Tuesday, July 14, 2009

Republicans - Inconsistency is a Tool for Killing Health Reform

One of the most interesting aspects of the Senate's Health Committee hearings on health reform is how Republicans argue all sides of the case in order to kill the bill.

For example: they spend a lot of time asserting that Medicare and Medicaid are monumental failures because they cost too much and because large percentages* of doctors refuse to accept Medicare or Medicaid patients. But, of course, if one increases how much the government pays providers under those two programs, the costs will only be higher. The Republican solution? Obviously, they want to kill Medicare but, during the hearings, the idea seems to be to move Medicaid recipients into the private market (the health care exchanges).

With respect to the health care exchanges, the Republicans are endlessly creative. They argue about who should be eligible for subsidies. One proposal, to move people at the 150% of poverty level to Medicaid, fails their smell test because, first, it is unfair to those who are at 151%** of the poverty level and because Medicaid is a failed system giving second-class care. But, of course, if the alternative is to provide subsidies to those people so they can buy health insurance from an exchange, the cost of the bill goes up. Which is unacceptable.

Then we come to penalties for individuals and companies who don't buy health insurance. The size of the penalties, of course, is a real issue. But, although Republicans admit that it has to be high enough to encourage both to buy health insurance rather than simply pay the penalty, they object to even small penalties ($750 per full-time employee) because they will discourage small businesses from hiring new employees and might even force them to fire employees. Obviously, setting an appropriate penalty is a key to mandates which are key to covering everybody. But Republicans know that if they kill the penalties or make them really small, lots of people and businesses will rationally choose to pay the penalty rather than buy health insurance and that will put an added burden on the system which could lead to its failure - which, of course, is what they want.

Another argument about small businesses came up today. Sen. Murkowski of Alaska proposed that "small business" be defined for the purpose of the bill not as a company with less than 25 employees but as one with 500 employees because that is what the SBA uses as the definition for a small business. Now most of us don't normally consider a 500-person company to be small. And I think it was Enzi, as usual, who pointed out how unfair it would be to the company that wanted to add another employee (from 500 to 501**) because the penalty or requirement to buy health insurance would then kick in. Now, remember, Republicans like our employer-provided health care system; they just don't want to penalize companies who choose not to provide health insurance, no matter what their size.

Paying for the system? Republicans have proposed amendments specifically prohibiting higher taxes or penalties or any other method that might be used to pay for the program in order to, according to them of course, keep Obama's promise not to raise taxes. Without these elements, the program becomes prohibitively expensive. So they could oppose the bill on the grounds that it will increase the deficit.

Republicans are sure that "free market competition" will solve the cost and access problems, but they object to letting the Secretary of HHS negotiate rates for a public plan. Why? Because it will inevitably lead to the Secretary's imposing reimbursement rates which is the problem with the Medi programs. Republicans worry a lot about what may happen in the future because "that's what always happens". One of their solutions is to set the rates of a public plan as an average of the rates in the state. That many states in the country have health insurance markets that are either monopolies or duopolies - where there is, in essence, no market pressure to reduce rates - is irrelevant.

And, of course, they oppose any kind of reimbursement system based on "best practices". So how do they expect to stop the huge annual growth in health care costs? Well, letting the "free market" work. I wish, just once, some Democrat would point out that we've always had a "free market" and it doesn't seem to have held down costs. (They might also point out that Republicans assured everybody back in the 1990s that HMOs would increase coverage and decrease costs.)

And, as usual, the Republicans continue to try to talk the bill to death. Yesterday, Coburn introduced an amendment to replace the entire bill that they have been arguing about for weeks. I think this must be at least the second or third time the Repubicans have tried this. And, each time, they argue their side for ages. (I've lost track of the number of Republican amendments that have consumed a full hour of debate each - and the number of amendments proposed and pending has reached, I think, somewhere into the 400s.) Obviously, a Democrat-controlled committee isn't going to junk a bill they've spent weeks on so the only reason for this kind of amendment is to prolong the process - past the August recess.

Indeed, I am baffled by the continuing efforts of Democrats to accept Republican amendments of any kind since they must know that they will not get a single Republican vote to move the bill from the committee to the floor. Is it possible that Democrats still just don't understand Republicans?

* - this committee, and, for that matter, the rest of the Congress, needs a CBO for statistics. Representatives and Senators on both sides of the aisle throw statistics around willy nilly, rarely providing a source. A lot of time, I suspect the stats come out of their own heads, based on their oh-so-good personal experience. I'm not sure it will help the Republicans who tend to ignore studies that contradict "what they know" (even after the CBO scored a revised bill as costing about 600 billion rather than 1.5 trillion, Republicans continued to use the latter number).

**Democrats can be really dumb. Whenever an issue comes up about what constitutes a small business, or what penalty makes sense, or the percent of poverty or whatever, a Republican will wax eloquent about the poor business or person who just misses the cutoff point (26 employees, 151% of poverty), etc. I keep waiting for some Democrat to point out that this happens whenever one uses a cutoff point for anything. Earning one more dollar in income can move a person from one tax bracket to another. Short of never using a cutoff point for anything, this lack of fairness is inevitable.

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