Saturday, August 01, 2009

What's Stalling Health-Care Reform?

With health-care reform packages stalled as Congress leaves for August recess, The Post asked lawmakers and experts what the biggest obstacle to reform has been and how it might be overcome. Below are contributions from Raul M. Grijalva, Walt Minnick, Michael O. Leavitt, Rick Scott, Norman J. Ornstein, Douglas E. Schoen, Henry E. Simmons, Ralph G. Neas and Maxine Waters.


Democratic representative from Arizona; co-chair of the Congressional Progressive Caucus

The greatest obstacle in this historic debate has been our underestimating the health-care industry's opposition to fundamental reform.

To many of us, the initial cornerstone of reform was a single-payer approach. Lack of political will took that off the table. The fallback was a meaningful public option, defined by stability of coverage, costs and quality. This affordable plan, with guaranteed access, would compete with the insurance companies. When the industry and its allies realized we would be prioritizing our nation's health over their egregious profits, they quickly painted "the government" as the enemy, and, though we recognized this opposition, we didn't take our case to the public. Convinced that Americans already understood the benefits of a robust public option, we decided to play an inside-the-Beltway game, and we started to lose the public relations war.

Nearly every American has a health-care horror story involving their insurance company. The public is fed up with our broken system. We can overcome our public relations slip-up if we help our constituents understand that the industry, not the government, is responsible for the ever-increasing rates and scaled-back coverage they receive.


Democratic representative from Idaho; Blue Dog Coalition member

Most people agree on the most important points of health-care reform: We must reduce costs. We should not increase our deficit. All Americans should have secure, stable coverage. But a lack of public confidence in the congressional process has proven a massive obstacle. While it's true that members from both sides have worked together diligently, occasional public disputes have weakened public confidence in our ability to craft an effective plan.

That's unfortunate, because most members of Congress want bipartisan, collaborative consensus on reform. I am encouraged by the work of the Senate Finance Committee and Chairman Max Baucus, who understands what we in Western politics have learned the hard way: No one wins when everyone fights.

Whether it is natural resources, water, economic development or a major undertaking like health-care reform, the Western way is to bring people together, look for agreement and move toward a solution. That is happening in Congress, but it must be more visible to overcome the toughest obstacle of all in our effort to reform health care: Convincing Americans they can trust us to do this right.


Secretary of health and human services from 2005 to 2009

Simply stated: Partisan overreach. The Democrats produced a bill that is simply over the top on federal government control and that includes more new taxes than our economy can stand. It is just too much Washington.

Many thought it was poor tactics that caused Hillarycare to flat-line in the 1990s. Most thought the organizers of Obamacare could avoid the same mistakes. But we are now learning that partisan overreach is hardwired into political parties when they are handed power after a decade in the wilderness. They simply cannot help themselves.

The Clinton health-care proposal overreached, and it cost Democrats control of Congress. You can argue that we Republicans did the same on welfare reform. We passed partisan bills; they were twice vetoed. Then we got down to bipartisan problem-solving. A decade later, both sides take satisfaction in the success.

This time around, the end won't arrive with a presidential veto. It will be average Americans attending town meetings to voice their outrage.

This nation desperately needs real reform. Once we weather the partisan overreach, one hopes we can get down to the business of designing what people want: a tax-neutral, deficit-neutral change that rewards value, not volume. It can happen, and it needs to happen. It is time.


Chairman, Conservatives for Patients' Rights

Congress misunderstood what Americans want. In poll after poll, Americans have consistently said they want lower costs, not a government-run insurance company denying them treatments or drugs and giving them poor care. What has been proposed, however, is a massive power grab, in the form of the public insurance option.

Putting a national board to do comparative-effectiveness research in the stimulus bill scared everyone as to whether the government was setting itself up to deny care. Americans believe the focus should be on the economy and their jobs, not a government takeover of health care. Blue Dog Democrats sense the outrage and have wisely tried to kill the government-run insurance disaster.

There are many ways to reduce health-care costs that won't cost taxpayers a dime: Give the same tax breaks to everyone who buys insurance; standardize claims forms; require doctors and hospitals to post prices and outcomes; and reward people for eating right, exercising and not smoking. If Congress were to consider some of these, it might have an easier time passing reform.


Resident scholar, American Enterprise Institute

Look at three factors for the difficult path for health reform. First is the public: The universal public definition of health reform is, "I pay less." But the message when reform rubber hits the road is almost inevitably, "Watch out, you will pay more so others pay less."

Second is the dysfunction in our politics, which make broad bipartisan consensus so difficult unless there is an immediate, gut-churning crisis -- and even then, it is no sure thing. (Look at the unanimous House Republican opposition to the stimulus plan even as our economy was teetering at the edge of deflation and depression.) Achieving major social reform without bipartisan support is a very heavy lift. And without bipartisan leadership support, the public grows even more wary that their definition of reform will be violated.

Third is the sheer substantive difficulty of "fixing" deep-seated problems that spread over one-sixth of the economy, in a complex, intertwined system that is half public and half private.

Even so, there is a better-than-even chance that a serious, if not far-reaching, reform plan will get through this Congress. The need is deep enough, the president is savvy enough and the majority Democrats will be desperate enough to make something happen.


Democratic pollster and author; adviser to President Bill Clinton from 1994 to 2000

The principal reason for gridlock is that the Obama administration and the Democrats in Congress have misread public opinion on health care. Voters want an overhaul, and they strongly believe that there needs to be an expansion of coverage. But there is far more concern about the size, scope and cost of the initiative than the Democrats have realized. There is also great concern about the level of taxation in America going forward. And there is deep fear that a government bureaucracy will supplant or interfere with the doctor-patient relationship. This fear has been exemplified this week by the notion that, somehow, the federal government will make life-and-death decisions but not pay for end-of-life-care.

There is every reason to believe, as evidenced in the recent survey data, that a 1994-type swing against the Democrats could materialize if their budget, health-care and cap-and-trade policies prove as expensive and unwieldy as many Americans fear. But polls also clearly suggest that the people will embrace a bipartisan agreement on health care that incrementally but inexorably expands coverage, controls costs and does not entail a public option.

Given the weakened position of the Republican Party, there is every reason to believe that any such compromise will benefit the Democrats. The Republicans' best hope is that continued gridlock on the health issue will further erode the president and the Democrats' standing and lead to a swing back to the GOP.


President and CEO, respectively, National Coalition on Health Care

Major legislative reform involves complicated policy choices and even more complex politics. Despite multiple obstacles, heroic efforts by congressional leaders and the administration have kept reform moving forward and positioned for enactment this year

However, we view the failure of lawmakers to effectively address slowing the increase in health-care costs to all payers -- not just the government -- as the greatest obstacle to reform. The failure to address systemwide cost containment was avoidable. Lawmakers only had to follow the Congressional Budget's Office's December road map on how to generate health-care savings in the short term, and today we would be closer to enactment of sustainable and systemwide reforms.

As a nation, we now must also make the tough choices necessary to ensure the health and economic well-being of future generations far beyond the proposed 10-year CBO budget horizon -- especially since the CBO's projections fail to attribute any savings to critical investments in prevention, disease management or wellness within that time frame. Several arduous months lie ahead; there is still time.


Democratic representative from California; member of the Congressional Progressive Caucus

It's a familiar story: Special interests who benefit from the status quo are aggressively resisting reform. In this case, insurance companies, drug companies and other health-care industry organizations have blanketed the halls of Congress with well-paid lobbyists to protect their profits and kill a meaningful public option. The industry is also using its vast financial resources to run misleading ads, use scare tactics and fatten the campaign coffers of certain members of Congress.

As The Post reported, Blue Dogs "have set a record pace for fundraising this year . . . surpassing other congressional leadership PACs in collecting more than $1.1 million through June, [more] than half the money [coming] from the health-care, insurance and financial services industries."

Republicans by and large never wanted health-care reform. Unfortunately, Blue Dogs -- a group of conservative Democrats who claim to want to reduce costs -- are also now serving as guard dogs for the insurers and drugmakers and increasing costs by insisting on higher pay for doctors in their communities.

Health-care industry resistance to change was predictable and could not have been avoided, but it can be overcome. Instead of spending more time negotiating with Blue Dogs, we must remind them that many of their districts include sizable constituencies that desperately need and truly want reform.

If push comes to shove, Senate Democrats can pass a good reform bill without Republicans, and progressives in the House will show leadership that we, too, are a force to be reckoned with.

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Health Care Realities PAUL KRUGMAN

NY Times

At a recent town hall meeting, a man stood up and told Representative Bob Inglis to “keep your government hands off my Medicare.” The congressman, a Republican from South Carolina, tried to explain that Medicare is already a government program — but the voter, Mr. Inglis said, “wasn’t having any of it.”

It’s a funny story — but it illustrates the extent to which health reform must climb a wall of misinformation. It’s not just that many Americans don’t understand what President Obama is proposing; many people don’t understand the way American health care works right now. They don’t understand, in particular, that getting the government involved in health care wouldn’t be a radical step: the government is already deeply involved, even in private insurance.

And that government involvement is the only reason our system works at all.

The key thing you need to know about health care is that it depends crucially on insurance. You don’t know when or whether you’ll need treatment — but if you do, treatment can be extremely expensive, well beyond what most people can pay out of pocket. Triple coronary bypasses, not routine doctor’s visits, are where the real money is, so insurance is essential.

Yet private markets for health insurance, left to their own devices, work very badly: insurers deny as many claims as possible, and they also try to avoid covering people who are likely to need care. Horror stories are legion: the insurance company that refused to pay for urgently needed cancer surgery because of questions about the patient’s acne treatment; the healthy young woman denied coverage because she briefly saw a psychologist after breaking up with her boyfriend.

And in their efforts to avoid “medical losses,” the industry term for paying medical bills, insurers spend much of the money taken in through premiums not on medical treatment, but on “underwriting” — screening out people likely to make insurance claims. In the individual insurance market, where people buy insurance directly rather than getting it through their employers, so much money goes into underwriting and other expenses that only around 70 cents of each premium dollar actually goes to care.

Still, most Americans do have health insurance, and are reasonably satisfied with it. How is that possible, when insurance markets work so badly? The answer is government intervention.

Most obviously, the government directly provides insurance via Medicare and other programs. Before Medicare was established, more than 40 percent of elderly Americans lacked any kind of health insurance. Today, Medicare — which is, by the way, one of those “single payer” systems conservatives love to demonize — covers everyone 65 and older. And surveys show that Medicare recipients are much more satisfied with their coverage than Americans with private insurance.

Still, most Americans under 65 do have some form of private insurance. The vast majority, however, don’t buy it directly: they get it through their employers. There’s a big tax advantage to doing it that way, since employer contributions to health care aren’t considered taxable income. But to get that tax advantage employers have to follow a number of rules; roughly speaking, they can’t discriminate based on pre-existing medical conditions or restrict benefits to highly paid employees.

And it’s thanks to these rules that employment-based insurance more or less works, at least in the sense that horror stories are a lot less common than they are in the individual insurance market.

So here’s the bottom line: if you currently have decent health insurance, thank the government. It’s true that if you’re young and healthy, with nothing in your medical history that could possibly have raised red flags with corporate accountants, you might have been able to get insurance without government intervention. But time and chance happen to us all, and the only reason you have a reasonable prospect of still having insurance coverage when you need it is the large role the government already plays.

Which brings us to the current debate over reform.

Right-wing opponents of reform would have you believe that President Obama is a wild-eyed socialist, attacking the free market. But unregulated markets don’t work for health care — never have, never will. To the extent we have a working health care system at all right now it’s only because the government covers the elderly, while a combination of regulation and tax subsidies makes it possible for many, but not all, nonelderly Americans to get decent private coverage.

Now Mr. Obama basically proposes using additional regulation and subsidies to make decent insurance available to all of us. That’s not radical; it’s as American as, well, Medicare.