Public Option Nears Finance Committee Vote

The public option debate in the Senate Finance Committee was originally scheduled for a vote today, but it was pushed back to Tuesday. While the chief cheerleaders on the committee are not entirely hopeful about its prospects in the committee, they certainly sounded confident about it overall.

"The health care bill that is signed into law by the President will have a good, strong, robust public option," (Chuck) Schumer said.

How that will happen remains an open question. But the Senators assured reporters on the call that we're all going to get a taste of their passion and persuasiveness on this issue at the ongoing Senate Finance Committee hearings on Friday.

"I think it's a great idea," (Jay) Rockefeller said of the public option. "Chuck Schumer thinks it's a great idea. And we're going to be all over it tomorrow." [...]

Schumer said that "a large majority of Democrats are for a public option" -- but that the ratio is higher in the House than the Senate, and higher in the Senate than in the Senate Finance Committee.

"I think we have a real good chance on the Senate floor," he said.

Schumer and Rockefeller have a lot of weapons at their disposal. First off, there's the pure popularity of the measure, which has ticked up in recent weeks, at 65/26 in the latest New York Times poll. This is also true in the case of swing district Democratic seats, who not only express a fundamental desire for health care reform this year, but support a public option and reject a trigger. This is also a crucially important piece from that polling:

It's wrong to think about the public option in isolation from other elements of reform. Forcing an individual mandate without a public option is a clear political loser (34% Favor / 60% Oppose), and only becomes more palatable when a public option is offered in competition with the private sector (50% Favor / 46% Oppose)

And swing district voters have already decided the private sector has failed to keep healthcare affordable, and want a public option now (48%) instead of waiting for a trigger (36%).

A mandate without a public option will be extremely unpopular because people can sense that the idea of a forced market for private insurers is designed in the interests of those insurers, not them. This is really elementary stuff.

I don't know if whether this report about Blue Dogs fading in their opposition to the public option relative to other health care goals is a sign that they're learning from these reports or not. They seem to be more interested in the regional disparities in Medicare reimbursement rates, which is really a payoff, but if those rates were adjusted, opposition to a public option tied to Medicare rates in some fashion would probably fade away. Especially considering that it's the fiscally responsible thing to do, per the CBO.

The original House bill required the public plan to pay providers 5 percent more than Medicare reimbursement rates. But as part of a package of concessions to Blue Dogs, the House Energy and Commerce Committee accepted an amendment that requires the HHS Secretary to negotiate rates with providers. That version of the plan will save only $25 billion.

In total, a public plan based on Medicare rates would save $110 billion over 10 years. That is $20 billion more than earlier estimates, a spokesman for House Speaker Pelosi said.

We'll see if this arsenal of evidence can convince Senators who really just want to protect the status quo, and more important, protect industry profits. We're finally going to see where they stand when the Finance Committee votes. We'll be watching.

Rotten To The Core

So Senate Democrats on the Finance Committee offered an amendment that would enable the federal government to bargain for lower drug prices for their bulk purchasing, a direct assault on the White House/Big Pharma deal from a few months back. Basically it would shift poor seniors back onto Medicaid for their drug purchasing, where the government can negotiate discounts. This would save the government over $80 billion dollars.

And Tom Carper of Delaware defended the secret deal in the most amazing of ways:

I was not involved in negotiations with PhRMA but I believe that the administration was, obviously PhRMA was, and I presume this committee was involved in some way in those negotiations.

And what PhRMA agreed to do through those negotiations is to pay about
80 billion dollars over 10 years to help fill up half the donut hole. That's my understanding. And they are prepared to go forward and to honor that commitment. As I understand it, the commitment from our colleague Senator Nelson would basically double what was negotiated with PhRMA.

And whether you like PhRMA or not -- remember I talked earlier today in our opening statements, I talked about four core values, and one of those is the golden rule, treat other people the way I want to be treated?

I'll tell you -- if someone negotiated a deal with me and I agreed to put up say, 80 dollars or 80 million dollars or 80 billion dollars and then you came back and said to me a couple of weeks later -- no no, I know you agreed to do 80 billion and I know you were willing to help support through an advertising campaign this particular -- not even this particular bill, just the idea of generic health care reform? No, we're going to double -- we're going to double what you agreed in those negotiations to do. That's not the way -- that's not what I consider treating people the way I'd want to be treated.

That just doesn't seem right to me.

This is incredible. The deal is transparently one to protect drug industry profits. There's just no doubt about this. Carper is saying that it's more important to get a few generic ads in support of health care reform than to save the US taxpayers $80 billion dollars. Backroom deals must be honored even if they hurt people. That's the "golden rule" in Washington.

Did Carper not know that cameras were rolling when he said this?

Might Have Worked 5 Months Ago

This series of DNC ads blaming Republicans for wanting to eliminate Medicare is dead-on, ruthless, and entirely too late. In August, the Republicans got the jump on defining Democrats as wanting to finance health care reform by cutting Medicare. That opinion hardened, and even though 80% of the GOP did indeed vote to eliminate Medicare back in April, it's a useless data point now, just a comeback in the debate instead of a powerful tool to frame the opponent before they get to frame you. I'd say these ads were completely worthless, except maybe they can be pulled out the next time there's a debate over Medicare. But not now. It looks completely reactive and defensive now, even though it's fundamentally correct.

Way to go, DNC.

The Dope On The Baucus Plan

I alluded to it before, but here's the draft framework for Max Baucus' plan from the Senate Finance Committee. If you don't have the time to read all 16 pages, Ezra Klein has posted a summary.

I'm trying to figure out who, if anyone, gets better health care coverage from this plan. So far I can only come up with one class: people making 100-133% of federal poverty level who can now qualify for Medicaid. For everybody else, the quality of coverage looks to my eye to be worse, though I could be missing something.

Folks in Medicare get 50% off of any prescription drugs that fall in the donut hole, but the grants of patents well beyond current law will cost them more for drugs they could be getting generically in the long run. We don't know the effects of making Medicare more efficient, but they're designed to be invisible, i.e. offering the same care at a lower cost to the government. So I'd call that a wash.

Those in the exchanges will get subsidies, of dubious affordability, up to 300%, and between 300-400% the cost of premiums will be capped. However, the coverage itself can be crappier than current law, and almost certainly will be. The out-of-pocket limits are good, but that only exists for "covered services" - for anything else you're on your own. Those covered services have to include the following:

...preventive and primary care, physician services, outpatient services, emergency services, hospitalization, day surgery and related anesthesia, diagnostic imaging/screenings (including X-rays), maternity and newborn care, pediatric services (including dental and vision), medical/surgical care, prescription drugs, radiation and chemotherapy, and mental health and substance abuse services that meet minimum standards set by federal and state laws.

They also would restrict caps on lifetime benefits. Which is fine. But there will now be a whole insurance industry sector in how to properly define what falls inside and outside primary care, surgical care, hospitalization, etc. And remember, the entire regulatory apparatus for these major insurance reforms, which will be fought in court by multi-billion dollar companies, is a state-level ombudsman's office. And even with those credits, the coverage doesn't appear to be affordable.

If you get insurance through an employer, your health care coverage is about to get a whole lot worse.

Employer Responsibility. Employers would not be required to offer health insurance coverage. However, employers with more than 50 full-time employees (30 hours and above) that do not offer health coverage must pay a fee for each employee who receives the tax credit for health insurance through an exchange. The assessment is based on the amount of the tax credit received by the employee(s), but would be capped at an amount equal to $400 multiplied by the total number of employees at the firm (regardless of how many receive a credit in the exchange). Employees participating in a welfare-to-work program, children in foster care and workers with a disability are exempted from this calculation.

As a general matter, if an employee is offered employer-provided health insurance coverage, the individual is ineligible for the tax credit for health insurance purchased through an exchange. An employee who is offered unaffordable coverage by their employer, however, can be eligible for the tax credit. Unaffordable is defined as 13% of the employee’s income. The employee would seek an affordability waiver from the exchange and would have to demonstrate family income and the premium of the lowest cost employer option offered to them. Employees would then present the waiver to the employer. The employer assessment would apply for any employee(s) receiving an affordability waiver. Within five years of implementation, the Secretary must conduct a study to determine if the definition of affordable could be lowered without significantly increasing costs or decreasing employer coverage.

A Medicaid-eligible individual can always choose to leave the employer’s coverage and enroll in Medicaid. In this circumstance, the employer is not required to pay a fee.

Coverage offered by an employer of any size, including fully insured and self insured plans, is not required to comply with the list of benefits required of plans in the non-group and small group markets. Employers must provide first dollar coverage for prevention services (except where value-based insurance design is used), however, and cannot have a maximum out-of-pocket limit greater than that provided by the standards established for Health Savings Accounts (HSAs).

So small businesses can opt out of giving their employees health insurance and pay a fraction of the cost, about $20,000 for 50 employees. That will become the chic thing to do. If the employees aren't paid more than the requirement for Medicaid, employers can scrap coverage and let their employees take Medicaid and pay no fee. They are incented not to give their employees a living wage, in other words. And if they make coverage available for those above 133% FPL, they are bound by no standards like that coverage on the exchange, and their employees couldn't reject that coverage for something half-decent. Assuming regression to the mean, virtually every employer will immediately move to offering the shittiest coverage imaginable. They could only get to the exchange if the employer coverage is unaffordable, or 13% of their total income. So an employer, "AlmartWay" in Marcy Wheeler's construction, could conceivably take 12.9% of an employer's income for offering a plan that probably wouldn't cost that much.

Hell, if I were a rapacious manager like AlmartWay's completely hypothetical managers were, I'd turn employee health care into a profit center because (if I read this right) you could require employees to pay back 12.9% of their income for health care, and the only thing you'd really have to promise in return is preventative care. So I predict, if this bill passes in anywhere near this form, that AlmartWay will start making its own employee health care a big profit center because they will be stuck.

By golly. This is even a health care plan Blanche Lincoln and Mark Pryor and their biggest constituent could love!! Though frankly, Bad Max's plan is even worse than Wal-Mart itself--with a call for part time mandates and no disability discrimination--called for (though maybe Wal-Mart was thinking of the free subsidy for its Medicaid eligible employees all along).

And... there is no employer mandate, but the "free rider" aspect of the coverage will, in all likelihood, incentivize employers not to hire anyone who doesn't have family money.

Under the proposal, employers who do not offer health coverage would have to pay the full cost of the subsidies provided to employees who purchase coverage through the new health insurance exchange and qualify for a subsidy because their family income is below 300 percent of the poverty line. [1] But employers would not have to contribute to the health insurance costs of employees with higher family incomes. The new requirement would apply to firms with 50 or fewer employees.

The proposal would make it considerably more expensive for employers to hire workers from lower-income families than workers from higher-income backgrounds to do the same job. As a result, it would distort hiring decisions. Employers would have strong incentives to tilt hiring toward people who have a spouse with a good income (or have health coverage through a family member), teenagers whose parents make a decent living, and people without children (since the eligibility limit for the subsidies in the new health insurance exchanges will increase with family size). Low-income women with children in one-earner families would be particularly disadvantaged [...]

While language could be included to try to ban such discriminatory effects, it would be virtually impossible to enforce effectively. It would be extremely difficult to prove in court that an employer has passed over one applicant and hired another because of the health surcharge that employers would face if they hired people receiving health insurance subsidies.

Moreover, most low-income job applicants who do not get hired could not afford to hire attorneys to initiate legal proceedings. For the tiny number that might be able to institute proceedings, the legal complaint likely would take months and, more likely, years to adjudicate. In short, the fact that low-income workers would cost an employer up to several thousand dollars more to perform the same job could not easily be overcome.

This differential treatment of workers based on their family income also would likely influence employer decisions about which of their employees to let go when they trim their workforces to cut costs, such as during a recession. Workers from low-income families would cost the firm significantly more to retain than other workers who are paid the same wage to do the same job.

Although this clearly is not intended, the proposal likely would have discriminatory racial effects on hiring and firing. As noted, it would discourage the hiring of lower-income people. And since minorities are more likely to have low family incomes than non-minorities, a larger share of prospective minority workers would likely be harmed.

This is essentially legalized class-based discrimination.

So, worse coverage for employers, arguably worse coverage for individuals and small businesses, same for Medicare patients, probably better for a sliver of Medicaid patients. And it criminalizes people for not giving 13% or so of their paycheck to private health insurers. The affordability credits are nice, but don't look sufficient. Here's a contrary view.

The legislation really would protect millions of Americans from medical bankruptcy. It really would insure tens of millions of people. It really will curb the worst practices of the private insurance industry. It really will expand Medicaid and transform it from a mish-mash of state regulation into a dependable benefit. It really will lay down out-of-pocket caps which are a lot better than anything people have today. It really will help primary care providers, and it really will make hospitals more transparent, and it really will be a step towards paying for quality rather than volume.

To put it more starkly, it really will be the most important progressive policy passed since Lyndon Johnson. The subsidies should probably sit at 400 percent of poverty, and the employer mandate should be reworked, but such failures are relatively easy to fix, and may well be patched over by the time the legislation arrives on the Senate floor. The fact that a bill of this size and scope can still be considered disappointing is evidence that the doors of the possible have been thrown wide open.

This ignores the reality that most insurers, like now, won't abide by the rules because there's no policeman to enforce them (an ombudsman? Really?). As well as the reality that the subsidies don't make health care affordable. And it will be hard to expand on this reform, considering that there's no public option, a weak insurance exchange and useless co-ops. In fact, considering that it cements in the broken system we already have and just fills in the cracks, it looks basically like it was written by the industry itself. That's because it was.

Trigger Happy Jack

Over the weekend, Ben Nelson, the most conservative Democrat in the Senate and as such a decent bellweather for where the health care policy might go, appeared to support a trigger for the public option, as long as it wasn't a "hair trigger." DougJ surmised that his conception of a hair trigger would be one that might actually go off, and he would prefer a trigger that just remains hypothetical forever. And he's right. There's a trigger in the 2003 Medicare Part D bill that would allow the government to sell prescription drugs through a public option if the drug companies couldn't do it properly themselves. And that trigger never got pulled. So Ben Nelson wants that same dynamic play out in the overall health care bill.

Ezra Klein argues that the public option on offer would not equal cost control because it doesn't use Medicare bargaining rates and its own pool of customers is too small to bargain for anything meaningful. Which is true - ask Ian Welsh - and why I support both using Medicare bargaining rates and opening up the exchanges to those who get coverage from an employer. It's also true that getting a public option into place will increase the possibility that it can be opened up or paired with Medicare rates in the future, whereas no public option on this go-round will make it nearly impossible to get one later - basically the same exact heavy lift as we're seeing now. There's also a distinction to be made between cost control to the federal government and cost control to the individual premium purchaser. A non-profit public option that still uses the Department of Health and Human Services to bargain for rates will have a lower cost to the individual in that market. The CBO estimate of 10 million subscribers is just an estimate - but it should be said that even with those numbers, the CBO saw the public option as a net savings of $150 billion over ten years, contra Tom Brokaw. If the public plan can offer the same basic coverage at a lower cost, people will buy it. And insurers will lower their premium costs to capture more of the market share. They call it "price wars" in other industries, and it's been virtually non-existent in the insurance market forever. The Swiss version of regulated insurance mandates works because basic coverage is provided entirely by non-profits.

As Matt Yglesias says, Switzerland is a country which "came late to the universal health care game thus did it in a way that involves a lot of compromises with existing interest groups." The single-payer countries all enacted their proposals in the early postwar period at the latest, when the health industry wasn't as large and powerful and medicine wasn't as advanced. It has clearly gotten progressively harder to outflank the more entrenched special interests. That's what we're seeing today with the move toward a trigger that will never trigger itself. That may be evident in the House bill even though it has a public option, considering the meager nature of that option and the too-low coverage subsidies.

But this is a game of inches. And we need to enact as much as possible in this moment of opportunity, and move to the cost controls and refining of the elements later. We need to inscribe universal coverage in the American system with a major check on for-profit insurers. That's why the wavering from House liberals desperate to bargain is extremely troubling.

Amid fresh signs that the White House is preparing to back a scaled-down health care overhaul that would only include a public insurance option as a fallback plan, several House liberals told Roll Call that they could support such a bill depending on how it was structured.

The “trigger” approach has been considered a deal-killer by liberals on and off Capitol Hill, and the willingness of some Congressional Progressive Caucus members to entertain it reflects a recognition that a bruising August recess has imperiled prospects for reform and redrawn expectations for what is possible.

“This is a way to get a bill,” Rep. Bill Pascrell (D-N.J.) said. “I believe it’s worth listening to because I want legislation that is going to, in some shape or form, expand coverage and bring down the cost of health care.”

Liberals stressed that the shift does not amount to an abandonment of their commitment to a “robust” public insurance option. They said they would only support a trigger if that approach guaranteed the same access, quality and affordability.

“I don’t want to give the impression that I’m so flexible that I’m willing to compromise away meaningful reform,” Rep. Jim McGovern (D-Mass.) said. “But there may be a variety of ways of getting there than the one I originally formulated in my mind.” [...]

“We’re the caucus that least marches to a unified drummer — that’s not what we do,” Rep. Mike Capuano (D-Mass.) said. “I’m serious about increasing access and quality, but that doesn’t mean it has to be a grand slam home run. I’ll take a ground-rule double if that’s what it takes. I’m happy to compromise if that’s what it takes. But compromise is compromise — it’s not rolling over.” [...]

Rep. Sam Farr (D-Calif.), a Progressive Caucus member, said he did not support the approach but did not foreclose on it, either. “It depends on how strong that trigger is,” he said. Farr said he has seen triggers implemented effectively in California. “Triggers work, but they’ve got to be really clear as to how they operate,” he said. “The only way I could see it getting progressive votes is by making sure the public option is strong and goes into operation.”

(Farr's actually right, but he won't be writing the bill and the language on the trigger, and surely he knows it will be written to never come into existence.)

There's just no reason to even participate in an article like this. It only serves to weaken the position of the caucus. Mike Capuano in particular clearly has no negotiating skills whatsoever - telling the world that the Progressive Caucus has no unity?

I recognize that these members want a reform bill badly. But use your poker face, fercryinoutloud. The other side of the caucus certainly is.

...They could play it like John Conyers:

“It is clear that real reform means injecting real competition into the insurance market to improve affordability and drive down health care costs. The centerpiece of this reform is a robust Medicare-like public health insurance plan tied to the Medicare provider system. Like many of my colleagues in both the House and Senate, I will oppose any health care reform bill that lacks such a plan. I will also oppose any legislation that seeks to replace a robust public health insurance option with health care cooperatives or which ties the availability of the public option to a trigger mechanism. In this effort, I stand in solidarity with House progressives, the majority of my friends in organized labor, millions of health care providers, and 72 percent of the American people.

Left-Wing Demagogues Found!

Republicans really aren't the problem right now on the health care bill, but here's a message that the Democratic National Committee could have put out in April, when 4/5 of the GOP caucus voted to kill Medicare:



Ryan Grim has the report.

I would have gone with that "Republicans want to end Medicare" line and repeated it 15 times to fill the 30 second spot.

This is at least a bar fight. They can do endless variations off of this. One senior's story: "Medicare saved my life. And Republicans wanted to end it?" A kid talking about how his grandmother was kept alive through Medicare and Republicans wanted to kill his grandma. Get creative!

...The DNC's actually been slugging it out pretty well. This spot calling Dick Cheney wrong about everything is pretty nice. They're a little late and a little reactive on these, however. Take the offense, all the time. Tomorrow, put out a spot about how Republicans think kids should drop out of school. Then one about how they think old people should eat cat food.

Wanted: Left-Wing Demagogues

That after months of tea parties and protests against Big Gubmint takeovers and socialism, the Republican Party would come out as the defenders of Medicare has got to be one of the most hilarious things I've ever witnessed. If the rank and file agitators had half a brain they'd recognize how they've been played for suckers.



Nothing like limited-government conservatism.

This is of course a big sham.

Michael Steele tells me the Democrats want to dismantle Medicare. So my first question is simple: Why do Democrats hate Medicare?

The hypocrisy is shameless. I won't go through the history of Medicare, but for Republicans to say that you should trust us on Medicare is like Colonel Sanders guarding the chicken coop. I think most seniors know that, and these scare tactics will boomerang. I don't think people will buy it, since the guys peddling this stuff are the very people who have been trying to undermine and weaken Medicare for years and years. There was a budget alternative put forward by Paul Ryan this year that would have ended Medicare as we know it and given all seniors a voucher to get their health care on the private market. And they voted for it. So we know what they wanted to do with Medicare.

Actually, people don't know this story. Because Democrats haven't bothered to tell it.

Here's that alternative budget. The Ryan proposal would have converted the entire Medicare program into a voucher system, throwing seniors onto the individual market with a fixed amount of money to purchase their own plan. It didn't have insurance regulatory reform, to my knowledge, so all the voucher money in the world wouldn't have helped one senior get coverage from companies who would deny all of them based on a pre-existing condition.

Now, establishment Democrats may find this funny, but they haven't informed the public that, five months ago, 80% of the GOP caucus voted to eliminate Medicare and turn it into a private, voucher-based individual market without guaranteed coverage. They just expect seniors to know about some alternative budget vote.

How the hell would they know?

Was one ad created telling America what Republicans were willing to do to their health care? Was one flyer sent from the vaunted DNC voter file into targeted senior-heavy districts explaining this tale? Was any talking head discussing on television the goal of the GOP to eliminate Medicare, and their votes for it?

I mean, this was the kind of stuff Democratic strategists at least used to be good at. If you can't scare seniors to death over a vote to ELIMINATE MEDICARE, you cannot hope to win a health care fight. It's at least worth a try now, but it may be too late at this point; seniors are already nervous about cuts that would come in a new bill, and they no longer trust Democrats to do right by them. A well-timed push back in April could have shut down the resonance of the entire tea party movement. "Republicans want to eliminate your Medicare... Democrats want to strengthen it, for you and for future generations." Is that so hard?

Sometimes I think this isn't a political party but an elaborate episode of Candid Camera.

The Revolt Of The Septuagenarians

Ezra Klein had a column in the Washington Post over the weekend explaining why senior citizens, who favor Medicare, oppose a government-run health insurance program for people other than them. They think Medicare will be diluted by expansion and reform. That's a fairly simple "I got mine" theory of why seniors don't support health care reform. I don't necessarily think of Grandma as a selfish bastard, however. They are as caring and compassionate as anyone else on this rock we call home. They may fear the rug being pulled out from their coverage - and on this, Democrats haven't made the sell about how seniors stand to gain big from reform, particularly through lower prescription drug spending - but I think a simple campaign showing how the grandkids won't have any hope of getting medical care under the status quo would theoretically undermine the selfishness argument. And AARP has been making their own sell to seniors. I think Klein's secondary point hits the mark a little more:

Seniors are also the most conservative segment of the population and are getting more so. They constitute not only the sole age group that Obama lost in last year's election, but also the sole age group in which his results were worse than those of John Kerry in 2004. And both Obama and Kerry underperformed Al Gore's 2000 results.

"The Roosevelt seniors are being replaced by the Reagan seniors," says Paul Begala, who helped run Clinton's 1992 campaign. A May poll by the Pew Research Center found that for the first time in 20 years, the GOP is now an older party than the Democrats.

The June Post-ABC poll asked whether respondents would prefer a smaller government with fewer services or a larger government with more services. Seventy percent of seniors -- the segment of the population with government-run health care and a government pension, also known as Social Security -- preferred a smaller government, compared with 37 percent of people 18 to 29. Seniors are the age group most solidly opposed to the public option. In fact, in the August Post-ABC poll, they were the only age group in which a majority opposed it. "Seniors are like the American West," says Julian Zelizer, a Princeton historian. "They depend on government and then say they hate it."

The age divide has animated most of the anger in town hall meetings and tea parties, which is not about health care reform but about Obama. He had a similar problem attracting senior support during the Democratic primary. Seniors as a demographic are simply more easily targeted by smear campaigns from the right, and more receptive to them. Nobody wants to talk about the role of race in all this, but I don't think it's hard to figure it out. Fear of a black President still runs deep over a generation that's more conservative in their thinking. I think Matt Bai is correct to look on the bright side:

The good news for Obama and his party, of course, is that they still enjoy an enviable level of support among voters just breaking into the work force and among those now drifting into middle age. And that means that if reigning Democrats can manage to get health care policy right this time, and maybe even add some fundamental energy reforms, they might still be able to cement more hopeful attitudes about government for generations to come, much as Roosevelt did in his day. Today’s younger voters might never be as party-affiliated as their grandparents were, but neither may they turn out to be as cynical about their leaders as their parents often seem to be. If the president has his way (which is to say, if the worst nightmares of Republicans come to pass), those voters may someday live out their retirements in Arizona or Nevada, spinning stories for their grandchildren of the days when Barack Obama was twice elected president, when government managed once again to make things better instead of worse and when politicians still bothered with these things called town halls.

But it's going to be a hard slog, because of the people who most commonly vote in elections, particularly midterm elections, today.

Somebody Get The Giant Hook

Past national chairmen of political parties have gone on to be longtime Senators, Governors, even Presidents. This Michael Steele really is single-handedly destroying that legacy.



Steve Inskeep is not exactly the toughest interviewer in the world, and even he bats him around. My favorite part:

INSKEEP: Here's another thing that I'm trying to figure out: Within a couple of paragraphs of writing we need to protect Medicare, you write that you oppose President Obama's, quote, plan for a government-run health care system.

Mr. STEELE: Mm-hmm.

INSKEEP: Now you're a veteran public policy official. You're aware that Medicare is a government-run health care program.

Mr. STEELE: Yeah, look how it's run. And that's my point. Take Medicare and make it writ large across the country, because here we're now - how many times have we been to the precipice of bankruptcy for a government-run health care program?

INSKEEP: It sounds like you don't like Medicare very much at all...

Mr. STEELE: No, I'm not saying that. No, Medicare...

INSKEEP: ...but you write in this op-ed that you want to protect Medicare because it's politically popular. People like Medicare.

Mr. STEELE: No, no, no, no, no. Please, don't...

INSKEEP: That's why you're writing to protect Medicare.

I think the trained dolphins at Sea World could have pulled off those backflips better.

I know I've made this statement before, but in 2005 every news outlet in America told us that Howard Dean was a ticking time bomb, that he had to watch his mouth or it would get the Democratic Party into trouble and he would destroy it utterly.

Consider the alternative.

The Schizophrenic Knight

In high school we did a stage-play production of Monty Python and the Holy Grail. That's right, suck it, Spamalot, we were 15 years ahead of our time. One of the scenes we performed included the three-headed knight. Because I love that film, I knew all the words at the time, but my cohorts in the three-headed knight outfit didn't remember their lines. So at the last minute, I went out as the "Schizophrenic Knight" (I know, there's a difference between schizophrenia and multiple personalities, but I was in high school and under a deadline) and did the entire colloquy as a soliloquy.

I'm reminded of this when I see Michael Steele's performance the past couple days:

Yesterday, the Republican National Committee announced a “Seniors’ Health Care Bill of Rights,” in which they announced that they would “protect Medicare.” “We want to make sure that we are not cutting the Medicare program,” said RNC Chairman Michael Steele on ABC’s Good Morning America.

But on Fox and Friends this morning, Steele undermined his new argument that Medicare is a sacrosanct program that must be protected by calling it “a very good example of what we should not have happen with all of our health care.” Asked to respond to Rep. Anthony Weiner’s (D-NY) argument that “if you like Medicare and you don’t want to make any cuts to it, then you’re basically defending a single payer system,” Steele launched into an attack on the program, implying that it would be better if it were privatized.

The winger id has become so inundated with this contradictory language and truisms that are in complete conflict with one another that I'm sure this makes sense to somebody. Being Republican means that two sentences like "Medicare is a disaster! Long live Medicare!" are perfectly coherent side-by-side.

This is basically why Republicans are irrelevant in national politics. They speak in some kind of Windtalkers code that you need a secret unscrambler ring to decipher, and most people just don't want to do the work. However, Democrats have failed in explaining their policies as well, so people have nothing to go on but results. And they're not seeing much of that out of this Administration, either.

Lies Of Steele

Michael Steele doesn't know what he's talking about when it comes to health care. This is an uncontroversial statement. He's still talking about death panels and rationing, and he's still vowing to keep government hands off of seniors' Medicare. He's talking about the $500 billion that can be excised from Medicare and Medicaid payments, through reducing lobbyist-driven overpayments to things like Medicare Advantage that do nothing to improve treatment, as if those are direct reductions of Medicare outcomes for patients.

They are lies. And Steele's column is a collection of outright lies. But considering that this is no penalty for lying, you can hardly blame Steele for getting away with as much as possible.

Howard Kurtz moans that the "death panels" wouldn't die in spite of journalistsic efforts to debunk the ridiculous notion, writing that "even when they report the facts, [journalists] have had trouble influencing public opinion" and calling the experience "a stunning illustration of the traditional media's impotence." Let me identify a problem that has helped create this impotence: a lack of follow-through.

Having identified Sarah Palin, Newt Gingrich, Chuck Grassley, John McCain and, today, Michael Steele, as spreading falsehoods about health care reform even after they have been broadly discredited, will the journalists Kurtz mentions offer them any sanction? Or will these public figures continue to be extensively quoted in newspapers and on television?

We saw another one this week, as Fox News decided to bring us the new scare tactic, "death books." But media like those Kurtz cover have two choices in this respect. They can ignore the lie, and let it confine itself to Fox News, Drudge, the right-wing blogosphere and talk radio, which is arguably larger than the traditional media's reach. Or they can report on the lie, debunk it, and hope their debunk trumps the initial lie. Now, I don't really respect how media covers the lies, by hyping them endlessly and getting around to the debunks a few days later. But Kevin Drum is on to something here.

It's true: crankery used to go largely unreported. But that's not much of an option these days — or at least, the media doesn't treat it as an option. And the reason is obvious: crankery isn't limited to beady-eyed obsessives with mimeograph machines in their basements anymore. It's beamed out in practically raw form to an enormous audience by Drudge, talk radio, Fox News, and the blog/Twitter/Facebook channel. Once that's happened, mainstream outlets don't feel like it's ignorable.

Plus there's the fact that although news pages (and perhaps the straight news reports from TV anchors) may have mostly debunked the death panel story, op-ed pages and chat shows retailed it with vigor. What's more, even in the news pages most of the debunkings came days or even weeks after the crankery had already reached a fever pitch.

What do do? Fighting back is the obvious answer, but that's a two-edged sword since it also gives the crankery an even higher profile. Ditto for faster reaction from the news desks.

I dunno. We now live in an era of mass-market crankery ("saturation bullshitting," in g.powell's memorable phrase), and that's that. Either some bright cognitive researcher needs to figure out how to actually fight crankery, or else the rest of us have to figure out how to get things done even in the face of a permanent lunatic fringe. All legal ideas welcome.

I believe that progressives and Democrats could go on the offensive a bit more, and make Republicans defend their own positions rather than allowing them the space to concoct false memes about the opposition. But with Washington still wired for conservatism, and Drudge still the traditional media assignment editor, there's not a lot to do here. You will always have that push and pull between giving lies legitimacy and letting them fester unanswered.

I do agree with Matt Yglesias' assessment of Steele's op-ed, particularly its appearance in the Washington Post. If the claims in an op-ed aren't factual, newspapers are not required to print them.

So congratulations to Fred Hiatt for landing such a buzzworthy piece of nonsense for his publication and I hope the right-wing enjoys the giant tax hikes we’ll be enacting down the road once they show the political world that any attempt to trim Medicare spending, no matter how modest, will be savaged by opportunists on the other side.

Yep. Seems to me like Steele and his counterparts are walking right into a trap here, even if it's not realized for decades.

...I liked Anthony Weiner's take: "I have never heard such a ringing defense of a single-payer program like Medicare than I heard from Michael Steele today."

CA-10: An Interview With Lt. Gov. John Garamendi

John Garamendi has been seeking votes in California for well over 30 years. He first took a run for the Governor's mansion in 1982, and was set to do so again in 2010 until the seat in CA-10 opened up, and he was inspired to return to Washington, where he served in the Clinton Administration in the Department of the Interior. He has the most diverse record of anybody in the race, with stints at the federal level, the state legislature, and in two statewide offices, as the Insurance Commissioner and now Lieutenant Governor. In our interview, we discussed health care, lessons learned from regulating insurance, No Child Left Behind, saving the NUMMI plant in Fremont (more on that from Garamendi here), and foreign policy in Iran. I found Garamendi to come at issues in a very comprehensive and thoughtful way, and you can see this for yourself below. A paraphrased transcript follows.

DD: Thanks for talking with me today.

John Garamendi: My pleasure.

DD: So how's it going out there on the campaign trail?

JG: It's going very well. Every day, I feel we're moving along well. You have everything being done that is normally done in these campaigns. We have a strong volunteer grassroots organization committed to getting out the vote. Phonebanking has started, we've hit about 30-40 thousand homes. We're walking in different communities. We just had a meeting in Rossmore, with 300 people turning out. So I think it's going very well.

DD: Your last several campaigns have been statewide, with district-level campaigning being more retail, how are you finding it?

JG: To me, it's exactly the same, only it's done in a smaller area. I've always believed strongly in retail politics. The only difference is that after the event's over, I don't have to get on a Southwest Airlines plane. We did an African-American church out in Fairfield over the weekend, same as any African-American church in Southern California or anywhere else. It's just easier for travel.

DD: OK, let's hit some issues. First off, health care. August is this time where everyone's making their feelings known about health care in their districts. What are you hearing in yours?

JG: I am hearing a strong element for single payer, or Medicare for All. As you may know, I've led that debate in this state for many, many years. I've always found it the most efficient, most cost-effective way you can possibly do this. Just send your premiums to the Medicare office.

So I hear a lot of individuals trending in that direction. And some of the unions, the California Nurses Association, are also trending in that direction. There is also a concern about the complexity of the legislation moving through Congress. And people want to see at the very least a public option to compete with the insurance companies. Also, with a lot of seniors, the drug issues concern them, both with fixing some of the issues with Medicare Part D and also maintaining what they like about Medicare. So that's the range.

DD: Would you vote for any bill that didn't have at the least a public option that's available from day one, without a trigger?

JG: Well, I've always been a strong voice for Medicare for All. The fallback position is the public option. That's already a compromise. And so the legislation had to have a public option, I can't go any further away from that. The other thing I want to express is that I understand insurance reform, which is a lot of this bill. I was the main regulator for insurance companies in the largest state in the union. So I bring a set of knowledge to this debate that not only doesn't exist among my competitors, but doesn't exist in Congress.

DD: Let's talk about that. Right now, insurance companies are regulated in the states, and so the regulations vary from one place to the next, and can be corrupted by local interests. Do you support a federal role in insurance regulation?

JG: This is something that we have to figure out with insurance reform and with respect to financial regulation. The regulatory mechanisms need some clarity. It simply won't work to write a law saying to the insurance companies, "Take all comers." They will not do it. So you need a police force. Someone to enforce that law. Will that be federal, or based where it is now, at the state level? That's the kind of detail that must be worked out. I mean, we've had auto insurance here in California that's supposed to take all comers, and they find numerous ways to avoid that. And of course, this is why I support Medicare for All. You don't have to worry about any of that. But as long as we're going with health insurance reform, I can add something to that process.

DD: What are the pluses and minuses of putting this in the hands of the Feds?

JG: If it's a federal process, you'd have to set up a massive new federal bureaucracy. In the positive sense. But you have to have a police force, because otherwise, the insurers won't do it. That's a major, expensive undertaking for the federal government. There's an advantage to the existing mechanism in that it already exists, like with Medicare or Medicaid. However, you mentioned some of the problems with how the regulation changes depending on the state. So both options have shortcomings. Either way, if we have a bill based on insurance reform, it has to be dealt with. And I've been dealing with these companies for eight years of my life. I know how to do this.

DD: Medicare for All will apparently get a vote now. Is that helpful?

JG: It's enormously helpful. It got pushed to the side of the debate for too long. Medicare provides about 60% of the care in dollar terms already in this country, and it's very popular. If you bring the rest of the population in, on a per-person basis, the cost would decline dramatically. The money in the private system is good enough to get this done and cover everybody. And the other important thing is that Medicare allows individual choice of provider. Whatever doctor you like, you can keep them. Of course, we know that private insurance restricts your choice of doctor. So this is the big lie in this debate, the idea that Medicare would have government telling you what doctor to pick. That's what happens right now.

DD: Let's move on. I noticed on your website you took a lot of time talking about the need to rebuild manufacturing. We're seeing this cash for clunkers program becoming very successful as an economic stimulus for the auto industry. Is that the kind of incentive-based programs that we can use to bring back manufacturing to America?

JG: Not exactly. The auto industry is not central, but it is important. That's why I'm trying to save the NUMMI plant. 1,200 businesses are direct suppliers to NUMMI. The auto supply industry is one of the largest in America. So cash for clunkers will help NUMMI. But what I'm talking about with respect to manufacturing is an economic theory that I developed in the 1980s. Basically, I figured that you need certain things to maintain the ability to lead as an economic power. You need a world-class education system and a commitment to research and development. Through both of those, you can create new things, with a high profit margin, whatever those things are, but new innovations that people find valuable. Eventually, those new things become a commodity, and once that happens, like all commodities, it seeks the lowest-wage place to be made. So those things get pushed off, and you have to create more new things, to keep feeding that engine. So that's what I'm talking about, high-end manufacturing.

DD: Couldn't the NUMMI plant be retooled to serve as a place to manufacture those new things, be they innovations in solar or wind technology or new batteries?

JG: Well, we tried this a few years back. I endorsed a bill in the legislature to provide a specific exemption for sales tax on manufacturing equipment to retool the NUMMI plant for hybrid vehicles. And that probably would have been enough to keep NUMMI open. But it didn't pass. Right now, what we're doing is putting together a package for NUMMI of incentives that will hopefully keep them in California. But it's more complex than that. This is like a divorce. You have GM and Toyota fighting over who owns what widget on the line. So there are legal issues in play now. I think we can get it done, because that's a very efficient plant, one of the most efficient in the country. But we have to manage this divorce.

DD: Education is another issue you talk about a lot. The Department of Education just put out this Race to the Top program to offer money to the states with good outcomes, but they are restricting the funds to states which incorporate student testing into teacher evaluations, and because California doesn't do that, they don't qualify. What are your thoughts on that, and this larger divide between education reformers and groups resisting their reforms?

JG: My question about it is basically, what is the equation between the test and teacher evaluations? Are we talking about just the test score? In that case, do I get to choose the students? Because the students and their backgrounds are a contributing factor to their performance. So it's a complex equation. There's a socioeconomic element to it. And it's very difficult to do to take everything into account. I don't think that testing should be the sole measure of a teacher evaluation. There are multiple factors. My daughter's a kindergarten teacher, and this year she got to school and there were a lot more kids in her class. So is that a factor? I think we need to evaluate teachers, but we must be fair.

DD: Do you support a reform like paying teachers more to go into poor-performing inner city areas?

JG: I've always supported reforms like that. I put up a bill in the 1980s to pay more to math and science teachers, to make sure we were attracting the best of them. And I support sending good teachers into the inner city. We have to pay our teachers better if we want to get the best outcomes.

DD: We are having such a tough time in California, what can the federal government do to alleviate some of the burden here where we are destroying our social safety net during a deep recession?

JG: Well, just to go back to education, one thing the federal government can do is fix No Child Left Behind. It was a great concept, but not good in detail. The reauthorization is coming up, and the Feds had better fund it. You can't place a burden like that on the states and expect them to deliver. So funding, and some reform of the law, has to get done. I don't think testing should be the only evaluation of students. There's a place for it, but we're building a nation of robots by teaching to the test. I have significant concerns about No Child Left Behind that need to be addressed.

DD: What about beyond that. Would you support a second stimulus focused on the states?

JG: I don't know whether there will be a second stimulus. But the problem is pretty elemental. California is the 7th, 8th-wealthiest place on Earth. We have made a decision, and it was a decision, not to invest in education. We have plenty of money to fund it, but we made the decision not to. The leadership has refused to use that wealth in the greatest resource we have, and that's our education system. It's clear to me that the federal government cannot substitute for the effort that California must make for themselves. We need investment, coupled with serious reform, to break the gridlock. Voting to tax students by raising college rates is just insanity. And the regents and trustees refused to support legislation for an oil severance tax to fund higher education. I brought it to them, and they wouldn't support it. We are the only oil producing state with no tax on the natural resources coming out of our ground. The oil companies have been able to take it for free for over a century. It's madness.

So the federal government cannot substitute for California. But I'll fight to bring money back to the state. First by funding No Child Left Behind. And also, there's the issue of medical services. The formula for state participation in Medicaid in California is 50-50, an even split between the Feds and the state. In other big states, that ratio is different. In Illinois, New York, it's more like 60-40, 70-30. Getting a better split in that formula represents a huge amount of money for California. And there are numerous formulas like that. So experience counts in understanding all that.

DD: OK, final question. On your website, I noticed very strong language supporting Israel, and also warning Iran not to continue with their alleged nuclear program. And you advocate for stopping shipments of refined oil to Iran if they refuse to cooperate. Now, I'm assuming that was written before the most recent uprising.

JG: It was, yes.

DD: Do you still believe, given the events over there, that it's a good idea to stop refined oil shipments, when it may hurt not the regime, but the very people in the streets who are resisting it?

JG: There's no doubt that the effect of an embargo would hit the economy and the people. That's what it's designed to do. I've thought long and hard about this, after watching the events take place, and I still believe in the concept. What you have over there is the current government's legitimacy being questioned. Does that mean they are more willing to negotiate on the nuclear program, to bring something tangible to the people? We don't know. So I think you have to pull together the interested groups, and that's Europe, and Russia, Pakistan, the Arab states, they might be more interested than us. And you create a larger coalition to change the behavior of the government. The uprising actually helps in that regard. And like in any negotiation, you have to have a big stick. So I would not drop the embargo possibility. And again, all of this is down the road a piece. Now another big stick would be bombing their facilities, and I think there are some unadvisable consequences to that. So I'd rather use the other stick.

DD: Thanks so much for talking to me today.

JG: Thank you.

Freedom Riders

Turns out that the teabaggers at one town hall meeting in Texas weren't from the area:

Last night, Rep. Gene Green (D-TX) hosted a rowdy town hall meeting to discuss health care reform. Fox’s local Houston affiliate reporter, Duarte Geraldino, reported that he talked to the participants and found that “some attendees admit they don’t live in the district.” How did they get there? Geraldino noted “an internet campaign” by far right activists urging their allies to attend and heckle Democratic Representatives. Geraldino then aired a clip showing one participant acting disrespectfully towards Rep. Green. “Pay close attention to the man behind the congressman,” Geraldino says in this clip, “he seems to have forgotten the part about respect.” Watch it:

Here's my favorite part:

During the town hall, one conservative activist turns to his fellow attendees and asks them to raise their hands if they “oppose any form of socialized or government-run health care.” Almost all the hands shot up. Rep Green quickly turned the question on the audience and asked, “How many of you have Medicare?” Nearly half the attendees raised their hands, failing to note the irony.

Decades of conservative message dominance has convinced a healthy portion of the public that a government-run program isn't run by the government. Failure to counteract that message 30 years ago is deeply affecting this debate today. Paul Waldman writes:

After decades of being told that the federal government is a sinister, rapacious beast with nothing but evil intents, the idea that a complex bill might contain a Soylent Green provision isn't too far a stretch. Nonetheless, it remains entirely possible that before long, health reform will no longer be a debate but will become an actual policy, one that will succeed or fail on its own merits. As both sides have understood (the Republicans more so than the Democrats, however), this battle is so critical because the stakes go to the heart of each party's approach to the role of government.

Both parties hope that the successful implementation of their favored policies will lead to a broader acceptance of their ideology. Republicans want to privatize government services not only as an end in itself but to show people that the private sector works better than government. In the same way, Democrats advocate for effective government services not only to solve an immediate problem but to demonstrate that government can in fact do some things very well.

Unfortunately, the successful implementation of a government program doesn't necessarily convince people that government can successfully implement programs. Antipathy toward government even among many who receive both Medicare and Social Security -- two of the most successful government programs in history -- is remarkably strong. In fact, by some measures, the elderly have the most skeptical views of government. For instance, in the latest version of the Pew values survey, 64 percent of those over 65 -- who are either on Medicare and Social Security or know that they will be soon -- said that "when something is run by the government, it is usually inefficient and wasteful" (see page 34 here). That compares to only 43 percent of those age 18 to 29.

Part of that is just the tribal identity with conservatism (which is stronger in those over 65, based on most surveys) trumping the shared knowledge of government programs like Medicare and Social Security. Because these same people generally really like those programs; they've just convinced themselves, in a supreme case of cognitive dissonance, that government doesn't work well (except for whatever it is they're getting). And mainly, that's because they've heard this repeated from the conservative noise machine for thirty years, virtually unchallenged and sometimes enthusiastically endorsed by Democrats.

Or perhaps there's another answer. The polls are showing that people under 50 support health care reform at much higher levels than people over 50. It's no accident that the strongest smears against the plan have to do with killing grandma or taking things away from Medicare. They like what they have and are wary of extending it to the rest of the population, mainly because of how it might impact them.

But this is a funny type of skepticism. Seniors don't oppose government-run health insurance. They like it too much. Americans over 65 live in a welfare state that most Europeans could only dream about. They have single-payer health care and government-run pensions. Most of their political activity is either an effort to expand those programs or a defense against anything that could in any way harm them. That includes not only direct changes, like cuts to Medicare, but indirect changes, like health-care reform that would focus new resources on the uninsured.

This is a reversal of the normal politics of opposition. Generally speaking, people who oppose health-care reform are worried we're going to end up with something like what Canada has. Not seniors. They have something like what Canada has (Canada, in fact, also calls their health insurance program "Medicare"). And they like it. They report higher rates of satisfaction with their health care than do people in employer-sponsored insurance. They're worried, rather, that they might end up with something like what the rest of America has. And having spent time in both Medicare and private health insurance, they don't want that. They don't want that at all.

The fight to get successful government recognized is an ideological fight. To those who already have evidence of successful government, the fight is somewhat different. They still echo the conservative line of "government is teh suck," but they don't want their government programs tampered with. How do you thread that needle?

The Wit And Wisdom Of Arthur Laffer

The economist Arthur Laffer is often cited as one of the most influential in modern conservative history. This is what he said on CNN today.

If you like the Post Office and the Department of Motor Vehicles and you think they’re run well, just wait till you see Medicare, Medicaid and health care done by the government.

Yes, just wait until you see Medicare and Medicaid done by the government. Once the government gets their hands on those government-run insurance programs, they might balloon administrative costs all the way up to 3% versus the private insurance industry's 20-30%!

Again, this is a prominent conservative economist who either doesn't know, or doesn't want you to know, that Medicare is a government-run program. I'd bet on the latter.

Also, I agree with Krugman, since when did the post office deserve a reputation as a whipping boy? Last I checked, they take a piece of paper that you give them anywhere in the country for 44 cents! That's a ridiculous bargain, and for the most part terribly efficient. I've been on enough customer service lines with private companies - I'm sure everyone has - to know that their bureaucracy and systems are plenty awful in their own right. This idea that the government screws everything up and private industry is teh roxxor is a total myth.

Democrats Behaving Badly - For Good, Not Evil!

It's so rare when Democrats push back and show some sturdiness, that it's worth noting when it happens. First, here's Jello Jay Rockefeller eviscerating the "co-op" idea floated by Kent Conrad:

Ed: It's not going to work. There's really no successful model out there to support the basis of signing on to a co-op. Would you sign on to a co-op or is that unacceptable?

Rockefeller: That's unacceptable and I can almost prove it. We've been in touch with all the folks that oversee, represent all the co-ops in the country on all subjects and they point out that there are probably less than twenty health co-ops in the country. There are only two that really work that well. One in Puget Sound, one in Minnesota, except for those two, they are all unlicensed. All present health co-ops are all unlicensed, they're unregulated. Nobody knows anything about them, nobody has any control over them and nobody has ever said, which is stunning to me, no government organization or private organization has ever done a study to what effect they might have in terms of bringing down the insurance prices.

They are untested, they are unlicensed, they are unregulated, they are unstudied. Why would we even think about putting them in as a control on this massive insurance industry instead of the public option?

Rockefeller actually knows what he's talking about because he's been studying the issue for decades, unlike Conrad, who threw a dart at a board and hit the magical Broderist middle with the co-op brainstorm. Rockefeller does not seem like he'll play along on this bait and switch.

Then there's Anthony Weiner forcing the "no government takeover of health care" Republicans to be as good as their word.

Yesterday, Rep. Anthony Weiner (D-NY) decided that it was “put-up or shut-up time for the phonies who deride the so-called ‘public option.’” He offered an amendment that would eliminate government-run Medicare:

Not a single member of Congress voted for the amendment, and Republicans were blasting it as a “political farce.” Last night, Weiner went on MSNBC and explained the GOP’s hypocrisy:

WEINER: Well, for some reason, I guess Republicans don’t like publicly funded, publicly administered health plans except for Medicare, and, I guess, except for the Veterans Administration and except for the health care that our military gets from the Department of Defense. The fact of the matter is, what we’ve learned is that government administered health care works pretty darn well. It’s got lower overhead and people like it.

So, when my Republican colleagues pound the drum and pound the podium about how they hate government-run health care, I guess they haven’t looked at what they get.

Visit msnbc.com for Breaking News, World News, and News about the Economy

Sometimes this spine-stiffening happens for about a week, but I like this week's Democrats.

Bigmouth Strikes Again

Betsy McCaughey has popped up before this year, claiming that the stimulus package included funding for comparative effectiveness research, which would "have the government essentially dictate treatments." It played into the worst fears, stoked for years by conservatives, of the government running health care and "getting between you and your doctor," unlike the great system we have now, where an insurance company bureaucrat does that. It's the same strategy as trying to get Americans to fear the Canadian health care system, even though the opposite is closer to reality.

It must be fun to be McCaughey, as her entire job appears to be misreading Congressional legislation and writing columns about it. This is what she did in 1994, writing the seminal piece "No Exit" in The New Republic, filled with distortions about the Clinton health care plan, that set the conventional wisdom against it. She's like an inverse I.F. Stone, ferreting out government malfeasance where none exists. The difference, of course, is that McCaughey is funded by powerful interests: she sits on the board of directors of a medical device company, has received stock options from that same company, and is part of a think tank funded by pharmaceuticals. So she's well-compensated for her deliberate misreadings.

The most recent installment, playing out over a number of days, is her contention that the House health care bill "would make it mandatory — absolutely require — that every five years people in Medicare have a required counseling session that will tell them how to end their life sooner." Once again, she plays into the usual conservative tropes with false attacks about government taking control of your life.

And these claims get the standard fact-check treatment, and reporters try to pin her down, and McCaughey says things like "it doesn't say that in so many words, but it would allow for it to happen in the future," and eventhe President has to go ahead and rebut this in a town hall:

Q I have heard lots of rumors going around about this new plan, and I hope that the people that are going to vote on this is going to read every single page there. I have been told there is a clause in there that everyone that's Medicare age will be visited and told to decide how they wish to die. This bothers me greatly and I'd like for you to promise me that this is not in this bill.

THE PRESIDENT: You know, I guarantee you, first of all, we just don't have enough government workers to send to talk to everybody, to find out how they want to die.

I think that the only thing that may have been proposed in some of the bills -- and I actually think this is a good thing -- is that it makes it easier for people to fill out a living will.

Now, Mary, you may be familiar with the principle behind a living will, but it basically is something that my grandmother -- who, you may have heard, recently passed away -- it gave her some control ahead of time, so that she could say, for example, if she had a terminal illness, did she want extraordinary measures even if, for example, her brain waves were no longer functioning; or did she want just to be left alone. That gives her some decision-making power over the process.

The problem is right now most of us don't give direction to our family members and so when we get really badly sick, sadly enough, nobody is there to make the decisions. And then the doctor, who doesn't know what you might have preferred, they're making decisions, in consultation with your kids or your grandkids, and nobody knows what you would have preferred.

So I think the idea there is to simply make sure that a living will process is easier for people -- it doesn't require you to hire a lawyer or to take up a lot of time. But everything is going to be up to you. And if you don't want to fill out a living will, you don't have to. But it's actually a useful tool I think for a lot of families to make sure that if, heaven forbid, you contract a terminal illness, that you are somebody who is able to control this process in a dignified way that is true to your faith and true to how you think that end-of-life process should proceed.

You don't want somebody else making those decisions for you. So I actually think it's a good idea to have a living will. I'd encourage everybody to get one. I have one. Michelle has one. And we hope we don't have to use it for a long time, but I think it's something that is sensible.

But, Mary, I just want to be clear: Nobody is going to be knocking on your door; nobody is going to be telling you you've got to fill one out. And certainly nobody is going to be forcing you to make a set of decisions on end-of-life care based on some bureaucratic law in Washington.

And that's that! Whew, we dodged a bullet there!

Except House Republicans will continue to pronounce that Obama wants to kill old people. And not just the rank and file, but the Minority Leader. And Democrats still get the cards and letters about how that nice Ms. McCaughey tells them that government agents will descend on their house with some rope and a pillow good enough for suffocatin':

But Representative G. K. Butterfield, Democrat of North Carolina, said he heard many expressions of concern from constituents when he answered telephone calls to his office on Tuesday.

“The longer we wait to vote,” Mr. Butterfield said, “the more opportunity our opponents have to put out false messages. Seniors fear they will lose Medicare. They worry they will have to discuss plans for end-of-life care every five years.” [...]

The House Republican leader, Representative John A. Boehner of Ohio, said, “This provision may start us down a treacherous path toward government-encouraged euthanasia.”

Representative Robert E. Andrews, Democrat of New Jersey, said, “I have met seniors who think their Medicare will be taken away, which is false.”

Not that some people even know that Medicare is a government program anymore.

So this is the game. McCaughey gets on conservative media, pretends to be an expert about all things health care, and just makes shit up about the bill. This lays a near-impossible trap for anyone who cares about honesty - leave the claims alone and watch them fester, or debunk them and give them even more attention. If you're Politico, and your core mission is to start controversy, you can achieve a two-fer by printing headlines like "Will proposal promote euthanasia? and debunking the story deeper inside the article.

Democrats had this game figured out by 1995.



And yet it persists. Because the bullshit flies so fast that tamping it down is just an impossibility. John Thune yesterday went ahead and claimed that "most Americans" would pay 50 cents of every dollar in taxes under the health care bill. You can blame corporate media for failing to get out in front of the nonsense, but you're not going to get Fred Thompson's radio show, which is where this latest McCaughey smear originated, to value the truth.

The strategy of delay from those who want to kill the health care plan relies on a steady stream of bullshit from all areas of the conservative noise machine. Some of this opposition gets privileged by the media, some of it rebutted. But it's all "out there." And it has a cumulative effect, piece by piece, until the plan no longer seems worth doing (which, if it's the Senate Finance Committee version, might be true). You have politicians literally arguing for speed in the process because they don't want their opponents to have time to mainline more lies into the media bloodstream.

McCaughey won't go away. And no matter how discredited Republicans get, their ability to find outlets for their bullshit will probably only grow. All of it goes back to a central argument about the nature of government, an argument that Democrats all too often don't want to have. If the majority of people had any belief that government could act as a positive force in people's lives, the barrage of lies would not matter nearly so much. If you never make that argument, you leave the field to people like Betsy McCaughey.

Obama Cracks Down On The Blue Dogs

The President met with key Blue Dog Democrats on the House Energy and Commerce Committee last night, and they appear to have reached an agreement on the MedPAC reform that the White House has been pushing to get Medicare structural issues out of politics and into the hands of independent observers that can work to lower costs system-wide.

The White House's proposal to strengthen the Medicare Payment Advisory Committee, which makes recommendations on how Medicare pays health care providers, won support from Rep. Henry Waxman (D-CA) and Rep. Frank Pallone (D-NJ), according to Rep. Mike Ross (D-AR), but they haven't finalized an agreement.

"We came out of the meeting with an understanding that we're moving in that direction, based on the fact that the CBO tells us that it's the biggest single item we can address as it relates to cost containment," Ross told Dow Jones.

Ross also said they agree with Obama's four main goals for health care reform, according to Politico.

"He said it must be deficit neutral. He said it must contain cost and reduce health care inflation. He said we've got to cover as many people as we possibly can, making health insurance affordable for them. And that we need insurance reform, that we've got to cover pre-existing conditions. We share all of those principles, all those concerns," Ross said.

Kevin Drum likes the idea and agrees that rate setting should get nowhere near Congressional appropriators. Just the President's engagement on this issue is winning converts, as Blue Dogs assess their own self-preservation and recognize that Democrats either hang together or hang separately, with those in vulnerable districts like them the first in the noose.

Does the MedPAC inclusion turn the House bill into a bill that cuts costs? Some experts believe it does even without MedPAC reform, and that the CBO is just being too conservative. Of course, the CBO probably won't score something like MedPAC reform in the bill anyway, and then skittish Blue Dogs will claim that did nothing to control costs. Then there's this problem, which I hadn't fully grasped:

...the cost of expanding coverage--that is, strengthening Medicaid and giving people subsidies with which they can purchase insurance--comes to a little over $1 trillion over ten years. The House bill raises a roughly equal amount of money through a combination of savings within the health system (changes to Medicare reimbursement, etc.) and an income tax surtax on very wealthy people. So it's deficit neutral in that sense. (what about the money employers who don't provide health care would pay, is that included in this?)

The "but" is because of what's called the "sustainable growth rate" or SGR. Every year, there is supposed to be an automatic reduction in Medicare payments to physicians. Every year, Congress at the last second postpones the cut, because it would have a drastic effect on physician incomes and perhaps (as a result) the availability of physician services. Obama and the Democrats said they it's time to 'fess up and admit that nobody is going to allow those cuts to take place. But doing that means we're on the hook for another $200 billion in spending over the next ten years.

Some would say you have to include that in the cost of a reform plan, particularly since that promise was a key reason the American Medical Association now says it supports reform. And if you do that, the House plan does not pay for itself. It's in the red for about $200 billion over ten years. (I'm rounding figures to keep it simple.)

Others would say it's essentially a separate expenditure--an obligation we were already forced to meet and that shouldn't be added to the price tag of reform. The wonks say "it's baked in the cake already."

So that must be where conservatives are getting that number, although Nancy Pelosi sent out a press release three days ago that says paygo legislation will cover that SGR and even produce a surplus. It sounds like the AMT patch that gets added every year to save middle-income taxpayers $80 billion dollars. We never outright fix these things, and our overall budget suffers because numbers-crunchers expect that money to be there before Congress pulls out the rug.

With all of these knotty questions, I don't think anyone should be surprised that the timeline is slipping. The House may be able to pass a bill, and the Senate Finance Committee may be able to come up with some agreement, by the August break.

Which begs the question, why go on break at all? We have this enormous bill that's central to our economy, a deadline to deal with it either as a standalone or through budget reconciliation, and the Congress wants to go home for three weeks? In three weeks in America, 143,250 people lose their health care on average, 53,000 slip into bankruptcy for medical reasons, and 1,265 die without coverage. Why go on recess? Staying to finish the job would alleviate the worry of Reps. "getting hammered" in their districts (though I actually don't think it would go that way) and would keep on the timeline that the White House wants.

No recess.

Cost Control Is A Political Problem

Doug Elmendorf, who runs the Congressional Budget Office, testified today that the health care bills under suggestion in Congress would increase public health care spending and continue to threaten the long-term budget outlook.

Under questioning by members of the Senate Budget Committee, CBO director Douglas Elmendorf said bills crafted by House leaders and the Senate health committee do not propose "the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount."

"On the contrary," Elmendorf said, "the legislation significantly expands the federal responsibility for health-care costs."

Though President Obama and Democratic leaders have said repeatedly that reining in the skyrocketing growth in spending on government health programs such as Medicaid and Medicare is their top priority, the reform measures put forth so far would not fulfill their pledge to "bend the cost curve" downward, Elmendorf said. Instead, he said, "The curve is being raised."

To which I respond, of course. This is the fundamental problem with health care reform that I've mentioned earlier. Nobody wants to do the trade-offs. There are plenty of cost-control options on the table. One would be capping or eliminating the employer deduction on health benefits, which Elmendorf cites as "a federal "subsidy" that encourages spending on ever more expensive health packages." Another would be putting public health reimbursement rates into the hands of MedPAC and away from the parochial concerns of Congress members, which leads to overpaying for providers in many cases (though lots of Medicaid and Medicare reimbursement rates are low). There are comparative effectiveness reviews that would sweep away ineffective treatments that are too expensive relative to their benefit. There are proposals to change the long-term pay structure of Medicare for providers, away from fee-for-service and toward primary care emphasis and bundled payments. There's the option to make insurers pay the negative externality of denying care by slapping an operating fee on them. And there's a public option that can use Medicare bargaining rates, which would lower costs by 20-30% per individual.

But the unions don't want to break up the inefficient employer-based system and put their gold-plated insurance policies at risk. Congresscritters don't want to lose the power to set Medicare reimbursement rates for their localities. Device makers and their allies want to ensure that their devices aren't rendered useless through research and study. Doctors and hospitals and insurers all want to preserve their profits. And nobody is intellectually honest enough to call for cost controls and a public option that would legitmately drive costs down. Harry Reid's rejoinder is instructive:

Senate Majority Leader Harry M. Reid (Nev.) dismissed Elmendorf's push for the benefits tax. "What he should do is maybe run for Congress," Reid said.

The truth is that we have too shitty a political system right now to get real reform. We might get it incrementally, and can build on it. But the CBO isn't saying anything people don't know. It's just that politicians are afraid to lead.

Holding Back The Tide

The White House has done a pretty good job of rolling out these deals with the health care industry. They made the main announcement of $2 trillion in savings months ago, and that got a large news hit. Then they've been dribbling out each element of the industry and their pledges to lower costs. We haven't reached $2 trillion - in fact, we haven't come close - but every time they do it, the White House gets another news hit. It's pretty brilliant.

The latest is an agreement with the hospital industry to give back $155 billion in profits over a decade, on the heels of an $80 billion dollar agreement with the drugmakers to help fill the dreaded donut hole for prescription drugs for seniors. Because of the way in which Max Baucus (who is brokering most of these deals) and the White House have done it, assenting to changes in how they are paid, this money can be used to help pay for reform, unlike the $2 trillion, which was outside the purview of the CBO. But they seem to be bargaining, like the drug industry, for the best deal they can get, instead of designing the policy and forcing the various industries to accept it.

Still, you have to wonder: Could these industries be giving up more? The drug deal, at least, doesn't look all that great--except, perhaps, to the drug industry. My reading of the agreement--and, to be clear, there's still a lot of ambiguity here--is that the drug industry has agreed to kick in some of its own money to help fill in the "donut hole" in the Medicare drug benefit.

That's very nice and will, I think, make it easier for seniors to afford their drugs. But it also seems that, as part of the deal, seniors have to buy more drugs from name-brand manufacturers rather than generics. It's entirely possible that the name-brand drug industry--that is, the companies represented by PhRMA--could actually come out ahead [...]

The expected hospital agreement seems may be more signfiicant--and, for liberals, more encouraging. Although it's impossible to know without seeing the details, $155 billion is a decent chunk of change. That could represent a serious sacrifice on the part of the hospitals.

On the other hand, it's not clear whether, perhaps, this is an example of some hospitals effectivelly cutting a deal that hurts others. Insofar as the savings come from reduced payments for charity care--payments that now flow through Medicaid--is this a case in which suburban and speciality hospitals actually do just fine but charity hospitals take a hit?

Perhaps the most important question to answer is what these industry groups are getting in return. Changing payments to the health industry isn't simply about generating savings that can finance expansions of insurance coverage. It's also about changing the behaviors of these industries--and, in so doing, creating a health care system that offers better quality care for less money.

To accomplish that, reform should ideally include measures like strengthening the hand of the Medicare Payment Advisory Commission (MedPAC), developing more data on comparative effectiveness (CE), or building a strong public insurance plan. But hospitals don't like the idea of a stronger MedPAC, drug makers are pretty hostile to good CE, and insurers (among others) hate the idea of a public plan. When the industries cut these deals, are they prying promises from Baucus--or the White House--not to push too hard on these levers?

The effect has been to set a ceiling for what the drugmakers and the hospital industry and the other stakeholders will accept, brokered through the most conservative and industry-friendly committee in Congress, Max Baucus' Senate Finance Committee. Any committee that seeks more savings from industry immediately gets attacked, even though they never made such an agreement.

Having struck a bargain with Senate Finance Committee Chairman Max Baucus (D-Mont.), the industry is aggressively targeting individual House Democrats, warning of repercussions in the 2010 elections if they go along with a tougher set of savings advocated by House Energy and Commerce Committee Chairman Henry Waxman (D-Calif.).

PhRMA, the powerful Pharmaceutical Research and Manufacturers Association lobby, is openly playing one chairman against the other. Billions of dollars are at stake; a politically sensitive population, the elderly, is caught in the middle. With House Democrats expected to finalize their bill this week, President Barack Obama could face pressure to come off the sidelines and spell out better where he stands.

What Baucus agreed to specifically in his June 20 bargain is still in some dispute. But PhRMA is bluntly telling House moderates that the senator will oppose the rebates demanded by Waxman and that the smart move is to kill that provision outright and save themselves political pain in 2010.

Then there's the effort in the Senate Finance Committee to deny women legal medical services inside any insurers operating inside the Health Insurance Exchange:

The Senate Finance Committee has been writing a health care reform bill and struggling to create legislation that will have bipartisan support. Chairman Max Baucus considered several compromises to win Republican support, so they can claim it is bipartisan legislation. One of these potential compromises comes in the form of an abortion exclusion, which would prevent abortion services from being covered by some or all insurance plans in the Health Insurance Exchange. We fear that members of the Senate Finance Committee are considering such a compromise.

Remember, most of the groups inside the insurance exchange are private companies. I thought conservatives didn't want to put a government bureaucrat between the patient and the doctor. I guess when it comes to reproductive choice, that's OK.

The Senate HELP Committee's favorable budget score raised hopes that a workable solution was on the way, which was affordable and used a public health insurance plan to increase that affordability. But there's a whole maze of committees and votes to maneuver through. And the Senate Finance Committee is really building a dam to hold back the tide of a legitimate overhaul. Must be all of that industry money.

...see also the tactic of arbitrarily lowering the cost of the bill for no real reason other than $1 trillion is a nice round number.