It’s Not Just Entitlements, The Real Issue: Controlling All Health Care Costs
The current cry to reduce Federal deficits and debt growth by reducing Medicare and Medicaid entitlements is totally missing the key issue: the need to moderate all health care inflation. This should be the time for a national debate on how to best tackle the underlying cost problem, for the sake of our future, the economy, and access to health care.
The June 13-19, 2009 Economist editorialized: “America has the most wasteful [health] system on the planet. Its fiscal future would be transformed if Congress passed reforms that emphasized control of costs as much as the expansion of coverage that Barack Obama rightly wants.”
Health reform failed to get an adequate handle on all health care costs. Now there are constant calls by various expert commissions and many in Congress for entitlement spending reductions. Such cuts will create enormous new problems by failing to address the underlying, real problem of health costs and inflation.
Cutting just Medicare and Medicaid without addressing the whole problem is like squeezing a balloon—the balloon starts looking very strange very fast. While it is difficult to tell how much cost-shifting may occur and it will vary from market-to-market, some Medicare and Medicaid cuts probably get passed through in higher costs to the private sector—hardly a helpful action. (Congressional Budget Office, December 2008, Key Issues in Analyzing Major Health Insurance Proposals, p. 116) Cuts that are too deep in Medicare will also end up causing providers to be reluctant to see seniors and people with disabilities—as happens all too often today in Medicaid. In time, quality may be threatened.
And Medicare and Medicaid are not particularly driving the problem of soaring health care costs. As various studies have shown, over the long haul, Medicare has probably inflated slightly less rapidly for a comparable package of services than the private sector has. Recent reports by the Medicare Payment Advisory Commission (MedPAC) show that high quality, efficient hospitals have made a little money on Medicare, while private insurers have often failed to control costs, and have paid less effective hospitals 132 percent of the costs of running an efficient hospital. (See, for example, MedPAC’s March 2009 Report to Congress, Section 2A.)
A Comprehensive Approach To Health Care Cost Containment
It is past time for a comprehensive solution to ensure the affordability of a fundamental need: access to health care. We should say that access to reasonably affordable health care is a basic national need, like access to clean water and air, and treat it like a regulated utility—like your water–where cost growth is kept within a reasonable range and where a reasonable quality service is widely available (but if you want to go buy Perrier, you can).
Instead of squeezing one part of the health care cost balloon (Medicare and Medicaid), we need an “all saver” system. Under this system, any provider in the health care sector which inflates its billings faster than the growth in the CPI plus, say, one percent (adjusted for changes in population, new technologies, increased productivity, and changes in the severity of the cases that provider treats) would owe a rebate of the excess amount to its customers—both private and public. If the rebate were not provided, that excess income would face a 100 percent tax. The Federal government could do this under the Commerce clause, or, to enable providers and patients to opt out, could require participation by those accepting payment from Medicare, Medicaid, and payers claiming tax-deductible medical expenses.
How would the plan work? Complicated? Yes, but soon very doable with today’s health information technology systems and the coding systems developed by Medicare and others. It would take several years to set the system up, but it would work like this. Let’s say a hospital in a base year of 2013 had $100 million worth of billings. If consumer inflation were 4 percent and if the system allowed another 1 percent (just because we do highly value health care and some extra growth is a reasonable choice), then in 2014, the hospital could bill $105 million. (Let’s assume that an expensive new technology is available that costs an extra $1 million, but let’s also assume that increase is coincidentally offset by a national increase in productivity of 1 percent that saves about $1 million.)
If the hospital bills its customers $110 million in 2014, yet those customers are no sicker or more complicated to treat than in 2013 (as proven by the audited billing codes or adjusted for coding creep), the hospital will owe its customers $5 million in rebates. If Medicare paid 40 percent of the bills ($44 million), it would receive back 40 percent of the $5 million excessive inflation ($2 million). If a large employer’s health plan paid 20 percent of the provider’s bills, it would get $1 million back, and so forth.
If a provider did not want to participate, they could insist on only after-tax cash customers, and individuals would be free to use such doctors and hospitals.
Changing The Debate
Instead of focusing on Medicare/Medicaid cuts, Congress should be debating ideas of how to moderate all health care spending while minimizing interference in the practice of medicine. The plan I’ve described is just one option, and of course it would have to be adjusted to deal with many complexities. For example:
- How could the plan be made fair to new doctors and facilities with one-time extra start-up costs and no history of billings?
- How could the plan use quarterly payments or rolling averages to avoid many providers shutting down in December?
- How could society encourage further innovation, perhaps by offering more inflation for drugs certified as breakthroughs by the Food and Drug Administration?
- What cosmetic-type services could or should be exempt?
- What MedPAC-like advice and constitutional governance would be best?
Of course, if over the next decade reforms such as electronic medical records, comparative effectiveness research, and new bundling of the way we pay for services sufficiently ‘bends’ the spending curve downward, this system could be suspended. But it is doubtful those changes will do enough, and it is time to act on a comprehensive solution.
Incidentally, slowing all health care inflation would not only save enormous amounts in Medicare and Medicaid; over time it should achieve huge extra CBO/Joint Tax scorable savings, because the private sector and individuals will claim less in tax-deductible expenses for health care.
Budget reform that gets a handle on all health care inflation will solve most—or at least the toughest–of the ‘entitlement and future debt problems facing the nation. The entitlement problem is overwhelmingly a Medicare problem, driven not so much by more seniors or an aging population as by constantly soaring per capita costs of care. If we try to solve the entitlement problem just by cutting Medicare and Medicaid, we will destroy those programs. We need a total solution, because soaring health care costs are distorting the economy and our future as a successful nation.
Now is the time for this debate.
By: William Vaughan, Health Affairs Blog, Originally published March 3, 2011
Why It’s Okay To Hate Union Workers
By now you’ve heard the cookie joke. You know: a CEO, a tea party member, and a union worker are all sitting at a table when a plate with a dozen cookies arrives. Before anyone else can make a move, the CEO reaches out to rake in eleven of the cookies. When the other two look at him in surprise, the CEO locks eyes with the tea party member. “You better watch him,” the executive says with a nod toward the union worker. “He wants a piece of your cookie.”
It’s funny for the same reason most good jokes are funny, because it contains a strong element of truth. This little game, pitting one group of working class voters against another, isn’t just a trick, it’s the trick. It’s what enables bankers to rob the nation blind and walk away. It’s what lets executives take an ever larger share of corporate income when they’re doing well, a larger share when they’re doing poorly, a larger share when they’re staying, and a larger share when they’re leaving. It’s what allows corporations to sit on the greatest stacks of money the world has ever seen, turn profits that dwarf those of even a few years ago, and still demand that their workers surrender a little more. A little more. A little more, please. Thanks, now get out.
Not only that, they get their workers to fight for them. Fight for surrendering their own rights, and fight to take those rights from others.
The engine of this schism is always powered by the same forces: fear and envy. There’s always someone out there to be the “other,” someone whose cultural values don’t line up with yours. Someone who is getting a better deal than you. Robber barons and corporations have always been good at promoting factionalism, and of course it helps when you have the media and politicians under your thumb. No doubt nobles played the same game to keep their comfy seats throughout history. Heck, there was probably a nice “Intro for New Pharaohs” scroll that explained how to keep the stonecutters jealous of the hieroglyph carvers, just so neither group ever got around to wondering if carving Rootintootin III’s face on blocks the size of houses was really the best use of their time.
For America, the tea party movement is just an update of a very old script.
You could see the same forces at work in 1843, as factionalism split the Whig Party and produced a third party movement. The American Republican Party first appeared on local election ballots in New York. This wasn’t the Republican Party that would emerge over a decade later, but it was one of several movements and parties that boiled up out of the Whig’s weakness. Supported by business organizations and trade unions , the party scored shocking victories in its first elections first in New York then in Philadelphia. Almost overnight, the party spread and within a year it had become a national movement challenging the established parties in almost every state. Both major parties quickly adjusted their policies to try and accommodate this new entity, but the new party had a focus and energy that delivered surprising wins in Boston, in Chicago, and in several other cities.
What powered the movement? Most of the energy came from a source that’s still highly potent today: demonization of immigrants. The leaders of the movement (which soon changed its name to the American Nativist Party and then just the American Party) warned that the uncontrolled wave of immigration was destroying what made America great. The new immigrants lacked both education and culture. They were insular, odd, and dangerous; unwilling to adopt American customs and values. They were shiftless, without the productive and creative spark of Americans, but at the same time they were willing to work so cheaply that they threatened to steal jobs from American workers.
These immigrants were other. This invading army had their own language, their own music, and most threatening of all they brought with them a corrosive philosophy, one that was the enemy of both democracy and capitalism. This philosophy was out to cripple trade and destroy companies. It encouraged laziness, diminished respect for personal property, and threatened established institutions. Despite these un-American tendencies, traitorous and corrupt politicians had been elected who were beholding to these immigrants. These America-hating politicians refused to pass tough federal laws to clamp down on immigration. They even argued that state and local laws limiting immigrant’s rights were unconstitutional. They tolerated or encouraged their new philosophy. Some even embraced it. In response, the American Party platform mandated English as the official language and restricted the government from printing documents in other languages, it sharply limited immigration and raised the requirements for citizenship, and it limited all political offices (including school teachers) to native born Americans.
The wave of dangerous immigrants came from Ireland and Germany. The anti-American philosophy they propagated was Roman Catholicism.
The nativism that spurred the appearance of the American Republican Party mirrors exactly the feelings and ideas that now power anti-immigrant movements in Arizona and across the nation. If the hatred for union workers, government workers, and really anyone not part of their own small group may not be precisely the same, but it’s a close cousin. It’s not racism, but it fills that racism-shaped hole in society’s soul. For tea partiers, the lazy, fat-cat teacher taking home a big pension on the government dime has replaced the Cadillac driving welfare queen. It doesn’t matter that both are myths. Both of them are just placeholders for the other, a symbol of that person you just know is out there taking advantage of you – a focus for unfocused anger. A focus provided by people who are so, so relieved that you’re willing to keep looking enviously at other workers and never glance up to see what your betters are doing.
At America’s founding, there were dire predictions that the nation would not last out one election cycle. Then, as now, there were far more poor than rich. What was to prevent the have-nots from passing legislation that stripped wealth from the hands of the haves? Democracy was seen as utterly incompatible with capitalism. Traders and businessmen viewed it with horror, certain that they would be overrun by the mob. But it never worked that way.
Instead, those at the top have always found it easy to get people to champion their cause. There’s always a group that feels wounded, angry and neglected. This group is susceptible to being told that they’re better than some other group, that some other group is getting a better deal, that some other group deserves to be put in its place. It doesn’t matter if that group is called Irish or Italian, Black or Hispanic, Union members or government workers. Anyone can be painted as a threat with enough hot air and yellow journalism. Anyone.
In the heyday of the American Republican Party, members developed a not-so-secret phrase. Asked what they knew about party activities, they were taught to respond “I know nothing.” Because of this, members of the group soon carried the name “Know-Nothings.” Over a century and a half later, there may not be anyone eager to embrace the title of Know-Nothing. But as long as some working class voters are willing to carry the billionaire’s water by attacking other workers, there are certainly plenty of Learned Nothings around.
By: Mark Sumner, Daily Kos, March 6, 2011
How To Kill A Recovery-Republican Style
The economic news has been better lately. New claims for unemployment insurance are down; business and consumer surveys suggest solid growth. We’re still near the bottom of a very deep hole, but at least we’re climbing.
It’s too bad that so many people, mainly on the political right, want to send us sliding right back down again.
Before we get to that, let’s talk about why economic recovery has been so long in coming.
Some economists expected a rapid bounce-back once we were past the acute phase of the financial crisis — what I think of as the oh-God-we’re-all-gonna-die period — which lasted roughly from September 2008 to March 2009. But that was never in the cards. The bubble economy of the Bush years left many Americans with too much debt; once the bubble burst, consumers were forced to cut back, and it was inevitably going to take them time to repair their finances. And business investment was bound to be depressed, too. Why add to capacity when consumer demand is weak and you aren’t using the factories and office buildings you have?
The only way we could have avoided a prolonged slump would have been for government spending to take up the slack. But that didn’t happen: growth in total government spending actually slowed after the recession hit, as an underpowered federal stimulus was swamped by cuts at the state and local level.
So we’ve gone through years of high unemployment and inadequate growth. Despite the pain, however, American families have gradually improved their financial position. And in the past few months there have been signs of an emerging virtuous circle. As families have repaired their finances, they have increased their spending; as consumer demand has started to revive, businesses have become more willing to invest; and all this has led to an expanding economy, which further improves families’ financial situation.
But it’s still a fragile process, especially given the effects of rising oil and food prices. These price rises have little to do with U.S. policy; they’re mainly because of growing demand from China and other emerging markets, on one side, and disruption of supply from political turmoil and terrible weather on the other. But they’re a hit to purchasing power at an especially awkward time. And things will be much worse if the Federal Reserve and other central banks mistakenly respond to higher headline inflation by raising interest rates.
The clear and present danger to recovery, however, comes from politics — specifically, the demand from House Republicans that the government immediately slash spending on infant nutrition, disease control, clean water and more. Quite aside from their negative long-run consequences, these cuts would lead, directly and indirectly, to the elimination of hundreds of thousands of jobs — and this could short-circuit the virtuous circle of rising incomes and improving finances.
Of course, Republicans believe, or at least pretend to believe, that the direct job-destroying effects of their proposals would be more than offset by a rise in business confidence. As I like to put it, they believe that the Confidence Fairy will make everything all right.
But there’s no reason for the rest of us to share that belief. For one thing, it’s hard to see how such an obviously irresponsible plan — since when does starving the I.R.S. for funds help reduce the deficit? — can improve confidence.
Beyond that, we have a lot of evidence from other countries about the prospects for “expansionary austerity” — and that evidence is all negative. Last October, a comprehensive study by the International Monetary Fund concluded that “the idea that fiscal austerity stimulates economic activity in the short term finds little support in the data.”
And do you remember the lavish praise heaped on Britain’s conservative government, which announced harsh austerity measures after it took office last May? How’s that going? Well, business confidence did not, in fact, rise when the plan was announced; it plunged, and has yet to recover. And recent surveys suggest that confidence has fallen even further among both businesses and consumers, indicating, as one report put it, that the private sector is “unprepared to fill the hole left by public sector cuts.”
Which brings us back to the U.S. budget debate.
Over the next few weeks, House Republicans will try to blackmail the Obama administration into accepting their proposed spending cuts, using the threat of a government shutdown. They’ll claim that those cuts would be good for America in both the short term and the long term.
But the truth is exactly the reverse: Republicans have managed to come up with spending cuts that would do double duty, both undermining America’s future and threatening to abort a nascent economic recovery.
By: Paul Krugman, Op-Ed Columnist, The New York Times, March 3, 2011
Republican Budget Cuts Promote ‘Trickle Up’ Poverty
How appropriate that Washington’s most challenging budget crisis in decade coincides with the Republican Party’s centenary birthday celebration of Ronald Reagan, whose attacks on “welfare queens” and the social safety net in the name of deficit reduction caused indisputable collateral damage to middle class Americans. The Ronnie-like budget cuts that Republican leaders are proposing today—against unemployment insurance, food stamps, Medicaid and subsidized housing—all boast the potential to carry on the Reagan tradition of hurting the very middle class they aspire to help.
Why? Because the cuts to the programs the Republican leadership in the House of Representatives are targeting would increase poverty, and more poverty lowers property values, diminishes the quality of life, and drives up family taxes and expenses of middle class Americans.
Cuts to federal housing programs will increase homelessness. Combine increased homelessness with vacant public housing and you have a cancer that will spread, reducing property values in communities across our nation. Or consider cuts to unemployment and food stamps. These are likely to cause grocery stores in urban, suburban, and rural areas—many of which serve the middle class—to either close or lower the quality and selection of their wares, just to preserve profit margin.
A persistently high unemployment rate may well also translate into desperation and increased property and personal crimes. Not only will more crime lower our quality of life, it will drive up the cost of local policing. That could mean higher local taxes meet crime-fighting demands.
Public schools were once the first choice of middle class families; these schools are the first to fail as poverty rises. Where school was once free, poverty forces many middle class families today to shell out thousands of dollars to educate their children. These new costs are a fact of life for more and more middle class Americans as poverty spreads across the country. Sadly it’s at just the time they can least afford it.
Let’s be clear. No one rejoices at the prospect of spending billions of dollars for subsidized housing or food stamps or Medicaid. And Glenn Beck acolytes and progressives alike can agree that good paying jobs are better for families than a plethora of government subsidies. But the problem is that our economy and the policies that drive it are not creating enough decent paying jobs for all able-bodied Americans to cover their basic household expenses. Federal subsidies for basic needs make up for the shortcomings in our economy. And they help a surprising number of people.
To be sure, we can find ways to run these programs more effectively and more efficiently. And that’s where the hard work of budget cutting should concentrate. The ubiquity of technology, even in low-income communities, presents a huge opportunity to shed administrative costs. We should also find ways to better align these programs so that they enable workers and their families to more successfully move out of poverty. If we are serious about protecting and expanding the middle class, then the tough discussions on how to overhaul the delivery of these income-support programs need to commence.
But it’s simply not in the interest of most Americans to swing an ax at these programs amid a nascent economic recovery. Today, over 10 million Americans are collecting unemployment, and nearly that many citizens are in apartments with rents subsidized by the federal government. More than 40 million Americans put food on the table with the aid of food stamps. Fifty million Americans are able to go to the doctor or the hospital because of the Medicaid program. And fully one in six Americans is dependent on federal and state support for their basic necessities of life.
The consequences of reducing federal income supports will be devastating on the poorest among us. But the impact will not be contained to them. Remember: Ronald Reagan tried to convince us that wealth trickles down. His enduring legacy, however, is that poverty trickles up.
By: Donna Cooper, Senior Fellow-Center for American Progres, February 14, 2011
Do Republicans Really Oppose Making Health Care Insurance Cheaper?
The health-care debate has a cyclical nature, and I don’t want to keep writing the same posts over and over again. So rather than write a whole new piece on the GOP’s rediscovery of the Congressional Budget Office’s estimate that the health-care law will reduce the labor supply (which they recast as “destroying jobs”), I’ll just link to the long post I did on the subject in January.
In case you don’t want to click over, though, the short version is this: If you make health-care insurance cheaper and make it harder for insurance companies to deny people coverage, then a certain number of people who would like to leave the labor force but can’t afford or access health-care insurance without their job will stop working.
To understand why, imagine a 62-year-old woman who works for IBM and beat breast cancer 10 years ago. She wants to retire. She has the money to retire. But no one will sell her health care under the status quo. Under the health-reform law, she can buy health care in an exchange because insurers can’t turn her away due to her history of breast cancer. So she’ll retire. Or imagine a 50-year-old single mother who wants to home-school her developmentally disabled child but can’t quit her job because they’ll lose health care. The subsidies and the protections in the Affordable Care Act will give her the option to stop working for awhile, while under the old system she’d need to stick with her job to keep her family’s health-care coverage. That’s how health-care reform can reduce the labor supply. If either case counts as a destroyed job, then so does my winning the lottery and moving to Scotland in search of the perfect glass of whiskey.
Moreover, this would happen for any health-care reform that reduced costs and improved access. So when Republicans say that they want a better health-care reform bill that does even more to reduce costs, they’re calling for legislation that, according to them, would “destroy” even more jobs than the Affordable Care Act. If they’re against all legislation that might destroy jobs in this way, then they’re against making health care cheaper. In fact, by that logic, we could just jack the price of health-care insurance up and make it easier for insurers to turn individuals away. Then even more people would have to stick with their employers. Job creation!
By: Ezra Klein-The Washington Post, February 11, 2011
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