Politics: On the So-Called Summit

TORONTO, ONTARIO - Presumably, others will better cover the political aftermath of the so-called "Health Care Summit" held in Washington, DC earlier today, not that much appears likely to come of it. I want to offer just three points.

First, Wyoming senator John Barrasso obviously did not watch the NTV interview with Newfoundland and Labrador premier Danny Williams available at this web site. Williams made it very clear that he was satisfied with the provincial health care that had found his heart problem and offered him options for addressing it. He chose to take the option of going to the United States because he was in a hurry and wanted to minimize recovery time in order to get back to work. Basically, he was an elitist--he spent extra money to get a world-class procedure. Did the Wyoming Republican really want to emphasize costly, discretionary procedures, such as that obtained by Williams in the US?

Second, and following closely from that point, I don't understand why more isn't made of the fundamental contradiction in the Republican argument about quality of care. They go off about the United States having the best health care system in the world, and then say they want to focus on cost control. Why do the people that live and breathe the free market not seem to understand that "you get what you pay for." If one doesn't fundamentally reform the system (say, to a single-payer system that minimizes overhead), the only way to reduce costs in a fundamental way is to avoid expensive procedures and minimize payments to health professionals and providers. Yes, liability reform would help at the margins (and I wish the Democrats would include it in their proposals just to get it off the table, even if it isn't a panacea), but fundamentally, the only way to make the system less expensive while maintaining the health insurance industry is to pay less for it. Pretending that won't affect quality is disingenuous.

Finally, I am greatly disappointed with the media coverage of this event. Granted, I didn't sit through the hours of what might best be described as bickering, but most coverage sure didn't even try to get at the substance of the day. Even CBC radio and television, as well as the commercial networks, focused on the silly exchange between President Obama and Senator McCain in which they referred to the election being over. In video coverage, only the the PBS NewsHour chose to air any of the few moments of agreement during the day and generally tried to capture the strongest points raised by both sides. Is there really only one outlet for real journalism left in North America?

Politics: Will Health Care Reform Happen?

TORONTO, ONTARIO - In an unusual Saturday session, the United States House of Representatives actually passed a health care reform bill, the so-called Affordable Health Care for America Act, on 7-November-2009 by the narrow margin of 220-215. Much of the media discussion has focused on the immediate challenges for the health care reform effort, namely trying to find a compromise bill that can actually pass both the House and the Senate. However, I think the long-term challenges for the bill to actually be implemented may be much greater, and I find it surprising that nobody is talking about that reality.

The first thing that strikes out at me is that the bill passed by the House has most of its provisions actually take effect in 2013. Having time to transition into a new system, rather than creating problems by shocking the system, makes sense. However, looking at what has happened with recent credit card legislation is instructive--credit card companies used the time before the new rules took effect to drastically hike fees and rates on customers. Health insurance companies, who have in a very real sense only been held in check by the threat of reform, will no longer have any reason to hold back on increases, and will try to make all the money they can before 2013.

Of course, there are two elections before 2013. If Republicans are smart, they will campaign in 2012--however untruthfully--that health care premium increases in 2010, 2011, and 2012 were the fault of health care reform and promise to repeal the legislation. It seems entirely conceivable to me that this could be an effective campaign theme and lead to Republican majorities in the House, Senate and retaking the White House in 2012. While it would be very difficult for the Republicans to get a filibuster-proof 60 seats in the Senate by 2012, a clear landslide in their direction would probably bully the Democrats into not filibustering, and repeal could occur.

Even if the Democrats hang on to at least one chamber and prevent repeal of the legislation before it takes effect, there is another method that the opposition will undoubtedly use. Christian Scientists will be supported in what, based on the current legislative language, will be an inevitable effort to have the act declared unconstitutional. They will argue that it is unconstitutional for the government to require them to purchase an insurance policy that is of no use to them, as they do not partake of most health care services. Whether a valid constitutional argument or not, I would fully expect the current conservative-dominated Supreme Court--likely still to be in place when a hypothetical case might get there--to use the case as an excuse to issue a very narrow ruling overturning the legislation.

Those on the right go to great lengths to support their positions politically, showing in my lifetime a take-no-prisoners, no-compromise attitude that liberal Democrats frankly do not understand. If supporters of health care reform think they will not face that kind of action-oriented opposition even after legislation is passed, they are insane. They need to ensure that in their immediate efforts of trying to write legislation that can actually pass both chambers that the resulting language will stand up to a court challenge and cannot easily be reversed in early 2013. Otherwise, all their current efforts will have proven to be an incredible waste of energy.

Radio Pick: Other People's Money

TORONTO, ONTARIO - This week's radio pick continues a series of picks on health care. Sometimes good story-telling and analogies can really help to gain insight on a complicated issue. One of the best story-telling shows on the radio today is This American Life from Chicago Public Radio, which this week teamed up with NPR News for a Planet Money report on the health care system in the United States. Analogies with "food care" (think "universal food coverage") and with the growing pet insurance industry really drove home some points about health insurance reform in the United States in this 59-minute program.

Listen to streaming MP3 of This American Life "Other People's Money"

Radio Pick: Frist and Dean on Health Care

TORONTO, ONTARIO - In a week of "progress" on health care reform in the United States, it seems appropriate to pick out for my weekly radio pick an intelligent discussion of the topic aiming for finding compromises. Such a conversation occurred when doctor-politicians Bill Frist and Howard Dean appeared on WBUR's On Point. Not only was the discourse civil in the 45-minute program, but the two actually appeared to agree or be in striking distance of agreeing on a number of points, something rare in radio coverage of the topic of late.

Listen to MP3 of On Point "Frist and Dean on Health Care"

Politics: What Health Care Do You Want?

TORONTO, ONTARIO - There is a sizable contingent of people in the United States that claim to be satisfied with their health care plans, if we believe the polls. I simply don't understand that. Have they not noticed the decrease in the quality of their medical plans (or increase in cost) in the past decade?

The last time that I was actually satisfied with my health care plan prior to moving to Canada was in 1998. I was still in college and underage, so I was covered by a parental health care plan. As I was living outside of my parents' home state, an inter-HMO agreement for students was invoked and I found myself covered by Blue Cross Blue Shield of Massachusetts. One form submitted set up this coverage. I then received a welcome package in the mail, and with one phone call selected a primary care physician. I only visited that doctor once in a year (I think related to an upcoming foreign trip), and that visit cost me $5 in co-payments. My parents probably didn't get their money's worth for covering me that year, but had anything serious happened, co-payments would have been minimal and I'm certain the medical system around Boston would have treated me well.

In the private sector, I never had a decent health care plan. I never paid very much for myself (most of the time, I paid nothing, and I think not more than $120 a month at my last job in the US in 2005), but that was not true of my peers with larger family. A peer at my last job was paying nearly $1200 a month to cover a family of four. Compare that with a maximum charge (for people making more than $200,000 a year) in the province of Ontario of $900 per person per year; most people pay about half of that.

Far more galling than the cost was decreasing amount of benefits. Well removed from the $5 co-payments of my youth, my last health care plan had a $5000 annual deductible that had to be met before it would pay anything. Prescription drugs, of course, were on a separate deductible of similar magnitude (I don't remember the exact number). Basically, unless I was hospitalized at some point during the year, the plan wasn't going to pay anything. It amounted to catastrophic health insurance (and, in fact, it wasn't really that, as I believe it had a $100,000 cap over which it paid nothing).

I thought this plan was pretty awful. However, when I talked to a nurse during a physical in 2005, I found out that she had a $1000 annual deductible. My plan may have been with a Paid Provider Organization instead of the Health Maintenance Organization (HMO) that had run the 1998 plan that I liked, but HMO benefits had declined, perhaps not quite as dramatically, based on conversations I've had with friends and family, even those who are public employees.

Does anybody remember what health care plans were like as late as the 1990's? Perhaps a few people working for large businesses still have such plans, but certainly not the 84% of insured people who claimed to be satisfied with their plans in a recent poll, never mind the 18% of those under 65 who don't have any health insurance at all. Have people lost their minds, or have their expectations been so lowered that they are happy to have any insurance at all? I don't understand.

Radio Pick: Real Death Panels

TORONTO, ONTARIO - This week's radio pick is a short-form piece. In the recent mainstream media explosion over the "death panel" misinformation being spread by opponents of health insurance reform, very few have made the point that such death panels already exist, they just aren't run by the government. It was left to talk show host Dave Ross to report on this insurance company reality, brought out in this minute and a half commentary that ran on the CBS radio network.

Listen to MP3 of Dave Ross Commentary "Real Death Panels"

Politics: A Health Care Mess

TORONTO, ONTARIO - In case you missed it, Nate Silver has one of the most amusing explanations of the difference between the Canadian and British health care systems I've ever seen. The only problem with making this distinction is that it isn't particularly relevant. As much as I personally might like a Canadian-style single-payer system, no current bill in Congress (of consequence, anyway) proposes one any more than they propose a British-style, government-run health care system. All are modifications of or additions to the existing privately-run health insurance systems.

As plenty of others have pointed out, the problem in trying to defend the attempt at health insurance reform in the United States is that there is no single proposal or even set of clearly leading proposals to defend. While a few things (like a government-run health care system, or a single-payer system) are clearly not in any bill, it really isn't clear what provisions will be in what passes through Congress. Thus, it is not possible to defend provisions--or even decide if the overall package is worth defending. At this point, it is possible that a bill that would genuinely improve the situation for most US citizens will emerge, but it is also possible that a really bad bill might emerge.

For reasons already discussed, the Obama administration has made the decision to let Congress write the health care legislation. In doing so, they have run into what New York Times columnist David Brooks warned about before the process started--that genuine health care reform could only take place after campaign finance reform, as otherwise special interests would ruin the process. About a month ago, Brooks expanded this idea to contrast "legislative pragmatism" with "policy pragmatism," making the case that trying to create legislation that would pass was at odds with creating policies that would actually work.

Perhaps much as Obama has tried to learn from the failure of the Clinton administration to pass health care reform, during this August recess his administration will come to see their own potential failure in favoring legislative pragmatism. If Obama rises above the current legislative mess, says something to the effect of "Congress did the ground work, but now it's time for me to build on their good work and present a bill we can all rally around," then perhaps a coherent, defensible bill that might pass will still emerge. However, that takes leadership from the White House that has yet to be seen in this administration. For the sake of actually improving the health care insurance system, instead of just expensive fiddling with it, I hope that happens.

Politics: Another Lesson from 1994?

TORONTO, ONTARIO - During the 1994 push for health care reform in the United States, Representative Jim Cooper, a then-relatively junior Democratic Congressman from Tennessee, impressed me by bringing forth an alternative to Clinton administration's reform plan. Cooper's bill, which some dubbed "Clinton Lite," more closely approximated the "managed competition" model that I thought at the time was most logical reform path. More importantly, Cooper's bill had at least limited bipartisan support. Some people believe that if President Clinton had shifted course and put his weight behind the Cooper bill instead of sticking with the plan his administration had proposed that the bill might actually have passed, and the United States would have a very different health care environment today.

Much has been made of the Obama administration's careful attention to past mistakes in health care reform initiatives in today's effort. His administration has tried to control the language, referring to a "public option" as the core of his vision, responding to the past attempts by opponents to talk about "governments" and "mandates," implying a government-run health care system that has never polled well in the United States. Rather than presenting his own plan to Congress as Clinton did, Obama has left it up to Congress to actually write the legislation. Finally, Obama has looked back to the Lyndon Johnson administration's fast passage of Medicare after an election as a model for the timing this time, which is why he is pushing so strongly right now for passage of a bill.

Oddly, Jim Cooper this time around has called on Obama to slow down, perhaps not heeding the lesson from 1965. However, Cooper may again be seeing through the practical politics of Congress. He does not support the bill that seems to be emerging from the House leadership, but instead that of Senator Ron Wyden of Oregon. In many ways, Wyden's proposal, called the "Healthy Americans Act," is reminiscent of the 1994 Cooper bill as it emphasizes health care plan portability in a private system without the "public option" that Obama has been touting. As described on Wyden's web site, the emphasis is on requiring private companies to accept people into their plans, and on cost containment, an element that does not seem to be emphasized in what is emerging from the Democratic party leadership. Most importantly, though, the Wyden bill has bi-partisan support. As pointed out by political blogger Nate Silver, the Healthy Americans Act not only has drawn support from centrist Republicans, but from all over the political spectrum.

The Healthy Americans Act of 2009 may be the Cooper bill of 1994--an alternate proposal that could pass if the president throws his weight behind it. It would require Obama to give up on the "public option" that he has been touted, but considering that the worst problem with the US health care system is cost containment and most analysts think the Wyden bill addresses that better than other proposals, there seems to be reason for him to change course. Has Obama learned this lesson from 1994? We'll have to see.