Posts tagged ‘health care’

The Failure of Institutions

By , 26 December, 2009, 2 Comments

Another round of reader requests led to the following reflections on 44’s latest moves on two issues near and dear to me: health care and climate.

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Health Care: A Reader Request

By , 27 October, 2009, 1 Comment

A reader emailed yesterday asking what I made of Harry Reid’s decision to bring the public option back from the dead, and whether I could explain the politics and policy in lay terms. Here’s what I wrote [some day-after edits in parens]:

Basically, the various committees in the Senate and the House have each developed their own bills, which have passed the committee’s own votes. Harry Reid, as Senate leader, gets to take those bills and combine them into a NEW bill, which the whole Senate then votes on. It has to get 60 votes to pass a [procedural] barrier called cloture. Basically, 60 Sens vote for it, and after that, the Senate has 30 hours before it has to pass the bill or not. During those 30 hours, they can consider amendments relevant to the bill but cannot consider any other policy matters. And on those amendments, only 51 votes are needed.


Once the full Senate passes the bill, that version goes back to the House, where they can either pass it as is, OR if they tweak it too, the full Senate has to re-vote on it. That can be dangerous, because the House is further left than the Senate and is likely to add things the Senate won’t pass. So Reid is likely to try and manage the negotiations such that the Senate votes on the bill in a form the House can quickly pass and send straight to the Prez. It seems that the Schumer opt-out version of the pub-op is the one that can potentially get through both House and Senate.

How can it get through the Senate? Two ways–either Reid knows of a few senators who will vote for it but haven’t said so yet, in which case, he writes it INTO the bill he brings to the floor and it gets 60 votes at cloture, after which they tweak/amend some and its over. OR he can only get the 50+ votes for it we know about right now in which case he DOESN’T put it in. They get 60 votes cloture on a bill sans public option, and then introduce the pub-op AS an amendment, at which point they only need to get 51.

On the policy of this [opt-out] version of the pub-option: I’m not a fan but it’s better than the Snowe trigger compromise.

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Must See TV

By , 8 October, 2009, No Comment

I have mixed feelings about cable opinion anchors. I find their shouting and character gimmicks infuriating, on left and right, but I think at least in the world of American TV news, they do longer segments that let them spend more time on issues they care about than their ‘straight’ news counterparts and I value that in a soundbyte era. [I also agree with Dan Drezner that talking head shows were actually better when left and right yelled at each other than they are now, yelling at themselves]

That said, I don’t watch Olbermann or O’Reilly, Matthews, Dobbs or Kudlow unless I’m at the gym and need distraction. However, I heard on the grapevine that Olbermann would be devoting a whole hour to an opinion talk—a ‘special comment’—on health care last night. Since I’m rather obsessed with the issue at the moment, I set my DVR and just watched the results. Summary: he’s wrong about a LOT, but this is powerful and eloquent stuff. Worth watching.

Visit msnbc.com for Breaking News, World News, and News about the Economy

I Stand Corrected

By , 1 October, 2009, No Comment

Three weeks ago, I thought we were moving towards a coherent piece of health care legislation. I was wrong. Let me review this one more time:

A. If your primary goal is achieving universal insurance coverage, you can: 1. Have a single payer system where the government provides insurance; 2. Have an employer mandate with a super-strong public option where the government might as well provide insurance; or 3. Have a universal individual mandate with aggressive regulatory reform and generous subsidies.

Of these three, the first, single-payer, hasn’t ever been on the table. The third—otherwise known as the Wyden-Bennett bill—would be the easiest on the public fist, as well as the most conducive to medical innovation. On those grounds, it’s my favorite.

B. If your primary goal is reducing the cost of medical treatments, you can: 1. Have a single-payer system where the government centralizes and rations care; 2. Have a super-strong public option where the government might as well provide it; 3. Have aggressive reform of our medical profession and training, with incentives for people who set up small community clinics, say, or better tuition grants for folks who go to med and nursing schools.

Of these two, the first has never been on the table. The second would undermine medical innovation (see point a, above). The third, which I support, isn’t something that can be legislated, but has to be pursued long term.

If this is still confusing, watch the awesome animation below.

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Trying to Save Health Care Reform

By , 10 September, 2009, 1 Comment

The speech exceeded expectations. As I’ve argued in earlier posts, there are only two routes to achieving GUARANTEED universal coverage: an individual mandate and an employer mandate, both with subsidies for the poor. There are also only two routes to finance those subsidies: massive regulatory overhaul or economies of scale in a state-supported public insurance system. Any plan that tries to compromise by having a mandate without a finance mechanism won’t be able to achieve universal coverage goals; any plan that doesn’t have a mandate isn’t even trying.

Since the presidential campaign, Obama has promised to achieve the liberal goal of universal coverage while speaking the conservative language of efficiency, positing universal coverage as a possible byproduct. Then, when challenged from the Left, he would try to hedge it by offering universal mandates without a finance mechanism, afraid to commit to either regulatory overhaul or a public option.

That changed last night.

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Health Care, Revisited

By , 5 September, 2009, 2 Comments

Before the President addresses Congress on Wednesday, I thought it was time to revisit health care reform.

Throughout the town-hall melodrama this summer, I have been struck by the focus, from liberals and conservatives alike, on the politics, rather than the policy merits, of reform. To some degree, that is the legacy of Hillarycare: the Clinton administration went so deep into closed-door policy sessions to actually produce a pretty decent bill, that they forgot to sell their plan politically and alienated all the constituencies they needed to get it passed.

Obama, by contrast, has become so preoccupied by having something—anything—to show for himself by year’s end, that he has tried to float above the policy debate, be all things to all people, and avoid tying himself to any specific proposals. (This is a recurrent problem with Obama’s liberal-tarian decision-making process.)

The result is that the right has been able to destroy all the major bills with surface-level claims about their political or ideological implications rather than engaging with their content.

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How to Handle Health Care

By , 20 June, 2009, 7 Comments

Here’s how insurance works. You sign up for a plan, and based on how likely to be sick you are, you get a quote for your monthly premium. If a particular insurer has a roster of clients who are 90% sick folk and 10% healthy folk, the base premiums they use will be higher than if the balance were 50-50, because they will need to pay out more funds to cover their clients and need more revenue from premiums to do it. But the people who have an incentive to buy health insurance are A. old or B. sick, precisely the demographics that drive premiums up. Now factor in that we have two insurance companies that are state-run, Medicare and Medicaid, populated ENTIRELY by the elderly and ill. The cost to the taxpayer of maintaining those is even higher.

Meanwhile young people elect not to buy insurance because they are cavalier about their health; by the time they want coverage, they are old or sick, so the cost of a plan is high. Some of them wind up being poor enough that Medicaid covers them, but that only adds to high cost and inefficiency of Medicaid as an insurance plan populated only by the most expensive clients. (Proposals to make Medicaid open to all would only make this worse.) Some of them wind up being wealthy enough that they can pay the high premiums of the private insurers. The rest are our 50 million uninsured.

Why can’t these consumers bid down the cost of private sector insurance? Once reason is that regulatory oddities prevent them from voting with their wallets–if I, a New York resident, see a plan in California that suits me better (maybe it covers more of what I want and less of what I don’t), I should be able to buy it, sending a signal to New York area firms that they should lower their prices to compete. The HMOs have successfully lobbied state and federal governments to prevent that from happening. Certainly lifting such odd regulations would bring private sector costs down, but it wouldn’t solve the tax-dollar-drain that is Medicare/Medicaid, nor would it guarantee costs falling enough to insure everyone.

Why are the costs of insuring the sick so high anyway? Other countries–most of the EU–pay for ALL their citizens out of tax money and still spend less than we do. One reason is that they make sure their state-run insurers don’t cover the silly things some of our private ones do (Viagra) and that they do cover smart preventative care (testing people with the right risk factors for chronic diseases like diabetes, then following through with them on diet and exercise). Granted, preventative care can be done wrong or wastefully, but this is more a matter of improving medical education than one of insurance pricing.

Another reason is that they ration care by buying just one brand of everything in bulk: you don’t get to choose between Prozac and Zoloft. Getting rid of coverage for discretionary things like Viagra and improving preventative care would be smart things to steal from them. Getting rid of drug diversity probably isn’t, because our population is larger and more diverse than theirs and the effectiveness of these drugs has a lot to do with genes. So copying the European model wholesale (ie going for single-payer) is a bad idea.

Moreover, we need a robust drug development sector in this country because it’s one of the few areas where America can still lead innovation and create jobs. Manufacturing is dying, IT is migrating, clean-tech is light-years away from maturity and services (hoteliers, accountants) can only take you so far. We have to make stuff, and this is one thing we’re still relatively good at. So economically, crippling pharma by going for single-payer doesn’t make much sense.

Here’s a better system:

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Gordon’s Day

By , 2 April, 2009, 2 Comments

Gotta hand it to Gordon today. Somehow, he’s pulled world leaders back from their insanity to agree to principles for that were, only a day ago, the butt of jokes among policy wonks. A triumph.

In the past week, much of the American media has referred to the IMF infusion in particular as though it were proposed by President Obama in the lead-up to this meeting. That’s wrong.

As readers of this blog will know, the whole combination of trade, aid, and regulation was the brainchild of Gordon Brown and the subject of his speech in Congress some weeks ago. At the time, the American media focused on his praise of the United States and on the symbolism of the moment, so American readers never processed the weight of his policy prescriptions.

Meanwhile, the Obama administration, realizing that a dramatic expansion of fiscal stimulus was not in the cards, began talking up the IMF infusion as though it were their plan, and journalists in the US political press have followed suit. World leaders were smart enough to let Gordon announce the comminque himself (he did superbly; video below), but the talking heads in the American press still spent the evening news discussing whether this as an achievement of the Obama team.

Obama and his celebrity charm get some credit for helping curmudgeonly Gordon get this done; surely Obama had some role in stopping Nicholas Sarkozy from throwing another tantrum. But the policies–using the IMF as a form of trade subsidization and trade as a form of development aid–don’t bear any signs of his input. That my colleagues in the political media insist on declaring otherwise only facilitates conservative critiques that they are in Obama’s tank.

Moreover, I find this strategy of taking credit for others’ ideas unnerving. There were two stories buried in the inside section of the NYT these past weeks about a Congressional effort–led by Ted Kennedy–to devise a health care bill, even before the administration has a Health Secretary. The emerging plan sounds a lot more like Hillary Clinton’s proposal from last spring than the Obama plan, but if it looks liable to get Congressional passage, you can bet it will get Obama branding.

Come on, Mr. President. Your popularity ratings are sky-high, where Gordon Brown is fighting for his political life. You are young with years ahead of you, where Ted Kennedy is singing his swan song. Take a back seat, for once, and give credit where it’s due.