Reforming Whose Entitlements?

private-healthAside from the dubious continuation of bank-coddling bailout policies, perhaps the most dissonant domestic policy theme expressed by President Obama is “entitlement reform.” He just used the phrase again in a speech on the economy at Georgetown University. In fact, he went so far as to equate it with health care reform.

Surely, the President knows that the concept of entitlement reform has long been used by fiscal conservatives as a euphemism for making substantial benefit reductions in Medicaid, Medicare and Social Security. Time and time again, these “reformers” have used overheated rhetoric and misleading projections to try to steamroll the country into gutting these vital social insurance programs. Their effort in 2005 to privatize Social Security—fronted by George W. Bush—was met with a firestorm of opposition.

It remains unclear whether the Obama Administration plans to travel along the same path or is appropriating the rhetoric about “fiscal responsibility” to serve a more progressive agenda. It is encouraging that the Administration is willing to spend heavily on social programs as part of the Recovery Act plan for addressing the recession. But health care policy is still an open question.

Obama’s effort to unite health care reform and entitlement reform is rooted in the idea that large cost savings are possible in the medical system. In the past, it was assumed that cutting costs went hand in hand with limiting treatment or reducing the income of doctors and hospitals. Obama offers a different paradigm. He wants us to believe that investments in health information technology, such as those contained in the Recovery Act, will bring down costs by raising efficiency.

Computerization of medical records may solve the problems caused by poor penmanship among physicians, but it is hard to see it bringing down costs to any great extent. On the contrary, it has all the makings of an expensive boondoggle benefitting big service providers such as McKesson Corporation.

What President Obama and other Democratic Party leaders seem unwilling to acknowledge is that the most effective way to cut costs is to take the profit out of health coverage. A single-payer or Medicare-for-All system, such as that proposed in Rep. John Conyers’ HR 676 and promoted by groups such as Healthcare-NOW, would save hundreds of billions of dollars by eliminating the vast and oppressive bureaucracy of the private insurers. That would be real entitlement reform.

The Corporate Crime Fighting Budget

The call to boost taxes on the wealthy to start paying for healthcare reform is not the only refreshing thing about the budget outline just released by the Obama Administration. There is also a marked shift toward tighter regulation of business. Here are some features of what might be called the Corporate Crime Fighting Budget:

Cracking down on corporate polluters. The Environmental Protection Agency—a joke during the Bush Administration—is slated for a 34 percent increase in funding. This would result in a hike in the budget for core functions such as enforcement to $3.9 billion, an all-time high for the agency.

Cracking down on abusive employers. Obama wants the Department of Labor—another agency enervated by the Bush crowd—to get a smaller increase than EPA, but the additional funds are intended to rebuild DOL’s responsibilities in workplace monitoring. The budget document proposes to “increase funding for the Occupational Safety and Health Administration, enabling it to vigorously enforce workplace safety laws and whistleblower protections, and ensure the safety and health of American workers; increase enforcement resources for the Wage and Hour Division to ensure that workers are paid the wages that are due them; and boost funding for the Office of Federal Contract Compliance Programs, which is charged with pursuing equal employment opportunity and a fair and diverse Federal contract workforce.”

Prosecuting white-collar crooks. The section on the Justice Department in the budget document says that the Administration will seek [not yet quantified] “resources for additional FBI agents to investigate mortgage fraud and white collar crime and for additional Federal prosecutors, civil litigators and bankruptcy attorneys to protect investors, the market, the Federal Government’s investment of resources in the financial crisis, and the American public.”

Thwarting purveyors of tainted food. The Administration plans to “take steps to improve the safety of the Nation’s supply of meat, poultry and processed egg products and to ensure that these products are wholesome, and accurately labeled and packaged.” The proposed budget for the Agriculture Department “provides additional resources to improve food safety inspection and assessment and the ability to determine food safety risks. This will lead to a reduction in foodborne illness and improve public health and safety.” The Food and Drug Administration, which is under the auspices of the Department of Health and Human Services, would also get a hike in funding.

Restricting plunderers of national resources. The section of the budget document on the Interior Department outlines the Administration’s intention to rein in the windfalls long enjoyed by extraction companies with leases to drill and mine on public lands. The plan includes “a new excise tax on offshore oil and gas production in the Gulf of Mexico to close loopholes that have given oil companies excessive royalty relief” as well as the imposition of user fees and more realistic royalties for oil and gas drilling on federal lands.

Controlling drug and healthcare price gouging. The general framework for healthcare reform released by the Administration as part of the budget document contains plans to slow down the growth in Medicare costs. This includes a proposal to force providers of privatized coverage under the name of Medicare Advantage to participate in competitive bidding. Medicare drug costs would be reined in by tightening oversight of Part D spending and by preventing brand-name pharmaceutical companies from paying generic drug producers to keep their low-cost products off the market.

To these should be added tax proposals that would put an end to various boondoggles that have enriched oil companies, hedge funds and other anti-social elements. Some of Obama’s proposals (especially regarding healthcare) do not go nearly far enough, but the budget as a whole represents a major break from the priorities of the Bush Administration. Though you would hardly know that from the geeky, matter-of-fact way it is being promoted by Budget Dirtector Peter Orszag (photo).

Budget documents are, of course, merely wish lists conveyed by the executive to the legislative branch. In the short term, the main impact of Obama’s blueprint will be to launch a massive wave of business lobbying. Now it is up to Congress to resist the entreaties of those paid persuaders and make it clear that the days of unchecked corporate giveaways have come to an end.

Nationalization Would Be Good for Our Health

Nationalization—a term alien to most Americans taught to believe in the ideology of a free market—is now at the center of a public discussion on how to address the ongoing crisis of the country’s major financial institutions. For most observers, nationalization is viewed as an unfortunate and temporary step that would be taken to restore troubled banks to health and then turn them loose on the market again.

Yet perhaps we shouldn’t be thinking in such narrow terms. If the taboo against government ownership is disappearing, now might be the time to consider applying that solution to another industry that causes Americans a great deal of grief: for-profit health insurance.

Long before the banking system became a national embarrassment, health insurance companies—especially health maintenance organizations—were a leading symbol of market forces running amok. A wave of consolidation put the industry under the control of a handful of huge for-profit corporations whose business plans are based on the denial of as much care as possible. Despite being hit with a variety of class action lawsuits filed on behalf of patients and healthcare providers, their practices remain largely unchanged.

Calls for healthcare reform have grown, yet mainstream analysts insist that private insurers have to remain a central part of any new system. Although it is the norm in most other developed countries, the conventional wisdom is that government-managed coverage—the single-payer approach long advocated by groups such as Physicians for a National Health Program—is unthinkable here.

That’s not because single-payer isn’t feasible. On the contrary, it’s the for-profit system that leaves a lot to be desired in the efficiency department. Consider this: According to their latest financial statements, the five largest private U.S. health insurers—UnitedHealth, WellPoint, Aetna, Humana and Cigna—together spent more than $36 billion on marketing, administration and other non-medical costs last year. This represented 19 percent of their total costs, which doesn’t include the administrative costs they impose on doctors, hospitals and other healthcare providers. By contrast, in Canada’s government-run single-payer insurance system, administration accounts for only 3.4 percent of total costs.

If the five big U.S. private insurers were that efficient, they would be spending only about $7 billion a year on non-medical costs. In other words, they are wasting nearly $30 billion a year on functions that do little to promote the physical well being of their subscribers. In fact, a large portion of the waste represents their efforts to reduce care and thereby raise profits, which for the five totaled more than $8 billion last year despite a difficult economic environment.

A great deal of the waste among private insurers reflects the huge workforce—totaling more than 200,000 at the top five firms—they employ to operate their immense bureaucratic machine. Imagine how much better our system would be if most of those 200,000 people were retrained to be healthcare providers rather than deniers, and the billions in wasteful spending went toward lowering premiums and improving care.  Some researchers have estimated that the replacement of the multiplicity of private and public payers into a single national system would eliminate $350 billion a year in wasteful expenditures.

In his speech to Congress this week, President Obama was emphatic about moving on healthcare reform soon, but he was vague about details.  Vast sums are being spent to at least partially nationalize banks. Why not use some of those funds to take over the health insurers that create their own form of financial distress?

It is an auspicious time to take the plunge. Thanks to the slumping stock market, the stock prices of the big insurers are cheap. The total market capitalization of the big five is currently only about $74 billion. For far less than what has been spent giving dubious capital infusions to banks, the federal government could buy out all the shareholders of the large insurers and move their subscribers into a federally operated system—perhaps an extension of Medicare—that could use cost savings to remove restrictions on coverage and enroll the uninsured.

I know there are a lot of complications, but this may be a rare opportunity to cast away old assumptions about what is possible and seek radical rather than patchwork reform. Nationalization of shaky banks may prove to be a futile effort; the federal takeover of private medical insurance would pave the way to a more humane and effective healthcare system.