He tried to lay off responsibility on the White House, as if the Senate wasn’t an independent and coequal branch of government. Then he tried the old “we don’t have 60 votes” song, as if he hadn’t been telling us for years that all we need are 60 votes in the caucus and we’re home free.

Reid’s excuses are running out of gas, and Nevada has noticed.  There’s a good piece in the Las Vegas Sun by Lisa Mascaro in the Sunday paper:

The ball’s in Reid’s court: Passing the public option

A majority of Americans support the public option, including a slim majority of Nevadans, according to polls.

As the Senate begins the health care debate in earnest this week, these divisions will test core Democratic beliefs and Reid’s ability to devise a compromise that can keep his 60-member caucus operating as one.

“Make no mistake, Sen. Reid, and Sen. Reid alone, controls the fate of the public option and whether or not millions of Americans get coverage without the stranglehold of big insurance corporations,” Jane Hamsher, president of the progressive Firedoglake blog, wrote in a statement. The blog’s political arm is urging Reid, if necessary, to use a procedure known as reconciliation, which would require 51 votes, rather than 60, to ensure the public option stays in the bill.

Harry Reid has tremendous procedural powers as the Senate Majority leader. He’s probably the second most powerful man in the country, and he can make anyone’s life miserable — even Joe Lieberman’s — if he wants to.

There is nothing that Lieberman, Landrieu, Nelson and Lincoln fear more than reconciliation right now, because it takes away all their power. Yes, I know, reconciliation won’t be easy, but if the Democrats would rather do this “fast” than “right” they will probably get what they deserve in 2010 (though the rest of us will be the big losers).

Will Harry Reid have the guts to stand up to Lieberman and protect people like this, and this, and this?

If he doesn’t, all the list building he’s been doing, taking out ads and asking people what they have done today for the public option, has been nothing more than a cynical ploy to stoke his reelection campaign with potential donors.  A “big show” so that Harry can shake his head and say “gosh darn it, we tried our best, what can you say” as Wellpoint’s stock skyrockets.

Been there, done that.  Remember the cots in the Senate for that all-night filibuster to end the war?  Because I sure do.

Not kicking that football ever again.

The problem is that Pfeiffer did not attack Krauthammer for being an idiot with bad ideas. He did not point out that Krauthammer is advocating for a health care “reform” that would most likely make it impossible for him to find private individual health insurance if he lost his current employer coverage. Instead, Pfeiffer went after Krauthammer by pointing out that all his ideas were already in the bill, and in the process, he indirectly endorsed his foolishness.

What is truly scary is that Dan Pfeiffer claims the Senate bill would allow for the sale of insurance across state lines by saying:

Section 1333 of the Senate bill allows for interstate health care choice compacts. Coupled with insurance market reforms to ensure individuals are not discriminated against, this policy will expand health care choices to millions of Americans.

While I think interstate health care choice compacts are bad ideas, they are not a huge concern to me. If a state wants to de facto eliminate its right to set minimum benefit packages by passing a law entering into a state compact with a state with lower standards, at least the state actively chose to do that by passing a law.

The real concern with section 1333 is that it also includes the terrible “nationwide plans” provision wanted by AHIP. If a state does not actively opt-out of this program, insurance companies would get to start selling insurance plans in the state which do not need to follow state law. This provision in effect guts all state regulations about coverage, and the worst part is that it would require states to actively pass a law to prevent this from happening.

If states don’t pass a new law soon, their current laws about health insurance will be shredded by the Senate bill. States with strong insurance laws but that happen to currently have Republicans governors (Vermont, California, Hawaii, Minnesota, etc…) could easily see their insurance regulations eliminated if the Republican governors refuse to sign a law opting out of the “nationwide plans.”

I don’t know why Pfeiffer did not mention nationwide plans in his article. It goes way further in terms of allowing the sale of insurance across state lines than the interstate health care choice compacts provision. Pfeiffer must either be unaware of them, or the White House is actively trying not to draw attention to this radical provision. Either way, it sends a cold chill up my spine.

Orszag suggested that others who have questioned the bill haven’t been as thorough as Brownstein. He noted that The Atlantic reporter identified specific pages of the bill while interviewing him for the piece.

“I would say to folks in the looser range, ‘What specifically else would you do?’” he added.

This must be a joke. Ron Brownstein’s pathetic article was “thorough” because he listed page numbers and he talked to the experts Orszag wanted him to talk to. But a critical reading of the piece reveals that Brownstein knows almost nothing about health care.

It is one thing that the Obama administration decided not to try to pursue many proven cost-cutting solutions because they are too politically difficult. I understand you need to pick your battles, and governing is the art of the possible. But pretending these proven cost-controlling ideas don’t even exist is governmental malpractice.

Since Orszag asked, “What specifically else would you do?” I’ll give him 13 very specific proven solutions:

1. A minimum medical loss ratio for insurance companies mandating that they spend at least 90 cents of every dollar they take in as premiums on health care. This is based on the crazy idea that health insurance should insure people’s health instead of corporate profits.
2. Turn all health insurances companies into non-profits. Most countries that are not single payer (Switzerland, Germany, Belgium) require all basic health insurance plans to be non-profits.
3. On the new exchanges, create a much stronger risk adjustment mechanism, like in the Netherlands, to encourage competition on quality and cost effectiveness, instead of the cherry picking of healthy customers.
4. Allow undocumented immigrants to buy health insurance on the new exchange with their own money. It will increase the size of the risk pool and reduce the cost of uncompensated care in this country.
5. On the new exchanges, use more tightly defined benefit packages, and define plan levels based on deductible and copay size, instead of actuarial value. This will simplify comparison shopping and encourage the selection of more cost-effective HMO’s, instead of PPO’s
6. Allow for drug re-importation. People in every other first world country pay much less for the same prescription drugs. Let Americans buy these cheaper drugs from Canada or Europe.
7. Allow Medicare to directly negotiate lower drug prices. Medicare Part D was one of the biggest corporate giveaways in American history. Allow Medicare to use its size (as the VA system does) to directly negotiate for lower drug prices for seniors.
8. Eliminate direct-to-consumer drug advertising. It only increases the unnecessary use of medicine.
9. Follow the FTC recommendation by providing shorter exclusivity periods for biosimilars. The current bills create an extremely long 12-year exclusivity period. Going with the FTC recommendations will  increase the availability of much cheaper generic versions of life saving biologics.
10. Create a robust public option that can use Medicare rates and Medicare’s provider network.
11. Create a single provider reimbursement negotiator like basically every other industrialized nation. The lack of this is the single biggest reason why, as a nation, we pay several times what other countries do for the same procedure.
12. Create a fully integrated, government-run health care HMO, based on the VA health care system, which would be an insurance option for all Americans.
13. Finally, adopt a Medicare-for-all single-payer system for everyone in the country.

These ideas are not radical or untested. All of them (except the exclusionary period for biosimilars) are being used in this country and/or other countries to reduce cost. These are all proven cost control solutions. Implementing all or most of these ideas would save our country trillions on health care over the next decade.

I know the Obama administration is aware of these cost saving ideas because several of them (drug reimportation, direct medicare drug price negotiation, robust public option) were part of his campaign’s health care plan. Obama traded away most of these cost saving reforms to PhRMA and other industry lobbies in exchange for campaign ads. If you trade away most of the cost controlling reforms to bring the different industries on board, you have no right to go around complaining when people say your reform plan does not do enough to control cost.

Hundreds, if not thousands, of lobbyists are likely to be ejected from federal advisory panels as part of a little-noticed initiative by the Obama administration to curb K Street’s influence in Washington, according to White House officials and lobbying experts.

The new policy — issued with little fanfare this fall by the White House ethics counsel — may turn out to be the most far-reaching lobbying rule change so far from President Obama, who also has sought to restrict the ability of lobbyists to get jobs in his administration and to negotiate over stimulus contracts.

Lobbying isn’t an inherently evil activity, it just often works out that way. After the White House announced a ban on lobbyists filling administration slots, Tom Malinowski was knocked out of the running because he was a lobbyist for Human Rights Watch. A waiver was given to William Lynn III, a lobbyist for Raytheon, however, who got a top deputy job at the Pentagon.

Tom Daschle works at the biggest lobbying shops in town, and yet he’s not a registered lobbyist. Neither is Dick Gephardt, who nonetheless picks up a check from PhRMA for his troubles. He runs a “PR firm.”

But the biggest question mark of all is next to Newt Gingrich’s name. His “Center for Health Transformation” is not registered as a lobbying shop. Newt isn’t registered as a lobbyist. And yet here’s a statement from Nathan Deal (R-GA):

In an effort to achieve the goals of increasing transparency and improving a patient’s right to know, I have worked in close collaboration with former Speaker of the House Newt Gingrich and his staff at the Center for Health Transformation in developing the Health Care Transparency Act of 2009.

A member of Congress is writing legislation in “close collaboration” with Newt’s outfit. And CHT’s Ron Bachman testified before the Health Subcommittee pushing Deal’s bill (PDF). Who’s paying Newt? Will they financially benefit if this bill passes? Well, who knows? Because Newt, like Daschle and Gephardt, isn’t a registered lobbyist, they don’t have to report that kind of information.

Lobbyists are often the people who know best the state of play on any given issue because they’re talking with people on the Hill all day and they know who is trying to do what. From an optics perspective, banning “lobbyists” from advisory boards sure appears like a good move. The problem is, it sweeps up a bunch of people who are lobbying in the public interest who have no financial interest at stake. And somehow, the legal definition of “lobbyist” doesn’t seem to cover many of those who are peddling influence for big bucks.

I’m certain there are people who have thought about this a great deal, but “Do you or an organization you work for stand to profit as a result of the actions of this panel?” seems a more effective threshold for participation in federal advisory boards.

The definition of “lobbyist” seems a bit too flexible to prohibit the biggest of the professional influence peddlers from getting their claws in.

Our good friends at DeSmog Blog do incredible work exposing PR scam artists who have completely distorted the climate change debate.  They are going to be here when James Hoggan is on Book Salon with his book The Great Climate Coverup on December 6.  With an introduction by Leo DeCaprio, the book exposes the techniques used by paid lobbyists and PR flaks that have led us to this sorry state of affairs – and they’re not afraid to name names.  I highly, highly recommend it.

Though they normally cover climate change, they recently weighed in on the 42 members of Congress who helpfully inserted lobbyist language into the Congressional Record in favor of endless patents on biologic drugs on behalf of the prescription drug industry.  Said Brendan Demelle:

Big Pharma, just like the climate denial industry, is willing to sell future generations down the river in exchange for a few more years of blockbuster profits for entrenched corporate powers.  (While the climate denial machine’s victims are mostly the unborn generations who will experience the worst effects of global warming, the pharmaceutical industry’s victims have names and faces today.)

Such grotesque lobbying tactics, coupled with huge cash outlays from industry to elected officials, are designed to protect short-term profits at the expense of human health and the planet.

Is this really the best we can do for our children and grandchildren?

No kidding.  What happened to the First Hundred Hours?  Hmmm. . . nice show for the 2006 rubes I guess.

A lot of people are asking why HCAN is spending money praising Blanche Lincoln this morning:

Health Care for America Now has launched new television ads praising the two Democratic senators from Arkansas and giving quiet support to Ben Nelson, the centrist Democrat from Nebraska.

HCAN, as the coalition is known, includes liberal groups such as Campaign for America’s Future and MoveOn.org and labor unions such as the AFL-CIO.

[]

Airing on broadcast and cable in Little Rock, Jonesboro, and Ft. Smith, that ad praises Lincoln and Pryor for standing up to health insurance companies.

Hmm….”standing up to health insurance companies.” Well, that is a bit of a stretch. Goldman-Sachs expects health insurance stocks to rise by 59% with no public option, but drop 36% if there is one to challenge their monopolies and help keep costs down. Blanche  has taken over half a million dollars from insurance companies in campaign donations.  She went on to the floor of the Senate and guaranteed them no public option by offering up a “ransom note” on the health care bill with her pledge to join a Republican filibuster. How that qualifies as “standing up” to them is anyone’s guess.

But they’re spending $175,000 in Arkansas.  That will pretty much wallpaper the state with accolades for Lincoln for “standing up” to health insurance companies, when actually she pledged to filibuster the public option on Saturday.

People gave $10, $15, $20 from their social security and fixed income checks to help FDL Action PAC put up an ad in Arkansas in September telling Blanche Lincoln to “act like a Democrat, or we’ll find someone who will.”   It wasn’t one of those cheap, shitty cable buys that raises a bunch of money and then spends only a small fraction of it on ads nobody ever sees.  We raised $80,000 and spent more than that ($85,000, I believe)  wallpapering the state with 1,000 points of prime time network buys for two weeks.  The average person in Arkansas saw the ad 10 times.  Our goal was to draw out primary challengers.

It was the talk of the state, it freaked Lincoln out, and PhRMA jumped in with an ad buy in her defense (which they put out through Americans for Stable Quality Care) the next week.

But if anyone is surprised that HCAN jumped in to undo all of that, they shouldn’t be.  Blanche Lincoln is an incumbent.  HCAN is an extension of the incumbency protection racket.  They get their money because the Democratic Party and the White House direct donors to them for the purpose of using health care reform for political advantage. PhRMA has paid for their ad buys.  Their job is to see that $80 million in health care reform money makes its way into the pockets of loyal Democratic operatives and makes it easier for Democrats to get reelected.

If left to their own devices, I think the people at HCAN would do the right thing. I don’t even think Richard Kirsch is venal, he’s just unbelievably stupid.

August 13:

“We are absolutely surprised at the way that the right focused so much on this as soon as August began,” said Richard Kirsch, campaign manager for HCAN.

November 18:

The push to provide late air cover comes after a bruising at the hands of the U.S. Chamber of Commerce, which has dumped a multimillion-dollar sum into ads, and the 60-Plus Association, a conservative seniors’ group.

“We were surprised by the scale,” said Richard Kirsch, national campaign manager for Health Care for America Now.

Really? The Chamber dropped $100 million on lobbying alone last year, and somebody is surprised they’re spending like drunken sailors against health care reform?

Because the unions are on the board and there was division in those ranks over how health care reform was going to go down, there were few opportunities to “do the right thing,” and when that happened, HCAN took them for optical reasons if nothing else.  But their list of “accomplishments,” next to their stated goals, are pathetic.

Everyone bought into the “coalition” concept because that was where the money was going to flow, and they figured, well, better us than somebody else. But they did so at the price of their own personal credibility, and they’ll always have to wear that.  Their concern for “health care reform” lasted only as long as there wasn’t money involved, and when millions of dollars entered the picture, most of their energies were spent trying to appear to be doing something they weren’t.

Remember Richard Kirsch’s “Guns of August?”  How does protecting Blanche Lincoln from a primary challenge and insulating her from responsibility for shilling for insurance companies fit into that?

The whole “coalition” model is busted, at least as a vehicle for reform.  As a way for Democratic operatives to get rich, it’s quite good.  Same thing happened with AAEI and immigration.  Tens of millions of dollars in foundation money from Atlantic Philanthropies, Robert Wood Johnson and Soros that was earmarked for non-partisan health care reform got shoveled out the door for attack ads against Republicans.

If HCAN’s ads on behalf of Lincoln were a surprise to anyone, they shouldn’t have been.  They will continue to operate as part of the Democratic party infrastructure, try to kill primary challengers and move to protect their “own.”   And that means Blanche Lincoln.  If health care reform happens in the meantime, well, what a happy coincidence.

The problem is Brownstein just doesn’t understand health care systems. Take for example this jewel:

And, with only a few exceptions, that’s just about all the systemic reforms analysts from the center to the left have identified as the most promising strategies for changing the economic incentives in the medical system. (The public competitor to private insurance companies championed by the Left would affect who writes the checks in the medical system, but not what the checks are written to pay for.) Most of the other big ideas for controlling costs (such as medical malpractice reform) tend to draw support primarily among Republicans.

This one paragraph should show you how completely Brownstein lacks even the most basic knowledge about health care reform. The CBO concluded the Republicans’ “big idea” for controlling cost, extreme medical malpractice reform, would save/generate $54 billion for the Federal government. (I would challenge Brownstein to name another single Republican idea that would actually reduce cost, because they did not include any in their alternative bill two weeks ago, and I have heard of no others from them.) Let’s compare this to the public option.

According to the CMS, the strong public option (which paid Medicare rates plus 5%) promoted by House progressives would have costs 18% below that of private health insurance companies. The CBO concluded it would have saved $110 billion. This public option design was still considered weak by reform activists. Mandating that Medicare providers take part in the public option would have saved another $91 billion. If the public option could pay Medicare rates instead of Medicare rates plus 5%, that would have saved roughly another $50 billion. These savings are with the public option only being available to the small number of people on the new exchange.

Allowing every company to buy into this super-robust public option would give them a choice that would be roughly 20% cheaper than their current insurance plan. If even some of those savings were passed on to employees in the form of higher salaries, that would translate into hundreds of billions in increased tax revenue. This one progressive idea, which could save about $250-800 billion, is bad mouthed by Brownstein, yet he claims the Republicans continuous screaming about tort reform, which would save only $54 billion, is one of the “big ideas” for controlling costs.

The Senate bill would make some cost saving baby steps away from fee-for-service medicine, but this is not the real way to get serious about cost control. This is just “reform” to make believers in “free market economagic” happy. If Brownstein really wants to know why the rest of the industrialized world spends about half of what we do on health care (on a per capita basis), I have a nine step solution:

Step 1: Call the German Ministry of Health.
Step 2: Ask why they spend so much less on health care.
Step 3: Call the French Ministry of Health.
Step 4: Ask why they spend so much less on health care.
Step 5: Call the Japanese Ministry of Health.
Step 6: Ask why they spend so much less on health care.
Step 7: Call the Belgian Ministry of Health.
Step 8: Ask why they spend so much less on health care.
Step 9: Repeat Steps 1 thru 8 with as many countries as needed.

What these countries all have in common is a single reimbursement rate negotiator. It is either a government agency or regulated cabal of all insurance providers that set most reimbursement rates. That is why they pay so much less for everything. They pay 30%-500% less for doctor visits, hospital stays, drugs, lab tests, procedures, etc. Our insane system of hundreds of insurers secretly negotiating reimbursement rates individually with thousands of providers and manufactures is a recipe for administrative waste, inefficiency, higher prices, and more expensive care.

The number one reason we pay so much more for health care has nothing to do with overusing care because of a fee-for-service system. It is just that the “fee” we pay for those services is so dramatically higher than any other nation’s.

It is not just what the public option’s “checks are written to pay for.” The hope was the public option could negotiate better rates, and therefore write smaller checks. It could create system-wide change if other insurers  followed suit.

This line from Brownstein is just comically wrong:

And, with only a few exceptions, that’s just about all the systemic reforms analysts from the center to the left have identified as the most promising strategies for changing the economic incentives in the medical system.

Take, for example, the sweetheart PhRMA deal preventing almost any savings from the drug industry. We spend about $200 billion a year on  prescription drugs in this country. We spend roughly 20% more per capita on drugs than the second highest country, France, and roughly twice as much as most european countries. If we implemented progressive solutions like drug reimportation and allowing Medicare to directly negotiate for drug prices, that would save at least a hundred billion bucks. If we allowed the government to negotiate drug prices for everyone in the country, like most countries do, we should at least be able to get our per capita spending on drugs to a level similar to Canada. That would be roughly half a trillion dollars in savings on drugs over only the next 10 years.

There is a wealth of progressive cost control solutions that were not even considered in Congress. All told, they would have saved our country trillions over the next decade. On the other hand the Senate bill makes only tiny steps to slightly reduce over-utilization. Brownstein does the nation a disservice by publishing this article while completely ignoring the real cost issue. Rahm Emanuel commits a near-criminal act by making people at the highest levels of our government read this article as if it had any value. No wonder the health care reform plans have been so bad so far. With the reform effort led by fools who don’t even understand the nature of the problem, it is no wonder existing proposals contain almost no real solutions.

Well, about 2 yrs before I left I began worrying about some of the plans the health insurance companies were trying to force on us. They were trying to push a higher burden of the cost onto the public and I knew that people in states like Arkansas and Tennessee where I come from couldn’t take that financial burden. Also, I was not happy about having to be a part of killing healthcare reform. I’d been a part of that effort before and I didn’t want to do it again. But what really got me was a trip I took to visit my parents in 2003 in Virginia and I heard about this event called Healthcare Expedition. So I said, alright, let’s check this out and I was just stunned by what I saw. There were poor people standing in the rain to get medical treatment from volunteer doctors in animal stalls. It was a real eye opener. The desperate straits these people were in hadn’t hit me until then and I wasn’t proud of the job I was doing.

How do insurance industry executives live with themselves while this is going on? According to Potter, “[i]n the insurance industry, especially executive positions, you are totally isolated from people and their needs” and instead are “focused on trying to satisfy Wall Street.” That’s not a big surprise, of course, but it’s powerful coming from a former industry insider-turned-whistleblower. With regard to health insurance industry talking points on health care reform, Potter says that they are largely “designed to scare people with regards to the public option.” Potter adds, “It’s disturbing to see this kind of misinformation being spread by, say, a senator from Arkansas.”

Yes, it certainly is, which is why FDL has put together this ad and is asking for your help in paying to run the ad in Arkansas. Thanks, and great work by Blue Arkansas!

The president, I think, is going to have to tell the left wing of his party and the balking liberal Senators that it is crazy to pull down the entirety of health care over this one issue which the president has already said is not the be all end all of health reform.

…And in print:

[M]y concern about letting the public option jeopardize health reform is precisely because I think that expanding access to health care is such a moral imperative.

The problem is that Marcus and all the other public-option-doesn’t-matter wankers are conflating “health care” with “health insurance.”  Sure, if we have mandates without a public option, lots of people will have insurance, but it’ll be overpriced crap with steep deductibles and lousy coverage.  Forcing people to buy shitty insurance they can’t afford doesn’t sound like much of a moral imperative to me, but then I’m not Ruth Marcus.  Or an insurance company.

Everyone agrees that not enough people have insurance, but it’s the details where the devil is.  To rip off recycle quote a post I wrote back at my place a few months ago:

Progressives: There are 45 million people in this country without health insurance!  This is an outrage!

Insurance Industry: There are 45 million people in this country without health insurance!  This is an outrage!

Everyone agrees that there are too many uninsured, but where progressives see pain and death and need, insurance companies and their allies see untapped bank accounts and retirement funds.  Progressives want to help the uninsured, insurance companies want to milk them.  And the Ruth Marcuses of the world can’t tell the difference.

PhRMA is running ads asking Joe Lieberman to support the Senate bill. It is possible that PhRMA is scared of the progressive block.

Scarecrow explains why he thinks there needs to be a viable public option.

Immigration may become a new sticking point with Rep. Gutierrez saying it might be impossible for him to vote for a bill that bans undocumented immigrants from buying health insurance with their own money.

Part 2 of my series about what the Senate bill does better: the Cantwell basic health program.

People need to know the difference between trying and only pretending to try.

Note: I will be traveling for Thanksgiving so this will be the last health care highlight for the week.