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The headline story in the June 28, 2010 issue of the Kansas City Star, by Dave Helling and Steve Kraske, is “Mailings turn aggressive”. It is about direct mail campaigns by those seeking elective office, how they have become a major part of the campaigning, and how the content is almost entirely negative – and sometimes hard to believe. For example, a state legislator running for Congress has a mailer attacking his primary opponent as a “Nancy Pelosi Democrat”, although the only obvious similarity this “staunch conservative” former legislator has with Ms. Pelosi is that they are both women.
The more interesting aspect is not the attack aspect of the ads, but that most of the non-attack “positive” campaigning, touting the candidates’ strengths and thus implicitly responding to attacks, is (among Republicans) to emphasize their negativity. Jerry Moran, a Republican congressman from Kansas’ “Big First” district is running against Todd Tiahrt, congressman from the 4th district (Wichita), for the Senate seat of Sam Brownback (who is odds-on favorite to be our next governor). Both have essentially the same, straight-down-the-Republican-line voting record, but Tiahrt has accused Moran of being less conservative. A recent Moran ad indicates that he fights for Kansas and then lists all the things he has opposed – which is essentially everything that the Obama administration has done. Moran is a nice, personable man and presumably has some good positive ideas, but apparently in the campaign it is not cost effective to promote them. (Note that the Tiahrt campaign takes the same tack, except when attacking Moran for not being conservative enough.) In the Republican primary proudly embracing charter membership in the “Party of NO” is apparently the name of the game, It is possible that in some parts of the country, candidates in the general election will feel pressure to say what they are for, but only if absolutely necessary. In Kansas, where the Republican nominee is pretty much guaranteed victory in most venues, it probably won’t.
In a recent article in Health Affairs, “The political challenges that may undermine health reform”[1], Theda Skocpol ties some of these trends to the future implementation of health reform. She accepts that there will be Republican gains, but also discusses the ways in which Democrats will likely respond, hoping to blunt those gains and prevent a complete Republican takeover of Congress. In its absence, she notes it is likely that most of the part’s of PPACA will be implemented, slowly and quietly, although some of the parts most likely to engage support (elimination of discrimination against those with pre-existing conditions on the individual market and allowing children to stay on their parents’ policies until 26) are front-loaded, going into effect this year. Among the most interesting things she says (to me, a non-political scientist), is that “Political scientists have long know that Americans are what is called ‘operational liberals’; they like specific government benefits. Yet these same Americans are also ideologically conservative, when arguments about government versus the free marked are posed in general rhetorical terms.”
Actually, this makes it almost sound like Americans are “operationally selfish”. Indeed there are many who are, like the family physician I knew in Texas who would mostly rant against the liberals in Washington and the need to elect more conservative Texans, until, in a cost-saving measure pushed through by those fiscal conservatives, the government delayed sending out Medicare payments to physicians. That was intolerable to him! Dr. Skocpol continues: “That is why we will see Republicans doing all they can to keep the argument at the systemic level through early 2012, when they hope to elect a president who will support repeal or make fundamental changes in the 2010 legislation.” No question that arguing against Big Government is going to win more votes than opposing Medicare, or Social Security. And few of the reliably conservative Republican farmers in Kansas (or elsewhere) are going to be won over by arguments against agricultural subsidies. In Missouri, which has more Democrats than Kansas but has a legislature controlled by Republicans, a statewide referendum is about to take place which would prohibit the federal government from forcing people to purchase health insurance. It is being sold with “freedom” arguments, and might well be unconstitutional, but it will be interesting to see how people vote. When turnout is light, the poor and uninsured are less likely to turn out than those who, like the bill’s legislative sponsors, already have insurance; in particular older voters, already receiving Big Government Socialized Medicine Medicare are likely to vote.
While there is much to criticize in PPACA (done very well by John Geyman, “Hijacked: Stolen health care reform V” in the Huffington Post), there is definitely some good. The insurance companies have backed off their threats to not cover people (or at least children) with pre-existing condition, suggesting that people will begin to see some real benefits. The real issue is seen in Dr. Skocpol’s final sentence, above; the Republicans are running on general conservative principles, but should they gain power they will implement a very anti-regular-people agenda, as was done under the Bush administration. This is not limited to health care; while “everyone” (me, for sure!) hates the bankers who brought on the financial crisis (see Maureen Dowd in the NY Times, July 28, 2010: “Washington gave the Wall Street banks billions, and, in return, they stabbed us in the back, handing out a fortune in bonuses to the grifters who almost wrecked our economy”), the Republican party leadership, far from punishing them or reining them in, has tried to block legislation that would even gently restrict their most outrageous activities.
If we are lucky, maybe voters in Missouri and in other places will show that “operational liberals” who “like specific government benefits” are not all like that Texas doctor, and will also support specific benefits that help others. We have seen many polls showing that a majority of Americans favor universal health care even for all, so the sense of common purpose is not dead. Maybe they won’t, but we can hope.
[1] Health Affairs, July 2010; 29(7):1289-91.
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Showing posts with label Moran. Show all posts
Showing posts with label Moran. Show all posts
Wednesday, July 28, 2010
Monday, September 21, 2009
Medicare for All: Moran's logic, not the idea, is flawed
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I recently received an email from one of our Kansas Congressmen, Jerry Moran, Republican from the First District that covers essentially the western 2/3 of the state. (He is not my congressman, who is Blue Dog Democrat Dennis Moore, but we are a small state in terms of population with only 4 congressmen, and I get emails from many of them. Plus Rep. Moran is one of two Republican congressmen from Kansas running to succeed Sen. Sam Brownback who is resigning to become – the result is foreordained – our next Governor.) The email contained the text of an editorial that Rep. Moran posted on his website http://www.jerrymoran.house.gov/index.php?option=com_content&task=view&id=1524&Itemid=103 to explain why he did not think that expanding Medicare to cover everyone, as has been advocated by many, including myself, was a good plan for health reform. Unsurprisingly, the title was “A Medicare-Type Public Option Does Not Make Sense”.
Rep. Moran acknowledges that “This idea is supported by some in Washington and, at first glance, may appear appealing to many. Certainly, this idea seems easier to understand than other proposals that are being pushed in our nation’s capital and in the media.” He is a thoughtful man, not a reflex yahoo. He then goes on to give four reasons why it is a bad idea, and that he does “…not see how this plan will protect and enhance care for Kansans.” His four points are:
“Medicare is going bankrupt – The Medicare trust fund that pays for inpatient hospital stays is currently paying out more in benefits than it is collecting through payroll taxes. As a result, this fund is expected to go bankrupt in 2017, just eight years from now. Additionally, Medicare faces overall shortfalls of nearly $38 trillion, nearly three times current GDP levels…
Providers suffer major losses treating Medicare patients – Kansas health care providers and hospitals operate on razor-thin margins because they are drastically underpaid by Medicare. When Medicare underpays doctors and hospitals, the cost is shifted to private insurers. The average family in a private PPO health plan pays an additional $1,788 a year to compensate for Medicare underpayments. If these rates were expanded to those who currently have private insurance, many Kansas hospitals would be forced to close their doors and access to doctors and nurses in the state would be further limited.
Current Medicare fraud is staggering – According to the FBI, Medicare and Medicaid lose an estimated $60 billion or more annually to fraud. This amount equals 10% of all health spending in the U.S. Congress needs to address this problem in Medicare and Medicaid before creating a massive new program that would be susceptible to the same fraud.
Medicare regulations are a mess – The morass of regulations governing Medicare prevents progress and impedes doctors, nurses, and other providers from efficiently caring for patients...Bureaucrats in Washington set Medicare payment rates for providers and hospitals and these rates are so low that many doctors refuse to see Medicare patients. An expansion of this regulatory mess will lead to fewer providers and diminished health care access for Kansans.”
I had to write back and comment that these arguments, too, have pretty major flaws. They fall into three major categories:
First, misunderstanding (or misrepresenting) the source of the high cost of health care.
It is sick people who cost money. This is why, as I have pointed out, the key issues of health reform is so difficult to "sell" to most people, who are not (currently) really sick. The cost of what is perceived as “health problems” by the young, healthy journalists and Congressional aides -- colds, checkups, rotator cuffs, meniscuses, blood pressure checks – is essentially rounding error in the cost of health care. What costs money are the sick people -- the elderly who have multiple diseases and require mutliple hospitalizations, people with cancer, babies in neonatal intensive care, multiple trauma victims from car accidents. 5% of the people account for 55% of health costs; 10% for 70%. More than 50% of the people all together are about 3%. That is why insurance companies make money by underwriting -- insuring the healthy, disenrolling (or excluding, or sending to Medicare) the sick. Most of the people who cost the most are already in Medicare. The rest of us would cost much less per capita.
If everyone was in Medicare, we'd have one system to pay our health bills, and Moran’s first issue could be addressed because all health care $ now spent by employers would go into the pool, while the sickest people are already in the pool, so the marginal cost of putting everyone else in would be must less than the income.
The second flaw is that his argument, in both his second and fourth point, is that providers are unhappy with how much (or little) Medicare pays and how complex their regulations are. On the other hand, his third point attacks providers (presumably the same group) because of the massive amount of “fraud” they are perpetrating on the Medicare system. You can’t have it both ways unless you can be sure that the “fraud-meisters” (presuming there really is extensive fraud) are not the same ones, doctors and hospitals, who are making the complaints you validate in points two and four. And there is no way to do that. The answer for these two points is the same as for #1 – with everyone in the same system we could increase our payments for certain services in Medicare. And, of course, not pay more, or even pay less, for certain other services. By having the one payer, we could make policy that says we are going to pay for what we value (e.g., primary care) and not for excessive technological interventions that are not needed.
The third issue, fraud, mentioned above, is arguable. Much of what the government calls fraud is unintentional incorrect billing. To the extent that there are providers -- the same providers the Congressman worries about underpaying in the second point – who are committing fraud, this needs to be addressed, and would be able to be more thoroughly address with a single source of payment. Does Rep. Moran think no one commits fraud against private insurers? Certainly those private insurers would not agree!
The third flaw is in Rep. Moran’s fourth point regarding complex Medicare regulations. Boy, are they ever! But so are – even more so – those of private insurers. And the problem is made many times worse because of the plethora of different insurers, all with their own rules and regulations, and indeed with the same insurer having different rules for different people in different plans or employed by different companies. Cleaning up the Medicare regulatory complexity is important, but could be done by the government. If we had everyone in Medicare, it would be all cleaned up. If we continue to have multiple private insurers, it will stay a mess anyway. And blaming “bureaucrats” for low Medicare payments is at best disingenuous; Medicare pays what Congress will support. If Congress wants to pay more, they can appropriate more, at least for Part B and D. And this argument runs absolutely counter to the first, which is that Medicare is going broke. It sure isn’t from lack of parsimonious administration.
Rep. Moran concludes by saying “Medicare guarantees health care for seniors. But, what good does it do to have an insurance card if there is no doctor, nurse, or hospital to provide care? Instead of expanding Medicare, Congress should address Medicare’s current challenges and consider common-sense reforms to make quality coverage more affordable and more accessible for Americans. Medicare cannot pay all of its bills now and the problems will be exponentially magnified if it is expanded to include an additional 114 million Americans.”
Congress should address Medicare’s current challenges, and the most effective way to do so would be to put the other (?114 million) Americans into it. This would dilute the number of sick people already in the program with the younger and healthier, support the program financially with the current employer contributions now going to private insurers, and, most importantly, put all of us in the same plan together, all of us concerned about how well it works and how it spends its money.
Because, Congressman, we really are all in it together.
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I recently received an email from one of our Kansas Congressmen, Jerry Moran, Republican from the First District that covers essentially the western 2/3 of the state. (He is not my congressman, who is Blue Dog Democrat Dennis Moore, but we are a small state in terms of population with only 4 congressmen, and I get emails from many of them. Plus Rep. Moran is one of two Republican congressmen from Kansas running to succeed Sen. Sam Brownback who is resigning to become – the result is foreordained – our next Governor.) The email contained the text of an editorial that Rep. Moran posted on his website http://www.jerrymoran.house.gov/index.php?option=com_content&task=view&id=1524&Itemid=103 to explain why he did not think that expanding Medicare to cover everyone, as has been advocated by many, including myself, was a good plan for health reform. Unsurprisingly, the title was “A Medicare-Type Public Option Does Not Make Sense”.
Rep. Moran acknowledges that “This idea is supported by some in Washington and, at first glance, may appear appealing to many. Certainly, this idea seems easier to understand than other proposals that are being pushed in our nation’s capital and in the media.” He is a thoughtful man, not a reflex yahoo. He then goes on to give four reasons why it is a bad idea, and that he does “…not see how this plan will protect and enhance care for Kansans.” His four points are:
“Medicare is going bankrupt – The Medicare trust fund that pays for inpatient hospital stays is currently paying out more in benefits than it is collecting through payroll taxes. As a result, this fund is expected to go bankrupt in 2017, just eight years from now. Additionally, Medicare faces overall shortfalls of nearly $38 trillion, nearly three times current GDP levels…
Providers suffer major losses treating Medicare patients – Kansas health care providers and hospitals operate on razor-thin margins because they are drastically underpaid by Medicare. When Medicare underpays doctors and hospitals, the cost is shifted to private insurers. The average family in a private PPO health plan pays an additional $1,788 a year to compensate for Medicare underpayments. If these rates were expanded to those who currently have private insurance, many Kansas hospitals would be forced to close their doors and access to doctors and nurses in the state would be further limited.
Current Medicare fraud is staggering – According to the FBI, Medicare and Medicaid lose an estimated $60 billion or more annually to fraud. This amount equals 10% of all health spending in the U.S. Congress needs to address this problem in Medicare and Medicaid before creating a massive new program that would be susceptible to the same fraud.
Medicare regulations are a mess – The morass of regulations governing Medicare prevents progress and impedes doctors, nurses, and other providers from efficiently caring for patients...Bureaucrats in Washington set Medicare payment rates for providers and hospitals and these rates are so low that many doctors refuse to see Medicare patients. An expansion of this regulatory mess will lead to fewer providers and diminished health care access for Kansans.”
I had to write back and comment that these arguments, too, have pretty major flaws. They fall into three major categories:
First, misunderstanding (or misrepresenting) the source of the high cost of health care.
It is sick people who cost money. This is why, as I have pointed out, the key issues of health reform is so difficult to "sell" to most people, who are not (currently) really sick. The cost of what is perceived as “health problems” by the young, healthy journalists and Congressional aides -- colds, checkups, rotator cuffs, meniscuses, blood pressure checks – is essentially rounding error in the cost of health care. What costs money are the sick people -- the elderly who have multiple diseases and require mutliple hospitalizations, people with cancer, babies in neonatal intensive care, multiple trauma victims from car accidents. 5% of the people account for 55% of health costs; 10% for 70%. More than 50% of the people all together are about 3%. That is why insurance companies make money by underwriting -- insuring the healthy, disenrolling (or excluding, or sending to Medicare) the sick. Most of the people who cost the most are already in Medicare. The rest of us would cost much less per capita.
If everyone was in Medicare, we'd have one system to pay our health bills, and Moran’s first issue could be addressed because all health care $ now spent by employers would go into the pool, while the sickest people are already in the pool, so the marginal cost of putting everyone else in would be must less than the income.
The second flaw is that his argument, in both his second and fourth point, is that providers are unhappy with how much (or little) Medicare pays and how complex their regulations are. On the other hand, his third point attacks providers (presumably the same group) because of the massive amount of “fraud” they are perpetrating on the Medicare system. You can’t have it both ways unless you can be sure that the “fraud-meisters” (presuming there really is extensive fraud) are not the same ones, doctors and hospitals, who are making the complaints you validate in points two and four. And there is no way to do that. The answer for these two points is the same as for #1 – with everyone in the same system we could increase our payments for certain services in Medicare. And, of course, not pay more, or even pay less, for certain other services. By having the one payer, we could make policy that says we are going to pay for what we value (e.g., primary care) and not for excessive technological interventions that are not needed.
The third issue, fraud, mentioned above, is arguable. Much of what the government calls fraud is unintentional incorrect billing. To the extent that there are providers -- the same providers the Congressman worries about underpaying in the second point – who are committing fraud, this needs to be addressed, and would be able to be more thoroughly address with a single source of payment. Does Rep. Moran think no one commits fraud against private insurers? Certainly those private insurers would not agree!
The third flaw is in Rep. Moran’s fourth point regarding complex Medicare regulations. Boy, are they ever! But so are – even more so – those of private insurers. And the problem is made many times worse because of the plethora of different insurers, all with their own rules and regulations, and indeed with the same insurer having different rules for different people in different plans or employed by different companies. Cleaning up the Medicare regulatory complexity is important, but could be done by the government. If we had everyone in Medicare, it would be all cleaned up. If we continue to have multiple private insurers, it will stay a mess anyway. And blaming “bureaucrats” for low Medicare payments is at best disingenuous; Medicare pays what Congress will support. If Congress wants to pay more, they can appropriate more, at least for Part B and D. And this argument runs absolutely counter to the first, which is that Medicare is going broke. It sure isn’t from lack of parsimonious administration.
Rep. Moran concludes by saying “Medicare guarantees health care for seniors. But, what good does it do to have an insurance card if there is no doctor, nurse, or hospital to provide care? Instead of expanding Medicare, Congress should address Medicare’s current challenges and consider common-sense reforms to make quality coverage more affordable and more accessible for Americans. Medicare cannot pay all of its bills now and the problems will be exponentially magnified if it is expanded to include an additional 114 million Americans.”
Congress should address Medicare’s current challenges, and the most effective way to do so would be to put the other (?114 million) Americans into it. This would dilute the number of sick people already in the program with the younger and healthier, support the program financially with the current employer contributions now going to private insurers, and, most importantly, put all of us in the same plan together, all of us concerned about how well it works and how it spends its money.
Because, Congressman, we really are all in it together.
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