Public Support for Reform Rising

"I thought when people began to realize what was in the health care package that they would see it's a good, solid program and that would dispel some of the misinformation."
                                   -Claudia Harris, 72, of Orem, Utah, an English professor at BYU

Turns out Claudia may be right!  See this article on a new poll showing the highest level of public support since the passage of reform.

Dissecting the Republican Position

Let's consider:

1. The Republicans say there has been totalitarianism. It seems to me the majority ruled, as it has done since the founding of our Republic. Totalitarianism?

2. The Republicans say they have been entirely shut out of the process. But the fact is that more than 200 Republican amendments were accepted in the health reform bill as part of the process. Shut out?

3. A Republican leader predicted that the passage of the bill would be "Armageddon." That could be up there with the "Mission Accomplished" banner as one of the biggest political blunders of all time.

4. Senator Brown says it will not help Massachusetts. But the facts are that thousands of low income individuals will now be eligible for new subsidies, almost 80,000 seniors will benefit from the donut hole fix and Massachusetts will receive an extra hundreds of millions of dollars in Medicaid matching funds. It is hard to understand how one could rationally say this does not benefit Massachusetts.

5. Republicans say mandates are un-American and unconstitutional. But they were for them before they were against them. In an interesting article in today's Globe, the AP documents how the health insurance mandate began as a Republican idea in the 90's as an alternative to the Clinton plan. But when the Dems picked it up, they had to be against it.

6. And how about Romney? You'd think he would learn, as his wishy-washy position on abortion over the years could have cost him the nomination in 2008. Yet here he is, the leader who deserves enormous credit for spearheading the successful reform plan in Massachusetts -- upon which the federal plan was based - and now he opposes the federal plan and wants it repealed. How he thinks he can credibly even think about running for President, given such a disingenuous flip-flop, is beyond me.

7.  The Republicans claim this is a big government take-over and we are leading to socialized medicine.  Again, this ignores reality.  There is no public option.  The states create exchanges, simply to allow individuals who lack private insurance to gain better bargaining power in the purchase of insurance through private plans.  There is no new public plan or government take-over.  There is greater government regulation over insurance companies -- but even Republicans say they want this and the public surely does. 

8. The Republicans repeatedly say that the American people overwhelmingly are against this bill.  Yet, a Gallup poll conducted right after passage showed that 49% of Americans support the legislation and 40% do not. 

9.  Finally, the Republican strategy is now to run in the Fall on repeal of the law. Repeal?! Do they know that repealing the law requires not just taking over the majority in both houses, but actually taking over a veto-proof majority, which all experts from all sides believe is virtually impossible. And that's now their strategy?

They took a big gamble. They all voted against it. They hoped it would take down the Obama Presidency. But they lost. It didn't. And now they are left to explain how their strategy was actually in the interest of the American people, and not just a raw political scheme. They will have a tough time.

It's Done!

219-212.  History is made.

The End In Sight!

It's hard to believe, but by the end of today we may actually have a health reform bill moving to the President's desk for signature (followed by passage in the Senate of a reconciliation bill to fix the worst parts of the Senate bill). If it happens, it will not only be a great victory for our President, who will have achieved more than any other President since 1965, but also (and more importantly) a great victory for our nation.  It's going to be close and no one is claiming victory yet.  But I knew things were looking up when I read that nuns had departed with the Catholic Church to support the legislation. 

On this, the frist full day of Spring, hope springs eternal!

The Health Care Summit: Analysis and A Way Forward

A very interesting day indeed. On the substance, both sides scored points and put forth thoughtful and credible arguments about how to move forward on health reform. Before going any further, let's stop and celebrate that point alone. How refreshing! Real dialogue and debate on meaningful issues. Sure, there was some posturing and demagoguery, but no talk of death panels (at least not that I heard) or other misinformation and distortion that has been spewed about over the past year. That alone is a big win for our country.

In the end, score it a tie on the substance. Few will be moved from their positions by the substantive arguments. But here's the interesting thing. This public debate has not been about the substance. The irony is that the public hates the bill, but likes everything in it. The debate, sadly, has been more about process and size and scope. The public is incredibly confused and, given the economic climate, quite scared about what they perceive (correctly) to be a massive change that may cost a lot of money. And that has been fully and effectively manipulated by Republicans in saying it is too big and we should start over. (It is also quite cynical because you have to be from Mars to not know that their true goal is to cause a massive failure by the President, then criticize him for wasting everyone's time and not getting anything done while he had a majority, all in the hopes of gaining seats in November).

And this leads to my reason for believing that politically, today will prove to be a huge win for the President. First, he demonstrated to the country he is serious about these issues, wants to engage in real dialogue to try to forge a compromise, and showed courage to put himself out there to the World to debate the substance of such important topics (could you imagine George W. Bush doing this?). And as usual, he was quite articulate and came across as very sincere. The public likes him and this will add greatly to his credibility on this issue. Whether or not they agree with everything that is in the bill, they will believe that he really does want to do the right thing for the country and for them (and they will likely respect and reward that, notwithstanding their concerns with the bill, in the same way the country did not like many of Bush's policies after 9-11, but nevertheless respected and rewarded him for wanting to do everything he could to protect them. I believe this is the main reason Bush won the election in 2004).

Second, the Republicans were in a bit of a bind. They have been saying all along the entire legislation is crap. Yet today they engaged in a serious debate about issues in these bills and actually reached agreement in several areas, thereby giving validity to at least certain portions of the bills. The fact is that many provisions of the bills were put in at the request of Republicans. So they have now conceded (implicitly or otherwise) that there are some substantive and serious provisions in the legislation. And given the fact that the President took the initiative to proactively reach out to them to forge a compromise, they will be under intense pressure now to actually make some compromises of their own or they will truly look like the "Party of No." Thus, no longer will they be able to effectively pursue their slash and burn agenda of dismissing and trashing the whole bill.

Now for the way forward. As I have said all along, the House should pass the Senate bill.  But here are three specific ways they should improve it. First, they should remove all of the most egregious "special deals." Even though these deals exist in all legislation, this issue has done more than anything else to infect the process and distract and outrage the public. And there is no substantive defense to most of it. It undermines the Dems efforts to try to act with integrity in the best interest of the country at large. And of course stripping the bill of these deals removes the best talking point of the Republicans. Second, the Senate should agree to other modest changes by the House to give them a "win" and allow them to claim victory in making improvements to the bill. It won't change much about the substance, but it will go a long way to making house members feel better and give them something to run on in November (i.e., "thanks to my insistence, we actually improved the bill."). 3. Finally, and this will be most controversial, the Democrats should add a serious and meaningful provision on malpractice reform. It is simply indefensible, in this age of out-of-control healthcare costs, to not take on this issue. It is true that actual malpractice costs add relatively little to the cost of health care. But defensive medicine (the practice of ordering tests and procedures for fear of being sued if you don't) adds quite a bit. And by not taking it on, you appear as if you are trying to curry favor with trial lawyers. The fact is that everyone must give their pound of flesh if we are to succeed in this effort and the failure to address this issue in such a comprehensive bill is a huge and unacceptable void.

If the Dems do these three things, they have preserved the "heart" of their comprehensive reform, which is good for the country. But they have also improved the bill, stripped it of its most insidious components, and added an issue that should have been in from the beginning. They will also being showing real compromise, which will improve public support, and they will put the Republicans in a real box. How could the Republicans ever say the Dems did not compromise in good faith when they added perhaps their number one priority (malpractice reform). This will probably result in a few Republican votes. But even if it doesn't, the Dems will gain the upper hand politically and can move to reconciliation in a far better posture to defend their actions come November. One can hope. What say you?

Music to My Eyes

Judy Feder wrote a thoughtful story today for Kaiser Health News that makes the case - far better than I did in yesterday’s post - on why the House should vote to accept the Senate bill. It is a must-read. Her concluding remarks say it all: "But after decades of trying and failing, hoping and waiting, can anyone who truly values reform say no to this opportunity to get to work? To me, that would be unconscionable."

Pass the Senate Bill

On January 20, I wrote a long-winded post providing my "sober analysis" of the Massachusetts Senate race.  My conclusion was that the only viable option on health reform is for the House to pass the Senate bill.  Yesterday, a prominent voice joined the drumbeat.  As noted in The Hill, former Senator Tom Daschle, the almost-Secretary of Health and Human Services, called on House Democrats to do the same.  “You could argue that there is just as much political downside to not to pass this than to pass this,” Daschle said.  He is right.  But more importantly, it is good policy.  As I have said before, the bill is far from perfect, but it will meet the moral imperative of covering 30 million individuals who now lack health insurance in the richest nation in the world.  And it will start us down the long and necessary road of transforming our healthcare system.  Saying "no" is easy.  And there are many naysayers.  Some say it does not do enough to bend the cost curve.  They are right.  But doing nothing is worse and will almost-certainly lead to implosion of the system.  Moreover, the bill does plant many important seeds (via PILOT programs) to start to bend that curve.  So it is a start we can build on.  The House should have the courage to say yes.  It is harder than saying no, but it will pay dividends for generations.

Will Republicans Suffer the Fate of Icarus?

In Greek mythology, Icarus and his father Daedalus (an inventor) were imprisoned by King Minos of Crete. Daedalus knew that the only escape route was by air, so he used his skills to build wings - made of wax - for himself and Icarus. Daedalus warned Icarus not to overreach; for if he flew too high, the sun could melt the wax of his wings. You know the end of the story -- Icarus fell in love with flight and through his exhilaration, he ignored his father's warning and flew higher and higher. The sun melted the wax on his wings and he fell into the water and drowned.

Republicans seem to me to be getting dangerously close to the sun. In their apparent exhilaration by Obama's shrinking poll numbers and national ambivalence on health reform legislation, they have plowed full steam ahead to do everything possible to oppose national health reform. Now they are even taking the fight outside of the legislative process.  Thirteen Republican state attorneys general, led by South Carolina AG Henry McMaster, are threatening to sue the federal government over the deal that was cut with Senator Ben Nelson from Nebraska -- to fund 100% of the state's Medicaid expansions -- to secure his vote for the bill. As far as I can tell, there is no remotely-legitimate legal basis for this suit. I wonder if these attorneys general have contemplated suit when their states have been beneficiaries of numerous Congressional earmarks over the years?

I also see in a story from Slate.com that the Republicans are launching an effort to repeal the bill (before it is even passed, mind you!) to curry favor in the 2010 Congressional elections.

Here's the deal. Are there legitimate things to gripe about in the bill? Absolutely. But the Republican strategy has not been to constructively discuss those issues and try to improve the bill. It has been an all out assault. Moreover, despite some concerns, at the end of the day, the American public tends to be reasonable and pragmatic. And notwithstanding some not-so-good things in the bill, any ordinary, reasonable, prudent person (a term we use in the law) cannot deny the inescapable conclusion that this bill will do a ton of good, which far outweighs the not-so-good. For crying out loud, it will provide health insurance to 31,000,000 people who do not have it today! It advances the ball on improving quality, promoting efficiency and bending the cost curve. See my prior posts (you can look at the category list under "health reform") for the many other ways this bill does good.

Perhaps the Republicans know something I do not (very likely). But I cannot help but think that through their unwavering efforts to do nothing other than try to kill the most significant advancement of social health legislation in a generation, they will be seen at the end of the day to be brazenly placing their own political interest above the national interest. Political parties - both Democrat and Republican - have a dubious history of overreaching when they feel the exhilaration of flight. It looks to me like that may be about to happen again.

What You Won't Hear About in the Senate Bill

This past summer, I wrote an op ed in the Boston Globe entitled Retooling the Medicare/Medicaid Model.  In the piece, I discuss the enormous fragmentation and dysfunction that exists between the Medicare and Medicaid programs.  Although housed within one agency, these two gargantuan government programs are incredibly siloed and often work at cross purposes, thereby adding significant cost to the system.  This is seen most clearly in the so-called dual-eligible population -those high cost individuals who are on both programs.  Here is what I recommended: 

"The Obama administration can reorganize CMS so that it focuses as much on the unique needs of populations as it does on the rules of payment. CMS should create a program integration unit devoted exclusively to breaking down silos between the two programs and working with states to eliminate barriers to seamless care for dual eligibles. Doing so will go a long way to reducing costs - and free up resources for more far-reaching reform."

I was delighted to read recently that the Senate bill does just that.  Buried on page 517 of the bill, in section 2602, it establishes a Federal Coordinated Health Care Office within CMS for the purpose of, "bring[ing] together officers and employees of the Medicare and Medicaid programs at [CMS] in order to more effectively integrate benefits under [both programs] and . . .  improve the coordination between the Federal Government and States."

Hooray!  And the best part -- unlike the several-year delay of most major sections of the bill, this one will become effective in March, 2010.  You will not hear or read about this provision because it does not make for a good sound bite.  But this new Office - if it realizes even half of its promise -- will have a profound impact on improving care and reducing cost for some of the costliest individuals on our public programs.  So tell that to the next person who tells you that the bill will do nothing to bend the cost curve!  Please read my Op-Ed for more background.  And let's hope this provision makes it through conference.

Poem on Health Reform

Ron Pollack is the President of Families USA and a strong advocate of health reform.  He wrote this poem as he waited for the vote on Sunday night. Thanks to Scott Harshbarger for passing it along.  Have a wonderful Christmas everyone!


TWAS THE NIGHT BEFORE CHRISTMAS

Twas the night before Christmas and all through the Senate
The Democrats were working for a fundamental tenet:
All Americans should have health care at a reasonable price
By forcing insurance companies to finally play nice.

The reform bill they pushed took some very strong positions,
Like no one denied coverage due to pre-existing conditions.
Premiums, in the future, would need to be fair
With no differences for women and people needing care.

The Democrats made sure that the bill they designed
Would give folks *cross the nation some real peace of mind.
Health care would not end if jobs changed or were lost
As all could choose health plans at an affordable cost.

For seniors needing medicines, the bill had much to extol:
It plugged gaps in their coverage, like the bad *doughnut hole.*
And for empty-nesting parents, there was reason to rejoice
Kids could keep family coverage, this was now a parent*s choice.

But all Republicans scoffed and persistently said *no*
With the sometimes exception of their colleague, Ms. Snowe.
With obstructions and filibusters, they tried every delay
To stop the bill and kill reform, before Christmas day.

So Leader Reid called his colleagues from left and from right,
For all 60 to join him, lest they lose this big fight.
Now Nelson, now Lincoln, now Franken and Wyden,
On Lieberman, on Bingaman, on Harkin and Cardin.

Christmas eve turned to night, and when the votes were all counted,
The filibusters and obstructions were completely surmounted.
The vote was inspired by the memory of Ted
Who*d applaud the victory for the cause he had led.

The work isn*t over, there*s much yet to be done
The Senate and the House bills must be merged into one.
But the vote on Christmas eve offers reason to cheer
*Cause health care reform will pass in the new year.

So call your fine leaders, and let your voice be heard,
With letters and emails, we must spread the word.
Our message is clear, and it shines a bright light*
*Health care coverage for all, and for all it*s our right.*

60-39

It's done!  Moves on to conference.

July 2, 2009

That day may go down in history as one of the pivotal events in bringing about national health reform - a goal that has eluded national leaders for a generation.  That was the day that Senator Edward Kennedy delivered a letter to the leaders of our state: the Governor, the Senate President and the Speaker of the House, urging them to amend the law to provide for a temporary gubernatorial appointment (pending the results of a special election) "should a senate vacancy occur."   Of course, we all knew what vacancy he was talking about: the one that would be brought about by his impending death. 

At a time when this man had everything else in the world to think about, when he had every right to wallow in self pity, he chose instead to make this urgent appeal because he knew that it could make all the difference in the world.  He invoked the names of John Adams and Daniel Webster to underscore the fact that the "voices and views" of Massachusetts representatives in Congress "have shaped America's progress." 

As it turns out, Senator Kennedy's words were prophetic.  Paul Kirk - the Senator appointed by Governor Patrick after the law was changed - will likely cast the 60th and deciding vote to pass health reform in the Senate.  Without him, they would not have the votes.  And by the time a new Senator will be elected and sworn in, it probably will be too late. 

Ted Kennedy's emotional plea undoubtedly had a large impact on the Governor and the Massachusetts legislature to amend the law, as there was strong political pressure to do otherwise.  Ted Kennedy will no doubt be in the history books alongside Adams and Webster.  And for his many acts over his long career, this one on July 2nd may turn out to be one of the most significant in shaping America's progress on an issue so near and dear to his heart.

The sausage will taste so good

I love a nice hot sausage at Fenway on a summer evening.  But I know that if I had to see that sausage being made, I would probably get sick to my stomach.  The debate on health reform now taking place in the United States Senate is like watching sausage being made in the worst possible conditions.  It is frankly painful to watch.  An article in today's New York Times describes it as follows:

"Nasty charges of bribery. Senators cut off mid-speech. Accusations of politics put over patriotism. Talk of double-crosses."

But I must confess to feeling a sense of enormous excitement when I learned of the deal struck over the weekend to finally bring Nebraska Senator Ben Neslon into the fold.  They now have 60 votes.  The deal may actually hold together.  The most significant reform of our health system in a generation may actually happen.  Thirty million Americans may actually get health insurance. 

There are still plenty of ways it can fail, but for the first time in a while I can see a clear path to victory.  And I know that when that happens -- like the taste of that wonderful sausage at Fenway -- I will think not of how it was made, but how wonderful it tastes!

The President Agrees

"If we don't do something, premiums are guaranteed to rise." 
       -President Obama speaking today on the cost of doing nothing on health reform.  He surely must have read my November 24th post below.

The Poisoned Well

The Engage with Grace movement (see post below) was so impressive because it sought to bring about real and meaningful conversations about important - but difficult -- health care topics.  If we are to succeed as a nation in improving our health outcomes and lowering cost (or at least lowering the rate of cost growth), we need to get much more comfortable having these difficult conversations.  Yet, we continue to allow certain voices to poison the well, as occurred earlier this year with bogus claims of "death panels", which was followed by the immediate stripping of reasaonble provisions from reform legislation in order to avoid the topic like the plague. 

It looks like this may be happening again on another topic: whether women under 50 should get routine annual mammograms.

The cost of doing nothing

There has been enormous focus - as there should be - on the cost of national health reform. But in order to have a meaningful debate, we must also consider the cost of no reform. Here are just a few basic facts about the status quo. Per capita spending on health care in the United States is this highest of any country in the World. But not just a little higher. It is double the spending in other industrialized countries with high standards of living. This includes Germany, Canada, France, Australia and the United Kingdom. But that's not all. Our costs are growing at a faster rate than these other countries and our health spending is a higher percentage of GDP than these other countries. In short, by any conceivable measure, we are a huge outlier compared to the rest of the planet. But surely we must be delivering better quality of care for all of this extra spending, right? Wrong. Under most standard measures of quality (except perhaps for "rescue" care), other countries are delivering far better results than we are. If we were a business, we would be on the verge of bankruptcy. And the only way a business avoids bankruptcy is to substantially reform its business. (If you are interested in two views on the economic benefit lost from not pasing health reform, see this Op Ed in the Globe from earlier this month by Linda Bilmes and Rosemary Day.

The Big Cost Shift

Health care reform moved one step closer to reality last evening when the Senate attained the necessary 60 votes to begin debate. Passage is still anything but certain, but it is looking more promising than just a few short weeks ago when many wrote it off as all but dead. One remaining concern is that many in our country do not see the uninsured as "their" problem and lack sympathy because they believe the uninsured will always get care they need in an emergency room if they have a true crisis. The Obama administration and Congressional leaders have failed to clearly and directly rebut these misperceptions. For health reform to gain broader support, we need to do a much better job of getting people with insurance to understand that the plight of those without insurance is their problem too. Here is how we can do it.

Those who lack insurance do in fact show up in emergency rooms and they are taken care of. But this becomes what is known in the hospital world as uncompensated care. Hospitals are required to provide the care, but in order to survive, they must find a way -- like all businesses in similar circumstances - to cover the costs of that care. So they shift the cost of that care to private payers (the same way they do for underpayments from Medicaid and Medicare, our government programs that pay all hospitals at rates that are below their costs). They do so by negotiating higher rates from private payers. Those private payers then pass on these higher rates to employers in the form of higher premiums. And those employers then pass on those higher premiums to their employees. The result is that all employees are in fact already paying the cost of uncompensated care. It is indeed a societal problem. What's worse, when those who lack insurance seek care in the emergency room, they are doing so in the most expensive setting - so the costs are extremely high. If they had insurance, they would get preventive care (at much lower cost) and would be able to avoid those expensive ER visits and hospitalizations. That is a key reason we need health care reform.

Until the public clearly understands the big cost shift that goes on in our health care system, we will continue to struggle to gain broad support for national health reform.