Commentary by Dave Durenberger – June 27, 2012

GET READY TO LISTEN TO THE SUPREMES PLAY HEALTH POLICY GURU

On Thursday of this week the John Roberts Supreme Court will issue its second “landmark decision” (after Citizens United), this one upholding Congress’ power to set market rules for private and public (Medicaid) health insurance. This opinionator believes that Justices Roberts and Kennedy in particular respect the role that the Court must play in upholding respect for our elected institutions at times like this when the nation’s views on complex policy are divided, mainly by political partisanship. 

If it fails to uphold the law, it is more likely than not the bipartisan entitlement reform, which was launched in the last two Congresses, will have to struggle with putting a new health policy reform law before the next Congress. We cannot truly reform our economic security systems such as Social Security, Disability Insurance, Medicare, Medicaid and Long-Term Care without dealing with the systemic failures in health care and health policy.

The presidency and the Congress has been rendered ineffective to deal with the role of government in complex and costly systemic failures, for the most part, by the decision of Republican national and state-elected officials en masse to abandon systemic reform of anything until they control the presidency and enough of the Congress to pass their own version of market reforms. This is not a healthy prospect for efforts to resolve state or national deficit problems when taxpayers are already carrying 46% of the costs of the current health insurance system.

WHY DOES IT HAVE TO BE SO HARD?

It took more than 20 years for the Obama health policy law to take shape at the hands of Republicans and Democrats in Congress. The language of PPACA (Obamacare) can be traced to: (a) the experiments with Medicare financing reform in the 1970s, 1980s and 1990s; (b) the bipartisan House and Senate Medicare Catastrophic Act of 1988; (c) the bipartisan House-Senate Pepper Commission of 1989-90 which followed the repeal of Medicare Catastrophic; (d) the mainstream coalition of 27 Republican and Democratic senators which developed an alternative to the Clinton Health Security Act of 1993; and (e) the Gingrich-Gramm Republican “Just Vote No” Republican alternative. That’s on my watch.

During the balance of the 1990s, there were efforts by Republicans such as Senate Majority Leader Bill Frist and House Ways and Means Chair Bill Thomas to introduce market rules and public financing reform of a health care industry that simply refused more Medicare “market reforms.”  With Republicans in control of the presidency and much of the Congress after 2000, market reforms were abandoned for President Bush’s 2003 Medicare Modernization Act to include prescription drug coverage, Medicare Advantage and health savings accounts. After 2004, the Senate Finance Committee Republican and Democratic leaders undertook a patient effort to gather all the policy reform experiments and research together in a 95-page report in 2008 designed to guide the next president toward bipartisan change.

THE BEST REPUBLICAN ARGUMENT FOR THE A.C.A. FINANCING REFORM

• It creates private health insurance markets in America that provide the incentives consumers need to shop for price plus performance (value).

 

• It introduces health care market competition by reducing the cross-subsidies in the current “competitive” model in which hospitals must subsidize charity, low-income and the poor. Hospitals pay public reimbursement by raising prices on the privately insured. 

 

• Its potential to “privatize” the most costly social insurance programs in this country such as Medicare and the most valuable public assistance programs such as Medicaid is a Democratic concession by the single payer, Medicare-for-all, all-payer partisans.

 

• It “taxes” the healthy, the young and the able” through private not public “premiums” for a service each will eventually need. In the same way we currently tax everyone for the police, fire and correctional services required by a few.

 

THE HEALTH INSURANCE INDUSTRY

Lost in all the SCOTUS briefs is a debate between the old and new health insurance industry. The old industry likes the casualty insurance model in which premium prices vary with the consumer risk and the ability to dodge risk. These are the folks that employ brokers to sell products to individuals and small groups and favor regressive, tax-free health savings accounts to improve affordability. They also favor selling disability insurance to youngsters who won’t use it and long-term care insurance to oldsters who want asset protection.

The new health insurance model uses claims data to inform provider and consumer behavior and designs third-party payment models that assist providers willing to bear the risk of change to share in the savings from success. Some of these (the Kaiser Permanente Group model), are a combination of insurance and care delivery built on a co-op chassis in which profits are shared among insurer, provider and consumer. These plans, with appropriate government policy reform, favor selling disability insurance to everyone, which helps cover the cost of supportive services for persons with disabilities.

All the hybrid insurance companies we hear about today are evolutionary. There will be no one-size-fits-all health or disability insurance approach. But getting the national and state government out of paying fees for services via public insurance programs such as Medicare and Medicaid is an important step not yet taken by national policy reformers. It’s a step toward which Republicans can make a serious contribution as they wend our way toward premium supports and debit cards (their phrases, not mine).

BI-PARTISAN SELF-INTEREST TRUMPS OBAMACARE FINANCING

The ACA, a.k.a. Obamacare, expands insurance coverage to life-saving health care and medical technology to 32 million of some 50 million uninsured Americans. Every segment of the health care industry has agreed that the benefits of expanding coverage far outweigh the costs of some financial concessions they have made to achieve it, which is usually in the form of financial reimbursement changes. The exception is the medical device industry, which has fought making any concessions, and its congressional proponents who are currently engaged in repealing the one concession forced on them, an effective 1.5% profits tax for 10 years on companies with annual sales over $5 million. Democrats in Minn. such as Senators Klobuchar and Franken, and Congressman Tim Walz, oppose repeal of the law they voted for but favor gutting it of the revenue required to make it work. The Star-Tribune, which regularly publishes the self-serving opinions of the industry about how the FDA is driving U.S. jobs and innovation overseas, and only rarely digs deeply into the genuine health and safety issues associated with a local industry that some time ago passed from real medical innovation to iterative invention, editorializes here clearly on this bit of congressional double-speak.

WHAT IS ROMAN CATHOLIC HEALTH CARE?

Most of the hospitals and many of the long-term care facilities in the upper Midwest were created by members of one religion or another, mainly Christian and Jewish. Today, few are owned by the religions or churches that founded them, except for Roman Catholic religious orders that sponsor some of the very largest “systems” of hospitals and long-term care facilities. There are so few actual members of these religious orders that the institutions are largely governed and operated by lay persons of all faiths.  But the mission of these “sponsored” institutions includes fulfilling the “healing ministry of Jesus Christ.” 

The “ministry of healing” is a mission shared with every other hospital and long-term care institution, nonprofit and for-profit, in this country. It’s not proprietary to the Roman Catholic Church. The medical miracles performed are derived from highly sophisticated technology and highly-trained medical professionals. Practically every healing service is financed by private and public insurance, public assistance and cross subsidies by insurers and by tax exemptions and related public support. Look at the role Catholic health systems are playing in building for-profit Accretive Health and Conifer collection agency companies to maximize hospital patient payments.

These religious orders, by church law, are subject to the bishop of the diocese in which they are located. But few, if any, dioceses financially underwrite the institutions; if needed, the orders themselves must. But the bishop, as in the case of the infamous Bishop of Phoenix who fired the religious CEO of St. Joseph’s Hospital in his city for an alleged immoral life-or-death judgment about a patient, assumes the Church has power to determine the morality of each decision taken in Catholic institutions. So, the Roman Catholic Church this week begins a Fortnight for Freedom after having turned out 60,000 faithful in 158 dioceses in this country in “Rallies for Religious Freedom.”

A PLETHORA OF GOVERNMENT PROGRAMS CAN DO THE JOB

A week ago, the bishops won an internal victory when the Catholic Healthcare Association agreed its hospitals should not be required to provide birth control coverage in employee health plans in exchange for the broadened publicly financed coverage for the hospitals’ customers. Then they weakly added the argument “that the government has a plethora of programs that they can use to make contraceptives available right now,” said CHA CEO Sister Carol Keehan, who added, “If you want them available to women, please do it through a government program.”

We all know how difficult it is for poor women to access government programs in many states and there is the taxpayer pressure on most states to cut spending. We have all heard the incessant attacks by elected members of Congress on Planned Parenthood and its family planning funding. These attacks are driven largely by Christian broadcasting and pro-family political action “values voters.”  Many of us have experience with the relentless efforts by the Church and its Republican allies to stop public funding for these public programs and 90% of us have experience with contraception despite the Roman Catholic Church’s claims for the imperatives of moral law.

In an America that guarantees its citizens access only to life-saving emergency health care, with a growing number of persons who are priced out of health insurance or are ineligible for public assistance, Catholic health care relies heavily on the adequacy of payments from insured patients to cross-subsidize its charity care. For this reason, the religious orders that sponsor hospitals that serve about 20% of the patients in this country supported the insurance coverage provided by the PPACA (Obamacare).  But the U.S. bishops did not, claiming the law required public funding of abortions. 

RELIGION WILL DECIDE WHAT RELIGION DOES 

The new insurance provisions of the law were implemented to include new insurance rules and evidence-based insured benefits to be provided employees. The bishops objected to the inclusion of birth control benefits, claiming the Catholic hospital was an extension of the ministry of Jesus Christ in which the churches, as religious institutions, were engaged and that Catholic moral teaching prohibits the practice of birth control by any means other than abstinence from sexual relations.  The bishops argue that the Constitution protects the Church’s “self understanding” of the religion’s purpose and that the purpose of the Catholic hospital ministry is to advance Catholicism as a religion, (per Rev. Michael Place, immediate past-president and CEO, Catholic Health Association).

If this country is to continue to rely on a private system of health and long-term care, and an increasingly large private health insurance system, and an increasingly large public financing of both insurance and care services, then the continuation of the “healing ministry of Jesus” must at some point recognize the limits of freedom of religion. The Roman Catholic Church in America is in no way deprived of any of its constitutionally protected religious rights, including the right to form consciences of its adherents, or to protect the sanctity of human life, by the requirement that order-sponsored health care institutions provide employees a choice of conception prevention services.

FOX NEWS REPORTER HIRED AS VATICAN MEDIA ADVISOR

Greg Burke, 52 years old, has been reporting from Rome for Fox News for some time. Greg is a celibate Opus Dei numerary and a friend of Cardinal Timothy Dolan of New York. Now he will be the “press secretary” to the Vatican. Only a Fox News reporter could pull that off. Closer to home, Bishop John Neinstedt of the Archdiocese of St. Paul-Minneapolis, after a two-year study, has dissolved the 60-year-old corporation that publishes the archdiocesan newspaper The Spirit. This will eliminate the employee union but promises some of those employees jobs in the archbishop’s own communications department.

THE CHARTER SCHOOL MOVEMENT CELEBRATES ITS 20th ANNIVERSARY

Four thousand Americans gathered in Minneapolis last week to celebrate the start in this community of the national “charter school” movement and to honor a Minnesotan who has spent all 20 years and more working to make school choice and charter school alternatives possible.  Jon Schroeder, the former editor/publisher of the Grant County (MN) Herald in Elbow Lake, came to work in my Senate office after selling the paper and moving with his wife Dana and three kids to the Linden Hills neighborhood.  The youngest was born on the day I was last re-elected in 1988 and today is one of the most gifted, multi-talented young women I’ve met and an honors graduate of Northeastern University in Boston. I called her “Baby Helen” in public until her fourth birthday, when she told me to knock it off.

Jon Schroeder helped guide the work that Senator Joe Lieberman (D-CT) and I did in 1990 to pass the first federally authorized support for charter schools, which helped to get new President Bill Clinton involved in school alternatives in public education. Jon also helped write, with Senator Paul Simon (D-IL) staffer Robert Shireman, now in DOE, the Income Dependent Education Act to bring sanity and predictability to higher education self-funding. Jon encouraged thousands of teachers to get involved in revolutionizing public education by changing its schools and what went on there. He wrote the legislation on National Service Learning, which I got passed, and kept the national fires burning under reforming public education by changing public schools.

WHY MUST IT TAKE SO LONG

When Joe Lieberman and I passed the charter school law it was our belief, as it was the belief of its Minnesota founders, that charter schools would be created by elected boards of education at the local level so they could design and demonstrate the value of alternative schools within each school district.  Rather than buy more busses to move more kids to failing schools, let teachers experiment with creating their own schools against district outcomes standards to apply to all of their owned and chartered schools. Change we can believe in was stalled by the reluctant opponents of change of any kind.

Former MN Senator Ember Reichgott-Junge (D) has memorialized some of this and a lot of the bipartisan school reform work in her book Zero Chance of Passage.  Dana Schroeder did a lot of the work on this book as well. Another charter school book to watch for is Born to Rise by Deborah Kenny, the founding CEO of Harlem Village Academies, due out this month from Harper Collins. See WSJ 6/25/12.

CHANGE WE CAN BELIEVE IN

Ask anyone in elected office at any level of government whether this country is in the middle of a popular sea-change in the role of government. Of course we are. Evidence of the shortcomings of public policy, public institutions and public leaders is everywhere. Changing the leaders will not solve the problem since none yet seem able to articulate where change will lead. They are good at why, but not where.  The same is also true of much of what passes for the influences on public opinion:  the media, the professions, corporate finance and production executives, institutional and association governance, religion, foundations and think tanks. The vision thing, if you will.

ROMNEY V. OBAMA IS NOT YET A CHOICE

Except for those who have a stake in what they have now, or a stake in changing those with a stake in the past present. Reagan speech-writer Peggy Noonan is a barometer for articulated leadership. In her weekly WSJ column, she begged for vision from newly elected President Obama for nearly 18 months before she gave up. Today she is begging Mitt Romney for the same  knowing, I suspect, she’s not likely to get it since you just can’t change men who believe they are “self-made.” You can give them the farm to get started and position papers, talking points, words and phrases that capture the base and the moment when they turn to politics, but not the vision that inspires confidence. 

A PURPOSEFUL LIFE

The “vision thing,” or the ability to articulate shared hopes and dreams, comes only to those who early on found purpose and meaning in life itself outside themselves and their “achievements.”  I, for one, found meaning in my faith education and purpose in being “led where I did not expect to go.”  But I did not put it together into a way of life until my friend Tad Piper introduced me to Robert Greenleaf and Servant Leadership and until I learned it all the hard way.

Our mutual friend Bill George, retired Litton MicroWave, Honeywell International and Medtronic CEO, calls it “authentic leadership” and has a life-work built around corporate leadership change. So far, Bill’s been on call to use the failures of authenticity to educate his peers more often than he has been able to use his own example of an authentic life that provides authenticity in leadership.

So long as leadership failures are the fodder for Internet and cable “news,” and so long as the titans of the financial industry, the gaming industry, the energy fuels industry, the religion industry and the partisan political culture industry get all the time and our attention, it will be tough to motivate Americans and those who vote to look inward rather than upward for the models of meaning for a purpose-full life. And the authenticity that comes from feet to real fires.