I was listening to the Senate debate on health care on C-SPAN late Friday (December 4, 2009). Medicare is not something I've followed a whole lot, so I wanted to see what the issues were. But what struck me most as I watched was how inconsistent the Republican statements were with their ordinary day-to-day rhetoric about the evils of big government and the importance of fiscal responsibility. Frankly, watching all the contortions they needed to do to rationalize their opposition du jour was making my head hurt. But this stuff is important, so I did my best to endure it.
The Senate debate went on for several days, and I was peeking in just for a few hours of one of those days. What I offer here is not a summary of the full debate, nor an expert analysis from someone who's a master at all of these issues. But as I listened, I was full of thoughts that I wanted to write down just for the record, and for discussion with others who might have been listening, too, or even those who missed out and want to get caught up.
To begin with, someone must have read them the riot act about even hinting at cutting Medicare because the only way you could recognize their position as Republican was the astonishing degree of lockstep that accompanied this deviation from the position they normally allege. For an in-depth look at this phenomenon of moving in complete agreement at all times, see David Brin's recent article Democrats & Republicans: two kinds of inner party struggle, where Brin sums up the matter at one point by saying:
“When it comes to the republican denizens of the U.S. Capitol, the current style of GOP partisan uniformity has had an odd effect—of rendering them into doctrinal clones who matter only en masse, never as individuals.”
“I am disappointed that the Democratic Leadership continues to push forward with a big government, more spending and higher taxes approach as their solution for reforming our health care system. ... Washington-run programs undermine market-based competition through their ability to impose price controls and shift costs to other purchasers. At a time when major government programs like Medicare and Medicaid are already on a path to financial collapse, ... Washington-run programs undermine market-based competition through their ability to impose price controls and shift costs to other purchasers. ... Our nation is facing a national deficit of $1.4 trillion, the highest since World War II, let us commit to a fresh start and write a truly bipartisan and fiscally responsible solution that we can all be proud of.”
—Orrin Hatch (October 26, 2009),
in a press release on his web site
“During a heated debate over the America's Healthy Future act, the prospect of the public option was raised. Sen. Orrin Hatch (R-Utah) called public option a ‘Trojan horse, for a single payer system.’ Hatch compared health care reform to how the Medicare system has turned out, calling the Medicare program a “Fiscal Meltdown.”
—Talk Radio News Service
(September 29, 2009)
In spite of his previously expressed lack of confidence in Medicare's fiscal soundness, calling it a “Fiscal Meltdown,” and his professed commitment to fiscally responsible solutions, Senator Orrin Hatch Friday made remarks that seemed to refer to the Medicare Advantage program as money well spent and funding that must not be touched.
Speaking about the history of Medicare Advantage, Hatch said:
“Now those on the left want to do away with this important program that benefits seniors and minorities in an amazing set of ways. Well, I'm against that. I hope our colleagues on the other side realize what they're doing. It just isn't right. Vision care and dental care and so many other approaches that really work through this program will be taken away from these people. And they're going to have to spend $175 to $250 bucks a month to get what they got for an average of about $54 a month. And these are people who need our help.”
By the way, Hatch didn't say “... what they got for an average of about $54 a month from a government program,” but I'm sure he meant to. It's good to see him praising the effectiveness of a government-run program because so often you'd get the impression from Republicans that the government can never do anything right. But, in fact, the Democrats dispute whether the changes in cost will have the effects Hatch predicts.
Medicare Insurance Program
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over, or who meet other special criteria. The medicare program also funds residency training programs for the vast majority of physicians in the United States. Medicare operates as a single-payer health care system.
—Wikipedia
So I guess the argument that money matters or that the Medicare system has real problems is a good issue to raise when trying to promote fears about the Public Option, but is totally out of bounds when discussing Medicare itself. The Republicans seem to love to criticize these programs, perhaps because talk is cheap and it's not a crime to offer rhetoric inconsistent with one's voting record, but when it comes to actually doing something about it, their position can vary widely.
In the Friday's hearing, Hatch went on to say:
“I understand my colleague from Oregon was discussing Medicare Advantage and talking about CEOs of Medicare Advantage companies living “high off the hog,” saying that this a rationale for $120 billion dollars in Medicare Advantage cuts. I have two responses for my good friend from Oregon: This is not about Medicare insurance company CEOs. This is about preserving the choice of coverage for seniors.”
Medicare Advantage
“Medicare Advantage Plans are health plan options that are part of the Medicare program. If you join one of these plans, you generally get all your Medicare-covered health care through that plan. ... When you join a Medicare Advantage Plan, you use the health insurance card that you get from the plan for your health care. In most of these plans, generally there are extra benefits and lower copayments than in the Original Medicare Plan. However, you may have to see doctors that belong to the plan or go to certain hospitals to get services.”
—medicare.gov
Senator Debbie Stabenow spoke on behalf of an amendment (Number 2899) that she proposed. The amendment, which was later approved, began, “At the appropriate place insert the following section: ‘No cuts in guaranteed benefits.’ It clarified that the intent of the pending legislation was not to make a change in guaranteed Medicare benefits.”
My sense was that the Republicans felt the word “guaranteed” was significant in some extra special way here, hiding some attempt to crowd out all of Medicare Advantage, or more likely they had constructed some elaborate spin intended to scare listeners into believing that this was so. What was perhaps most fascinating about this spin was that the “scary part” was that people might end up having to purchase these items on the free market. On any other day, you wouldn't find them claiming that was scary. But, in this hearing at least, the Republicans were Medicare's BFF and the free market was the Devil incarnate.
When Senator George LeMieux (R-FL) said:
“No one is objecting to a competitive situation where we have these companies providing more services for less costs, but we want to make sure that the services are still there, so I would ask unanimous consent to have that phrase ‘guaranteed by law’ to be eliminated from the amendment,”
Senator Stabenow was quick to respond:
“We are happy to talk about how we might address what he might be concerned about but unfortunately the reality is the for-profit companies are objecting to competitive bidding and the language that my colleague has suggested would include items that have been offered to get people into for-profit plans like gym memberships and other things that have been of great concern.”
At issue, as nearly as I could discern, is that because the features of Medicare Advantage are elective, and not a standard part of Medicare, they were not protected by Stabenow's proposed wording.
Senator Sherrod Brown (D-OH) noted:
“I was in the House of Representatives ten years ago when Medicare Advantage began, when the insurance companies said ‘we can save Medicare 5% on all its cost by bringing forward Medicare Advantage.’ Well, then when the Republicans took control of everything, ... the insurance companies decided we can't save 5% any more, we need a 13% bonus. Well, the chickens have come home to roost ...”
By way of illustration, Brown cited a recent news article entitled “Humana Third Quarter Profits up 65%, Sees Strong Medicare Advantage Gains.” He quoted from the article:
“Humana's third quarter earnings rose 65% amid improved margins at its government, i.e. Medicare Advantage, segment. The company gave an initial 2010 forecast which the health insurer projects substantial Medicare Advantage membership growth resulting in revenue of $32B to $34B, well above analysts' average estimate of $29.6B. That forecast takes into account reductions in Medicare Advantage payments. Now Mr. President, as the Senator from Rhode Island knows, the presiding officer and Chairman Harkin and Senator Stabenow, all of whom have been strong supporters their whole careers of Medicare, strong supporters of Medicare, when we see people who've opposed Medicare, they opposed the creation 40 years ago, they opposed—they tried to privatize Medicare with Speaker Gingrich a dozen years ago, now they're Medicare's biggest defenders? I don't think so. What they have been is they've been the insurance industry's biggest defenders and that's really what that debate the last three days was all about.”
Medicare Tax
Medicare is partially financed by payroll taxes imposed by the Federal Insurance Contributions Act (FICA) and the Self-Employment Contributions Act of 1954. In the case of employees, the tax is equal to 2.9% (1.45% withheld from the worker and a matching 1.45% paid by the employer) of the wages, salaries and other compensation in connection with employment. Until December 31, 1993, the law provided a maximum amount of wages, etc., on which the Medicare tax could be imposed each year.[6] Beginning January 1, 1994, the compensation limit was removed. In the case of self-employed individuals, the entire 2.9% tax of self employed net earnings must be paid by the self-employed individual, however half of the tax can be deducted from the income calculated for income tax purposes.
—Wikipedia
Brown also had another point to make:
“What's important is we guarantee Medicare services, which we will, we quit subsidizing the insurance companies as we should quit subsidizing them, and then that $90 tax that every Medicare beneficiary has to pay, that $90 that goes to insurance subsidies will be taken away so that Medicare fee for service, regular Medicare members, which is 80, 81, 82, 83% of Medicare beneficiaries won't be paying that insurance company Republican tax that they've had to pay ever since Medicare advantage, the subsidies to insurance companies were increased.”
Yes, strangely enough, today the Republicans were supporting a continuation of an across-the-board tax where 4 out of 5 participants were taxed for a service only desired by 1 out of those 5, resisting any review of the appropriateness of this policy. After hearing them argue vociferously against this practice in discussion of the Public Option, well, you can perhaps guess why my head continued to throb as I heard this.
Senator Bob Corker (R-TN) began his remarks by saying:
“I plan to support the Hatch amendment regarding Medicare Advantage but it's not because I don't believe that we need to do some things to cause Medicare to be more solvent. And I do believe that Medicare Advantage does have some subsidies to insurance companies that are higher than they should be.”
I winced, my headache compounded by these little wording dances that all of the Republicans were doing.
Of course, these Republicans must know they are being recorded by C-SPAN and that inevitably their blind support of a large government bureaucracy as “working just fine” against a good-faith attempt by Democrats to do some prudent trimming is going to come back to haunt them. So they're trying to vaccinate themselves against criticism by peppering their statements with such words that acknowledge the desperate need for a fix but nevertheless and mysteriously also conclude it's okay to live with the problem for a while—probably until the Republicans can suggest a similar fix. And yet I'm sure that had a Republican made the same proposal, they would be all over it. Or maybe not. Perhaps the senior lobby is so powerful that they're willing to sacrifice their principles to save their seats.
Corker continued, “The fact is, though, that this bill is taking money from a program that is insolvent, Medicare, and using that to create an entitlement.” Among a chain of rationalizations for toeing the party line, Corker offered:
“I'm going to support the Hatch amendment even though I would love to work with my friends on the other side of the aisle to do those things to make Medicare more solvent but I think what is so objectionable to all of us is to know that we have an insolvent Medicare program that the trustees have said is going to be bankrupt in the year 2017 and my friends on the other side of the aisle are taking money from that program to leverage a new entitlement.”
Senator Dick Durbin (D-IL), Majority Whip, later answered Corker's concern by saying:
“the Congressional Budget Office tells us yes, untouched the Medicare program, in seven or eight years, faces insolvency, but this bill adds five years of solvency to Medicare right off the top. Right off the top, five more years of solvency. Something that you won't acknowledge, but you should.”
As Durbin explained:
“This is a basic choice. Will we continue to subsidize private health insurance companies who are overcharging the Medicare program by 14%. Will we take that money out of Medicare to continue the subsidy for profitable private health insurance companies. It's that basic.”
Corker may have felt the matter of inefficiency could just as well wait to another day, but Durbin pressed on that point as well:
“Let me also add that if we're going to bring down the costs of Medicare, so that the recipients get quality care, we have to get rid of these outrageous subsidies to private health insurance companies, the Medicare Advantage program. We also have to be honest about those providers overcharging Medicare. Why does it cost twice as much in Miami for the same service that's given to Medicare patients in Rochester, Minnesota. It shouldn't. Somebody's ripping off the system. If we can't ask those honest questions, then I'm afraid we're not going to put Medicare on sound financial footing. We can do that, but we can't do that by saying, well, we've just to continue to subsidize private health insurance companies out of Medicare.”
Sen Sheldon Whitehouse (D-RI) made a similar point.
“Those of us who have been privileged to debate the Public Option have seen a relentless insistence on the Public Option operating on a level playing field with the private insurance industry. ... Now we have a situation in which we have private industry operating at a 14% advantage and subsidy against Medicare and suddenly the other side's interest in a level playing field has evaporated. Suddenly their interest is in doing once again, the astonishing coincidence that characterizes this debate, in the interest of the insurance industry. ...
“If it's a Public Option, they want it to compete on a level playing field and even then they are against it. If it's privately subsidized coverage, getting an advantage against the public system, then they're for it. Then they're for it. I urge consistency and I support the efforts to bring some discipline to Medicare advantage as the private insurance industry promised. We're doing no more than holding them to their words.”
![[medicine/money logo]](/files/medicine-money1236814423.gif)
And again the double-standard in a back-and-forth between Senator Kay Bailey Hutchison (R-TX) and Sen Tom Harkin (D-IL). Paradoxically, while pressing for Medicare Advantage, a public health insurance option, to be sustained, Ms. Hutchison insisted, “when I hear all of this debate, it's like everything has to be more government, bigger government, government is better than the private sector.” And yet Medicare Advantage is a government program and this was said in the context of seeking to sustain that program. As if underscoring my point here and refuting her own, she went on, “Medicare Advantage is an option. It's not a mandate. It's an option that allows seniors another choice, to get eye care, hearing aids. ... we need more competition, not less.”
Harkin latched immediately onto the hypocrisy of this argument in responding:
“It's interesting to hear the last speaker just say something about don't take away the option here for the seniors on Medicare Advantage yet they have an amendment to take away the option for people to buy insurance against having a disability, so they can stay in their own homes and have support. It's voluntary, it's not mandatory. No one's forcing anybody to do anything, and I say to my friend from Texas yet there's an amendment on that side to take that away, to take away that voluntary program, the Class Act, so that people can voluntarily put money in to protect themselves against a future disability. Let's kind of keep our arguments a little bit straight around here.”
And the debate continued. Senator Mike Johanns (R-NE) launched into a very heartfelt discussion of “what this legislation does to real people.” But unfortunately, his analysis was superficial and showed little interest in working through the details. He focused on the “home health care” For example, he complained that:
“I did a video conference with Medicare providers in Nebraska. These Nebraska home health care providers reported this legislation will cost them $120 million in my state. What does that mean? $120M may not sound much around here where we talk about trillion dollar programs. $120M to the people of Nebraska in home health care, 68% of home health care agencies in Nebraska will be in the red by 2016.”
This sounded dire to me at first. But he had mentioned earlier that “9000 Medicare-approved home health agencies existed in 2007. ... 74 of those are in my home state of Nebraska.” That's 0.822% of the total agencies. And so I wondered if that rate of shortfall was typical throughout the US, how much would it cost to repair. If I did my math right, and if those numbers are predictive (which they might not be), that's a $14.6B shortfall these changes would make. So even if you took Senator Johanns' complaint as true, he's complaining that if you cut $42 billion, you end up with a $14.6B shortfall. So it sounds like he's agreeing this is a good trade-off, and that it just needs a little tweaking. He's certainly not done the work to show that this is a bad trade-off.
Toward the end of the portion of this long debate that I tuned in for, Senator Amy Klobuchar (D-MN) gave what I thought was a really nice summary speech. The entire speech was well-reasoned and well-presented, but I'll include here only the introduction. I recommend the entire text.
“The way I look at this in my state is a matter of affordability and cost. ... I always try to remember three simple numbers of all the numbers we're going to hear in the next few weeks, and those are the numbers the numbers 6, 12 and 24. Ten years ago it cost $6000 for an average family to pay for their health care, a year. Now it's $12,000, with a lot of people paying a lot more. Ten years from now if we don't do anything it's going to be somewhere between $24 and $36,000, something regular people just can't afford. Six, twelve, and 24. If we don't act, costs will continue to skyrocket. The country spent $2.4 trillion on health care last year alone, that's one out of every 6 dollars spent in the economy. And by 2018, nation health care spending is expected to reach $4.4 trillion, over 20% of our entire economy. Despite spending one and a half times more per person on health care than any other country, many of our people don't have health care coverage and many are losing their coverage because of pre-existing conditions or because it simply is costing too much.”
She cited a number of other statistics, then said:
“Medicare—something that people who are 55 want to get when they're 65, people who are 65 want to keep until they live to the ripe old age of 95. But if we don't do anything about it, it's going in the red by 2017. So how do we do this? How do we get to a place we want to go? Well, we must get our money's worth from our health care dollar. Otherwise costs are going to continue to wreak havoc on the budgets of Government, businesses and individual families.”
She proceeded to make a number of good specific suggestions, but for brevity I'm not going to include them all here since that part is not my focus in this article. Instead, I want to focus on the fact that no change is going to be without pain. Yet the Republicans are trenched into a position of trying to buy off the elderly vote, probably their only remaining vote, by telling them that we can solve our present fiscal crisis without any change whatsoever to anything. That's unrealistic. We can try to hold coverage as constant as possible but if we don't manage expenses, that won't be possible. Republican rhetoric on any other day would insist that we must cut out the fat in any program, but on this day they were preaching their tried-and-true refrain: terror. That was very disappointing because this was a great opportunity for bipartisan agreement on belt-tightening and increased efficiency, and the moment was lost.
It's fitting, therefore, that my last series of quotes are from comments by Senator Jim DeMint (R-SC), whose remarks tied the event together in a neat little bundle for me. He began with what was little more than whining, seemingly peaved about having to work long hours—as if that wasn't the fate of Americans everywhere these days if they're lucky enough to be working at all:
“Mr. President we're here on a Friday evening being told we're going to work through the weekend, maybe next weekend, all the way up to Christmas Eve, with the intent to rush through a bill that many have called, and I agree, one of the worst pieces of legislation, and one of the biggest threats to health care that we've ever seen here in this country. And apparently the majority wants to rush this through. And intimidate the minority into allowing it to go through by keeping us here on weekends over the holidays.”
Of course, it's not the Democrats who are in a hurry, it's the American people. And it's not that Americans need it by Christmas, it's that they need it now. It's just that Christmas is the next thing on the Republican calendar that appears to matter to these Republican Senators, who are otherwise content to let the Medicare trust fund continue like a juggernaut, unchallenged, until its upcoming self-destruction in the all too near future. DeMint did not stop there, though. He went on:
“I'm proud that Republicans are standing together against this bill, and standing with the American people to stop the Democrat government takeover of health care in America, and to stop them for paying for it by cutting nearly $500B from Medicare and raising taxes on millions of Americans. ... I think the majority must think Americans are not paying attention or maybe even that they're not real smart, that you can take $500B out of a program that's already bankrupt and expect the benefits to stay the same. ...
“If there is waste and fraud in Medicare, and we know there's some, we should find it and put that money back into the Medicare system so that we can keep our promises to seniors. Every Democrat here in the Senate has already voted for goverment takeover of health care, to cut Medicare to pay for it, and to raise taxes. Some of them say they were just moving the debate forward. There's no way you can take this money out of Medicare without hurting the programs. ... Every Republican voted no. Every Republican in this Senate has stood with the American people and said no to a health care bill that takes over the most personal and private part of our lives.
“I'm proud of our party and our leadership. And Americans have been asking to see the differences between the Republican and the Democrat parties, and I think now more than ever, on this issue, you're going to see the Democrats standing with government controlled health care, cuts in Medicare, increased taxes, and on the other side, Republicans, we're gonna stay here through Christmas and New Year's and whatever it takes to stop this bill and to sit down and really reform the system in a way that will lower cost and improve care for all Americans. We need to continue to talk about these bigger issues, particularly how it affects Medicare.”
DeMint actually went on to talk about the very real fact that under a public program, some procedures are not going to be cost effective. But rather than acknowledging that budgets will inevitably have that effect, he took the opportunity to again spin things toward terror. He didn't use the term “death panels” that I noticed, but he did mention the recent issue about mammograms with the intent of creating the same kind of fear that death panels have evoked.
And yet he's proud of Republican leadership. He's proud of leadership by fear? There are a lot of criticisms I have of Obama's approach to government and even his stands on individual issues, but they are minor compared to the criticisms I had of the Bush administration. And in particular I think the key thing that is happening right these days is that we're discussing things like adults. The government has stopped beating citizens back with a broom like we were the target audience of Grimm's Fairy Tales, needing to be made sufficiently scared of the world that they learn never to venture out without supervision. Voters of the United States are, by definition, adults and need to be engaged as such.
This discussion was about how to make some targeted cuts of a very realistic nature. It might have some rough edges, but the Democrats are prepared to deal with those rough edges. What they are not prepared to do is to throw up their arms and say “I guess no change whatsoever is possible because any change at all might adversely affect someone.” I'm reminded of a remark made by Dr. Amar Bose, founder of the Bose Corporation, in a talk I saw at MIT some years back. It sticks with me because it is so simple and yet so important in so many situations: “Better implies different.” You can't make something better without changing it. The Republicans know the system is not working the way it should. So they know it needs to change. And yet the thrust of their collective argument in this debate was that it's fine to fix things just as long as you don't change anything in the process.
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Comments
Now they want to work across the aisle? Of course I've heard that here and there from them all along, but then they offer nothing. They complain about a 2000 page bill, and at first thought, it does sound like a lot of paper, but Stephen King's newest novel is 1075 pages, so 2000 is hardly large by comparison.
Another thing that bugs me to no end is the R's say they want to reduce costs for the public, but are hell bent against the public option, which is designed to do just that.
The biggest obstruction to the whole shebang is the million dollars a day that Big Insurance has been throwing out there for months to stop this bill. Most on the right and many on the left want or need that money for reelection. That sucks for the public. They take profits paid by the public and use them against the same public. In the meantime, the country is slipping down hill because so many other things are not getting done and the R's know it and use that anyway they can to make the D's look bad.
They know that failure for the D's means failure for the country, but they don't seem to care. It's all about the politics. Win at all cost, scare the hell out of everyone, then run the country into the ground. The American public doesn't pay close enough attention to what is going on so they fall for the ploy time and again and vote against their own best interest.
I know I drifted way off topic here, but I'm extremely frustrated with the circle jerk we've gotten from The R's and the Blue dogs (it's like watching an hour of Glenn Beck). This thing can't go too far into next year or we'll lose the whole thing. It seems that the 60 vote water mark is too high a threshold to try to reach and actually get anything done. We also need to get control of the lobbyists and corporations that have so much influence in Washington. Nothing seems to get done in the interest of the public anymore and it's killing everyone that works for a living. That is if they are lucky enough to have a job.
Another great piece of work, Kent! Do you have anymore of that Tylenol?
I remember as a child hearing my grandfather ask my mother how a person in her right mind could vote Republican when they don't give a damn about the working class. He's probably turning over 5000 rpms in his grave and about to red line over what they have done to the middle class.
You're a brave soul to wade through it all.
And still, the 100,000 pound purple elephant (our billion dollar a-day, evil, undefined foreign empire) looms in the room. How any of these people have a right to complain about the deficit (with few exceptions) is beyond me.
It's a shame, I think they actually have some good things to say when they finally enter discussion mode. McCain (in text I left out only because it was slightly off-topic) grumbled about the fact that 5 states are getting special treatment protecting Medicare Advantage when others are not; that seems wrong. And if more comments were offered in good faith, as legitimate debate points, I think they could be taken seriously. That one should, of course, be rectified. But most of the debate offered by the Republicans right now is so obviously not real that it gives a bad name to the notion of being a Republican. (Reason enough for anyone who has not seen it to read my article My Secret Shame: Confessions of a Republican Wannabe.)
Did you see how Aetna will be forcing 650k off their roles this next year in an effort to increase profit? Aetna only made over a billion in last year of which the CEO took home over 100 million. Let's hear it for reform.
I appreciate the work you put into this, but would trade a month in Phuket to hear those senators debate single payer and mean it, instead of weasel words about medicare.