The Democrats Have A Plan For Controlling Health-Care Costs, Paul Ryan Doesn’t
There’s increasingly an understanding that the mixture of cuts and taxes in Paul Ryan’s budget aren’t quite fair, and the underlying assumptions it uses don’t quite work. But it’s left people hungry for a budget that does work, and annoyed that Democrats haven’t provided one. “If Democrats don’t like his budget ideas, they should propose their own,” writes Fareed Zakaria. “The Democrats and Obama now have to offer a response,” warned Andrew Sullivan. “As of this evening, the Democratic policy plan consists of yelling ‘You suck!’” complained Megan McArdle.
I’ve made similar comments. And I think those comments are mostly right. Democrats need to step up on taxes, on defense and non-defense discretionary, on Social Security, and on energy. But there’s one huge, glaring exception: controlling health-care costs. There, the reality is that Democrats have a plan and Ryan doesn’t. But the perception, at this point, is just the opposite.
At the heart of Ryan’s budget are policies tying the federal government’s contribution to Medicare and Medicaid to the rate of inflation — which is far, far slower than costs in the health-care sector typically grow. He achieves those caps through cost shifting. For Medicaid, the states have to figure out how to save the money, and for Medicare, seniors will now be purchasing their own insurance plans and, in their new role as consumers, have to figure out how to save the money. It won’t work, and because it won’t work, Ryan’s savings will not materialize.
Even Ryan’s fans agree you can’t hold health-care costs down to inflation. But even if you grant that Ryan’s target is too low, his vision for reforming Medicare would like miss a more reasonabke target, too. Consider the program Ryan names as a model. He said his budget converts Medicare into “the same kind of health-care program that members of Congress enjoy.” The system he’s referring to is the Federal Employee’s Health Benefits Program, and cost growth there has not only massively outpaced inflation in recent years, but actually outpaced Medicare, too. Ryan’s numbers are so fantastic that Alice Rivlin, who originally had her name on this proposal, now opposes it.
Democrats don’t just have a proposal that offers a more plausible vision of cost control than Ryan does. They have an honest-to-goodness law. The Affordable Care Act sets more achievable targets, and offers a host of more plausible ways to reach them, than anything in Ryan’s budget. “If this is a competition betweenRyan and the Affordable Care Act on realistic approaches to curbing the growth of spending,” says Robert Reischauer, who ran the Congressional Budget Office from 1989 to 1995 and now directs the Urban Institute, “the Affordable Care Act gets five points and Ryan gets zero.”
The Affordable Care Act holds Medicare’s cost growth to GDP plus one percentage point, which makes a lot more sense. It’s the target Ryan’s Medicare plan originally used, back when it was called Ryan-Rivlin. But the target is not really the important part. The important part is how you achieve the target. And the Affordable Care Act actually includes reforms and new processes for future reforms that would help Medicare — and the rest of the medical system — get to where the costs can be saved, rather than just shifted.
The Affordable Care Act’s central hope is that Medicare can lead the health-care system to pay for value, cut down on overtreatment, and cut out treatments that simply don’t work. The law develops Accountable Care Organizations, in which Medicare pays one provider to coordinate all of your care successfully, rather than paying many doctors and providers to add to your care no matter the cost or outcome, as is the current practice. It also begins experimenting with bundled payments, in which Medicare pays one lump-sum for all care related to the successful treatment of a condition rather than paying for every piece of care separately. To help these reforms succeed, and to help all doctors make more cost-effective treatment decisions, the law accelerates research on which drugs and treatments are most effective, and creates and funds the Patient-Centered Outcomes Research Institute to disseminate the data.
If those initiatives work, they head over to the Independent Payment Advisory Board (IPAB), which can implement cost-controlling reforms across Medicare without congressional approval — an effort to make continuous reform the default for Medicare, even if Congress is gridlocked or focused on other matters. And if they don’t work, then it’s up to the Center for Medicare and Medicaid Innovation, a funded body that will be continually testing payment and practice reforms, to keep searching and experimenting, and when it hits on successful ideas, handing them to the IPAB to implement throughout the system.
The law also goes after bad and wasted care: It cuts payments to hospitals with high rates of re-admission, as that tends to signal care isn’t being delivered well, or isn’t being follow up on effectively. It cuts payments to hospitals for care related to infections caught in the hospitals. It develops new plans to help Medicare base its purchasing decisions on value, and new programs to help Medicaid move patients with chronic illnesses into systems that rely on the sort of maintenance-based care that’s been shown to successfully lower costs and improve outcomes.
I could go on, but instead, I’ll just link to the Kaiser Family Foundation’s excellent primer (pdf) on everything the law does. The bottom line is this: The Affordable Care Act is actually doing the hard work of reforming the health-care system that’s needed to make cost control possible. Ryan’s budget just makes seniors pay more for their Medicare and choose their own plans — worthy ideas, you can argue, but ideas that have been tried many times before, and that have never cut costs in the way Ryan’s budget suggests they will.
That’s why, when the Congressional Budget Office looked at Ryan’s plan, they said it would make Medicare more expensive for seniors, not less. The reason the deficit goes down is because seniors are paying 70 percent of the cost of their insurance out-of-pocket rather than 30 percent. But that’s not sustainable: We’ve just taken the government’s medical-costs problem and pushed it onto families.
No one who knows health-care policy will tell you that the Affordable Care Act does everything we need to do in exactly the way we need it done. That’s why Resichauer gave it a five, not a 10. But it does a lot of what we need to do and it sets up systems to help us continue doing what’s needed in the future.
Ryan’s proposal, by contrast, does almost none of what we need to do. It appeals to people who have an ideological take on health-care reform and believe we can make Medicare cheaper by handing it over to private insurers and telling seniors to act like consumers. It’s a plan that suggests health-care costs are about insurance, as opposed to about health care. There’s precious little evidence of that, and when added to the fact that Ryan’s targets are so low that even his allies can’t defend them, the reality is that his savings are largely an illusion.
The Affordable Care Act has taken a lot of hits. It’s not popular, and though very few of the political actors confidently attacking or advocating it can explain the many things it’s doing to try and control costs, people have very strong opinions on whether it will succeed at controlling costs. But the irony of everyone demanding Democrats come up with a vision for addressing the drivers of our deficit in the years to come is that, on the central driver of costs and the central element of Ryan’s budget, Democrats actually have something better than a vision. They have a law, and for all its flaws, their law actually makes some sense. Republicans don’t have a law, and their vision, at this point, doesn’t make any sense at all.
By: Ezra Klein, The Washington Post, April 8, 2011
“Revere America”: Another Conduit For A Super-Wealthy Family To Influence Elections
On March 23, 2011 a group called Revere America issued a dire-sounding PRNewswire press release titled, “Americans Fear Loss of Freedom on Anniversary of Health Care Reform Law.” It warned that “a majority” of Americans view health care reform as “a threat to their freedom” and cited a poll by Bill McInturff of Public Opinion Strategies to prove it. The release came well after Revere America had spent $2.5 million on attack ads in the 2010 mid-term elections to defeat Democratic candidates in two states — New York and New Hampshire — who had voted in favor of health care reform. Just prior to the mid-term elections, in the autumn of 2010, Revere America ran a a slew of false and misleading attack ads against the health care reform bill that erroneously called health reform “government-run healthcare” (a Republican and insurance industry buzz-phrase). The ads said that the new law will result in higher costs and longer waits in doctors’ offices. In another false claim aimed at inducing fear, the ads told viewers that “your right to keep your own doctor may be taken away.”
But who, or what, is Revere America? And how did it pull together enough money in less than a year to run a multi-million-dollar attack ad campaign, engage an expensive, professional polling firm and pump their message out on PRNewswire?
“Revere America”: Another Veil for a Wealthy Family
Revere America (RA) is a Delaware-based advocacy organization that sprang up in April, 2010. Like so many similar groups springing up after the Supreme Court’s ruling in Citizens United, RA is set up in a way that allows it to accept corporate donations, and that keeps it from having to reveal its funders. RA’s titular head at the time of its startup was former New York Governor George Pataki. The group pushes to repeal health reform, also known as the Patient Protection and Affordable Care Act, which Pataki described a “horrific” and “costly bungle.” Donations to RA are not tax deductible, which would seem to make donating huge sums of money to the group less attractive to large numbers of people if it was a real grassroots group made up of ordinary people.
The Collier’s Hamilton Yacht ClubBut it turns out that Revere America is not made up of ordinary people, and its primary funder isn’t all that concerned about money. According to Citizens for Responsibility and Ethics in Washington (CREW) and other sources, Revere America’s primary funder is Parker J. Collier of Naples, Florida, the wife of Miles Collier, a wealthy Florida land baron and real estate developer. Ms. Collier has given half a million dollars to the Republican Party of Florida, $60,800 to the Republican National Committee, and gave an overall total of $1,239,014 to Republican interests — and that was just in 2009-2010.
The Collier money flowing towards Republicans and Revere America is old family money. Parker’s husband, Miles Collier, is the grandson of Barron Collier, who bought over a million acres in south Florida in the early 1900s, and after whom Collier County, Florida is named. Through their company, Collier Enterprises, the Colliers develop tony yacht, golf and members-only country clubs in southwest Florida, where the rich play, dine and sail. In recent years, Collier Enterprises has even been developing entire towns in Florida.
Influencing Elections Throughout the U.S.
The Collier’s private, members-only golf clubFor the Colliers, though, it apparently isn’t enough to have all the amenities of uber-wealth. Through Revere America, the family’s apparent political front group, the Colliers have also been using their money to influence elections throughout the rest of the country. They have financially supported far-right Republican candidates not only in New York and New Hampshire, but in many other states, including Michele Bachmann (R-Minnesota), Senator Scott Brown (R-Massachusetts), and Republican Sue Lowden in her failed primary bid to gain the Senate nomination in Nevada, to name just a few. The list of Republican candidates RA funded and Democrats they worked to defeat in the 2010 election cycle numbers over 100, with some elections meriting six figure donations — amounts that far exceed what individuals can legally donate to influence an election.
The professional Republican pollster doing work for RA, Bill McInturff, conducted the message and advertisement testing for the infamous “Harry and Louise” television commercials that helped defeat the Clinton-era health care reform effort. Some of McInturf’s other clients include insurer Blue Cross Blue Shield Association, America’s Health Insurance Plans (the health insurance industry’s lobbying group) and drug maker Pfizer — all of which have a stake in undermining health care reform.
Pataki resigned as RA’s chairman in February, 2011, citing a Florida judge’s ruling the same month that the new health reform law’s federal mandate to purchase health insurance is unconstitutional. Pataki cited this ruling, and the House of Representatives’ symbolic vote to repeal health reform, as creating a good time for him to step down, and as proof that RA had been “successfully launched.” RA’s spokesperson and president is now Florida attorney Marianne R.P. Zuk, who is listed in Florida incorporation records as an officer or director for several Collier-owned companies.
Revere America is a “grassroots group” for the uber-wealthy Collier family in the same way that Americans for Prosperity is a “grassroots” group for the uber-wealthy Koch brothers. Such groups are conduits through which the super-rich are increasingly exerting powerful influence over elections nationwide. RA is yet another group that demonstrates the growing trend in which the wealthiest Americans — in the forms of both human beings and corporations — use their money to create fake “grassroots” front groups to hide behind and influence elections across the U.S.
Be on the look out for many more such groups to crop up in the future as the richest one or two percent of U.S. citizens come under increasing pressure to pay their fair share of taxes, and as we move closer to the 2012 elections.
By: Anne Landman, Center for Media and Democracy, April 8, 2011
No, Rep Paul Ryan’s Budget Proposal Is Not Brave
Prominent opinion writers have spent the last few days fawning over Rep. Paul Ryan’s budget plan, which would essentially abolish Medicare and Medicaid while lowering taxes on top earners, and many of them have deployed a litany of superlatives usually reserved for costumed superheroes. Commentators like David Brooks and Jacob Weisberg have described Ryan’s plan as “brave,” and “bold,” and the word “courageous” has been ubiquitous.
But the closer people look at Ryan’s plan, the clearer it becomes that the plan isn’t all that brave. Let’s take stock of all the recent revelations about it.
Ryan’s plan included a laughably implausible unemployment analysis from Heritage predicting it would bring unemployment down to 4 percent by 2015 and 2.8 percent by 2012 — an analysis Heritage then quitely retracted by attempting to disappear it from the internet. Ryan’s plan claims to save money while repealing the Affordable Care Act, even though the CBO has said repealing the ACA will increase the deficit. Ryan implied that his plan was supported by President Bill Clinton’s former OMB Director Alice Rivlin, even though it isn’t. It cuts taxes on top earners, when the easiest way to reduce the deficit is to let the Bush tax cuts expire.
Ryan’s misleading claims aren’t the only thing that isn’t particularly brave about his plan. After accusing Democrats of “raiding” Medicare with the Affordable Care Act, Ryan spares the elderly voters who supported Republicans in 2010 by making sure only he guts medical care for future seniors (he still calls it “saving Medicare,” however). And as the Center for Budget and Policy Priorities noted, 2.9 trillion in Ryan’s budget comes from cuts in programs focused on low-income Americans. It doesn’t touch defense spending.
In other words, it focuses on cuts to programs that benefit those most likely to vote Democratic, while preserving programs that serve those more likely to vote Republican.Rewarding your constituencies while punishing the other side’s is how partisan politics usually works, but there’s nothing particularly brave about it.
Ryan himself said during the rollout that his plan isn’t so much a budget as a “cause.” As Steve Benen wrote yesterday, the cause here is destroying the modern welfare state so that rich people have to pay less in taxes. The only reason so many people think Ryan’s plan is “brave” is because they agree with this cause.
When we call a person brave, what we usually mean is that his or her “bravery” is being employed towards an end we agree with. In this case, those who are hailing Ryan’s proposal as brave are doing so because they agree with its goal, which — no matter how many times people insist otherwise — is not deficit reduction. It’s destroying the social safety net. It just so happens that’s a cause a lot of wealthy people with a disproportionate influence on our political discourse happen to believe in. So they think it’s brave, even if the numbers are phony and even if it disproportionately punishes the poor. But there’s nothing at all brave about it.
By: Adam Serwer, The Washington Post, April 7, 2011
In This Fantasy Budget Deficit And Debt Fight, the Tea Party Refuses To Take ‘Yes’ For An Answer
Suppose I told you that I knew of a simple way to alleviate the budget deficit problem, and that it would require Congress not to do anything at all. You’d conclude that this was the poor start to a late April Fools’ column.
But unhappily the April Fools’ joke unfolding in the nation’s capital is the fantasy budget and spending debate itself. It’s rooted in an unreality that is about to crash into an unyielding real world, possibly in the form of a government shutdown.
The Congressional Budget Office, a nonpartisan fiscal scorekeeper, projects the budget deficit will be $1.5 trillion this year, or 9.8 percent of gross domestic product. In order to achieve budget stability and sustainability, according to economists, that figure should be around 3 percent of GDP. But here’s the good news: The CBO projects that the deficit will “drop markedly over the next few years as a share of output and average 3.1 percent of GDP from 2014 to 2021.” We’re saved! And it gets better: “Those projections . . . are based on the assumption that tax and spending policies unfold as specified in current law.”
In other words, all Congress has to do is what they seem ideally suited to these days—nothing. Ah, but there’s the rub. CBO continues that its projections “understate the budget deficits that would occur if many policies currently in place were continued, rather than allowed to expire as scheduled under current law.” Those policies include the Bush tax cuts. They also include annual spending punts that enjoy broad bipartisan support, like preventing the Alternative Minimum Tax’s bracket creep from snagging the middle class, and the “doc fix,” which pushes back a scheduled cut in Medicare payments.
So the solution isn’t so simple. But lawmakers wishing to do more than talk about dealing with the deficit could demand offsets for these policy changes. Instead, we’re reminded of the reality that even the toughest self-styled budget hawks–including Budget Committee Chairman Paul Ryan, who describes dealing with the deficit as a “moral imperative” but advocates extending the Bush tax cuts in full in perpetuity at a cost of nearly $4 trillion–are actually strutting budget peacocks more concerned with perception than results, or fiscal results anyway.
Take, for example, the Republican Study Committee, the hawkiest of the GOP budgetary birds of prey and enforcers of the party’s economic dogma. Going by reputation, they should be able to proffer a budget plan to bring the deficit into line. But the Concord Coalition, a group focused on eliminating the deficit, last month used CBO numbers to examine a scenario under which the Study Committee got its tax-and-spending wish list, which includes an extension of the Bush tax cuts, repeal of the Obama healthcare law (which CBO scores as a money-saver, meaning that repeal adds to the deficit), and $2.7 trillion saved in a spending freeze and cuts. The result? “Under this scenario, the resulting deficits would be $2.1 trillion larger over 10 years,” according to Concord, which concludes, “A budget that uses honest numbers and reflects Republicans’ current policy preferences will result in large continuing deficits.”
But nevertheless, and in the face of six recent years of GOP control over both the White House and Congress, Republicans have won the budget perception battle, and soundly. A poll released last week by Democracy Corps, a group of prominent liberal pollsters including Stan Greenberg and James Carville, found that independent voters are “still hesitant to trust Democrats on spending.”
Meanwhile the debate in Washington has focused almost entirely on spending cuts, even though polls show that voters are more concerned about jobs and the economy than the budget and the deficit—and even though most economists agree that the GOP’s proposed spending cuts would set back the recovery.
But the clearest example of the GOP having the Democrats on the run can be found in the current negotiations aimed at averting a government shutdown in a week. House Republican leaders originally wanted $32 billion in spending cuts for this year; that figure prompted a conservative backlash that ended with the House passing $61 billion in cuts. Now, according to press reports, negotiators have settled on $33 billion in cuts. In other words, the GOP, which controls one of three players in this negotiation, has already achieved its original budgetary goal. In this regard, House Speaker John Boehner seems to have (intentionally or not) used his Tea Party wing as a perfect foil to pull the debate to the right.
But judging by last Thursday’s Tea Party demonstration on the Hill—aimed at the GOP, mind you—conservatives don’t seem capable of banking their win and moving on to the next fight. They see anything less than total victory as an abject surrender.
And in that sense reality is about to intrude upon their budgetary-political fantasy land. The reality is that while voters like spending cuts in the abstract, polls show they object to the particulars of the GOP agenda. That reality is already taking hold at the state level where, Politico reported last week, the wave of newly elected governors trying to get tough on budgets have seen their approval ratings collapse.
And the experience of state governments also provides an insight into the possible winners and losers in a government shutdown. A pair of political scientists published a paper last year looking at the effects of such budgetary breakdowns (167 of them since 1988) at the state level, reports the Washington Post’s Ezra Klein. The study found that voters tend to punish legislators while rewarding the executive. So a shutdown would benefit President Obama while hurting lawmakers in both parties.
So if members of Congress let the government shut down on Friday, they will be the real April fools.
By: Robert Schlesinger, U.S. News and World Report, April 6, 2011
Congressional Budget Office Looks At “RyanCare” Rationing And It Ain’t Pretty
The Congressional Budget Office has released its preliminary analysis (PDF) of House Budget Committee Chairman Paul Ryan’s budget, and I wouldn’t say it’s pretty. According to the CBO, Medicare beneficiaries will be left paying more for less. The CBO goes about this in a bit of a confusing way, setting a “benchmark” that corresponds to the cost of purchasing a private plan equivalent to Medicare, and then seeing how much more that plan would cost than Medicare under two different scenarios. Compared with either scenario, RyanCare costs a lot more than Medicare:
Under the proposal, most elderly people would pay more for their health care than they would pay under the current Medicare system. For a typical 65-year-old with average health spending enrolled in a plan with benefits similar to those currently provided by Medicare, the CBO estimated the beneficiary’s spending on premiums and out-of-pocket expenditures as a share of a benchmark: what total health-care spending would be if a private insurer covered the beneficiary. By 2030, the beneficiary’s spending would be 68 percent of that benchmark under the proposal, 25 percent under the extended-baseline scenario, and 30 percent under the alternative fiscal scenario.
If Medicare’s beneficiaries are getting less for more, Medicaid’s are simply getting less, period:
Federal payments for Medicaid under the proposal would be substantially smaller than currently projected amounts. States would have additional flexibility to design and manage their Medicaid programs, and they might achieve greater efficiencies in the delivery of care than under current law. Even with additional flexibility, however, the large projected reduction in payments would probably require states to decrease payments to Medicaid providers, reduce eligibility for Medicaid, provide less extensive coverage to beneficiaries, or pay more themselves than would be the case under current law.
As the CBO recognizes, a lot of what Ryan is doing isn’t saving money so much as shifting costs. Poor people and seniors don’t need less health care because Medicare and Medicaid are providing less health care. They just have to pay for more of it on their own. And as the CBO says, it’s hard to imagine Congress simply ignoring their pleas for help:
Under the proposal analyzed here, debt would eventually shrink relative to the size of the economy — but the gradually increasing number of Medicare beneficiaries participating in the new premium support program would bear a much larger share of their health care costs than they would under the current program; payments to physicians and other providers for services provided under the traditional Medicare program would be restrained (as under the two scenarios); states would have to pay substantially more for their Medicaid programs or tightly constrain spending for those programs; and spending for federal programs other than Social Security and the major health care programs would be reduced far below historical levels relative to GDP. It is unclear whether and how future lawmakers would address the pressures resulting from the long-term scenarios or the proposal analyzed here.
By: Ezra Klein, The Washington Post, April 5, 2011
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