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Sick and Wrong

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STEP TWO: GUT THE PUBLIC OPTION

Once single-payer was off the table, the Democrats lost their best bargaining chip. Rather than being in a position to use the fear of radical legislation to extract concessions from the right — a position Obama seemingly gave away at the outset, by punting on single-payer — Republicans and conservative Blue Dog Democrats suddenly realized that they had the upper hand. Pelosi and Senate Majority Leader Harry Reid would now give away just about anything to avoid having to walk away without a real health care bill.

The situation was made worse as the flagging economy ate away at Obama's political capital. Polls showed the percentage of "highly engaged" Democrats plummeting, while the percentage of "highly engaged" Republicans — inspired by idiotic scare stories from Rush Limbaugh and Sarah Palin about socialized medicine and euthanasia — rose rapidly. By late summer, "the depth of Republican support was starting to rival the breadth of Democratic support," said noted statistician Nate Silver. The more the Republicans and Blue Dogs fidgeted and fucked around, the easier it would be for them to kill the public option. Democrats, who on the morning after Election Day could have passed a single-payer system without opposition, were now in a desperate hurry to make a deal.

The public option is hardly a cure-all: Among other things, it does nothing to reduce the $350 billion a year in unnecessary paperwork and administrative overhead that makes the current system so expensive and maddening. "That's one of the big issues," says an aide to a member of the progressive caucus. "None of this addresses the paperwork issue. It might even make it worse." But the basic idea of the public option is sound enough: create a government health plan that citizens could buy through regulated marketplaces called insurance "exchanges" run at the state level. Simply by removing the profit motive, the government plan would be cheaper than private insurance. "The goal here was to offer the rock-bottom price, the Wal-Mart price, so that people could buy insurance practically at cost," says one Senate aide.

The logic behind the idea was so unassailable that its opponents often inadvertently found themselves arguing for it. "Assurances that the government plan would play by the rules that private insurers play by are implausible," groused right-wing douchebag George Will. "Competition from the public option must be unfair, because government does not need to make a profit and has enormous pricing and negotiating powers." In other words, if you offer a public plan that doesn't systematically fuck every single person in the country by selling health care at inflated prices and raking in monster profits, private insurers just won't be able to compete.

Will wasn't the only prominent opponent of reform openly arguing in favor of the insurance industry's right to continue doing business inefficiently. Sen. Ben Nelson, who together with Baucus are the Laverne and Shirley of turncoat Democrats, complained that the public option "would win the game." Senate Minority Leader Mitch McConnell admitted that "private insurance will not be able to compete with a government option." This is a little like complaining that Keanu Reeves was robbed of an Oscar just because he can't act.

For a while, the public option looked like it might have a real chance at passing. In the House, both the ways and means committee and the labor committee passed draft bills that contained a genuine public option. But then conservative opponents of the plan, the so-called Blue Dog Democrats, mounted their counterattack. A powerful bloc composed primarily of drawling Southerners in ill-fitting suits, the Blue Dogs — a gang of puffed-up political mulattos hired by the DNC to pass as almost-Republicans in red-state battlegrounds — present themselves as a quasi-religious order, worshipping at the sacred altar of "fiscal responsibility" and "deficit reduction." On July 9th, in a harmless-sounding letter to Pelosi, 40 Blue Dogs expressed concern that doctors in the public option "must be fairly reimbursed at negotiated rates, and their participation must be voluntary." Paying doctors "using Medicare's below-market rates," they added, "would seriously weaken the financial stability of our local hospitals."

The letter was an amazing end run around the political problem posed by the public option — i.e., its unassailable status as a more efficient and cheaper health care alternative. The Blue Dogs were demanding that the very thing that makes the public option work — curbing costs to taxpayers by reimbursing doctors at Medicare rates plus five percent — be scrapped. Instead, the Blue Dogs wanted compensation rates for doctors to be jacked up, on the government's tab. The very Democrats who make a point of boasting about their unwavering commitment to fiscal conservatism were lobbying, in essence, for a big fat piece of government pork for doctors. "Cost should be the number-one concern to the Blue Dogs," grouses Rep. Woolsey. "That's why they're Blue Dogs."

In the end, the Blue Dogs won. When the House commerce committee passed its bill, the public option no longer paid Medicare-plus-five-percent. Instead, it required the government to negotiate rates with providers, ensuring that costs would be dramatically higher. According to one Democratic aide, the concession would bump the price of the public option by $1,800 a year for the average family of four.

In one fell swoop, the public plan went from being significantly cheaper than private insurance to costing, well, "about the same as what we have now," as one Senate aide puts it. This was the worst of both worlds, the kind of take-the-fork-in-the-road nonsolution that has been the peculiar specialty of Democrats ever since Bill Clinton invented a new way to smoke weed. The party could now sell voters on the idea that it was offering a "public option" without technically lying, while at the same time reassuring health care providers that the public option it was passing would not imperil the industry's market share.

Even more revolting, when Pelosi was asked on July 31st if she worried that progressives in the House would yank their support of the bill because of the sellout to conservatives, she literally laughed out loud. "Are the progressives going to take down universal, quality, affordable health care for all Americans?" she said, chuckling heartily to reporters. "I don't think so."

The laugh said everything about what the mainstream Democratic Party is all about. It finds the notion that it has to pay anything more than lip service to its professed values funny. "It's a joke," complains one Democratic aide. "This is all a game to these people — and they're good at it."

The concession to the Blue Dogs comes at a potentially disastrous price: Without a public option that drives down prices, the cost of other health care reforms being considered by Congress will almost certainly skyrocket. The trade-off with conservatives might be understandable, if those other reforms were actually useful. But this is Congress we're talking about.

STEP THREE: PACK IT WITH LOOPHOLES

Even seasoned congressional aides, who are accustomed to sitting through long and boring committee meetings, have found the debate over health care reform uniquely torturous. Unlike other congressional matters, where there is at least a feeling that the process might at some point be completed, the endless sessions over health care have led many staffers to fear that they will be locked in hearing rooms for the rest of their lives, listening to words like "target" and "mandate" and "doughnut hole" being repeated ad nauseam by weary, gray-faced, saggy-necked legislators — who begin, after weeks of self-inflated posturing, to look like the ugliest people in the universe. "You come out of these hearings," says Behan, the aide to Sen. Sanders, "and the number of interconnected, moving pieces going in and out of these bills is insane — the case for single-payer health insurance makes itself."

For those looking to fuck up health care reform — or to load it up with goodies for their rich pals — the tedium actually serves a broader purpose. Given that five different committees are weighing five different and often competing paths to reform, it's not surprising that all sorts of bizarre crap winds up buried in their bills, stuff no one could possibly have expected to be in there. The most glaring example, passed by Ted Kennedy's HELP committee, would allow the makers of complex drugs known as "biologics"
doctors in the public option "must be fairly reimbursed at negotiated rates, and their participation must be voluntary." Paying doctors "using Medicare's below-market rates," they added, "would seriously weaken the financial stability of our local hospitals."

The letter was an amazing end run around the political problem posed by the public option — i.e., its unassailable status as a more efficient and cheaper health care alternative. The Blue Dogs were demanding that the very thing that makes the public option work — curbing costs to taxpayers by reimbursing doctors at Medicare rates plus five percent — be scrapped. Instead, the Blue Dogs wanted compensation rates for doctors to be jacked up, on the government's tab. The very Democrats who make a point of boasting about their unwavering commitment to fiscal conservatism were lobbying, in essence, for a big fat piece of government pork for doctors. "Cost should be the number-one concern to the Blue Dogs," grouses Rep. Woolsey. "That's why they're Blue Dogs."

In the end, the Blue Dogs won. When the House commerce committee passed its bill, the public option no longer paid Medicare-plus-five-percent. Instead, it required the government to negotiate rates with providers, ensuring that costs would be dramatically higher. According to one Democratic aide, the concession would bump the price of the public option by $1,800 a year for the average family of four.

In one fell swoop, the public plan went from being significantly cheaper than private insurance to costing, well, "about the same as what we have now," as one Senate aide puts it. This was the worst of both worlds, the kind of take-the-fork-in-the-road nonsolution that has been the peculiar specialty of Democrats ever since Bill Clinton invented a new way to smoke weed. The party could now sell voters on the idea that it was offering a "public option" without technically lying, while at the same time reassuring health care providers that the public option it was passing would not imperil the industry's market share.

Even more revolting, when Pelosi was asked on July 31st if she worried that progressives in the House would yank their support of the bill because of the sellout to conservatives, she literally laughed out loud. "Are the progressives going to take down universal, quality, affordable health care for all Americans?" she said, chuckling heartily to reporters. "I don't think so."

The laugh said everything about what the mainstream Democratic Party is all about. It finds the notion that it has to pay anything more than lip service to its professed values funny. "It's a joke," complains one Democratic aide. "This is all a game to these people — and they're good at it."

The concession to the Blue Dogs comes at a potentially disastrous price: Without a public option that drives down prices, the cost of other health care reforms being considered by Congress will almost certainly skyrocket. The trade-off with conservatives might be understandable, if those other reforms were actually useful. But this is Congress we're talking about.

STEP THREE: PACK IT WITH LOOPHOLES

Even seasoned congressional aides, who are accustomed to sitting through long and boring committee meetings, have found the debate over health care reform uniquely torturous. Unlike other congressional matters, where there is at least a feeling that the process might at some point be completed, the endless sessions over health care have led many staffers to fear that they will be locked in hearing rooms for the rest of their lives, listening to words like "target" and "mandate" and "doughnut hole" being repeated ad nauseam by weary, gray-faced, saggy-necked legislators — who begin, after weeks of self-inflated posturing, to look like the ugliest people in the universe. "You come out of these hearings," says Behan, the aide to Sen. Sanders, "and the number of interconnected, moving pieces going in and out of these bills is insane — the case for single-payer health insurance makes itself."

For those looking to fuck up health care reform — or to load it up with goodies for their rich pals — the tedium actually serves a broader purpose. Given that five different committees are weighing five different and often competing paths to reform, it's not surprising that all sorts of bizarre crap winds up buried in their bills, stuff no one could possibly have expected to be in there. The most glaring example, passed by Ted Kennedy's HELP committee, would allow the makers of complex drugs known as "biologics" to keep their formulas from being copied by rivals for 12 years — twice as long as the protection for ordinary pharmaceuticals. The notion that an effort ostensibly aimed at curbing health care costs would grant the pharmaceutical industry lucrative new protections against generic drugs is even weirder when you consider that earlier proposals, including one supported by Obama, would have protected brand-name drugs for only seven years.

Another favor to industry buried in the bills involves the issue of choice. From the outset, Democrats have been careful to make sure that a revamped system would not in any way force citizens to give up their existing health care plans. As Obama told the American Medical Association in June, "If you like your doctor, you will be able to keep your doctor, period. If you like your health care plan, you'll be able to keep your health care plan, period. No one will take it away, no matter what."

That sounds great, particularly in conjunction with the new set of standards for employer-provided insurance outlined in the House version of reform. Under the bill — known as HR 3200 — employers must provide "essential benefits" to workers or face a stiff penalty. "Essential benefits" includes elements often missing in the fly-by-night plans offered by big employers: drug benefits, outpatient care, hospitalization, mental health, the works. If your employer does not offer acceptable coverage, you then have the right to go into one of the state-run insurance "exchanges," where you can select from a number of insurance plans, including the public option.

There's a flip side, though: If your employer offers you acceptable care and you reject it, you are barred from buying insurance in the insurance "exchange." In other words, you must take the insurance offered to you at work. And that might have made sense if, as decreed in the House version, employers actually had to offer good care. But in the Senate version passed by the HELP committee, there is no real requirement for employers to provide any kind of minimal level of care. On the contrary, employers who currently offer sub-par coverage will have their shitty plans protected by a grandfather clause. Which means …

"If you have coverage you like, you can keep it," says Sen. Sanders. "But if you have coverage you don't like, you gotta keep it."

This grandfather clause has potentially wide-ranging consequences. One of the biggest health care problems we have in this country is the technique used by large employers — Wal-Mart is the most notorious example — of offering dogshit, bare-bones health insurance that forces employees to take on steep co-pays and other massive charges. Low-wage workers currently offered these plans often reject them and join Medicaid, effectively shifting the health care burden for Wal-Mart employees on to the taxpayer. If the HELP committee's grandfather clause survives to the final bill, those workers who did the sensible thing in rejecting Wal-Mart's crap employer plan and taking the comparatively awesome insurance offered via Medicaid will now be rebuffed by the state and forced to take the dogshit Wal-Mart offering.

This works out well for the states, who will get to purge all those Wal-Mart workers from their Medicaid rolls. It also works great for Wal-Mart, since any new competitors who appear on the horizon will be forced to offer genuine and more expensive health insurance — giving Wal-Mart a clear competitive advantage. This little "glitch" is the essence of the health care reform effort: It changes things in a way that works for everyone except actual sick people.

Veteran legislators speak of this horrific loophole as if it were an accident — something that just sort of happened, while no one was looking. Sen. Ron Wyden of Oregon was looking at an early version of the bill several months ago, when he suddenly realized that it was going to leave people stuck with their employer insurance. "I woke up one morning and was like, 'Whoa, people aren't going to have choices,'" he recalls.

As a means of correcting the problem, Wyden wrote up a thing called the Free Choice Act, which like many of the prematurely sidelined ideas in this health care mess is actually quite sensible. The bill would open up the insurance "exchanges" to all consumers, regardless of who is offered employer-based insurance and who isn't. But Wyden has little hope of having his proposal included in later versions of the bill. Like Sanders, who hopes to correct the committee's giveaway to drugmakers, Wyden won't get a real shot at having an impact until the House and Senate meet to hammer out differences between their final bills. In a legislative sense, the bad ideas are already in the barn, and the solutions are fenced off in the fields, hoping to get in.

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Matt Taibbi

Matt Taibbi is a contributing editor for Rolling Stone. He’s the author of five books and a winner of the National Magazine Award for commentary. Please direct all media requests to taibbimedia@yahoo.com.

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