There is no reason a Republican should hate a health care exchange. It’s the free market, or as free as you can practically get when it comes to health care. The existing health care market is not working. I fully believe in the free market when it works, but when it doesn’t, it’s time for the government to step in. Health care exchanges are probably the lightest touch the government can give when it comes to market interference. It’s as innocuous as a food court where customers can look at all the options and decide where they want to eat. That’s why health care exchanges were part of Mitt Romney’s health care plan in Massachusetts, and why Newt Gingrich essentially supported exchanges in 1994. Letting multiple insurance companies freely and transparently compete for premiums, instead of putting everybody into a single-payer insurance system, has been a bedrock principle of conservative health care reforms forever. At least when they were putting forward serious plans.

I can see why middlemen like insurance sales people would be against exchanges: it is taking away from their cut. I don’t agree, but I can sympathize. I can’t sympathize, though, with Republicans who oppose it simply to give Obama a defeat. Especially when they waste $1 million to do so. There really is no excuse for this.

• Current Mood: Engaged
• Currently Listening To: "Little Miss Strange", Jimi Hendrix

The U.S. government is planning on using what are essentially secret shoppers to determine how accessible doctors are to new patients and whether they treat people differently based on what kind of insurance they have. Although such undercover operations are par for the course in areas like retail, doctors are rather apoplectic that they will be treated like a sales clerk at Macy’s. Some are even going so far to call it “Big Brother” tactics, which seems to be a bit much considering that one of the goals is simply to determine whether doctors are telling the truth when they say they will accept new patients on Medicaid.

What it really demonstrates, however, is that no matter how much people argue that shopping around for a triple bypass should be little different from shopping around for a new car, it’s not going to happen. Smart comparison shopping isn’t going to solve the problems of rising costs and limited access because most people do not see health care as a retail activity. It’s a life-or-death activity, and one where one party has an inordinate expertise advantage. It’s only thing to compare the MPG stickers on a car and how well it handles when you are on the highway; it’s quite another to try to compare post-op complication rates at various hospitals and put that into the context of procedure cost (if you can even find that information to begin with).

A policy predicated on the belief that health care “consumers” are going to be able to bend the cost curve all by themselves by careful cost-benefit evaluations is doomed to failure.

• Current Mood: Lagging
• Currently Listening To: "Hallelujah", Leonard Cohen

The issue of employer-provided health care is in the news, as a poorly-done study is arguing that a large number of employers are planning on dropping their health care coverage in response to the new health care law. There is little reason to believe this is true, as many other studies show the opposite, and McKinsey refuses to release their study methodology, prompting many people to believe they are fudging their numbers. In the short term, it is important to reassure people that their employer will not drop coverage in the future during the implementation of the law. However, over the long term, I don’t see a need for any reason to link insurance to employment, especially since the goal is universal coverage. Why have one system for the employed, and one for the unemployed, especially if it is hard to move your coverage between the two realms?

Some may think that such a system would require single-payer health care. Sure, that would be easier to administer, but in no way would it be a requirement. You could just as easily be able to pick your insurance from several private options, in exactly the same way that you can go to one of several wireless phone providers to choose your coverage. For those who do not choose coverage, they would be assigned the baseline coverage from some private insurer by lottery. No penalties for not buying coverage and evading the mandate, no jail time, no fines. Just automatic signup. Plus, no changes to your coverage if you switch jobs or become unemployed.

When you get right down to it, if the goal is universal coverage, there is no good reason to tie insurance to your job. Obviously, the transition should be managed and orderly, but a transition should be made nonetheless to a system where employment matters as much to your insurance choice as it does to your choice of phone provider.

• Current Mood: Yin
• Currently Listening To: "Are You Experienced?", Jimi Hendrix

If Minnesotans have had their fill of Pawlenty, and we have, why does he think the rest of the country will want what he’s selling? Who knows? But he seems to be running under the assumption that the best way to win the Republican nomination is to appear “saner” than the rest of the candidates, all while running a completely content-free campaign, full of slogans and absurd assumptions, but quite short on facts. His ridiculous economic plan, to grow at 5% a year for a decade (which hasn’t happened since the Great Depression, even under his hero Ronald Reagan), has been panned by all rational economists, even Republicans. His just-as-laughable “Google test” for government services has been mock just as much (as many commenters have pointed out, since Pawlenty himself exists on Google, doesn’t that mean we don’t need him in government?). His tax plan would balloon the deficit by cutting taxes lower than they are now, even though federal taxes are already at historical lows. But still he clings to these ideas like a bit of flotsam in a storm, hoping that his competitors will drown before him.

It would be nice if he were challenged on some of these things. Why can’t somebody in the media put this graphic (courtesy of Paul Krugman) in front of him and ask him what it means for health care and what he will do about it if President:

Pawlenty had eight years as governor of Minnesota to do something about health care. He didn’t. No bending the cost curve, no successful pilot programs, no real effort to provide health insurance to under-served populations other than what was already in effect. Health care spending rising out of control is one of those serious issues that demands reality-based solutions. Even saying, “I don’t care that people can’t afford health insurance and I will not have the government step into the health care market” would be more honest that some of his current campaign proposals.

I used to think TPaw was Minnesota’s Don Quixote, tilting at windmills without a chance of getting the nomination. Given the terrible field for the Republicans so far, however, it’s not as impossible as I once thought, and that’s a bit frightening. I’ve lived through eight years of Pawlenty in Minnesota, kicking the can down the road, raising taxes without admitting it, and doing little to grow jobs or improve the human and physical capital of the state. I would prefer not to see that happen to the rest of the country. But he’ll try, sloganeering and flip-flopping his way towards a hoped-for nomination.

• Current Mood: Sore
• Currently Listening To: "25 or 6 to 4", Chicago

The law is the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986. This law makes it a requirement for hospitals to provide care to those who need it, regardless of ability to pay. Not only that, but even if you are unable to pay for treatment, you are still held liable for its cost. This law, passed under Reagan, was seen as a lot of things: a solution to “patient dumping”, an unfunded mandate, and an invitation for undocumented people to get free medical care, among other things. What this bill was not widely seen as, however, was unconstitutional. Aside from the arguments of some random bloggers, I know of no serious lawsuits or arguments against the constitutionality of the EMTALA.

So what does this have to do with the recent health care bill? Well, plenty. EMTALA pretty much acknowledges that health care is not something that can be denied in this country due to an inability to pay. Not only that, but EMTALA spells out responsibilities on both those who seek care, and the hospitals that provide care: hospitals can’t deny certain care based on inability to pay, and patients are held liable for care that is provided to them. In other words, if even the most rabid anti-health care reform opponent is found unconscious on a street corner, the hospital that receives him has an obligation to provide care, and the patient has to pay for it, even if he or she didn’t consent to it. Thus, theoretically, everybody in the U.S. is a part of the health care market.

Although there is a fair amount of opposition to the health care reform bill, again, there is not any serious opposition to EMTALA. As far as I know, there have been no attempts to repeal it in Congress, and I suspect that the vast majority of people in the U.S. would find such a repeal to be morally repugnant. But that creates a problem: if hospitals are required to give care, and patients are required to pay for it, then how do we ensure that care is reasonably paid for and that the market can function? The most valid critique of EMTALA is that it is an unfunded mandate on hospitals, and that is certainly true: emergency care providers like HCMC routinely write off tens of millions of dollars on provided care that they will not be reimbursed for, leading to higher property taxes and insurance premiums for the rest of us. This funding problem is a huge driver of increased health insurance costs in this country.

Thus, the question becomes, how do we pay for this care in a method that is fair to both the patient and to the hospital? The health care reform bill is an attempt to do that. It’s certainly not perfect, but I don’t see how it can be unconstitutional to regulate health insurance when every person in this country, citizen or not, can at any time become an unwilling party to the health care market. To eliminate this issue, we’d have to repeal EMTALA, and once again leave hospitals to decide whether they will provide care for the indigent or simply turn them away. Only then would we come close to having a health care market that people could seriously opt out of.

I have no idea when the Supreme Court will take up the court case on the constitutionality of the health care bill. When they do, though. I would be very surprised if they didn’t point to the EMTALA as evidence that the health care market truly is universal in the U.S., and therefore subject to Congressional regulation in the name of interstate commerce.

• Current Mood: Monday
• Currently Listening To: "Magical Mystery Tour", The Beatles
• Just Watched: The Social Network

If Jimmy John’s unionizes, then if anything I’ll go there more. Just like I buy my groceries at Rainbow or Cub instead of Target, because Target workers are not union and generally get crappy benefits (Target workers are treated little better than Walmart workers; the fact that they have avoided the negative reaction is a testament to their much better PR organization). I don’t mind paying a few bucks more for groceries knowing that the person checking me out at least has health insurance; similarly, I won’t mind paying more at Jimmy John’s to get the same assurance.

What I really don’t get is this: if small business owners are so scared of union drives, why don’t they support universal health care of some sort, be it public, private, or a combination? Lack of health insurance is generally a major driving force behind drives for unionization; if everybody had health insurance (that the business didn’t even directly have to pay for!) then the threat of unionization would be that much less. Not to mention that a lack of benefits would no longer be a detriment to hiring the best workers you can get. In short, disconnecting health insurance from employment and covering everybody would benefit small business owners in just about every way.

Frankly, I don’t get it. That is, though, my typical reaction when reading Star Tribune reader comments.

David Frum’s “Waterloo” post got a lot of attention from both conservatives and liberals when health care passed (it also proved to be the last straw for the American Enterprise Institute, which fired him last week). Frum is a conservative that I certainly don’t always agree with, but argues rationally and speaks what he believes to be the truth even when Republican party leaders do not want to hear it. In college, one of my poli sci instructors put together a list of books by authors from liberal to conservative that he considered to be the best academic writing about politics; Frum’s “Dead Right” was on it, and I dutifully read it, finding it to be quite interesting. The point I’m trying to make is that Frum is the kind of conservative this country needs more of: arguing based on reason and belief instead of name-calling.

After reading his Waterloo post, I added his FrumForum to my RSS feed (joining The American Conservative as the conservative blogs I read, which is another decently written one, although I outright ignore Pat Buchanan’s insane screeds). Sure enough, last week an intelligent post popped up that talked about three important issues that reform will have to address going forward, all of which I fully agree with:

First, employer-based health insurance. I think it’s long past time we totally decouple health insurance from employment. The notion that health insurance is something we expect employers to provide is an accident of history, cemented into place via the tax code. Now that we have nearly-universal coverage for everybody, there is no need for employer-based health insurance. We could eliminate that pretty quickly, but pretty messily, by removing the tax advantages that employer-provided health insurance have, but I think there are better ways to do that. I’m not quite sure who is against changing this. Perhaps unions, who want to be able to negotiate better benefits packages for their workers?

Second, health care value. Spending more has not led to better health outcomes. We have reached the point of diminishing returns, and we need to ratchet back on the wasteful spending that doesn’t deliver. Identifying this, and more importantly, getting rid of it, will be a huge challenge.

Third, improving overall health. Health insurance does make a difference in terms of improving health, but it is certainly not the only thing. Universal health coverage without cutting back on unhealthy activities like smoking, obesity, and a lack of physical activity will just lead to higher health costs with no increase in actual health.

I’m not going to agree with all of the conservative answers to these problems, but it is far better for our country when all sides sit down and agree to take about these real issues, instead of one side talking about death panels and other non-sequiturs. More rational discussion like this, please.

• Current Mood: Weekend
• Currently Listening To: "Hello, I Love You", The Doors

When the reports were rolling in on Sunday, and passage of the bill became more and more inevitable, it made all the phone calls, lit drops, roads trips, and door knocking worthwhile. Sure, there are other important issues other than health care out there. I like fiddling with tax policy and transportation, there’s the environment we need to take care of, there’s energy policy, and a thousand other things. But universal health care is the big one. America has long been on the wrong side of this issue, apart from all other industrialized countries, and our health and pocket books suffer as a result. Universal health care is the last large promise that we can make as community: that if you get sick, you will be covered. Even if you were sick before, even if you aren’t working right now, you will be covered. This is a far cry from a system where you get care if you pay for it, and if you don’t have the money you are at the mercy of others. That’s fine when it comes to luxuries, it’s even fine when it comes to some of life’s necessities. But to dole out health care based on ability to pay is not only unfair, it damages our communities in the long run.

This bill is by no means perfect. It needs to be improved. But the first step has been achieved: health care will now be seen as a right, not something to leave entirely up to the whims of who has money and who doesn’t. We’ll have problems along the way. We’ll screw up. But we’ll also find what works, and we’ll share those solutions. We’ll work together to reduce the cost of care, to reduce mistakes, to eliminate pointless treatments that do no good. We’ll eliminate the dead weight in our economy that this wasteful spending hangs around our necks.

But more importantly, we’ll tell those people who are sick that they no longer have to fear. If they lose their jobs, they don’t have to worry about losing insurance. They don’t have to worry that if they get too sick, or become to “expensive” to their insurance company, they’ll be left to fend for themselves. For people in good health, these seem like academic exercises. For all those people with so-called “pre-existing conditions”, however, this is not abstract. It’s a matter of life or death, and even those people who oppose health care reform will soon know a friend or loved one who is helped by this, if they don’t already. I know that I do.

Am I happy about how this was done? No. I’m saddened that insurance companies, having decades to prove that they could cover everybody regardless of health at a reasonable cost, chose instead to pursue profits at the expense of people. I’m saddened that too many Republicans chose to take themselves out of the process instead of working for common solutions. Ideologically, this bill is incredible moderate. It differs little from what Republican Mitt Romney did in Massachusetts, or what Republican Richard Nixon proposed when he was president. It took single-payer off the table from the start, and abandoned even a public option and Medicare buy-in. If Republicans had been at the table from the beginning instead of trying to torpedo reform, it may have been a better bill. Now we’ll never know.

I’d like to see changes to this bill. I’d like to see a public option. I’d like to completely decouple insurance from employment (as well as decoupling other things from employment like 401(k) plans to reflect a more mobile, fluid, and information-based economy). I’d like to see more flexibility in providing primary care to people: not everybody needs to see an M.D. I don’t care much for the Hyde amendment. We’ll need to see what cost-control measures work best and expand them.

These things will come in time. For now, it feels good to achieve something meaningful, something that fundamentally improves the lives of millions.

• Current Mood: Hopeful
• Currently Listening To: "Another One Bites The Dust", Queen

Let’s face it: in America, the norm is not a collective, “we’re all in this together” sense of community. It’s the rugged individualism of myth. Most people have no problem with seeing others go without: be it jobs, education, shelter, or even food, the sense of a lot of people is that anybody here can just “pull themselves up by their bootstraps” and acquire all of these things if they really tried, and if they don’t, it’s a problem of character. There are no widespread pushes to build public housing for all the homeless, and even a couple hundred dollars a month in food stamp benefits is seen by many as welfare that just leads to dependency. It’s our culture. Given the mythos that is drummed into us from an early age, these beliefs are at least somewhat understandable.

But when it comes to health care, it’s a bit different, and as a society we have seen fit to draw a line. Make no mistake: there are plenty of people in this country that die from homelessness or lack of food, and by and large, it is accepted, or at least not talked about seriously. But when it comes to health care, where the threat of death is immediate and in your face, at least most Americans don’t think that the poor and the uninsured should be left to figure things out for themselves. That’s why hospitals have to provide care, regardless of ability to pay. The fact that we mandate this without having a sane way to pay for it is troubling, but at least we say “no” to literally letting people die on the sidewalk outside of emergency rooms because they can’t pay for treatment.

The comments from some Republicans these days, however, show that even this level of human decency may be a bridge too far for them. It boggles the mind that they can have such a low level of empathy. Perhaps the reason is that a lot of them have always had heath care and insurance, and literally can’t think of what it would be like to go without. However, it has to go beyond that: I’ve been lucky (and I do ascribe some of it to luck, not just my “hard work”) to have never gone a long period without insurance in my life. But I know plenty of people who have not been as lucky, and I can put myself in their shoes. That’s what empathy means. Perhaps there are other, more sinister reasons. Our journalists, however, have not seen fit to ask them why they believe these things.

I’m an atheist, but I do know the meaning of the phrase “There but for the grace of god go I.” A lot of so-called Christian Republicans seem to have forgotten the meaning of that phrase entirely. When people can be so callous to the plight of the health of the truly poor and destitute in this country, when they can tell them to just figure it out on their own, it is troubling for the very fabric of our society. The thinking behind these statements moves away from a lack of empathy to a place that is even more dark. The question is, can it be stopped?

• Current Mood: Walking Subcaucus Time!
• Currently Listening To: "Girl With No Eyes", It's A Beautiful Day
• Just Watched: Into The Wild

Obviously, without a health care bill Congress can’t give voters a guarantee of coverage or nice things like that. The stimulus bill gave people a few bucks more a week in their paychecks, which is easily forgotten. It also led to a politically embarrassing method of calculating “jobs saved” by the stimulus (and really? Nobody thought this through before the numbers were crunched?); however, it did save jobs, and the Obama administration and Congress would do well to trot these police officers, teachers, and other people whose jobs were saved at every opportunity. They are really failing to take advantage of this. Reminding people of their extra four bucks every paycheck won’t cut it. Things like Cash for Clunkers and the home buyers’ credit helped a few people, but even more thought it was bad policy and bad politics, which I happen to agree with.

Financially, Congress did pass some big changes to credit card regulations; unfortunately for Congress, the credit card companies decided to screw over customers before the regulations went into effect. Again, it doesn’t seem like they thought that one through. Instead of giving people who are in danger of losing their homes bankruptcy cramdown, which would actually work, the HAMP program has been a dismal failure, even leading to increases in the amount of money homeowners owe. Not exactly something you can campaign on. TARP, while probably averting a major financial catastrophe, is not exactly seen by the majority of Americans as a good thing, especially since the banks are already going crazy again.

It’s not even all about money. Giving voters something to feel good about can do wonders. Obama voters voted for hope and change, but since the election there has been very little of it. Obama kicking “Don’t Ask, Don’t Tell” down the road is a bewildering political decision: most people support it, and it would make voters feel good to end a kind of discrimination that is becoming less and less acceptable (although CNN is reporting he will ask Congress to repeal DADT tonight). Obama and Congress have also dropped the ball on increased government transparency, like putting all bills online ahead of time. Again, simple to do, but makes people feel good.

With the relatively skimpy list of substantive accomplishments, it’s little wonder that Obama voters are feeling unmotivated. It’s not like legislation such as the Lilly Ledbetter Fair Pay Act are unimportant; they certainly are. But Obama voters didn’t vote for incremental change. They wanted significant changes in the way government works in their lives, and significant changes in their own financial situations. They gave a lot to Obama, and they understandably want something in return.

In a short while, Obama will give his State of the Union address. From the sound of things, he won’t be making any grand statements on health care. He probably won’t be doing a whole lot to make voters feel better about themselves. He’ll talk about increasing the child care tax credit (probably good politics, although as a tax policy purist I despise it), and accelerated business depreciation (now that’s an exciting topic!). It’s not exactly the transformational address that many people are looking for. Will it give voters a good reason to return Democrats to power?

• Current Mood: Worn out
• Currently Listening To: "Let It Rain", Eric Clapton