MONDAY, FEBRUARY 7, 2011
For those who are really interested in health care and the budget, especially those who buy the idea that ACA savings are probably overstated because they depend on budget discipline from future Congresses, I highly recommend Ezra Klein's post today skewering Paul Ryan's Medicare plan. The gist of it is that Ryan's plan is just as dependent on budget discipline in the future in the face of prospective real cuts as the ACA is. So if you buy that criticism, Ryan's plan won't work either.
Of course, that's nothing compared to the GOP rhetorical strategy on ACA repeal, which is to specifically target the budget cuts included in reform as a front-tier talking point. And then there's the flat out myths (10/6, for example). And the whole doc fix thing -- hey, does Ryan's plan count the budget expense of doc fix?
All in all, it's just really hard to take budget concerns seriously as the root of GOP opposition to ACA.
Unfortunately, it's a bit hard to figure out exactly what the basis for opposition is. There's the tyranny and constitutional objections thing, but see Jonathan Cohn's point last week about social security privatization. Perhaps it's just based on myth and falsehood (that is, opponents really believe that ACA is all about the death panels), but that presumably shouldn't apply to elite opponents of the law. There's the idea that it's all about opposing whatever it is that Democrats want, which is true enough -- but doesn't really explain long-term opposition to health care reform, or why health care looms so much larger for conservatives than the other accomplishments of the 111th Congress.
My best guess is that it's bits and pieces of all of those, including at least some (mistaken but sincere, even if they're also willing to use arguments that cut the other way) concern about costs. The core of it, however, at least if I had to guess, is that ACA really is a "takeover" in the sense of really making affordable health care an absolute responsibility of the federal government. Such takeovers may or may not lead to expanding the size of government, or its direct reach into peoples' lives -- since the late 1970s, liberal Democrats have shifted to favoring market-based schemes for liberal ends. But even if it doesn't expand the size of government, it does expand the size of government obligation. And that's a pretty big deal, and one that conservatives are quite right, from their point of view, to oppose.
To speculate a bit more...
The problem for conservatives, however, is that they've lost the game long ago: it is clearly impossible for a viable national party to argue that the government should stand by and do nothing if costs are exploding, if insurance companies deny coverage to large groups, if insurance companies do all sorts of outrageous things to their customers. How do I know that? Because Republicans, despite pressure from Tea Partiers who say that they want a very small government and threaten primaries to those who disagree, feel obliged nevertheless to accept government responsibility for health care, at least rhetorically. That's why they claim to want to repeal and replace, not just repeal: they are rhetorically just as committed to a government solution as the Democrats, even as they are also committed to, well, not doing that. Next time you hear someone make a fuss about polling that shows conservative self-identification far higher than liberal self-identification, keep that in mind: whatever people mean when they say they're conservative, most of them surely don't think that the federal government should have little responsibility for health care. Or, for that matter, the economy.
All of which (along with some opportunism, something that all politicians and all parties are guilty of) makes for some remarkably incoherent policy pronouncements.
For those who are really interested in health care and the budget, especially those who buy the idea that ACA savings are probably overstated because they depend on budget discipline from future Congresses, I highly recommend Ezra Klein's post today skewering Paul Ryan's Medicare plan. The gist of it is that Ryan's plan is just as dependent on budget discipline in the future in the face of prospective real cuts as the ACA is. So if you buy that criticism, Ryan's plan won't work either.
Of course, that's nothing compared to the GOP rhetorical strategy on ACA repeal, which is to specifically target the budget cuts included in reform as a front-tier talking point. And then there's the flat out myths (10/6, for example). And the whole doc fix thing -- hey, does Ryan's plan count the budget expense of doc fix?
All in all, it's just really hard to take budget concerns seriously as the root of GOP opposition to ACA.
Unfortunately, it's a bit hard to figure out exactly what the basis for opposition is. There's the tyranny and constitutional objections thing, but see Jonathan Cohn's point last week about social security privatization. Perhaps it's just based on myth and falsehood (that is, opponents really believe that ACA is all about the death panels), but that presumably shouldn't apply to elite opponents of the law. There's the idea that it's all about opposing whatever it is that Democrats want, which is true enough -- but doesn't really explain long-term opposition to health care reform, or why health care looms so much larger for conservatives than the other accomplishments of the 111th Congress.
My best guess is that it's bits and pieces of all of those, including at least some (mistaken but sincere, even if they're also willing to use arguments that cut the other way) concern about costs. The core of it, however, at least if I had to guess, is that ACA really is a "takeover" in the sense of really making affordable health care an absolute responsibility of the federal government. Such takeovers may or may not lead to expanding the size of government, or its direct reach into peoples' lives -- since the late 1970s, liberal Democrats have shifted to favoring market-based schemes for liberal ends. But even if it doesn't expand the size of government, it does expand the size of government obligation. And that's a pretty big deal, and one that conservatives are quite right, from their point of view, to oppose.
To speculate a bit more...
The problem for conservatives, however, is that they've lost the game long ago: it is clearly impossible for a viable national party to argue that the government should stand by and do nothing if costs are exploding, if insurance companies deny coverage to large groups, if insurance companies do all sorts of outrageous things to their customers. How do I know that? Because Republicans, despite pressure from Tea Partiers who say that they want a very small government and threaten primaries to those who disagree, feel obliged nevertheless to accept government responsibility for health care, at least rhetorically. That's why they claim to want to repeal and replace, not just repeal: they are rhetorically just as committed to a government solution as the Democrats, even as they are also committed to, well, not doing that. Next time you hear someone make a fuss about polling that shows conservative self-identification far higher than liberal self-identification, keep that in mind: whatever people mean when they say they're conservative, most of them surely don't think that the federal government should have little responsibility for health care. Or, for that matter, the economy.
All of which (along with some opportunism, something that all politicians and all parties are guilty of) makes for some remarkably incoherent policy pronouncements.
Of course, that's nothing compared to the GOP rhetorical strategy on ACA repeal, which is to specifically target the budget cuts included in reform as a front-tier talking point. And then there's the flat out myths (10/6, for example). And the whole doc fix thing -- hey, does Ryan's plan count the budget expense of doc fix?
All in all, it's just really hard to take budget concerns seriously as the root of GOP opposition to ACA.
Unfortunately, it's a bit hard to figure out exactly what the basis for opposition is. There's the tyranny and constitutional objections thing, but see Jonathan Cohn's point last week about social security privatization. Perhaps it's just based on myth and falsehood (that is, opponents really believe that ACA is all about the death panels), but that presumably shouldn't apply to elite opponents of the law. There's the idea that it's all about opposing whatever it is that Democrats want, which is true enough -- but doesn't really explain long-term opposition to health care reform, or why health care looms so much larger for conservatives than the other accomplishments of the 111th Congress.
My best guess is that it's bits and pieces of all of those, including at least some (mistaken but sincere, even if they're also willing to use arguments that cut the other way) concern about costs. The core of it, however, at least if I had to guess, is that ACA really is a "takeover" in the sense of really making affordable health care an absolute responsibility of the federal government. Such takeovers may or may not lead to expanding the size of government, or its direct reach into peoples' lives -- since the late 1970s, liberal Democrats have shifted to favoring market-based schemes for liberal ends. But even if it doesn't expand the size of government, it does expand the size of government obligation. And that's a pretty big deal, and one that conservatives are quite right, from their point of view, to oppose.
To speculate a bit more...
The problem for conservatives, however, is that they've lost the game long ago: it is clearly impossible for a viable national party to argue that the government should stand by and do nothing if costs are exploding, if insurance companies deny coverage to large groups, if insurance companies do all sorts of outrageous things to their customers. How do I know that? Because Republicans, despite pressure from Tea Partiers who say that they want a very small government and threaten primaries to those who disagree, feel obliged nevertheless to accept government responsibility for health care, at least rhetorically. That's why they claim to want to repeal and replace, not just repeal: they are rhetorically just as committed to a government solution as the Democrats, even as they are also committed to, well, not doing that. Next time you hear someone make a fuss about polling that shows conservative self-identification far higher than liberal self-identification, keep that in mind: whatever people mean when they say they're conservative, most of them surely don't think that the federal government should have little responsibility for health care. Or, for that matter, the economy.
All of which (along with some opportunism, something that all politicians and all parties are guilty of) makes for some remarkably incoherent policy pronouncements.
What makes Paul Ryan confident in his Medicare plan?
By Ezra Klein
Here's a question for Paul Ryan, or anyone who supports Paul Ryan's plan: Why are the cost savings in his bill possible, while the cost savings in the Affordable Care Act aren't?Ryan has been warning that one of the ways the Affordable Care Act saves money in Medicare might be overstated. This was the subject of his first hearing on the legislation, in fact. You can read a wonky exploration of the question here, but the basic argument is that the bill limits how fast a particular class of doctor payments can grow. Right now, they grow as fast as Medicare grows -- which is fast. A lot faster, in fact, than the economy grows. Health-care reform limits increases in these payments to one percentage point faster than however fast GDP is growing. But if the law doesn't get Medicare's costs under control, Ryan says, simply cutting payments won't be sustainable because doctors will leave the program, seniors will complain and Congress will reverse itself. On the bright side, the law has a ton of projects and reforms meant to slow Medicare's costs. The question is whether they'll work.
But Ryan's skepticism about Medicare's ability to hit these targets is selective. As Uwe Reinhardt points out, if you look at what Ryan himself proposes to do to Medicare, it shares a crucial similarity. In the Ryan-Rivlin plan, seniors stop getting Medicare and begin getting a check to buy private insurance products that Medicare has certified. How does that save money? Well, it doesn't. Might actually cost money, for reasons I'll explain in a second. What saves money is that the check can only grow in value at GDP plus one percentage point -- that is to say, the same rate that Ryan considers implausible in the ACA.
This might make sense if Ryan and Rivlin had a much more plausible explanation of how their program would save Medicare money, but they don't. As CBO says (pdf), seniors will have to "purchase less extensive coverage or pay higher premiums" under Ryan-Rivlin. And it's actually worse than that, as Medicare is cheaper than private insurance, and so forcing seniors to buy private plans rather than Medicare will mean they pay more for the same health-care coverage. Here's CBO again:
Medicare’s current payment rates for providers are lower than those paid by commercial insurers, and the program’s administrative costs are lower than those for individually purchased insurance. Beneficiaries would therefore face higher premiums in the private market for a package of benefits similar to that currently provided by Medicare.
So Ryan's plan is to hold down costs in Medicare by giving seniors less money to purchase more expensive private insurance. If you could make that stick, it would indeed hold down costs. But it's a lot more painful, and it includes many fewer mechanisms for cost control, than the Affordable Care Act. And yet when it comes to the ACA, Ryan firmly believes that seniors will quickly and successfully force Congress to reverse any reforms that degrade their Medicare experience. That's a fair enough concern, of course. What's confusing is why it isn't doubly devastating when applied to Ryan-Rivlin.
Photo credit: Harry Hamburg.
By Ezra Klein | February 7, 2011; 10:03 AM ET
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