Possible compromises for healthcare reform

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Erik Kain

Erik writes about video games at Forbes and politics at Mother Jones. He's the contributor of The League though he hasn't written much here lately. He can be found occasionally composing 140 character cultural analysis on Twitter.

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  1. Avatar Zach
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    says:

    I wish I lived in a country where your piecemeal plan was possible, but I can’t see any way you could expect to succeed on any of those compromises (by succeed I mean get 60 Senate votes from any combination of members).

    1. “Shift the regulatory burden from the states to the federal government to avoid the same problems we’ve seen in the credit card industry.” Is there any compromise on the strength of regulation here that would simultaneously satisfy 60 Senators? All Republicans and many Democrats that favor the insurance industry would balk at anything approaching the most rigorous state regulations, and the remainder of Democrats would accept nothing less. I’m also curious whether this might actually raise constitutional issues (forbidding states to regulate insurance).
    2. Tort reform + Cadillac tax + low-income vouchers = the worst possible health reform conceivable for unions. Maybe if you attached it to the EFCA.
    3. Cutting Medicare benefits; third rail stuff unless Wilford Brimley becomes President and scams old folks into going along with it.
    4. Raising taxes; third rail.

    I think those would all be great reforms and put us on the right path, but I can’t see how any of them are remotely achievable in the current political framework. You can imagine some of it coming to fruition through the sort of budget commission that was voted down two days ago, but hoping for a budget commission with teeth is probably worse.

    I also don’t really see Republicans accepting tort reform as their end of a compromise. They don’t benefit from it; they just advocate it in substitute of any real plan to lower health costs. It’s probably better for them never to pass it and to rant against absurd lawsuits being the Democrats’ fault in perpetuity.Report

  2. Avatar Michael Drew
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    says:

    I think the subject of changes to health care have been demonstrated to be pretty scary for voters and poisonous for politicians. I don’t think the prospect of spreading such changes out over the course of years is a prospect many Democrats would find very appealing. In theory I think better policies could result from that. But I also think it would be good to have a process that is already this protracted result in some new settled status quo that consumers can get acquainted with, after which further changes can be made, rather than explicitly saying that that there won’t be a new normal for quite a while, only a shifting policy environment that will subject be to political winds.Report

  3. Avatar greginak
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    says:

    Eric- I’ll put this as politely as a i can. The repub’s don’t have a freaking bill. they floated a handful of ideas they like that don’t solve the basic problems our system has, isn’t paid for and got roundly laughed at by the CBO.

    The piecemeal reform strategy is a clusterF waiting to happen. I know that i’m a liberal so by definition i am fiscally irresponsible, but the one bill at a time idea is a fiscal disaster. Pols will vote for, and the people will be all for, voting for the things they want without the naughty parts like taxes. that would be a fiscal disaster. we would be spend, spend, spend without paying for it.

    I know it is de rigueur to hate on the current bill, but is actually a fairly adult way of handling reform. it has lots of good things with mechanisms to pay for them.

    As somewhat of a side note, there was big vote today that might even make the piecemeal strategy impossible. The senate voted on PAYGO today. It passed on a party line vote, with all the “fiscally responsible” Repub’s voting against it. So A) don’t expect the R’s to go along with anything, even if it is responsible and B) i’m not sure we can, nor should we, be able to add spending without equivalent cuts or taxes.Report

    • Avatar Zach in reply to greginak
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      says:

      Republicans vote down paygo because it makes across the board tax cuts that are paid for by the laffer curve sprinkled with pixie dust impossible. There’s now no way to pass a tax cut in this Congress that isn’t coupled with a tax hike and/or letting existing cuts sunset.

      I’m sort of surprised Obama didn’t propose a capped capital gains cut (capped by total benefit or income). Include that and small business cuts/credits in the budget and you’ll make the GOP vote against the sort of tax cuts that everyone likes to promote in order to save tax cuts for the wealthy.Report

    • Avatar Koz in reply to greginak
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      says:

      “I know that i’m a liberal so by definition i am fiscally irresponsible,…

      Yep.Report

  4. Avatar Michael Drew
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    says:

    Also, on majority/minority responsibility. Absolutely Democrats are ultimately responsible for their time in the majority. But Republicans will be responsible for theit time in the minority as well. Ultimately voters are likely to blame the party in power for failure, but if thRepublicans were to make such a spectacle of themselves that the voters turned on them and rewarded Dems for even minor achievements given unified opposition at a time of majoe challeges, there would be nothing fundamentally mistaken about that. It’s a legitimately alive political fight that the simple statement,”This party has a large majority; they’re responsible for what happens” doesn’t necessarily resolve. Today’s events are mildly encouraging, though ultimately I place no great hope on seeing Republicans rethink their fundamental political stance yet this cycle.Report

    • Avatar Michael Drew in reply to Michael Drew
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      says:

      To be clear: this latest Spectacular Legislative Failure-Show, which is a trademarked production of the “Democrat” Party, is brought to you exclusively by Barack Obama, Harry Reid, and Max Baucus. But the conditions that set the stage for it were made possible with generous support from the Republic Party.Report

    • Avatar Koz in reply to Michael Drew
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      says:

      “Ultimately voters are likely to blame the party in power for failure, but if the Republicans were to make such a spectacle of themselves that the voters turned on them and rewarded Dems for even minor achievements given unified opposition at a time of major challenges, there would be nothing fundamentally mistaken about that.”

      Of course that’s exactly what we’ve found out over the last year, something about which the Democrats have convenient amnesia or put fingers in their ears so they don’t have to hear the music. The voters could have blamed the GOP for obstruction, the Demo’s want the voters to blame the GOP for obstruction and have made arguments why the voters should blame the GOP, but the voters have their own minds, and they haven’t done it.

      The Democrats have completely failed to make their case for the health care bill. The public opposes the health care bill, and a substantial part of them are mobilized against it, and the GOP is representing their interest in the inside game. They are not going to turn against the GOP, they are cheerleading for it.Report

  5. Avatar zic
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    says:

    One of the frustrating things about the health care discussion is even determining what’s being discussed. E.D.’s suggestions, on their own merit, seem aimed at the cost of insurance. But the cost of insurance is based in great part on the cost of care.

    I commend you for the list; but I think it displays a big problem people have in understanding the complexity of controlling health care costs; not just health care insurance, and producing good health care outcomes. I’d refer you to the Brooking’s Institute study, Bending the Curve, which found that piecemeal efforts won’t work well, and recommended a four-pillar approach:

    First, as a foundation for improving value, all stakeholders in the system need better information and tools to be more effective. Second, provider payments should be redirected toward rewarding improvements in quality and reductions in cost growth, providing support for health care delivery reforms that save money while emphasizing disease prevention and better coordination of care. Third, health insurance markets should be reformed and government subsidies restructured to create competition and improve incentives around value improvement rather than risk selection. This step requires near-universal participation in insurance markets to succeed. Finally, individual patients should be given greater support for improving their health and lowering overall health care costs, including incentives for achieving measurable health goals.

    As an example, there’s NYT editorial today on a dispute between UnitedHealthCare in NY hospitals:

    One issue is how much money UnitedHealthcare will pay the hospitals for services provided to its members. The insurer claims that it was shocked that hospital negotiators were seeking a 40 percent increase in reimbursement rates, especially when subscribers are demanding they rein in premiums. The hospitals say they were appalled to find that UnitedHealthcare wanted a reduction of 7 to 10 percent in reimbursement levels at a time when its largest hospitals are barely breaking even.

    The editorial offers a view into another poorly-understood issue of health care:

    A second issue is UnitedHealthcare’s demand that the hospitals notify it within 24 hours when a beneficiary is admitted — or suffer a 50 percent cut in reimbursements for that patient. The insurer says the faster it has that information the faster its case managers can look for ways to shorten a hospital stay — reducing costs and hospital-borne infections — and help organize post-hospital care to prevent relapses.

    Hospitals are notoriously poor at coordinating post-discharge care, and insurers, who have the fullest records of what doctors a patient has been seeing, are in a good position to help do it. The hospitals suspect that UnitedHealthcare is looking for an excuse to cut reimbursements. The company denies that.

    (emphasis mine.)

    The best record of our medical care resides not in our doctor’s files, but in our insurer’s files. And the best analysis of effective treatments. The data we need to mine to control health-care costs is proprietary. And current analysis is, I’m quite sure, weighted toward profit models, not outcomes. And I’m equally sure this is not what consumers/citizens would opt for, else there wouldn’t be so much concern about insurance. Not to mention the notion that health care decisions should be made by a doctor/patient and not the insurance company.

    I’m just not sure incremental change will get us anywhere; I’d propose that this health care reform is the first step to incremental change that addresses the many complex issues that have to be balanced for meaningful health care reform.

    It’s like a balloon that’s being inflated and we’re trying to squeeze it and prevent the inflation. If you hug it here, it will bulge there. You’ve got to provide pressure over the entire system to succeed.Report

  6. Avatar Michael Kirsch, M.D.
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    says:

    The Dems will never use the reconciliation ‘nuclear’ option. If they did, then the election in November would be Massachusetts redux. They’re already spooked. See http://bit.ly/3rA5vR .Report

    • Avatar Bo in reply to Michael Kirsch, M.D.
      Ignored
      says:

      Huh? Reconciliation is the nuclear option now? Seems like a weird claim, since that normally refers to ending the filibuster outright, not using reconciliation to pass legislation. Last time I checked, Congress ends up using reconciliation to pass legislation every year, thanks to the Senate being dysfunctional without it.Report

  7. Avatar Michael Kirsch, M.D.
    Ignored
    says:

    Bring it on, Bo! There’s a reason the Dems are running away from reconcilation faster than they are running away from tort reform.Report

  8. Avatar Michael Kirsch, M.D.
    Ignored
    says:

    @Bo and Prosser, I hope the Dems are taking order from you folks.Report

  9. Avatar mike farmer
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    says:

    The American public has been softened and will accept healthcare reform if it’s clear and focused. The problem is that the radical elements on the left will not compromise. A bill can be passed tomorrow if a group of adults get together and develope a plan which makes sense and doesn’t have expensive bribes and payoffs to special interests. The idea that backroom deals are necessary is a dangerous cynicism which pulls a dirty trick and places a principled approach below realpolitick — when all else fails, lower your standards — and this is what people oppose. The people are saying they don’t value hypocrisy above transparency, common sense and good judgement — they are demanding something this big be done right, and they are not simply ignorant of sausage-making — they are demanding something better and healthier than sausage — because they know deep down that in order to make healthcare reform effective, it will take shared sacrifice — I have a feeling people will sacrifice, if everyone sacrifices — no one really believes in something for nothing anymore. As a libertarian, my ideas are much more drastic than anything that will possibly pass — I know a libertarian approach will not fly — the second best option is reform where everyone is inspired to freely choose sacrifice in order to expand coverage and lower costs by not expecting a lot given for nothing, then hope for the best.Report

    • Avatar zic in reply to mike farmer
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      says:

      The problem is that the radical elements on the left will not compromise.

      We did compromise. No single payer, no public option. . . we adopted Romney Care, and the radical right says, “no.”

      the second best option is reform where everyone is inspired to freely choose sacrifice in order to expand coverage and lower costs by not expecting a lot given for nothing, then hope for the best.

      It’s what’s for dinner! We’re in perfect agreement!

      I’d never thunk it possible~Report

  10. Avatar Koz
    Ignored
    says:

    There is no slamdunk here, but it’s not that horrifically hard when you figure out what the zeroth order problem is.

    Which is, the vast majority of health care expenses are paid by third parties. Therefore, demand for health care services continues to rise explosively since the cost of those services is not felt by those who are consuming them. Period. End of. Full stop. QED.

    Therefore the answer, whether it’s done in an incremental way or a comprehensive one, is about unwinding the system of employer-centric tax-deductible plans and government programs which provide health care. Getting rid of Medicare Advantage and putting excise taxes on Cadillac health plans is decent enough start right by itself.

    Of course, what the D’s and liberals really want is to expand free or low cost coverage, which isn’t the solution to anything but is actually the problem itself. And they’re blaming the GOP for not going along with it.Report

    • Avatar Art Deco in reply to Koz
      Ignored
      says:

      We also have cultural problem in this country that a critical mass of people expect to receive mundane medical services and pay only a nominal toll for them, not to mention the critical mass of people who misunderstand the distinction between insurance and welfare, not to mention the critical mass of folk who think of insurance companies as bottomless money pits who should be obligated to fork over the bucks whenever a physician says ‘jump’.Report

  11. Avatar North
    Ignored
    says:

    Good post E.D. I agree in general though I’d specifically be more pessimistic over your second options than you seem to be. The Dems have sunk about as much capital into this subject as they’re willing to. If the current HCR bill sinks then I wouldn’t expect them to go back to that subject again optimistically in Obama’s term, pessimistically in this decade. They really want to achieve something and then focus on something that isn’t as controversial. Frankly it’s likely HCR or an completely ineffectual fig leaf. Now on the subject keep in mind that reconciliation isn’t technically necessary. If the house were to merely pass the senate’s bill it could be on the president’s desk within the week. Reconciliation would be needed if the house wants to make any budget impacting alterations to the bill to make it go down sweeter with the house caucus. The consensus is that some reconciliation adjustments will be needed to get the bill through the house. If you’re on the HCR deathwatch the indicator to watch is the budget. When the budget expires the reconciliation option expires as well and would have to be written into the new budget (heavy lifting that). At that point HCR’s chances go from doable with some spine to genuinely uphill skiing. So that should allow us to get a good idea of where Obama and the crew are going.Report

  12. Avatar Scott
    Ignored
    says:

    Newfoundland Premier Danny Williams will undergo heart surgery later this week in the United States.

    Another endorsement of the Canadian system.

    http://www.nationalpost.com/news/story.html?id=2510700Report

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