HCR Savings begin seeping into public consciousness

Yglesias passes on a great tidbit:

Everyone knows that health care costs are a major component of the federal budget, but they also have important implications for state budgets, so Mainers will likely be interested to learn that the Affordable Care Act signed into law earlier this year will save their state money.
Mal Leary of the Bangor Daily News explains:

A state analysis of the impact of the new federal health reform law indicates it will cost Maine in the near term, but will save the state tens of millions of dollars a year after it is fully implemented in 2014.

This is the type of news that is sure to bubble up over the next 6, 12, 24 months that spells complete doom for all the HCR naysayers and Palin '12 grand-standers. 

Chait on Gerson's EC

Good stuff.   Chait busts up two vacuum-chamber rattles about Health Care Reform.

First, that Obama and the left hid the cost of HCR in the "doc fix"

This isn't part of the "overall cost of the entitlement." It's part of the cost of running Medicare. The cost exists irrespective of the Affordable Care Act. The paper savings from lower physician reimbursements were not used to cover insurance subsidies in the bill. If health care reform had died, Congress would still be passing a doc fix. Gerson's charge is utterly, unambiguously false.

Then that HCR is an entitlement for the un-needy

Focus on Gerson's claim that the Affordable Care Act benefits citizens who are not "vulnerable." By what possible standard is this true? The primary beneficiaries are people who can't afford to buy health insurance! They're vulnerable to getting sick and suffering terrible pain, bankruptcy, or even death either because they or a family member has a preexisting condition, or because their employer doesn't offer health insurance and they're priced out of the dysfunctional individual market. That's not "vulnerable"?

McArdle on the Mass Health Care debacle

In the wake of Mass insurers posting huge losses for the 1st quarter, Megan sees it as an ominous sign of doom on the horizon for the rest of the country.  While her points are valid, she leaves out the question of price gouging on the part of the large conglomerate provider networks like Partners which go along with the ignorant election year power play that Deval pulled this spring. 

I'm not quite so pessimistic.  For one I don't foresee that level of ignorance from Team Obama.   Give it a gander and decide for yourself. 

This is huge

Looking for someone to blame for rapidly rising Health Care costs in Massachusetts?   Look no further than Partners Health Care Systems.   You've got the largest collection of hospitals and physicians in the region using their power to demand their rates be 15-60% higher than other groups for the same services.   Just because they bargain collectively.  Fuck that. 

Luckily, The Justice Department is finally calling bullshit: 

The US Department of Justice has opened a civil investigation into possible anticompetitive behavior by Partners HealthCare System Inc., the region’s most powerful hospital and physician network.

In a letter sent to Partners and the state’s three largest health insurers on April 19, investigators from the Justice Department’s antitrust division demanded documents relating to Partners’ “contracting and other practices in health care markets in Eastern Massachusetts.’’

The letter, obtained by the Globe, said the probe sought to determine whether the practices violated the Sherman Antitrust Act, which bars companies from using their market power to limit trade or artificially raise prices. The parties were told to respond by May 19.

The federal probe comes as Massachusetts business and government officials wrangle over how to control soaring medical costs, and who is to blame for a decade of skyrocketing insurance premiums.

Boston-based Partners has been under growing scrutiny because of its market power and ability to draw high prices from insurers. The company employs about 5,500 physicians and operates a half dozen smaller hospitals, in addition to their prestigious Harvard-affiliated Boston teaching hospitals, Mass. General and the Brigham.

Everyone is so quick to blame the insurers as profit hogs, but no one looks at how well groups like Partners have been doing for the last decade or so.  Remember, 90% of premiums collected by insurers from YOU go towards medical costs.  The biggest group of medical professionals and facilities get paid more than everyone else.   The insurers - a lot of whom are non-profit - are held hostage by their collective bargaining. 

This is how to stop the bleeding.   Bravo to the Justice Dept.

Deval Patrick - you're doing it wrong, ctd.

Dammit all, Deval.

Using crappy public opinion of health insurers to your political advantage is a deceptive practice, to be sure, and to boot he clearly doesn't understand how premiums are established.  In fact he probably thinks like these commenters on Boston.com do:

Thanos73 wrote:

ToniCa wrote:
"Deval just doesn't get it. Health care cost increases come from hospitals and doctors. The insurance companies have to increase their rates based on what the hospitals and doctors charge them"

Wow, you really need to put the pipe down. The Insurance companies dictate rates to Doctors and Hospitals, they don't negotiate.

Thanos73 here may want to ask the hundreds of people who work in Provider Contract negotiators and Actuaries at insurance companies what they think about his comment.  Does he really think payers pull premium increases out of thin air? 

Then there's this...

JasonSeacrest wrote:

I have yet to hear from the Insurance carriers WHY they needed these huge increases (yet again.). There's no inflation..so why are only YOUR costs increasing?

Is it to feed the stockholders that 10%+ return on their investment? Nobody else is getting raises, why should you?

EXPLAIN!

SURE, JASON!   In Massachusetts fully-insured plans are Not for Profit, so it's not as if shareholders are making a ton of money every year because (drum roll, please) there are no shareholders!  Why isn't Jason calling his PCP and asking why he's getting that 10% raise every year?   The misconceptions in this debate are staggering. 

Look, I get it: we all saw Erin Brokovich and know there are evil health insurance companies out there that deny services for the really sick and reject coverage for those with pre-existing conditions all while whistling their way to the bank.  Those companies needed to be dealt with and ObamaCare did that for the other 49 states.  But in Massachusetts, land of Non-Profit health, universal care and bans on preX denials?  Why the hell are you stomping all over us?  We're not the bad guys!!

As I've noted before on this blog, this concept of limiting the premiums without addressing what drives 90% of those costs addresses the symptom and not the disease.  Provider contracts are negotiated on a bi-annual basis and those contracts that are already set for this coming year can't be changed because they're, you know, legally binding and all that.  Also premiums are based upon utilization as well and there's been a spike, which the proposed rates were an answer to.  So basically two unmovable forces are crashing head-on into the now-easily-moved-because-Deval-said-so force.

It's a bandaid and one of two things will happen as a result.  1) Payers with already shaky bottom-lines will be in trouble and you could see some smaller plans go out of business, or 2) Rates will go up in subsequent - *ahem* non-election - years to offset the loss caused by this year's rejection.

Another crappy thing about the potential byproducts are their indirect impact on the national health care debate.   For Republican's dying for talking points to bash ObamaCare, this overreach by Deval Patrick and Massachusetts democrats comes at just the right time.  "Look at Massachusetts!   They passed universal health care and within three years were setting costs in the private market!"

My prediction:  when Fallon or one of the other smaller insurers goes out of business, the first headline you'll see on Fox News:  "ObamaCare claims first victim!"  Even though anyone with half a noodle in their head  knows the two are not related. But it doesn't have to have a basis in reality if it sounds scary! 

If this is Deval's Hail Mary for re-election, he may have just tossed it right through the hands of Barrack Obama.

HCR Debate, the screenplay

Some truth in comedy, from Nicole Belle:

Democrats: "We need health care reform"
Republicans: "Liberal fascists! Give us a majority and we'll do it better"
Democrats: "Done, you have majority of both houses"

12 years later, health care is irrefutably worse in every respect for every single person in the United States

Democrats: "We need health care reform"
Republicans: "Liberal fascists! Americans are tired of partisan politics!"
Democrats: "OK, let's compromise"
Republicans: "OK, get rid of half your ideas"
Democrats: "Done"
Republicans: "Too liberal, get rid of half your ideas"
Democrats: "Done"
Republicans: "Too liberal, get rid of half your ideas"
Democrats: "Done"
Republicans: "Too liberal, get rid of half your ideas"
Democrats: "Done"
Republicans: "Too liberal, get rid of half your ideas"
Democrats: "Done. Time to end debate"
Republicans: "Too liberal, we need more debate, we will filibuster to prevent you from voting"
Democrats: "OK, we'll vote--sorry guys, debate is ended. It's time to vote on the bill"
Republicans: "Too liberal, we vote no"
Democrats: "OK, it passed anyway--sorry guys."

One month later

Republicans: "Wait--wait, OK, we have less of a minority now so we can filibuster forever."
Democrats: "Sorry, the bill already passed, we need it to pass the House now"
Republicans: "But we have enough to filibuster"
Democrats: "Sorry, the bill already passed, we need it to pass the House now"
Republicans: "Liberal fascists! You haven't listened to our ideas! You've shut us out of this whole process!"
Democrats: "Sorry, show us your proposal"
Republicans: "Smaller government"
Democrats: "That's not very specific"
Republicans: "OK, here's our detailed proposal--It's our common-sense ideas we spent 12 years not enacting"
Democrats: "OK, we'll add a bunch more of your ideas"
Republicans: "Liberal fascists! You included all these back-room deals"
Democrats: "OK, we'll get rid of the back-room deals"
Republicans: "Liberal fascists! You're using obscure procedural tricks to eliminate the back-room deals!"
Democrats: "No, we're using reconciliation, which both parties have used dozens of times for much larger bills"
Republicans: "Liberal fascists! You're pressuring Congressmen to vote for your bill! Scandal!"
Democrats: "It's called 'whipping', it's been done since 1789"
Republicans: "Liberal fascists! Can't you see the American people don't want this?"
Democrats: "This bill is mildly unpopular (40-50%), doing nothing (your proposal) is extraordinarily unpopular (4-6%)"
Republicans: "We need to start over! We need to start over!"
Democrats: "We should really consider voting--"
Republicans: "Liberal fascists! Start over! Clean slate! Common-sense! America!"

Is it really about Health Care?

Frank Rich's opinion piece in today's NYT is a wonderful collection of the GOP Hysteria over the Health Care bill and a frightening comparison to the similar freakouts after passage of the New Deal, Medicare and Civil Rights laws.

To be sure, this bill nothing even remotely close to the budget atrocity the Palins and Boehners want to make it out to be, costing roughly $94B per year for the first ten years, revenue generation and other savings excluded.  In the grand scheme of the $1.3T deficit Bush handed to Obama by the end of 2009, it's a drop in the bucket.  But this isn't really about "government takeover" or "power grabbing" the way the RNC/FNC puppets want you to believe it is, but rather a frantic collective clawing at the floor while being dragged out of power.

That a tsunami of anger is gathering today is illogical, given that what the right calls “Obamacare” is less provocative than either the Civil Rights Act of 1964 or Medicare, an epic entitlement that actually did precipitate a government takeover of a sizable chunk of American health care. But the explanation is plain: the health care bill is not the main source of this anger and never has been. It’s merely a handy excuse. The real source of the over-the-top rage of 2010 is the same kind of national existential reordering that roiled America in 1964.

In fact, the current surge of anger — and the accompanying rise in right-wing extremism — predates the entire health care debate. The first signs were the shrieks of “traitor” and “off with his head” at Palin rallies as Obama’s election became more likely in October 2008. Those passions have spiraled ever since — from Gov. Rick Perry’s kowtowing to secessionists at a Tea Party rally in Texas to the gratuitous brandishing of assault weapons at Obama health care rallies last summer to “You lie!” piercing the president’s address to Congress last fall like an ominous shot.

If Obama’s first legislative priority had been immigration or financial reform or climate change, we would have seen the same trajectory. The conjunction of a black president and a female speaker of the House — topped off by a wise Latina on the Supreme Court and a powerful gay Congressional committee chairman — would sow fears of disenfranchisement among a dwindling and threatened minority in the country no matter what policies were in play. It’s not happenstance that Frank, Lewis and Cleaver — none of them major Democratic players in the health care push — received a major share of last weekend’s abuse. When you hear demonstrators chant the slogan “Take our country back!,” these are the people they want to take the country back from.

They can’t. Demographics are avatars of a change bigger than any bill contemplated by Obama or Congress. The week before the health care vote, The Times reported that births to Asian, black and Hispanic women accounted for 48 percent of all births in America in the 12 months ending in July 2008. By 2012, the next presidential election year, non-Hispanic white births will be in the minority. The Tea Party movement is virtually all white. The Republicans haven’t had a single African-American in the Senate or the House since 2003 and have had only three in total since 1935. Their anxieties about a rapidly changing America are well-grounded.

No, It's really just rhetoric...

Urging your movement to violently mobilize against our elected leaders, that is.   Sarah Palin seems to have no problem doing so.   John McCain seems to have trouble... with condemning such behavior.   Has this whole world gone crazy?!   Yes it has, says Ezra Klein: 

I don't want to exaggerate the importance of the death threats being made against congressmen who voted for health-care reform. Nuts are nuts. But there is a danger to the sort of rhetoric the GOP has used over the past few months. When Rep. Devin Nunes begs his colleagues to say "no to socialism, no to totalitarianism and no to this bill"; when Glenn Beck says the bill "is the end of America as you know it"; when Sarah Palin says the bill has "death panels" -- that stuff matters.

And the stuff on talk radio, of course, was worse. So take the universe of people who really respect right-wing politicians and listen to right-wing media. Most of them will hear this stuff and turn against the bill. Some will hear this stuff and really be afraid of the bill. And then a small group will hear this stuff and believe it and wonder whether they need to do something more significant to stop this bill from becoming law. And then a couple will actually follow through. And one will cut the gas lines leading to house of Rep. Tom Perriello's brother after seeing a tea partyer post the address online.

(via Sullivan)

Frum - One Sensible Voice on the Right

David Frum follows up on his Waterloo column from yesterday and adds some credible ideas for the GOP going forward:

• Shifting the tax on high-end earners to another source of revenue; ie. carbon tax 
• Stop defending Employer-based care and embrace individual choice 
• Reduce regulation on the exchanges to promote more flexibility for the insurers to create affordable plans
• Move to end the small-business fines for payrolls of  > $500K, to promote competition among employers

These things, he says, are better alternatives to campaigning solely on the repeal of the measure as a whole.   He then goes on - brilliantly, I might add - to reprimand the conservative establishment for the vitriol and anger that has warped and negated any rational debate and discourse for the last 14 months: 

That platform is ambitious enough -- but also workable, enactable and likely to appeal to voters. After 18 months of overheated rhetoric, it's time at last for Republicans to get real.
I've been on a soapbox for months now about the harm that our overheated talk is doing to us. Yes, it mobilizes supporters -- but by mobilizing them with hysterical accusations and pseudo-information, overheated talk has made it impossible for representatives to represent and elected leaders to lead.
Now the overheated talk is about to get worse. Over the past 48 hours, I've heard conservatives compare the House bill to the Kansas-Nebraska Act of 1854 -- a decisive step on the path to the Civil War. Conservatives have whipped themselves into spasms of outrage and despair that block all strategic thinking.

Maybe there's hope after all.  

Finally!

A great day for anyone who honestly cares about fixing a broken system that consumes 1/6th of our nation's GDP - honestly being the key term, of course.  A quick glance of the left and right of today's blogosphere highlights that ever-deepening chasm between the two sides, what with their reactions to the Health Care reform bill.   Most interesting is what each side is taking away from the fight and what it says about their true interests. 

Democrats celebrate a victory for the 32M people who will be insured by the plan, the protections for those with pre-existing conditions, and a meaningful first step towards controlling the costs of a system that is clearly unsustainable. 

Republicans are knocking the process and celebrating - prematurely, to be sure - the perceived political fallout of their counterparts. 

Sensing a pattern here?  One side acted on what was and is right; their careers and partisan control be damned.   The other?  Pretty much the exact opposite.  To the right at large, it's not about doing what's right and fixing what's broken, but rather demagoguery and doing whatever it takes to pander to the widest voting bloc in order to regain power by any means possible.  

How's that for honesty?    I imagine this will backfire horribly on the right, as there's a lot of time between now and November and their only hope is that improvements in other areas of the country are overshadowed by their own ugly rhetoric and vile name-calling and propaganda.   

Bartlett on Tom Scully's Op-Ed

Whenever discussing the "tremendous cost" of the Health Care bill, if you dare mention the $1 trillion unfunded Medicare Part D program to a Republican, they respond by putting fingers in both ears and start screaming la-la-la-la-la-la-la over you.  

Bruce Bartlett explains:

This morning's paper carries an op-ed criticizing health care reform primarily on the grounds that it will cost too much. It urges that the plan be sharply scaled back so that it will get bipartisan support.

If this op-ed were written by a Republican member of Congress it would be unremarkable; not even worth publishing. But this particular op-ed was authored by someone who appears to have meaningful expertise on the subject. The writer, Tom Scully, is identified as the former administrator of the Centers for Medicare and Medicaid Services and a White House official during the George H.W. Bush administration.

Given this resume, one might think that Scully was a career health professional, an expert that those on both sides of an issue might look to for counsel and guidance. In fact, Scully is a rank Republican political hack who was responsible for one of the most reprehensible episodes in recent American political history. It was Scully who helped ram through Congress the totally unfunded Medicare Part D program that will cost taxpayers roughly $1 trillion over the next decade--that's $1 trillion more than Obama's plan, which is fully paid for according to the Congressional Budget Office.

 Worth the read.   Included within, he also reposts his November '09 detailing of Scully's hypocrisy with a great lead-in:

Rather than go through the whole sorry story again, I am reprinting below my Forbes column from last year in which I discussed Scully's duplicitous behavior. Included are hyperlinks documenting his culpability for saddling taxpayers with trillions of dollars of debt just so his party could buy the votes of seniors and win the 2004 election.

The GOP's Worst Nightmare Coming True

Oh this is just too good to not post.   I practically have wood over here.   Here's a great string of posts by Sullivan and others on the CBO report and other Health Care Reform related items. 

The first being a grid that shows pretty clearly how silly the right's grandstanding of Obama's inexperience has been (i/r/t pundits/blowhards citing how disjointed his own party was around the HC Debate)   New year, new tactic, new solidarity. 

 -- Nate Silver on why the left is suddenly unified behind the bill:

Personally, I think the reason for the increase in support is mostly this: the Democratic leadership, and particularly President Obama, are now fighting for this bill tooth and nail. They didn't necessarily have to do this; they could have thrown in the towel, passed off some bipartisan crap that didn't do much to help the uninsured, and called it a day. That's what Rahm Emanuel wanted to do, as Chris Bowers points out. But that isn't what Obama did: instead, he's gone all-in on the thing, potentially staking his Presidency on the outcome. Liberals like the idea of being the scrappy underdog -- being the fighter -- and Obama, after a strangely aloof performance on the health care bill throughout 2009, has been fighting the good fight.

Then some fiscal sanity figures.   Not too F'n shabby, if you ask me.  

-- Ezra Klein unpacks the CBO score:

The bill will cost $940 billion over the first 10 years and reduce the deficit by $130 billion during that period. In the second 10 years -- so, 2020 to 2029 -- it will reduce the deficit by $1.2 trillion. The legislation will cover 32 million Americans, or 95 percent of the legal population. To put this in context, that's more deficit reduction than either the House or Senate bill, and more coverage than the Senate bill.

-- Hotline:

The bill is now headed to the House Rules Committee, where Dems will finalize their options for moving forward. Floor action is expected on Sunday, 72  hours after the bill gets posted online.

 Chait on getting close:

MSNBC's First Read reports, "We’re told that the White House and House Dem leaders are fewer than five votes away from 216." I have always thought that the key is to get within four or five votes. Once you're there, you're very likely to win. Why? Because then the White House and Democratic leaders can concentrate all their attention on a few holdouts. And they can make an irresistible argument: If you don't vote for this bill, you will be responsible for the political and moral disaster that ensues. I just don't think anybody is willing to be the person who kills health care reform. They may hold back, they may want to see if the bill is going to die anyway, and they may want somebody else to go first. But when the finish line is in sight, they won't say no.

Even a little means a lot

Hard to argue with Jonathan Cohn's piece on TNR.  He breaks down how the current versions of the bill may only reduce cost marginally over the short term but that in the long-term - by implementing a variety of control measures in moderation to see what works and what doesn't - it can be very beneficial.   Certainly more beneficial than the unsustainable status quo.   

Some of the people complaining about this bill seem to acknowledge the political forces at play. If it's not possible to pass a bill with stronger cost control, they suggest, there should be no bill at all--or, at least, not one that looks like this one. They'd prefer only a very small expansion of coverage, if any, until real cost control has set in.

But here, too, the political logic isn't so simple. Just think about hospitals for a second. Reducing spending on health care is going to require a massive change in the way both public and private insurers pay them.
[...]
You could make the same argument about other interest groups--or what the public, as a whole, would be willing to tolerate. The most aggressive cost control efforts from left and right would start by getting everybody out of their present insurance arrangements. Good luck trying to enact that.

To be absolutely clear about this, I would support health care reform if it did nothing more than expand and strengthen health insurance coverage. I think it's a moral imperative, as much for the sake of the middle class as the poor. But it so happens that the bill moving through Congress will do something more. It will reduce the cost of care--not by a lot and not by as much as possible in theory, but as much as is possible in this political universe. That's far better than the alternative, which is to do nothing.

Deval Patrick - you're doing it wrong (again!)

Raise your hand if you want Health Care costs to go down (or stop going up)

Wow, that's just about everyone.  No surprises there.   Now raise your hand if you think capping insurer premium hikes without capping provider contract hikes is a financially viable way to control premiums.

Confused?   Well don't feel bad because the Governor of Massachusetts doesn't understand this either.  See, if 90% of premiums cover medical expenses and those expenses can rise by 10-12%  but the premiums can't rise higher than 4.8%, then there's a bit of a discrepancy on the bottom line. 

Simple-minded people like using lemonade stands for analogies and I like simple terms so let's try this one.   Little Cindy runs her lemonade stand and can only purchase lemons from Massachusetts lemon growers.   One of those growers is a massive conglomerate that has banded together most of the biggest lemon farms in the state for bargaining power.   They pretty much dictate what the costs should and will be for all farmers in the state.  Every year this massive group jacks up the cost of lemons by 10-12%.

Now, Deval Patrick doesn't like that every time he stops at Cindy's stand the cost for a glass goes up.  So he makes a law that says Cindy can't raise her lemonade cost but in the meantime the lemon growers can still demand the big increase because no law prevents that.   Eventually, where does Cindy's margin go?  How can she pay workers' salaries to squeeze the lemons and run the stand?   She can't and now little Cindy is on little kiddie unemployment.  

Look, from a free market perspective, telling the doctors they can't make money is no better than telling insurers they can't but by imposing this on the insurer side is treating the symptom but ignoring the cause.  The biggest mistake the general public makes is to constantly lay the blame solely at the feet of the insurers without ever asking why the docs' costs have to go so high every year. 

What can you do to help?  Well, unless you're a physician or a contract negotiator at one of the payers, you can't have a direct impact.   But indirectly you can be prudent about the care you utilize and push back on your doc when they order excessive tests or visits for ridiculous things.  

One of my bigger pet peeves was when my doc prescribed my a pump blocker for heartburn.  He told me when he wrote it that I would have to take this medication for the rest of my life.   But then when the script ran out, the office manager told me I had to come in for a refill?!  Huh?   We already know what I have to take and why and no magical new information can be garnered from the visit.  Why on earth would I be asked to come in for this needless formality?    Because it's in the doctor's best interest to schedule as many appointments as possible.  Straight Cash Homey.  Obviously I argued this point and established a standing order with my primary for the meds.   It's that easy.   

So be smart.  Ask questions.  Demand that your health care costs are being used in efficient ways.  You have the right and you certainly have reason to do so, if you want premiums to go down.

Those Condescending Elitists

Not that this should come as any surprise, but the Right has already begun their whine-fest from the Health Care Summit.  Apparently because that elitist a-hole Obama comes across so damned smarmy.   I love the give and take between Chait and Poheritz.   Pretty much epitomizes the two sides of this debate:

Earlier I noted of the health care summit that the Republicans in attendance seem to be divided between those who have no data at their disposal and those who have incorrect data. It is therefore difficult for President Obama, who obviously has a deep command of the issue, to engage with those Republicans without somewhat projecting condescension.

John Podhoretz shoots back:

Here’s how. By not being condescending. That’s how.

Never mind facts vs fiction; It's all in the delivery.  I wonder if the right will ever realize how this tactic looks from the outside.  It's plain to see that they're essentially cheerleading ignorance and opposing intelligent thought.

Lost in Health Insurer Hatred

Yglesias has a great write up on excuse-making by two Dems, acting to protect Sallie Mae's interests from the SAFRA bill:

When you have a substantial inefficiency, you also have a whole bunch of people whose jobs depend on that inefficiency. That’s why it’s hard to treat coal the way we should and that’s why it’s hard to treat Sallie Mae the way we should. It’s also an important reason why “Medicare for All” isn’t really the political no-brainer that people sometimes claim it is—insurance companies employ tons of people, the vast majority of whom are not cackling and evil executives.

Now at the end of the day, I don’t think policy should be made on that basis. The best path, over the long-run, to ensuring good jobs for all Americans is to have sustainable prosperity built on economic growth. And that means accomplishing our public sector tasks in efficient ways—no needless subsidies to private student lenders, no teachers who stay on the job no matter how badly they do, no unnecessary health insurance company middlemen taking a slice of all our spending, no Medicare payments for useless or harmful treatments, etc. But all of this stuff is very challenging to do in part because of special interest money but also in part simply because behind every instance of waste stands someone whose livelihood depends on the waste.

(my bold for emphasis)

Hey, I'm one of those livelihoods!   Since a private payer pays my salary -- and, to some extent, since I'm not convinced that fully-government-controlled anything is the best direction -- I stand behind those evil corporations and lobbyists who strive to prevent Single-Payer Health Care.  Conversely, my job security is also one of the big reasons why I favor the recent incarnations of the health care reform bill:   They leave the private market - and all the employees who work for them - very much intact.  

This much is lost on both fringes.