White House Preparing to Step Up on Health Care
The Obama administration has been assiduously pushing for health care reform from day one, but the president has tended not to speak out much on the specific details of the debate. Instead, the strategy has been to talk in a fairly general way about the desirability of reform and leave specifics up to congress so as to ensure maximum buy-in from key legislators. But according to Sheryl Gay Stolberg from The New York Times, we’re about to witness something of a shift in strategy whereby the “is preparing an intense push for legislation that will include speeches, town-hall-style meetings and much deeper engagement with lawmakers.”
One particular area of focus, it seems will be the public option. This is crucially important and also, I think, something where a lot of legislators will be looking to the White House for leadership. In the early months of this debate, I don’t think it was totally clear how strongly the administration was behind the idea of a public option. More recently, they’ve put their shoulders into it more and the Hill seems to be responding. But in most respects the trickiest issue before the congress remains the question of revenue. It’s not tricky as an intellectual matter, it’s easy to come up with reasonable tax measures that would get us what we need. But it’s politically very tricky.
No real news to that, but the fact of the matter is that it’s on the revenue side where progressive policy really faces its toughest challenges and it remains to be seen what kind of case Obama can make to the public.
32 Responses to “White House Preparing to Step Up on Health Care”
Register
RSSLogin
Topic Cloud
ArchivesBlog RollAbout Matt YglesiasContact Me
Donate
June 7th, 2009 at 10:13 am
“But in most respects the trickiest issue before the congress remains the question of revenue.”
Actually, of course, the trickiest issue before the congress remains the details of the public option.
If the public option is done wrong this summer, it will never get fixed. And if the public option is done right this summer, it will act as a cornerstone to support a sane heatlhcare policy for decades to come.
Revenue, on the other hand, will be far easier to fix going forward if it is done incorrectly today. It’s only the trickiest issue if you don’t grasp the big picture.
—–
Robert Reich does a competent job of laying out the basic outlines of the territory where the shadow fights on the public option will take place.
June 7th, 2009 at 10:54 am
It’s really hard to trust that Obama intends to do the right thing here. He hasn’t in any previous instance that wasn’t purely symbolic, so I’ll believe it when I see it.
You can’t break every single promise you’ve made to a group of people and expect them to trust you. Those on the left (the real left, not you guys. You’re extremely moderate) just don’t have much faith in Obama right now.
People like Matt didn’t go out and work for Obama. People like that sat on their asses and maybe donated a little money. Yet people like Matt got everything they wanted, and we got nothing. I have no doubt whatever ‘public option’ Obama campaigns for will be extremely weak.
June 7th, 2009 at 10:56 am
Obama lied like Bush in his weekend radio talk on health care reform.
http://www.google.com/hostednews/ap/article/ALeqM5hriv3YGa_SuVkRpGJE3ts_kTEvoQD98LQMAO0
http://stateofthedivision.blogspot.com/2009/06/in-search-of-explanation-complexity-on.html
June 7th, 2009 at 10:59 am
What Petey said. The big insurance companies know it too, which is why they are shitting out their intestines (a pre-existing condition) over this. The revenue side is moot if the implementation is screwed up, whether by design or as a consequence of appeasing the Senate-industrial complex.
I think Reich is correct to warn of the dangers of the “trigger” concept, and of punting it down to the states, which are usually much more susceptible to local corporate pressure, while being less visible (and accountable) to the public.
June 7th, 2009 at 11:02 am
It’s really hard to trust that Obama intends to do the right thing here.
You don’t “trust” on an issue like this. You trust that Obama is sufficiently savvy in political terms to appreciate the consequences of selling out on healthcare, and as a result, make him do it.
June 7th, 2009 at 11:11 am
The revenue would be much less tricky if auctioning of emission permits were still on the table.
Public option or no, I want to know where the aggregate cost savings are supposed to come from. HOw do we get health spending as a percent of GDP down?
June 7th, 2009 at 11:18 am
Psuedo, I don’t. If he were sufficiently politically savvy he would have done quite a few things differently.
He would have done a lot more to turn the economy around. The fact that we have a good chance unemployment to will be above 10% at the beginning of 2011 will do more to doom the Democratic party than this ever could. He doesn’t seem to care about that.
It really seems to be that the Democrats only exist to slow-walk progress in the event that Republicans fail to stop it altogether.
June 7th, 2009 at 11:19 am
I consider myself a progressive guy, and I’m a healthcare professional knowledgeable about the reform effort, but I’m still having a hard time understanding why a public option is so necessary.
I certainly don’t have a right-wing instant revulsion to anything that starts with the letters “gov-,” it’s just that I think regulation is just a powerful a tool as well. The insurance industry’s agreement to end pre-existing condition pricing eliminates their most egregious practice (and this is by far the greatest victory I think we can achieve in the reform effort). Benchmark plans and state-side clearinghouses will have a lot of power to simplify the system and reorient competition to price. And giving MedPac the power to implement new reimbursement systems in medicare seems much more important both for improving cost and quality. That’s what we should be fighting for, IMHO.
It seems that by insisting on the public option we’re taking the most antagonistic approach. I’d almost be relieved if I found out this was staking out a left-most position that we could use to get greater concessions on more important issues.
June 7th, 2009 at 11:23 am
Well Thomas, you can spend a lot of money we don’t have revenue for in order to get a system that won’t ever work.
Or we can spend a lot of money we don’t have revenue to cover for a system that will work to some degree.
Doing nothing isn’t going to happen, so the revenue really is moot point. Unless you have some hardcore ideological aversion to deficit spending, there’s no point in considering it right now. If you do, then you’d probably be against any kind of healthcare system at any time. People who hate deficit spending hate social safety nets, regardless of how little an impact they actually have on the deficit. Hell, I’d go so far as to say that they hate deficit spending BECAUSE they hate social safety nets, but realize that attacking safety nets on any other grounds would be suicide.
June 7th, 2009 at 11:31 am
HOw do we get health spending as a percent of GDP down?
I’ll link to this again, which is what all the koolkids are linking to. New Yorker, 6/01/09. Maybe this time I will read to the end.
Cost Conundrum
My impression from the early part was that the doctors in McAllen were prescribing excessive diagnostics etc not because of fear of lawsuits (Texas passed tort reform) but because they could, because it was profitable, and because someone would pay the cost.
June 7th, 2009 at 11:32 am
“I consider myself a progressive guy, and I’m a healthcare professional knowledgeable about the reform effort, but I’m still having a hard time understanding why a public option is so necessary.”
Well, considering that a public option will end up taking money out of your pocket, I’m not particularly surprised that you might have a hard time understanding why it is so necessary.
Similarly, flesh-eating bacteria have a hard time understanding why antibiotics are necessary.
—–
Of course, for the American public that is seeking to get reasonable healthcare at a reasonable price, a public option is the only thing that will force future congresses to do the right thing once the spotlight has been taken off healthcare reform.
That’s why the industry is fighting so hard to force the public option to be stillborn or ineffectual. And that’s why creating a robust public option is so crucial for the American future.
June 7th, 2009 at 11:38 am
“My impression from the early part was that the doctors in McAllen were prescribing excessive diagnostics etc not because of fear of lawsuits (Texas passed tort reform) but because they could, because it was profitable, and because someone would pay the cost.”
The type of massively profitable incompetent medicine practiced in McAllen is most at risk from exposure to competition from a robust pubic option.
June 7th, 2009 at 11:51 am
Bob McManus:
A big change that would fix that kind of health care cost inflation would be moving from a fee-for-service payment model (where doctors are paid a certain amount per procedure) to a per-capita payment model (where doctors are paid a certain amount per patient) combined with a bonus for patient health outcomes (which is used to make sure that doctors don’t skimp on their patients to game the per-capita system).
A lot of the countries with lower health costs than ours use the per-capita payment model. Now, this isn’t something that’s likely to come into the bill per se, but if (for example) Obama’s idea for empowering MedPAC to really make the decisions for Medicare (and presumably the public option as well) is implemented, then its something that could soon thereafter begin to drive down costs both for Medicare and for the public option as well.
As for the underlying story, I think it’s good Obama’s getting involved but not trying to run the details like Clinton did – he’s focusing on a key core issues that make up a solid “floor” for the bill, and he’s backing up Kennedy and the progressives, which is something he’s not always done. Re the backchat up the thread – besides the stimulus and the budget, there actually hasn’t been that much major legislative action from the Obama administration. Most of the disappointments that people have had have come from executive action or legal cases – on the legislative front, Obama’s track record is ok. The stimulus wasn’t the best it could be, and arguably his team screwed up as newbies often will, but the budget was strongly progressive and pushed through reconciliation. From where I stand, Obama’s legislatively hitting .500 with two at-bats.
June 7th, 2009 at 12:20 pm
“You can’t break every single promise you’ve made to a group of people and expect them to trust you. Those on the left (the real left, not you guys. You’re extremely moderate) just don’t have much faith in Obama right now.”
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Not that you don’t have a point in regards to Obama playing a moderate game, but hyperbole (”every single promise”), labelling (”the real left, not you guys. You’re extremely moderate”) and presuming to speak for an entire group of people (”Those on the left just don’t have much faith”) REALLY undercut that point, especially as many of those statements are false or unprovable.
Stick to facts. Say what Obama’s doing wrong and why it’s wrong, leaving the moral outrage for the conservatives.
June 7th, 2009 at 12:26 pm
“You can’t break every single promise you’ve made to a group of people and expect them to trust you. Those on the left (the real left, not you guys. You’re extremely moderate) just don’t have much faith in Obama right now.”
I’m not terribly moderate, and I think the lack of faith is justified, but it should be tempered with an awareness that the key roadblocks to progress are the Blue Dogs, the dysfunctional and thoroughly undemocratic nature of the US Senate, and the weakness of the Senate Democratic Leadership. The willingness to fight for the reconciliation option shows, to me, that Obama understands this.
Savvy or not, Obama is a finesse guy who doesn’t like to twist arms. We knew this about him all along, and he took great pains to demonstrate it throughout the campaign. No one should be surprised or disappointed that he’s playing a finesse game. But I absolutely agree that delivering health care reform with a robust public option is the acid test for his first year in office.
If his slow-walking on DADT, unwillingness to pursue justice on the torture front, watered-down down cap and trade, spinelessness on marriage equality, hand-holding and ass-kissing of useless Senate Moderates delivers a solid health care reform, then I think Obama gets a strong B+ and some folks on the Left owe him a few apologies. If not… you guys told us so, and we were wrong.
June 7th, 2009 at 12:33 pm
So far Obama has kept a lot more campaign promises than he has broken, with a lot more in the works, and a few more stalled. And you don’t have to take my word for it:
http://www.politifact.com/truth-o-meter/promises/
Of course by far the biggest category at this point is “no action”, but he hasn’t been in office that long.
June 7th, 2009 at 12:37 pm
It seems that by insisting on the public option we’re taking the most antagonistic approach.
The most antagonistic approach is demanding single-payer right now, in which private insurance packs up its clipboards and gets out of Dodge. (Or, at very least, diminishes to the kind of supplementary role it occupies in France.)
Single-payer advocates don’t get into the committee room with Max Baucus right now, and whatever you think of Ed Schultz, he’s done a fine job of ensuring that the public option can’t be bipartisan’d out of the debate, by making clear that there’s a coherent, non-fringe position that sees private insurers an unnecessary middleman for most medical treatment.
There’s the argument that a public plan is single-payer through the backdoor — that if enough people have an option that doesn’t fuck them over on a regular basis, then it’ll eventually kill off the private insurers. I’m ambivalent about that, but I’m not ambivalent about the need to have something in place to keep the bastards honest.
The Gawande article makes the point that people generally don’t know the extent to which their treatment just happens to align with the highest profit margins of those making diagnostic decisions. McAllen just happens to be one of those places where the majority of physicians “treat patients the way subprime-mortgage lenders treated home buyers”.
June 7th, 2009 at 12:52 pm
Obama has a lot on his plate. We have had decades of inaction on key problems. I can recall an ethics class in medical school in about 1990 and we were discussing how we couldn’t keep spending 12% of GDP on healtcare. It is now 17% and my offices health insurance premiums were increased by 24% this year. That would lead to a doubling in 3 years.
Our economy was truly on the brink and the last thing that Obama can afford to do is anything that would risk that.
There will be an incredible push to do nothing. We will hea horror stories about rationing of care, long waits, delays in lifesaving treatment but don’t we have that now to some degree? And aren’t we spending 1.5X the amount of the next closest country? Hopefully we will see rationale adult thinking and come up with an affordabe, universally available plan and then allow the have’s to purchase more if they want. Isn’t that what we do with other “necessities”? We try to have safety nets so everyone can have a basic house, food, and public education. We should do the same with healthcare. I fear that the right will scare the masses and the left will get bogged down in trying to make everything equal for all. I also think that free care is a bad thing People need to have some personal skin in the game. It doesn’t have to be much but in my practice, the VIP’s (money is no object, someone else is paying) are the ones who overuse resources the most.
I don’t like the idea of a federal beauracracy running medicine but we have an insurance company one running much of it now.
I am not sure that the US is ready to have an adult conversation on what govt. can do for them and what it will cost. We will have right wing media rallying there 30% or so and there will be a significant number of others who will vote for whoever promises the easiest and most painless solution.
June 7th, 2009 at 12:57 pm
I’m going to start an Intrade contract that says “By Dec 2009 Matt Yglesias will write at least one post which doesn’t leave an important word out. Then I’m going to sell it short and be rich.
June 7th, 2009 at 1:14 pm
If people (particularly liberals and ‘the left’ etc) just sit this one out, instead of doing everything they can for the most massive and effective mobilizing, and just lazily and passively hope and blog that Obama and Congress do what they want, then they (we) pretty much deserve to get reamed again and not have any decent healthcare reform.
June 7th, 2009 at 1:19 pm
Re: It’s really hard to trust that Obama intends to do the right thing here. He hasn’t in any previous instance that wasn’t purely symbolic
If you’re standard is perfection (or 100% what you yourself want done according to your personal priorities), then you’re bound to be dispapointed. But compare the Obama administration to the Bush administration, and it’s light years better (yes, I know that’s a pretty low bar to surmount). If McCain had been elected instead would we even be talking about a major healthcare overhaul?
Bottom line: Don’t let the best be the enemy of the good.
Re: You can’t break every single promise you’ve made to a group of people and expect them to trust you.
Are you sure any such promises were made? Or are you reading things into candidate’s Obama’s words that weren’t there? And on healthcare at least Obama is pretty much where we was at during the campaign; he never said anything about single payor you know so if anyone is disappointed that he’s not backing that, they were not paying attention last year.
Re: The fact that we have a good chance unemployment to will be above 10% at the beginning of 2011 will do more to doom the Democratic party than this ever could.
If unemployment is still high next in two years the blame will rest with George “Herbert Hoover” Bush, just as the real Herbert Hoover (who was much more compoetent and much less malicious than Bush) was blamed for the Depression not just through the 1930s but for as long as significant numbers of Depression survivors were among us. It’s only now, when the Depression era folks can be found mainly in the cemeteries, that the revisionists have been making any headway at reapportionining blame for that calamity.
Re: There will be an incredible push to do nothing.
I don’t think “nothing” is on the table, at least not the way it was in 1994. Many of the interest groups who banded together to sink the Clinton reform, are now demanding change as well. There’s even voice in the GOP suggesting that it would best to get healthcare over and done with so it would cease being a Democrat-winning issue.
June 7th, 2009 at 1:29 pm
I certainly don’t have a right-wing instant revulsion to anything that starts with the letters “gov-,” it’s just that I think regulation is just a powerful a tool as well.
That’s assuming that anyone enforces the regulations, and that they’re not chiseled away to nothing by a series of under-the-radar executive and Congressional moves, which will happen as the political winds change. The insurers are much more afraid of public competition– a massive entity (risk pooling, remember?) that has low administrative costs and also no profit requirement– than of regulation. They can game a fully private system if they stick together (for these purposes, they’re essentially a cartel), and play the different states’ rules against each other to keep their high profitability, but on a national playing field, against an insurer that gets most young people as well as the sickest ones, and that can’t be destroyed easily… well, that’s a lot scarier.
As a side note, that’s why I hope (not a real policy wonk, so I can’t really critique what’s out there right now) that whatever funding is necessary to make this happen is designed to go towards the system as a whole more than the public insurance itself. That gives room to criticize private insurers for taking government money, and separating the public plan enough to make it financially independent means that there will be fewer opportunities to defund it when the GOP regains power.
June 7th, 2009 at 2:10 pm
Petey, thanks for the unnecessary attack. It’s good to know that the time and effort docs put in is still well respected. Since I’m primary care, I probably stand to gain from the public option, and it will probably put money in my pocket. So now you look like an idiot.
And you still didn’t explain how the public plan was necessary. You just said it was.
June 7th, 2009 at 2:13 pm
Sorry, that last post was by Carlos, I was just thinking about Petey.
And just one more thing: I’d like to point out that I participate in a large-scale pilot project that reimburses me per-patient rather than per-procedure. And although the data’s still out, I think its the key to reform. I just think that’s why we should be pushing for the changes in MEDPac rather than a public option, which doesn’t directly address reimbursement.
*sigh,* my job used to mean something to people.
June 7th, 2009 at 2:59 pm
Petey’s first comment in this thread may be the first thing he’s written that I’ve ever agreed with. Didn’t last long.
June 7th, 2009 at 3:01 pm
“and also no profit requirement”
You need to keep in mind that 40% of the private health insurance provided in the US is provided by non-profit insurance companies – BCBS, Kaiser Permanente, etc.
June 7th, 2009 at 3:07 pm
*sigh,* my job used to mean something to people.
It’s up to you and your like-minded peers to claim it back. There aren’t many countries in the developed world where it’s smart to second-guess diagnostic recommendations because your PCP might have a referral bonus or a financial stake or a sweetheart deal.
June 7th, 2009 at 3:14 pm
“Since I’m primary care, I probably stand to gain from the public option, and it will probably put money in my pocket … And you still didn’t explain how the public plan was necessary.”
Well, you are saying here that having a viable public option would help channel resources into primary care, which I think everyone agrees is correct policy, no?
And a public option will have similar effects toward correct policy throughout the system.
But the multitude of reasons a public plan is necessary have more to do with the mechanics of government than the mechanics of medicine. One prime example of this is that without the government being a player, it simply won’t have the expertise and will to be an able regulator. Another example is that having an annual budget line makes reforms less vulnerable to future political assault.
June 7th, 2009 at 3:40 pm
pseudonymous in nc said “It’s up to you and your like-minded peers to claim it back.”
I disagree. If the way doctors are paid is what’s primarily driving the breakdown of the patient-physician relationship (and it’s certainly the biggest part, in my opinion), then I’m precisely the last person who has any ability to claim it back. I have no control over reimbursement schemes besides voluntary participation in research projects; as far as the money side goes, I’m just an average voter. Physician interest groups like the AMA don’t represent my views; when something closer forms, like Physicians for Single Payer (I’m not for single payer but its certainly closer to my heart than the AMA), they’re not really included in the discussion. In my opinion the AMA represents a minority of physicians, but due to its historical standing, strong funding (from catering to wealthy specialists), and lobbying infrastructure it dominates competing voices.
Also, I humbly submit that the breakdown in the physician-patient relationship is a two way street. Crass commercialism has invaded both sides of the aisle, and the problems of McAllen TX are not just greedy docs looking to make a buck, but intervention minding patients who have come to treat physicians as pill-dispensing machines and think you’re cheating them if they don’t come out of your office without a prescription. I’m a big fan of nudge behaviorism theory: we need to start nudging things and form a change in culture, and that means changing both the ways doctors and patients behave.
June 7th, 2009 at 3:50 pm
Petey Says: Well, you are saying here that having a viable public option would help channel resources into primary care, which I think everyone agrees is correct policy, no?
I was annoyed with you, and I spoke too hastily, and I’m sorry about that (both for insulting you and muddying my point). I was wrong to say that I will benefit from a public plan. That is not necessarily the case. I will only benefit from a public plan if it concurrently involves a change in the reimbursement structure geared towards primary medicine. In my opinion, this is a separate issue. Medicare contains sufficient scale to propagate changes in the system without a public option. Furthermore, the elderly and chronically ill patients are precisely those who would most benefit from a different approach from their physicians.
I can see some value in your point that a public option might be a stronger plan politically. However, I’m not sure if this is true. Medicare Part D was a government run public plan that was quickly sullied by various poision pills inserted by commercial interests. Furthermore, if we’re gonna have to fight tooth and nail for the public plan at the expense of other, in my opinion more important, reforms (like MEDPac changes), I just don’t see the value.
I don’t get your point about the government not having expertise if it’s “not a player.” The government is a “player,” it runs half of the medicine in this country already. And the regulatory options available to us seem strong. Mandate a certain baseline plan. Then have benchmark plans that fit into certain categories like “high-deductible,” or “premium coverage.”
I’d also strongly advocate for limiting the Employer Exemption not just as a revenue source, but to allow the individual market to compete. It is insane to me that a man who has lost his job loses his healthcare. That has a huge impact on cost, access, and outcomes. I can’t practice good preventative medicine if I don’t know whether you’ll be able to afford to come to my office next month.
There’s just so many things worth fighting for besides the public plan, and I think they have more benefit.
June 7th, 2009 at 10:01 pm
[...] reform. The White House is sending the message to lawmakers and the American public that it “is preparing an intense push for legislation that will include speeches, town-hall-style meetings and much deeper engagement [...]
June 8th, 2009 at 8:23 am
Michael Moore’s movie “Sicko” detailed what is wrong with health care in this country. Health care is astronomical when it doesn’t have to be. WHY do health insurers charge so much and pay so LITTLE?
Get the pharmaceutical and health insurers lobbies OUT of the White house so we can make health care AFFORDABLE for everyone, not just the corporations and/or privileged few.