just punishment, resign my public office because of the deficiency of my character, and I'd check myself into a rehab clinic, ASAP. I mean, wouldn't most people feel some remorse, and want to repent and work to rehabilitate themselves?
Instead, Barkus is still out there, still a drunk, and, probably as soon as he's walking again, back behind the wheel. And he'll be passing laws over you. So much for personal responsibility.
* * *
As always, there's plenty of news from Hardin.
The Billings Gazette got its hands on the "memorandum of understanding" between Hardin and the APF - which it had to get by court order, apparently because it's pretty embarrassing to Hardin officials - that revealed the city did have an agreement with Hilton's company to have the APF supply Hardin with a police force for $250K. The contract toned the language down, but the memo certainly explains the Hardin Police Force decals on APF SUVs.
Naturally, with all the furor over these SUVs, Hardin is looking to start its own police force.
But the American Police Force takeover of the Hardin jail only looks dead. While Hardin put the deal with APF on hold after revelations of Michael Hilton's checkered past, a mysterious APF investor stepped forward (anonymously, of course) and noted the firm would still pursue the Hardin jail contract, only without "Captain" Michael Hilton on board.
Imagine if the Greeks had been so brilliant as to hide their Trojan Horse full of soldiers inside a second larger Trojan Horse!!!!1!1!
That's what Jon Kyl thinks co-ops are, in a Huffington Post story that laid plain, once more, what an indescribably ridiculous political party the GOP has become.
First, the public option was a terrible idea because it is supposedly a Trojan Horse for single-payer. Now private co-ops are a terrible idea because they are a Trojan Horse for a public option. I imagine soon we'll be outlying private insurance because it is just a Trojan Horse for health insurance cooperatives. Or something.
Bottom line, though, if the co-ops are off the plate because Republicans won't back them generally and Grassley won't back anything that a whole bunch of Republicans won't back and, don't forget, a whole lot of Democrats think the cooperative idea is kind of inane anyways since cooperatives are already legal and some currently exist, I think this just reemphasizes my earlier point: we're getting steadily closer to a good bill as we get a little closer to a chance of no bill at all.
So. There was a meeting hosted by a president in Montana yesterday. While I'm at the NN09 in Pittsburgh, I followed Facebook accounts of the ugly, ugly protests - and Charles Johnson's coverage in the Gazette left out the uglier aspects of the Tea Baggers, the white supremacists, the Obama = Hitler signs, etc & co, and the pushing and shoving that went on. (Rumor: a Tea Bagger was arrested?) Remember: these protests are not about health care....
I'd point you to the various summaries of Obama's speech in Bozeman, but better to read what he said. For me, the biggest news was that he reaffirmed his commitment to the public option, and his continued advocacy for a surtax on the wealthy (as opposed to taxing health care benefits) as a means for paying for health care reform. You'll notice that both stances differ substantially from where Baucus (apparently) stands.
By making a rare presidential visit to Montana, Barack Obama has put even more pressure on the rural state's senior senator, Max Baucus, and his panel to produce bipartisan health care legislation in just a month's time.
Given the context of this visit - the fact that Baucus' committee is essentially single-handedly holding up health care and gutting provisions that the Democratic caucus thinks crucial to reform - you can't help but think Obama's visit is intended to put pressure on Max by appealing directly to his constituents. And then there's this from the Gouras report:
For his part, Baucus doesn't appear worried that a bipartisan group of six senators has already blown through several targets for producing a Finance Committee bill. The veteran senator has told Obama that "it will be ready when it's ready" - even if that means waiting until September.
Heh. Tough words, eh?
Probably as a result of signals from the White House, which Jane Hamsher helps us interpret. The WH, through Emmanuel, is blaming Baucus for the logjam in Congress, and he and Jim Messina are being set up to take the fall if all fails, and for any untoward deals cut in Baucus committee with the health-care industry. (Wasn't it in the Indy's profile that Baucus said his whole life prepared him for this legislation? Little did he know how prescient that comment may be...)
So now Obama's in Montana playing "good cop."
Oh, and in case you want a good laugh, check out Montana GOP chair (and Missoulian!) Will Deschamps lame attempts to put forth positive policy on health care:
Deschamps said the current system does have problems, but he doesn't think the federal government ought to be the one trying to fix it. Asked what role central government should play in health care changes, Deschamps said he "didn't have a hard and fast answer."
He said the government should use other means to change health care.
"Maybe they should spend their time in the (public relations) end of it," he said. "They should promote healthy living."
Some people can afford health insurance, but choose not to buy it, he said, particularly young people who don't think they'll get sick.
"There ought to be some way to encourage them to buy health insurance without government interference," he said.
That would lower premiums for everyone else.
Uh...okay...so basically stick with the status quo. Cool.
Big hubbub on the 'tubes today about the arrest of Henry Louis Gates Jr, an African-American Harvard professor who was arrested for "breaking in" to his own house. Well, more accurately, he was arrested for disorderly conduct after being accused by a white police officer of breaking into his own house.
But here's the thing: Gates broke no law. He shouldn't have been arrested.
Meanwhile, note that racial motivations or there absence have really nothing to do with the nature of Officer Crowley's misconduct. What happened basically is that Crowley accused Gates, whether for good reason or not, of breaking into his own home. Gates, pissed off, offended Crowley. At which point Crowley, even though he was now perfectly aware that Gates was not guilty of anything, decided to exact revenge by manipulating the situation to create a trumped-up disorderly conduct charge. That's not professional policing, and it's not a good use of the City of Cambridge's law enforcement resources. That's why the charges were dropped, and that's why it's fair to say that Crowley was acting stupidly racial issues aside.
It seems clear to me that race did play a part in this arrest: someone called the guy in, probably because of his skin color. No doubt Gates was belligerent and rude. But there's no law against being rude. To me, this is really a story about a minor abuse of power.
Predictably, righties have swarmed all over this story and have created a familiar narrative for the incident. The arresting officer, Sgt. Crowley, is a salt-of-the-earth blue-collar good guy, a hero! For trying to save a black man, even! Mouth-to-mouth! He even taught a class on how not to do racial profiling, fer chrissakes! And then come all these elitist dandies to crucify this poor man and defend the ungrateful privileged uppity black man...it's enough to make yer blood boil, ain't it?
Recognize the pattern? Sure you do. It's the age-old Nixonian strategy of shaving off blue-collar votes by invoking the fear of black privilege. Only these people get to fold a president into their narrative...
Yowza. Rep. Joel Boniek (R-Livingston) got some notice earlier this month for comparing our President to Hitler in an interview with the L.A. Times (story I found was on the WSJ website):
Boniek at one point equated Obama with Hitler, Mao and Stalin, saying each loved his country in his fashion, with disasterous consequences. "He's ruining the country I love," Boniek said of Obama. "He doesn't know what freedom is."
Well, that's pretty offensive, but it gets worse. The Livingston Enterprise in an article I can't find online gets Boniek to clarify his views:
"Hitler should be remembered for more than being a mass murderer," Boniek said last week.
"The point I'm trying to make" is that no matter what Obama is doing, "it shouldn't impugn his love for his country," Boniek said of Obama.
Get that, Boniek referenced Hitler, Mao, and Stalin to emphasize Obama's patriotism, not his mass murdering tendencies.
What really seems to be the push is for the government to take over our health care and make it a single payer system with the government in charge.
Why in tarnation would we want to do this. The government all ready provides all the health care for the Indians in our country and look how screwed up that system is. The government run Veterans Health care is in no better shape than the Indian Health Care system.
WITH THESE TWO EXAMPLES OF OUR GOVERNMENTS ABILITY TO RUN HEALTH CARE, WHY WOULD WE WANT TO LET THEM TAKE CHARGE OF THE WHOLE COUNTRIES HEALTH CARE? CAN ANYBODY ANSWER THIS SIMPLE QUESTION?
First, Sam, a single-payer system is not the VA and Indian health care systems writ large. Those are examples of government-run health systems, not health insurance. A single-payer system is one in which a single entity - public or private, profit or non-profit - distributes all the insurance policies in the health-care system. Your question is flawed. Single-payer advocates do not favor letting government "take charge of the whole countries health care." Just the insurance.
Second, VA health care for one is not as bad as you make it out to be. In 2006, the VA hospital system was the best in health care. That should make you pause when you read articles about poor care at those hospitals - likely the care is worse at your local private hospital...only they don't talk about their problems in the newspaper. In fact, as Atul Gawande recently reported, the more market incentives are inserted into the health care providers' pay, the worse and more expensive treatment is. If there is poor service at VA hospitals, it could be because many of them have been privatized - like Walter Reed. And no doubt the influx of returning Iraqi and Afghani war veterans have taxed the system.
As for Indian health care...well, as the very article you linked to points out, most Native Americans on reservations don't have health insurance. That is, the poor, government-funded care American Indians do receive is much better than what private health care facilities would provide on reservations - which is nothing. Ask yourself: wouldn't there be more incentive for health care providers to treat impoverished Americans if the country had universal coverage? That is, even the poorest among us would have her health care bills paid by an insurer. And if there's a single problem with clinics on reservations, it's that they lack the funds to treat the number of patients that need care. The problem here is inadequate funding, not government bureaucracy. (And again, I'm paraphrasing the article you linked to.)
Of course, all of Sam's questions and misconceptions would have cleared up by a few minutes' Googling - or even a careful reading of the articles he linked to. But the the problem here is anti-health-reform conservative propaganda reinforcing already existing prejudice, not a lack of information.
And, frankly, it's against these prejudices that Obama needs to use his bully-pulpit. These misconceptions need to be slain if we're going to have real and effective reform.
Watching Bill Maher rake the president over the coals for his lack of substantive advocacy for real reforms, I realized that he's right on: Obama's been sitting back, playing insider politics, the passive player in health care reform, as well as any other meaningful reform that needs to be done to solve the myriad pressing problems plaguing the country.
And like Lindsay [Lohan], we see your name in the paper a lot, but we're wondering when you're actually going to do something.
Sorry, folks. But this president is not fighting for real health care reform. It's nibbling that leaves insurance companies still running the show.
And the banks. The banks that brought us to financial ruin and got bailout money are laughing at us about how easy it was to get back to business as usual.
And scientists keep saying that, if we want to keep living - you know, on Earth - it's kind of essential we reduce carbon dioxide by forty percent in the next ten years. Obama's bill? Calls for four percent.
This is not getting the job done. And this is not what I voted for. And this is why I don't want my president to be a TV star. Because TV stars are too worried about being popular and too concerned with getting renewed. Oh, you can relax about that one, Mr. President. The party is doing everything to ensure you'll get re-elected. The Republican party!
Speaking of the Republicans. If you can't shove some real reform down their throats now...then when?
Folks, Barack Obama needs to start putting it on the line in the fights against the banks, the energy companies, and the health care industry. I never thought I'd say this, but actually, what he needs in his personality is a little George Bush. He needs to stop worrying about being loved and bring out that smug, insufferable swagger that says, "suck on it, America!"
George Bush had horrible ideas. Torture, deregulation, pre-emptive war, tax cuts for the rich. But he pushed them through in their full measure, never mind Congress, or the Constitution, the Geneva Convention...Magna Carta...Hamurabi's code...
The point is, he didn't care if it made him unpopular with every human on the planet not named Cleetus or Fred Barnes. Which it did. What we need to do is marry the good ideas that Barack Obama has with a little bit of that Bush attitude and certitude. I'd love it if Obama came out one day and said, "Jesus told me to fix health care!"
In conclusion, Bush was bad. But he never cared if he were seen out at a restaurant having a burger with Dick Cheney. If he wanted a burger, he picked up the phone in the White House and said, "I'm the president! Bring me a burger!" And they would say, "sir, this is NORAD. Would you please stop ordering burgers into the red phone."
I'm glad Obama is president, but the audacity of hope part is over. Right now I'm hoping for a little more audacity.
Saw this linked to in a few places earlier, but I hadn't yet heard that the Obama Administration is bought and paid for by the insurance companies.
I've gotten a few emails and seen the single-payer protest clip that is below. I have to admit to being underwhelmed. If I was in Congress, I'd be inclined to give single-payer a look. But I'd probably also end up where I am now, supportive of a mix of public and private insurance options for people.
The strangest thing, though, is this idea, both here in Montana and nationally, that Max Baucus is thin line standing between America and single-payer health care. That if only Max Baucus would invite a single-payer advocate to a Finance Committee meeting that Chuck Grassley's perpetual frown would turn upside down and that we'd all move to candy mountain with Charlie the Unicorn and the healthcare would be free and have sprinkles.
But I digress.
The place we're at in health care reform right now is that there is some broad consensus among leading Democrats, ranging from Barack Obama to Kathleen Sebelius to Ted Kennedy to Max Baucus to Howard Dean, of what health care reform looks like. It includes some Medicare reform; a "connector" or "exchange" to help people navigate the insurance market; significant regulation of private insurance including guaranteed issue, community rating, and some guaranteed benefits package to be determined; and a public health insurance option in some form. To various extents, all of these players are negotiating with Republicans, pharmaceuticals, hospitals, doctors, insurance executives and others to work out something that can get passed. I'm not privy to all of those negotiations or strategy. In all likelihood, most of the readers of Left in the West aren't either.
But that's the consensus framework. There are other approaches we could, in theory, take. We could try the McCain plan. We could try single-payer. We could model the French limited multi-payer or the British NHS system. Or whatever. But we're not doing those things either.
Occasionally, people ask me why I'm supporting what I'm supporting, as though what Matt Singer supports is newsworthy in the slightest. I don't think what I support is either interesting or important.
To some extent, the constant "I have a plan" nature of policy discussions in America is good in terms of promoting serious long-term policy thought. But it isn't very useful in terms of actually getting something passed this year, which is what we're currently trying to do. For most of us, the relevant conversation on November 1st of last year was Barack Obama or John McCain, Denise Juneau or the crazy lady, etc., etc.
At some point in politics, the questions we face become binary. Healthcare reform isn't quite there yet where we crunch down to: vote to pass it or vote for the status quo. But we're at least to the later portion of the primaries, where the contestants have been winnowed down to a narrow field and, perhaps unsurprisingly, those candidates are marked more by their similarities than their differences.
Big changes in American politics take years and huge amounts of work. Even unsuccessful attempts at big changes in American politics take years and huge amounts of work. And the most incredible thing about is that even the most "powerful" players -- people like Barack Obama, Ted Kennedy, and, yes, Max Baucus -- are more caught in the storm than creating the winds.
That isn't to say we don't have power. All of us have a lot more power to kill reform than we do to get something passed. It is easier for Barack Obama to veto a bill than to pass one, for Ted Kennedy or Max Baucus to shut down an option than to get consensus for one, for a single Senator to help filibuster than to get cloture, and for activists decide that they would rather demand a full loaf than get 2/3 of one and as a result not even get a crust.
This has turned into a rant, so I'm going to stop. I'm more than happy to take feedback in comments here and, as folks may have noticed, the diary and comment options give even single-payer advocates (and even libertarians) the ability to write whatever the hell they want here (although the community can shut down comments). So by all means, let 'er rip.
(Rep. Rehberg can't keep up with our new President. - promoted by Matt Singer)
A friend just sent me a copy of the Sheridan County News. The paper is not online, but it appears that our Congressman was recently in Plentywood where he had some advice for President Obama and the Sheridan County News covered it:
Speaking specifically about President Obama, Rehberg said, "He's moving too fast. He's trying to do too much. It's time for the president to slow down."
I guess when you're the guy whose own Chief of Staff said your top accomplishment was cutting the birthday cake for Billings' birthday (and you haven't had a non-public sector job in over two decades) tackling health care, the economy, unemployment, two wars and a pandemic may seem a bit ambitious.
"Time and again," Rehberg has backed legislation that matters to Montanans, Iverson says. He's sponsored bills to recognize Billings' 125th anniversary, push for a water project in Fort Peck, and congratulate Carroll College's football team for its 2007 league win. Most importantly, supporters say, Rehberg co-sponsored the CLEANUP (Clean, Learn, Abolish, Neutralize, and Undermine Production of Methamphetamines) Act to focus federal authorities on the meth problem. The bill is still in committee.
"That's a major policy accomplishment," Iverson says.
I'm in DC this week for a series of meetings and just got done watching our senior Senator give a talk at the Center for American Progress Action Fund on health care reform.
There were some positive notes -- he spoke highly of a public health insurance option and didn't take using the reconciliation option off the table; he said he wants it to be bipartisan, but not at the expense of a good bill, etc. For more of a roundup, check out my tweets on it either on Twitter or Facebook (where you can comment).
At the heart of the conversation, as always of late (it seems), was the public health insurance option. Unsurprisingly, private insurance companies REALLY, REALLY hate it. So do Republicans. But here's what I don't get. Virtually all of the cost control measures being discussed -- from monopsony negotiating power to comparative effectiveness and moving away from fee-for-service -- rely on a public health insurance option, either directly or indirectly through modeling good insurance behavior (and imposing it on a wildly uncompetitive insurance industry).
So if we take the public health insurance option off the table, the question becomes -- how do we control costs without it? In theory, we can do one of three things:
Hope insurance companies adopt better cost control practices on their own.
Impose fierce regulations so that private insurance basically becomes a publicly-controlled, privately-profitable industry, but where meaningful competition DOES NOT EXIST.
Throw people to the wolves.
Compared to a straight-forward public option, these all strike me as asinine choices. Number two strikes me as the most likely compromise point, but I can't see why either liberals or conservatives would rather end up here than with a public health insurance option (although I can see why private insurance companies would).
Note: this is the justification for even having a relatively toothless public health insurance option -- one prohibited from negotiating and required to operate without public subsidies. Such an operation could still apply market pressure by embracing the moves away from fee-for-service and deploying comparative effectiveness research.
Am I missing something?
Update -- As with the panel at CAPAF, I still don't know if anyone has a realistic answer to this other than extremely fierce regulation of insurance companies. Again, insurance companies are probably OK with that alternative. Guaranteed revenue streams make up for harsh regulations. But both quality and cost will suffer for it because of the elimination of market incentives. We'll instead be hoping that government gets it right.
To put it another way, this solution -- government deciding exactly how insurance will work with private companies getting the profits -- has all the worst aspects of central planning and capitalism run amok.
So here's a crazy statistic: 34.3% of Montanans under the age of 65 went without health insurance for at least a one month period during 2007 or 2008.
Those numbers come from Families USA, a great outfit that advocates on behalf of health care consumers.
The vast majority of these uninsured individuals were working (or are minor children of working parents).
There's no age breakdown for Montana, but the national data is startling:
The likelihood of being uninsured declined among adults as they grew older. The percentage who were uninsured was highest among 19- to 24-year-olds (49.5 percent) and 25- to 44-year-olds (36.3 percent).
I'd wager the data gets bad for the mid-20s bloc. These are the folks just entering the job market, changing jobs frequently (almost always with a break in coverage), unable to stay on their parents' coverage, and lacking access through college.
I should also note that excluding the over-65 population in these conversations is actually crucial to get an accurate picture. All elderly Americans are insured through Medicare. While in need of some tweaks, Medicare works pretty darn well. The question is what will we do for the rest of us. And just baseline access to insurance is very, very far from reality.
The Commonwealth Fund released a new report recently, "The Path to a High Performance U.S. Health System." Commonwealth's contribution is notable because they are avid students of international systems and have also gone out of their way to rigorously crunch numbers of most of the proposals being offered in the U.S., ranging from right-wing McCain-like proposals to near-single-payer options.
Commonwealth's proposal is outlined here in a nutshell:
This report from the Commonwealth Fund Commission on a High Performance Health System offers recommendations for a comprehensive set of insurance, payment, and system reforms that could guarantee affordable coverage for all by 2012, improve health outcomes, and slow health spending growth by $3 trillion by 2020-if enacted now to start in 2010. Central to the Commission's strategy is establishing a national insurance exchange that offers a choice of private plans and a new public plan, with reforms to make coverage affordable, ensure access, and lower administrative costs. Building on this foundation, the report recommends policies to change the way the nation pays for care, invest in information systems to improve quality and safety, and promote health. By stimulating competition and delivery system changes aimed at providing more effective and efficient care, the policies could yield higher value and substantial savings for families, businesses, and the public sector.
Here's the crazy news. I did some back of the envelope math. The $3 trillion in savings that Commonwealth expects by 2020 means that in 2020 health care spending will still be as large a portion of GDP as it currently is. The good news is that there is reason to believe that we will have finally stopped health care spending growth as a share of GDP -- and we may finally be actually improving health outcomes as a result.
While I'm at it, check out Ezra Klein's interview of Andy Stern, head of SEIU and one of the people at the center of the hardcore push for reform. Lots of interesting nuggets in there on SEIU's strategy, Max Baucus's surprising aggressiveness, and NFIB's conversion from opponent of reform in '93/'94 to very, very worried about costs today (worried about costs? The more progressive solution, the better the cost containment).
