Friday, February 12, 2010

Turn your head and cough

Avedon Carol made a good point the other day, about all the talking and squawking about the "health care summit" which the GOPpers may or may not attend:
I'm just annoyed that process is more important than policy once you're inside the bubble. The right-wing wrote too much of health insurance bill, but instead of talking about that, we're supposed to talk about why they should vote for it since it's so full of their own crap.
Indeed. It turns out on simple examination that the health insurance care bill passed by the Senate is already chock-full of right-wing ideas. Not that this comes as any surprise, but still it's nice to have the details. In the face of that, the reaction should have been "How the fuck did this crap get in there? Why the hell did you keep capitulating to a bunch of wacko reactionaries who you knew or at the very least should have known damn well wouldn't agree to anything that actually helped people no matter what you offered them?"

Instead, the chatter - which the rest of us are apparently supposed to feel obligated to echo - is "Whoa! They get what they want and still oppose it! This is gold!" Steve Benen, for example, is admitting that the purpose of Obama meeting with GOPpers is to "score a key public-relations victory ... give Democrats cover and put Republican intransigence on full display." (Above links via AC.)

Put more bluntly, it's not that the Senate bill is a good bill, it's that, well, it's politically useful! How kewl is that?

Perhaps that's the emphasis because it's getting ever harder to justify the claim that the Senate bill is a clearly good thing. First there is the fact that the claim that financing it though an excise tax on falsely-labeled "Cadillac" health plans won't hurt working people because what employers save in health insurance costs will be passed on in the form of higher wages is outright false, as shown last month by Lawrence Mishel of the Economic Policy Institute. (Via Firedoglake.)
Proponents of this theory point for evidence to the latter half of the 1990s, a five-year period when wages were growing rapidly while growth in employer health care spending was relatively constrained. They contrast the period from 1995 to 2000 with the periods from 1989 to 1995 and 2000 to 2006, when wages stagnated while health care costs grew much more rapidly.

There is logic to their argument, but it is only skin-deep....

[D]igging just a bit beneath the surface reveals the following:

1. Health care costs are not large enough to substantially move wages as these proponents claim;

2. Examination of actual wage and benefit trends confirms that changes in the trajectory of health care costs did not materially affect wage trends over the last 20 years; and

3. The wage behavior described - accelerating in the late 1990s and more slowly thereafter - actually best characterizes wage growth for low-wage workers who have minimal access to employer-based health care. Conversely, this pattern of wage-growth over time is least pronounced for higher paid workers with the most health coverage.

Clearly, this “health care theory of wage determination” is wrong....
What's more, the notion that raising costs for individuals via higher deductibles and co-pays - which is one of the conscious intents of such a tax - saves money by making us "more conscious consumers" without harming health has long been known to be false and it may actually increase the pressure on public health care spending. In fact, a working paper from the National Bureau of Economic Research, issued nearly three years ago, studied the effects of a policy change that raised patient cost-sharing for retired public employees in California.
We find that physician office visits and prescription drug utilization are price sensitive.... [W]e find substantial “offset” effects in terms of increased hospital utilization in response to the combination of higher copayments for physicians and prescription drugs. These offset effects are concentrated in patients for whom medical care is presumably efficacious: those with a chronic disease. Finally, we find that the savings from increased cost-sharing accrue mostly to the supplemental insurer, while the costs of increased hospitalization accrue mostly to Medicare; thus, there is a fiscal externality associated with cost-sharing increases by supplemental insurers.
Now in case that wasn't clear, let me translate: Increasing health care costs to consumers results in them going to the doctor less often and either not getting or skimping on needed meds. That tends to lead to more hospitalizations - with the result that the savings go mostly to the insurers and the costs go mostly to Medicare.

(On a related point, the Urban Institute argued last year that such "consumer-directed health care" - what a foully-misleading name - threatens to remove
physician-patient trust as a fundamental underpinning of the health care system. Although physicians have deviated from ideals of professionalism in various ways, patients still rely on physicians, as professionals, to serve their patients' best interests. ...[T]he competitive vision that is core to consumer-driven care would inevitably replace professional ethics with, at best, commercial ethics....
Put another way, despite our cynicism it's unlikely that we see our own doctors, particularly if we have a regular one, the same way we see someone trying to sell us a used car. But the more important money becomes in the transaction, the greater the similarity in how we see the two.)

Those two points - insurance savings are not passed along as wage increases and raising the cost of health care means people get less of it - would appear to be self-evident. Indeed, so much so that it's hard to imagine why they have been taken seriously as arguments absent the drive to "do something about health care" while embracing the intent to change the system as little as possible. But together they do serve to point up the fatal flaw at the heart of the whole set of proposed changes:

It has been noted a number of times that the structure that would be established by the Senate bill is at least somewhat similar to that which exists now in Massachusetts. The state program includes mandated coverage (with penalties for not having insurance), MassHealth (the state's Medicaid program), and the Health Connector (which allows people and small businesses to shop for private insurance while providing subsidies to low-income individuals and families, and so has similarities to the proposed exchanges).

While it has struggled with costs and has cut back on some benefits (for example, legal immigrants are no longer eligible for assistance and dental coverage has been restricted to those with incomes below the federal poverty level) the program has undeniably increased the number of people in Massachusetts with health insurance, with the state claiming last fall that only 2.7% of the state's residents remain uninsured, about half the rate before the program began over three years ago.

However, that is not the real story. As always, as I and others have said repeatedly, the issue is not access to health insurance, it is access to health care. Again, I have to thank the folks at Firedoglake for a link, this one to a report by the Kaiser Commission on Medicaid and the Uninsured.
According to a March 2009 Urban Institute report, health reform has improved access to health care services for newly insured and previously insured adults. Over ninety percent of adults in Massachusetts have a usual source of care and most reported seeing a doctor in the previous year. However, the affordability of health care remains a barrier to receiving care for some residents. Of the total population, 21 percent went without needed care in the previous year because of cost. People with disabilities and those in fair and poor health experienced the greatest barriers to accessing care. [Emphasis added.]
(Links to the actual Urban Institute studies, done for the state, are here and here.)

Despite all the efforts, despite the near-universal reach of health insurance, still one out of every five people in Massachusetts went without needed care because they couldn't afford it. I want to emphasize again that nearly all of those people had health insurance - in fact, a minimum of 18 of those 21 percentage points, nearly 86% of the total number, did. And I'm going to say it a third time to really drive it home: Six out of every seven people who had to forego needed health care in Massachusetts last year had health insurance.

It can't be said enough times: Health insurance does not equal health care. Full stop. And the fatal flaw at the heart of the entire discussion about health in and among Congress, the White House, and the media is the utter failure to recognize and address that simple fact.

Which brings up one last thing, one last but extremely important thing. Greg Sargent pointed to a CBS News poll in January that headlined a result that Obama’s approval rating on health care had dropped to 36%. That was down by 11 percentage points since October. However, the poll did two other things: One, it compared Obama to Congress - and he did better than Democrats, who did better than Republicans. More importantly, it didn't ask, as most polls have, some form of "Are you for or against the health care reform bills in Congress?" Instead, it asked what people thought about the proposals; so far as I'm aware, it's the only news poll which has.

People were asked how they thought health care reform in Congress was doing on three points: covering Americans, controlling costs, and regulating health insurance companies. In each case, did they think the proposals go too far, not far enough, or are about right. In all three cases, a plurality said the proposals do not go far enough.

No, it is not a majority, but it is a plurality and it does show clearly and unquestionably that there is a real and sizable constituency for real change, for real advances, for real progress. It's also worth noting that if you include the "about right" numbers, then even after all the months of unremitting attacks, all the foot-dragging, all the town hall screaming, all the references to Hitler, all the accusations of "socialism" and "government takeover" and "death panels" and "they're gonna kill grandma" and my favorite "keep your government hands off my Medicare," still less than one in three Americans thinks what's being proposed goes too far.

Now, you know that I am very much in the "not far enough camp" and that I think the best thing thing that could happen for the longer term is for the bill to fail because enough progressives in Congress - and yes, there are some - stand up and say "This is just not good enough." And it is precisely for that same reason that I think the poll is worthy of note - because no, it does not demonstrate any sort of national consensus for a single-payer plan or, even less, a national health system, but it does indicate that some good amount of the declining support is not for health care reform but for what is being presented as health care reform. And while the screechers and the shouters, with their diatribes and dissembling, may have snowed the Democrats, snowed the White House, and snowed the media, they have not snowed the public.

Footnote: That CBS poll also indicates how skewed media coverage of issues is, a little window into how mass media thinks and what drives it: The poll asked people what they thought the most important issue facing the country is. Of the seven choices offered, the economy got the biggest response, at 44%. Health care was next with 14%. Terrorism was fourth, at 7% - even the rarely-covered wars in Iraq and Afghanistan ranked higher, at 8%. But the survey summary contained nine questions on terrorism, including airport security and Gitmo, but only two on the economy and two on health care.

Footnote to the Footnote: So what came in fifth on the list of concerns, with just 3% of responders picking it, barely ahead of poverty/homelessness and defense/military? The deficit. Bang that drum louder, bozos, it appears you haven't succeeded in scaring people yet.

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