Remember The Health-Care Reform Debate?: How The Landscape Has Changed
As a participant in the great health-care wars of 2010, it’s been — I don’t know: Amusing? Depressing? Annoying? Vindicating? — to watch Rep. Paul Ryan’s budget run over every principle or concern that Republicans considered so life-or-death a mere 400 days ago. A partial list:
Big changes need to be bipartisan changes. “The only bipartisanship we’ve seen on [the health-care] bill is in opposition to it,” said Eric Cantor, now the House majority leader. “When the stakes are this high – reforming 20 percent of the U.S. economy – there must be constructive conversations and negotiations from Republicans and Democrats in both houses of Congress,” wroteformer representative Tom Davis. The Ryan budget, which is unquestionably a more ambitious document than the Affordable Care Act, passed the House with no Democratic votes and four Republicans voting no. The only thing bipartisan was the opposition, etc. This appears to have given no Republicans anywhere any pause.
Polls matter. In March 2010, John Boehner was very, very upset that Democrats were working to pass a health-care law that a slight plurality opposed in polls. “President Obama made clear he is willing to say and do anything to defy the will of the people and force his job-killing health care plan through Congress,” he thundered. Last week, Speaker Boehner and the Republicans passed Ryan’s budget. How do its elements poll? Much, much worsethan the Affordable Care Act.
The Affordable Care Act’s Medicare cuts will devastate hospitals! Last fall, Ryan’s health-policy guru was saying,“The official Medicare actuaries have determined that approximately 15 percent of hospitals will be driven out of business in less than ten years if these cuts go through and called the cuts ‘clearly unworkable and almost certain to be overridden by Congress.’” Now those same cuts are in Ryan’s budget. C’est la vie, I guess (that’s French for “only Democratic cuts hurt hospitals”).
The Affordable Care Act’s savings don’t begin quickly enough! When the tax on expensive employer-provided insurance plans was pushed back to 2018, conservatives were outraged. “The odds are high that the excise tax will never actually happen,” wrote David Brooks. “There is no reason to think that the Congress of 2018 will be any braver than the Congress of today.” It was a fair argument: Cost savings that begin in the future are less certain than cost savings that begin now. So when does, say, Ryan’s voucherization of Medicare begin? Not 2012. And no, it’s not 2018. It’s 2022.
There’s no reform in the Affordable Care Act. “It would take Sherlock Holmes armed with the latest GPS technology and a pack of bloodhounds to find ‘reform’ in the $2.5 trillion version of the health-care bill we are supposed to vote on in the next few days,” then-Sen. Judd Gregg wrote. But apparently Holmes got his iPhone out, because now the Affordable Care Act is chock-full of reforms. In fact, it’s the model Republicans are following. “It’s exactly like Obamacare,” Sen. John Cornyn saidof the Ryan plan. “It is. It’s exactly like it.” And he meant that as a compliment!
The Congressional Budget Office will score anything you tell it to. “Garbage in, garbage out,” Sen. John McCain said. “Can you really rely on the numbers that the Congressional Budget Office comes out with?” asked Fox’s Steve Doocy. Now, of course, Republicans are touting CBO’s estimates of Ryan’s savings.
First, “do no harm.” That was former Republican National Committee Chairman Michael Steele’s big applause line. “Republicans want reform that should, first, do no harm, especially to our seniors,” he wrote in The Washington Post. Cantor said the Affordable Care Act would “cut Medicare for our seniors and increase premiums for many Virginians.” Say what you will about Ryan’s budget, but going from paying 25-30 percent of your Medicare costs to 70 percent cuts your Medicare while increasing your premiums. Steele also said that “we need to protect Medicare and not cut it in the name of ‘health-insurance reform.’ ” Instead, it’s getting cut in the name of tax cuts. To be fair, Ramesh Ponnuru saw this one coming, so I can’t say conservatives were denying it at the time.
I’m sure I’ve forgotten a couple, but that’s what the comment section is for. The natural next question is whether Democrats have been similarly hypocritical in their opposition to Ryan’s plan. So far as I can tell, we’ve not seen it: Democrats think the plan puts too much of a burden on the backs of seniors and the poor — two things they worried about constantly during the Affordable Care Act — and cuts too many taxes for the rich. They also note that the Congressional Budget Office says privatizing Medicare will make it more expensive — the same finding that led to liberal advocacy for a public option. But if I’m missing something here, I imagine it, too, will come up in comments.
By: Ezra Klein, The Washington Post, April 21, 2011
Ludicrous and Cruel: America Is Being Punked By GOP Voodoo Economics
Many commentators swooned earlier this week after House Republicans, led by the Budget Committee chairman, Paul Ryan, unveiled their budget proposals. They lavished praise on Mr. Ryan, asserting that his plan set a new standard of fiscal seriousness.
Well, they should have waited until people who know how to read budget numbers had a chance to study the proposal. For the G.O.P. plan turns out not to be serious at all. Instead, it’s simultaneously ridiculous and heartless.
How ridiculous is it? Let me count the ways — or rather a few of the ways, because there are more howlers in the plan than I can cover in one column.
First, Republicans have once again gone all in for voodoo economics — the claim, refuted by experience, that tax cuts pay for themselves.
Specifically, the Ryan proposal trumpets the results of an economic projection from the Heritage Foundation, which claims that the plan’s tax cuts would set off a gigantic boom. Indeed, the foundation initially predicted that the G.O.P. plan would bring the unemployment rate down to 2.8 percent — a number we haven’t achieved since the Korean War. After widespread jeering, the unemployment projection vanished from the Heritage Foundation’s Web site, but voodoo still permeates the rest of the analysis.
In particular, the original voodoo proposition — the claim that lower taxes mean higher revenue — is still very much there. The Heritage Foundation projection has large tax cuts actually increasing revenue by almost $600 billion over the next 10 years.
A more sober assessment from the nonpartisan Congressional Budget Office tells a different story. It finds that a large part of the supposed savings from spending cuts would go, not to reduce the deficit, but to pay for tax cuts. In fact, the budget office finds that over the next decade the plan would lead to bigger deficits and more debt than current law.
And about those spending cuts: leave health care on one side for a moment and focus on the rest of the proposal. It turns out that Mr. Ryan and his colleagues are assuming drastic cuts in nonhealth spending without explaining how that is supposed to happen.
How drastic? According to the budget office, which analyzed the plan using assumptions dictated by House Republicans, the proposal calls for spending on items other than Social Security, Medicare and Medicaid — but including defense — to fall from 12 percent of G.D.P. last year to 6 percent of G.D.P. in 2022, and just 3.5 percent of G.D.P. in the long run.
That last number is less than we currently spend on defense alone; it’s not much bigger than federal spending when Calvin Coolidge was president, and the United States, among other things, had only a tiny military establishment. How could such a drastic shrinking of government take place without crippling essential public functions? The plan doesn’t say.
And then there’s the much-ballyhooed proposal to abolish Medicare and replace it with vouchers that can be used to buy private health insurance.
The point here is that privatizing Medicare does nothing, in itself, to limit health-care costs. In fact, it almost surely raises them by adding a layer of middlemen. Yet the House plan assumes that we can cut health-care spending as a percentage of G.D.P. despite an aging population and rising health care costs.
The only way that can happen is if those vouchers are worth much less than the cost of health insurance. In fact, the Congressional Budget Office estimates that by 2030 the value of a voucher would cover only a third of the cost of a private insurance policy equivalent to Medicare as we know it. So the plan would deprive many and probably most seniors of adequate health care.
And that neither should nor will happen. Mr. Ryan and his colleagues can write down whatever numbers they like, but seniors vote. And when they find that their health-care vouchers are grossly inadequate, they’ll demand and get bigger vouchers — wiping out the plan’s supposed savings.
In short, this plan isn’t remotely serious; on the contrary, it’s ludicrous.
And it’s also cruel.
In the past, Mr. Ryan has talked a good game about taking care of those in need. But as the Center on Budget and Policy Priorities points out, of the $4 trillion in spending cuts he proposes over the next decade, two-thirds involve cutting programs that mainly serve low-income Americans. And by repealing last year’s health reform, without any replacement, the plan would also deprive an estimated 34 million nonelderly Americans of health insurance.
So the pundits who praised this proposal when it was released were punked. The G.O.P. budget plan isn’t a good-faith effort to put America’s fiscal house in order; it’s voodoo economics, with an extra dose of fantasy, and a large helping of mean-spiritedness.
By: Paul Krugman, Op-Ed Columnist, The New York Times, April 7, 2011
Cutting Medicaid Means Cutting Care For The Poor, Sick And Elderly
The part of Paul Ryan’s budget that’s going to get the most attention is his proposal to privatize and voucherize Medicare. But the part that worries me the most is his effort to slash Medicaid, with no real theory as to how to make up the cuts.
Ryan’s op-ed introducing his budget lists Medicaid under “welfare reform,” reflecting the widespread belief that Medicaid is a program for the poor. That belief is wrong, or at least incomplete. A full two-thirds of Medicaid’s spending goes to seniors and people with disabilities — even though seniors and the disabled are only a quarter of Medicaid’s members. Sharply cutting Medicaid means sharply cutting their benefits, as that’s where the bulk of Medicaid’s money goes. This is not just about the free health care given to some hypothetical class of undeserving and unemployed Medicaid queens.
But perhaps cutting it wouldn’t be so bad if there were a lot of waste in Medicaid. But there isn’t. Medicaid is cheap. Arguably too cheap. Its reimbursements are so low many doctors won’t accept Medicaid patients. Its costs grew less quickly than those of private insurance over the past decade, and at this point, a Medicaid plan is about 20 percent cheaper than an equivalent private-insurance plan. As it happens, I don’t think Medicaid is a great program, and I’d be perfectly happy to see it moved onto the exchanges once health-care reform is up and running. But the reason that’s unlikely to happen isn’t ideology. It’s money. Giving Medicaid members private insurance would cost many billions of dollars.
That’s why it’s well understood that converting Medicaid into block grants means cutting people off from using it, or limiting what they can use it for. You can see CBO director Doug Elmendorf say exactly the same thing here. There’s just not another way to cut costs in the program. You can, of course, work to cut costs outside of the program, either by helping people avoid becoming disabled or making it cheaper to treat patients once they become disabled or sick, but those sorts of health-system reforms are beyond the ambitions of Ryan’s budget.
To get around some of this, Ryan’s op-ed talks about state flexibility, with the implication being that states have some secret Medicaid policies they’ve been dying to try but that the federal government simply hasn’t let them attempt. But the truth is there’s been a tremendous amount of experimentation in Medicaid over recent decades. Indiana converted its Medicaid program into health savings accounts. Tennessee based its program around managed care. Massachusetts folded its Medicaid money into Mitt Romney’s health-care reforms. Oregon tried to rank treatments by value. Some of these reforms have worked well and some haven’t worked at all, but none have solved the basic problem that covering the sick and disabled costs money, and you can’t get around that by trying to redesign their insurance packages. For that reason, block-granting Medicaid ultimately means cutting health-care coverage to the poor, the elderly and the disabled, even as it doesn’t actually address the factors driving costs throughout the health-care system.
By: Ezra Klein, The Washington Post, April 5, 2011
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