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
The Anniversary of the Affordable Care Act: A Year Later, The False Attacks Continue
Conservatives often push myths and misconceptions of the Affordable Care Act of 2010 as a way to increase opposition. During the debate in Congress in the run-up to passage of the new health reform law, conservatives pushed wild accusations that the law would be a “government takeover” and establish “death panels,” claims that were labeled “the lie of the year.” Now, a year after the Affordable Care Act was signed into law, inaccurate claims and mistruths against the law continue.
Conservatives continue to make false claims against the law as a way to repeal it, undermine consumer protections, and put insurance companies back in charge of our health system. The reason these false statements endure is clear: There are those who would rather take us back to the way our health system was before when insurance companies were in charge rather than move forward and protect our care.
This issue brief is a response to recent false attacks conservatives have made against the law. As we will demonstrate, the Affordable Care Act will create jobs, lower health care costs for families, help small businesses provide health insurance to their employees while maintaining the private sector’s key role in health insurance, and ensure we provide quality health care to all Americans at a lower cost to them and American taxpayers.
The Affordable Care Act will help create jobs
The Affordable Care Act helps our economic recovery by bringing health costs under control, freeing businesses to use that money to invest in job creation. The real threat to job creation is the conservative push to take us back to the old health system where costs were on an unsustainable path. Harvard University professor and Center for American Progress Senior Fellow David Cutler found that repealing the Affordable Care Act—and going back to the unsustainable costs—would cost up to 400,000 jobs annually over the next decade.
To push this “job destroying” argument, conservatives cite the nonpartisan Congressional Budget Office’s estimates that the law will reduce the labor supply (although conservatives dismiss CBO reports when they conclude the law will cut the deficit and reduce premiums). Yet conservatives fail to recognize that one reason for this reduction is that older workers, now forced to hold on to jobs to get health insurance, will now be able to retire—with insurance—when they choose.
The Affordable Care Act lowers premiums and costs for families
The Affordable Care Act takes steps to get our health costs under control and lowers costs for families. The real threat to costs is the conservative push to repeal the law. Cutler found that repealing the Affordable Care Act would increase total health spending by $125 billion and raise family premiums by nearly $2,000.
More small businesses are providing health coverage to their employees, thanks in part to the Affordable Care Act
Conservatives try to downplay the impact of the small business tax credits to provide health insurance to their employees. The truth is that last year, more than 4 million small businesses were eligible to receive a tax credit to make health coverage more affordable. According to the Los Angeles Times, “major insurers around the country are reporting that a growing number of small businesses are signing up to give their workers health benefits,” adding that an “important selling point” was the small business tax credits.
The Affordable Care Act keeps the employer-based health system intact
Conservatives claim the Affordable Care Act will undermine the employer-sponsored health coverage that millions of Americans enjoy when the state health insurance market exchanges become functional. This is not true. According to Mercer’s recent “National Survey of Employer-Sponsored Health Plans,” the vast majority of employers, particularly large employers, will continue to offer their employees health coverage. Indeed, the survey notes that if the Affordable Care Act follows the Massachusetts health law, “few employers of any size” will choose to drop coverage.
The Affordable Care Act ensures quality care and has flexibility for states
The Affordable Care Act provides states with considerable flexibility. Each state gets to decide how to set up their own marketplace of health options for consumers to choose which plan suits them best. States have flexibility in how they implement insurance reforms and consumer protections. The law encourages state innovation by allowing them to obtain waivers from some requirements provided the alternative proposal provides comparable coverage and affordability. President Obama recently endorsed legislation from Sens. Ron Wyden (D-OR) and Scott Brown (R-MA) that would move the start date for those waivers by three years.
At the same time, conservatives argue there is not enough flexibility in the Affordable Care Act. They criticize the Obama administration for granting too many waivers on so-called “mini med” plans that have a low annual limit. Since many of the consumer protections and mechanisms to increase patient choice—such as the state marketplaces—are not operational until 2014, the administration has in some instances granted waivers from the law’s early requirements, to avoid leaving people with nothing. CAP Senior Fellow Judy Feder told Congress that until the law is fully implemented, the goal should be to “make matters better, without making them worse.”
States can save money from the Medicaid reforms under the law
Medicaid is a federal-state health program that provides health coverage to predominantly lower-income families, elderly people, and people with disabilities. The federal government matches state funding on the program. For people made newly eligible for Medicaid by the Affordable Care Act, the federal government will pay 100 percent of costs in the early implementation of the Affordable Care Act. In the later years, states will have to pay only 10 percent.
Conservatives charge that the Affordable Care Act will increase state Medicaid spending by $118 billion. An Urban Institute study, however, found that states will save between $40.6 billion and $131.9 billion from 2014-2019 by replacing state and local spending for uncompensated care and mental health with federal Medicaid funds and by replacing federal Medicaid funding for adults with incomes over 133 percent of the federal poverty level with federal subsidies in the marketplaces.
There is no secret $105 billion hidden in the law
Conservatives such as Reps. Michele Bachmann (R-MN) and Steve King (R-IA) claim that $105 billion of mandatory funding was secretly put in the law unbeknownst to members of Congress. This is false. The Washington Post’s Fact Checker said this claim is “bordering on ridiculous” and “does not have credibility.” The truth is there was a considerable amount of transparency before the Congress approved the Affordable Care Act. In the House alone, there were: 79 bipartisan hearings, totaling 100 hours; 181 witnesses; and 239 amendments considered. The House bill was posted online 30 days before committee markup.
The law keeps Medicare solvent and cuts the deficit
Conservatives argue that the Obama administration “double counted” the Medicare savings for the law, arguing it went to save the Medicare Trust Fund and cut the deficit. The facts are these: The law cuts the deficit by $1 trillion over the next two decades and keeps Medicare solvent until 2029—12 years longer than before the law was passed. The Center on Budget and Policy Priorities explained how this works before the House Budget Committee:
There’s no double-counting involved in recognizing that Medicare savings improve the status of both the federal budget and the Medicare trust funds. In the same way, when a baseball player hits a homer, it both adds one run to his team’s score and also improves his batting average. Neither situation involves double-counting.
Conclusion
The conservative false attacks are meant to repeal the Affordable Care Act and bring our health system back to the time when insurance companies could discriminate because of a pre-existing condition. Despite these false attacks, the facts are clear: Millions of families, small business owners, and seniors are seeing the benefits of the Affordable Care Act. More than 4 million small businesses are eligible to receive tax credits to make health coverage more affordable. As many as 4 million seniors received help to make their prescription drugs more affordable. Already this year, more than 150,000 seniors with Medicare had a free wellness exam. And children with pre-existing conditions can no longer be excluded from insurance plans. We should move forward with this law and tell those who want to repeal it that we won’t go back.
By: Tony Carrk, Center For American Progress, March 21, 2011
State Crises Mean New Language Of Deceit
For most of history, we had undebatable definitions of words such as “bailout” and “bankruptcy.” We understood the former as an undeserved public grant, and the latter as an inability to pay existing bills. Whatever your particular beliefs about these concepts, their meanings were at least agreed upon.
Sadly, that’s not the case during a deficit crisis that is seeing language redefined on ideological terms.
“Bailout” was the first word thrown into the Orwellian fire. As some lawmakers recently proposed replenishing depleted state coffers with federal dollars, the American Conservative Union urged Congress to oppose states “seek(ing) a bailout” from the feds. Now, Rep. Paul Ryan, R-Wis., says, “Should taxpayers in Indiana who have paid their bills on time, who have done their job fiscally be bailing out Californians who haven’t? No.”
Ryan, mind you, voted for 2008’s TARP program — a bank bailout in the purest sense of the term. But one lawmaker’s rank hypocrisy is less significant than how the word “bailout” is being used — and abused. Suddenly, the term suggests that federal aid would force taxpayers in allegedly “fiscally responsible” Republican states to underwrite taxpayers in supposedly irresponsible Democratic ones.
Aside from stoking a detestable interstate enmity, this thesis ignores the fact that state-to-state wealth transfers are already happening. According to the Tax Foundation, most Republican-voting states receive more in federal funding than they pay in federal taxes, while most Democratic-voting states receive less federal money than they pay in federal taxes.
That means traditionally blue states like California are now perpetually subsidizing — or in Ryan’s parlance, “bailing out” — traditionally red states like Indiana. Thus, federal aid to states could actually reduce the state-to-state subsidies conservatives say they oppose.
Congressional Republicans will undoubtedly ignore these facts. Their proposed solution to the budget emergency could instead be a Newt Gingrich-backed initiative letting states default on outstanding obligations by declaring bankruptcy. Again, the word is fraught with new connotations.
Whereas sick or laid-off individuals occasionally claim a genuine inability to repay debts and thus a need for bankruptcy protections, states can never legitimately claim such a need because they are never actually “bankrupt.” Why? Because they always posses the power to raise revenue. The power is called taxation — and destroying that authority is what the new bankruptcy idea is really about. It would let states avoid tax increases on the wealthy, renege on contractual promises to public employees and destroy the country’s creditworthiness.
Blocking state “bailouts” and letting states declare “bankruptcy” are radical notions, especially in a bad economy. One would result in recession-exacerbating public layoffs; the other would institutionalize an anti-tax zealotry that destroys tomorrow’s middle class in order to protect today’s rich. That’s why advocates of these ideas have resorted to manipulating language. They know the only way to make such extremism a reality is to distort the vernacular — and if we aren’t cognizant of their scheme, they will succeed.
By: David Sirota, Syndicated Columnist, Sun Journal-published March 8, 2011
No Glory For Governors Trying To Do The Right Fiscal Thing
If you want to get national attention as a governor these days, don’t try to be innovative about solving the problems you were elected to deal with – in education, transportation and health care. No, if you want ink and television time, just cut and cut and cut some more.
Almost no one in the national media is noticing governors who say the reasonable thing: that state budget deficits, caused largely by drops in revenue in the economic downturn, can’t be solved by cuts or tax increases alone.
There is nothing courageous about an ideological governor hacking away at programs that partisans of his philosophy, including campaign contributors, want eliminated. That’s staying in your comfort zone.
The brave ones are governors such as Jerry Brown in California, Dan Malloy in Connecticut, Pat Quinn in Illinois, Mark Dayton in Minnesota and Neil Abercrombie in Hawaii. They are declaring that you have to cut programs, even when your own side likes them, and raise taxes, which nobody likes much at all. Rhode Island’s Lincoln Chafee has warned of possible tax increases too.
Indeed, to the extent that Quinn received any national press coverage, he got pilloried in conservative outlets in January when he signed tax hikes that included a temporary increase in Illinois’ individual income tax rate from 3 percent to 5 percent.
Despite all the commotion around whether the federal government will shut down, the clamor in the states may be even more important than what’s happening in Washington, which is missing in action on the moment’s most vital fiscal question.
What states are doing to ease their fiscal agonies will only slow down our fragile economic recovery, and may stop it altogether. The last thing we need right now are state and local governments draining jobs and money from the economy, yet that is what they are being forced to do.
As the last three monthly reports from the Bureau of Labor Statistics showed, an economy that created a net 317,000 private-sector jobs lost 70,000 state and local government jobs. Cutbacks are dead weight on the recovery.
In a more rational political climate, President Obama would have resurrected the lovely old Republican idea of federal revenue sharing. Washington should have continued replenishing state budgets for two more years, until we were certain the economic storms had passed. Instead, anything that might be called “stimulus” – “S” is now a scarlet letter in politics – was rejected out of hand.
The federal government could also help the states by picking up more of their Medicaid costs. In the long run, health-care spending should be a responsibility of the national government – as it is in almost every other wealthy democracy. A national commitment would end the specter of states forcing already financially beleaguered citizens off the health insurance rolls.
Such ideas are off the table because the current rage is not for figuring out how to make government work better – a cause that once united governors of both parties – but for cutting back even its most basic and popular functions.
Consider the new budget Gov. Scott Walker announced in Wisconsin on Tuesday. Among other things, he proposed cutting state aid to schools by $834 million over the next two years, a 7.9 percent reduction.
On top of that, Walker would make it harder for localities and school districts to make up for the shortfall by limiting their ability to raise property taxes. This isn’t about education reform. It’s about forcing larger class sizes, layoffs, reductions in extracurricular activities or cuts in teacher pay and benefits. But, hey, if it’s labeled “government,” let’s slash it.
What’s truly amazing, as Stateline.org reported recently, is the number of governors who are cutting taxes at the same time they are eviscerating programs. A particularly dramatic case is Florida’s Republican Gov. Rick Scott. He faces a $3.5 billion budget gap – and is pushing for $2 billion in corporate and property tax cuts.
Historically, times of fiscal stress forced states to make useful economies in programs that didn’t work or were not essential. But what’s happening in so many places now is a reckless rush to gut the parts of government that all but the most extreme libertarians support – and that truly deserve to be seen (one thinks of education and programs for poor children) as investments in the future.
And those governors doing the hard work trying to balance cutbacks and tax increases get ignored, because there’s nothing sexy about being responsible.
By: E. J Dionne, Op-Ed Columnist, The Washington Post, March 3, 2011
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