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
No, Rep Paul Ryan’s Budget Proposal Is Not Brave
Prominent opinion writers have spent the last few days fawning over Rep. Paul Ryan’s budget plan, which would essentially abolish Medicare and Medicaid while lowering taxes on top earners, and many of them have deployed a litany of superlatives usually reserved for costumed superheroes. Commentators like David Brooks and Jacob Weisberg have described Ryan’s plan as “brave,” and “bold,” and the word “courageous” has been ubiquitous.
But the closer people look at Ryan’s plan, the clearer it becomes that the plan isn’t all that brave. Let’s take stock of all the recent revelations about it.
Ryan’s plan included a laughably implausible unemployment analysis from Heritage predicting it would bring unemployment down to 4 percent by 2015 and 2.8 percent by 2012 — an analysis Heritage then quitely retracted by attempting to disappear it from the internet. Ryan’s plan claims to save money while repealing the Affordable Care Act, even though the CBO has said repealing the ACA will increase the deficit. Ryan implied that his plan was supported by President Bill Clinton’s former OMB Director Alice Rivlin, even though it isn’t. It cuts taxes on top earners, when the easiest way to reduce the deficit is to let the Bush tax cuts expire.
Ryan’s misleading claims aren’t the only thing that isn’t particularly brave about his plan. After accusing Democrats of “raiding” Medicare with the Affordable Care Act, Ryan spares the elderly voters who supported Republicans in 2010 by making sure only he guts medical care for future seniors (he still calls it “saving Medicare,” however). And as the Center for Budget and Policy Priorities noted, 2.9 trillion in Ryan’s budget comes from cuts in programs focused on low-income Americans. It doesn’t touch defense spending.
In other words, it focuses on cuts to programs that benefit those most likely to vote Democratic, while preserving programs that serve those more likely to vote Republican.Rewarding your constituencies while punishing the other side’s is how partisan politics usually works, but there’s nothing particularly brave about it.
Ryan himself said during the rollout that his plan isn’t so much a budget as a “cause.” As Steve Benen wrote yesterday, the cause here is destroying the modern welfare state so that rich people have to pay less in taxes. The only reason so many people think Ryan’s plan is “brave” is because they agree with this cause.
When we call a person brave, what we usually mean is that his or her “bravery” is being employed towards an end we agree with. In this case, those who are hailing Ryan’s proposal as brave are doing so because they agree with its goal, which — no matter how many times people insist otherwise — is not deficit reduction. It’s destroying the social safety net. It just so happens that’s a cause a lot of wealthy people with a disproportionate influence on our political discourse happen to believe in. So they think it’s brave, even if the numbers are phony and even if it disproportionately punishes the poor. But there’s nothing at all brave about it.
By: Adam Serwer, The Washington Post, April 7, 2011
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