Friday, January 08, 2010

Unhealthy compromise

Just as perfection must not be the enemy of the good, compromise should not abet the inadequate. - Dave Colavito, writing at The Huffington Post on Friday to urge disinvestment from the health insurance industry until reforms are made.
Updated So Digby makes reference to a "provocative" post from Tuesday by Chris Bowers at OpenLeft, who wonders aloud if any of the "supposed opponents" of the health care deform bill, "whether lefties or teabaggers," will work for GOPper Scott Brown in the special senatorial election in Massachusetts later this month and thereby "seize this newfound opportunity to defeat the bill."
Brown has a chance, even if only an outside chance. If Brown wins, he would probably be sworn in on January 21st. While there is an off-chance the final vote on health care reform will have already taken place by then, odds are that negotiations on the health care bill will still be ongoing.
Brown would be a 41st GOPper vote, enough to block final passage, and thus his election "would bring a sudden and surprising end to the health care reform legislative process." Bowers goes on:
For lefties, working for a Republican might be more difficult to swallow [than it would be for teabaggers]. ... [But] this might be the best remaining chance to stop a trillion dollar giveaway to the insurance industry. And what of all those calls to run primary challenges against Progressives in Congress who vote for the health care bill? Here is an opportunity to pre-emptively take out an incoming progressive Senator before she even votes for the health care bill.
Digby called that "a very interesting strategic argument" but it is, in fact, nothing of the sort. Not only was there nothing "provocative" about Bowers' post, there was nothing about any real "strategy," either. It was, rather, a pathetic attempt at Swiftian satire, intended as a sneer at anyone opposed to the mockery of health care "reform" that has emerged by saying in essence "Then why aren't you working for Scott Brown? Huh? Huh?"

Look, the idea, even the suggestion, that progressives would further empower reactionaries in order to defeat the health insurance bill is idiotic nonsense. But it's the kind of thing those of us who are aware of the longer-term defeat what is happening now represents have had to abide: Besides being considered everything from foolish to "living in a dream world" to being ready to see people die in order to express a dislike of Joe Lieberman (Or was it Blue Dogs? Depends on the day, I guess), now we are either closet right-wingers or useful idiots.

There are two ways the legislation could be stopped, neither of which I expect to happen: One is if it is defeated by GOPper and reactionary opposition, the other is if it is rejected by a sufficient number of progressives voting it down avowedly because "This is just not good enough." Short-term, the result is the same; longer-term, that is, in terms of strategy, the conviction among progressive opponents such as myself is that the latter simply is more likely to advance the goal of actual universal access to adequate health care than accepting the pending legislation is, especially considering its likely final form - that is, something close to the Senate bill.

That form is one that even as its advocates avidly, breathlessly, declare its vital, indeed "historic," nature, even they have to admit is seriously (although, they insist, not fatally) flawed. In fact, it's so flawed that National Nurses United, the largest professional organization and union of registered nurses in the US, with 150,000 members, came out against it last month.
“It is tragic to see the promise from Washington this year for genuine, comprehensive reform ground down to a seriously flawed bill that could actually exacerbate the healthcare crisis and financial insecurity for American families, and that cedes far too much additional power to the tyranny of a callous insurance industry,” said NNU co-president Karen Higgins, RN. ...

“Sadly, we have ended up with legislation that fails to meet the test of true healthcare reform, guaranteeing high quality, cost effective care for all Americans, and instead are further locking into place a system that entrenches the chokehold of the profit-making insurance giants on our health. If this bill passes, the industry will become more powerful and could be beyond the reach of reform for generations,” Higgins said.
I haven't heard much - anything, actually - about that source of opposition among the oh-so-"realistic" portions of the lefty blogosphere busily chiding the rest of us for our unwillingness to concede defeat via a false claim of victory; maybe it's because even the must hypnotized of the Obamabots can't bring themselves to claim that registered nurses don't care about patients and health care.

It just seems that every time I hear something new about this business, it gets worse. We're already heard, for just a few examples, that there's an individual mandate but no real cost controls, that the "ban" on recissions is bogus, being no stronger than what has existed since 1996, and that there are restrictions on abortion rights. And then there's the fact that the Senate bill continues the bizarre anti-trust exemption for the health insurance industry. And despite - or equally likely because of - all the compromises, over 40% of the uninsured will still be uninsured 10 years from now when the program is "fully in force" (as of 2019, 23 million uninsured under the Senate bill versus 54 million uninsured under "current law" - CBO figures).

More recently, we (or at least I) have learned about the "wellness" provisions, under which, no, you can't be turned down for insurance (after 2014 when the provisions go into effect, that is), but you can be charged up to double it you fail "wellness" programs because you are overweight or smoke or don't exercise enough - or have diabetes, high blood pressure, high cholesterol, or any number of other chronic medical conditions.

Double? How about triple, quadruple, rates based on age or having certain conditions. Remember, you are required to have insurance, so you can't refuse to pony up. Meanwhile, insurers will be able to sell policies “across state lines,” with the result the same as it was for credit cards companies' ability to avoid usury laws: Insurers will set up shop in the states with the fewest, weakest, consumer protections and sell from there, effectively avoiding the stronger laws in other states.

Oh, and here's one I just learned about a couple of days ago, via California Progress Report:
Under the Senate version of the healthcare bill, caps are NOT eliminated for existing policies. If you have health insurance now, your caps remain in place, unless you can get a new health insurance policy. But since most new (and affordable) plans are only going to the young and healthy, this leaves most of us out in the cold. ...

This problem is so severe that an estimated 300,000 Americans will reach their lifetime limit by 2019. And since most people reaching this limit have chronic conditions, any lifetime limit on their healthcare policy could be an actual limit on their lifetime.
(Sidebar update: In my December 8 post, linked above, I referred to caps being maintained so long as they were not "unreasonable." In a subsequent manager's amendment, that was removed, eliminating caps. But as California Progress Report now makes clear, that only applies to new policies.)

But wait! What about all those good effects? What about the "expanded coverage?" Well, as NNU Co-president Deborah Burger put it,
“Those wishful statements ignore the reality that much of the expanded coverage is based on forced purchase of private insurance without effective controls on industry pricing practices or real competition and gaping loopholes in the insurance reforms.”
Or as I put it recently, it's not 30 million more people with health insurance, it's 30 million people forced to buy health insurance - some number of who will
find themselves with low-cost, high-deductible policies that still leave them without access to health care because even as they can afford the premiums, they can't afford the deductibles.
Well, maybe, but still this is a First Step! A Good Start! One that will be Improved Upon in the Years To Come! I'll leave aside the fact that Medicaid and Medicare (passed nearly 45 years ago) were also supposed to be "first steps" as well as my confusion about how the same federal government that I am branded some kind of fool for thinking could be forced into a true universal coverage program will eagerly embrace one if we just pass this half-assed bill first, which together leave me wondering about just how many years are in a "to come," and defer once again to NNU.
NNU Co-president Jean Ross [said] “the bill seems more likely to be eroded, not improved, in future years due to the unchecked influence of the healthcare industry lobbyists and the lessons of this year in which all the compromises have been made to the right.”
Again, that's an argument I've previously made, that future efforts will not be directed to expanding or improving the program but to defending it against attacks. Indeed, it's already happening, Talking Points Memo reports:
With Democratic senators united on the health care bill ... their campaign arm has settled on an attack plan for 2010: Republicans would "repeal" it if they win control.
The damn thing hasn't even been passed yet and already the Dems' focus is not "we'll make it better" but "we'll keep it from getting worse."

But I think the thing that gets me off more than anything else about the whole crappy business - not necessarily the worst or most damaging aspect, but the bit that just gripes me the most - has been the attitude of the O-crowd, that is, the White House. Even some who accuse me of believing in "magical ponies," claiming with utter conviction and exquisite stupidity that I believe that if progressives reject this bill that next year national health care will be created, even some of them have openly agreed that I was right in saying that the Democrats (and particularly the White House) screwed it up at the very start by tossing single-payer into the trash heap before the issue was even engaged, compromising and backing up even before the debate began.

So what is the one thing the White House has weighed in on? What is the one thing that has moved Barack Obama to say "I want this in the bill?" Not a public option, not ending antitrust exemption, nothing about recissions or caps or Medicare expansion or abortion rights or quality standards or regulatory enforcement mechanisms. No, the one thing the O-man has specifically endorsed is the plan to finance the program via a whopping 40% excise tax on employer-provided insurance plans worth more than $8,500 a year for individuals or $23,000 a year for a family for four - the so-called and often-misnamed "Cadillac" insurance plans. The House bill calls for the program to be paid for by a surtax on those individuals making over $500,000, and couples making more than $1 million, a year - but we can't have that, oh no! Tax the rich? Out of the question!

No, we've got to finance this largely on the backs of the middle class, most particularly union members who gave up wage increases and oftentimes bargained away other gains or benefits in order to protect and improve their health insurance coverage. Doing that is the one thing that Barack Obama has specifically endorsed.

Why did I use the term "often-misnamed" in referring to "Cadillac" plans? The Washington Post reported on Thursday that
[h]ealth analysts recently questioned the assumption that the tax would target only the most lavish insurance packages, nicknamed "Cadillac plans." The analysts, writing in the journal Health Affairs, found that some less-generous plans could be taxed because they are costly for other reasons. The location of an employer and the type of industry, for example, have as much to do with the cost of plans as the generosity of the benefits and the kind of plan. Smaller businesses, especially those with a preponderance of older workers, tend to have higher premiums, as do certain industries, including the health-care sector.
The same WaPo article notes that
[w]hen the legislation would go into effect in 2014, only a small fraction of all plans would be taxed, but more would be captured over time: roughly a quarter by 2019, collecting about $150 billion over 10 years.
So in less than 10 years from now, one-fourth of employer-provided insurance plans would be subject to a 40% excise tax because they would be considered, in effect, luxurious. Just like the quarter of us who drive Cadillacs and other luxury cars.

And just what is the point of this? What about this hit-the-middle-class-and-union-members tax has got the White House all hot and sweaty? Why, it's the "cost-containment potential." The tax is levied on the insurance companies, who will pass the cost along to employers, and then
employers and employees would shift to less-generous plans that would make patients more sensitive to costs, slowing the growth in health-care spending.
Do you get it? Do you see? The problem, according to the White House and the health-care economists they listen to, is you. You "overuse" health care. You are insufficiently "cost-conscious." It's all your fault. You don't comparison shop for a cardiologist. You don't independently investigate and evaluate treatment options for your cancer or your diabetes or your hypertension and generate a cost-benefit analysis. You don't personally compare the clinical trials for Avapro and Diovan. And the way to (I love this phrase) "bend the cost curve" is to reduce your coverage and make you spend more out of pocket for what remains through higher deductibles and co-pays - so you'll use less health care, thus keeping the cost down. In other words, the way to make health care more affordable is to make it less affordable.

No wonder economics is called "the dismal science."

And it's trash. It won't work. The vast majority of people simply do not have the skills, do not have the requisite knowledge, to do the sort of cost-benefit comparison shopping this crap necessarily envisions. Rather, in the face of higher costs, people are just as likely to cut back on needed care as unneeded care, making health outcomes worse, not better, and potentially increasing health care costs in the long run as conditions go untreated until they become crises.

And they have to know it won't work. The Centers for Medicare and Medicaid Services of HHS reported that the "cost bending" effect of the excise tax would be to reduce national health expenditures in 2019 by - hold on to your hats - 0.3%! That's right, reduced coverage and higher out-of-pocket costs will together succeed in cutting overall spending by less than one-third of one percent. That's the cost-containment to be achieved by paying for this whole pile on the backs of union members and the middle class.

But we have to do it that way - because fer god's sake, we can't tax the rich!

The thing now is, at the end of it all, I'm resigned to the fact that this bill is going to pass. It's too important to too many Democrats, too important to too many faux progressives, too important to President Hopey-Changey, and as usual the concerns of real progressives are mocked or dismissed or ignored or trampled while the Dimwits and the reactionaries must be appeased. I hope that it can be improved at least in some ways before final passage but I have little faith it will be.

Still, defeat need not mean surrender. Even as Rose Ann DeMoro wrote at The Huffington Post of "An Inglorious End to the Promise of Reform," Jean Ross of NNU said
“nurses will continue to work with the thousands of grassroots activists across the nation to campaign for the best reform, which would be to expand Medicare to cover everyone, the same type of system working more effectively in every other industrial country. The day of that reform will come.”
While I think "Medicare for all" is more of a slogan than a program, I do agree the day of reform, real reform, will come. But I am convinced that passage of this bill, by allowing every enabler of the health insurance industry to say "Health care reform? We did that already," pushes that day further off rather than brings it closer. And that is a real tragedy.

Footnote: The Washington Post article I cited includes a quote from one Jonathan Gruber, identified as "an MIT economist and a leading proponent of the new tax." He dismisses concerns about the effect of excise tax, saying "slightly higher" deductibles are
enough to make people more cost-sensitive but not enough to make them skip necessary care. ... "There's literally no evidence out there that people are going to suffer."
Turns out that Jonathan Gruber has been paid nearly $400,000 in sole-source contracts with HHS since March to consult on the "President’s health reform proposal." Um, isn't commenting as "an MIT economist" on a program about which you have are being paid to consult something of an ethical conflict of interest?

Updated with two corrections: Based on a USA Today report, the post originally said "don't feel left out if you don't have employer-provided insurance: Another part of the Senate plan is an 0.9 percentage point increase in Medicare withholding." However, according to the New York Times, that increase would only apply to individuals with incomes over $200,000 a year or families with annual incomes over $250,000. The reference has been deleted.

Also, the incomes affected by the proposed surtax in the House bill has been corrected. Previously the post said it applied to "those with incomes in excess of $1 million a year." The correct figure is $500,000 a year for individuals and $1 million a year for couples.

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