PNHP

White House as helpless victim on healthcare

White House as helpless victim on healthcare

By Glenn Greenwald
Salon.com, Wednesday, Dec 16, 2009 05:17 EST

Of all the posts I wrote this year, the one that produced the most vociferous email backlash — easily — was this one from August, which examined substantial evidence showing that, contrary to Obama’s occasional public statements in support of a public option, the White House clearly intended from the start that the final health care reform bill would contain no such provision and was actively and privately participating in efforts to shape a final bill without it.  From the start, assuaging the health insurance and pharmaceutical industries was a central preoccupation of the White House — hence the deal negotiated in strict secrecy with Pharma to ban bulk price negotiations and drug reimportation, a blatant violation of both Obama’s campaign positions on those issues and his promise to conduct all negotiations out in the open (on C-SPAN).  Indeed, Democrats led the way yesterday in killing drug re-importation, which they endlessly claimed to support back when they couldn’t pass it.  The administration wants not only to prevent industry money from funding an anti-health-care-reform campaign, but also wants to ensure that the Democratic Party — rather than the GOP — will continue to be the prime recipient of industry largesse.

As was painfully predictable all along, the final bill will not have any form of public option, nor will it include the wildly popular expansion of Medicare coverage.  Obama supporters are eager to depict the White House as nothing more than a helpless victim in all of this — the President so deeply wanted a more progressive bill but was sadly thwarted in his noble efforts by those inhumane, corrupt Congressional “centrists.”  Right.  The evidence was overwhelming from the start that the White House was not only indifferent, but opposed, to the provisions most important to progressives.  The administration is getting the bill which they, more or less, wanted from the start — the one that is a huge boon to the health insurance and pharmaceutical industry.   And kudos to Russ Feingold for saying so:

Sen. Russ Feingold (D-Wis.), among the most vocal supporters of the public option, said it would be unfair to blame Lieberman for its apparent demise. Feingold said that responsibility ultimately rests with President Barack Obama and he could have insisted on a higher standard for the legislation.

“This bill appears to be legislation that the president wanted in the first place, so I don’t think focusing it on Lieberman really hits the truth,” said Feingold. “I think they could have been higher. I certainly think a stronger bill would have been better in every respect.”

Let’s repeat that:  “This bill appears to be legislation that the president wanted in the first place.”  Indeed it does.  There are rational, practical reasons why that might be so.  If you’re interested in preserving and expanding political power, then, all other things being equal, it’s better to have the pharmaceutical and health insurance industry on your side than opposed to you.  Or perhaps they calculated from the start that this was the best bill they could get.  The wisdom of that rationale can be debated, but depicting Obama as the impotent progressive victim here of recalcitrant, corrupt centrists is really too much to bear.  

Yet numerous Obama defenders — such as Matt Yglesias, Ezra Klein and Steve Benen — have been insisting that there is just nothing the White House could have done and all of this shows that our political system is tragically “ungovernable.”  After all, Congress is a separate branch of government, Obama doesn’t have a vote, and 60 votes are needed to do anything.  How is it his fault if centrist Senators won’t support what he wants to do?  Apparently, this is the type of conversation we’re to believe takes place in the Oval Office:

The President:  I really want a public option and Medicare buy-in.  What can we do to get it?

Rahm Emanuel:  Unfortunately, nothing.  We can just sit by and hope, but you’re not in Congress any more and you don’t have a vote.  They’re a separate branch of government and we have to respect that.

The President:  So we have no role to play in what the Democratic Congress does?

Emanuel:  No.  Members of Congress make up their own minds and there’s just nothing we can do to influence or pressure them.

The President:  Gosh, that’s too bad.  Let’s just keep our fingers crossed and see what happens then.

In an ideal world, Congress would be — and should be — an autonomous branch of government, exercising judgment independent of the White House’s influence, but that’s not the world we live in.  Does anyone actually believe that Rahm Emanuel (who built his career on industry support for the Party and jamming “centrist” bills through Congress with the support of Blue Dogs) and Barack Obama (who attached himself to Joe Lieberman when arriving in the Senate, repeatedly proved himself receptive to “centrist” compromises, had a campaign funded by corporate interests, and is now the leader of a vast funding and political infrastructure) were the helpless victims of those same forces?  Engineering these sorts of “centrist,” industry-serving compromises has been the modus operandi of both Obama and, especially, Emanuel.

Indeed, we’ve seen before what the White House can do — and does do — when they actually care about pressuring members of Congress to support something they genuinely want passed.  When FDL and other liberal blogs led an effort to defeat Obama’s war funding bill back in June, the White House became desperate for votes, and here is what they apparently did (though they deny it):

The White House is playing hardball with Democrats who intend to vote against the supplemental war spending bill, threatening freshmen who oppose it that they won’t get help with reelection and will be cut off from the
White House, Rep. Lynn Woolsey (D-Calif.) said Friday.  “We’re not going to help you. You’ll never hear from us again,” Woolsey said the White House is telling freshmen.

That’s what the White House can do when they actually care about pressuring someone to vote the way they want.  Why didn’t they do any of that to the “centrists” who were supposedly obstructing what they wanted on health care?  Why didn’t they tell Blanche Lincoln — in a desperate fight for her political life — that she would “never hear from them again,” and would lose DNC and other Democratic institutional support, if she filibustered the public option?  Why haven’t they threatened to remove Joe Lieberman’s cherished Homeland Security Chairmanship if he’s been sabotaging the President’s agenda?  Why hasn’t the President been rhetorically pressuring Senators to support the public option and Medicare buy-in, or taking any of the other steps outlined here by Adam Green?  There’s no guarantee that it would have worked — Obama is not omnipotent and he can’t always control Congressional outcomes — but the lack of any such efforts is extremely telling about what the White House really wanted here.

Independent of the reasonable debate over whether this bill is a marginal improvement over the status quo, there are truly horrible elements to it.  Two of the most popular provisions (both of which, not coincidentally, were highly adverse to industry interests) — the public option and Medicare expansion — are stripped out (a new Washington Post/ABC poll out today shows that the public favors expansion of Medicare to age 55 by a 30-point margin).  What remains is a politically disastrous and highly coercive “mandate” gift to the health insurance industry, described perfectly by Digby:

Obama can say that you’re getting a lot, but also saying that it “covers everyone,” as if there’s a big new benefit is a big stretch. Nothing will have changed on that count except changing the law to force people to buy private insurance if they don’t get it from their employer. I guess you can call that progressive, but that doesn’t make it so. In fact, mandating that all people pay money to a private interest isn’t even conservative, free market or otherwise. It’s some kind of weird corporatism that’s very hard to square with the common good philosophy that Democrats supposedly espouse.

Nobody’s “getting covered” here. After all, people are already “free” to buy private insurance and one must assume they have reasons for not doing it already. Whether those reasons are good or bad won’t make a difference when they are suddenly forced to write big checks to Aetna or Blue Cross that they previously had decided they couldn’t or didn’t want to write. Indeed, it actually looks like the worst caricature of liberals: taking people’s money against their will, saying it’s for their own good — and doing it without even the cover that FDR wisely insisted upon with social security, by having it withdrawn from paychecks. People don’t miss the money as much when they never see it.

In essence, this reinforces all of the worst dynamics of Washington.  The insurance industry gets the biggest bonanza imaginable in the form of tens of millions of coerced new customers without any competition or other price controls.  Progressive opinion-makers, as always, signaled that they can and should be ignored (don’t worry about us — we’re announcing in advance that we’ll support whatever you feed us no matter how little it contains of what we want and will never exercise raw political power to get what we want; make sure those other people are happy but ignore us).  Most of this was negotiated and effectuated in complete secrecy, in the sleazy sewers populated by lobbyists, industry insiders, and their wholly-owned pawns in the Congress.  And highly unpopular, industry-serving legislation is passed off as “centrist,” the noblest Beltway value. 

Looked at from the narrow lens of health care policy, there is a reasonable debate to be had among reform advocates over whether this bill is a net benefit or a net harm.  But the idea that the White House did what it could to ensure the inclusion of progressive provisions — or that they were powerless to do anything about it — is absurd on its face.  Whatever else is true, the overwhelming evidence points to exactly what Sen. Feingold said yesterday:  “This bill appears to be legislation that the president wanted in the first place.”

UPDATE:  It’s also worth noting how completely antithetical claims are advanced to defend and excuse Obama.  We’ve long heard — from the most blindly loyal cheerleaders and from Emanuel himself — that progressives should place their trust in the Obama White House to get this done the right way, that he’s playing 11-dimensional chess when everyone else is playing checkers, that Obama is the Long Game Master who will always win.  Then, when a bad bill is produced, the exact opposite claim is hauled out:  it’s not his fault because he’s totally powerless, has nothing to do with this, and couldn’t possibly have altered the outcome.  From his defenders, he’s instantaneously transformed from 11-dimensional chess Master to impotent, victimized bystander.

The supreme goal is to shield him from all blame.  What gets said to accomplish that goal can — and does — radically change from day to day.
UPDATE II:  I’ll be on MSNBC this afternoon at 3:00 p.m. EST with David Shuster/Tamron Hall discussing this post.

UPDATE III:  Over at Politico, Jane Hamsher documents how Joe Lieberman’s conduct on the health care bill provides the perfect vehicle to advance the agenda of the White House and Harry Reid.  Consistent with that, she independently notes media reports that White House officials are privately expressing extreme irritation with Howard Dean for opposing the Senate bill as insufficient, but have nothing bad to say about Lieberman, who supposedly single-handedly sabotaged what the White House was hoping for in this bill.

UPDATE IV:  Immediately prior to the MSNBC segment I just did — video for which I will post when it’s available — an NBC reporter explained how Robert Gibbs used his Press Briefing today to harshly criticize Howard Dean for opposing the health care bill.  Why did Gibbs never publicly cri
ticize people like Blanche Lincoln, Ben Nelson, Joe Lieberman and the like if they were supposedly obstructing and impeding the White House’s agenda on health care reform (this is a point Yglesias acknowledges as a “fair” one)?  Having a Democratic White House publicly criticize a Democratic Senator can be a much more effective pressure tactic than doing so against a former Governor who no longer holds office.

Meanwhile, as one would expect, health insurance stocks are soaring today in response to the industry-serving “health care reform” bill backed by the Democratic Senate and White House — the same people who began advocating for “health care reform” based on the need to restrain on an out-of-control and profit-inflated health insurance industry (h/t Markos).

UPDATE V:  Here’s the roughly 4-minute segment I did with David Shuster today:

http://www.salon.com/news/opinion/glenn_greenwald/2009/12/16/white_house/index.html

Single-Payer Amendment Withdrawn after GOP Delay Tactics

By Emily P. Walker
MedPage Today, December 16, 2009

WASHINGTON — In an earnest but doomed attempt to create a single-payer healthcare system, Sen. Bernie Sanders (I-Vt.) brought up a Medicare-for-all amendment to the healthcare reform bill on Wednesday, but was forced to withdraw it in the face of Republican stalling tactics.

Sanders, the chamber’s only vocal proponent of a national health insurance program, introduced an amendment to create just that — and expand coverage to every U.S. citizen.

“Every American — 100%, not 94% — would have health insurance,” he said in an impassioned speech on the Senate floor.

He referred to the current Senate bill, which would expand coverage to 94% of legal U.S. citizens, according to the Congressional Budget Office.

Sanders said his amendment would save $350 billion in administrative expenses by eliminating private insurance companies from the picture.

Sen. Tom Coburn (R-Okla.), an ob/gyn, demanded that the 776-page amendment be read by Senate clerks — a move that is always an option, but very rarely invoked. Coburn complained that he hadn’t seen Sanders’ amendment before it was brought to the floor.

The reading began at noon and continued on for several hours until Sanders withdrew the measure, ending a monotone afternoon read-a-thon that further delayed work on the healthcare measure. Sen. Dick Durbin (D-Ill.) estimated that reading the whole amendment would have taken 10 hours.

After withdrawing the amendment, Sanders delivered a few more pointed words in favor of loosening the insurance industry’s grasp on medical care and the need for universal coverage.

“A Medicare-for-all program is the way to go,” he said. “And I know it’s not going to pass today. I know we don’t have the votes. I know the insurance company and the drug lobbyists will fight us.

“But mark my words . . . the day will come when this country will do the right thing. And on that day, we will pass a Medicare-for-all single-payer system.”

David Himmelstein, MD, the national spokesperson for Physicians for a National Heath Program, told MedPage Today he wasn’t surprised by the maneuvering that blocked the amendment from coming up for a vote.

“It’s another in a long line of bizarre dancing that Congress has been engaged in that distract from debating the issues,” said Himmelstein, an associate professor of medicine at Harvard. “The whole debate has been a circus and sounds like another side show in the circus.”

Himmelstein said he agrees with Sanders that meaningful reform can only be achieved with a single-payer system because there is too much waste in the private insurance industry.

He criticized the current reform effort for “dumping hundreds of billions of dollars into the private insurance industry for a short term gain.”

He said the current debate “is akin to debating whether you ought to use aspirin or Tylenol for someone with cancer.”

After Sanders’ amendment, the Senate took up a defense spending measure.

It is appearing less and less likely that the Senate will vote on healthcare reform before Christmas, which Senate Majority Leader Harry Reid (D-Nev.) has said is his goal.

Reid has yet to introduce his manager’s amendment, which will include a series of changes to the older version of the healthcare bill.

Republicans can again request that the amendment be read aloud. Hoping to avoid that, Democrat leaders have told the GOP that the amendment will be available publicly for at least 72 hours before it’s brought up on the floor.

http://www.medpagetoday.com/PublicHealthPolicy/Washington-Watch/17585

Testimony of Dr. Dwight Michael before the Pennsylvania Senate Banking and Insurance Committee

12/16/2009

Good morning Chairman White and distinguished members of the Senate Banking and Insurance Committee. 

I am Dwight Michael, a Family Physician. 

I am here to share my reformed and informed belief that Senate Bill 400 is by far the best way to provide high-quality, affordable, accessible healthcare to all PennsyIvanians at a cost to practically all of us that is less than what we currently pay.  

I am in my 25th year of practice in Gettysburg, Pa.  Our group of 5 family physicians is independent.  I am a Republican and have been fairly conservative in my views over the years.  I formulate my own opinions based on my research and my experiences. 

I have been asked to focus my comments on why SB 400 is beneficial to physicians.

First, SB 400 will allow physicians to focus much more of our time on the actual care of the patient.  With our present multipayer system, we spend an increasing and inordinate amount of time dealing with pre-authorization of care ordered.

This care includes: Medications, treatments, diagnostic procedures such as CAT scans, MRIs, xrays, and lab work.

Denials by insurance companies are all too frequent.  The time spent to gain coverage for the recommended care is increasingly burdensome.  A study from the journal, Public Affairs, May 2009, concludes that each physician in America spends $68,000/year just interact with the private health insurance industry.

Our practice participates with 20 different insurance companies, all of which have their own set of rules and hoops to jump through.  I have become convinced that their “rules” have much more to do with their profit margin than they do with good patient care.

SB 400 will streamline our care by providing one set of rules by which to practice, based on clinical effectiveness research, clinical outcomes studies that prove the benefit of care we provide, both testing and treatments.

This bill will markedly simplify the current environment in which we work.  It truly will give us more time to see patients.

Second, SB 400 will provide improved ability to track and trend physicians’ care with its emphasis on the use of information technology.  If there are providers who are not providing the standard of care, these providers will receive constructive criticism with expectation that they will improve their care to their patients. 

Third, SB 400 will strengthen the patient/physician relationship.  How?  Patients will be able to choose their providers of care and stay with them.  The present Private Health Insurance dominated system causes patients to leave my practice because their employer can no longer afford the plan they have.

If their plan changes to one that we do not participate in, then the patient is practically forced to leave our practice for a physician’s practice that participates in their plan. 
This happens every year in my practice.

SB 400 actually gives the patient the right to choose and stay with their providers.  The insurance industry no longer controls this choice with their preferred networks.

I went into Family Practice so that I could take care of patients and their families over the course of many years.  I believe that I can provide better care to patients because I know and understand the patient and the people around the patient over time.  This has played out in some of my families.  Our present lack of a coordinated healthcare system necessitates employers’ frequent decisions to change health insurance plans just so they can afford coverage.  This trend has greatly compromised the continuity of care that I believe is so important to quality of care. 

Fourth, I believe that SB 400 will provide “fair reimbursement” for providers’ services.  Fees for independent providers’ services and global payments for hospitals’ and other institutions’ services will be negotiated annually based on the previous year’s expenditures.

One of the stated goals of SB 400 is to strengthen primary care.  This is critical to improved care throughout the state and nation.

We, as a nation, are presently spending at least an extra $400 billion dollars a year in excessive administrative costs due to the Private Health Insurance industry’s role as the middleman.

I believe that if we eliminate the excessive administrative costs of the Private Health Insurance industry, we can save huge sums of money that can be used to provide better care of all Pennsylvanians and can fairly reimburse providers for their care.

Enacted SB 400 will be a win-win for the citizens of Pennsylvania, patients and providers alike.

By the way, don’t forget the 2+ billion dollars per year in savings we will achieve with the reduction in the costs of healthcare premiums of governmental employees when all levels of government in Pennsylvania are considered.

Fifth, I believe that even though the excellent medical liability piece of last year’s bill has been removed, SB 400 will provide an improved medical liability environment in Pennsylvania for all providers.

Presently, part of the award in a medical liability case includes “medical expenses”.  SB 400 will pay for medical expenses and therefore this cost will not be added to the award granted to the plaintiff.

This improved medical liability environment will make Pennsylvania a much more attractive state for physicians to practice.  I repeat, physicians will want to work in Pennsylvania.

I have followed developments in Washington very carefully this year.  At this moment, I believe that their “solution” will fall woefully short of the mark of providing affordable, accessible, high-quality healthcare for all.  Our state government has received a few black eyes recently.  When your committee leads the way, when our legislators pass SB 400, and when SB 400 is enacted, your will be honored by Pennsylvanians, young and old.  Future generations will thank you.
You will be the saviors of our state’s healthcare system.

You will do this while allowing almost all taxpayers to spend much less on healthcare, all costs considered.

Future generations of Americans will credit you as the fathers of our nation’s exemplary, civilized healthcare system, a system in which every person receives healthcare.  Pennsylvania will be the state that blazes the trail our nation finally takes to provide civilized healthcare for all.

Thank you!

Sen. Sanders' floor speech on his single payer amendment

United States Senate
December 16, 2009
The reading of the Sanders single payer amendment continues in its third hour…
Senate President: The Senator from Vermont.
Sen. Bernie Sanders: I withdraw my amendment.
Voice off camera (believed to be Sen. Tom Coburn): Regular order, Mr. President.
Senate President: The Senator has that right. The amendment is withdrawn.
Sen. Sanders: Mr. President. Pursuant to the thirty minutes…
Senate President: Under the previous order, the Senator from Vermont is recognized for thirty minutes.
Sen. Sanders: Mr. President, let me begin, not by talking about my amendment, but by talking about Republican action right here on the floor of the Senate. Everybody in this country understands that our nation faces a significant number of major crises, whether it’s the disintegration of our health care system, the fact that seventeen percent of our people are unemployed or underemployed, one out of four of our children are living on food stamps, we’ve got two wars, we’ve got global warming, we have a twelve trillion dollar national debt, and the best the Republicans can do is try to bring the United States government to a halt by forcing a reading of a seven hundred page amendment. That is an outrage! People can have honest disagreements, but in this moment of crisis it is wrong to bring the United States government to a halt.
Now, Mr. President, I am very disturbed that I am unable to bring the amendment that I wanted to bring to the floor of the Senate dealing with a Medicare for all single payer program…
… I was more than aware and very proud that this amendment would have been the first time in American history that a Medicare for all single payer bill was brought before a floor of Congress.
C-SPAN video of Sen. Sanders remarks (36 minutes):
http://www.c-span.org/Watch/watch.aspx?MediaId=HP-A-27367

Yesterday’s Quote of the Day message left off as the reading of the the Sanders amendment to the Senate health reform bill continued. It was suggested that this abuse of process and lack of civility on the part of Sen. Coburn and the Republican leadership be used as a teaching moment. That moment is here. The video of this Senate floor speech by Sen. Sanders should be shared with others who believe that everyone in our nation should have the health care that they need without having to face financial hardship.

Sen. Coburn demands a reading of Sen. Sanders' single payer amendment

United States Senate
December 16, 2009

SA 2837. Mr. SANDERS (for himself, Mr. BURRIS, and Mr. BROWN) submitted an amendment intended to be proposed to amendment SA 2786 proposed by Mr. REID (for himself, Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to the bill H.R. 35

Beginning on page 1, strike line 6 and all the follows to the end and insert the following:

(b) Table of Contents.–The table of contents of this Act is as follows:

TITLE I–AMERICAN HEALTH SECURITY
…

Full amendment (366 pages):
http://c-span.org/pdf/sanders_amend_2837.pdf

The reading of the amendment (live now – Dec. 16):
http://www.c-span.org/Watch/C-SPAN2.aspx

Comment: 

By Don McCanne, MD

Today’s message was to have been composed after the introduction of and action on Sen. Bernie Sanders’ (I-VT) single payer amendment to the Senate health care reform bill. His amendment would replace the body of the entire bill with a single payer bill.

When Sen. Sanders made the usual request that the reading of the amendment be waived, Sen. Tom Coburn (R-OK) objected and demanded that the entire amendment be read under rules of regular order.

After one hour, 27 of the 366 pages have been read (or 767 pages in the GPO format). At that rate the reading should be completed at about 1:00 AM tomorrow.

Sen. Coburn is a physician. The Oath of Hippocrates states, “I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.” As a United States Senator involved in a legislative process that should bring benefit to all patients in the nation, this oath should be sacrosanct. Apparently Sen. Coburn is determined to embellish his reputation as Dr. No, quite smug in carrying out his deleterious and mischievous acts.

Might the nation ask why a bill is so important that it must be read in its entirety? Maybe this a teaching moment that we can use to shift the dialogue from deceptive partisan rhetoric into a rational discussion of health policy science. The general public might be astonished to learn that we actually can provide high quality care to everyone at a price we can afford.

At least they can no longer claim that we can’t pass a bill that hasn’t been read.

Sen. Coburn demands a reading of Sen. Sanders’ single payer amendment

United States Senate
December 16, 2009

SA 2837. Mr. SANDERS (for himself, Mr. BURRIS, and Mr. BROWN) submitted an amendment intended to be proposed to amendment SA 2786 proposed by Mr. REID (for himself, Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to the bill H.R. 35

Beginning on page 1, strike line 6 and all the follows to the end and insert the following:

(b) Table of Contents.–The table of contents of this Act is as follows:

TITLE I–AMERICAN HEALTH SECURITY
…

Full amendment (366 pages):
http://c-span.org/pdf/sanders_amend_2837.pdf

The reading of the amendment (live now – Dec. 16):
http://www.c-span.org/Watch/C-SPAN2.aspx

Comment: 

By Don McCanne, MD

Today’s message was to have been composed after the introduction of and action on Sen. Bernie Sanders’ (I-VT) single payer amendment to the Senate health care reform bill. His amendment would replace the body of the entire bill with a single payer bill.

When Sen. Sanders made the usual request that the reading of the amendment be waived, Sen. Tom Coburn (R-OK) objected and demanded that the entire amendment be read under rules of regular order.

After one hour, 27 of the 366 pages have been read (or 767 pages in the GPO format). At that rate the reading should be completed at about 1:00 AM tomorrow.

Sen. Coburn is a physician. The Oath of Hippocrates states, “I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.” As a United States Senator involved in a legislative process that should bring benefit to all patients in the nation, this oath should be sacrosanct. Apparently Sen. Coburn is determined to embellish his reputation as Dr. No, quite smug in carrying out his deleterious and mischievous acts.

Might the nation ask why a bill is so important that it must be read in its entirety? Maybe this a teaching moment that we can use to shift the dialogue from deceptive partisan rhetoric into a rational discussion of health policy science. The general public might be astonished to learn that we actually can provide high quality care to everyone at a price we can afford.

At least they can no longer claim that we can’t pass a bill that hasn’t been read.

Sen. Coburn demands a reading of Sen. Sanders' single payer amendment

United States Senate
December 16, 2009
SA 2837. Mr. SANDERS (for himself, Mr. BURRIS, and Mr. BROWN) submitted an amendment intended to be proposed to amendment SA 2786 proposed by Mr. REID (for himself, Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to the bill H.R. 35
Beginning on page 1, strike line 6 and all the follows to the end and insert the following:
(b) Table of Contents.–The table of contents of this Act is as follows:
TITLE I–AMERICAN HEALTH SECURITY
…
Full amendment (366 pages):
http://c-span.org/pdf/sanders_amend_2837.pdf
The reading of the amendment (live now – Dec. 16):
http://www.c-span.org/Watch/C-SPAN2.aspx

Today’s message was to have been composed after the introduction of and action on Sen. Bernie Sanders’ (I-VT) single payer amendment to the Senate health care reform bill. His amendment would replace the body of the entire bill with a single payer bill.
When Sen. Sanders made the usual request that the reading of the amendment be waived, Sen. Tom Coburn (R-OK) objected and demanded that the entire amendment be read under rules of regular order.
After one hour, 27 of the 366 pages have been read (or 767 pages in the GPO format). At that rate the reading should be completed at about 1:00 AM tomorrow.
Sen. Coburn is a physician. The Oath of Hippocrates states, “I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.” As a United States Senator involved in a legislative process that should bring benefit to all patients in the nation, this oath should be sacrosanct. Apparently Sen. Coburn is determined to embellish his reputation as Dr. No, quite smug in carrying out his deleterious and mischievous acts.
Might the nation ask why a bill is so important that it must be read in its entirety? Maybe this a teaching moment that we can use to shift the dialogue from deceptive partisan rhetoric into a rational discussion of health policy science. The general public might be astonished to learn that we actually can provide high quality care to everyone at a price we can afford.
At least they can no longer claim that we can’t pass a bill that hasn’t been read.

Sheils and Haught analyze the House and Senate bills

Comparing the Cost and Coverage Impacts of the House and Senate Leadership Health Reform Bills: Long Term Costs for Governments, Employers, Families and Providers

Prepared for: The Peter G. Peterson Foundation

By John Sheils and Randy Haught
The Lewin Group
December 7, 2009

Impact on National Health Spending

Both bills would result in an increase in administrative costs. These include the cost of administering private insurance to newly covered people, the cost of administering coverage under Medicaid and the cost of processing eligibility for premium subsidies under the bill.

Both bills would result in a substantial growth in national health expenditures. Total health spending over the 2010 through 2029 period would increase by $781 billion under the Senate bill and $955 billion under the House bill.

http://www.pgpf.org/resources/lewin-senate-house-comparison.pdf

Comment:

By Don McCanne, MD

What is health care reform going to cost us? To help answer this question, numerous reports have been generated by the Congressional Budget Office (CBO), the Office of Management and Budget (OMB), the Office of the Actuary of the Centers for Medicare and Medicaid Services (CMS), the Council of Economic Advisers (CEA), private foundations, and numerous consulting firms representing the private insurance industry.

Although politicians are using sections of these reports selectively to advance their own agendas, if you read all of the reports you cannot escape the conclusion that the measures designed to slow the growth in health care costs do not begin to offset the anticipated increases in spending. Further, they show that an unacceptable number of individuals will remain amongst the ranks of the uninsured.

This new, highly credible report (credible in spite of ownership by UnitedHealth) by John Sheils and Randy Haught draws the same conclusions. National health expenditures will increase over the amounts projected were there no reform, and about 20 million people will still be uninsured.

One comparatively small number in this report is that administrative costs will increase by about $87 billion in the next decade under either the Senate or the House bill. But this number has much greater significance than the amount would suggest. Not only is this an additional cost, it also adds on to the $4,000 billion in administrative waste that we could recover in the next decade if we merely changed to a single payer system of financing health care. That would free up enough funds to cover our nation’s unmet health care needs.

Sheils and Haught analyze the House and Senate bills

Comparing the Cost and Coverage Impacts of the House and Senate Leadership Health Reform Bills: Long Term Costs for Governments, Employers, Families and Providers

Prepared for: The Peter G. Peterson Foundation

By John Sheils and Randy Haught
The Lewin Group
December 7, 2009
Impact on National Health Spending
Both bills would result in an increase in administrative costs. These include the cost of administering private insurance to newly covered people, the cost of administering coverage under Medicaid and the cost of processing eligibility for premium subsidies under the bill.
Both bills would result in a substantial growth in national health expenditures. Total health spending over the 2010 through 2029 period would increase by $781 billion under the Senate bill and $955 billion under the House bill.
http://www.pgpf.org/resources/lewin-senate-house-comparison.pdf

What is health care reform going to cost us? To help answer this question, numerous reports have been generated by the Congressional Budget Office (CBO), the Office of Management and Budget (OMB), the Office of the Actuary of the Centers for Medicare and Medicaid Services (CMS), the Council of Economic Advisers (CEA), private foundations, and numerous consulting firms representing the private insurance industry.
Although politicians are using sections of these reports selectively to advance their own agendas, if you read all of the reports you cannot escape the conclusion that the measures designed to slow the growth in health care costs do not begin to offset the anticipated increases in spending. Further, they show that an unacceptable number of individuals will remain amongst the ranks of the uninsured.
This new, highly credible report (credible in spite of ownership by UnitedHealth) by John Sheils and Randy Haught draws the same conclusions. National health expenditures will increase over the amounts projected were there no reform, and about 20 million people will still be uninsured.
One comparatively small number in this report is that administrative costs will increase by about $87 billion in the next decade under either the Senate or the House bill. But this number has much greater significance than the amount would suggest. Not only is this an additional cost, it also adds on to the $4,000 billion in administrative waste that we could recover in the next decade if we merely changed to a single payer system of financing health care. That would free up enough funds to cover our nation’s unmet health care needs.

Gawande’s Rx is no solution

[The following letter to Washington Post columnist David Broder from Dr. Ray Bellamy of Florida discusses not only Broder’s recent arguments, but also those of Dr. Atul Gawande at The New Yorker.]

December 11, 2009

Mr. David Broder
Washington Post Writers Group
1150 15th Street NW
Washington, DC 20071

Dear Mr. Broder,

I read with interest your column titled “Health Care Brings Freshman Senators to the Forefront” in today’s edition of the Tallahassee Democrat. I agree cost control is the key issue in health reform and has not been addressed in current congressional efforts. The output from Congress seems focused mostly on what is politically possible and increasingly on what can be supported by 60 votes, not true reform.

The mainstream media seems to have bought into the notion that, since the Republicans are trying to block reform and perhaps make health reform “Obama’s Waterloo,” the House and Senate output should be supported. Although allowing for deep flaws in the legislation, there is the feeling that incremental steps toward a better system are good. You and the excellent writer you reference, Dr. Atul Gawande, have apparently bought into this mindset. Allow me to disagree.

Gawande, in his latest article in The New Yorker titled “Testing, testing,” speaks of small-scale pilot projects in the proposed legislation with hope they will show the way toward cost savings.

Yet we already have pilot projects all over the world that have met with dramatic success: nearly every other developed country has universal coverage with higher citizen satisfaction and far higher medical outcomes at roughly half the per-capita cost as U.S. health care. Half the cost.

Why do we need new pilot projects? We have the knowledge that the only two successful health care models in these countries are either (1) highly regulated nonprofit insurers who sell health policies as an inducement to the purchase of profitable property, fire and auto insurance, or (2) some version of single payer.

We know no country utilizes a system like the model Congress is proposing and that none like it has ever been successful. Eight prior state efforts using this model all failed, usually within a few years. Massachusetts, currently starting its third year with a similar model, is not able to control costs, and has the most expensive health insurance in the world. This is the model for what Congress has proposed.

Medicare for All is criticized for being a “government takeover.” Really, we have entrusted health care to private insurance long enough to know that their business model of avoiding the sick, then dumping those who do need care rather than spreading the risk as insurance is supposed to do, does not work. Medicare has a 92 percent enrollee satisfaction rate. Private insurance cannot approach that.

Critics also charge that Medicare is bankrupt. What do you expect when the funding is provided by a dwindling collection of payroll taxes from fewer and fewer workers to support current Medicare enrollees who are swelling in numbers? Funding Medicare with a 2 percent or 3 percent progressive income tax would be the answer – an amount that would certainly be less than what most people pay today for premiums, co-pays, deductibles, uncovered services and other out-of-pocket health care costs.

The individual mandate to have insurance, as proposed by the House, is an effort to avoid adverse risk selection, which occurs when those who are currently young and healthy wait to purchase insurance until they get sick. Insurance obviously works best with the largest possible risk pool and that is why health savings accounts and skimpy coverage for different groups are bad ideas. What would work best is every American covered in the same risk pool. We could have comprehensive coverage, all with the same policy as every member of Congress – truly egalitarian – for what we currently pay in health care in this country now: $2.4 trillion annually.

Gawande mentions the benefits of improved information about what works, comparative effectiveness, and the problem of overutilization (which he headlined in his previous New Yorker article). Yet look what instant information would be available if we had single payer: instant data on comparative effectiveness, overutilization, and disease outbreaks anywhere in the country.

Gawande has also written about a Texas border town, McAllen, with high utilization and cost. His information was obtained through Medicare data, which is the best nationwide health care data we have available. Single payer would give us such high-quality information instantly for the entire nation, not just the Medicare population.

Gawande also speaks of the need for tort reform, of which there is essentially none in current congressional proposals. If we had truly universal comprehensive, egalitarian Medicare for All, we would eliminate the cost of future medical expenses from all personal injury lawsuits, not just Med-Mal. This is a major component of economic damages in personal injury lawsuits.

Current congressional proposals retain the main low-hanging fruit for cost cutting and reward it: the wasteful administrative expense, marketing cost, profits of the for-profit insurance industry. To the current 31 percent administrative waste in the system, Congress proposes to add additional bureaucracy and a czar so we are likely to reach 35 percent overhead and waste. That figure, the highest in the world almost by a factor of two, could be lowered for a saving of $400 billion a year within our current budget, with the savings used to cover every one of us without raising costs.

The additional opportunity to sensibly manage our nation’s health budget with the inevitable rationing decisions necessary in the future, with global budgeting and so on, would also stem from a single-payer system.

Now one last word on true reform: if we moved away from fee-for-service reimbursement for physicians and instead provided incentives for them take salaried positions, like those in the Veterans Administration and the U.S. military (along with those at the Mayo Clinic), there would likely be huge additional savings. Socialized medicine? No. By and large, you’d still private physicians working in private hospitals.

Under a single-payer arrangement, patients would have more free choice of physician and hospital than we have now. Every American would have the choice to go to the Mayo Clinic, so the competition would surely result in improvements for all facilities and caregivers.

I read what you write and what Dr. Gawande writes with interest, but in this case I strongly disagree. Congress needs to start over on health reform, and this time it needs to compare single-payer Medicare for All with other options. I guarantee you that single payer will win hands down.

Sincerely,

Ray Bellamy, M.D.

Dr. Ray Bellamy is an orthopedic surgeon in Tallahassee, Fla.

Evidence Based Talking Points

Talking Point 1: Administrative costs consume 31 percent of health spending, most of it unnecessary.

“Costs of Health Care Administration in the U.S. and Canada.” Woolhandler, S., Campbell, T., & Himmelstein, D.U. (2003), N Engl J Med, 349, 768-775.

Talking Point 2: Nearly two-thirds of all bankruptcies are caused by medical bills. Three-fourths of those bankrupted had health insurance at the time they got sick or injured. 

“Medical Bankruptcy in the United States, 2007: Results of a National Study.” Himmelstein, D.U., Thorne, D., Warren, E., Woolhandler, S. (2009), Am J Med, 122, 741-746.

“Medical Bankruptcy Fact Sheet.” Himmelstein, D.U., Thorne, D., Warren, E., Woolhandler, S. (2009).

“Medical Bankruptcy Q&A.” Himmelstein, D.U., Thorne, D., Warren, E., Woolhandler, S. (2009).

Talking Point 3: Taxes already pay for more than 60 percent of US health spending Americans pay the highest health care taxes in the world. We pay for national health insurance, but don’t get it.

“Paying for National Health Insurance – And Not Getting It.” Woolhandler, S. & Himmelstein, D.U. (2002), Health Affairs 21(4), 88-98.

Talking Point 4: Despite spending far less per capita for health care, Canadians are healthier and have better measures of access to health care than Americans. Taiwan’s new single payer system (adopted in 1996) has improved access to care (before its adoption, 40 percent of the population was uninsured), controlled costs, and is model of efficiency. Despite having the highest per capita health spending in the world, the U.S. health system ranks very poorly in international comparisons of quality, outcomes, patient satisfaction, and other measures.

“Access to Care, Health Status, and Health Disparities in the United States and Canada: Results of a Cross-National Population-Based Survey.” Lasser, K., Himmelstein, D.U., & Woolhandler, S. (2006), Am J Public Health, 96, 1300-1307.

“Does Universal Health Insurance Make Health Care Unaffordable? Lessons from Taiwan.” Lu, J.F.R. & Hsiao, W.C. (2003), Health Affairs, 22(3), 77-88.

“Learning from Taiwan: Experience with Universal Health Insurance.” Davis, K. & Huang, A.T. (2008), Ann Intern Med, 148, 313-314.

“It’s The Prices, Stupid: Why The United States is So Different From Other Countries.” Anderson, G., Reinhardt, U.E., Hussey, P.S., & Petrosyan, V. (2003), Health Affairs, 22(3), 89-105.

Talking Point 5: Business pays less than 20 percent of our nation’s health bill. It is a misnomer that our health system is “privately financed.” 60 percent is funded by taxes and the remaining 20 percent is out-of-pocket payments.

“A Reappraisal of Private Employers’ Role in Providing Health Insurance.” Carrasquillo, O., Himmelstein, D.U., Woolhandler, S., & Bor, D.H. (1999), N Engl J Med, 340, 109-114.

Talking Point 6: For-profit, investor-owned hospitals, HMOs, and nursing homes have higher costs and score lower on most measures of quality than their non-profit counterparts. For-profit hospitals have higher death rates.

“The high costs of for-profit care.” Himmelstein, D. & Woolhandler, S. (2004), Can Med Assoc J, 170, 1814-1815.

“Payments for care at private for-profit and private not-for-profit hospitals: a systematic review and meta-analysis.” Devereaux, P.J., et. al. (2004), Can Med Assoc J, 170, 1817-1824.

“A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals.” Devereaux, P.J., et. al. (2002), Can Med Assoc J, 166, 1399-1406.

“Costs of Care and Administration at For-Profit and Other Hospitals in the United States.” Woolhandler, S., & Himmelstein, D.U. (1997), N Engl J Med, 336, 769-775.

“Quality of Care in Investor-Owned vs. Not-for-Profit HMOs.” Himmelstein, D.U., Woolhandler, S., Hellander, I., & Wolfe, S.M. (1999), J Am Med Assoc, 282, 159-163.

“Does Investor Ownership of Nursing Homes Compromise the Quality of Care?” Harrington, C., Woolhandler, S., Mullan, J., Carrillo, H., & Himmelstein, D.U. (2001), Am J Public Health, 91, 1452-1455.

“Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis.” Vikram R Comondore, P J Devereaux et al,  BMJ 2009;339:b2732, doi: 10.1136/bmj.b2732, Aug. 4, 2009.

Talking Point 7: Immigrants and emergency department visits by the uninsured are not the cause of high and rising health care costs.

“Health Care Expenditures of Immigrants in the United States: A Nationally Representative Analysis.” Mohanty, S., et. al. (2005), Am J Public Health, 95, 1431-1438.

“US Emergency Department Costs: No Emergency.” Tyrance, P.H., Himmelstein, D.U., & Woolhandler, S. (1996), Am J Public Health, 95, 1527-1531.

Talking Point 8: The uninsured do not receive all the medical care they need: one-third of uninsured adults have chronic illness and don’t receive needed care. Those most in need of preventive services are least likely to receive them.

“A National Study of Chronic Disease Prevalence and Access to Care in Uninsured U.S. Adults.” Wilper, A., et. al. (2008), Arch Intern Med, 149, 170 – 176.

Talking Point 9: The U.S. could save enough on administrative costs (almost $400 billion in 2009) with a single-payer system to cover the uninsured.

“Costs of Health Care Administration in the U.S. and Canada.” Woolhandler, S., Campbell, T., & Himmelstein, D.U. (2003), N Engl J Med, 349, 768-775.

“Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance.” Woolhandler, S., Himmelstein, D.U., Angell, M., & Young, Q.D. (2003), J Am Med Assoc 290, 798-805.

“Summary of Fiscal Studies: How Much would Single Payer Cost?”

“Canadian Health Insurance: Lessons for the Unites States.” U.S. General Accounting Office. (1991), GAO/HRD-91-90 Canadian Health Insurance.

Talking Point 10: Competition among investor-owned, for-profit entities has raised costs reduced quality in the U.S.

“Competition in a publicly funded healthcare system.” Woolhandler, S. & Himmelstein, D.U. (2007), Brit Med J, 335, 1126-1129.

“Market-Based Failure – A Second Opinion on U.S. Health Care Costs.” Kuttner, R. (2008), N Engl J Med, 358, 549-551.

Talking Point 11: The Canadian single payer healthcare system produces better health outcomes with substantially lower administrative costs than the United States.

“A systematic review of studies comparing health outcomes in Canada and the United States.” Guyatt G.H., et al. (2007), Open Medicine, 1, E27-36.

“Access to Care, Health Status, and Health Disparities in the United States and Canada: Results of a Cross-National Population-Based Survey.” Lasser, K., Himmelstein, D.U., & Woolhandler, S. (2006), Am J Public Health, 96, 1300-1307.

“Who administers? Who cares? Medical Administrative and Clinical Employment in the United States and Canada.” Himmelstein, D., Lewontin, J.P., & Woolhandler, S. (1996), Am J Public Health, 86,172-178.

“Costs of Health Care Administration in the U.S. and Canada.” Woolhandler, S., Campbell, T., & Himmelstein, D.U. (2003), N Engl J Med, 349, 768-775.

“Mythbusters: Canada has a communist-style healthcare system.” Canadian Health Services Research Foundation. (2005).

“Mythbusters: The cost of dying is an increasing strain on the healthcare system.” Canadian Health Services Research Foundation. (2003).

“Mythbusters: User fees would stop waste and ensure better use of the healthcare system.” Canadian Health Services Research Foundation. (2001).

“Privatizing health care is not the answer: lessons from the United States.” Angell, M. (2008), Can Med Assoc J, 179, 916-919.

Talking Point 12: Computerized medical records, chronic disease management, and malpractice reform do not save money. The only way to slash administrative over-head and improve quality is with a single payer system.

“Hospital computing and the costs and quality of care: a national study.” Himmelstein, D.U., Wright, A & Woolhandler, S. (2009), Am J Med, 2009 Nov 16.

“Hope And Hype: Predicting The Impact Of Electronic Medical Records.” Himmelstein, D.U. & Woolhandler, S. (2005), Health Affairs, 24, 1121-1123.

“Disease Management: Panacea, Another False Hope, or Something in Between?” Geyman, J. (2007), Ann Fam Med, 5, 257-260.

“Costs of Health Care Administration in the U.S. and Canada.” Woolhandler, S., Campbell, T., & Himmelstein, D.U. (2003), N Engl J Med, 349, 768-775.

“A Better Quality Alternative: Single-Payer National Health System Reform.” Schiff, G.D., Bindman, A.B., & Brennan, T.A. (1994), J Am Med Assoc, 272, 803-808.

“How Single-Payer Health System Reform Improves Quality.” PNHP Document

“You Can’t Leap a Chasm in Two Jumps: The Institute of Medicine Health Care Quality Report.” Schiff, G.D. & Young, Q.D. (2001), Public Health Rep, 116, 396-403.

“Medical Malpractice. Health Care Quality and Health Care Reform.” Schiff, G. (2003), Forum Report #4. PNHP NY Metro.

Talking Point 13: Alternative proposals for “universal coverage” (e.g. based on the Federal Employees Health Benefits Program, the old “Clinton health plan” or the recent reform in Massachusetts) do not work. State health reforms over the past two decades have failed to reduce the number of uninsured.

“State Health Reform Flatlines.” Woolhandler, S., Day, B., & Himmelstein, D.U. (2008), Int J Health Serv, 38, 585-592.

“FEHBP: A Feeble Model for Universal Health Care.” Rodberg, L. & Landy, J. (2004), On the Issues #2. PNHP NY Metro.

“Health Reform You Shouldn’t Believe In.” Angell, M. (2008), The American Prospect, April 21.

“Getting the Facts Right: Why HillaryCare Failed.” Navarro, V. (2007), PNHP Newsletter.

“The Massachusetts Way?” Rodberg, L. (2008), The New York Times, Sept. 26.

Talking Point 14: Drug companies spend more on marketing (31 percent) and profits (20 percent) than on R & D (13 percent). Lower drug prices would not jeopardize drug innovation, much of which is, in fact, publicly-funded.

“Extraordinary Claims Require Extraordinary Evidence.” Light, D.W. & Warburton, R.N. (2005), J Health Econ, 24, 1030-1033.

“Global Drug Discovery: Europe Is Ahead.” Light, D.W. (2009), Health Affairs, web exclusive, w969-w977.

“Will Lower Drug Prices Jeopardize Drug Research? A Policy Fact Sheet.” Light, D.W. & Lexchin, J. (2004), Am J Bioethics, 4, W3-W6.

“Foreign Free Riders and the High Price of U.S. Medicines.” Light, D.W. & Lexchin, J. (2005), Brit Med J, 331, 958-60.

Talking Point 15: Co-pays and deductibles are not necessary to control costs and reduce necessary care as much as unnecessary care. It is a myth that patient overuse will bankrupt any system without cost-sharing and that the demand for healthcare is “infinite”.

“Cost Sharing in Health Insurance – A Reexamination.” Rasell, M.E. (1995), N Engl J Med, 332, 1164-1168.

“Health needs, health-care requirements, and the myth of infinite demand.” Frankel, S. (1991), Lancet, 337, 1588-1590.

“Does universal comprehensive insurance encourage unnecessary use? Evidence from Manitoba says ‘no.’” Roos, N.P., Forget, E., Walld, R., & MacWilliam, L. (2004), Can Med Assoc J, 170, 209-214.

Talking Point 16: Universal coverage cannot be achieved with U.S.-style investor-owned private insurance companies. Every other industrialized, capitalist country has some form of non-profit national health care. For-profit, private insurance (mostly “gap” coverage) accounts for less than 5 percent of health expenditures in Europe.

“International Health Systems for Single Payer Advocates.” Hellander, I.

“PBS Frontline Interview with T.R. Reid, Fall 2008.” Reid, T.R. (2008).

“Sick Around the World.” Reid, T.R. (2008).

“Private health insurance and access to health care in the European Union.” Thompson, S. & Mossialos, E. (2004), Euro Observer, 6(1).

“Health Care Systems – Four Basic Models.” Reid, T.R.

“Health care reform must start with a plan to simplify.” McCanne, D. (2008), Quote of the Day, Sept. 18.

Talking Point 17: A majority of physicians (59 percent), and an even higher proportion of Americans (two-thirds) support single payer national health insurance or “Medicare for all.” Polling indicates that people are also willing to pay “higher taxes” for guaranteed coverage and that even the term “socialized medicine” has lost its negative connotations.

“Support for National Health Insurance among U.S. Physicians: 5 Years Later.” Carroll, A.E. & Ackerman, R.T. (2008), Ann Intern Med, 148, 566.

“Single-Payer, Health Savings Accounts, or Managed Care? Minnesota Physicians Perspective.” Albers, J.M., Lathrop, B.P., Allison, K.C., Oberg, C.N., & Hart, J.F. (2007), Minn Med, 90, February.

“PNHP Backgrounder: Recent Public Polls on Single Payer.” PNHP. (2007).

“PNHP Backgrounder: Physician Polls on Single Payer Prior to 2008.” PNHP. (2008).