Last Helicopter Out of Saigon!

Jeff goldsmith In popular psychiatry, a classic passive aggressive gambit is “malicious compliance”- intentionally inflicting harm on someone by strictly following a directive, even though the person knows that they are damaging someone by doing so. In Washington, the most skilled practitioner of this dark art is Speaker Nancy Pelosi If health reform craters, Pelosi will disingenuously claim that she did precisely what the President asked of her, and blame the Senate and the President for its failure.

In reality, Pelosi’s “leadership” almost fatally wounded health reform last summer. If the process does collapse, the blame should fall squarely on her shoulders. Her poor political judgment led directly not only to squandering a nearly 80 vote majority, but also exposed embarrassing and ill-timed disunity among Democrats on a signature domestic policy issue. It won’t be the Republicans that killed health reform, but incompetent Democratic Congressional leadership.

Last July 14, Speaker Pelosi unveiled the opening bid in the health reform process- HR 3200, America’s Affordable Health Choices Act of 2009. This bill was drafted largely without input from their Republican colleagues or from important Democratic moderates. It also put into legislative language virtually exactly what the President promised in his campaign, without considering seriously the political implications for the actual passage of the legislation- a political form of malicious compliance. Democratic moderates felt their input had been ignored and they were immediately trapped on the wrong side of this issue.

HR3200 had an immediate polarizing effect on the health reform debate, and the damage control process was on. In a sense, health reform has never recovered. Pelosi’s bill summoned the right wing talk radio demons (and the inimitable Betsy McCaughey) out of their caves, reviving long dormant rhetoric about a “government takeover of the health system”. This label has clung stubbornly to all subsequent versions of the legislation.

Unfortunately, the critics weren’t too far wrong. HR 3200 effectively federalized the employer health benefit. It mandated that employers offer a “one size fits everyone” health benefit to their workers, the benefit precisely defined by federal statute. It imposed an 8% payroll tax on employers who did not provide the benefit, pushing their federal payroll tax to 23% if you include Social Security and Medicare. It also moved the top tax rate for federal income taxes for businesses filing as “subchapter S” to 46%, a level not seen since Jimmy Carter was in the White House.

Given unemployment was climbing toward 10% at the time, HR3200 would have simultaneously diminished corporate cash flow and increased the cost of hiring new workers for firms that did not presently offer health coverage- a recipe for no recovery.

HR 3200 created new health insurance premium subsidy for workers covering and estimated 20 million new people, but without any meaningful brake on future federal subsidies. To enroll these new folk, however, health insurers would have to comply with provisions of a new federal health insurance exchange, whose rules would have effectively ended medical underwriting.

The health coverage gated through the exchange was no longer be “insurance”, but a federally defined health care entitlement financed largely by employers. The bill also created a public health insurance option, which had the effect simultaneously of competing with and financially undermining private health insurers. All of this was to be overseen by a politically appointed Health Choices Commissioner, in effect, a commissar for the health insurance system. This nominally private-sector approach had a distinctly Soviet flavor.

Almost immediately upon HR3200’s release and for the following seven months, the Democrats have been playing defense on health reform and losing. Democrats elected from Red or Purple states ran from the bill as fast as their legs would carry them. They rebelled against the “public option”, the employer mandates, as well as the tax increases required to fund the premium subsidies.

Moderate Democrats also objected to subsidizing private coverage of abortions and to any enrollment of people in the US illegally (roughly 7-8 million of the uninsured). It might have been possible to address these concerns “privately”, e.g. in the initial drafting process, but by the time HR 3200 was released, many After almost four months of contentious negotiations, a revised version of the House bill passed by only five votes, one of which came from a stray Republican.

By the time Democratic moderate concerns had been clumsily and publicly accommodated (in the late fall), the resulting House bill had gravely offended three core constituencies of the Democratic party- women, Hispanics and the single-payer advocates, without materially addressing the critics of a huge expansion of federal power (and spending). The Democratic base lost enthusiasm for the bill while Democratic moderates continued to struggle with the “government takeover” label. By late fall, the legislation had acquired the odor and toxic sheen of a rotten side of tuna.

In the court of public opinion, the ensuing seven months (with a brief blip after Labor Day after a well- crafted Obama defense of health reform), were all down hill for health reform. Opposition to the process, as much as the substance, of health reform hardened, aided materially by a flurry of dealing making around the Senate bill (Medicare or Medicaid carve outs for Florida, Louisiana and Nebraska most visibly).

The late January loss of Ted Kennedy’s seat to an insurgent “Tea Party” Republican, Scott Brown, was an unmistakable warning sign that even formerly unassailable Blue State Democrats were now at risk. Political pundit Charlie Cook, who follows the Congressional races at a microscopic level, wrote recently that the Democrats have been in free fall since August. They lost gubernatorial races in New Jersey and Virginia, county executive races in solidly Democratic Fairfax County (VA) and Westchester and Nassau Counties (NY). A surge of inconvenient scandals- David Paterson, Charles Rangel and Eric Massa- all in New York- have further tarnished Democratic credibility. Cook placed the odds on the Democrats losing the House this November at 50-50 and sliding.

On the eve of the Presidential health reform “summit”, a Newsweek poll revealed that independent voters, crucial to re-election of Democratic moderates, opposed passage of health reform by a stunning 62-29% margin. Despite the White House’s feeling that the President could paint the Republicans into a corner and blame them for halting health reform, a Politico.com reader poll after the summit suggested the Republicans decisively outpointed the President (52%-19%) by stressing the fiscal and economic risks of the bill. There aren’t a lot of undecided voters left on the health reform issue- and strongly “anti-” sentiment outruns strongly “pro-” sentiment by almost two to one.

Now the White House and Democratic leaders are in the final scramble to find votes to send the President something he can sign and declare this endless and divisive process over. Speaker Pelosi suggested last week that, regardless of the damage they may suffer at the polls in November, House Democrats owe her and the President a reaffirmation of their support. Pelosi basically ordered her troops to swallow their reservations about this bill and fall on their swords.

Gloria Borger of CNN reported late last week that a “senior White House aide” characterized the coming vote on health reform as “the last helicopter out of Saigon”, the most unfortunate political metaphor of the Obama era thusfar. (For younger people, that helicopter was ferrying South Vietnamese collaborators with the United States off the roof of the CIA compound before the North Vietnamese Army flooded into Saigon). What did the “senior White House aide” mean? That the Communists are coming and congressional Democrats need to save themselves and run for the hills? It sure doesn’t sound like a clarion call to do the right legislative thing.

It isn’t the Communists that are coming. It’s a lynch mob. And the angry horde is going to discriminate between “progressives” and moderates. They are simply going to find and hang as many public officials as they can get their hands on – incumbent Congresspeople, Senators, Governors, state legislators, county executives. Unfortunately for the Democrats, the majority of those incumbents are Democrats. I’ve not seen such a toxic electoral atmosphere in my lifetime.

If she cannot find the votes to pass health reform, Speaker Pelosi will be deflecting blame and knifing her White House colleagues in the back all the way to the guillotine. If it passes, it will be in spite of, rather than because of, her advocacy. By maliciously complying with the President’s mandate, Speaker Pelosi and her arrogant, tone-deaf management of the legislative process badly damaged the prospect for lasting health reform. She should scramble for a seat on that last helicopter herself.

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  1. Thanks for a very interesting web site. Where else could I get that kind of info written in such an ideal approach? I’ve a project that I’m simply now operating on, and I’ve been at the look out for such information.

  2. I’m well aware of the history of Vietnam. As I made clear, my comment was about what could have been meant by “the last helicopter out of Saigon.” The quote made it appear that the vote to pass reform is being compared to the last helicopter, and that the aftermath will be defeat at the polls in November. In that case, the vote is an attempt to salvage something and do the right thing, however partial and incomplete, and even though (electoral) defeat is coming. This is contrary to Jeff Goldsmith’s interpretation of the statement. In any case, Jeff and I agree that whatever analogy was being made, it wasn’t a very good one. As in, it doesn’t really describe the situation with the health care vote. I hope we can be done with that discussion now.
    About those the snide (I mean, heartfelt) comments about docs in their 30s, presumably in response to my statement that good things are coming from the younger generation of physicians: The point is not that younger is better. Seasoning matters, which is why I said good things are “coming,” as in, over the course of 20-30 years as the physicians gain experience and dominate the field. The point was that the current crop of docs 55 and up is the most resistant to certain reforms that many, many folks who study this for a living say are critical to improving quality while curbing cost growth.
    Related to this, a nice article in the Times about reigning in the physician cowboy culture.

  3. Harris, my point was that you bridge the gaps in private through consensus building, not by trapping your members and then have to negotiate embarrassing givebacks on key issues in public. Perhaps those gaps were unbridgeable, but we’ll never know. Pelosi’s poor political judgment badly damaged this process and squandered the considerable advantage of huge Congressional majorities by airing a lot of the party’s dirty linen in public.
    It may be, as Matthew suggested, that the party is unworkably broad ideologically , but master politicians of both parties (Roosevelt and Reagan) made that difficult bridging process look easy. The process was also badly damaged by tossing Daschle under the bus, and by the loss of Ted Kennedy, who had enough credibility with all the Democratic factions to have worked something out.

  4. When do we start the battle to reform reform? This will surely crater, pass or not pass.
    The young doctors do not work like their elders, but patient volume rquires docs like me and not like the life-style crowd. If this becomes law, the post office at Christmas will look like heaven compared to your ER at 3 AM.

  5. Jeff, I’m baffled by this paragraph: “Moderate Democrats also objected to subsidizing private coverage of abortions and to any enrollment of people in the US illegally (roughly 7-8 million of the uninsured). It might have been possible to address these concerns “privately”, e.g. in the initial drafting process…”
    As far as I know, the House bill at no point would have subsidized coverage of illegal immigrants, despite Republican claims to the contrary. And it appears that the conservative Dems’ concern about abortion coverage blew up at the very last minute last fall, and was resolved by Pelosi through the Stupak amendment.
    You fail to acknowledge that making both the conservative Dems happy while satisfying the core Dem constituencies of women, Hispanics, and single-payer advocates was a difficult or impossible task.
    This piece isn’t up to your usual high standards of analysis.

  6. So, all you smart thirtysomethings, get up and lead the way, make the world the wonderful place you envision it, with your laptops leading the way!
    He he he, your age group is no better, it is the arrogance and cluelessness leading the way in that comment! Dismiss generations ahead of you? Be ready for the one following you to repay you in spades!!!

  7. “The Left has also raised the banners of jihad against insurers”
    The ruler41 is correct regarding this, but not the criticism regarding weak proposals to lessen or roll back costs. That comes in the next reforms that will certainly occur.
    Forget “socialist”, I believe in “communism”. Insurance in a way is communism. Jeder nach seinen Fähigkeiten, jedem nach seinen Bedürfnissen is a slogan for community-rated insurance and one that should be followed.
    “loggorheaic” logorrheic = logo(r)- < logos=word rhe=flow -ic = adjectival ending -a = substantive ending. Doubling of r consonant when beginning and ending same consonant of joined Greek-origin words. Doesn't anyone know etymology in this weblog?
    "We abandoned millions of our allies in that war to death camps and two decades of political repression and stagnation"
    Not an accurate summary of the denouement of the Vietnam escapade, but then again this is not the place for that discussion. Were all collaborators with the Nazis in occupied countries during WWII forgiven by those who were partisans fighting to evict the Germans after the departure of the Germans?
    "However I am more than amused by the Kaiser survey which said that 60% of Americans opposed the bill until they were told what was in it, when 60% then supported it!"
    This of course says it all. What if the benefits of single payer/insurer among other changes beneficial to the "people" were explained clearly to those "people"? Overwhelming support for it and other features.

  8. Jd, we lost the Vietnam War. We abandoned millions of our allies in that war to death camps and two decades of political repression and stagnation. The last helicopter saved thirty people. I found the metaphor bizarre in context.
    Also agree that burnt out docs ought to go do something else. I don’t want an Exhausted MD taking care of me. I want someone who really wants to see me when I walk into the exam room.
    Agree emphatically that there are lots of positive trends w/ the younger docs, including the work-life balance thing and a new and much more constructive view of HIT. It’s just the quantitative shortfall of them; it’ll take a decade or more to fix. And it isn’t just primary care docs that are short. general surgery has almost disappeared, as have a lot of the 24/7 specialties except ER).
    Matt, don’t pray for total collapse. It will hurt, again, millions of people before we get them help. We just need pragmatic, consensus oriented, thoughtful political leadership. We’ve got it in the White House. Now we need it in Congress. If we keep driving off the thoughtful people and send in wave after wave of ideologues (of the leftward or rightward persuasion), we’ll never get the government we need to fix it. And of course, if you ask people about the benefits of these bills, they’ll say “sure. bring ’em on”. It’s the price you pay for them that’s at issue. . .
    Maggie, isn’t the Kool-Aid starting to make you sleepy?

  9. All this talk of physicians retiring does not fill me with dread. For one thing, the older ones are the most resistant to necessary change. If a pilot says: “Screw the FAA, flight protocols, safety checks and all that stuff, my instinct and personal experience tells me how to fly a plane,” we’d think he was a nutty old codger. But we are supposed to honor physicians for the same “do it my way” attitude? Good riddance! Physicians in their 30s are on board with the HIT, evidence-based, group practice train to a far greater extent. Good things are coming to the recipients of care from this generation.
    Also, the physician shortage such as it exists or may soon exist, was in large part created through a bottleneck in medical school and a preference for more lucrative specialist careers (money again!), not a lack of demand to become a physician. As this article points out, only one medical school in the entire US was created in the 80s and 90s. Supply did not keep up with demand, and now finally lots of new schools are opening and current ones are expanding. And of course, we will continue to hire new physicians from abroad to fill gaps. Not an ideal solution by any means, but an unfortunate necessity in some low income and rural places for now.
    Matt, I don’t think we’ll reach a crisis moment leading to single-payer, but other than that you are dead-on about the forces at work.
    Nate, I’m not sure what motivated the silly swipe about the last helicopter being noble. What does the nobility (or not) of that act have to do with the justness of the war as a whole, or how well-run it was? It’s perfectly possible to do the right thing at a given moment even after screwing up something much bigger which preceded it. The whole premise of the example is that the final deed follows something that has gone wrong, so I didn’t ignore that but rather used it in my interpretation. I do find it odd that you disrespected the final efforts to go back for our allies to save them from torture and death. In any case, I was trying to make sense of the phrase in context, which didn’t seem to fit the spin Jeff Goldsmith was putting on it. Still doesn’t.
    Jeff, you say the one comment worth rereading is Exhausted’s “heartfelt” one. Being heartfelt is not enough. Opinions have to be supported by data. Is there anyone posting in this thread who (aside from bouts of sarcasm) isn’t earnest and heartfelt? Exhausted is not more heartfelt than the rest of us. It seems to me that he has fewer coping mechanisms for adversity than the rest of the posters.

  10. “if we dont have this we end up at 30% uninsured and 25% of GDP in ten years”
    On the bright side we know for a fact no liberal projection on healthcare spending has been correct in 50 years so there is an excellent chance Matt’s doomsday projection will never happen.

  11. Or perhaps there will come a point in time at which the politicians who are demanding “expansion of coverage” as a quid pro quo for addressing costs are ejected from office, and a point in time at which employers can no longer afford to fund policies of insurance which encourage their employees to insist on every available benefit, regardless of cost.

  12. I love the discussion. Personally I think that nothing is doable without a severe and current collapse. The Democrats have to contain the Jeff Goldsmith’s of the world who basically want the Heritage individual mandate solution that is in the Senate bill AND the Dennis Kucinich’s who will ONLY vote straight single payer. And of course the unions will NOT NOT NOT give up tax deductibility of health benefits and remain the party’s biggest paymaster and suppliers of feet on the street.
    Given all that, plus the nutjob Catholic bishops Stupak amedment plus/minus the intransigence of the Republicans, I think Nancy Pelosi did an OK job getting this through when she did–even when she knew the bill would move right in reconciliation–(Pre-the Massachusetts disaster.)
    Now in a post Scotty Brown world I’m deeply suspect that anything will pass, whatever Maggie Mahar tells me about the votes being in the pocket.
    However I am more than amused by the Kaiser survey which said that 60% of Americans opposed the bill until they were told what was in it, when 60% then supported it!
    Nonetheless, if we dont have this we end up at 30% uninsured and 25% of GDP in ten years–which is a guarantee for draconian single payer when the shit really hits the fan.

  13. “Before Medicare 13% of seniors needed help with their medical bills, now 19% of Medicare enrollees are on Medicaid, that would seem to show “some reform” actually made things worse.”
    Nate, you said this before, but I am not sure how the fact that we have more poverty amongst seniors today is any indication that Medicare caused it. Maybe without Medicare we would have had 30% unable to pay their bills. Is there any way to tie this change directly to Medicare as opposed to other economic factors?

  14. Margalit why is this terrible bill always better then no reform?
    Before Medicare 13% of seniors needed help with their medical bills, now 19% of Medicare enrollees are on Medicaid, that would seem to show “some reform” actually made things worse.
    Before mental health parity almost all plans included some benefit, faced with the higher mandated benefit a lot of plans just dropped M&N all together, again “some reform” was worse then no reform.
    I could go on all day with examples of “some reform” making things worse then they were before. History actually shows quit clearly that the American public should expect this bill to make things much worse then they are now. 45 years of not perfect enough reform is what created the current system you hate so much.

  15. Jeff–
    Yes, we need more primary care docs, but you seem to ignore what is actually in the legislation to encourage primary care. And we have three years for these incentives to have an effect–before 30 million Americans will gain insurance.
    First, the legislation encourages Medicare to begin paying bonuses to primary care docs who set up medical homes, or join accountable care organizations, or agree to accepting “bundled” payments. These bonuses would be based on outcomes and could be quite large.
    Secondly, the Secretary of HHS can take these pilot projects and expand them, nationwide, without going through Congress. (This is a change — in the past, these experiments were mainly temporary “demonstrations”
    and HHS couldn’t expand them without going through Congress. Different rules for pilot projects– see the latest NEJM, article by Mechanic and Altman and my post on wwww.healthbeatblog.org here.//www.healthbeatblog.com/2010/03/
    The post also provides examples of Medicare demonstrations that saved a large amount of money– until Congress blocked expansion. But now, Medicare is turning these “demonstrations” into “pilot projects” which means that they don’t have to be approved by Congress. HHS can simply roll them out everywhere that doctors are interested in the new programs.
    Where will the money come from? Cuts in other areas. Medicare has already announced that it is slashing fees for some diagnostic tests, particularly those done in doctors’ offices. (Research shows that when docs buy or lease the equipment, they recommend twice as many diagnostic tests. )
    In addition Medicare has announced that it is planning a series of pay increases for primary care docs and cuts for some specialists and some services over 4 years. It has already announced the first one this year: a 4% hike for primary care docs, a 3% hike for nurse practitioners and a 6% cut for cardiologists. This is just the first i n a series of pay hikes that primary care docs can expect to see. Compounded over 4 years, 4% here, 4% there will add up– especially because it’s in addition to the bonuses.
    In all of these areas private insurers have said they will follow Medicare’s lead–as long as Medicare goes first and provides political cover.
    Finally, the legislation includes a huge increase in funding for loan forgiveness and scholarships for med students who choose primary care so that they don’t graduate with large loans.

  16. “… the fear and tragic wastage of a war gone terribly wrong, and of people left behind, betrayed, to suffer the invasion of the bloodthirsty horde. Have our politics reached this point?”
    Not yet.
    The way I read Jeff’s title, the last helicopter is the last chance for “moderate” Democrats to vote against the bill in order to prevent reelection loses. Saving your Congress seat is hardly the same as saving your life, and citizens democratically casting a vote in support or opposition to policies, are hardly bloodthirsty hordes.
    However, letting this health care issue simmer untouched for another decade, just because the first stab at reform is not perfect enough, may very well take us to Saigon.

  17. Thanks, Jeff, for an insightful and provocative analysis. It doesn’t feel fair to me to lay all of that blame on Nancy Pelosi, as it seems to me that many people have worked together to get us to this sorry state of affairs. I’m intrigued by the “last helicopter out of Saigon” remark. Those of us old enough to remember seeing the people clinging to the underbodies of those machines, others reaching skyward for salvation in the face of the impending arrival into the city of the enemy, will have a visceral reaction to the analogy — the fear and tragic wastage of a war gone terribly wrong, and of people left behind, betrayed, to suffer the invasion of the bloodthirsty horde. Have our politics reached this point? May be. DCK

  18. “She rounded up the votes. She refused to compromise
    with Republicans.”
    I’m not sure how Pelosi’s refusal to compromise with republicans (and democratic moderates)is evidence of having spine. It seems to me that the best way to CYA is to represent your progressive (CA- local voter) consistuency uncomrpomisingly. When reform fails due to her lack of compromise, she’ll still have a job (albeit a reduced one) because she did not stray from her constituencies’ ideals. In the context of a democracy, having spine means taking a risk and sticking your neck out to actually get something passed.
    It’s the more moderate politicians who will pay the price. Pelosi is secure.

  19. Isn’t that how markets work?
    its not really a market when the government decides how many people can be trained and what they will make. One year the federal government is paying hospitals to train doctors then the next year they pay them not to train doctors. Its been a great example of central planing gone horribly wrong.

  20. Yes, Jeff, I agree with your last paragraph. I am seeing medical home and accountable care experiments taking place right now, before the bill went into effect. However, the same doctors that bitterly object now, are going to object even louder if the government attempts to “tell them how to practice medicine” and so will the public at large.
    We must have pilots and studies and it’s probably the only way to change behavior in this field. What do you think would be the reaction if CMS announced tomorrow that they will not pay for surgeries where checklists were not used?
    The shortage of physicians is really a shortage in Primary Care. I think we have more than enough specialists. Yes, we should increase reimbursements to Primary Care docs. This has been discussed for a very long time and I’m sure it will happen, but only in conjunction with medical homes and accountable care organizations.
    And, yes, it will take three years to run all the pilots and studies, but the bill does not become effective before that and the hordes of uninsured are not going to storm the bastions of medicine before that.
    In the mean time I would also suggest that we start educating more physicians. If the current generation is nearing retirement and we have not produced proper replacements, than we should start taking care of this now and there are several ways to do that.
    I have always advocated for primary care docs, but I am getting a bit impatient when specialists are complaining about the coming cuts, and I am even more impatient when specialists are silencing primary care docs who are also suggesting the need for more equitable valuation of physician services.
    Medicine is probably the highest paid profession in this country. Some docs are at the bottom of the scale and it so happens that these are exactly the docs needed to improve quality and reduce costs of care, so we should pay them more and expand their services.
    The ones at the top, of which we have too many, will see a decline in revenue. Isn’t that how markets work?

  21. “reduce provider fees, reduce insurers fees, reduce patient choices.”
    Ironic Margalit that you miss the best option
    Reduce utilization. We should pay doctors more for the right care, insurers should spend more on service and education and thus will need higher fees, and finally patients should have more choice not less. Pretty much sums up why the left is incapable of fixing the problem.
    “but it seems to me that the last helicopter was a noble act.”
    LOL only a liberal could spin the last helicopter out as a nobel act, sure ignore the terrible management of the war, ignore the millions being left to die, ignore the aboning a war we had won becuase the politics of it were bad and ya just maybe you can spin it as nobel.
    Would you say all these same kind things about Newt and Delay? Why would cold cash Jefferson take bribes, why would B Clinton get BJs in office, weren’t they both professional and smart and desire to keep their job?
    “the public at large also agrees with Pelosi that health insurers are the main force driving up health care costs.”
    Keep telling yourself this, what blog poll told you this Ezra Klien or Daily Kos?
    ExhaustedMD do you like the Ocean? Have a business partnership for you and as many of your MD friends as you can get. I did some insurance enrollments on in TX and the gambling boats, you board in the US sail out to international waters then do as you want free from over protective US regualtion. I’m thinking we could outfit a couple boats with all the supplies and equipment you need and treat people free of this new montrosity.
    I could sell them reasonable insurance free from all the mandates and requirements of Obama care and you can treat them as you see fit and charge what you will. Going to the doctor already takes a full day, this way instead of a waiting room with stale magazines you get the deck of a cruise ship and maybe some shuffle board.

  22. Of all these comments, the one which bears re-reading because it is a cry from the heart is Exhausted MD’s. There are tens of thousands of him and he’s right- they’re burnt out and ready to go do something else. 58% of the docs in the US are over 55. They’ve worked their asses off (less than half their time spent actually taking care of patients thanks to the Kafkaesque minstrations of our health insurance system) and before all this health reform hoopla repeatedly told surveyors that they intended to retire or gear down within three to five years. In Dec 2008, 45% of ALL practicing docs told Merrit Hawkins surveyors that they would retire within three years if they were financially able to do so (e.g. not just the fried boomer docs).
    The crash, and withering of their retirement funding, froze a lot of them in place. Many have taken refuge in hospital employment, but when there is sustained recovery in the stock market, they are GONE, and there will be a 40% drop in net physician effort for each young doc that takes their place because most of them want to work part time. And, per Exhausted MD, the departed MD’s will blame health reform (even though they were planning on leaving practice anyway!).
    Exhausted’s numbers (e.g a non-incremental 15% departure) is probably close to right.
    What did the legislation do? Well, the original House bill DID postpone the 21% Medicare pay cut which loomed on March 1. That disappeared because bill was not deficit neutral- and the problem is still not resolved. It brought Medicaid primary care payments (in some places as low as $10 a visit!) up to the inadequate Medicare rates which have driven a lot of docs in places like Florida and Arizona out of business. It promised experiments (“science projects”) with an enhanced primary care model called the “medical home”, which exchanges more comprehensive services designed to improve care co-ordination for higher payment. This will take at least three years to prove out, and require increases in Part B payments (to be funded from where?) to implement. And there was more funding for the National Health Service Corps which could help docs who want to practice in designated shortage areas (the entire country will actually be short by the time Exhausted and his colleagues depart the scene) to get their med school loans paid down. That was about it. It was nowhere near enough, because Congress people really don’t understand the magnitude of the generational shift taking place in medical care.
    The 15 million person Medicaid expansion will result in lots of newly covered poor people in geographic physician deserts with limited or no primary care capacity, with the result that people will flood into emergency rooms for care, just as they did in Massachusetts. The other 20 million newly covered people will discover mysterious four to six month waits for appointments with primary care docs, if they can find any with open practices, just like in Massachusetts. And Congress will appoint a Commission to find out what went wrong.
    There’s a huge reality gap between the people in their airless rooms (no longer smoke filled) who wrote this legislation and the actual front lines of medical care.
    Most of the docs in Congress were moderate Dems, Blue Dogs or Republicans who didn’t get to participate in the drafting process. The failure to deal with the looming physician shortage was the most grievous systemic failing of these bills, among many. I’ve been out on the circuit talking about this with physician communities and hospital execs, and believe me, there’s a problem here. It’s like a gigantic iceberg. You could see it coming a mile off and we’re still going to run right into it.
    For those still awake, Margalit, the most important way to contain cost is to change incentives to docs (to encourage earlier and more personal care for chronic conditions and reduce the abusive overuse of imaging technology), hospitals (to reduce the likelihood of errors or readmissions) and patients (to manage their own chronic disease risks more effectively).
    Again, there are promising experiments in these bills (which were on the drawing boards before health reform and also in the President’s FY10 budget). But it will take three to four years to fiddle with them, gather the data needed to craft new payment incentives and then put them in place IF Congress gives CMS the Innovation Center and funding to do them.

  23. You can run from it, but you can’t hide: The voters who have insurance aren’t willing to fund your egalitarian wet dreams.

  24. For a good description of the drivers and composition of hospital costs, at least for a teaching hospital in Massachusetts, check out BIDMC’s comments submitted to the state’s Department of Healthcare Finance and Policy at:
    For a list of all of the entities that submitted comments, see:

  25. Margalit, you posted your pithy response while I was disgorging my loggorheaic one. I eventually get to making the same point. We agree.
    Back in 2007 and 2008, I was saying on this blog that any administration that wanted to deeply reform (reduce) the cost of care would need to engage in a months or year long campaign to educate the public on the cost drivers of health care. Where do the dollars really go, and for how much of that is there solid evidence that it does any good, and where do other nations get by with less without any adverse health effects or waiting lines for care?
    We got none of that, not in any sustained or consistent way.
    The public doesn’t have the patience or interest for elaborate wonkery, but people on the whole are smart enough and interested enough for short bursts of clarified, well-honed presentations of the essential facts as we know them. But you must repeat them and drill in the new facts (choose 5, tops) that you want to drive the debate and to get the public on your side for reform. Because without it, I don’t see how Republicans or Democrats have a hope of checking the industries that book health care expenses as revenue.

  26. Wow, my first thought is that this is a terrible analysis, but it is so totally at odds with what I had thought was going on that I’ll hold off on that judgement and simply state why this makes no sense to me.
    First, there are errors of fact about the legislation, as Peter and Maggie pointed out.
    Second, Pelosi wants reform to pass. She didn’t want to undermine the possibility of passing anything and destroy the party’s ability to govern in the process. On what f*cking planet could that seriously be thought to be Pelosi’s game plan? Out of some kind of spite that Obama told her single payer was off limits, she’s going to take actions that would remove her party from power and take away her position as Speaker of the House? Do you think Pelosi got to where she is without knowing the meanings of compromise and incrementalism? Or that she got to be elected Speaker without being a professional?
    Third, I’m not sure the exact meaning of the last helicopter out of Saigon metaphor, but it seems to me that the last helicopter was a noble act. We were evacuating allies. We could have left them there. It was the last good deed. If passing reform is the last helicopter out, doesn’t that mean it is the last good act the Democrats can do before the Republicans (playing the role of North Vietnamese) swarm in?
    Fourth, supporting my previous interpretation, Pelosi has said that she thinks Democratic congressmen should be willing to sacrifice their re-election for this legislation. Taking her at her word, which I do, this is hardly the view of someone who wants to sabotage the legislation or who doesn’t want to do the right thing.
    Fifth, Pelosi and most Democrats understand that their chances are far better if they pass something than if they don’t. So, self-sacrifice should be a rare occurance, and the smarter political move would be to vote for the Senate bill (the option available at this point) so that Democrats can show something for their work and don’t demoralize their base too much. So while self-sacrifice is called for, self-interest (usually a stronger motivation) is also consciously at work here from what I’m reading in the press. Again, there is no attempt from Pelosi that I have ever heard of to sabotage this whole thing (as opposed to a nut like Kucinich.)
    Sixth, the massive delay in passing this legislation and allowing the Republicans to demagogue it came from the Senate. There were promises this would be wrapped up by June, but the Senate let it drag on for fateful months of dithering that produced no results and gave no indications that it would bring Republicans on board.
    Seventh, far from being close to getting some kind of bipartisan billing, as was pointed out, as Peter pointed out no Republicans were willing even to sign on to the Democratic goals let alone the means to achieve them. None signed on to the stimulus bill in a moment of crisis, though they now line up for photo-ops when the checks are handed out. There were more forced cloture votes in the Senate in 2009 than in any year in history, by far, for things that often weren’t even controversial. Luntz and kindred strategists have made it clear that the Republican game plan is to ensure Democrats have as few bills pass as possible by fall 2010 so that they appear incompetent. Denying universal health care is obviously a linchpin of that strategy. So this idea that a kumbaya bi-partisan consensus could be reached is ridiculous. Go ahead Charlie Brown, run to kick that football Lucy is holding one more time. I blame the Senate for its dithering far more than I blame the House for its tone-deafness, as Mr. Goldman put it.
    Eighth, I agree with almost everyone else that the House legislation does a bad job at cost control. But the question is, why? I think here Pelosi and the Democratic base do need to take the blame, because they have convinced themselves that the biggest problem they face is the health insurers. I don’t think Obama believes it; he’s just using rhetoric that will work to get him over the hump. But I think Pelosi believes it. She thinks if you bring “more competition” among health insurers, or reduce their profits, or steal their underpants, or something, you’re going to squeeze out so many billions that health care will become affordable again. It’s deeply misguided, and it’s sad. So the cost controls on the provider side didn’t exist in the House bill because a big block on the Left doesn’t really see them as urgently needed, and because the provider lobbies are so powerful they didn’t want to mess with them and earn their wrath.
    Having said that, the public at large also agrees with Pelosi that health insurers are the main force driving up health care costs. She is not out of touch with main street on this, but unfortunately reflects it. And for that reason I never thought a bill that took an axe to costs would succeed this year. Those of you who keep arguing we need to reform costs first are out to lunch. If you think fighting the insurer lobby is hard, you have no idea what you’re in for fighting the provider and pharma lobbies, when you aren’t offering anything in return. Talk about a bloodbath.
    Would it have been better for the House to vote only after the Senate was ready to vote? Maybe, but I also remember at the time a lot of pressure to see some sign of progress so that the story in the press every day wasn’t “Democrats can’t get their act together.”
    Was it a mistake not to involve moderates with health care knowledge like Rep Cooper? Yes, I think the legislation suffered because of it. But I distinguish those moderates from blue dogs who don’t know much of anything about health care, but reflexively see themselves as defending the (short-term) interests of business. They should have been kept at arm’s length, as they were.
    Last thought: Pelosi had more votes than it appeared. If needed, more could have been leaned on to vote for the bill. My money is still on health care reform (insurance reform) passing a few months before November 2010.

  27. Jeff,
    I never wrote any legislation and I do acknowledge the complexity of the issue, but the way I see it, you can only do three things to cut costs (other than the fraud & waste mentioned ad nauseam): reduce provider fees, reduce insurers fees, reduce patient choices.
    Do you really think that any significant step in any of these directions would have had a chance of being accepted at that (or this) point in time?

  28. I am just curious, regarding all these hopeless romantics who think that any health care legislation, ie what is going to be passed in the next 2-3 weeks, will improve health care THIS year, what will you use as a defense or apology WHEN, what I CONSERVATIVELY estimate will be 15% (about 1 in 6-7) doctors will either sizeable reduce or end their practices BY 2014? That will be the reality this bill will do to physicians.
    Yes, all those more than qualified nurse practitioners, physician assistants, non MD doctorate degree titles otherwise, will just step in and provide equal, if not better care for those near 300 Million patients who will be flocking for services in greater numbers than they do now.
    Not that it is nothing less than terrible that, as of now, people who cannot afford health care services more often do not access them, but, bad legislation is better than no legislation, is that right, you hopeless romantics?
    Gee, last I checked, neutral was better than negative, but, you folks must have gone to school and learned the new math techniques that guide Washington budget balancing these days. Well, you supporters deserve the representation you clamor for. And, people will remember your undying support in months to years to come, when reality plays out. It is in print, and for some of you, over and over again ad nauseum.
    I really hope some of you get so screwed financially, and should you have the audacity to try to renege on your position later, I hope readers who recognize your names call you on your hypocrisy, at least your lack of vision.
    The time to be nice and polite is gone. Attack me all you want, in the end, I know my words and position will be unfortunately correct. Unfortunate, because this legislation will end my career and leave needy people out to dry. Because, and I know all you supporters do not get it as you aren’t affected by it, I won’t work on a vow of poverty, and that is what is the unspoken expectation by these hopeless romantics.
    Hey, doctors are overpaid, because all we do is help people. Truly an overpaid effort for the public! That is, when we are not secretly planning to try to kill you all with our henious efforts to provide care! Oh, I forgot, all those caring and well intended politicians will legislate new clinical interventions to make health care better than it is now. What is the color of the sky in your world, heath care legislation supporters? I know what it is: BLACK!
    Thank you, all of you health care legislation stalworts. You service to your country and your peers is thankless. And, you are not welcome!
    And to any physician colleagues who come and read here and do nothing, good luck by 2014. I am sure your practices will be better by the Fall, much less within the next 4 years. These hopeless romantics depend on your silence and inaction. Or, maybe you were one of those stalworts behind the president last week!
    9 paragraphs. Hopefully my last here for a long time!

  29. Far more civilized, m’dear, than talk of “troglodytes” and “small-minded cruelties.”

  30. “suicide bomber”, “jihad”, “Dracula” and the “image of the cross”
    Are these literary flourishes of the pen, or typical conservative response to differences of opinion?

  31. Maggie, I’ve actually drafted legislation (my first job out of grad school) and analyzed it for more than thirty years. I read every line of HR 3200 twice. (I don’t need help from Peggy Noonan, believe me). There is no, repeat, no meaningful cost control in the House bill. There are a lot of “science projects” which may turn into new payment models. Even the modest reductions in hospital updates or in Medicare Advantage subsidies which help pay for reform do nothing to alter the inflationary trajectory of federal health spending (which rose at 10.4% in 2008).
    The House pointedly refused to take the most important cost management step- creating an independent Medicare Commission, a vital step according to the President and his budget director Peter Orszag to depoliticizing the management of the Medicare program. The Senate bill created the Commission but neutered it by forbidding it from reducing hospital or physician payments for a decade.
    The House bill also refused to shut down the self-referral machines Atul Gawande wrote about in his fabled New Yorker article on McAllen, Texas, actually grandfathering in the physician-owned hospital whose owners raised money for the Speaker and her colleagues. The sole nod to Atul was a requirement that physicians publicly disclose their conflicts of interests, a remedy that will have no meaningful effect on spending.
    By permitting the progressives in her inner circle, notably Henry Waxman, to dominate the drafting of HR 3200, Pelosi invited rebellion from the more moderate members of her own caucus. Instead of co-opting them privately, she presented them with an immoderate fait accompli, and, as the post suggested, badly damaged the party unity required to assure passage of health reform.
    She and the President both misread the 2008 election as a mandate for progressive reconstruction of our society. It was a “throw the bums out” election. And there will be another one in eight months, whether she can find the votes for this dreadful legislation or not.

  32. There was a time when socialists proudly proclaimed their name, rather than recoil from it like Dracula from the image of the cross.

  33. Peter how about a financial windfall tax on firms and individuals that received exceissve benefits from government. We could start with Goldman Saks and George Soros and anyone on the other side of an AIG dirivitive contract that got paid in full.

  34. and unions and politicians peter. Unions contribute more then anyone else.
    If you have a “minimum” set of benefits set so high and inclusive that also includes no lifetime or annual max and you limit annual out of pocket you have created a one size fits all polict dispite what maggie and peter claim. If either knew anything about insurance they would know a $20 co-pay and a $10 co-pay are not different policies in any meaningful measure.
    Alternative funding, self funding, and any future new idea not already accpeted by congress would be gone, all that would be left was one failed concept of what insurance should be.

  35. “I got an idea, how about a 50% tax on political contributions?”
    Absolutely, then the corps, PACs and high earners will fund this bill – that’s pay-go. Thanks for the idea Nate.

  36. Goldsmith writes: “the most skilled practitioner of this dark art is Speaker Nancy.”
    Is Goldsmith trying to call Pelosi a witch?
    He claims that the House bill she produced was “polarizing” (a word often used to explain why Hillary Clnnton couldn’t become president–she’s a “polarizing figure”
    Hat-tip to Minvet for her/his comment on this post: “look forward to your learned treatise on how Planned Parenthood v. Casey had an immediate polarizing effect on the abortion debate.” Yes, exactly.
    From the point of view of many progressives, the House bill was significantly better than the bill that Senate finance produced
    Unfortunately, Goldsmith’s description of the bill is filled with misinformation (Just one point: as Peter points out, what Goldsmith calls “one size fits all” insurance was a minimum benefit– what all insurers must provide to everyone, with no holes in the policy.
    See Peter’s comment for other lapses in Goldsmith’s logic.
    Goldsmith is completely off-base in what he says about the effect the legislation will have on the economy. See this post on how the legislation saves money http://www.healthbeatblog.com/2010/03/peggy-noonan-
    (Goldsmith must be getting his information from Peggy Noonan.)
    Finally, for the record, both I and other progressives who I know (male as well as female) are extraordinarily impressed by the job Pelosi has done.
    She rounded up the votes. She refused to compromise
    with Republicans. She understood, from the outset that they didn’t want universal coverage–something that became clear to everyone at the Summit where Republicans said they are willing to cover 3 million uninsured, but not 30 million.
    When everyone said reform was dead, she kept going.
    The woman has energy. She’s smart. She’s articulate. She is still pushing for a public option (something the majority of Americans want) as a separate of legislation and the president has told House liberals that he will work for it. (He has 3 years; I suspect they’ll do it.)
    If we don’t get health care reform , it will be because we don’t have enough Representatives who possess Pelosi’s spine, her persistence, and her willingness to take risks–and, excuse me, her balls.
    As she told legislators not long ago: “We’re not here to get re-elected. We’re here to serve the public good.” (That’s a paraphrase but close to the spirit of what she said.)

  37. The Left puts me in mind of the Hamlet-like suicide bomber in The Hurt Locker. Having got himself gussied up with explosives that can’t be deactivated, and then changed his mind, he now kneels abjectly in a deserted square, gibbering and awaiting detonation. They have only their inflexible, ideological zeal to thank for getting themselves into this posture. They have worn out creation insisting that there can be no humanitarian middle ground between wanton indifference to medical need and “equal access for all.” Middle America has rightly rejected this contrived dichotomy as frivolous. The Left has also raised the banners of jihad against insurers, seeking to persuade the naive that expenses offloaded onto insurers will not come back to rest on the shoulders of consumers. All the while, they have outdone themselves in attempting to distract from the fact that they have hardly done diddley squat to deal realistically with rising medical costs. And anyone who believes there must be a better way of going about this is a “sociopathic, wack-a doodle tool of special interests.” This shoots beyond mere impudence to hubris.

  38. “If employers are so up-in-arms why don’t they advocate for single-pay where they won’t pay anything for coverage?”
    Peter is so right, its not like employers pay taxes or anything. It’s not like people that own those businesses pay taxes. Let the government take it over and the bill magically disappears, why didn’t we think of this sooner.
    “Again, who was going to pay for this?”
    I got an idea, how about a 50% tax on political contributions?
    Maybe after this great post we won’t ever hear it blamed on the Republicans on this blog again. Democrats could have passed anything they wanted but they couln’t agree on what to pass. Republicans just pointed out the obvious shortcommings of the bills.

  39. Jeff, excellent post. The Vietnam war analogy is right on target. Of course, the title of Tom Rick’s book on the 2nd Iraq war provides another good analogy: “Fiasco.”

  40. I look forward to your learned treatise on how Planned Parenthood v. Casey had an immediate polarizing effect on the abortion debate.

  41. “It won’t be the Republicans that killed health reform, but incompetent Democratic Congressional leadership.”
    I agree as well. However, the original error was made by the White House. The complete lack of involvement in the early stages of drafting the bill, in an attempt to not repeat the Clinton administration mistakes, was too complete. Hind site is indeed 20/20, but I can’t believe that this administration was so oblivious (or so it seems) to what was being cooked in Congress.
    Since we are talking about helicopters, let me digress to tanks. There is a saying where I come from that when you aim at a target, the first shell is to the left, the second to the right and the third is the bull’s eye.
    Mr. Clinton held the reigns to tight, Mr. Obama too lose, so the next President to try should get it right.
    The only problem I see is that we don’t have time for a third attempt because the enemy is dangerously close already. In such case, you take whatever damage the second shell made and send in the infantry. It is of course harder this way and the price is much higher, but when, unlike Saigon, your country’s life is at stake, you just can’t afford to get on the last helicopter because it has no place left to land.

  42. “It won’t be the Republicans that killed health reform, but incompetent Democratic Congressional leadership.”
    I fully agree!
    “Democratic moderates felt their input had been ignored and they were immediately trapped on the wrong side of this issue.”
    Moderates or Blue-Dog-Republican Democrates?
    “Pelosi’s bill summoned the right wing talk radio demons (and the inimitable Betsy McCaughey) out of their caves, reviving long dormant rhetoric about a “government takeover of the health system”.
    Did you think ANY Democratic ideas on healthcare were going to be less than raw meat thrown to the Limbaugh Wolves?
    “HR 3200 effectively federalized the employer health benefit. It mandated that employers offer a “one size fits everyone” health benefit to their workers, the benefit precisely defined by federal statute.
    Was it one size fits everyone, or a minimum level of coverage? Were those “Cadillac Plans” outlawed?
    “It imposed an 8% payroll tax on employers who did not provide the benefit, pushing their federal payroll tax to 23% if you include Social Security and Medicare.
    We have an employer funded health system, who else was going to fund this? Do employers want more of those unfunded mandates, and don’t employers want the deficit to be contained and reduced? If employers are so up-in-arms why don’t they advocate for single-pay where they won’t pay anything for coverage?
    “It also moved the top tax rate for federal income taxes for businesses filing as “subchapter S” to 46%, a level not seen since Jimmy Carter was in the White House.”
    I’m for taking health coverage responsibility away from employers and funding it through general taxation. Again, who was going to pay for this?
    “Given unemployment was climbing toward 10% at the time, HR3200 would have simultaneously diminished corporate cash flow and increased the cost of hiring new workers for firms that did not presently offer health coverage- a recipe for no recovery.”
    What about the employer COBRA subsidy for employers to cover that 10%, who was paying for that?
    What about the healthcare coverage to the self employed where write-offs and subsidies pay for their healthcare? What about the small business exemption, tax credits and insurance exchange to lower their premiums?

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