James Pethokoukis

Politics and policy from inside Washington

More on where healthcare reform is heading …

Jul 28, 2009 15:23 UTC

From superanalyst Dan Clifton of Strategas Research:

Should the Senate Finance Committee reach an agreement, the plan will likely take the form of an $800bn package inclusive of: a) an individual mandate; b) an employer mandate and a state based cooperative; c) insurance reforms such as guaranteed issue and community rating; d) a health insurance exchange subsidized up to 300 pct. of the poverty limit; and, e) an expansion of Medicaid in the range of 125 to 133 pct. of the poverty line. Notes – The health insurance exchange (part d) and the expansion of Medicaid (part e) are key to getting coverage, but also carry the highest cost – rendering them vulnerable to potential delays in program and eligibility implementation.

Healthcare endgame on Capitol Hill

Jul 28, 2009 14:54 UTC

A Capitol Hill source tells me that a public healthcare option is dead, dead, dead in the Senate and thus dead overall. While some healthcare reform proponents hope to use the August recess to rally support, more likely it will be that the Dems will be telling the troops and interest groups that if you want some kind of healthcare bill, give up pushing for a public option. At this point, it is a waste of time, energy and money. But this does not mean Dems still might not push through some pretty big changes. As another source put it:

We might end up seeing something similar to what we chatted about before (individual mandate, highly regulated insurance market, major subsidies).  I see this as mostly a symbolic victory, as the Dems can get most of what they want without calling it a public option, frankly. Pretty close (to the Massachusetts model), I’d assume.


Um, the government (ie: congress) does NOT have a “public healthcare” or a “public plan”. Congress gets their insurance through PRIVATE insurance companies, in a co-op, hence it’s less expensive. That is what the Rebuplicans are currently suggesting, giving the American public EXACTLY THE SAME benefits as they currently enjoy!!!

Posted by Tania | Report as abusive

Healthcare reform has to pass because … because … well, it just has to is all!

Jul 24, 2009 19:40 UTC

Ezra Klein does his gosh-darned best to help restore momentum to healthcare reform, which he is sure people will love to bits if only it passes:

Democrats know full well that there are two plausible outcomes to the health-care reform process. Health-care reform will fail, dealing a huge blow to the Democratic Party and giving Republicans tremendous momentum as we enter the 2010 campaign season. Or health-care reform will pass, and Democrats will criss-cross the country touting the largest legislative accomplishment in decades. Republicans may still attack them on the plan. But attacking a historic legislative success is a whole lot harder than attacking a historic legislative failure. Republicans know that, which is why they want to kill the bill. Democrats know it too, which is why they won’t let them.


lol, keep on reaching there ezra…. Too bad they see it as just a political matter.

Posted by jason | Report as abusive

GOP healthcare alternative? It’s pretty flawed, too

Jul 24, 2009 17:54 UTC

Ugh. So House GOPers have put out their alternative to ObamaCare. It’s really more of a statement of principles with a few numbers. Yes, it is  a good idea to level the playing field between those who get their insurance through their employers and those who buy it on their own. But this is the part that put me back on me heels:

Strengthens employer-provided health coverage by helping the 10 million uninsured Americans who are eligible, but not enrolled in, an employer-sponsored plan get health care coverage. The plan does this by encouraging employers to move to opt-out, rather than opt-in rules.

Employer-based covering should be scrapped, not strenghthened. (In fact, doing so really is key to reform.)  The great Arnold Kling gives five good reasons why:

  • The cost of health insurance is disguised from consumers, because firms do not report what they pay in premiums. Workers are under the illusion that their health coverage is inexpensive, and if they subsequently find themselves having to obtain their own health insurance, they are offended by the cost and instead choose to go uninsured.
  • Workers who are concerned about the availability of health insurance may suffer from “job lock.” They might wish to leave their job for self-employment, pursuit of formal education, an opportunity with a smaller firm, or early retirement, but the potential loss of health insurance is a deterrent.
  • Workers may not enjoy the range of insurance choices that they would have if health insurance were not negotiated for them by employers. For example, if they could choose their own insurance, some workers might elect coverage with higher co-pays and deductibles but lower premiums, in order to have more cash income.
  • Because employer-provided health insurance is subsidized through the tax system, the benefits accrue relatively more to high-income workers.
  • Workers who are fired or laid off can find themselves without health insurance at a point where they can least afford to be uninsured.

    A tax incentive to have some sort of medicial saving plan
    could make the diffrence…Save more early for old age. 401k for medicial? I see it as a way to phase out social security and reduce our dependance on goverment and vica versa. Insurance could come down like car insurance. Parents would cover their kids at birth so no prexisting conditions, even better before conception. Still didn’t see anything about tort reform..NO plan can work without that!

    Posted by Tom | Report as abusive

    Public doesn’t like direction of ObamaCare

    Jul 24, 2009 11:26 UTC

    Why is Obama suddenly talking a lot more about healthcare costs? (And maybe he should do something more akin to a PowerPoint presentation when talking about this stuff. Remember those old Ross Perot presidential campaign commercials where he used charts?) Maybe because of this (from the WSJ):


    The Reid/Obama healthcare conundrum

    Jul 23, 2009 19:47 UTC

    Good point from Marc Ambinder:

    We know how Senate Majority Leader Harry Reid is going to spend his recess: he has to figure out how to match the Senate HELP Committee’s plans for health insurance reform with what the Senate Finance Committee is willing to pay.  …  In announcing that the Senate simply could not come to an agreement before the recess, Reid is acknowledging that the Finance Committee’s draft, which is due on the floor before the recess, isn’t going to pay for everything the HELP Committee wants. … Reid made this news on the day after the President explicitly defended his timeline and gave what he considered to be the best argument in favor of reform. The message: you didn’t help us last night, Mr. President.  …  Nothing will doom the chances for health care reform more than the perception that health care is doomed.


    Sorry, Mr Pethokoukis, but this particular health care “reform” needs to be doomed. It needs to have a stake driven through its heart, salt poured in its mouth and its head cut off and buried separately. Nothing less.

    Posted by Kyda Sylvester | Report as abusive

    What Obama forgot to talk about last night

    Jul 23, 2009 17:17 UTC

    Obama presented a false choice last night, either the status quo or Obamacare. But what about empowering consumers and letting markets work? A great post from the Health Care Blog makes some great points on this very issue. It looks at two fictional familes and shows how each deals with three different medical problems —  back pain, chest pain and dementia? The Smiths are passive and rely on the doctor while the Joneses aggessivey reserach their problems and question authority. Here is one example:

    When Sam Smith’s back pain flared at age 45, he was quick to accept his doctor’s recommendation for an MRI and a visit to an orthopedic specialist to make sure it wasn’t serious. The MRI showed a possible cause of the pain and (just to be sure) Sam had surgery the following week, marveling at the efficiency of the system. The cost: about $40,000 for surgery, hospital, physician care and rehab.

    When Jay Jones, also age 45, had an identical bout of back pain he reviewed a back surgery decision aid on the Web—even before his first visit. He learned that back surgery is not usually needed or always successful. For him the case for surgery was not very strong.

    When his doctor recommended an MRI, Jay pointed out that a decision aid helped him learn that 50 percent of back pain cases go away in four weeks, 90 percent in six months, and only 10 percent of back pain cases need surgery. Jay also learned that MRI reports often find things that can lead to surgery even though they were not the cause of the pain. With that information he asked if he might put off the MRI and the surgery while he determined if his back would get better on its own—it did. The cost: $150 for the office call and $12 for the over-the-counter medications. Back surgery is among the most overprescribed treatments.

    How to get more Smith families to act like Jones families, as well further empowering the Joneses. Some recommendations:

    Supporting the Joneses

    Job 1 is to help the Joneses succeed in their efforts by giving them evidence-based, easy –to-use decision aids and self-management guides to implement three basic rules:

    • The Self-Care Rule: Help people do as much for themselves as they possibly can. With the right tools we have become our own travel agents, bankers and investment counselors. We create our own Websites and edit our own movies. Rule #1 would bring that same innovation to health care.
    • The Guidelines Rule: Help people ask for the care they need. Too often in health care there is a gap between what we know works and what we do. On average, people with chronic disease get only about half of the care they should. Conversely, we are often suggested expensive and invasive treatments when simpler treatments do just as well or even better. By giving patients easy-to-read versions of the same medical guidelines their doctors use, they can ask for and get the care they need.
    • The Patient Choice Rule: Help people say “no” to recommended care that is not likely to improve their lives. With the benefit of good information people should be able to decline duplicative or overly expensive testing, unnecessary drugs or surgeries not likely to make a positive difference in their lives—particularly in the last years of life.

    All three rules can be implemented quickly and effectively by implementing patient facing “meaningful use” requirements for electronic medical records and by expanding MyMedicare.gov into a virtual health home.

    Motivating the Smiths

    The second task is to motivate the Smiths to become more engaged in their own healthcare by offering economic and structural incentives to them and to those who serve them.

    • Reduce co-pays for services that prevent complications.
    • Reduce co-pays or premiums for people who use patient decision aids.

    The self-care rule: I once had the recurrence of an infection for which the standard of care is immediate treatment with antibiotics. But it was a weekend and I didn’t want to go to the ER for a non-emergency. Since the symptoms are quite uncomfortable, I hit the Web to see what I could do to alleviate them until that Monday. The first website I happened to hit was British. It said the condition should resolve itself in a couple of days. It advised treating the symptoms and if it didn’t resolve in a few days, see the doctor for antibiotics. It also told how to create an “unfriendly” environment for the bacteria. (All the American websites said the same thing: see a doctor immediately for treatment with antibiotics.) I then called my pharmacist who said he’d have the palliatives waiting for me. I followed the Brit’s advice and the infection was gone within 48 hours.

    My telling of this little anecdote does not mean I necessarily endorse Mr. Pethokoukis’ proposals, but this is exactly the kind of conversation we should be having right now (and good luck finding any sign of it in the legislation wending its way through Congress). I, too, am a big fan of the HSA model. Most of the time, all the majority of us need are the services of a nurse practitioner or even a physician assistant (I use them whenever possible and I have great insurance). We’ve known for years that we’ve been over-using and abusing antibiotics, as well as any number of other drugs. We need to find ways to stop our abuse of the system that fall well short of having government dictate to us.

    Every segment of the health care industry, including we the consumers of health care, is responsible for the mess we find ourselves in, but IMO none more than the government. I find it ludicrous that the same government now considers itself the solution.

    Posted by Kyda Sylvester | Report as abusive

    Why Obama might have just killed Obamacare

    Jul 23, 2009 16:19 UTC

    If President Obama’s prime-time speech and news conference were intended to push national healthcare reform over the political goal line, then the effort almost certainly failed. Do more Americans today better understand the still-evolving plans floating around Capitol Hill than they did yesterday? Unlikely.

    Take the idea of a health insurance exchange, a feature found in all the Democratic congressional plans. Obama described it as a “marketplace that promotes choice and competition,” as if it were a healthcare version of eBay. Actually, the exchanges would be a government regulatory mechanism that could severely limit consumer choice. Or maybe not. In any case, there are few outside of Washington think tanks who have any idea this idea would work in practice across the country.

    Nor was the president clear about the exact role of the government in a changed healthcare delivery system. Although Obama said any bill he signs would “keep government out of health care decisions,” the whole point of Obamacare is to use government to transform how doctor’s provide service by altering incentives.

    Now maybe it would be a nudge — to use the language of behavioral economists — from Washington rather than a shove, but few non-experts have any sense of how a typical doctor visit might change. Sure, having a physician prescribe a cheaper blue pill rather than a pricier red pill if they both work the same is a no brainer. But what if the red pill is pricier, no more effective but has fewer nasty side effects like nausea? Or what if the red pill is 40 percent more effective but costs 80 percent more? Who is going to make the red pill-blue pill decision?

    But Obama really wasn’t giving a closing argument as to why his plan would be the right solution to America’s healthcare problems. Instead, lackluster public interest in the issue — at least as compared with the recession and rising unemployment — led him to spend considerable time explaining yet again why reform is needed and needed now.  Ideally, as the White House sees things, the public would have already accepted its narrative that a) Team Obama stabilized the bad economy it inherited, b) although economy is slowly mending it will take time for the jobs to appear, and c) so while we’re waiting, let’s fix healthcare. But Obama probably didn’t help himself by burying his most powerful argument for middle-class voters with health insurance — that rising healthcare costs prevent bigger wage increases.

    Then again, maybe the president’s real problem boils down to his apparent belief in the false choice he presented: “You know, just a broader point, if somebody told you that there is a plan out there that is guaranteed to double your health care costs over the next 10 years, that’s guaranteed to result in more Americans losing their health care and that is by far the biggest contributor to our federal deficit, I think most people would be opposed to that. Well, that’s status quo. … So if we don’t change, we can’t expect a different result.”

    Yet it might not be a case of Americans being too comfortable with the status quo as much as it is one of Americans being extremely uncomfortable with Obama’s version of a new status quo.

    So was the president successful in getting out his message? Here’s one bad sign: The top morning news shows led not with healthcare but with Obama’s slam against police officers that arrested his friend and college professor Henry Louis Gates Jr. With Congress stymied and public interest waning, a muddled message means a lost opportunity for Obama and healthcare reform.


    The present form of Health Care proposed by the Obama administration contains regulations that state when a person reaches sixty-five or older, rather then be given adequate health care, they will be consuled on why they would be better off not accepting any further medical help. Instead they will be advised to accept letting nature take it’s course and to die peacully without being a burden to the health care system. If that is not sinister, I don’t know what is.

    Posted by gwobama | Report as abusive

    Did Obama help or hurt himself with press conference?

    Jul 23, 2009 15:31 UTC

    I will be posting my column soon, but if you want to know what the rest of the MSM thinks, MSNBC’s Howard Fineman is a good stand-in:

    I’ve been covering Barack Obama for a few years, and it’s usually crystal clear what he is up to. Not last night. This is the first time I’ve asked myself: What was THAT all about? His prime time press conference was worse than a waste of time. … The president — who seemed tired and distracted and clearly in need of a vacation (dealing with health care will do to you) — pretty much just stood there for an hour, filibustering his way through non-answers and recycling old patches of rhetoric. It was like the old Muhammad Ali “rope-a-dope” — except that this bout didn’t end with the champ springing to life and knocking out his arm-weary foe. This time, the champ just left the ring. … Does all this mean that health-care reform is dead or near death? No … [but] if the president wants real system-wide reform … last night he wasn’t any close to his goal.


    “filibustering his way through non-answers and recycling old patches of rhetoric.”

    Sounds like a description of his entire campaign. When did you start paying attention?

    Posted by George Roberts | Report as abusive

    Paging Alan Frumin! Why reconcilliation may be no Dem silver bullet for healthcare reform

    Jul 22, 2009 20:44 UTC

    Trying to push healthcare reform through the Senate (via the reconcilliation process) with just 51 votes is problematic at best for the Dems. This, from my pal Rich Lowry:

    Just talked to Sen. Judd Gregg, who has taken a preliminary look at how much of a health-care bill could be moved through the budget reconciliation process in the Senate, thus making it unnecessary to get 60 votes. He thinks big parts of it won’t qualify. This involves parliamentary arcana, so bear with me. The Byrd rule determining what qualifies for reconciliation says, among other things, that a provision must have more than a merely incidental budgetary impact, i.e. it has to be a real budgetary measure and not a policy change that you hope to hustle through reconciliation just because it’s easier. Looking at the Kennedy bill as a test case, Gregg thinks the public option clearly wouldn’t meet this test. It’s essentially a policy event, not a budget event. Neither would the so-called “gateways” or exchanges, the insurance market reforms (guaranteed issue, etc.), or the 84 new authorized programs in the bill. What most obviously meet the test are the tax increases and the Medicare cuts. Ultimately, the Senate parliamentarian makes the call. But it’s clear that reconciliation isn’t the simple expedient for pushing through health-care legislation that some are portraying it to be.

    Me: The Senate parlimentarian is Alan Frumin. Here is a bit on him from The Hill:

    Frumin was criticized in 2003, first by Republicans after he ruled that they couldn’t use reconciliation rules to consider a $350 billion tax cut bill. A few weeks later, he piqued Democrats by dismissing as out of order several of their amendments to a Defense Department authorization  bill.

    Frumin, who normally sits below the presiding officer on the Senate dais, has worked in the parliamentarian’s office since 1977. He went to college at Colgate, has a law degree from Georgetown and has co-authored a book on Senate rules.

    Budget experts believe Frumin can take the heat.

    “He’s known for being substantively rigorous and he understands the value of precedent,” said Stan Collender, a partner at Qorvis Communications and a former Democratic budget aide. “He’s not likely to just come up with a ruling that’s completely off the wall. He’s known to do his job really well and tries to call it pretty straight.”