Health care bill making progress

By DAVID BROOKS
Published: December 17, 2009 NYT
Times Topics: Health Care Reform
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The first reason to support the Senate health care bill is that it would provide insurance to 30 million more Americans.

The second reason to support the bill is that its authors took the deficit issue seriously. Compared with, say, the prescription drug benefit from a few years ago, this bill is a model of fiscal rectitude. It spends a lot of money to cover the uninsured, but to help pay for it, it also includes serious Medicare cuts and whopping tax increases — the tax on high-cost insurance plans alone will raise $1.3 trillion in the second decade.

The bill is not really deficit-neutral. It’s politically inconceivable that Congress will really make all the spending cuts that are there on paper. But the bill won’t explode the deficit, and that’s an accomplishment.

The third reason to support the bill is that the authors have thrown in a million little ideas in an effort to reduce health care inflation. The fact is, nobody knows how to reduce cost growth within the current system. The authors of this bill are willing to try anything. You might even call this a Burkean approach. They are not fundamentally disrupting the status quo, but they are experimenting with dozens of gradual programs that might bend the cost curve.

If you’ve ever heard about it, it’s in there — improved insurance exchanges, payment innovations, an independent commission to cap Medicare payment rates, an innovation center, comparative effectiveness research. There’s at least a pilot program for every promising idea.

The fourth reason to support the bill is that if this fails, it will take a long time to get back to health reform. Clinton failed. Obama will have failed. No one will touch this. Meanwhile, health costs will continue their inexorable march upward, strangling the nation.

The first reason to oppose this bill is that it does not fundamentally reform health care. The current system is rotten to the bone with opaque pricing and insane incentives. Consumers are insulated from the costs of their decisions and providers are punished for efficiency. Burkean gradualism is fine if you’ve got a cold. But if you’ve got cancer, you want surgery, not nasal spray.

If this bill passes, you’ll have 500 experts in Washington trying to hold down costs and 300 million Americans with the same old incentives to get more and more care. The Congressional Budget Office and most of the experts I talk to (including many who support the bill) do not believe it will seriously bend the cost curve.

The second reason to oppose this bill is that, according to the chief actuary for Medicare, it will cause national health care spending to increase faster. Health care spending is already zooming past 17 percent of G.D.P. to 22 percent and beyond. If these pressures mount even faster, health care will squeeze out everything else, especially on the state level. We’ll shovel more money into insurance companies and you can kiss goodbye programs like expanded preschool that would have a bigger social impact.

Third, if passed, the bill sets up a politically unsustainable situation. Over its first several years, the demand for health care will rise sharply. The supply will not. Providers will have the same perverse incentives. As a result, prices will skyrocket while efficiencies will not. There will be a bipartisan rush to gut reform.

This country has reduced health inflation in short bursts, but it has not sustained cost control over the long term because the deep flaws in the system produce horrific political pressures that gut restraint.

Fourth, you can’t centrally regulate 17 percent of the U.S. economy without a raft of unintended consequences.

Fifth, it will slow innovation. Government regulators don’t do well with disruptive new technologies.

Sixth, if this passes, we will never get back to cost control. The basic political deal was, we get to have dessert (expanding coverage) but we have to eat our spinach (cost control), too. If we eat dessert now, we’ll never come back to the spinach.

So what’s my verdict? I have to confess, I flip-flop week to week and day to day. It’s a guess. Does this put us on a path toward the real reform, or does it head us down a valley in which real reform will be less likely?

If I were a senator forced to vote today, I’d vote no. If you pass a health care bill without systemic incentives reform, you set up a political vortex in which the few good parts of the bill will get stripped out and the expensive and wasteful parts will be entrenched.

Defenders say we can’t do real reform because the politics won’t allow it. The truth is the reverse. Unless you get the fundamental incentives right, the politics will be terrible forever and ever.

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I've gone back and forth on this bill; but in the end, I come out with Krugman and Victoria Kennedy. It's far, far from ideal, but the system it will create is better than what we have now. The fight for a better and democratic (note the lower case "d") health care system will have to continue. For now, the corporate/insurance interests are still controlling the democracy through 'divide and conquer' techniques based on misleading information and arguments. The fact that Palin's 'death panel' arguments (or Glen Beck's idiocies) can resonate with any appreciable segment of the U.S. population tells us all we need to know about the failure of our basic (K-12) education system to teach critical thinking. In the meantime, the fact that 30 million more Americans will be able to get health insurance is no small matter, nor is the fact that a person, who now can't get any insurance because of pre-existing conditions, will be able to (even if the premium will be higher, so long as it can be paid, it beats a family losing everything it owns in order to pay for health care for a sick or injured family member). - - -


Paul Krugman: Pass the Bill
http://www.nytimes.com/2009/12/18/opinion/18krugman.html?_r=3&scp=3&sq=krugman&st=cse

Victoria Kennedy: Health bill 'imperfect' but necessary: Kennedy widow
http://www.google.com/hostednews/afp/article/ALeqM5j0m7LbkCWtIOGK-kQWO3bZQDnuug

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even without lowering the cost, of course the whole point to the health care reform was to extend health care to millions of "healthy" americans without healthcare so that we can keep them healthy and keep them from having catastrophic events that could have been prevented earlier.... this is the biggest way to save healthcare spending in the decades to come. But if we were to simply lower the medicare age, we lose on this point because now we are enrolling younger retired age population who may already have catastrophic event, only now on medicare. without lowering the cost then truly, where is the benefit besides more "old=potentially sick but yet undetected" people get sick on government plan and increase our health care spending. then we fall back to our last weakest point of passing health care reform, we just pass something so that it is easier for us to modify this one in the future than try to write the whole thing from the beginning and also have the pop get used to the idea so that next modification comes around ppl are less scared.. so we hope...

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I see where Krugman is coming from, and if I was a Senator (heaven forbid!), I would be forced to support the bill too. But it's tragic that our legislative system allows one or two senators to take a major historic reform hostage, and it's unfortunate that there is so much misinformation and so little support for single-payer reform and inevitable health care rationing.

Surely passing this bill is preferred to the status quo, and yes some incremental improvements can be made to the legislation over time, but I think the bill squanders our current rare opportunity (with all the stars in alignment) for fundamental reform of cost-incentive-accountability structures that is truly needed. Obama and others have said that if we don't pass health reform now, we'll have to wait another generation as costs continue to rise. Politically that is possible (hard to get a fillibuster-proof majority in the Senate to coincide with an administration of the same party), but I think the huge economic pressures of pricier care, plus the retiring Boomers, will compel us to revisit the health debate more frequently. Who knows if future presidents will be more Bush than Obama, and when the next Ted Kennedy will emerge to keep the Senate morally grounded? I think many progressives are disappointed that this is the best "change" we can get with Obama at the helm and a solidly Democratic (though still centrist-conservative) Senate.

The House version has the public option, foreign drug imports, tougher abortion restrictions, and more mandates for insurers (85% of premiums must be paid out as benefits, more oversight, less monopoly). All of those are toxic to Senators, so they'll probably be scrapped. But without the abortion amendment, I don't know if the Blue Dog House Dems will be on board with 2010 midterms around the corner (does Pelosi have a majority without them, Joseph Cao notwithstanding?). Liberal Reps have a right to be pissed about this bill, but I think they will end up voting for the Senate version rather than causing trouble and fragmenting their own party that is desperate for a political win. The Senate wants to tax Cadillac health plans and curb the wasteful Medicare Advantage program, but both are very unpopular with the rank-and-file, pro-union House Dems. So I guess it's not a sure thing Obama will sign this sucker by Christmas, and of course the GOP will do everything they can to stall and let the holidays sap momentum away.

What sucks is that the "party of no" GOP more or less walks away clean. The right wing spin suggests that they were the "patriots" who fought to protect the "good ol' American values of freedom and small government" in health care from a radical Obama who hates white people, but really they were just boulders in the road of inevitability. They'll declare victory because they killed the public option and "socialized medicine". If we want to go broke continuing to over-medicate patients, over-pay doctors/insurers, and under-perform in this country, then by all means do nothing. But the GOP literally didn't offer any constructive alternatives during this whole 6-month process. Obama should have never tried to take the bipartisan route - he'd have better luck negotiating with North Korea. Did he really expect them to cooperate on making him look good? The minute the right started mouthing off and misbehaving, he should have put them in their place. If he came down on them in the bold, righteous manner that he delivered his Nobel speech, we'd be in much better shape now. But instead the Dems were timid all summer while the tea parties and talk show hosts sowed the seeds of confusion and misplaced anger.