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
Government Shutdown Over Pap Smears: GOP Culture War Is Alive And Well
Last night Ryan Grim reported that the GOP may force a government shutdown largely over funding for Planned Parenthood under Title X:
At a late-night White House meeting between the president and key congressional leaders, House Speaker John Boehner (R-Ohio) made clear that his conference would not approve funding for the government if any money were allowed to flow to Planned Parenthood through legislation known as Title X. “This comes down to women’s health issues related to Title X,” a person in the meeting told HuffPost.
The negotiations are dominated by men: All of the principal negotiators in both parties are male, as are most of the senior staff involved. (House Democrats, led by Minority Leader Nancy Pelosi (Calif.), have largely been left out of key talks.)
House Republicans have been insisting the roadblock to cutting a new budget deal is not just the culture-war riders attached to the spending plan, but a source familiar with a top-level White House meeting earlier Thursday said most of the discussion in fact was about the riders.
The Hyde Amendment already prevents government funding for abortions, and abortions are a tiny part of the services Planned Parenthood provides.
The government is on the verge of being shut down because Republicans want to inset a provision into the budget that would prevent millions of women from getting contraception or cancer screening. This could be brinkmanship:Because the Republican base sees a shutdown as an end unto itself, the Republican leadership has a really strong political incentive to stretch this out as long as possible and cut a deal at the last minute. If this is the case, then culture war rhetoric serves as political cover for Republican leaders who want to cut a deal that might be hard to sell to the base.
In the past few weeks, we’ve been treated to a bevy of coverage insisting that Republicans have abandoned the culture war and are focusing on fiscal issues. Republicans like these stories because they make them look less extreme. But as Greg noted earlier today: “In its current form, at least, the budget debate is not meaningfully about fiscal matters. It’s over abortion, women’s health, and whether our environmental policies should be premised on climate science.”
What’s more, it’s not like pursuing the culture war and trying to defund the federal social safety net for women are mutually exclusive goals. In this case, they’re complimenting each other — when you’re trying to appease the Republican base, there isn’t a much better sweet spot intersection between the culture war and fiscal conservatism than women’s reproductive health.
By: Adam Serwer, The Washington Post, April 8, 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
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