Ezekiel Emmanuel helpfully provides clues.
Bear in mind that this is a pro-Obama, pro-ObamaCare piece.
To control costs and improve quality in health care, [hah! - Aggie] the White House economic team believed that we had to change the way physicians are paid. About 85% of payments to physicians are fees for individual services—which gives doctors incentives to order more tests and interventions. Fee-for-service puts volume above value; it rewards treating sickness rather than promoting health.
“Bundled payments” are widely recognized as a promising new approach to paying doctors. If fee-for-service payment is like ordering a la carte, bundled payment is like a prix fixe menu: It puts all the costs for an episode of care together for one price. A bundle payment for, say, a hip replacement would include X-rays beforehand, the surgeon’s fee, the artificial hip itself and rehabilitation therapy afterward. Since the doctors are paid one fee for the entire episode of care, regardless of how many tests and scans and drugs they order, they no longer have an incentive to provide unnecessary care for a few extra bucks. When implemented in hospital settings, bundled payments have been shown to encourage providers to improve efficiency and eliminate unnecessary procedures without stinting on care.
We presented the idea of phasing in bundled payments, especially for chronic conditions, to the rest of the White House reform team, where we found some strong support. But then we hit a brick wall. Many of our colleagues who worked for Medicare feared that creating the bundles would be too hard and warned that Medicare didn’t have the computer infrastructure to handle it.
The arguments went back and forth, but the Medicare bureaucracy wouldn’t budge. Ultimately, the ACA authorized 10 demonstration projects that could be expanded if they worked—a good start, but a far cry from the more ambitious bundling plan many of us had hoped to see.
Ok, let’s deconstruct. Dr. Emmanuel is telling us that physicians are corrupt and steal money by ordering unnecessary tests. These procedures line their pockets. His solution is to change the way they are paid, such that they can only charge for one broad treatment – cancer or fix broken wrist, but not break it out into those pesky payments which are simple to abuse. My question: What prevents unscrupulous physicians from simply skimping on treatment in order to maintain their lifestyles? Why wouldn’t they order insufficient testing and treatment? He’s already told us they are crooks, but they are not dumb crooks, are they?
Dr. Emmanuel uses another example to show just how corrupt President Obama is. Hey, he could have been a doctor!
Another clash, over what health wonks call the “tax exclusion,” vividly demonstrated that good policy can overcome politics.
In 1954, the Internal Revenue Service created a tax exclusion for health insurance premiums, which is why health benefits offered through an employer aren’t subject to income or payroll taxes. This makes an additional dollar of health insurance (which isn’t taxed) more valuable than an additional dollar of wages (which is).
Economists—liberal and conservative alike—overwhelmingly denounce the tax exclusion. It drives costs higher while keeping wages down, it is regressive, and it is a major drag on the federal budget—lowering revenue by a whopping $250 billion a year.
During the 2008 presidential campaign, Senator John McCain proposed eliminating the exclusion and replacing it with a $5,000 tax credit to help families buy health insurance. The Obama campaign ran more than $100 million worth of ads pounding McCain, accusing the GOP nominee of “taxing health benefits for the first time ever.”
Get it? Obama spent 100 million bucks saying that McCain was a big, bad wolf because he wanted to correct a situation that everyone believes is stupid. So what did our hero, Barack Obama, do?
Once Obama was in office, his advisers split on the issue. The economists wanted to limit the exclusion, but the political team didn’t want to touch it. David Axelrod, the president’s political guru, even showed us a montage of Obama’s campaign commercials to remind the economic team of his stated position. The president himself repeatedly insisted on the principle of fidelity: Campaign promises weren’t to be contravened without a very good policy rationale.
One Friday in July 2009, the president made a surprise appearance at a meeting of key health-care advisers. When the discussion moved from pleasantries to substance, I argued for limiting the tax exclusion. Obama already understood that this would raise revenue to fund the expanded coverage, but that wasn’t reason enough to change his position. So I tried a different argument. If reform was to succeed, it had to control rising health-care costs, which threatened to overwhelm the economy. Limiting the tax exclusion, I argued, was the most powerful lever the president had to control costs on the private side.
Ultimately, Obama authorized a new tax-exclusion policy despite the heartburn he knew it would cause his political base—particularly labor unions. We proposed a tax on high-cost “Cadillac plans,” which will begin in 2018. Reversing a campaign position took a lot of guts, but this was good policy, and the president showed leadership in endorsing it.
Hem. That’s one way to spin it. Another is that he lied in order to get elected, then changed his promise in the face of reality. Like he has done again and again. If you like your plan you can keep your plan, stupid.
And this last little bit shows you just how classy Rahm Emmanuel is, Ezekiel Emmanuel is, and Barack Obama is:
Late one summer afternoon, I met my brother Rahm—then the White House chief of staff—in his West Wing office. We chatted, and then he asked in his usual staccato, “What else is going on, Zeke?”
“I’m also working on the medical malpractice proposal I told you about,” I began.
He immediately cut me off: “Shut the f— up! We are not doing malpractice. Period. Every time the AMA comes in here, they don’t talk about malpractice.” Their first, second and third priority, he said, was the formula used by Medicare to determine doctors’ pay. “We don’t need to do malpractice for the doctors, and I am not alienating the president’s base for nothing,” he barked. “Stop it.”
He concludes with this little gem:
Despite multiple near-death experiences, the law the president signed in 2010 was historic—and I’m proud to have done my small part. It isn’t perfect; no legislation in a democracy will ever be. But it was heartening to learn that sometimes, sound policy can trump politics when politicians show leadership.
Wow. Isn’t that fascinating? His view is that …politicians showed leadership and we have a terrific example in ObamaCare. It’s an alternate universe, isn’t it? A more objective way to look at this data would be to observe that Obama and the Democrats shoved a bill through Congress without a single Republican vote. They did so without reading or understanding what they had put together and passed. The final result was such a mess that they had to break every single campaign promise associated with the bill. There was nothing noble or encouraging in any way about what happened here. It wasn’t “democratic” and it damaged our “democracy” by pointing out that we don’t really have a democracy or the rule of law.