THE TREATMENT NOVEMBER 22, 2009
Watching CSPAN-2 over the weekend, I was mesmerized by a succession of Senators lambasting the Senate's health reform bill--especially its reliance on Medicaid.
One says that the program is too stingy. He recounts a heartrending tale of seriously-ill Texas children going without needed care because pediatric specialists would not take low Medicaid reimbursement rates. Another notes disparities in neonatal mortality between Medicaid and private insurance patients. "Care delayed is care denied," he intoned to great effect. A third laments that poor people will be consigned to the "medical Gulag" of Medicaid. A fourth suggests that the only reason poor people are made eligible for Medicaid rather than for private coverage is to make the CBO numbers look better. A fifth--worried about the impact on state budgets--notes that Utah Medicaid covers nonworking parents only up to 48 percent of the poverty line. (He didn't seem to notice that such painful state policies are really arguments in favor of the Senate bill.) A sixth drew liberally from an unflattering Washington Post account of the Mayo Clinic's low proportion of Medicaid patients, and its reticence to serve Medicare primary care patients.
Many of these charges are standard fare from single-payer advocates and other progressives unhappy with the Senate bill. It’s a little odd coming from a succession of pasty white guy conservatives. It's odder when one considers what is left unsaid. For all the talk of the perils and indignities of Medicaid expansion, not much is said about the third tier of American medical care: that provided to the uninsured.
There is also the matter of basic consistency. Jonathan Chait has noted that health reform opponents will deploy ideologically and logically incoherent arguments to achieve maximum demagogic effect. Chait's law was on ample display in this debate.
Senators who called the Senate bill too stingy went on to call it a $1 trillion or $2.5 trillion monstrosity that will increase the deficit. One might expect Republicans to lament alleged excess of a public health nanny state that requires insurers to cover popular but dubious medical interventions, thereby raising costs. Yet when that procedure is mammography for women in their forties, Republicans are quick to describe the U.S. Preventive Services Task Force's reticence to endorse such screening as tantamount to government rationing.
Virtually every Republican senator professing to worry about the impact of health reform on state budgets opposed the stimulus package, which included very large Medicaid subsidies to state government. Fiscal moderates who supported the stimulus proudly voted to cut specific stimulus provisions designed to support state and local governments.
Republicans are conspicuously slow to mention provisions of the House and Senate bills that address the precise Medicaid issues they discuss. Law Professor Tim Jost recently posted a terrific summary of the Senate bill.* He provides the chapter and verse on how the bill would provide substantial subsidies to states to finance expanded Medicaid coverage. Republicans concerned about unfunded Medicaid mandates presumably would prefer the House bill, which raises provider reimbursement, with the federal government picking up most of the bill.
Republicans' two-pronged attack highlights the carelessness of President Obama's $900 benchmark that has become an implicit ceiling on Democratic health reform efforts. A policymaker recently told me: "I used to think that congressmen made weird deals out of pork barrel politics. One of my first lessons here was that the real reason was to hit a CBO scoring number." Democrats are earning no praise from Republicans for the painful decisions required to reach this figure. Yet in ways large and small, the $900 billion ceiling makes health reform less effective, less timely, and less humane than it might otherwise be.
*Jost's analysis is one of many terrific resources that have been quickly generated in response to some of the most complex legislation ever debated. Yeah there have been maddening falsehoods about death panels and the like. Yet for all the standard complaints about superficial or horse-race coverage, health reform has attracted the most helpful and sophisticated media analyses of actual policy substance I have ever seen. However this year's debate will end, the quality of coverage on matters of health care access, cost, quality, and the resulting budget implications will serve the nation well.