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Rahm Emanuel: 'The goal isn't to see whether I can pass this through the executive board of the Brookings Institution'

Obama's chief of staff is annoyed at all the critics who like to imagine a better health-care reform bill but have no idea how to pass such a thing:

“Let’s be honest,” Rahm Emanuel said in a recent interview. “The goal isn’t to see whether I can pass this through the executive board of the Brookings Institution. I’m passing it through the United States Congress with people who represent constituents.”

He went on: “I’m sure there are a lot of people sitting in the shade at the Aspen Institute — my brother being one of them — who will tell you what the ideal plan is. Great, fascinating. You have the art of the possible measured against the ideal.”

It's worth remembering that Emanuel's definition of success as a bill "I can pass" cuts both ways. Susan Collins, for instance, gave the New York Times a bunch of quotes on how the legislation doesn't do enough to lower costs. But if Collins actually had an idea that would lower costs, and if she would actually give Rahm her vote in exchange for including that idea, she would get her idea in the bill. Same goes for virtually any Republican, and most conservative Democrats. When people such as Collins complain that the bill doesn't do enough to cut costs, that's at least in part because crucial legislators like her have not been willing to do enough to cut costs. Emanuel would be as happy to pass a radical bill that does a lot on cost control as a modest bill that does very little. Maybe even happier.

By Ezra Klein  |  November 10, 2009; 12:36 PM ET
Categories:  Health Reform  
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Comments

You get an Amen on this post. It is striking to me how many people criticize the bills in Congress because they don't do enough to lower costs, but then they oppose vehemently all of the provisions that would lower costs. Strong version of the public option--don't want that. It might lower costs. Excise tax on cadillac plans--don't want that. It might lower costs. Stronger penalties for failing to buy insurance--don't want that. It might lower costs. But we want the bill to lower costs.

Posted by: StokeyWan | November 10, 2009 12:54 PM | Report abuse

I have been very disturbed what I have been hearing on one news network about C Street in Washington D.C. I was wondering why no one has picked up on this story . The C street residence is a secretive religious group which houses members of our Congressman and Senators. Jeff Sharlet has done extensive research on this group and wrote a book called" The Family" Senator Ensign from Nevada just left the organization for drawing attention to it. This is a good investigative story that we the people need to be informed about. These lawmakers need to be accountable for the laws they cast upon us.Especially when they believe they are above the law. They are Democrats and Republicians that belong to this organization. We need a good journalist to do an extensive investigation on these members.Please don't ignor this story. We also need to know ,they list this house as a church do they receive tax benefits which is important. What happened to seperation of church and state? If anyone starts this investigation we may see Health Care Reform get passed.

Posted by: jnjkelly48 | November 10, 2009 1:13 PM | Report abuse

You're right to highlight how flawed Emanuel's strategy is, i.e. if the administration and the Democratic base continue to cave into the demands of centrist and conservative Congress-critters, why, hell, we'll get meaningful reform. As Andrew Sullivan says, "if it smells like 1993, then it's probably Rahm." Meanwhile, back on planet Earth, we can all see that the entire GOP, including so-called moderates like Mark Kirk and Mike Castle, are itching to derail reform and win back power. The goal posts keep moving further and further to the right . . . not the change I voted for a year ago.

All the tax cuts for the wealthy won't earn Susan Collins' vote. All the coddling of Lieberman despite his treachery won't stop him from joining the Republicans in a filibuster. All the calm talk about transcendent bi-partisanship won't douse the insane rhetoric of the teabaggers. All the Stupak language won't shift John Barrow's position.

Next up: Olympia Snowe's disavowal of her own trigger.

Posted by: scarlota | November 10, 2009 1:20 PM | Report abuse

"Emanuel would be as happy to pass a radical bill that does a lot on cost control as a modest bill that does very little. "

If that was true, I think we would have heard about the White House kicking their tires on Wyden-Bennett, when this whole thing started in Feb/March.

The reality is that "radical" was the only thing that was off the table-- "we won't change your health care if you already like what you have" was the fundamental tenet of Obama's approach to reform.

Posted by: wisewon | November 10, 2009 1:26 PM | Report abuse

"I"? "I can pass.."?

Posted by: truck1 | November 10, 2009 1:30 PM | Report abuse

The director of the agency where I worked for 17 years would not tolerate easy, empty criticism/complaints/whining about the deficiencies in a particular policy under discussion UNLESS the remarks were prefaced or immediately followed by a suggestion or proposal for a solution. In other words, if you cannot offer a solution, then sit down and shut up until you can.

In this way, he created a solution-focused culture in our workplace that led to many creative, effective policies and a "can do" attitude among staff.

Congress people could learn a lesson or two from my Director's approach.

Posted by: onewing1 | November 10, 2009 1:35 PM | Report abuse

What an entertaining post. Blaming the lack of cost control on legislators who are not driving the bill but are expected to jump on board, head and neck first, with meaningful cost reduction proposals is simply laughable. You want them to do the politically dangerous work - taking away something from a constituent - all because you think they should participate in a reform process that only exists because their party last power? No, the onus for cost control proposals is not on Susan Collins, but rather on those sponsoring this legislation.

Posted by: bobopapal | November 10, 2009 1:47 PM | Report abuse

--"But if Collins actually had an idea that would lower costs, and if she would actually give Rahm her vote in exchange for including that idea, she would get her idea in the bill."--

Here's an idea to "lower costs": Get government out of the health care business.

Go on, put that in the bill.

Posted by: msoja | November 10, 2009 1:47 PM | Report abuse

"Excise tax on cadillac plans--don't want that. It might lower costs. "

I wish that someone could explain to me how the fact that an individual pays 50% more than the national average is a predictor that she might be prone to over treatment and causing rising health costs. After all, the average woman in the individual market pays 30%-50% more than a man for identical coverage. Insurance in high-cost areas is more expensive for all individuals. And everyone under 65 pays many times more than seniors for coverage equivalent to what is offered in various MediGap policies.

A tax on insurance to subsidize someone else's insurance is not health policy, it's just a financial shell game. If Democrats were really interested in reducing costs, they would start with ...*costs*. They could for example, ban direct marketing to consumers of prescription drugs and prohibit co-pay rebate programs.

That would *reduce* actual costs for everyone much more than the bogus excise tax. What it wouldn't do though, would be to raise money for subsidies.

Those who support the excise tax should be honest about what is going on. No one expects the excise tax to have any real effect on consumption of health treatment. Its most visible result will be to increase insurance costs for those who are already paying for their own insurance and leave the employer-paid market undisturbed.

Posted by: Athena_news | November 10, 2009 1:51 PM | Report abuse

Athena, I don't think you are correct that it won't affect employer based plans. That's why unions don't like it--because they have been able to secure better health insurance in lieu of higher wages. But the goal of the excise tax is to get people to choose more managed care plans, which do reduce costs. The average costs in the individual market are going to be leveled out by other reforms.

I think a number of progressive Democrats would like to start with actual costs in the way you suggest, but unfortunately there are a relative few in this country who are interested in fundamental changes to the health care system in this country.

Posted by: StokeyWan | November 10, 2009 2:04 PM | Report abuse

But if Collins actually had an idea that would lower costs, and if she would actually give Rahm her vote in exchange for including that idea, she would get her idea in the bill


THe problem is that politicians don't have the "stones" to do it. You want an idea, "require all insurers to be non-profits". You want a much better idea and much better and longer lasting cost control, "CAPITATION".

There you go, two ideas on how to control costs. Do you think politicians want to go against the doctor lobby or the insurance lobby to get those two done??

Posted by: visionbrkr | November 10, 2009 2:06 PM | Report abuse

Yeah, No one on the Republican side has been making any recomendations to cut costs through tort reform or interstate purchase of health insurance. No Republican has introduced an amendment to the Health Care bill in the House to cut costs through tort reform an interstate purchase of health insurance only to see the amendment defeated on a party line vote. No Republican Senators offered any amendments in the Finance Committee only to see them defeated on party line votes. No Republican Senators offered any amendments in the Health Committee only to see them defeated on party line votes. Senator Bennett has not cosponsored any legislation with Senator Wyden to fundamentally alter health care and control costs. Senator Collins herself has not sponsored S. 242 to allow reimportation of prescription drugs and lower costs.

Oh, wait none of the above is actually true. Republicans have actually done all of these things. In fact, if tort reform and interstate ourchase were in the bill, we probably wouldn't be having this conversation now because the Dems would have been able to use those concessions to peel off 3-6 R votes in the Senate and 15-25 in the House, and the bill would already be law.

Posted by: WoodbridgeVa1 | November 10, 2009 2:17 PM | Report abuse

WoodbridgeVA1,

And by not being in the bill, do you mean the parts of the Baucus bill that allow for multi-state, regional, and national exchanges to allow purchase of insurance across state lines, or are you referring to the parts of the House bill that include the same options? The failure of Wyden-Bennett should be a pox on both houses. It had limited support by both but insufficient support by either to become law. Frustrating, to be sure.

Posted by: StokeyWan | November 10, 2009 2:44 PM | Report abuse

I don't think there's a lot of evidence that Rahm would be "happy to pass a radical bill that does a lot on cost control as a modest bill that does very little." I know he's saying that publically, but his actions behind the scenes indicate it's not the case. At all.

Some of which you've hit on: the White House took some of the most "radical" items off the table from the start, which meant that a far weaker position was being negotiated down from. The White House cut its deals with elements of Big Health, less for "cost savings" potential but more in the hopes that:

* those elements of Big Health would play nice in this legislation (good luck)

* those elements of Big Health would keep the money flowing to the Dems in the coming election cycles

He leaked a variety of quotes, on and off the record, about things such as Triggers that undermined the stronger GOP positions. He took the Progressives to the woodshed, but never really took the Blue Dogs that are his own invention to a similar woodshed.

The bill Rahm really wanted was to the *right* of what came out of the Senate Finance Committee.

John

Posted by: toshiaki | November 10, 2009 3:32 PM | Report abuse

"But the goal of the excise tax is to get people to choose more managed care plans, which do reduce costs."

What if the individual is already in a managed care plan ... one that costs 50% more than the national average because she's a middle-aged woman in a high-cost area? What is supposed to happen to her? Is she supposed to be satisified with a plan that offers poorer coverage and greater out of pocket expenses because Congress didn't actually work on costs?

"I don't think you are correct that it won't affect employer based plans"

Those who support the excise tax do not seem to grasp the size of the disparity between employer-paid and individual rates. If you compare FEHB plans with what an individual in the same market can buy, you'll see that equivalent coverage is rarely available for individuals and lesser coverage costs much more -- frequently above the $8000 threshold. So, the total premium for a federal employee in Atlanta is significantly cheaper than what a middle-aged woman pays for markedly less coverage. Premiums for the far more generous federal plan is well under $8K but the individual woman's lesser coverage would be considered "gold-plated".

The excise tax an ill-conceived idea that has nothing whatsoever to do with assuring that everyone has access to affordable treatment. In fact, it ensures that individuals who can currently afford to pay their own way will be less able to do so in the future. The assumption that anyone whose premiums exceed the "average" by 50% has better coverage is simply wrong.

And how will self-insured plans, those that have no premiums, be valued?

Posted by: Athena_news | November 10, 2009 3:37 PM | Report abuse

Athena--I had a self insured plan, and when I got COBRA they were able to put a price on it, so there must be some mechanism to do this.

I agree there are many other problems with the excise tax. For example, we had staff in our office making less than $10/hr who essentially worked for the no-deductible no co-pay health benefit our company offered. Assuming it will be hit with the excise tax it's suddenly going to cost much more to employ these people. I don't know what will happen.

Posted by: bmull | November 10, 2009 5:23 PM | Report abuse

athena and bmull,

self insured plans have what is called "cobra equivalent rates". What that in layman's terms means is they take the total cost of the plan in a given year and average out what it cost PEPM (per employee per month) and voila you have your cobra rates and what i'd expect you'd factor the excise tax on.

Now that being said within a company (espeically the smaller of the large employers (between 100-1000) that self insure the sick paying for the healthy in an extra way here but that's how it goes.

Posted by: visionbrkr | November 10, 2009 7:19 PM | Report abuse

visionbrkr and bmull, thank you for the explanation about self-insured companies. I'm still unclear though about two things:

1. The tax is imposed on *insurers* who offer policies with premiums that exceed $8000/individual. As I noted, many middle-aged women in high-cost areas are paying more than the $8000 for "normal" coverage in the individual market today. How is that handled? Are they supposed to just live with poorer coverage?

2. What happens in the case of small businesses where coverage is rated by age, sex, and claim history? Those companies pay more for equivalent coverage, especially if they have had a recent high-cost claim.

The bottom line is that the price of the premium is not a definitive indicator of actual coverage. Why is it bad for individuals who pay for their own coverage, or employees of small businesses to have *coverage* comparable to that enjoyed by corporate employees.

Posted by: Athena_news | November 11, 2009 10:53 AM | Report abuse

Example:

Using the Massachusetts connector, a 60-year old woman in Waltham is offered 13 plans that this proposal would consider "gold-plated".

The lowest of those is the Harvard Pilgrim *HMO* (which is designated a "best buy"), comes with a $20 copay for doctor's visits, $15/$25/$50 copays for drugs and a $1000 deductible.

In what universe is that considered "Cadillac"? Most corporate employees would consider that standard coverage and Medicare Advantage programs are typically much more generous. Taxing care for those women would not contain actual costs at all, it would just decrease their personal health security. Imposing a tax on their coverage to subsidize someone else's private insurance is not good health policy, it's bad policy masquerading as "fiscal responsibility".

Posted by: Athena_news | November 11, 2009 11:12 AM | Report abuse

Athena_news,

no problem.

answers below:

1--i'm guessing the idea would be that they would go on the exchange and that should be a little less expensive??(although I don't necessarily know that'll be the case because there's very little true cost containment features in this plan. If they're not subsidized it will absolutely cost them more but I don't think you'll hear many people talk about these people around here.

2--that's a common misnomer that an individual small employer's own claims impact their costs. Small employers in my state for example are pooled with all other small employers in the 2-50 market so XYZ plumbing for example with 5 employees could have 5 cancer patients but their costs would be subsidized by all other small employers and if they were completely healthy then they'd be doing the subsidizing. But again without an individual mandate you're seeing many of those healthy employees opting out and if there's only the sick left you have one reason for costs being the way they are. I'm not certain that every state does it that way but i expect it to be very similar.

The best situation would be (IMO) the Wyden Ammendment. You could have EVERYONE in the country on the exchanges and allow employers big and small buy and sell their employees' costs on the exchange. For example if those 5 employees in XYZ plumbing want a good plan they buy a gold plan from ABC insurance co and they pay a higher premium for it and the exchange bills XYZ plumbing the cost for it. If employees want lesser plans then they bill the employer the lesser rate. It gives employees choices, increases negotiating power with physicians and hosptials to the highest degree possible (so they wouldn't like it) and reduces costs that way. ALso you could do capitation in that type of a market fairly easily. If you're a doctor and you want to see patients on the exchange (and its the ONLY option) then you're going to accept whatever is paid. Just make sure you don't make it too low you disincent providers from practicing medicine. Oh and go ahead and force insurers to be non-profits while you're at it.

I never got why big business and labor was against the Wyden Ammendment when its explained that way. Their only fear is loss of control and if they can still control their employees in that way it gives employees choice of 10-15 or more options, lower costs and everybody wins.

Posted by: visionbrkr | November 11, 2009 11:14 AM | Report abuse

athena,

i think you have a distorted view honestly of large group employer plans. Some are good, many are being stripped away over the last several years due to costs. I have a client who just bought a market segment of a large bailed out insurer now owned by the taxpayer who has 3 letters in their name. In that i became privy to the large bailed out insurer's medical plans and costs.

Their plan is crap and your example of the pilgrim plan is much better.

For example the bailed out insurer had costs that were 15% for doctor visits, 10-15% for hospitalization with a fairly high cap based on your salary and an in network deductible of between $300 and $1800 again based on your salary (the lower the salary the lower the out of pocket costs).

Again that's no cadillac either. The Cadillac is now reserved for big whigs on Wall Street and teachers (and their plans are being phased down too due to budget shortfalls).

If you want to see where the market is going look at who knows what drives costs. Most every health insurer now offers only HSA options for their employees. That's where we're going in the next 10+ years.

Posted by: visionbrkr | November 11, 2009 11:24 AM | Report abuse

"If they're not subsidized it will absolutely cost them more but I don't think you'll hear many people talk about these people around here."

Well that's a big problem ...and one of the consequences of treating health care reform as a poverty program rather than addressing it as an issue that affects every man, woman, and child. Too many so-called progressives, are happy to sacrifice individuals who are paying their own way now if it means they can say that they helped "the poor", without having to give up any of their own coverage.

If the net effect of the exchanges is going to be to decrease the actual coverage available to individuals and raise co-pays, Congress should prepare for a backlash -- similar to what happened to the legislation for catastrophic coverage in the 80s.

FYI: I just looked at the FEHB offerings for the same zipcode. The standard plans all seem to have lower deductibles than the individual plan and comparable charges for doctor visits and drugs. I do agree with you though that the pubic employee plans -- appear to have held up better than those from private employers. Unless we get actual reform, the only people who will have decent coverage will be public employees.

It seems to me that individual plans should be excluded from this tax. People who are spending their own money to meet their own health and financial should not have that coverage taxed beyond their reach -- and certainly not to subsidize some one else's insurance.

Posted by: Athena_news | November 11, 2009 6:03 PM | Report abuse

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