Commentary from Dave Durenberger

February 18, 2010

MORE THAN POLITICAL THEATER
President Barack Obama has turned a corner in his presidency. Two "wake-up" calls - in Detroit on Christmas and IN Massachusetts January 20 - may be the cause. A third is the fact that health reform legislation is off the floor of the Senate and into a congressional conference committee. So the president can turn his - and our - attention to other matters…and retake the initiative on health care policy - if it's even possible - as he will at the Blair House Summit on February 25. In his September 9 address to a joint session of Congress, he said he wasn't the first president to attempt to expand access for all Americans to affordable health care. But he intended to be the last.

I spent the first week of February in Washington, getting out just ahead of the snow. All the independent "experts" with whom I talked agreed that some very good health policy legislation has been lost to bad politics and deliberate obfuscation. As a result, people have concluded that the Republicans may be exaggerating a lot, or even lying about content. But the Democrats cannot be trusted to get it right. That is probably a reflection on the trust Americans appear to have in Congress and in Democrats. Where they do not agree is on whether the legislation can be passed, at this stage, with Democrats only.

The president knows that. He also knows Americans are more concerned about the cost of health care than the polls on the reform legislation let on. His key staff debated whether to drop the reform effort (Rahm Emmanuel) or to see it through to the end (David Axelrod). It's obvious now where President Obama stands and that's a good sign. Both the State of the Union and the follow-up with House Republicans says this president will not be deterred by the "our way or no way" approach of the Congressional Republicans. He will force them to put up or shut up on the bills as they stand…on February 25 and thereafter.

THE BEST WAY TO APPROACH A FOUR-HOUR DIALOGUE ON HEALTH REFORM
The president's role is to comment on how closely various proposals come to his principles for reform and for meeting the expressed needs of Americans. It's not his job to get into the details of legislation. So the best way to organize the meeting is to ask the doctors whose judgment is most respected today on health policy to run the meeting. I'd vote for Mark McClellan, M.D., who served President George W. Bush as FDA commissioner and as administrator of the Center for Medicare and Medicaid Services (CMS). His co-chair could be Donald Berwick, M.D., the most respected leader in health care quality improvement in America. He's also rumored to be President Obama's eventual choice to head CMS.

It would also be wise to have Glenn Hackbarth, the eight-year chair of Medicare Payment Advisory Commission and its executive director Mark Miller, participate. And ask Peter Orzag, the head of OMB, and Douglas Holtz-Eakin, who had the job at CBO before Orzag. I would consider having HHS Secretary Kathleen Sebelius invite her predecessor Secretary Mike Leavitt to participate. Leavitt was the Republican governor of Utah and Sebelius the Democratic governor of Kansas. Each of these people is respected for professional and policy expertise and conviction, not for ideology.

All of that assumes that the policy is the problem. I think it is with the American people. They don't get it. But in Washington, many think the problem is politics, and not just Republicans. There's the bombs tossed by Massachusetts voters, Arkansas Senator Blanche Lincoln's 31% re-elect numbers, and the decision of Indiana Senator Evan Bayh to give up his Senate seat and his $13 million campaign war chest. And then there is the resort to the reconciliation process at this late stage, the insistence of GOP on medical malpractice punitive damages caps and insurance mandates, the abortion language, and the problems raising any taxes to pay for the coverage expansion: Too much for a four-hour "summit" to handle.

HEALTH INSURANCE RULES
In the lead-up to the president's Blair House Summit on February 25, one of the policies that ought to unite Republicans and Democrats is health insurance reform. Republicans have advocated greater use of private insurance as a market-based replacement for public insurance programs like Medicare and Medicaid. They advocate some new insurance rules such as guaranteed issue and portability. And they recently have suggested that "shopping across state lines" will increase competition and lower premium costs. Most, but not all, Republicans advocate for reforming income tax treatment of health insurance to provide equivalent subsidies for all, whether buying as part of a job or not.

Some Democrats advocate for single-payer or"Medicare for All' public insurance. Democrats writing the reform legislation, however, see health reform as universal insurance coverage and see the importance of reforming the rules by which insurance companies compete so as to get a much greater percentage of premium dollars into health and medical services rather than into marketing and administering plan benefits. Democrats also advocate for evidence-based basic benefits to qualify tax subsidies and for creating market rules to include guaranteed renewal, rating band limitations and national rules to assure genuine competition based on value determined by consumer choice. Why, they argue, should we run the risk of losing consumer protection from misrepresented sales in 50 states with 50 different sets of rules and regulations? Democrats are divided on whether a "public plan" is necessary to assure markets that work to lower costs.

What keeps the partisans from a bipartisan solution? (1) Some health insurance companies whose products would be disadvantaged in national markets and with national market rules. Most of these are selling individual plans - such as Wellpoint, the big national company whose over-reliance on individual plans and on stock market approval drove them to huge increases this month. (2) Anyone in the insurance business who knows state regulators are more easily influenced than those who set national rules and want to keep McCarron-Ferguson protection for the only industry in America that refuses to play by market rules; that states regulate consumer protection and (in 25 states) prices. They do not set rules by which companies compete.

(3) Advocates for consumer-driven health care, which includes a lot of Republicans seeking simplistic solutions to complicated problems. (4) It includes hundreds of thousands of physicians who believe they are practicing as well as they can and that they can more easily influence patients than they can comparative effectiveness and evidence based care measures. (5) Then there are financial institutions making a mint selling Health Savings Accounts to the young, the healthy and the desperate because HSAs are a tax-free, publically- financed subsidy for high-deductible insurance which has no guaranteed issue, renewal or rating band limits.

MINNESOTANS DROPPING HEALTH INSURANCE
We used to be the top state in the country in terms of health insurance coverage. Massachusetts topped us a couple years ago with their bold move. But we are also falling back so it may be easier for others to pass us up. Kathleen Call at the School of Public Health at UMN reports on her research showing Minnesota has gone from 7.2% uninsured in 2007 to 9.1% in 2009. That's 480,000 Minnesotans without coverage last year, two-thirds of whom have been without for more than a year. Blacks are 16% uninsured, Indians 18.8%, and Hispanic/Latino 28.6%.....22% of persons age 18-24 and 17% of families below 200% of poverty are uninsured.

GOVERNMENT RUN HEALTH CARE
Fifty percent of all the money spent on health care services today is spent assisting Americans to access medical and long-term care services via insurance. About 25% of that supports employed persons whose employers provide access. The other supports national programs for which Congress is responsible - Medicare, Medicaid, TriCare, the VA Healthcare, the Indian Health Service. One hundred percent of the Defense Department's TriCare program for military personnel and families is run by private insurance companies. About 65% of the federal state Medicaid programs are managed by private insurance contractors. Private "carriers and intermediaries" also help administer payment policies for Medicare.

Even though these programs have to take all categorically eligible persons who are also the most difficult to insure in the private insurance market as it exists today, the costs of running these programs is a fraction of the cost of running private insurance. If the August 2009 town hall meetings were any test, these programs have a much higher consumer satisfaction level than do private insurance policies.

If Congress does not pass the legislation it's already agreed upon, with whatever modifications Republicans might add, the political winners will be advocates for single-payer health insurance who have been telling us right along that there is no comparison between current "government run" health insurance and private insurance that doesn't make the public programs look better. Private health insurance reform and physician/hospital payment reform can make the private approach much more effective. But we can't begin to get there without this reform legislation.

THE HEALTH REFORM THAT SCARES BOTH PARTIES
This is worth reading. Michael Millenson is the Chicago-based journalist who launched a crusade for health care quality a decade ago with his book on quality failure in our system. Today he writes about the Medicare reform of which I was an author that still stands as a hallmark for bipartisanship. Read it at http://www.kaiserhealthnews.org/Columns/2010/February/021610Millenson.aspx

HEALTH REFORM
I'm always asked if I've read every bill I ever voted for. The answer is no, but I've always known everything that's in each one. That why you send reps to D.C. and supply them with staff. One way for the "just say no" crowd to attack reform legislation is to say the bill is 2,074 pages long. I went back and checked out the bipartisan reform bill of 1994 put together by 22 senators from both parties to accomplish the reform goals better. It was 1,020 pages. That, too, is a lot, but I'd personally had a hand in every provision. Like it or not, I knew what I was doing. That's why you elected me.

by Tom Toles

WHO CAN YOU TRUST?
The president's effort to be the last to try to provide health care coverage for all Americans has faltered badly for a lot of reasons which might sink any major legislative effort. But after a week in Washington, where they assess public opinion better than most, I've come to the conclusion that the reformers never sought or earned the trust of the American people. I'm told the Republican chair of the board of one of the biggest hospital systems in this country remarked recently after a summary presentation by an expert on policy reform, "That's the first time I've ever heard the legislation explained in ways that I can understand it as a person and as a hospital person.' I'm a Republican, but I know Republicans in Congress have been lying to me. But, as for the president and his party, they've never expressed their efforts or their commitment to them in ways caused me to trust them. And this is so big, I don't trust it.

HOW TO ACHIEVE ENTITLEMENT SOLVENCY
George Will writes in the Washington Post of President Mitch Daniels (R-IN) and Vice President Paul Ryan (R-WI) launching America in 2013 on the road to reforming the tax, social insurance and health care entitlement programs which are all headed for bankruptcy somewhere out there in our future. Aside from the difficulty of imagining the current national GOP electing northern Republicans on a southern party base, I like the idea that someone in my party is thinking about an "end game" for assuring my grandchildren's economic security.

As he did in an op-ed in the Wall Street Journal, Congressman Ryan claims to bring down health care cost escalation with refundable tax credits, health savings accounts, state re-insurance pools and Medicaid and Medicare funding of private insurance premiums. He "saves Social Security" by raising the age of eligibility and partially privatizing along the G.W. Bush lines. His income tax plan is a flat tax of 10% and 25% with a $100,000 income transition plus elimination of death and alternative minimum taxes and of taxes on dividends, interest and capital gains.

Simple. Except, as President Reagan proved in 1983 and again in 1986, you can't get from here to there on tax or social insurance entitlement reform without Democrats. Republicans have never been trusted to mess with past promises to meet our future needs - even when they have a president and a congressional majority. As a result, the politics comes not in the goals, but in the legislative process for getting from here to there.

Will suggests that the Party of No is not, because Daniels has a record in Indiana to prove it, and Ryan has lofty goals. This was the year, and health care the entitlement reform opportunity, for Daniels, Ryan and others to present President Obama with their reform ideas and the pledges to vote for them and for some Democrat ideas as a means to a lofty end. House Republicans and most Senate Republicans didn't even try.

TAX REFORM AND ENTITLEMENT REFORM REQUIRES A NEW LOOK AT U.S. FEDERALISM
It became clear during the long debate over health policy reform that members of Congress have strikingly different views on the role of the 50 states in health care financing and delivery. At last count, 27 state legislatures had passed or were considering prohibitions against mandating that their citizens buy health insurance. Congressional efforts to set national rules by which all health insurance plans must compete (guaranteed issue, renewal, basic benefits) were being thwarted by state insurance commissioners and some insurers who want that power to remain with the 50 states. Every bill has authority for states to experiment with delivery system reform. The list is much longer.

Including a big one: The disparity among the states in their taxing capacity, in what percentage of federal taxes paid by their citizens' return to the states in the form of federal program expenditures, and in the wide differences in costs/benefits to each state from expanded insurance and Medicaid coverage.

Example: Dr. Joe Thompson, the surgeon general (chief health officer) of Arkansas analyzed the Senate health policy reform bill and found that it would cost Arkansas taxpayers $95 million to comply with the bill, but that they would receive $2 billion in new federal money for expanded coverage. By the way, an Arkansonian- Len Nichols of the New America Foundation in D.C. - wrote up this finding in an op ed in the Little Rock paper. The Arkansas Democrat, which is a really right wing paper, refused to publish it.

Example: If the states of Texas and Mississippi levied the same percentage tax on incomes, transactions and property, the levy would raise twice as much money per capita in Texas as it would in Mississippi. Both states are notorious for high levels of uninsured citizens. But Texas is much higher than Mississippi, even though it has twice the capacity. Texas refuses to tax income, choosing to pass health care costs on to patients and private insurance payers.

Example: Federal programs such as Medicaid base federal matching on per capita income in the states, not on whether the states are actually levying taxes on that income or on sales, or property. Washington, D.C., has the highest per capita income of any "state" in the country. But it also has the highest percentage of residents below the poverty line.

Example: North Dakota and Wyoming are the only two states with budget surpluses this year. One of the reasons is that they export their taxes to other states (like Minnesota) in the form of coal, which they produce, and tax before it leaves so we end up paying for it. Alaska, Texas and a bunch of other states do this with oil and gas.

SENATOR JIM DEMINT
South Carolina continues to make its contributions to the Republican Party of 2010. Senator Jim DeMint was never a great fund-raiser, having pulled in a paltry $300,000 during the 2008 election cycle. Thanks, however, to the events of the last 18 months, his Senate Conservative Fund has raised $1.3 million from 27,000 donors, has an e-list over 100,000 and Jim now considers himself "the conservative seal of approval" for Republican candidates. In early February, DeMint had raised over $300,000 for Marco Rubio, whose Senate candidacy in Florida is designed to keep FL Republican Governor Charlie Crist out of the U.S. Senate. . . . . I've seen it all before. DeMint of SC has become the Senate replacement for Jesse Helms (R-NC) in what passes for the Confederacy's conservative seal of approval on Republican policy platforms.

CHARLIE WILSON'S WAR COMES TO AN END
Like everyone who served with him, I enjoyed east Texas Congressman Charlie Wilson (D-TX). I chaired the Senate Select Committee on Intelligence during the time Charlie led the effort to overcome Reagan administration opposition to arming the Afghan mujahidin with Stinger missiles so they could take down the Soviet -manned version of our drones and drive the USSR out of the country. Yes, folks, the movie was about as real as it was. It didn't adequately cover Bob Dole's role in entertaining the mujahidin leadership whenever they came to Washington and rallying GOP support for the covert action which no one was supposed to know we were running in Afghanistan.

JOHN MC CAIN GOES CONSERVATIVE
Senator John McCain did not return to the Senate quite the same person he was when he launched his second campaign for the presidency, and far from the McCain who took on the governor of Texas in the 2000 Republican primaries. In a sense, he was beaten by George W. Bush twice - once in the 2000 campaign and again in the legacy of eight years as president. In a larger sense, though, John beats himself. Just read anyone's version of the mid-September 2008 financial panic and the White House meeting candidate McCain called and then bombed out of. . . . . Now John will meet former GOP Congressman J. D. Hayworth in an Arizona primary. J.D. is a fun guy to be around, a real Arizona right-winger, and a worthy representative of the new Republican "base." No one in AZ believes J.D. can beat John, but they seem to enjoy seeing John's independent political streak disappear.

BOB CORKER GOES BIPARTISAN
Senate Republicans are mad at Senator Bob Corker (R-TN) these days. Once again, he has taken on the GOP Senate in trying to work with Banking Committee Democrats on financial market rules legislation. Corker came to the Senate in 2006 in Dr. Bill Frist's Senate seat, having defeated Congressman Harold Ford, Jr., who is now on Wall Street contemplating a Senate run in New York. Corker is an entrepreneurial businessman and politician. He played a leadership role on TARP and on the GM "bailout" legislation. Each time because ranking Banking committee chair Richard Shelby (R-AL) refused to play ball with the majority. Shelby also gained fame this month by putting 70m holds on 70 presidential appointees up for Senate confirmation to show his pique with the president's proposals to cut spending on a couple projects located in Alabama.

SENATORS EVAN BAYH AND DAN COATS
Indiana is gradually replacing Minnesota as a "fly-over state" community that produces first-class public servants in business, civic life and politics. It is somewhat more conservative than we. But it knows the meaning of "progressive." Indianapolis may still not be Minneapolis-St. Paul, but not for lack of effort and for steady progress in which all are encouraged to become civic leaders. Governor Mitch Daniels (R-IN) is a former congressional and presidential aide and a former Eli Lilly executive who has become one of the most creative heads of state, turning fiscal crisis into state-local government redesign.

Dan Coats (R-IN) served two terms in the Senate, succeeding Dan Quayle when Dan was elected vice president in 1988. Coats refused to run for re-election to a third term because, as he told us repeatedly, he had promised Indianans he would be a two-term senator if they elected him. Since leaving in 1998, Coats has been a lawyer with an Atlanta law firm which is also one of the largest in D.C. and served four years as President Bush's ambassador to Germany. Ten days ago, Dan announced he is likely to run for election to the Senate in Indiana. On Monday, incumbent Evan Bayh (D-IN), who succeeded Coats, announced he will not run for a third term. Bayh, unlike his more liberal dad, Senator Birch Bayh (whom Quayle defeated in 1980 to become the youngest Senator ever), Evan Bayh is a fiscal conservative who says the Senate has become a challenge to those who believe in change.

LEN NICHOLS
Len Nichols is moving from the New America Foundation to the faculty at George Mason University's Center for Health Policy Research and Ethics. It's in the Health and Health Sciences Department at the fast-growing northern Virginia University which is now up to 32,000 students.

PATRICK KENNEDY'S NEXT LIFE
Jim Ramstad says Ted Kennedy's son Patrick is making the right life move with his decision to leave the Congress and seek a new life outside the political arena. Said Patrick aptly: "In a sense, I got into elected politics to get closer to my family." Ramstad says Patrick is "burned out' on Congress. Retired Senator Max Cleland (D-GA), who is also very close to Patrick, calls it "a passage from what we know to what we don't know."

DICK PETTINGILL TACKLES THE UNHEALTHY PEOPLE CULTURE
Former Allina CEO Dick Pettingill is spending a semester as a Harvard Advanced Leadership Fellow. Check his blog. Dick's leadership quest is to change our health culture - no small feat. In last week's report to friends (Organizing Project Zip Code) he comments, "Already I've met with the leaders of Healthy People 2020 and the Robert Wood Johnson's Commission on Building a Healthier America. It is quite clear the lack of ideas is not the problem. The challenge is to translate those compelling ideas into actions that improve health status, educational achievement and economic performance. Some state that the most important indicator that will predict health status and education achievement is your zip code! Thus, the code word for my studies....Project Zip Code.'

DICK FRANCIS
Died in the Cayman Islands at age 89. In an era when formulaic mystery novels sell off airport bookstore shelves in the millions per copy, Dick Francis was an original. A British jockey by profession, he turned his experiences into race track novels on which I feasted. I was introduced to Francis' writing by another great mystery novelist, Marshall Houts, who wrote for Earl Stanley Gardner's Court of Last Resort, and on his own, from a home in Laguna Beach, CA. Starting with Dead Cert in 1962, I have read all of Dick Francis, including those now written with his son Felix Francis.

ENDING THE BUSH - CHENEY ERA
Republicans in Congress and conservatives elsewhere were as quick as any to disown the Bush-Cheney administration, especially its expansion of the role and the costs of our national government, in which Republicans in Congress were complicit, starting with washing their hands of the September 2008 effort to rescue U.S. financial markets. The Obama-Biden administration has not hesitated to remind them that more than half the accumulated spending deficit comes from Bush-Cheney national security, tax and economic policies, and that some recent spending has helped restore confidence in markets and in a new economy.

However, Dick Cheney, of Bush-Cheney, will never acknowledge error. Nor will he allow Democrats to lay off any part of the economic crisis on Bush-Cheney or its war policies. His current tête-à-tête with Vice President Biden over Iraq and Afghanistan is illustrative. In a war of words, Cheney accuses President Obama of capitalizing on Bush-Cheney war policy to claim that reducing the threat of fundamentalist terrorism is a police action not a "war," that Obama-Biden are claiming credit for successful Bush-Cheney strategies in Iraq-Afghanistan which they opposed. Cheney, of course, is leading the biennial election year campaign by GOP to paint Democrats as soft on security. This is NOT a war in which either President Obama or Vice President Biden should engage. Let history decide, not Joe Biden…or Dick Cheney.

GAME CHANGE
"Change' is just a word without the strength and experience to make it happen.". . . presidential primary candidate Hillary Clinton in mid-2007 as she began to take back the campaign momentum she had lost earlier to Barack Obama. Public opinion polls, however, were showing the American public preferred change to experience, by nearly a margin of 2:1, and thus was history made as illustrated by John Heilemann and Mark Halperin in the definitive work on the 2008 presidential election. This was the first election since 1960 in which the president would come from the U.S. Senate. Because each of the three Senate rivals remains a major national player, this well-done history is worth the read.

31 DIED JUMPING FROM GOLDEN GATE BRIDGE
Meanwhile the public owners of the Golden Gate Bridge are debating whether to invest $50 million to install a net extending from 20 feet below the bridge to 20 feet out from the bridge. It would take three years to design and install and no money has yet been found for the project.

"I feel very humble, but I think I have the strength of character to fight it." . . . Bob Hope on receiving the Congressional Gold Medal.

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