The Future Of Health Care Reform

Harold Meyerson writes:

Not to be difficult, mind you, but what is it that the Democrats see themselves running on in the next 75 days -- or, for that matter, the next two years? Health-care reform? Since many of its benefits don't kick in until 2014, it exists in the minds of millions of Americans chiefly as a nebulous threat.

Jacob Hacker writes:

Sen. Tom Harkin put the point well when he described the health bill as a "starter home." What Harkin neglected to mention is that the home isn't built yet, and the construction zone is in the path of a hurricane -- the fast-approaching storm of runaway health costs and hard-core conservative opposition. In the face of these challenges, reformers have three great priorities: implementing the law, protecting and defending it from the already-mounting attacks, and renovating and improving Harkin's "starter home" to make it a sustainable structure. The next health-care battle will require organization, narrative, and strategy at least as much as the last did. And this time, reformers will need to call plainly for a greater government role -- armed, if they take their three big tests seriously, with concrete examples of government getting things right.

Atrios comments:

I think it's fair to say that HCR as passed is a potential path to a path to a better health insurance system, but absent a public option or similar there's no guarantee that we're actually on even the path to the path yet. A public option would have been the simple fix to a lot of potential problems, and also would have been quite difficult to take away.

What is the potential political path to the potential path that Hacker recommends? One of the debates about the health bill was whether it provided such a political path. At best, the path is murky and dubious.

But the bigger question is whether Democrats and progressives even agree that a "greater government role" is critical to health care reform. For all the sturm und drang about firebaggers and whether the health bill was the biggest progressive accomplishment in 30 years, lost was the fundamental issue that people disagreed about the POLICY. While much invective was hurled, in both directions, very few acknowledged that the Ezra Klein/Jon Cohn axis really did not care about "greater government involvement" in health care and health insurance in the form of expanded public health insurance. Ed Kilgore was the exception:

[The Obama Administration exchange] approach was inherently flawed to "single-payer" advocates on the left, who strongly believe that private for-profit health insurers are the main problem in the U.S. health care system. The difference was for a long time papered over by the cleverly devised "public option," which was acceptable to many New Democrat types as a way of ensuring robust competition among private insurers, and which became crucial to single-payer advocates who viewed it as a way to gradually introduce a superior, publicly-operated form of health insurance to those not covered by existing public programs like Medicare and Medicaid. (That's why the effort to substitute a Medicare buy-in for the public option, which Joe Lieberman killed this week, received such a strong positive response from many progressives whose ultimate goal is an expansion of Medicare-style coverage to all Americans).

Now that the public option compromise is apparently no longer on the table, and there's no Medicare buy-in to offer single-payer advocates an alternative path to the kind of system they favor, it's hardly surprising that some progressives have gone into open opposition[ . . .]

To garner support of public insurance reform advocates, there was the promise of a "next time." Hacker, who supported the health bill, accepted that promise. And his article is indicative of that. Many advocates for the health bill (the Klein/Cohn axis) really do not care if there is a next step for public insurance reform. their goal is an expansion of the exchanges - in essence full implementation of Wyden-Bennet.

The fundamental question is does public insurance reform really have a near term political future? I think the answer is decidedly no. Further expansion of the market based exchange reform is obviously the most likely path for further reform.

The expansion of Medicaid eligibility in the health bill is the end of the line for expansion of public insurance reform for the foreseeable future. Frustrated advocates for this approach were, as Kilgore forthrightly acknowledges, not wrong to complain about the health bill.

The Klein/Cohn axis won the battle of health care reform in the Democratic Party. They should be pleased. Their demand that EVERYONE be pleased however, is wholly unreasonable.

Winners celebrate. Losers commiserate. That's the way of the world.

Speaking for me only

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    I haven't looked into the (5.00 / 2) (#1)
    by andgarden on Wed Aug 18, 2010 at 09:25:52 AM EST
    mechanics of this, but does anyone believe that it will be easy to fund the subsidies if the Republicans have even a little bit more power in Congress?

    I have a suspicion that we won't even see the starter home built.

    That will only make the bill better! (5.00 / 1) (#3)
    by observed on Wed Aug 18, 2010 at 09:37:16 AM EST
    because the theory won't get tested by reality.

    The Republicans have already said (5.00 / 5) (#5)
    by MO Blue on Wed Aug 18, 2010 at 09:40:57 AM EST
    that they would not fund it if they get control of Congress. They don't even have to become the majority party as there are enough Dems willing to vote for their policies.

    I have said all along that there was a real possibility that what little good is in the legislation could be stopped but elements like the cuts to Medicare and excise tax on good policies left in place.  


    The thing is, even if (5.00 / 5) (#8)
    by dk on Wed Aug 18, 2010 at 09:49:48 AM EST
    huge Democratic majorities remained, it is likely that the subsidies would not be able to keep up with the ruanaway rise in healthcare costs that are assured by the continuance of the poorly regulated private model that the democratic leadership supports.

    Of course, the democratic leadership will point to republicans and "conservative democrats" as the bad guys (and, of course, they are bad guys), but that it really a red herring for the obvious outcome of flawed (for most Americans, at least) policy.


    "Subsidies would not be able to keep up (5.00 / 4) (#15)
    by MO Blue on Wed Aug 18, 2010 at 09:59:22 AM EST
    with the runaway rise in healthcare costs."

    If current actions are an indication of future actions, the Dems would initially just use it as an excuse to gut other "safety net programs." Once they are all underwater, whichever party is in charge could truthfully says that they are not working and eliminate them.


    Yup, I think that's (none / 0) (#20)
    by dk on Wed Aug 18, 2010 at 10:16:27 AM EST
    what they would do too.

    Excise tax! (none / 0) (#10)
    by andgarden on Wed Aug 18, 2010 at 09:50:55 AM EST
    . . .they would say.

    The most miserable part about all of this (none / 0) (#9)
    by andgarden on Wed Aug 18, 2010 at 09:50:14 AM EST
    is that a comeuppance for the Democrats will inevitably make things worse.

    A starter home designed by people (5.00 / 3) (#16)
    by observed on Wed Aug 18, 2010 at 09:59:24 AM EST
    who live in gated communities. Klein et. al. never had their eye  on the ball, which was to ensure that health CARE be available to people who lack it now.

    Yeah (none / 0) (#27)
    by lilburro on Wed Aug 18, 2010 at 10:59:09 AM EST
    I asked this question during the debate and was told once something popular is in place like that, it is hard to take away.

    Now, will it even have time to get in place?


    Klein/Cohn axis won the battle (5.00 / 9) (#2)
    by MO Blue on Wed Aug 18, 2010 at 09:35:45 AM EST
    and everyone including the Democratic Party lost the war. Democratic claims that the health bill was the biggest progressive accomplishment in 30 years have not helped them in the polls or in convincing the majority of voters that this legislation was good policy.

    IMO the decision to spend so much time to produce so little was a poor one. The time would have been better spent fighting publicly for real ways to create jobs here at home for American workers.

    I agree (none / 0) (#4)
    by Big Tent Democrat on Wed Aug 18, 2010 at 09:38:05 AM EST
    When one attempt at reform fails by (5.00 / 5) (#24)
    by Anne on Wed Aug 18, 2010 at 10:31:30 AM EST
    not even getting off the ground, and the next attempt fails because it was based on bad policy and does not provide the benefit to those who really need it, what are the chances the "losers" will ever be given a third opportunity?

    And how would that effort be championed - "This time, we think we can get it right?"

    Not bloody likely.

    And this is something the single-payer/Enhanced Medicare For All proponents knew going in - that this was probably going to be the last chance to truly bring reform to the system, bring down costs and improve access and affordability - and that if the Dems didn't get it right, not only would that adversely affect the people themselves, but would forever brand Democrats as totally incompetent on health reform.  In other words, we would be worse off than ever.

    Medicaid expansion is great, but it doesn't jibe with the target the Cat Food Commission has on it, on Medicare and Social Security; if you expand the number of people who can participate, but reduce the benefits available, it seems like the embodiment of "Hey! It's better than nothing!"

    Meanwhile, of course, more and more people are sliding into poverty because the Obama administration and the Congress have failed on the jobs front; when you hear that health care costs going down recently is proof that the reform is already working, don't listen: health care costs have gone down because more people cannot afford to access it.  

    It isn't just the future of health reform that looks bleak.

    People not accessing health care because (5.00 / 3) (#26)
    by MO Blue on Wed Aug 18, 2010 at 10:47:25 AM EST
    they cannot afford to access it is one of the features built into the "new, improved, progressive insurance system."

    First error was not (5.00 / 1) (#30)
    by KeysDan on Wed Aug 18, 2010 at 11:21:39 AM EST
    working for Medicare for all. Disregarding that reasonable objective, the second error in extension of health care was to include "reform" of Medicare when most of what was needed to streamline the program is now and can be further  accomplished by pilot programs and new regulations.

    Of course, the reason for its inclusion was to finance about half of the costs ($500 billion) of the health care for those under 65 and avoid new taxes. The ways and means to capture Medicare "savings" so as to support the new program to that extent has not, to this day, been fully articulated.  The argument that the president and Peter Orszag  did set forth, that cutting health care spending would make people healthier, was based, in large measure, on the Dartmouth Atlas.

    As I commented on at the time, the Dartmouth Atlas seemed more polemic than research.  At best, its conclusions were being misinterpreted.  Since passage of the act the Atlas has been challenged for its  statistical evidence, including not adjusting for price and cost of living differences around the country and not taking into account care that prolongs or improves life (the authors, Fisher and Skinner do a much better job in their refereed publications, e.g. Annals of Internal Medicine).

    If this was not enough for "cost savings", Medicare continues to be in the sights of the Cat Food Commission.  Moreover, inclusion of Medicare in extension of health care reform served to fuel and support the demographics of the tea party movement with misunderstood threats (keep the government out of my Medicare) and fears of "death panels".

    Yes, when reform is still "just words" (5.00 / 1) (#31)
    by Cream City on Wed Aug 18, 2010 at 11:26:36 AM EST
    it hardly makes for a good campaign slogan.  

    The accomplishment so far is that Congress voted.

    Now, getting Congress to do its job may seem like a heckuva campaign slogan inside the Beltway.  But for millions looking for jobs as well as millions with them, who are working more to make up for all of those laid off, and who are making less, it hardly is a winner to boast that the Dems showed up for work.  And that what they did at work will start working for the country years from now.

    As the saying goes, that's "nice work if you can get it."  Now, we will see if they get to keep it.

    I don't see it that way (none / 0) (#6)
    by seabe on Wed Aug 18, 2010 at 09:46:06 AM EST
    I've always thought Cohn/Klein to be more of the mind of digby. I'm not sure that I'll be able to find her post, and I haven't looked for it and don't plan to, but I specifically remember her saying that she did not care which direction we went in because other countries have shown prominence in both methods of delivering care. I always thought Cohn/Klein shared this view; in that they're not against expanding public health insurance, nor even single payer (correct me if they've specifically stated otherwise), this is what they saw on the table and advocated in favor of it, as it's worked in other countries.

    Ah yes (5.00 / 3) (#7)
    by andgarden on Wed Aug 18, 2010 at 09:49:01 AM EST
    "we're just like the Netherlands/Switzerland!"

    All of these people are smart enough to see the difference between what we pass and what the other countries have.


    We're clearly not even close (none / 0) (#11)
    by seabe on Wed Aug 18, 2010 at 09:51:33 AM EST
    to what they have, but it could be, and that's their point. I'm not arguing that this is the best method, as I would prefer Britain's method--cheapest model for the best care ratio--but I shared digby's sentiments: there are clearly other models that can work.

    Frankly, I'm happy (5.00 / 1) (#12)
    by andgarden on Wed Aug 18, 2010 at 09:53:19 AM EST
    getting that model to "work" in this country is about as likely as getting Congress to pass Medicare for all. Which is to say: we're right back where we started.

    Fair enough. (none / 0) (#13)
    by seabe on Wed Aug 18, 2010 at 09:57:23 AM EST
    Er, delete "I'm happy" (none / 0) (#14)
    by andgarden on Wed Aug 18, 2010 at 09:58:26 AM EST
    ?????? "Not happy?" (5.00 / 1) (#29)
    by oculus on Wed Aug 18, 2010 at 11:09:38 AM EST
    P.S.  What the heck is a "New Democrat?"  

    New Democrat (5.00 / 2) (#48)
    by cal1942 on Wed Aug 18, 2010 at 08:20:28 PM EST
    What we called a Republican 40 years ago.

    From my comment (none / 0) (#43)
    by andgarden on Wed Aug 18, 2010 at 02:05:23 PM EST
    it was an autocomplete error.

    "New Democrat" always meant 90s Clintonism to me. But frankly, I don't think it has a set definition.


    Since Switzerland has no Medicare program either (none / 0) (#18)
    by Dan the Man on Wed Aug 18, 2010 at 10:11:23 AM EST
    as the nytimes points out:

    Unlike the United States, where the Medicare  program for the elderly costs taxpayers about $500 billion a year, Switzerland has no special break for older Swiss people beyond the general subsidy.

    those who believe the US should be like Switzerland (like Krugman) should be advocating we eliminate Medicare altogether and put the elderly in the magical exchanges like Switzerland does.

    For some reason, Krugman does not support that plan though and instead bashes Paul Ryan for supporting exactly such a thing.  Of course, Ezra Klein is smart enough to realize that for Switzerland/exchange lovers, that's the next logical step:

    In his [Ryan's] telling, his proposal unleashes market forces by pulling people out of Medicare, out of Medicaid and out of the employer-based market. He envisions insurance exchanges and better information on quality and cost.

    I always see these big numbers (none / 0) (#22)
    by jimakaPPJ on Wed Aug 18, 2010 at 10:21:11 AM EST
    re Medicare "costing." In this case the magic number is 500 billion.

    Medicare is funded through a payroll tax, client premiums of around $110/month, deductibles of 20% and entrance fees of $800/hospital visit.

    So what is the "cost?" Is it the total? Is it what the taxpayer/client payments don't cover?

    I think the numbers probably have Medicaid included. And Medicaid has absolutely nothing to do with Medicare.


    I think I said that (none / 0) (#17)
    by Big Tent Democrat on Wed Aug 18, 2010 at 10:00:36 AM EST
    To wit, they did not care about the public insurance reform.

    But they DEFINITELY cared about the exchanges.


    In the meantime the (none / 0) (#19)
    by jimakaPPJ on Wed Aug 18, 2010 at 10:12:44 AM EST
    insurance corps are jacking up the prices because they can:

    1. see the increased costs of mandated coverage.

    2. know they can get away with it.

    The smartest thing the Democrats can do is to run against this ungodly mess. Declare that they will repeal and replace it with a single payer system based on the Medicare Model.

    Will they? Well, no one ever accused politicians of doing the smart thing. Or the best thing.

    BTW - Tracy, TriCare is jacking up the premiums on military retirees. Does that impact you?

    The smart thing to do (5.00 / 1) (#28)
    by Untold Story on Wed Aug 18, 2010 at 11:06:39 AM EST
    would be to actually figure out exactly
    WHY health care is so expensive?

    Next, since it is obvious that health care is the only booming economy today, then the government needs to regulate prices as well as insurance premiums.

    Otherwise we are tossing the ball back and forth in the political arena.


    The sarcastic answer to your question (5.00 / 3) (#33)
    by Anne on Wed Aug 18, 2010 at 11:57:05 AM EST
    is that it's expensive because people actually use it; with a terrible economy, costs will go down because people can't afford to access care.

    A related sarcastic answer is that it's all the lawyers' fault: if not for the frivolous lawsuits, doctors would not have to practice defensive medicine and we could stop ordering all those unnecessary tests.  

    These two things play right into the hands of those who believe that (1) if you can't afford the care, you shouldn't get it and (2) pencil-pushers in cubicles are better guardians of health care than either the providers or the patients.

    "Managed care" has not lowered the cost.  Caps on malpractice awards have not made a dent in costs, either.  Premiums have continued to rise, co-pays have continued to rise - and so have insurance company profits.

    If you want to learn more about why we are in the state we're in, I would suggest you check out www.pnhp.org; yes, they are unabashedly pro-single-payer, but there is a wealth of information that is both eye-popping and mind-boggling.

    And after you survey current conditions and solutions, it will not be hard to figure out why single-payer/Enhanced Medicare For All was taken off the table, shut out of hearings, media coverage and demonized: it threatened the insurance industry that funnels boatloads of cash into congressional pockets, and by extension, the jobs of those same legislators.

    We were had - and worse - expected to stop whining about it and be grateful.


    At this point I'd be happy if all (5.00 / 1) (#45)
    by hairspray on Wed Aug 18, 2010 at 05:56:21 PM EST
    health care providors were non profit and insurance was heavily regulated.

    Thank you - you nailed it! (none / 0) (#47)
    by Untold Story on Wed Aug 18, 2010 at 06:59:06 PM EST
    Sorry, I am totally stunned . . . (none / 0) (#36)
    by Untold Story on Wed Aug 18, 2010 at 12:20:05 PM EST
    Why do you need, not just one, but two sarcastic answers to my question "Why is health care so expensive?"

    Usually volume (since more people are using it) decreases cost.

    Managed care has indeed lowered costs for insurance companies.

    Caps on malpractic made no dents - well, there, again it did.  The insurance companies are able to charge physicans (in turn charged to the patients) more for malpractice insurance coverage as they are not regulated.


    As long as physicians are allowed to participate in profit-sharing of diagnostic centers and hospitals we will see medical care increase, imo.
    (Conflict of interest)

    And, as long, as we have insurance companies having full authorization without any regulations whatsoever, we will continue to see higher health care costs.

    The money may well be going into politicans pockets as well as physican pockets directly from these insurance companies.  However, sadly this is not helping the average Joe on the street.

    Instead we need some honest attention to the rising health care crises and determine that insurance companies and physicians, who seem unwilling to regulate themselves, be regulated by the Federal government.

    Hillary Clinton's health care plan was quite good, but for some reason didn't get passed.

    Members of my family are in the health care 'booming' industry, so, please I hear it firsthand and really do know lots of the inside stuff that goes on between insurance companies and physicians.  It is not a case of one hand washes the other - this is a case of one hand massages the other!  


    Why not just stop feeding the (5.00 / 2) (#37)
    by Anne on Wed Aug 18, 2010 at 12:50:17 PM EST
    insurance industry beast that bears significant responsibility for why we are in the mess we're in - and which Obama's "historic" reform will not be able to control or regulate to the extent necessary?

    Not that the Congress is even interested in regulation; it's not.

    Managed care may have lowered costs to insurance companies, but those savings have not been passed on to patients; if they are getting less care, why should they have to keep paying more for what they do get?

    Insurance companies make money by denying care; the less money that goes out the door, the more they get to keep.  Which is one reason they are fighting to include in the calculation of the new Medical Loss Ratios spending on "care" things that have nothing to do with care.  

    I gave you several sarcastic answers not out of animosity, and not directed to you, personally, but out of frustration with the reality of the entire situation; apologies for upsetting you.


    Sorry, not upset but rather stunned (none / 0) (#40)
    by Untold Story on Wed Aug 18, 2010 at 01:24:08 PM EST
    as you are my 'idol' poster so to speak!  I'd vote for you if you ran in 2016 actually!

    Yes, all of what you say is exactly true.  

    I do not always (or ever, really) express myself well, but that was my thought - everything is going in favor of these insurance companies and their cohorts the physicians.  Whatever costs they incur are passed on to the patients.

    [Perhaps I am a wee bit bias since my name
    is also Ann - without the 'Green Gables' e]


    I'm on board with this idea n/t (none / 0) (#21)
    by PatHat on Wed Aug 18, 2010 at 10:20:38 AM EST
    I agree - I thought Medicare for all was (none / 0) (#23)
    by ruffian on Wed Aug 18, 2010 at 10:27:43 AM EST
    a very winning idea.

    I was left with the conclusion that most pols of both parties (as apposed to the populace) just do not support that level of government-run healthcare. I'm sure if we follow the money we can figure out why not.


    Suggestion: Offer an Exchange buyin for Medicare (none / 0) (#25)
    by Dan the Man on Wed Aug 18, 2010 at 10:36:16 AM EST
    recipients.  Since progressives love the Exchange and think it's awesome, I'm surprised they haven't proposed that yet.

    Hard to have any public discussion on (none / 0) (#32)
    by Farmboy on Wed Aug 18, 2010 at 11:47:09 AM EST
    the future of health care reform when the recent bill is viewed by the majority of people as "Obamacare," that it calls for rationing and "Death Panels" and IRS SWAT teams; is modeled on Canada/UK/Sweden/whatever plans, and other lumps of misinformation.

    That's the biggest reason the issue is a negative for this November: when Democrats talk about The Patient Protection and Affordable Care Act, people say, "Sure, that sounds nice. You should have passed that. But we hate you for voting for the Obamacare instead."

    More problems yet to come (none / 0) (#34)
    by jbindc on Wed Aug 18, 2010 at 11:59:57 AM EST
    With the "Mini-Health Plans"

    One challenge in implementing healthcare reform is that there's a lot of fine print in the Affordable Care Act (ACA). And some of that fine print could subvert the goals of the overall legislation.

    One example -- the subject of a recent Kaiser Health News report -- is the waiver process that would allow insurers to continue offering low-cost, low-benefit plans that don't provide real access to healthcare when the insured become seriously ill. Favored by small businesses and larger companies with low-wage workers, these "mini-plans" have low benefit limits. They may cap the amount the plan will pay for doctor visits or hospital care or may have low overall limits on coverage. For example, some plans will not pay more than $50,000 a year.

    Under the ACA, the minimum annual coverage limit for health plans is supposed to be $750,000 per person, rising to $2 million in September 2012. Ceilings on annual coverage are supposed to be eliminated entirely by 2014. But insurance companies can obtain waivers to keep their mini-plans if they can show that switching to comprehensive coverage would lead to significant premium increases or force employers to drop insurance benefits.

    Insurers and consumer advocates are lobbying the Department of Health and Human Services (HHS) to write rules that would favor their point of view. If HHS takes a liberal stance on waivers, many workers would continue to be bankrupted by high medical costs that exceeded their coverage. But if its regulations are very restrictive, some employers may drop benefits rather than increase them. This will be an increasingly difficult problem as premiums continue to rise, although it's unclear whether the law authorizes waivers after 2014.

    If no waivers are granted (none / 0) (#42)
    by andgarden on Wed Aug 18, 2010 at 02:04:20 PM EST
    people will be forced onto the exchange. It's not a bug, it's a feature!

    Well, I'm glad what was passed will help (none / 0) (#35)
    by vicndabx on Wed Aug 18, 2010 at 12:03:42 PM EST
    rather than hurt.  Here's a novel idea - just because you didn't get exactly what you thought would work, doesn't mean you actually lost out.  I'm not suggesting you jump for joy, but beating one's self up about what you think you lost isn't in order either, IMO.

    Eh? (5.00 / 3) (#38)
    by Dadler on Wed Aug 18, 2010 at 01:00:37 PM EST
    So those who passionately believe they were had, that what was passed is wholly inadequate and skewed once again toward corporate profit, they should, what? Not keep agitating for their beliefs and strongly held values on this issue?

    We're supposed to remember: (5.00 / 2) (#39)
    by Anne on Wed Aug 18, 2010 at 01:04:31 PM EST
    "Hey! It's Better Than Nothing!" and be grateful they even tried.

    Better yet (none / 0) (#41)
    by coast on Wed Aug 18, 2010 at 01:48:25 PM EST
    "It was Bush's fault" and smile.

    No (5.00 / 1) (#44)
    by jbindc on Wed Aug 18, 2010 at 02:06:18 PM EST
    "At least it wasn't the other guy who got elected!"

    (Right up there with, "You may have a black eye, but at least he didn't break your nose!")


    Considering the fact that the Ds are working (none / 0) (#46)
    by BTAL on Wed Aug 18, 2010 at 06:48:35 PM EST
    to repeal a major funding source of HCR - the 1099 requirement for all business purchases over $600, how is this going to maintain the deficit neutral and/or deficit reduction status?

    The other major political slight of hand that the D majority is also being caught out on is the intentional avoidance of the Medicare "Doc Fix" costs.  That 3 card monte, even with the ~3 month past the election date fix, will come back to bite.