Archive for the ‘Health Care Reform’ Category

Greenhouse Effect Strikes Again?

Saturday, July 7th, 2012

Love this story about how Chief Justice Roberts initially voted with the conservative majority to overturn the individual mandate, if not the entire ACA, but that he eventually changed his vote, siding with the liberal Justices to uphold the core of the law.

This was insult to injury for seething Republicans, already smarting from the decision itself, to know that they came so close to victory, but couldn’t seal the deal. For many Republicans, this was another in a series of disapointments, going back to the Reagan-Bush Era when Republicans expected Supreme Courts packed with their appointees to consistently vote to enact the conservative agenda.

Republicans have dubbed the tendency of Republican appointed Justices to shift their opinions to the left as they spent more years on the bench, ”The Greenhouse Effect” named for Supreme Court Reporter Linda Greenhouse, but a shift to the Left for Justice Roberts seems very unlikely. In fact, this decision is in keeping with the promises Justice Roberts made during his confirmation hearing when he said that a Judge’s role was to be a neutral umpire, calling balls and strikes, applying the rules, not creating them, as well as his focus on the legitimacy of the Court throughout history.

Despite the Republican rage, we should be under no illusions that Justice Roberts is undergoing some sort of leftward drift. After all, this is the activist court that brought us Citizens United as well as many other cases that are fundamentally re-writing the rules to benefit the powerful at the expense of those without. In the days before the Supreme Court Arguments in this case, I linked to an article by Dahlia Lithwick in which she argued that Chief Roberts would write an opinion upholding the ACA

And then—having been hailed as the John Marshall of the 21st century—he will proceed to oversee two (decades) during which the remainder of the Warren Court revolution will be sent through the wood chipper.

Unfortunately, I suspect that we will look back at history in 20 years and see that she was exactly right.

Towards An America That Does Big Things

Saturday, July 7th, 2012

Last weeks Supreme Court Decision upholding Obamacare was a big win for the president and a big win for the uninsured. More importantly, it was a big win for people who still believe in an America that can do big things.  The Federal Government was designed to make passage of major legislation difficult, but in our modern era, the checks and balances created by the Framers 200 years ago have more often become a way for entrenched interests to veto policies that impose any costs on special interests, effectively preventing anyting from getting done on important issues as long as a loud minorities are opposed to them.

We have huge issues to resolve in this country: unemployment, ever increasing amounts of debt, runaway health insurance costs, a broken immigration system, crumbling infrastructure, global warming and an intractable addiction to fossil fuels, just to mention a few. And on all of these issues, we have faced a political system that has not been up to the task of resolving them.

The Affordable Care Act is not great legislation. In fact, in many ways, it is a symptom of our broken political system where every special interest had to be bought off in order to pass the legislation. Most of the provisions that dealt with cost control were taken out of it after Republican’s demagoged them. Still, whether you believe that the Affordable Care Act was a good law or a bad one, it’s clear that it tried to deal with a major problem in our society and, if it was overturned, it would have been the last attempt to deal with this issue in a generation. 

Judge Robert’s decision was the right one as is the effect of Robert’s decision. As Republicans made clear this week, the decision doesn’t end the debate over the Act. What it does is put the decision back into a realm where the public can decide whether they want to keep it or overturn it. If the legislation is so bad, then the Republicans need to elect a Republican President and Congress in order to overturn it.

It is certainly possible that the ACA will be gutted by the next president and Congress. But I am glad that the decision will be made by the votes of hundreds of millions of people in both parties, not just 5 Republicans judges in black robes.

Obamacare Supreme Court Primer

Tuesday, March 27th, 2012

Here’s Ezra Klein and Sarah Kliff with everything you need to know about health care reform’s Supreme Court debut.

They provide some good links to analysis of the case. It looks as though most scholars seem to agree that, whether you like the individual mandate or not, there is a ton of Supreme Court precedent that supports the ability of Congress to enact a law like this. The Commerce Clause in the Constitution gives Congress the ability to regulate interstate commerce, and as Bloomberg View puts it

The question is what qualifies as interstate commerce. For most of the second half of the 20th century, the answer has been clear…pretty much anything.

Is a farmer growing wheat for his own consumption engaging in interstate commerce? Yes. A small restaurant in Alabama refusing to seat blacks? Yes. A sick Californian growing her own medicinal marijuana, as allowed by state law? Yes. And so on.

and if these cases are considered appropriate use of the Interstate Commerce Clause, then certainly a requirement that is central to controlling the cost of an industry that accounts for 18% of the economy qualifies as well.

And lest you are tempted to cite the Founding Fathers to denounce requiring purchase of a private good, you would be wise to remember that George Washington signed a bill in 1792 mandating that all free men purchase a gun (Big Government indeed).

Perhaps the most interesting take on the Supreme Court’s decision comes from Dahlia Lithwick, who predicts that the Justices will stay away from a narrow decision striking down the law and keep their powder dry for the upcoming battle to dismantle the Warren Court’s legacy:

They will hear six hours of argument next week. They will pretend it is a fair fight with equally compelling arguments on each side. They will even reach out and debate the merits of the Medicaid expansion, although not a single court saw fit to question it. And then the justices will vote 6-3 or 7-2 to uphold the mandate, with the chief justice joining the majority so he can write a careful opinion that cabins the authority of the Congress to do anything more than regulate the health-insurance market…. And then—having been hailed as the John Marshall of the 21st century—he will proceed to oversee two years during which the remainder of the Warren Court revolution will be sent through the wood chipper.

Lithwick’s analysis sounds about right to me. Say what you will about John Roberts, but you have to admire his ability to smile politely and show the world a reasonable disposition while he works behind the scenes to radically alter the rules of the political system that Americans have come to understand them in the modern era. 

I say he and his team pass on this one so they have a freer hand when the eyes of the country aren’t focused on them.

A Glorious Mess

Tuesday, March 23rd, 2010

A great piece from Eugene Robinson on the importance of House Democrats standing up to the Tea Party and making history.

Health Care Reform After Scott Brown

Monday, January 25th, 2010

Well, a rough week for the Democrats to say the least.

 A few thoughts on the situation.

No neutral (or even biased) observer can look at the events of the past year and say that Harry Reid has been an effective leader. He got rolled consistently throughout this process. He took the bait at the beginning when a handful of Republican’s said that they would negotiate in the Finance Committee on a health care bill and he continued to buy into that line through the fall when it became increasingly clear that they didn’t share his goals and weren’t negotiating in good faith. As the process dragged on and on, he got rolled by all of the conservative Democrats that could basically take this bill or leave it and as every one got their concessions in his quest for the magical 60 vote filibuster-proof margin. Then he had an agreement on allowing people to buy into Medicare at the age of 55, which would have at least turned up the heat on the big insurance companies a little bit. Joe Lieberman proceeded to roll him on that one. 

Every time Reid got rolled, the process was extended a little longer and every time he got rolled, someone got another concession out of him…and support for what he was working on declined. Last week the Republicans got what they had been waiting so impatiently for with the election of Scott Brown and the destruction of Reid’s 60 vote strategy.

So where to go from here?

Republicans say (as they have been saying since the election of Barack Obama) that the Democrats should abandon their agenda and act more like Republicans. The polls are against the plan, the American people don’t like it, the Democrats should listen to the will of the voters.

Unfortunately for the Republicans, that’s not the type of system we have. It’s a representative democracy, not a Greek government by referendum. A majority of the American people didn’t support the surge in Iraq. A majority of American people think that we should get out of Afghanistan. A majority of people don’t think the economy gets better when you give out tax breaks to rich people.  A majority of people (depending on which week you asked the question) regularly supported a public option for health care. Would the Republicans have wanted the people who were in power to just take a poll and abide by the results? Of course not.  

The duty of elected representatives is to do the research, find out what they think is best for the country, enact that policy, and then do your best to convince the American people that the decision you made was the right one. 

The election of Scott Brown is close to a total disaster for the Democrats. But the Democrats should find the silver lining. Harry Reid’s 60 vote strategy was a failure. With the passage of the Senate bill by the House and an agreement by a majority of Democrats, the Congress should be able to circle back and make changes with a 50 vote majority that will improve the bill. If Mary Landrieu, Ben Nelson, Lieberman, etc. don’t want to vote for the new changes, they can take cover and the concessions they got over the past year can (and should) be deleted from the bill. Who knows, maybe that will help them to avert disaster in their state. I doubt it, but we’ll see.  

Once it is passed, there will be real accomplishments to point to (no denial of pre-existing conditions, 30 million new people insured) instead of just two competing versions of reform and a bunch of publicity on the sweetheart deal that conservative Democrats got.

On a more fundamental level, the Democrats face a real test here. Scott Brown’s election is a punch in the face to Barack Obama. How he and the Democrat’s respond will affect how they are judged by the American people. Will they alter their strategy, but continue to fight for what they believe in, or will they cower in a corner for the next year and play defense in anticipation of the beating they may receive in November?

George W. Bush was often on the wrong side of public opinion (and of history in my opinion). But he prided himself on doing what he thought was right, no matter what the polling said. The Democrats could learn a bit from his example and stand up for what they believe in. If they don’t, people are increasingly going to ask if they believe in anything at all.

The election of Scott Brown has shown that 2010 is going to be a brutal year for the Democrats, just like 1982 was a brutal year for Republicans. But If all they bring to the voters is excuses on why they couldn’t get anything done, I have no doubt that they are going to get a worse beating than if they pass this legislation.

Corporate Reform: Better than No Reform at All

Tuesday, September 8th, 2009

This is one from the archives.


With the debate swirling around health care reform, I took a few weeks to do some more research on the  American health care system and the reforms that have been proposed a little more.

The way I see it, the Republican attack machine has done it’s job to make sure that whatever reforms are passed will be watered down to the point where nothing will be done to harm the corporations. Reform may still pass, but it will be totally on the terms that the corporate insurance companies, big Pharma etc., deem acceptable.

Here’s my take on the whole thing.

The Current System

Just to give you a little intro, I’ve compiled some stats on the state of health care in the United States so that we can all understand what we are dealing with.

There is one category among which the United States leads with regards to health care and that is the amount that we spend. All surveys agree that the United States spends more than any other country in the world on health care. The United States spends $2.1 trillion dollars a year on health care. That is about 30% more based on population and wealth than the average industrialized country. American families now spend about 1 in 4 dollars on health care.  

Well what do we get for these high costs? I have heard more than one conservative pundit say that we get the “best health care system in the world.” Sorry, not even close. It’s difficult to measure what country has the “best” system because it all depends on what variables you put in, but the most cited study is the World Health Organization which ranks us 37th (!). 

Somehow, ”We’re Number 37!” just doesn’t have the same ring as ”We’re number one!” 

Now I don’t want to put too much stock in this rating system. It obviously has some flaws, but even on the rankings that are just related to outcomes, almost all advanced countries have better national health statistics than the United States does.

In addition to high costs and poor performance, consider the following:

  • Over the last decade, employer-sponsored health insurance premiums have increased 119 percent. 
  • That number is four times the rate of inflation and wage increases during that same period 
  • The Congressional Budget Office has estimated that job-based health insurance could increase 100 percent over the next decade
  • Approximately 1.5 million families lose their homes to foreclosure every year due to unaffordable medical costs
  • 62 percent of all bankruptcies filed in 2007 were linked to medical expenses. Amazingly, of those who filed for bankruptcy, nearly 80 percent had health insurance.

Think about that last one for a sec. Those 80% of people who had health insurance thought they were insured…until they actually got sick…and now they’re bankrupt.

  • Finally,  despite the huge amount we spend on health care approximately 10-15% of Americans are still uninsured.

Of course, the cost of health care in the United States has a huge effect on federal budgets as well. As with private insurance, Medicare and Medicaid’s costs have been increasing faster than the economy. CBO projects that at the current rate, Medicare and Medicaid costs will grow from 5% of GDP today to 10% by 2035. Entitlements as a whole will be growing because of the retirement of the Baby Boomers, but CBO estimates that 80% of the increase in those programs will be due to the increased costs for Medicare and Medicaid. 

 So when you hear Republicans complain about “record deficits” under Obama, think about reforming insurance, because a huge percentage of those deficits are based on rising health care costs.

The public deserved a rational debate about what the issues, what has been proposed to fix them and what additional items should be added to the list. Instead it got Sarah Palin and the Death Panels, Charles Grassley and the Pulling of the Plug on Grandma and a bunch of teabaggers yelling at their Congressmen. What this amounts to is a scorched earth policy that has made reforms that any observer without ideological blindfolds on knows we need much harder to get in the future. It’s not very patriotic, but it did the job that the corporate paymasters wanted done.

What Is in the Democratic Plans?

The purest version of the Democrats plan came in the original House version of the legislation. It consisted of the following elements.

Insurance Exchange

  • The establishment of an insurance exchange where people whose employers didn’t offer health insurance could purchase health insurance from eligible plans
  • As part of this exchange and as part of the individuals choices, a public plan that resembles Medicare
  • Initially, only individuals who are not covered or companies with 10 or less employees could purchase insurance through the exchanges, this would increase to 20 or more in 2014. Future expansions would be determined by an independent board.

Insurance Regulations

  • A regulation of private insurers that prevents them from denying coverage for a pre-existing condition, bars “recission” (where the insurance company collects benefits for years until you get sick and then tries to kick you off the plan as soon as they have to pay).
  • Regulations on minimum coverage that insurers need to provide in order to be included in the exchange

Mandates, Incentives and Subsidies

  • Companies that have a payroll of over $250,000, will either need to offer health insurance with minimum benefit requirements or pay into a pool to help fund subsidies for people who are not covered. The payment varies from 2.5% of payroll for a 250,000 business and maxes out at a 8.5% for businesses that have over $400,000 in payroll.    
  • Individuals who do not have insurance will need to sign up for health insurance or face a 2.5% tax
  • Provides tax credits for people up to 400% of poverty level ($43K for individuals, $88K for a family of 4) to make buying into the system more affordable

So basically, this sets up a system to insure the uninsured and a set of incentives to get employers to provide insurance or fund the program and individuals to buy into the system. It also provides badly needed regulation of insurance that most people agree on.

So far, the battle lines have mostly been drawn around the dreaded public option. As I noted before, this basically adds one additional option for people who do not have insurance and small firms that want to buy into the system–a system that resembles Medicare (the 2nd most popular government program we have).

Well, why should we have a public insurance option? Aren’t the for-profit companies doing okay? Obviously not (see above). Well then, what could the public option do better?

 Well first, it could reduce costs. American’s mostly get private health insurance from their employers and recent studies have shown that US health insurance companies have the highest administrative costs in the world. They spend roughly 20% of every dollar on non-medical costs. These costs include paperwork, reviewing claims and marketing. In comparison, France spends 4% on administrative costs, Canada spends 6% and Taiwan spends 1.5%. Our own “socialized” system of Medicare spends 2% to 8%, depending on what numbers you use.

I don’t have the breakdown on where the higher costs are for the for-profit insurance, but one has to assume that part of the increased costs include health companies’ research to determine who has a pre-existing condition and should not be allowed to participate in a plan, efforts to deny coverage to people who are currently sick because they filled out their paper work incorrectly or just generally finding technicalities to deny coverage to people who need it. With many of these excuses avoided, surely the insurance companies will still be able to compete against a government run system. We all know how inefficient the government is, right? Who would want to even join that plan? Well, the CBO estimates that about 10 million people would join that system by 2019. For those of you doing the math at home, that’s about 3% of Americans in a ten year period.

I don’t want to spend a lot of time debating this issue, because it’s probably dead. The Democrats might have 50 votes to pass it, but they don’t have 60, which is what they need in the Senate. What may pass is a “trigger” whereby the insurance companies have to meet certain benchmarks (undetermined at this time, but one assumes cost cutting) by a certain date or the public option goes into effect. This could actually work if the benchmarks were strong because I have no doubt that the insurance companies will do whatever it takes to eliminate any competition.

So, to sum it up, the reforms will basicially provide some much needed regulation of the insurance industry, mandates that encourage employers to provide health care and individuals to buy and some subsidies to make it more affordable.

A list of what the reforms won’t do is too long for this forum, but certainly it would include the following: it won’t reform the inefficient for-profit health care system we have in the US, it doesn’t include enough for preventative care and nutrition, it doesn’t include tort reform, it doesn’t create national standards that are proven to decrease costs without compromising care… the list could go on. I think that these omissions are mistakes. When you consider the damage that ballooning deficits could do to our economy and our global standing, it’s clear that we need all hands on deck. But when you have an environment when even the president making a speech to schoolchildren about personal responsibility is sold as a socialist plot, a set of politicians on the other side who don’t have the balls to make tough decisions and a sensationalist media that just covers the pitched battles instead of educating the public, then change comes slow.

If history is any guide, Democrats won’t have a better chance to make change than now. They need to pass what they can now, get some modest reforms and move on to the rest of the issues that are confronting this country.

This issue isn’t going to go away, and we’ll be back here in a few years to fine tune the details.

Anyway, that’s my take.

I guess we’ll hear the president’s tomorrow.