In his address to the nation, President Obama made it clear: Jobs are now his #1 priority.
This is what most Americans wanted to hear. They fear that he has spent too much time on health care, and has not paid enough attention to climbing unemployment. This does not mean that they oppose health care reform legislation—it’s just that there are tired of hearing about it. And the need for jobs is more pressing.
It was a strong speech—particularly when the President acknowledged that “The only way to move to full employment is to lay a new foundation for long-term economic growth, and finally address the problems that America's families have confronted for years.” One jobs bill will not solve the problem.
President Obama also opened the door to a college education for many students when he pledged: “let's . . .give families a $10,000 tax credit for four years of college and increase Pell Grants. And let's tell another one million students that when they graduate, they will be required to pay only ten percent of their income on student loans, and all of their debt will be forgiven after twenty years – and forgiven after ten years if they choose a career in public service.”
These are good ideas. But what about health care?
Hours before the State of the Union address, some believed that the President would save health- care reform for the very end of his speech. The pivotal question was this: would health care seem an after-thought or a climax?
It would be neither. Rather than turning to reform as he closed his address , the president tucked the issue into the middle of his speech. One might even say that he “buried” the subject in the middle of a 90-minute oration.
When he finally came to health care, the President began by going for the laugh-line: “Let’s clear a few things up. . . . By now it should be fairly obvious that I didn’t take on healthcare because it was good politics.”
This set the tone for what he would say. Obama would be a amiable, not angry and not confrontational. This president does not change his style.
Tonight, once again, he was striving for consensus: “As temperatures cool, I want everyone to take another look at the plan we have proposed.” At that moment, it wasn’t clear who he was appealing to: Republicans? Or House liberals who are reluctant to vote for the Senate bill?
If the President was asking Republicans to take another look at the legislation, he is misjudging their interest in helping his administration accomplish anything.
Throughout much of the State of the Union, Republicans sat glued to their seats, stony faced, refusing to applaud. At other points, they were chuckling, smirking at each other as if to say: “Who does this guy think he is?” At one point, they laughed at him. I cannot remember either party ever showing as much disrespect during a State of the Union address.
I had hoped that the president would signal to Democrats that he expected them to come together: the easiest and surest way to pass the legislation would be if the House voted for the Senate bill. But the president did not say this.
On the other hand, President Obama did not suggest that Congress should settle for a stripped-down bi-partisan health-care plan. He emphasized that “The approach we've taken would protect every American from the worst practices of the insurance industry. It would give small businesses and uninsured Americans a chance to choose an affordable health care plan in a competitive market. It would require every insurance plan to cover preventive care.” These things would not happen under a scaled-back version of the legislation.
He came close to telling Democrats what they need to do: “Don't walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people. Let's get it done.”
Most importantly, the president underlined the fact that according to the Congressional Budget Office (which has a history of underestimating how much healthcare reform plans will save) “our approach would bring down the deficit by as much as $1 trillion over the next two decades..” This leaves opponents with something to explain: if the bill doesn’t control spending, how is it going to reduce the deficit?
I hoped that, as he finished his speech, the president would return to the subject of health care and make it clear that if we want to save the economy, we must have health-care reform. He didn’t do that.
But at the very end, he did show a moment of defiance, a flash of fire: “We don’t quit. I don’t quit. Let’s seize this moment . . ..”
As he said those words, I can only hope that President Obama was thinking of the Senate bill.
Dear Ms. Mahar,
I am about 200 pages into “Money Driven Medicine.” I am finding it informative and will written.
What, specifically, in the Senate Health Care bill addresses the issues you raise in “Money Driven Medicine”? Please provide sections of that bill which address these issues?
I just found your blog, so perhaps you have addressed this in a different post or article somewhere else. If so, please provide a link to there.
Thanks,
Tom M
I’m still trying to figure out how he’s going to double our exports in 5 years. What do we make that the rest of the world wants? And want two times as much of it. Unless he invented the new Snuggie II to be made in Troy, Ohio.
A president can talk to Congress while the rest of us are doing something else; he doesn’t need a national TV audience for that purpose. I believe remarks ostensibly directed to his Congressional audience were intended for the larger public viewership at home. Reaching out for concensus tends to appeal to the broad American middle exasperated with hyperpartisanship, and would achieve its purpose even if no consensus is achieved (the likely outcome). “I don’t quit”, or the scolding of Republicans for obstructionism and Senate Democrats for “running for the hills” seems aimed at reinvigorating support from the progressive left of the spectrum who have doubted Obama’s fighting spirit.
The same probably applies to the appeal to reconsider healthcare reform, the intended audience most likely being a public relatively disenchanted with the reform effort. I judge it unlikely that Congressional Democrats will be eager to push for comprehensive reform as long as that public attitude prevails, and so the effort will be critically dependent on changing public perceptions.
In this regard, it is probably time for both the president and reform proponents to seize the moment, and at least move toward negotiating a successful bill while some favorable responses to the president’s speech remain fresh in the public mind. A post-speech poll makes this point regarding not only healthcare, but other Administration agenda items as well –
http://www.mediacurves.com/Politics/J7719-ObamaStateofUnionPost/Index.cfm
The only way forward is to make huge effort about how repubs though minority are using filibuster on every single legislation. 40% of public is unaware of the senate’s convoluted procedures.So, how do you think the polls will look like and all that 40% is tired of this bickering for the past one year. People clearly want bipartisanship and president should make it crystal clear why he is failing even when is trying his hardest( at cost of some of own base). Right Repubs are making a better case.
As Ray has said, the president should indeed make it clear that the 40% undemocratic state representation in the Senate is the real reason why he and others cannot govern anymore. He should also point out the huge population disparities and resultant power disparities involved in this Senate faulty representation mechanism!
However, many, many in this country now almost believe that God has given us our constitution so we can’t mess with it even if our own demise is the result of not messing with it, IMO. In truth, special interests love the colossal leverage this Senate makeup gives them. You just have to buy a few votes in Wyoming to counteract 50 times those votes in CA! Pretty good bargain in a negative democratic sense, no??
The Senate is functioning exactly the way the Founders intended it, and exactly the way both parties want it to function. Anything to the contrary is tactical blathering. The only reason the Democrats are complaining now is that they are now in the majority — and, by the way, did not need any Republican votes to pass their bill.
There is zero, zilch, nada possibility that the filibuster rule will be changed. The Democrats do not want the filibuster to go away, no matter how much they like to blame it for their inability to deliver their own party’s votes. They’ll need it in the future.
The rules of the Senate are entirely — entirely — about increasing the power of the Senate as an institution versus the other organs of government. (A maneuver which was granted them by the Constitution, by the way.)
If you think the Constitution is no longer useful, then amend it. If you want to throw it out and start over, you’ll get anarchy and a free-for-all with blood in the streets, in my humble opinion. Which is probably why the drafters included the mechanism to amend in the document.
Obama was smug, arrogant and utterly without class to criticize the Supreme Court as it sat right in front of him and Democrats stood up next to the Justices to applaud the attack — like a high school pep rally.
If he needs more electoral reverses to internalize his mortality then so be it. Let November come.
And this:
“Throughout much of the State of the Union, Republicans sat glued to their seats, stony faced, refusing to applaud. At other points, they were chuckling, smirking at each other as if to say: “Who does this guy think he is?” At one point, they laughed at him. I cannot remember either party ever showing as much disrespect during a State of the Union address.”
— is precisely the way your party treats Republican presidents.
And this:
“The only way to move to full employment is to lay a new foundation for long-term economic growth, and finally address the problems that America’s families have confronted for years.”
is more nonsense. The country has been at full employment many times without whatever is percolating behind his collectivist brow, and will be again.
“A new foundation for long-term economic growth”? Like what? Smaller banks? Higher taxes? Transfer payments from future real jobs to present government jobs?
I guarantee you as he uttered those words he had no idea what they meant.
Perhaps this continues the somewhat off-subject thread here, but I heard an interesting suggestion from Doris Kearns Goodwin yesterday: supporters of health reform (or for that matter any other progressive legislation in the Senate) should just let the opponents filibuster. What will the public think as they see Senators reading recipes et al. for hours on end rather than doing the business of the USA? I don’t know exactly how the threat of filibuster replaced the actual filibuster, but it seems that the minority has not been required to actually filibuster in recent years in order to hold up legislative action. All that is required anymore seems to be an empty threat of filibuster. What’s with that? So the majority could just continue to work in committee or in their offices while the opponents are blathering, no? Except to their base, this might not be so good politically for the minority, after all.
Tim wrote:
The rules of the Senate are entirely — entirely — about increasing the power of the Senate as an institution versus the other organs of government. (A maneuver which was granted them by the Constitution, by the way.)
——————–
Everything you said is a statement of the current political situation concerning the Senate. However, I am trying to show how we no longer can govern for the majority of people because of this distortion. I stand behind my points that the non-democratic representation in the senate blinded of state populations (which are real people BTW) allows small groups to control large populations despite the large population’s desires. Eventually you will get your anarchy with this kind of distorted power, IMO.
Tom M
Tom– Welcome to the blog.
Always good to hear that someone is reading the book!
The central chapter of the book talks about overtreatment– when more care is not better care.
As I say in the introduction, quoting Karen Davis, two factors drive health care inflation in the U.S.–a) overtreatment. About 30% of our health care dollars are wasted on unncessary tests, unproven procedures, and over-priced drugs and devices that are no better than the older products they are trying to replace. We also are over-medicated; this is particularly true of older people.
How does reform legislation address this?
I don’t have page numbers in front of me, but if you search “Medicare” and programs, you will find many proposals for programs that would cut waste by realigning the financial incentives in the Medicare program.
In particular, we need to move away from paying doctors “fee for service” since fee for service payments encourage them to “do more.”
Instead of paying for volume, we need to pay for the quality of care– pay more for better outcomes at a lower cost.
We know that hospitals like Mayo and Intermountain are able to do this. Patients who go to these medical centers undergo fewer tests and procedures, see few specialists and spend fewer days in the hospitals than very similar patients who go to other hospitals.
The Dartmouth reserachers compared some of our most famous academic medical centers, adjusting for the race, age and income of patients and comparing patients suffering from the same problems. They found it cost Medicare 50% less when patients were treated at Mayo rather than UCLA medical center.
One thing the Dartmouth reserach has shown is this: higher quality and lower costs go hand in hand.
When hospital patients experience complications following surgery, fall victim to medication mix-ups of acquire infections in the hospital, bills are much higher.
In addition, doctors at the most medical centers that enjoy the best outcomes often are on salary, rather than being paid fee-for-service. They have no incentive to do more.
In addition because these doctors all work for the same organizaiton, they tend to collaborate.
The reform legislation would expand programs that reward doctors for joining “accountable care organizations” like Intermountain where they work together with one goal in mind: better outcomes at a lower cost.
Not higher revenues– lower costs.
In Money-Driven Medicine I also talk about the high cost of drugs and devices.
The Pharma industry, which makes both, has enjoyed very, very high profit margins for years.
The House bill contains a provision that would let Medicare negotiate for discounts on durgs– this is something that the governments of every other developed country do.
This provision is not in the Senate bill, but I am hopeful that, over the next three years, we amend reform legislation to let Medicare negotiate for better prices.
The VA is allowed to do this and has been very successful.
The Senate legislaiton also would create an independent medical advisory panel made up of physicians and other health experts that would take a look at Medicare’s fee schedule, adjusting fees to pay more for servcies that we know provide great benefit to patients (primary care, preventive care, chronic disease management) while lower fees for some very lucrative servcies that tend to be done too often and provide little benefit for many patients.
Finally the Senate bill encourages Medicare to experiment with “bundling” payments to doctors and hospital for a single episode of care. Every doctor who saw the patient for 3 months before he was admitted to the hospital (the primary care doc who sent him to a specialist, the specialist who sent him to a surgeon, etc.) plus everyone who cared for him in the hospital, , plus everyone who care for him for 3 months after discharge (re-hab, follow-up, etc) plus the hospital itself would receive a single lump sum payment for that episode of care for that patient.
(The payment would go to the hospital and the hospital would divvy it up. This may sound complicated, but they are doing it at Geisinger and it works)
There lump sum would come with a signicant bonus for quality ( good outcomes at a reasonable price when measured against benchmark medical centers like Mayo, Geisinger, Intermountain, etc.
This method encourages doctors and the hospital to collaborate–no one gets the bonus unless they do a good job as a team.
In the book, I write at length about how destructive and expensive it is when doctors and hospitals compete with each other. Bundling payments would encourage more collaboration.
Let me add that the reform legislation does not spell out exactly how and where to cut costs– it proposes pilot projects that will be expanded if they work.
I’ve written a couple of posts about why we shouldn’t expect the legislation to lay out a “master plan”– see https://healthbeatblog.com/2009/12/gawande-and-berwick-on-why-reform-legislation-cannot-lay-out-a-master-plan-.html
and https://healthbeatblog.com/2009/12/-gawande-and-berwick-on-why-reform-legislation-cannot-lay-out-a-master-plan-part-2-.html#more
It’s crucial to recognize that health care reform will be a process, not an event.
We don’t want poiticians in Congress deciding where to cut costs; this needs to be done by physicians and medical experts, using a scalpel, not an axe.
Ideally the Independent Medicare Advisory Panel would be making these decisions and Congress’ ability to interfere would be limited (as it was when an independent commission made recommendations for closing military bases.)
Finally, the legislation calls for comparative effectiveness reserach which will help tell us which treatments are most effective for patients who meet a particular medical profile.
Jenga, Fred, RAy, NG, Tim, Tim
Jenga I too would question how we are going to double exports.
Even if we invested more in manfucaturing, the cost of living in the U.S. makes the cost of labor very high– most of the world cannot afford are products. They too expensive and so just not competitive with products made in Asia and elsewhere.
If we invest in research and development, I can imagine that we could make products for a “green” world–but even then, I would have to think that solar panels made in Asia would be cheaper.. . .
It seems me to that we need to focus on service jobs that would improve the quality of life in the U.S.–more teachers and teachers’ assistants and smaller classes in our public schhols, cleaner parks, public spaces and cities; a cleaner environment; repair of infrastucture; good affordable daycare subsidized by the government; pre-school; urban farming (rooftop farming growing vegetables in inner cities. Because you save the cost of transporting perishable goods, this can be economical and a good way of getting fresh, nutrious food to cities.)
No doubt there are some specialized areas where we could expand exports. But double them overall??
Fred–
Yes the speech was definitely aimed at the public. If you want reform, you should send a message to your respresentatives in Washington.
Tell them that you realize the Senate bill isn’t perfect, but it represents a start, and that it should be passed as soon as possible.
Ray–
Yes, the SEnate rules make it very difficult to get anything done.
I think that the President’s televised meeting with Republicans yesterday may help some voters realize what he is up against: Republicans just don’t want to compromise.
This is why I think that Democrats are going to have to do it without the Republicans. If House liberals vote for the Senate bill, they have the votes to pass it.
NG– I agree that, at this point in our history, the two Senators per state rule does not seem at all equitable.
But clearly this is not the time to try to revise the Constitution– the country is too polarized. It would never happen.
But it is something that constitutional scholars are thinking about. Senate rules also need revision. Down the road, I hope we will do this.
Tim,
During 8 years of the Bush administration, no one in Congress ever shouted “you lie”. Legilsators never laughed at him while he was addressed Congress.
They didn’t read newspapers or hold up signs while he addressed Congress..
Moreover, Republcans pushed through virtually every major piece of legislation that Bush wanted–even when Bush lied to us about weapons of mass destruction.
Finally, this isn’t “my party.” I’m not a Democrat.
Tim– You might want to read my post on the economy. You also might want to do a little Googling about the economic poroblems that our middle-class has faced over the past 30 years.
The “the problems that America’s families have confronted for years.” is not a reference to unemployment, but to stagnant wages (adjusted for inflation) for all but the highest-income workers.
Meanwhile, the cost of some of the necessities of life– including college tuition and heath care have skyrocketed.
I read “Money Driven Medicine” Over a year ago and have read other books such as T.R. Reed’s “The Healing of America”
These books have convinced me that a single payer system would be the most effecient, but I doubt that we can get there from where we are today.
I was impressed with the President’s state of the Union address and hope the public and the Congress takes the message to heart.
The Republicans message of “NO” will come back to bite them. To me it seems that they are telling the public to “Drop dead we don’t care”
I just found your blog, so perhaps you have addressed this in a different post or article somewhere else. If so, please provide a link to there.
The US electorate has fired multiple warning shots that it does not want a communist takeover of our healthcare system and 16% of our economy. If you can’t read the pending disaster from the electorate taking back it’s country with the incredible Dem defeat in Massachusetts, then you haven’t been listening to the American public. The President has now learned that he did not have a mandate to jam socialism down our throats. Let’s give him credit for refocusing on jobs and punting a horrible health reform bill into oblivian. As Obama learned, no legislation is better than bad legislation. There are very simple ways via incremental steps to fine tune our health care system. The President has admitted defeat on the issue, and he now may listen and recognize that people do VOTE.
Hoyt–
On this blog, we try to avoid uninformed rants that toss around phrases like “Communist takeover.”
That’s why people probably won’t respond to your comment.
John H–
A single-payer system would cut administrative costs. The Commonwealth Fund estimates that as a result, a family plan that now costs an average of $13,000 (this includes both what the employer pays and what the employee pays) might cost $11,000.
That’s a significant savings,but it’s a one- time savings, and wouldn’t solve- our biggeset problem: health care inflation.
Compared to private insurers, Medicare has very low administrative costs. But Medicare is still very expensive, and getting more expensive each year. This is becuase the amount that Medicare pays out to hospitals, doctors, etc. has been going up 6% a year, year after year.
Each year, health care providers “do more” and Americans undergo more tests, more surgeries, more outpatient procedures. They take more drugs and have more medical devices implanted in their bodies.
We have about two decades of reserach showing that roughly 1/3 of these treatments are unncessary– the patient doesn’t benefit. (See http://www.dartmouthatlas.org)
Meanwhile, the price of virtually everything– drugs, devices, tests– keeps going up each year.
That combination of higher prices and spiraling volume is what drives health care inflation.
Other developed countries spend far less than we do not so much because the government pays all of the bills (though that does reduce administrative costs) but becuause the government regulates prices for doctors, drugs, hospitals etc, and keeps a cap on volume. (Different countries do this in different ways, but they all address the problem of rising volume of services and rising prices. And that’s what makes healthcare so much less expensive.
Their specialists are paid far less (even after adjusting for differences in cost of living). Their hospitals are much less expensive–and less resort-like. Many fewer private rooms. Less emphasis on amenities–carpeting, art-work, etc.
More emphasis on infection control. Hospitals in Germany, for instance, are pretty Spartan but very clean. And the care is usually very good.
In other countries, government refuse to pay drug-makers whatever they ask; they negotiate for discounts.
Finally, I do have one big problem with single-payer: What if Jed Bush became president? (And a legilsators who share his views rode in on his coat-tails and took over Congress?)
Margaret Thatcher did untold damage to the UK health care system, and since it was single-payer, patients had no place else to go.
IF Jed Bush were president I would like to have alternatives to the government run health care system. Some of our non-profit insurers–groups like Intermountain, Geisinger, Kaiser in Northern California are excellent. I would like to know that I had those alternatives.
When people talk about single-payer, they always assume that we’ll have a good government that puts the intersts of patients first.
But as we know, that isn’t always the case. Sometimes we elect a very bad government . . .
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