Better or Worse

by: Mike Lux

Fri Dec 11, 2009 at 11:15


The new Senate deal over the public option has its good points and bad points, which I wrote about on Wednesday, and which everyone right now is analyzing and debating. A lot of how people feel about it, though certainly not all, is a classic glass half full vs half empty argument: it all depends on whether you tend to see things in a positive or negative light, and whether you are optimistic that progressives can build on what's good about this in the future, or whether you think that's false optimism given the power of the insurance industry. Given my generally more upbeat nature, I am starting to feel more positive about this deal in terms of what can be built on in the future, even though I remain generally growly about the compromises we have had to make.

Discussing the upside and downside of the deal announced Tuesday night is not the purpose of this post, however, since that has already been done by me and hundreds of other people. I will no doubt come back to the nature of the bill as details emerge, but today's topic is about focusing on working on making the bill better, and working to keep it from getting worse. One of the problems in the fast moving and intense phase we are in right now is that if we spend too much time debating or bitching about the merits of a particular compromise, the compromise might get worse before the ink is dry, or we might lose the chance to make it better.

As I wrote a few days back, there is no such thing as a done deal on a policy issue as big as health care until the President actually signs the bill. All the good things announced in Tuesday night's compromise are under vicious assault by the big health industry lobbies, and the bad things still might get negotiated for the better in the conference committee or even in the manager's amendment in the Senate. The hospitals, American Medical Association, and insurers are bitterly attacking the Medicare buy-in; the insurers hate the 90% provision (that at least 90% of their revenue has to go into paying out benefits), and don't like being forced to compete the way they are in the federal government health plan; even the trigger, as weak as it is, is under assault. Basically, everything that progressives might like in this compromise is under fierce assault by the big health care special interests.

At the same time, there is an opportunity, mostly in conference committee, to improve the details of this package in some significant ways. The numbers and language around Medicaid could be negotiated upward. The cost formula for people getting in on the Medicare buy-in can be negotiated for the better. S-CHIP provisions could be strengthened and more children and youth could be covered as a result. A whole range of issues around the public option related package could potentially be improved if House progressives bargain aggressively and smartly. And there are still so many issues beyond the public option that need to be bargained over in conference committee (I have written about all these issues here, and Chris Bowers had a good summary here) that are incredibly important- the issues around both the financing package and the subsidies for poor and middle income people alone are of truly profound economic and political importance. And we have to continue to battle conservative threats to screw both women on abortion coverage, and immigrants on everything.

At the end of the day, as unfortunate as the overall public option defeat is, if we can get Medicare buy-in for 55-64 year olds, expansions in coverage for children and youth through S-CHIP, major expansions in Medicaid coverage, decent subsidies for the uninsured to buy coverage in a more competitive marketplace, and strong new insurance regulations, that would be a pretty remarkable accomplishment. But none of this is done, and this bill can get either a little better or a lot worse. We need to focus right now on pushing to improve the bill wherever we can, rather than getting caught up too much in debates over just how good this still theoretical, still undefined "deal" actually is. Whatever the outlines of this deal currently are, the best parts will go away fast if progressives don't keep pounding away on getting the best possible deal.    

Mike Lux :: Better or Worse

Tags: , , , (All Tags)
Print Friendly View Send As Email
Better or Worse | 36 comments
"The hospitals, American Medical Association, and insurers... (0.00 / 0)
...are bitterly attacking the Medicare buy-in"
For heaven's sake, WHY? Shouldn't they be happy about more of the people, in the age where Emergency room visits are bconing more likely, will have Medicare coverage? Do they rather want to have freloaders who will leave the hospitals holding the bills? Doesn't make any sense to me...
Maybe because Medicare reimburses at lower rates than private insurance (0.00 / 0)
(when you can get your private insurance to pay out) and doctors, hospitals and other providers see the expansion of Medicare as a reduction in compensation.

Isn't it already the case that some physicians, clinics and hospitals actively try to avoid treating Medicare patients for basically the same reasons?


"It sounds wrong...
     ...but its right."

[ Parent ]
I've read that, too. But at the same time, more people with insurance.. (0.00 / 0)
..means less people defaulting on their bills. So, I still wonder if the clinics and hospital have really calculated this in.
[ Parent ]
Anecdotally from my physician friends and colleagues (0.00 / 0)
the suggestion is that Medicare is no less laborious to deal with in terms of claims and reimbursement than private. This may be a function of the paperwork swamp, not sure.

Even when people "default" on their bills, there is paperwork to file and accounting to be done. The services are paid for - by someone - so it is not like the providers get nothing.

We tend to overlook the simple solutions in these discussions, but the fact is that if one result of this HCR is a uniform, portable and trackable national standard for medical records, the downstream benefits are huge. This is where folks should look to big institutions for models, VA, Mayo, and the like. The upfront costs are involved in set up and conversion ("migration" they call it in practice), but once its in place, information flows more readily.

Same with insurance claim forms. Even with 100's of payers, one can legislate and regulate standard forms to simplify paperwork and facilitate information transfer.  

"It sounds wrong...
     ...but its right."

[ Parent ]
Real rates (0.00 / 0)
The real story is this, at least with one surgeon I know.  Charges are very high but mostly window dressing.  In his case, Medicare pays about 6% of standard charges (Medicare insists that charges be adjusted downwards), managed care pays about 6 to 8.5% of charges depending on the plan, out of network and other insurances pay 20 to 25% of charges, a few really good plans pay 50 to 60% and an even smaller number of incredibly wealthy foreigners pay 50 to 75%.

Under the current Senate bill all plans charging singles over $8,500 per year or families over $23,000 will be taxed at 40%, presumably for the overage.  The scuttle butt is that the insurance companies will eliminate them.  In metro NYC, only the lowest , most restrictive managed care is offered at the non-Cadillac rate. That leaves the docs and hospitals with a managed care or Medicare economy.

FireDogLake is now reporting that an annual benefit cap and a lifetime benefit cap have been added to the Senate bill.  This benefit cap is undefined or rather defined as "reasonable."  The chronically ill or those with very expensive procedures will be pushed over to taxpayer expense.

[ Parent ]
This issue gets directly to wealth redistribution (0.00 / 0)
and is a major detail in any reform. How are docs reimbursed for services? Surgeons are near the top of the food chain because their practice is very procedure intensive and they can bill each procedure separately and can see many patients per week. The family practioner is at the other end of the spectrum. Few procedures to bill and alot of time spent with each patient. The main way they get more money reimbursed is to cut the time with each patient and go for volume. As a result, surgeons are in aggregate more wealthy than family care physicians. A good HCR initiative will redistribute that wealth and some will not like that outcome.


"It sounds wrong...
     ...but its right."
[ Parent ]
Are we past the time when (4.00 / 1)
pushing for reconciliation is the best way to "keep pounding away on getting the best possible deal?"

I'm not sure how reconciliation would've been worse or harder than what's been going on.

And this quote from Robert Reich, (4.00 / 1)
via AMERICAblog is pretty damning.

But we still end up with a system that's based on private insurers that have no incentive whatsoever to control their costs or the costs of pharmaceutical companies and medical providers. ... The Senate bill allows an independent commission to hold back Medicare costs only if Medicare spending is rising faster than total health spending. So if health spending is soaring because private insurers have no incentive to control it, we're all out of luck. Medicare explodes as well.

.... Remarkably, the Senate bill still keeps Big Insurance safe from competition by preserving its privileged exemption from the antitrust laws.


[ Parent ]
WH is thinking (0.00 / 0)
"damn. we just get Dean on board and lose Reich."
[ Parent ]
the 90% provision needs context (0.00 / 0)
With a mandate for people to buy insurance, the pool of insured will go up significantly.  With a larger customer base, and more cash flow, the insurance companies can sustain a lower profit margins (i.e., 90% of revenue paid out as benefits).    
[ Parent ]
January 3 (0.00 / 0)
The House bill with Stupak got 220 votes.  Cao switched only after he knew it got 218.  The margin of error is incredibly thin.  Florida Dem Robert Wexler is leaving on January 3 and the seat will be vacant for three months.  That leaves 219 Democrats seemingly on board for the next 23 days.  Grijalva is voting no.  It's 218-217.  Wexler goes and it is a tie at 217.  No bill, I would think.

No wonder paranoia strikes deep in the Whie House.

[ Parent ]
But did you read the link? (0.00 / 0)
They'd be voting 'no' on things like pre-existing conditions and rescission--if it was structured right. Because a strong public option doesn't run afoul of the Byrd Rule (as I halfway understand it). So you'd be voting to waive the Byrd rule, explicitly to enact protections against rescission, etc.
[ Parent ]
Btw, Mike, what about the most important question: Will Joe vote yes? (0.00 / 0)
Without Lieberman's vote guaranteed, all this discussion is totally useless, and just a wast of time.
This is just way funnier than anything I could make up (4.00 / 2)
DOes anyone else get what you just did? You are now moving the ball yet again.  There is no "done deal" because each time you say "well there will be bill, and any bill is a good bill." Simple question,a nd I want a simple answer: Is there any point at which you think this bill is bad? If so, name the line.  
I think there are two approaches. (0.00 / 0)
The first is to support any bill that improves, however slightly, the current situation. That makes sense. What progressive would vote against progress? And then after supporting a mediocre bill, we'll hope to improve that bill in the future.

The second is to oppose any bill that doesn't make sufficient (however we define that) progress, in the hopes that the progressive willingness to scuttle a mediocre bill now will position us to pass a better bill in the future--one so much better that it overcomes the incrementalism of the first approach.

[ Parent ]
I am not asking the options (4.00 / 2)
I asking the diarist whether he has any line in the sand at all. It sounds like the answer is no. You also leave out an option. A bill is so shitty that it produces no incremental reform, but instead actually makes things worse.  
[ Parent ]
I understood your question. (0.00 / 0)
 
[ Parent ]
Is it possible that you and Lux share the same "line in the sand" (4.00 / 2)
But disagree as to whether the current bill has crossed that line?

Good luck getting a straight answer to your question. I agree it is a critical point. He is very hard to pin down.

"It sounds wrong...
     ...but its right."

[ Parent ]
I want to frame the theatre going on here (4.00 / 2)
Essentially terms are being used, but then meaning is hollowed out.  
[ Parent ]
yeah, well (0.00 / 0)
about that:

bottom line (0.00 / 0)        

A public option. No Snowe triggers, no Conrad co-ops.

Regulations that stop insurers from fucking people over through recissions, pre-existing conditions clauses, lifetime caps.

No Stupak amendment in final bill.






not everything worth doing is profitable. not everything profitable is worth doing.
[ Parent ]
As long as (4.00 / 1)
we have to fight to 60 for every scrap of meat in the bill, but the mandate is safely tucked into the dough, we lose.  Saint Joe and his apostles of no will always keep us from 60 as long as there is any actual reform in the bill.  Why shouldn't they?  The game is rigged this way for their benefit, as long as we play ont heir court it's their rules.

We need to get this to a 51+ vote, any way we can, to negate the effect of these gremlins.  We will not get anything useful with them in the driver's seat, it's just impossible.  And if we can't get an up or down vote, we need to nuke Harry Reid and stop DC until we can get up or down votes on future legislation.

There is just no way to make money when the machine has a rigged payout.  You'll always lose and the more you play, the more certain the outcome.

If only there were (0.00 / 0)
another way forward. Sadly, I can't think of one.
[ Parent ]
Something you wrote last week (4.00 / 1)
is still applicable:

Don't panic, just keep organizing for what you want.

If this is going to be the Democratic Party's version of Medicare D.... (4.00 / 2)
...I want no part of it.  Medicare D is no more than just another open tap for the health care industry, and does its job poorly, if at all.

This is fast becoming just another fig leaf to give more money to them while providing the aroma, but not the fact, of increased health care for those in need.

And frankly, I'm very leery of anything useful coming out of conference.  Given the extreme level of FUD (Fear, Uncertainty, Doubt) that's been going on throughout this process, it's just another level of obfuscation that can be used towards hiding more garbage to be stuck with.

Let this bill die.  Let Lieberman kill it.  Presently, I'd rather spend my efforts taking down the people in my own party who care about the interests of money before those of citizens.

Does (4.00 / 2)
a partial political success lead to disillusionment or does it simply encourage future successes?  I suppose that is the real question here.

In light of this I have been reading a fair about the Civil Rights Act of 1957.  Never heard of it?  With good reason, it was so watered down as to be mostly meaningless.  LBJ is held up to many as the ultimate example of the guy who could win legislative battles, but he was unable to break the Southern Filibuster in 1957.  He simply could not get the votes.

Nonethless, I find this quote from a Time Magazine Story written at the time of the debate interesting:


In this sort of strategic situation, the civil rights forces are bound to keep coming on, this year, next year, year after next, inexorably. Even now Dick Russell's rearguard is fighting from a line set back more deeply in the Southern heartland than ever before. For all of his brilliant strategic success in breaking the back of the civil rights bill of 1957, some sort of civil rights bill, however scrawny, will almost surely be enacted one day soon, and the fact of the passage may, in the long perspective of history, count for more than the substance.

Richard Brevard Russell of Georgia, quiet, able, dedicated defender of the old cause, knows this too. "You're just fighting a delaying action," a philosophical friend in Georgia once observed. "I know," said Dick Russell. "But I am trying to delay it-ten years if I'm not lucky, 200 years if I am." But Dick Russell does not really trust to luck in fighting his Senate campaigns. He believes, as he told his Southern colleagues at their secret caucus, in fighting a "case on the merits." And over the long pull, Dick Russell does not have much of a case.


The right, and even the Rubin retreads don't have much of a case.

So I guess the answer to my question above is whether we will keep coming.

IS THIS "a partial political success" or just another fata morgana? (4.00 / 1)
That's also the question here, and it's still unanswered. Is the bad Joeke on board or not? If not, what the eff are we talking about? Just pipe dreams!
[ Parent ]
The Civil Rights Act (4.00 / 2)
of 1957 was far more meaningless than the hcr that is being debated.  So the analogy suggests hcr's passage is likely to increase the pressure for further changes to the health care system.

But I don't know the answer, and there damn sure is no one around like MLK to make sure we keep coming.  

[ Parent ]
civil rights were part of a movemnet (0.00 / 0)
healthcare is not. There was not a decades long gap in the struggle. Brown v board had just happened.  the strategy had been on going for years before that. The civil rights act of the 1960s were  the result of a continous process that is not present here. Health care reform  is being touted as the final solution not one that is part of a larger moment.  
[ Parent ]
there has been a continuous process (4.00 / 1)
just because it's not covered here, doesn't mean it's not happening. not there yet, but movements don't sprout up full grown, they take years, usually decades of work. social movement politics isn't measured by a 2 year election cycle.

here's some info and links if you are interested (i especially recommend the first of the 6 part series in bold):

INTERVIEW: Dr. Andy Coates

...what happened this year was really remarkable and very positive. How many people are on full-time paid staff for single payer in the whole country? Less than a dozen or so, if that? Yet, there was a year of sustained mobilization, starting before Obama's election, that grew and grew, from local, volunteer organizing.

The AFL-CIO convention passed a resolution this fall that endorsed single payer and the broader concept of social insurance, building on support for HR 676 within the unions. And then the Democratic Party leadership had to maneuver and spin all year long, trying to keep single payer off the table.

Mobilization for Healthcare for All

Two-thirds of Americans support Medicare-for-all (#1 of 6)
Two-thirds of Americans support Medicare-for-all (#2 of 6)
Two-thirds of Americans support Medicare-for-all (#3 of 6)

daily Articles of Interest
Single-Payer National Health Insurance Resources

this is just a fraction of recent info, but i'll stop for now. plenty of places to get plugged in to help if that is something you are interested in being part of.

[ Parent ]
Because the more time progressives spend now putting lipstick on the pig... (4.00 / 1)
...the higher will be the disappointment if Joe Lieberman comes along with is 12 gauge and shoots it!
[ Parent ]
I'm not worried about hitting the wall repeatedly until it breaks... (4.00 / 1)
...I'm worried about health care legislation that will do little more than reinforce the wall we need to break through, and I fear that we will end up doing just that, as we did do under Republican leadership with Medicare D.

My question, with respect to Johnson, is whether we can learn any lessons from his passage of Medicare and apply them to our present quandary.  If not, then I think we need to make it clear to our political leadership that they are failing us, those who elected them, and that runs from Obama, whose leadership on this issue has been minimal at best, on down.

If that means letting a bad bill die (and frankly, I believe nothing less than a multi-million march, perhaps a "sit-down strike on the Mall", on Washington DC, with complete, continuous coverage and display throughout of those who are suffering the most in our collective faces, day after day after day, will prevent this bill from being both further watered down and reinforcing the present untenable situation), then let it happen and put some real fear into our political leadership.  

Better yet, to make it clear to them in no uncertain terms - lead, or get out of the way.

[ Parent ]
What is Lux asking for? (4.00 / 2)
For us, the helpless spectators, to cheer him on in his pathetic efforts.

I am age 61.  Without subsidy, the Medicare buy-in would be useless.  Kill it.

bruhrabbit's question is a good one, but we know the answer.

Full Court Press!  http://www.openleft.com/showDi...

before and after (0.00 / 0)
At the end of the day, as unfortunate as the overall public option defeat is, if we can get Medicare buy-in for 55-64 year olds, expansions in coverage for children and youth through S-CHIP, major expansions in Medicaid coverage, decent subsidies for the uninsured to buy coverage in a more competitive marketplace, and strong new insurance regulations, that would be a pretty remarkable accomplishment.

Admittedly, when it comes to crony capitalism in the revolving doors between New York and Washington, I don't see the glass as either half full or empty---I see it shattered on the floor in a thousand pieces, the water long since sopped up by those who can most afford to fleece it from the rest of us.

Suppose, hypothetically, all of the things above happen. In other words, they are all in the bill that Obama signs into law.

But what happens when the words in the legislation become parsed by the reality of how they are put into practice down on the ground of actual healthcare transactions? Who polices the inevitable gaps between rhetoric and reality?

For example, take "strong insurance regulations". Suppose the bill decrees that insurance companies will not be permitted to refuse people coverage for "pre-existing conditions"---but they are permitted to charge them double or triple [or more] for the premiums?

See what I mean? The legislation can say one thing while in fact the reality will actually be the exact opposite. People can't be turned down for insurance, but they can't afford to buy it. How much of this sort of bullshit will we see down the road?

for instance (0.00 / 0)
the so-called ban on recissions

the "more competitive marketplace" between 3 or 4 large companies, who certainly won't be colluding on prices in any way, absolutely not. it's just the Ineluctable Logic of the Marketplace that causes us to all raise premiums by more or less the same amount every year.

the subsidies that, until they are cut, are only linked to increases in general inflation, not in the costs of the premiums they subsidize. so that will work well.

etc etc etc. it's a fine bill. or, it will be, when it actually exists.

not everything worth doing is profitable. not everything profitable is worth doing.

[ Parent ]
from Jon Walker on FireDogLake on reimbursement cap (0.00 / 0)
The AP is also reporting that there is talk about "fixing" the reimbursement "problem." The reason Medicare is such a cost-effective program is due to its ability to use its large size to negotiate very good rates. The lower reimbursement rates are a-cost controlling feature, not a bug. Remove that advantage, and Medicare buy-in becomes dramatically more expensive.

Now, if the "fix" was to just have this group of people reimburse providers at Medicare rates plus 5%, that would be a pure giveaway to the doctors and hospitals, but at least a workable program. If the "fix" were to use "negotiated rates," that is when things all start falling apart. You can't really have negotiated rates with providers without allowing providers to opt-out of the Medicare buy-in program, but stay in the Medicare program. Given the small number of people able to use the program, it will not be able to negotiate rates that are nearly as good.

This change would result in this fake Medicare program having much higher premiums and a smaller provider network. It would also result in greater administrative overhead. This fake Medicare would lack almost all the benefits of Medicare. A Medicare buy-in program that does not actually allow people to fully buy into real Medicare is a farce. Beware: it looks like we are about to get fake Medicare for Christmas.


It gets more and more pathetic.  Back to the question.  Is there any healthcare bill Lux wouldn't support?

Full Court Press!  http://www.openleft.com/showDi...
basically, medicare buy-in is a decoy (4.00 / 1)
It's being floated about as a balloon for liberalists like Mike lux to play with, hoping it'll somehow, someway stay afloat to take attention away from the lead ball, perched and ready to drop. The brilliant idea here was to give a bone to liberal advocates to chew on, thus preventing a full court press bemoaning the loss of the public option. It buys "them" time. Them being the pass-any-bill, as long as it has mandates and cuts to medicare built-in.

The politics of HCR is everything. The substance is ephemeral - there you see it, there it's yanked away. as people in the progressive camp become enamored with the words "medicare buy-in", getting busy churning out one rosy scenario after the other -none having much to do with the bill as it'll come out . Does anybody really think that conservadems have good intentions? they have political intentions bought and paid for by those who fund their campaigns. And that should be all we need to watch and analyse, not some wishful scenario.

The sooner we start looking at reality, the better, which dictates that we ask - not what's the least we are willing to accept but what's the most "they" (insert favorite power-that-be) are likely to give. The answer - for the realist - is very little. That should make the entire debate here a lot easier, because our decision then becomes purely political as well - are we willing to support a bad bill, in the interest of denying the republicans a victory?  

[ Parent ]
Better or Worse | 36 comments
USER MENU

Open Left Campaigns

SEARCH

   

Advanced Search

QUICK HITS
STATE BLOGS

Home | RSS/XML Feed | Register | Contact

  © OpenLeft 2007-2010, Powered by SoapBlox

Powered by: SoapBlox