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1. Wyden had plenty of quality Democratic company in voting for MMA: Baucus, Kent Conrad, Feinstein, Tom Carper, Ben Nelson, Breaux, Landrieu, Blanche Lincoln, Zell Miller AND John McCain. Medicare lacked two crucial things to offer the benefit directly: the IT part (PBM’s had the newest IT in the industry) and the detachment from Congressional “earmarking” of favorite drugs or drug classes.
   The rollout was terribly managed (one CEO friend referred to CMS’s handling of the bidding and enrollment as a “goat rodeo”), something that should be sobering for anyone advocating yet another health plan initiative. CMS has a tiny staff to allocate to stuff like this- is a new Medicare like plan for under 65s the highest and best use?. What about all the Medicare reform stuff you are advocating? Who’s going to actually do the work?
   However, MMA was WAY less expensive than forecast (even with this year’s “catch up” on rates) and the seniors that have it don’t want to give it up. Don’t bother quoting Paul Krugman on healthcare; your own expertise is far broader and deeper.
   I was a long time Barrons subscriber (and source for many of its healthcare stories).

2. tcoyote-
   I don’t know Wyden, and was not accusing him of
   anything that many Congressmen don’t do–making a deal:
   I’ll do this if you do that.
   What I can’t fathom is why anyone would make a deal in order to pass such a truly terrible bill. (Many Republicans also hated it.) It was terribly chostly, and it caused chaos for seniors trying to get prescriptions (see what Paul Krugman says in his New Yorker article about this) . .. .
   It would have made far,far more sense for Medicare to offer its own prescription benefit–something less complicated and much less expensive.
   A 15% rebate for all branded drugs would be a good beginning. But we also have to signal to Pharma that we are not intersted in drugs that cost $100,000 a year
   unless they are miracle cures (which is not likely).
   Don’t quite know how you have managed to read me for 20
   years unless you read me back at Barron’s– but I’ll
   take the compliement . ..
   Peace.

3. It certainly wasn’t you I was attacking. I’m a twenty year fan of your writing. Rather, it was the sloppy analysis and the partisan stridency, which adds heat but little light. The pharmacuetical companies have, as suggested above, far more serious problems that whether Medicare tries to “bargain” with them. Orszag suggested a simpler remedy: simply mandate a 15% “rebate” for all branded drugs.
   I thought your innuendo that Wyden received some “quid pro quo” for his vote was truly obnoxious. Evidence, please? Ron is a person of great integrity, and may well have believed that a flawed drug benefit was better than no benefit at all, and that it was time to end the partisan logic that prevented the Democrats from enacting a benefit when they controlled Congress ’cause it was more expedient to blame the Republicans from blocking it.

4. Dan– I also have read Wyden’s Healthy American’s act–and I, too, fail to see how it will control costs.
   Tcoyote–
   I assume that the gratutious personal attacks are meant to distract from the fact that you don’t have answeres to the questions. (A typical Conservative strategy: see Greg Anrig’s excellent book, “The Conservatives Have No Clothes.”
   You have not addressed the fact that Wyden’s bill leaves out a public-sector alternative. Why? The only reason that I can see is that competition with a public sector alternative would make it clear that most insures do not know how to offer value for our health care dolalrs.
   I’ve also read the most recent CBO report– several times. And I’ve written about it.
   Tcoyote– finally, and most importantly, you side-step what bothers me about Wyden: he crossed party lines to vote for a major piece of legislation that is generally viewed as one of the biggest boondoggles of the Bush
   administration.
   Much of that legislation will almost certainly be repealed in the coming months.
   Why would he vote for it? We know at least one legislator was bribed. What was in it for Wyden? I am not suggesting that he took money, but there must have been some sort of quid pro quo. I don’t thik that anyone can argue, with a straight face, that he thought it was a good bill.
   As for negotiating drug prices, Medicare has the clout because of the large number of patients that it represents—and it can begin steering patients away from ovevpriced block-busters.
   As The Century Foundatoin’s Working Force on Medicare Reform has discussed, Medicare doesn’t have to say “No” we won’t cover that drug. It can say: “we’l raise the co-pay on that drug to $50–becuase there is no medical evidence to show that it is better than a less expensive drug which also appears to be safer.”
   A high co-pay will also lead patients to ask questions—and the information about benefits and risks will get out to the public.
   Medicare also can say: “We’re going to cut the amount that we pay doctors for administrering that drug in their offices by 30% because medical evidence suggests that the benefits (an average 3 weeks of extra life) do not outweigh the side effects.
   And with new drugs, Medicare very definitely can, and probably will, begin saying “No” even if the FDA has approved them. (Though it’s all but certain that the FDA is going to raise the bar for approval.)
   So Medicare has plenty of leverage–which is why Pharma is so afraid of Medicare being giving the authority to negotiate prices.

5. I’ve read Wyden’s Healthy American’s Act. Why it would reduce health care costs escapes me. It’s just another dress up for appearances sake. The number one issue in America is health care costs. While it’s true that issues like uninsured Americans is a related subject, nothing in Wyden’s plan seriously targets health care costs.
   Please stop parading around everybody. Let’s talk about the big issues, which are hospital and specialist costs. Are we capable of getting a grip on these areas?

6. “Under Wyden’s healhtcare plan, I know that there would be both community rating and guaraneed issue–which is very good.”
   Wrong! Community rating and guaranteed issue are very bad. Notice we don’t have community rating for auto, homeowners, life insurance.
   Oh yeah, with community rating a bunch of baby boomers can stick it to the 20 somethings – again.
   Guaranteed issue = guaranteed antiselection, as everybody waits until they are on their way to the hospital to sign up.

7. tcoyote says-
   “These companies are to the high tech world what the Big Three are to the auto industry- cautious, swollen, bureaucratic, lawyer-driven behemoths that have failed in their fundamental mission of scientific discovery, despite nearly limitless R+D spending and huge federal tax subsidies for same. It is a classic example of Drucker’s curse: he whom the gods will destroy he will first give thirty years of prosperity”
   YOU GOT THAT RIGHT!
   Dr.Rick Lippin
   Southampton,Pa

8. What the pharmaceutical companies wanted to avoid in MMA was a Veterans Administration formulary that actually tossed their cash cows out the window (what, no Lipitor, no Crestor?). The VA and a lot of state Medicaid programs have kicked the stuffings out of their drug costs with highly restrictive formularies and hard ass price negotiations. What the industry wanted from Medicare was a porous formulary with no political teeth.
   What has happened instead, abetted by the now decade long drought in new drugs, is that the PBM’s have kicked the stuffings out of them instead and their stocks are selling at multiples once reserved for electrical utilities. Irony of ironies. The drug benefit has cost something like 40% less than the genius actuaries who almost torpedoed the benefit estimated when MMA passed, but the rhetoric of a “giveaway” to the industry lingers in the poisoned air of partisan rancor (see above).
   These companies are to the high tech world what the Big Three are to the auto industry- cautious, swollen, bureaucratic, lawyer-driven behemoths that have failed in their fundamental mission of scientific discovery, despite nearly limitless R+D spending and huge federal tax subsidies for same. It is a classic example of Drucker’s curse: he whom the gods will destroy he will first give thirty years of prosperity.
   They are terrified of a national Health Board because they don’t want to defend their economic contribution to the nation’s health scientifically. And the tragedy of Daschle’s demise is that they might actually get their way. Only an insider could have persuaded Congress to let go of the reins, and the irresistible impulse to protect the indefensible.
   No maverick or health crusader will successfully persuade Congress to abandon its four decade long coddling of the health care industry (sheltering specific drug classes, like the injectibles, defending $600 toilet seat pricing for durable medical equipment, instead of Home Depot pricing, raising Medicare payments for handfuls of rural hospitals by magically classifying them as urban, deciding what % pay increases doctors should get every year, etc.). Daschle correctly diagnosed the fundamental problem with health reform: we cannot afford to do it with our present “pay to play” political system.
   Only an insider could get Congress stop the “guaranteed income” stuff and actually craft a health reform plan we could afford. I wonder if there is anyone with enough intellectual honesty and cohones to pull it off.

9. rbar, let me start: you cannot negotiate a price when you have nothing to bargain with. Medicare is mandated to include a wide range of drugs. It can’t pretend that it will walk away from the bargaining table if the price isn’t lowered, because Medicare is expressly forbidden from considering price in the formation of its formulary.
   Now, if the rules were changed and Medicare could act like the national health systems of other nations that consider cost in creating their formularies, that is a different matter. Private insurers do this to some extent already with their tiered formularies, and that has actually had a pretty big impact on controlling price increases in drugs (mostly by encouraging greater use of generics, which have low or no cost sharing).

10. tcoyote, you seem to know your stuff, but please give me an explanation why the drug prices in the USA are by far the highest worldwide, and whether you think sthg should be done about it, and what.

11. Hopefully the President doesn’t read HPMB or THCB. Just as would have been the risk with a more tax-compliant Daschle, putting someone in charge of HHS/reform who already has a published agenda is more likely to result in attacks on the agenda than on its forward progress (c’mon, you know how politics works).
    I happen to think that the Wyden/Bennett bill is, although imperfect, currently the best thing out there. I’d rather see Senator Wyden advancing it across the Senate aisle as a sensible and practical compromise than having to defend it against partisan attacks (and yes, I know it has bi-partisan support right now, but wait until it’s the Administration’s bill!).

12. No room at Hotel Mahar for moderates, I guess. The right and center wings are closed. It would help if Maggie actually read Wyden’s bill before opining what it does to the insurance industry. It completely restructures private health insurance- it defines the benefit, it drastically restricts underwriting practices and profits and provides transparency not evident today, to the point where it is not clear that it is actually insurance any more.
    And unlike the trillion dollar campaign health reform give-aways of scarce tax payer dollars, the CBO said Wyden’s bill was revenue neutral in a snapshot full implementation year (2014), and actually makes money after that. Wyden and John Kitzhaber are actually fairly similar politically- they are pragmatic, independent Democrats, and politicians of exceptional quality, whether they meet your “progressive’ litmus tests or not. There has never been a whiff of conflict of interest about either of them. (And it is a credit to their character that both of them would be miserably unhappy at HHS).
    BTW, Maggie should study the December CBO report on budgetary options for Medicare. There are no scorable savings from the federal government “directly negotiating” with pharmaceutical companies. If you read the analysis, it says “negotiations by the Secretary would produce small if any savings because the Secretary would not have sufficient leverage in such negotiations to secure significant discounts on most drugs beyond those already obtained by the PDP’s and MA-PD’s.” Maybe that Orszag guy is really a closet Republican. . .

13. Kitzhaber might do well in the White House job? Health Care reform czar? Instead of running HHS?
    These are TWO VERY DIFFERENT HUGE jobs
    Rick Lippin

14. I have trouble getting past the fact that Wyden’s vote in favor of the Medicare Modernization Act (which gave a windfull bonus to insurers and explicity prohibted Medicare from negotiating for discoutns) was key to passing the legislation.
    Here’s the story of how the bill was passed (from
    HealthBeat http://www.healthbeatblog.org/2008/04/the-high-cost-o.html
    “The Medicare Prescription Drug, Improvement, and Modernization Act (also known as the Medicare Modernization Act) came to the House for final approval at 3:30 a.m. on November 22, 2003. It was losing, 219-215, until the House Leadership, in a very unusual move, held the vote open for hours while the Leaders twisted arms. At 5:50 a.m. the legislation passed the House 220 to 215.
    Representative Nick Smith later claimed that he was offered campaign funds for his son, who was running to replace him, in return for changing his vote from “nay” to “yea. ” He subsequently recanted this statement. Nevertheless, the House Ethics Committee and the FBI launched investigations into whether members of the House had in fact offered Smith a bribe to vote for the measure.
    In October 2004, the Committee issued its report, revealing that “Majority Leader Tom DeLay admitted that he offered to endorse Smith’s son Brad, who was running for Congress at the time, in exchange for Smith’s “yea” vote on the Medicare bill,” though the investigation couldn’t find out who offered Smith the money.
    Following the House vote, on November 25, the legislation came to the Senate for final consideration. Once again, it almost didn’t make it. Senator Tom Daschle raised a budget point of order. Sixty votes were necessary to override it, and for a few minutes, the vote was stuck: 58-39. It seemed that Daschle had a credible chance of blocking passage—until Senators Lindsey Graham, Trentt Lott and RON WYDEN voted in quick succession in favor to pass the vote 61-39. Thus Wyden, a supporter of health care reform, helped save the insurance industry’s pork.
    If “pork” seems a little harsh, how about “excessive corporate subsidies”? That’s the phrase the AFL-CIO, the American Federation of State, County and Municipal Employees, Families USA, and the Medicare Rights Center used in a letter they sent to congressional leadership this week protesting what the groups called a “waste of taxpayer dollars . . .”
    ~~~~~~~~~~
    It’s good that Wyden has friends on both sides of the aisle, but do we want someone who is ready to reach a hand across the aisle to pass what is generally perceived as one of the worst (and slimiest) bills that ever made its way through Congress?
    Should one vote prevent Wyden from becoming healthcare czar? Probably not.
    But I would like to know much more about his relationship with the insurance industry, Pharma etc.
    Has he taken money from these industires? (Keep in mind that is what disqualified Daschle, not the tax problem. The deal-breaker was the fact that in the past two years he had taken $200,000 in speaking fees from the health care industry, creating the appearance of conflict of interst.
    We already have enough conflict of interest in healthcare, as HealthCare REnewal’s Roy Poses will tell you.
    Under Wyden’s healhtcare plan, I know that there would be both community rating and guaraneed issue–which is very good. But I don’t think his bill forces private insurers to compete against a public-sector alterantive (Medciare-fro all). Instead, it would hand the uninsured over to the for-profit insurance industry–all of those new customers, government subsidies in hand. . .
    A bailout for the insurance industry??
    I think it’s essential that private insuers be tightly regulated, and it’s becoming clear to me that, to keep them honest, we probably need to insist that insurers have to compete with a public-sector insurance plan on a level playing field.
    The fact that this is the one point that they refuse to negotiate on (see http://www.healthbeatblog.com/2009/02/families-usa-director-ron-pollack-explains-what-could-block-health-care-reform.html )
    tells you something — they know that Medicare could provide better care for less.
    If that’s the case, can we really afford to subsidize
    private insurance that offers poorer care for more??
    Finally, at The New Republic, Noam Scheiber writes:
    A colleague points out that Wyden is less than beloved by his Senate colleagues, so maybe it’s not the most inspired idea. There’s also the issue of liberal skepticism of Wyden, whom they feel is too eager to work (and compromise) with his GOP counterparts. But, from Obama’s perspective, that doesn’t strike me as a bad thing necessarily.
    Couldn’t we find someone that both liberal and more centrist Democrats like? Also, are we sure we want a Washington insider?
    I’d vote for former Oregon Governor John Kitzhaber–An ER doctor and healthcare reformer of great intelligence and integrity. He’s also extremely charistmatic and a very good speaker.

15. As a physician and former employee of Sen. Wyden, I completely agree with his endorsement for the position of HHS. He is, and has been, a trusted, respected, ethical, and transparent member of the U.S. Senate with a wealth of understanding about the Health Care Sphere. He would be an excellent choice!
    David Rosenthal MD

16. Back in 2006 on this very blog there was an overview of his health care plan https://thehealthcareblog.com/the_health_care_blog/2006/12/policy_wydens_h.html that is still useful. Basically he proposes an end too employer based insurance as well as to Medicaid.
    “The bill is a replacement of employer-based health care with the purchase of individual insurance via regional pools, which look very like Clinton-style regional health alliances–except they’re now called “health help agencies”. No underwriting, guaranteed issue, community rating and an individual mandate with subsidies up to 400% of poverty and a minimum benefits package equivalent to the BCBS plan in the FEBHP. ”

17. Yes- And he can tap,from his own state, Dr (former Gov of Oregon) John Kitzhaber to help?
    Or don’t they share similar views?
    Rick Lippin