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National

Harry Reid the Insomniac

“Senator” Reid must suffer from insomnia to schedule a vote at 1:00 AM on a Monday to torture his fellow members of the Senate as they vote on a bill to torture their constituents throughout America. That is how Harry Reid fits the definition of “insomniac” as a noun.

The definition of “insomniac” as an adjective also fits because his actions will cause a lot of sleepless nights among people who previously believed they had some freedoms left in this country. Even more dangerously, every lawyer and CEO in the health care industry will undoubtedly suffer from insomnia as they try to figure out how to profit from the 2700 page bill that has not even been released online yet as far as I can find (I can only see the “original” 2074 page version of the bill).

I understand the urgency of meeting an artificial deadline on Christmas day for a bill that won’t take effect for another 4 years but I wonder why this could not have waited another 6 or 8 hours until a decent time for a vote. I’m always distrustful of a fast moving legislative body but more than any other rushed vote this move is reminiscent of some other midnight political proceedings that were driven by a desire for power.

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National

GOP Sheep with No Shepherd

Yet Another Fire Dog Lake post led me to this Progressive Change Campaign Committee poll. My interest in the poll focused on the results of two questions:

Would you favor or oppose a health care bill that does NOT include a public health insurance option and does NOT expand Medicare, but DOES require all Americans to get health insurance?

and

Would you favor or oppose a health care bill that does NOT include a public health insurance option and does NOT expand Medicare and does NOT require all Americans to buy health insurance — but DOES provide significant subsidies to low- and middle-income families to help them buy insurance?

I was specifically interested to compare the Republican responses to these two questions. The first question offers essentially what the health care bill has been boiling down to – a mandate with no public option or alternative. The second offers no mandate, no public option or alternative, but offers subsidies for those who cannot afford insurance. Republican leaders have been fighting against the first option openly without really talking about the second possibility. The results in the republican response are interesting. Those opposed to either option were virtually identical (61% and 60% respectively). Those who were undecided nearly doubled from the first question to the second because they had not been told what to think, had never considered the possibility themselves, and could not think on their feet. Because of that, the number who favored the first question – which is clearly the worst of the two – was 5 points higher than those who favored the second.

This party needs shepherds who know where to lead rather than goats who know only to oppose.

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National

No Public Option, No Mandate

Over at Fire Dog Lake, Jon Walker challenges those with the “we can fix it later” mentality (which may or may not include enough senators to pass this bill) to hold the individual mandate out of the bill as a hostage to ensure that Congress will have leverage to come back and replace all the things they have compromised away in this bill already.

Progressives should make the rallying cry of “no public option, no mandate” an unmovable demand, now and in the future. Progressives in Congress should refuse to support the individual mandate until it is accompanied by the government guarantee of a decent, cost-effective public health insurance option.

To me that sounds like killing two birds with one stone – we could get a bill without a public option as the Republicans have worked so hard to remove already and we could get a bill without an individual mandate which is the most serious infraction contained in the bill (more serious than the public option ever was).

I would be perfectly content, if the bill passes now without either of those provisions, to never come back and “fix the bill” (at least the way he is thinking of it). But I’d rather gain a temporary victory against the individual mandate and have to come fight against it again in the future, than have the individual mandate pass and face the prospect of having to try and reverse it later.

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National

Howard Dean is Right

Few people would predict that I would agree with Howard Dean as often as I do, fewer still should be at all surprised that I agree with him when he says of the Health Care Bill:

This is essentially the collapse of health care reform in the United States Senate. Honestly, the best thing to do right now is kill the Senate bill.

Then again, I also agree with President Obama when he said:

the federal government “will go bankrupt” if Congress does not pass a health care bill

Of course we begin to disagree from there because I’m confident that we will go bankrupt at least as fast with his health care bill (any version of it) as we will if we do nothing. We need reform, but we don’t need this reform. Once again I agree with Howard Dean’s take on the cost issue:

He said he also doesn’t see cost-control measures but, rather “a whole bunch of bureaucracies and a lot of promises.”

While we disagree with what health care reform this nation needs I was dismayed by the truth pointed out by Chris Cillizza as he explained why he feels confident that despite all the wrangling, Congress will pass a health reform bill:

The broad strategy adopted by the White House toward health care is based on a single fundamental belief: coming out of this extended fight with nothing to show for it amounts to a political disaster not just for the President but for congressional Democrats as well.

“It’s a huge problem if nothing gets passed,” said one senior Democratic strategist. “Huge.”

Howard Dean is right about the dangers of that strategy:

We’ve gotten to this stage … in Washington where passing any bill is a victory, and that’s the problem. Decisions are being about the long-term future of this country for short-term political reasons, and that’s never a good sign.

I even agree with Howard Dean that there are some good elements in the current Health Care Reform bill. At least, I agree with him if Section 9002 is still in the bill. (As an aside, when did they return to the term “health care reform” from the more accurate “health insurance reform” that they had begun using earlier this year?)

I still contend that the only proper way forward on health care reform (and the only possible way forward when debate over this bill finally ends – regardless of the outcome) is to stop trying for some sweeping omnibus overhaul bill and pass individual pieces of legislation to take baby steps forward. If this bill passes the very first baby step forward will have to be the repeal of the individual mandate.

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General

Your Employer: Competitor or Collaborator?


photo credit: Trypode

This question is framed in terms of employer sponsored health care benefits, but it really applies to any employer/employee interaction. Are you working with your employer, or are you competing with your employer? To put it another way, is your employer working with you, or simply working you?

I ask this because in the health care debate there are two groups of people who have opposing views on this. One group argues that employer sponsored health care as the dominant source of health insurance coverage is destructive because it distorts the health insurance market by locking people into few if any options for insurance and locks them out of the economic decisions about what plans they want. They also argue that everything your employer spends sponsoring health care coverage is money out of the employees paycheck. The other group argues that employer sponsored health care is a good thing because that is the only way most people can afford coverage and if the employer were to drop coverage the money they save would not go back into paychecks, but would simply pad their bottom line.

The second group obviously views the employer and employee as competitors. These are the people who favor unions because the employee’s need to band together in order to stand up to their employers. This adversarial relationship dampens production and hampers progress. Before anyone gets too upset with this analysis let me just say that there have been situations where unions were necessary but they are no panacea.

Let me explain why I think the first perspective is more accurate based on my own experience.

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General

The Health Care Issue as a Catalyst for Debate


photo credit: the queen of subtle

When I saw that Jim DeMint had written an article titled Our Health Care Mess Is a Symptom of a Much Bigger Problem my interest was piqued partly because I like DeMint as a senator and partly because I had just been saying the same thing in a series of comments with a reader from New York. It was exactly as DeMint predicted in his final paragraph:

The current debate over health care reform is a symptom of a bigger problem in Washington. But it can be the catalyst for a wider debate about the proper role of government in our lives.

The comments I was receiving demonstrated exactly what DeMint was talking about when he said:

All of these things have happened because we’ve stopped asking, “Should government attempt to solve this problem?” Instead, we start by asking, “How should government fix the problem?” It’s now considered a sign of admirable restraint to occasionally ask, “How much should we spend?” And somehow we started thinking that anything less than a trillion dollars is a bargain. (emphasis mine)

We can’t expect to come up with the right answer when we start by asking the wrong question. For too long we have been asking only how the government should fix our problems and not if the government has any business fixing those problems. Obviously there are some problems that the government should fix, but there are many that it should not address.

Because er have been asking ourselves the wrong question we find ourselves as a nation in this situation:

There’s not a word in the Constitution about the government deciding what medical tests private health insurers should pay for. Nothing about the government deciding how much executives on Wall Street should earn, or what kind of light bulbs and cars we should buy. There’s nothing about the thousands of parochial earmarks that fund local bridges to nowhere, golf courses, bike paths, sewer plants, and tea pot museums.

There’s nothing about these or many other things in the Constitution because they have nothing to do with the proper role of a federal government in a free society. But these are exactly the kinds of things our government spends its time and money on, and we don’t even question anymore why that is.

As the length of that list indicates we have had many opportunities to ask the right question. Hopefully health care will be the issue where we finally step back and ask the right question. Once we ask the right question we will begin to understand the truth that:

It matters because every time we give a job to the government, we take away some control that people have over their lives, and we take away a little bit more of their freedom. In return for letting government try its hand at solving a problem, we as citizens cede our ability to try for ourselves to find a better way.

It’s awkward to admit it, but my colleagues in Congress have led this country into the woods despite our oath of office. We swore to protect and defend the Constitution of the United States and to bear true faith and allegiance to it. The Constitution prescribes a very limited role for the federal government. There is not a word in our oath, or in the Constitution, about most of what we do. As we’ve wandered off the path of liberty, there are few crumbs left of the Constitution in the halls of Congress to lead us out of the woods. (emphasis mine)

If we honestly ask the right question we will undoubtedly reach some uncomfortable conclusions such as the fact that the government has already overstepped its bounds with things we would rather not alter, like Social Security and Medicaid/Medicare, but if we continue to shut our eyes to that primary question there will be no way to reverse our downward spiral, the best we could ever manage to do is quit digging the hole deeper.

Categories
culture National

Medical Cultures

[quote]I have called David Goldhill’s How American Health Care Killed My Father a must-read for anyone who wants to speak up in the health care debate. The New Yorker also has a must-read article on the issue called The Cost Conundrum. In that article we are introduced to the town of McAllen, Texas where Medicare spends much higher than average amounts per capita than the national average ($15000 vs $8000) in an area with much lower than average per capita income($12000 vs $21500) and cost of living. Atul Gawande, himself an associate professor of surgery at Harvard Medical School, introduces us to the town and begins an attempt to discover why the costs of health care are so high in McAllen.

Are the people there less healthy? No, they have higher rates of some health conditions than average and lower rates than average of other conditions. Overall health fails to explain the cost differential.

Was the quality of health care being provided higher than average? While they were not lacking for available medical technology or facilities the quality of care was, once again, nothing unusual.

McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.

Gawande went to dinner with some McAllen doctors and showed them the data on health care costs in McAllen:

Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.

He then asked them why they thought the care was so costly there. One suggested the cost of malpractice insurance but then they admitted that since Texas had passed caps on malpractice lawsuits they had virtually no lawsuits to drive up the cost of care.

Finally a general surgeon among the dinner party declared that the issue in McAllen was overutilization.

Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. “But young doctors don’t think anymore,” the family physician said.

Anecdotal evidence and agreement is fine, but Gawande went in search of more concrete evidence.

To determine whether overuse of medical care was really the problem in McAllen, I turned to Jonathan Skinner, an economist at Dartmouth’s Institute for Health Policy and Clinical Practice . . . I also turned to two private firms—D2Hawkeye, an independent company, and Ingenix, UnitedHealthcare’s data-analysis company—to analyze commercial insurance data for McAllen. The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.

Having identified the cause of the high costs the search was on for an explanation of why there was so much overutilization. The answer was in the culture of the medical practitioners in McAllen – they were very profit oriented rather than results oriented. I believe the one place that Gawande’s article falls short is that he stopped with exploring the cultures among the medical community and failed to examine whether the general community culture in McAllen helped to foster that inefficient mindset among the medical practitioners in the area. I’m willing to bet that such a short-sighted culture in the medical community might not need encouragement from the local culture, but could not survive if the local culture were one that actively discouraged a similar outlook in the community at large.

Talking to a surgeon from McAllen, Gawande concludes that whether we have a public option, single payer, or private health insurance will not matter if the culture in McAllen continues to become more common as it has been doing.

In contrast to McAllen, Gawande explores the cultures in the Mayo Clinic and the Medical community of Grand Junction, Colorado and finds that both of these low-cost, high-quality health care systems took very different approaches to each arrive at “accountable-care {organizations} . . . {where} leading doctors and the hospital system adopted measures to blunt harmful financial incentives  {and} took collective responsibility for improving the sum total of patient care.” He also lists four other high-quality low-cost health care systems each of which has a culture of accountable care – the Geisinger Health System, the Marshfield Clinic, Intermountain Healthcare, and Kaiser Permanente.

Whatever approach Congress tries to take to reform our health care system they and the American people need to understand that we cannot successfully plant a Health Care tree. The only workable approach will be to plant Health Care seed and help it to grow into a health new health care system.

Categories
General

2074 Pages of Loopholes

With Thanksgiving weekend behind us all politically interested people can look forward to the Senate opening work on the healthcare bill. According to Senate Majority Leader Harry Reid:

. . . senators {will} work on weekends if necessary to hammer out compromises on thorny issues like a government-run insurance plan, abortion coverage and holding down costs.

“The next few weeks will tell us a lot about whether senators are more committed to solving problems or creating them,” Reid said.

I make no pretense that I have abandoned my day job and any semblance of a life to read through the entire 2074 pages of H.R. 3590 but I have read through the entire 13 page index of the bill and looked up a number of sections that either looked interesting or concerning to me. Of course my first question is how will this affect my health insurance situation (that may give some insight into the 12 sections I reviewed). The real question in this debate is whether there will be anyone who takes the time in the coming weeks (according to the story linked above we may expect up to 3 weeks of debate) to read the entire bill and break down what it actually means for consumers and the nation – going beyond the party-line soundbites that we will no doubt be subjected to constantly through the media for as long as the debate lasts.

After reading through my chosen sections I found seven that were interesting enough for me to write about them. (For anyone who is curious, there are approximately 350 sections to the bill – 50 times what I am doing today.) I will review them in the order they appear in the bill.

Categories
culture National

The Dangers of a Crisis Mentality


photo credit: paparutzi

Soon after the election last year in the Wall Street Journal, Gerald Seib wrote about the  opportunity presented by the financial crisis for Barack Obama. Perhaps he was simply reacting to Rahm Emanuel’s statement that, “you never want a serious crisis to go to waste.” Seib summed up that perspective on crisis by saying that:

The thing about a crisis is that it creates a sense of urgency. Actions that once appeared optional suddenly seem essential.

That really captures the essence of a crisis mentality. Unfortunately it only looks at the silver lining while ignoring the cloud in front of it. The assumption is that we all can see the dangers of the crisis cloud. Unfortunately the only part of the crisis cloud that most people see is the front side – the possibility with any crisis that we will fail. The problem is that right in front of the silver lining he spoke of there is the hidden backside of the crisis cloud which we conveniently forget.

Because of the sense of urgency that tends to accompany a crisis we not only begin to view once optional courses of action as essential, in many cases we go beyond that and begin to view once forbidden courses of action as excusable.

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National

Half-Truths from the White House

I am not naive enough to expect more than a half truth from a political leader anymore but I am still naive enough to do what little I can to expose the half of what they say that is false. The White House blog sets out to expose the Republican Leaders’ Plan to “Delay, Define, and Derail” health care legislation. Their closing statement is the classic half truth:

. . . while we remain committed to working with those in both parties who have good-faith proposals about how to strengthen the final reform bill, we will not stand idly by in the face of false accusations aimed to score political points or maintain the status quo at all costs.

They toss around the “false accusations” claim within eye-shot of publishing some false accusations of their own. For example, in that very statement they imply that  Republicans have offered no good-faith proposals. That’s not the first time they make that claim in their post. Earlier they said:

Republican leaders will resort to the time-honored tactic of attempting to stall reform to death – raising arbitrary and disingenuous hurdles under the guise of wanting further debate, when in reality they have no intention of offering constructive proposals.

Every time they make the claim that Republican’s have offered no constructive proposals voters need to recognize that only two types of administrations could make that claim right now. Either the administration is lying through their teeth (the more likely of the two) or else they are genuinely unaware of the good faith proposals that Republicans have offered such as HR 3400, which Democrats in control of Congress are not even willing to debate. Either kind of administration (dishonest or ignorant) is extremely dangerous to our nation. If they are dishonest they must be stopped. If they are ignorant they must become informed. I’m willing to work on both routes until I can prove which kind of administration we have.

Another half truth offered by the White House in that post is to reassert the claim (by using the CBO) that their bill will lower the deficit.

Republican leaders intend to repeat their claims that reform “will raise insurance premiums on individuals and families, while failing to lower the overall amount of money that the U.S. spends on health care… even though the nonpartisan CBO predicted the [Senate Finance Committee] bill would reduce the deficit and lower the cost curve, even as it extends coverage to millions of uninsured Americans.”

It has already been shown by history that the CBO estimate is based on the shakiest footing imaginable because it depends on Congress doing what it has never done before – cutting medicare spending. Until democratic leaders can show how they will actually fulfill the mythical fiscal promises in the bill that make that CBO estimate possible there’s no reasons to believe them over the Republicans. No matter who is proposing a bill there is no reason to pass it so long as there are significant unanswered questions about how it will actually work.

The Democrats are proposing bills that will not take effect for years and which depend on premises that are not dependable and then they wonder why people are hopping off their “Hope and Change” train.