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White House prepared to compromise, but not capitulate


The White House just released a letter (pdf) pledging to move forward with health-care reform and include some of the Republican proposals offered at the Blair House Summit. The lucky policies are:

1) "Senator Coburn had an interesting suggestion that we engage medical professionals to conduct random undercover investigations of health care providers that receive reimbursements from Medicare, Medicaid, and other Federal programs."

2) "Funding to states for demonstrations of alternatives to resolving medical malpractice disputes, including health order to advance our shared interest in incentivizing states to explore what works in this arena, I am open to including an appropriation of $50 million in my proposal for additional grants."

3) "Senator Grassley raised a concern, shared by many Democrats, that Medicaid reimbursements to doctors are inadequate in many states, and that if Medicaid is expanded to cover more people, we should consider increasing doctor reimbursement. I’m open to exploring ways to address this issue in a fiscally responsible manner."

4) "Senator Barrasso raised a suggestion that we expand Health Savings Accounts (HSAs). I know many Republicans believe that HSAs, when used in conjunction with high-deductible health plans, are a good vehicle to encourage more cost-consciousness in consumers’ use of health care services. I believe that high-deductible health plans could be offered in the exchange under my proposal, and I’m open to including language to ensure that is clear.

Of these, the fourth is the most relevant. And if we were dealing with an actual negotiation in which both sides agreed that we should have a bill ensuring near-universal coverage at no cost to the deficit, it might be enough.

But that's not the negotiation we're in. Instead, as Lamar Alexander said, Republicans have "come to the conclusion that we don't do comprehensive well." And the president is not compromising on that point. "Piecemeal reform is not the best way to effectively reduce premiums, end the exclusion of people with pre-existing conditions or offer Americans the security of knowing that they will never lose coverage, even if they lose or change jobs," says the letter. "I look forward to working with you to complete what would be a truly historic achievement."

Photo credit: By Jason Reed/Reuters

By Ezra Klein  |  March 2, 2010; 2:10 PM ET
Categories:  Health Reform  
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Next: Fightin' words


Is there a way to include these provisions in a bill contigent on Republicans supporting the final legislation? That is, if (and when) it becomes clear they won't offer a single vote in favor, Dems strip these from the final and ram it through?

Posted by: imherefortheezra | March 2, 2010 2:18 PM | Report abuse

Are you missing a "not" in that last paragraph? "And the president is NOT compromising on that point"?

Posted by: you-dont | March 2, 2010 2:19 PM | Report abuse

Ezra, I believe you have a typo in the last para. Think you wanted to say, And the president is not compromising on that point.

Posted by: ctnickel | March 2, 2010 2:20 PM | Report abuse


I don’t know if you write your own headlines on this blog but the headline does not really match the actual story. Looking at both your story and the letter itself, I see quite clearly where the Obama administration is prepared to, yet again, compromise and even embrace Republican ideas. What I don’t see is what leads you (or the headline writer) to conclude that Obama isn’t ready to capitulate.

Or is the implication that he wants to compromise more before finally capitulating? That’s the only way the headline makes sense in the context of the post.

Posted by: MitchGuthman | March 2, 2010 2:23 PM | Report abuse

Health Savings Accounts haven't been held much to accountability. Where's the data on who buys them, why they buy them, and what happens when they buy them?

Setting aside the possibility that the Republicans play HSAs in their homes like Guitar Player because it's good amusement, I strongly suspect that HDAs are just a tax refuge for the filthy rich - but I can't demonstrate that from studies I've seen.

Where's the beefy data?

What happens when someone who isn't filthy rich gets a series of medical bills that can't be paid by lack of immediate funds but don't qualify for payment by the HSA because the high deductible hasn't been reached? Is bankruptcy or the ER (with its limits of 'stabilizing care only') the only choices?

Please Ezra, tell us some info that penetrates the fog of GOP propaganda surrounding HSA's.

Posted by: JimPortlandOR | March 2, 2010 2:26 PM | Report abuse

I just don't get the logic of adding in repiglican ideas unless they actually result in repiglican votes for the bill.

The 4 pillars of repiglican HCR are already in the bill.
-no public option
-selling across state lines (exchanges)
-individual mandate (repiglicans were for it before they were against it)
-insurance reforms that repiglicans say they are for.

Why give up even more for no return?

Posted by: srw3 | March 2, 2010 2:27 PM | Report abuse

Capitulating would be to scarp the bill and start over, which is what Lamar and all the GOPers are demanding. It is an unreasonable demand. Obama is incorporating some of their ideas, and when (yes, please, WHEN) it passes, he can beat them over the head for having passed a bill that has things THEY WANT but that got NO affirmative votes from them.

Smart. Compromising (in the good sense of the word) and far from capitulating.

As Andrew Sullivan would say "Meep. Meep." The Obama roadrunner will zoom past an outmaneuvered Obama.

Now if we can just teach Obama to not wait till he's darn near cornered before pulling ahead!

Posted by: RalfW | March 2, 2010 2:28 PM | Report abuse

Oops, I meant, Obama will zoom past an outmaneuvered GOP.

Shoulda used the preview button!

Posted by: RalfW | March 2, 2010 2:29 PM | Report abuse

Ezra: shouldn't the sentence in your last paragraph read "the President is not capitalizing on that point"? You seem to have left out the "not," but the gist of the paragraph clearly implies it should be there.

Posted by: retr2327 | March 2, 2010 2:39 PM | Report abuse

"Compromise" in the title is a little misleading ... implies both sides "give and gain" something. All I see is Ds giving and Rs gaining.

Posted by: onewing1 | March 2, 2010 2:50 PM | Report abuse

I'm distrustful of the President who has seemingly tried to duplicitously trick the voters into a defacto SIngle-Payer system all along without having an ounce of political courage to make the case for it.

Having said that, I believe the inclusion of high deductible insurance is a very good move and look forward to some follow-through. The question is why wouldn't everyone get high deductible insurance until they got sick----then suddenly join the comprehensive. It would seem so long as there is guaranteed access to comprehensive, the fiscal model for catastrophic becomes irrelevant....perhaps the President realizes this and is being dishonest?

Posted by: FastEddieO007 | March 2, 2010 2:56 PM | Report abuse

Clever move, sets the stage for a media strategy where the prez says "see, the summit worked, we have these bipartisan ideas." That provides cover to move ahead with reconciliation when the Republicans refuse to sign on.

Posted by: etdean1 | March 2, 2010 2:58 PM | Report abuse

So respectively the first three suggestions are: undercover healthcare inspectors, "health courts" and higher spending. What are the bets that the same Republicans who proposed these ideas will have turned them into anti-reform talking points by next week?

Posted by: bigmandave | March 2, 2010 3:00 PM | Report abuse


Obama is ahead? Really?

Posted by: MitchGuthman | March 2, 2010 3:30 PM | Report abuse

*I'm distrustful of the President who has seemingly tried to duplicitously trick the voters into a defacto SIngle-Payer system all along without having an ounce of political courage to make the case for it.*

That just goes to show you HOW devious he is, FastEddie: not only doesn't he support single payer, he doesn't even try to get it in a bill, and the bill never has single payer in it, but that's all part of his and the Democrats strategy for single payer! By not supporting it and not voting for it and not having a bill with it! That's how deep the conspiracy runs!

Posted by: constans | March 2, 2010 4:31 PM | Report abuse

It sure must be nice to have everyone bend over backwards time and again to offer you concessions. Pity the only way to get that is to be functionally sociopathic, but still, it's got to feel good.

Posted by: adamiani | March 2, 2010 4:41 PM | Report abuse

@JimPortlandOR, there is quite a bit of data out there on CDHP/HSAs. The American Academy of Actuaries released a report last year

there is also this from the CBO:

And plenty more, including some work at Health Affairs. 2 minutes of googling will give you all you need.

-----"I strongly suspect that HDAs are just a tax refuge for the filthy rich"

You can only contribute 3050/year to an HSA, saving someone in the top bracket about 1100 in taxes. And the money can only be used for medical expenses. It's a bit silly to think this is a huge giveaway to rich people.

-----"What happens when someone who isn't filthy rich gets a series of medical bills that can't be paid by lack of immediate funds but don't qualify for payment by the HSA because the high deductible hasn't been reached?"

I think you're misunderstanding what exactly an HSA is. There really isn't any difference between an HSA and a normal insurance policy, other than an HSA plan having limits on the deductible and out of pocket costs (deductible must be at least $1200, total out of pocket cannot exceed $5950, basically there's just a limited range of benefit designs that qualify, but those overlap to a large degree with the standard plans). You can then contribute up to $3050 to your account, and use that to pay your medical expenses. You're automatically getting a discount on those expenses since you're able to pay with pre-tax dollars. The idea that HSAs are something that only benefits the "filthy rich" is not at all true.

Posted by: ab13 | March 2, 2010 4:48 PM | Report abuse

Expanding on that last bit: a middle class family can benefit quite a bit from choosing an HSA. Choosing a plan with a (for example) 3000 deductible for the whole family, they'll save a decent chunk of money on the premium every month, and save on taxes by deducting the amount they contribute to their account. Yes, they'll be required to spend 3K on health care before the plan starts paying, but they'll get the insurer-negotiated discounts on that care and pay it with pre-tax dollars, and the funds will always carryover from year to year if they don't have many expenses. The one thing missing is more price transparency so that they can be better consumers when using that first 3K in care (with obvious caveats about emergency care, catastrophic illness, etc, yes no one expects you to shop on price when you've just been in a car accident).

Posted by: ab13 | March 2, 2010 4:55 PM | Report abuse

Ezra, I have to say, my sense is that public opinion is really turning on health care and on the administration in general. I don't know what's going to go on with independents, but Democrats are getting a major second wind. Just check out the comments on articles here on the WaPo; there's a similar surge in liberal energy on a couple of other sites I frequent.

My sense is that this energy stems mostly from having the Republicans in the news so much. Not just Shelby and Bunning, but the health care summit and the meeting with House Republicans really brought home for a lot of people that Democrats are interested in intellectually engaging with the problems in this country whereas Republicans are not. Anything the administration can do to keep this reality in the spotlight will have a tremendous positive impact on the administration's ability to pass progressive legislation.

Posted by: jeffwacker | March 2, 2010 8:26 PM | Report abuse

Instead of hiring a bunch of "undercover patients" as Coburn suggests, why not just incentivize patients to report fraud and mistakes by rewarding them with 25% of the overpayment amounts. This includes simply reviewing your bill to determine it is accurate which most people with insurance or Medicare generally overlook.

Posted by: cmccauley60 | March 2, 2010 8:54 PM | Report abuse

This will empower and reward honest conduct and scare the hell out of dishonest and incompetent providers.

Posted by: cmccauley60 | March 2, 2010 8:56 PM | Report abuse

"I believe that high-deductible health plans could be offered in the exchange under my proposal, and I’m open to including language to ensure that is clear."

Now he's got this Republican's attention. Really got it. Eliminate that 2.9% new income tax and raise some of the revenue from capping the exclusion and I'm on board.

Of course, Ezra "that's not the negotiation we're in" Klein is beginning to sound awfully obstructionist.

Posted by: bgmma50 | March 2, 2010 9:39 PM | Report abuse

Coburn's idea for "undercover investigations by medical professionals" actually sounds like a good idea. Retailers do this all the time to make sure they aren't being ripped off--calling them "mystery shoppers"

It's hard to imagine medical providers actually looking forward to this, though...undercover people coming in to look for Medicare fraud?? Jeebus. I guess Coburn's a doc, so he must know what doctors' want.

Posted by: stevedwight | March 2, 2010 9:43 PM | Report abuse

While the repubs may have shown that they are not the party of "no ideas," it remains to be seen if they can be anything other than the party of "no."

Posted by: 3speedbike | March 2, 2010 10:02 PM | Report abuse

Both the title and the comments here are pretty absurd. None of these are a "compromise" to conservatives. As every Republican made clear at the summit, we need to Start Over. Lipstick on a pig.

All that the president is doing is trying to help Democrats pretend that Republicans are being intransigent, to make it easier for them to justify a Yes vote. That's _all_ he's doing. Calling these a compromise is disingenuous, regardless of how much progressives dislike them.

Posted by: MikeR4 | March 3, 2010 12:53 PM | Report abuse

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