The Other Health Care Fires

The public option vote was expected, and we'll see a lot more wrangling and floor amendments and other votes before that's done. Supporters picked up Tom Carper and Bill Nelson, so progress was made, actually. I'd like to look at some of the other aspects of the bills moving through Congress, which also have important implications, and what the progress looks like on those fronts:

• Byron Dorgan, Kent Conrad's colleague from North Dakota, will fight to stop the White House/Big Pharma deal from getting implemented. He's going to offer amendments to the final bill to allow reimportation of prescription drugs from Canada, at a savings of $50 billion dollars over 10 years. Surely the free-traders won't have a problem with that, and if they do, they can put a pool together and find the $50 billion that we're otherwise wasting by restricting such a common-sense measure.

• Jay Rockefeller is looking to extend the bill protections to "self-insured" health plans. I just found out about this a couple weeks ago. Apparently, 70 million people in America work for large corporations which self-insure. They have health insurance companies to administer the billing, but the corporation is taking on all the risk themselves. And, they reap the profits, too. These corporations have essentially turned their employee health care into a small profit center. And none of the regulations in the bill would impact these 70 million, simply based on who their employer is. Those employees should have the same protections, regardless of how "well" the self-insured market is working currently.

• In terms of pernicious amendments, anti-abortion activists want to block the exchanges from providing reproductive choice as part of their health care coverage. That would include private companies, and would represent the government telling private insurers what they cannot cover. That's fine to free marketeers because it would restrict legal medical services like reproductive choice. It's complicated, but the anti-abortion types want to use the Hyde Amendment to say that anyone getting subsidies to use the exchange couldn't buy a plan which covers abortion. Thing is, Jon Cohn writes that taxpayers already subsidize plans that offer reproductive choice:

Remember, the single largest tax subsidy in health care today is the tax break for employer-sponsored insurance. If you have insurance through your job, then you're getting government assistance just as surely as if Washington wrote you a check. And if your policy happens to cover abortion services--which about half of you do, according to the Kaiser Family Foundation's annual benefits survey--then the taxpayers are helping to subsidize it.

I'm not trying to accuse abortion rights opponents of hypocrisy or inconsistency. I'm sure they'd eliminate everybody's subsidy if they could. By trying to keep funding out of the exchanges, they're trying to hold the line--to keep more abortions from happening. I don't agree with their position, but there's nothing illogical about it.

But I suspect a lot of voters think the distinction makes sense for a different reason. They have mixed feelings about abortion, so they like the idea of supporting choice in principle while opposing taxpayer funding. The trouble is, it's not a meaningful distinction because of the employer tax subsidy, which (much to my regret, for unrelated policy reasons) is here to stay.

This is a larger attempt to overturn Roe v. Wade without going to court, basically.

• House Democrats will probably add the tax on high-dollar insurance plans into their funding mechanism for health care. Unions hate it, because they've given up wage increases for high-quality health care. But the employer deduction, as Cohn says above, is very pernicious and inefficient, and taxing insurance plans is a way to get at it. I would think that companies would welcome cash payouts over maintaining such high-price health care benefits. Hijacking health care reform to save parochial interests, when we should be moving away from employer-based health care entirely, doesn't make sense.

The Art Of The Deal

The Senate Finance Committee preserved the White House deal with Big Pharma yesterday, but the vote was extremely close. So much so that I'm not convinced they'll be able to hold that deal on the Senate floor.

During the third day of the committee’s markup of the legislation, the vote on the Medicare amendment introduced by Sen. Bill Nelson (D-Fla.) provided the most awkward political moment yet for committee Chairman Max Baucus (D-Mont.) — not to mention the White House, which made a deal with drug makers to limit their exposure.

Baucus and Democratic Sens. Tom Carper (Del.) and Robert Menendez (N.J.) joined the panel’s Republicans in beating back the amendment on a 10-13 vote.

Despite Nelson’s failure to attach the language to the committee’s bill, the argument among Democrats is far from over. Senate Majority Leader Harry Reid (D-Nev.) promised to support the amendment when the bill reaches the Senate floor, Nelson said. The House’s healthcare reform bill includes similar provisions.

Maybe Ben Nelson or Evan Bayh or Mary Landrieu agree with these three - Delaware and New Jersey are big pharma states, but I don't see Ted Kaufman (who's a short-timer and who voted for cramdown in bank-heavy Delaware) or Frank Lautenberg giving in on this. I'm just not seeing 10 votes among Democrats against this policy. Blanche Lincoln voted for this in committee. So did Kent Conrad. It was Bill Nelson's amendment. Who are the conservaDems left?

I wouldn't be surprised if the White House twisted enough arms to get their deal, but I don't see a whip count that gets them there. We'll see.

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?

Coinkydink

Ryan Grim has been all over the story of Big Pharma's deal with the White House and Max Baucus, and despite the denials from everyone, Grim notes that the language in Baucus' draft matches the terms of the deal.

In August, the Huffington Post published a memo that outlined exactly what each side was going to do for the other. And Big Pharma was getting a lot more than they were giving up.

Pharmaceutical Research and Manufacturers of America senior vice president Ken Johnson said that the outline "is simply not accurate." White House spokesman Reid Cherlin concurred: "This memo isn't accurate and does not reflect the agreement with the drug companies."

But now that the bill is out, let's fact check those denials.

1) The memo said that PhRMA would "[a]gree to increase of Medicaid rebate from 15.1 - 23.1%".
The finance bill, on page 56, increases the Medicaid rebates for patented drugs from 15.1 to 23.1 percent.
Check.

2) The memo said that the parties had agreed "to get FOBs done." FOBs refer to follow-on biologic drugs - vaccines and other drugs made from living cells that are the fastest growing field of pharmaceutical research.

PhRMA wants extended patent protections from generic biologic drug makers. A finance committee aide said that the Baucus bill doesn't address biologics, leaving that to the Senate health committee's bill. The health committee bill gives drug makers 12 years of market exclusivity -- five more than the White House proposed -- and allows a 12-year extension with a minor tweak to the drug. The protection is worth billions to drug makers and is entirely unnecessary to encourage research, according to the Federal Trade Commission, which recommended zero years of market exclusivity.

"Already biologics take up at least 30% of Medicare part B spending and this proposal has been rolled into the overall health care reform bill, which is meant create cost savings, which it will not do," Jane Andrews, a medical student at the Johns Hopkins University and a member of Universities Allied for Essential Medicines, wrote in an e-mail to HuffPost. "It's simply a giveaway to BIO/PhRMA from Congress supported by the American Association of Universities."

Check (more or less.)

There are more, just go read. Baucus actually doubled the fee on the industry, from $1.2 billion a year to $2.3 billion, but the rest pretty much matches up. No importation of drugs from Canada, no negotiating with drugmakers for cheaper prices on prescription drugs, no shift of drugs into Medicare Part D.

There's no denying that this deal has been made, and the consequences are also clear. Right now, Democrats are worried about the coverage subsidies in the bill, believing they don't make health care affordable enough. One reason for the constraint is that these deals artificially limit the amount of money that can be wrung from inside the system. Because it's an article of faith that you cannot say the word "taxes" in Washington, as a result poor people who can't afford health insurance may pay the price for deals with Big Pharma, a kind of tax on the lower classes.

I hope avoiding the Harry and Louise ads were worth it. Fortunately, no groups on the right managed to make any headway attacking the overall plan.

I'm sorry, "death panels"? Never heard of it.

Deal Of The Century

So Max Baucus will reveal his long-awaited wet kiss of a bill tomorrow, with subsequent votes in committee in the coming week. We've already seen an outline of it, so we know that it would still cripple people financially who have the temerity to get sick, it would criminalize people who do not buy inadequate private coverage from the insurance industry, it would incentivize employers to offer crappy coverage and discriminate in hiring against people who have no coverage from a family member, and it would not include a public insurance option to compete with private plans. It won't even include a trigger, because the original trigger backer, Olympia Snowe, has decreed that it's a dead letter. Those weak state-based co-ops designed to allow nonprofits like Blue Cross, some of which control 90% of the insurance market, to access billions in government seed money, will be as close as we get in the Finance Committee to a public option. Seemingly, the only reason for the death of the trigger is that Susan Collins said they might lead to a (horrors!) public option, and Snowe probably wants her along as cover for a final bill.

You can pretty much tell what a steaming pile of garbage the Baucus bill would be by the fact that the drugmakers are going all in to support it.

The drug industry’s trade group plans to roll out a series of television advertisements in coming weeks specifically to support Senator Max Baucus’s health care overhaul proposal, according to an industry official involved in the planning.

The move would be a follow-up to the deal that drug makers struck in June with Mr. Baucus and the White House. Under that pact, the industry agreed to various givebacks and discounts meant to reduce the nation’s pharmaceutical spending by $80 billion over 10 years.

Shortly after striking that agreement, the trade group — the Pharmaceutical Research and Manufacturers of America, or PhRMA — also set aside $150 million for advertising to support health care legislation.

President Obama has cited the deal with the group as signifying a new era of cooperation. But some critics say the advertising fund could be wielded against alternative approaches to health care legislation. Some House Democrats, including Henry A. Waxman of California, are seeking drug industry givebacks not covered in the deal with Mr. Baucus and the White House.

You rarely see bribes like this spelled out so succinctly and directly. $150 million is certainly more money than has been spent on health care advertising to date. And it's all going toward the Baucus plan, based on a quid pro quo agreement. Other committee chairs like Henry Waxman want to find more savings that what Big Pharma agreed to by letting the government to bargain for lower drug prices, like many other industrialized nations. But Baucus dutifully abided by the deal, and so his plan will get the ad backing. Matt Taibbi further explains.

The $150 million it committed to support Obama’s bill is now being rolled out in pro-reform ads, which are being aired mostly in the districts of freshman congressmen. The ads are cheesy, half-hearted tripe blandly supporting the weak-as-fuck remnants of Obama’s health care plan, an example being this “Eight Ways Health Reform Matters To You” ad that salutes the end of coverage denials for those with pre-existing conditions.

Now we’re also seeing pressure from a group of freshmen and Blue Dogs, who have composed a letter to a quartet of House Committee chairs requesting that the Waxman language be removed from the health care bill and replaced with the PhRMA language, which happens to be the language the White House is pushing and which will appear in the Baucus bill in the Senate. The pro-PhRMA language retains the preposterous government subsidy to the pharmaceutical industry in the form of laws banning Medicare from negotiating market rates. It is completely useless and of no possible social benefit to anyone except pharmaceutical companies, but this group still managed to get 60 people to sign this bill.

What does this letter say? Does it argue that the PhRMA language is better for America than the Waxman language? Does it say it will cost taxpayers less and provide cheaper drugs to more people? Hilariously, no. What it says is that this PhRMA language, while worse than the Waxman language, is not quite so bad as you think (it doesn’t save as much as the Waxman language, but it still has a 50 percent price reduction, which isn’t terrible!). Moreover, the letter says, substituting this language will help the bill get passed! Here’s the actual language, addressed primarily to Waxman:

“Your efforts to remove this onerous burden on Medicare beneficiaries… are to be greatly commended. However the commitment by President Obama and the AARP to support legislation that would provide a 50 percent reduction is a dramatic step forward in helping fill the doughnut hole. Equally important, it moves us toward our goal of health care legislation.”

In other words, your attempt to put in a real reform is cool and all, but PhRMA has us by the balls, so help us out.

At the same time, the drug industry is employing scumbag from way back Tony Coelho, who may be single-handedly responsible for Democratic silence in the face of the decimation of American manufacturing in the 1970s and 1980s, to attack comparative effectiveness research, another part of the Obama plan. I guess there's nothing two-way about that loyalty.

While we were going back and forth on a public option, this backroom deal to fund future Democratic campaigns (I don't believe for a second that the $150 million will be spent now, but on protecting conservative Democratic incumbents who protected drug industry profits next year) in exchange for backing off a huge subsidy to giant corporations was put into motion. Baucus' delay actually may have crimped this and forced Big Pharma to start spending now. With industry out in front, however, a bill will probably pass.

Just don't read it so closely.

$2.3 Billion Settlement From Pfizer

Say what you will about the Obama Administration, but they did manage to squeeze $2.3 billion out of Pfizer for violating FDA regulations. The investigation occurred mainly during the Bush Administration, but let's just say I'm less confident that a follow-through like this would actually occur. And with the President engaging in backroom deals with industry to keep their guns silent on health care reform, it comes at an opportune time.

“It’s another step in the administration’s ongoing effort to prosecute any individual or organization that tries to rip off health care consumers and the federal government,” said Kathleen Sebelius, secretary of health and human services.

Republicans and Democrats on Capitol Hill have accused the Obama administration of failing to crack down adequately on health care fraud, arguing that huge savings in government health programs could be found with better enforcement. The settlement had been expected. Pfizer, which is acquiring a rival, Wyeth, reported in January that it had taken a $2.3 billion charge to resolve claims involving Bextra and other drugs. It was Pfizer’s fourth settlement over illegal marketing activities since 2002.

“Among the factors we considered in calibrating this severe punishment was Pfizer’s recidivism,” said Michael K. Loucks, acting United States attorney for the Massachusetts district.

For context, the $80 billion in savings negotiated over 10 years from the pharmaceutical industry would translate to $8 billion annually, so the White House picked up 1/4 of the annual savings just from this settlement (not that it would be applied, I'm just adding for context).

I don't think the Big Pharma deal is worth it and will cost consumers in the long run. But a commitment to actual regulations might force the drugmakers into compliance, and provide even more savings at the high end.

Of course, if we start actually regulating drug companies or work to cut into their record profits, we'll stifle their innovation and ruin their made-up market share:

Atlantic blogger Megan McArdle wrote a post on pharmaceutical companies last month, and while replying to one of her commenters, she said this:

The United States currently provides something like 80-90% of the profits on new drugs and medical devices. Perhaps you think you can slash profits 80% with no effect on the behavior of the companies that make these products. I don't.

Last week, during a Washington Post online chat, this exchange took place:

Anonymous: You said that medical innovation will be wiped out if we have a type of national health care, because European drug companies get 80% of their revenue from Americans. Where did you get this statistic?

Megan McArdle: It wasn't a statistic--it was a hypothetical.

You'd think McMegan would agree to resign at this point.

60 Again Shortly?

We're getting closer to Massachusetts being able to appoint an interim successor until the special election that will be held January 19 fills the slot once held by Ted Kennedy. I didn't think Massachusetts lawmakers would be constrained by appearances on this one. Plus, they are fulfilling the expressed desire of the electorate to have two Senators, including one who shares Ted Kennedy's beliefs and policy positions.

By the way, the whitewash of Kennedy from a liberal lion into the great conciliator and compromiser who would have bargained away the public option in a second is truly insidious. Jed Lewison, who was there during the Medicare Part D fight, has some good thoughts on this over at Daily Kos. In short, Kennedy opposed the Medicare deal because it became an industry trough-feed at the end. Despite this, conservatives keep parroting this "compromiser" spin, particularly with respect to that vote.

The reason for Fox's lie couldn't be more obvious: they desperately want Democrats to cave on the core elements of health care reform, and they think that creating a false narrative about Ted Kennedy will make their wish come true.

Ted Kennedy probably wouldn't want us to pass meaningful health care reform solely to honor his legacy. In fact, of all the reasons health reform needs to be passed, that's probably not even on the list.

But Ted Kennedy's passion for health care reform does inspire us to achieve the goal of universal, affordable coverage. And the record shows us that despite his best efforts, Republicans cannot be trusted to be fair partners in the process of getting there.

More.

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.

The Single Payer Vote

I think it's great that single payer will get a vote on the House floor. It's important to set a marker for the future and separate friends from enemies (although, it being a free vote, you'll have more support than probably exists - see the Employee Free Choice Act free votes in 2007-2008). But this line troubles me:

In another part of the deal, the House bill would allow the federal government to negotiate prescription drug prices and use the savings to lower insurance premiums in the health exchanges that would be established in the bill, according to a copy of the agreement obtained by The Hill.

Another provision calls for finding additional savings through other methods by simplifying Medicare and Medicaid administrative costs.

The cuts sought by the Blue Dogs would remain in place unless the drug negotiation and other initiatives yield savings. But any savings would be used to lower premiums.

I believe that negotiations on drug prices will yield savings. So this could work out fine. But there's a strong implication there that the single payer vote was traded in exchange for keeping the Blue Dog-Waxman deal intact. That would be a mistake and a shame, with real-world implications for the middle class and the poor. We'll know when Nancy Pelosi merges the bills, at any rate.

Given the reality of this vote, the biggest thing single payer advocates could get out of it is a full analysis of HR 676 from the Congressional Budget Office. Incredibly, despite the amount of sponsors and the fact that it's been around for years, there has been no CBO analysis of the bill yet, and I think that a score showing that single payer would cost less than the Rube Goldberg plan under discussion and cover more people definitively would be fairly powerful and useful. In a perfect world we would pay a portion of taxes and get insurance coverage, period, end sentence. It appears we're going the route of unwinding an inefficient system slowly. The more information gleaned about the better option, the faster that unraveling can take place.

But if subsidies are more meager as a result of getting a vote, I'm against punishing those who can't afford insurance for the sake of symbol. Especially when Democrats are trying to foreground a message of taking on the insurance companies. Lawmakers are in broad agreement on regulating the insurance market and providing subsidies to those who can't afford insurance. Those also happen to be the two most popular and tangible elements of any bill. They shouldn't be messed with.

Tax-Free Ads

The more we wade into this health care debate, the more we uncover things that simply astound. In an article about curbing prescription drug ads on television, there's this nugget:

Meanwhile, Representative Jerrold Nadler, Democrat of New York, has introduced a bill called the Say No to Drug Ads Act. It would amend the federal tax code to prevent pharmaceutical companies from deducting the cost of direct-to-consumer drug advertisements as a business expense.

“You should not be going to a doctor saying, ‘I have restless leg syndrome’ — whatever the hell that is — or going to a doctor saying, ‘I have the mumps,’ ” Mr. Nadler said in an interview. “You should not be diagnosed by some pitchman on TV who doesn’t know you whatsoever.” [...]

Representative Charles B. Rangel, Democrat of New York and chairman of the House Ways and Means Committee, said last month that legislators would consider ending the tax break for drug ads as a way to raise money to pay for the health care overhaul. But, after lobbying from broadcasters and newspapers, Mr. Tauzin said, legislators quickly abandoned the idea, concluding that such a measure would not raise significant money.

With lawmakers still fighting over how to finance health care reform, Mr. Nadler said he hoped his bill might find an audience.

“On First Amendment grounds, I am not going to say we will ban” drug advertising, said Mr. Nadler, who represents parts of Manhattan and Brooklyn. “But they should not be able to get taxpayers to subsidize it.”

Meanwhile, Representative Daniel Lipinski, Democrat of Illinois, is pushing his own bill that would end the tax deduction for drug company spending on advertisements.

Drug companies get a TAX DEDUCTION for running ads for their drugs. Is this true of Frosted Flakes? Audi? Xerox? Does any other company in America get subsidized for airing commercials to get America to buy their products? It's not "significant money," though, so ending this direct payout from taxpayers to drug companies got shelved.

Set aside for a second the hypochondria that a nightly barrage of ads telling you that you have restless leg syndrome or iron-poor blood or any of a thousand ailments induces. Set aside the self-medication and the boiling down of complex medical issues into 30-second spots showing couples running through a field. Set aside how drug ads increase demand for medications and thus the costs. Set aside that some of these ads run before the Food and Drug Administration even completes their studies of the side effects. You mean to tell me that I'm helping PAY for these things, too?

Fun fact in the article: only the United States and New Zealand allow direct-to-consumer drug advertisements.

...and here's the part where I revise and extend my remarks, as the deduction under discussion is about business expenses and not a straight tax deduction. Maybe I should put a big blinking banner at the top of this one saying IGNORE. They ain't all gems, folks. I will take solace in the fact that, contra Mitch Albom, I know what marginal tax rates are. But just a little solace.

I think the point of having advertisements for prescription drugs at all can still be debated, however, for reasons described above.

The Blue Dog Lament

As you may know by now, 40 members of the Blue Dog Caucus sent out a letter vowing to withhold their support for health care reform without what they call "significant changes." What's interesting about the letter is how insignificant the changes actually are. Among other things, they want:

• a deficit-neutral policy, which is what every single proposal for this bill has included;
• aggressive solutions to bending the cost curve, which also is a goal of pretty much everyone;
• protecting small businesses, which every iteration of the plan has, including the employer mandate proposals that exempt certain small businesses and make them eligible for purchasing health care through the insurance exchange;
• rural health equity, a pretty small point;
• a public option that doesn't use Medicare bargaining rates, which isn't different from what, for example, Chuck Schumer has called for, although I find that to be a toothless public option, which I'll explain later;
• time to read the bill, which I support;
• bipartisanship, which is the most ridiculous of these demands, but which actually does exist in the bill on the Senate side, where dozens of Republican amendments have been included in the HELP Committee markup.

So what's the problem here? Well, dig a bit deeper and you'll see. In short, the Blue Dogs want to reform the health care system without implementing things that would reform the health care system. They want to bend the cost curve and find savings from within the current system, yet they also want "rural health equity," which actually means spending more on rural health. That would INCREASE costs. Similarly, a separate letter signed by many Blue Dogs ask Henry Waxman to cancel plans to reinstate price controls on prescription drugs to help seniors. The entire point of Waxman's proposal is to plow savings from the current exorbitant prices paid to drug-makers back into the system. And finally, there's the matter of the public option. Here's the language in the letter:

We also wish to reiterate our support for the recommendations previously made by our coalition regarding how to appropriately structure a public option. In order to establish a level playing field, providers must be fairly reimbursed at negotiated rates and their participation must be voluntary. A "Medicare-like" public option would negatively impact hospitals, doctors and patients. Medicare reimbursement is on the average 20 to 30 percent lower than private plans and this inequity is even greater in some parts of the country. Using Medicare's below-market rates would seriously weaken the financial stability of our local hospitals and doctors.

So, they don't want a public option using Medicare reimbursement rates because they're 20-30% lower than private plans. Which means they want to spend 20-30% MORE on provider rates, while... controlling costs, somehow. The entire point of a public option would be to lower overall costs to individuals and government; a plan on a "level playing field" is just another non-profit with little leverage to change the overall dynamic. The Blue Dogs are just being incoherent.

You don’t save money by magic. You save money by spending less money. You can do that by just letting a large and growing number of people go without adequate health care. Or else you can do that by spending less money on overpayments, inefficient processes, and unnecessary treatments. But you can’t do that without taking a bite out of someone’s bottom line. The Blue Dogs seem to be looking for a free lunch, or else just grasping at straws for reasons to object to the bill.

I think it's the latter. Like with the effort in 1993, the Blue Dogs are inventing reasons to resist a health care overhaul. It's obvious from the contradictions in their argument.

But lurking behind all of these complaints, according to several sources I consulted Thursday evening, is a general wariness of taking a political plunge on health care. Like their counterparts in the Senate, House members don't like taking hard votes. Raising taxes, cutting spending, anything that takes money ouf of people's pockets--these are not things they want to do, even in the service of a greater, more popular cause.

And now they're getting nervous. They're seeing the president's popularity dipping, however incrementally. They're watching the Senate chase its tail over the same controversies. And having just taken what were--for many of them--similarly tough votes on an energy bill, they're not exactly thrilled about "walking the plank" again.

Never mind the literally clueless arguments from conservatives, or the complete hash from contrarians over health care - in the end, Democrats hold the fate of this bill in their hands. And lots of them don't want to face up to the fact that their concerns about costs are solved in this case by MORE progressive reforms, not less. It hurts their wittle feelings. And maybe they'll just use their go-to lament about bipartisanship, when the minority on this issue exists to prevent anything from being signed into law.

Fortunately, some Blue Dogs have spoken out on this issue in an intellectually coherent way. But unless more of them come around, this is how an overhaul will either be whittled down to nothing or just plain die - because so-called fiscal conservatives want to stick their fingers in their ears rather than face up to the facts.

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.

Filling The Doughnut Hole

Insurance companies are not the only bad actor in the health care industry. To a degree all of them are. Some doctors overtreat and order up unnecessary tests. The medical device industry pushes their products even if they have no utility. Hospitals charge exorbitant rates. The incentives in the system are entirely wrong. And of course, then there's the pharmaceutical industry. And in 2002, they negotiated with President Bush and the Republican Congress to put the doughnut hole into the Medicare Part D bill. What was that? Well, your prescriptions were covered up to the first $2,700, and then you had to pay full price until you hit $6153.75, essentially offering no benefit to the elderly who consume enough drugs to meet that lower bound. It was a forced gap put in by an industry looking to make a buck, since the consumer has no bargaining power in that doughnut hole, while the government does. And under the current President and the Democratic Congress, they returned to the negotiating table and said end this now. So the industry will.

Drug manufacturers have tentatively agreed to provide as much as $80 billion worth of discounts on medicines purchased for government programs such as Medicare, providing a bit of cash for President Obama's expensive and ambitious attempt to give health coverage to every American.

The accord, approved yesterday by the board of the Pharmaceutical Research and Manufacturers of America (PhRMA), is a voluntary pledge by the industry to reduce what it charges the federal government over the next 10 years, according to a source close to the negotiations who spoke on the condition of anonymity because of White House sensitivity about the talks.

If health-reform legislation is enacted, the agreement would bring financial relief to about 3.4 million elderly and disabled Americans who currently fall into a coverage gap known as the "doughnut hole." Medicare recipients must now pay the full price of brand-name medications after they have incurred a total of $2,200 in drug expenses, until reaching an outer limit of $5,100.

Under the proposal, U.S. drug companies would provide half-price discounts to Medicare recipients in the "doughnut hole" and provide other unspecified discounts and rebates for a total of $80 billion in savings to the government.

"This is real money on the table," the source said.

The White House put out slightly different numbers for the doughnut hole, but basically it means that Medicare would purchase those drugs in the middle, and they can get more for their money. This leads to lower costs. The President released a statement, and here's part of it:

"As part of the health reform legislation that I expect Congress to enact this year, pharmaceutical companies will extend discounts on prescription drugs to millions of seniors who currently are subjected to crushing out-of-pocket expenses when the yearly amounts they pay for medication fall within the "doughnut hole" - any payments by seniors not covered by Medicare that fall between $2700 and $6153.75 per year. The existence of this gap in coverage has been a continuing injustice that has placed a great burden on many seniors. This deal will provide significant relief from that burden for millions of American seniors.

"The agreement by pharmaceutical companies to contribute to the health reform effort comes on the heels of the landmark pledge many health industry leaders made to me last month, when they offered to do their part to reduce health spending $2 trillion over the next decade. We are at a turning point in America's journey toward health care reform.

It doesn't seem like much of a deal for the pharmaceutical companies, but if you add 30 million or so Americans to the rolls of the insured, that's a big ol' market for new prescription drugs. Plus, Medicare, the largest purchaser of drugs in America, has a certain amount of leverage. I don't mind them making a profit - but they must offer fair and equitable prices for their work and try to create products people need to alleviate pain and disease instead of hair growers and boner pills.

The doughnut hole has long been one of my biggest bugaboos about the power of industry, and I'll be happy to see it cut in half. That's a tangible benefit for seniors and something around which they can rally for comprehensive reform.

Budget Musings

The President's budget for FY2010 is online. This is a pretty remarkable leap forward, and offers the ability for geeks and wonks of all stripes to dig into the line-by-line appropriations and see what the President is offering. While Congress will almost certainly change some of these terms, a lot of what's here is promising while not totally sufficient. Bill Scher has a good overview of two of the major concerns, energy and health care.

Over the course of the 10-year budget window, President Barack Obama envisions a $634 billion fund for health care reform that would provide coverage for all Americans, paid for by higher taxes on the wealthy and various budget savings -- a dramatic gesture that confirms the deep commitment from the White House to solve the health care crisis.

But as the White House acknowledges and The Treatment's Jonathan Cohn observes, $634 billion is but a healthy down payment. More will be needed [...]

On energy and climate, I wrote yesterday about the stunning news that the White House expects to have revenue from a carbon cap and emissions trading system to combat global warming and transition to a clean energy economy.

Such a plan would raise significant revenue, particularly in the early years of the plan while the carbon cap would be looser (it would gradually tighten over time). However, the White House understandably wants to return the vast majority of revenue from polluters to consumers, to reduce the impact of short-term price spikes and refute charges that the plan amounts to a tax hike.

But that means the White House only expects to use $15 billion to invest in clean energy. The Apollo Alliance concludes we need to invest $50 billion a year for 10 years to transition to a clean energy economy. Again, a good down payment, but not all we need.

The other big funding tranche, education, is getting a pretty good deal, more than even a lot of optimistic education advocates expected. It looks like Obama will reauthorize No Child Left Behind but with the actual funding to make it work. There is a definite effort to split the difference between reformers and teacher's unions on things like charter schools, where I think he can get significant Republican buy-in. And this is great:

Recognizing that the push for college access for low-income and minority students must be complemented by a new focus on college completion, the administration is proposing a $2.5 billion Access and Completion Incentive Fund, "to support innovative State efforts to help low-income students succeed and complete their college education."

The administration wants to originate all student loans in the direct lending program, cutting out wasteful middle-men. This is a very good thing, as it will save the federal government billions of dollars that can be funneled back to students.

There is just no need for the government to invent a secondary student-loan market, adding an unnecessary layer of inefficiency. Good thinking.

There's also a dedicated state grant program for high speed rail of about a billion dollars a year. Again, great, but somewhat insufficient. And there is a provision to speed the development of generic drugs into the market and tear down attempts by drugmakers to block them, which would save the government and consumers billions.

Still, there are concerns. First of all, while most of the fuzzy math is gone, the budget depends on pretty robust growth in 2011 and 2012. Obviously Obama feels that the results of his policies will return us to better times, and that may be true, but he's using pretty optimistic numbers. The other issue is the military budget. Again, Bill Scher:

Congressman Barney Frank argues we can and should cut our $670 billion military budget by 25 percent. That includes spending for our wars in Iraq and Afghanistan.

Disregarding the President's budgeting for Iraq and Afghanistan (because I don't believe we can discern too much on his strategy from the budget numbers), Obama's basic defense budget is scheduled for a slight increase in 2009: from $513 billion to $534 billion.

The WSJ reports that there is likely to be major weapons reductions in the future, as a result of putting the wars in Iraq and Afghanistan back on budget.

President Barack Obama has talked about the need to prune some high-end Pentagon acquisitions programs and withdraw most U.S. combat troops from Iraq by mid-2010, both of which should result in significant defense-spending reductions. But the president plans to direct additional financial and military resources into Afghanistan, so much of the savings may be offset by new spending on the troubled war effort there.

That could force the military to cut back its spending on its most-advanced weapons, and the Pentagon plans to overhaul its weapons-purchasing system.

I'll have more as I keep reading.

...One thing I'm noticing, reading over the President's budget, is that it is a starkly ideological document. Almost shockingly so. For example, read pages 5-17, describing what got us into this mess. And many of the backpedal steps that Obama made on domestic issues during the campaign are not in here at all. Nothing on nuclear power in the energy section. Nothing on offshore drilling - in fact, the only thing is an excise tax starting in 2011 to stop oil companies from getting excessive royalty relief. I'm not sure if all the numbers line up, but rhetorically it's really on point.

Limits Of The Imagination

There was a fairly amazing article in yesterday's Washington Post that I think hits on many of the features of this newfound effort to worry about the deficit and entitlements precisely at the moment when a Democratic President enters office facing a huge crisis requiring major public spending. The basic thrust of the story by David Brown, a doctor and science reporter, is that health care spending will inevitably expand forever, and there's nothing we can do to control costs, and pretty soon we're going to face a crossroads between wanting to live longer and healthier lives and being able to afford it. This was not in the opinion section.

This difficult truth, which has emerged over the past half-century, is leading the United States and the rest of the industrialized world into a new era of humankind [...]

Last year, 16 percent of the nation's gross domestic product went for health care, about $7,600 per person. In terms of human effort, health care is the new food. By 2016, when it reaches 20 percent of GDP, it will be the new shelter. If it grows at its present rate through the first three-quarters of this century, it will consume 38 percent of GDP by 2075. It will then be the new food and shelter.

This isn't a mistake. If it were, we might have a chance of stopping it. It's success -- the way things are supposed to be, and the way we want them to be.

"At the end of the day, when it comes to controlling health care costs, the enemy is us," said Drew Altman, head of the Henry J. Kaiser Family Foundation. "Americans want the latest and best in health care technology, and we want it down the street, and we want it now."

It sounds so simple, doesn't it? Americans greedily want to be healthy, and they demand the latest and greatest, and the costs skyrocket.

Now, nowhere in this analysis is any explanation of the method of delivery of the US health care system, and how its inefficiency may just be, I don't know, the source of the problem. I'm trying to remember when I barged into a doctor's office and insisted on an artificial heart because the guy down the street just got one. No, what happens is that I pay thousands of dollars in premiums to a for-profit insurer, and when I try to use my coverage, I barter with some customer service rep for hours on end trying to get them to sign off, and she gets paid along with a whole staff to keep treatment costs down, and her salary and the salary of the marketing team at the insurance company and the PR guys and the pharmaceutical reps bringing in free lunches for the doctors and the CEO's private jet all fall under that big number of "health care spending."

Also, health care spending grew at its lowest rate in a decade last year, mainly because the economy started slowing down, people started using CHEAPER generic drugs (I thought Americans wanted the best and they wanted it now?), and because of lower rates of growth for administrative costs in - wait for it - Medicare, the public not-for-profit alternative health care delivery system.

Now, it would be simply gauche to point out that the current health care delivery system sucks up all kinds of money for insurance industry profits and admin costs, and that the high cost of premiums force 47 million people to go without health care and use emergency rooms as their personal physician, jacking up costs prohibitively. That couldn't possibly explain all that growth in spending.

Except consider the current series of health care bills before Congress, and recognize that the plan which would cover the most uninsured and the plan which save the most money are THE SAME PLAN. Matt Yglesias has the charts to prove it, from this Commonwealth Fund report. As Yglesias notes, because that DFH Pete Stark wrote the bill that combines reducing the most uninsured with saving the most money, it's deeply unserious and outside the boundaries of conventional Beltway debate.

Stark’s is the best again. And yet there’s no chance whatsoever that we’ll actually do this because his plan, though the most practical, is also the most left-wing. Far too left-wing for the United States of America

Some folks, of course, will oppose the Stark plan because they’re right-wingers who don’t want to expand health care coverage. And some folks, will want to focus their energies on other, worse, plans because those plans have a better chance of passing. But what’s incredibly frustrating is that a lot of people who claim to want to change public policy to expand health care coverage and better control health care costs will nonetheless fail to embrace Stark’s plan or anything similar for no real reason other than ideological posturing. It just can’t be the case, as a matter of centrist dogma, that the best solution is actually the most left-wing solution. It’s a far more ideological stance than anything you’ll ever hear from Pete Stark or from me. But the people hewing to it will insist on being called pragmatists.

Pragmatists like David Brown, who says that we're all going to have to live with the costs of better medical care and drugs, and if it costs too much to save someone's life, well we just have to grapple with that Malthusian Spectre. It can't possibly be that bringing America's health care costs in line with every other industrialized nation on the planet would both help to fix the deficit and entitlement concerns AND deliver better quality and more affordable health care to every American.

That just cannot be. If it's such a good idea, why wouldn't we have thought of it by now?

This all reflects a very ideological problem, where the case for liberal government has either not been made or drowned out by the right for the past 40 years, and so the Very Serious People in Washington view that case as a pollyanna scenario. And in the exchange, we all suffer.

The CIA Endorses Marital Rape

Welcomed With Flowers, Sweets And Prescriptions

by dday

I suppose I shouldn't be alarmed by this, but I have to confess to being a little taken aback by the snickering and high-fiving in the blogosphere over the CIA's attempt to curry favor with Afghan tribal leaders by offering them Viagra.

The Afghan chieftain looked older than his 60-odd years, and his bearded face bore the creases of a man burdened with duties as tribal patriarch and husband to four younger women. His visitor, a CIA officer, saw an opportunity, and reached into his bag for a small gift.

Four blue pills. Viagra.

"Take one of these. You'll love it," the officer said. Compliments of Uncle Sam.

The enticement worked. The officer, who described the encounter, returned four days later to an enthusiastic reception. The grinning chief offered up a bonanza of information about Taliban movements and supply routes -- followed by a request for more pills.

There's a certain logic to using personal items as barter (or bribery, if you prefer) for warlords and tribal leaders to extract information about the Taliban insurgency. At the same time, does anyone credibly think that those four women this guy is married to are entirely willing spouses, and the consequent sex performed as a result of the Viagra entirely consensual? One of the most persistent problems in Afghanistan - indeed, one of the ostensible reasons used by people like Laura Bush to justify the invasion beyond the need to root out al-Qaeda - is the terrible life circumstances for women. I fail to see how use of erectile dysfunction pills created by men and for men improves their quality of life. Megan Carpentier gives the explanation with which I concur:

SPENCER: So what should we understand to be the anticipated effects on Afghan women of this Viagra-based counterinsurgency effort?

MEGAN: Well, one could argue that by supplying the aging warlords with Viagra, you are depriving their wives of a needed and biologically expected semi-permanent respite from performing unwanted sexual acts that would otherwise be forced upon them. In the interests of fairness, I suppose its possible that these warlords attempt to treat their wives with the utmost care and respect and provide them with sexual satisfaction instead of using them as living, visible extensions of their power over people that the warlords can additionally stick their dicks into.

SPENCER: But that's not where we should take this discussion! Are we in a situation where the expected consequence of the CIA Viagra program is marital rape? Should everyone who isn't Dennis Prager find this problematic?

MEGAN: Well, are we in a situation where we would deny that such is a possibility? I don't think we make good policy by ignoring the consequences, nor am I saying that giving the dudes Viagra is not preferable to giving them, say, weapons. But is it possible that we're providing them with the means to force themselves on their wives (who likely had no choice in being their wives) that nature has otherwise denied them? Yes. Plus, I did have to go find a way to relate it to women's issues [...]

SPENCER: Right, but now that we've got that covered: what should we do next? Stop the program?

MEGAN: Well, I'm not exactly one to go around advocating marital rape. Nor are — one assumes — operatives on the ground in any position to survey the wives of the warlords to determine whether the dick pill sex is consensual or wanted. Nor do the women in question have the vocabulary — culturally speaking, that is — to likely describe the sex as coercive or forced. In a society in which wives are expected to submit to their husbands and sex is not intended for their benefit or pleasure, nor are their moods or desires taken into account, they probably wouldn't consider a formerly impotent husband with a handful of Viagra and some impotent time to make up for much more than their unlucky lot in life. And, if the benefit — as you stated above — is not only that the formerly impotent husband doesn't take said impotence out on our troops but also refrains from taking it out physically on the wives, are they substantively better off being unhappily sexed than physically beaten? The fact that women in America have those choices and the freedom to think about them is a great thing, and handing out or not handing out Viagra to impotent warlords doesn't give Afghan women those choices or freedoms. Nor does allowing a Taliban or al Qaeda-led insurgency to win back the government. But that doesn't mean that our choices should remain unexamined.

There's a top-rated diary on Daily Kos right now entitled Dennis Prager Endorses Marital Rape. Somebody explain to me how the CIA isn't doing functionally the same thing.

And there's a larger point. We barge into foreign societies without a coherent understanding of the underlying culture and try to use whatever means to get the locals on our side, and the unintended consequences that result are never examined either before or after the fact. They are considered prices to be paid for "success," whatever that means. I think it's actually fairly impossible for me to determine the full effects of giving Viagra to Afghan warlords, in much the way that introducing a change in where a butterfly flaps its wings in the past can alter the future. But I'm fairly certain that those effects are completely ignored by the elites who think they can control events thousands of miles away through little inducements and bribes. I haven't read all of
Legacy of Ashes but I wonder if I'd find anything if I searched the index for the part where anyone games out the ripple effects of the agency's actions. Probably not.

Maybe what should be considered, instead of the boner pills, is why we're in Afghanistan in the first place. Rather than social engineering, we could use local law enforcement and intelligence sharing to limit or remove the capacity of anyone in the region striking beyond their borders, and we allow local and regional actors to determine their own way forward instead of arrogantly assuming we know what's best for these people, and trying to install a central democracy where none has ever existed. Alternatively, we could figure out what other drugs they might like.

Health Care Conversations

The science is in, to borrow a phrase, on the US healthcare system. It costs more and treats less, and as a result America is less competitive and far less healthy.

"Our health-care system is fraught with waste," says Gary Kaplan, chairman of Seattle's cutting-edge Virginia Mason Medical Center. As much as half of the $2.3 trillion spent today does nothing to improve health, he says.

Not only is American health care inefficient and wasteful, says Kaiser Permanente chief executive George Halvorson, much of it is dangerous.

Those harsh assessments illustrate the enormousness of the challenge that awaits President-elect Barack Obama, who campaigned on the promise to trim the average American family's health-care bill by $2,500 a year. Delivering on that pledge will not be easy, particularly at a time when the economic picture continues to worsen.

That's a paradoxical final statement. Delivering on the pledge should be as simple as removing the inefficiencies in the system, which can be viewed in working models in every other industrialized nation in the world. But that's not how the political ball bounces here in the greatest country since the dawn of man. While it pains me to say that Newt Gingrich is making a bit of sense on this question, he's ignoring the realities of where that useless spending flows.

A high-performance 21st-century health system, they say, must revolve around the central goal of paying for results. That will entail managing chronic illnesses better, adopting electronic medical records, coordinating care, researching what treatments work best, realigning financial incentives to reward success, encouraging prevention strategies and, most daunting but perhaps most important, saying no to expensive, unproven therapies.

"There is more than enough money in the system," said former House speaker Newt Gingrich, who runs the District-based Center for Health Transformation. "We just are not spending it well." [...]

With those sorts of variations, the Dartmouth team concluded that as much as 30 percent of medical spending -- or $700 billion -- does nothing to improve care.

Even if only a third of that could be invested in critical programs, "imagine the possibilities," said Peter Orszag, head of the Congressional Budget Office, who was nominated last week to be director of the Office of Management and Budget in the Obama administration. "Given the scale of it, I am puzzled as to why we are not doing more to improve the efficiency of the health system."

Of course, when Gingrich talks about "not spending money well," he's talking about keeping treatment from those who need it. But what it means in practice is reflected in this horror story, which shows you where that staggering amount of money goes that doesn't improve care - into drug and insurance company coffers:

The study cost $130,000,000 and included 42,000 patients. It compared the effectiveness of four types of blood pressure drugs: a calcium channel blocker, an alpha blocker, an ACE inhibitor, and a simple diuretic. The diuretic performed best. It was the sort of finding worthy of celebration. Health costs are too high, and rising too quick. Our flabby society gets bad readings when it straps on the blood pressure cuff, and soon enough we'll all be on these drugs. And here were study results saying that the diuretic, a generic drug which sells for pennies, outperformed its pricey, patented competitors. So what happened? Not a whole lot [...]

Diuretics sales jumped, but only by a few percentage points. "[They] should have more than doubled," says Curt Furberg, who chaired the study. And in a world where doctors prescribe medications based on a simple reading of the latest evidence, maybe they would have doubled. But we don't live in that world. We live in a world where pharmaceutical companies have big budgets and sophisticated public relations teams. Pfizer, for instance, put up $40 million to ensure that their Cardura, their alpha blocker, was included in the study. That proved a mistake. Patients on Cardura were more than twice as likely to require hospitalization for heart failure [...]

The basic reality was this: The pharmaceutical companies had a skilled team and a lot of money promoting their drugs. No one was promoting the generic diuretics. Folks looking to things like comparative effectiveness review to save the health care system should take the story seriously. Evidence is only effective if physicians use it. And right now, they have no real reason to use it. Even in a system this expensive, there's no internal incentives to aggressively cut costs. Maybe it's time there were. If doctors were paid by capitation -- if they got a fixed amount of money per patient, and they kept whatever they didn't use, as happens in England -- it's hard to imagine they wouldn't have been more interested in these study results.

I believe Peter Orszag, a very sharp economist, and the Obama team are listening to these complaints about efficiency. They've set up discussion forums on the issue and allowed high-level policymakers like Tom Daschle to respond personally. So let's be clear - the best cure-all for the American health care system would be to remove the rapacious greed at the heart of all this wasted money. Drug companies and insurers spend less on care and more on administrative and PR costs because that's where the profit maximizers are. Until profit can either be driven through providing care, or profit is completely removed from the system, there will not be meaningful progress on health care.

Cindy Story Fizzles

The mystery of the missing Washington Post article has been solved, as they published a very long front-page story today about Cindy McCain's drug addiction. I have to say that I think they puled their punches, however. Mainly it removes John McCain's involvement from the story, and the DEA investigation just sort of ends, according to their account. A lot of the burden is placed on heavyweight lawyer John Dowd instead of McCain himself. There's no mention of her securing a passport to hide her drugs on travel, there's no mention of McCain's office strong-arming the DEA to drop the charges. These are elements that Tom Gosinski was willing to put on the record to other journalists. WaPo didn't think they were worthy.

It reads more like a puff piece with a slight edge to it. You certainly learn about Cindy's criminal activities, but not about the abuse of power.

Very depressing.

Spike

Digby already mentioned the breaking story about John McCain's strong-arming of the DEA to stop them from investigating his wife's prescription drug theft. Raw Story adds more to the case.

Tom Gosinski, a former employee of the medical-aid charity Cindy McCain used as personal supplier of Percocet and Vicodin, is speaking out publicly for the first time.

On Wednesday, Gosinski sat down with RAW STORY and other outlets to tell his story and distribute copies of his personal journal from his time with the American Voluntary Medical Team in the last half of 1992, where he voiced ever more acute concerns and frustrations over McCain's drug use and its impact on her mood and job performance.

"My journal wasn't to trash Cindy or anything," he says. "My journal was kept because I came in contact with so many people. It was a way of keeping an ongoing biography of all the people I met, so I could refer back to it."

He says he can't buy the official McCain camp line that Cindy's drug abuse was kept from her husband, he saw and heard too much for any of their stories to make sense -- like the time Cindy was allegedly taken to the hospital after an overdose and John rushed in to berate the doctors and nurses there before moving Cindy to their secluded Sedona ranch. Then there were the Hensley family interventions and the fact that Cindy's drug abuse came to be something of an open secret among employees of the charity.

There's a lot here, from Gosinski being fired and blackballed for knowing too much about Cindy's drug abuse, to Cindy getting a diplomatic passport from her husband's Senate office so she wouldn't be searched in airports with all of these drugs, and on and on.

It's a dense story. But there's another aspect to it revealed today by John Aravosis. Apparently, the Washington Post recorded an interview with Gosinski that they are hiding from the public.

Go to Google. Type in the name "gosinski." Look at the sixth result.



John Mccain abused his power to keep it a.... secret, perhaps? This isn't a story about the wife, it's a story about the Senator possibly using his office to obstruct justice for personal gain. Sounds a lot like Troopergate in fact. Definitely a story.

But when you click the link and go to the Washington Post's Web site, there's nothing there, just a blank template with no content.

I just checked this a second ago. It's still on Google, and there's still a blank template at WaPo when you click on the link.

This is a spiked story. There's plenty of precedent for this in 2004, when 60 Minutes delayed broadcast of a story about Iraq, Niger and yellowcake that would have been very damaging to President Bush until after the election. There are other examples as well.

This now becomes the scandal. It is completely inappropriate for the Washington Post to spike a legitimate news story about the corruption of a Presidential candidate, especially considering that candidate is running on this platform of reform. And all the other news outlets need to be informed of this as well. If there's enough pressure, one of them may see the tactical value in going forward with interviewing a willing witness before their competitors. If that's how the news business still works, anyway.

Some phone calls need to be made.

Support The Troops' Drug Habit

It's just touching what this government does for our men and women we send into battle. If they have concerns about the overextended tours of duty, or the multiple deployments, or the lack of body armor or safety equipment, and the undefined mission, our boys in uniform get the best blue pills money can buy:

For the first time in history, a sizable and growing number of U.S. combat troops are taking daily doses of antidepressants to calm nerves strained by repeated and lengthy tours in Iraq and Afghanistan. The medicines are intended not only to help troops keep their cool but also to enable the already strapped Army to preserve its most precious resource: soldiers on the front lines. Data contained in the Army's fifth Mental Health Advisory Team report indicate that, according to an anonymous survey of U.S. troops taken last fall, about 12% of combat troops in Iraq and 17% of those in Afghanistan are taking prescription antidepressants or sleeping pills to help them cope. Escalating violence in Afghanistan and the more isolated mission have driven troops to rely more on medication there than in Iraq, military officials say.

At a Pentagon that keeps statistics on just about everything, there is no central clearinghouse for this kind of data, and the Army hasn't consistently asked about prescription-drug use, which makes it difficult to track. Given the traditional stigma associated with soldiers seeking mental help, the survey, released in March, probably underestimates antidepressant use. But if the Army numbers reflect those of other services — the Army has by far the most troops deployed to the war zones — about 20,000 troops in Afghanistan and Iraq were on such medications last fall. The Army estimates that authorized drug use splits roughly fifty-fifty between troops taking antidepressants — largely the class of drugs that includes Prozac and Zoloft — and those taking prescription sleeping pills like Ambien.

And if the combination of psychotropic drug use and the horrors of a war zone prove too much for them upon return to the states, that's OK - they just stick them in the back of the base by the firing range:

FORT BENNING, Ga. -- Army Sgt. Jonathan Strickland sits in his room at noon with the blinds drawn, seeking the sleep that has eluded him since he was knocked out by the blast of a Baghdad car bomb.

Like many of the wounded soldiers living in the newly built "warrior transition" barracks here, the soft-spoken 25-year-old suffers from post-traumatic stress disorder. But even as Strickland and his comrades struggle with nightmares, anxiety and flashbacks from their wartime experiences, the sounds of gunfire have followed them here, just outside their windows.

Across the street from their assigned housing, about 200 yards away, are some of the Army infantry's main firing ranges, and day and night, several days each week, barrages from rifles and machine guns echo around Strickland's building. The noise makes the wounded cringe, startle in their formations, and stay awake and on edge, according to several soldiers interviewed at the barracks last month. The gunfire recently sent one soldier to the emergency room with an anxiety attack, they said.

"You hear a lot of shots, it puts you in a defensive mode," said Strickland, who spent a year with an infantry platoon in Baghdad and has since received a diagnosis of PTSD from the military. He now takes medicine for anxiety and insomnia. "My heart starts racing and I get all excited and irritable," he said, adding that the adrenaline surge "puts me back in that mind frame that I am actually there."

It's like they're TRYING to create another generation of strung-out homeless veterans.