UPDATED: Health care statistics, undermining health care debate?

Peter Orszag
Image via Wikipedia

UPDATE: I had originally written this post based mainly off of the NY Times piece linked to below, coupled with my own knowledge of health care policy, but it seems that this article has sparked a vigorous debate in the blogosphere regarding just how accurate it's claims about the Dartmouth Health Atlas are.  I have edited parts of my post below to take into account new information, but for more, see Kevin Drum at Mother Jones, David Leonhardt at the NY Times, or the Dartmouth Health Atlas authors' response.  Needless to say, the situation is far more complex than the Times writers acknowledge, involving statistical analysis and the extrapolation of data.  More info below my blog posting.

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There's a fascinating article out today in the New York Times about a Dartmouth study on health care spending and the resultant health outcomes across hospitals, states, and regions of the U.S.  The study was used by the Obama Administration and Congressional Democrats to make the case for the efficacy of cutting health care spending while actually improving patients' health outcomes.  The article paints a picture of the Administration's efforts to sell their plan via the study:

Mr. Orszag even displayed maps produced by Dartmouth researchers that appeared to show where the waste in the system could be found. Beige meant hospitals and regions that offered good, efficient care; chocolate meant bad and inefficient.

The maps made reform seem relatively easy to many in Congress, some of whom demanded the administration simply trim the money Medicare pays to hospitals and doctors in the brown zones. The administration promised to seriously consider doing just that. (emphasis added)

Mr. Orszag is Peter Orszag, Budget Director of the Office of Management and Budget at the White House, and one of the primary cheerleaders for health care reform within the Administration.  Color-coded maps are like catnip to legislators eager to provide pseudo-intellectual cover for their legislative aims, as they can simply point to the maps to make their overly simplistic arguments to their constituents.  The idea that politicians would ever think that health care reform is easy is truly scary.  We really need more economists and statisticians in Congress.

But while the research compiled in the Dartmouth Atlas of Health Care has been widely interpreted as showing the country’s best and worst care, the Dartmouth researchers themselves acknowledged in interviews that in fact it mainly shows the varying costs of care in the government’s Medicare program. Measures of the quality of care are not part of the formula. (emphasis added)

Did you catch that?  The Dartmouth study solely looks at the cost of care, not the quality of care, yet somehow or another the link between lower spending and better care was made by policymakers in Washington.  How did that happen?

In addition to their hospital rankings, the Dartmouth researchers have also done separate studies of how Medicare spending affects patient care regionally. A 2003 study found that patients who lived in places most expensive for the Medicare program received no better care than those who lived in cheaper areas.

Because some regions spent nearly a third more than other regions without any apparent benefit, the Dartmouth team concluded that at least one dollar in three was wasted by Medicare. When applied generally to the nation’s health care system, that meant about $700 billion could be saved.

But as it began publicly discussing its research, the Dartmouth team often extrapolated beyond this basic finding. Not only do high-spending regions fail to provide better care, the Dartmouth team began to argue, but those regions actually offer worse care. 

While I haven't seen the exact data the Dartmouth team examined in making these claims, the argument that one-third of Medicare spending is wasteful seems like a rather large extrapolation to make.  The blunt instrument of health care spending statistics does not lend itself to nuanced analyses of the quality of doctors or nurses at a hospital or of their clinical judgments in deciding what treatments to order for patients.

Last year, New Yorker writer (and practicing doctor) Atul Gawande wrote a major article about McAllen, Texas, the city with the highest per-capita Medicare spending in the country after Miami, a city with a much higher cost-of-living and more elderly population.  Gawande describes a meeting he has with a group of McAllen doctors, one of whom responds to Gawande's inquiry about the high spending thusly:

“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures. 

The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”

Naturally, when the incentives for doctors are to over-prescribe treatments so that they are compensated, they will tend to run more tests than necessary, and to focus on moving their patients into the more expensive treatment programs, rather than lower-cost preventive medicine treatments, which may be more effective.  So when the Dartmouth researchers make the arguments that higher cost equates to worse outcomes, that may indeed be true, as more health care does not always mean better health care, but it cannot be the case universally across the country.  If a doctor correctly diagnoses a serious ailment, and prescribes a necessarily expensive treatment regimen for it, then simply looking at the spending figures will not be able to take into account the correct diagnosis of that ailment.

In interviews, Dr. Fisher and Mr. Skinner acknowledged that there was no proven link between greater spending and worse health outcomes. And Dr. Fisher acknowledged the apparent inconsistency between his statements in interviews with The New York Times and those made elsewhere, saying that he was sometimes less careful in discussing his team’s research than he should be.

In any case, the more-is-worse message has resonated with insurers, whose foundations now help to finance the Dartmouth Atlas. Dartmouth researchers also created a company, Health Dialog, to consult for insurers and others on Dartmouth’s findings. Valued at nearly $800 million, the company was sold to a British insurer in 2007 and still helps to finance the Dartmouth work.

It appears that, surprise, if as a researcher you make arguments that resonate with insurance companies, they will take a financial interest in your research.

Ultimately, the problem here is twofold: 1) high per capita Medicare spending in an area may signify the overutilization of care by doctors, but to make the conclusion that higher spending is always wasteful goes too far; 2) researchers and academics who create studies that fit neatly into the narrative that the powers-that-be seek to promulgate (in this case the Obama Administration and the health insurers) will have their conclusions amplified, despite arguments to the contrary.  This resulted in the further muddying of the already opaque health care reform discourse in which nothing is quite as cut-and-dry as we might wish.  While I still believe the reform bill was a good step towards a healthier America, it's unfortunate that the system has been gamed by so many parties.

UPDATE, cont...Further muddying of the waters:

3. Some research has shown that even the most glaring cost
differences noted in the Dartmouth research are associated with
improved outcomes for those conditions where something close to random
assignment of patients to alternative patient regimes occurs. The guy
who is doing this work is Joseph Doyle at MIT. If the Times article
had described some of his work, readers would have learned something.
For example, you can be pretty sure that people who suffer coronaries
while on vacation do not choose in which county to have the heart
attack. Doyle studied such patients. He found that they did better
in Florida counties that spent most, the very counties that the
Dartmouth folks have held up for their poor average outcomes. He also
found that preemies who were a couple of grams under the threshold at
which they are described as in need of intensive care did materially
better than did preemies a couple of grams over that threshold and,
hence, treated as normal births. The weight difference was too small
to matter medically and went in the wrong direction; the intensity of
care mattered.

Doyle's reasearch and the finding on the inverse relationship between
Medicare spending and private spending, together with the fact that we
can't predict worth crap who will and who will not benefits from many
procedures means not that the Dartmouth people are wrong, but that any
savings will be very hard to achieve without doing more harm than good
and will be very slow in coming. The Administration, and Orszag in
particular, were wrong in neglecting the warning to forecasters of
Scottish economist, Alec Cairncross, 'Give a number. Or a date.
Never both.'

Brokering dialogue with the Tea Party

Image via Wikipedia

Last week was my spring break from UCLA, and instead of going to a tropical locale with umbrella drinks, I decided to get a jump on earning course credits and learn new skills through taking a class on public mediation.  For those of you not familiar with mediation as a form of dispute resolution, the basic concept is that two parties (referred to as "disputants" in our training course) will agree to meet with a neutral mediator, and the mediator will work to facilitate a dialogue between the disputants to foster an understanding of each other's interests between them.  The mediator will attempt to structure the dialogue so that the disputants can come to a resolution between each other that is mutually agreeable, not a resolution that is imposed by a judge  or arbitrator, as in other dispute resolution approaches.

The key aspects of the mediation strategy are in active listening, where the mediator seeks to give full attention to each disputant to hear their side of the story, and then, through active listening, to discover what each disputant's interests are.  "Interests" in a dispute can range from the purely economic, as in unpaid wages owed a worker, to the purely emotional, as when a person feels disrespected by his/her spouse.  Mediation is an attempt to deal with not only surface-level concerns, such as money issues, but the deeper feelings that may lie underneath those issues that conspire to prevent the disputants from reaching a mutually satisfactory resolution.  In mediation lies the idea that conflicts can be an opportunity for greater understanding and better relationships between individuals, not just power struggles where the winner takes all.

When I entered the class, I figured that I would simply learn some new skills for conflict resolution, skills that would be especially handy for me since I am a person who fears conflict with others.  What I discovered, however, was a new approach towards dialogue and communication, and a new framework through which to view political and policy debates.  By attempting to "hear" the other's concerns - to not judge the other immediately, but to give them an opportunity to feel heard and respected - I found that the disputants would be able to give voice to the feelings underlying their side of the dispute.  Once the two parties' emotions were acknowledged, resolution became more possible.

Since President Obama's inauguration, and especially with the raucous health care reform town hall meetings last August, I have been troubled by the rise of the Tea Party movement in American politics.  Beyond the basic inconsistencies of the Tea Partiers' main messages (if they're so concerned with government spending, where were they during the 8 years of the Bush Administration's unprecedented deficit-spending?  If they're so concerned with increasing taxes, why are they protesting when the Obama Administration just gave tax cuts to 95% of Americans (okay, maybe 92%)?  If they're worried about Big Government, why didn't we hear a peep out of them when President Bush presided over the largest expansion of government since the days of FDR?) I have puzzled over what is uniting all of these generally white, older, lower- to middle-class conservatives in such strident opposition to a government that is seeking to make their lives better.  Are they just mad that "their guy" lost the election?  It's doubtful that such resentment would still sustain such a large movement a year and a half after the election ended.  Are they all just racist?  I have to admit that I've certainly thought and expressed that belief in recent months, but again, it's hard to believe that such a large swath of the population would be motivated solely by racial issues.  No, I believe that race plays a significant role, but it's something more subtle than that.

Yesterday, a classmate forwarded me a link to a post by Steve Benen of Washington Monthly magazine that helped to clear up my thinking on the Tea Partiers and their sympathizers across the country.  Benen discusses a fascinating Dallas Morning News article profiling a family that is suffering under the strain of breast cancer, unemployment, and high out-of-pocket health care expenses; in other words, exactly the kind of family that the health insurance reform bill is intended to help.  But the family opposes the health reform bill, fearing government inefficiency and death panels, which Benen states

...makes the response all the more fascinating. Amy Townsend appears to have heard the right-wing propaganda, and seems inclined to believe it. "Every government program," she told the paper, "none of them work very well." 

The Townsend family is, however, currently getting by on unemployment benefits (a government program), and is holding onto some coverage through COBRA (another government program), which they can afford thanks to federal subsidies (through another government program). 

The point isn't to mock the Townsends or to question their judgment. The point is to appreciate the power of conservative political rhetoric in 2010. Many of those who stand to benefit from a stronger safety net have been led to believe they want a weaker one. Many of those who'll finally be able to get better care under a health care system that's been screwing them over have been convinced that they won't, or can't, benefit from reform.

There's a lot to unpack here.  I have thought a lot about an idea that many Democrats subscribe to (and that Benen represents well here), which is that the GOP convinces people through "rhetoric" or "propaganda" to vote against their own "interests," as if their interests are strictly economic in nature.  It's an essentialist argument on its face, that people can be defined solely by their economic concerns, and it gives credence to the widespread conservative critique of liberal conceit; that liberals believe they "know" another person's interests better than the people themselves do.

My contention is that the Tea Partiers are protesting mainly against the "face" of the government that is supposed to represent them, and the changing of American culture that has been going on for decades, but the evidence of which had been remarkably suppressed by the Bush Administration and its overwhelmingly white male leadership (with the notable exceptions of Condoleeza Rice and Colin Powell, of course).  Now we have not only a black President, but a female Speaker of the House, female Secretary of State, black Attorney General, Asian-American Secretary of Energy, etc.  This is not the government that many Americans are used to, and I think that, while one can call the Tea Partiers' reactions "racism" (and I certainly have!) I have come to believe, as noted above, that it's more subtle than that.  People feel that their government no longer represents them - they can no longer "see themselves" in the government, and they can't trust those "other people" to handle their tax money, help them afford health care, protect them from terrorism, etc.  As noted above, the vast majority of Tea Partiers are conservative and white, and would likely not vote Democratic anyways.  But then watching Fox News increases peoples' levels of fear and distrust by Fox speaking directly to their feelings of being unsettled with the "new order" running the government, and telling them that those feelings are widespread and that people should act on those feelings rather than hearing what the other side actually has to say.

So all this to say that I think that people also have an "interest" in feeling that their government represents them and their interests, and that speaking to their intellects, rather than their gut feelings of disorientation, will not ultimately be very productive for Democrats.  While this family in the article quoted may be going directly against their own economic interests, they are choosing instead to act on their interest in being represented by a government they "recognize," I suppose.  I'm not at all trying to justify the Tea Partiers, and I certainly do believe there is a strong racist element in the Tea Party movement, I've just been trying to imagine what it is that people react to so viscerally, and these last few paragraphs are what I've come up with thus far.

So how does one have a productive dialogue with the other side?  I'm not really sure yet, but through my basic studies of mediation I came to this point in my understanding of the Tea Party movement, and I believe that mediation represents a potentially useful tool for engaging in that dialogue.  How one engages a national dialogue is far beyond me, but I believe that initially at least it comes down to showing respect on an individual level, and an understanding that another's experience of the world is not your own.  So if you encounter a person who holds diametrically opposite views to your own, and there is not a fear of physical violence ensuing between you, I'd say take a moment to really listen to their concerns, you might be surprised what they tell you.

I plan to revisit this topic in future posts, and I'm in the process of formulating a major research project for next year that just might involve mediation...stay tuned.  In the meantime, if you're interested in learning more about the power of engaged dialogue, take a look here.

A Public Service Announcement

Speaker Pelosi and President Obama, take a bow
I didn't think I would blog tonight, despite many interesting developments in the political world since Sunday night (did you know that 24% of Republicans think our President could be the Antichrist?)  I strive for substance over filler on this blog, and I didn't feel I could summon the mental energy to write a quality post, but something caught my attention which was just too good not to share.  Following up on Sunday's posting about the health insurance reform bill, I was directed to this fantastic, clearly-defined blog posting from Speaker Pelosi's website detailing further what Americans can immediately expect from the health care bill; there's something for everyone:

(And before you check the posting below, just another note that the health care bill has now jumped in popularity since even last weekend, "By 49%-40%, those polled say it was 'a good thing' rather than a bad one that Congress passed the bill."  Compare that to approximately 45% for/48% against on March 9th, not too shabby.  Now that Americans can stop hearing about the sausage-making that went on for 14 months and can start focusing on what the legislation will actually do for them, these reform measures will only rise in popularity.  Also, Sen. Harry Reid is aiming to have the Senate pass the reconciliation bill on Saturday, which will put the final fixes to the reform bill in place, so we will be officially free and clear of this debate.  Onwards to financial reform!)

Lastly lastly: this photo is just beyond words.

What’s In The Health Reform Bill For You Right Away?

March 23rd, 2010 by Karina

Under the legislative package the House passed on Sunday (the Senate-passed health bill as amended by the reconciliation bill) many key provisions take effect this year - here are some of them:

IF YOU ARE A SMALL BUSINESSES OWNER:

SMALL BUSINESS TAX CREDITS—Offers tax credits to small businesses to make employee coverage more affordable. Tax credits of up to 35 percent of premiums will be immediately available. Effective beginning for calendar year 2010. (Beginning in 2014, small business tax credits will cover 50 percent of premiums.)

IF YOU ARE A SENIOR:

BEGINS TO CLOSE THE MEDICARE PART D DONUT HOLE—Provides a $250 rebate to Medicare beneficiaries who hit the donut hole in 2010. Effective for calendar year 2010. (Beginning in 2011, institutes a 50% discount on brand-name drugs in the donut hole; also completely closes the donut hole by 2020.)

FREE PREVENTIVE CARE UNDER MEDICARE—Eliminates co-payments for preventive services and exempts preventive services from deductibles under the Medicare program. Effective beginning January 1, 2011.

HELP FOR EARLY RETIREES—Creates a temporary re-insurance program (until the Exchanges are available) to help offset the costs of expensive health claims for employers that provide health benefits for retirees age 55-64. Effective 90 days after enactment.

IF YOU HAVE PRIVATE HEALTH INSURANCE:

NO DISCRIMINATION AGAINST CHILDREN WITH PRE-EXISTING CONDITIONS—Prohibits health plans from denying coverage to children with pre-existing conditions. Effective 6 months after enactment. (Beginning in 2014, this prohibition would apply to adults as well.)

NO RESCISSIONS—Bans health plans from dropping people from coverage when they get sick. Effective 6 months after enactment.

NO LIFETIME LIMITS ON COVERAGE—Prohibits health plans from placing lifetime caps on coverage. Effective 6 months after enactment.

NO RESTRICTIVE ANNUAL LIMITS ON COVERAGE—Tightly restricts new plans’ use of annual limits to ensure access to needed care. These tight restrictions will be defined by HHS. Effective 6 months after enactment. (Beginning in 2014, the use of any annual limits would be prohibited for all plans.)

FREE PREVENTIVE CARE UNDER NEW PLANS—Requires new private plans to cover preventive services with no co-payments and with preventive services being exempt from deductibles. Effective 6 months after enactment.

NEW, INDEPENDENT APPEALS PROCESS FOR NEW PLANS—Ensures consumers in new plans have access to an effective internal and external appeals process to appeal decisions. Effective 6 months after enactment.

MORE FOR YOUR PREMIUM DOLLAR—Requires plans to put more of your premiums into your care, and less into profits, CEO pay, etc. This medical loss ratio requires plans in the individual and small group market to spend 80 percent of premiums on medical services, and plans in the large group market to spend 85 percent. Insurers that don’t meet these thresholds must provide rebates to policyholders. Effective on January 1, 2011.

NO DISCRIMINATION BASED ON SALARY—Prohibits new group health plans from establishing any eligibility rules for health care coverage that have the effect of discriminating in favor of higher wage employees. Effective 6 months after enactment.

IF YOU DON’T HAVE HEALTH INSURANCE:

IMMEDIATE HELP FOR THE UNINSURED WITH PRE-EXISTING CONDITIONS (INTERIM HIGH-RISK POOL)—Provides immediate access to insurance for Americans who are uninsured because of a pre-existing condition - through a temporary high-risk pool – until the Exchanges up and running in 2014. Effective 90 days after enactment. (Beginning in 2014, health plans are banned from discriminating against all people with pre-existing conditions, so high-risk pools would phase out).

EXTENDING COVERAGE FOR YOUNG PEOPLE UP TO 26TH BIRTHDAY THROUGH PARENTS’ INSURANCE – Requires health plans to allow young people up to their 26th birthday to remain on their parents’ insurance policy, at the parents’ choice. Effective 6 months after enactment.

GENERAL REFORMS:

COMMUNITY HEALTH CENTERS—Increases funding for Community Health Centers to allow for nearly doubling the number of patients served over the next 5 years. Effective beginning in fiscal year 2010.

MORE PRIMARY CARE DOCTORS—Provides new investment in training programs to increase the number of primary care doctors, nurses, and public health professionals. Effective beginning in fiscal year 2010.

HEALTH INSURANCE CONSUMER ASSISTANCE—Provides aid to states to establish offices of health insurance consumer assistance to help consumers file complaints and appeals. Effective beginning in FY 2010.

A NEW, VOLUNTARY, PUBLIC LONG-TERM CARE INSURANCE PROGRAM—Creates a long-term care insurance program to be financed by voluntary payroll deductions to provide benefits to adults who become functionally disabled. Effective on January 1, 2011.

And in 2014, once the exchanges have formed, more insurance reforms go into effect, including:

NO DISCRIMINATION AGAINST ADULTS WITH PRE-EXISTING CONDITIONS
BAN ON HIGHER PREMIUMS FOR WOMEN
PREMIUMS BASED ON AGE CAN ONLY VARY BY A MAXIMUM OF 3-TO-1 RATIO
CAP ON OUT-OF-POCKET EXPENSES for private health plans

Why I Support The Health Insurance Reform Bill

Speaker of the House Nancy Pelosi

The interminable march towards health care reform (HCR) is continuing in earnest today, with an end finally (FINALLY) in sight.  So what is actually happening right now?  And what's this "reconciliation" business all about?  There's no good way to sum up parliamentary procedures into a bite-size format, so bear with me, as this email will be long.  

Procedural Issues

In brief, the House of Representatives voted today on the HCR bill passed by the Senate in December.  The Senate bill, as you may have heard, includes some rather unsavory deals that were cut in order to win 60 votes and to pass the bill; deals such as the "Cornhusker Kickback" that was negotiated by Sen. Ben Nelson (D-NB) that would provide indefinite federal funding to cover the expected increase in Nebraska's Medicaid costs due to expanding coverage to more people (Medicaid is paid for in part by federal funds and in part by state funds, so any increase in Medicaid costs will cost the states directly).  The Kickback and other deals that were made for specific Senators in specific states to win their votes are obviously not terribly popular with rank-and-file Democrats, and so by the House voting for the Senate bill as it is, they made those Senate deals into law.

However, over the last few weeks President Obama, Nancy Pelosi, Harry Reid, and other key Democrats in both chambers of Congress have worked out a deal to pass a reconciliation bill that "fixes" all of the deals that were passed in the Senate bill and that will work to further reduce the deficit (the Congressional Budget Office, the main non-partisan arbiter of all things budgetary, has stated that the bill will reduce the federal deficit by $140 billion over the first 10 years it is in place and by $1.2 trillion over the second 10 years it's in place, although those numbers are subject to a large amount of skepticism on both sides).  This reconciliation bill will be voted on tonight by the House once the Senate bill is passed by the House, and then that reconciliation bill is supposed to be passed by the Senate, hopefully later this week, although the timing is debatable.  Members of the House are afraid that the Senate will seek to alter the reconciliation bill, upsetting the delicate balance that has been struck between leadership and the members, although Senate leadership has worked to reassure nervous House Democrats that the Senate will pass the bill as-is.  Any changes that are made in the Senate will have to be voted upon again by the House before President Obama can sign the bill, delaying the legislation further, an outcome Democrats are working to avoid.  

So is the use of reconciliation by the Democratic majority "unconstitutional" or a "nuclear" procedure, as Republicans have sought to portray it?  Well, considering that the majority of the uses of reconciliation have come when Republicans were the majority in Congress (16 out of 22 reconciliation bills) it seems a bit rich for Republicans to call it an extraordinary procedure now.

Finally, abortion.  A lot of hay has been made in the last few weeks about whether there is any federal funding of abortion in this HCR bill, and the fact is, there never was any federal money for funding abortions.  There is a provision in the House called the Hyde Amendment, that bans spending federal money on abortions, and the HCR bills that have been debated have always upheld that provision.  It has now been reported that President Obama has issued an Executive Order banning the use of federal money on abortions, as an extra safeguard, so thankfully, this argument is now moot.

Why I Support The Bill

The primary reason that I am in favor of passing this bill, despite the fact that it does not include the most effective cost-saving measures of either a public option or single-payer system, is that the bill enshrines in US law the fundamental concept that health care is a right, not a privilege.  For too long in this country, we have consigned our fellow Americans to suffer from treatable, often preventable illnesses and conditions by claiming that people have the "choice" to buy health insurance if they want it.  Sadly, the reality has never been quite so simple.  Two of the more significant reforms in this bill are those ending the denial of health insurance for those people with pre-existing conditions, and making illegal the use of rescission (where the insurer cancels your health insurance just when you need it most due to a usually dubious claim of "fraud" on your insurance application).  These two revisions alone will help keep far fewer people from going bankrupt due to medical care (click for shocking statistics).  

Consider the fact that if you receive your health insurance through your employer, as the vast majority of Americans do, what will you do if you lose your job?  You will have COBRA coverage for a few months, but generally COBRA is quite expensive, and moreover, it's temporary.  How many of you who are lucky enough to have jobs still are unwilling to leave a job that is no longer satisfying because you are afraid of losing your health insurance?  Is that lack of mobility not an impediment to your freedom?  Does not the health insurance system we have now foreclose upon choices that we would otherwise have if we were assured of health insurance?  Far from reducing our freedom as many opponents of the bill have claimed, this bill will greatly enhance freedom and will enhance job mobility.

For small business owners and entrepreneurs who would like to start out on their own, but are not able to afford exorbitant health insurance costs, this bill provides subsidies for health insurance for their employees.  Whereas the current system has skewed the benefits towards existing companies, and especially towards companies with large employee bases that can be insured under group plans, this bill begins to level the playing field between newer and more-established businesses, and between larger and smaller businesses.  

As a young person, I will be paying for this bill for the rest of my days, and despite that (in fact, because of that) I still support it.  I have faith that the bill will be improved, refined, expanded, and remade in time.  Young people are the linchpins upon which reform depends.  The reason we have coverage mandates in the bill is so that younger, healthier people (who tend not to buy health insurance) will be forced to buy insurance.  Younger people tend to have better health than the not-as-young, and because of that, it is unlikely that a young person will spend as much on health care as they pay in annual premiums.  The idea is that the insurance companies will shift those excess premium dollars (after shaving off a nice profit) to pay for more expensive people's health care, who may have spent more on care than they paid in premiums.  So they need us, which is a reason why the HCR bill has a provision that allows dependent children to be covered under their parents' health insurance plan until they're age 26.  As long as somebody's paying the premiums for their insurance and not costing insurance that much money on care, the insurance companies are happy.

Finally, I support this bill because even if you have insurance and you're happy with it, you already are paying for the uninsured.  In fact, you're paying quite a lot for the uninsured, and it'll only get worse unless something is done.  When a person does not have health insurance and gets sick, they'll probably wait until they're really sick and then go to the emergency room for treatment.  As everyone is surely well aware, emergency room treatment is the most expensive kind, and when patients can't pay the hospitals back for the care they've received, the hospitals then charge insurers more for patients with insurance, which leads to higher premiums for insurance, which more people can't pay, and so they become uninsured...the cycle goes on.  This bill is an attempt to stop that cycle.

It's not perfect by any stretch of the imagination, but this bill is far, far better than the status quo.  For more information, see the two links below, both by the non-partisan Kaiser Family Foundation's Health News:

The Immediate Effects of The Health Reform Bill

A Consumers' Guide to Health Reform

More Highlight Videos from the Health Care Summit

I had said yesterday that President Obama came off well at the summit, and that the health insurance reform bill is actually quite moderate, and here's some video proof of that:



Yes, I'm a policy wonk, but this is a fascinating exchange, and well worth the 7.5 minutes to watch.  Obama explains just how difficult it is to craft reasonable health care regulations, since the government has to be responsive to industry concerns as well as those of individual consumers on what is an extremely personal topic.

Lastly, Speaker Nancy Pelosi courageously and valiantly stood up for the public option and called out Republican lies in regards to whether the reform bills allow for public funding of abortions and Medicare benefit cuts for seniors (neither are in either of the reform bills from the House or Senate.)  There have been egregiously misleading statements made about these bills by the GOP, statements that any person with an internet connection or access to a newspaper could very quickly refute, yet they continue to try to scare the public into opposition.  Bravo to Speaker Pelosi - see her in action below:

The Health Care Summit

So what happened today at the big health-care summit?  Democrats went to great lengths to express the reasonable aspects of their health insurance reform bill in the face of unified Republican derision to any discussion of reform that didn't have the word "tort" appended to the beginning of it (watch Sen. Dick Durbin dismantle the tort reform myth in the video posted below - fascinating).  The health care reform proposal that has emerged from the Obama Administration is actually quite a moderate bill (which includes many individually popular reforms within it) but you sure wouldn't know it from the Republican responses to the proposal.  To sum up in a few words, the Republicans demanded that the Democrats start over with a "clean sheet of paper" (code for "adopt Republican ideas or else") and that they reduce the length of the bill from its current circa 2,500-page length.  When President Obama released a condensed 11-page outline bill earlier this week, however, House Minority Leader John Boehner (R-OH) called that bill "too short."  Republicans also claimed that individuals will be forced to pay higher premiums under the reform bill (the Congressional Budget Office flatly disagrees with this argument.)  Obama just can't win, it seems.

So what's next, given that the philosophical differences that have been apparent for months between the parties are still clear as day after the summit?  Well it appears that Democrats are gearing up to pass the bill with a majority vote (reconciliation is the technical term) without Republican support of any sort.  I say great, let's put this behind us and get on to finding ways to create jobs in this country again.

Here's a compilation of the day's highlights (since I presume nobody had the time to watch all 7.5 hours):

The Upside of Scott Brown's Election...

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...the Democrats in the Senate have finally been freed of having to seek the ever-elusive "60th vote" to pass health care reform.  I had discussed the reconciliation process a few months ago, but it finally seems that Harry Reid is prepared to use a majority vote to pass health care reform, regardless of what the "moderate" Democrats say.  By losing the 60th seat in the Senate, Democrats have been forced to seek other methods to pass legislation than negotiating with their own corporate-owned members (see Ben Nelson, Mary Landrieu, Joe Lieberman, etc.) and this has led directly to using the reconciliation rule.  So this week a major push has been made by a range of Senate Democrats to include a public option in the reconciliation bill, with Senators from Dianne Feinstein (pretty moderate) to Chuck Schumer (former head of the Democratic Senatorial Campaign Committee during the 2006 and 2008 elections, who is widely regarded for his political acumen) signing on to the letter to Majority Leader Reid.  But hold on a minute, isn't the public option a HUGE LOSER among the public?  Don't Americans want less government intervention?  Well, not really, it turns out.  A poll of Nevada voters released yesterday contains some stunning revelations - 56% of Nevada voters favor "the national government offering everyone the choice of buying into a government administered health insurance plan" versus 38% opposed.  Nevada, if you'll remember, was a major battleground state in the 2008 election; after being solidly Republican for many years (with a strong Libertarian, anti-government streak to boot) President Obama prevailed there in the general election, so Nevada's a pretty good bellwether state through which to gauge the national mood.  The poll also has implications for Harry Reid's reelection prospects, as he is not doing too well in polling in his home state, so a strong move to pass Democratic legislation could in fact help his prospects in Nevada.


We will see what happens, and I'll try to be a bit better about posting timely information, as health care reform continues to provide lots of twists and turns to keep track of.

The Bipartisanship Myth

I have noted before that Cenk Uygur of The Young Turks is one of my favorite bloggers out there.  But tonight, reading his latest posting on the Huffington Post, he hit the nail on the head when discussing the Democrats' love for "bipartisanship" in all things, but especially in the health care and financial reform debates:

And the Democrats are perfectly happy to [compromise] because they take the same, if not more, amount of money from those same corporate lobbyists [as the Republicans]. Except they have the meddlesome problem of pretending to be for the people. Republicans are not burdened with this; everyone expects them to help the rich and the powerful. But the Democrats need cover, and they have the perfect excuse in the mantle of bipartisanship. What could they do, the Republicans made them do it! And aren't they so reasonable for compromising?

I highly recommend reading the entire article, as it neatly lays out just how it is the Democrats have managed to accomplish very little of substance despite having the largest margins in decades in the Senate and the House, not to mention the Presidency.  There is a perpetual balancing act among American politicians of between being a good member of one's political party and engaging in electoral self-preservation (often at the expense of one's party).  At the same time, the campaign finance system that is currently in place makes it highly profitable for politicians to kowtow to corporate interests for their own personal gains (in the form of campaign contributions and favorable "issue ads" being run in their districts).  Similarly, the national committees of the two parties also have incentives to keep their corporate sponsors happy, as the corporations will then provide more donations to the parties who will then cultivate and fund the campaigns of more mini-corporatist candidates in elections around the country.  So in this context, the corporate line is the party line is the individual legislator's line - the corporation wins every time, since the corporation's interests are everywhere reflected in our political system.

This truth of government by corporation is nowhere more evident than in the recent Supreme Court decision Citizens United v. Federal Election Commission.  One does not have to look far to find strong reactions to the 5-4 majority ruling and opinion in that case, but the overwhelming consensus is that the Supreme Court has effectively granted US citizenship to corporations, with every faculty intact but the right to cast a vote for a political candidate.  I am rather tired tonight, and not in the best position to discuss the implications of this case fully, but let me say this: corporations exist for no other reason than to make a profit.  That is their sole motivation.  While corporate interests have been donating to politicians (and hence altering their political calculations) for years, Citizens United gives those interests expanded rights to pursue their ends through political channels, rather than through competition in the open marketplace.  This ruling creates incentives for corporations to find the politicians who will do their bidding most effectively, rather than spend more money on R&D to improve their product or service.  The ruling also creates incentives for politicians to be the most effective advocates for their corporate sponsors that they can be, regardless of the effects on the public at large.  The money is, in effect, divorcing us from our elected representatives.  This is nothing particularly new, mind you.  But these activities have never in our country's history been given such explicit sanction by our highest court, and the effects have the potential to be disastrous.

Elections have consequences, and those consequences are often most apparent in the makeup of the Supreme Court, where justices have lifetime appointments.  We need a lot more Sonia Sotomayors to make up for this ruling.

A Reinvigoration

It's been quite a long time since I've posted anything here, due to many factors, not least of which is a new, very intense quarter of studies that began shortly after the New Year.  In that time there have been scads of news stories that are of major interest to me, and potentially to some of my (admittedly few) readers out there.  A few of those stories include the election of Scott Brown to the U.S. Senate in Massachusetts and the subsequent wrench that has been thrown into the White House and Congress' plans to pass health care reform; Paul Volcker's elevation by President Obama through a new drive for financial reform; and the reconfirmation of Ben Bernanke as Federal Reserve Chair.  I hope to cover these other stories, at least in passing, in subsequent posts.

While I have missed the opportunity to comment on those major stories, I thought tonight would be an appropriate time to at least restart this blog in the new year by pointing your attention to a video of President Obama's fascinating Q&A session with the House Republican Caucus at their annual retreat in Baltimore today.  It's unclear how much of this historic and enlightening event the mainstream media will cover in their newscasts, however I can't recommend watching the clip in its entirety enough.  I read somewhere today that the last time a sitting president took questions from members of Congress was in 1974 when President Ford addressed Congress about Nixon's resignation.  This is democracy in action folks, the sharing and debating of ideas.  President Obama absolutely makes mincemeat out of the Republican talking points while at the same time remaining respectful of their ideas.  Beyond that, however, in a few of his answers Obama engages his meta-themes of criticizing sensationalist media coverage and calling for a return to respectful, vigorous discourse between the parties.  He most skillfully demonstrates how to have vigorous yet respectful discourse by systematically dismantling the false assumptions and facts that underlie the questions the Republicans pose to him (including one from Rep. Jeb Hensarling of Texas that claims that Obama's monthly deficits are larger than any of President Bush's annual deficits!  Insane!)  The President calmly yet firmly argues that when Republicans demonize the opposition and make claims that Obama is trying to create a "Fascist" or "Socialist" government, the politicians paint themselves into a very small corner with their constituents, message-wise.  Once they are stuck in that corner, they will not be able to negotiate with the White House very easily, as their constituents will accuse them of having sold-out to the White House.  He's a very deft politician, our President, and that deftness was on full display today.

Between the State of the Union and today, I wonder if we're getting Candidate Obama back?  The fighting, tough-talking candidate who won a landslide election?  Now that we have President Obama, we need him to follow the talking up with doing, but this is a good start, nonetheless.

Another reason to pass the healthcare bill...

Senate Minority Leader Mitch McConnell.  Image via Wikipedia

Is so that the Republicans in the Senate won't block funding for the troops anymore???  Yes, this is truly crazy, but the GOP attempted last Thursday to delay the healthcare bill through filibustering the defense appropriations bill; by holding up the defense bill, that could throw off the carefully crafted schedule Harry Reid put together to pass healthcare before the Christmas recess.  The Senate's parliamentary maneuvers and roadblocks have been on full display during the healthcare debate of late, however, Congressional historians agree that filibustering one non-controversial bill to block a controversial one is rather unprecedented.  Mitch McConnell, Senate Minority Leader, proving once again that principles can always take a backseat to political expediency.

UPDATE: Let's pass healthcare reform

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UPDATE BELOW: I had started a post earlier bemoaning the state of the healthcare reform bill, but over the last few hours I've been reading many persuasive arguments for both killing the Senate bill as it now stands (quick recap: no public option of any sort, mandates for 30 million currently uninsured people to buy coverage, premiums capped at 8% of income...more here courtesy of Sen. Paul Kirk, Ted Kennedy's replacement and former Chief of Staff) and for voting in favor of it.  I'm torn, and here are the two most persuasive arguments pro and con:

In favor of the bill (with great graphics): Igor Volsky.

Against the bill (with a strong and principled argument): Cenk Uygur.

Cenk argues that the public option was the focal point of so much progressive advocacy because it fundamentally alters the rules of the health insurance game, in the sense that health insurers only make a profit through taking your premium payments and finding ways to pay out less in benefits than you pay to them in premiums.  The incentive for insurers, therefore, is to deny care when possible, which is morally repugnant on its face.  The public option would provide an oppositional counterweight to the reigning insurance industry model in the form of health insurance that is not concerned with profit so much as providing the most effective care the most efficient way possible.

It's heartbreaking to have to give up the public option at this point, however the fact is, there will be time to tinker with the bill, and key Democrats are now saying that the public option will be "revisited" legislatively as early as 2010.  After looking at Volsky's graphics and reading about how much money average families and individuals are projected to save on their health insurance, I have to support the bill.  The subsidies to help people pay for the insurance they will now be required to purchase are generous as they currently stand, and if our ultimate goal is to insure more people, then despite the compromises involved, this bill needs to pass.

UPDATE: Here is the most complete and understandable breakdown of how heath care reform will affect the premiums various families of four will pay as of 2016 (once the program if fully phased-in).  Be sure to zoom in on the table embedded in the text - it's quite impressive.  My hope is being restored, little by little...

Money in Washington, or, How the Democrats Became Beholden to Business Interests

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Bill Moyers, who recently announced he will be retiring from weekly television to our collective detriment, shows that his style of intrepid journalism still makes for must-see-TV with his Friday episode of Bill Moyers Journal. Moyers interviews The American Prospect's Robert Kuttner and Rolling Stone's Matt Taibbi on the Obama Administration's various capitulations to the wills of monied interests from health care to financial reform. If you would like a succinct and informative look at how things have gone so wrong so quickly in Obama's still-young Administration, I highly recommend you take half an hour and watch the program. Hat tip to CitizenofEarth on DailyKos for drawing my (and others') attention to this episode.
In the Moyers discussion, Taibbi makes the argument that the Democrats, and especially Rahm Emanuel, Obama's Chief of Staff, have made a business decision to win the fundraising battle with Republicans by appeasing business interests:

And I think, you know, a lot of what the Democrats are doing, they don't make sense if you look at it from an objective point of view, but if you look at it as a business strategy- if you look at the Democratic Party as a business, and their job is basically to raise campaign funds and to stay in power, what they do makes a lot of sense. They have a consistent strategy which involves negotiating a fine line between sentiment on the left and the interests of the industries that they're out there to protect. And they've always, kind of, taken that fork in the road and gone right down the middle of the line. And they're doing that with this health care bill and that's- it's consistent.

In a sense, a connection can be seen between the health insurance industry's business model and the "business model" of modern politics: the only way to make profits is to deny the people who use your services the services that they have rightfully paid for, with that payment being, in this case, insurance premiums, votes, or public opinion. For instance, the insurance industry can use rescission and other nefarious tactics to deny health care to people when they need it most, and politicians (in this case, Obama and his minions) can use soaring rhetoric and populist talk to sell voters an idea of the politician they will get, and then when the rubber meets the road, they will aggresively capitulate to the monied interests who invested so heavily in their campaign over the will of the voters who voted them into office in the first place. The Democrats can only reap the "profits" of continued campaign financing from Big Business if they deny the will of the voters, since the reforms that voters overwhelmingly support will result in reduced profit margins for Big Business. The calculation it comes down to, as Robert Kuttner accurately places it in the Moyers interview, is that campaign donations from business will outweigh the wills of individual voters who will be turned off by a politician's being beholden to monied interests:

Look, there are two ways, if you're the President of the United States sizing up a situation like this that you can try and create reform. One is to say, well, the interest groups are so powerful that the only thing I can do is I can work with them and move the ball a few yards, get some incremental reform, hope it turns into something better. The other way you can do it is to try to rally the people against the special interests and play on the fact that the insurance industry, the drug industry, are not going to win any popularity contests with the American people. And you, as the president, be the champion of the people against the special interests. That's the course that Obama's chosen not to pursue.

It appears that Obama and his team have misread the situation in this country; they do not understand the deep-seated anger towards the companies and the individual CEOs and executives that have brought us to this point of a failing financial system that has brought the world to its knees, combined with a domestic health care system that is responsible for 22,000 deaths per year due to a lack of insurance and many thousands driven into bankruptcy due to catastrophic medical expenses. American voters can see that the decks are stacked against the little guys/gals, but sadly our political class still believes we can be deceived by positive talk and rhetorical spinup . I hope that Obama wakes up to the fact that he is widely being seen as allied with business interests against American interests, or else his presidency will become a failed one when that is the last thing that this country needs.

Obama, Health Care Reform, and Corporate Chicanery: Capitulating the Battle and Losing the War

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So health care reform is virtually over, the chance for progressives to win out and to really cut costs and inject competition into the health insurance market has passed, and the corporations won out again. As noted below, I was despairing earlier today, but after reading Bob Cesca's latest piece at Huffington Post, I feel slightly better. His main point is that, despite being truly, utterly pissed off about how things have transpired in the health care debate, there is too much still at stake to actually "kill the bill." To wit:

Yet I can't help but to believe that killing reform will only heap an even larger failure on top of losing the public option, the Medicare buy-in and so forth. Only this time, it won't be a failure limited to an ideological or political routing. The failure of health care reform will invariably mean at least another decade (if not two decades) of a desperate health care system in crisis. Another decade or two of medical bankruptcies and deaths due to a lack of insurance -- exponential premium hikes and rescissions. You know the list.

If I stop being pissed off long enough to take a good look at what remains in both the Senate and House bills, there aren't necessarily fool-proof solutions to these problems, but there are regulations, subsidies and reforms that will ameliorate a significant chunk of the present crisis. For example, the Senate bill will reduce the cost of insurance for a family of four earning $54,000 from around $19,000 per year to around $9,000 per year.

[snip]

Do progressives really want to tell working-and-middle class families of that they're not allowed to get a $10,000 annual break on their insurance payments? If you're okay with that, I admire and respect your integrity, but I just can't be a part of it. Objective reality dictates that there's no other path at this point but to support the bill and to subsequently endeavor to fix it.

So incremental reforms it is, but at least 30+ million additional Americans will have insurance coverage, despite having to pony up the cash to buy that insurance themselves. Let's hope those subsidies come through, and that they're generous...

But the larger issue here is a sense that our President is selling us out. He could have drawn a line in the sand and fought harder for the public option, rather than pay lip service to it to appease the liberal base. He could have fought for pharmaceutical reimportation from Canada to help save the US taxpayer over $100 billion over the next 10 years, as he had when he was a Senator, however he brought his considerable political weight down on the side of killing that reform effort in order to preserve his backroom deal with the pharmaceutical companies to preserve their profits as long as they did not work to destroy reform. Beyond health care reform, the sense that Barack Obama is not living up to be the President we voted for is also apparent in the "financial reform" efforts I wrote about earlier today, and Cenk Uygur writes passionately about that sense, laying out a concise summary of all that is disappointing about our President thus far. In brief:

But I don't put the civil liberties and the wars in the same equation as the other issues I mentioned. Why? Because it's one thing if I disagree with your policies and principles, if they are genuinely held. Ok, that's a sad day for me but doesn't necessarily indicate that you're wrong or unprincipled (no matter how much I might disagree with you). What I mind is the give-aways to corporate lobbyists that have nothing to do with your principles and have everything to do with politics and money. What I mind is when you sell out the American people to protect corporate America. I hate it when the Republicans do it and pretend to be for the little guy. And I hate it when this administration does it and pretends to be for change.

There was always going to be buyer's remorse when a huge portion of the voting public places their hopes and dreams in one man who must work within the system that is presented to him, however I don't think anyone expected the remorse to be quite this sharp, on so many issues of such great importance to our country. I hold out hope for a change from Obama, but hope is fading fast these days.

UPDATE II: Health Care Reform to be Killed?

Updates below...

Today is a tough day across for liberals.  Whether that is a positive development in you opinion or not, health care reform is something that, if done right, could help so many people in so many ways that any setback in the reform movement should be cause for concern among many. The health care bill in the Senate has been diluted by special interests (read: moneyed interests) and their lackeys in Congress to the point where it appears to be more beneficial to the American people to simply start over with a fresh bill. Howard Dean, one of the foremost experts on health care in American politics today, argues to kill the bill too:

"This is essentially the collapse of health care reform in the United States Senate," Dean said. "Honestly the best thing to do right now is kill the Senate bill, go back to the House, start the reconciliation process, where you only need 51 votes and it would be a much simpler bill."

Ah yes, the specter of reconciliation rears its controversial head again. The main bone of contention amongst liberals is that the cost-saving measures (the public option, for instance) have been either weakened to the point of irrelevancy or stripped out entirely, so that enforcing a universal mandate for Americans to purchase insurance without adequately affordable options beyond private insurance will anger many citizens (and voters). A development on that level could be disastrous for the country's health care system and,in an electoral sense, for the Democrats more generally. The Obama Administration is interested in getting a bill passed, no matter what the cost, to ensure an electoral "win" for the President on his signature domestic initiative, health care reform, but the repercussions of a bad bill getting passed could reverberate for many years. As I had written earlier, if the reform bill falls too heavily on young people's pocketbooks, then you can be sure that their allegiance to Obama's policies will be quite fleeting, and in fact could result in a backlash. Let's hope that cooler heads prevail, and the rush to pass something doesn't overwhelm the desire to enact a more-perfect bill.

UPDATE: Timothy Noah of Slate has a key writeup of what health care reform's failure could mean for the American public, and it's not pretty, as contrary to what many have come to believe (myself included) the reform bill would have effects beyond the uninsured:

A reasonable summary would be: health reform would make life easier for just about every person who needs to buy his or her own health insurance. It would also reassure those of us in the lucky 59 percent who didn't have this problem but could easily imagine acquiring it, especially amid the current economic turmoil. That's just about everybody. Health reform lends, says Hacker, the "security of knowing there's somewhere to get insurance outside of employment." Should it fail to pass, you would not have that security.

As I've mentioned before, it's difficult to put a price on the security that comes with knowing that even if you were to lose your job you would be able to have health insurance at a relatively affordable price (that's what the subsidies are for).  This bill may not be everything liberals want, but this is still farther than the American people have ever come before, and the effect passing it would have would be humongous.  We can tweak it later, once 31 million fewer people are uninsured.

UPDATE II: Okay, now I'm depressed.  Glenn Greenwald of Salon argues that Obama is simply using the intransigence of the Senate, and especially Sen. Joe Lieberman, as a foil to enact the handout to the health insurance industry he always intended.  The argument is that the Democrats will reap the benefits of the healthcare industry's deep pockets for campaign donations down the road if they help out the industry now by not reforming too much.  Sad, sad, sad.  Industry is poised to win again against the needs and desires of average Americans.  Are we entering a new Gilded Age, or have we already been in one for the last decade or more?  More on that theme presently...