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
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
Ludicrous and Cruel: America Is Being Punked By GOP Voodoo Economics
Many commentators swooned earlier this week after House Republicans, led by the Budget Committee chairman, Paul Ryan, unveiled their budget proposals. They lavished praise on Mr. Ryan, asserting that his plan set a new standard of fiscal seriousness.
Well, they should have waited until people who know how to read budget numbers had a chance to study the proposal. For the G.O.P. plan turns out not to be serious at all. Instead, it’s simultaneously ridiculous and heartless.
How ridiculous is it? Let me count the ways — or rather a few of the ways, because there are more howlers in the plan than I can cover in one column.
First, Republicans have once again gone all in for voodoo economics — the claim, refuted by experience, that tax cuts pay for themselves.
Specifically, the Ryan proposal trumpets the results of an economic projection from the Heritage Foundation, which claims that the plan’s tax cuts would set off a gigantic boom. Indeed, the foundation initially predicted that the G.O.P. plan would bring the unemployment rate down to 2.8 percent — a number we haven’t achieved since the Korean War. After widespread jeering, the unemployment projection vanished from the Heritage Foundation’s Web site, but voodoo still permeates the rest of the analysis.
In particular, the original voodoo proposition — the claim that lower taxes mean higher revenue — is still very much there. The Heritage Foundation projection has large tax cuts actually increasing revenue by almost $600 billion over the next 10 years.
A more sober assessment from the nonpartisan Congressional Budget Office tells a different story. It finds that a large part of the supposed savings from spending cuts would go, not to reduce the deficit, but to pay for tax cuts. In fact, the budget office finds that over the next decade the plan would lead to bigger deficits and more debt than current law.
And about those spending cuts: leave health care on one side for a moment and focus on the rest of the proposal. It turns out that Mr. Ryan and his colleagues are assuming drastic cuts in nonhealth spending without explaining how that is supposed to happen.
How drastic? According to the budget office, which analyzed the plan using assumptions dictated by House Republicans, the proposal calls for spending on items other than Social Security, Medicare and Medicaid — but including defense — to fall from 12 percent of G.D.P. last year to 6 percent of G.D.P. in 2022, and just 3.5 percent of G.D.P. in the long run.
That last number is less than we currently spend on defense alone; it’s not much bigger than federal spending when Calvin Coolidge was president, and the United States, among other things, had only a tiny military establishment. How could such a drastic shrinking of government take place without crippling essential public functions? The plan doesn’t say.
And then there’s the much-ballyhooed proposal to abolish Medicare and replace it with vouchers that can be used to buy private health insurance.
The point here is that privatizing Medicare does nothing, in itself, to limit health-care costs. In fact, it almost surely raises them by adding a layer of middlemen. Yet the House plan assumes that we can cut health-care spending as a percentage of G.D.P. despite an aging population and rising health care costs.
The only way that can happen is if those vouchers are worth much less than the cost of health insurance. In fact, the Congressional Budget Office estimates that by 2030 the value of a voucher would cover only a third of the cost of a private insurance policy equivalent to Medicare as we know it. So the plan would deprive many and probably most seniors of adequate health care.
And that neither should nor will happen. Mr. Ryan and his colleagues can write down whatever numbers they like, but seniors vote. And when they find that their health-care vouchers are grossly inadequate, they’ll demand and get bigger vouchers — wiping out the plan’s supposed savings.
In short, this plan isn’t remotely serious; on the contrary, it’s ludicrous.
And it’s also cruel.
In the past, Mr. Ryan has talked a good game about taking care of those in need. But as the Center on Budget and Policy Priorities points out, of the $4 trillion in spending cuts he proposes over the next decade, two-thirds involve cutting programs that mainly serve low-income Americans. And by repealing last year’s health reform, without any replacement, the plan would also deprive an estimated 34 million nonelderly Americans of health insurance.
So the pundits who praised this proposal when it was released were punked. The G.O.P. budget plan isn’t a good-faith effort to put America’s fiscal house in order; it’s voodoo economics, with an extra dose of fantasy, and a large helping of mean-spiritedness.
By: Paul Krugman, Op-Ed Columnist, The New York Times, April 7, 2011
GOP DeathWish?: Republicans Pushing To Revamp Medicare Could Find Themselves Voted Out Of Office In The Next Election
One of the biggest and most frequent mistakes in politics is for a party to misread its mandate. When it happens, independent and swing voters get angry and punish a candidate or a party on Election Day. Because American politics is a zero-sum game, punishing one party means rewarding the other party—even when the latter is not necessarily deserving of support. Frequently, the party that benefits from the spanking mistakenly interprets it to mean that the public is embracing every aspect of its agenda. Republicans shouldn’t forget that their party had dismal favorable/unfavorable poll ratings last fall. They won because they weren’t Democrats.
There is no question that the Republican base, conservatives, and supporters of the tea party want to take a meat ax to government spending. When Republican congressional members return home and meet with their constituents, they are encouraged to vote against continuing resolutions and for deep spending cuts. These supporters have intensity, and they adamantly oppose any compromise with Democrats.
It would be a blunder, however, to think that such views drove the election. Republicans, conservatives, and tea partiers did not throw Republicans out of their House and Senate majorities in 2006, and they did not vote to increase the size of the Democratic majorities and elect Barack Obama president in 2008.
Independent voters were the ones who cast their ballots for Democrats by an 18-point margin in 2006 because they were mad at President Bush and upset about the war in Iraq, not to mention Republican scandals and the general performance of the GOP Congress. Two years later, these same voters were still angry at the president, were afraid of the financial crisis, and didn’t care for GOP presidential nominee John McCain.
In 2010, these independent voters were unimpressed by the economic-stimulus package, didn’t like cap-and-trade environmental regulation, and really didn’t like the Democratic health care package. Those over or approaching 65 years of age also feared that health care reform would erode Medicare benefits. Even those unaffected by the reforms rallied to defend Medicare.
Polling is very clear. Most voters want to see the federal budget balanced and spending cut. However, they don’t want Social Security, Medicare, or Medicaid touched, and, oh yes, they don’t want taxes increased. Now, anyone with an IQ over room temperature knows that all of this is impossible. Spending on Social Security, Medicare, and Medicaid, along with interest on the national debt, amounts to approximately half the federal budget.
There is no doubt that significant budget cutting is necessary and that Medicare and Medicaid must be reformed. No one can doubt the courage or sincerity of House Budget Committee Chairman Paul Ryan, R-Wis. But it’s little short of suicidal to drop a Medicare reform package—even a voucher plan that would be optional for those currently older than 55—into tough budget negotiations stymied over Republican demands for deep spending cuts. Democrats have some experience with older voters going ballistic, even with changes that wouldn’t affect them.
For many seniors, doing anything to Medicare that can’t be portrayed as an increase is essentially a cut, and they will fight it to their last breath. From a political standpoint, Medicare reform is very dangerous territory. House Republicans are not just pushing the envelope—they are soaking it with lighter fluid and waving a match at it.
One can understand why Republicans are pushing so hard. Their base is demanding that they do so. And if congressional Republicans resist, many of them can look forward to primary opposition next year. But it seems that GOP members of Congress have become so consumed with pleasing their base that they are ignoring general-election voters and the independents who drive the wild gyrations in American politics.
Congressional Republicans would be well advised to pay attention to the results of the latest Pew Research Center poll (conducted March 30 to April 3 among 1,057 adults) that asked Americans whether they would prefer that their lawmakers stand by their principles even if it meant that the government would shut down, or whether they would rather have their lawmakers compromise on a budget even if they didn’t agree with it. Among Republicans and Republican-leaning independents who agree with the tea party movement, 68 percent said they would rather have a lawmaker who stands by his or her principles. But among all Republicans, only 50 percent said stand by their principles, while 43 percent said compromise. Among all adults, 55 percent said compromise; among independents, 53 percent said compromise, with 36 percent siding with the principles option.
The bottom line: GOP primary voters are very different from general-election voters. It would be a very shortsighted strategy for Republican members—especially those in swing districts—to focus too much on primary voters. A lot of Democrats did the same thing in 2009 and 2010. Many are now former members of Congress.
By: Charlie Cook, National Journal, April 7, 2011
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