Holiday From History

People often say “politics is a contact sport”. That’s true as far as it goes. Politics is zero sum game: someone wins and someone else loses. But the uglier part of politics is the morally repaginate things one has to do in order to do the right thing. Take for example Social Security:

No self-respecting liberal today would support Franklin Roosevelt’s original Social Security Act. It excluded agricultural workers — a huge part of the economy in 1935, and one in which Latinos have traditionally worked. It excluded domestic workers, which included countless African Americans and immigrants. It did not cover the self-employed, or state and local government employees, or railroad employees, or federal employees or employees of nonprofits. It didn’t even cover the clergy. FDR’s Social Security Act did not have benefits for dependents or survivors. It did not have a cost-of-living increase. If you became disabled and couldn’t work, you got nothing from Social Security.

Today, all of that has changed, Social Security is the bedrock of the American welfare state. It affords Americans who have worked hard all their lives, the opportunity to live comfortably. But in order to get Social Security passed, FDR made concessions that were morally wrong. Or were they? Was it okay for FDR to sign New Deal legislation that excluded African Americans? Should we take the view that he did the best he could within the constrains of the politics of his time? And if so, is that the marker of a just action?

All this comes to mind after reading a masterful account by Jane Hamsher of how the Obama administration has systemically cut deals with the for-profit medical industry in order to get health reform passed. It’s so good I’m going to paste a chunk of it here:

On May 11, “stakeholders” including the AMA, PhRMA, the hospitals and the device manufacturers delivered proposals to the White House promising to “voluntarily” reduce cost increases over the next 10 years. In an effort to keep them “at the table,” Baucus’s Chief of Staff Jon Selib and Finance Committee staffer Russell Sullivan told stakeholders at a May 20 meeting that their participation in the process of crafting a health care bill was contingent on them “holding their fire”

The goal of keeping stakeholders at the table was threefold:

1. Keep them from advertising against the White House plan
2. Keep them from torpedoing vulnerable Democrats in 2010 so there isn’t a repeat of 1994
3. Keep their money out of GOP coffers

You can see the fingerprints in the deals that they made: the $150 million PhRMA was spending on ads for health care reform, the $2.5 million they spent helping vulnerable freshmen…[The] primary objective would be to keep anyone from funding a GOP ascendancy

You should really read the whole thing to get an idea of the back room deals the White House has made in order to achieve two key political goals: 1) Keeping the for profit medical industry from using their wads of cash resources to defeat reform b) stopping these same industries from handing money to Republicans during the next election cycle. It’s really quite ugly stuff, and President Obama is responsible for it. In addition, the President has made deals with the pharmaceutical lobbyist he repeatedly denounced, going as far supporting the removal of cost controls on the pharmaceutical industry from legislation.

But then you read things like Families USA’s 10 Reasons to Support Health Care Reform and see what a significant step in the right direction the President’s proposal would be. Make no mistake, if Obama is successful in getting reform through Congress, the lives of millions of Americans would be improved. Sick people would no longer be told they couldn’t get insurance because they had a preexisting condition, and in turn go bankrupt in an effort to save their life. Insurers could no longer dump people from coverage plans once they became too ill and too costly. Small business firms would be able to provide their employees with health insurance.

But at what cost? Is the White House wrong for cutting these deals? It’s easy to conclude yes, but we can just as easily imagine a world in which the these deals weren’t struck. We can imagine a world in which the insurance industry pours its resources into defeating reform. We can imagine a financially rejuvenated Republican Party taking back the House and Senate in 2012. But mostly we don’t need our imaginations, because thats what happened in 1994. Moreover, we live in a world where reform may not happen despite the fact that the President has made these concessions. In light of this, what can we conclude about these arrangements?

I mean this not as a defense of the President, but only to point the complexity and ugliness inherent in the political process. The flip side of the question “At what moral cost?” is “What would you be willing to do provide every American health care?” Politics is much more than a contact sport, it is a case study ethics and morality. It leave me wondering where should our politics intercede with our morality?

In order to get back in the saddle with this blogging thing, I kindly asked some of my friends to throw me questions about health reform and politics more generally. Thanks to everyone that sent in a question. You had my love and appreciation before, now I have no choice but to double down on that love. So here we go:

#1) How will health reform affect me?/In Layman terms describe the proposed plan? (Wuta O, Autumn K)

Before my explantion, I should first say that a picture is worth a thousand words:

The chart explains what would happen should the Obama’s plan make it through Congress. I should start by saying it’s hard to explain health reform in general, so if I’m not clear please let me. The basic goals of the plan are to a) ensure that every American has affordable health insurance b) reduce costs long term costs c) stop insurance companies from doing really mean things to people. Here is how that works:

A)  If you have insurance through your employer(which most Americans do) nothing really changes for you. The only thing that the plan does do to is give more protections from insurers. This mean that your insurance company can longer revoke your insurance because you got sick, deny you coverage based a preexistent condition(say if you had diabetes prior to getting your job). There are other important things provisions, such as caps on out of pocket expenses(how much of your income would you have to spend before you got help from the government), but basically those of us who already have insurance will gain increased protections from insurers and the knowledge that if things go wrong you won’t be bankrupted by medical costs and will be able to good coverage in some how.

B) This is the most perhaps the most important part of health reform. The proposed reform would create a Health Insurance Exchange(s). Think of this as health insurance super market. Right now, most folks don’t choose what insurance company they get. You basically get the insurer that your employer provides. The creation of Exchanges gives consumers choice who they sign up with. Like at the super market, you will be able to “shop around” i.e. compare prices, and pick the plan that best suits your needs. One of the insurance plans in the Exchange  may be government run insurer aka the Public Option*.

The creation of the Exchange(s) is a very good thing. They will be regulated by the government so people don’t screwed over and there will be required minimum amount of coverage that insurance plans have to offer.

But there is a catch. Only people who DO NOT currently receive insurance through their employer– think the self employed, small business owners, and people whose jobs don’t provide health insurance– will be able to go shopping in at the Exchange. So all of the Public Option goodness that may or may not exist, most of us will not be able to part in!

C) The government will help people who cannot afford to buy insurance get insurance. More people will have access to Medicaid.

That there folks, is ALL that is being proposed. And as simple as these reforms may seem, they would make huge difference in the lives of millions of Americans. There is more I could say about how the plan seeks to bring down long term health care costs, and the mechanisms it would put in place to ensure that we get to universality, but you didn’t ask! But that’s VERY important because health care cost are going EAT the country alive if we don’t pass reform.

#2) How can Obama get all the Democrats on board? And why aren’t they already?  (Anthony C)

That is the million dollar question. I’m pretty sure Democrats will pass some form of health reform this year. Whether that reform is good legislation or takes steps to bring down long term costs remains to be seen. But if health form fails, then ALL Democrats will look really really bad.

That said, what is getting lost in the hoopla is that we are going through through the legislative process. In order to increase their influence over the final bill, Senators and Congress folk are likely to say they don’t support the plan or particular parts of it. That’s what politics looks like.

We also need to remember that FDR, Truman, Nixon, Carter, and Clinton all failed at passing health reform. Where we are today(all but one of the relevant Congressional committee has passed a version of health reform) is further than reform has ever gotten. Evar! But the issue at hand is complex(it’s not even understandable in pretty flow charts). Moreover, it the creeps in the terriotry of very powerful monied interests. And we all know that monied interests own Congress.

Also politics is a zero sum game. Meaning that if Democrats lose, Republicans win. So Republicans are going to do whatever they can to stop reform from passing. Who cares if it means the federal government would collapse within a generation? So yes, some Democrats are nervous, but there is broad consensus amoung Democrats on the basics of the plan(all the stuff listed above). There are few questions that remain: How to pay for reform? How generous should the subsidies be? How should the exchanges be set up? But Democrats generally agree on the shape of reform. So the question isn’t can Obama get the Dems on board–most of them are–but rather are a small group of about five Democratic Senators serious about passing health reform? And are they willing join with Republicans in blocking it?

This has less to do with Obama leadership– and to be clear I’d like to see him do more than he’s currently doing come September– but about how sucky Senate and Congress is in general.

#3) If there isn’t a “public option” remaining in the current health bill, to what extent are private health insurance and pharmaceutical companies being held any more accountable (or less dominant) than under previous government administrations? without sarcasm, to what extent is this progress? (Nicholas MB)

This is a good point to talk about the Public Option more generally. As I said in this post the Public Option is not the most important part of health reform. Most Americans won’t be able to sign up for it. At least not initially.

The original rationale behind the Public Option was two fold. The thinking was the a government insurer(note the difference an government insurer and government run health care) would be able to offer cheaper prices to consumers. Thus over time more and more people would join the Public Option and one day we would find ourselves with de facto single payer(meaning one insurer) health care. Because of this, the overall costs of health care would fall, as the cheaper more efficient Public Option competed against private insures.

But in a concession to the insurance pharmaceutical  companies Democrats decided to limit the number of people who would be able to sign up for the Public Plan. One can debate whether this a good idea or not, but it has meant the insurance/pharmaceutical industries have put their weight money behind reform. As crooked as that sounds, it has made passing reform much easier than it otherwise would have been.

The current hope is that we can get the Public Option passed now and in the future expand the number of people who can join it. That would be a very good thing.

But the Public Option has become is symbol for liberals who in their gut don’t trust Obama. They want to see him fight for something they believe in. I’m sympathetic to this argument, and I think it would be a huge mistake for the White House or Congressional Democrats to concede the Public Option at this point. I still think the Public Option can it make through Congress.

However, if passing health reform depended on trading away the Public Option, it’d be the right call to do so. But we are no where near that point. Obama needs to stand firm on this, in order send a message to the base that he can be trusted. Although, I think, in the end it wouldn’t make much of a difference with those folks anyway. The reasons they don’t trust him go deeper than the Public Option.

#4) Is there any truth to the idea that a public health option will turn us into the next Canada, with long lines and wait list for care? *These lines and wait periods are supposedly so long that many Canadians are traveling to the US to get medical care sooner, at an additional expense. (Maria P)

No. Lyons recently hired a teacher from Canada. Him and I were talking the over day and he told me that he was sad he was going to have to give up his Canadian health care. No one leaves America, travels to another industrialized country, and says that they are going to miss their American health care. The truth is that in Canada and most other industrialized nations, health care costs their government and their citizens a lot less. In addition, they receive better care for their money than we do.

And as for those for those long lines? Thats pretty much bull shit:

The fiscal austerity of the 90’s, which helped drop costs of the program, did make for a worse health care system, or at least one that netted less satisfaction. Wait times for elective surgeries increased, though it should be noted that Canadians wait, on average, less time for vital operations such as transplants. Oh, and the “hordes of Canadians rushing across the border for care thing”? Mostly myth.

The only verified cases are a) folks in the US on vacation or b) folks who don’t want to wait for an elective procedure and can pay to do it out of pocket. Think about that for a second – the primary criticism of the Canadian system is the “wait times/they come here” combo, but what’s really going on is a prioritization of procedures and a few rich folks deciding not stand in line.

So in Canada, it’s the rich who can’t get the care they want, but everybody can get the care they need. Here, the rich can get all the care they want, and many of our poor and lower-middle class can’t simply wait in line for elective procedures — they simply can’t get them.

If you meet somebody in the street who offers to teach how to play hockey and trade you their Canadian health care, do yourself a favor and say yes.

#5) How will the implementation of an Electronic Health Record System impact both the private and public sectors of Health Care? Will any of the costs associated with this implementation be passed on the consumer? What is the current status of defining “meaningful use” (Ekeem MB)

This one was tough. Ekeem, the questioner, could probably do a better job answering it. But I’ll give it the old college try.

Earlier this week I visited my doctor. He came into the room with my file. As we talked he looked it over and wrote indecipherable notes on random parts of the form. At the end of the visit I handed my file to the receptionist who placed it a giant filing cabinet. Similarly, a few weeks back, after my bike accident I went to the ER and the nurses did same thing. And that’s how medical records are kept all over this country: by hand and in paper.

The problem is that this practice is extremely wasteful. It takes hours to file papers, and time send them somewhere, say another specialists office. All this costs money that you pay for indirectly. This is waste in the system that drives up the overall costs of health care. Aside from being wasteful, that lack of an EHR can actually lead to people getting sicker or dying. Obama’s has been pushing the idea that doctors, clinics, and hospital’s(providers)need to adopt Electronic Health Records(EHR) and related health IT.  It is believed that we can drastically reduce costs and save some lives be switching to EHR. It remains to be seen how much money implementing EHR would actually save. But we know that Veterans Administration(the health care we provide to our veterans) has saved a ton of money through the implementation of EHR and health IT. As for in the private practices, here is a study that shows implementing EHR only marginal reduced costs in private practices

What’s this business about “meaningful use”? The stimulus bill contained $20 billion for providers that implemented EHR and health IT systems. The problem, as Ekeem can attest to, is that adopting a health IT system is really hard, and if done poorly can have very dangerous consequences. The other piece is that in order to get the money, providers have to prove that they are making “meaningful use” of “certified” health IT systems. So with billions of dollars on the table, and vague terms like “meaningful use” to be played with, one can imagine how this is turning out:

Unfortunately, billions of taxpayers’ dollars are about to be poured into expensive, inadequate proprietary software, thanks to a provision in the stimulus package. The bill offers medical facilities as much as $64,000 per physician if they make “meaningful use” of “certified” health IT in the next year and a half, and punishes them with cuts to their Medicare reimbursements if they don’t do so by 2015. Obviously, doctors and health administrators are under pressure to act soon. But what is the meaning of “meaningful use”? And who determines which products qualify? These questions are currently the subject of bitter political wrangling.

Vendors of proprietary health IT have a powerful lobby, headed by the Healthcare Information and Management Systems Society, a group with deep ties to the Obama administration… The group is now deploying its lobbying clout to persuade regulators to define “meaningful use” so that only software approved by an allied group, the Certification Commission for Healthcare Information Technology, qualifies. Not only are CCHIT’s standards notoriously lax, the group is also largely funded and staffed by the very industry whose products it is supposed to certify. Giving it the authority over the field of health IT is like letting a group controlled by Big Pharma determine which drugs are safe for the market.

Hit the link above to find out more about the status of EHR and “meaningful” use. Also check this site out. As for the costs getting passed on to consumers, my guess would yes. It’s going to take a lot of money get health IT right and as much the stimulus was gutted in the Senate who knows if $20 billion is even enough. I’d add that conservatives would tell you that having consumers feel the costs of health care more directly would actually be a good thing for the system.

I must say, that was pretty awesome health reform wonkery!  Thanks to everyone that sent in questions. In the next post I will answer all non health reform related questions.

Writing in today’s Washington Post Steve Pearlstein tells the dirty fucking hippes to kick rocks and roll over on the Public Option:

Enough already with the public option!

It is not the be-all and end-all of health-care reform. It is not the long-awaited safety net for the uninsured. And if, as many liberals hope, it turns out to be nothing more than Medicare for All, it won’t do anything to hold down long-term growth in health spending.

The public option is nothing more than a political litmus test imposed on the debate by left-wing politicians and pundits who don’t want to be bothered with the real-life dynamics of the health-care market. It is the Maginot Line of health-care policy, and just like those stubborn French generals, liberal Democrats have vowed to defend it even if it means losing the war.

Pearlstein concluded by reminding anyone under the age of 15 to stay off his lawn.

Seriously though, Pearlstein’s crankiness brings to light the inanity of the last few days of recrimination, after recrimination on the left. On the one hand we have the White House eating shit from the base, for saying for saying nothing new about the Public Option. Monday evening, Rachel Maddow took to airwaves to declare that the White House had given up on the Public Option. This made for great teevee, except for the fact that no such thing had occurred. Maddow was joined by liberals across the world, whose worst nightmare and most common reflex had come to fruition. Yes, Obama had let us down, just like we knew he would we ahd feared.

As pointed out by Ezra Klein and others the Public Option is not the most important of health reform. The insurance reforms on the table, the individual/employer mandates, along with the advent of a national health insurance exchange are as crucial if not more so than the Public Option. Moreover, the proposed expansions of current government insurance programs-Medicaid and Medicare- will do a lot to make the lives of American better. All of this is pointed by Pearlstein in his article.

Paul Krugam gets at the crux of the matter here. The point being missed by the White House, liberals’ who share in Maddow’s anger, and the Very Serious policy types like Pearlstein, is that the Public Option isn’t about the Public Option.

It’s kinda like arguing with your partner about the soup they made for dinner. It’s never really about the soup. The Public Option is a lot more than an litmus test imposed by folks who don’t want to be bothered with the real life challenges of the healthcare market.(To clear, many of the bloggers Pearlstein condemns would probably be able to enroll in Public Option) The Public Option has come to symbolize Obama’s commitment not just to his base, but also his commitment good policy.  It doesn’t matter how important the actual policy is, its has become about the signal it sends to Republicans, the base, and the public. The reason that Obama can’t afford to compromise on Public Option is not because without it the bill would become so bad it wouldn’t be worth supporting. Rather, Obama can’t gave in on the Public Option because it would validate the worst caricatures of him held by left of Democratic Party and the nut jobs in the Republican Party. The caricature being that of a President who won’t stand firm when it matters most, who is willing to hand Bo over to Bad Newz Kennels if it came do to it.

What’s kinda odd here is the similarities between this and so many over moments in Obama’s political history. Remember when the Public Option was the Residual Forces in Iraq? Or when the Public Option was the individual mandate? Or better yet when the Public Option was the price tag attached to the stimulus? This is the dynamic of politics in the age of Obama. Why don’t folks seem to get this yet? It’s not about the soup.