We take billions from struggling young families earning $35,000 who can barely make ends meet, let alone save for college or retirement, and use the money to pay for Social Security and Medicare benefits for seniors who earn more than $100,000. We do this even though those seniors are getting back far more than they ever paid into the system.
November 12, 2011, 4:02 PM
Billions Wasted on Billing
By EZEKIEL J. EMANUEL
LAST year I had to have a minor biopsy. Every time I went in for an appointment, I had to fill out a form requiring my name, address, insurance information, emergency contact person, vaccination history, previous surgical history and current medical problems, medications and allergies. I must have done it four times in just three days. Then, after my procedure, I received bills — and, even more annoying, statements of charges that said they weren’t bills — almost daily, from the hospital, the surgeon, the primary care doctor, the insurance company.
Imagine that repeated millions of times daily and you have one of the biggest money wasters in our health care system. Administration accounts for roughly 14 percent of what the United States spends on health care, or about $360 billion per year. About half of all administrative costs — $163 billion in 2009 — are borne by Medicare, Medicaid and insurance companies. The other half pays for the legions employed by doctors and hospitals to fill out billing forms, keep records, apply for credentials and perform the myriad other administrative functions associated with health care.
The range of expert opinions on how much of this could be saved goes as high as $180 billion, or half of current expenditures. But a more conservative and reasonable estimate comes from David Cutler, an economist at Harvard, who calculates that for the whole system — for insurers as well as doctors and hospitals — electronic billing and credentialing could save $32 billion a year. And United Health comes to a similar estimate, with 20 percent of savings going to the government, 50 percent to physicians and hospitals and 30 percent to insurers. For health care cuts to matter, they have to be above 1 percent of total costs, or $26 billion a year, and this conservative estimate certainly meets that threshold.
How do we get to these savings? First, electronic health records would eliminate the need to fill out the same forms over and over. An electronic credentialing system shared by all hospitals, insurance companies, Medicare, Medicaid, state licensing boards and other government agencies, like the Drug Enforcement Administration, could reduce much of the paperwork doctors are responsible for that patients never see. Requiring all parties to use electronic health records and an online system for physician credentialing would reduce frustration and save billions.
But the real savings is in billing. There are at least six steps in the process: 1) determining a patient’s eligibility for services; 2) obtaining prior authorization for specialist visits, tests and treatments; 3) submitting claims by doctors and hospitals to insurers; 4) verifying whether a claim was received and where in the process it is; 5) adjudicating denials of claims; and 6) receiving payment.
Substantial costs arise from the fact that doctors, hospitals and other care providers must bill multiple insurance companies. Instead of having a unified electronic billing system in which a patient could simply swipe an A.T.M.-like card for automatic verification of eligibility, claims processing and payment, we have a complicated system with lots of expensive manual data entry that produces costly mistakes.
The Affordable Care Act requires the Department of Health and Human Services to develop operating standards for electronic eligibility determination and payment — steps one and six — in the next few years, but we need to go further. We need the standard operating rules to encompass authorizing tests and treatments, submitting claims, verifying where in the process a claim is and the real-time adjudication of denials. And we must accelerate the process, covering all steps by 2015. Finally, the government needs to require that all parties — doctors, hospitals, insurers, government agencies — use the electronic systems.
This platform of electronic eligibility, claims and payment would — in addition to saving billions of dollars in paperwork — facilitate anti-fraud measures like those used by credit card companies. It would ease the administrative burden on doctors, letting them do the work that really matters — treating patients. Finally, it could improve care through built-in guidelines; if a doctor tried to schedule a stent implantation for a patient with stable heart disease, the system could tell him to try medication first; if he tried to order an M.R.I for a patient with normal back pain, it could tell him to prescribe physical therapy first.
There is nothing more infuriating than needless paperwork that wastes tens of billions of dollars. Banks, Fed Ex and scores of other businesses have eliminated paper bills and payments, and allow people to easily track transactions and packages online. It’s not brain surgery. Health insurance billing can also be brought into the Internet era.
Next week, I’ll write about broader, more systemic and bigger ways to save — concierge medicine for chronically ill patients and the bundling of payments.
Support Builds for a Plan to Rein In Medicare Costs
By Sandra G. Boodman, Published: September 12
Every year like clockwork, Anna Peterson has a mammogram. Peterson, who will turn 80 next year, undergoes screening colonoscopies at three- or five-year intervals as recommended by her doctor, although she has never had cancerous polyps that would warrant such frequent testing. Her 83-year-old husband faithfully gets regular PSA tests to check for prostate cancer.
“I just think it’s a good idea,” says Peterson, who considers the frequent tests essential to maintaining the couple’s mostly good health. The Fairfax County resident brushes aside concerns about the downside of their screenings, which exceed what many experts recommend. “Most older people do what their doctors tell them. People our age tend to be fairly unquestioning.”
But increasingly, questions are being raised about the overtesting of older patients, part of a growing skepticism about the widespread practice of routine screening for cancer and other ailments of people in their 70s, 80s and even 90s. Critics say there is little evidence of benefit — and considerable risk — from common tests for colon, breast and prostate cancer, particularly for those with serious problems such as heart disease or dementia that are more likely to kill them.
Too often these tests, some doctors and researchers say, trigger a cascade of expensive, anxiety-producing diagnostic procedures and invasive treatments for slow-growing diseases that may never cause problems, leaving patients worse off than if they had never been tested. In other cases, they say, treatment, rather than extending or improving life, actually reduces its quality in the final months.
“An ounce of prevention can be a ton of trouble,” observed geriatrician Robert Jayes, an associate professor of medicine at George Washington University School of Medicine. “Screening can label someone with a disease they were blissfully unaware of.” Dartmouth physician Lisa M. Schwartz cites one such case: a healthy 78-year-old man who was left incontinent and impotent by radiation treatments for prostate cancer, a disease that typically grows so slowly that many men die with — but not of — it.
The U.S. Preventive Services Task Force, an independent panel of experts that evaluates the risks and benefits of screening tests, does not endorse PSA testing or routine colon screening after age 75. The panel, whose recommendations will guide some coverage decisions under the 2010 federal health law that expands access to screening, says there is no evidence for or against mammography after age 74 and recommends that most women stop getting Pap smears to detect cervical cancer after 65.
So far the task force’s guidelines appear to have had limited impact. Researchers in June reported in the journal Cancer that nearly half of primary-care doctors would advise a woman with terminal lung cancer to get a routine mammogram — even if she was 80 years old. A 2010 JAMA study of more than 87,000 Medicare patients found that a “sizeable proportion” with advanced cancers continued to be screened for other malignancies. Last May, Texas researchers reported in the Archives of Internal Medicine that 46 percent of 24,000 Medicare recipients with a previous normal test underwent a repeat colonoscopy in less than seven years and sometimes as few as three — compared with the 10 years recommended by the task force. In nearly a quarter of cases, the repeat test was performed for no discernible reason. (Medicare is supposed to cover the screening test, which can cost about $2,000, only once a decade if no cancer or polyps have been found, but the program paid for all but 2 percent of the procedures reviewed by the Texas researchers.)
A grim diagnosis for our ailing health care system
By Robert J. Samuelson, Published: November 27
Even had it succeeded, the supercommittee would have failed. Ultimately, the only way to control federal spending and deficits is to suppress the upward spiral of health costs. These are already the budget’s largest single expense (27 percent in 2010, compared with 20 percent for defense), and their continued rapid growth, combined with the scheduled introduction of Obamacare, will soon bring them to nearly one-third. The supercommittee didn’t have the time or staff to solve a problem as contentious and complex as health care.
It remains urgent. Americans know that expensive medical care is squeezing non-health government programs and, through higher employer insurance costs, take-home pay. But they console themselves that U.S. health care “is the best in the world.” Among experts, this view has long been debated, but a new study from the Organization for Economic Cooperation and Development (OECD) in Paris suggests that the debate is over: It’s not true.
As societies grow wealthier, people want — and can afford — more health care. Still, U.S. health spending (about $7,960 per person in 2009) is in a league of its own. It’s 50 percent higher than Norway’s ($5,352), the next costliest. U.S. spending is more than double Britain’s ($3,487), France’s ($3,978) and the OECD average ($3,233).
Despite this, Americans aren’t notably healthier than people in other advanced countries, the study reports. Life expectancy in the United States (78.2 years) lags behind Japan’s (83 years) and the OECD average (79.5 years). It roughly equals Chile’s and the Czech Republic’s, says Mark Pearson of the OECD. Americans don’t have much to show for their system’s enormous cost, even if the gaps in life expectancy partly reflect differences in lifestyle and diet.
There are some bright spots. Cancer care is one area of superior performance; the five-year survival rate for breast cancer in the United States is 89.3 percent, while the OECD average is 83.5 percent. But the treatment of chronic illnesses such as diabetes and asthma may be worse. The U.S. rate of emergency hospitalization for asthma is three times that in France and six times that in Germany or Italy.
Indeed, by some indicators, Americans get less medical care than do people in other advanced countries. The number of practicing U.S. doctors (2.4 per 1,000 population) is less than the OECD average (3.1 per 1,000), as is the number of annual doctor consultations (3.9 per capita in the United States versus 6.5 for the OECD average).
What propels U.S. health spending upward? The OECD’s answer comes in two parts: steep prices and abundant provision of some expensive services. In 2007, an appendectomy cost $7,962 in the United States, $5,004 in Canada and $2,943 in Germany. A coronary angioplasty cost $14,378 in the United States, compared with $9,296 in Sweden and $7,027 in France. A knee replacement was $14,946 in the United States, $12,424 in France and $9,910 in Canada. Knee replacements in the United States were almost twice as common per 100,000 population as in the rest of the OECD. So were MRI exams and angioplasties.
This is a devastating portrait. At times, the U.S. health care system delivers the worst of both worlds: pay more, get less. Unfortunately, the message isn’t new. America’s fragmented and overspecialized health system maximizes returns to providers — doctors, hospitals, drug companies — but not to society. Fee-for-service reimbursement allows providers to reconcile their ethical duty (more care for patients) and economic self-interest (higher incomes). The more they do, the more they earn. Restraints are few, because patients and providers both resist limits on their choices. Government regulators and private insurers are too weak to control costs.
Countless thousands of conscientious doctors provide most Americans with good care and some with superb care. But the system needs a fundamental overhaul to deliver more value for money. There are essentially two ways to do this.
One is a voucher system that, through tax credits and fixed Medicare premium subsidies, would allow patients to shop for the best health plan. Competition, the theory goes, would force hospitals and doctors to restructure the delivery system; health plans would compete on the basis of price and quality.
The other way is a government-run, single-payer system that would — somehow — include strict budget limits on doctors, hospitals and other providers. Lower administrative costs alone wouldn’t provide enough savings to control overall spending. If open-ended reimbursement survived, so would the existing system.
What’s involved is transforming almost one-fifth of the U.S. economy. The supercommittee couldn’t do that. But it could have proposed legislation to create two teams of experts to design rival plans that would be ready for the next president. One way or another, if we don’t act, we’re surrendering our future to runaway health spending.
No insurance against price increases
Article by: JACKIE CROSBY Star Tribune Updated: November 19, 2011 – 3:53 PM
Big jumps in the cost of long-term care policies lead to worries that many will skip coverage for nursing homes and old-age care.
When Dean Di Tosto bought long-term care insurance in 1998, he believed he was locking in a low rate.
Now the 83-year-old Minnetonka resident feels duped. His insurance company, John Hancock, hiked the premiums twice in the past three years. The payments could go from $140 a month to $202 a month, a 44 percent increase.
“I understand the need for these increases,” he said. “I’m not a dummy. But it should affect future new policyholders, not those of us who have already put in thousands of dollars. Many people can’t go out and make more money to make up the difference.”
Trapped between fast-rising costs for care and weak returns on their investments, insurers have been raising long-term care premiums by double-digit percentages in Minnesota and nationwide. John Hancock, one of many companies to seek increases from the state, secured average rate increases of 13 percent in 2008 and 40 percent in 2010.
Some worry that higher premiums will make people less likely to get long-term care insurance — a potentially serious problem at a time when aging baby boomers’ needs for long-term care are about to explode. Ultimately, that could force people to lean on government programs to pay for nursing-home care and other costs.
“We’ve identified it as a priority for our health reform cabinet,” said Commerce Commissioner Mike Rothman, whose office regulates the insurance industry. “We’re looking at it, monitoring it, and making sure that when those rate increases come in, that they’re not exorbitant.”
More than 180,000 Minnesotans have long-term care insurance policies, designed to help seniors pay living costs later in life without being forced to deplete savings or sell their homes. The average cost of care is about $48,000 a year, but nursing homes can cost $80,000.
Insurance pays a fixed amount of daily benefits for a certain period of time. Premiums are based on such factors as age, gender and health.
State and federal lawmakers have spent considerable energy trying to encourage the middle class to plan ahead with long-term care insurance, without much luck.
The Obama administration last month scrapped the CLASS Act, a long-term care insurance program and major piece of federal health care reform. Minnesota launched a program in 2008 that allows median-income households that buy long-term care policies to shelter some assets if they apply for Medicaid. Still, only about 11 percent of people in the state have the insurance.
Even though the Medicaid program was designed as a safety net for people in poverty, middle-class seniors routinely deplete their assets and turn to the state.
In Minnesota, Medicaid pays about 40 percent of elderly long-term care. Costs could rise fivefold by 2035 to an “unsustainable burden” of $5 billion, according to a report last year from the Citizens League.
A difficult business
Long-term care coverage is a relatively new product. Though policies have been available since the 1970s, sales didn’t start taking off until 1996 when the federal government offered modest income tax advantages.
A combination of factors has driven the recent price increases.
Insurers set their rates on assumptions that some people would let their policies lapse. But people held on to policies longer than expected. And their claims are bigger because they’re living longer.
Low interest rates have had perhaps the biggest impact, because insurers planned to cover claims based on reserves they invested. When those investments fell short of expectations, insurers turned to policyholders to make up the difference.
“It’s the perfect storm,” said Amy Pahl, who advises insurance companies on long-term financial projections and regulatory matters for the actuarial firm Milliman.
“You’re looking at collecting premiums and investing them for 30, 40 or 50 years before a payout,” she said.
“Ten or 15 years ago, interest rates appeared to be sustainable at 6 or 7 percent. Every American knows that’s unachievable now.”
The difficulty of making the risks and financing work over such a long time horizon has led a number of companies to get out of the business, including Blue Cross and Blue Shield of Minnesota, Allianz Life and Ameriprise, Paul said.
A decade ago, 130 companies sold long-term care insurance. Today there are about 20, she said.
Deb Newman — whose Richfield-based company, Newman Long Term Care, is one of the biggest long-term care sellers in the country — has sympathy for policyholders facing increases. She’s one of them.
A policy she bought 18 years ago went from $725 annual premiums to about $1,100. Even so, it’s a better deal than waiting, she said. Similar coverage would cost someone who bought a policy now about $5,000 annually.
“People are understandably surprised when the insurance companies say, ‘Oops,’ we have to go back and increase everyone’s premiums by 40 percent,” she said. “But it’s still a tremendous value relative to what they could purchase today.”
The squeeze is especially tough for people who bought policies in the 1980s and 1990s. Some of those policies didn’t cover assisted living or adult day care, because they didn’t exist at the time.
Minnesota has tightened its long-term care law to add consumer protections and force insurers to build a stronger case to regulators for premium hikes. But those rules only affect policies written in 2002 and beyond.
In an e-mailed response to questions, a John Hancock spokeswoman said, “The company has always tried to provide alternatives to policyholders facing rate increases so they can keep premiums close to their current levels.”
The alternatives include reducing the benefit period, adjusting the benefit amount or allowing policyholders to reduce inflation coverage, the company said.
Di Tosto, a former marketing executive who runs a small business with his son, said he can afford higher premiums for himself and his wife, Inga. He remains angry that his choices are to pay up, reduce his benefits, or cancel and lose the $50,000-plus he has paid over the past 13 years.
He’s made it a crusade to push elected officials to do more to protect the state’s elderly and infirm.
“Many people are old and too feeble to fight,” he said. “Somebody has to stand up.”
Medicare spending growth rising slower but enrollment will rise
By Lori Montgomery, Published: December 22
Throughout Medicare’s 46-year-old history, monitoring the cost of the government health plan for the elderly has been a bit like the old joke: No one asked if spending would jump. They only asked how high.
But in early 2010, the number crunchers at Medicare headquarters in Baltimore saw something surprising: a sharp drop in the volume of doctor visits and other outpatient services. Instead of growing at the usual 4 percent a year, the number of claims was suddenly climbing by less than 2 percent. Was this a one-time blip, or a fundamental shift in how seniors were receiving care?
At first, chief Medicare actuary Rick Foster thought it was a mistake, perhaps a glitch in data collection. No other explanation made sense. Congress had just passed far-reaching health-care legislation that mandated cuts in Medicare spending. But the law was so new that rules for implementation had not been written.
As spring wore into summer, the trend inexplicably held. Spending growth on outpatient services, known as Part B, fell sharply.“We thought, ‘Wow, what’s happening?’ ” Foster recalled in an interview. “Part B cost growth has slowed down so much, we’re seeing virtually the lowest rates ever.”
Budget analysts treat the news as a temporary aberration that is unlikely to brighten a bleak outlook dominated by this fact: An average of 10,000 baby boomers will turn 65 every day for the next 20 years, eventually doubling the program’s enrollment. Annual Medicare spending is projected to reach nearly $1 trillion by 2021, approaching a fifth of all federal outlays. If per-person costs return to the usual rate of growth — and history suggests they will — the program will rapidly become the biggest driver of the national debt.
But the drop serves to highlight an often-overlooked truth: Medicare spending per person is rising more slowly than spending in the private health sector. And, because of the cuts that were part of last year’s Affordable Care Act, it is expected to mirror overall growth in the economy for much of the next decade, staying well below targets set by Congress.
“Medicare is not out of control,” said Robert Berenson, vice chairman of the congressionally appointed Medicare Payment Advisory Commission , which studies the program’s finances. “This bloated and inefficient program is not bloated and inefficient.”
Instead, the immediate and inescapable problem is a demographic one: the enormous wave of baby boomers who started enrolling this year. That concern suggests different solutions, experts say, from those needed to cope with runaway costs.
The politically charged debate over Medicare tends to proceed, however, as though the solution lies entirely in squeezing more savings out of the program, a goal that budget experts say will be difficult to reach. Not only are the proposed remedies largely untested, but there is a fundamental ideological divide over which ones to pursue.
President Obama and congressional Republicans agree that reining in Medicare is critical to reducing deficit spending and, therefore, the government’s need to borrow. But most Republicans say the Affordable Care Act won’t work and have vowed to repeal it. Many favor ending Medicare as an open-ended benefit and limiting spending for each beneficiary. Private insurance companies would compete with traditional Medicare, with the hope that vying for clients would push down costs, as some say has happened in the Medicare prescription drug program.
Doyle McManus: Touching the ‘third rail’
Politicians talking about Social Security’s problems isn’t enough; offering specific plans to fix the program is what’s needed.
September 15, 2011 | Doyle McManus
“We have not had the courage to stand up and look Americans in the face,” Texas Gov. Rick Perry said when he was asked about Social Security at the Republican presidential debate this week. “It has been called a Ponzi scheme by many people long before me. But no one’s had the courage to stand up and say, ‘Here is how we’re going to reform it.’ ”
Including, it turns out, Rick Perry. In all the sound and fury over Social Security over the past few weeks, the Texas governor has never actually spelled out how he would fix the program. Nor have most of the other candidates who trumpet their purported courage in saying that Social Security is in trouble.
That’s what’s been wrong with the noisy GOP “debate” on our national pension plan. It’s been all chest-thumping and Ponzi-scheming — lots of attitude but little substance. It’s provided little clarity for voters who want to know what these potential presidents would do if elected.
Not that President Barack Obama has done much better; he’s tiptoed around endorsing specific proposals, too.
It doesn’t take much courage to tell voters that Social Security faces a fiscal squeeze. They know that already.
The reason is well-known, too: Social Security uses taxes paid by current workers to pay retirees, and after millions of baby boomers retire, there will be fewer workers paying in for every retiree.
Does that make Social Security a Ponzi scheme? Not really. Unlike a Ponzi scheme, Social Security is open about how it works: Anyone who’s paying attention knows it’s a pay-as-you-go system. And unlike a Ponzi scheme, Social Security should be pretty easy to fix.
At some point — estimated at 2036 — Social Security will be able to pay only 77 percent of the benefits it has promised. It won’t be flat broke, but it will be like a bankrupt company, able to keep operating but unable to pay all of its bills.
It’s not hard to figure out how to fix that. You can raise taxes, or reduce future benefits, or do some of each. Democrats tend to lean toward tax increases, and Republicans tend to lean toward benefit trims — when they’re willing to admit that they have any thoughts on the issue, that is.
That’s where courage comes in. The hard part, for politicians, is telling voters what painful steps they back, which means spelling out who would pay what share of the cost.
Perry hasn’t done that. Instead, the Texas governor started out with a position that was radical but clear: He said it was a mistake to enact Social Security and Medicare in the first place and implied that both should be dismantled.
“Why is the federal government even in the pension program or the health-care delivery program?” he asked in a television interview last year. “Let the states do it.”
After his position drew fire in the past few weeks from candidate Mitt Romney, Perry backtracked. “America’s goal must be to fix Social Security by making it more financially sound,” he wrote in an op-ed forUSA Today. How? He didn’t say.
Then, in Monday’s debate in Tampa, Fla., Perry tried to have it both ways. He promised that Social Security will be there for the elderly — “slam-dunk guaranteed” — except he’d still like to think about replacing it. “The issue is: Are there ways to move the states into Social Security for state employees or for retirees?” he asked.
Romney, to his credit, has been more specific — and more consistent. In his pre-campaign book, he endorsed two basic options for fixing Social Security: increasing the retirement age and reducing future benefits for upper-income earners. He rejected raising taxes.
In his book, Romney made an argument for raising the retirement age — a measure that is, in effect, a benefit cut for anyone whose eligibility is delayed. But polls have shown that raising the retirement age is unpopular. That may be a reason you haven’t heard Romney talk much about his proposals; he’d rather talk about Perry’s instead.
What about Obama?
In his 2008 campaign, the president offered a traditional Democratic solution to the problem: raise payroll taxes on upper-income workers. “I believe that cutting benefits is not the right answer, and that raising the retirement age is not the best option,” he said then. That’s about as specific as he’s been.
Last year, the co-chairmen of Obama’s own deficit-reduction commission, Alan Simpson and Erskine Bowles, proposed a plan with options from both sides of the menu: increase payroll taxes, raise the retirement age, reduce future benefits for high-income earners and trim cost-of-living increases for current recipients.
The reactions were predictable. Democrats howled at the idea of trimming current benefits. Republicans dismissed the idea of increasing taxes. Obama thanked Simpson and Bowles for their work, but he didn’t endorse their plan.
If we fix Social Security between now and 2036, the solution is likely to look something like what Simpson and Bowles proposed — after suitable wrangling over how big each component should be.
Meanwhile, let’s have a truce on calling Social Security a Ponzi scheme, promising voters that benefits will never be cut or claiming that it takes courage to talk about the subject at all.
Most Americans already agree that Social Security needs to be fixed. The courage will come in showing them how.
A new report suggests steps to help sustain the program for generations. But the fixes require political courage.
Can tiny changes save Social Security?
Report: Tweaks to taxes, benefits can eliminate shortfall
WASHINGTON — Social Security faces a $5.3 trillion shortfall over the next 75 years, but a new congressional report says the massive gap could be erased with only modest changes to payroll taxes and benefits.
Washington’s year of drama leaves little done regarding debt
By Lori Montgomery, Published: December 27
Reid Ribble, a Wisconsin roofing contractor-turned-Republican lawmaker, has helped change the way Washington talks about the national debt. That’s not to say he has done much about the debt itself.
Nearly a year ago, Ribble and other newly elected House Republicans came to Capitol Hill on a single-minded mission to shove the federal debt to the top of the congressional agenda. They succeeded. At every opportunity, they demanded cuts in spending, forcing a series of white-knuckle showdowns that have kept the government in a state of perpetual crisis. Washington nudged close to a public conversation about the kind of government taxpayers want and what they are willing to pay for it.
Last week, however, Ribble went home for the holidays with little to show for all the political drama. The debt stood at $15.1 trillion, $1 trillion more than when he got to town. By the end of next year, projections show, it will grow by an additional $1 trillion. Ribble said he and his allies had cut spending for 2012 by only about $7 billion, a sliver so tiny Ribble could measure its impact in minutes.
“We’ve saved the American taxpayer about 17 hours of spending. That’s it,” he said. “When you just really stop and think about it, we’ve made very little progress.”
Look past 2012, and the budget deals of the past year make a more significant dent. They reduce spending by more than $1 trillion over the next 10 years, the largest debt reduction in two decades. Yet no one, of any ideological stripe, is bragging about the accomplishment. Instead, the Capitol is pervaded by an atmosphere of failure, of opportunity blown.