Obama's Secret Moves On Health Care

Marc Ambinder Provides A Behind-The-Scenes Look Into White House Maneuvering In The Health Care Debate

(CBS)  The "On The Marc" column is written by The Atlantic's Marc Ambinder, CBS News' chief political consultant.

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President Obama's kid glove theory of legislating on Health Care reform was too soft a touch for senior members of Congress who were tasked with writing health care legislation.

But last month, conflicts between Senate committees and between the Senate and the House reached a point where the lack of guidance from the White House about details was producing significant confusion about what Mr. Obama really wanted -- aside from the vague generalities about access to quality, affordable health care that he has stuck do since becoming president.

The White House was urged to be more specific on the following questions:

1. What role should states play in the health insurance exchanges? How much authority would individual states possess to regulate plans that were offered within their states?

2. Should there be a "public plan," and should it be "robust" -- the adjective used to describe a plan that could supplant private health insurance plans, or merely "competitive" -- revenue neutral and not receive any special attention or funding from the government?

3. Would Mr. Obama be willing to accept new taxes on health benefits?

4. Would he support proposals to give non-partisan, non-profit expert committees actual authority to streamline Medicare and Medicaid (absent a Congress veto)?

5. How much out of pocket money should individuals be expected to pay?

6. Did the White House want an expedited timetable? Was it content with the speed of legislative efforts?

Deciding whether to answer these questions put the White House in a little bit of a bind. Legislative director Phil Schilliro has made it his mission not to give Congress any rational reason to fight the administration on anything related to health care.

The more specifics Mr. Obama provided, the more fights there would be. From the start of the health care debate, Mr. Obama did not want the White House to be an obstacle.

Even his endorsement of the particulars was vague. The White House has not, in private, even, argued for a "robust" public insurance option. That's partly because there is no consensus among Obama advisers about the wisdom of a plan that would significantly increase government health care expenditures above and beyond the $1.2 trillion or so Mr. Obama expects to spend over the next ten years.

White House chief of staff Rahm Emanuel has floated the idea of a public plan that would be weak for a while -- perhaps five years -- and give the insurance industry the chance to cut costs, improve the quality of care and increase access (there would be metrics). And then, if the private sector failed, the public plan would suddenly be placed before the American people as an alternative to their current plan -- and it would be heavily subsidized, would cost less, and would cover more things.

Sen. Olympia Snowe (R-Maine), who often speaks with Emanuel, has proposed a hover-craft like plan in Congress.

The Cost?

The White House proposed to pay for universal health insurance by limiting charitable deductions for those in the top two tax brackets.

That proposal was DOA.

Senate Democrats, backed by the health care policy community, believe that the easiest and less intrusive way to pay for approximately half of the cost of reform over ten years would be to end the tax exemption for employer-provided health care benefits. Mr. Obama campaigned against this idea when Sen. John McCain (R-Ariz.) proposed it during the campaign, but he is not prepared to stand in the way of Congress.

How much would be taxed? Who would be taxed? This is a debate the White House will leave to Congress, too, although White House health care advisers clearly have some ideas and are sharing them privately.

For now, it's sufficient for members of Congress to know that Mr. Obama won't veto a bill that includes new taxes.

The Public And Doctors

The White House plans to stick to what it does best: using the bully pulpit of the presidency to convey urgency and to engage the stakeholders. That's been the strategy from day one, and we saw it amped up yesterday with the president's trip to Wisconsin, and will see it next Monday, with his speech to the skeptical docs at the American Medical Association conference.

The AMA's opposition to a public plan notwithstanding, the Obama administration believes that it's important, politically, to appear to be engaging the doctors in a way that the Clinton administration failed to do. The AMA's political and cultural biases aside, they worry that if the public perceives that doctors, as a community, oppose whatever plan emerges from the various Congressional actors, final status negotiations, to borrow a phrase from Middle East diplomacy, will be hard to achieve.

On the other hand, getting docs to buy into the idea of reform -- and making sure that the public is made aware of this buy-in -- gives the Democrats some maneuvering room.

On Monday, a White House official said, Mr. Obama will "offer the doctors a seat at the table. Whether they sit there is up to them. But everyone will know that they've gotten the offer."

[Dr Dan 123]

This is what happens when a crackhead get's in power.

[cydygitt1]

OK - so you just defined the problem - so how is universal health care going to change this set-up?
Posted by forrestlayne
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I'm glad you asked.
1. Coverage at lower cost to patients. All the federal government payers (VA, military, medicare, medicaid) provide coverage at lower costs because they are non-for profit and have less overhead costs. Having a competitive public plan will force private insurers to reduce their overhead and charge lower premiums if they wish to compete and stay in business.

2. Bargaining Power- can serve to lower and drug prices, insurance premiums, and maybe even costs for diagnostic tests/procedures. Being part of a government pool similar to the congressional plan gets you a lower premium than shopping for insurance as a single buyer. The government, as a payer, can bargain for lower drug prices just like the VA does. All that leads to less money in the pockets of these industries. Caveat: being too agressive can actually hurt pharmaceuticals and biomed companies in coming up with new technologies,,, etcc. (but not necessarily)

3. Universal coverage brings more people into the system. This can provide more revenue and increased economic activity within the healthcare system. It also provides opportunities to reduce cost by avoiding ER visits and providing better preventive care (primary and secondary).


4. Universal coverage helps avoid other problems
- Insurers reduce administrative cost since they won't have to screen patients and
decide what services to pay for or not.
- insurers have less incentives to increase premiums since they now have more
customers
- Having more economic activity also bring more business to pharmaceuticals and
biomed companies, which helps offset their reduced profit from the government
bargaining for lower prices. this also goes for private insurers

5. Universal healthcare facilitates reforms that can reduce other costs. For example, health IT will potentially reduce wastes. Best practices, implementing evidence-base medicine can help avoid unnecessary tests and procedures.

This is just to answer your question on the cost side, reducing the amount of extra money that go into the bank coffers of corporations and shifting it to patient care and cost savings to society at large. I didn't touch on the benefits to quality of care or just the moral and economic value of keeping citizens healthy.
Posted by lagnappe
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Thank you......this was such a good post with much valuable information that I feel it needed to be repeated in its entirety!

[cydygitt1]

I have experience with both, as a physician. I am not aware of problems getting medicare to pay up any more than problems with private insurance companies. I have received several letters from private insurers refusing to pay for hospital stays and other services for patients. Medicare has had solvency problems in the past and there hasn't been any draconian cuts in benefits.
On the other hand, private insurers face the same questions even to a greater degree. Their fiduciary duty is to increate profit. They do so but cutting cost (i.e cut benefits, deny coverage, limit reimbursment rates, ration care) and increase revenue (i.e charge more money). How do you think, they actually increase their profits even in tough economic times? In the 1990s, HMOs tried to cut cost by limiting payments to providers, restrict patient choice, require gatekeepers, and yes ration care,etc... Contrary to some people's perception, that was almost entirely from the private sector. And when the American people kicked up dust about it, they retracted by responded by providing less coverage and charge more for premiums.

The point is we raise all these fears about the government but we forget to compare it to the private sector. When it comes to healthcare coverage and delivery, the private sector has not proven to be better in any way.

As for the VA, I can testify to some of the problems that exist. However, studies show that the VA is just as good in quality of care and patient satisfaction as the rest of the healthcare system. Veterans get a lot of cool services from the VA ( i can list them for you). And they are second to none in cost control and cost-effectiveness.

You wanted facts, you got 'em.
Posted by lagnappe
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Thank you for stating some of the facts, while the ignorant have decided to just remain ignorant and spew the same old, tired propaganda from the usual suspects, protecting their huge profit margins at the patient's expense.

It seems easy for them to continue to rail against any government-run health care as rationing care and slow payments, but as you pointed out, this is exactly what the private for-profit insurance industry does as well to make larger profits.

The ignorant also try to push the high cost of malpractice insurance onto lawyers and frivolous lawsuits, but in actuality, this has just been the insurance industry making-up for a loss in profits due to their investments in a poor market, just like 2001-2002, where malpractice insurance almost doubled when payouts for lawsuits went down!

[cydygitt1]

Again I ask - WHERE DOES ALL THE MONEY FROM THE EXISTING HEALTH CARE COSTS END UP? WHO ULTIMATELY GETS THAT MONEY?
Posted by forrestlayne
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It goes to administrative costs, profit margins and pockets of the biomedical, pharmaceutical and insurance industries. It's no secret and it doesn't take a rocket scientist to know it. You can track the rising cost of healthcare and rising profits in these industries on the same trajectory. Even when everyone is up a creek, these industries continue to make a killing and sometimes even increase their profits. It's pretty darn obvious...

Otherwise, if you increase efficiency,limit or eliminate profit-making (i.e profiteering) in the insurance industries, you will have solved a lion share of the problem.

Posted by lagnappe
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Exactly! But it seems that despite it not being rocket science, the rightwads keep asking the same obvious questions over and over again, as they condone the huge profits and administrative costs of the for-profit industry -- adding nothing to providing health care!

Just like the 30% of unneeded and unnecessary repeat testing, it doesn't take a rocket scientist to know that eliminating that waste would bring down health care costs too!

[Slrman]

Martha_123 - What an inappropriate and ignorant comment. How about something that provided idiots like you with a large dose of ****?

[Slrman]

The vagueness (dare we say evasiveness?) from BHO worries me. Perhaps the ultimate goal is to supplant ALL health care with a government-funded and run plan. That could be a disaster of galactic proportions. After all, what field has the government ever entered that they have not made worse? I can see a "competitive" plan and coverage for those who do not and cannot afford anything else. But "Big Brother" scooping in all of it?

Here in Brazil, there are affordable private plans and government support for some drugs (like diabetics) and people (unemployed and elderly) but these are all eventually administered by private providers. It works very well and no one is ever denied health care for any reason. Nor is it expensive. Maybe BHO needs to consult with someone here?

[cydygitt1]

I for one, am completely tired of paying for the best health care to all those government employees including the wealthy congresscritters, without getting exactly the same health care through taxes that they already enjoy!
Posted by cydygitt1
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Exactly what kind of health care do you want?

Posted by forrestlayne
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Ooooops.....your reading comprehension seems to be getting much worse!

Sorry, but I thought I said exactly what I wanted above -- exactly the same health care through taxes that the congresscritters already enjoy.

[cydygitt1]

Demand universal health care, throw the insurance companies out of their parasitic game of feeding at the trough of human misery.

DEMAND UNIVERSAL HEALTH CARE,

or vote everyone out that votes for more millionaire insurance cretins.
Posted by nofoolling
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Yep.....some sort of 'single-payer' system would certainly be a more efficient way of spending that huge $2.5 Trillion or 18% of GDP sum we currently throw down the rat hole of for-profit health care in America making the insurance companies much wealthier!

[cydygitt1]

How many new drugs and medical advances have come out of countries with socialized medicine?
Posted by forrestlayne
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And how many medical advances have come out of universities through government grants and not out of the private sector wanting to prolong sickness for profit?

[cydygitt1]

Again I ask - WHERE DOES ALL THE MONEY FROM THE EXISTING HEALTH CARE COSTS END UP? WHO ULTIMATELY GETS THAT MONEY?
Posted by forrestlayne
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Again I ask, why all YOU people are so lazy and cannot do your own homework?

To give you some quick examples of some of the wasted $2.5 Trillion currently:
lobbyists
congresscritters
administrative costs
middlemen profits
CEO pay and bonuses
advertisements
propaganda like CPR

[cydygitt1]

Stop government by the corporations, for the corporations. Shoot a lobbyist, if you want affordable healthcare!

Posted by vista8635
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That is probably the most realistic approach to lowering health care costs in the U.S. and coverage of everyone for health care, by an OPEN SEASON on the GREEDY lobbyists that add absolutely nothing to our health care except higher costs and more propaganda!

[cydygitt1]

This is a complex problem but I honestly don't believe that government is the answer. Those clowns are already running the auto industry, banks, etc,etc.
Posted by xlib
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While this is truly a complex problem, I don't see YOU or any of the party of NO, offering real solutions or new ideas to solve those problems -- just more attacks on existing systems and making the comparison with Canada's 35th health care in the world vs. our 37th rated health care system. Why not compare it with the best rated health care systems in the world where human longevity is the highest and infant mortality is the lowest? Why not take the best parts out of the best rated health care systems in the world to model a new health care system for the U.S., since we already spend more than double per person that they all do, so why not use it more efficiently here in the U.S.?

Spending $2.5 Trillion or 18% of GDP on a bad system that just rewards for-profit insurance companies by denying coverage and keeping 50 million Americans uninsured is completely ludicrous. Let's use that huge sum more wisely for better health care!

BTW, it has been said over and over again by the GOP bozos, that President Obama has nationalized the entire private sector, but in actuality, only 0.02% of the private sector has been somewhat nationalized, so the vast majority or 99.98% of all business in the U.S. is still in the private sector. Your fearmongering without facts is getting the best of you and your kind, and mostly falling on deaf ears.

[cydygitt1]

the underlying complaint here is that - It costs too much -
Well - Find out why health care costs are so high - follow the money - Where does all that money go? Once you find out that answer then the solution should be clear.

Posted by forrestlayne
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Some of us already know exactly where all the money goes -- and it is the unnecessary repetitive tests in 30% of the cases, unneeded administrative costs, excessive CEO pay and bonuses, and huge profits by the for-profit insurance company middlemen that provide NO health care at all -- just decisions made by lawyers working as claims supervisors.

Paying someone excessive money to make health care decisions is ridiculous, since they should be made by physicians and patients -- not insurance companies putting profits well ahead of patient's well being.

[cydygitt1]

So you are saying universal healthcare is FREE health care? Nobody has to pay for any healthcare? How is that possible - something for nothing?

Posted by forrestlayne
------------------------

NO! Apparently, reading comprehension is not your strong suit, since I never said anything even remotely resembling that silly remark!

I said that we already spend $2.5 Trillion or 18% of GDP on health care, more than double the rest of the industrialized world per person, so how is that FREE?

Why do you foxnewsus propagandus junkies keep repeating the same garbage?

We simply need to remove the decision making from the for-profit insurance companies and have the decisions made by physicians and patients.

[piperdoc]

Having been a physician in the military for 13 years, the military and government health care is cheaper because they ration care. Patients routinely wait 2 months for treatment to specialists The care is generally good, however many government physicians are not necessarily the hardest workers, due to the non-fee-for-service payment system (salary). The physician gets paid the same amount whether he or she sees 1 patient or 30 patients in a day. Additionally, government support staff are not always the hardest working lot, hard to fire due to union rules, arcane job transfer rules etc..I found this all very frustrating and I left the military medicine system when I had pain back my time in service for my training. I am now happily in private practice where I have better support so I can spend more time seeing patients and I am not left doing non-physician tasks that I did in the military, but had a hard time getting the support staff to do it well, so I ended up doing it myself. Any government plan will eventually end up as rationing care by politicians and unaccountable bureaucrats as it will be too expensive when it ends up being "free" and the patients do not see the real cost of healthcare. Private sector competition would be more effective just as the medicare drug plan has been - under projected budget - as the drug companies competed in this program.

[doctorhousecall]

Since i was not consulted, you will not find my name on your insurance card. Mr Lincoln freed the slaves. CBS reported it at the time. I don't have to treat you and you don't have to have me as your doctor. Free country.

I WILL be happy to be your doctor if you pay me directly. Visa, Master Card, American Express, cash check or PayPal are welcome. If you are my patient any thing of value will work. A dozen eggs, a chicken, anything.

Do not ask me to work for the government or an insurance company. I will not do it. I refuse to deal with universal ANYTHING. My liberty trumps your "rights".

[oldestee]

I'm glad you asked.
1. Coverage at lower cost to patients. All the federal government payers (VA, military, medicare, medicaid) provide coverage at lower costs because they are non-for profit and have less overhead costs. Having a competitive public plan will force private insurers to reduce their overhead and charge lower premiums if they wish to compete and stay in business.
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Do you think if Medicare and Medicaid ETC. were trying to make a profit or at least break even their costs would rise, AND THEY WOULD NOT BE GOING BROKE!!!!!!!!!!!!!!!!!!
Their will be no competition the GUBMENT idea is control and they have limitless resources to drive the privates out of business!!!!!!!! If it was not control why do they not allow now the deduction and refunds of private purchased insurance on the income tax(it is currentiy limited to itemizers and then only the amount over 71/2%) think of the COMPETITION for the business!!!!!!! Similar to the EIC!!!!!!

[joule18]

The people in our government do not get socialized care, but care provided by private entities whose price for such care in negotiated and whose business is competed for.

Besides, we all know that any premium paid for government workers is well justified and paid by our taxes.

Perhaps we should be in collectives that do the same.

[nofoolling]

Author Of Torture Memos Can Be Sued

The above story is running right now on this site, but CBS isn't letting folks comment on it.

I wonder what they're afraid of?

Maybe 10,000 pages of negative posts lol.

[valwayne]

We know in Canada and Great Britain that the average person is paying 50% or more of their income in income taxes to support Government Health Care! In Obama's America we're headed there anyway! We also know that health care is severely rationed for old people. No sense wasting precious dollars and keeping people alive who are going to die soon anyway. Just like paying taxes is a patriotic duty in Obama's America, old people will have a duty to die if they get sick. We also know that if you need surgery or other critical expensive treatment the wait to see a specialist can be years, and getting treatment additional years. The plan of course is that many who need the most expensive treatment will just die before the Government has to provide it. In Canada if you are scheduled for treatment in the fall you stand a good chance the program will run our of money in the fall and you'll have to wait for new budgets in the following year. However, despite all of that Obamacare may be the way to go. At the rate he is destroying our economy and unemployment is rising we may all be out of work and Obamacare will be better than nothing. Welcome to Obama's America......see Zimbabwe!