Wednesday, February 25, 2009

Public health response to President Obama’s speeach

From the perspective of public health, President Obama’s speech was nearly a home run. He addressed the fundamental policies that will improve the health of the nation:

Political participation, income equality, education, and peace.
He called for generosity, resilience, and community.
He explained his economic policy, and gave us hope.

He also said he would reform the health care system.

He said he would do it quickly, in consultation with key stakeholders: doctors, businesses, and workers. He emphasized that the focus would be to control the costs of health care, which are skyrocketing a century after Teddy Roosevelt first called for reform.

But he hedged his bets. His plan will be only a “downpayment on what we must have: quality affordable health care for every American.” He stuck with the program for cost control he campaigned on: large investments in preventive care and electronic medical records, and reducing waste, fraud and abuse. There will be a new effort to conquer cancer, and better benefits for veterans.

It's genuinely exciting and encouraging to hear, “It cannot wait, it must not wait, it will not wait another year.” Now, the hard realities set in. There are two fundamental conditions for controlling health care costs that the U.S. lacks, in contrast with every other industrialized country. One is getting everyone covered. We can't stop whipsawing prices until we have everyone in the same tent. The other is authorizing a negotiating entity -- in most cases the government -- with the political will and the power to take on the customary practices of the medical industrial complex. This includes wringing out the administrative waste for which we continue to reward the predatory health insurance industry, as well as clinical excesses. More rational financing systems are generally associated with systems that produce better outcomes. Predicting that it will work in reverse is ... optimistic.

It's an enterprise that will require, at some point, taking a hard stand. The public that the President inspired to organize over the last year will have to provide the ballast for this effort to succeed.

Having dispatched the knotty problem of health care, the President said we would also have to address the equally difficult problems of Social Security. In fact, as he is well aware, the minor fiscal adjustments required to sustain Social Security are but a blip compared with the task of fixing our health care system. The reference to tax-free universal savings accounts seemed to be a troubling nod to the Peterson Institute, which has been waxing frantically in full-page ads about the U.S.’ deficit spending on “entitlements” while referring only in passing to the trillions detonated in Iraq. (Baseline Scenario, February 2009, by Peter Boone, Effective Intervention, and Simon Johnson, Peterson Institute for International Economics.

Meanwhile, the best the Republican respondent Gov. Bobby Jindal could do to attack the competence of government was to decry the Republicans' own failures during Katrina. He distorted Obama's quality improvements as government-run health care. Interestingly, he did not say that his own prescription, to leave health care decisions to doctors and patients, would apply to the reproductive choices of women, girls and families.

Monday, February 23, 2009

Health Reform: The Cure for Medicare and the Economy

Today's national budget summit proposes to address a wide range of economic issues. The Peterson Institute and others have tried to use the crisis to shoehorn in tired proposals to privatize Social Security and Medicare, and cut back on benefits. While public outrage has derailed unfounded attacks on Social Security, the vital Medicare program faces budget problems. The solution for Medicare is universal coverage for affordable, appropriate health care.


There is no real funding problem with Social Security. Public outrage is slowing down initial attacks on Social Security.

Medicare, however, does face a budget crunch. This vital federal program provides critical coverage for 45 million people. While it controls costs better than any private sector health insurance plan, it is subject to pressures from our fragmented, inflationary, irrational health care system. In addition, Bush-era policies intended to privatize and defund Medicare have taken a toll.

Congress and the Obama Administration have already taken some important intermediate steps, by reversing some of the Bush-era programs. They have pledged to reduce over-payments to private, competing plans, that now receive 13% more funds than traditional, public Medicare. They waived an automatic trigger that would have mandated budget cuts. Newly authorized comparative effectiveness studies will help guide health care providers toward the best medical care practices, rather than those that bump up income for the medical industrial complex.

The Peterson Institute and allies have no real solution, except that government should "spend less" on the program: that means cutting benefits, and shifting costs to individuals. That approach lost the election in November, and is obsolete in the face of the economic crash.

The way to assure that the Medicare program we depend on survives is to do what every other country has done: use the authority of the government to assure that everyone has coverage for health care, and that the payments are affordable for all of us. Universal coverage for affordable, appropriate health care is the solution for Medicare and for the economy.

See for more.

(Even the Medicare Trustees report that Medicare is solvent until 2019:

Thanks to Sid Socolar for forwarding the link below to a critique of Peterson by William Greider and the Campaign for America's Future. - Ellen Shaffer

"Irresponsible, Thy Name Is Peterson" |


Sunday, February 8, 2009

Defending entitlements

Ronald Brownstein's National Journal article of Feb. 7 presents a misguided and confounding attack on "entitlements." He states in the course of 2 sentences (in "The Solvency Solution"):

"The president's universal health care plan will cost at least $100 billion a year. Washington can't shoulder such costs, much less simultaneously increase investment, without eventually generating significant savings from existing entitlements..."

Medicare IS the major entitlement that threatens runaway costs, and if the President's "universal health care plan" actually succeeds, "Washington" could in fact "shoulder such costs," because it would be "eventually generating significant savings from existing entitlements."

We shouldn't choose. We can't choose. Health reform is the answer to the entitlement problem, and one of the answers to the current economic crisis.

But confusing statements by Brownstein, and more importantly by policy-makers, raise echoes of the roundly defeated attacks by the Bush Administration. They lumped entirely resolvable minor problems with Social Security funding (the other main entitlement) with the knottier - but also resolvable - problem of controlling health care expenditures. They also lumped endless tax cuts with alarms about entitlements to suggest that the solutions lie in undermining the already shaky social safety net: people's lives at the service of The Economy, rather than the reverse. This agenda was a non-starter even during the last 4 years, and showed no greater signs of life in the recent election.

There is not a feedback mechanism on the National Journal website. But I've asked Mr. Brownstein - generally a fair-minded observer, who has worked both for Nader and with the Hoover Institution, and is also a columnist at the L.A. Times - to explain what he means.

More importantly, what do Senator Conrad (quoted by Brownstein) and President Obama have in mind? Budget Committee Chair Conrad seems to get it right, commenting on health reform in a recent interview:

And not only does it [health reform] have to be paid for, but it also has to bend the longterm
cost curves so that we do begin to deal with what has been described here. Time
is running out. We can wait; we can kick this can down the road. However, if we
do, this problem only grows, and the solutions will become more draconian, more
difficult, more painful. It is in all of our interests to act. I believe the
President understands that. I believe his top economic advisers are committed to
an approach to take these problems on. This is not going to be easy, and it is
not going to be fun, but it has to be done.

Conrad has joined former U.S. Comptroller General David Walker in calling for the creation of a bipartisan process to confront the looming budget crisis. Walker, who is now the President and CEO of the Peter G. Peterson Foundation, has unveiled a new Peterson Foundation $1 million-plus advertising campaign to raise public awareness of the nation’s deteriorating long-term fiscal condition. The effort is also supported by Senator George Voinovich (R-OH), Representative Jim Cooper (D-TN), and Representative Frank Wolf (R-VA). The campaign rhetoric and agenda bear watching.

- Ellen Shaffer

Wednesday, February 4, 2009

Health Reform: Where Now

With Tom Daschle's withdrawal, the President has lost a strong advocate for his "hybrid" approach to health reform, which would leave private sector employment-based health insurance in place, while also aiming to expand the role of public sector insurance plans; and a person with the chops to approach Congress, if not necessarily to move it.

Health advocates are wondering: Will there be leadership on health reform this year? In choosing a successor nominee, will the Administration look to a friend of the industry? of consumers? An advocate for the status quo, or a change-maker? What will be the policy space to build on Congress' early support for strong public sector health insurance/social insurance programs, and to advocate for alternatives to the hybrid proposal?

Daschle's approach was middle-of-the-road. Clearly, that's not where opponents of reform are heading. If we're really going to move on health reform this time we need a strong, seasoned advocate for reform, who understands and is familiar with: 1. The importance of a strong government payer/purchaser to control costs and assure universal coverage. The lack of this feature is the great weakness of the "hybrid" plans proposed by Daschle and others, and why they always struggle and fail at the state level; and 2. The institutional players.

Two great candidates:

1. Theodore Marmor is a Yale University Professor Emeritus in the Schools of Management and Law and the Department of Political Science and an Adjunct Professor in Public Policy at Harvard’s Kennedy School of Government. The former Director—from 1992 to 2003-- of the Robert Wood Johnson Foundation’s post-doctoral program in health policy. The second edition of The Politics of Medicare appeared in 2000); the first edition of this book became something of a political science classic and launched his career in health politics, policy and law. His best known other works include Understanding Health Care Reform (Yale Press, 1994), Why Are Some People Healthy and Others Not? (Aldine de Gruyter, 1994), and America’s Misunderstood Welfare State (Basic Books, 1992) co-authored with Yale colleagues Jerry Mashaw and Philip Harvey.

Marmor began his public career as a special assistant to Wilbur Cohen (Secretary of HEW) in the mid-1960s. He was a member of President Carter’s Commission on the agenda for the 1980s, and a senior social policy advisor to Walter Mondale in the Presidential campaign of 1984. He is an active member of
the Institute of Medicine of the National Academy of Sciences and the National Academy of Social Insurance.

2. Sheila James Kuehl is best known to Californians as the state Senator from the L.A. area who twice spearheaded passage of the state single payer bill, SB 840. She served as Speaker pro tempore during the 1997–98 legislative session, becoming the first woman in California history to hold the position. She was elected to the California State Senate in 2000, and has repeatedly been voted the "smartest" member of the California Legislature. She was also a founding member of the California Legislative LGBT Caucus. A child actor, many of us remember her role as Zelda in "Dobie Gillis."

Throughout her career as a legislator, Kuehl has taken a leadership role on health care policy. Her foremost objective has been securing passage of legislation to establish a single-payer health care system in California. SB 840 passed both houses of the legislature in 2006, but was vetoed by Governor Arnold Schwarzenegger; it was reintroduced in 2007 and again passed in both the Assembly and Senate, to face another veto by the Governator.