RyanCare vs. The Public Option
If you want to understand why the budget debate so infuriates people who actually care about deficits — and, in particular, people who actually care about health-care spending — consider this: The central health-care reform in Paul Ryan’s budget, the one that’s got him so many plaudits for courage, would actually increase costs. The health-care reform that progressives have been pursuing for more than two years would cut them. And yet calling for Medicare to be privatized and voucherized is considered serious, while calling for a public option is considered tiresome. But let’s go to the tape.
Back during the health-care reform fight, the Congressional Budget Office looked at the likely effect of adding a public option that paid Medicare rates. “In total, a public plan based on Medicare rates would save $110 billion over 10 years,” the agency concluded. Importantly, the savings would come because premiums would be lower. The basic mechanism here is not complicated: Just as you get better deals by shopping at a mega-retailer like Wal-Mart, you get better deals by working with a mega-insurer like Medicare. Size matters.
As for Ryan’s plan, CBO’s take was just the opposite. “Under the proposal,” they said, “most elderly people would pay more for their health care than they would pay under the current Medicare system.” That is to say, health-care costs go up. Now, federal health-care spending goes down, as seniors are paying 70 percent of their costs out-of-pocket rather than 30 percent. Or, in CBO-ese, Medicare beneficiaries “would bear a much larger share of their health care costs than they would under the current program.” Of course, back in the real world, seniors are going to react poorly to being unable to afford health-care insurance, and those savings won’t manifest.
But even putting that aside, it makes for a very stark contrast. The progressive reform that won’t happen would cut health-care costs. The conservative reform that won’t happen would increase health-care costs. One idea makes insurance cheaper and one makes it more expensive. And yet the idea that makes insurance cheaper is pretty much off the table, while the idea that makes it more expensive — and that almost certainly wouldn’t work — is considered a very serious proposal worthy of brow-furrowing debate.
By: Ezra Klein, The Washington Post, April 25, 2011
Insuring The Elderly, Insuring The Poor
Democrats, Republicans and Independents all believe the government is responsible for providing health care to the elderly. Democrats and independents, but not Republicans, believe the government should also provide health care to the poor:
All groups are more likely to favor guaranteed health care for the elderly than for the poor. But the dropoff between the two policies is very different. Democrats by a plus 77% margin favor covering the elderly, but only favor covering the poor by a 52% margin. That’s a 25 percentage point gap between covering the elderly and covering the poor. For independents, the falloff is a very similar 28 percentage points. For Republicans, the falloff is 61 percentage points, from a +15 point margin for covering the elderly to a -46 point margin for covering the poor.
The best way to understand this is by grasping the link between ethnocentrism and support for universal entitlements and both opposition to means-tested entitlements. Ethnocentric attitudes among whites, controlling for all other beliefs, correlate with support for universal programs and with opposition to programs for the poor. White racial conservatives favor programs that benefit people like them — and hey, everybody gets old — and oppose programs for people unlike them — the poor being disproportionately non-white, and even more proportionately so in the white imagination.
Cutting Medicaid Means Cutting Care For The Poor, Sick And Elderly
The part of Paul Ryan’s budget that’s going to get the most attention is his proposal to privatize and voucherize Medicare. But the part that worries me the most is his effort to slash Medicaid, with no real theory as to how to make up the cuts.
Ryan’s op-ed introducing his budget lists Medicaid under “welfare reform,” reflecting the widespread belief that Medicaid is a program for the poor. That belief is wrong, or at least incomplete. A full two-thirds of Medicaid’s spending goes to seniors and people with disabilities — even though seniors and the disabled are only a quarter of Medicaid’s members. Sharply cutting Medicaid means sharply cutting their benefits, as that’s where the bulk of Medicaid’s money goes. This is not just about the free health care given to some hypothetical class of undeserving and unemployed Medicaid queens.
But perhaps cutting it wouldn’t be so bad if there were a lot of waste in Medicaid. But there isn’t. Medicaid is cheap. Arguably too cheap. Its reimbursements are so low many doctors won’t accept Medicaid patients. Its costs grew less quickly than those of private insurance over the past decade, and at this point, a Medicaid plan is about 20 percent cheaper than an equivalent private-insurance plan. As it happens, I don’t think Medicaid is a great program, and I’d be perfectly happy to see it moved onto the exchanges once health-care reform is up and running. But the reason that’s unlikely to happen isn’t ideology. It’s money. Giving Medicaid members private insurance would cost many billions of dollars.
That’s why it’s well understood that converting Medicaid into block grants means cutting people off from using it, or limiting what they can use it for. You can see CBO director Doug Elmendorf say exactly the same thing here. There’s just not another way to cut costs in the program. You can, of course, work to cut costs outside of the program, either by helping people avoid becoming disabled or making it cheaper to treat patients once they become disabled or sick, but those sorts of health-system reforms are beyond the ambitions of Ryan’s budget.
To get around some of this, Ryan’s op-ed talks about state flexibility, with the implication being that states have some secret Medicaid policies they’ve been dying to try but that the federal government simply hasn’t let them attempt. But the truth is there’s been a tremendous amount of experimentation in Medicaid over recent decades. Indiana converted its Medicaid program into health savings accounts. Tennessee based its program around managed care. Massachusetts folded its Medicaid money into Mitt Romney’s health-care reforms. Oregon tried to rank treatments by value. Some of these reforms have worked well and some haven’t worked at all, but none have solved the basic problem that covering the sick and disabled costs money, and you can’t get around that by trying to redesign their insurance packages. For that reason, block-granting Medicaid ultimately means cutting health-care coverage to the poor, the elderly and the disabled, even as it doesn’t actually address the factors driving costs throughout the health-care system.
By: Ezra Klein, The Washington Post, April 5, 2011
Tea Party Tailspin: Anger And Shifting Momentums
The Tea Party is synonymous with anger. Anger defined it. Anger fueled it. Anger marred it. Anger became its face and its heart. But anger is too exhausting an emotion to sustain.
A poll released Thursday by the Pew Research Center found that anger at the government among Tea Party supporters fell by 40 percent from September 2010 to this month. Furthermore, anger among Republicans fell by more than half, and anger among whites, the elderly and independents fell by 40 percent or more.
On the other hand, the percentage of Tea Party supporters who said that they trusted the government always or most of the time doubled from last March to this March, and the percentage of Republicans saying so nearly doubled. In fact, the percent of both Republicans and independents saying so is now higher than it has been since January 2007.
Less anger? More trust? What happened? The midterms happened, that’s what.
Elections have a way of cooling passions, especially when voters get what they want. (Remember how lethargic many Democrats became after November 2008?) Electoral success not only satisfies, it pacifies. The enormous gains by Republicans during the midterms assuaged much of the country’s grief. The pressure began to subside. The novelty dimmed. The urgency evaporated.
Yet Tea Party leaders are still sniping from the sidelines, holding politicians to overreaching promises made when the electorate was still stewing. Judson Phillips, founder of the Tea Party Nation, wrote a post on its Web site this week saying the House speaker, John Boehner, looks “like a fool” and should face a primary challenge in 2012 for not pursuing enough spending cuts this year.
For these Tea Partiers, any concession is a crime worthy of expulsion.
A September Pew Poll found that only 22 percent of those who identify with the Tea Party admire political leaders who make compromises. This is not the way the rest of the country feels. Fifty-five percent of Democrats and 36 percent of Republicans said that they admired politicians who compromise.
Staunch Tea Partiers seem to be guided by the worst kind of fundamentalist political extremism — immutable positions derived from a near-religious adherence to self-proclaimed inviolable principles. This could well be their undoing.
During the right’s season of anger, passion and convictions galvanized Tea Party supporters into an army of activism. But the vehicle is outliving its fuel. The movement is losing momentum. In fact, Tea Party-backed governors like Scott Walker in Wisconsin could be providing the rallying cry on the left to pick up the mantle of anger and send the momentum back the other way.
If Tea Party leaders continue to operate as if anger is still a major part of their arsenal and Republican politicians continue to feel pressured into untenable positions, Democrats could enjoy their very own Charlie Sheen-ism come 2012: “Winning!”
By: Charles Blow, Op-Ed columnist; Original article published in The New York Times, March 4, 2011
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