Passing the Democratic Health Care Bill is Not the “Right Thing To Do”

Any big health care bill will be full of compromises—political or otherwise. But this bill doesn’t even come close to deserving to be called “health care reform.”

As the Democrats make their final push to pass their health care bill many of them, and most notably the President, are arguing that it should be passed because it is the “right thing to do whatever the polls say.”

Their argument is powerful: We will never get the perfect bill. If this fails who knows how long it will be before we have another big proposal up for a vote. There are millions of uninsured unable to get coverage because of preexisting conditions or the inability to pay the big premiums and this bill would help them.

But as an unavoidable moral imperative, enacting this bill would fall way short:

• It is unsustainable. Promises are being made that cannot be kept. As the President has said many times, we need fundamental health care system reform or the promises we have already made—the Medicare and Medicaid entitlements, for example—will bankrupt us. What few cost containment elements the Democrats seriously considered are now either gone from their final bill or hopelessly watered down—most notably the “Cadillac” tax on high cost benefits and the Medicare cost containment commission.

• It is paying off the people already profiting the most from the status quo. Many of the big special interests, that will have to change their ways if we are really going to improve the system, are simply being paid off for their support. The drug deal, the hospital deal, promises not to cut or change the way physicians are paid, all add up to more guaranteeing the status quo rather than doing anything that will bring about the systemic change everyone knows is needed.
  

• Nothing in these bills will fundamentally change our current fiscal course. As the CBO, and every other expert has said, if this bill becomes law we will continue on the same cost trajectory we are already on. Yes, the CBO says the Democratic plan will reduce costs during the next ten years by about $100 billion—but that only means they would be $100 billion less than the $35 trillion they would have been anyway! That is merely a rounding error on the track we are already on.
  

• There is nothing here that will stop unaffordable health insurance rate increases. Lately supporters have said this bill is the solution to the recent big individual health insurance rate increases we have been reading about in the press. But there is little in this bill that will mitigate or control any such increases because so little would be done to impact underlying health care costs.

We often hear the argument, “Let’s get this entitlement expansion bill passed and it will force us to deal with costs later.” If we don’t now have the political courage to face daunting health care costs in the face of exploding deficits how will we have that courage later?

I will suggest that adding 30 million more people to an unsustainable system expecting it will create an even bigger crisis and thereby force real reform is tantamount to reboarding the Titanic in the hopes it will sink faster. It is also hard to see how doing such a thing is the politically courageous thing to do.

Just where is the moral imperative in ramming a trillion dollar entitlement expansion through knowing full well it will make our long-term deficit nightmare even worse—for those now uninsured and for everyone else?

The Democratic health care bill makes little if any systemic changes to the health care system—certainly not at the level we need.

The Democratic health care bill makes promises we cannot keep.

Proponents of the Democratic health care bill make the claim that it will make health insurance affordable, improve our deficit outlook, and make our health insurance system sustainable. None of those claims are even close to being true and everyone who knows anything about this debate knows that.

Heck of a foundation for doing the “right thing.”

The Issue Has Become Arrogance Not Health Care

Away from Washington people I talk to are just amazed at what the Democrats are in the process of doing on health care.

What I think the Democratic leadership is missing is that this is no longer about passing a health care bill in the minds of lots of these voters—a majority of voters from what the polls say.

To these people, this is about Democratic arrogance. What the polls don't measure is the anger I hear from people who can't believe what is going on. After the last few recent state elections and all of the polls that overwhelmingly say, “stop” or “start over” they just keep plowing along anyway. To defend themselves, the Dems point to the many times the Republicans have used the legislative tactic of reconciliation before—the Bush tax cuts, Part D, welfare reform.

They are right. But those were popular bills.

The Dems may be scoring debating points but instead what the voters I talk to see is a demonstration of political arrogance—not a health care legislative process.

The Democratic logic is that they have already voted for it so they might as well put a finished product on the table for people to appreciate on Election Day.

But the problem with that logic is that the the bill’s real benefits—eliminating pre-existing conditions and medical underwriting as well as the subsidies to buy insurance—don’t start until 2014.

What voters, particularly the swing independent voters, now see is not a health care bill but political arrogance—and that is really the issue Democrats are going to have to deal with.

What I think this is finally going to come down to is a few House Democrats putting their finger in the air to see which direction the political wind is blowing from. It's pretty clear to me there will be a gale force wind blowing from the direction of "no."

Why Rush Vendor Certification of EHR Technologies?

Why Rush Vendor Certification of EHR Technologies?

by DAVID C. KIBBE and BRIAN KLEPPER

A surprise move by ONC/HHS indicates the wheels may be falling off health IT reform at about the same rate they've fallen off Democrats' broader health reforms.

David Blumenthal and his staff have unveiled two separate plans to test and certify EHR technology products and services. We don't think this is a good idea. We've supported the purpose and spirit of the ARRA/HITECH incentive programs, and believe ONC's/HHS' re-definition of EHR technology puts it on a trajectory to improve the quality and efficiency of health care in the U.S. But this recently-announced two-stage EHR technology certification plan bears all the marks of a hastily drawn up blueprint that, if rushed into production, could easily collapse of its own bureaucratic weight.

The new Proposed Rule puts vendors through the wringer, twice. As defined by ONC, vendors with "complete EHRs" and those with "EHR modules" will have to find an "ONC-approved testing and certification body" (ONC-ATCB) that will take them through a "temporary certification program" from now until end of 2011. Then in 2012, under a "permanent certification program," they'll have to switch over to a National Voluntary Laboratory Accreditation Program (NVLAP)-accredited testing body for testing, after which they must seek an "ONC-approved certification body" (ONC-ACB, not to be confused with ONC-ATCB) that can provide certification. The ONC-ATCB will be accredited by ONC, but the ONC-ACBs will be accredited by an "ONC-approved accreditor" (ONC-AA).

Confused? This is just the start. We can't imagine many federal agency Notices of Proposed Rule Making (NPRM) that have created, in a single document, more new acronyms. And the prose in the document can challenge even the most focused minds. For example, the drafters of the NPRM recognize that things could get a little complicated, saying:

"Should CMS finalize its proposed staggered approach for meaningful use stages, we recognize that some confusion within the HIT industry may arise during 2013 and 2014 because of this apparent inconsistency and the divergent use of the term “meaningful use.”

But, then they go on to clarify:

"We would anticipate, therefore, that ONC-ACBs would clearly indicate the certification criteria used when certifying Complete EHRs and/or EHR Modules, and identify certifications according to the calendar year and month rather than the meaningful use stage to reflect the currency of the certification criteria against which the Complete EHRs and/or EHR Modules have been certified. Consequently, if an eligible professional or eligible hospital were seeking to obtain a certified Complete EHR or certified EHR Module in 2014, for instance, that eligible professional or eligible hospital would look for Complete EHRs and EHR Modules certified in accordance with certification criteria current in 2014, rather than Complete EHRs and EHR Modules certified as meeting certification criteria intended to support meaningful use Stage 1, Stage 2, or Stage 3. We request comments on ways to ensure greater clarity in the certification of Complete EHRs and EHR Modules."

Got that? Glad they're requesting comments, though we're not sure where to start. The use of the word "staggered" to describe ONC's programs is apt: this new NPRM is going to leave a lot of people staggering, as in punch drunk.

We would like to see ONC and HHS abandon temporary certification in favor of a single, permanent certification process, even if it means delaying testing and certification until mid- or late 2011. The hurry appears to be related to the need to have at least some EHR technology tested and certified by the end of 2010, so at least some physicians and hospitals can meet the meaningful use criteria. That would require them to use "certified EHR technology" by the official start year for the incentive programs, 2011.

But we don't think this timetable makes sense any longer, and the rush may jeopardize the whole program. Between meaningful use, accreditation, testing, and certification, there are simply too many moving parts to implement and coordinate in too short a time.

Delays seem inevitable. For example, we know that the release of the meaningful use final rule will be postponed until early summer and perhaps longer due to the large number of comments received and their implications. A consortium of physician membership groups will soon recommend that the meaningful use criteria be simplified. It also predicts that many small and medium sized medical practices will sit on the sidelines during 2011 and 2012, rather than rush into risky attempts to meet the meaningful use requirements. In addition, CMS has said it won't be ready to accept EHR technology product and service data until 2012, at the earliest. That timeline could be ambitious by about a year.

The ONC/HHS interim final rule (IFR) may have inadvertently caused another kind of delay. It set initial standards and implementation specifications for EHR technology - we applauded this - endorsing a modular EHR technology approach that opens the door to industry innovation. But it will take time for market entrants to bring modules and components to their customers, and perhaps longer to integrate different EHR vendors' modules in plug-and-play fashion. In other words, by opening up the market, ONC/HHS created circumstances that will almost certainly delay the goals it seeks.

So what if, to get the certification process right, ONC were to postpone payments by one year? It would be worth it.

The "permanent certification" plan in this new NPRM is very reasonable. Under it, NIST would be involved in setting up the testing of EHR technology software under the auspices of the National Voluntary Laboratory Accreditation Program. A single accrediting body would be chosen by ONC/HHS to oversee, supervise, and accredit the certification entities, following established international standards, including the International Organization for Standardization's (ISO) standards 17011 and Guide 65, that have guided conformity assessment in numerous industries, and ISO 17025 that is used for assuring quality of testing and calibration laboratories.

So each vendor would follow an orderly progression: first, ensuring that the product meets the technical testing criteria and then, having passed those technical tests, moving on to certification. The stability of this process has much to commend it.

We're not alone in thinking that delaying the EHR incentives start date is a good idea. At a HIMSS session on Monday, March 1, Congressman Tom Price (R-Ga.), an orthopedic surgeon, said that ONC's delay in issuing guidance on the certification process has prompted him to organize Congressional members. They'll send a letter to federal officials asking to postpone the start date for for demonstrating meaningful use to qualify for incentive payments. Price said members of Congress are currently collecting signatures for the letter and could send it to HHS within a week.

David Blumenthal is smart, dedicated, and is hiring many talented, experienced people into ONC. But rushing ARRA/HITECH's policy and statute beyond what is humanly possible could ultimately be at cross-purposes with the very goals they're trying to achieve.

David C. Kibbe, MD, MBA and Brian Klepper, PhD write together about health care technology, innovation, market dynamics, and reform. Their collected writings can be found here.

"What a Disaster Looks Like"

In case you missed Peggy Noonan's column in the WSJ yesterday, let me suggest it is worth your time.

I think she hit the nail on the head:

It is now exactly a year since President Obama unveiled his health care push and his decision to devote his inaugural year to it—his branding year, his first, vivid year.

What a disaster it has been.

At best it was a waste of history's time, a struggle that will not in the end yield something big and helpful but will in fact make future progress more difficult. At worst it may prove to have fatally undermined a new presidency at a time when America desperately needs a successful one.

In terms of policy, his essential mistake was to choose health-care expansion over health-care reform. This at the exact moment voters were growing more anxious about the cost and reach of government. The practical mistake was that he did not include or envelop congressional Republicans from the outset, but handed the bill's creation over to a Democratic Congress that was becoming a runaway train. This at the exact moment Americans were coming to be concerned that Washington was broken, incapable of progress, frozen in partisanship.

You can read her full column here: "What a Disaster Looks Like--ObamaCare Will Have Been a Colossal Waste of Time If We Are Lucky."

After the Failure of Reform

After the Failure of Reform
by
Brian Klepper and David C. Kibbe

The stalemate in the bi-partisan health care summit was cast the moment it was announced. Republicans demanded that the reform process start anew, and Mr. Obama insisted on the Senate bill as the framework going forward. The President may now offer a more modest reform bill that can demonstrate some progress on the health care crisis, but that remains to be seen.

We hoped the White House would seize the opportunity presented by Massachusetts’ election of Scott Brown to begin again, huddling away from the lobbyists to develop a new set of provisions that would include reasonable Republican elements, like medical liability reform, as well as other meaningful cost reduction provisions excluded from the first round of bills: pricing/quality transparency, a move away from fee-for-service reimbursement, and the re-empowerment of primary care.

They took a different path. As Ezra Klein speculated in the Washington Post, Mr. Obama and his advisers may believe that, with the 2010 elections bearing down on Congress, there is too little time to begin again.

But this is a questionable political calculation. The reform process soured the American people and American business on the health care bills. A January 27 Towers Watson/National Business Group on Health (NBGH) survey found that 71% of employers believe the bills "will increase the overall cost of health care services in the United States." A February 11 Rasmussen survey found that 61% of voters think the bills should have been scrapped and the process started over.

And no wonder. Over the past year, the legalized bribery that is special interest lobbying was fully on display, with members of both parties (but led by the Democrats) taking contributors' money with a gusto unprecedented since the Republican feeding frenzy set off by Newt Gingrich's K-Street Project. A new report from the Center for Public Integrity shows that "more than 1,750 companies and organizations hired about 4,525 lobbyists — eight for each member of Congress — to influence health reform bills in 2009." Together, they spent $1.2 billion on health care, more than one-third of the $3.47 billion spent by special interests in 2009 to buy influence over policy.

And then there was the brazen political deal making. Mary Landrieu brought $300 million in federal aid home to Louisiana for voting with the Democratic Leadership, which the GOP promptly dubbed "the Louisiana Purchase." Ben Nelson got the Feds to pay for most of Nebraska's Medicaid expansion...in perpetuity. And, on the eve of the Massachusetts Senatorial election, the White House cut a deal that exempted unions from the tax on "Cadillac health plans" until 2018.

The resulting reform provisions - a cynical combination of expert advice, uncompromising ideology and donor quid pro quos - would have extended entitlements while rescuing the industry at the top of a financial bubble, exacerbating the cost growth problem during a recession by replacing dwindling private funding with public dollars. At the same time, the bills specifically avoided committing to approaches that could wring excessive cost from the system.

In truth, either passing or blocking such poor bills would have had little impact on the increasingly threatening crisis. Short of starting over, American health care will continue to face some very harsh realities. More individual and corporate purchasers, particularly small employers, will be priced out of coverage as health care costs explode. This erosion in mainstream coverage is translating to a reduction in total health plan premium - the engine of the health care economy - and to escalating uncompensated care cost loads throughout the system. A plummeting number of insured patients will find it harder and harder to pay for a rapidly growing number of uninsureds and under-insureds.

These are recipes for instability and disaster. And as health care - the nation's largest economic sector, representing one dollar in six and one job in eleven - becomes increasingly unstable, so does the larger US economy.

Americans are increasingly aware that a government in which both parties are compromised by political ideologies and special interests will likely leave them to their own devices in dealing with health care. American business had, to a great extent, put health care benefits decisions on hold until reform was complete. Now it is resigned to continuing to cope with that burden, but with a renewed commitment to innovation. A February 22nd Towers Watson/NBGH survey found that "83% of companies have already revamped or expect to revamp their health care strategy within the next two years, up from 59% in 2009," a clear sign that businesses now think they need to act on their own behalves. (Of course, most individual Americans don't have that latitude.)

One thing is clear. Without reform as it was constituted and the subsidies it promised, the industry faces an onslaught of actions from the marketplace that will focus on its excesses, drive down reimbursement, and hold it more accountable. A long list of innovations - re-empowered primary care; data collaboratives that identify and then create incentives for making the best choices; new technologies like minimally invasive surgeries, point-of-care testing, and clinical decision support tools; medical tourism; clinical groupware; check lists; Health 2.0 business-to-business ventures that streamline health care processes - are now proving they can improve the quality of care while reducing cost.

The result is inescapable. No system this far out of balance can remain unchanged indefinitely. So long as it was influencing the policy process, the health care industry would never course correct in ways that are in our national interest. But as the environment continues to intensify, the market will be driven to embrace and integrate these solutions. One way or another, the health industry is in for real change over the next few years.

Meanwhile, until America meaningfully addresses cost and access through policy, proper health care will continue to be out of reach to many and will threaten many more with personal financial ruin. It will continue to sap the nation's economic strength, and compromise our efforts to lead and compete internationally.

Which is why the President should begin again, and make achieving serious health care policy reform a dedicated goal. In the process, he could challenge special interest influence over policy, and work to refocus the political process on the common interest. We believe the American people can see how the current paradigm is corroding our nation, and would rally behind this approach. More to the point, this was the premise of Mr. Obama's election. The American mainstream is waiting for him to assert his leadership in this way.

Health care reform has stalled and possibly failed for the moment. But the stakes are so great for America that failure cannot be an option.

Brian Klepper and David C. Kibbe write together on health care reform, market dynamics, innovation and technologies.

Post-Summit Health Reform: What a Mess

Everyone agrees our health care system is unsustainable and too often unfair. At the White House health care summit, that was the only common ground between Democrats and Republicans.

Many Americans are either left-brain liberals or right-brain conservatives, with the remainder somewhere in the middle. These left- and right-brain types look at the same facts but come to different conclusions—no matter what.

This past election, something unique occurred. The independents were so frustrated with the Republicans about the Iraq war, the financial meltdown and the spendthrift ways of Congress that they swept liberals into power and apparently gave them a mandate to pass health care reform.

The liberals set about doing just that. No false advertising was involved—they crafted health care bills consistent with their campaign promises. But when conservatives erupted over the legislation last summer, they reminded many of those independent voters about their more-moderate political instincts.

You can read the rest at Kaiser Health News.

The White House Health Care Summit--Democrats: 0 Republicans: 0 -- The Republicans Win

There is politics and there is policy.

On the policy front what we saw today was the same exchange of the old talking points we have watched for a longtime. No progress was made toward any kind of health care bill. That is no surprise--this was never going to be the place to fashion any kind of compromise.

At the end the President asked the Republicans if it was worth it to spend another month or six weeks trying to come to some agreement. I am glad he did that. I am not optimistic but a "yes" from the Republicans would be the right answer for the country.

On the political front this was a win for Republicans because it was a draw. Granted, they have a very thin health care agenda but all they had to do was hold their own over the course of the day. Politically, if not on policy, they did that. No minds were changed in the room and likely none out in the country. The left will still say get on with passing this, those on right will say kill it, and the majority of critical swing voters will still be concerned that the Democratic bills are going too far too fast in the face of the Great Recession. This is the biggest reason I don't hold out a lot of hope there will be a lot of Republican willingness to come to the table--at least before the November elections.

Ironically, this "bipartisan summit" may have just increased the political cynicism in the country because it went off so predictably.

Most importantly, I don't see the President and the Democratic leadership having accomplished their real goal: To "stiffen the spines" of the moderate Democratic votes they need to ram their health care agenda through using reconciliation rules.

A week from now, I expect the polls will still show only about the same 40% approval rating for the Democratic health care agenda and the moderate Democrats won't have the political cover they need to vote for a reconciliation strategy.

Unless the President gets a positive response from the Republicans on his offer to spend a few weeks trying for a bipartisan bill, it will be on to "Plan B" for the Democrats.

Recent post regarding "Plan B":
Obama to Uneasy Democrats: Please Walk the Plank for Me But If It Doesn't Work Out Here's Plan B

Live Blogging During the Health Care Summit

I am blogging live with a number of others at the NewsHour site.

Obama to Uneasy Democrats: Please Walk the Plank for Me But If It Doesn't Work Out Here's Plan B

The President and the Democratic leadership have been pushing hard on the idea that the Democrats should ram their unpopular health care bill through by using reconciliation--no matter how many Democrats in swing districts lose their jobs over it this November.

But Laura Meckler had an important story in the Wall Street Journal yesterday that is bound to give many of the nervous moderate Democrats some real insecurity about walking that plank for their leader:

President Barack Obama will use a bipartisan summit Thursday to push for sweeping health-care legislation, but if that fails to generate enough support the White House has prepared the outlines of a more modest plan.

His leading alternate approach would provide health insurance to perhaps 15 million Americans, about half what the comprehensive bill would cover, according to two people familiar with the planning.

It would do that by requiring insurance companies to allow people up to 26 years old to stay on their parents' health plans, and by modestly expanding two federal-state health programs, Medicaid and the Children's Health Insurance Program, one person said. The cost to the federal government would be about one-fourth the price tag for the broader effort, which the White House has said would cost about $950 billion over 10 years.

Officials cautioned that no final decisions had been made but said the smaller plan's outlines are in place in case the larger plan fails.

So much for all of this confidence they have the votes to pass their big health care bill.

The President’s Health Care Plan—Not a Game Changer

It is hard to see how the health care plan the President released this morning changes anything.

There is nothing new in it save a health insurance rate regulatory board that is an awkward political proposal at best. What powers would it really have and how would it operate in conjunction with the states already charged with insurance company oversight are just two of the first questions it does not answer.

Fundamentally, what good would insurance rate regulation do if the President’s plan has only tepid cost containment built into it in the first place?

There are not the votes in the House right now to pass this new proposal—or the Senate bill. There are not likely even the votes in the Senate under a 51-vote rule for the President's new plan.

That could change if the President scores a game changer on Thursday at Blair House that finally moves the polls from the 40% approval rating Democrats have had on health care to something over 50%.

But there is nothing in the White House health care proposal that was released this morning that will do that.

If the President thinks he can do it alone on the back of his “communication skills” then all the adulation on the part of his supporters, like his Nobel Peace Prize, has gone to his head.

If Obama wants to score a real game changer on Thursday, when the Republicans call for starting over on health care, I will suggest, the President ought to say, “Deal.” Then call on the Republicans to join he and the Democratic leadership in 60 days of intensive negotiations to get a bipartisan deal. That would really put the Republicans on the spot—and Democrats as well.

If what both sides want is bipartisan health care reform then what they should be agreeing to do is achieve that in a time certain with no preconditions on the table.

Then let’s see who comes to the table in good faith.

The outcome of that exercise, successful or not, would give us a real health care issue to take to the polls in November.

Wellpoint and Their “39%” Rate Increase

Wellpoint is getting killed in the press over a “39%” rate increase for their individual health insurance block in California.

HHS Secretary Sebelius has pointed to the Wellpoint individual rate increases demanding an explanation. The President even brought it up in his interview on Sunday. At a time Democrats are fond of calling insurance executives “villains” this story just adds more fuel to the fire.

No less than five reporters have called me in the last day asking me to explain it all.

Falling back on my industry experience it is probable:

• The “39%” headline is anecdotally the biggest increase the press has found—the average is probably less albeit in the high 20% range.
• This is likely driven by a combination of increasing medical cost trend, a bad economy, and anti-selection as healthier people disproportionately drop their coverage leaving a sicker group in the pool.
• The rate increase is probably “defensible,” at least actuarially, based upon the actual experience in that block.

When the day is done this probably says more about why systemic health care reform is so critical than about any one company’s behavior. Last week we heard national health care spending skyrocketed to 17.3% of the economy. This is a real life example of what that macroeconomic statistic really means.

But I am not about to defend Wellpoint having been burned once. A few years ago Lisa Girion of the Los Angeles Times called me to say Wellpoint was retroactively rescinding health insurance policies for inadvertent and immaterial mistakes people had made on their health insurance applications. Falling back on my years of industry experience, I said that couldn’t be true—only the sleazy insurers pulled that sort of thing, Blue Cross of California would never do that.

Of course, Lisa was right and it was the beginning of the California rescission controversy. Not what I would call the best example of public relations at a time the country was debating the industry’s future.

So, what Wellpoint needs to do, and do yesterday, about these increases is to be transparent. Put all of the facts on the table.

Is this another symptom of a health care system run amuck or the actions of a “villainous” insurance company?

Just what is it that Wellpoint is waiting for?

****

Update

Perhaps this is what they were waiting for. Here's what happens when you stand there like a deer in the headlights and let events take over.

From the LA Times today:

Congress opened an investigation Tuesday into Anthem Blue Cross' rate increases in California as President Obama cited the company's premium hikes -- some as high as 39% -- in his bid to pass national healthcare legislation.

The House Committee on Energy and Commerce and its Subcommittee on Oversight and Investigations announced they are examining the increases, which are set to take effect March 1. Anthem is the state's largest for-profit insurer and a unit of Indianapolis health insurance giant Wellpoint Inc.

Committee Chairman Rep. Henry Waxman (D-Beverly Hills) and subcommittee Chairman Rep. Bart Stupak (D-Mich) asked WellPoint's chief executive, Angela F. Braly, to appear at a Feb. 24 hearing of the subcommittee in Washington. They requested that she provide a detailed explanation of the reasons for the rate increases, which have enraged policyholders.

The Health Care Summit—Who’s Gonna Win the Photo-Op?

Getting Democrats and Republicans to constructively engage on health care is the best way to make progress.

To date, the Democrats have blown health care reform once again by being too arrogant in thinking they could just ram their version through.

The Republicans have no health care proposal. Their “black book” list of ideas they handed the President in Baltimore is a collection of second and third tier proposals at best.

So, what is the Blair House meeting about?

Well, I am not optimistic that it will be about real bipartisanship and a good will attempt to change the game.

It will more likely end up being an opportunity for each side to simply continue the petty bickering and once again try to convince a majority of voters their ideas really aren’t so bad.

Obama hopes his health care details will finally appeal to viewers as they realize he holds the only real plan. The problem with that logic is that the Democratic health care reform “well” has already been irretrievably “poisoned”.

The Republicans would like voters to believe their list of ideas will appeal to voters but the reality is that all of the attention they will now get will likely lead to a consensus, particularly among independent observers, that the Republicans, save for their tort reform proposals, aren’t holding any real cards.

I doubt either side will end up winners here.

The Democrats will only reinforce the sense they just don’t get it and Republicans will continue to come across looking like they think voters have forgotten that they were the bums who lost the last two elections.

When the day is done, I will suggest the Republicans are right about this: They all need to start over.

When Baucus and Grassley were in the midst of their Senate Finance negotiations last summer, I said I didn’t see them being able to accomplish anything—not because they couldn’t have. To me, the real problem was that the talks were taking place at the far out edges—left and right. Republicans were being told that bipartisanship was the same thing as capitulation—“Our bill is the only way.”

Republicans, including the Republican members of the “gang of six” in Finance last summer, had and have no plan. But, in Finance, they were quite willing to agree to a far-reaching bill that would have covered tens of millions of those presently uninsured. Things got a lot closer than most people realize. I do think the Democrats can eventually—although not likely in this election year—bring lots of Republicans onboard a new initiative that first takes the current bills off the table.

Real bipartisanship will occur when both sides find common ground in the middle and begin to work their way as far out toward both the left and right as they can and still hold the needed votes. It is about starting in the middle where they agree.

It's my sense that Blair House will be about the same old here’s my plan and if you want to be bipartisan you will come on board with my ideas. It will not be middle-out and it will fail to jumpstart anything for that reason.

Presuming that is the Obama strategy, the best thing the Republicans could do is call for new negotiations with no preconditions and let the Democrats just continue defending the plan that has already been roundly rejected.

They really do have to scrap it all and start over.

A Way Out of the Health Care Wilderness?

I just came across an interview that I will suggest we all may have missed and perhaps charts the way out of this health care reform wilderness we now seem to be in.

It was on February 2nd and was between the Washington Post’s Ezra Klein and rising Republican House star Paul Ryan (WI).

Ezra asked Ryan about the bipartisan Wyden-Bennett bill as a place for both sides to find common ground. It’s a bill that blends the Democratic notion that everyone needs to be covered sooner rather than later with the Republican idea that we use tax credits to make people better consumers. And, the bill pays for itself on the front-end.

Ryan responded, “I have a lot of respect for that plan. If I were a Democrat, it’s the bill I’d be on. He’s got more mandates than I’d like. But if Ron Wyden and I were in a room, we could hammer out a deal by tomorrow.”

“If Ron Wyden and I were in a room, we could hammer out a deal by tomorrow”?

Well if all you guys need is a room there are plenty of those on Capitol Hill.

I suggest Ron Wyden give Paul Ryan a call and get to it!

“Plan B” Has Begun

With word that the House is likely to take up the repeal of the health insurance industry anti-trust exemption it is now clear the Democratic leadership has begun Plan B.

It is also clear that this is much more a part of a political Kabuki dance then any substantive effort at even piecemeal health care reform.

The House probably has the votes to pass the repeal. The Senate does not. I doubt that even all of the 59 Senate Democrats will vote for it if and when it does come up on the floor of the Senate.

The base of the Democratic Party, as well as many “progressive” Dems in the House and Senate, are rabidly mad about not being able to ram their health care bill through. That is why you continue to hear all of the talk about reconciliation options even though there is no chance such a scheme would pass either the House or Senate.

But what to do?

The apparent answer is to bring up a few smaller health care bills the Democratic leadership views as popular back home and expect the Republicans will vote against them. Right now health care is a big negative issue for the Dems given the unpopularity of their effort to date. But if they can be seen trying to pass a few smaller measures “we can all agree on” only to be thwarted by Republican opposition their hope is they can turn the table on this issue to their advantage—well before they get to November.

Interesting politics but no hope for any real progress while these games play out.

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When the Democrats say they believe they can still pass a health care bill are they bluffing? That's my opinion.

Here is a first rate story from Politico on their options and the dismal political reality each faces.

Friday in Baltimore--The Way to Actually Accomplish Something

Intentionally or unintentionally, my sense is that the White House came out of Baltimore thinking they are now on to something, and I hope the Republicans took the same lesson away.

Constructive good faith political engagement in Washington actually works.

It is just incredible that House Minority Leader John Boehner has had not direct contact with the White House for about a year. A pox on both their houses for that. The party leadership never talks to each other--save being across the table from one another on talk shows. The two sides just level charges and counter charges at each other apparently never caring whether they actually accomplish some good policy for the rest of us.

But a funny thing happened in the midst of Friday's photo-op meeting between the President and the Republican House caucus. Good faith, an airing of ideas, and a mutual respect of each other's views actually resulted in both a political coup for both sides and some very first level progress on important issues--not the least was health care.

Can you believe it? Good manners and good intentions actually have a political value!

I will suggest that the next best step is for the President to take the lead in inviting the Republican and Democratic leadership to the White House on a regular basis in an attempt to broker some real progress on the important issues. If the President wants to turn his job approval ratings around that kind of good faith leadership would take them to the stratosphere.

I am not suggesting that the very thin Republican "play book" has any big ideas for health care reform. But I do believe that many of the Democratic ideas to cover 30 million people could be embraced by lots of Republicans if the two sides could show each other some respect and not just try to jam the majorities' ideological ideas (Republican or Democratic) down the other's throat. It wouldn't also hurt the Democrats to concede some points to the Republicans.

As bad as the left has been recently in thinking they were just going to ram a health care bill their way because of the results of the last election, I saw the right do exactly the same thing when they had control in recent years. (Remember the Republican chairman of the House Ways and Means Committee who tried to get the minority Democrats arrested for boycotting a meeting?) That kind of "take no prisoners" approach to government is what is really at the heart of gridlock while the country just continues to drift downward.

Worst case, if we did see a real effort and it eventually broke down, the side that would lose would be the side that didn't behave themselves. Now that would be a political outcome we could all live with.

The State of the Union--The President Came to a Fork in the Road and He Took It

As Yogi Berra said, "When you come to a fork in the road, take it."

The President came to a fork in the road tonight on health care reform. Would he do what many liberals have demanded--push harder to pass the Democratic health care bills? Or, do as many moderate Dems and some Republicans have called for--work to get a smaller but bipartisan health care bill?

Listening to his speech he seems to be taking both forks.

Continue pushing the Democratic plans: "As temperatures cool, I want everyone to take another look at the plan we’ve proposed. There’s a reason why many doctors, nurses, and health care experts who know our system best consider this approach a vast improvement over the status quo."

Looking for a bipartisan approach: "But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know. Here’s what I ask of Congress, though: Do not walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people."

The President came to that fork in the road tonight and instead of giving the Congress a clear sense of where he was willing to put his remaining political capital he just took it.

Is he willing to put his Congressional majorities on the line in an election year to keep pushing for the now unpopular health care bills? Or, is he willing to put his political capital on the line in an effort to pull the far left in his own party to the center and call the Republicans out on their offer of bipartisanship in order to produce a modest bill?

In the wake of the President's State of the Union Address, we have no better idea just where he wants to lead his party, the entire Congress, or the country on health care reform.

Plan B—There Isn’t One—But There Could Be

As the State of the Union approaches Democrats are considering their health care policy options. There are lots of reports about “Plan B”—pushing through the Senate bill with a parallel corrections bill that could be passed in the Senate using reconciliation rules.

That’s as dead as the original House and Senate health care bills. Moderate Democrats have no stomach for such a legislative stunt in the face of Massachusetts and bad health care polls. Many liberals even question that strategy.

Everyone is awaiting this week’s State of the Union speech. Will the President:

1. Embrace the call by many on the left to Democrat-up and just ram it through?
2. Call for a scaled back bill built around modest and popular first steps that could attract bipartisan support?
3. Just jabber in a way no one can figure out which course he really supports?

My bet is on number three.

As I have said before, I think getting even a modest bill is a long shot in this election year but it is not impossible.

I like the idea of focusing on tax credits for small business as a first priority more than trying to help the individual market. The small group market is guarantee issue and government tax credits have the impact of encouraging matching funds—government money would encourage employer contributions making coverage even more affordable for the uninsured.

Add to that a modest Medicaid expansion, the albeit tepid cost containment parts of the current bills such as the pilot programs and giving CMS more authority to implement them, modest insurance reforms like ending rescission and funding for high risk pools, proving good faith with Republicans by including tort reform, and we have a bipartisan down payment on health reform.

Democrats need to erase the bad taste voters so far have for their dead health care efforts. They could do that with this kind of modest first step health care bill. Republicans also have something to prove on health care—the Democratic problems shouldn’t be confused with any sense on the part of voters that Republicans have yet to make any constructive contribution to this debate.

In my mind, the smart political move for Democrats is to call the Republicans out on their offers to be bipartisan by putting a deal on the table Republicans couldn’t refuse.

If the Republicans take the offer, the Democrats can get beyond the health care political mess they are in. If the Republicans don’t, the Dems have the leverage they need to turn the tables on the Republicans before the November elections.

They could also, coincidentally, actually help out a few million people.

Lots of folks think there is no chance anything positive can now come out of this poisoned political environment.

I am not so cynical.

A Smaller Bipartisan Health Bill? What It Could Look Like

In the wake of the Massachusetts vote, Democrats are scrambling to find a way out of the health care political mess they are in.

Right now they are in a daze standing by waiting to see if any of the "trial balloons" they have launched gain any traction. So far, ideas to ram though the now toxic Senate bill in the House in one parliamentary form or another are falling flat.

Last night, the President formally launched one of his own trial balloons--doing some kind of a scaled back bipartisan bill.

The problem with bipartisanship now is that the Republican base is not about to let any of their own Senators do anything to take the Dems off the political meat hook they are now dangling from.

Democrats could well try to create a very popular stripped down health bill with a win-win objective--if it passes they are off the hook and have something to take to the November elections and if Republicans block it they have themselves an issue on which they can try to neutralize the Republicans.

But that sounds great in principle--health care details are always problematic.

What follows is a post that I did the day after Barack Obama was elected President. In it I suggested a modest bipartisan bill was the only thing I could see passing in 2009--or 2010 for that matter.

You will note that suggestion #1 has already been accomplished--as well as some positive health IT steps.

From Wednesday, November 5, 2008:

There is Now a Real Bipartisan Opportunity in Health Care

President-Elect Obama, and about every candidate for Congress, has said he wants to change the partisan tone in Washington. Obama, the Democratic Congressional leadership, and the Republicans have a terrific opportunity to do just that on health care when they all come to Washington early next year.

As I posted earlier, I do not believe there is any chance we can see the enactment of the comprehensive Obama health plan in the near term.

But there are a number of important steps that can be taken next year and each of them have enjoyed strong bipartisan support during the past year:

1. Reauthorizing the State Children's Health Insurance Plan (SCHIP) and increasing the number of kids covered from six million to ten million. The Congress passed exactly that kind of reauthorization twice by strong bipartisan margins only to come a few votes short of being able to override two Bush vetoes of the bill. Those attempts met pay-as-you-go requirements by boosting the cigarette tax to pay for it.
2. Rearranging Medicare spending by equalizing the payments private Medicare plans get with the payments the traditional Medicare plan receives for the same seniors. The Medicare physicians face a 21% fee cut on January 1, 2010 and there are other serious cost issues for Medicare. In July, the Congress took the first step toward payment equalization with a veto proof margin of 70-26 in the Senate and 383-41 in the House. The really hard part here is crafting a new Medicare physician payment system that is desperately needed but the first step, where to get the money, has strong bipartisan support.
3. John McCain and Barack Obama had a number of similar and relatively non-controversial cost containment ideas in their health plans which would cost the federal government little or nothing. These similar proposals included the expansion of health information technology and a patient medical record; improving transparency about health care quality and costs including prices, errors, staffing ratios, infection rates, and disparities in care and costs; wellness initiatives including an emphasis on healthy lifestyles; development of best practice standards, requirements for disease management programs; requiring effectiveness reviews for procedures, devices, and drugs; and requiring providers to collect and report data to ensure standards for health quality are followed.
4. There is bipartisan support for assisting small business in providing and paying for health insurance. In 1999, 56% of employers with 3-9 workers provided health insurance to their workers. By 2007, that had dropped to 45%. By contrast, employers with more than 200 workers provide health insurance 99% of the time. The one place employer-provided health insurance is melting away is in the small employer area. A modest bill to assist the small employer enjoys support among both Republicans and Democrats.

A big $100 billion [per year] comprehensive health care reform plan like the Obama health plan is not realistic in these times of financial crisis.

But, there is already bipartisan support for a children's health insurance (SCHIP) extension and the means to pay for it, reform of Medicare provider payments and the means to pay for that, a list of commonly agreed to cost containment initiatives that would cost the government little or nothing, and bipartisan support for help to the small employer to offer health insurance.

To be sure these steps would only make a dent in the number of those uninsured and these bipartisan cost containment items will only help our cost problem around the edges.

But all of these bipartisan steps would be progress, are doable, and are affordable.

President-Elect Obama and the Democratic leadership can do what the last two Presidents did--promise bipartisanship and then quickly employ the same old partisanship out of the mistaken belief they had the majorities in Congress that would enable them to steamroll the opposition. That mistake led to the 1994 Republican takeover of the Congress in the first case and two straight election defeats, in 2006 and 2008, in the second.

President-Elect Obama, the Democratic leadership, and the Republicans have the road map at hand to truly show a bipartisan commitment to health care change and progress. They could actually break the gridlock on health care and make some modest progress.

Will they take the road less traveled or just give us more of the same?

Stick a Fork in It! The Democratic Effort to Pass a Health Bill is Dead

Tuesday’s Republican victory in Massachusetts means the current Democratic health care bills will not be on the President’s desk in 2010.

Forget the crazy talk of ramming something through—including just having the House pass the pending Senate bill.

I’ve talked to lots of people in the past few months that didn’t like the Democratic effort but conceded that the Dems won the 2008 election on a platform to do health care their way. They would say, “elections matter” and could, albeit begrudgingly, understand Democratic attempts to pass their brand of health care.

But losing Ted Kennedy’s former seat in Massachusetts with the singular issue being health care?

The game has changed. Democrats just can’t any longer spin the polls that for months have been so negative on the Democratic health care efforts.

The conclusion is now crystal clear—the people don’t want this. For goodness sakes—they rejected it in Massachusetts! On the political shocker scale this rivals “Dewey Defeats Truman” and the '94 elections.

When Bill Clinton lost the '94 elections, he went before the press the next day and took responsibility for what happened and then spent the next two years successfully rebuilding his presidency.

Obama and the Democratic leadership really only have that course in front of them now.

Defying the American people at this point with these foolish hypotheticals about how they could still thwart the obvious will of the people and pass their bill would only result in their digging themselves into an exponentially deeper political hole.

I am not sure Reid, Pelosi, and Emanuel understand this—they have proven to be incredibly politically tone deaf all winter.

But I will tell you something you can take to the bank—a lot of their House and Senate moderate Democrats do understand what this means and you can expect them to begin moving off these bills in the next 24 to 72 hours. A trickle will lead to a stampede and that will be it.

There will be no interest in staying aboard the kamikaze flight Reid and Pelosi are now piloting straight into the 2010 elections.

In the end, this was 1994 all over again. The Democrats thought they could unilaterally do health care their way and blew it just the way they did 15 years ago--out of pure political arrogance.

Let me repeat something I must have said on this blog a hundred times—health care is too big an issue to be done in any way other than a bipartisan fashion. One side simply can’t move something this big, complex, and controversial without lots of political cover from the other side. This bunch, to their peril, never understood the lesson that both Social Security and Medicare were passed by comfortable bipartisan margins.

There is no doubt in my mind that there were at least 10 Republican Senators that were ready to deal in good faith on this issue—the “gang of six” plus the Republicans who had signed on to the Wyden-Bennett bill, for example.

But when Max Baucus was given the opportunity to try for a bipartisan solution, his hands were tied—bipartisanship was defined as Republicans having to sign-on to the Democratic bills their leadership and the left wing of the party were overly confident they could pass on their own.

Health care is an easy issue to demagogue. The opposition will always do it. Republicans, including these ten Senators, did a lot of it the past few weeks. That is why the opposition needed to be neutralized in the first place with real bipartisan support.

As readers of this blog know, I have been pessimistic about this effort for more than a year. But, today I also believe there is a way to pass a substantial bipartisan health care bill that would cover at least 30 million people, reform the insurance markets very much like the Democratic bills would have, and begin a process of real systemic change. I also believe that can happen in the next couple of years. It could all be in place by the same 2014 date the Democrats had in their bill.

But for now, the overly confident and unwilling to compromise Democrats blew it again.

With their solid majorities and popular new President, whom else do they have to blame?

The only way for them to make this election-year mess worse would be to ram their bill through. There are lots of Republicans in this town secretly hoping they will at least try!

The Silver Lining in the Massachusetts Vote

The Silver Lining

by Brian Klepper and David C. Kibbe

Massachusetts voters' stunning rejection of Democrat Martha Coakley, in favor of a not-very-impressive Scott Brown, should be exactly the splash of cold water that the Democratic party - and Congress as a whole - needed. The defeat can be understood in two ways: one large and one fairly small.

First, the large one. This will probably send reform back to the drawing board. Health care is too much in crisis and too pressing to be pushed completely off the table until certain issues - including both access AND cost - are addressed.

Second, this election marks the loss of a single critical Senate seat, but it is also very loud warning shot. The mandate received at the end of 2008 was a resounding call to throw out the Republicans who for more than a decade had ridden roughshod over American values. Yesterday, the Democrats, in one of their most secure strongholds, received the same message. Whatever people in DC think, rank-and-file Americans - not those on the right or left, but the swing voters in the middle who actually determine election results - are very unhappy with the gaming that's been vividly displayed over the last year under the guise of health care reform.

The distaste expressed yesterday probably has little to do with the specific provisions of the bills, except for the largest generalities: that they expand coverage while avoiding a commitment to changes that could significantly reduce cost. But along the way, voters have witnessed -- with an immediacy and transparency that has only been available as a result of the Web -- lawmaking in its worst tradition. There was the White House's deal making with powerful corporate interests like the drug manufacturers even before the proceedings began. And the tremendous lobbying contributions by health care and non-health care special interests in exchange for access to the policy-shaping process. Or the outright bribery of specific Senators and Representatives in exchange for votes. Last week's White House deal with the unions that exempted them from the tax on "Cadillac" health plans until 2018 must have seemed like a perfectly OK arrangement to the people in the center of all this activity, but to normal people who read the paper, it was emblematic of the current modus operandi: If you have power and support the party in power's muddled agenda, you get a special deal.

The most tempting mistake now for the Democrats would be to dig in. President Obama's most appealing characteristic -- the one that got him elected -- was his embrace, his embodiment even, of approaches that would revise the traditional kinds of politics we've seen for the last year throughout the health care reform process. Of late, the most telling complaint about this Presidency so far has been disappointment that, once in office, he seemed to cave in so easily.

Undoubtedly, many Republicans are now rejoicing over the Democrats' loss and the possible defeat of any health care reform legislation. That's unfortunate. The health care crisis is real and remains unaddressed. The pressures it creates, particularly for powerful interests like business, will force Congress to return to it and develop meaningful solutions. Hopefully (though probably unlikely), Congress and particularly the Democrats, will be chastened and wiser. There's a big opportunity here to make lemonade.

There is a new, bipartisan movement in Congress, highlighted on NPR two weeks ago, that would revisit the rules around the relationships between special interests and lawmakers. This is an issue that trumps and is more important than all others, because if every policy is ultimately shaped by those with enough money to buy Congress' favor, then our democracy will be unable to hold.

The silver lining in yesterday's election was that it was a mild, if critical, reminder that, whatever DC thinks, America's center is just as displeased with the current governance as it was with its predecessors. Faced with a much larger rejection in the 1994 elections, President Clinton went on TV, took full responsibility, and then spent his time rebuilding. The good news is that today is a new day, and that, if they're interested in what's good for America over the long term rather than simply themselves over the short term, Congress has the ability to start again in ways that could please the American people and actually work to our collective advantage.

Brian Klepper and David C. Kibbe write together about health care technology, market dynamics and reform.