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Sick and Wrong

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STEP FOUR: PROVIDE NO LEADERSHIP

One of the reasons for this chaos was the bizarre decision by the administration to provide absolutely no real oversight of the reform effort. From the start, Obama acted like a man still running for president, not someone already sitting in the White House, armed with 60 seats in the Senate. He spoke in generalities, offering as "guiding principles" the kind of I'm-for-puppies-and-sunshine platitudes we got used to on the campaign trail — investment in prevention and wellness, affordable health care for all, guaranteed choice of doctor. At no time has he come out and said what he wants Congress to do, in concrete terms. Even in June, when congressional leaders desperate for guidance met with chief of staff (and former legislative change-squelcher) Rahm Emanuel, they got no signal at all about what the White House wanted. On the question of a public option, Emanuel was agonizingly noncommittal, reportedly telling Senate Democrats that the president was still "open to alternatives."

On the same day Emanuel was passing the buck to senators, Obama was telling reporters that it's "still too early" to have a "strong opinion" on a public option. This was startling news indeed: Eight months after being elected president of the United States is too early to have an opinion on an issue that Obama himself made a central plank of his campaign? The president conceded only that a "public option makes sense."

This White House makes a serial vacillator like Bill Clinton look like Patton crossing the Rhine. Veterans from the Clinton White House, in fact, jumped on Obama. "The president may have overlearned the lesson of the Clinton health care plan fiasco, which was: Don't deliver a package to the Hill, let the Hill take ownership," said Robert Reich, who served as labor secretary under Clinton. There were now so many competing ideas about how to pay for the plan and what kind of mandates to include that even after the five bills are completed, Congress will not be much closer to reform than it was at the beginning. "The president has got to go in there and give it coherence," Reich concluded.

But Reich's comment assumes that Obama wants to give the bill coherence. In many ways, the lily-livered method that Obama chose to push health care into being is a crystal-clear example of how the Democratic Party likes to act — showering a real problem with a blizzard of ineffectual decisions and verbose nonsense, then stepping aside at the last minute to reveal the true plan that all along was being forged off-camera in the furnace of moneyed interests and insider inertia. While the White House publicly eschewed any concrete "guiding principles," the People Who Mattered, it appeared, had already long ago settled on theirs. Those principles seem to have been: no single-payer system, no meaningful public option, no meaningful employer mandates and a very meaningful mandate for individual consumers. In other words, the only major reform with teeth would be the one forcing everyone to buy some form of private insurance, no matter how crappy, or suffer a tax penalty. If the public option is the sine qua non for progressives, then the "individual mandate" is the counterpart must-have requirement for the insurance industry.

"That was their major policy 'ask,' and it looks like they're going to get it," says Dr. Steffie Woolhandler, a Boston physician who is a prominent single-payer advocate.

The so-called "individual mandate" is currently included in four of the five bills before Congress. The most likely version to survive into the final measure resembles the system in Massachusetts designed by Mormon glambot Mitt Romney, who imposed tax penalties on citizens who did not buy insurance. Several of Romney's former advisers are involved in the writing of Obamacare, including a key aide to Ted Kennedy who was instrumental in designing the HELP committee legislation. The federal version of the Massachusetts plan would slap the uninsured with a hefty tax penalty — making the HELP committee clause barring people from opting out of their employer-provided plan that much more outrageous.

If things go the way it looks like they will, health care reform will simply force great numbers of new people to buy or keep insurance of a type that has already been proved not to work. "The IRS and the government will force people to buy a defective product," says Woolhandler. "We know it's defective because three-quarters of all people who file for bankruptcy because of medical reasons have insurance when they get sick — and they're bankrupted anyway."

STEP FIVE: BLOW THE MATH

Health care is a beast — a monster. The House 3200 bill alone is 1,017 pages long and contains countless inscrutable references to other pieces of legislation, meaning that in order to fully comprehend even those thousand pages one really has to read upward of 9,000 or 10,000 pages. There are five different versions of this creature, each with its own nuances and shades, and solving a highly complex mathematical challenge like reconciling the costs of each of the five plans would be beyond even minds who were (a) expert at such things and (b) motivated to get it right. Imagine the same problem in the hands of a bunch of second-rate country lawyers and mall owners, and you about get the idea of what the congressional picture looks like.

For instance: All five of the bills envision a significant expansion of Medicaid. As it stands, the LBJ-era program, which celebrated its 44th birthday on the day before Nancy Pelosi laughed at the progressives, awards benefits according to a jumbled series of state-by-state criteria. Some states, like Vermont, offer Medicaid to citizens whose income is as high as 300 percent of the federal poverty level, while others, like Georgia, only offer Medicaid to those closer to or below the poverty level.

The House plan would expand Medicaid eligibility to automatically include every American whose income is 133 percent of the poverty level or less. For those earning somewhat more — up to 400 percent of the poverty level — federal subsidies would help pay for the cost of a public or private plan purchased via the insurance "exchanges." That worries state governments, which currently pay for almost half of Medicaid — and which are already seeing their Medicaid rolls swelled by the economic meltdown. A massive surge in new Medicaid members — as many as 11 million Americans under the current proposals, according to the Congressional Budget Office — might literally render many big states insolvent overnight.

Democrats pointed out that under the House plan, the federal government would pay the costs of any "newly eligible" members of Medicaid. But that phrasing, it turns out, was a semantic trick designed to undersell the cost to the states. When Massachusetts imposed a similar mandate under Romney, thousands of people who were already eligible for Medicaid, but had not enrolled, immediately joined the program in order to avoid the tax penalty for being uninsured. So while the House plan would pay for "newly eligible" patients, it won't cover the "oldly eligible."

Congress in this instance is behaving like corporations in the Enron age, orphaning hidden costs and complications through clever wording and accounting. Another neat trick involves the federal subsidies for low-income people who make up to 400 percent of the poverty level. The Congressional Budget Office projects that under the House bill, the subsidies will cost upward of $773 billion by 2019. But some aides think that number could end up being much higher. "Without a real public option to drive down costs, the federal support to make sure everyone gets coverage is going to get very expensive very fast," says Behan, the aide to Sen. Sanders.

Here's the other thing. By blowing off single-payer and cutting the heart out of the public option, the Obama administration robbed itself of its biggest argument — that health care reform is going to save a lot of money. That has left the Democrats vulnerable to charges that the plan is going to blow a mile-wide hole in the budget, one we'll be paying debt service on through the year 3000. It also left them scrambling to find other ways to pay for the plan, making it almost inevitable that they would step in political shit with seniors everywhere by trying surreptitiously to whittle down Medicare. As a result, the Democrats have become so oversensitive to charges of fiscal irresponsibility that they're taking their frustrations out on people who don't deserve it. Witness Nancy Pelosi's bizarre freakout over the Congressional Budget Office. When the CBO questioned Obama's projected cost savings, Pelosi blasted them for "always giving you the worst-case scenario" — which, of course, is exactly what the budget office is supposed to do. When you start asking your accountant to look on the bright side, you know you're not dealing from a position of strength.

To recap, here's what ended up happening with health care. First, they gave away single-payer before a single gavel had fallen, apparently as a bargaining chip to the very insurers mostly responsible for creating the crisis in the first place. Then they watered down the public option so as to make it almost meaningless, while simultaneously beefing up the individual mandate, which would force millions of people now uninsured to buy a product that is no longer certain to be either cheaper or more likely to prevent them from going bankrupt. The bill won't make drugs cheaper, and it might make paperwork for doctors even more unwieldy and complex than it is now. In fact, the various reform measures suck so badly that PhRMA, the notorious mouthpiece for the pharmaceutical industry which last year spent more than $20 million lobbying against health care reform, is now gratefully spending more than seven times that much on a marketing campaign to help the president get what he wants.

So what's left? Well, the bills do keep alive the so-called employer mandate, requiring companies to provide insurance to their employees. A good idea — except that the Blue Dogs managed to exempt employers with annual payrolls below $500,000, meaning that 87 percent of all businesses will be allowed to opt out of the best and toughest reform measure left. Thanks to Harry Reid, Nancy Pelosi and Barack Obama, we can now be assured that the 19 or 20 employers in America with payrolls above $500,000 who do not already provide
option to drive down costs, the federal support to make sure everyone gets coverage is going to get very expensive very fast," says Behan, the aide to Sen. Sanders.

Here's the other thing. By blowing off single-payer and cutting the heart out of the public option, the Obama administration robbed itself of its biggest argument — that health care reform is going to save a lot of money. That has left the Democrats vulnerable to charges that the plan is going to blow a mile-wide hole in the budget, one we'll be paying debt service on through the year 3000. It also left them scrambling to find other ways to pay for the plan, making it almost inevitable that they would step in political shit with seniors everywhere by trying surreptitiously to whittle down Medicare. As a result, the Democrats have become so oversensitive to charges of fiscal irresponsibility that they're taking their frustrations out on people who don't deserve it. Witness Nancy Pelosi's bizarre freakout over the Congressional Budget Office. When the CBO questioned Obama's projected cost savings, Pelosi blasted them for "always giving you the worst-case scenario" — which, of course, is exactly what the budget office is supposed to do. When you start asking your accountant to look on the bright side, you know you're not dealing from a position of strength.

To recap, here's what ended up happening with health care. First, they gave away single-payer before a single gavel had fallen, apparently as a bargaining chip to the very insurers mostly responsible for creating the crisis in the first place. Then they watered down the public option so as to make it almost meaningless, while simultaneously beefing up the individual mandate, which would force millions of people now uninsured to buy a product that is no longer certain to be either cheaper or more likely to prevent them from going bankrupt. The bill won't make drugs cheaper, and it might make paperwork for doctors even more unwieldy and complex than it is now. In fact, the various reform measures suck so badly that PhRMA, the notorious mouthpiece for the pharmaceutical industry which last year spent more than $20 million lobbying against health care reform, is now gratefully spending more than seven times that much on a marketing campaign to help the president get what he wants.

So what's left? Well, the bills do keep alive the so-called employer mandate, requiring companies to provide insurance to their employees. A good idea — except that the Blue Dogs managed to exempt employers with annual payrolls below $500,000, meaning that 87 percent of all businesses will be allowed to opt out of the best and toughest reform measure left. Thanks to Harry Reid, Nancy Pelosi and Barack Obama, we can now be assured that the 19 or 20 employers in America with payrolls above $500,000 who do not already provide insurance will be required to offer good solid health coverage. Hurray!

Or will they? At the end of July, word leaked out that the Senate Finance Committee, in addition to likely spiking the public option, had also decided to ditch the employer mandate. It was hard to be certain, because even Democrats on the committee don't know what's going on in the Group of Six selected by Baucus to craft the bill. Things got so bad that some Democrats on the committee — including John Kerry, Chuck Schumer and Robert Menendez — were reduced to holding what amounts to shadow hearings on health care several times a week, while Baucus and his crew conducted their meetings in relative secrecy. The chairman did not even bother to keep his fellow Democrats informed of the bill's developments, let alone what he has promised Republicans in return for their support of the bill. "The Group of Six has hijacked the process," says an aide to one of the left-out senators.

This leaves Democrats on the committee in the strange position of seriously considering pulling their support for a bill that will emerge from a panel on which they hold a clear majority. Other Democrats are also weighing an end run around their own leadership, hoping to sneak meaningful reforms back into the process. In the House, Rep. Anthony Weiner of New York refused to support the bill passed by the commerce committee unless he was allowed to attach an amendment that will enable Congress to vote on replacing the entire reform bill with a single-payer plan (Bernie Sanders is working on a similar measure in the Senate). On the labor committee, Rep. Dennis Kucinich of Ohio took a more nuanced tack, offering an amendment that would free up states to switch to a single-payer system of their own.

It's highly unlikely, though, that the party's leaders will agree to include such measures when the five competing reform bills are eventually combined. On the House side, "Pelosi has unfettered discretion to combine the bills as she pleases," observes one Democratic aide. Which leaves us where we are today, as Congress enjoys its vacation, and the various sides have taken to the airwaves in an advertising blitz to make sure the population is saturated with idiotic misconceptions before the bill is actually voted on in the fall.

The much-ballyhooed right-wing scare campaign, with its teabagger holdovers ridiculously disrupting town-hall meetings with their belligerent protests and their stoneheaded memes (the sign raised at a town hall held by Rep. Rick Larson of Washington — keep the guvmint out of my Medicare — is destined to become a classic of conservative propaganda), has proved to be almost totally irrelevant to the entire enterprise. Aside from lowering even further the general level of civility (teabaggers urged Sen. Chris Dodd to off himself with painkillers; Rep. Brad Miller had his life threatened), the Limbaugh minions have accomplished nothing at all, except to look like morons for protesting as creeping socialism a reform effort designed specifically to change as little as possible and to preserve at all costs our malfunctioning system of private health care.

All that's left of health care reform is a collection of piece-of-shit, weakling proposals that are preposterously expensive and contain almost nothing meaningful — and that set of proposals, meanwhile, is being negotiated down even further by the endlessly negating Group of Six. It is a fight to the finish now between Really Bad and Even Worse. And it's virtually guaranteed to sour the public on reform efforts for years to come.

"They'll pass some weak, mediocre plan that breaks the bank and even in the best analysis leaves 37 million people uninsured," says Mokhiber, one of the single-payer activists arrested by Baucus. "It's going to give universal health care a bad name."

It's a joke, the whole thing, a parody of Solomonic governance. By the time all the various bills are combined, health care will be a baby not split in half but in fourths and eighths and fractions of eighths. It's what happens when a government accustomed to dealing on the level of perception tries to take on a profound emergency that exists in reality. No matter how hard Congress may try, though, it simply is not possible to paper over a crisis this vast.

Then again, some of the blame has to go to all of us. It's more than a little conspicuous that the same electorate that poured its heart out last year for the Hallmark-card story line of the Obama campaign has not been seen much in this health care debate. The handful of legislators — the Weiners, Kuciniches, Wydens and Sanderses — who are fighting for something real should be doing so with armies at their back. Instead, all the noise is being made on the other side. Not so stupid after all — they, at least, understand that politics is a fight that does not end with the wearing of a T-shirt in November.

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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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