Twin Cities Public Television tells the story of how this “Slavery by Another Name“ was perpetuated until early in WW II when the federal government finally stopped practices like peonage and rent-a-convict and ended the practice of using usurious debt to imprison blacks and chain-gangs to compel them to build the roads and highways of the south.  TPT executive producer Catherine Allan did a masterful job, with help from University of Virginia historian Douglas Blackmon,  in producing a one-hour masterpiece.  

The film premiered to acclaim at Sundance and across the country February 13th.  I must say it is a shocker to know there is a large part of this nation which, despite laws to the contrary to which it has been forced to comply, still has trouble recognizing the destructive force of prejudice on America and American families.  Sidelight:  Catherine “Kitty” Allan is our neighbor in Crocus Hill/St. Paul and was a grade school classmate of my wife Susan at Grant School in San Francisco.

On February 14th, the HBO presentation “The Loving Story” adds another dimension to our understanding of how hard it is for some Americans to change.  In 1967 the U.S. Supreme Court banned laws against inter-racial marriage which existed in 16 states.  By a unanimous decision in the case of Loving v. Virginia, the Court declared “marriage one of the basic civil rights of man, fundamental to our very existence and survival.” 

Chief Justice Earl Warren wrote, “to deny this fundamental freedom on so unsupportable a basis as the racial classification embodied in these statutes…which are so directly subversive of the principal of equality at the heart of the 14th Amendment, is surely to deprive all the State’s citizens of liberty without due process of law.”  The Loving Story is about Richard Loving and Mildred Jeter and this is their story and that of hundreds of thousands of young Americans who had to break the law so that millions of Americans of every race could raise up a more understanding and tolerant America.

To read more about this couple, read David Wiegand’s Feb. 14 article from the San Francisco Chronicle.

The difference: President Obama of necessity must stand on his record which probably will include the deflation of expectations which many of us experienced. Governor Romney, on the other hand, must stand on the record of the national Republican party, the people it sent to Congress in 2010, the political contortions of presidential candidates like Romney, Gingrich and Pawlenty, and the polarizing views of its right-wing supporters. That is a challenge I doubt Mitt Romney is capable of overcoming in a nation which knows that the toughest decisions must come from consensus not from contentiousness.

…So did President Obama describe the state of the union facing Americans as they recover from the near economic disaster that’s called the great recession, and prepare to decide whom to trust with the reins of government for the next four years. It was a well-crafted and effectively delivered speech. Partisans on both sides of the congressional aisle agree it was a tone-setting 2012 campaign speech. Over the next nine months, you and I will have to decide whether the president’s policy reform agenda is worthy of our support. Or whether we are willing to trust Republicans like Mitt Romney and Newt Gingrich and a party with a very different policy record to which they promise to return.

I am a veteran of President Reagan’s Republican approach to nation-building. With very few exceptions, the foundations for policy change in domestic and foreign policy were laid by presidential leadership and the congressional leader response of both parties. Efforts to strengthen the economy and build the defense system’s capacity to end the bi-polar conflict with the Soviet Union were bi-partisan. Government programs were cut, but government spending increased. Taxes were cut, taxes were raised, and income tax policy was reformed. Entitlement programs like Social Security were saved by increasing taxes and the age of eligibility. Medicare spending was reduced by hospital price regulation and privatization and the benefit structure was reformed.

The Republican Vow To Make Barack Obama a One-Term President

As the president pointed out in his state of the union speech, he inherited two wars he didn’t support and an economic collapse that had already cost Americans 4 million jobs before he took office, and another 4 million before he and his congressional majority could staunch the flow.  Without any support from congressional Republicans whose Senate leader famously swore that “our principal goal is to make Barack Obama a one-term president.”

Everything the Republicans have done since seems dedicated to that cause. Even though you have overwhelmingly voiced your disapproval of the tone-deaf polarization in Washington, the Republican presidential primary debates are all the evidence you need that bi-partisanship works only on their terms. Congressman Brad Sherman (R-CA) says it well: “We’re within nine and a half months of the country telling us whether to honor the instructions they gave us in 2008 or the ones they gave us in 2010.”

A Rising Tide Lifts All Boats

A popular description from the Reagan years of how a healthy economy, not government, can make everyone better off.  But the Reagan experience reminds us, as President Obama did this week, that changing the role of government is more important to changing the economy than giving free rein, tax cuts, and deregulation to businesses that are unwilling to play by the same rules as everyone else.

We Americans are all in this together. We deserve to share in the success of working together toward shared goals. But how do we set those goals in a political system divided by partisans and ideologues and wealthy Super PACs? Someone has to show the way. It’s called “leadership.” In America, that task is the president’s because he’s elected to represent the country, not the state or regional interests of a federal system of representation. To represent America as a united country in the world of nations.

The party leaders of the Senate and the House have the responsibility for showing us how best to achieve these national goals.  That’s how we built the capacity during the Reagan and Bush 41 years for the economic recovery of the Clinton years. Newt Gingrich deserves no special credit for this achievement. Until his ascendancy to power in the House,  it was bi-partisan congressional policy reform in health, energy, the environment, trade, tax and entitlement policy – many of the policies about which President Obama spoke this week – that did the nation-building the country needed.

The Unique Case of Health Policy Reform – Obamacare

Analysts are asking why, in a state of the union speech loaded with policy reform designed to restore a uniquely American economy, was there no mention of what supporters and detractors have agreed to call Obamacare? Economists can agree that a national economy which commits twice as much to paying for worker and retiree health care as all of its competitors, without a value return, cannot compete in tomorrow’s global marketplace.

The national health goals and the financing, payment and accountability policies in Obamacare were designed to change that. They were agreed on and written over the years since the failure of Clinton reform by Republicans and Democrats in Congress. It was bi-partisan policy, supported by many leaders of the health business and professions. 

The environment in which Obamacare became law in 2010 cast doubt on its credibility. There were no bi-partisan Republicans. Since August 2009, Republicans have dedicated themselves to making Obamacare a pejorative by which to defeat real health care reform and the president who made the tough “now or never” decision.

The rationale for the new law’s policy reforms can be found in health care leadership, in health care and medical system professionals. It can be found in the leadership of some of our largest health insurance companies who know from experience what it takes to improve health and reduce cost.  Not a one of these leaders wants to be made a political pawn in a senseless battle in the campaign for the presidency and control of the congress. So you don’t hear from them.

The mystery, from the date of passage in March 2010, is why don’t we hear from the champion of change we can believe in? I don’t know the answer to that – and nobody I know who has to work hard to implement the law, and call on others in states across the country to help do so, knows the answer. That, in itself, casts doubt on the value of what could be a priceless piece of bi-partisan policy.

A Republican President Will Not Repeal Obamacare . . . Sen Norm Coleman (R-MN)

In a Sunday television interview, former MN Senator and close Romney adviser Norm Coleman said a Republican president “will not repeal the new law in its entirety.” Some of it will have to be replaced as too costly he said, but repeal is impractical. The Romney campaign immediately announced that Romney is totally committed to repeal. Or, as Romney said in the Florida debate: “What I will do if I’m president, I will repeal Obamacare and return to states the authority and the rights to craft their own programs to care for their poor.”

The Real Deal – Or – Just Another Newt

Real Republicans are scratching their heads over the new Republican voters. People who helped them “shellack” Democrats across the country in 2010 have now spent six months analyzing presidential candidates. And their choice may not be the real Republicans’ candidate at all. It might be “Mr. Speaker” – the man from Georgia who has been a Republican a lot longer than Mitt Romney and is clearly not the choice of those who know him best from his 33 years in Washington, D.C.

Is former House Speaker Newt Gingrich for real as a presidential candidate? You betcha. And he’s doing it with a demonstrated lack of prudent judgment and moral character that would disqualify him for consideration in any election but this. So he’s got to be good. Why real? Because we have a different Republican audience this year. Newt can read an audience like no politician in America.  He has a chameleon’s skill at marketing himself to the moment. Drawing on a mind for facts and figures, an imagination that translates what you are saying into what he wants you to hear, and an ego that doesn’t register error. Michael Gerson in the Washington Post hits Newt’s nail on the head.

All Newt needed was a chance to contrast himself with the other candidates. That didn’t come until the field narrowed and the primary voting began. After South Carolina, it’s simply Newt v. Mitt.  The media heat and the need for money is so strong right now, that Santorum must follow Perry out the back door leaving Ron Paul to play the Republican Ralph Nader role. That’s the way the campaign to unseat President Obama will go – on into the spring.

What Newt’s Got That Romney Does Not                   

Newt’s a hot speaker. Both of them are in the $40,000 per speech category (compared to Bill Clinton’s $100,000). But Mitt doesn’t need the money and doesn’t seem to think it’s all that important. Here’s what one audience member at a trade association meeting says of Newt: “He was great. Everyone had fun. He gave us lots of time.” What more can a DC-based trade association ask for in a speaker that he be a crowd-pleaser?

Newt ‘s connected. This is the “lobbyist” thing they’re debating. Every lobbyist in D.C. knows Newt gets called on to help out his GOP leader successors when they’re in a pinch. Like when he was called in to lecture a caucus of conservative GOP House members to support the big-spending Medicare Prescription Drug bill in 2003 and came out having made a sale contingent on adding Health Savings Accounts – which certain of Newt’s Transformation Center clients wanted. Ask yourself why health care business interests would pay anyone $55 million over 2001-10 “to visit with a really important guy who really knows a lot,” quoting the Newt himself. 

Plus, like a number of other former members who do not register as lobbyists, he is active in raising money for, contributing to and talking policy with elected reps and candidates.

Newt ’s bi-partisan. Actually, he’s not in fact, but that makes him an attractive buy for groups who can get him to co-endorse with Nancy Pelosi, Al  Sharpton or Hillary Clinton.

Newt’s his own nonprofit private equity firm. Starting with the Progress and Freedom Foundation he created on his ascendancy to the speakership in 1995, Newt has made it a practice to take advantage of the perception that D.C. interest groups have that helping power will also help their interests.

Newt’s opinions on health care get considered. Lobbyists for organizations with membership in Newt’s Health Care Transformation Center use position papers, crafted by the center with attribution to Newt, to influence members and people like me who respect Newt’s knowledge of health policy.

Presidential candidate Rick Santorum says of his buddy Newt: “He has grandiose ideas, incoherent thoughts and no discipline.” Will Rick last long enough to help Romney prove that?

Is There an Alternative to Mitt V. Newt?

Governor Mitch Daniels of Indiana proved once again in the Republican response to the president this week that he is. He always has been, but his family was more important a year ago, and must be today as well. Former Governor Jeb Bush of Florida has it in him to run for president. But he’s ineligible this time because his brother is being blamed for a lot of the spending problems and the financial industry problems that anger the Republican right. Former MN Governor Tim Pawlenty is solid for Romney and N.J. Governor Chris Christie is anxiously reading the GOP national base right now and preferring N.J.

Who Are These Republican Voters ?

Theda Skocpol is a chaired professor of government and sociology at Harvard who has long written on health policy. She recently teamed with a Ph.D candidate at Harvard named Vanessa Williamson to produce a most readable book on the Tea Party called The Remaking of Republican Conservatism.

In a nutshell, their research shows that these “new” Republican voters, like the Utahans who threw conservative Republican U.S. Senator Bob Bennett out of office and threaten to do the same to Senator Orrin Hatch,  believe that Barack Obama is the face of a future they fear. They are predominantly older, white, educated, well-off, evangelical Christian Americans who believe that government  income re-distribution policies favor people not at all like them. And that the growing sum of our national dependence on undeserved income substitution is endangering the economic futures of Americans like them and their children.

Exit polling of South Carolina primary voters also sums up why it is that a Newt Gingrich stands a chance to be their standard bearer. Just about half the voters said their choice for president on the Republican ticket is the person best able “to beat Obama.” In second and third place at 23% and 19% are experience and moral character. Can you believe these people capable of understanding what it takes to be president? Can you believe that Mitt Romney’s going to be able to elevate experience and character enough to win the endorsement battle?

David Brooks opines in the New York Times: “I wonder if the Republican Party has become the receding roar of white America as it pines for a way of life that will never return.”

The Republican Party ‘Shade Tree’ Problem

A friend likens the Republican voter base of 2010-12, as reflected in the Republican House of Representatives and in every one of the GOP candidates for president this year, to a shade tree. This Republican tree casts its shadow over everyone who carries a Republican label to the polls in 2012. 

That may be good in the old confederacy and the mountain west, but not in the states that President Obama is likely to need most to nail down the Electoral College vote. As of today, he has at least 240 electoral votes; enough to win. Republicans can get the demographic edge by strengthening their political edge. They’re not doing a very good job of that right now.

How Much Does It Really Matter?

In 2012, Republican leaders and Republican  voters  and their billionaire Super PACs will get just what they’ve been asking for with their polarizing “party of NO attitude” nationally and in states like Minnesota. The message of the first Florida debate and the primary is simple: Mitt Romney can’t take it to Barack Obama, and Newt Gingrich is much too complicated and unpredictable to inspire the confidence we need in our president. The rest of Florida, and the rest of the country, will begin to focus on what we might expect from President Obama in 2013. And how this election experience affects both parties in the future.

Former Wyoming Republican Senator and classmate Alan Simpson of Bowles-Simpson debt-reduction commission fame says President Obama can credibly argue that he sought a balanced plan of spending cuts and tax increases, while Congressional Republicans would not. Simpson believes if and when Obama is re-elected, Republicans “will realize they spent four years in one noble cause, which was to defeat him. And they didn’t, which makes them easier to negotiate with in a second term.”

Steve Bell, long-time budget adviser to former Sen. Pete Domenici (R-NM) says that “if you really look at the issue of fiscal restraint and deficit reduction, the president has been much more in the center.” Bell argues that Republican behavior on fiscal issues is making the case for the president in this campaign.

Readings in Contemporary Policy And Politics

My holiday gifts included the following:  Buckley by Roger Williams University Law Professor Carl T. Bogus. For an old-fashioned conservative like me, the book is an insightful journey through contemporary American conservative thinking/politics and its foundations and expressions (as in current Republican politics).  Tom Brokaw’s The Time of our Lives reminds us why polarizing politics is for real, but isn’t really who we are. It’s “our moral muscles, our service muscles, and our sacrifice muscles that we need to exercise,” according to Brokaw.

Worried about the impact of campaign politics on federal spending and the national debt? While we concern ourselves with entitlement reform, what do we do to reform our entitlement attitude toward national security spending?  Top Secret: The Rise of the New American Security State by award-winning Washington Post reporters Dana Priest and William Arkin is a well-researched analysis of our national reaction to 9-11-01. It also answers the question: Why is Washington, D.C., the fastest growing city in America?

With all that investment in security, there is little in improving executive decision-making. Blink of an Eye, by my former Senate colleague Bill Cohen, is “a gripping tale of intrigue” according to Cohen’s former boss, Pres. Bill Clinton. From a true insider’s view of presidential decision-making, Cohen takes us to the edge of a nuclear war aimed at Iran with a believable surprise ending. And if you want more, there is The Increment by David Ignatius, a novel of the Iran War built on the foundations of the Iraq War by one of the best national security reporters in the business.

Presenters are John Carr, the Executive Director for Peace, Justice, and Human Development at the U.S. Council of Catholic Bishops, whose views on behalf of Catholic Bishops on the law’s implications for abortion, contraception and others nearly derailed passage of the law in 2010. And Bob Kennedy, who is the Chair of the Department of Catholic Studies at the University of St. Thomas and has written on professional ethics and the economic dimension of the Catholic social tradition. Moderator is former U.S. Senator (R-MN) David Durenberger, Senior Health Policy Fellow and NIHP Chair at the university, who supports the law and its implementation.

Learn more about the program.

Former Governor Mitt Romney will not find being the party’s candidate for president an easy task unless the power of establishment money and endorsements (John McCain being the latest), can swing convention delegates next August. If Romney is the candidate, he appears to lack the emotional capacity to make the case against an incumbent president. All that money can buy negative messaging, but it can’t change the messenger.

Former Senator Rick Santorum has the authenticity people look for in leadership, but he has always demonstrated a rigidness in his beliefs about the role of government that will not serve him well in a general election campaign. Santorum’s late-night speech in Iowa was as impressive as anything coming out of the year-long campaign.

Former House Speaker Newt Gingrich is now angry with the national Republican establishment which he and his “contract with America” colleagues created in the years since 1995. It’s the single issue, special interest, money-as-influence establishment – not his own history of transformational histrionics – that he believes knocked him off his primary perch.

Former Congressman Ron Paul and his stand on national security policy will become less convincing as the party primaries march through the bellicose South and at some point Senator Rand Paul (R-KY) tells dad “enough already.”

Governor Rick Perry heads back to his day job in Texas before heading to South Carolina and Florida and Congresswoman Michele Bachmann heads back to hers in Minnesota’s 6th District. Former Governor Jon Huntsman gets the message in Romney’s New England, and Herman Cain, well, rebuilds bridges.

President Barack Obama benefits from the GOP leadership ambivalence as he ramps up the decisions that only a president, faced with a do-nothing-he-asks Congress, must make. While the need for a decisive president becomes more obvious each day that the news from around the world tests the frail nature of autocratic leadership and the promises of democratic institutions.

Republicans have designed the 2012 campaign around the need for authentic leadership for a better America. The primary rhetoric focuses too much on their own candidates to the point they seem to be talking to themselves rather than the country. And failing to define just what a vote for the Republican presidential candidate can mean for the average American.

For the last four weeks, many of us have been in an Advent mode, waiting on the fulfillment of the expectations of an ancient people.  A fulfillment symbolized by the birth of a faith, hope charity, and forgiveness which for 2,000 years has motivated our optimism about the meaning and purpose of life. In my little public service, policy and politics realm, it’s getting more difficult to distinguish my faith from the religion, the policy and the politics claimed by many who share it. That, however, is a subject for another time – perhaps 2012, which I face with perhaps impractical optimism. It will be a year in which I plan to spend some time talking about leadership.

So let’s start with that – where we first met Barack Obama – and now meet Ron Wyden and Paul Ryan

Many of us will remember our introduction to State Senator (D-IL) Barack Obama as a keynoter at the 2004 Democratic National Convention. That speech impressed a lot of people who had been around before the current cultural divide in this country which makes diversity not a key to American  exceptionalism, but a part of the polarization of our social, communal and political life. This polarization has had a sponsor in the Republican party and in right-wing media since U.S. Senator Barack Obama became a presidential candidate of his party.

Republicans at every level of government in the 50 states across this country have one thing in common:  Their objection to President Obama’s health care policies as reflected in the new reform law called Obamacare. So it’s big news when one of the champions of the Republican “Repeal and Replace Obamacare” movement joins with a senator who helped pass it with a plan to reform the biggest of all health programs – Medicare. Read more about Sen. Ron Wyden (D-OR) and Paul Ryan (R-WI) on my blog.

Back To The Future Health Policy

Before there was a law with a mandate that everyone own health insurance, there were 50 state laws mandating that every insurance plan offered for sale in the state contain dozens of specified medical services. Each of these mandates had a medical sponsor in the profession that benefitted from the technology or procedure. And a patient group sponsor that helped them with the politics. The cost of these plans increased to the point where most employers would “self-insure” against employee health care costs to avoid the mandated benefits.

The ACA, or Obamacare, set out to create national rules by which all insurance companies would compete for bearing some share of the risk of insuring most all Americans and qualifying for the public subsidy that goes with it. The final law settled for something less than national rules, but did require an evidence-based “essential health benefit” in insurance plans to qualify for subsidized access to Health Insurance Exchanges. The medical industry quickly geared up to assure that each of its many services be included as “essential health benefits.” The Chamber of Commerce countered by saying “affordability and flexibility” were essential in plan benefits.

HHS recently decided to allow states to select from among plans already operating within their state, “essential benefits that best meet the needs of state residents.” Any plan selected must include preventive care, emergency services, maternity care, hospital and physician services, and prescription drugs. In the future, states will find out what limits on cost-sharing HHS will allow.  So back goes the lobbying to the states. The critical element of any individual mandate’s costs, to both consumers and taxpayers, will be decided with no one happy as a result.

A December 21 article in the New York Times takes a look at President Obama’s approach to health law in the states.

Young Guns Shoot Down Senate GOP Leadership

The new Republican House in Washington ended its first year in much the same way the Minnesota Senate ended its first year in the majority, and the GOP presidential primary campaign entered the caucus/election season: With falling poll numbers, no defining policy goals and smiling Democrats. No less an authority on conservative politics than the editors of the Wall Street Journal claim that “Republicans are drowning out victory in the sounds of their circular firing squad.” Speaker Boehner had disagreements also among the “young guns,” with Majority Leader Eric Cantor (R-VA) and Whip Kevin McCarthy (R-CA) favoring a tax holiday for corporations added to the President Obama payroll tax extension and the speaker opposing it as bad politics.

Mitch McConnell Has Survived A Lot

The Republican leader of the Senate was the implied victim of the House Republican Christmas Eve rebellion on the payroll tax extender. On the assumption he misread Boehner/Cantor et al in the House. I’ve known Mitch McConnell for 27 years in the Senate and before that as county executive in Louisville, KY. Mitch McConnell is a master of politics and does not make mistakes like the House Young Guns have been making in reading their own freshman class. 

The first nine months or so of the Obama presidency, following on the last two years of the Bush presidency, were hard on him. But he recovered to set a goal of making the former a one-termer, dealing with his Jim DeMint extreme right, freshmen Tea-partiers, moderates (2), bi-partisan entitlement reformers, and sensible conservatives. He’s been able to anticipate Democratic leader Harry Reid’s tactics, thinks he can now read the Obama White House like a book, and can muster filibuster votes with ease and a majority of Republicans for emergency room tactics like the current two-month tax cut extension.

The Minnesota Senate is Another Story

Minnesota conservatives controlled the MN State Senate every year from the state’s founding in 1858 through 1970. Since then, it’s been in the minority much more than the majority. Until the 2010 electorate sent 22 new Republicans to St. Paul – more than were there when they arrived. They elected Amy Koch the first woman majority leader in history, an office from which she resigned after just a year and, after 24 hours of speculation, her male assistant leaders claimed to have pressured her resignation because of allegations of inappropriate relationships with a male staffer.

They thereupon sent Cal Ludeman, the Secretary of the Senate, to a suburban restaurant to fire one Michael Brodkorb, the MN Republican party vice chair and tough, bright young gun himself, who had been sent to the Senate to make sure the new majority there and in the House, hewed the party line against spending, taxes, government, and newly-elected Governor Mark Dayton (D). Whether Brodkorb abused his power and set off complaints from other staffers no one knows because no one is talking. Except the assistant Senate leaders who are busy lining up votes to replace Sen. Koch.

Did The U.S. Senate Botch The Berwick Confirmation At CMS?

Regular readers of this commentary know I believe it did. Especially the Senate Finance Committee Democratic majority which has jurisdiction over Medicare and Medicaid – the business of CMS –which never called the hearing necessary to get the confirmation done.  Senator Tom Harkin (D-IA), chair of the other health policy committee, Senate Health, Education, Labor and Pensions (HELP), said as much to The Hill newspaper.  “If it had been in my committee, he would have had a hearing.  I would have let the Republicans make fools of themselves and I would have shown what credentials he has. And then let’s have a vote.”

Finance Committee chair, Sen. Max Baucus (D-MT) says “there never were 60 votes for Berwick’s confirmation,” citing a letter signed by 42 Republican Senators objecting to Berwick’s views on health care which they interpreted as suggesting he favored rationing. With every major hospital and physician association supporting Berwick, it was simply a matter of time before the kind of Republicans that could buck the party tide on entitlement funding would have had to relent on Berwick. The Democratic concern about the path chosen by Finance is that it is the same tactic that killed off former Democratic leader Sen. Tom Daschle’s chance to be HHS Secretary; and it has become too typical of the Obama administration approach to the party of NO.

Dodging The Doc Fix

The Republican opposition to Obamacare has complicated bipartisan efforts to replace the Medicare Part B physician payment policy. Since 1997, physician fees for service increases have been limited to the amount of the CPI increase which is usually less than medical CPI. The difference between actual service volume and the inflation adjuster (SGR) has been growing substantially and Congress has always made up for it with pay increases. Until the last couple years. The total cost of “making up” for what docs claim to be their due is currently $38 billion over two years; and $300 billion over the next ten years.  The House vote this week means docs see a 27.1% pay cut come January 1 (or Jan 18, 2012, if HHS delays the cut).  Mad docs? You betcha. At whom? That’s the 2012 $64 question.

Is Obama Undermining Social Security With His Payroll Tax Reduction?

Both Republican and Democratic members of Congress expressed concern about the impact on Social Security stability of current reductions in the 12.4% payroll tax. The political assumption is that the longer the tax cut is prolonged, the more difficult it is for members of Congress to restore it. Experts say the greater problem for the program is the fact that 10,000 Americans a day are reaching 65 and the number will only increase. Bob Reischauer, former CBO chief and head of the Urban Institute and a public trustee for Social Security says, “The nightmare I have is that when it comes time to raise the tax back up to 6.2% (for individuals), conservatives are going to propose that these two percentage points of payroll tax get devoted to individual retirement accounts. That will precipitate a huge fight and could change Social Security in a fundamental way.”

Other Health Policy News

Three of the major health care systems in the Minneapolis area are among 32 chosen to be pioneer accountable care organizations by CMS: Allina, Fairview-UMN, and Park Nicollet. Mayo chose not to apply, and HealthPartners has been the kind of health system that the ACO is modeled on since 1957!  The Boston area has similar ACO coverage, as does southeastern Michigan. Making it possible to see much quicker change from hospital/clinic systems that do health care, to genuine health systems designed to enhance the health of members.

Indiana and Louisiana’s Republican Governors were turned down by HHS in their efforts to waive the ACA medical loss ratio requirement that 80 to 85% of insurance premiums must go to health care services. Because the governors are ideologically wed to high deductible individual indemnity insurance plans who can’t get their MLRs down unless they get a much larger share of the market. Another blow to insurance broker efforts to keep a percentage of every policy sold for a service which the new law basically considers non-essential anymore.

Medical technology companies have gradually become very large international sales and marketing companies.  During challenging times they lay off some pretty good sales reps. The news in health care today is that they are all finding jobs selling hospital, specialty hospital, cosmetic surgery, and clinic services in increasingly competitive medical markets. Says Paul Ginsburg, president of the Center for Studying Health System Change, “When you look at the health system, this is a waste of resources.  It’s a zero sum game.”

In an important breakthrough in accessing performance data on docs, the Medicare data base will become available to about 25 national organizations composed of doctors, health insurers, business groups, consumers and governments that are dedicated to improving health care at the local level.

For more than the 33 years, since I was elected to the U.S. Senate, members of Congress have been working to bend the national health care cost curve. Mainly by changing how the Medicare program pays health care providers. In 1993, President Clinton focused not just on Medicare, but sought to change other policies to reduce the impact of other cost drivers in health care. Part of his effort to expand insurance coverage to every American. He was defeated in this effort by Republicans, led principally by House GOP leader Newt Gingrich, who went on to become Speaker when Republicans won the House in the 1994 election.

Democrats in Congress and President Obama were more successful in 2010. They passed the Affordable Care Act (ACA) which, besides targeting the cost drivers in health care and accountability in Medicare payment policy, expanded coverage and set important national policy goals. Healthy people, health communities, and a reformed health care payment and delivery system. As they did in 1993, Republicans opposed the ACA and have unanimously sworn to repeal and replace it should they win the Presidency in 2012.

So it’s news that a House Republican and Senate Democrat who are both health policy aficionados, have agreed to work jointly on a plan to privatize the Medicare program. And to limit the amount of federal spending on Medicare, the health insurance program on which 46 million aged and disabled Americans have come to depend. Because they have paid into it all their working lives.

Proposals to privatize Medicare are not new. Medicare piloted them successfully with risk-bearing HMOs starting in 1985. In regions of the country with integrated care systems the HMO was successful in reducing Medicare spending substantially –from 15% to 17% in Minneapolis-St. Paul and Rochester in just two years – and in bending the cost curve for non-Medicare patients as well.

Unfortunately, most of the country didn’t know what an HMO was. Doctors, hospitals, and insurers resisted getting to know them because they were doing just fine under traditional Medicare’s fee for service system. Plus the AMA had been fighting HMOs for decades in their historic battle against “corporate medicine”. Private Medicare (like Medicare Advantage today) has continued parallel with traditional Medicare. But the new national corporate insurers insisted on getting paid more than traditional Medicare or they wouldn’t compete.

They fought efforts in 1997 by a Republican House to require them to bid competitively for Medicare business. Congress caved to the entreaties of the medical markets that threatened bankruptcy under the new GOP payment policy. And health care costs went back to rising uncontrolled by any sensible payment policy.

The Medicare Reform Proposal

The passage of Obamacare, the realities of expanded insurance market opportunities, and the fact that health care delivery systems are getting religion on the need to improve quality and lower costs, has changed all that. Both medical providers and medical insurers want it to succeed in achieving its goals. In parts of the country the corporate goals of both traditional hospital and clinic systems and health insurers is to become “health companies,” focused on building life-long relationships that deliver patient-centered care with every experience and involve informed patients in health and health therapy decisions.

The problem with the Ryan-Wyden, or the Wyden-Ryan policy change has little, but enough of significance, to do with the policy. And everything to do with the Politics of Polarization. The my-way-or-the-highway view of health policy taken by Republicans. And that includes Mr. Ryan. Starting with the blood-oath to repeal the ACA/Obamacare.

Then to replace it with a market-based theory that consumers, armed with taxpayer subsidies and high deductible insurance, will make all the decisions necessary to make health care costs – and taxes – and the federal budget deficit – affordable to everyone in this country. Without rationing access to needed health, health care, and long-term services for Americans.

Dr. Donald Berwick served 20 years as founding director of the Institute for Healthcare Improvement, before President Obama made him the administrator of the Medicare and Medicaid program. And Republicans in the Senate made him a whipping boy for Obamacare. On December 7 – a week after leaving CMS – Berwick returned to IHI to share the lessons learned in 17 months in public service. He referred to it as the honor of a lifetime to serve in government with 5,000 people who gave every day of their lives to make the health care system better.

He made it clear that the U.S., if it chose to do so, could create over time the highest quality, best value health system in the world. We could do it for somewhere between 12 and 15% of our GDP. Instead of the escalating 17% of GDP system we have today. Then he spelled out exactly what we and they needed to do after we get our policy makers, Republican and Democrat, to agree to such and audacious goal.

Getting one Republican and one Democrat to agree limit public spending on a public/private version of Medicare was not on his list as the place to start.

Unfortunately, it didn’t last long. Health care providers complained about having payments limited by inflation rather than the real costs to them of delivering services. And, as usual, many physicians simply prescribed more patient visits, diagnostics and the like, so as to make up for lost income. So every year Congress felt compelled to make up physician payment losses resulting from its own legislation or risk having providers pull out of Medicare. With Republicans in control of both Congress and the White House in 2003, instead of fixing the problem by changing the payment policy to encourage and reward more conservative practice patterns, Congress added to the problem and its costs by enacting Medicare benefit expansions like prescription drugs and Medicare Advantage.

The new health reform law, a.k.a. Obamacare, authorizes payment incentive changes to improve care quality and reduce excess utilization. Policies like Accountable Care Organizations, bundled payments and innovative payment projects. But Republicans insist on repealing these policies along with Obamacare and replacing them with Medicare Advantage for all and with a premium support tax subsidy the amount of which Congress can control. 

In the meantime, American physicians are losing money every year seeing Medicare beneficiaries like me. So the House Republicans are proposing to add a provision to legislation which the president wants passed to extend the social security payroll tax reduction, which would increase Part B payments for this year and next by 1 percent at a total cost to taxpayers of $38.4 billion. If the change were permanent, it would cost $300 billion over 10 years. However, not all taxpayers. Despite the GOP pledge never to raise taxes on the wealthy, they propose to increase Medicare premiums for those earning more than a $1 million a year; to reduce the funds authorized for the Affordable Care Act (ACA) implementation, especially on preventive health, and to take big cuts out of hospital payments. By enough to help offset the $38.4 billion pay increase for doctors.

A: First, the involvement of Ron Wyden means bipartisanship and bicameraliship in Congress is so unusual as to add credibility to a product that to date has had only Republican sponsors and them divided. Even though the history of reform has some bipartisan demonstrations of the success of the principles involved.

Second, the timing of it means that Republicans are losing confidence in Repeal and Replace as an appropriate response to Obama’s policy efforts as they approach a presidential an congressional election.  The involved health care community and the informed citizenry would like a chance at really improving quality and access and lowering costs.  Not another four years debating the pros and cons of private vs. public insurance, national vs. state government, markets vs. government, rich vs. poor.

Third, it’s a Washington policy answer to a systemic problem and, like so many policy “solutions” in which I was involved in the 1980s especially, it’s a good cart ahead of a mediocre to bad horse.  As former CMS administrator Don Berwick has pointed out, Medicare isn’t the problem, health care payment and delivery policy is the problem and, right now, Obamacare, appropriately implemented by the insurance and health care industry, with some policy reform help from Republicans working with Democrats in Congress and state legislatures and governorships, is more important than privatizing Medicare.

Chose the day before Thanksgiving to announce his resignation as acting administrator of CMS, effective December 2.  He told me how grateful he was to have had the opportunity to help launch the nation’s health care system on a patient-centered quality and safety strategy which just might justify the comparatively large amount of money we ask Americans to invest in health care.  Knowing well that if the strategy is successful , and the ACA reforms can be implemented on schedule, that the costs to average Americans will actually become more affordable over time. See also the Robert Pear interview in the Dec. 3 New York Times.

Being CMS Administrator is not a job Don Berwick sought. The job sought him out and people like me encouraged him to take it. The president gave him the opportunity – a historic health care/Medicare/Medicaid reform law to implement. And that’s about it. The path to passage of the new law left Americans uncertain about its value to them at a time when they desperately needed some certainty. About the new economic realities and the potential for an end to the old rising health care costs and insurance premiums.

Public support for the task Berwick was willing to undertake needed a lot more public support, much more wholehearted and visible support from the health care system leadership, and enthusiastic support as well from those who passed the law. Which only the president could  provide. He hardly tried. Neither did the Democratic leadership of the U.S. Senate, especially Finance Committee Chair Max Baucus (D-MT). Afraid to take on Republican critics of anything and everything the president was trying to do.

Congressman Paul Ryan Is Committed To Repeal If Not Replace

I enjoyed a short visit in D.C. last month with House Budget Committee chair and health policy advocate Paul Ryan (R-WI). Turns out, we met when he worked with Sen. Bob Kasten (R-WI) in 1986 and have a policy mentor in common – Prof. Alain Enthoven of Stanford. I wanted to hear from the GOP expert just what “replace” means as in “Repeal and Replace Obamacare.” Republican presidential candidates have all sworn to see to the repeal of Obamacare (the ACA).  Since that’s not likely, Ryan carries a lot of weight in designing Republican health policy in the next Congress, should the party win the presidency.

Ryan speaks with the conviction of one who has been asked his view on the subject many times.  Consumer choice is critical to controlling costs. Universal coverage isn’t possible until public subsidy costs are more predictable, people not third-party payers are making informed choices, and price, quality, and value are made transparent. Health insurance exchanges are a transition to informed choice in the individual and small group market. And to the end of the employer-provided market.  

Medicare Advantage will substitute private health insurance, with a tax-funded premium subsidy, for the current public/private insurance program. Medicaid has already taken on too many constituencies for any public insurance system and should be a block grant of money to the states for means-tested access to care, preferably via private health plans.

With A Republican President and a Republican Congress

Ryan expects a Republican President to initiate changes in the ACA as soon after his inauguration as possible and to direct Congress to pass reforms through a Republican House and through the Senate with the help of conservative Democratic Senators. The vehicle would be the same budget reconciliation process which Republicans kept Obama and the Democrats from using to pass the ACA. Because it requires only 51 votes in the Senate. Thus avoiding the hundreds of filibusters which 2009-10 Senate Republicans used to stymie Obama on each piece of significant policy change. Truth be told, President Obama and Senate Majority Leader Harry Reid caved on the 51-Senators vote reconciliation issue in 2009 hoping it would help involve some Republicans in the reform effort.

My impression is that Republicans plan bi-partisanship health policy to be whatever they decide it is. That insurance reform will preserve as little of ACA reform as possible and as many insurance brokers as want to play. That a regional approach to Medicare – to better reflect the cost containing geographic practice variation and care delivery accountability – isn’t in the political cards for Republicans given their geographic constituencies. Public subsidies for private insurance and defined contribution public insurance are critical to Republican commitments to reduce government spending rather than to expand access. More we didn’t have time for.

The Transformer Meets Some Interesting 2012 Republican Voters

The closer we get to caucus and primary time the less interesting the debates and the more interesting the Republican voters become. Just what are they looking for in a president? Ideology? Principle? Demonstrable leadership? Executive ability? Take-charge personality? Experience of the kind they seem to think the current president didn’t have? Maybe even trustworthiness? 

Every candidate, except Ron Paul and Rick Santorum, has been in the lead at one time or another. Newt Gingrich, who was counted out by his own staff and by Washington pundits a few months ago, is now in the lead. As then social conservatives who have borne Bachmann/Santorum/Perry up on their golden wings look for an anyone but Romney, Newt Gingrich is the transformer.

What’s a “Transformer” in Today’s Politics?

It appears that Newt Gingrich is by far the most experienced guy in the political capital of the world at media-driven public opinion. He has learned what it takes to stride through minefields unscathed. While leaving the tenderfoot competition behind. Throughout his long (1978-2012) career in and out of elected office, Newt is a man who has risen to the top on the mistakes that others make (often with help from him). While he consistently disclaims responsibility for his own poor judgment and lack of a moral compass.

A gifted young man from Georgia, with ambition and personality to match, goes to Washington and succumbs to its ethical standards. Only after he uses the ethics process to take down a couple of the kings of the Democratic caucus, plus a few others, does he take power. Only to lose it when he himself is found guilty of violating standards of conduct. Without acknowledging a thing, he launches a second career influencing the way his former colleagues approach legislation.

Newt has the confidence of a history lover who believes himself destined to make it. So he’s able to rise above his called-out shortcomings as though a pundit analyzing the foibles of homo politicus. No one among the Washington Republican cognoscenti believes Newt can beat Barack Obama, regardless of the economy.

In fact, one of the best, former MN Congressman and lobbyist Vin Weber suggested to John Harwood in the New York Times this week that the Republican Party might do for President Obama in 2012 what Democrat George McGovern did in 1972 for President Richard Nixon.

A transformer in politics is someone with policy credentials who can convert the credibility of an office once held into boundless energy to attract moneyed special interests to the presumed influence the transformer has over the less well-endowed who occupy positions of policy power.  Without ever registering as a lobbyist. Newt isn’t the only one (GOP or Democrat) in Washington, but he’s better at it than any other and the only one with the nerve to run for president without having to prove any of his policies have ever worked.

What Do Americans Expect of Their President?

Newt Gingrich is now doing well in polls because, after a dozen candidate debates, Republicans think he’s smart enough to beat President Obama head-to-head in a debate. Newt is smart enough to market that product well in a market of candidates who seem to have oversold themselves on policy ideology. Policy “ideas” and debate effectiveness will not bring voters to the polls. In tough times, “presidential” will. Which is why the GOP cognoscenti have been endorsing Mitt Romney. He looks the part and has the executive experience to suggest he has what it takes.

To do what? As President George W. Bush said, “I’m the decider.” When the 3 a.m. phone call comes from half-way around the world, people expect prudence (good judgment) in the president and in those he relies on to translate events and experience into critical decisions. Especially where Americans’ security, not just their “exceptionalism,” is at stake.

Critical to prudence in a national leader is foresight – an above average guess about what is likely to happen in the future and when. We expect a degree of confidence in facing both expected and unexpected events that frees a president to deal creatively under all kinds of stress.

In difficult times, the president is also expected to have the information and the insight not available to average Americans, the media, or other world leaders. Because our president is at the top, we expect he can see farther and know more. A president with the “leadership gene” is able to use both to our benefit, whether we agree with him or not.

In special times, like these, we expect our president to use all of his gifts to conceptualize the challenges we face as individuals in the context of the past and present of which we are aware, and of the future upon each of us is dependent. And to persuade us, and others in leadership positions on whom we depend, that the future lies in a shared responsibility for changing our lives, our economy, our institutional behaviors, or national security. All that in an intemperate and impatient, but interconnected world.

Above all, our president must be a person who is trustworthy because he earns our trust and that of others in positions of leadership, here and abroad. Because he deserves it. Not just because he won a Nobel Peace Prize. This is where consistency of character, family, and honesty in relationships comes in. A president, above all, must walk his talk. Because for each of us, so much is at stake in our decisions to delegate so much power to this one person.

The Leadership Gene

“A leader is a person who must take special responsibility for what’s going on inside him – or herself, inside his or her consciousness, lest the act of leadership create more harm than good.”

~ Parker Palmer in Leading From Within. Quoted most recently in the best-selling Strengthening the Soul of Your Leadership by Ruth Haley Barton.

Most Americans will never really know their president. We are left to judge him or her by his or her words and the consistency of the decisions this special leader makes on our behalf. And by what those who know him or her best, and know themselves as well, will tell us about our president. Or our party’s candidate for president.

Suppose We had an Election and No One Showed Up

I give a lot of Rotary speeches to a cross section of business and professional Minnesotans. The last one on Monday in St. Louis Park, the Twin Cities suburb where Al Franken, Norm Orenstein, and the Coen brothers grew up. The most challenging question every single time this year has been, “Is the current political polarization cyclical or permanent?” Usually followed by something like, “why bother voting?”

My answer is always “cyclical” but I never can predict the length of the cycle. Some instinct, probably fed by my optimism gene, tells me that despite all signs to the contrary, 2012 is an election where our voices can  be heard and our votes will count. I watch U.S. Senate races because they best reflect what a variety of Americans believe they require of elected representatives. Like Scott Brown (R-MA) in January 2010. For example, races in Nebraska and North Dakota which had been polling Republican this summer are changing to even or Democrat ahead.  Stay tuned.

99 Percent

It took me 20 minutes from home to my office one day last week. During that time, I heard on the radio that the Pew pollsters found a substantial drop in public confidence for the Tea Party approach to politics and governance. That a federal judge in Pennsylvania refused to approve a deal between the SEC and Citigroup which made $285 million for the government. Because the deal allowed Citigroup to deny responsibility for any wrongdoing. That Senate Republicans were considering going along with an extension of payroll tax cuts if Obama dropped his demand to pay for it by restoring the tax rates which Republicans cut on the wealthy.

That the Egyptian people were voting like mad for the first time in four decades. That the Occupy movements in Los Angeles and Philadelphia were moving off public property but not “folding their 99 percent tents.”  And that the Dow Jones stock average had gone up nearly 50 points (to an eventual gain of 489 points) while I was driving in to work.  One of those days with a hint in it of “change we might be able to believe in.”

Believe that the polarization which has infected public policy making, government leadership, and the ability of anyone to turn around the greatest recession since the 1930s, might be not be a permanent way of doing business in America. It is possible that Americans have seen through the polarizing force of right-wing media rant and slant which had made it seem impossible for anyone to hear the voices of those Americans whose lives and futures have been forever changed by the events of the past decade.

Their voices replaced by the voices of politicians, oil companies, national unions, the chambers of commerce in America all demanding jobs-jobs-jobs by reducing government to its smallest possible size. Where all it can do is help subsidize economic activity using a labor force much of which will not have the long term security of jobs, income, or private or social insurance. I think that’s what “Occupy/99 Percent” is all about.

Rita Parenteau – Couldn’t Last Forever

Many of you know Rita Parenteau as the executive coordinator of NIHP, associate publisher of The Commentary, scheduler of my time. Rita decided to take early retirement from her nine year career as an employee of the University of St. Thomas and its Opus College of Business. Lucky for me, Erica Lyons has stepped in to help me until a new coordinator for our health care program staff is recruited. Erica started as a student intern with NIHP in the fall of 2003 and has been employed at OCB since her graduation here in 2006.

I am regularly posting new content on my website and blog, nihp.org. You can subscribe to the NIHP.org RSS feed to get up-to-the-minute updates.

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