Why Are People Acting Like Health Care Reform Never Happened?
Ezra Klein, responding to the widespread perception that Paul Ryan has a plan to tackle medical cost inflation and Democrats don’t, points out that this is the opposite of the truth:
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.
Keep in mind that the Congressional Budget Office made the very conservative decision not to assign savings to these measures, on the assumption that since they had never been tried before, there was no way of measuring how well they would work, so it gave them no financial savings value. And the Affordable Care Act also included a limit on the tax deduction for expensive health insurance, a powerful cost-saving tool that the CBO did score.
But to zoom out for a second, what Klein’s identifying here is part of a larger phenomenon. It’s not just that the debate about health care costs seems to take place as if the ACA never happened. The entire political debate seems to take place as if the ACA never happened. Moderate liberal Jacob Weisberg lamented liberal opposition to Paul Ryan as advocating government health care for the old but nobody else — when of course we now have government-provided health insurance for everybody else (except illegal immigrants.)
The deficit hawks embrace Paul Ryan’s plan as a starting point of a debate about deficit. (David Brooks today: “Because he had the courage to take the initiative, Paul Ryan’s budget plan will be the starting point for future discussions.”) But of course the ACA was not just a starting point but an enormous stride forward. Ryan proposes to undo much of it. Yet he is the courageous leader, and his critics passive observers.
What happened? The details of the ACA’s cost-containment are wonky, and few people paid attention to them. Staunch liberals either didn’t care about cost containment, or devoted their energy to agitating for more sweeping alternatives. Moderate liberals supported the measure, but, taking their cue from policy wonks, took the very honest posture of conceding that some parts might not work as planned, and thus contributed to a massive asymmetry of passion. Centrists simply assumed that any deficit plan that wasn’t a grand bipartisan deal could not be a real deficit plan, since their fundamental premise is that a grand bipartisan deal is the only way to address the deficit. And the whole health care issue was sucked into the vortex of an unhinged debate, so that millions of conservatives understand the whole package as nothing more than an assault on freedom, with little or no grasp of the particulars.
The end result of all this is a debate around an issue with a peculiar backwards character.
By: Jonathan Chait, The New Republic, April 4, 2011
Mangled Mandate: How Paul Ryan And The GOP Are Misreading The American People
As with any election, there are competing narratives about what message the voters were sending last November when Democrats got routed in the mid-terms. Each party has offered a view on the meaning of the election. In the Democrats’ view, an economically anxious electorate was focused on jobs and repudiated Obama’s party for not delivering on job growth. In this telling, voters did not reject a liberal agenda but saw health care and other issues as diversions from their immediate pressing economic concerns. And there is some evidence to support this view: Nearly two out of three voters picked the economy as the single most important issue in deciding their vote, and Republicans won that vote. Republicans, on the other hand, argue that voters threw out Democrats in record numbers because they recoiled at incredible levels of government spending. And, indeed, some exit polling showed that voters registered their opposition to a more activist federal government: 56 percent said the government is doing too much, while only 38 percent said the government should do more to solve problems. Meanwhile, 40 percent of voters favored deficit-reduction.
Now, Republicans are intent on using their interpretation of the election to achieve their policy goals. They are offering a budget blueprint that slashes spending on Medicare and Medicaid and other government programs. Representative Paul Ryan’s plan dramatically cuts services to the middle class. As my colleague Jonathan Chait has pointed out, these cuts would be made by lowering taxes on the wealthy and corporations. The whole proposal, in other words, represents a giant redistribution of wealth away from the middle class toward the rich. As the Congressional Budget Office notes about Ryan’s plan for Medicare, for example, “most elderly people would pay more for their health care than they would pay under the current Medicare system.” What Ryan is really saying, then, is in the middle of this recession, after a decade of declining wages, the real problem in our country is that middle-class Americans have too many services and the rich have been too put upon. And he seems to think he has public support to back him up.
But are Ryan and other Republicans about to walk over quicksand, fooled by the illusion of firm ground beneath their feet after the November elections? Do Americans really want slashes to programs that serve them? Evidence suggests not—meaning Paul Ryan is teetering on the edge of a cliff, threatening to take all House Republicans down with him.
Even the Tea Party movement, whose momentum was built on outrage at government spending, seems to be waning somewhat; the movement’s rallies that once boasted huge numbers now bring only hundreds to the Capitol. As poll analyst Charlie Cook has pointed out, independents have also shifted to being more neutral toward government intervention in the economy over the last few months—from 60 percent saying the government was trying to do too much in October to only 47 percent agreeing with that idea now. (Or, seen from another angle, in the same time frame, people saying the government should do more has risen from 38 percent to 51 percent). And, perhaps even more ominous for Republicans, according to a recent Kaiser poll, 56 percent of Americans do not support any Medicare reductions, 35 percent support minor reductions, and only 8 percent support major reductions. The story is the same with Medicaid: 47 percent do not support Medicaid reductions, 39 percent support minor reductions and 13 percent support major reductions.
Dress it up as he likes, Paul Ryan is proposing to do just what polls show the American people don’t want—to shift more costs shift to individuals, including middle-class Americans. And many House Republicans agree with him, although, already, a few members are refusing to embrace the Ryan budget proposal. Politico has reported that several more vulnerable Republican members, including Blake Farenthold, Sean Duffy, and Ann Marie Buerkle, have called the plan bold, yet not embraced the details.
After every election, the victors try to define and act on their mandate. As Ryan and other Republicans rush through their effort to slash spending, however, they would do well to ask themselves whether it’s what the public really wants—or whether they’re woefully misreading the voters, and setting themselves up for disaster in the next election.
By: Neera Tanden, The New Republic, April 7, 2011
The Hostage Crisis The Next Time, And The Next Time, And The Next Time
The federal government survived the hostage crisis created by House Republicans, but emerged staggering from the deal struck Friday night. The compromises were damaging, the amount of money cut from a sickly economy was severe, and the image of Washington as a back-alley dogfighting garage will not soon fade.
The Republicans set the terms of the debate at every point, and learned that they can push the fumbling and fearful Democrats far to the right. Within hours, they began revving up to create the next crisis.
Although much of the final deal has not yet been made public, it is clear it could have been far worse. The White House refused to accept many of the most radical cuts in the original House bill, including deep reductions to Head Start, AmeriCorps, Pell grants, public broadcasting and competitive education programs. Financial and health care reform will continue but with reduced money. The worst right-wing demands were dropped, including a cutoff of funds to providers of abortion and family planning, and an end to regulation of greenhouse gases. And nearly half the cuts came from a side of the budget that will do less harm to the economy and the most vulnerable.
Nonetheless, the Republicans did far better than they could possibly have imagined when the process began, winning $38.5 billion in cuts, more than even the House leadership had proposed. That’s on top of the $40 billion in additional spending that President Obama had originally proposed for this fiscal year, which was dropped. About $13 billion will be cut from the departments of Labor, Education, and Health and Human Services. The State Department and foreign assistance will lose $8 billion.
Key investments in roads, rails and other vital public works will again have to wait, and because these cuts will change the spending baseline for future budgets, may never be restored to their proper levels. (Defense spending will go up by only $5 billion over the next six months, not the $7 billion Republicans wanted.)
Democrats also agreed to the ideological demand of House conservatives that the District of Columbia be banned from spending any money for abortions, a cruel blow to the poor and largely African-American women who need those services. The ban was lifted in 2009.
The worst aspect of the deal, however, was the momentum it gave to Republicans who have hoodwinked many Americans into believing that short-term cuts in spending will be good for the economy. After the agreement was reached, President Obama actually patted himself on the back for agreeing to the “largest annual spending cut in our history.”
He should have used the moment to explain to Americans what irresponsible cuts the G.O.P. demanded just to keep the government open. Now, having won the philosophical terms of this debate, the House is eagerly anticipating the next and far more serious showdown: the need to raise the federal debt ceiling by May 16.
If it is not raised, the government will go into default, which could have a disastrous effect on the credit markets and the economy. House Speaker John Boehner said after the budget deal that there was “not a chance” the Republicans, who like to pretend they are the fiscally responsible party, would agree to raise the ceiling “without something really, really big attached to it.” He may be pandering to his Tea Party members, but the threat is real.
Mr. Obama will speak this week about a plan to reduce the long-term deficit, and aides are already making it clear he will finally demand that taxes for the rich must go up. The fight next time will be rougher and the principles need to be stronger. The Democrats’ message must be far more convincing than it has been, and their counterattack against Republican irresponsibility far more powerful.
By: Editorial, The New York Times, April 10, 2011
What The Republican Budget Plans Tell Us About Republican Values
The Republicans want you to believe that they’re concerned about the deficit. Of course, that concern is a lie. They don’t care about the deficit. They only care about using the deficit as an excuse to pursue their extremist agenda. And the single most extreme part of it is their war on people. On workers. On women. On immigrants. On the environment that keeps us all healthy and alive. If they cared about the deficit itself, they’d have noticed that the previous three Republican presidents produced consecutively the largest deficits in human history, each outdoing his predecessor, and the most recent Republican president not merely shattering his father’s unprecedented standard, but actually having to destroy the federal surplus built by a Democratic president in order to do so. An impressive feat, by any measure. But when Republicans talk about deficits, you know they are lying. Republicans destroy surpluses and create record deficits. That’s the truth.
If Republicans cared about the deficit, they wouldn’t have held middle-class tax cuts hostage for a ransom of tax cuts for the very wealthy, tax cuts that the very wealthy do not need. Tax cuts for the wealthy that won’t create jobs or stimulate the economy. Tax cuts for the wealthy that added to the federal deficit, the same federal deficit Republicans now pretend to be so worried about that they need to slash and burn federal spending. Spending for such things as food assistance for low-income Americans, which Republicans want to cut even as they retain farm subsidies. Spending for such things as life-saving immunizations. Spending for such things as food and health assistance around the world, without which some 70,000 children could die. And not content to make Americans go hungry and die of preventable diseases, and for tens of thousands of children around the world to starve to death, rather than have the very wealthy pay more taxes, Republicans also have their “hearts” set on eliminating Medicare and eviscerating Medicaid. And they want to repeal the Obama health plan, even though doing so would make the deficit even worse.
Let’s not pretend that Republicans actually care about the deficit. If they did, their approach in addressing it would be responsible and humane. Republicans don’t care about the deficit. They only care about cutting government programs that help people in need. It’s part of their larger agenda of blatant class warfare. Republicans prefer that millions of people suffer, and that at least tens of thousands of people die, rather than that the very wealthy once again pay the taxes that eliminated the previous Republican deficits to create the previous Democratic surplus. Leave it to the mental health professionals to diagnose the psychology of such values. If anyone can afford mental health professionals, with states now also in budget crises thanks to the genius of tax cuts.
But lest you think that Republicans don’t have any spending priorities at all, keep in mind that they do want to use federal money, just so it is spent in pursuit of their Medieval social agenda. But that’s just relative pocket change. While Republicans seem actually to want for people in need to suffer and die, they also want to throw unfathomably budget-busting pallets of cash at their favorite budget sinkhole. As reported by Ryan Grim:
While media attention focuses on the cuts to government spending demanded by House Republicans and broadly accepted by Democrats, the Pentagon is poised to reap billions more in federal funds, according to sources close to the discussions. The confines of the budget negotiations established by the two parties results in a system where every extra dollar going to military spending ends up being offset by a dollar reduction in spending on domestic social programs.
Got that? It’s an actual tradeoff. Punish more people in need to free up more cash for the Pentagon. The Democrats actually proposed some reductions to the Pentagon budget, and in January Defense Secretary Robert Gates and Chairman of the Joint Chiefs Mike Mullen outlined plans for responsible Pentagon budget cuts:
“A major objective beyond creating monetary savings is to make this department less cumbersome, less top heavy and more agile and effective in the execution of its responsibilities,” Gates said. “My hope and expectation is that as a result of these changes over time, what had been a culture of endless money, where cost was rarely a consideration, will become a culture of savings and restraint.”
But Republicans know better than the Defense Secretary and the Chairman of the Joint Chiefs. Grim:
Democrats and Republicans are now moving toward an agreement that would increase defense spending. But Democratic sources close to the talks said the Democrats’ spending recommendation remains roughly $2 billion shy of that of their Republican counterparts. A spokesman for the Senate spending panel declined to comment, citing ongoing talks. A spokesman for Senate Democratic leadership did not respond to requests for comment.
So the Pentagon itself says it doesn’t need more money, but not only are Democrats being pushed to give them more, the Republicans are insisting that the amount the Democrats are offering, and which the Pentagon says it doesn’t need, still isn’t enough! But it’s so important that we cut the deficit that we have to cut funding that feeds the hungry, prevents disease, and cares for the sick. And keep in mind that it’s not as if the Pentagon is anything remotely close to being underfunded. So what is it? Do Republicans think the answer to everything is to throw money at it? Do they have so little respect for the men and women in American uniform that they think they need such hardware overkill in order to protect the homeland? Are Republicans perpetually mired in a state of priapic adolescent arrested development, thinking the measure of their machismo is the size of their arsenal? Or is it just good old corporate welfare for the military industrial complex? Maybe it’s some combination of all of the above. But it’s a staggeringly irresponsible waste of resources that does nothing to enhance our national security.
As The Center for Arms Control and Non-Proliferation made clear, the United States spends more than eight times as much on defense as does the next closest country, Russia. The United States spends more than twice as much as does the next major military presence, which is America’s combined NATO allies. And not that it will satisfy paranoid Republicans, but the United States spends more than three times as much as do imagined potential adversaries Russia, China, Saudi Arabia, Iran, Pakistan and Venezuela combined. And for those particularly paranoid Republicans, the United States also spends more than 10 times as much as does that most sinister of all perpetual antagonists: France. And to put it in terms of actual budget and policy priorities, there is this concise explanation from The Center on Budget and Policy Priorities:
Between fiscal year 2001 (the last year for which appropriations levels were set under President Clinton) and fiscal year 2008, funding for domestic discretionary programs has been more constrained than any other area of the budget and has shrunk both as a share of the budget and as a share of the economy. In contrast, appropriations for defense and other security-related programs have increased more rapidly than any other area of the budget — even more rapidly than the costs of the “big three” entitlement programs: Social Security, Medicare, and Medicaid.
Republicans don’t care about the budget. They are using the budget as an excuse and red herring to recast the very nature of the United States government, and the very nature of the United States. They don’t care if those in need suffer and die. They don’t care about jobs. They don’t care about a social safety net. They do care very much about protecting the very wealthy. They do care very much about wealthy corporations. And the one thing at which they want to throw truly unimaginable amounts of money is the military. This is a huge clue as to their mindset. Because when you stop and consider the consequences of causing more and more suffering and unrest among more and more people while at the same time ensuring that the military is much more powerful than any military anywhere needs be, the only conclusion that can be drawn is that Republican values are not only inhuman and inhumane, they are dangerous and creepy.
By: Laurence Lewis, Daily Kos, April 10, 2011
No More Republican Hostage Strategies: On Debt Ceiling, Just A “Clean Bill”
On Fox News this morning, House Majority Leader Eric Cantor (R-Va.) said he’s prepared to play a dangerous game with the federal debt limit — he’ll help block an extension without “guaranteed steps” on unspecified cuts to public investments.
It is, in other words, another hostage strategy. Last week, the message was, “Give us what we want or we’ll shut down the government.” Going forward, the new message is, “Give us what we want or we’ll wreak havoc on the global economy and trash the full faith and credit of the United States government.
The details of the ransom note apparently haven’t been written yet, but we’re getting clues.
The down-to-the-wire partisan struggle over cuts to this year’s federal budget has intensified concern in Washington, on Wall Street and among economists about the more consequential clash coming over increasing the government’s borrowing limit.
Congressional Republicans are vowing that before they will agree to raise the current $14.25 trillion federal debt ceiling — a step that will become necessary in as little as five weeks — President Obama and Senate Democrats will have to agree to far deeper spending cuts for next year and beyond than those contained in the six-month budget deal agreed to late Friday night that cut $38 billion and averted a government shutdown.
Republicans have also signaled that they will again demand fundamental changes in policy on health care, the environment, abortion rights and more, as the price of their support for raising the debt ceiling.
The stakes of the Republicans’ hostage strategy are significantly higher than the budget fight, at least insofar as the consequences would be more severe. Had the GOP shut down the government, it would have been awful for the economy; if the GOP blocks an extension of the debt ceiling, the results could prove catastrophic. As the NYT noted, “The repercussions in that event would be as much economic as political, rippling from the bond market into the lives of ordinary citizens through higher interest rates and financial uncertainty of the sort that the economy is only now overcoming.” The likelihood of “provoking another credit crisis like that in 2008” is very real.
It’s exactly why Federal Reserve Chairman Ben Bernanke recently warned congressional Republicans not to “play around with” this, adding that lawmakers shouldn’t view the debt ceiling as a “bargaining chip.”
Republicans freely admit they’re doing it anyway. Indeed, they’ve been rather shameless about it.
http://www.washingtonmonthly.com/archives/individual/2011_03/028426.php
It seems to me President Obama’s message should be pretty straightforward: “To prevent a crisis, I expect a clean bill.”
This isn’t complicated. Democrats and Republicans have, routinely, raised the debt limit many times. Neither party has ever held it hostage, or made sweeping demands. Economists, government officials, and even financial industry leaders have all told Republicans to reject the political games and do what’s right.
What’s more, as we discussed yesterday, even Republicans know how this has to turn out. House Speaker John Boehner (R-Ohio) recently said failing to raise the debt limit “would be a financial disaster, not only for us, but for the worldwide economy.” Sen. Lindsey Graham (R-S.C.) said failure to raise the debt limit would lead to “financial collapse and calamity throughout the world.”
Democrats and Republicans can have a larger debate about entitlements and debt reduction in the fight over the next fiscal year budget. But there’s not enough time for that to occur before we hit the debt ceiling.
Just pass a clean bill, prevent a calamity, and get ready for the larger budget fight.
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