SUNDAY, OCTOBER 24, 2010
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Don’t go earnest on us, Jon. We’ll go insane.
rally from B1
Health care’s price problem
health care from B1
said Jon Kingsdale, who oversaw the implementation of Massachusetts’s 2006 health-care law. “We just pay a lot more for each of those units than other countries.” The 2010 law does little to address
this. Its many cost-control provisions are geared toward reducing the amount of care we consume, not the price we pay. The law encourages doctors and hospitals to join “accountable care or- ganizations” that have financial incen- tives to limit unnecessary care; it beefs up “comparative effectiveness research” to weed out inefficient treatments; and it will eventually tax the most expensive insurance plans to restrain consumers’ superfluous use of health care. Such measures could reduce redun- dant tests, emergency room visits and hospital readmissions, which would help control the costs of Medicare, where the government sets rates. But they are less likely to lower prices out- side Medicare and stem the growth of private insurance rates. The main reason for this is politics. Remember how drawn-out the health- care battle was? It started in the spring of 2009 and was waged for a full year. The bill’s proponents in the White House and in Congress had some ink- ling of how tough the fight with the in- surance companies would be. Taking on hospitals, doctors, and drug and device manufacturers as well — the people you’d face in a showdown over prices — might have been fatal. So there was no price fight. The law
will go on to face a likely post-midterm Republican onslaught — and disman- tling it may be easier if Americans think it does little to restrain costs. It is one of those fine political ironies: The law de- rided as socialism may have had an eas- ier time winning favor from a skeptical public if it was, well, a little more social- ist. It’s pretty far from socialist as it stands. The administration decided not to seek lower drug rates for Medicare, and it didn’t press for a “public option,” a government-run insurance plan that people under 65 could buy into. While supporters of the public option sold it as a way to compete with insurers, the real target was hospitals and doctors. A public option would have created a na- tionwide purchaser of health care that could have exerted leverage on provid- ers to cut prices. This would have low- ered the law’s costs by reducing the sub- sidies needed to make insurance afford- able. To avoid the wrath of hospitals and
doctors, proponents of the bill rarely emphasized this cost-control argument. Nonetheless, when conservative “Blue Dog” Democrats weakened the public option in committee, they cited opposi- tion from providers. And when the bill’s supporters floated a close alternative to the public option — letting people over 55 buy into Medicare — the reaction from Sen. Olympia Snowe, the moder- ate Maine Republican, said it all: “I am talking to a lot of my providers . . . and I know they are mighty unhappy.” Snowe exposed where the lobbying strength lay: No senator ever spoke of listening to “my insurers.” “The public hates the insurance in-
dustry and trusts doctors and hospi- tals,” said Richard Kirsch, head of the liberal coalition Health Care for Amer- ica Now. “But what killed the public op- tion was the hospitals, not the insur- ance industry.” Politicians wanted to avoid a confron-
tation over providers’ prices. So a differ- ent policy argument took hold: The real reason everything cost so much was the overuse of health care, not the actual prices of treatment. This argument came primarily from
Dartmouth College researchers who had amassed data showing wide dis- parities in Medicare spending among different regions. Hospitals in the low- er-spending areas, mostly in the Upper Midwest and the Northwest, seized on the study to argue that the key to con- trolling costs was to reward providers like them. The case was popularized by Atul Gawande’s widely read New Yorker article in June 2009 focusing on McAl- len, Tex., one of the highest spenders in the Dartmouth rankings. If health-care delivery in places such as McAllen could
ARMEND NIMANI / AFP/GETTY IMAGES
How Hillary Clinton sees the world Every four years, the Pentagon puts out its Quadrennial
Defense Review (QDR), a massive document laying out military strategies, objectives, threats and doctrine, and setting priorities from spending on future weapons systems to the training of America’s armed forces. But what about the diplomats? Not to be outdone,
Secretary of State Hillary Rodham Clinton announced last year that the State Department would begin issuing its own
am announcing that I will have an an- nouncement sometime . . .”) was a great tweak of all the useless “exploratory committees” and “listening tours” that politicians serve up and that, for no good reason, are treated as a big deal. But when you actually announced the
Reinhardt and others titled “It’s the Prices, Stupid.” The price problem is only getting worse, researchers and an- titrust investigators have found, be- cause of consolidation among provid- ers, and it could be exacerbated by goading them to form even bigger net- works.
But the notion that we pay more, de- spite using health care less, never caught on during the long march to re- form. The main culprits driving our health-care costs were deemed to be in- efficient doctors in a few corners of the country and demanding consumers — say, people seeking unnecessary surgery or patients with unhealthy habits and chronic conditions. The camp that believes volume is the main problem disputes the idea that bigger networks of hospitals and doc- tors would make the price problem worse. “The more we’re able to encour- age integrated systems of care, the bet- ter,” the new Medicare director, Donald Berwick, a Dartmouth data champion, told me before his nomination by Oba- ma.
KRISTIN LENZ
Berwick and his allies say they never meant for overuse of care to become the sole focus. Elliott Fisher, the lead Dart- mouth researcher, said he did not in- tend for his data to be “interpreted as letting off the hook” those providers that kept overuse in check but charged high prices. “We clearly need to do both” prices and volume, he said. But we didn’t do both in the health-
be brought in line with lower-spending places such as the Mayo Clinic’s home town, Rochester, Minn. — through the formation of integrated networks of sal- aried doctors — costs could be reined in. The theory caught fire at the White
House. It gave President Obama and his then-budget guru Peter Orszag a way to talk about costs without taking on doc- tors and hospitals; instead, the White House could simply differentiate be- tween providers that offer “value” and those that don’t. But the Dartmouth rankings, and the concept they supported, did a “disserv- ice” to the debate, said Robert Berenson of the Urban Institute. For one thing, he and others say, the figures overstate re- gional differences in Medicare spend- ing, which shrink when socioeconomic factors are taken into account. Second, rates of Medicare spending are not nec- essarily representative of health-care spending for people under 65. Some of the places that do well in the Dart- mouth rankings charge high prices for non-Medicare patients — and were, not surprisingly, among those pushing hardest against a public option. More broadly, the skeptics argue that merely providing care in smaller quan- tities will not sufficiently lower costs. They note that Americans already have shorter hospital stays and fewer doc- tors’ visits than people in other ad- vanced countries. What sets us apart is our high prices for these health-care “units”— a finding trumpeted in a land- mark 2003 paper by Princeton’s Uwe
.
care law, which raises the question of what will happen once the overhaul proves inadequate to the price problem. Perhaps the public option will be recon- sidered, as many liberals hope. Perhaps there will be a new push for lower drug prices. Or maybe there will be a return to the rate-setting that prevailed dec- ades ago, when hospitals, insurers and state officials worked together to agree on prices. Maryland is the only state that still does this, and data suggests that it has kept its cost growth lower than average. Massachusetts is consid- ering a similar approach. Would such measures have a chance?
Perhaps. For one thing, as skeptical as insurers are of government interven- tion, they are glad to discuss reform that aggressively goes after providers. “We have a major cost problem, and we have to get on with the job of attacking it — with every stakeholder who is re- sponsible for that,” said Karen Ignagni, the insurance industry’s chief lobbyist. And the public? The Brookings Insti-
tution’s Henry Aaron predicts that there may be support for tougher action on high prices once the principle of uni- versal health coverage is established, since taxpayers will be on the hook for more of the cost of insurance. “If we at- tacked costs right at the front end, [the legislation] would have died,” he said. “Now, we’ll have a mechanism that will force us to address it. There are only so many fronts you can fight a war on at the same time.” That’s assuming, of course, that the
law survives long enough to enjoy any embellishment.
macgillisa@washpost.com
rally nine days later, I started worrying. There you were, claiming leadership over 70 to 80 percent of America, calling for solutions that we could “agree to try and could ultimately live with.” Criticiz- ing “the loud folks [who] over the years dominate our national conversation on our most important issues.” Your deliv- ery was hilarious (as were the rally signs), but your words were those of a politician. The whole time I was half- expecting you to suddenly meet us at Camera 3 and whisper that, of course, this wasn’t real, this wasn’t you. This whole thing reminds me of your
“Crossfire” appearance back in 2004, when you confronted Paul Begala and Tucker Carlson over the left-right noise pollution of their show. Your message — “Why do we have to fight?” “Why do you argue?” “Stop hurting America” — got the sound bites, but most memorable was your response when Carlson im- plored you to be funny. “No,” you said, “I’m not going to be your monkey.” In other words, you were being seri- ous. And your message that day sounds a lot like the message of the rally: “Take it down a notch, for America.” At the time, critics said you were too
preachy, and I admit I worried that the exchange would shatter the illusion of “The Daily Show.” But you pulled it off. Rather than bring you down, “Crossfire” has become part of official Stewart lore. Now you’re doing something similar, but on a much larger stage, and this time you’re insisting that it’s not real, that it’s all a satirical “construct.” I really hope so, but I’m not sure. If satire is the art of say- ing something fake and pretending it’s real in order to make a point, you seem to be doing the opposite with this rally: Doing something real and pretending it’s fake in order to make your point. We don’t need you to hold a rally to re- store America’s sanity. We go to that rally every Monday through Thursday night, when we tune in to your show. We keep watching because you call out the endur- ing ridiculousness of politics and, for half an hour, you make us laugh about it rather than despair over it. We don’t ex- pect you to end it or fix it; no one can, and your naming it is enough. As you told the “Crossfire” guys, you thrive on the theater of politics: “The absurdity of the system provides us the most materi- al.”
We already have a formerly hilarious
satirist turned sober politician. America doesn’t need another Al Franken. We need Jon Stewart. And who is that? Over the years,
there’s been a lot of semi-academic psy- cho-babble trying to deconstruct you. Is Jon Stewart good for America or bad for democracy? Is he our media critic in chief or the nation’s moral con- science? Is he a liberal activist mas- querading as a comedian or the voice of a generation fed up with conventional politics? And there has been more hyper-
ventilating as the rally draws near. In Salon, Glenn Greenwald at- tacked you for your supposed mid- dle-of-the-road moral equivalence between extremist crazies on the left and the right; Slate’s Timothy Noah, by contrast, worries that you, Stephen Colbert and the adoring throngs will come off as such pedantic, anti-tea-party hyp- er-liberals that the backlash will affect the midterms. I’m fairly certain that your rally
won’t change the face of Amer- ican politics or alter the fate of the republic. But I worry that it will change you — or our perceptions of
you. You’ve always been able to deflect those Meaning of Stewart debates by saying, not entirely convincingly, that hey, it’s just fake news. After this rally, though, you won’t be able to say that with a straight face. Now it’s real news. Some news organizations have even pro- hibited their staffers from participating in your rally, just like any old political event. Beware the company you keep.
2001, not long after the 9/11 attacks, were raw and real — and that was probably as serious as we’ve ever seen you on your show. But even in those horrific circum- stances, you seemed aware of how out of character you were, and you offered a preemptive apology. “I’m sorry to do this to you,” you said
N
that night. “It’s another entertainment show beginning with an overwrought speech of a shaken host, and television is nothing if not redundant. So, I apologize for that.” (You even joked that the cast of “Survivor” would soon be weighing in with its post-9/11 insights.) In the middle of the speech, though, you also gave a perfect description of what you do — and why we like it. “The show in general, we feel like, is a privi- lege,” you said. “Even the idea that we can sit in the back of the country and make wisecracks, which is really what we do. We sit in the back and we throw spitballs.” Keep throwing spitballs from the back. Don’t try to move to the front of the country. You and Colbert are America’s Statler and Waldorf come to life, mock- ing the proceedings as they unfold.Don’t risk that by entering the political fray so overtly. By all means, Colbert should hold his “March to Keep Fear Alive.” If right-wing television hosts are having rallies and upending “The View” these days, Colbert’s character should abso- lutely follow suit. You should show up at the Mall on
Oct. 30, have a cameo and walk off the stage. And keep our Moment of Zen go- ing.
lozadac@washpost.com
o doubt, being earnest makes sense sometimes, particularly when there is no alternative. Your emotions on “The Daily Show” episode of Sept. 20,
ASSOCIATED PRESS
What’s the
big idea?
Quadrennial Diplomacy and Development Review. “Instead of simply trying to adjust to the way things are,” Clinton said in July 2009, when she announced the initiative, “we need to get in the habit of looking to the horizon and planning for how we want things to be.” So, how does Madam Secretary want things to be? The QDDR won’t be made public until next month, but in a 5,500-word essay forthcoming in the November/December issue of Foreign Affairs, Clinton offers a preview:
It’s not all about governments anymore. “In the 21st century, a diplomat is as likely to meet with a tribal elder in a rural village as a counterpart in a foreign ministry, and is as likely to wear cargo pants as a pinstriped suit,” Clinton writes. She calls on diplomats to engage directly with the private sector, civil society and opinion leaders, especially in authoritarian states. How? By drawing from all agencies of the U.S. government to create a “global civilian service of the same caliber and flexibility of the U.S. military.”
Note the second “D” in QDDR. Clinton wants to elevate development as a co-equal
among the priorities of U.S. foreign policy. “Strengthening middle classes around the world will be key to creating the just and sustainable international order that lies at the heart of the United States’ national security strategy,” she writes. She also threads the needle on the old debates about the links between destitution and extremism:
“Poverty and repression do not automatically engender terrorism,” Clinton says, “but countries that are impoverished, corrupt, lawless . . . are more prone to becoming havens for terrorists and other criminals.”
Diplomats at war. Clinton notes that one in five U.S. diplomats is working in
Iraq, Afghanistan or Pakistan. In Iraq, for instance, there are 1,600 civilians working alongside the 50,000 U.S. troops still there, and in Afghanistan, some 1,100 diplomats and civilians are leading reconstruction and development efforts and “will remain there after U.S. troops are gone.”
More cash is needed. “The House and Senate have appropriated hundreds of billions of dollars for the military missions in Afghanistan and Iraq,” Clinton writes. “The diplomatic and development activities there represent a fraction of that cost, yet the funding often gets bogged down in old debates over foreign aid. . . . These missions can succeed, but only with the necessary congressional leadership and support.” And that is really the critical question. Clinton and her colleagues at State can write all the strategy documents and policy reviews they want, but in midst of an economic crisis and exploding deficits, will they get the resources to see their vision come to life?
—Carlos Lozada
lozadac@washpost.com
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