The President's Next Step

Matt Yglesias says the President shouldn't lead on tax reform, while Andrew Sullivan thinks he should.

Yglesias is correct that there are political risks of getting out front on this, but there are also political (and policy) risks of not taking this head on. Now that we have a second stimulus through the extension of the tax rates and a payroll tax holiday, a credible long term deficit reduction strategy is correct on the policy merits. For the President, it is likely the best politics as well, because leading on the deficit issue is likely the only way to win back independents in key states like mine (North Carolina) that the President narrowly won in 2008.

We will deal with the deficit and cumulative debt at some point, the only question is whether we do so only after an economic crisis when our options will be limited, or whether we do so in a reasoned manner. Now is the time to fight this out.

A two-pronged approach makes the most sense for the President: try and work with the Senate on tax reform, while insisting that the House Republicans follow through (after their repeal vote) and make clear what they would do to replace the health care law.

The President shouldn't allow the House Republicans off the hook after the repeal vote, but he should go back on offense and continue to ask: when are the committees going to start writing the replace part? If you have good ideas, lets have them and see if we can work something out. Remind them how easy they said it would be to enact common sense reforms that would truly address costs. See what the CBO thinks of their plans. Of course it is much easier to be opposed to something than it is to describe what you are for.

There are some consequential ways the Affordable Care Act could be changed to both address the unpopularity of the individual mandate, but more importantly to take some next needed steps to address health care costs. Modification bills along these lines (and perhaps others) would be good news, and the hardest steps on costs will only be done with both parties participating.

The President's Deficit Commission report (Bowles/Simpson) was approved by 5 of the 6 Senators on the panel, and this signals the potential for a consequential reform emerging from the Senate. All of the Senators voting in favor of the report, including leading conservative Tom Coburn, said the plan wasn't what they would have personally written, but they all know that a serious, long term deficit reduction strategy will look something like Bowles/Simpson, with an overall tax reform at its heart. The Senate being so closely divided means anything will take both sides participating (7 Republicans will have to vote to override a filibuster), and the President should seek to work with the Senate on a long range tax reform/deficit reduction plan. Given all the words that have been said about needing to address the deficit by House Republicans, a White House/Senate deal would produce enormous pressure on the House to get involved, and of course to shape any bill that would emerge.

If we ever adopt a serious, long term deficit reduction plan that moves us toward a sustainable federal budget, the last political step will include members of both parties passing a bill that is akin to their holding hands and jumping off a cliff together. The President is the only person who can take the first step toward the edge.

Small Steps

My friend Frank Hill with an interesting post talking about talking with people who differ from you on issues, big and small.

Frank and I met via correspondence around one of the columns I wrote on health reform for the Raleigh (N.C.) News and Observer. We were disagreeing about some aspect of the pending health reform law (I don't even remember what) but we started talking and sharing our distinct perspectives (Frank was Chief of Staff for Sen. Elizabeth Dole, and Rep. Alex McMillan from Charlotte).

The more we talked, the more we realized that our basic motivation for being involved in public policy discourse was fear about what we are leaving for our children, both in terms of debt, but also the seeming inability of our system to practically solve problems. We have become friends and have a project or two cooking together. Meeting and talking with Frank actually has helped me to clarify what I believe about some issues, and also to appreciate and see how 'the other side' thinks about some of them. However, Frank is no longer 'the other side' but now a friend.

Politics of illegitimacy

It is a bit off-topic for this blog, but several students have written and asked me what I think of the events in Tucson. It was a terrible human tragedy and a very sad day for our nation. It was a particularly grievous act in my mind simply because the shooting took place while an elected representative was going about her duties to represent her constituents.

We don't know why the shooter did what he did, but from past assassinations we know there is often a complex etiology for such attacks that tends to include mental illness. The role that rhetoric and imagery could have on violence is an important question, but I simply don't have an evidence-based answer. Yet, this event feels like a momentous occasion that is worthy of introspection.

As I thrash about and try and make sense of this tragedy and what it means for our nation going ahead, I settle on something I have been thinking about for awhile, and which has crystallized in my mind the past few days. The disturbing trend in American politics for losers of elections to decry the winners as being illegitimate.

I first voted for President in 1988 and I voted for the winner in that election. The country moved on pretty well.

I voted for the winner again in 1992, but there was a very different context to the aftermath of Bill Clinton's election. There was a general sentiment from some quarters that he was illegitimate as President because he received less than 50% of the popular vote cast due to the presence of Ross Perot's strong third party candidacy. Of course, the President is elected by the Electoral College and there is no stipulation that the winner must get a majority of the votes cast, though that typically was the case in modern times.

In 1996, President Clinton was re-elected with less than 50% of the votes cast (49.2% to be exact), again due to Perot being a candidate. It always bothered me that opponents of the President whom I knew personally would argue that he was illegitimately elected due to the fact that 'more people voted against him than for him.'

President Obama won approximately 53% of the popular vote, and had the largest Electoral College victory since President Reagan. Of course that hasn't stopped some of his political opponents from arguing that he is illegitimately elected even though the issue of his citizenship was long ago decided. Much of the opposition to the President has been tied to his 'otherness' I think, which is all designed to label him as illegitimate, which would make his policies all the more heinous.

Of course, my chronology skipped an election.

In 2000, the tables were turned, and I voted for the loser, Al Gore, who got more votes than did President Bush. Even though I had been irritated by the phrase after the 1992 and 1996 elections, this didn't stop me from saying to some that 'more people voted for Al Gore than President Bush' which is of course true but constitutionally irrelevant. I can vividly remember calling President Bush the 'President Select' before his January 2001 inauguration in derision of the Supreme Court's ruling in Bush v. Gore that settled the disputed election.

Several people older than I who are not big fans of President Obama have told me that they haven't seen the country 'as angry as it has been the past 2 years' in their lifetime. I always remark that they must not have come to Durham or Chapel Hill, N.C. between 2003-2008! Self righteous rage against one's political opponents is truly bipartisan.

There was a ubiquitous bumper sticker and tee shirt in Durham, N.C. around 2003 that said 'Somewhere in Texas a Village is Missing its Idiot.' This always made me chuckle until one day I heard one of my young children say that President Bush was dumb. I sternly told her that was disrespectful and asked her who she had heard that from. She said simply, you Daddy.

For some reason, I cannot get that out of my mind this week as I try and make sense of the tragedy in Tucson.

I think the essence of the progressive/liberal hubris is that we think we are smarter than everyone else. Instead of listening, and then trying to be persuasive and make the case, we are tempted to construct a defense mechanism that says that if you don't quickly adopt my view it is just because you don't understand. If only the country was filled with those as smart as me.....

I think the essence of the conservative hubris is the belief that conservatives are more moral/noble/patriotic than others. They are tempted to write off those who disagree with them as being unworthy of America because they think we don't love it enough. If only the country was filled with those as good as me.....

At their heart, both sources of hubris say that people with different views are illegitimate in one way or another. Someone who is illegitimate is not worth talking to, respecting, listening to, understanding, or even debating reasonably. Certainly not worthy of compromising with to solve the huge problems facing our nation.

BCBS NC and UNC

Word this morning of a major development in the local health care delivery marketplace where I live: Blue Cross/Blue Shield of North Carolina and the University of North Carolina Health System are beginning a joint venture to provide health care delivery services to BCBSNC customers in the Durham/Chapel Hill area. This joins the largest private insurer in the State of North Carolina with the very large UNC health system.

The plan is for 5,000 BCBS NC customers to be cared for at this facility, and only persons covered by the insurer will be treated by the new organization, with care being provided by UNC. The goal is to improve quality and lower cost via increased data sharing and organization. It is being heralded as an uber-medical home approach that will test new ways of interacting with patients and linking data to improve care. My biggest question is who will receive care in this new venture?

I would assume that many of the persons getting care at this facility would be State Employees who work at UNC health care or the University of North Carolina at Chapel Hill. However, the State plan is a self-insured plan that is administered by BCBS NC. Not sure if that fits the description of BCBS NC 'customers' or not? BCBS NC also has many employees in this area, so it could be that many of those who will receive care in the new facility will be their employees; again, I believe that BCBS NC has a self-insured plan that they administer for their own employees, so it is not clear if their employees are included in the planned 5,000 patients. Presumably the number will also include persons in the area covered by group or individual policies written by BCBS NC.

There has been tremendous aggregation in the local health care market, with many medical practices being bought up by UNC or Duke over the past decade, and especially the past 3-4 years. Duke owns Raleigh Community Hospital, and UNC has large linkages with Rex Health Care in Raleigh, which recently lead Wake Medical Center in Raleigh to seek records about UNC's dealings, and to claim that UNC was acting in a predatory manner in Wake County.

In short, the big player hospital and health systems are all trying to lock up as many physician practices, and therefore patient streams, as possible. And they are also looking for ways to improve care and reduce costs. This type of experimentation is what is needed in our health care system, but of course we don't know the results until they implement and evaluate this venture.

It is easy to say any change is due to health reform. In one sense that is correct. But, the aggregation was happening before health reform, and it will continue regardless of what happens next in Washington. The facts on the ground in the health care system are that we are spending ourselves into oblivion and our outcomes suggest we aren't getting our monies worth. We have to do something different. Ventures such as the one described lay out the hope of better organization leading to better care, potentially at lower cost.

The downside is the further aggregation of medical care delivery into fewer and fewer providers, reducing consumer choices. At least in the Research Triangle Area of North Carolina, the cow is well out of the barn on the medical practice aggregation issue and the only question remaining is how many large provider systems will remain in 10 years. Given that reality, and the fact that it is not easy to imagine moving away from this aggregation, it is good to test and evaluate new models such as this one.

Update 4:30pm 1/11/11:Someone from BCBS has told me that BCBS NC employees can use this facility, as can self-insured plans that are administered by BCBS; discussions between BCBS NC and the State Employees Health Plan about potential benefits of this facility for State employees are underway.

Christians and rationing

Charles Camosy with an interesting discussion of how he thinks Christians should view rationing of health care services.

EOL Switch Again

Word that Medicare is reversing its course and will not allow expanded discussion of patient choices such as advanced directives and options such as palliative care as part of Medicare annual exams. This is bad in policy terms and serves to limit access to important care for America's elderly. I guess the politics were understood to be too negative, especially the notion by some that this effort was sneaky and done in secret, put out in the federal register with little fanfare. OK.

Sing this from the rooftop, no more secrets.

We will all die. It is a matter of when, and from what. I want my grandmother, my mother, my father, myself, my wife and everyone I know to be able to hear the truth about prognosis, choices and quality of life. I want to make sure that informed consent means both 'informed' and consent which means 'made a choice.' Palliative care focuses on improving quality of life regardless of prognosis. I want access to it, again for those I love and for me. Everyone doesn't have to make the same choices my family makes or that I make.

Lets talk about this more, over and over. When you have an inevitable outcome of death, eventually there will be diminishing returns on what we do to forestall death. If you don't believe this, you believe it is possible you could live forever. You cannot. Lets talk about these facts as a country and figure out what we want to do. But, we need to start from the only thing I know to 100% true of the health care system: we will all die, it is only a matter of when, and from what. What do we want to be true about the care available in the Medicare program (8 in 10 deaths in the U.S. occur among Medicare beneficiaries) as this reality unfolds?

Quick update: I don't know if there was a faulty procedure in how Medicare put out this change; if yes, that is quite amateurish; if no, then politics are overriding policy/best care for patients.

It is a good to revisit health reform

The Republican majority in the House of Representatives is moving ahead with a repeal vote of the Affordable Care Act (ACA), which is set to take place on January 12, 2011. The conventional wisdom is that this is a waste of time because it would take 60 votes in the Senate to repeal the ACA and two-thirds of the House and Senate to override the inevitable Presidential veto.

I disagree. It is good news that we will revisit health care reform. I have written consistently that the ACA was a good step, in large part because it was a step. The law that was passed has the chance to begin to address health care costs if implemented, and substantially expands coverage, but we know that we will have to do more in the future to get a handle on health care costs. And we must do more soon because our long term deficit problem is fundamentally a health care cost problem.

One of the benefits of passing the ACA is that it has put the health care system in play, making further changes to health care inevitable. There are certainly policy options that would improve the ACA, and if the Republicans used their new found majority in the House to push some of these options like capping the tax exclusion of employer paid health insurance premiums to slow health care cost inflation, they would deserve credit.

Here are some thoughts I have about what a compromise between Democrats and Republicans could look like. If Republicans are inexorably opposed to an individual mandate now, then lets produce true universal coverage and do away with the need for one. I would trade true universal catastrophic coverage for scaled back insurance benefits and no individual mandate in a second.

The Republicans promised in the election that they would repeal the ACA. Fair enough, have the show vote. But, after that, they owe it to the country to provide clarity in the direction they would take the nation on health care reform. They have to shift from defense to offense. There is no evidence they have an offense.

Now is their chance to prove me wrong: they control the House of Representatives, and all the committees. They need to move beyond slogans and sound bites and write a bill. If it is so simple to address costs and 50 Million uninsured persons, the bill will be short and everyone can read it and get to know it well. Then have hearings on their bill. Mark it in a committee(s). Have the CBO score the bill. Let the country talk about it, and how it compares to the ACA. Debate the best way forward. And then put it to a vote in the full House of Representatives. The Republicans not only owe specificity to the country, they owe it to themselves if they want to be taken seriously on matters of health policy.