Thursday, September 10, 2009

Good speech, now the hard part

The President was effective last night at laying out the need for reform, especially how the current system harms people with insurance currently (we all pay for uncompensated care via higher premiums). I thought the public university v. private university analogy was very effective re public option.....someone should have been using that one for the last 6 months, but it doesn't really matter as public option will go by the wayside.

While the delay of the Senate Finance Committee has been viewed as a harm, this may now help the President as they have an outline but still time for negotiations amongst Democrats and perhaps with Republicans such as Snowe or even others....but mostly a chance to get more conservative Democrats on board.

Several thoughts about the next steps:
(1) any Republican Senator could get a lot on malpractice reform added to the Senate finance committee bill if they agreed to support it....heck the conservative Democrats may be able to get alot on that issue. AMA's wildest dream med mal proposal for public option trigger? Any takers on either side.....

(2) Similarities to 1993-94. The House could easily pass a bill then, just as now. But, the focus then (as it will now) turned to what will the Senate really do? Then the House insisted the Senate go first and the Senate never got to a floor vote and so neither did the House. I am sure there will be some moves in the Democratic House caucus to not want to vote on public option knowing it won't pass in the Senate. Maybe Pelosi should allow a House vote on Weiner's single payer bill soon, letting everyone (Dems and Repubs) blow off some hyperbolic steam, and then see what the Senate does.

(3) What is different from 1993-94, politically. Democrats didn't think it was possible to lose the House. They did the next election. So, in 15 years, we went from Democrats control all three branches to Republicans control all three branches and now back to Democrats control all three branches. If a reasonable bill can't be passed, then the Democrats really have trouble saying they can govern the country. So, the biggest difference from 1993-94 is that the congressional Democrats know they must deliver.

(4) What is different from 1993-94 from a system perspective. I remember many saying in mid-1990s that there was no way we could spend more....there must be a ceiling somewhere? Haven't found it yet. Also, we are now only 10 years away from the looming Medicare financing train wreck that will result from the baby boomers aging into Medicare. The train wreck has three parts: (1) more retirees on Medicare; (2) fewer workers to pay payroll and income taxes to finance Medicare; and (3) rate of cost growth. The only one of these that can be changed is number 3....numbers 1 and 2 have been inevitable SINCE I WAS BORN IN 1967, simply because the baby boomers had fewer children than did their parents.

If we don't pop the bubble of cost growth now, 10 years from now there will be some very hard choices....and the options get tougher the longer you wait.

The President's proposal of an Independent Medicare commission followe the Senate finance committees outline of similar. And the Patients' Choice Act, the main republican alternative has such a commission, and has the most stringent applicaiton of cost effectiveness research of any bill I have read. This is the best chance for slowing cost growth in Medicare.....Congress isn't capable of addressing these detailed issues of payment rates, coverage decisions and the like reasonably.

To summarize, today we are 10 years from a Medicare train wreck and in 1994 we were 25 years from the same train wreck. So, there are political and actual reasons why there should be a better chance of getting something done this time as compared to 1993-94.

(5) Finally, I was in graduate school in 1994. I was a straight Medicare for all single payer guy know, either my grandmother should be liberated from it, or it might be pretty good for me (well, that is still true, but I digress). So, I was constantly picking holes and bickering with all my friends about the President's sell out plan and the like....lets take this issue to the next election and come back and do it right next time. Oops.

I would now prefer Medicare for everyone with persons under age 65 having catastrophic insurance (say $10,000 deductible indivdiual; $15,000 family). Robust private insurance market for insurance covering the gap, and let everyone purchase private gap insurance in after tax dollars. Premium subsidies for gap insurance for low income persons. Heck, maybe the insurance companies could do just fine with that.....and Republicans are always saying they want catastrophic insurance and choices. Most persons won't spend into the government catastrophic insurance range in a given year. So, most care will be paid out of pocket and/or via private insurance purchased by an individual.

But, that ain't going to happen. So, for me, we have got to work a compromise that moves the ball down the field, and it has got to have some ways to address cost inflation in the system. If we could get the rate of uninsured approaching 5%, and have a strong IMAC and a cap on the tax exclusion of employer paid premiums which would slow cost growth in the non elderly part of the system, that would be pretty good.

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