Thursday, August 6, 2009

Obligatory health care post

When I worked in the Clinton correspondence office, one of my issue areas was health reform. This was back in 1994, the really ugly year. I spent a lot of time trying to learn the details of the Clinton plan and to understand congressional committee procedures. I dealt with a lot of very critical letters. Some were from insurers and medical practitioners, worried that certain procedures wouldn't be covered or that their businesses were going to suffer. Some were from conservative ideologues who were convinced that, should Clinton's plan pass, visiting an American doctor was going to become like obtaining toilet paper under Brezhnev or living in a gulag under Stalin or playing dreidel under Hitler. Just about every day, of course, we had C-SPAN on in the office, and I heard congressional statements morph from "We will have health reform this year" to "The President's health care bill is deader than Elvis."

All this is to say that I've seen this movie before, and I didn't like the ending.

If you haven't read it, Ezra Klein's piece comparing the Obama and Clinton health reform efforts is really fascinating. He notes that Clinton was criticized for crafting the whole reform himself and not letting Congress figure it out, while Obama is being criticized for leaving it all up to Congress and not giving supporters something specific to rally around. He also notes that the Clinton plan was probably a lot more ambitious than anything Obama's pushing for today. It actually saw the way health care was going in this country and sought to create some workable rules:
The managed-care revolution of the mid-90s was, by the early years of that decade, clearly inevitable; the financing and delivery of health care could not remain separate forever. But this was a dangerous change. Insurers make money by denying claims. Money they spend on health care is money they lose (they even have a name for it: the "medical-loss ratio"). Private insurance is a bit like a fire department that turns a profit by letting buildings burn down.

So Clinton sought to cage managed care inside managed competition, which would regulate the behavior of insurers and force them to compete for patients. This would give consumers more power against their insurance companies, drive the bad actors from the market and generally protect against the excesses of managed care. Clinton's plan also included a handful of other safeguards, like out-of-pocket caps and an independent appeals process, designed to protect consumers from deficient insurance.
But Clinton's opponents sought to defeat the plan, raising fears that care would be rationed and costs would go up and that consumers would have less choice. This, of course, is exactly what happened, except that Clinton's plan didn't pass.

Now the same fears are being raised today. I have to say that the hostility makes me a bit sick. Of course, I have no problem with heated, polarized debate, but this is nothing of the sort. This is trying to whip people into a frenzy by scaring them to death without actually informing them of anything substantive. Here's the text of an e-mail I received from the Colorado GOP the other day:
Republican Call to Action – Help defeat Obamacare!
Four important things you can do to help:

1.) Call and email your member of Congress and let them know you oppose this legislation
2.) Write a letter to the editor
3.) Forward this email to your friends and family
4.) Participate in one of the “Hands off my Healthcare” rallies taking place throughout the state Thursday, August 6th – Friday, August 8th. Please see schedule below:

The Patients First bus “Hands off my Healthcare” tour will be coming to Colorado this Thursday, August 6th , Friday, August 7th and Saturday August 8th for a rally against a government takeover of your healthcare. Nearly 2,000 Coloradans have already rallied in Denver and Colorado Springs against Washington’s plans to dictate our health care choices. Now the rest of Colorado gets their chance for their voices to be heard.
What exactly are they protesting? There are several plans being considered by Congress right now. What does the Colorado GOP object to? Expanding health insurance? Creating more competition among insurers? We don't know.

At this point, only two factors give me any confidence that some version of health reform will pass this year:
  1. The Democrats have (at least nominally) 60 votes in the Senate, which they did not have in 1993-94.
  2. The Democrats remember how the failure of health care contributed to their loss of control of both chambers of Congress in 1994, and they do not want to repeat that.
Sorry for the rant.


Eric Rubin said...

i hate republicans. i mean, they have this deep seeded fear of government control when in fact they are more controlled than any of us. are they the stupidest people on earth? all signs point to yes!

Lori said...

Let me preface this comment with the understanding that my saucy snark is not to be taken too seriously, but my concerns are:

As for the "who gets the blame for developing/not developing" a rallying cry, it is disconcerting to say the least to hear that neither the President nor several members of Congress have actually READ what they are going to vote on. How can they rally around something so nebulous as "healthcare reform?" without knowing what it will actually do?

It's almost like trying to rally a vote around something as vague as "hope and change..." oh, yeah, that seemed to work, too!

Seth, what are your thoughts about expanding Medicare/Medicaid to the currently uninsured, or moving toward a catastrophic insurance program? Not many of us really NEED insurance for the actual basic doctor's visit once or twice a year; it's to fend off what happens if you become chronically or catastrophically ill/injured.

I actually figured out that our dental insurance pretty much equals what we'd pay per year in regular dental visits (that's with 5 kids, mind you), and the benefits are only a discount on the big stuff that MIGHT happen (not even braces, though...just cavities, root canals, etc). So there might as well be only catastrophic (so to speak) dental insurance, too.

I think we'd all get a better idea of what the costs are, there would be far less abuse of the system/programs, and it would wind up being less than what we're paying now, without having to have the government takeover healthcare.

Oh, and's deep-SEATED fears...Republicans hate misspellings and capitalization errors as much as government control. :-)

Seth Masket said...

Lori, a few points. First of all, nobody picks on Cousin Eric.

Second, while this may come as a shock, almost no member of Congress reads any of the bills he or she votes on in their entirety. It simply can't be done. There are not enough hours in the year for that to happen. This is reflective of the fact that federal legislation is inherently complex. It has many authors and participants who need their concerns addressed. Plus, designing fair, effective legislation is almost never simple. Members of Congress have no choice but to defer to people they trust -- the authors of the legislation, the committee leaders who examine the bills in detail, their own policy staffers.

As to this point:
How can they rally around something so nebulous as "healthcare reform?" without knowing what it will actually do?
Okay. But by the same token, how can Republicans rally against something so nebulous as "healthcare reform" without knowing what it will actually do?

Finally, yes, I'd very much be in favor of extending Medicare to a broader segment of the population. It seems a much simpler solution than anything currently being debated, but it would likely engender at least as much resistance since it would be, you know, nationalized health insurance, even though we've had that for the elderly (and the poor, and active and retired military, and members of Congress, etc.) for years.

Seth Masket said...

These shameful episodes of the DNC dismissing Obamacare opponents as paid shills -even running disengenuous TV ads to slander them- while SanFranNan is halucinating and seeing imaginary Swastikas- should make clear to anyone just what these far-left elitists think of your opinion

Um... what?

Eric Rubin said...

thanx fer gedding my back cuzin. i haet misspellings two but the jisst uv my cament wuz reel - reepublickans are earrashionally ufrade of everything.

pee.ess. Cuz - wut iz thu orajin uv thu 'elitist' claim? wear did it cum frum? it maeks no sens two me

Seth Masket said...

Eric, there's a lot that's wrong in Tom Frank's book What's the Matter with Kansas?, but one of the things he gets right is the description of how conservatives use the term "elitist" as weapon against liberals. This might go back to Nixon or maybe earlier. But the gist is that Republicans tend to be wealthier than Democrats. This has been true for a long time and is truer today than it was a few decades ago. It is also a fact that there are more poor people than wealthy people. It's hard, therefore, for Republicans to win elections by claiming to represent the wealthy.

So what they do is reframe the debate somewhat. Society isn't divided between the poor and the wealthy; it's divided between the "elite" and the "common folks." The elite are defined as Ivy League graduates, government bureaucrats, professors, Hollywood celebrities, etc. By definition, they're out of touch with the common folks. As Frank says, conservatives have redefined class by erasing economics.

Now, as it turns out, there's not much evidence that this is influencing voters much. The white working class is still mainly voting Democratic; they haven't been converted by the anti-elitist talk. But it's still a rallying point for conservatives and it gets them some good press once in a while.

Eric Rubin said...

thankx for the background.

cuzin e

p.s. i still hate republicans.

Lori said...

Aw, shucks, Eric...just kiddin' around! Hating us isn't going to get the job done, even if you are related to the nicest Democrat in the world. Gosh, I forgot how sensitive y'all are.

Maybe nobody can read the entire bill because: a) it's written in way too much legalese [yes, I know it's a LAW, therefore SOME legalese must enter the picture], b)it's too broad in scope, or c) they don't bother to try!

I used to work for a state legislative news service where we summarized the bills at least for our clients. That's a step in the right direction, yes?

So, until we get past "I hate Republicans," nobody will listen to anybody, like two of us on opposite sides of the coin on lots of things, saying the same thing: What about looking at expanding Medicaid? What about catastrophic insurance? What about anything, ANYTHING specific, that doesn't cost a $googleplex? (ok, we Republicans can tend toward hyperbole on occasion, but we recognize that fact)

While most people would agree that healthcare and insurance costs are too high, not everyone agrees that what is being proposed will actually lower costs, or at least not without the danger of loss of quality along with it.

And just for the record, I'd never classify the average Democrat as an elitist. I do think most politicians of any stripe are elitist.

Sorry for picking on your family, Seth.

Seth Masket said...

Nah, feel free to pick on my family, Lori. No biggie.

A few points. First of all, expanding Medicare or just ensuring catastrophic insurance would be great steps. And maybe that's all that will end up happening this year. But the problem isn't just that reform will cost a lot. The fact is, if we do nothing this year about health care reform, health care will still cost a lot, and will keep getting more expensive. Maybe health reform can get that under control. Some of that inflation comes from insurance company profits, but only some. Some of it comes from over-prescription of medication. Some is from people going to emergency rooms because they don't have insurance that can cover routine checkups. Some comes from innovative medical care, such as MRI scans, that are really good to have but just cost a lot. Even a full Canadian-style insurance plan would only deal with some of this.

The thing is, even if we continue to spend a lot on health care, what are we going to get out of it? Right now, we're paying much more in health care costs than any other developed country does without seeing any real advantage over those countries in terms of health outcomes or patient satisfaction.

Oh, one other point. It's really not in anyone's interests for members of Congress to read every bill they vote on it their entirety. They could be doing much better things with their time, and they can make plenty of shortcuts in figuring out whether they like the bill or not. Do you read every page of the voter guide before voting? I don't think anyone does. And yet, if we did, it probably wouldn't change any of our votes. The shortcuts we use (party ID, endorsements, etc.) are really quite useful.

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