Speech Before the Radiologists
Posted on April 20, 2009Health Care Reform: Putting it all in Perspective
Thank you for this invitation.
Many years ago, my cousin married a radiologist.
Nice guy. Conservative Republican, so I like him.
Smart guy too. In fact, a couple of years ago, he told me to start buying gold.
Wish I had listened to him.
I understand that as a group, like my cousin, you have a lot of interests outside the field of medicine.
But there is no better time to be coming to Washington for a provider group than right now.
Our new President, Mr. Obama, has taken the advice of the famous architect Daniel Burham. He has made no little plans.
He has called for the complete restructuring of education in this country. He is pushing to restructure our energy industry. He promises to tackle the looming problem of entitlements. He wants to raise taxes on the rich and give money to the poor (and middle class). He, of course, wants to restructure the banking and investment industries.
He has even weighed in on the College Football bowl system.
And, last, but certainly not least, he wants to fundamentally change the way we deliver health care in this country.
Looking at the Obama plan, it all sounds so simple:
• Require insurance companies to cover pre-existing conditions.
• Create a new Small Business Health Tax Credit to help small businesses provide affordable health insurance to their employees.
• Lower costs for businesses by covering a portion of the catastrophic health costs they pay in return for lower premiums for employees.
• Prevent insurers from overcharging doctors for their malpractice insurance and invest in proven strategies to reduce preventable medical errors.
• Make employer contributions more fair by requiring large employers that do not offer coverage or make a meaningful contribution to the cost of quality health coverage for their employees to contribute a percentage of payroll toward the costs of their employees health care.
• Establish a National Health Insurance Exchange with a range of private insurance options as well as a new public plan based on benefits available to members of Congress that will allow individuals and small businesses to buy affordable health coverage.
• Ensure everyone who needs it will receive a tax credit for their premiums.
• Reduce Costs and Save a Typical American Family up to $2,500 as reforms phase in:
• Lower drug costs by allowing the importation of safe medicines from other developed countries, increasing the use of generic drugs in public programs and taking on drug companies that block cheaper generic medicines from the market
• Require hospitals to collect and report health care cost and quality data
• Reduce the costs of catastrophic illnesses for employers and their employees.
• Reform the insurance market to increase competition by taking on anticompetitive activity that drives up prices without improving quality of care.
And how does he pay for it?
By really socking it to folks who make more than $250,000 a year.
But this is not the first time that a new President has offered a bold new plan to reform health care.
As part of his Square Deal program, Teddy Roosevelt, the man who preached the doctrine “walk softly and carry and big stick”, promised universal health care. But when he ran on such a plank in 1912, he lost.
Roosevelt got his inspiration from, of all people, Otto Von Bismark.
Bismark, famous for uniting Germany with blood and iron, pushed for universal health care, not because he was a liberal, but because, as a conservative, he thought it would keep the masses from revolution.
Widespread employer-based health care started in the United States during the Second World War.
When Harry Truman tried to change that system shortly after the war, he was beaten soundly by the American Medical Association.
Proponents of universal health care tried a more piecemeal approach for the next couple of decades.
For example, in the 1960’s, they tried to pick off the poor and the elderly by creating Medicaid, a program aimed at those who couldn’t afford any health care, and Medicare, a program for all older Americans.
Bill Clinton made another run at universal health care when he got elected.
I was working for House Minority Leader Bob Michel at the time, and believe me, Republicans were very concerned about how they would counter the President’s wife and his big majorities in the House and the Senate.
As often happens in one government rule, the Democrats over-reached.
Mrs. Clinton created a task-force and then came up with incredibly complex piece of legislation that was easily lampooned by the Republicans.
They were able to work with provider groups and insurance companies to come up with a simple alternative that appealed to moderate and conservative Democrats who didn’t like the heat they were getting from the provider groups, and didn’t especially like Mrs. Clinton.
Amid all of the Democratic scandals in the House, (Dan Rostenkowski etc) the effort collapsed. But the issue didn’t go away.
In fact, my other former boss, Denny Hastert, took health care very seriously, as did Newt Gingrich.
There were two big political causes of the 1990’s, after the Clinton health care debacle. One was health care portability. The other was the famous patient bill of rights.
One was doable. As chief deputy whip, Hastert pushed through what later became known as the Kennedy-Kassenbaum or the HIPPA bill.
HIPPA made it easier to bring your health care with you from one employer to another.
It also made it harder to disclose patient information. I am sure you are all familiar with the paperwork that goes along with HIPPA.
The patient’s bill of rights legislation was aimed at the dreaded HMO’s. I remember when HMO’s were more hated than bankers.
The legislation seemed like a no-brainer. Give patients some rights. Treat them with respect. Give them a choice of plans. Participate in treatment decisions.
But still it collapsed, despite passing both the House and the Senate, mostly because of principled opposition from Republican leaders like Don Nickles and Denny Hastert.
And of course there was the Medicare/Prescription Drug Reform legislation.
I remember when I went to my grandfather’s funeral.
My elderly aunts and uncles all approached me in 1999 and they all asked me a simple question: when am I going to get my drugs for free.
The grass roots on this was very simple: old people wanted drugs.
It was the most difficult vote I have ever seen in my life.
You wouldn’t think spending 400 billion dollars would be that hard. But it was.
Conservatives didn’t want to expand government with a new expensive entitlement.
Democrats didn’t want to give Republicans a victory, especially on an issue as popular as prescription drugs.
And when the vote came on the House floor, it was basically a tie for 3 hours.
3 hours, while opponents scrambled to kill it. 3 hours while proponents scrambled to pass it.
It was brutal on that House floor. But it got done. And it got done because of a rare compromise between the AARP and PHrma.
AARP got what is wanted, which was cheap drugs for its members, subsidized by the government. The Drug Makers got what they wanted, a big new benefit, without price controls.
It was truly a remarkable compromise and an impressive accomplishment.
And it remains a popular program that actually saves lives.
I go through this history because I think it helps put the current debate in some perspective.
Passing universal health care is hard.
If it were easy, it would be done by now.
The President and his team have learned a few things about this process from the Clinton experience.
First, don’t create a huge bureaucracy that will scare the public.
Second, don’t put Hillary Clinton in charge.
Third, have the Hill lead the process, not the Administration.
Fourth, try to get buy-in from the business community.
Fifth, have rich people pay for it all.
All in all, it seems very simple really.
And the Democrats will attempt to do with very little Republican support.
Just as House Republicans didn’t vote for the stimulus or the budget, I doubt very seriously that Nancy Pelosi will go out of her way to get Republicans to support this health care package as it comes out of the House.
The big question is what happens when it comes to the Senate.
Will the Senate attempt to do health care under budget reconciliation, a procedural maneuver that allows it to pass with a simple majority and not a super-majority.
It certainly seems that way, as both the House and Senate included reconciliation instructions in the budget bills that passed their respective bodies.
If they do, then there is no need to be bipartisan.
Screw the Republicans.
But if they screw the Republicans, they lose all of their leverage with their own left wing. And if the left wing insists on things that will hurt the free market and kill jobs – and believe me, they will do that – they risk losing support from not only the business sector, but also from moderate Democrats.
It may seem like this is a done deal politically for the Democrats.
But a look at the polls hints at some reasons why they should overreach.
Let me read from one poll from Kaiser Permanent:
One of the key questions of health care reform is how to pay for it. The survey suggests that, as has long been the case, the public is split down the middle in its willingness to sacrifice financially in order to cover more individuals: roughly half (49%) say they are not willing to pay higher insurance premiums or taxes, while a similar percentage (47%) say they are.
• There are big partisan differences here, with most Democrats (59%) saying they are willing to pay, most Republicans unwilling to pay (67%), and independents divided (49% willing, 47% unwilling).
• When offered a list of potential taxes that could be used to pay for expanding health insurance for the uninsured, the only options with majority support were those likely to impact the fewest people, in particular, smokers and the wealthy. Roughly seven in ten (72%) strongly or somewhat favor increasing the cigarette tax, increasing taxes for people from families earning more than $250,000 per year (70%), or repealing current income tax cuts for those earning more than $250,000 per year (61%).
• The survey also suggests that as in the past early support for a number of reform proposals could fade in the face of arguments that opponents might raise in a public debate. For example, seven in ten Americans (71%) say they favor the idea of employer mandates. But when given the argument often made by critics that this may cause some employers to lay off some workers support falls dramatically, to just under three in ten (29%).
• The same pattern holds on the topic of individual mandates. Roughly two in three (67%) favor requiring all Americans to have health insurance with help for those who could not afford it. When given the criticism that some people may be required to buy health insurance they find too expensive or do not want, support falls to two in ten (19%).
• Americans seem most concerned that any health care plan not raise their costs or involve government limiting or dictating their choices.
• According to the survey, nearly two-thirds (65%) say they would be less likely to support a plan that would get the government get too involved in personal health care decisions, more than six in ten (61%) would be less likely to support a plan that increases people’s insurance premiums or out-of-pocket costs, and more than half (56%) would be less supportive of a plan that limits an individual’s choice in doctors.
• Any debate over health reform options will also involve negotiating the very different views of rank and file Democrats and Republicans. Democrats are significantly more likely to place a priority on action on health care, which ranks second on their priority agenda (61% say it is a top priority), compared to Republicans, who rank it eighth (23%).
• More than three-quarters (77%) of Democrats think health reform “is more important than ever” due to the economy, while six in ten (62%) Republicans believe the nation “cannot afford to take on health reform now
What does that all mean for you? What are the lessons you can learn from last hundred years of health care reform efforts?
First, if you want to be part of the decision making process, you must make your voice heard. If there is one group that has credibility on this issue, it is you.
Second, getting the right message is extraordinarily important. In 1993 and 1994, the message was easily defined. The plan was too bureaucratic. In 2003, the message was also easily defined: give me drugs. To win, you must make your message easily understandable.
Third, don’t ignore the Republicans. It is more likely that they will agree with your views and take up your cause. And, they have more time on their hands.
Fourth, don’t argue policy, argue passion. Policy arguments are boring. But the personal stories that bring passion to the debate excite the soul and move the masses.
Fifth, this is harder than it looks. America is not Germany. The American experience is one of immigrant groups who work hard to earn the American dream. Those who have quality health care worked hard to get it, and while they instinctively support the idea of universal health care, they resent the thought that they have to pay more for somebody who hasn’t worked as hard.
Sixth, it is easy to bite off smaller chunks than it is to stuff the whole enchilada down your throat. Medicare, Medicaid, HIPPA, SCHIP, and even prescription drugs, were aimed at discrete populations that clearly either needed help (children, the poor, or the elderly) or had active groups pushing to get it done (AARP and PhRma).
In conclusion, the President has a couple of big decisions to make. Will he try to do everything at once or will he choose to take smaller bites? For example, will he focus on cost containment, on universal coverage or on everything?
Will he choose to be bipartisan or will he decided to simply ignore the Republicans?
Will he stick the rich with the bill or will he have a broad-based funding effort?
And finally, what will his big message be as he attempts to get this thing done? Will he be more specific than “Yes We Can”?