Map of life expectancy at birth from Global Education Project.

Friday, June 19, 2009

The Defeatocrats Writhe Again

So the CBO tells the Senate Finance Committee their health care reform bill will cost $1.6 trillion, so Chairman Max Baucus immediately decides he needs to scale the bill back so it will cost less. "[The bill] included an array of coverage provisions that were drastically scaled back from earlier versions, as lawmakers seek to shrink the bill's overall cost. The proposal, for instance, would reduce the pool of middle-class beneficiaries eligible for a new tax credit meant to make insurance more affordable. The absence of a "public option" marks perhaps the most significant omission. Obama and many Democrats had sought a public option to ensure affordable, universal coverage, but as many as 10 Senate Democrats have protested the idea as unfair to private insurers."

Baucus met with several Republicans in order to craft a bill that would be acceptable to them, and this appears to be his trial balloon.

The Senate Democrats are fools, when it comes to public policy, and when it comes to politics.

Public Policy: The way to save money is not to scale reform back and do less: the way to save money is to do have more radical reform. Dartmouth University -- you know, that commie college in the People's Republic of New Hampshire -- has for two decades kept careful track of patterns of health care spending in the U.S. Not that the Senators who are writing the "reform" legislation would ever bother to inform themselves about anything so effete as actual facts, but it turns out there are huge variations in patterns of medical spending around the U.S., with no perceivable relationship to people's health or medical outcomes. "[Physicians] in higher-spending regions . . . were much more likely than those in lower-spending regions to recommend discretionary services, such as referral to a subspecialist for typical gastroesophageal reflux or stable angina or, in another vignette, hospital admission for an 85-year-old patient with an exacerbation of end-stage congestive heart failure. And they were three times as likely to admit the latter patient directly to an intensive care unit and 30% less likely to discuss palliative care with the patient and family." But wait, there's more:

[I]n regions where there are more hospital beds per capita, patients will be more likely to be admitted to the hospital—and Medicare will spend more on hospital care. In regions where there are more intensive care unit beds, more patients will be cared for in the ICU—and Medicare will spend more on ICU care. And the more CT scanners are available, the more CT scans patients will receive. Conversely, in regions where there are relatively fewer medical resources, patients
get less care—and Medicare spends less. So geography becomes destiny for Medicare patients.

Using more resources and spending more money would not be controversial if it produced better health care or better outcomes. So the critical question underlying the variations in practice and spending is: What is the relationship between quantity
and quality? Over the past ten years, a number of studies have explored the relationship between higher spending and the quality and outcomes of care. The findings are remarkably consistent: higher spending does not result in better quality of care, whether one looks at the technical quality and reliability of
hospital or ambulatory care, or survival following such serious conditions as a
heart attack or hip fracture.

So if you want to save money, don't cover fewer people -- STOP WASTING MONEY! Will the AMA like that? No. Will the drug companies like it? No. Will the medical device manufacturers like it? No.

And suprisingly, perhaps, the insurance companies won't even like it. Sure, they spend more for many patients than they have to, but they just charge higher premiums and work harder to keep sicker people off their books in order to keep their profits high. If they tried to compete by constraining physicians from providing wasteful services, the doctors and hospitals would just stop taking their insurance, and they'd be out of business. So they're in this thing together. Actually solving this problem will require taking control of their business -- which also contains another tempting target for cost savings, that 25% or so they spend on marketing, denying benefits not because the proposed services are wasteful but because the people have pre-existing conditions, kicking sick people off their roles, paying huge executive salaries, and delivering profits to their owners.

So that public option would indeed be unfair to the insurance companies. Of course, in order to make it work, you'd have to do what the AMA absolutely loathes, and that is require doctors to accept it. That way, it can require them to follow evidence based guidelines. The publicly sponsored plan will accept everybody and it won't have profits, executive salaries, or underwriting expenses. Over time, it will make the insurance companies go away. Too bad. Bye bye.

Politics: The overwhelming majority of Americans want meaningful reform. They even want universal, comprehensive, single payer national health care. If some people right now are afraid of it or are inclined against it, they'll change their minds and like it after all when it works, just like the people in Europe like what they've got. Ergo, if you were for it, and the Republicans were against it, you will get all the credit and they will get none.

Why, then, is it necessary to have a bill that they will accept so that they can share the credit? And that's assuming there is any credit, because a half-assed bill won't work, and the people won't like it, and then you will get the blame. The Republicans will get much less of the blame because the whole thing was your idea, you just dragged them along and they did their best to water it down, or else just think how much worse off we'd be.

The Democrats do not need one single Republican vote to pass meaningful, progressive health care reform. So why grovel for their approval? It's insane. Screw 'em.

Update: From CQ, via Kos:

Senate Finance Chairman Max Baucus of Montana plans to take a break from the grind of crafting a health care overhaul to serve as a Democratic rainmaker with a few of his friends along the Madison, Gallatin and Yellowstone rivers in the Treasure State this weekend.

Lobbyists and political supporters will get their chance to cast fishing lines and drive golf balls with the Senate's top tax writer at his Fly-Fishing & Golfing in Big Sky event. The cost is $2,500 per person, $5,000 for a political action committee. And for the same price, more fun lies ahead at Camp Baucus, the summer camp he holds for friends and their families in his home state between July 31 and Aug. 2. . . . Baucus brushed aside . . .criticism. "There's no problem. I've been doing these events for more than 10 years," he said. Baucus said he did not know how many contributors would be attending.

Res ipsa loquitur.


robin andrea said...

I have been writing and calling my senators and representative. I wrote the White House yesterday, and I faxed them a letter. I'm furious. This really isn't about appeasing the freakin' republicans, it's about our elected representatives being bought and paid for by the health care industry. Our voices and votes don't matter.

Anonymous said...

Is there any way to force the folks in Congress to be covered themselves by the weakest aspect of whatever plan they pass? Maybe by the pressure of public opinion? It seems like that might help them focus their minds on what is really needed.

Cervantes said...

Yes, you could exclude them from the Federal Employees Health Benefits program and force them to buy non-group insurance on the open market.

That would be a neat trick but of course they'd have to vote to do that so it doesn't seem very promising.

kathy a. said...

i hope this fight is just starting. robin, you inspired me to a few letters myself.

it kind of sucks that this is happening right in the middle of the economic meltdown, when people are worried about more jobs being lost. but on the other hand -- maybe this is the perfect time for a health care slugfest. there is a *lot* of public sentiment against waste and against the unfairness of huge corporate profits at the expense of everyone else.

kathy a. said...

i don't even have words for your update, cervantes. if i had $2500 burning a hole in my pocket, there are thousands of places i'd feel better spending it.