Friday, July 31, 2009

Health Care: Nullification & Beef Jerky Edition

Thers asks:
Suppose, arguendo, the minority Senate GOP somehow engineers nuclear war and mass human extermination. At that point, would it be politically feasible to challenge the sacred principle of the filibuster?

Probably not; let's not get crazy, now. This is after all a serious policy blog and demands to be treated as such.
via Daily Kos' pundit wrapup -

Nate Silver:

Instead of Grassley and Enzi, Baucus should be sitting in a room with Ben Nelson and Mary Landireu -- and maybe Olympia Snowe. Those are the swing votes -- the pressure points -- the people with whom there's actually something to be negotiated. If Grassley wants to come in and snack on beef jerky and spitball a few ideas, then sure -- door's always open. But I don't know what good he's doing the Democrats by being given so leverage over the process.

via DemfromCT's Health Care Friday
  • Oh, noes!!! Obama is proposing a government plan!!! That's socialism!! That's un-American!! That's -um- what 30% of the country has now. Gallup sez:

    Nearly 30% of Insured Have Government Plans, Up From '08
    Percentage with employer-provided care fell from 2008 to 2009

  • Speaking of Gallup, one can argue that Frank Newport is misinterpreting these numbers a bit.

    The wariness with which the public approaches the possible effects of healthcare reform on their personal situations is evident from results showing that more Americans say healthcare would worsen their medical care and reduce their access to healthcare, than say it would have the contrasting, positive effects. These "net negative" results contrast with the net positive perceptions Americans have about the likely impact of healthcare reform on the U.S. more generally -- albeit one that is quite muted.

    My interp is that the "no change" is truly neutral, and it's the "gets worse" number that matters... and that's only 34% - the usual number for the conservative base that hates anything the Democrats propose. If "no change" + "improves" is 55-60%, that's rather good. After all, if it doesn't hurt me and helps you, why not? The key is to track the 34% "worsen" over time.

C&L: Jay Rockefeller explains the fallacy of Conrad's "co-ops" in President Baucus' health care bill: "It's unacceptable"

Hold back the jello. Jay Rockefeller was on this morning with Andrea Mitchell and complained about the Kent Conrad "co-op" plan which he said was basically unworkable. He then went on The Ed show and hit it even harder. Jay is a supporter of the public option and was pissed that the co-op proposal was inserted in the Baucus bill since it was never even talked about during the general election. Isn't it nice that Baucus has killed the public option just to work with Republicans? Conservatives don't even have to win elections to get what they want. That's some deal they have.

Ed: It's not going to work. There's really no successful model out there to support the basis of signing on to a co-op. Would you sign on to a co-op or is that unacceptable?

Rockefeller: That's unacceptable and I can almost prove it. We've been in touch with all the folks that oversee, represent all the co-ops in the country on all subjects and they point out that there are probably less than twenty health co-ops in the country. There are only two that really work that well. One in Puget Sound, one in Minnesota, except for those two, they are all unlicensed. All present health co-ops are all unlicensed, they're unregulated. Nobody knows anything about them, nobody has any control over them and nobody has ever said, which is stunning to me, no government organization or private organization has ever done a study to what effect they might have in terms of bringing down the insurance prices.

They are untested, they are unlicensed, they are unregulated, they are unstudied. Why would we even think about putting them in as a control on this massive insurance industry instead of the public option?

There aren't any co-ops throughout much of the country, but to appease the conservative Dems we're supposed to throw six billion dollars around and hope that the states will try to make them workable. Is this insane? Watch the whole clip, but you get the idea from this one statement. Kent Conrad's big proposal is a complete sham, but President Baucus is trying to cram that down the throats of the country, which will render all health-care reform useless. All hail bipartisanship!

Everyone expected this to be a very busy week for the health care reform campaign(s), and it has been. Whether we're any closer to actual progress is far less clear.

Let's start with the Senate, where a center-right Gang of Six were supposed to finish their negotiations and produce a "bipartisan" bill before the recess. Now, negotiators say, that's not going to happen -- and even if it did, the resulting legislation may be so awful, other Democrats on the Senate Finance Committee may not be able to stomach it anyway.

At the same time, the NYT reports today that the Republican leadership has told its members -- including those in Finance Committee negotiations -- that delaying the process as long as possible is a necessity. Why? Because GOP leaders have apparently decided that they shouldn't "let Democrats head to their home states for the August recess boasting of any progress." Indeed, those same leaders have warned Chuck Grassley that if he helps Dems pass a reform bill, they may punish him by blocking him from becoming the ranking member on the Judiciary Committee next year.

Democrats, in other words, are trying to strike a reform compromise with lawmakers who want neither reform nor compromise. That is, for lack of a better word, insane.

As for the House, the compromise that brought some Blue Dogs on board with reform will apparently help get a bill out of Waxman's House Energy and Commerce Committee, but it's outraged dozens of House liberals, who insist that they can no longer support the legislation now that conservative Democrats have weakened it. At last count, 57 House Progressives say they are prepared to vote against the bill on the floor.

It creates a very difficult dynamic -- keep this week's changes, lose liberal votes, and watch health care reform die just inches from the finish line. Or, get rid of this week's changes, lose the Blue Dogs, and watch health care reform die just inches from the finish line.

Jonathan Cohn says just about all of the relevant players fighting for reform seem, at this point, "more than a little bit concerned."

...Democrats still haven't agreed among themselves on the most challenging issue in reform: how to pay for it. There's no shortage of viable ideas on that front. Senator John Kerry's proposal to tax health benefits by taxing insurers, rather than the insured, offers some hope for a broadly acceptable compromise. But the Democrats aren't there yet.

Will they get there soon? And get there in time? It's the question not just about financing, but about reform as a whole.

Stay tuned.


Opponents of health care reform successfully pushed for a series of delays with the hope that conservatives could kill the effort over the August recess. Supporters of reform are preparing to make sure that doesn't happen. DCCC Chairman Chris Van Hollen (Md.) told Chris Cillizza, "We are not going to allow supporters of the status quo to swift-boat health care reform in August."

The message doesn't seem especially complicated: tie reform opponents to the unpopular insurance industry. Greg Sargent obtained a copy of a script a liberal group will use to target GOP lawmakers over the break:

"The insurance industry makes more than $15 billion a year in profits. Now that money is going to fight health care reform. In Washington, opponents of health care reform are spending more than a million dollars a day, just on lobbying alone. On top of that, the insurance companies give millions to the politicians who support them.

"Congressman Roy Blunt has taken more than half a million dollars from the insurance industry. No wonder he's against reform that will lower costs, give us more choices, and keep the insurance companies honest. Meanwhile we are left paying more than three times what members of Congress pay for good health care. It seems that Roy Blunt is against anything that will hurt the insurance companies' bottom line. Call Roy Blunt and tell him to side with us, not the insurance companies."

Similarly, Brian Beutler reports on a strategy memo distributed to members of the House Democratic caucus, which emphasizes the importance of holding insurance companies accountable. The memo argues:

Remove them from between you and your doctor. No discrimination for pre-existing conditions. No dropping your coverage because you get sick. No more job or life decisions made based on loss of coverage. No need to change doctors or plans. No co-pays for preventive care. No excessive out-of-pocket expenses, deductibles, or co-pays. No yearly or lifetime cost caps on what insurance companies cover.

It's the consumer-focused message embraced by the White House, coupled with the insurance-industry criticism that, I imagine, polls well.

Democrats are reportedly calling their effort "Health Care ER" -- ER for "emergency response" -- that will include radio ads, online activism, and traditional grassroots activities, though it's unclear how much money is behind the recess campaign.

It's obviously intended to, at a minimum, match the right's efforts. With a little luck and effective messaging, reform advocates might even end up in a better position after the recess than before it.

Sudbay: It's been a fundraising frenzy for the Blue Dogs

No wonder Blue Dog Rep. Herseth Sandlin was so ecstatic when the Blue Dogs delayed passage of health insurance reform. The delay bought the Blue Dogs another couple months of obscene fundraising. The Blue Dogs have been sucking up money from the industries impacted by the legislation:

The roiling debate about health-care reform has been a boon to the political fortunes of Ross and 51 other members of the Blue Dog Coalition, who have become key brokers in shaping legislation in the House. Objections from the group resulted in a compromise bill announced this week that includes higher payments for rural providers and softens a public insurance option that industry groups object to. The deal also would allow states to set up nonprofit cooperatives to offer coverage, a Republican-generated idea that insurers favor as an alternative to a public insurance option.

At the same time, the group has set a record pace for fundraising this year through its political action committee, surpassing other congressional leadership PACs in collecting more than $1.1 million through June. More than half the money came from the health-care, insurance and financial services industries, marking a notable surge in donations from those sectors compared with earlier years, according to an analysis by the Center for Public Integrity.

A look at career contribution patterns also shows that typical Blue Dogs receive significantly more money -- about 25 percent -- from the health-care and insurance sectors than other Democrats, putting them closer to Republicans in attracting industry support.
Is anyone surprised? This hasn't been about policy for the Blue Dogs. They've made craven political calculations that are filling up their campaign coffers.

Krugman: Health Care Realities

At a recent town hall meeting, a man stood up and told Representative Bob Inglis to “keep your government hands off my Medicare.” The congressman, a Republican from South Carolina, tried to explain that Medicare is already a government program — but the voter, Mr. Inglis said, “wasn’t having any of it.”

It’s a funny story — but it illustrates the extent to which health reform must climb a wall of misinformation. It’s not just that many Americans don’t understand what President Obama is proposing; many people don’t understand the way American health care works right now. They don’t understand, in particular, that getting the government involved in health care wouldn’t be a radical step: the government is already deeply involved, even in private insurance.

And that government involvement is the only reason our system works at all.

The key thing you need to know about health care is that it depends crucially on insurance. You don’t know when or whether you’ll need treatment — but if you do, treatment can be extremely expensive, well beyond what most people can pay out of pocket. Triple coronary bypasses, not routine doctor’s visits, are where the real money is, so insurance is essential.

Yet private markets for health insurance, left to their own devices, work very badly: insurers deny as many claims as possible, and they also try to avoid covering people who are likely to need care. Horror stories are legion: the insurance company that refused to pay for urgently needed cancer surgery because of questions about the patient’s acne treatment; the healthy young woman denied coverage because she briefly saw a psychologist after breaking up with her boyfriend.

And in their efforts to avoid “medical losses,” the industry term for paying medical bills, insurers spend much of the money taken in through premiums not on medical treatment, but on “underwriting” — screening out people likely to make insurance claims. In the individual insurance market, where people buy insurance directly rather than getting it through their employers, so much money goes into underwriting and other expenses that only around 70 cents of each premium dollar actually goes to care.

Still, most Americans do have health insurance, and are reasonably satisfied with it. How is that possible, when insurance markets work so badly? The answer is government intervention.

Most obviously, the government directly provides insurance via Medicare and other programs. Before Medicare was established, more than 40 percent of elderly Americans lacked any kind of health insurance. Today, Medicare — which is, by the way, one of those “single payer” systems conservatives love to demonize — covers everyone 65 and older. And surveys show that Medicare recipients are much more satisfied with their coverage than Americans with private insurance.

Still, most Americans under 65 do have some form of private insurance. The vast majority, however, don’t buy it directly: they get it through their employers. There’s a big tax advantage to doing it that way, since employer contributions to health care aren’t considered taxable income. But to get that tax advantage employers have to follow a number of rules; roughly speaking, they can’t discriminate based on pre-existing medical conditions or restrict benefits to highly paid employees.

And it’s thanks to these rules that employment-based insurance more or less works, at least in the sense that horror stories are a lot less common than they are in the individual insurance market.

So here’s the bottom line: if you currently have decent health insurance, thank the government. It’s true that if you’re young and healthy, with nothing in your medical history that could possibly have raised red flags with corporate accountants, you might have been able to get insurance without government intervention. But time and chance happen to us all, and the only reason you have a reasonable prospect of still having insurance coverage when you need it is the large role the government already plays.

Which brings us to the current debate over reform.

Right-wing opponents of reform would have you believe that President Obama is a wild-eyed socialist, attacking the free market. But unregulated markets don’t work for health care — never have, never will. To the extent we have a working health care system at all right now it’s only because the government covers the elderly, while a combination of regulation and tax subsidies makes it possible for many, but not all, nonelderly Americans to get decent private coverage.

Now Mr. Obama basically proposes using additional regulation and subsidies to make decent insurance available to all of us. That’s not radical; it’s as American as, well, Medicare.
Yglesias: The Fire Department: A Public Option

Tina Dupuy had a nice item in the Huffington Post yesterday noting that urban firefighting in the United States was once a private for-profit industry. Then around the middle of the nineteenth century, cities began to decide that this system was too haphazard, corruption-prone, and unfair and thus began the dread big-government takeover of firefighting:

Yet if we had to have the “conversation” about the firefighting industry today, we’d have socialism-phobic South Carolina Sen. Jim DeMint on the TV every chance he could get saying things like, “Do you want a government bureaucrat between you and the safety of your home?”

Rep. John Boehner of Ohio would hold press conferences and ask, “Do you want your firefighting to be like going to the DMV? Do you want Uncle Sam to come breaking down your door every time some Washington fat cat says there’s a fire?”

It’s a good point. Anyone who’s honest about it is ultimately going to have to admit that direct public-sector provision of services is something that can be done in a quite high-quality way. Obviously, low-quality service is also possible. The fact of the matter regarding the DMV is that even though people find DMV lines important, people also just don’t care about it very much. No lifelong Democrat has ever crossed party lines to vote for a Republican gubernatorial candidates because he’s fed up with the low-quality of the DMV and excited about injecting some new blood into the stodgy motor vehicles bureaucracy.

By contrast, people do care about crime and Rudy Giuliani was able to get elected in super-Democratic New York City. Any mayor with a lick of sense at least attempts to provide a crime control agency that performs well. I think the evidence from the UK is that NHS quality is a constant subject of political debate and politicians are forever attempting to achieve better performance. This, I take it, is the reason why the NHS is so successful at delivering cost-effective treatment outcomes. A very low budget by world standards is why its outcomes don’t look great in absolute terms.

Meanwhile, in the United States it is worth keeping in mind that public provision of health care services isn’t on the table. And we don’t need to guess what public provision of health insurance might look like; Medicare is a very large and not-at-all obscure government program. It’s not perfect, I’m not even sure I’d say it’s great, but it measures up quite well in terms of both cost and quality relative to the private sector.

If Americans are lucky, later this year, health care reform proponents will overcome conservative opposition, institutional obstinacy, procedural morass, and internal Democratic division and pass a landmark piece of legislation.

And if that happens, they'll soon after find that far-right policymakers in some states hope to block reform before it's implemented. Indeed, they're already laying the groundwork. Take Florida, for example, where nearly 4 million people currently have no health care coverage.

Earlier this week, Florida State Senator Carey Baker (R) and State Representative Scott Plakon (R) introduced a state Constitutional amendment that, if adopted, would prevent Floridians from enrolling in any federal health care legislation. [...]

"We believe this unprecedented power-grab by President Obama and Congress is clearly not in the best interests of the citizens of Florida," Baker and Plakon said in a joint statement. Baker, who is a Republican candidate for Commissioner of Agriculture and Consumer Services, participated in the right-wing tea parties on July 4. Both he and Plakon are sponsors of a "sovereignty" memorial, a measure meant to serve "as a notice and a demand to the Federal Government ... to cease and desist, effective immediately, from issuing mandates that are beyond the scope of [their] constitutionally delegated powers."

Their amendment to ban health care would need approval by a three-fifths vote in both the House and Senate. If passed by the legislature, Florida voters would vote on the constitutional amendment on Election Day 2010.

Texas, meanwhile, has one of the nation's highest rates of uninsured residents -- roughly one in four Texans go without coverage. Its Republican governor, Rick Perry, recently said he's "willing and ready" to block reform from taking shape in his state, calling it "encroachment." What's more, Republican lawmakers in Arizona have approved a ballot measure that would, if approved, allow the state to override a federal health care law that includes individual or employer mandates.

The legality of these right-wing efforts is dubious. I imagine far-right policymakers in various states didn't like Social Security or Medicare when they became law, either, but they're still national programs, doing an enormous amount of good.

But it's nevertheless interesting, since a) the fight with conservatives can continue long after reform passes (if it passes); and b) these efforts are a reminder of just how far off the ideological cliff some elements of the GOP have gone.

Yglesias: Health Insurance Industry’s Strategic Bribery

In Scarface Tony Montana expresses his view that “In this country, you gotta make the money first. Then when you get the money, you get the power.” And of course there’s something to that. But as Ryan Powers demonstrates with this chart, it also works to get the power first. Then when you get the power, you get the money:


The business of influence and access peddling in Washington is often thinly veiled in pseudo-respectable claims that industry groups donate to candidates who they believe are predisposed to agree with their public policy priorities. But I think it is more accurate to say that industries donate to individuals who they perceive as predisposed to being bought. Indeed, if the health insurance industry really based its contribution decisions on who they thought would be more likely sympathize with their desire to keep the health care system as it is, they would do well to always direct a majority of their cash to GOP candidates. But they don’t. [...]

This is hardly a novel point on my part. But I think it’s important to keep in mind as we watch individuals who campaigned on and for the Obama agenda work to block or water down that agenda in the House. While I have not looked at the data, I expect there would be similar trends in the Senate.

Right on. This is why the very same members likely to be concerned that expanding coverage to the poor is too expensive also tend to be the same members who oppose saving money through the introduction of a robust public option embedded in a strong health insurance exchange. There are some visions of “health care reform” that are compatible with the interests of insurers, and the job of on-the-take Democrats is to try to steer legislation into that harbor.

Meanwhile on another level this kind of dynamic just embeds large advantages for incumbent candidates. A public financing scheme would be good for the country and good for progressive politics, but not necessarily good for potentially vulnerable left-of-center incumbent elected officials, so it’s hard to get anyone jazzed about the idea.

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