Death of a Sales Job (A Three Act Ploy)

With apologies to Arthur Miller[1] . . .

President Obama went back before the cameras again Wednesday, providing yet another recycling of fading rationales for his health reform product that more voters would rather leave on the Capitol Hill store shelves than purchase.

But "attention must be paid"[2] whenever the president speaks.

He tried to claim that "we have now incorporated most of the ‘serious' ideas from across the spectrum about how to contain the rising cost of health care." Perhaps that includes compromising on the implementation date for taxing the extra amount of premiums in the most expensive and comprehensive private insurance plans (just short of waiting either "in perpetuity" or "forever;" whichever comes sooner and still meets the approval of organized labor). Of course, the president's search for Republican health care ideas he could deem "legitimate" was only slightly more aggressive than O.J. Simpson's never-ending search for the killers of Nicole and Ron. He came up with four low-dose remedies that border on homeopathy.

The Meager Products of the "Search"

First, a few million more dollars to assist small state-level experiments in medical malpractice reform featuring special health courts as an alternative to jury trials. Of course, no actual changes in permanent malpractice law and regulation would be supported before the light soon went out on these pilot projects, and they appear very unlikely to produce any consequential changes.

Second, Obama warmed to the idea of conducting undercover investigations of Medicare and Medicaid providers to search for waste, fraud, and abuse (standard line items in those programs' annual budgets, to be sure). No one has figured out where the cops posing as patients will hide their badges when in the examining room, nor why private health insurers don't have the same degree of such problems and manage to head them off much differently. ("We don't need no badges! I don't have to show you any stinkin' badges!")[3]

Third, the president came out in favor of paying Medicaid doctors more. How much more? What would it cost? How would it be done? For how long? Actual details TBA later, if ever. (See Medicare and sustainable growth rate fixes for a measure of skepticism, although Medicaid reimbursement has nowhere to go but up.)

Fourth, Obama said that health savings accounts tied to higher-deductible insurance policies actually may be permitted to be sold in new health insurance exchanges. Note that the nation's foremost expert on inadequate "Acme-brand" high-deductible insurance and defender of minimum federal standards for "real" insurance (see Health Summit, last week) did not actually say anything about changing the minimum actuarial values required in both the House- and Senate-passed health bills for qualified insurance plans within the exchanges, or whether contributions to HSAs would count as "insurance" dollars. Or whether HSAs would be exempt from the first-dollar coverage mandates and income-based caps on out-of-pocket spending supported by the president and his congressional allies.

The president again appeared to be frustrated that political opposition and the public's aversion to his once-popular health plan had kept its journey to enactment long, halting, and still unfinished.

("I've always tried to think otherwise, I guess. I always felt that if a man was impressive, and well liked, that nothing . . ."[4] Cue the beginning of his tragic fall.)

Rhetorical Diversions

He resorted again to several well-worn diversions. First, the straw man of "do nothing" and "walk away" hopped onto the stage, as if the president's embattled plan to do even worse than that, and prevent anything better from being considered, was a better alternative. Second, Obama rhetorically crossed his fingers and recited the howler that "I don't believe we should give government bureaucrats or insurance company bureaucrats more control over health care in America." He must have forgotten about the hundreds of future rules, standards, and implementation decisions delegated in the House and Senate bills to the HHS Secretary, the oxymoronic Health Choices Commissioner, and other new administrative bodies. Even a clear plurality (45%)[5] of Americans has come around to the conclusion that, facing a prisoner's dilemma in health coverage, they'd rather take their chances with private insurers.

President Obama also said that health care "easily lends itself to demagoguery and political gamesmanship, and misrepresentation and misunderstanding." Look, that's a legitimate point. For example, he mangled his recycling of the uncompensated care/emergency room/cost shifting factoid, concocted earlier this year by Families USA, that the uninsured are subsidized at the cost of $1,000 per family whenever they walk into an emergency room. He usually attributes that entire cost to the private insurance premiums of the average family; this time it was taxpayers picking up the entire tab. The actual costs are much lower[6] and their distribution is quite different,[7] but that would spoil a tall political tale. The president then rolled out his universal coverage ball of wax argument to assert that insurance reforms to prevent coverage denials for pre-existing conditions and to limit the amount that families are "forced" to pay out of their own pockets rest on everybody having access to coverage (read: individual mandate, except for those with economic hardships--who would seem to need subsidized coverage the most!). He must have dismissed out of hand proposals for substantially expanded federal funding of serious high-risk pools and extension of HIPAA portability protection to those with previous continuous coverage entering and exiting the individual market,[8] because he certainly doesn't understand them. Oh, and about those unlimited amounts of money paid out of pocket? They averaged less than 12 cents out of every dollar of U.S. health spending in 2008,[9] they are projected to decline to 10.4 cents per dollar by 2019,[10] and the U.S. ranked sixth-lowest in this regard among 27 OECD countries as of 2007.[11]

Sadly, there was more (double-counting Medicare savings, promising health choices as good as those for members of Congress, no actual legislative language yet, etc.) even though it all was packed into less than 15 minutes. However, there was no time left to spell out the imminent political strategy to go with a contorted version of budget "reconciliation" (the one whose name shall not be spoken).

But the president will be back on the road to Pennsylvania and Missouri next week to talk about the health legislation and "do everything in my power to make the case for reform."

"He's a man way out there in the blue, riding on a smile and a shoeshine . . ."[12] (and a teleprompter).

Thomas P. Miller is a resident fellow at AEI.


  1. Wikipedia, "Death of a Salesman," available at (accessed March 9, 2010).

  2. "Authors: Death of a Salesman Quotes, Famous Death of a Salesman Quotes,", available at (accessed March 9, 2010).

  3. Wikipedia, "Stinking Badges," available at (accessed March 9, 2010).

  4. Arthur Miller, Death of A Salesman (New York: Penguin Press, 1949), 75.

  5. "Private Insurance Companies," The American, January 26, 2010, available at (accessed March 9, 2010).

  6. Thomas P. Miller, "Healthcare Dreams, Healthcare Realities," The American, July 16, 2009, available at (accessed March 9, 2010).

  7. Thomas P. Miller, "Covering the Uninsured: Springing a Leak in the 'Cost-Shifting Hydraulic,'" Health Affairs Blog, available at (accessed March 9, 2010).

  8. Thomas P. Miller and James C. Capretta, "The Insurance Fix," National Review, November 2, 2009, available at

  9. Christopher J. Truffer, Sean Keehan, and Sheila Smith et al., "Health Spending Projections Through 2019: The Recession's Impact Continues," Health Affairs 29 no. 3 (2010): 522-529, available with subscription at (accessed March 10, 2010).

  10. Ibid.

  11. Thomas P. Miller, "Health Care Reform: 'The Debate,'" Grand Valley Summit on Health Care Reform, January 28, 2010, 6, transcript available at (accessed March 9, 2010).

  12. "Death of a Salesman," SparkNotes, available at (accessed March 9, 2010).

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