Seniors, Are You Paying Attention To Paul Ryan’s Medicare Plan?
Tea Party members who railed against health care reform because of the spin they were sold about how “Obamacare” would affect Medicare played a big role in returning the House of Representatives to Republican control.
I’m betting that many of them, if they’re paying attention to what Rep. Paul Ryan (R-Wisconsin), wants to do to the Medicare program, are having some serious buyer’s remorse. If Democrats are wise, they’re already drafting a strategy to remind Medicare beneficiaries, including card-carrying Tea Party members, just how fooled they were into thinking that Republicans were the protectors of the government-run program they hold so dear.
As a speaker at an especially contentious town hall meeting during the summer of 2009, I saw firsthand just how many senior citizens were snookered about how reform legislation would alter Medicare. Shortly after I testified before Congress about how the insurance industry was conducting a behind-the-scenes campaign to influence public opinion about reform, Rep. Bill Pascrell (D-New Jersey) invited me to share my perspective as a former insurance industry insider at his September 3, 2009, town hall meeting at Montclair State University.
More than 1,000 people had crammed into the school’s auditorium, not so much to hear the speakers as to express their opinions. Reform opponents were on one side of the auditorium, and reform advocates were on the other side. I had to shout just to be heard above the insults the groups were hurling at each other. Many of the reform opponents were carrying signs that read, “Hands Off My Medicare!” They clearly had bought the lie that the Democrats planned to dismantle the program.
There was no doubt in my mind that the insurance industry was the original source of that lie. While insurers liked the part of reform that would require all Americans not eligible for Medicare or Medicaid to buy coverage from them, they did not like the provision that would eliminate the overpayments the federal government has been paying private insurers for years to participate in the Medicare Advantage program, which was created when Republicans controlled both chambers of Congress in the late 1990s.
A little history: A provision of the Balanced Budget Act of 1997, written primarily by the insurance industry and backed by House Speaker Newt Gingrich and Senate Majority Leader Trent Lott, gave Medicare beneficiaries the option of getting their benefits through private insurers. Republicans envisioned this as the first step toward the total privatization of Medicare.
The Insurance Industry’s Government Favor
The problem was that insurers were reluctant to jump in unless they could be assured of a substantial profit. To get them to market Medicare Advantage plans, the government agreed to give them a big bonus. As a result, we the taxpayers now pay private insurers 14 percent more than the per-patient cost of the traditional Medicare program. These overpayments have contributed significantly to the record profits insurance companies have been posting in recent years, even though only 22 percent of people eligible for Medicare have bought what they’re selling.
The insurers were not able to keep the Democrat-controlled Congress of 2010 from eliminating those bonuses when they passed the Affordable Care Act. The law will indeed reduce future Medicare spending — not benefits — by an estimated $500 million over the next 10 years in a variety of ways, one of which is to stop overpaying insurers. This means that they will not get an extra $136 billion that they — and their shareholders — had been counting on, and they’re really bummed about that.
Knowing they fare much better when the GOP is running things on Capitol Hill, they devoted millions of the premium dollars we paid them to help elect more Republicans to Congress.
An Insurer-Funded Misinformation Campaign
The insurers funneled millions of dollars to their business allies and front groups in an effort to convince the American public that the Democrats wanted to cut Medicare benefits. Not only is that not true, but the new law actually adds an important new benefit and greatly improves another. For the first time, Medicare now pays for preventive care. And the law closes the hated “doughnut hole” in the Medicare prescription drug program.
But thanks to the success of the insurer-funded misinformation campaign, many seniors went to the polls last November convinced that the Democrats not only had created death panels in the Medicare program, they had also slashed their benefits.
The insurance industry funneled $86 million to the U.S. Chamber of Commerce to pay for TV ads that charged that the new law would “cut Medicare.” Also joining in on the campaign of lies was the 60 Plus Association, a group that, according to the Washington Post, AARP and other sources, has received the lion’s share of its funding over the years from the pharmaceutical industry and other special interests.
The 60 Plus Association ran TV ads in numerous congressional districts last fall against Democrats who had voted for the reform law. The ads were amazingly effective. Most of the Democrats they targeted lost.
The irony, of course, is that the GOP had no intention of preserving Medicare as seniors have known it since it was created more than 45 years ago. Ryan’s plan to reduce the deficit — which was approved by the House last week — would complete the privatization of Medicare that insurers and their Republican allies have been plotting for years.
The Republican Effort to Kill Medicare: a Losing Proposition
Ryan wants to give Medicare beneficiaries a voucher they can use to get coverage from a private insurance company. Initially, the vouchers would enable beneficiaries to get coverage comparable to what they have today. But the value of the vouchers would diminish over time. The Congressional Budget Office predicts that 65-year-olds would be paying 68 percent of their Medicare coverage costs by 2030, compared with 25 percent today.
What this means is that almost all Medicare beneficiaries would eventually be woefully underinsured, just as an estimated 25 million younger Americans already are and just as most of the nation’s elderly — the ones who could afford coverage at all — were before Medicare was enacted in 1965. (Most senior citizens had no health coverage before Medicare because insurance companies refused to sell it to them. That’s why it was so urgently needed.)
Ryan’s plan is a losing proposition for just about every American who lives long enough to qualify for Medicare benefits, but it is the business model that insurance firms have been dreaming of for years. It would enable them to reap profits that would make their earnings today pale by comparison.
If Democrats have any hope of keeping control of the Senate and regaining the House, they better be able to explain what’s really going on in ways that even the Tea Party seniors will understand. If I were a Democratic strategist, I would be ordering enough “Hands Off My Medicare” signs to blanket the country.
By: Wendell Potter, Center for Media and Democracy, April 18, 2011
The Long Game In The Budget Battles: Advantage Obama
Late last year, when President Obama overhauled his economic team, some people complained that the departure of Larry Summers and Christina Romer left the White House short of first-rate economists. That may have been true, but what the White House lost in intellectual sparkle it more than made up for in Washington know-how. With Gene Sperling as head of the National Economic Council and Jack Lew as budget director, it boasts two veterans of the Clinton-era budget war—two men who know how to outmaneuver right-wing Republicans.
In the past few months, Sperling and Lew have been playing from the nineteen-nineties playbook. Initially, they produced a budget for 2012 that didn’t do very much at all about long-term deficits, and was instantly proclaimed dead on arrival. Budget hawks cried foul. But the White House was playing a long game, and its budget proposal was merely an opening gambit. Then came Congressman Paul Ryan with his radical “roadmap” to budget balance over the next ten years, which featured slashing reductions in domestic spending, more big tax cuts for the rich, and the conversion of Medicare to a voucher program. I irked some readers by saying that Ryan deserved credit for at least making a specific proposal, but I still believe liberals everywhere should be grateful. By spelling out what the Republicans would do to Medicare and Medicaid, he may well have deprived his party of the White House for the foreseeable future.
If you want to know why Ryan’s “budget-cutting” plan makes no financial sense, the Financial Times’ Martin Wolf spells it out very clearly in his latest column, which is based on an analysis by the non-partisan Congressional Budget Office analysis. If you want to know why Ryan’s plan is political poison, look at Ezra Klein’s blog, where he cites a recent opinion poll showing that a plurality of Republicans—yes Republicans—think the best option for Medicare is to not cut it at all. To say the very least, Ryan presented President Obama with a big opportunity to occupy the center ground. And despite the jibes about him being a covert socialist, this is clearly the ground on which the President feels most comfortable.
And so to today’s budget speech, in which Obama presented his own eminently centrist plan to reduce the deficit without privatizing Medicare, without slashing domestic spending to the point where many government programs won’t be able to operate, and without introducing any big tax increases. I wouldn’t sweat the individual numbers that Obama presented, such as his claim that his proposals would cut the budget deficit by four trillion dollars over twelve years. Forecasting the budget deficit next year is a challenge. Forecasting the deficit three years out is extremely difficult. Ten-year budget projections are largely meaningless.
What is important is the big picture. Where Ryan proposes radical changes to taxes and spending that would alter the social contract between government and governed, President Obama is arguing that we can trim our way to fiscal sustainability. Some cuts here, some tax breaks eliminated there, and, lo and behold, the deficit will be down to two per cent of G.D.P.
To be fair, the President isn’t saying it will be easy. If by 2014 Congress can’t come up with enough cuts to stabilize the debt-to-G.D.P. ratio, he is calling for a “debt failsafe” trigger that would involve spending reductions in all programs except Social Security, Medicaid, and low-income programs. To slow the growth of entitlement spending, he is proposing to beef up the Independent Payment Advisory Board, which the health-care reform act created, and setting it at a target of keeping Medicare growth to the rate of G.D.P. growth plus half a per cent. Even the Pentagon, which has been largely exempted from budget pressures since 9/11, would have to find some (overly modest) cuts. But compared to what Ryan is proposing, these are all relatively minor changes.
Is the plan credible? Without seeing the details, it is hard to say. In the fact-sheet it circulated today, the White House avoided saying which tax loopholes it is in favor of eliminating—the mortgage interest deduction?—and it also failed to provide any projections about, say, the level of federal spending and debt as a percentage of G.D.P. in 2020. That vagueness was certainly deliberate. At this juncture, the White House still doesn’t want to reveal all of its hand. Rather than placating the budget hawks with a definitive and fully worked out set of proposals, the Administration is betting that the bond market will give it more time—time in which the American people can learn more about the specifics of Ryan’s proposals, and get even less enthusiastic about them.
This game still has a long way to run. But if I were a betting man, and occasionally I am, I would wager on Sperling and Lew coming out on top rather than the congressman from Wisconsin.
By: John Cassidy, The New Yorker, April 13, 2011
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
Junior High Theatrics And Our Cowardly Congress
• Democrats excoriated Republicans for threatening to shut down the government, but this mess is a consequence of the Democrats’ own failure to ensure a full year’s funding last year when they controlled both houses of Congress.
That’s when the budget should have been passed, before the fiscal year began on Oct. 1. But the Democrats were terror-stricken at the thought of approving spending bills that Republicans would criticize. So in gross dereliction of duty, the Democrats punted.
• Republicans say they’re trying to curb government spending and rescue the economy — but they threatened to shut down the government, even though that would have been both expensive and damaging to our economy.
The shutdowns in late 1995 and early 1996 cost the federal government more than $1.4 billion, the Office of Management and Budget reported at the time. Much of that sum was for salaries repaid afterward for work that employees never did because they were on furlough. There were also lost fees at national parks and museums: tigers must be fed at the zoo, even if nobody is paying to see them.
It’s particularly reckless and callous to threaten a shutdown when the economy is already anemic. Among the federal workers and contractors potentially losing paychecks, some would miss payments on their homes, their credit cards or their children’s college tuition.
• Republicans are posturing against abortion in a way that would increase the number of abortions.
Conservatives have sought to bar federal funds from going directly to Planned Parenthood and the United Nations Population Fund. The money would not go for abortions, for federal law already blocks that, and the Population Fund doesn’t provide abortions. What the money would pay for is family planning.
In the United States, publicly financed family planning prevented 1.94 million unwanted pregnancies in 2006, according to the Guttmacher Institute, which studies reproductive health. The result of those averted pregnancies was 810,000 fewer abortions, the institute said.
Publicly financed contraception pays for itself, by reducing money spent through Medicaid on childbirth and child care. Guttmacher found that every $1 invested in family planning saved taxpayers $3.74.
As for international family planning, the Guttmacher Institute calculates that a 15 percent decline in spending there would mean 1.9 million more unwanted pregnancies, 800,000 more abortions and 5,000 more maternal deaths.
So when some lawmakers preen their anti-abortion feathers but take steps that would result in more abortions and more women dying in childbirth, that’s not governance, that’s hypocrisy.
• The House Republican budget initiative, prepared by Representative Paul Ryan, would slash spending and end Medicare and Medicaid as we know them — and it justifies all this as essential to confront soaring levels of government debt. Mr. Ryan is courageous to tackle entitlements so boldly, and he has a point: we do have a serious long-term debt problem, and Democrats haven’t had the guts to deal with it seriously.
Unfortunately, the new Republican initiative would worsen government debt problems, according to the Congressional Budget Office. The C.B.O. (whose numbers Republicans regularly use to attack Democrats) estimates that with current trends, debt will reach 67 percent of gross domestic product in 2022. But it finds that under the Republican plan, because of increased tax cuts, debt would reach 70 percent of G.D.P.
In other words, the Republican position is that America faces such a desperate debt crisis that we must throw millions under the bus — yet the result is more debt than if we do nothing.
What does all this mean? That we’re governed by self-absorbed, reckless children. Further evidence comes from a new study showing that American senators devote 27 percent of their press releases to “partisan taunts” rather than substance. “Partisan taunting seems to play a central role in the behavior of many senators,” declared the study, by Justin Grimmer of Stanford and Gary King of Harvard.
A bewildered Chinese friend asked me how the world’s leading democracy could be so mismanaged that it could shut down. I couldn’t explain. This budget war reflects inanity, incompetence and cowardice that are sadly inexplicable.
By: Nicholas Kristof, Op-Ed Columnist, The New York Times, April 9, 2011
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
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