What’s Left of the Ryan Plan?
By James Kwak
Jennifer Steinhauer in the Times reports that some Republicans are running away from the Ryan Plan (you know, the one that changes Medicare from a health insurance plan to an underfunded subsidy), while others are trying to figure out if they should support in order to gain Tea Party votes. As policy, of course, it never had a chance to pass the Senate or of being signed by President Obama (and every Republican staffer Politico could find agrees), so it was pure political theater from the start. As Paul Krugman points out, the goal may have been to win over the pundits — a group that is vastly more concerned with the deficit than ordinary voters — but even that failed. (They got Jacob Weisberg, but he backpedaled furiously, and they got David Brooks, which was mainly amusing because then we got to watch Krugman trying to observe intra-Times decorum by not going after Brooks by name). Now Republicans are wondering if the loss of a Congressional seat in a conservative New York district was Ryan’s fault.
But while I’d like to think that the nation is recovering its senses, at least on what Republicans mean for Medicare, I’m not optimistic. Brad DeLong put it well:
“the political lesson of the past two years is now that you win elections by denouncing the other party’s plans to control Medicare spending in the long run — whether those plans are smart like the Affordable Care Act or profoundly stupid like the replacement of Medicare by RyanCare for the aged — sitting back, and waiting for the voters to reward you.”
Remember that at the same time they were plotting the destruction of Medicare as we know it,* the Republicans were also attacking the Obama administration for planning to reduce Medicare spending (from its projected levels, not its actual levels). Remember when Mitch McConnell’s office released press releases, on consecutive days, saying, “Cutting Medicare Is Not What Americans Want” and “Expanding Medicare ‘A Plan for Financial Ruin’”? Politically, the only mistake they made — if they made one at all — was putting out those press releases on consecutive days from the same office. I’m certain that a majority of Americans would agree with both of those positions, standing on their own.
Most likely, the Republicans will reposition the Ryan Plan as an attempt to “save Medicare” (wait, they’re already doing that). They will try to eliminate the provisions in the Affordable Care Act that attempt to reduce Medicare costs by making Medicare spending more efficient, like the Independent Payment Authorization Board, demonizing them as government intrusion into medical treatment decisions. The answer, they will say, is a “Medicare” system free of government involvement. And if they can create enough gridlock to make sure the Affordable Care Act fails, then five or ten years from now, when the debt projections are even worse, they will take another shot at privatizing Medicare. Remember, this wasn’t the first one: Newt Gingrich took a shot back in 1995. As long as the Republicans can use voters’ fears of “big government” to block real reforms to Medicare, time is on their side. At some point, even if they have to wait twenty years, the fiscal imbalance will be so big that they will be able to eliminate Medicare.
The Obama administration knows this game. They knew what they were doing when they put cost-control measures into the Affordable Care Act, and I’m sure Obama will veto anything that prevents those measures from working. But it’s still an uphill battle.
* No, I don’t think this is an overstatement. The Ryan Plan would change Medicare from a guaranteed level of health insurance coverage to a voucher that may or may not buy you health insurance at all.
I’m sure Obama will veto anything that prevents those measures from working
Obama (and the Democrats generally) has a great facility for adopting Republican messaging and giving away their best arguments. The best example is Obama adopting the “govt must tighten its belt” framing when we need counter-cyclical spending. Steny Hoyer is already backsliding on Medicare.
foosion
May 25, 2011 at 11:46 am
I think (speaking as a lefty) that it’s quite easy for us to point blame and say “RyanCare” is the reason for the Republican’s loss of the congressional seat in NY. Apparently it’s even easy for Paul Ryan himself to lay the blame on this…… But I think if lefties, or anyone makes this argument, it’s a little silly.
I think for people with especially strong egos in “the beltway”, David Brooks would easily fall into this group as he has an ego probably large enough to cause some kind of cosmic anomaly, it’s easy for those people in “the beltway” to think their little policy quarrels are what the average voter is thinking about. What is the much more likely cause of this was the Tea party and the Republican party had two extremely crappy candidates, with the Tea party wacko taking whatever votes Corwin would have needed to win the race. And in typical liberal idiocy (again, I am speaking as a Democrat) the left has taken the excuse handed to them by the right and repeated it parrot style.
The point Democrats should be taking away from this, is how much damage the Teabagger party could do to Republicans in coming elections, keep very quiet, get a big bag of popcorn, a Super-Sized Dr. Pepper, and enjoy the show.
Moses Herzog
May 25, 2011 at 2:25 pm
You assume the GOP will have some control over both chambers for the next 20 years!
I expect GOP will settle for a commitment to enact some much-needed streamlining in the Medicaid/Medicare establishments, which both sides want anyways. Democrats can cry foul, GOP can cry foul, and everyone grits their teeth, signs the budget, and plots the other’s demise in 2012. And the beat goes on.
jesse
May 25, 2011 at 2:39 pm
“The Affordable Care Act” of President Obama has more exemptions than the IRS Tax Code…coupled that to the nth`degree factor regarding the K-Street Pharma(Rx)/ HealthCare lobbyist put together!
Ryan’s Plan was an absolute joke, and a intellectual travesty to the Republican Party. But, “Two Wrongs don’t Make a Right”? There both failures.(JMHO)
We are in this deficit not because of Medicare or Social Security but rather the $11 Trillion Dollars wasted in the last eleven years on “America At War” lies regarding Iraq, and Afghanistan, and now Pakistan! Can you imagine that “Twenty-Four Nut-Job Characters” has cost our country so much? We’ll it has, do the math! When we could have just gotten old Bin Laden… ten years ago (no physical evidence…just an ad hoc “Trust Me” ceremoniously burying at sea, what gives with that?).
Currently Obama is getting himself heavily involved in Libya, and following the Bloody British with subtle talk again about North Korea.
He’s a bigger “War President” than Bush #43 and even a bigger “Multinational’s Business” advocate, and that goes for the Banksters, and BIG Oil, period!
Tell me? What has he done for the millions of Americans defaulting on their mortgages, and the unemployed? The Seniors will get no cost of living increase for the third year in a row…but taking care of Foreign Aide Recipients to the tune of ~$45 Billion Dollars giveaway doesn’t phase his administration one iota!
What this country needs is “Single-Payer Health Care Program” period, but that’s too easy and saves to much money. sorry for my “Redundancy [?]” that creates nothing but heartburn for me as I pen my frustration.
Thankyou James and Simon
God Bless You…Julian Assange
earle,florida
May 25, 2011 at 2:51 pm
If you care about the future of the American economy, then the three most important problems to solve are health care costs, health care costs, and health care costs. (Health care costs include, but are not limited to, Medicaid and Medicare. The growth of privately paid health care costs threatens the solvency of many industries.)
The problem is that neither the Democrats nor the Republicans has a sensible plan for this. The Ryan plan, of course, just takes away the money and leaves the elderly to play Russian roulette about whether to see a doctor when having chest pains–they call that “consumer empowerment.” The problem with the ACA is that its cost containment mechanisms are smoke, mirrors, and wishful thinking. The most plausible of its mechanisms is the independent payment advisory board (IPAB). The IPAB, in principle, is just what we need. But in the ACA it has been designed to fail. It is forbidden by statute from recommending a wide range of things, almost all of which are necessary if we are going to get a grip on health care costs. It will not attract talented, independent people because the job is structured to be suitable only for somebody who is independently wealthy and nearing retirement. Furthermore, Congress can override its recommendations by coming up with something that saves the same amount. But we are all too familiar with how Congress games that kind of system to claim they are saving when in reality they are not. I have ranted often on this blog about the illusory nature of the ACA’s other “cost containment” measures and won’t go there again today.
There will be a day of reckoning. We cannot have health care costs growing so much faster than GDP indefinitely. American Health Care as we know it is a dead man walking. The question is whether we plan and implement an orderly takedown of the existing system, phasing in the radical changes it needs (e.g. end of fee-for-service, banning the provision of services that are net harmful, useless, or nearly useless, and restricting useful services to those who actually need them), or whether we will wait until things are so desperate that the hideous Ryan plan will look, in retrospect, like a missed opportunity!
If we start now, there is time to implement a new, better health care system that creates more health and sucks up less wealth. But nobody in Washington has any serious intention of doing this because it requires facing down the health care and insurance industries. It’s all political theater with no substance on either “side of the aisle.”
CBS from the West
May 25, 2011 at 3:53 pm
Time did a quick piece today showing the factual and logical flaws in Ryan’s defense of RyanCare. If Dems let the GOP reposition as James describes, then they are morons.
http://swampland.time.com/2011/05/25/paul-ryans-sisyphean-task-selling-medicare-reform/
thoughtbasket
May 25, 2011 at 7:06 pm
“Romney`Care ?” Tell me it ain’t so…said the stern agnostic snubbing Mr. Ambiguity! This is definitely going to be picked-up by Romney as a back door reprieve, thus energizing his presidential campaign hopes? (JMHO)
What’s this? Vermont Steps Closer to “Single-Payer Health Care” (5/22/11) ie.) a factual prototype for implementation beginning 2014. I personally have lived in Vermont part time my entire life…and love the hardy people that make up this extremely patriotic state!
Ref:
http://www.Kaiserhealthnews.org/Stories/2011/May/22/vermont-single-payer-health-care-npr.aspx
Kudos to TippyGolden Press :-))
earle,florida
May 25, 2011 at 8:20 pm
I don’t know why we all try so hard to put a logic on the current Zeitgeist. There is no real logic. Not logic in traditional sense. Their is a logic of the moment, tho… a logic of right-now. That is, it is all geared so that whatever will keep people who are rich right now rich tomorrow, that’s what they want.
And as the writers of this blog have pointed out, it’s not like this is a Republican or a Democratic stance. They both agree that they love rich people. How much they hate poor people and middle class people is all they have to debate about.
Pardon my cynicism. I was just reading about Rockefeller and the birth of the Trusts.
Eat The Babies
May 25, 2011 at 10:04 pm
singlepayer state by state
anonymous
May 25, 2011 at 10:58 pm
I find the entire debate completely fascinating. Last month I began to receive Medicare coverage. My premium is $127 a month, deducted from my Social Security. I understand, at my age, the importance of reliable, affordable medical coverage, just as I did before I became eligible, since prior to last month I hadn’t had any health insurance in nearly 15 years. Thankfully, I am incredibly healthy.
Of course, there’s only one realistic solution, since the cost of maintaining the current plan for all those who are eligible, is truly unsustainable. The realistic solution is Medicare-for-all. Simple. No insurance, unless you can afford a supplemental policy. Thus, the government gets complete control over all costs and all payments. It tells the drug companies what they can charge, tells doctors what they can charge, and simply pays for everyone. This is the most popular of all of the things mentioned during the health reform debates. It is rational, and the government can deal with the actual costs on the current basis, charging everyone premiums like an insurer, but without bias (except that the payroll tax contribution will be paid on the basis of earnings). Sad that his hasn’t gotten any traction!! That fact is probably entirely due to the power of the health oligarchy. I can’t think of any other rational explanation.
Bayard Waterbury
May 26, 2011 at 1:00 am
Bayward, that plan would work as long as the Gvt actually knew what they were doing, they don’t, hence the UNsystainable health care costs. Its the same with car insurance, I pay dearly, but I am such a good driver that I never make a claim. Costs are derived by the chance of fatality or an expensive fix, and then rise from there. Where as they should be derived from good or bad behavior and visits to the er or operating table over a longer period of time. Beginning with education in grade school and tooth brush, rather than a play ground and soda.
Owen Owens
May 26, 2011 at 5:56 am
James Kwak said, “the one that changes Medicare from a health insurance plan to an underfunded subsidy”
More correct would be, “the one that changes Medicare from an underfunded health insurance plan to an underfunded subsidy”
Speed
May 26, 2011 at 7:31 am
Strategically, I think the GOPs plan is to continue to undermine effective cost controls on Medicare until it gets so fat that there is no choice but to radically change it or kill it. Looking at the last few years, that’s pretty apparent. There is no other logical explanation for “death panels” than that IMHO.
The Ryan plan has HUGE total cost increases built in. I don’t think Ryan is stupid. I think he knows exactly what he is doing with his plan. I don’t think that ANY politician of any party would be totally honest or even know about the full breadth of the consequences of their actions. That said, neither Obama or Ryan want to have an honest, public, conversation about the real issues and the real solutions to mass health care. There are too many constituents who don’t like either side. But on balance, Ryan is the less honest one on this front given that Medicare (and for that matter Medicaid) is a popular public program and very few but the anarcho-libertarians want to see it destroyed.
Ian
May 26, 2011 at 11:03 am
Can you imagine if the Dems somehow started thinking rationally(and eased away from their corporate contributors) and combined the obvious strategy of defending Medicare that Delong states:
“by denouncing the other party’s plans to control Medicare spending in the long run — whether those plans are smart like the Affordable Care Act or profoundly stupid like the replacement of Medicare by RyanCare for the aged — sitting back, and waiting for the voters to reward you.”
with raise the top rates back to 39.6%; treat passive income as noon-passive income; reimplement the Estate Tax; stop susidizing big oil and big agriculture; and reduce US military spending?
Strange how giving people what they tell you they want(real or imagined) wins elections.
EMichael
May 26, 2011 at 12:07 pm
James,
I still think the Ryan plan was an attempt to set the goalposts far to the right so that minor changes could be made now and over time, make more and more changes so that eventually Medicare is not what it used to be. Also, the fact that the proposal got as far as the Senate tells me they are moving things, like you say, attempt after attempt.
ep3
May 26, 2011 at 12:08 pm
I agree with the posts by CBS from the West and Bayard Waterbury. In their article It’s the Prices, Stupid, by Uwe Reinhardt and others (Health Affairs, Vol. 22, No. 3, 89-105 (2003)) the authors show that citizens of other developed countries get more medical care than we do but pay less on a per capita prices because our prices are so much higher. Our doctors charge more than in other developed countries, our hospital costs are greater, our medical tests cost more, and our drugs are more expensive. Other countries negotiate lower medical costs because the agencies that pay for health care – the government in some countries, tightly regulated nonprofits in others – have more negotiating power than our insurance companies and a greater willingness to use their power in holding down costs. While I supported the Affordable Care Act, I felt and feel that it has to be modified to give the government more power over medical costs or it has to be replaced by a single payer system or full fledged socialized medicine, as in our VA. A step like this won’t happen soon, but it has to happen sometime.
Stan
May 26, 2011 at 12:22 pm
Voila!
Ref: “Government Takeover? : Not According to Health Care Industry”
http://www.dpc.senate.org/fs-111-2-125.html
Vis-a-Vis…DJI (30) {Rx Behemoths with open-ended bidding Contracts brought to you by a Democrat whom now works as a highly paid lobbyist for the Rx Industry)
PS. This individual was chosen for the Obama team but couldn’t pass the muster…seeing he had problems with the IRS via “Turbo-Tax”?
Guess Who?
Pfizer Inc.
Merck & Co., Inc.
earle,florida
May 26, 2011 at 12:52 pm
Senator Tom Daschle
oops….http://www.dpc.senate.org/doc/fs-111-2-125.html
earle,florida
May 26, 2011 at 1:01 pm
@Bayard Waterbury
“The realistic solution is Medicare-for-all. Simple. No insurance, unless you can afford a supplemental policy. Thus, the government gets complete control over all costs and all payments…”
I wish it were that simple. Think about “defense.” The government is a monopsony purchaser of defense goods and services. But they don’t tell the defense contractors what to charge. Due to political influence, the defense contractors tell the government what to pay! It will be the same with health care if we just implement Medicare for all or some other type of single payer program: the health care industry will impose its desired costs on the government and they will rise just as uncontrollably as they do now.
The key is that the health care system itself has to be dismantled and rebuilt. The perverse incentives to overtest and overtreat need to be eliminated (read, among other things, eliminate fee-for-service). There need to be _independent_ commissions that carry out unbiased evaluations of the effectiveness and cost of different treatments and allocate fixed resources to maximize health rather than profits. The health care industry has to be barred from interfering with the process. And standards of accountability for real quality of care need to be developed, validated, and then enforced. (These would be rather different from current quality standards which almost always give points for doing things but rarely give credit for abstaining from doing things that shouldn’t be done.) If we restructure the health care system along these lines, it may make little difference whether the government has a monopsony or whether there is also private sector involvement.
But just turning the existing system over to the government to run will not improve things.
CBS from the West
May 26, 2011 at 2:25 pm
@Bayard: The Medicare-for-all you propose is of course the solution, and anyone who has seriously studied the problem of delivering decent health care to Americans at something approaching a reasonable level of cost has known this for DECADES.
However, the medical profession, the drug industry, the insurance industry, the non-profit and for-profit hospital industry, etc.–the entire ball of wax I call the medical-industrial complex–has no interest in providing such care. They are interested in making gobs of money, and have purchased the government (with the latter’s full cooperation) to ensure their continued ability to do so.
Just saw a great quote from JK Galbraith:
“Every successful revolution begins with the kicking in of a rotten door.”
It seems we are waiting for that door to disintegrate on its own.
Carla
May 26, 2011 at 4:19 pm
We can save Medicare; so long as we do the opposite of the Republicons: rather than privatize it, fully socialize it: the Veterans Administration’s fully socialized healthcare system is also the highest rated and far lowest-cost (2/3 the cost of private healthcare) healthcare system in the US.
bmz
May 26, 2011 at 5:02 pm
Single payer works not (simply) by allowing the government (if it chooses, etc) to negotiate prices down. It works by eliminating the perverse incentives of the insurance industry to operate by shifting costs and risks to everyone else, and negotiating prices only on their own behalf (which providers then attempt to cost shift to others). The whole layer(s) of administration (including high paid CEOS and agents) on all sides could be eliminated. The health insurance “industry” is merely a socially functionless (or worse) pool of profits. Or you could say it serves the “death panel” function.
However, I am also concerned about the US government not being able to negotiate costs as well as other countries. That seems quite possible, but why is it? Is the US the most corrupt (as well as a morally bankrupt empire) country on earth? Sometimes it seems that way. But where is the research?
Charles Peterson
May 27, 2011 at 12:53 am
An Independent Payment Authorization Board is not a cost control measure. Like the Ryan plan, it is a payment control measure.
The Ryan plan controls the amount Medicare will pay out by setting a dollar amount Medicare will pay for premiums and co-pays, and limiting the growth rate of those payments. Ultimately, Medicare pays an ever decreasing share of the recipients’ costs. Medicare’s payments are controlled, with the excess cost being shifted to the patient.
On the other hand, the IPAB plan controls payments by limiting the types of services Medicare will pay for or the conditions under which it will pay for those services. To some extent, doctors will make their diagnoses in such a way as to circumvent those restrictions. To the extent that those restrictions succeed, the cost of those procedures will simply be shifted to the patient.
Neither plan does anything to control costs. To do that, we need to change how healthcare is paid for. Currently, insurance companies negotiate with the largest hospitals and doctors’ groups, then all healthcare providers (HCPs) are paid the same rate. This eliminates any price competition among HCPs. Imagine if the largest oil (or computer or breakfast cereal) companies were permitted to band together to negotiate as high a price as possible for the entire industry.
We need HCPs competing on cost! One way to do that would be to require:
(1) HCPs must charge all patients the same price for the same service regardless of insurance status (BCBS, Aetna, Medicare, none);
(2) HCPs must post prices on-line and in their waiting rooms;
(3) insurance companies must post what they pay for each service.
I could then decide if Dr. X is worth the extra $30 I would have to pay for a checkup compared to Dr. Y. This would give HCPs incentive to keep costs down, which is absent in our current system.
bigD
May 27, 2011 at 12:07 pm
@ Charles Peterson
“The whole layer(s) of administration (including high paid CEOS and agents) on all sides could be eliminated. The health insurance “industry” is merely a socially functionless (or worse) pool of profits. Or you could say it serves the “death panel” function.”
True, but it is actually not that large a portion of health care costs, and even if eliminated, it would produce a one-time savings but would not fundamentally alter the exponential climb in costs.
“However, I am also concerned about the US government not being able to negotiate costs as well as other countries. That seems quite possible, but why is it? Is the US the most corrupt (as well as a morally bankrupt empire) country on earth? Sometimes it seems that way. But where is the research?”
Well, I don’t know any formal research in this area–I would love to see some myself. Look at defense spending–it’s as big a mess as health care despite a government monopsony. Look at Medicare Part D (Prescription Drugs): the law specifically prohibits the government from negotiating prices! What reason is there to think things would be different if the feds ran the entire health care system?
I’m not opposed to a government run health care system, by the way. I’m just saying that it is the health care system itself that needs to be radically rebuilt: simply putting government in charge will not accomplish that. And if we appropriately bring the system under control, I’m not sure it makes very much difference whether it is exclusively publicly run or some private involvement remains.
@bigD
“…the IPAB plan controls payments by limiting the types of services Medicare will pay for or the conditions under which it will pay for those services. … To the extent that those restrictions succeed, the cost of those procedures will simply be shifted to the patient.”
If the restrictions are properly crafted, they will not shift the cost to the patient–they will eliminate most of these services altogether. The cost spiral in health care is partly due to rising prices, but a big piece of it is the explosion in the volume of services provided. Everyone who has studied this agrees that presently at least 30% of all health care services are useless or worse–my personal opinion is that it’s closer to 50%. If properly empowered, a health care commission would ban certain tests and treatments, or restrict their use to situations where there is evidence to support their use.
There would be some grey areas, of course, where the balance of harms and benefits is close to even and perhaps dependent on personal value judgments. In that case, the commission would allow the procedure but disallow insurance coverage for it. That would shift the cost to those patients who choose to avail themselves of a service that is of borderline value and clearly not necessary. Frankly, I don’t find that a problem, especially since in this context the absence of coverage would be a strong signal to patients that the procedure in question is of minimal value. I believe most patients would avoid those procedures and incur no cost.
But, of course, all this would be contingent on a commission that is appropriately independent, knowledgeable, and empowered.
CBS from the West
May 27, 2011 at 1:18 pm
@CBS: “If the restrictions are properly crafted, they will not shift the cost to the patient–they will eliminate most of these services altogether.” Nonsense! The Independent Payment Authorization Board (IPAB) will not have the authority to outlaw medical services. It may be able to refuse to pay for certain services based on a particular diagnosis, but that is far removed from “eliminating” a service. Even then, a physician can alter a diagnosis so that a particular procedure meets IPAB muster.
“Everyone who has studied this agrees that presently at least 30% of all health care services are useless or worse…” If you have any studies to document this (not just speculation in a news article), I would definitely like to see it. A 2008 CBO report did NOT find consensus (certainly not “everyone”) and said that such unwarranted procedures have only made a small contribution to the increases we medical costs over recent decades.
“Many economists believe that induced demand affects health care spending, but there is no consensus on the magnitude of the effect. Even if induced demand accounted for a substantial part of the level of health care spending at any point in time, analyses of long-term spending growth have not found it to be a large factor.” http://www.cbo.gov/ftpdocs/89xx/doc8947/01-31-TechHealth.pdf
Finally, insurance companies already expend a great deal of time and resources doing exactly what the IPAB is slated to do in an effort to keep their expenses down. I am skeptical that a new government bureaucracy will be significantly more successful.
bigD
May 27, 2011 at 3:51 pm
@bigD: Looking at all healthcare systems, foreign and domestic, it is clear that the only way to truly reduce costs while not reducing healthcare benefits or quality, is to fully socialized Medicare/Medicaid like our Veterans Administration. Usually we could rely on the Republicons to demagogue that proposal; but they are the ones who are screaming that we MUST reduce Medicare costs, and they already maintain that the ACA, much less Medicare, is socialism; so they are pretty well hoisted on their own petards.
bmz
May 27, 2011 at 5:30 pm
@bigD
I didn’t say that the IPAB, as constituted in the ACA would be able to do this. In fact, my complaint is precisely that the ACA prevents them from doing that (and a lot of other things they should be able to do).
Your final paragraph is actually a good characterization of what the IPAB is slated to do: do for Medicare what the insurance companies do for themselves. And that is precisely what is wrong with the IPAB: it is limited to things that the insurance companies have already proven don’t work! (And even then the IPAB is subject to Congressional veto.)
As for physicians’ being able to game the system by altering diagnoses to meet payment requirements, that is sometimes the case and sometimes not. When it is the case, monitoring of billing practices and other techniques may be needed to identify patterns of abuse. No system, of course, will eliminate all unnecessary services. But we have a long way to go and I don’t see how anything other than a powerful panel of independent, knowledgeable, unbiased experts can do the job properly. And frankly, I don’t think we will succeed unless we also abolish fee-for-service.
The overuse I’m referring to is the persistent use of procedures for which the evidence is clear that nothing good is accomplished. Much of back surgery done for chronic back pain is a good example. So are a great deal of knee surgery, and a substantial fraction of cataract surgery. There is also the application of heroic measures to patients for whom it is clearly futile. The list goes on and on.
For a population-based review of the evidence about the extent of overuse of medical care and its economic implications, I recommend Wennberg, Fisher, and Skinner, “Geography and the Debate Over Medicare Reform.” Health Aff (Millwood). 2002 Jul-Dec;Suppl Web Exclusives:W96-114. They (and the articles the reference) extensively document the vast geographic variations in health care costs, and how increased costs are NOT associated with better outcomes. From this one can infer that much of the expenditure in high-cost practices is simply wasted effort that produces nothing of value.
It will not be easy to eradicate useless health services, and we will never get it all. But at present we’re not even really trying.
CBS from the West
May 27, 2011 at 5:56 pm
There is a longer-term strategy (I suspect) to the Ryan “plan” — this is the real plan part of the plan. The strategy is one of war-of-attrition. We’ve seen over thirty years of it in Reagan tax cut policy, Reagan-Bush-Clinton-Bush-Obama privatization, and elsewhere in Israel’s settlements.
How’s it work? Begin with something that raises alarms. A great example is the Israeli settlement program which, decades ago, provoked considerable alarm even among some conservatives. Count on a poorly educated, docile, and malleable media to take the “he said/she said” approach. In the case of settlements, it was only “he said.” Palestinian concerns typically got _no_ airing at all in the US. In the case of tax cuts or privatization, you get your foot in the door.
The strategy is also evident in Big Tobacco campaigns for smoking and right-wing campaigns on climate change or evolutionary theory. You don’t need to win in the short-run. Get timid, obedient media hacks like those at NPR or CNN or the Washington Post or the Times to just relay the message. Plant the seed, fertilize and water.
The short-run successes come in the form of blocking policy (blocking higher taxes for the rich, blocking better educational policy, blocking Palestinians aspirations — whatever). In the long run, people become habituated to a certain way of thinking (raising taxes is anathema, settlements are facts too long in place to be removed, etc.)
The likelihood that we will see privatization of Medicare and Social Security should have been laid to rest with the revelations of Wall Street crimes. But a crucial part of the strategy — indeed, what makes it a strategy — is that it forms part of a greater whole. The whole here is the Divine Right of Wealth. Oligarchy. Neo-feudalism. It goes by a number of names. It amounts to creating an environment in which the vast majority remain passive while their rights and wealth (what little there is off it) are transferred into the hands of an extraordinarily privileged few.
I am — I assume obviously — on the left side of the spectrum, and though I state things tendentiously, the general point is one gaining currency in a very respectable liberal to moderate mainstream. Among economists and related thinkers (and I certainly think I’ve heard Simon Johnson say things to this effect) are: Paul Krugman, Joseph Stiglitz, Thomas Piketty, Esther Duflo, James K. Galbraith, Galbraith’s late father John Kenneth (who was singularly eloquent on these issues), Larry Bartels…. There are more.
My main point of disagreement with James Kwak regards the role of Obama and like-minded Democrats in this. The Clinton administration emphatically did want to privatize Social Security. I see no reason to doubt that Obama is of a similar mind. He takes tactical positions for short-term political gain, but he essentially a descendant of Reagan.
hughsansom
May 27, 2011 at 10:57 pm
It was the inefficiency of the democratic system itself, that bankrupted the country.
Owen Owens
May 28, 2011 at 7:01 am
Let’s put *health care* in context of these two following quotes:
“Of all tyrannies, a tyranny exercised for the good of its victims may be the most oppressive¬. It may be better to live under robber barons than under omnipotent moral busybodies¬. The robber baron’s cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end, for they do so with the approval of their own conscience¬. C. S. Lewis
Good intentions will always be pleaded for any assumption of power. The Constituti¬on was made to guard the people against the dangers of good intentions¬. There are men in all ages who mean to govern well, but they mean to govern. They promise to be good masters, but they mean to be masters.
-Daniel Webster”
When you do put the health care *costs* in the context of these two wise observations from mightier-than-the-sword authors
the *plan* is obvious.
Pin them to producing the data – ie. so many unnecessary procedures must mean that people are healthier than the health insurance companies know?
And the bottom line remains the same – get out the real stats – a minority of patients (not the elderly, either, my friends) suck up the majority of health care costs. The minority just wants to make sure that the majority who have been paying for 1.8 BILLION CEO packages keep paying them 10K a year (insurance and deductible) and still get billed to get a cast for a broken toe or an tetanus shot (oh those pesky MANUAL LABOR costs!!!).
Ryan’s *Plan* has no basis in an analysis of FACTS and DATA.
A senior member of the family ended up in the emergency room last Sunday morning….ER staff looked hollow with exhaustion – so I asked what the story was and they mentioned how the ER was flooded with cases on May 21 with freaked out people who believed the world was going to end and the anxiety and stress was triggering all sorts of circulatory events.
I suggested they send the bill to the Family Network TV station. At this point, after all the decades of “No” to non-profit health insurance – I think we can do the same – send our health care bills brought on by MANUFACTURED rapid poverty, homelessness, unemployment, hunger, increased crime, degraded public services meant to maintain sanitation and clean water
send the health care bill to the self-proclaimed D.C. *leadership*.
Constitutional Convention to get an Energy Plan in place and BURN THE PATRIOT ACT.
Annie
May 28, 2011 at 11:39 am
Men and women of good will have *earned* the right to establish, maintain and participate in a classical democracy.
There is not one single area of the daily needs to *chop wood and carry water* that is not under attack
by liars, thieves and murderers.
Recent stat is that the *wrecking crew* of global nihilists costs 7 TRILLION to operate…
7 TRILLION in *power* to back up the “NO!” to the producers of a band aide having the *right* to buy a band aide without first needing to pay a master 20 x cost of band aide to get *access* to what they produced at work – ironically, the band aide…
Reading “Reckless Endangerment”…
Looks like the 2012 Presidential Election is turning out to be the elegant politics of how things work when a GANG has established rulership over the ‘hood – no none wants to go up against the GANG…
BURN THE PATRIOT ACT on Memorial Day, for God’s sake!
Is that what everyone who defended another DIED for over centuries – to evolve technology that allows PREDATORS to burn down YOUR house via quantum *money* games…?
Annie
May 29, 2011 at 10:05 am
Brad DeLong touts the Affordable Care Act as the smart way to control health care costs. Smart, my ass. What we got with the Patient Protection and Affordable Care Act was a Republican an Heritage Foundation proposal pushed into law by a Democratic President. We got madated underinsurance. A big profit boost to the private health insurance companies. And, a nation still without cradle to birth, guaranteed coverage. Shame on you James for letting this on your blog.
Paul P
May 31, 2011 at 5:45 pm