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The TNR Q&A: Jay Rockefeller

TNR: I want to talk to you about MedPAC, or IMAC, MedPAC on steroids…?

ROCKEFELLER: What is this, MedPAC on steroids come from?

TNR: It’s an OMB thing.

ROCKEFELLER: What’s the deal? It’s MedPAC.

Aide: It’s strengthened MedPAC.

TNR: It’s stronger than MedPAC, so you give it steroids. It’s probably not the greatest analogy if you think it through, given that we’ve been talking about sports.

ROCKEFELLER: Well it sounds like a joke, see, it sounds like it’s up and then chhhh. Go ahead. I’m all serious.

TNR: To start with the general here, let’s just talk about this proposal a bit, what it does…

ROCKEFELLER: What it does, it takes politicians ... gives them the authority and the power to make all decisions about reimbursement in Medicare, and whatever happens in Medicare happens to the rest of the world later on. My reasoning for the thing is very simple, and I have to say this gracefully ... Congress doesn’t know much about health care. Remember the F-22 vote the day before? To me it was a marvelous parallel. I have jobs in West Virginia, 50 of them that would last four more months for the F-22. But it’s a classic example of what Congressmen do on the subject, they vote their states’ interest. That’s fine, because jobs are jobs, but in health care, episodes of health care for older people, Medicare age, go on every day in every corner of America, 24/7, doctors’ offices and hospitals, all the rest of it. ... It’s refined knowledge, it’s in the weeds to the ultimate. They have to strengthen their staff enormously for investigative work. They have to do research so that they can attach outcomes. Somebody does something to you because you’re an old man, and whatever they do Medicare reimburses its fee for service. Wrong way to do business. Fee for good service. That means you’ve got to measure the outcomes, what’s the result of your hospital, what’s the result of this doctor’s group organization that wants to see a big update in reimbursement. So to me, just the idea, literally makes me happy, of taking Congress and all of lobbyists out of the ball game. And I think of poor K street with people making six and seven figure salaries, who are just bloody experts. West Virginia has an oxygen potential, so I get one of these people to help me or go work on somebody at the finance committee to work on oxygen? I’m sorry, that’s just wrong. That’s just wrong. Money trumps substance.

TNR: Is there one particular example that you can remember recently where you’ve seen that happen? A particular lobby came in and you think...

ROCKEFELLER: The better question would be, could you think of an example where that didn’t happen? I’m serious. I mean, this is the not very attractive intermingling of fundraising and setting of public policy.

TNR: Now your friends over in the other chamber have been, some have been less enthusiastic about this. One of the criticisms is that it’s wrong to take these decisions out of the democratic sphere.

ROCKEFELLER: See that’s process. The White House should be painted White not Blue. It’s process, who cares about that? Isn’t what we’re meant to be doing with scarce dollars, with Medicare about to run out of, in reversal, going backwards on money in 2017 if we don’t change things fast, who cares about that? Whether they get to touch it? I talked to him the president other day, and I said there’s only one thing about you I resent Mr. President, and he knows there’s nothing I resent about him so that he wondered what it was, and I said, “Your MedPac idea’s better than mine.” And he did a very clever thing. He allows—I wasn’t going to let Congress vote at all, they don’t touch it—and he said no, let them vote, but there are no amendments, you can either take it or leave it, but you can vote. ...

TNR: People on the House who work on health care who I talk to, who I trust, who say we’re really worried, it sounds great now because we’re in charge of Congress and Obama’s in the White House, what happened 15 years from now when you have the second coming of George W. Bush, Boehner is now whatever, it’s a Republican Congress, can’t they just use this to gut the program in very short order in a way they couldn’t now?

ROCKEFELLER: The answer is both yes and no. Technically, yes. One Congress is never binding on the next one. Anybody can come change all the rules. But I think it’s going to be very difficult when you get a group of seventeen, or maybe it’ll be 25, big staff, thorough thing, being able to justify exactly why this hospital some place in New Mexico got reimbursed more because the outcomes are better. This is very sophisticated work, okay? Once you get that going, it establishes itself in the minds of people like yourself, and I think of serious congresspeople as frankly something we can’t do, and they’ve done, and once it gets a tiny bit of momentum it’s going to be very hard to reverse it, because it’s so obviously a better system than just bidding for better updates. And that’s what we have now.

TNR: The other complaint you hear, and this you hear less from liberals and more from conservatives, it’s the dreaded federal rationing board.…They’re going to come in they’re going to put your mother on an ice floe and send her away or whatever. There’s a more nuanced version which, “You know, it’s great that we’re going to have all these experts deciding what to reimburse but at the end of the day medicine’s just not that exact a science, it’s not that cookie cutter and there’s a lot of potential to use reimbursements to guide treatments in ways that doctors won’t be able to use their best judgment and patients will suffer. This is what I’d call the more nuanced version of that argument. What’s your response to that?

ROCKEFELLER: My response to that is that it’s highly unlikely. Look, anything we do, this would probably be the largest change in Medicare since 1965, wouldn’t it be? I haven’t thought about it, but it probably is. So there are always going to be some incidents that might prove their point because somebody ran out of time sizing up outcomes or measuring western Pennsylvania next to eastern Delaware or whatever it is, I don’t know. But it’s the way you have to do things. Accuracy of measurement about outcomes, it’s sort of like Medicare Advantage. We’ve never been able to take Medicare Advantage out of Medicare because Republicans love it so much. Of course, they’re not sick or poor, they can afford to pay, but it’s just bad policy, it’s just very bad policy. It takes money out of the people who really do need Medicare, and that’s that. My point is that, I grant you, it may not be perfect, it’s not a new institution starting up, it works now, it gives advice now. We just don’t pay any attention to the advice. But what I love about it is that the lobbyists can’t ply their trade on MedPac, they’re just not going to get anywhere. And what is there in democracy, in trying to do the right thing by the American people on health care which says that Congress has to be a part of what people get paid? Congress doesn’t have any part on what kind of research the Veteran’s Administration is doing, that’s decided by—well if Congress wants to pass a bill—but that’s decided by the federal government. Medicare is of the federal government. Medicaid is in the federal government. You just can’t use the word “public” or “government” and assume that things are going wrong. That’s one of the reasons I’m really for a public option, is because everybody talks about regulating insurance, and you can’t regulate insurance, these people are much too smart…

TNR: Since you brought up the public option that’s a nice segue. This co-op I guess is still floating around. My take on this has been for a while, “I don’t know what a co-op is, I guess it really depends on what a co-op looks like.” You could call it a co-op, have a co-op board that ran it, but if it does what a public option plan would do, then fine. My answer is that it’s sort of a label that can mean anything. I’m curious if that’s your attitude, and what are your criteria for a public plan? Give me two or three…

ROCKEFELLER: Public plan is it provides, within the free market system, within the American enterprise system, it provides competition to insurance companies, and it has one rather large advantage, it doesn’t have to make a profit. These companies, what is they have 120 percent increase in the fast six years in profits? You’ll know the figures, they’re huge, and those people need to have competition. No one pays much attention to insurance companies, everyone trusts insurance companies because they’re taking care of you. So nobody looks into them. I was stunned that we had to do this work on the commerce committee, the reason why? Because I copied Henry Waxman and got myself a bunch of people who do nothing but investigate. And they’re free floaters, they don’t report to anybody but the head of the committee and to me. And they’re meant to look in all the dark corners, and boy do they ever, and boy are they good at it. That’s the way we found out about this, what the insurance companies do, because ordinarily committees may not come up with that kind of stuff, so you’ve got to have tough people look at it. I don’t know, I’m just I’m tired of scamming…

TNR: The Finance committee—we keep hearing there’s not enough money. I keep worrying the package is getting thinned. Should I be worried about that?

ROCKEFELLER: Yes, you should be worried about that. And I have an idea about how all of us can solve that, and that’s the millionaire tax. For some reason all the Republicans are against that, and I think I can think that one through, but there’s also some moderate Democrats who are against that, and ... that’s a half a trillion dollars. Is it going to be painful? You have to look at that in terms of what can we pay out in terms of the demise of the growth of Medicare in 2017. When it starts going the other way, the world’s going to panic. So it’s a little bit like not doing something. You can save yourself a lot of pain by not fighting for stuff, but it’s very unhealthy. Our meeting this morning was fabulous. It was an hour and 15 minutes and no one wanted to leave. I was critical of the co-op thing, and Conrad and I had a discussion about that. The only place that they have co-ops is in the Midwest and in the Northeast. So to build a whole program based on something that very few people have experience with except for with agriculture, each state being different, it’s just not efficient as opposed to a national plan. But it was good. People got angry, which should happen. Stakes are high.

TNR: I get the impression that people like Conrad, other moderates in the Senate, I get the feeling that at the end of the day, Conrad isn’t out for a trillion dollars over the next ten years.

ROCKEFELLER: Want me to give you some suggestions? One is a millionaires tax. Secondly is: I think that it’s a pity that we don’t even begin to deal with end of life concerns. I stood with Jack Danforth on that back in 1989. We’ve gotten nowhere on it. 20 percent of Medicare is spent in the last 60 days of life--six months at the most. And we won’t even look at it. My mother died. It took my mother 12 years. She didn’t want to be kept alive. The Hippocratic Oath says ‘Do no harm’, it doesn’t say ‘Keep alive.’ And I think they did tremendous harm. I think that people with Alzheimer’s can look back and see themselves, and they have a subconscious that says they’re an embarrassment, that they’re useless, that they’re sort of throwaways in life. You talk about the importance of healthcare, and I think that’s something to be thinking about. The Pepper commission put out a complete plan on acute care and long-term care, how to pay for it and how to do it. It didn’t get anywhere, obviously, but it was a terrific product. We won’t even take up how to deal with end of life care. You talk about where we can save some money: that’s a place.

TNR: Well let’s stipulate, for example, that I agreed with every one of those views. I don’t think there’s votes for that.

ROCKEFELLER: Oh, I don’t think there is either.

TNR: So the question is: are we stuck? How does this work out?

ROCKEFELLER: You know how this works out? It’s people like me, who believe so passionately in the public plan because if you want to hammer insurance companies and say ‘I’m offering what you’re offering, but I’m offering it at better quality for half the price. What are you going to do about it?’ You want to bring them down? That’s the way to do it. You want to save money? That’s the way to do it. I’m not going to win that one. I don’t think that’s going to be a part of the finance plan that’s going to be put out. So it’s going to be co-ops. I can’t figure out it works, how it relates to health care, how it could possibly do anything but confuse everything. So the question comes at the end, when we have our mark-up on it. I’ll certainly vote against the co-op plan when it comes on trying to vote the bill out or not. That’s a big decision for me, because I’m number two in the finance committee on our side. All the liberals and some others look at me, and I’m the first called on to vote--that’s just how the finance committee works. I’m not sure, and I told this to Max today (presumably before he read those things I said about him). And I said, ‘Max, did you hear what I implied to you today, that don’t necessarily count me as a no on voting this out of finance?’ I think that’s the spirit— And the thing is, can we make a difference in conference? I don’t think we can make a difference in conference, because I think everybody is so dug into the nature of this and the personalities involved. ... I don’t think you can block things from going forward. I just don’t necessarily assume that I’m a no.

TNR: On the public plan.

ROCKEFELLER: No, on the whole bill.

TNR: There must be some line you wouldn’t cross.

ROCKEFELLER: The co-op is… I’ve been pretty involved in the SCHIP program. That’s given over to the exchange. It’s just turned over from a defined-benefits plan for 11 million children, that’s 22 or 23 percent of all the uninsured people in this country. Three times the Congress has passed it, Bush vetoed it, and then Obama signs it. All of a sudden they’re in the exchange. I don’t like that so much. We’ll see what happens.

TNR: The assumption a few months ago was that you were at that point, that you would vote no on what you saw coming up.

ROCKEFELLER: I think it’s always better to give nothing when you’re starting. What I have to face is what happens if the finance committee doesn’t do anything and the whole process breaks down.

Jonathan Cohn is a senior editor of The New Republic.