Month: July 2009

Whittling It Down To Nothing

by dday

Unlike in 1994, when The New Republic allowed an abominable article by Betsy McCaughey to codify the Villager mindset on health care, this year they have one of the brightest wonks in the business, Jon Cohn, driving their coverage. And this article about the pitfalls of a “just pass any bill” strategy is required reading.

Notwithstanding the predictable fits-and-starts of the legislative process, it seems likely that Obama will have a bill to sign by year’s end, thereby accomplishing what the Clintons famously could not. But then what? Having crafted a bill that can pass Congress, will Obama be signing a bill that people actually like? It’s a question best answered by examining another episode of the past–one that, although a mere footnote in political history, is fraught with warnings for today’s reformers.

The episode is the fight over the Medicare Catastrophic Coverage Act, which President Reagan signed in 1988. Its purpose was to plug some of the emerging gaps in the Medicare program: If you stayed in the hospital too long, Medicare just stopped paying the bills. The Act extended hospital coverage indefinitely, capped out-of-pocket spending for beneficiaries, and offered partial coverage of prescription drugs, among other things.

Or at least that’s what the law was supposed to do. After the bill passed with overwhelming, bipartisan support, a backlash developed, memorably culminating in a “riot” of angry seniors who chased a beleaguered Dan Rostenkowski–then chairman of the House Ways and Means Committee–into his car after a Chicago meeting. Less than two years after passage, before the bill’s implementation, Congress voted to repeal the act, again with sweeping margins.

Basically, the program only provided a catastrophic care benefit to a small amount of seniors who faced extended hospital stays, and because of a desire to keep the bill revenue-neutral, all seniors paid for the program in premiums and surcharges. Those charges were modest, but people got the perception that they were paying more for nothing. As Cohn explains, the parallels are eerie.

Fast forward two decades, take a closer look at what’s happening on Capitol Hill, and you may notice some familiar storylines. In order to make sure reform can pay for itself, lawmakers are talking about slowing down implementation, so that the program is not fully on line until 2014. They’re also talking about offering fewer subsidies to help people obtain insurance. In a nod to centrists who don’t like the idea of too much government, there’s a strong push to gut or even eliminate proposals for the public insurance plan, which was supposed to provide security for individuals and competition for private insurers […]

Put aside, for a moment, the policy merits of these moves. The politics are lousy. Obama would be in danger of producing legislation that seems to offer little up-front benefit, particularly for the electorally vital middle class. And if some of these people end up paying even modestly higher taxes to help finance reform they’re not likely to be happy about it. It’s hard to imagine such legislation provoking a backlash that could produce total repeal. It’s not so hard to imagine such legislation creating bad political feelings, the kind that linger around until the next Election Day and pave the way for legislative retrenchment later on.

Let’s bring back the policy merits: they too are lousy. Smaller subsidies along with an individual mandate will strain individual budgets, and a lack of a check on the insurance companies with no public option and a weak national insurance exchange will allow that strain to worsen with ever-expanding premiums. Slowing implementation just keeps in place a broken system causing 18,000 Americans to die every year.

Whatever mash of policies that come out of Washington, in health care – unlike some other legislation – practically the entire population will be intimately familiar with the consequences. It would be nearly impossible to distort the benefits or demonize the negative effects. It will be what it will be. And so designing a policy based on bipartisanship rather than effectiveness is a complete folly. Democrats and the White House have basically put forward this health care reform as a signature accomplishment. If they design something where the benefits aren’t readily apparent, and people’s premiums remain high, the public will get the message.

If Harry Reid and Nancy Pelosi muscle health reform through Congress, if President Barack Obama signs a bill in the Rose Garden and hands the pen to an ailing Sen. Ted Kennedy, if health reform, in other words, passes with fanfare and attention, Democrats own it. This will not be a quiet accomplishment. They will have told the American people that on this historic day, under this historic administration, they have begun to bend the curve and and tame the insurers and guarantee coverage and generally fix this huge problem that so many before have promised action on but so few have succeeded in tackling.

And if, 10 years down the road, the plight of the middle class has worsened and cost growth hasn’t slowed and the only real difference is that more tax dollars go towards low-income subsidies, Democrats will be blamed for that. Their arguments will have less credibility. Republicans will run ads about “the last time a Democrat told you he could reform American health care.” […] If Democrats pass a bill that gets the policy wrong, they run a real risk of losing trust on what’s arguably their core issue. This is high-stakes stuff.

It’s not that I disagree with Digby at all – now is a rare chance to enact universal health care, and we should not shy away from it because it doesn’t meet every single proper contour. But there are undeniable consequences to a bad policy. And, I would add, needless consequences. For once, the most popular policies line up with what will likely be the most cost-effective ones that provide the greatest tangible benefits. I suspect that the CBO will score a public option that uses Medicare rates, like the one in the House, in such a way that proves it would save both the federal budget and ordinary Americans hundreds of billions of dollars. Heck, the studies have already been done. The same with adding subsidies, which would attract more people into compliance with the system and lower the hidden cost of treating the uninsured.

Considering the fact that Democrats need only 50 votes to enact this reform, a fact that even the White House acknowledges, and considering the statistical fact of 60 Democratic Senators, there is absolutely no reason to build the policy around bipartisan support in Washington, but bipartisan support in the COUNTRY. Not only will there be massive goodwill for enacting decent health care reform, but a massive political backlash if that reform is wanting or if conservative Democrats, who are the only ones that can stop the policy at this point, shut it down. Bernie Sanders has this absolutely right.

Look, the Democrats said give us 60 votes so we can come up with something. They gave it to us! I’m not a Democrat, I’m an Independent, but I caucus with the Democrats. They gave us 60 votes. So how many do we need? Seventy? Eighty? I understand that there are some Democrats, without ascribing motives, who are not comfortable voting for a strong public plan period. But I think it is not asking too much that they vote against the Republican filibuster […]

Look, I like Chuck Grassley. But people in the country are not sitting around saying, “We need a good bipartisan bill! That’s what we need!'” They’re saying we need good, universal coverage for every American, man, woman, and child. And it needs to be affordable. If Chuck Grassley and Olympia Snowe and these other nice people I know decide to vote against it, that’s fine. People in America aren’t sitting up nights worrying how they’ll vote. The goal should not be bipartisanship. It’s passing something that is strong and good.

There is good reason for short-term political optics to pass whatever can be passed. But limiting the possible, and sacrificing the long-term benefits of the policy, makes no sense. The Democratic leadership seems to have forgotten how to pressure its caucus, or at least the moderate members. They can withhold re-election funding. They can change committee assignments. They can deny legislation written by particular Senators to come to the floor. They can impose all sorts of hardships, and the threats can be wildly larger than the exchange – just vote against a Republican filibuster. Then you can vote against the bill if you like.

Capitulating to that moderate axis will mean a poor bill that will lose the support of the public. When life and death is at stake, we cannot afford an outcome, nor do we need to.

Update:

from digby…

I hope that nobody thinks I disagree with this on the basis of the post dday links above or this one about the Jon Cohn article he references. Of course we should pass the best possible bill we can pass and we should pressure the Democrats in whatever way we can to do so. I just draw the line at saying that if can’t have single payer there’s no point in passing a bill at all. It’s not just optics. It’s getting universal health care on the books after 65 years of trying. If they can get that with a public option and a legitimate financing framework, we would, in my view, be foolish to say it isn’t good enough and wait for another 20 years for the next bite of the apple.

And for those who say the public option is bullshit and nobody really knows what it is, read this by Jacob Hacker, one of the people who conceived of the idea in the first place. He isn’t an insurance company hack, he’s a progressive professor at Berkeley.

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Shocked

by digby

Spackerman:

Remember how the Justice Department was supposed to declassify the 2004 CIA inspector general’s report on the “enhanced interrogation program” today? Not going to happen. There’s continued legal wrangling over how much to declassify. The latest I’ve heard is that the declassification could happen tomorrow — happy Fourth of July! — or perhaps next week.

Whodda thunk?

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How It Happens

by digby

FYI, here’s a brief history of Medicare:

1945 Harry Truman sends a message to Congress asking for
legislation establishing a national health insurance plan.

Two decades of debate ensue, with opponents warning of the
dangers of “socialized medicine.”

By the end of Truman’s administration, he had backed off
from a plan for universal coverage, but administrators in
the Social Security system and others had begun to focus
on the idea of a program aimed at insuring Social Security
beneficiaries.

July 30, 1965 Medicare and its companion program Medicaid, (which
insures indigent recipients), are signed into law by
President Lyndon Johnson as part of his “Great Society.”

Ex-president Truman is the first to enroll in Medicare.

Medicare Part B premium is $3 per month.

1972 Disabled persons under age 65 and those with end-stage
renal disease become eligible for coverage.

Services expand to include some chiropractic services,
speech therapy and physical therapy.

Payments to HMOs are authorized.

Supplemental Security Income (SSI) program is established
for the elderly and disabled poor. SSI recipients are
automatically eligible for Medicaid.

1982 Hospice benefits are added on a temporary basis.

1983 Change from “reasonable cost” to prospective payment
system based on diagnosis-related groups for hospital
inpatient services begins.

Most federal civilian employees become covered.

1984 Remaining federal employees, including President, members
of Congress and federal judiciary become covered.

1986 Hospice benefits become permanent.

1988 Major overhaul of Medicare benefits is enacted aimed at
providing coverage for catastrophic illness and
prescription drugs.

Coverage is added for routine mammography.

1989 Catastrophic coverage and prescription drug coverage are
repealed.

Coverage is added for pap smears.

1992 Physician services payments are based on fee schedule.

1997 Medicare+Choice is enacted under the Balanced Budget Act.
Some provisions prove to be so financially restrictive
when regulations are unveiled that Congress is forced to
revisit the issue in 1999.

1999 Congress “refines” Medicare+Choice and relaxes some
Medicare funding restrictions under the Balanced Budget
Refinement Act of 1999.

2000 Medicare+Choice Final Rule takes effect.

Prospective payment systems for outpatient services and
home health agencies take effect.

Medicare Part B premium is $45.40 per month.

This primer leaves out something very important, however: what happened between Truman’s defeat of universal health care and the enactment of Medicare. There were several interim bills introduced to cover the elderly indigent, one of which was signed into law by Eisenhower. (Here’s a fascinating debate on the subject captured at Newstalgia.)

At the prospect of taking the next step of covering all the elderly and putting a “foot in the door” of socialized medicine, the AMA and the conservatives went into overdrive to stop it, helped by none other than Ronnie Reagan himself:

Operation Coffeecup was kept deliberately low-key and internal to the AMA, its Woman’s Auxiliary, and the trusted friends and neighbors of the Auxiliary women. Reagan’s efforts against Medicare were revealed, however, in a scoop by Drew Pearson in his Washington Merry-Go-Round column of June 17th. Pearson titled his item on Reagan, “Star vs. JFK,” and he told his readers:

Ronald Reagan of Hollywood has pitted his mellifluous voice against President Kennedy in the battle for medical aid for the elderly. As a result it looks as if the old folks would lose out. He has caused such a deluge of mail to swamp Congress that Congressmen want to postpone action on the medical bill until 1962. What they don’t know, of course, is that Ron Reagan is behind the mail; also that the American Medical Association is paying for it.

Reagan is the handsome TV star for General Electric . . . Just how this background qualifies him as an expert on medical care for the elderly remains a mystery. Nevertheless, thanks to a deal with the AMA, and the acquiescence of General Electric, Ronald may be able to outinfluence the President of the United States with Congress.

Reagan’s recorded remarks are quite extensive, and reveal a determined and in-depth attack on the principles of Medicare (and Social Security), going well beyond opposition to King-Anderson or any other particular piece of legislation.

Now back in 1927 an American socialist, Norman Thomas, six times candidate for president on the Socialist Party ticket, said the American people would never vote for socialism. But he said under the name of liberalism the American people would adopt every fragment of the socialist program. . . .

But at the moment I’d like to talk about another way because this threat is with us and at the moment is more imminent. One of the traditional methods of imposing statism or socialism on a people has been by way of medicine. It’s very easy to disguise a medical program as a humanitarian project. . . . Now, the American people, if you put it to them about socialized medicine and gave them a chance to choose, would unhesitatingly vote against it. We have an example of this. Under the Truman administration it was proposed that we have a compulsory health insurance program for all people in the United States, and, of course, the American people unhesitatingly rejected this.25

And what was this frightful threat that Reagan perceived as “imminent”?

. . . Congressman Forand introduced the Forand Bill. This was the idea that all people of Social Security age should be brought under a program of compulsory health insurance. Now, this would not only be our senior citizens, this would be the de­pendents and those who are disabled, this would be young peo­ple if they are dependents of someone eligible for Social Security. . . .

First you decide that the doctor can have so many patients. They are equally divided among the various doctors by the government. But then doctors aren’t equally di­vided geographically. So a doctor decides he wants to practice in one town and the government has to say to him, you can’t live in that town. They already have enough doctors. You have to go someplace else. And from here it’s only a short step to dictating where he will go. . . . All of us can see what happens once you establish the precedent that the government can determine a man’s working place and his working methods, determine his employment. From here it’s a short step to all the rest of socialism, to determining his pay. And pretty soon your son won’t decide, when he’s in school, where he will go or what he will do for a living. He will wait for the government to tell him where he will go to work and what he will do.

Four years later, Lyndon Johnson had a strong mandate and a huge majority and he enacted more progressive legislation than anyone but Roosevelt. But he settled for enacting Medicare, the program Reagan excoriated in that Operation Coffee Cup recording, rather than pushing for universal coverage as Harry Truman had done and potentially losing. Did he do the right thing?

It’s a good question in the abstract. And as a matter of strategy, it might well have been better to wait until they got enough support for universal health care. But for the elderly, poor and disabled people who needed health care at that time, it was undoubtedly the right thing to do. Had they simply allowed the earlier, inadequate indigent legislation to stand, which after five years still wasn’t enacted in all the states, many fewer people would have been covered. And considering where we now know the country was politically headed, we might not have gotten Medicare at all.

Reagan concluded his album with a pitch to the listeners to call their congressmen and said this:

And if you don’t do this and if I don’t do it, one of these days you and I are going to spend our sunset years telling our children, and our children’s children, what it once was like in America when men were free.

Ah yes, America is so “exceptional” and free that it takes us decades to do common sense things that other countries do all at once. And even then it’s two steps forward one step back a good part of the time.

Our political system is terrible, and we should change it. And we should work for candidates who are committed to the specific policies we care about and give them an explicit mandate to enact them. The celebrity politics to which we are so addicted is partly responsible for the fact that it takes decades to enact any change — we treat politics like “American Idol” or the Super Bowl and don’t bother to pressure our leaders to take firm stands on issues we care about when we have the opportunity. Changing that is fundamental to creating better policies.

But right now there is a real chance for the first time in 65 years to enact universal health care, however imperfect the specifics of it may be. I’m sure whatever they pass will be inadequate, just as medicare and social security were inadequate when they were originally passed. It seems to be the American way. But if our political and business elites have finally come to the consensus that America should join the first world and create a system that guarantees coverage to everyone, then I think we have to take the leap while we can. History shows that these chances don’t come along every day. In fact, they come along about every couple of decades and we very rarely can even take an incremental step. We need to get universal health care on the books.

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Activist Judges

by dday

Lost in the shuffle of the caterwauling about Sonia Sotomayor and the Ricci decision, aside from the fact that it reflects conservative judicial activism and the making of completely new law, is that it’s not even clear law. That must be what you get when you adjudicate by empathy toward white firefighters.

In ruling for a group of white firefighters in New Haven on Monday, the Supreme Court tried to address a damned-if-you-do, damned-if-you-don’t quandary for many cities and other employers: what they should do when an employment test yields results that overwhelmingly favor whites.

But many legal experts said that instead of setting forth clear new rules, the court’s decision left things as muddled as ever for the nation’s employers — and seemed to ensure much more litigation over the explosive issue of employment discrimination.

“We don’t see clear, bright-line guidance here,” said Lars Etzkorn, a program director with the National League of Cities. “This is going to be good for employment lawyers.”

The Court invented a new standard in applying these tests which will make it more difficult for anyone using such tests for promotions or to address workplace discrimination, from businesses to government employers. The talk the language of “strict originalism” and just being umpires calling balls and strikes, but in reality, they use the means at their disposal to make the decisions that fit a right-wing ideology. John Roberts, with help from Anthony Kennedy, has radically shifted the Court.

Chief Justice John G. Roberts Jr. emerged as a canny strategist at the Supreme Court this term, laying the groundwork for bold changes that could take the court to the right even as the recent elections moved the nation to the left.

The court took mainly incremental steps in major cases concerning voting rights, employment discrimination, criminal procedure and campaign finance. But the chief justice’s fingerprints were on all of them, and he left clues that the court is only one decision away from fundamental change in many areas of the law.

Whether he will succeed depends on Justice Anthony M. Kennedy, the court’s swing vote. And there is reason to think that the chief justice has found a reliable ally when it counts.

“In the important cases, Kennedy ends up on the right,” said Thomas C. Goldstein, a student of the court and the founder of Scotusblog, which has compiled comprehensive statistics on the current term. The two justices agreed 86 percent of the time.

If the Roberts gang has their way, by September of this year the Court will, in all likelihood, overturn a good bit of the McCain-Feingold campaign finance law, especially as it relates to corporate spending, opening up a loophole that could “allow unlimited spending from corporate treasuries for television advertisements and other communications to support or oppose candidates.” And Justice Sotomayor, replacing Souter, will have little impact on that.

George W. Bush’s legacy will live on for many, many years.

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Another Side Of The Crisis

by digby

I’ve written a few posts about this aspect of the health care crisis and it’s a serious problem for a lot of people in the individual insurance market. This story in the NY Times lays out the problem in all its ugliness: people are basically buying worthless insurance and paying high premiums for it:

Health insurance is supposed to offer protection — both medically and financially. But as it turns out, an estimated three-quarters of people who are pushed into personal bankruptcy by medical problems actually had insurance when they got sick or were injured.

And so, even as Washington tries to cover the tens of millions of Americans without medical insurance, many health policy experts say simply giving everyone an insurance card will not be enough to fix what is wrong with the system.

Too many other people already have coverage so meager that a medical crisis means financial calamity.

[…]

“Underinsurance is the great hidden risk of the American health care system,” said Elizabeth Warren, a Harvard law professor who has analyzed medical bankruptcies. “People do not realize they are one diagnosis away from financial collapse.”

Last week, a former Cigna executive warned at a Senate hearing on health insurance that lawmakers should be careful about the role they gave private insurers in any new system, saying the companies were too prone to “confuse their customers and dump the sick.”

“The number of uninsured people has increased as more have fallen victim to deceptive marketing practices and bought what essentially is fake insurance,” Wendell Potter, the former Cigna executive, testified.

Mr. Yurdin learned the hard way.

At St. David’s Medical Center in Austin, where he went for two separate heart procedures last year, the hospital’s admitting office looked at Mr. Yurdin’s coverage and talked to Aetna. St. David’s estimated that his share of the payments would be only a few thousand dollars per procedure.

He and the hospital say they were surprised to eventually learn that the $150,000 hospital coverage in the Aetna policy was mainly for room and board. Coverage was capped at $10,000 for “other hospital services,” which turned out to include nearly all routine hospital care — the expenses incurred in the operating room, for example, and the cost of any medication he received.

In other words, Aetna would have paid for Mr. Yurdin to stay in the hospital for more than five months — as long as he did not need an operation or any lab tests or drugs while he was there.

They market these policies as catastrophic care policies: at least you’ll be taken care of if you have a heart attack or get run over by a bus. You give up things like Doctor’s office visits visits and prescription drug coverage and you pay huge deductibles just so you’ll be covered if the very worst happens. And this is what they end up with.

There is no reason why the congress can’t fix this one. They should mandate a decent level of coverage for catastrophic care — you know, the very thing this fellow thought he was buying. Just making a disclaimer on the pretty brochure isn’t enough. The insurance companies can’t be allowed to sell policies that don’t cover necessary medical expenses. That’s just theft.

And this fellow should have been able to buy into a better plan than the crap he was offered. A plan like Medicare maybe. He’s 64. Is there really any reason why someone like him shouldn’t be able to buy directly into Medicare for a fee? I recall that the idea of allowing those over 55 to buy in was on the table at one point and it sounded like a good idea to me. Americans all tell the pollsters they want a lot of health care options. What’s wrong with that one?

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Looking In The Rearview Mirror

by digby

… and seeing carnage in your wake.

Today the ACLU and many bloggers who are concerned with the fact that the United States tortured prisoners and apparently has no intention of holding anyone responsible for it are blogging about a little known fact about the issue: the US Government didn’t just torture a bunch a prisoners, as bad as that was, and as horrible as it remains for those who survived it. The United States tortured many prisoners to death. This does not seem to be common knowledge, but the evidence is quite clear that this happened. Torture and death by torture was not isolated.

I know that in the fog of war and all that that killing becomes normal and people become uncivilized. But torturing prisoners to death is not considered legal warfare. It’s a crime, even in war and even on the battlefield, and we have prosecuted people for it as a capital crime.

Here’s Glenn Greenwald:

So often, the premise of media discussions of torture is that “torture” is something that was confined to a single tactic (waterboarding) and used only on three “high-value” detainees accused of being high-level Al Qaeda operatives. The reality is completely different.

The interrogation and detention regime implemented by the U.S. resulted in the deaths of over 100 detainees in U.S. custody — at least. While some of those deaths were the result of “rogue” interrogators and agents, many were caused by the methods authorized at the highest levels of the Bush White House, including extreme stress positions, hypothermia, sleep deprivation and others. Aside from the fact that they cause immense pain, that’s one reason we’ve always considered those tactics to be “torture” when used by others — because they inflict serious harm, and can even kill people. Those arguing against investigations and prosecutions — that we Look to the Future, not the Past — are thus literally advocating that numerous people get away with murder.

Once the White House capitulated on the remaining Iraq abuse photos, I pretty much knew that they would never release any kind of damning information and more or less assumed that the vaunted CIA Inspector Generals Report from 2004, which supposedly blows the lid off the torture regime, would never see the light of day in any detail. The same goes for the DOJ IG report. They’ll release something, I assume, but it will not be the straight story. I expect I will be dead before the whole story is officially revealed and confirmed.

Tomorrow they are expected to release the CIA report, heavily redacted and almost certainly useless. (Marcy Wheeler will, of course, be poring over it with a fine tooth comb and you never know what she might find. But I don’t think they’re going to be quite a sloppy as they were the last time.) They surely hope that is the end of it. But it isn’t. There are too many people involved and too much evidence to keep it covered up. By refusing to lance this boil they are allowing the poison to continue to infect everything until the whole body politic is putrid with it. It’s a big mistake.

Here’s hoping I’m wrong about that and they let the people see what has been done in their names. We deserve to know and the tortured dead deserve some justice. And if we want to just deal in pragmatic concerns, if anyone thinks that refusing to hold people accountable for what happened and showing the world that we can be trusted to civilized at least after the fact doesn’t make us less safe, they are out of their minds. This is how countries become pariah states.

The United States went crazy after 9/11 and tortured many, many people, at least a hundred of them to death. It happened. How do we live with that?

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