Commentary from Dave Durenberger

March 3, 2010

by Nick Anderson

THE BLAIR HOUSE SUMMIT MOVED THE NEEDLE
There was never much doubt going in or coming out of the seven hours of summitry that Republicans were not going to help the president reshape health insurance reform or coverage expansion, or health delivery and payment reform unless it included catastrophic-only individual indemnity insurance, funded by taxpayer financed HSAs, but without national rules on risk assumption. Plus tort reform (caps on punitive damages).

What astounded me, and what will prove to have moved the needle on health policy and system reform, is President Obama. No president in my memory could have or would have done what he did last Thursday. He displayed a grasp of the most complex system in the world, the environment in which it operates and the policies that can effect change in it. Better than any person I've ever seen. I don't believe I can recall a president do what he did Thursday, in a room full of supposed experts, on any subject in my 30-plus years.

So what? It may help Democrats pass the amended bill with majority votes in both Houses. It makes the president an effective campaigner in the 2010 elections. It assures me that on his watch getting change in costs and quality in the health care system will remain at the top of his agenda. Put him in front of any group of CEOs of any or all of America's $2.5 trillion medical industrial complex and he will inspire the change they should be embarrassed to have ducked in 2009.

In his own re-election campaign in 2012 I would not like to be the Republican presidential candidate who tried to take him down on why the richest nation on earth cannot find a way to spread the industry's wealth far enough to include all 306 million Americans regardless of health or economic status. Senator Tom Coburn (R-OK) acknowledged early that one-third of our health care spending is wasted to fraud and abuse, waste, poor quality, defensive medicine or insurance that isn't. That is not because we don't have enough "skin in the game" or that we have too many lawyers suing to stop the 98,000 deaths per year caused by hospitals.

MINNESOTA REPUBLICAN IN OBAMA HEALTH REFORM SUMMIT
Congressman John Kline (R-MN-2) attended the summit on February 25 as ranking Republican on the Education subcommittee. John prepared his constituents for his participation with these characterizations of the House and Senate bills: "President Obama has arrogantly ignored the wishes of the American people....again worked behind closed doors...another government takeover...job-killing mandates...Washington bureaucrats between you and your doctor...funding abortions...makes huge cuts in Medicare.' A man with an open mind.

John and the GOP team want to ignore a year's worth of effort, and several years of bipartisan effort which preceded it, and "hit the re-set button and start from scratch." So he posted on his Facebook page his "start from scratch" solutions to the problems in the system which have doubled health care costs for his constituents in the last 10 years: Tort reform, lawsuit limits, health savings accounts, portable family plans bought across state lines with a limited period of time in which plans must accept all applicants, and co-op purchasing.....Health savings accounts we have, other provisions are in the bill, and Minnesota has the second lowest malpractice premiums in the country without all his tort reform and lawsuit limits. The number of uninsured in Minnesota has doubled from 2007 to 2009 and thousands are being dropped from public insurance programs in the state each legislative session.

SLIT WRISTS - BLOOD OATHS - HEALTH REFORM
Ahead of last summer's famous "town hall meetings on health care," Minnesota Congress member Michelle Bachmann (R-6) suggested that her colleagues slit their wrists and take "a blood oath" to defeat whatever the House and Senate could agree to on health policy reform. There's no evidence that wrists were slit. But everyone in the Republican House and Senate obviously did the blood oath right about then.

Now, rumor has it that the only way to get health reform is for the House to approve the Senate bill and for the Senate to use its reconciliation authority to get 51 votes for amendments to the bill which will be agreed upon with House leadership in advance. Because House members don't trust the Senate to keep its word after the 25-day fiasco involving a Louisiana purchase, a Nebraska kick-back, and a Florida underwater land sale called Medicare Advantage preservation, a group of Democratic Senators are contemplating making oaths in blood to every wavering House Democrat that they will deliver on their promises.

FILIBUSTER - SENATE HOLDS - UNANIMOUS CONSENT - EARMARKS
It's amazing what seeming geniuses our founding fathers, and their mothers, were. Our constitution, the separation of powers and the bicameral Congress have allowed us to overcome obstacles that would have defeated any other peoples. I am not sure that the U.S. Senate as an institution has been tested before quite as much as it has been recently. Powerful leaders in both parties have always seemed to rise to the occasion in times of crisis to appeal to those who would use the safeguards built into the Senate to protect rights of a minority in the name of national rather than parochial or partisan interests.

The Republican minority in the Senate is a result of the way in which Republicans ran the country for years as reflected in the Senate elections of 2006 and 2008. The GOP partisans, however, have chosen a different interpretation. Somehow, the voters were wrong. President Bush was the problem (not Vice President Cheney). President Obama is a socialist and all Democrats are liberals. People are angry. We Republicans are people. We have a right to exercise the filibuster, the right to put holds on every presidential nominee who requires the consent of the Senate, the right to withhold unanimous consent for the Senate to do business. Because it's in "the national interest."

It is a leadership problem in the Senate and the Republican elected leaders no longer seem to be in charge. Senator Jim DeMint (R-SC) is in charge. Followed by GOP pollster Frank Luntz and his "sound bite" reactions to the majority, followed by Rush Limbaugh and Glenn Beck, followed by Roger Ailes and Fox News, Jim Dobson and the religious rights, and a horde of political wannabees.

THE STATUS QUO OR A SINGLE PAYER HEALTH SYSTEM
In April 2008, 40 veterans of the 1993-94 Clinton health reform effort - proponents, opponents and mainstreamers - came together for a weekend in Minnesota to advise the next president on how to get health policy reform passed into law. We didn't spend time on the policy side, but on how to deal with the environmental issues reformers must face in as complicated an issue as health care. Forty of us agreed on 10 recommendations we've dubbed "The Ten Commandments."

The first commandment was this: "The status quo is not acceptable. Doing nothing is not an option. The impact of health care costs on budget deficits, numbers of uninsured and underinsured, the unsustainable growth in public and private programs, impact on international competitiveness are just a few of the consequences of neglecting this issue.". . . To put an updated point on this: Right after members of the Senate returned to Washington from the President's Day Recess, a letter favoring a single-payer system was circulated by two and signed onto by a dozen. Within 24 hours. If this Congress cannot find agreement on expanding coverage and reducing costs this year, there will be a political backlash against continuing to do nothing…one favoring a single payer or Medicare for All approach. I feel it coming.

THE TIDE WILL TURN
If the Democrats in Congress can pass health reform legislation soon, you will begin to see some change in election politics. It's hard to believe that Senator Arlen Specter (D-PA) is now ahead of his Republican rival Pat Toomey by 49-42, but the Quinnipiac poll says he is. Americans are by nature optimistic. Hope will always beat anger, if someone gives us a cause. Congressional gridlock has given us the impression that both Republican and Democratic members of Congress have their own interests far ahead of ours. That makes us angry.

Hope: Where the president has been free to act without Congress, the nation seems to be making some progress. In particular, the war in Afghanistan, in which Obama is seen as deeply involved in strategy, has been having success. Presidential leadership on the domestic financial front seems to be paying off in much stronger markets, despite the power of industry lobbyists on an inept Congress. Free up the president to take the argument on health reform to the American people the way he took it to Congressional leaders last week, and attitudes will change.

by Jack Ohman

YOU CAN'T DO MALPRACTICE REFORM AND FIGHT AGAINST EVIDENCE-BASED MEDICINE (EBM)
Republicans and their M.D. allies want us to believe that health care costs can be reduced if doctors didn't practice so much unnecessary medicine. They call it "defensive medicine," but acknowledge that most docs do things to patients that don't need doing because the costs of doing so will be paid by unwitting patients and their insurance plans.

Malpractice reform, which must include capping punitive damages, is the price these docs want us to pay to get them to stop billing us for more medicine than we need. Newt Gingrich's Healthcare Transformation firm, abetted by something called the Jackson Group, both funded by doctors, is the latest to claim billions of dollars in useless, defensive medical services. GOP wants insurance rules left to the states, but wants the national government to decide how to end "defensive medicine."
Sponsors of the Senate health reform bill want to improve the quality of American medical care by reducing costly practices such as defensive medicine. They are also convinced much of this is "supply induced" medicine - practices dictated by over-supply of technology. Their answer is to "pay for performance" or "pay for outcomes" or pay for only medically necessary services. In other words, using evidence gathered over time from thousands of medical practices to promulgate guidelines for practice and provide docs access to the latest science. Along the lines of what is done in large multi-specialty and specialty medical groups in America today. The Republican docs don't believe in EBM. They don't want "government run health care," which they say EBM or P4P is. They want to be left alone, with lower medical liability premiums, and lower incentives for patients to question just how much medicine needs to be done.

HEY, MARTHA COAKLEY
Senator Scott Brown (R-MA) left MA Attorney General Martha Coakley to deal with health care reform in the state while he went to Washington to make sure it never happens. Massachusetts, we recall, did bipartisan health insurance reform which required insurers to cover every citizen in the state. As ex-governor Mitt Romney reminds us, the second half of the reform plan was the redesign of health care delivery to reduce the costs to those who get care in the state.

Last month, Attorney General Coakley released a report on the high cost of health care, pointing, among other things, to extensive evidence of anti-competitive behavior among health care providers. Huge price disparities that bear no relation to anything but market power, special pricing pacts between providers and between providers and insurance companies, most of them secret, and other forms of collusive behavior were pervasive. Coakley's report.

In case you think Massachusetts is an anomaly, these same collusive practices exist in nearly every state in this country. It's simply the way the medical industrial complex does business. Prices are nearly impossible to obtain because of confidentiality agreements among docs, hospitals, insurers and device companies, all of whom fear the impact of transparent pricing on what passes for market competition.

For example, a hospital allows cardiac and orthopedic medical specialists to charge what they want and the hospital will order devices from their specialists' "sweethearts" in the device industry at mark-ups the patients would choke on, for fear the doctors will take their business to a competitor hospital or go into business for themselves.

While most of today's Republican legislators think medical markets exist, Senators Chuck Grassley (R-IA) and Arlen Specter (D-PA) know they do not. Two years ago Chuck and Arlen introduced legislation requiring price transparency in medical devices. It's never come up for a vote even in what passes for major health reform.

ON THE SUBJECT OF MEDICAL COMPETITION
Writers and researchers on the subject of insurance reform continue to equate health insurance markets with the number of health insurance products from which consumers get to choose. The Coakley Report, for example, points out that insurers can't cut deals to reduce prices in markets dominated by one or two provider networks or health systems because prospective purchasers will insist on the insurer covering their doctor's network. In many big markets this is the case and it means medical prices are much beyond what they should be.

But there are exceptions in smaller states and in many mid-sized communities, where a dominant insurer, almost always a not-for-profit, has leveraged provider quality, safety and access improvement and cost containment. And care providers and insurance consumers are happy. Unfortunately, the same can't be said for Medicare as an insurer, which hasn't figured out a way to buy benefits and coverage through efficient local providers and insurers.

TAXING NONPROFITS
State governments are finding it impossible to raise adequate revenues to meet the needs that state and local governments have traditionally been called on to meet. There's no end in sight. And it's politically difficult to raise taxes from citizens. So an increasing number of states are turning to tax-exempt institutions who are enjoying the benefit of public services without paying taxes to offset the cost of the benefits.

This movement is serious. It has happened before. Elected officials question the "community benefit" being delivered by nonprofits in exchange for the tax exemptions. They should do so. This is particularly true with the proliferation of nonprofits for questionably charitable causes. It's also true for traditional institutions such as hospitals, nursing homes, schools and universities, and health insurance companies where for-profit, tax-paying institutions deliver the same or similar services.

Sen. Chuck Grassley (R-IA) hasn't been the first to question nonprofits about how they spend their "community benefit." I have raised this issue with hospitals in our Upper Midwest community who choose to use their exemption to overbuild specialty care, private rooms and competitive enterprises, rather than using the equivalent of their exemption to improve the health and the cost of health care in the community. There are notable exceptions, but still too many of the large nonprofits are loath to change.

70 FAT YEARS
In my Commentaries of late 2008 I spoke to the "New Economy" which was likely to result from the financial industry collapse and recession into which our country was sinking at that time. It seemed to me an appropriate time of crisis in which, as a nation, we assess how accustomed we'd all become to "having without paying" for so much our economy was capable of producing.

This includes perks such as minimum downpayment housing with interest-only mortgages; health insurance that comes with the job and is guaranteed for life - after retirement from the job; home-ownership as inflation-financed savings account; "sky's the limit" medical innovation made possible by a tax-payer funded national research budget that doubled every year and doubled family medical costs every 10 years. The list is long.

Frankly, I expected Senator Barack Obama, were he elected to be our president, to describe this new economy in terms that would allow us to see the transition across all Americans and their institutions. So that the policies necessary to prepare us to equitably share the loss of expectations and the change of our economic realities were equally shared as well.

President Obama, equipped with a Democratic congressional majority, has done a great deal to lessen the consequences of what once looked like a Second Great Depression. He is yet to explain how we might all contribute to a much more affordable economy for our children's children. Instead he's appointed a fiscal belt-tightening commission to deal with 70 years of entitlement programming that's eating our seed corn.

HOW MINNESOTANS REALLY THINK ABOUT ALL THIS: SEVEN LEAN YEARS
Thomas L. Friedman is a product of St. Louis Park, MN, public schools, like our new U.S. Senator Al Franken. Friedman's journalistic trap line is the world, but his judgment is that of a Minnesotan. The Fat Lady Has Sung is his 2-21-10 opinion piece in the New York Times and a "must read" in your home and the White House. "Our parents truly were The Great Generation. We, alas, in too many ways, have been what the writer Kurt Anderson called 'The Grasshopper Generation,' eating through the prosperity that was bequeathed to us like hungry locusts."

The task of government and leadership today is to trim, to fire, or to downsize services, programs or personnel. My friends call it "redesign." Conservatives call it tax less and spend even less. "What baffles me about Mr. Obama," says Friedman, "is how a politician who speaks so well, and is trying to do so many worthy things, can't come up with a clear, simple, repeatable narrative to explain his politics - when it is so obvious. . . The president needs to persuade the country to invest in the future and pay for the past - and past profligacy - all at the same time," says Friedman. To that I can only say, amen.

SHARED SACRIFICE BEATS AN ENTITLEMENT COMMISSION ANY DAY
As we watched the health care policy reform debate evolve, we saw every kind of chance to tighten our belts just a notch so those without belts could have one. The administration and the majority in Congress took a pass on every one of them - ostensibly to get a health insurance reform bill passed and signed. The insurance industry passed because some might lose business or their franchises to do business. Hospitals and doctors passed because they seem generically incapable of agreeing on anything other than malpractice reform and "control of health care by families and doctors."

Drug, device and diagnostic companies passed because they have a franchise on product pricing and utilization which they refuse to surrender to transparency for the public that finances their research and their profits. Labor unions and public employers passed because they, too, are incapable of asking retired employees to make any financial sacrifices so that future generations of employees can enjoy affordable jobs.

My Senate classmate Al Simpson (R-WY) was famous in the Senate for taking on impossible tasks. Immigration reform he worked on forever. He took on the AARP and its reluctance to do policy equity with a generation of Americans yet unborn. The military veterans lobby of "pot bellied bar stool warmers who never set foot outside the USA or sighted a weapon on a hostile."

Al's taking on another "mission impossible" with this entitlement commission which can't make a decision without eight Republican appointees agreeing. The president needs to take Tom Friedman's advice and give voice to "shared sacrifice" as an American value that hasn't been tested for 70 years. He can't wait much longer to do it either.

T-PAW MEETS THE CONSERVATIVE POLITICAL ACTION COMMITTEE (CPAC)
Governor Tim Pawlenty (R-MN) went to Washington for a meeting of the National Republican Governors Association chaired by his friend Haley Barbour (R-MS) which dealt a lot with state-based health policy and delivery reform. Tim also spoke to the mainline conservative organization in the country - CPAC - which represents what's left of the old Goldwater/Buckley/Reagan conservative Republican forces. It's reported that in a straw-poll presidential preference ballot, Tim received 6% support to Sarah Palin's 7%. Former MA Governor Mitt Romney polled 22% and Congressman Ron Paul 30%. Neither Palin nor Paul showed up in person.

The Minnesota governor did make headlines between the CPAC conference and the National Governors meeting. He hosted a "Late Night with TPaw" event at Fritz Brogan's Gin and Tonic tavern in D.C.'s tony Glover Park. Little more than a long bar and dance floor, Gin and Tonic usually has "a young, cute, preppy crowd" lined up around the block. A $50 charge for the TPaw event, which is hosted by Minnesota Congressmembers John Kline, Erik Paulsen and Michelle Bachmann, plus a bunch of GOP lobbyists, attracted lots of all ages.

GOD IS IN CONTROL
Our governor may not have helped his CPAC cause by starting out his speech by stating his conservative principles begin with his belief "that God is in control of our lives." That may not have gone over well at CPAC because most of these old-timers in the movement believe they are. Pawlenty is right when he says that Americans have lost trust in those who hold positions of leadership in our country. But not when he claims God controls events and mankind's collective and individual response.

On health care, the question and answer to our governor Pawlenty took some liberty with Minnesota history as well. In an eight-page interview with Mark Warren in Esquire Magazine, Tim was asked repeatedly "what is a Republican now, aside from merely opposing the president?" In response he claimed President Obama tripled the national debt in one year and Bush overstated the danger to the economy from a failing financial system, and that he would have cut taxes and let the banks, the American auto industry and homebuilding go belly-up.

On health care, the answer for our governor is simple and right out of the national Republican playbook: "Do you want the government taking the thing over, or you want to run that with your doctor and your family?" He says governors used to come up with great ideas - before 1994 and the Contract for America. "Ideas on education, tax policy, welfare reform and the like." To sharpen his point, you can read the entire interview without finding a Pawlenty "idea" that's become practice in Minnesota - other than reducing spending and taxes to balance the state budget. In eight years of trying.

Playing with history: Our governor says that we are one of the most liberal states in the country. He cites Senators McCarthy, Humphrey, Mondale, Wellstone and Franken as examples, and then unloads on his Republican predecessors as governor. Most of the Republicans who have succeeded here, according to Tim, have been mostly moderate, Democrat lite, citing an average 21% a biennium increase in Minnesota's budget compared to his 4%. "It's the history, the tradition, and the culture here. I am one who has confronted that."

WHO IS THE MOST CONSERVATIVE…(CPAC)
We know it's not our Governor Tim Pawlenty, although he is working on it. Nor is it Alaska's Sarah Palin. According to a poll taken for and at the Conservative Political Action Committee (CPAC) meeting in D.C. this month it is Senator James DeMint (R-SC), followed closely by Rush Limbaugh and Glenn Beck.

THE REAL MINNESOTA
Minnesota is a good example of a progressive state. Our legislators were conservatives and liberals until party designation in 1970. In fact, we had a conservative Senate in MN from statehood in 1858 until 1971. Most of our U.S. Senators were Republicans until Hubert H. Humphrey maneuvered Republican Governor Luther Youngdahl into a federal judgeship and assured his own re-election. Our DFLers and GOP/IRers were progressive. They were problem solvers, like our businesses and our unions.

In my political infancy I served with moderate Republican Governor Harold LeVander, who fought a 2/3 conservative/Republican legislature on the issue of creating a state sales tax which he opposed. The Republicans won. In my prime I served as an executive in a multinational business headed by another moderate Governor Elmer L. Andersen who, to this day, is revered as one of, if not the, greatest figure in MN history.

I served with and ran for Governor against Republican Al Quie, who had the misfortune to become Governor in the 1978 election that sent me to the Senate. Quie governed through the high inflation, high interest rate, energy supply crisis period when President Ronald Reagan fought a recession by cutting spending and taxes. Quie soldiered through, never once laying off the problems which beset the people of his state on the president of the United States. Even though unemployment in our state was 11% on the day in 1982 he could have run for re-election, but chose not to.

THE NEW HAROLD STASSEN
Republicans have a fair number of bright young national stars, some of whom are positioned to become candidates for president in 2012. Governor Mitch Daniels of Indiana shows lots of promise. But there must always be some oldster who has the "better ideas" from which the younger can learn. That title belongs to former House Speaker Newt Gingrich, the prolific idea man, book publisher, and health care transformer. Newt can do the contrast with Democrats without the rant of Limbaugh-Beck, and no one takes seriously his huge appetite to be "the man" who makes things happen.

JIM BUNNING WAS A GREAT PITCHER
But on this Democrats and Republicans agree. He is an impossibly inept U.S. Senator. Always seems to be about 10 years behind the curve. The latest: His continued objection to giving the Senate unanimous consent to proceed to the jobs bill, which the House passed nearly unanimously. Mitch McConnell and Republican Senators had to force Jim to agree to not running for a third term in the Senate from Kentucky. Now it's obvious to everyone why they did it.

TREKKING WITH WOLVES
Story by Greg Breining in the New York Times on snowshoeing in the Boundary Water Canoe Area, Minnesota.

QUOTABLES

"The idea that politics is paralyzed is a thumb sucker for Washington cocktail parties."... Rahm Emanuel, chief of staff, President Obama

"You can lead a man to Congress, but you can't make him think."... Milton Berle - as quoted by Senator Evan Bayh (D-IN) in New York Times op ed 2-21

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