Finally

A clip of President Obama responding to Republican questions at yesterday's House GOP caucus meeting:



I have to say that, with regard to the stimulus package, Democrats really need to hammer home the notion that so much of it was tax cuts and that a huge chunk of it was aid to state and local government and unemployed insurance/COBRA help.  Democrats need to really challenge the Republicans to defend "not doing the stimulus" and the situation - in small towns and cities across the country - that it would have led to.

This forum, by the way, was great.  It was great for our politics in that it is great for citizens to see members of the different parties talking and disagreeing in a civlized fashion.  It was also great for the President, because he finally was able to take head-on so much of the garbage that Republicans have been throwing around.  It was not great for the House Republicans, but they do deserve a bunch of credit for allowing cameras in the room for the whole thing (which, some are now saying, they came to immediately regret).

Why the Republican "alternative" is just not very good

Timothy Jost, over at TNR's health care blog, "The Treatment," explains why the Republican plan to reform the health insurance system is, in general, a really bad plan:

Association health plans are plans offered by groups--such as business or professional associations and chambers of commerce--to their members or to the employees of their members. Association plans are already common in the United States, but the regulation of them varies from state to state. The Republican bill would subject them to federal regulation, largely preempting the existing state regulations. Consumer protection under the federal law, however, would be quite minimal, focusing primarily on financial solvency. 

Congress has rejected Republican association health plan proposals in the past. The main reason has been concerns that association plans could pick off the best health risks, making it more difficult for higher risk individuals and groups to find coverage. Another concern has been the lack of consumer protection and fraud prevention in association health plan proposals. (See here and here.)

The Republican bill would also permit an insurer licensed in one state to sell insurance across state lines, largely free from regulation in the states in which the insurance was sold. The idea is to increase competition among insurers and to free insurers from burdensome state regulations. Both the House and Senate health reform bills also permit interstate insurance sales. But those bills would give the states substantially greater power to protect its consumers--because there is a very real concern that the sale of insurance across state lines could lead to a race to the bottom in insurance regulation, with a significant increase in risk segmentation in insurance markets and in fraud.

High risk pools, another idea endorsed by the Republican bill, already exist in 34 states and provide needed help to many Americans excluded from insurance markets because of their health status. (See here.) Too often, though, they offer insurance with high deductibles and out-of-pocket costs. The Republican bill would allow them to charge premiums of up to 150 percent of a standard premium. This coverage would simply be unaffordable to many of the uninsured.

It is hard to argue against malpractice reform. Our current system leaves most victims of medical negligence uncompensated while it infuriates doctors and primarily benefits malpractice insurers and plaintiff and defense attorneys. There is ample evidence, however, that simply capping recovery of non-economic damages and attorneys fees at low levels, as the Republican bill would do, has the primary effect of making it difficult for victims of malpractice to get legal representation and nearly impossible for those who suffer no-neconomic loss (such as loss of reproductive capacity, disfigurement, the death of a child, or loss of functional capacity by a person who is not employed) to get any compensation. 

Although it is commonly believed that defensive medicine is a major contributor to medical costs, there is little empirical evidence the support this belief. The CBO estimates that reductions in the utilization of medical care due to the Republican tort reforms would reduce national health care expenditures by only three tenths of one percent. The CBO also acknowledged that the Republican reforms might result in worse patient outcomes. We need malpractice reform, but it must do more than simply turn victims away from the courthouse door.

Click on the link above to read the full post.  He goes into CBO comparisons of the two parties' proposals, which is worthwhile. 

I'll just add that it is important to remember that these proposals have been brought up before, including several times when the Republicans controlled Congress from 2003-2006, and for some strange reason, they never even made it out of committee.  Why would that be?  My guess is that the Republican Party is just flat-out not serious about reforming the health insurance system.  

'B' 2012 Watch: January 2010

Back in November, I briefly posted thoughts on the 2012 race. This is a quick update of that.

I decided to limit myself to candidates that are at least semi-likely to run. Thus, I will only be considering candidates with at least 3% on intrade. With that said:

Qualifying candidates:

Mitt Romney (24.9)
Sarah Palin (18.0)
Tim Pawlenty (10.0)
John Thune (9.5)
Mike Huckabee (7.8)
Rick Perry (4.0)
Ron Paul (3.6)
Jeb Bush (3.0)

Top 5 Preferred Candidates for GOP Nomination

Again, these are just out of the qualifying candidates. I have also divided support for the top 5 from a pie of one to further explain my preferences.

1. John Thune (.40)
   
2. Mitt Romney (.30)
   
3. Tim Pawlenty (.25)
   
4. Jeb Bush (.04)
   
5. Rick Perry (.01)

I am ditching the "Dist...Vote" thing I did last time. It had no mathematical basis. Instead here is a "Power Rankings" type thing of (B's preference * intrade strength). Max. is 100 if a candidate is virtually guaranteed the nomination and also receives 100% of my support:

1. Romney (7.47)
2. Thune (3.8)
3. Pawlenty (2.5)
4. Bush (.12)
5. Perry (.04)

Likelihood of Final Vote

1. GOP (.82) (+.02)
2. Dem (.18) (-.02) 

Approval of President Obama (1-10/Binary): 3/Nay (no change) 

Sane talk on the health care reform bill

From National Journal's Jonathan Rauch, who says that the Senate bill passes the "Thune test":

"Doing nothing would be better than doing what they are proposing to do," Sen. John Thune, R-S.D., told CNN in December. Regardless of what you think of Thune's answer, he raises the right question about the Democrats' health care reform. Is it better than nothing?

Republicans think that doing nothing this year might yield a GOP House majority in 2011 and a better bill in 2012. Maybe. But after the last attempt crashed in 1994, it was 15 years before Congress was willing to try again. If the current effort fails, the next chance for comprehensive reform might not arrive for years.

In the meantime, piecemeal changes might make matters worse instead of better. Absent broader reforms, legislative scrambles to cut Medicare would mostly shift costs to private payers, and requirements to cover all comers could price private insurance nearly outof existence. A few more years of ad-hockery and Band-Aids might leave the public in the mood for exactly the kind of single-payer socialized medical system that Republicans dread. Doing nothing, in other words, is not a risk-free proposition, even for the John Thunes of the world.

The Democrats' shocking loss this week of the late Edward Kennedy's Senate seat in Massachusetts certainly increases the odds that Republicans will block the bill. Still, even without a filibuster-proof majority, House Democrats could finish the job by swallowing their pride and simply passing the Senate bill. Should they?

I think the answer is yes. The Senate health bill, though flawed, passes the Thune test.

True, it could have been so much better. If, for example, it were bipartisan (but Republicans chose to boycott it). If its "pay-fors" were more solid (but this is the U.S. Congress we are talking about). If it were serious about malpractice reform (but these are Democrats we are talking about).

The expansion of health care coverage to many, though not all, of the uninsured may prove to have found the exact sour spot: enough new beneficiaries to increase demand for health services and so raise system costs, but not enough to deliver the risk-spreading and efficiency-capturing benefits of true universality. Despite mandates, many people will manage to free-ride, and some who don't free-ride will pay more in premiums. There is plenty to worry about here.
So what's to like?

First, the expansion of insurance coverage to tens of millions more Americans and the abolition of the "pre-existing conditions" insurance exclusion are changes for the better. A friend of mine made a full recovery from prostate cancer, only to find that he could not get health insurance at any price. Stories like his are common -- too common to be politically sustainable, let alone morally acceptable.

On paper, Congress might have found better ways of making insurance available to high-risk individuals than by requiring insurers to cover them and by creating government-regulated markets ("exchanges") where these individuals can buy insurance; the alternatives, however, are complicated, lack political support, and in the end might make government even bigger. (Indeed, one striking feature of the reform bill, given its all-Democratic provenance, is the extent to which it leaves the existing infrastructure of private health insurance intact. In a few years, the public might be less willing to do that.)

Second, the bill is probably as close to paying for itself as the political system is likely to manage. It would be great if Congress made up-front reductions in other programs, rather than counting on, for example, Medicare savings that may or may not materialize. But, given the political unacceptability of horror stories like my friend's, the real-world alternative to plausible-maybe-almost-sort-of fiscal neutrality is something more like the Republicans' 2003 Medicare prescription drug bill, which made no attempt at all to pay for itself.

Although long-term budget projections are squishy, the Congressional Budget Office's are the best we have to go on. Notably, CBO scored the Senate bill as deficit-neutral (actually, it would slightly reduce the deficit) over the reform's second decade after enactment, which is well beyond the window of cost-shifting and timing gimmicks. We could do worse, and possibly will do worse next time around.

And what about bending the cost curve? Health care inflation devours wages, burdens employers, and could eventually bankrupt the government. A reform that fails to grapple with the cost problem, the critics say, is not worth having. I agree.

So how does the reform score on cost control? The original House bill does poorly. However, the Senate-passed bill is better on cost control than many people realize. Although far from optimal, it contains a potential pathway to a restructured health payment system that gets incentives right instead of wrong.

I'll return to that weasel word "potential," but first the major elements. Most economists believe that two pervasive market distortions fuel health cost inflation. The first is Medicare's fee-for-service payment system, which pays providers based on the number of procedures they perform, rewarding inefficiency. The second is the tax deductibility of employer-provided health insurance, which subsidizes high-cost policies, hides the costs of those policies from employees, and denies employees the opportunity to shop around.

Both distortions inhibit market discipline, and both originate with bad government policy. If socialized medicine is state payment for most health care, then the country is there already: When the value of the employer tax subsidy is included, the government (federal and state) pays for almost 60 percent of all U.S. health care, according to Paul Van de Water, an analyst with the Center on Budget and Policy Priorities. Dealing with Medicare and the employer tax deduction is therefore crucial to cost control.

Medicare is a tough problem, both because of the politics and because no one really knows how to fix it on a national scale. The reform bill includes programs designed to identify better payment methods, and it establishes a special commission that could, theoretically, help push through worthwhile Medicare reforms. There is no guarantee, obviously, that those schemes would work. But they might well improve the situation, and they are unlikely to do any harm.

As for the employer tax break, the Senate bill docks it. Not a ton. Only high-premium policies covering a minority of workers would be taxed. But even the limited tax is very important, for several reasons.

Crucially, the threshold for taxation would not rise as fast as health inflation. Translation: Gradually more and more employer-provided policies would be taxed. The change would be incremental, even glacial -- but slow seems to be the only pace with which Americans are comfortable.

Moreover, after reform is enacted, the taboo on taxing employer-provided health benefits will be shattered once and for all. From then on the question will be how much to tax, not whether. A door that had been welded shut will have been pried open. The country will be able to have a new kind of discussion, one in which the tying of health insurance to employment -- which is insane, when you think about it -- is no longer sacrosanct.

Meanwhile, the reform also includes a provision quietly inserted by Sen. Ron Wyden, D-Ore., that allows a narrow band of workers to cash out their employer's health insurance tax break and use it to buy a policy of their own choosing. In other words, instead of being captured by the employer, the tax subsidy would flow to the employee.

Again, the provision applies only to a few workers -- at first. However, as rising costs push up premiums, more workers would qualify. No less important, the provision puts in place both a precedent and a mechanism for rewiring the system so that consumers, not employers, can make the choices.
Taken together, these measures could set in motion a virtuous cycle. As health costs rise, more employer-provided health plans become taxable, giving employers an incentive to find cheaper plans. As employer-provided plans grow less generous, more employees have an incentive to take a tax credit and shop around, and, as premiums rise, more qualify to do so. Little by little, insurance coverage shifts toward an individual-based, consumer-driven market. And the faster health insurance costs rise, the faster the transition happens. The disease triggers its own antibodies.

Again, no guarantees. The transition would be very gradual, and political blowback could easily disrupt it. But the point is that the reform contains a pathway to sanity. No one can say that about the status quo.

Is Evan Bayh a spineless, weak, empty shell of a people's representative?

I'm just asking:

“The only we are able to govern successfully in this country is by liberals and progressives making common cause with independents and moderates,” Bayh said.  “Whenever you have just the furthest left elements of the Dem party attempting to impose their will on the rest of the country -- that’s not going to work too well.” 

This is pure garbage, and Bayh knows it.  In what universe are the furthest left elements of the Dem party imposing their will on anybody?  In the real world, liberals and progressives have been making common cause with independents and moderates on health care, which is why "the furthest left elements of the Dem party" are very disappointed in the quite tepid health care bill, the stimulus bill that had to be stripped down by $100-200 billion for no stated reason, the lack of activity on gay rights, the troop buildup in Afghanistan, and the failure to carry through any meaningful reform of the financial industry.

There are whispers of Mike Pence running against Bayh.  Obviously, I don't like Mike Pence and, yes, he would appear to make a more terrible senator than Bayh.  But after all this, I'm actually not sure just how much more terrible Pence would be than Bayh has been as of late.  And at least with Pence, we know what we'll be getting, but with Bayh, who knows?  

Voting for Pence is like buying a gallon of rotten milk that is already past its "best by" date: you know it's going to taste awful and be bad for you; voting for Bayh is like buying a gallon of milk with a mis-printed "best by" date: you think it's going to be delicious and nutritious, but it tastes of feet and old cheese, and on the bottom of the jug a printed label tells you that you really shouldn't have wanted non-spoiled milk in the first place because, well, that's just over-reaching.

Caption: Evan Bayh (D-IN), seen here at a town hall forum on how to use ridiculous claims about the fringe elements of one's own political party in order to avoid the responsibility that comes with being a leader, feigns trying to hear the concerns of an uninsured constituent.  Bayh used the same gesture when two other constitutents spoke: one was a woman who had been denied coverage because of a pre-existing condition, and the other had been repeatedly denied coverage that was included in his original insurance policy.  Bayh did not seem to have any trouble hearing anything that representatives of the health insurance industry had to say, especially those from WellPoint.

Supreme Court fights boldly to keep the voices of corporations and unions from being drowned out by the voices of actual people

From the NYT:

The Supreme Court threw out a 63-year-old law designed to restrain the influence of big business and unions on elections Thursday, ruling that corporations may spend as freely as they like to support or oppose candidates for president and Congress. The decision could drastically alter who gives and gets hundreds of millions of dollars in this year's crucial midterm elections.

By a 5-4 vote, the court overturned two of its own decisions as well as the decades-old law that said companies and labor unions can be prohibited from using money from their general treasuries to produce and run their own campaign ads. The decision threatens similar limits imposed by 24 states.

It leaves in place a prohibition on direct contributions to candidates from corporations and unions.
Critics of the stricter limits have argued that they amount to an unconstitutional restraint of free speech, and the court majority agreed.

The key change:

The decision's most immediate effect is to permit corporate and union-sponsored political ads to run right up to the moment of an election, and to allow them to call for the election or defeat of a candidate. In presidential elections and in highly contested congressional contests, that could mean a dramatic increase in television advertising competing for time and public attention.

In the long term, corporations, their industry associations and labor unions are free to tap their treasuries to assist candidates, although the spending may not be coordinated with the candidates.

Some might wonder how this is different - worse or better - than the corporate- and union-sponsored PACs that we have right now.  Well, those PACs aren't affected at all by this decision.  PACs can still give money directly to candidates and support them in other ways (while falling under the regulatory guidelines of the FEC) and they can still promote "issue advocacy" campaigns; however, that money has to come voluntarily from employees, members, and other parties.  It can't come directly out of the corporation's or union's treasury.  Now, coprorations and unions can draw from their vast reserves to spend as freely as they please to support or oppose specific candidates. 

Here are a few quotes from key players:

- ''The censorship we now confront is vast in its reach,'' Justice Anthony Kennedy said in his majority opinion. (Really? Vast?)

- Justice John Paul Stevens said in his dissent, ''The court's ruling threatens to undermine the integrity of elected institutions around the nation.'' (True, and one might add that said "integrity" is already pretty weak.)

- ''It's going to be the Wild Wild West,'' said Ben Ginsberg, a Republican attorney who has represented several GOP presidential campaigns. ''If corporations and unions can give unlimited amounts ... it means that the public debate is significantly changed with a lot more voices and it means that the loudest voices are going to be corporations and unions.'' (This would seem like an obvious problem in a government "of the people.")

- Sen. Mitch McConnell of Kentucky, the Senate Republican leader who filed the first lawsuit challenging the McCain-Feingold law, praised the court for ''restoring the First Amendment rights'' of corporations and unions. ''By previously denying this right, the government was picking winners and losers,'' McConnell said. (Is he saying that up until now, corporations have been losing?  If that's the case, I'd hate to see what the world looks like when they're winning.)

- Chief Justice John Roberts, in a separate opinion, said that upholding the limits would have restrained ''the vibrant public discourse that is at the foundation of our democracy.'' (That's right, your honor, you can't spell "vibrate public discourse" without "unlimited corporate influence." Thanks for the reminder.)

Perhaps the most repugnant element of this decision is that there wasn't actually a case before the court that required them to answer this issue.  Really, the question was a rather narrow one about whether or not a particularly new type of campaign "message" should fall under FEC regulations.  But some justices wanted to go a little further:

Stevens, in a 90-page opinion that dwarfed Kennedy's, complained that the court majority overreached by throwing out earlier Supreme Court decisions that had not been at issue when this case first came to the court.

''Essentially, five justices were unhappy with the limited nature of the case before us, so they changed the case to give themselves an opportunity to change the law,'' Stevens said.
The case began when a conservative group, Citizens United, made a 90-minute movie that was very critical of Hillary Rodham Clinton as she sought the Democratic presidential nomination. Citizens United wanted to air ads for the anti-Clinton movie and distribute it through video-on-demand services on local cable systems during the 2008 Democratic primary campaign.

But federal courts said the movie looked and sounded like a long campaign ad, and therefore should be regulated like one.

The movie was advertised on the Internet, sold on DVD and shown in a few theaters. Campaign regulations do not apply to DVDs, theaters or the Internet.

The court first heard arguments in March, then asked for another round of arguments about whether corporations and unions should be treated differently from individuals when it comes to campaign spending.

I'd be interested to know what some of you lawyers or soon-to-be lawyers think of this.