Kill the health care bill

Kill the bill.
I don't trust the judgment of very many political people these days, but one person I do trust is Howard Dean. Especially when he agrees with me. For those who'd like to see another side to the argument, here's the most thorough discussion I've seen.

Comments

I'm tempted to say kill the bill

but I've heard it has good things like letting kids stay on their parents insurance longer (I know I went insuranceless through late college and first year out of college while job searching for the first full time job and then waiting through the probationary period), and that it fights pre-existing conditions, and has some other good stuff. I worry though that killing this bill means no bill at all, rather than a minimally helpful bill.

I'm tempted to say try for two bills. Get what we can with this, and then start working on another right away to fix what stills needs to be done which is obviously a lot. I don't know if two bills is feasible or not, but I think it is more feasible than the idea that if we kill everything we've worked on so far that we'll end up with another single bill that gets the public option and a reduced age for medicare buy in.

But I'm going to leave it all at the "I'm tempted to say" rather than actually professing a strong preference for any given option, because frankly I don't know what the best way out of this situation is.

Let's make progress

85% of a loaf is better than no loaf, in this case.

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The measure of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little. - FDR

The endorsement from hell

I agree with you about Dean. He has a point. If they mandate that Americans spend hundreds of dollars a month on insurance many don't want, with the insurance companies still free to set costs and Franken's the medical loss ratio control dead, with pressure on employers to lower benefits to keep them nontaxable, with unintended consequences for SCHIP ( http://crooksandliars.com/susie-madrak/childrens-defense-fund-forcing-schip ), no drug reimportation, and at a cost of $800 billion ... the few remaining perks (like abolishing preexisting conditions - a big one) won't be worth the severe backlash.

If Obama fails to pass a bill, he (and the party) will surely suffer. If he passes a bill like that, won't the Democratic party suffer even more?

At every stage, we have been told "trust us" as the bills got weaker and weaker. We'll hear "trust us" again as it goes to conference, as if someone's going to pull a rabbit out of their hat (behind closed doors).

Mary Landrieu is in favor of passing the Senate bill now that the PO and Medicare expansion is gone. Think now it’s time to kill this thing?

Discuss...

No way

It would be ridiculous to kill the bill. If this bill passes it will be the single most significant domestic policy shift since the Great Society. It would be a huge step forward for the progressive cause, and would improve the lives of millions.

I could list off about a dozen things I think the bill could do better, but three facts remain:

1. It's the best we can do right now
2. It's much, much better than the status quo
3. We most likely will not get this chance again soon.

Exactly

And if I might suggest a fourth fact:

4. After a couple of years of operating under this step of reform, there will be impetus to move forward with more sweeping reforms.

Progress is always incremental, as there is always substantial inertia to overcome. This bill, with all its flaws, will go a long way toward overcoming that inertia.

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The measure of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little. - FDR

I don't see it that way

This bill, with all its flaws, not only won't overcome inertia, it will lock in a failed system for another generation and do absolutely nothing in any way, shape or form to control spiraling healthcare costs.

Calling this "reform" is like calling ketchup a vegetable.

Pass the bill

James,

On cost controls I would recommend Gawande's article: http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande.

The science of controlling costs is not well developed, but the Senate bill does a great deal to experiment and see what works. That is much, much better than doing nothing.

Also, keep in mind that until we get nearly everyone in the system we certainly can't control costs. To use that old philosophy phrase, expanding coverage is necessary, but not sufficient, for controlling costs and building a more coordinated system.

And for NC and other Southern states the Medicaid expansion alone is a huge step. Extending Medicaid to everyone below 133 percent of federal poverty level will immediately cover half of NC's uninsured. It will cover more than 60 percent of the uninsured in Mississippi. It will also end asset tests in Medicaid. That is a sea change.

There will also be an immediate cash infusion into high risk pools, which will be expanded. Many people who can't get insurance right now will get coverage immediately. Also, the insurance industry reforms are critical.

More importantly, I hope that everyone can see that this bill, with all of its flaws, is a big step. Right now, the Health Access Coalition gets contacted every week by people who can't find insurance. We have to tell many of these folks that there's nothing they can do. We live in a country where some people just don't get insurance. We can't do anything except help them find a free clinic.

Right now, for example, if you don't have children and private coverage is too expensive you basically can't get insurance. You don't qualify for Medicaid. There's nothing you can do.

If reform passes then almost all of the low-income people we work with will finally qualify for coverage. People who make a bit too much for Medicaid will get huge subsidies to purchase coverage. I can't tell you how excited I am by the prospect of telling people that they can get insurance. They have options.

That's not everything I would want in a health care bill. It's not even close. But it's sure as hell a lot better than nothing.

I had that article on my desk

Gawande makes a good case for the pilot-program approach, including this:

Almost half of it is devoted to programs that would test various ways to curb costs and increase quality. The bill is a hodgepodge. And it should be.

But that's a technical argument, not a political one. If almost half the Senate bill is pilot programs, is there enough in the rest of bill for average taxpayers to support it? The New Yorker argument is from an agricultural program from a hundred years ago. People today are likely more skeptical of government now and have a much shorter attention span. They want results now. Is there enough in there for a large plurality of people to get behind and to make it worth the money they are being asked to hand over to the insurance companies? (The SCHIP concerns that the Children’s Defense Fund raises about the House bill are not trivial.)

As someone else has argued, maybe this should be two bills. My concern is that people are so invested in passing this one, big bill that like desperate gamblers, they'll keep shoving quarters they don't have into the machine hoping for a big payout.

At this pace, the odds could just keep getting longer. How do we know when it is time to walk away?

I'd read that article already

and am a big proponent of experimentation in general, which is the only piece of the proposed legislation that seems forward-looking in my view.

Thanks for this comment ... you've given me pause.

This is getting out of hand

This whole health care bill debate is getting out of hand on blogs and on TV News networks and on talk radio shows not to mention smack dab right in the middle of downtown U.S. Senate. Any bill passed now will be forever fought over in the halls of our two U.S. legislatures. If passed, it will be the goal of progressives to enhance it year after year using legislative efforts to include in it what they couldn't get initially. And, year after year, conservatives will use those same efforts to take out things they weren't initially happy with. Depending on which party/political philosophy is in the majority, it is going to become a nightmare because of the way it will see neverending change.

For me, I have absolutely ZERO clue what is being considered now. Is the "public option" in or out? Will there be taxpayer funding for women choosing to have abortions? Just what does the "pre-existing condition" clause now say? Has there been a change now to fine people would have to pay if they opt not to be insured? Or, better put, does it still require everyone in the U.S. to secure health insurance in the first place? Just what is being given up? Just what would be left?

And you know what? I don't think many of the Senators outside the loop in formulating this know what this is going to look like if they actually do get the chance to vote on "something". And, what is going to happen once "something" is settled on in the Senate and it goes back to the House, which is part of the process???

I say again. With something this big and so important and so far reaching, why in the world are we not getting it right in the first place rather than just getting "something" done saying "something is better than nothing". That phrase might be correct, but that's a hell of a way to run a railroad, IMO.

Oh, went to the "edit" function: I have one more thing I want to say here. With the vast majority of the people in the U.S. including congresspeople and senators believing there is a great need for Health Care Reform but question HOW we get there, why would it be so terribly awful to put this current effort aside until ALL of the forces in our leadership in D.C. can come together in a TRUE bi-partisan group and hash the things out that are currently so dividing? I agree with the KOS article that had an "open letter" to Obama where the writer said that he believed that with the economy and the huge environmental concerns we have, it would seem that these should be priority one for Obama and for our nation.

Still worth it

Foxtrot,

What I consider the core provisions in the bills have never changed -- there will be health insurance exchanges so that you can compare coverage across companies and get group rates as an individual. You will get subsidies to buy insurance. You will only have to pay a certain percentage of your income to buy health care. In the Senate, there is no more public option.

In the House and Senate insurance companies will not be able to adjust your premiums based on health status. Everyone will be required to purchase insurance, with some exceptions, because the premiums will be heavily subsidized.

The House inserted ridiculous language that prohibits people from using subsidies to purchase insurance policies that cover abortion. That means insurance companies will likely sell stand-alone policies outside of the insurance exchange.

Other than the Stupak amendment the problem is not with what's in the legislation. Basically everything in the legislation is pretty good. The problem is what's not in the legislation. But I don't think that's a reason to oppose the bill. After lobbying on health care issues with no money -- only moral authority -- on our side, I can tell you that there is no area with more powerful special interests. Hospitals can kill any bill they want to kill. Doctors can kill any bill. Insurance and drug companies can kill bills. Medical device makers, pharmacy benefit managers, big businesses -- they can all kill bills. That's why we're not going to get a perfect bill.

But I will say again that right now there are people in North Carolina who can't get insurance. Some of them I am very close to. If this bill passes nearly everyone in North Carolina will be able to get insurance. I would find it very hard to look those people in the face and say, "Sorry, this bill would have expanded insurance to you and your children, but I'm looking for an even better bill. Maybe next time."

Just a question here

Cannot the things listed on this ncpolicywatch page be initiated without a massive bill that (it seems) few people really like in the first place?

You'd think so

but if you're going to pay off Big Insurance with tons of perks and kickbacks, you have to make it look like you did a lot of work.

J

PS You're really gettin' the hang of this linky business!

It's really makes it easier to present things, doesn't it?

Thanks for introducing me to the hyperlink thingy.

And, I'm glad you agree with what I've said here. This whole issue of Health Care for America has gone rotten, in my opinion.

Time to take a step back and look at it reasonably and without all the political hype and without so much dissention. All of this has made us all lose the true importance of Health Care Reform in the first place.

Repeat after me

"Health care reform, health care reform, health care reform, health care reform." If you say it often enough, does that make it real? Here's Kay, looking and sounding like a rubber stamp.

Again

Well, I personally agree with a whole lot of what Sen. Hagan is saying here. But, AGAIN, why should it take some extremely cumbersome program that is looking to cut some questionable/crazy stuff from Medicare to partly fund it be necessary to change some of the more problematic things within our health care system?

Seems to me each of these things that most of we Americans see as needing to be changed can be approached through LEGISLATIVE efforts.

EVERYONE believes that health care in the U.S. needs fixing. I just do not believe that this will happen in the most cost effective or expedient way through some massive program.

Yes, I am changing much of what I believe now. But, after all the foolishness that has been going on with this Health Care Bill, it is time more than just some obscure blogger (like myself) realizes some things that are plainer than the nose on our faces.

2014 - another great reason to kill this bill

Moreover, because subsidies don't kick in until 2014, it's possible that in a nightmare scenario, they could be dramatically cut or even eliminated before seeing the light of day. In the absence of any systemic reform, then, we face the unpleasant possibility that with a realignment of power in Washington, DC, we could end up with a mandate -- and fewer, or even no, subsidies.

Not just possible ... highly likely. It's a safe bet Democrats are going to be punished for their incompetence at the polls in 11 months.

Kill the bill, or at the very least, kill the mandates.

Again again :-)

Foxtrot,

Now it sounds like you are opposing programs in the bill, but most of the complexity in the legislation is warranted. We have a complex health care system.

One of the most important parts of the bill, for example, is establishing an insurance exchange like the one available to federal employees. That's the part on the Policy Watch page about "making premiums affordable."

That's just complicated -- there's no way around it. Setting up all of the cost control experiments is complicated. You could certainly pass each of these measures in separate bills, and each would easily be killed.

I know it just seems straightforward to, for example, expand Medicaid. That's easy enough. But it took years and years of fighting to even slightly expand health insurance to children -- arguably the most politically sympathetic group in our society. So you have to build in other provisions that can gain more support. You certainly don't have to believe me, but a Medicaid expansion would never, ever pass in a stand alone bill.

Again, I don't think there is much bad in the bill. The problem is that they took out several good provisions that would have made it better.

Our option now is to kill the bill and Adam Searing and I will continue to push the General Assembly to expand coverage by a couple of hundred people here or a couple of hundred there. Or we can pass this bill, which is not as good as we want, and immediately cover millions of people in North Carolina who cannot currently get insurance. Seems like an easy choice to me.

Immediately cover?

I'm not sure I see that. Nothing seems imminent ... subsidies don't kick in until 2014 at which point we could very well have a Republican Congress and no subsidies at all.

As someone somewhere wrote, everybody can buy crappy insurance now if they want and can afford it ... this seems to change very little in that regard.

Yes, I see that

I am like so many right now in that I just see there being so much confusion on all those complexities you refer to and what needs to be done to resolve all of it.

I WANT those that cannot get health insurance through no fault of their own to be able to obtain it. Sometimes I present myself here in ways that seem to be wishy-washy on issues, but make no mistake about my stance on this one. I am a supporter of health care reform not only for NC but for our entire country.

I am just getting sick and tired of all the politics being played that impairs the true direction we should be heading in with regard to this.

All I am saying is that perhaps there are other ways to accomplish that goal than what we're seeing currently. What I see right now is what "side" can win rather than actually accomplishing meaningful improvements in our health care system for the betterment of everyone in our state and country.

"Not as good as we want" is NOT good enough for me. That's all I'm saying. I see our leaders being better than that. Oh, and yeah, I do wonder a bit about the proposed cuts in Medicare to pay for what is being presented. Hey, if you're looking for someone here that just gives a great big OKAY to everything presented by the democrats, well, you're looking in the wrong place. We have to question things. If I can see where cuts in Medicare as proposed will not in any way take away from our senior citizens and are a justified way of creating dollars to fund this "program", then I will accept it and no longer question it. All of us will be 65 at some point in time. It is something we need to be sure is a correct move, don't you think?

Informative; frustrating; best of bad options

The link to NC Policy Watch and the comments of AdamL laying out positive content in the Senate bill even sans the public option or Medicare extension were informative to me. I have focused principally on the value of the public option and the private insurance nondiscrimination mandates and neglected some of the other points (especially Medicaid expansion).

I am inclined to conclude that there is substantial value to the legislation even without the public option included.

Having said that, I would personally vote to kill it in a New York minute if I believed that doing so would enhance our chances of getting a bill passed next year with the public option included. I don't. Here's why: Nearly every Republican Senator is plainly lacking either an operating conscience or a lick of common sense (or both) on the question of access to health care by low-income workers and their families. Add to that the handful of Democratic/independent "moderates" in the Senate for whom the same statement apparently can be made. As the topper, most of the balance of the Democrats there are absolutely unwilling to take the "nuclear option" of canning the filibuster altogether.

As we get closer to the mid-term elections, the timid in Congress will only grow more timid. They will never be convinced that their only hope for survival lies in effective action on matters like health care reform. The current near-paralysis of the Senate will deepen and harden into total paralysis.

So, no action next year. And James, I think your fear of a possible Republican resurgence in Congress is well-taken. Historically, it is even likely, regardless of the performance of the party holding the presidency. Meaning, no action during 2011-12.

By killing all health care reforms of significance at this time, do we improve the chances of a revolution at the polls in either 2010 or 2012 that will sweep in a progressive landslide to Congress, paving the way for the single-payer system?

I apologize to my friends for whom such hopes spring eternal, but I have a hard time even posing that question without breaking into laughter.

I have been arguing vehemently that "health care reform" without a public option to keep/make the big insurance companies (relatively more) honest is not truly "reform". Without it, private premiums will continue to climb at an intolerable pace. I still hold that conclusion. I will not give up pressing to add a public option in some strong form, regardless of whether the other provisions in this year's package are adopted.

Will killing those other provisions now make the pursuit of available public insurance coverage for everyone easier or faster? Sadly, no. Not in the real political world in which we have to live and work. We are not a utopia of democracy and never will be. We're more of a muddle-through kind of democracy, when we're lucky.

So is 30% of a loaf and another screaming frustration better than nothing now and nothing for the next four to eight years (except the same or worse screaming frustration)? Sigh. Yes.

Dan Besse

I do not know

"Getting some of what we want"

"Part of a loaf is better than no loaf"

"Best of bad options"

I do not know, everyone. Is this REALLY what we should be doing here?

I know, I'll probably catch the devil for saying that, but....just saying.

Yes

It sucks, but yeah that is what we should be doing here. There's 535 members of Congress, each of whom gets vote. There are literally hundreds of interests groups and industry lobbyists. Add all these voices together, and no one is going to get what they want. It's a miracle that the most important elements of the bill (subsidies and exchange) have survived.

Don't get me wrong

I like the debates that take place on BlueNC. I wouldn't want Foxtrot or anyone else to accept the Dem position without question -- I certainly don't. That's what makes BlueNC and Progressive Pulse more interesting to read than blogs that shun debate or don't accept comments at all.

See: http://www.johnlocke.org/lockerroom/

James, there is an immediate infusion to greatly expand the NC high risk pool, which will help in the near term. Once reform passes it will be important to explain the subsidies and how much they will help. But Republicans have steered pretty far away from criticizing the subsidies b/c they are popular. I think the individual mandate, which I also support, would get killed faster than premium assistance programs.

Foxtrot, here's why I support the Medicare changes. As you may know there is an organization called MedPAC that advises Congress on what payment changes should be made to Medicare. It makes these recommendations after huge amounts of analysis. I find the MedPAC reports incredibly helpful for understanding how our health care system works. MedPAC usually makes great and interesting suggestions for how to improve quality and save money in Medicare.

Then the MedPAC recommendations hit a wall of lobbyists in Congress. Let's say you are a company that makes MRI machines, and you start producing an MRI machine that also makes coffee. Of course, this machine is twice as expensive as a regular MRI machine b/c it makes coffee. The wealthiest hospitals buy this new MRI machine b/c then they can attract wealthy patients by advertising that it has cutting edge technology.

Then along comes MedPAC. MedPAC studies the issue and says that Medicare shouldn't be paying anymore for the MRI machine with a coffee maker than it would for a traditional MRI, b/c the coffee maker isn't improving care and it's only driving up costs to our health system.

Well, you then deploy hundreds of lobbyists to explain to Congress why Medicare should pay twice as much for the MRI machine with a coffee maker b/c it's neat and makes great coffee and it's manufactured in a bunch of Congressional districts. So Congress overrules MedPAC and pays twice as much.

We could go through each of the Medicare changes in the health reform legislation but they are all things that have been recommended for years and years by MedPAC as ways to improve patient care and cut costs. They are changes that lobbyists have been overriding for years and years. Of course, hospitals and medical device makers and other stakeholders are screaming that if you don't pay for the coffee machine then it's a benefit cut. But the truth is people will still get the MRI.

I hope that explanation helps. I believe strongly in Medicare. I would like to expand it to everyone over 50. I've looked at the cuts pretty closely and I've read the relevant MedPAC reports. I think the Medicare changes are necessary and long overdue. But that's just my opinion.

One thing we agree on AdamL

I love the proposal to bring people over 50 into the Medicare system. I have a number of friends/family that are on Medicare and to the person, they like what they have. Yes, I know it is a huge unfunded liability but IMO, that would be lessened by including more into the system knowing they will contribute. And, the 50 - 60 bunch most certainly would be a far less drain on expenditures than those older which could/would strengthen Medicare.

What I am suspect about is in cutting Medicare. What is involved in that? Can we trust our government to suddenly rid Medicare of the graft and corruption and abuses we've seen so much in the past (as is being suggested as a way to cut Medicare costs).

It is a legitimate concern. I am thinking you understand that.

I understand

Medicare has underspent on rooting out fraud for many years. Basically it was a way to keep overhead extremely low. So health reform increases funding for fraud detection, which the CBO and other analysts think will save money over the next ten years. That's overdue.

But most of the savings don't come from spending on fraud detection. One big chunk comes from reducing Medicare Advantage payments, as was always supposed to happen after MA was created. Insurance companies were supposed to deliver enhanced benefits at the same price as Medicare. The companies were paid extra to ramp up administration and marketing so that the program could get rolling. (I'm being charitable here.) Now it's time to end the extra payments and see which companies can provide enhanced benefits at the same price as Medicare.

Another chunk of Medicare savings come from efficiency updates to hospitals and other institutional health care providers. As MedPAC has pointed out, Medicare should exert more pressure on hospitals to improve efficiency. Hospitals with more financial pressure tend to deliver better care at lower cots. So reform aims to apply a little pressure and see if we can improve care at all hospitals.

Post-bill Narrative is More Important

Regardless of how this comes out of Congress--win, lose, or draw--the narrative that Democrats, especially progressive Democrats put around the accomplishment determines the future of healthcare reform more than the contents of the bill. And that narrative has to be framed to make healthcare a wedge issue in the 2010 campaign to increase the number of progressive Democrats in Congress.

If it is the Insurance Bailout and Middle Class Indenture Bill of 2010, we need to call out what it is and say that was all we could get through Congress, given the way Congress had been bought. And Republicans do not get a pass for not voting for the bill.

If it is the House bill, then we can push to strengthen the public option and move toward even tighter cost controls.

If the bill is killed of its own weight, we point out the influence of the healthcare industry in that failure and exactly who were the strategic members of Congress responsible for it -- Mike Ross, Heath Shuler, Max Baucus, Joe Lieberman, Mary Landrieu, Blanche Lincoln, and so on.

And we should be adamant that any changes not involve deals with the healthcare industry.

All of which is to say, it has become apparent that the bill will not be what the American people want. It will be what Congress delivers, if at all. All us voters are now irrelevant to the process; it's all the horsetrading in Congress. So we should focus on how to recover from this foul-up.

50 states, 210 media market, 435 Congressional Districts, 3080 counties, 192,480 precincts

Pass HCR!

Not much to add that others have not done a better job of doing. Let's get HCR passed and feel proud about it. No it is not everything we want, but nether was Social Security or Medicare when it was first passed. If this effort fails, based on past history it will more that a decade before it is brought up again, and it will be weaker than what we have now.

Kevin Drum and Ezra Klein explains better that I can on why killing the bill is a very bad idea.

You are probably right cutter

You make a good point saying that even though the current HCR bill in the Senate does not include many things that many want, it will either pass now (and then, of course, get approved by the House and then signed by the president)or it is very likely it will go the way of HCR efforts in the past.

I think there are so many critical parts of this bill that are being overlooked because of just a few specific issues that most likely will never be settled.

It looks like the only way this thing is going to get done is for the senators to get a bill that includes the critical parts that the vast majority agree upon and live to fight the battles on the few specific issues another day. There are great parts to this bill that will help our country get started in initiating health care reform (and let us not forget this thing is not even scheduled to go into effect until what, 2013?) and that the Senators will approve almost unanimously.

It has to start somewhere. Maybe, just maybe, a massive bill is the wrong way to go here. Maybe it should be done incrementally.

I am like most people that favor getting a health care bill in place watching/reading how this effort is going downhill fast. Maybe some egos are going to have to be bruised. It is becoming a political debacle, in my opinion.

I don't see it

Because the Senate subsidies aren't generous enough we should maintain a system with no subsidies?

In the current system people not only don't have money left over after a medical catastrophe, they are left with a pile of debt, foreclosures, and bankruptcy.

http://www.youtube.com/adamsearing#p/u/27/JXpW8g6d4QA