20 February 2009

The Workhorse Group

Another note from today's New York Times:

Since last fall, many of the leading figures in the nation’s long-running health care debate have been meeting secretly in a Senate hearing room. Now, with the blessing of the Senate’s leading proponent of universal health insurance, Edward M. Kennedy, they appear to be inching toward a consensus that could reshape the debate.
So, who's represented at the so-called "Workhorse group"?
The 20 people who regularly attend the meetings on Capitol Hill include lobbyists for AARP, Aetna, the A.F.L.-C.I.O., the American Cancer Society, the American Medical Association, America’s Health Insurance Plans, the Business Roundtable, Easter Seals, the National Federation of Independent Business, the Pharmaceutical Research and Manufacturers of America, and the United States Chamber of Commerce.
Dr Wes is annoyed at the representation of so many interest groups. I would counter, however, that a big part of the reason health care reform failed in 1993 was the failure of the Clinton administration to get all the stakeholders together and to come to consensus prior to the introduction of legislation. If the Chamber of Commerce is not on board, they will be on the outside throwing hand grenades and disrupting the process. They may never sign on -- I don't know. But AHIP and NFIB were active opponents of health care reform the last go-round, and if they are on board, that may go a great way towards removing massive obstacles to the legislation.

The key points of the emerging "fragile consensus" seem to be:
  • A mandate for all persons who can afford it to purchase health insurance;
  • Means-tested subsidies of the cost of purchase, for those who qualify;
  • Enforcement of the mandate via a tax penalty;
  • Community rating for private health plans;
  • A "Floor," or minimum standards for benefits provided by heath plans;
  • Expansion of Medicaid eligibility.
Still up for debate:
  • Pay or Play, or a requirement for large employers to provide health benefits or pay a supplemental tax;
  • A public plan, such as opening the FEHBP to any citizen, to compete against private insurance plans.
This is pretty good progress, if it can be believed -- and were I a cynical man, I might suspect that this memo was leaked to the Times to cement the compromises made thus far as "done deals." The insurers' lobby has apparently accepted the bitter pill of community rating (requiring them to charge all comers the same rate) in return for the universal mandate (which will bring many more customers to their business, expanding their revenue base to offset the expense of community rating). Fair enough. If the negotiations don't blow up, this is an excellent starting point. If the strongest opponents of reform can be co-opted into support, albeit tacit, or at least non-opposition, that will give Obama a huge leg up, and the ability to use the bully pulpit to argue for the few remaining progressive priorities.

Also interesting is the fact that the republicans have chosen to absent themselves from the process. One can infer from this that they will take the same tactic on health care reform that they did for the stimulus. Namely, whine about the lack of "bipartisanship" and reflexively oppose. Of course, if right-wing organizations like the Chamber of Commerce are in support, it will be hard to make any credible claim that this is ideologically-driven left-wing partisanship. This legislation is also more likely to attract support from GOP moderates like Snowe, Collins and Specter, making the obstructionists in the rest of the dead-end caucus that much more irrelevant. Just as well, since they still don't seem to have any new ideas.

One more note: apparently Obama is going to use his big Budget speech on Tuesday to open the debate about health care reform, and as I mentioned previously, Baucus is beginning Senate hearings on reform the very next day. And so it begins.


  1. This is encouraging. When Obama talks about bipartisanship he isn't necessarily talking about working with those in Congress who have taken a vow of opposition. He is talking about engaging various ideologies. That's a much better tact that just saying hell with it, and returning to the 50.1% rule. He's a pretty good leader.

  2. I hope something happens before my student health insurance runs out this summer. Even if I can buy some insurance somewhere! (try getting health insurance as a non-affiliated consumer)

  3. "I would counter, however, that a big part of the reason health care reform failed in 1993 was the failure of the Clinton administration to get all the stakeholders together and to come to consensus prior to the introduction of legislation."

    Wow. I would argue that the reason Hilliarycare failed was that most of the policy was developed behind closed doors with special interests (like the current Kennedy approach). Further, the fact that you are happy that special insterests are directing health care policy rather than those delivering the care is, well, stunning in it's own right. Are we not excluding the ultimate "stakeholders" in the debate: the doctors, nurses, and their patients in this debate?

    Oh, I forgot, they're just there to pay for the pork.

  4. Mandated health care?? Mandated minimal coverages...mandated, mandated, mandated!!!
    Dear God what happened to freedom in this country??

  5. My that's a handsome horse. Percheron?

    Anyway...it concerns me that a mandate that I must buy insurance does not imply that I will actually be able to receive care. I tend to agree with you guys in terms of getting "skin in the game" as a patient; further strengthening the role of the intermediary who may or may not pay for my care is not the way to do that, IMO. I don't think the insurance companies are the players that need help in our system right now.

  6. Wes,

    First of all, though I too am a member of the "Doctors are so awesome" club, I have to say that most doctors I have known, when it comes to health policy, couldn't find their asses with two hands and an ass-finding device. This applies in spades to more than a few MD bloggers, present company excepted. So I don't know that doctors as a group deserve a primary role in developing the policy. We should be represented, though, and you should have noted that the AMA is one of the groups at the table. I think you and I both share a lot of concerns about the AMA in terms of its effectiveness and how well it represents the interests of physicians, but to Washington, they *are* the physician lobby and at least they are there.

    As for "why" the Clinton plan failed, well, there were a *lot* of reasons. One was the fact that they tried to ram it down the throats of the business and insurance lobbies. I do not think the lack of transparency in itself was a cause of its demise. The "secret Clinton meetings" were railed against by those who were opposed to the plan from the very beginning, and used as a pretext for further opposition. But it wasn't the secrecy that doomed it -- much more determinative was the strength of the opposition, and the clumsy way the administration handled the politics.

  7. Kipper,

    Yes - percheron. Much bigger and more impressive than the puny Clydesdale (joke).

    You are right that health insurance reform is not itself a guarantee of access to health care. As Kevin MD has pointed out many times, once we all have insurance, there will not be enough primary care doctors out there to see us all. So getting funding for all is only one step in the process.

    And this is hardly an insurance company giveaway. It actually has the potential to compete them out of existence, if the public plan is properly implemented.


    Freedom is an illusion. You are mandated to buy car insurance, you are mandated to pay taxes, you are mandated to stay the hell off my lawn. Best get over it.



  8. Isn't that essentially the plan John Edwards was proposing in the primary, if you add in the public plan?

    Sounds like a good start to me.

  9. shadowfax,

    Perhaps freedom is an illusion, but if it is, then our value as human beings has just been taken from us and we are nothing more than a bunch of drones for whomever happens to be in power at the moment. OR perhaps freedom is not an absolute, and thus we have laws limiting that freedom, which is nonetheless real. I prefer the latter idea, and as a result of that, resent more and more encroachment on that freedom. What made this country the greatest in the history of the world was freedom, not an unfettered free-for-all, but a freedom to do our best, to take risks, to live our lives as we wanted to do, as long as it didn't impinge on another. The thought of a bureaucratic clerk somewhere, I don't care if he/she is in the government, the better business bureau, or wherever, telling me what is good for me and what I must do for "the common good" sticks in my craw. It is the very antithesis of what this country, its people and its heroes, have always stood for.
    Sorry, putting soap box away now, but I am so sad at what is happening to the country and its people, and when I look at all of these freaking mandates, my blood starts to boil (is that hemohyperthermia, perhaps??). I can't help but rage as I watch us turn into a herd of brain dead sheep being led to slaughter.

  10. Having a practitioner to see is certainly an important part of access. Cost is another. More and more lately it seems that seeing cash-only practitioners is less expensive to me than the balance billed after my insurance has had their say, plus I know the cost up-front rather than being surprised to learn that I owe a few hundred dollars 60 days on. I suppose that by making sure the practitioner receives some token payment if I turn out to be a deadbeat the insurance is providing some sort of benefit in this relationship...but not being a deadbeat, I feel like I get taken coming and going (and it's *not* the payment to the practitioner I begrudge, aside from the lack of transparency).

    I play contact sports, so I really can't go without health insurance. I really, really wish it was easier to kick it to the curb and actually talk payment directly with my care givers in the vast majority of non-traumatic situations where insurance seems to be doing more harm than good, though.

    What's worst about this is that I understand I'm speaking from a pretty privileged position (good income, good savings, good health, no dependents)...I can't imagine the health care cost trade-offs I'd be making if this was not the case, assuming I was insured to the same level as at present.


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