Matt Yglesias

The High Cost of American Treatments

This morning at the gym I listened to an excellent Planet Money podcast about why getting an MRI scan costs so much more in the United States than it does in Japan. It turns out to be a bit hard to say. This is clearly related to the fact that we have more of the very fanciest MRI machines, but it doesn’t seem to be all that tightly related and it’s not entirely clear in what direction the causation runs.

This is important because the biggest reason American health care is more expensive than what you see in other OECD countries is that we pay higher prices for basically the same stuff. In some pockets of health care, this gives us a clear edge in the availability of certain kinds of advanced treatments. The high prices we pay both helps fund R&D efforts and also means that if you’re going to rush something new to one market, you want it to be our market. But it doesn’t, as a whole, seem to have any obvious benefit in terms of health outcomes in part because the most valuable health care interventions (give antibiotics to kids with infections instead of letting them die) aren’t especially expensive or high tech.

Thousands of Uninsured Arkansans Seek Free Medical Care

NAFC photo

It’s not a coincidence that states with elected officials who are dubious about health reform tend to have the largest number of uninsured people. The same political culture that produces high uninsurance rates at the state level normally also produces federal officials who are hostile to measures to broaden access. But as long as the spotlight’s on Arkansas:

According to the Arkansas Department of Health, around 450 thousand Arkansans lack health insurance. More than a thousand of those uninsured made their way to Little Rock’s Statehouse Convention Center on Saturday for the National Association of Free Clinics “C.A.R.E.” event. [...] According to the NAFC, more than 90 percent of those who came on Saturday had three or more life-threatening conditions, such as hypertension, diabetes, cardio-vascular, and pulmonary disease. Dr. Kimberly Garner, who works for the Veteran’s Administration in North Little Rock and was one of the volunteer physicians at the clinic, says those kinds of numbers illustrate the need for change.

As of 2008, 19.2 percent of non-elderly Arkansans were uninsured (Arkansas seniors, of course, avail themselves of government-run health insurance), a bit higher than the national average. Many of those people would be made much better off by the health reform bill that passed the House or by the somewhat different one that passed the Senate. But Blanche Lincoln says that unless Democrats agree to kill the idea of introducing a public option into the mix, she’ll vote against a bill that would otherwise help many of her constituents.

Blanche Lincoln’s Website Still Says She Supports The Public Option

My colleague Igor Volsky points out that not only did Blanche Lincoln used to support a public option, as of last night at least that language was still up on her website:

Her specific belief that a public option, if enacted, would eventually receive public funds even if it’s created by a law that prohibits taxpayer subsidies is a little bit hard to understand. Right now there aren’t sixty votes in the Senate for taxpayer subsidies to a public option. Nor is there a majority in the House for taxpayer subsidies to a public option. Nor does the White House support such subsidies. And we’re at something of a high water mark for Democratic victories—how likely is a simultaneous leftward shift by all three branches?

Blanche Lincoln, Racing Horse

Blanche Lincoln has emerged as one of the pivotal votes in the US Senate debate about health care reform. So an article about her and her role in the debate seems like a smart thing for a newspaper to run. Which makes Spencer Ackerman’s tweet quite apropos: “Hey let’s say that I didn’t pay any attn to HC yesterday. Shouldn’t this piece tell me why Lincoln opposes the bill?”

Exactly. It’s striking to me how little scrutiny the stated views of public option opponents tend to get. Moderates are very rarely asked to explain what it is about an opt-outable level playing field public option that’s so horrible that it becomes suddenly worthwhile to filibuster an otherwise good bill that will put the country on a more sustainable fiscal course will improving millions of Americans’ access to health care.

Coal Groups Want to Block Health Reform to Kill Clean Energy

One crucially important, but not-so-well-understood aspect of American politics is that business groups in the U.S. tend to behave in a highly ideological, highly solidaristic manner rather than as narrow interest groups. For example, check out this interesting item from my colleague Lee Fang:

Corporate front groups and large business trade associations are funneling their resources into defeating health reform. Even though health reform will lower costs for small businesses and boost worker productivity economy-wide, it appears that corporate entities influenced by major polluters are hoping that the defeat of health care legislation will slow President Obama’s agenda and derail their true enemy: clean energy reform.

The West Virginia Chamber of Commerce, which is largely backed by the coal industry, candidly revealed this strategy in a letter released today to Sens. Jay Rockefeller (D-WV) and Robert Byrd (D-WV). The Chamber of Commerce demanded that the senators use “their clout and seniority” to obstruct the health reform debate until cap and trade legislation is taken off the table and the EPA is barred from regulating carbon dioxide as a pollutant. As Ken Ward of the Charleston Gazette noted, Rockefeller has already rejected a similar proposal of blocking health reform unless the EPA stops reviewing mountaintop removal permits. The coal lobby has also pressured West Virginia state legislators to pass resolutions opposing clean energy reform.

Part of what’s interesting about this is that, as a matter of logic, you could easily imagine trying to run this play in the other direction. The WV Chamber of Commerce could be working with Senators Rockefeller & Byrd to cement a broad, bipartisan alliance between WV legislators in which the Republicans join with the Democrats to support health reform and the Democrats join with the Republicans to protect the state’s coal interests. There’s nothing, in other words, particularly obvious, natural, or inevitable about this kind of linkage. But American business has a very strong tendency toward forming a broad ideological alliance against all forms of regulation and public services. You might, for example, think that “real economy” firms would want a well-regulated financial system but business groups show no signs of anything other than hostility to efforts to better-regulate the main banks.

Away We Go

Senators Lincoln and Landrieu have no both indicated that they’ll vote yes on the motion to proceed to the debate of the Senate health care bill. They’ve also both made it clear that they won’t vote for cloture on the bill unless the debate process leads to further concessions, especially on the public option.

That’s the day’s news. There’s hours more of debate to go, but we know what we need to know.

Big Type = Long Bills

The whole thing where members of congress criticize bills for being too long is ridiculous. It just makes no sense whatsoever on its face. But to understand how dishonest it is, you need to actually look at a page in a bill. This, for example, is an actual-size reproduction of a portion of page 58 of the Senate health care bill:

The bill is long in part because it’s a complicated bill with lots of words in it. But part of the issue is that bills are printed up with large type and a lot of spacing. I’m not exactly sure why they’re formatted this way, but anyone who’s ever worked on the Hill—including Republican members of congress of course—knows this perfectly well.

Yesterday I heard Orrin Hatch say the health care bill is longer than War and Peace or some such. But it’s not. There are just fewer words on each page:

And recall that despite GOP protestations to the contrary, the House bill actually has fewer pages than War and Peace. More to the point, conservatives don’t like the House bill any more than they like the Senate bill even though it’s much shorter. In fact, they like it less—it’s more left-wing. The length of a bill just isn’t a reliable guide to its content. In fact, some of what makes the Senate bill longer is it’s more “moderate” nature—doing Exchanges on a state-by-state basis, for example, requires more words. Providing an opt-out for the public option requires more words.

Do The People Need to Know the Truth?

Harvard Medical School Dean Jeffrey Flier’s complaints about the health care bill seem oddly vague to me and disconnected from any real knowledge of the provisions of the bill. But at the very end he makes some reasonable points:

So the majority of our representatives may congratulate themselves on reducing the number of uninsured, while quietly understanding this can only be the first step of a multiyear process to more drastically change the organization and funding of health care in America. I have met many people for whom this strategy is conscious and explicit.

We should not be making public policy in such a crucial area by keeping the electorate ignorant of the actual road ahead.

I’ll count myself as among those who quietly understands that something more dramatic than what’s in these bills is ultimately needed. And it definitely sounds good to say that we shouldn’t take these first steps without first having a great national deliberation about the bigger changes to come. But I also think that’s a pretty naive way to look at it. The fact of the matter is that the long-term fiscal outlook is dire:

Dealing with this will be hard. If the bill Harry Reid unveiled yesterday is signed into law, it will be easier. It will be easier in part because the bill directly tackles the fiscal problem and reduces the deficit. And it will be easier in part because senators and members of congress who are considering additional ideas to improve the situation will have a recent precedent available of legislative success. If the bill is defeated, tackling the problem gets harder. It doesn’t open the door to a broader national conversation in which citizens lose their bias toward the status quo or interest groups lose their desire to fight for the biggest possible slice of pie.

It would be nice if health reform did more to control costs and reform the delivery system than this bill does. But it does something to control costs and it does something to reform the delivery system. And it improves access for millions of people in need. To hold that latter factor hostage to a pie-in-the-sky belief that if the whole thing goes down in flames more radical change will somehow become possible seems to me to exhibit very strange political judgment.

The Social Construction of Health Care Biases

Ezra Klein said something important but, I think, slightly wrong about what kind of health insurance people prefer:

People tend to prefer PPOs to HMOs. PPOs tend to be more expensive than HMOs. But HMOs tend to have a higher actuarial value. The average PPO is in the low 80s, while the average HMO is 93 percent.

The reason is that PPOs make up for their easy access to specialists by building in more copayments and cost-sharing. HMOs offer more first-dollar coverage, and though specialists are more irksome to access, there’s less cost-sharing. But people prefer ease of access to coverage, so the HMO’s actuarial advantage doesn’t translate into a market preference. In other words, actuarial value isn’t everything.

It’s worth observing that Danish people have the reverse set of preferences.

Danes have two insurance options to choose from for outpatient care. Group 1 is an HMO-style system in which all doctors’ visits are free, but in order to see a specialist you need to get cleared by your primary care physician. Group 2 is a PPO-style system in which there’s cost-sharing when you see a doctor (the government still pays most of the tab, but you need to pay some) but you have the right to go see a specialist directly. Group 1 includes a staggering 98.5 percent of the population indicating an overwhelming preference for cheaper over easier access.

I think the strong, but opposite, US and Danish preferences are mostly about status quo bias. In the United States, HMOs were a relatively new innovation and people have proved willing to spend a considerable amount of extra money to avoid them. In Denmark it’s the reverse, and the Group 2 option is an innovation after decades of non-availability, and Danes seem uninterested in giving up their traditional free medicine in order to get more flexibility.

Kent Conrad Hasn’t Understood T.R. Reid Very Well

One of the strangest spectacles throughout the health reform debate has been Kent Conrad’s insistence on repeatedly citing T.R. Reid’s book The Healing of America as a source for erroneous factual claims about foreign health care systems. It’s especially noteworthy because as best I can tell not only are the things Conrad thinks are true not true, but Reid’s book says they’re not true.

This all started when Conrad started saying Reid’s book shows that France has a great system without a public option. In fact, the French system shows no such thing and Reid’s book says that “In practice, France acts like a single-payer system.”

Today, though, Conrad went on Dylan Ratigan’s MSNBC show. Ratigan’s hobbyhorse for weeks (months?) now has been to complain that the health reform bill isn’t dramatic enough in its impact on most people. He wants to see something more Ron Wyden-style that would sever the employment-insurance link more rapidly. I think this is a fair point, but it’s not practical and in the long-term it’s not going to matter since the bills in congress do head in that direction. Either way, Ratigan had Conrad on this morning to harass him about this, resulting in a dialogue in which Conrad asserts that Germany, France, Japan, Switzerland, and Belgium all have great employer-based systems. Ratigan points out once or twice that this is wrong, but Conrad insists, Ratigan seems to lose his confidence and pivots to Singapore, then Conrad comes back to his claim about Europe and Japan and says everyone should read T.R. Reid:

I think it’s fair to say that Ratigan had this right the first time. Employment isn’t totally irrelevant to French health care, but it works nothing like our employer-based system and most French people are covered by what amounts to a single-payer system. In Germany employers have a big role in financing people’s insurance premiums but, again, that’s not the same as what America’s employer-based system does. In America what happens is that the cost of your premium is split between you and your employer, but your choice of insurance options is determined by your employer’s HR department. The German system is more like a payroll tax that funds government subsidies for you to sign up for the “sickness fund” of your choice. In Switzerland “individuals — not employers or the government — choose from a broad array of health plans, sold by private insurance companies.”

I don’t know anything about Japanese or Belgian health care and I don’t want to look it up. But the common thread here, it seems to me, is that you shouldn’t confuse the idea of financing things through a levy on employers with the idea of a system in which the employer actually plays a large role. You might like at Social Security and decide that it’s an employer-based pension system, since it’s financed largely through payroll taxes and historically speaking eligibility for benefits was related to which sector you worked in (initially, for example, agricultural workers and domestic servants were excluded). Today, though, it’s actually a public sector pay-as-you-go pension scheme.

Health Care, Public Opinion, and Congress

Andrew Gelman, Nate Silver, and Daniel Lee bring the political science to try to understand senators’ behavior on the health reform debate. One interesting finding is that, at least as measured by answers to the question of whether the federal government should spend more money on covering the uninsured, geographic variation is real but much smaller than variation by age or income:

Another finding is that the state-by-state variation that does exist in terms of people’s level of support for health reform has very little to do with the stances taken by senators. Instead, the controlling concern of senators seems to be Barack Obama’s popularity rather than health care’s popularity:

For instance, Senator Blanche Lincoln, a Democrat who has been a less-than-strong supporter of the present health care bill, recently told The Times, “I am responsible to the people of Arkansas, and that is where I will take my direction.” But where does she look for her cue? Hers is a poor state whose voters support health care subsidies six percentage points more than the national average. On the other hand, Mr. Obama got just 40 percent of the vote there.

Likewise, in Louisiana, where the Annenberg surveys showed health care reform to be popular but where Mr. Obama is not, the Democrats are not assured of Mary Landrieu’s vote.

There are two kinds of ways you can think about the relationship between voters, public opinion, issues, and politicians. One, a hyper-rational way, is to say that voters will like politicians who champion popular causes. Another is to say that voters will like causes that are championed by popular politicians. My sense is that the press tends to implicitly assume the rational model, whereas the truth is mostly the irrational model. Senators, according to Gelman, Silver, and Lee seem to think that the irrational model is the key one in health reform.

This underscores the fact that the toughest “gets” are people over whom the White House has little practical leverage. Overt White House pressure on Lincoln might make her less likely to vote for reform, since an image of standing up to an unpopular-in-Arkansas president would be helpful to her.

CBO: Health Reform Deficit Reduction Not Due to CLASS Accounting Gimmicks

Tyler Cowen, looking for reasons to oppose a health care overhaul that will take a bite out of our long-term deficit problem, chooses to speculate that the “ok CBO rating” is due to an account trick related to the implementation of a new long-term care insurance program. The obvious way to resolve this worry would be see what the CBO’s report (PDF) has to say about it:

As noted earlier, the CLASS program included in the bill would generate net receipts for the government in the initial years when total premiums would exceed total benefit payments, but it would eventually lead to net outlays when benefits exceed premiums. As a result, the program would reduce deficits by $72 billion during the 10-year budget window and would reduce them by a smaller amount in the ensuing decade (an amount that is included in the calculations described in the preceding paragraphs). In the decade following 2029, the CLASS program would begin to increase budget deficits. However, the magnitude of the increase would be fairly small compared with the effects of the bill’s other provisions, so the CLASS program does not substantially alter CBO’s assessment of the longer-term effects of the legislation.

The bill contains provisions that have front-loaded positive impacts on the deficit and also have provisions that have back-loaded positive impacts on the deficit. The bill, rather intelligently, seems to balance this out well leading to net deficit reductions in the short-, medium-, and long-terms. The bill by no means solves the considerable long-term fiscal challenges to the United States, but it does improve the situation. If people want to say that on balance they think the bill is a bad idea, that’s fine, but to do so is to oppose what’s far-and-away the most politically realistic way to enact non-trivial long- and medium-term deficit reduction in the 111th Congress.

The Bronze Plan

One of the obvious ways to keep the price of a universal health insurance plan relatively modest is to water-down the definition of “insurance.” Nick Beaudrot observes that this is essentially what’s been done by Harry Reid to make the math work. The weakest form of insurance allowable inside the exchange—the so-called Bronze Plan—is not a lot of insurance. It’s essentially a “form of individual catastrophic insurance with some first-dollar coverage for certain pre-existing conditions tacked on.”

If I’m understanding the bill correctly, though, this strikes me as a pretty sensible place to compromise. Section 2713 in the general “making insurance better” title of the bill stipulates that:

A group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide coverage for and shall not impose any cost sharing requirements for—

(1) evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force;

(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and

(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.

In other words, you’d be guaranteeing individuals access to an affordable plan that covers catastrophic needs and preventive needs and that they won’t be locked out of by pre-existing conditions. All three of those things strike me as extremely high-value uses of my federal dollars. Spending additional federal dollars to provide people with more comprehensive coverage also strikes me as worthwhile. But I’m a big socialist who thinks people are too averse to taxes and generally undervalue public services. The things that are in the bill—catastrophic coverage, preventive coverage, financial relief for people with pre-existing conditions—are the really tasty low-hanging fruit of health care reform. Moving to a more comprehensive posture is something I’m supportive of, but in a fiscally constrained world it’s reasonable to consider the tradeoffs between spending money on things like that and spending it on preschool or hiring more cops or building more trains or what have you.

That said, reading legislative language is hard and so I’m not totally sure that I’m interpreting this correctly as saying that even the Bronze plan needs to cover preventive services.

Reconciliation is in the Vicinity of the Table

I think the Senate leadership has good reason to not want to try to push health care reform through under the budget reconciliation process. But I also think it’s much easier to imagine a pretty good bill passing under standard procedure if it’s clear to Senators that the alternative to breaking a filibuster is reconciliation rather than no bill. That levels the bargaining position. Progressive members are being asked to support a bill that contains provisions they don’t necessarily like on the grounds that the overall package is better than the alternative. That needs to be a two-way street in which moderate members are, likewise, prepared to vote for a bill even if they don’t get there way on every single point. The prospect of reconciliation is the best way to motivate that choice.

So I was glad to read this:

In response to a question from TPMDC Nelson told reporters that, at a meeting this afternoon with Sens. Mary Landrieu (D-LA) and Blanche Lincoln (D-AR), Reid “talked about process, procedure, discussion about reconciliation and a whole host of issues of that sort.”

“Nobody’s really jumping up and down to push for reconciliation,” Nelson said, “he’s not threatening that, but anybody can conclude that if you don’t move something on to the floor, that is one of the possibilities.”

That’s right. Doing nothing should not be an option. If it’s not possible to achieve cloture, then the best thing to do is get the best bill you can get through the reconciliation process.

Study: Stupak Would Lead to Abortion Coverage Phaseout

Via Brian Beutler, a study from the GW School of Public Health and Health Services confirms progressive fears that over time the Stupak amendment would have quite widespread consequences for the availability of insurance coverage for abortion services. As Beutler writes “though the immediate impact of the Stupak amendment will be limited to the millions of women initially insured through a new insurance exchange, over time, as the exchanges grow, the insurance industry will scale down their abortion coverage options until they offer none at all.”

This is essentially a consequence of one of the main good things about the health care reforms being considered in congress. They not only set up insurance exchanges that will help the currently uninsured in the short-term, they’re designed to have broader implications for the future and over time reshape the health care system.

Could Health Reform Be Repealed in 2012?

Mitt Romney and Ted Kennedy teaming up for universal health care in a happier and more innocent time.

Ron Brownstein writes about the fact that since health reform would largely be implemented in 2013, the GOP presidential nominee in 2012 will likely campaign on a promise to repeal it:

Some senior House Republicans have already pledged to repeal any health care bill if they regain the majority. And many GOP challengers in 2010 will surely echo them. But with Obama holding a veto pen, Republicans probably couldn’t mount a real threat unless they won the White House in 2012. One top adviser to a possible 2012 GOP presidential contender says that, given the GOP base’s hostility to the reform plan and independents’ unease, it is likely that “most potential [Republican] candidates will argue for wholesale replacement with their own version of health care reform.”

Brendan Nyhan brings some perspective to bear on this, but I think the most important thing to note is that “health care reform” is not really one “thing” that anyone is likely to “repeal” regardless of campaign season rhetoric. The question is what, specifically, would a Republican President do. And the answer in general terms is that if health reform passes and a Republican is elected in 2012 then he (or Sarah Palin) will try to reduce taxes on high-income individuals, reduce government on the poor, increase the budget deficit, and alter regulations in a more industry-friendly manner. But of course that’s what will happen if health reform fails and a Republican is elected in 2012 also. That’s what Ronald Reagan did, that’s what George W. Bush did, and the conservative movement appears to remain every bit as committed to that strategy as it’s ever been.

Specifically, Republicans seem very likely to try to reverse the cuts in Medicare Advantage and also roll back some Obama-era tax measures. It seems unlikely to me that they would attempt to actually unravel the mandate/regulate/subsidize structure of a health insurance exchange, but they would gut or kill a public option. They would also probably want to reduce subsidy levels and handle affordability by reducing regulation of insurers leading to folks getting a lower quality of insurance. And as ever there’d be much more emphasis put on cutting taxes than on offsetting spending reductions. What actually happens, of course, depends substantially on congress. Part of the story here is that the reforms Democrats are currently pushing are extremely modest and industry-friendly as is. Republicans just really hate taxes.

The Next Health Reform Debate

The initial aspiration of health reform was to simultaneously tackle the issues of cost and access. As the legislative process has done its work, the access aspirations have been trimmed somewhat but the cost aspirations have taken the really big hits. What we have now counts as a better-than-nothing start, but it leaves the basic structure of American medicine the same and the unsustainability of Medicare still in place. As Austin Frakt says:

That’s why the current debate over health reform is just the beginning–call it Health Reform Debate 1.0 (beta). Debate 2.0 will be about costs, specifically about payment reform. [...] payment reform that compensates providers, at least in part, on the basis of quality and cost control. That’s very vague. One can conjure up some specifics and some have. Few are thoroughly tested and none have been anywhere near the center of political debate. But they will, and soon.

Maybe. Another way of looking at it is that Obamacare could make it more feasible to just enact currently unthinkable right-wing schemes to cut Medicare. After all, the main point of the reform legislation in the congress is to be able to say that we now have an individual health insurance market that works—look at all these regulations and affordability credits and whatnot. But the programs being set up for people under the age of 65 are a good deal less generous than the existing program for the 65-and-over crowd. Under the circumstances, I think that would make raising the Medicare eligibility age politically easier than it is now. Not politically easy but politically easier than it is today and potentially politically easier than the substantively superior path of using Medicare to drive reform of the delivery system.

Crazy Person Pushes Lunatic Theory that Casting Hard-Right Votes is Sometimes Politically Problematic for Republicans

As everyone knows, when the Democratic president and Democratic congressional majorities press for the progressive legislation they campaigned on, it’s very politically risky. Meanwhile, nobody faces any risks for obstructing that agenda. After all, these Democrats all got elected by accident, not because any of them or anything they stand for is popular. That’s why Dave Weigel’s post about how Beau Biden is now leading Mike Castle by five points in polling instead of trailing hum by 20 is so nuts:

What’s responsible for the Biden surge? He’s grabbed the lead in vote-rich New Castle County, built up a 41-point lead among Democratic voters, and moved to only 5 points behind Castle among independents. According to the pollster, the shift “may be a result of negative publicity [Castle] received in the state after casting a ‘no’ vote for President Obama’s health care reform bill in the U.S. Congress.” Castle, who has thrived as a moderate Republican in an increasingly Democratic state, has been casting more partisan votes — against the stimulus package, for the Stupak amendment — that have been well-reported in Delaware.

Crazy talk! Meanwhile, the right is trying to give Rep. Kendrick Meeks (D-FL) a fighting chance of making it to the senate by spiking Charlie Crist’s effort to secure the GOP nomination and an easy win.

Harkin Floats Breaking GOP Filibuster by Attrition

This from Tom Harkin is going to be music to a lot of people’s ears:

“If the Republicans want to stay here this Saturday and Sunday to read the bill, then let them stay here,” Harkin said, adding that Democrats would hold a “live quorum,” where the sergeant at arms requests the presence of all absent senators.

“I’ll tell you, we’re going to do something like that,” Harkin said. “We are planning to do something that would require Republicans to be there 24 hours a day, and if they leave the floor, we’ll ask unanimous consent to dispense with the reading, and that’ll be the end of it.”

I’ll believe this when I see it. Breaking a filibuster via attrition is more difficult than is generally realized. The minority needs to have at least one guy available at all times to hold the floor and keep talking. The majority, meanwhile, needs to have basically all its guys on hand at all times. Otherwise, the minority can “note the absence of a quorum” and everything stops until everyone can be dragged into the chamber. It’s a bigger pain, in other words, for the majority than for the minority which is why you generally don’t see it attempted.

Putting Health Reform Fiscal Issues in Perspective

John Breaux and Bill Frist have an op-ed in Politico whose exoteric message is that congress should use the 2003 Medicare bill as a model for bipartisan health reform. The esoteric message is a reminder that the easiest way to get a bipartisan deal passed is to just have bipartisan agreement not to pay for it at all. That was the secret to the 2003 bill. First you take something a bloc of voters want—in this case prescription drugs—then you figure out a way to provide it in a manner that’s very good for the interests of stakeholders in the business community. Easy as pie.

Genetic Non-Discrimination Act

I like to think I pay closer attention to the news than your average American, but I had no idea this law was ever written. Apparently, no Gattaca-type scenarios are going to emerge:

The most important new antidiscrimination law in two decades — the Genetic Information Nondiscrimination Act — will take effect in the nation’s workplaces next weekend, prohibiting employers from requesting genetic testing or considering someone’s genetic background in hiring, firing or promotions.

But also:

The biggest change resulting from the law is that it will — except in a few circumstances — prohibit employers and health insurers from asking employees to give their family medical histories. The law also bans group health plans from the common practice of rewarding workers, often with lower premiums or one-time payments, if they give their family medical histories when completing health risk questionnaires.

“Genetic information is very broad,” said J. D. Piro, a principal in the Health Care Law Group at Hewitt Associates. “It doesn’t simply include my own genetic information, such as do I have a risk for cancer. It also includes my family medical history — do I have any relatives who have had cancer or leukemia.”

The political impulse to apply non-discrimination principles to health insurers reflects, I think, the fundamental fact that America really doesn’t want to see private health insurance play the kind of major role in our system that it plays. Discriminating against people based on their risk profile is what insurance companies. That’s the essence of the business. But the regulatory impulse with regard to the special case of health insurance is to try to curtail discrimination based on gender, discrimination based on age, discrimination based on genetic profile, etc. I sympathize with the impulse, but if you’re not going to have companies doing risk-based discrimination then the way to get that is to try to cut the insurance companies out of the whole sector.

We’d be happier, I think, if we just had the government cover catastrophic costs and preventive costs and then individuals would pay out of pocket for other stuff. Political debate could then center around how expansively to define “catastrophic” and “preventive” with the left pushing for expansive definitions (and higher taxes) and the right pushing for restrictive definitions (and lower taxes). We’d have a division between the realm of social responsibility and the realm of individual responsibility, people would contest where the line should be drawn, and private insurance wouldn’t be important to health care.

A Good While Longer, I Think

A very strange Scott Sumner post says it’s unfair to accuse American conservatives of opposing universal health care, because Dutch conservatives like the Netherlands’ universal health care system:

Yes, some conservatives oppose any form of universal health care. But at this point would any conservatives/pragmatic libertarians prefer the US health care system we will have 5 years from now over the Dutch, Swiss, or especially Singaporean universal health care plans? And our “universal” plan will still have 20 million uninsured. So for how much longer can progressives claim that universal coverage is the issue separating the left and right?

The Obama plan is, in my view, sort of loosely modeled on the Swiss and Dutch systems. And it’s attracted no support whatsoever from conservative politicians. But the GOP leadership did release a health care plan, focused on deregulation of health insurance companies, that would do nothing to reduce the number of uninsured people. I think it’s perfectly fair to say that universal coverage is the issue separating the left and right. When I see conservative politicians getting behind some version of universal coverage—even something like Martin Feldstein’s plan to give everyone catastrophic coverage—then I’ll stop saying conservatives don’t care about helping the uninsured.

False Hope and the Stupak Amendment

One reason private health insurance tends to cover abortions is that having an abortion is a lot cheaper than having a baby. Consequently, it kinda sorta seems like the Stupak Amendment might have a limited practical impact. Thus I’ve had thoughts along the lines of this from Mark Kleiman:

But what happens when some of the women you insure get pregnant and wants to terminate? Since perinatal care plus delivery would probably cost you $2500, while a first-trimester abortion costs about $200, you’d be happy to provide the abortion coverage gratis if you thought that otherwise even as many as one in twelve of those women would choose to carry to term. You can’t provide it gratis; that’s what Stupak provides. But you could provide it cheap, even to someone who’s already pregnant. Charge $50 for the abortion-coverage rider, effective immediately.

There seem to me to be logistical questions about this. But I don’t think the profit profit motives quite add up. After all, an abortion is not a hugely expensive medical procedure, and whether or not to carry a pregnancy to term is a major life choice. Consequently, I think we should anticipate the price-elasticity of abortions to be relatively low. In other words, in a Stupaked universe most women who find themselves with an unwanted pregnancy are just going to take the financial hit, not have the baby. Under the circumstances it doesn’t really make sense for insurance companies to provide the coverage at an actuarial loss.

The big losers here, however, will be the set of poor women who really may not be able to get together the few hundred dollars that would be needed. This is, of course, entirely typical of relatively “soft” abortion restrictions. Very few people are sufficiently hardcore to push for legislative measures that would really and truly make abortions generally unavailable. Instead the tendency is to create situations that leave loopholes for the affluent while making poor women bear the burdens of middle America’s somewhat incoherent moral stance on the issue.

Can The Filibuster Be Reformed?

I’ve gotten a few queries over the past week asking me to go beyond mere whining about the sorry institutional set up in the United States Senate to asking if there’s anything that can be done about it. The answer is that yes there is. Key elements of Senate procedure have been altered repeatedly throughout history and there have been failed efforts to do it that might have worked had folks been a bit more determined.

What’s missing right now is any sign from anyone politically important of any interest in turning up the heat. As Chris Bowers explains here it seems to be possible in practice for 50 Senators backed by the Vice President to force basically whatever procedural move they want. Traditionally, that’s not the way things have worked. Instead, having key people talk seriously about going this route has produced a political crisis and encouraged people to cut a deal. That’s how the filibuster got pared back from 67 votes to 60 votes. And it’s also how, as recently as 2005, Senate Democrats were persuaded to relent on several judicial filibusters.

But I’ve seen no sign of a serious public campaign of pressure from Barack Obama, Harry Reid, Nancy Pelosi, or other leading figures to delegitimize this minoritarian obstruction.

Too Much Ms. Nice Abortion Rights Advocate?

Dana Goldstein reviews some Monday morning quarterbacking of the abortion in heath care issue:

“Maybe we should have” created a more threatening pro-choice coalition earlier on, said [Eleanor] Smeal. She continued, “Here we are playing nice guy again, we didn’t want to make a fuss, we agreed to a compromise that was already over-generous. And then, bango! These guys go in there like gangbusters. Pelosi was held up, like by bandits. Now the women are saying, ‘That’s it, it’s enough.’”

It’s hard to know for sure, but I’m inclined to agree with this second-guessing. A persistent liberal failure in terms of legislative tactics seems to me to be the repeated belief that if you try to make a compromise proposal, that the compromise will be adopted and then you’ll get half a loaf. The reality of the way the legislative bargaining process works, it seems to me, is that you make a proposal and then a bloc of moderate legislators demands concessions. Whatever you propose, you then have to make concessions since the moderates wouldn’t be moderate if they didn’t make the liberals make concessions. So you might as well have had the bill start with a sweeping expansion of abortion rights—require that all Exchange plans offer a full suite of reproductive health services. Then you start bargaining.

Would that have worked? I don’t know. But the public option example strikes me as encouraging. It looks like if there’s a public option in the final bill, it’ll be a shadow of its original self. But had the proposal started with something like the “level playing field” public option then there’d be nothing left.