(photo: @Doug88888/flickr)

I see that the Conference of Catholic Bishops has figured out how the Obama Administration has either cleverly or by fumbling finessed the contraception insurance coverage issue while exposing the Bishops to the charge their demands are more about using government to restrict women’s rights than violating the moral conscience of a bunch of old men.

The Bishops are upset because they wanted contraception to be banned, and if not banned, then at least not covered by insurance, and if covered for some, then not covered for others, with the exceptions eventually swallowing the rule. They now realize they lost. Virtually everyone in the relevant group must be covered under the “compromise” rule.

Now they are forced to put aside their phony religious liberty argument — this was always about imposing their views on everyone else — and foment against the rule on the basis that no one should get contraceptives and government should enforce that restriction.

I’m sorry, but contraceptives became inevitable from the first bite at the apple, and there’s nothing the Bishops can justify now to take away Eve’s entirely reasonable response: “You can have a bite, Adam, but use a condom.”

They say “God works in mysterious ways . . . ” but this one has most of the media completely bamboozled into thinking Obama compromised or blinked or something. And perhaps even he may believe that. My front page New York Times tells me he was forced to “soften” the contraception policy to accommodate supportive liberal Catholics like Sister Carol, the head of a Catholic hospitals group. Fine. I’m glad they are happy, but I think what Obama did actually strengthened the underlying public policy.

Even stranger, the WaPost’s Sarah Kliff quotes Administration spokespeople doing their best to obscure how simple and clarifying the new rule is. To see this, recall that the medical cost studies show it costs less to provide contraception than to not cover it. One way this scheme might work, then, is that the insurers explain the policies one way to the employer, then interpret and implement them differently to the employee via a separate letter or rider. The care providers know this and bill accordingly. Then you realize that the insurers won’t be eating extra costs from covering contraception; they’ll be pocketing the savings because the premiums collected via the religious employers can assume that the employees aren’t covered, even though they are. The collective winking this requires is astonishing. The gods are smiling.

This was always about a health services issue and how it gets paid for, without letting ideological zealots dictate what services get covered. The fact that America still funnels health payments through private insurers and collects the premiums via employers redirecting what would otherwise be employee wages and salaries complicates matters, making US health care more costly, creating terrible incentives, and confusing everyone. So let’s sort out the basics.

When government does this, as it does for Medicare, everyone old enough is covered. We then collect the revenues through taxes on tax payers and workers, taken out of their paychecks. The government decides what medical services are covered. Employers don’t provide health care; they are agents for collecting payroll and withholding taxes, and it’s not their role to tell the government what medical services to cover. That’s an issue to be decided by government through their representatives and administrators. No responsible government would allow the Bishops to dictate their religious beliefs about which services Medicare can or cannot cover.

Employer-provided health insurance is inferior — more costly, subject to perverse incentives that must be regulated — but it’s subject to the same concepts. The government can still decide, if it chooses, which medical services to cover as a national health policy. So if the rule is cover contraception, then insurers must do that. The employers are still nothing more than tax collectors, or in this case, premium collectors, and once the government decides what must be covered, it’s not up to employers, religious or otherwise, to compel government not to cover something.

As I’ve argued before, the Bishops want to compel the government to choose covered medical services based on the Bishop’s religious preferences. That would obviously violate the establishment clause of the Constitution’s First Amendment. The Bishops also argue that many of their institutions self insure. So? If an institution wants to function as an insurance company, it can, but that doesn’t create any special privilege to ignore the coverage rules that apply to all other insurance companies.

What the revised Administration rule does is to separate the government’s role in deciding the essential medical services that insurers must cover from the revenue collection function of the employers who elect to offer employer-provided insurance. Employers don’t have to offer insurance, but if they do, the insurance must meet the minimum national insurance requirements.

The new rule properly puts religious institutions in the right context. The Bishops will squawk, because they want to control the government role. But they are fighting the First Amendment when they make that demand.

Digby shares some other views.

HHS and Sen. Ron Wyden (D-OR) believe in fairies and insurance markets

The notion that the health insurance exchanges required by the Affordable Care Act would reduce health care costs using “competition” between concentrated health insurers was always one or more unbridgeable chasms away from a plausible theory.

But the myths of competitive markets are so deeply ingrained in our political discourse it was inevitable that a nominal Democratic President not constrained by conceptual coherence and a corrupt Congress would try to sell us the conceit as the only politically feasible model for health care reform.  The economists — not to mention international experience — told us it was gibberish, but nobody cared.

Now, however, the Obama Administration has given up even the pretense of a competitive model for the state-administered private insurance exchanges.  From Saturday’s New York Times (i.e, a Friday night news dump):

In a major surprise on the politically charged new health care law, the Obama administration said Friday that it would not define a single uniform set of “essential health benefits” that must be provided by insurers for tens of millions of Americans. Instead, it will allow each state to specify the benefits within broad categories.

The first thing you note is that this move is one more step towards Mitt Romney, who argues that RomneyCare might be fine for Massachusetts, but each state should be free to decide for itself how best to provide health coverage — or not.  The White House political geniuses who have managed to position their guy as only barely beating or even with the most embarrassing and offensive array of GOP clowns in memory apparently think moving towards Mitt’s incoherent position will leave one less reason to vote against Mr. Obama; others might conclude it’s one less reason to vote for him.

But let’s return to the unproven theory that “competition” between private health insurers will produce better quality and/or lower prices for insurance and hence more affordable quality health care.  Even economists like Paul Krugman who supported the overall ACA package because, among other reasons, it promised through other means to cover tens of millions of the currently uninsured, warned us that private health insurance does not lend itself to the competitive model, but no one — including Democrats — paid attention to that point.

Still the theory of competitive markets depends on some very basic assumptions.  One of the most important is that for an exchange to make sense, the product must be a more or less uniform commodity/service.  Suppliers are then forced to provide that uniform product, buyers can compare on price or perceived fidelity to the uniform standards, and the invisible hand of competition will force markets to clear at the marginal cost.

But all but the most efficient suppliers hate the model and marginal cost pricing, so the first thing they do to undermine the ability of competition to push prices down to marginal cost is to claim their product is different, new, improved, and thus deserves a higher price — or conversely, claim their inferior/dissimilar product is the same as their competitor’s and thus deserves at least the same price.  Consumers have little power to determine whether this is true, and cannot afford to find out when they’re sick; the inherent information disadvantage is then exploited by suppliers.  So much for competition driving down prices, even if insurance markets were not highly concentrated, which they are.

What Mr. Obama’s HHS has done in the hope of beating Mitt Romney is to facilitate the market’s ability to be less competitive and thus to raise prices.

To be sure, each state could define it’s own uniform product, and HHS explains this as a virtue:

Under this approach, each state would designate an existing health insurance plan as a benchmark. The benefits provided by that plan would be deemed essential, and all insurers would have to provide benefits of the same or greater value. Plans could modify coverage within a benefit category so long as they did not reduce the value of coverage.

Whom are they kidding?  If Rick Perry’s Texas can define the state standards anyway they want, and decide whether private insurers who contribute to their campaigns qualify, and there’s only general federal guidance on categories of coverage,  we wind up with inferior or even phony health insurance in Texas compared to Massachusetts — exactly what we have today.  Does anyone believe that humans who happen to live in Texas, because they just moved there from Kentucky and West Virginia, have fundamentally different health needs from Californians or those in Nevada who just moved there from Michigan?  What was the point of a national reform with a national mandate?

And you have to wonder what this does to the fed’s arguments before the Supreme Court about the necessity of a national mandate premised on the commerce clause.  I thought it had something to do with the need for nationally applicable standards to address state and regional differences that adversely affected the national economy.  But perhaps with this Court, theoretical coherence is not important.

I might be more charitable towards giving states more leeway in defining minimum benefits if we didn’t have states like Mississippi and Louisiana, or governors like Scott Walker, Kasich, Rick Scott, et al,  and if the stingiest/most conservative states didn’t have such dismal records on withholding essential health care in the State Children’s Health Insurance Program and Medicaid.  Are we going to leave these decisions to the horror governors of Florida, Wisconsin and Ohio?  A principled, courageous President would be anxious to end the tolerance for such inhumane neglect.

It’s not as though America has no favorable experience in defining nationally uniform standards for medical coverage and then insisting that private insurance alternatives meet or exceed the minimum federal requirements.  It’s called Medicare, which, unlike the pretended “competitive” private insurance market, actually does lower health care costs.   Unfortunately, we keep getting “useful idiots” like Oregon’s Sen. Ron Wyden who can’t remember this.

(photo: HowardLake)

New York Times reporter Robert Pear and his editors try to resurrect a zombie proposal by the anti-Medicare zealots to displace the guaranteed benefits structure of Medicare.  Its just another attempt to push Paul Ryan’s voucher system that would systematically reduce benefits and shift rising health care costs to individuals, despite the fact this flawed approach has been repeatedly rejected by Congress and opposed by the vast majorities of Americans who want to preserve, not undermine, Medicare.

Worse, Mr. Pear tells us that “some Democrats” all nameless, support this approach for which the failed Super Committee has “built the case.”

Though it reached no agreement, the special Congressional committee on deficit reduction built a case for major structural changes in Medicare that would limit the government’s open-ended financial commitment to the program, lawmakers and health policy experts say.

Members of both parties told the panel that Medicare should offer a fixed amount of money to each beneficiary to buy coverage from competing private plans, whose costs and benefits would be tightly regulated by the government.

Pear tells us what we already know, that the GOP loves this idea — they’ve always wanted to dismantle a successful national health care system –and that it’s been endorsed by Newt Gingrich and Mitt Romney.  Now there’s a validation.

So which Democrats are signing on to this pernicious GOP scheme?  Pear doesn’t cite a single Democrat by name, unless you count Barack Obama and his embrace of a similar system for non-seniors in the Affordable Care Act.  Would it be too much trouble to identity these Democrats by name so that voters can confront them when they go home?

So what’s the “case” the Super Committee “built” in support of this scheme?  Pear does a bait and switch:

Competition among private insurers has already driven down costs for prescription drug coverage under Medicare. Medicare’s drug benefit is delivered entirely by private insurers. In addition, one-fourth of the 48 million Medicare beneficiaries are in private Medicare Advantage plans, offered by companies like UnitedHealth and Humana, which cover a wide range of doctors’ services and hospital care.

It’s apparently too much trouble for the Times to inform its readers that there’s little if any evidence that “competition” has “driven down costs” of drugs for Medicare.  What we know is that the drug costs under Medicare were less than some feared, but they remain significantly higher than drug costs in other advanced nations.  They’re also higher than the drug costs faced by the more effective Veterans Administration, a highly rated, totally federally operated system with no private insurers “competing.”

As Dean Baker and others have repeatedly reminded us, the VA pays substantially less for exactly the same drugs — partly because the VA can bargain for price, but Medicare can’t (thanks to GOP and conservaDem coddling of drugsters and private insurers) — and the VA offers health care even more highly regarded than regular Medicare.  Never mind the subsidies the drug companies get from extended patents and non-compete agreements against generics, all ratified or made worse in the ACA.

To be sure, the Medicare drug benefit has been a boon to seniors, but part of the higher price we pay for its expensive private structure is to create and perpetuate a private insurance bailout scheme that becomes self perpetuating.  The drugsters and their private insurance supporters are some of the largest contributors to politicians’ campaigns.  The 99% are paying for a protection racket for the 1%.

As for evidence that competition among private insurers will drive down general health care costs, where’s the evidence?  Aside from the fact that, as Krugman (citing Ken Arrow) tells us, health insurance is not amenable to market competition, the evidence the Times/Pear cites is that lots of seniors sign on to private insurance under Medicare Advantage.  But Pear neglects to mention that the private insurers under Medicare Advantage survived and grew by receiving an average of 14 percent subsidy paid by Medicare.  When the ACA proposed to reduce that subsidy the private insurers squealed, telling seniors in scary tv commercials that Congress was taking away their Medicare.

So the single piece of evidence Pear cites doesn’t show that this scheme will reduce the federal budget, if that is the problem that needs solving; it will instead likely increase the budget costs unless the government simply limits the vouchers as costs rise and shifts those rising costs onto seniors.

It’s inexcusable that the Times cites mainly private health industry analysts and the GOP’s Jeb Hensarling (R. Texas).  Pear also sites budget hysteric Alice Rivlin, who can’t seem to grasp that the only way this “helps” the budget is by forcing seniors to pay more or make do with less health care, while actually making the health cost problem worse.  Dean Baker notes the CBO has already done the math:

The Congressional Budget Official projected that a Republican plan along these lines, that was approved by House earlier in this year, would raise the cost of Medicare equivalent polices by $34 trillion over the program’s 75-year planning horizon. While this plan would save the government money by reducing its payments for Medicare, it would mean that future generations of workers would pay far more for health care in their retirement. The cost of Medicare equivalent policies would far exceed the typical retiree’s income by 2050.

The Times couldn’t find a single supporter of maintaining Medicare’s guaranteed benefit structure, to point out how dependent many seniors are on Medicare and how that and other guaranteed federal support keeps millions out of poverty.

Nor could it find a prominent economist to explain that its not the aging population or Medicare per se that is causing the real problem.  The real problem is the rapidly rising costs of the private health care system.  If we fail to bring our private health care costs more in line with the costs paid by other nations for equal or better care, it’s the economy that tanks, not just Medicare for seniors.   Simply dumping seniors (or anyone else) into that over-priced system when we know that government-sponsored systems like Medicare and the VA consistently provide health care at a lower cost means that you don’t care about health care, don’t care about seniors and don’t care about the threat the private health care system is posing to the American economy.

More:

Paul Krugman on Paul Ryan’s flim flam budget plan.

Jonathan Chait

I suppose we should be grateful that TNR’s Jonathan Chait voluteered to write an apologia for President Obama as a way to explain to those he identifies with “the left” why Obama’s not such a bad President and to remind the “left” there were extenuating circumstances that explain the President’s failure, or refusal, to achieve what the left wanted and the country needed.

But one has to wonder: is Chait’s defense all the President’s supporters have left?  Because when Chait leaves out what really matters to Obama’s liberal critics, the piece comes off as an argument for Obama announcing “I shall not seek, and I will not accept . . .”

To assess the President’s performance, one must start with a more coherent story of what Obama and the country faced in January 2009 and what those conditions called for after eight disastrous years of the Bush presidency.  Some of us said both before and after the election that the devastation wrought by Bush on the Constitution, on the idea of government, on the rule of law and on the economy was so crippling and massive, it would likely take years to reverse it. But some things were clearly priorities and needed to be addressed immediately. Read the rest of this entry →

The inimitable Digby points us to another effort by Rep. Paul Ryan to misrepresent his deeply unpopular Medicare voucher plan. It’s not clear whether Ryan simply doesn’t understand his own proposal or is just a serial liar.

Digby links to coverage (and the video here) at Think Progress, which catches Ryan admitting that his plan requires a “mandate” but then claiming falsely that “[i]t literally would be like Medicare Advantage.”

Q: If Medicare becomes a voucher program, would you require seniors to purchase private insurance and if so isn’t that an individual mandate? If you will not require them to purchase insurance how do you propose to prevent a situation where the costs of uninsured seniors is very expensive and gets passed on to me as a private policy holder? [...]

RYAN: Its mandate works no different than how the current Medicare law works today, which is you just select from a wide range of different plans. It literally would be like Medicare Advantage…

Having shown that Ryan’s plan has a “mandate” for those who later reach 67 (yeah, he’d raise Medicare’s eligibility age, too) just as the Affordable Care Act does for those under 65, TP’s Igor Volsky then adds this:

All this tells us is that the mandate isn’t some horribly coercive policy aimed at usurping individual freedoms. Rather, it is a mechanism by which government attempts to encourage more individuals to purchase coverage and expand the size of the health care risk pool, thus spreading the costs and risks of insurance across a larger population (and bringing down health care costs). It’s simply asking able individuals to take personal responsibility for their health care expenses and it’s something Republicans have supported in the past and (apparently) still favor.

Read the rest of this entry →

You could see this one coming. As soon as a local poll on the Massachusetts Senate race showed the Republican dead even among likely voters with Democratic candidate Martha Coakley (now MA’s Attorney General), you knew there would be leaks blaming Coakley for not conducting an inspiring or smart campaign.

Nevermind that a more recent poll by the Boston Globe shows Coakley with a solid 15 percentage point lead. No, the first poll showing Coakley at risk was a perfect opportunity to blame the candidate instead of the real culprits dragging down Democrats everywhere.

And who better than WaPo’s Chris Cillizza to spin the tale with anonymous sources who never mention the real culprits. Here’s how it’s done:

Democrats control both of the state’s U.S. Senate seats, the governorship, all 10 House seats and wide majorities in the state legislature.

And yet, the buzz in political circles over the past week is that state Sen. Scott Brown is rapidly making up ground on state Attorney General Martha Coakley in the Jan. 19 special election to succeed the late Edward M. Kennedy — movement that has Democrats scrambling to ensure they keep what should be a sure thing in their column.

Coakley used her name identification and fundraising edge to coast to a pedestrian victory over Rep. Mike Capuano, among others, in the Dec. 8 Democratic primary. But she has drawn heavy criticism from party strategists in the state and nationally for not doing enough to energize supporters in a political climate decidedly unfriendly to their party.

Nationally? Who are these national critics? Cillizza doesn’t name one. (Is that you Rahm?)

Well, national leaders are Rahm Emanuel, Larry Summers, Tim Geithner, and the President himself, who thinks the Federal Reserve should be run by the guy who missed the housing bubble, failed to regulate the banks and thinks pursuing full employment is a bad idea because it would risk the Fed’s reputation for fighting inflation.

And how exactly can a candidate running for national office "energize supporters" in this climate?

We have a President who breaks key campaign promises at the slightest sign of opposition. He first says he supports a public option to keep the insurance companies honest, but drops it; he opposes taxing health plans then supports it; he first said he wanted to reduce deductions for the wealthy but now isn’t willing to tax wealthy people to help pay to expand coverage; he once said we should bargain with industry for better prices but now thinks cutting sweetheart deals with lobbyists for big drug companies and giving breaks to large hospital and insurance companies is a swell way to control health costs. And his legislative team managed to hand control of what is or isn’t acceptable in the health bill to Joe Lieberman and Ben Nelson, after wasting months trying to hand it to Max Baucus, Kent Conrad and Olympia Snowe.

Yes, Martha Coakley will find it tough to energize Democratic voters, but that’s not Coakley’s fault. When you have anchors like Emanuel, Summers, Geithner, Bernanke, Reid, Lieberman, Nelson, Lincoln and Landrieu et al. dragging you down, and a President who doesn’t seem to care about breaking his word or notice that he’s now the Party’s biggest problem, it’s a wonder any Democratic voter still cares enough to show up.

“Why, oh why can’t we have . . . better Democratic strategists?” – DFHs

MSNBC’s Hardball invited two political strategists to explain what they would advise their respective parties on what to do next in the health care reform debate.

In the Republican corner we had Todd Harris, a savvy warrior, who has memorized the Luntz talking points and proceeded to repeat them. All of them. “Government takeover, Canada, delays, rationing, scare, lie, confuse.”

In the Democratic corner we had Steve McMahon, . . . uh, whose advice we can summarize/paraphase as follows:

“There’s 80 percent agreement on what reforms we should undertake, and that’s good enough. Obama once said he’d rather get 80 percent and strong bipartisan support than get 100 percent and no bipartisan support. Therefore, he should take the bipartisan deal in front of him.

“This means he should give up on the remaining contentious issues, such as a public health insurance option, because the Republicans don’t want that, and any tax on health benefits or wealthy peoples’ charitable contributions, because Democrats don’t want that. See how even handed that is?”

So, the consistent political advice to Republicans is to lie, confuse and scare people, hoping Read the rest of this entry →

Three weeks I ago I wrote about Republican strategist Frank Luntz’ disingenuous advice on how Republicans should lie about health care reform. Last week, Democratic strategist Paul Begala gave Democrats a response that not only rebuts Luntz’s dishonest framing but gives wavering Democrats a helpful framework for a Democratic health reform proposal.

It’s worth looking at Begala’s 9-page memo (pdf), because he’s close to Rahm Emanuel (and so presumably would not stray too far from the White House view) and because Democrats were encouraged to use the memo’s talking points when discussing health reform with their constituents over the Memorial Day break.

Two things struck me in the memo. First, I’ve been searching for some confirmation that the Democratic leadership and the White House would hold firm on Obama’s campaign pledge to create a public health insurance option to compete with and provide a model for how the private insurance industry should function. Although 28 Senators have sponsored a resolution supporting a public "exchange" or public "insurance pool," these are not the same as a public plan option, even though some of the resolution’s supporters sometimes use the terms interchangeably.

Begala’s memo unequivocally and unambiguously advocates a public health insurance plan option, describes it’s role in giving consumers another choice over private plans. In his framing, the public option provides the minimum coverage model that competing private plans would have to satisfy. If this is the emerging Democratic proposal, it would be a step forward from where we’ve been.

The second point relates to Obama’s own rhetorical position, which Begala finesses even though, I will argue, it undermines his core message. I’ll discuss that in a follow up post.

A clear Democratic commitment to a meaningful public plan has been elusive: Read the rest of this entry →

FDL’s Christy returned from a well-deserved vacation and asked whether anything had happened. It’s my job to update her, so . . .

Looking back, it seems nothing changed this last week. It’s same old, same old.

According to David Brooks’ [Thursday] column and appearances on News Hour and This Week (confirmed by Clarence Page on CNN), Obama adopted the Bush II (2005-08) not so bad terror policies, which Condi "we didn’t torture, but if Bush does it, it must be legal" Rice had managed to salvage by slaying Dick Cheney, who’s ghost emerged to become rhetorical head of the crazy 21 percent still left in the Republican Party so that he could argue against being prosecuted for war crimes, which we should not pursue because it would upset the Washington Post.

Cheney opposed the Obama policies on Gitmo, detention and torture by arguing that they’ll lead to al Qaeda nuking Montana when they break out of the local jail, which had to lay off people during the economic recession that was not caused by anything done in the last Administration[s]. He has to oppose Obama’s policies because they were either the same as or different from the Bush II policies, which Rice imposed on Cheney but which Obama rejected in the campaign because he didn’t think we would vote for Bush III but which we now think look like Bush II, or is it Bush I?

Early in the week, some hippies — defined as anyone who still believes in the Constitition and the rule of law — went to the WH to be told by the President himself that, in his view, they are hippies. Read the rest of this entry →

I can’t tell whether Politico’s Mike Allen is just shilling for Republicans or unwittingly exposing their duplicity. But Allen’s column on the advice Republican strategist Frank Luntz recently gave Republicans about how to talk about health care reform is a stunning example of the Republicans having nothing to say about how to fix the nation’s disgraceful health care system.

Allen’s column is mostly a summary of the report by Luntz insisting that Republicans embrace the rhetoric of public health concerns without identifying the underlying problem or actually proposing a single solution. Instead, Luntz tells Republicans to frighten Americans about any proposal that involves having "Washington bureaucrats control" your health care. Then lie about Canada and other countries while scaring folks about rationing, lines, waits, and denial of care.

Shorter Frank Luntz: Be empathetic, but lie and scare them; and never define a problem that actually requires a solution.

But that’s not the end of Luntz’ duplicity. Read through the whole Luntz spiel and you’ll not find a single mention of insurance companies. For-profit health insurance companies. Companies that deny coverage, deny payments, hassle patients, doctors, hospitals, drive many into bankruptcy and cause America’s health care costs to be double what they are in other countries. They apparently don’t exist. Read the rest of this entry →