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July 24, 2009

BILL MOYERS: Welcome to the Journal.

Push finally came to shove in Washington this week as the battle over health care reform escalated from scattered sniper fire into all-out combat.

REP. STEVE KING: Socialized medicine produces rationing of care

PRESIDENT BARACK OBAMA: One of the plans that we've talked about is a public option

MALE REPORTER: You've been pushing Congress to pass health care reform by August. Why the rush?

MICHAEL STEELE: $239 billion to the deficit by 2019.

REP. LOUISE GOHMERT: We're talking about a nightmare for the American people.

KATIE COURIC: It's not going to add to the deficit?

PRESIDENT BARACK OBAMA: It will not add to the deficit


BILL MOYERS: If this all seems to be getting more and more confusing, well join the club. It's hard to see what's happening through all the gunsmoke.

The Republicans have more than health care reform in their bomb sights -- they want a loss for Obama so crushing it will bring the administration to its knees and restore Republican control of Congress after next year's elections. In the words of Republican Senator Jim DeMint, "If we're able to stop Obama on this, it will be his Waterloo. It will break him."

The Waterloo of DeMint's metaphor, of course, was the battle in 1815 that ended Napoleon Bonaparte's rule as Emperor of France -- a humiliating defeat and a turning point in European history. Right-wingers like Glenn Beck see Obama as Napoleon, an emperor who must be stopped.

GLENN BECK: I mean, this guy is practically an imperial president now. When he starts to lose and people start to question him and push him back against the wall, he's not going to know how to react."

BILL MOYERS: The Republican strategy is almost identical to the way they turned health care into Waterloo for Bill and Hillary Clinton in 1993.

HARRY: Find more you like in the President's plan?



LOUISE: It just doesn't have the choice we want. Look at this.

BILL MOYERS:Back then, one of their chief propagandists, William Kristol, urged his party to block any health care plan for fear Democrats would be seen as, quote "...the generous protector of middle-class interests." Now he's telling the G.O.P. to "Go for the kill...throw the kitchen sink [at it] a stake through its heart... we need to start over."

So in lockstep are the Republicans that when strategist Alex Castellanos issued a memo on the battle plan, party chairman Michael Steele echoed it word for word in a speech at Washington's National Press Club.

Castellanos: "Slow down, Mr. President. We can't afford to get health care wrong."

MICHAEL STEELE: "Slow down, Mr. President. We can't afford to get health care wrong."

BILL MOYERS: Castellanos: "The old, top-down Washington-centered system the Democrats propose will empower Washington to restrict the cures and treatments your doctor can prescribe for you."

MICHAEL STEELE: "The old top-down Washington-centered system the Democrats propose is designed to grow Washington's power to restrict the cures and treatments your doctor can prescribe for you."

BILL MOYERS: Castellanos: "President Obama is experimenting with America, too much, too soon, and too fast."

MICHAEL STEELE: Your experiment promotes -- proposes too much, too soon, too fast.

BILL MOYERS: As the Republicans fired away, big business stepped up the attack, too, their lobbying and advertising guns blazing. In certain key states where members of Congress remain on the fence, the airwaves are vibrating with television commercials aimed at shifting hearts and minds away from any change that might threaten profits.

[ADVERTISEMENT SOT]: What will happen to your family's health care if Washington runs it?

[ADVERTISEMENT SOT]: Now Washington wants to bring Canadian-style health care to the US.

BILL MOYERS: President Obama rejected the Republicans' Waterloo metaphor, but mounted a massive media counteroffensive of his own.

PRESIDENT BARACK OBAMA: Another Republican senator, that defeating health care reform is about breaking me. So let me be clear. This isn't about me.

I have great health insurance, and so does every member of Congress. This debate is about the letters I read when I sit in the Oval Office every day, and the stories I hear at town hall meetings... I'm the President. And I think this has to get done.

BILL MOYERS: But the President's already stepped on booby traps of his own making, and minefields laid by his own party, especially when the Congressional Budget Office reported that his reforms, instead of controlling costs, would send the national debt further into the stratosphere.

Meanwhile, supporters who want to scrap the present system for fundamental change are staring glumly through the fog of war at a battlefield in total disarray. They fear that in the White House's desire to get a bill -- any bill -- passed by Congress, it will have been so compromised, so bent to favor the big interests, that it will be less Waterloo than water down, a steady diluting of what they'd hoped for, or America needs.

The big drug companies are already so pleased with what they've been promised that they've brought back Harry and Louise -- the make-believe TV couple who helped take down the Clinton health care plan.

LOUISE: Because everyday more and more people are finding out that they can't afford healthcare.

BILL MOYERS: But this time they're in favor of reform...

LOUISE: Coverage people can afford. Coverage they can get...

BILL MOYERS: Could it be that Harry and Louise are happier because this time, they're in on the deal?

What to make of all this? I've asked two expert analysts of health care to help me out.

Trudy Lieberman covers health care reform for the Columbia Journalism Review and directs the health and medicine reporting program at the City University of New York's Graduate School of Journalism.

Marcia Angell, a physician herself, is Senior Lecturer in the Department of Social Medicine at Harvard University Medical School and was the first woman Editor-in-Chief of the New England Journal of Medicine. She, too, has written widely and often about health care reform.

Welcome to both of you.



BILL MOYERS: So, Trudy Lieberman, is it Waterloo or no Waterloo, is that the question?

TRUDY LIEBERMAN: Waterloo for who? Whether it's a Waterloo for the American people, who aren't going to or may not get a resolution of this, and they certainly do need some help along the way with health care. Or is it, say, a political question for the President?

BILL MOYERS: Well, the Republicans have made it this week, clearly and sharply, a political challenge to him.

TRUDY LIEBERMAN: I think it's going to be interesting to see what happens. A lot of people have said this is a do or die issue for the President. That's certainly-- that rhetoric certainly hadn't been coming up really before the last several weeks.

MARCIA ANGELL: And I would say, on the politics first, that it is something of a Waterloo. In the sense that if he doesn't get it right he's going to be President for three more years. And the chickens will come home to roost.


MARCIA ANGELL: So-- well, it can-- the failure can show up before he's out the door. And then he's got a real problem. He was right in his press conference, when he talked about cost as the central issue. And he said, if we don't control cost, not only will the health system continue to disintegrate, but it'll drag the whole economy down with it.

What he has essentially advocated is throwing more money into the current system. He's treating the symptom and he's not treating the underlying cause of our problem. Our problem is that we spend two and a half times as much per person on health care as other advanced countries, the average of other advanced countries. And we don't get our money's worth. So, now he says, okay, this is a terribly inefficient, wasteful system. Let's throw some money into it.

BILL MOYERS: Into the same system?

MARCIA ANGELL: Into the same system. That's his problem. The other problem, in the press conference, was that he was trying to mobilize public support for a bill, and we don't know what that bill is.

TRUDY LIEBERMAN: I want to get to that point, because he's been vague right from the very beginning on this point. We have not known exactly what the Obama health plan has been. Even though the headline writers, and the press has been talking about his health care overhaul for months. And so, I like to step back and say, "Well, what exactly is he talking about? What exactly does he mean?" And he has not been clear on that.

BILL MOYERS: You said he's been AWOL, A-W-O-L--


BILL MOYERS: --on details.

TRUDY LIEBERMAN: He has been out to lunch on this. And I think that's a deliberate strategy on the part of the White House.


TRUDY LIEBERMAN: What they had done is learn from what they call the Clinton mistakes in '93-'94. And what happened then is that Hillary came out with this big 1 thousand-page bill, although we have now another 1 thousand-page bill. And let the special interest groups sort of pick it apart. This time, they decided not to do that. That they would be deliberately vague about this. And stay as vague as they could be until push came to shove.

And so basically, it's my belief that this whole discussion about health care reform is flying over the heads of the American people. They know about reform, but they don't know-- they know the words reform, but they don't know what they mean at all.

BILL MOYERS: I had the same reaction you did to that press conference. And I woke up Thursday morning after the press conference, to the headline of "The New York Times" that read, "President Seeks Public Support On Health Care." And in the margin of the Times I said, "Does the public know what is in this health care--"

MARCIA ANGELL: He doesn't know. Nobody knows. One thing we—

BILL MOYERS: Well, somebody has to know. They keep talking about it.

MARCIA ANGELL: Well, he says, let Congress do it. In their wisdom, they'll come out with something, and I will give you a few feel-good principles. And then we'll wait and see what happens. Because he doesn't want his fingerprints on it if it fails.

TRUDY LIEBERMAN: I feel the American people need to know what is in that bill. And what's in the bill is an individual mandate that is going to require all Americans with a few exceptions, to carry health insurance. And that means if you do not get insurance from Medicare or Medicaid or your employer. You're going to have to go out and buy health insurance.

And that is a lot of money for most people because most of them would buy it now if they could afford it. About 85 percent of the uninsured require subsidies, because they can't afford it. And I think this is going to come up as a big surprise to people to realize they're going to have to buy insurance from private insurance companies or face a tax penalty.

MARCIA ANGELL: Well, that goes to the cause of the problem. We are the only advanced country in the world that has chosen to leave health care to the tender mercies of a panoply of for-profit businesses, whose purpose is to maximize income and not to provide health. And that's exactly what they do.

BILL MOYERS: The President, as you were saying a moment ago, is saying to everybody who's not covered, we're going to mandate that you exercise that right. We're going to mandate that you buy some form--

MARCIA ANGELL: We're going to deliver the private insurance companies a captive market. That's right. And they love that.

BILL MOYERS: Say that again.

MARCIA ANGELL: They love that.

BILL MOYERS: The-- his policy does what? His program?

MARCIA ANGELL: Delivers to the private insurance industry a captive market.

BILL MOYERS: By the mandate.

MARCIA ANGELL: By the mandate.

BILL MOYERS: It says "Marcia Angell, you've got to--"

MARCIA ANGELL: For whatever price they want to charge. Right. And so, this will increase costs. And let me tell you what he's running into, and he'd like to be able to pull a rabbit out of the hat, but he won't be able to. If you leave this profit-oriented system in place, you can't both control costs and increase coverage. You inevitably, if you try to increase coverage, increase costs. The only answer, the only answer, and he said it at the beginning of his press conference, is a single payer system. In his first sentence, he said, that is the only way to cover everyone.

BILL MOYERS: But he's also said, if we were starting the system from scratch, we could have single payer. But we're not starting this system from scratch.

MARCIA ANGELL: You know, you don't pour more money into a failing system. You convert.

BILL MOYERS: I saw back in the spring-- the chief lobbyist for the Big Pharma industry, Billy Tauzin, used to be a member of Congress. He was on CNBC. And he was in support of this bill, whatever this bill is. Because it would broaden the industry's customer base by providing subsidies for people to buy--


BILL MOYERS: More coverage from the private insurers.

TRUDY LIEBERMAN: At whatever price they want to charge. It will be a bonanza for the health insurance industry. And a bonanza for the pharmaceutical industry. And for the doctors, too. Because the doctors are going to get more paying patients, because people will now have this ticket, this insurance card, that they can whip out when they need medical services.

BILL MOYERS: So, does this explain why Harry and Louise, who were around 15 years ago to help defeat Bill Clinton's health plan, Bill and Hillary Clinton's health plan, are back now in support? Seemingly to be in support?

MARCIA ANGELL: You bet it does. You bet it does.

BILL MOYERS: Let me show you the commercials that's been running now, watch closely.

HARRY: Well, it looks like we may finally get health care reform.

LOUISE: It's about time. Because everyday more and more people are finding they can't afford health care.

HARRY: Or they're losing coverage?

LOUISE: We need good coverage people can afford. Coverage they can get--

HARRY: Even if they have a pre-existing condition.

LOUISE: And coverage they can keep if they change jobs.

HARRY: Or lose their jobs. Sounds simple enough.

LOUISE: A little more cooperation, a little less politics. We can get the job done this time.

BILL MOYERS: Wouldn't that make you think that Big Pharma is supporting health care reform?

TRUDY LIEBERMAN: That's exactly--


TRUDY LIEBERMAN: That's what they're supposed to be--

BILL MOYERS: But on their terms, right?

MARCIA ANGELL: On their terms. Exactly. Exactly.

TRUDY LIEBERMAN: This is what those ads are supposed to do. They're supposed to make the ordinary person believe that they're good guys this time around.

BILL MOYERS: And on their terms means what for them?

MARCIA ANGELL: Well, they can charge whatever they want. That there will be no bargaining. That--


MARCIA ANGELL: That Medicare Part D will not bargain for lower prices. There'll be no formularies. You know, even this thing about the pharmaceutical industry is going to kick in $80 billion over ten--

BILL MOYERS: Have we heard--

MARCIA ANGELL: --years. That the President mentioned in the press conference.

TRUDY LIEBERMAN: Only if health care passes. So.

MARCIA ANGELL: First this is $8 billion a year for the pharmaceutical industry. This is chump change. And second, it's only for brand-name drugs. So, in a sense, it's a subsidy for the most expensive drugs.

BILL MOYERS: Do you believe the health care industry when it tells President Obama that "we will voluntarily cut costs"?

MARCIA ANGELL: No. I mean, these are investor owned businesses. If they behave like charities, heads would roll in the executive suites. They are there to maximize profits. And that's exactly what they do.

TRUDY LIEBERMAN: What's happened now is that the industries have gotten pretty much what they want out of the bills that are going forward.

And so, they need to build public support. They need to make everybody in the public realize that they actually are wearing white hats in this one. But behind the scenes, they are lobbying ferociously against the public plan, against cuts in doctors fees, against all kinds of things that they don't want. And for that they're using a different sort of lobbying tactic. All of these are communications or lobbying strategies that they know how to do and they are very excellent at doing them.

MARCIA ANGELL: It's clear that they can turn it to their advantage.


MARCIA ANGELL: That nobody is really trying to break their-- except the single payer people -- their death grip on the system. And here you have hundreds of for profit insurance companies that maximize their income by denying care to the people who need it most. And that's the insurance system. That's how we pay for health care.

But you also have to look at how we deliver health care. And we deliver that, primarily or largely, in for-profit facilities -- businesses, hospitals -- whose interest is in delivering only profitable care. So, we have a system that's through and through, in both the payment system and the delivery system, is oriented toward profits. Neither the Senate nor the House is doing anything to change that.

BILL MOYERS: The President says there will be a public option in my bill that will compete with the private insurance. To bring the cost down.


BILL MOYERS: That's what he said.

TRUDY LIEBERMAN: That's what he says. Again, we get back to the detail question and the particulars, which are so absent in this whole discussion. We don't know what a public plan will look like. And even if there's going to be a public plan. The insurers don't want it. It's not clear that the doctors want it. And the pharmaceutical companies don't want it.

So my question is, are they working behind the scenes to make sure this doesn't happen? My guess is-- my answer is, they probably are.

MARCIA ANGELL: A lot is said about how the public wants to cling to what it has. What I'm finding is something that confirms the polls that have been done. Showing that something like two-thirds of the public would favor a Canadian style or a Medicare for all style single payer system.

The same is true of physicians, now. About 60 percent of physicians favor Medicare for all, or a single payer system. So, what is against it? The pharmaceutical and the insurance industries are the biggest lobbies in Washington. They spend millions and millions on influential members of Congress. And the amount that they are spending now to the Chairman of the relevant health committees has increased enormously in the past few months.

BILL MOYERS: Just the other day the Chamber of Commerce began running an advertising campaign. And the Chamber says a new government run plan will undermine employer sponsored coverage and eventually lead to a government takeover of the health care system.

MARCIA ANGELL: Like Medicare.

BILL MOYERS: Alright. That will limit--

MARCIA ANGELL: That's scary.

BILL MOYERS: That will limit patients' choices. I mean, isn't that proving to be a convincing argument with the public? That seems to be--

MARCIA ANGELL: Well, it's phony, of course.


MARCIA ANGELL: It's phony, in the sense that Medicare is a single payer system, embedded within our larger market-based system. You have totally free choice of a physician in Medicare. You don't in most employer-sponsored private plans. Canada, totally free choice of doctors. So, this is simply not true.

BILL MOYERS: Let me show you both a couple of clips from the House floor recently. And get your comments on them. These are two Congressmen who are opposed to any kind of national insurance or general coverage. Look at this.

REP. STEVE KING: They're going to save money by rationing care, getting you in a long line, places like Canada and the United Kingdom and Europe. People die when they're in line.

REP LOUIE GOHMERT: One in five people have to die because they went to socialized medicine! Now I've got three daughters and a wife. I would hate to think that among five women, one of them is going to die because we go to socialized care and we have to have these long lists to get a mammogram. Once you find it to get treatment. It's insane.

TRUDY LIEBERMAN: We've heard these arguments since 1948. And what amazes me -- they opposed a national health system under President Truman. So, that notion, that conventional wisdom in America is pretty ingrained and pretty deep. What they fail to say here is that people are waiting in line in America. We ration care in America. We do it by income. People who don't have money and the ticket to health care, do not get the care.

So that rationing is taking place. But even people who do have insurance are waiting months for mammograms. In Florida, there's been a horrible shortage of places where women can go and get mammograms. And most people have to wait a long time to get an appointment with a doctor for an annual physical.

MARCIA ANGELL: If we continue to spend what we do, right now, on health care, but had a system that distributed it according to medical need, there would be no rationing. And if we held it at that cost, there would never be any rationing. So, it's simply not right. The problem is not the money, it's the system. There is more than enough in the system already. And that's why I don't think it's a good idea to pour more money into a dysfunctional system.

Obama said, in his press conference, the worst thing we can do is nothing. The most costly thing we can do is nothing. Now, I disagree with that. You can throw more money into this system and make it even more costly. But in a sense, we are at a point now, where we have to act. And we have to confront the private insurance industry directly.

BILL MOYERS: Do you see any evidence that the President wants to do that?

MARCIA ANGELL: No, no. But--

BILL MOYERS: Is willing to do that?

MARCIA ANGELL: But what I would say this time around, and now I am going to be very pessimistic, Bill. This time around, I don't think it's going to happen because of the power the pharmaceutical and insurance lobbies. I don't think it's going to happen. But I would rather see Obama go down fighting for something coherent and practical that the public could mobilize behind, than go down fighting for this amorphous plan that tries to keep these private insurance industry in place.

BILL MOYERS: It seems to me like they're more finessing than fighting.

MARCIA ANGELL: Well, he will have to fight. But I think he'll go down.

TRUDY LIEBERMAN: They've been finessing since the very beginning. They've been finessing since the campaign. During the campaign, he was not even willing to be pinned down. He had a whole list of things that he would like to do. But so did Hillary Clinton and John McCain. And in some ways, they really weren't all that far apart, except on the issue of long term care.

That is another time bomb that is awaiting America and nobody has talked about it. But aside from that, I see an Administration that is trying to keep this playbook going as long as possible. And to commit as little as possible until the 11th hour. And by then, it's going to be too late for the American people to know what's going to await them. And as a journalist, whose job it is to explain to the average person on the street what all of this means to them-- that's not happening. And as a journalist, that troubles me. The press has not dealt with the issue of how this is going to affect the auto mechanic on Main Street. Or the babysitter. Or--

MARCIA ANGELL: We don't know what this is.

TRUDY LIEBERMAN: But we know the outlines enough. We know about the individual mandate. We sort of know that if there's a public plan, it might be this tiering arrangement that has a bronze, silver, and gold kind of arrangement. And you can pay more if you have more. Which still perpetuates the problem that we have. We know enough so that journalists can write the story.

BILL MOYERS: Do I hear you both saying, in effect, what Bill Kristol, the Republican strategist said this week? "Kill this bill. Kill this proposal that Obama is pressing and start over?"

TRUDY LIEBERMAN: Well, not in fact.

MARCIA ANGELL: Not exactly.

BILL MOYERS: You're hesitating.

MARCIA ANGELL: I'm hesitating. Because I don't think he's grasped the nettle. And I don't think that even the best of the proposals that he is considering are going to be effective. And I worry about even the public option, because--

BILL MOYERS: You've been skeptical of the public option.

MARCIA ANGELL: I'm skeptical of that, because the power of the insurance industry is so great that I believe that they would use their clout in Congress to hobble the public option in some way. And have it become a dumping ground for the sickest patients, and then cream off the profitable ones for themselves. And then what people would decide is that the public option was no good. That the public couldn't do any-- the government couldn't do anything right. And that would be the wrong lesson to dwell on.

TRUDY LIEBERMAN: That's what some people fear will happen to Medicare. That it will be privatized in some way, to deal with--


BILL MOYERS: Part D is...

TRUDY LIEBERMAN: --and only the sickest people will remain in the Medicare pool of people, who get benefits. I want to go back to Kristol's argument. And what he well, we sort of know what the conservative plan might look like. It's basically a market-based approach that would rely on private insurance but also on what is a relatively new kind of insurance arrangement called "consumer-driven health care."

And by that we mean policies that have very high deductibles. I've seen some being sold, by some of the Blue Cross plans, as being $20 thousand deductibles. And $40 thousand if you go out of network. So, is that really insurance? And are people going to be buying these, because they will be affordable, because the higher the deductible, the cheaper the policy. And so then what's going to happen to them when a serious illness strikes, and they have to cough up the money? They're not going to have it. So, this whole issue of underinsurance, which is kind of tied in with the conservative approach, hasn't even been discussed.

BILL MOYERS: Given what you've said, why the rush? Why not slow this down and give this very big issue more due deliberation?

TRUDY LIEBERMAN: It's really a political calculation. And I think that they believe that they have to act quickly, because it might not happen. Because the sooner you have the special interests going back home, during the August recess and holding town hall meetings and talking to people in coffee shops, they're going to find that maybe this isn't something that people really want or have doubts about.

MARCIA ANGELL: Well, I think we are in a hurry. I think that President Obama's worried, that what happened with the Clinton plan can happen with him. And I do have a feeling of déjà vu all over again. That this is like 1993. That the opposition is having a chance to mobilize. To march out these Canadians who say they had brain tumors and had to die. Or these ads that say 20 percent of Europeans drop dead.

TRUDY LIEBERMAN: And Harry and Louise are back

MARCIA ANGELL: And I think he does. He is right to worry about that. And he is right to want to do it in a hurry. The problem is he is not doing the right thing.


MARCIA ANGELL: Well, the plan is not for all the reasons we've said. It leaves the bad guys in place. And it tries to kind of make concessions. And what the Clintons found out is they too wanted to keep the private insurance industry at the table. And maybe regulate them a little. And what the private insurance industry decided was, "Why should we take half a loaf when we can have the whole thing?" And that's what I'm seeing happen. Happening now.

TRUDY LIEBERMAN: We are having the same debate, almost, that we had in '93-'94. And it's something I've written about for the Columbia Journalism Review. It's actually the same debate we've had decades before. And it's the unwillingness to look at what we could learn from other systems. Single payer, multiple payers, as they have in Germany and Japan. Or even in the Netherlands, where there are private payers. What's really happening there?

So, I think there's an unwillingness on the part of politicians-- on the part of advocacy groups, some advocacy groups, to really educate Americans on what the possibilities are. And we at C.J.R. have been saying we really have not had a vibrant discussion about other possibilities.

MARCIA ANGELL: I think we have to start all over on this. I really do. I think we have to go for a single payer system. You could institute that gradually. You could do it state by state. You could do it decade by decade. You could improve Medicare. That is, make it nonprofit. But extend it down to age 55 and age 45 and age 35. It would give the private insurance industry a chance to go into hurricanes, earthquakes or something. To get out of the health business. It could be done gradually. I think that has to be done. And it's the only thing that can be done.

BILL MOYERS: The story goes on and we'll continue to talk about it in the months to come, alright? Marcia Angell, Trudy Lieberman, thanks for being with me on the Journal.

MARCIA ANGELL: My pleasure.


ERNESTINE TOMLIN: Claims department, Ernestine Tomlin. Nope not covered. We consider that an elective procedure. Meaning, we elect not to pay for it. Well it's not our fault you've had two heart attacks, you should have stopped at one. Of course you have your choice of doctor! Do you want the doctor we give you or not? It's your choice! You must think HMO stands for "Help Me Out." Remember, your health is our business, not our concern.

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