Cutting Costs Is Hard...No Wonder Folks Do Not Like It

From Ezra Klein at WaPo:
"Harvard economist (and former Obama campaign adviser) David Cutler runs through the 10 most promising cost control ideas of the past few decades and notes that six of them are fully included in the bill, three of them are at least partially present, and only one of them -- the public option -- is totally absent. "No one knows precisely how much medical spending increases will moderate," Cutler concludes. "But one cannot doubt the commitment to try. What is on the table is the most significant action on medical spending ever proposed in the United States."

One addendum to Cutler's op-ed: Cutting health-care costs is hard. And it needs to be distinguished from simply capping spending. When liberals say that single-payer will save a bazillion dollars, or conservatives point to Paul Ryan's plan and say that will save a bazillion dollars, they're talking about capping spending. Liberals do it on the provider side, saying that government will only pay so much for medical services people need, and the system will just have to adjust. Conservatives do it on the consumer side, saying that government will only give individuals so much for the coverage they need, and if that proves insufficient, then tough. But voters haven't evinced much appetite for either proposal.

So smart people have spent the past few decades trying to figure out softer ways to cut costs without cutting things that people need. One popular idea is to change payment systems so that they don't reward doctors for volume. That's in the bill. Another is to build more competitive insurance markets so that insurers have a more direct incentive to keep costs down in comparison to one another. That's in the bill. Another is to try to bring individuals closer to the true cost of the insurance coverage, which is currently hidden by employers. That's in the bill. And so on.

The problem, of course, is that no one knows how well this stuff will work. So the legislation is careful in implementation. It takes time to build up enough evidence so that doctors can confidently say what is unnecessary, and for whom. It takes time to figure out how to create new payment systems such that doctors don't find their practices in sudden chaos. It takes time to phase in taxes such that they nudge people rather than shove them, and it takes time to develop a new IT infrastructure and get doctors to use it effectively, and so on. We think a lot of this will work, but maybe it won't. So the bill is careful to move slowly. It tries a lot of different things on a fairly small scale in the hopes that some of them will pan out (hence the legislation's length).

That, of course, makes it harder to explain and less impressive when CBO looks at the savings it can predict with high levels of confidence. But until we decide to be radical with cost control, this is what moving forward looks like. As Cutler says, this is the most ambitious cost control bill Congress has ever passed. And that's a commentary both on the ambition of this bill and on the system's resistance to legislation that's yet more ambitious."
http://voices.washingtonpost.com/ezra-klein/2010/03/modest_far-reaching_cost_contr.html

Actually Governance v. Pontification And Obstructionism

TW: Spot on stuff from Klein (and Collins). So much opposition employs the method outlined below. Actual governance requires not tidy sound bites and fantasy policy but actionable policy. Yet opposition to actionable policy is easy by comparing it to fantasies (i.e "less guvmint, lower taxes...and psst oh btw lets not cut any services of any significance in fact...psst lets increase this or that of MY favored spending).

Responsible opposition makes some effort to recognize the realities of governance. Hence for example, filibustering might have a role but NOT as a tool to be employed on every freaking nomination or piece of legislation.

From Ezra Klein at WaPo:
"You don't usually get this much real talk in the conversations between Gail Collins and David Brooks. Here's Collins describing her colleague's M.O.

'You’re a man of good will with a fatal attraction to tidy programs. I admit it’s a very powerful approach. All during that health care debate, whenever things got impossible you could always say: “What I think they should do is pass the Wyden-Bennett Reform Plan,” and everybody would shut up and slink home to look it up on Google.

It’s a more elegant version of the Bipartisan Study Commission. Which, by the way, the Republicans recently filibustered.'

We're all vulnerable to this tendency. Skeptics of messy cap-and-trade legislation get to advocate elegant carbon taxes that wouldn't survive two seconds in the legislative process. Critics of the messy health-care reform bill get to call for Wyden-Bennett or single-payer despite the absence of any evidence that either policy is remotely achievable. Folks frustrated by the budget get to look at Paul Ryan's fantastical alternative and declare it the path forward.

It would be very annoying to go to a restaurant if people insisted on ordering the dish they wanted most in the world, rather than most on the menu. The problem, of course, is that American politics doesn't offer menus, and the politicians aren't very honest about what's achievable ("I'm sorry, monsieur, but the chef does not do nationalization"). Plus, however slim the likelihood of perfect policies is, they have absolutely no chance if no one advocates for them. But for all that, there's a difference between trying to push policy in a more perfect direction and letting perfection become your excuse for never passing any policy."

The Shelby Note To the White House

TW: You may have heard Richard Shelby, Republican Senator from Alabama, has held up ALL Obama appointees pending clearance of some of his earmarks. Click on the link below for the actual note he sent to the White House (via Ezra Klein, give it a few seconds to load).

http://contactsheet.org/cgi-bin/ransom.pl?thedata=Hey+Obama%2C%0D%0A%0D%0AMeet+me+in+the+park+outside+the+Senate+with+40+billion+dollars+worth+of+pork+%0D%0A%0D%0AOr+you%27ll+never+see+any+of+your+appointees+ever+again%0D%0A%0D%0AAnd+NO+COPS!!!!!!&Button=Generate+Ransom+Note

Clusterfuggery In Place Of Governance

From Ezra Klein:
"Bruce Bartlett thinks that Timothy Geithner is becoming a liability to Obama, but there's not much Obama can do about it.

'Geithner's political tone-deafness is becoming a serious liability to Obama. The problem with replacing him, as I have said earlier, is finding someone who is qualified, confirmable and not connected to Wall Street. Given that half the top political appointees at Treasury are still awaiting Senate confirmation, I think Obama may be stuck with Geithner no matter how low his stock falls. Is there a potential replacement who has paid his taxes, has populist leanings, knows Wall Street but isn't part of it, who wouldn't be filibustered by the Republicans?'

I made this point the other day, as well. A Senate that can't be trusted to confirm non-controversial nominees can't be trusted to confirm controversial nominees. In that way, holds and filibusters, which are supposed to make the executive branch's nominees more accountable, in fact makes confirmed nominees much less accountable, as the president can't trust his ability to easily replace them and so can't take the risk of firing them. I thought of ending this post with a line about how Republicans who want Geithner gone are actually making it impossible for him to go, but then I realized that Republicans probably don't want Geithner gone. They're served best by making him both unpopular and irreplaceable."
http://voices.washingtonpost.com/ezra-klein/2010/01/if_you_cant_hire_you_cant_fire.html

Many Of Us Are Entering the Sweet Spot

From Ezra Klein at WaPo:
"For the past 10 years, I have been studying happiness around the world, in countries as different as Afghanistan, Chile and the United States. It has been an amazing foray into the complexity of the human psyche and the simplicity of what makes us happy. What is most remarkable is how similar the forces driving happiness are in various countries, regardless of a nation's level of development.
Wherever I look, some simple patterns hold: A stable marriage, good health and enough (but not too much) income are good for happiness. Unemployment, divorce and economic instability are terrible for it. On average, happier people are also healthier, with the causal arrows probably pointing in both directions. Finally, age and happiness have a consistent U-shaped relationship, with the turning point in the mid- to late-40s, when happiness begins to increase, as long as health and domestic partnerships stay sound."
http://voices.washingtonpost.com/ezra-klein/2010/01/how_to_be_happy.html

Rationing!!!

TW: If we can put a cap on some of the demagougery, we will be able to bend the cost curve. Bending the curve should be a bi-partisan effort.

From Ezra Klein at WaPo:
"The dominant perception in American medicine is that more is better: More insurance is better insurance, and more health care is better health care. If that were unambiguously true, cost control would be a really hard choice: Every dollar you weren't spending would be a dollar of health benefit somebody wasn't getting. But that's not what the evidence shows. Consider, as David Leonhardt does, the case of Richmond, Va.

'Richmond has actually lost some of its hospital capacity over the last decade. In 1996, the area had 4.8 hospital beds for every 1,000 residents. Today, it has about three. The cause of this is, in large part, state regulations meant to cut down on supply. "Hospital care has been, in a word, rationed," Leonhardt says. The result?

The quality of care in Richmond is better than in most American metropolitan areas, according to various measures, and it continues to improve. Medicare data, for example, shows that Richmond hospitals do a better-than-average job of treating heart attacks, heart failure and pneumonia.

When I recently asked patients in Richmond whether they felt as if their care had been rationed, they found the question bizarre. “I feel like there’s nothing cheap about the care,” Janet Binns, a retired school district employee, said. After her elderly father fell down one morning, she e-mailed a doctor and was on the phone with him in minutes.

Yet when it comes to health care costs, Richmond’s rationing has made a clear difference. In 1992, it spent somewhat less than average, per capita, on Medicare — 126th lowest out of 305 metropolitan areas nationwide. Since then, though, costs have risen at a significantly slower pace than they have elsewhere. As a result, Richmond had the 39th lowest costs in 2006.'

The regulations that squeezed the Richmond medical industry are much stronger than anything being contemplated on the national level. The state has a strong "certificate-of-need" program in which doctors and hospitals who want to move or expand need to demonstrate that there's a good reason to do so. That cuts down on expensive entrepreneurial medicine, in which doctors build out, say, a specialty cardiology unit and then, magically, it turns out that the area needed a lot more heart surgeries than it had previously been getting. And that, in turn, lowers costs. But it's hard to imagine any similar command-and-control solution being adopted on the national level."http://voices.washingtonpost.com/ezra-klein/2009/12/in_health_care_more_is_not_alw.html

The Health Care Reform Will Address Cost Containment

TW: Atul Gawande reports on health care for New Yorker and has put together excellent stuff which we have highlighted before. He is out with a new piece focused on the cost containment measures in the proposed health care reform pending in Congress. The fundamental point is the bill attempts a plethora of approaches integrating cutting edge thinking on the topic. As I have said repeatedly, one person's health care cost is another's revenue. One person's frivolous test is another's reassuring procedure. Containing costs is complex at least the bill attempts to address the issue unlike those who merely sit back demagogue merrily along towards their next election.

From Atul Gawande at New Yorker as summarized by Ezra Klein:
"Pick up the Senate health-care bill -- yes, all 2,074 pages -- and leaf through it. Almost half of it is devoted to programs that would test various ways to curb costs and increase quality. The bill is a hodgepodge. And it should be.

The bill tests, for instance, a number of ways that federal insurers could pay for care. Medicare and Medicaid currently pay clinicians the same amount regardless of results. But there is a pilot program to increase payments for doctors who deliver high-quality care at lower cost, while reducing payments for those who deliver low-quality care at higher cost. There’s a program that would pay bonuses to hospitals that improve patient results after heart failure, pneumonia, and surgery. There’s a program that would impose financial penalties on institutions with high rates of infections transmitted by health-care workers. Still another would test a system of penalties and rewards scaled to the quality of home health and rehabilitation care.

Other experiments try moving medicine away from fee-for-service payment altogether. A bundled-payment provision would pay medical teams just one thirty-day fee for all the outpatient and inpatient services related to, say, an operation. This would give clinicians an incentive to work together to smooth care and reduce complications. One pilot would go even further, encouraging clinicians to band together into “Accountable Care Organizations” that take responsibility for all their patients’ needs, including prevention -- so that fewer patients need operations in the first place. These groups would be permitted to keep part of the savings they generate, as long as they meet quality and service thresholds.

...Which of these programs will work? We can’t know. That’s why the Congressional Budget Office doesn’t credit any of them with substantial savings. The package relies on taxes and short-term payment cuts to providers in order to pay for subsidies. But, in the end, it contains a test of almost every approach that leading health-care experts have suggested. (The only one missing is malpractice reform. This is where the Republicans could be helpful.) None of this is as satisfying as a master plan. But there can’t be a master plan."
http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?currentPage=all#ixzz0ZlZtZebl

Universal Care Saves Lives...

TW: On a day when a douche bag like Joe Lieberman is getting the publicity he so slavishily craves by screwing over his former party, it is good to re-visit yet again why health care reform is important. What does it mean in terms of lives saved if uninsureds are integrated into our deeply flawed system?

From Ezra Klein at WaPo:
"...The Institute of Medicine developed a detailed methodology for projecting the lives lost due to lack of insurance...We're very comfortable talking about the financial cost of health-care reform. We're less comfortable talking about the human benefits. But the fact that health insurance saves lives isn't controversial. A 2003 study examining cancer records from Kentucky found that uninsured women with breast cancer were 44 percent likelier to die than their insured counterparts. And that was after controlling for demographics, stage of diagnosis and initial treatment. A 2007 study found that the uninsured were 24 percent to 56 percent likelier to die of stroke, depending on the type. That study, too, controlled for all the relevant variables...

All this is intuitive. The uninsured are less likely to seek early care. They are less likely to get good care. They are less likely to return for follow-up care. They are less likely to be able to afford the maintenance of chronic conditions. At its most basic level, that's what this is all about. That's why people have been fighting for universal health care for almost a century now. That's why this matters, and why the basics of the bill -- subsidized access to health-care insurance -- are so terribly important. This is life and, well, death. Lots of it, in fact.

...Medicare saved lives. Medicaid saved lives. The health-care coverage that costs the average worker more than $13,000 saves lives. That's why we shoulder these expenses. And health-care reform will save lives, too. That's why we're doing it..."
http://voices.washingtonpost.com/ezra-klein/2009/12/the_150000_life_health-care_pl.html

The Devolution Of American Politics

TW: The tendency is always claim things were easier way back when. But what if a sea change in American politics has occurred? What if our governance processes rather than being tried and true through over 200 years of history are becoming time bound and sclerotic? What if obstructionism is a rational political approach but an irrational governance method.?

From Democratic House #2 leader Steny Hoyer (Maryland) via Ezra Klein:
"...it's not clear that minority obstructionism is bad politics. Back in the early 1990s, of course, Bill Kristol, among others, urged Republicans to kill the Clinton health-care bill. Not modify it, or improve it, or amend it, but kill it. And then they picked up more than 50 seats.

Newt Gingrich was of course the chief proponent of that policy, and he and Bob Michel, who was leader of the Republicans, disagreed. And Gingrich eventually succeeded in pushing Michel out. Michel’s view was you sit down, offer your input, and move forward. The theory was that the American people elected the legislative body to make policy and so you make policy. Gingrich’s proposition, and maybe accurately, was that as long as you, Bob Michel, and our party cooperate with Democrats and get 20 or 30 percent of what we want and they get to say they solved the problem and had a bipartisan bill, there's no incentive for the American people to change leadership. You have to confront, delay, and undermine and impose failure in order to move the public. To some degree, he was proven right in 1994."
http://voices.washingtonpost.com/ezra-klein/2009/12/hoyer_draft.html

Comparing Theory To Reality

Ezra Klein relating some testimony from a Brookings expert:
"From Brookings Institution expert Ted Gayer-
'I acknowledge that my arguments in favor of a carbon tax over cap-and-trade are made easier in that I am comparing my ideal hypothetical carbon tax to the actual cap-and- trade programs either passed by the House or proposed in the Senate. Indeed, a cap-and-trade program that included a safety valve and that auctioned allowances would achieve many of the economic advantages of a carbon tax.

The most frequent criticism of a carbon tax is that it would be politically unpopular. But to quote Milton Friedman, I think my role is to “prescribe what should be done in light of what can be done, politics aside, and not to predict what is ‘politically feasible’ and then to recommend it.” You, of course, have the more difficult task of determining what is politically feasible. But given the magnitudes of the costs and benefits associated with any climate policy, I recommend to you a careful consideration of the merits of a carbon tax.'

That's Brookings' Ted Gayer testifying before Congress on the merits of a carbon tax. Gayer is having this argument with the right people: Legislators who might not support a carbon tax, but should. Right now, a compromised cap-and-trade plan is more politically feasible, but that would of course change if congressmen stopped being terrible about this and threw in behind the policy that makes the most sense"
http://voices.washingtonpost.com/ezra-klein/2009/12/the_right_argument_for_a_carbo.html
TW: Both Gayer and Klein are progressives, as am I as u might have noticed. We all support a carbon tax over cap and trade. It is not that cap and trade is bad, it is that a carbon tax is more elegant and most importantly easier to understand. And to be clear, the single biggest complaint about the current cap and trade legislation is that it gives away the initial credits rather than sells them. Why is this? Bi-partisan opposition in coal states to any legislation that actually penalizes high carbon emissions. This dynamic would result in tax credits being provided to those same producers in a carbon tax regime.

But cap and trade is on the board, a carbon tax despite the occasional conservative think tank support remains theory only. As mentioned yesterday, if there was an opposition party interested in actual governing rather than single-minded opposition we might get a carbon tax.

Political Footballs v. Actual Legislation

TW: The sentiment expressed below jives with my own. I do not regard cap and trade as an ideal approach to climate change or more specifically energy and tax policy. A carbon tax would better. Many conservative pundits and economists agree with me. BUT where are the Republicans proposing a carbon tax. Answer there are none. Therefore one finds the conservatives screeching about cap and trade but again providing no actual alternative. If Republicans were front and center with a carbon tax, you would find me fully supporting them, but they are not because part of their party denies climate change and most of their party is paralyzed when it comes to anything remotely associated with increased taxation.

I circumvent the climate change denialists by arguing measures to manage carbon are needed independently of climate change. The imperatives to refine American energy and tax policy alone demand action regardless of one's views on climate change (which to be clear I am on the side of the vast majority of scientists who argue it is real). Pursuing a "green" economy with its related reduction of reliance on petro-states (both foreign and domestic) and re-vamping our taxes towards consumption instead of income are sufficiently worthy goals.

Things like health care reform and cap and trade wither when faced with the political realities of transformation into real legislation. Theoretical possibilities like a carbon tax are nice to talk up but ultimately ephemeral unless also exposed to those same political realities.

From Ezra Klein at WaPo:
"Quoting Paul Krugman-
'For here’s the way it is: we have a real chance of getting a serious cap and trade program in place within a year or two. We have no chance of getting a carbon tax for the foreseeable future. It’s just destructive to denounce the program we can actually get — a program that won’t be perfect, won’t be enough, but can be made increasingly effective over time — in favor of something that can’t possibly happen in time to avoid disaster.'

One way to make this point is that you see an enormous amount of smart commentary on the question of "what carbon pricing policy would we favor in a perfect world" but very little commentary on the question of "how do you improve the bills we're likely to pass?" Nor do many people argue that not passing anything now and not passing anything in the future is better than passing a compromised bill now. Instead, it's all just imagine a carbon-pricing pony ..."
http://voices.washingtonpost.com/ezra-klein/2009/12/the_carbon_pricing_pony.html

Sage Comments From Bubba

Bill Clinton as quoted by Ezra Klein at WaPo:
"I still think there is some chance the Israelis and the Hamas government and the Palestinian government could make a deal. Because I think that the long-term trend lines are bad for both sides that have the capacity to make a deal. Right now, Hamas is kind of discredited after the Gaza operation, and yet [the Palestinian Authority] is clearly increasing [its] capacity. They are in good shape right now, but if they are not able to deliver sustained economic and political advances, that's not good for them. The long-term trends for the Israelis are even more stark, because they will soon enough not be a majority. Then they will have to decide at that point whether they will continue to be a democracy and no longer be a Jewish state, or continue to be a Jewish state and no longer be a democracy. That's the great spur.

The other thing that has not been sufficiently appreciated is the inevitable arc of technological capacity that applies to military weaponry, like it does to PCs and video games and everything else. I know that these rockets drove the Israelis nuts, and I didn't blame them for being angry and frustrated -- it was maddening. But let's be candid: They were not very accurate. So it's only a question of time until they are de facto outfitted with GPS positioning systems. And when that happens and the casualty rates start to really mount, will that make it more difficult for the Palestinians to make peace instead of less? Because they will be even more pressed by the radical groups saying, "No, no, look, look, we are making eight out of 10 hits. Let's stay at this." I think one of the surprising things that might happen this year [2010] is you might get a substantial agreement. Nobody believes this will happen, and it probably won't, because of the political complexity of the Israeli government. But all I can tell you is, I spent a lot of time when I was president trying to make a distinction between the headlines and the trend lines. If there was ever a place where studying the trend lines would lead you to conclude that sooner is better than later for deal-making, it would be there."
http://voices.washingtonpost.com/ezra-klein/2009/12/clinton_how_better_weapons_cou.html

TW: Clinton makes good points (as he usually does, honest I am keeping my eyes out for similar insight from W. Bush...). Trend lines in the Israeli-Palestinian realm are troubling mostly for the Israelis although every day that goes by with the Palestinian mired in their poverty and partial anarchy is a day lost for them as well.

The weapons technology is also very interesting, one would think more accurate missiles would create a greater threat for Israel which it certainly does at a certain level. But the current inaccuracy provides a certain level of cover for the missile firers. Should they hit something it would be due to "bad luck" and the inaccuracy allows the perpetrators to maintain a certain level of terror without actually setting off the direct retribution should mass casualties occur.

Should they have missiles capable of actual accuracy then they would have to assume direct responsibility for their actions. Should mass casualties occur "chance" would no longer be part of the equation. The blame would be direct, retribution therefore more likely and most importantly more widely supported by outsiders such as Europe etc. As asymmetry between Israel and Hamas is reduced, the ability of Hamas to play the victim diminishes even as their ability to inflict damage potentially increases. As the conflict becomes more conventional the Israelis would retain their head to head superiority arguably making increased accuracy undesirable for Hamas/Hezbollah et al. There is a reason one frequently hears Hamas et al. boasting of rockets with increased range but not necessarily increased accuracy.

Why Not Pay For Wars?

From Ezra Klein at WaPo:
"A couple of weeks back, Matthew Yglesias had an insightful post noting that 'by far the fastest way to end the war in Afghanistan would be to ask General McChrystal’s staff to produce a plan to make it deficit neutral and find sixty votes in the Senate for his financing plan.'..."
http://voices.washingtonpost.com/ezra-klein/2009/11/death_and_taxes.html

From Joe Klein at Time:
"Congressman David Obey, who called for a tax to pay for the war in Iraq two years ago, has done it again. He's calling for a tax to pay for Afghanistan. It's a very good idea for several reasons:

1. A war is, one would hope, a temporary aberration from budget norms, requiring a jolt of new revenues. It is also the most consequential decision that a President and Congress can make; therefore, they should be willing to put their money where their mouths are.

2. The notion of shared sacrifice has somehow gotten lost in the shuffle. If we really "support" the troops, we should support the troops...In a war, every citizen should have to contribute something to the effort.

Some will say: it won't pass, and we have national security interests in Afghanistan. Trye enough. I'm in favor of continuing the Afghan campaign, and I'd be more than willing to pay my fair share for it...But there's a larger national interest that needs to be tested: in the Reagan era, a disconnect has developed between the people and their fiscal responsibilities. Any tax that ties one to the other over a concrete matter, like a war, will help rebuild the necessary relationship between spending and taxing. For Republicans who favor the war but oppose taxation, this would be a particularly crucial test of citizenship. (Although it should be noted that the Democrat Lyndon Johnson was the first to fudge the funding of a war, in Vietnam.)

If the public honestly wants the Taliban to return to power in Afghanistan and increase the risk of an Islamist military coup in Pakistan, then its views should be honored. I can't believe that will be the case...if the case is properly made. But if the public believes that U.S. national security requires a continuing presence in Afghanistan, then it should be willing to pay the tab."
http://swampland.blogs.time.com/2009/11/23/obeys-war-tax/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+timeblogs%2Fswampland+%28TIME%3A+Swampland%29

Byrd Sets a Unfortunate Record

TW: Completely agree with Klein here. The tradition of folks holding on far too long especially in the Senate and often on the Supreme Court is unfortunate (same could be said of some college football coaches). This dynamic demonstrates the power of incumbency which creates a self-fulfilling inertia. We have retirement ages for many professions for a reason. Why the Senate (or House etc.) should be different is not clear to me.

From Ezra Klein:
"Robert Byrd Jr...the 91-year-old West Virginian is officially the longest-serving member of Congress, having cast more than 18,000 votes and served for more than 20,000 days. Congratulations?

This will reveal me as something of a skunk, but these records are bad things, not good ones. Byrd has spent the past year too sick to reliably carry out his day-to-day duties. It's routinely mentioned that Democrats can't count on 60 votes because they don't know whether Byrd will be able to cast his vote. Similarly long-serving public figures such as Strom Thurmond and Thurgood Marshall spent their final years virtually incapacitated, totally reliant on staff.

There's a tendency in Washington to celebrate extremely long careers despite the fact that the extra length often extends the career beyond the point of useful service. People are honored for sticking around, when the courageous and hard thing would be to cede their seat or position. The celebration and historical permanence given to these sorts of records is part of why they do it. Byrd has accomplished much in his career, and there's plenty in his service worth honoring (his eloquent opposition to the Iraq war, for instance, but this isn't a record I'm eager to see others emulate."

My Fellow Americans...Such As They Are

From Ezra Klein:
"A couple of days ago, Ross Douthat and I spoke to a class that E.J. Dionne teaches. At some point, I was riffing about how it's a pretty odd political system in which a solid 45 percent of the people believe in death panels and yet public opinion on health-care reform is closely split. Douthat replied that he'd seen research showing that most of the people who say they hold extreme opinions do not, if questioned more deeply, hold those opinions. It's more of a group identification thing. I'm choosing to believe he's right, because I don't really know what to do with a polity in which 52 percent of Republicans believe ACORN stole the election from John McCain."
TW: I agree with Douthat, kinda. If pressed do people really believe this stuff, most probably not, but what group exactly are they identifying with?

From Andrew Sullivan:
"A new poll finds that 51 percent of Americans think canceling the rest of the stimulus would create more jobs. Derek Thompson is slack-jawed:

The idea that canceling the stimulus would create more jobs implies that passing the stimulus has actually killed more jobs than it's created, which is bonkers. Let's say you don't want to consider infrastructure spending or green technology spending or a single job that might have been created in the private sector. If nothing else, the tens of billions we've sent to state budgets have, without question, saved hundreds of thousands of jobs, like teachers, that are supported by state taxes. It's just a very basic fact.

They're watching Fox. Facts don't matter."

Hypocrisy

TW: Klein hits all the notes. Read the list of folks who voted for the Medicare Prescription Benefit, almost everyone of them has at some point this year pontificated about deficit spending blah, blah, blah. What makes my teeth itch is that folks cannot wrap their collective heads around the notion that deficits should be addressed when times are good, NOT when times are bad. None of these hypocrites lifted a finger during the W. Bush administration as national security spending exploded, medicare increased unabated and tax cuts for the wealthy were doled out like luxury candy.

Yet as Obama seeks to address a gaping hole in American society, the lack of universal coverage, a problem that is growing as more and more folks are squeezed out of coverage; all we hear from the hypocrites is blaaaah, guvmint is taking over, baaaaah.

From Ezra Klein at WaPo:
Quoting Matt Yglesias-
'John Breaux and Bill Frist have an op-ed in Politico whose exoteric message is that Congress should use the 2003 Medicare bill as a model for bipartisan health reform. The esoteric message is a reminder that the easiest way to get a bipartisan deal passed is to just have bipartisan agreement not to pay for it at all. That was the secret to the 2003 bill. First you take something a bloc of voters want — in this case prescription drugs — then you figure out a way to provide it in a manner that’s very good for the interests of stakeholders in the business community. Easy as pie.'

It is insane that the people who voted for the deficit-financed, $700 billion Medicare Prescription Drug Benefit are allowed to scream about fiscal rectitude this year. Just amazing. The occasional defense I've heard is that 2003 wasn't the middle of the most severe recession in memory. That's a defense in much the same way that poking yourself in both eyes so you can't see your assailant is a defense. Deficit spending makes more sense during recessions, not less. Deficit spending is also cheaper during recessions, as interest rates are lower because investors want to buy treasuries.

By the way, for those keeping score, the senators who voted for Medicare Part D and are still in the Senate are:

Lamar Alexander, Max Baucus, Bob Bennett, Kit Bond, Jim Bunning, Tom Carper, Saxby Chambliss, Thad Cochran, Susan Collins, Kent Conrad, John Cornyn, Mike Crapo, Byron Dorgan, Mike Enzi, Dianne Feinstein, Chuck Grassley, Orrin Hatch, Kay Bailey Hutchinson, James Inhofe, Jon Kyl, Mary Landrieu, Blanche Lincoln, Dick Lugar, Mitch McConnell, Lisa Murkowski, Ben Nelson, Pat Roberts, Pete Sessions, Richard Shelby, Olympia Snowe, Arlen Specter, George Voinovich and Ron Wyden. Lieberman did not vote.

None of these people have any authority to complain about the spending in health-care reform. When the CBO scored Medicare Part D, it concludes that the bill "would increase mandatory outlays by $407 billion for fiscal years 2004 to 2013 and would raise federal revenues by $7 billion over that period." In other words, it was a vote to add about $400 billion to the deficit in the first 10 years, and trillions more in the decades after that.

The health-care reform bills currently under consideration in both the Senate and the House actually cut money from the deficit, but they are being criticized as fiscally irresponsible by many of the people who voted for Medicare Part D. It's like watching arsonists calling the fire department reckless."
http://voices.washingtonpost.com/ezra-klein/2009/11/the_lessons_of_medicare_part_d.html

Big Week For the Catholic Oligarchy

TW: Conservative Catholic dogma had a big week. First they were by far the largest funder against gay marriage in Maine and prevailed in their quest to stop the "evil" of gay marriage. And now they (along with their allies from the Southern Baptists amongst others) wield their power to help keep abortion funding out of the public option. It is a free country so they have every right to do so. Does not mean I have to like it. If one is wealthy, like in so many other ways, one has many choices. If one is amidst the working poor and middle class, one succumbs to the whims of others.

From Ezra Klein:
"The final compromises before a bill comes to the floor are never very pretty. This one, however, is worse than I anticipated. Opposition from anti-abortion Democrats, driven in large part by aggressive activism from the Catholic Church, forced Democratic leadership to allow a vote on Bart Stupak's amendment limiting elective abortion coverage from both private and public insurers on the exchange. It reads:

The amendment will prohibit federal funds for abortion services in the public option. It also prohibits individuals who receive affordability credits from purchasing a plan that provides elective abortions. However, it allows individuals, both who receive affordability credits and who do not, to separately purchase with their own funds plans that cover elective abortions. It also clarifies that private plans may still offer elective abortions.

Because of the limits placed on the exchanges, most of the participants will have some form of premium credit or affordable subsidy. That means most will be ineligible for abortion coverage. The idea that people are going to go out and purchase separate "abortion plans" is both cruel and laughable. If this amendment passes, it will mean that virtually all women with insurance through the exchange who find themselves in the unwanted and unexpected position of needing to terminate a pregnancy will not have coverage for the procedure.
Abortion coverage will not be outlawed in this country. It will simply be tiered, reserved for those rich enough to afford insurance themselves or lucky enough to receive from their employers.

The amendment is expected to pass with relative ease. Republicans will join with anti-choice Democrats to push it over the finish line. Once the amendment passes, the bill is cleared for a vote, and all parties expect that vote to succeed. Today looks likely to end with a historic, and important, vote. A vote that is a first step towards helping more than 30 million people secure health-care coverage, and making sure hundreds of millions are better protected from the vagaries of the insurance industry. But Stupak's amendment is a bitter start. It is, however, not the end. Even if it muscles into the House bill, it will also have to pass in the Senate, and then survive conference, before it becomes law."

We Pay Much More PER UNIT Of Health Care

TW: These charts have been all over the blogosphere, but they are pretty important so in case you missed them. The theme is obvious we do not necessarily consume more health care than others but we sure do pay a lot more per unit of care than folks in other countries. The reasons are complex and for other posts but something we should keep in mind (and yes tort reform would help, a little, but that is not anywhere near the whole answer).



From Ezra Klein at WaPo:
"There is a simple explanation for why American health care costs so much more than health care in any other country: because we pay so much more for each unit of care. As Halvorson explained, and academics and consultancies have repeatedly confirmed, if you leave everything else the same -- the volume of procedures, the days we spend in the hospital, the number of surgeries we need -- but plug in the prices Canadians pay, our health-care spending falls by about 50 percent."
http://voices.washingtonpost.com/ezra-klein/2009/11/an_insurance_industry_ceo_expl.html

TW: This shows how the blogosphere for better or worse becomes circular.

From Economist:
"...Incidentally, I found that salaries chart on a Mark Perry post at Wall Street Pit, but he got it from a Greg Mankiw post, but he got it from a Derek Thompson post at the Atlantic, and he in turn got it from...an old Ezra Klein post. Something to beware of, out on the internets: the trail of "corroborating evidence" often looks like the information flows Dick Cheney set up to make it look like several sources had corroborated information on WMD in Iraq. Not that the figures here aren't accurate: this New York Times article confirms American doctors typically make two to three times as much as doctors in other industrialised countries."
http://www.economist.com/blogs/democracyinamerica/2009/11/americas_health_care_bargain.cfm

Guest Post From Max

TW: Our cat Max wanted this posted...

Via Ezra Klein at WaPo:
"So long as we're talking about meat, I might as well link this op-ed by Jonathan Safron Foer arguing that we should all eat dog. Foer is coming out with a book on vegetarianism soon, and though the initial excerpt in the New York Times seemed plodding and banal, this takes more, and more useful, risks:

'Dogs are wonderful, and in many ways unique. But they are remarkably unremarkable in their intellectual and experiential capacities. Pigs are every bit as intelligent and feeling, by any sensible definition of the words. They can't hop into the back of a Volvo, but they can fetch, run and play, be mischievous and reciprocate affection. So why don't they get to curl up by the fire? Why can't they at least be spared being tossed on the fire? ... What might be the reasons to exclude canine from the menu? The selective carnivore suggests:

Don't eat companion animals. But dogs aren't kept as companions in all of the places they are eaten. And what about our petless neighbors? Would we have any right to object if they had dog for dinner?

OK, then: Don't eat animals with significant mental capacities. If by "significant mental capacities" we mean what a dog has, then good for the dog. But such a definition would also include the pig, cow and chicken.'

And, as he notes, it's not as if dogs are always treated humanely, or always excluded from the food production system:

'But unlike all farmed meat, which requires the creation and maintenance of animals, dogs are practically begging to be eaten. Three to four million dogs and cats are euthanized annually. The simple disposal of these euthanized dogs is an enormous ecological and economic problem. But eating those strays, those runaways, those not-quite-cute-enough-to-take and not-quite-well-behaved-enough-to-keep dogs would be killing a flock of birds with one stone and eating it, too.

In a sense it's what we're doing already. Rendering — the conversion of animal protein unfit for human consumption into food for livestock and pets — allows processing plants to transform useless dead dogs into productive members of the food chain. In America, millions of dogs and cats euthanized in animal shelters every year become the food for our food. So let's just eliminate this inefficient and bizarre middle step.'

Circular Health Care Logic

TW: Klein does a simple example to focus on some of the circular logic inherent in some of the conservative opposition to health care reform.

From Ezra Klein at WaPo:
"Imagine a world in which there are only 10 people. All of them want to buy health care. But some of them are sicker, or older, than others. Two of the 10 people cost $10 to cover. Two of them cost $2. And everyone else costs $5.

Like in our own world, insurers are pretty good at discriminating against the sick. They deny the two bad risks coverage. Average premiums are thus only $4.25 a person. That's not too bad.
But it is a bit cruel. After all, the people who need insurance most are locked out of the system. Recognizing the inequity, the 10 residents of our imaginary land elect Schmarack Schmobama president, in part because he's run on a platform of universal health care. He comes into office and passes a law saying insurers have to offer care to everybody at a similar price, and there will be subsidies to help those who can't afford the cost. What happens to premiums?

Well, as Michael Gerson says in his column today, they go up. With the two $10 risks included in the total, average premiums are now $4.40. The subsidies help people who can't shoulder the expense, but that's not quite the point. As Gerson writes, health-care reform has made "the average insurance plan more expensive." This is the first reason, he says, that "non-Maine Republicans object to the Senate Finance bill."

But the average insurance premium is now more expensive because insurers can't discriminate against the sick, and they can't discriminate as much against the old. Most of us -- even those of us in the middle class -- eventually become sick, and eventually become old. Our insurance plan might be more expensive now, and so we consider ourselves losers, but we won't be locked out later, which would have been losing on a whole other scale. Whether we come out ahead in a single year may well be different than whether we come out ahead over time. After all, insurance itself is a hedge against catastrophic bad luck. On some level, so too is this bill.

Moreover, this is emphatically not why non-Maine Republicans object to the bill, or at least it wasn't at one point. Republicans have bent over backwards to proclaim their openness to insurance market reforms. Sen. Mike Enzi, for instance, told AARP that, "I support fundamental changes that would prevent insurance companies from denying access to anyone needing health insurance coverage." If everyone can access coverage, then the risk pool will become more expensive because the bad risks will no longer be locked out. Enzi, in other words, supports the fundamental change that raises average premiums.

Conversely, the pieces of the bill that have driven the most partisan bickering have been the elements that would drop the cost of average premiums. You may or may not like the public plan, but the Congressional Budget Office and many other analysts have said it will lead to lower premiums for consumers. The individual mandate has sparked a fair amount of Republican opposition, but its purpose is to pull healthy customers into the pool so average premiums remain low. The level of subsidies has created some controversy, but it will offset the premiums costs for most consumers.

Republicans have adopted the insurance industry's talking point that health-care reform will "make the average insurance plan more expensive." The problem is, most of them support, or have previously supported, the elements of the plan that drive that increase. And most of them oppose both the insurance industry's ideas for mitigating the problem (a much stronger individual mandate) and the elements of the Democratic bills that would drive down premium costs..."
http://voices.washingtonpost.com/ezra-klein/2009/10/is_this_why_republicans_cant_s.html