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But as things stand now, it's hard to see what—apart from the excise tax on Cadillac plans—health reform might do to tackle the problem of ever-more-expensive premiums in employer-based care. Between 1999 and 2008, employer-sponsored health insurance premiums increased six times faster than wages. For many of us, this is where the conversation began. The CBO's finding that health reform won't worsen this already-terrible problem is nothing to brag about.
Public spending. The Obama administration has insisted all along that health reform and deficit reduction are the same thing. The CBO's calculations show that's true only to a limited extent. A more honest assessment would be that the health reform bill would mostly be deficit-neutral.
In health care, the public-sector cost curve is a little less steep than the private-sector cost curve. Between 1970 and 2003, private health insurance spending rose 10.1 percent annually, as compared with 9 percent for Medicare. Why, then, do you hear so much talk about terrible out-of-control Medicare spending? Partly because it's public spending that contributes to a $1.4 trillion deficit; partly because many people expect that an aging population will cause Medicare's growth rate to overtake private health insurance's growth rate in a few years; and partly because an annual inflation rate of 9 percent is still pretty bad.
The Senate health reform bill, the CBO says, would cut $491 billion from government health programs (mostly Medicare) during the next 10 years and redirect it into subsidies to help lower-income people to purchase health insurance and expand enrollment in Medicaid and the Childrens Health Insurance Program. This has the Republicans—especially Sen. John McCain, R-Ariz.—in a swivet. (Never mind that McCain, during his 2008 presidential bid, proposed funding his health reform plan with cuts to Medicare and Medicaid that he refused to quantify but were estimated by the nonpartisan Tax Policy Center to amount to $1.3 trillion.) Overall, the increased coverage is projected to cost $848 billion over 10 years. To help pay for this, the Senate bill raises taxes by $486 billion. When the dust settles, CBO estimates, the net effect would be a $130 billion reduction in the deficit after 10 years.
But that $130 billion, budget experts have been quick to alert me, includes $72 billion that really shouldn't be counted. The $72 billion is savings generated by the Community Living Assistance Services and Supports (CLASS) program, a new voluntary program to insure against nursing-home and other long-term care. Participants must pay in for five years before they can become eligible to collect benefits, so of course the net effect during CLASS's first 10 years will be to build up cash reserves to be spent later. (By law, the program must pay for itself, something the CBO projects it will stop doing after 20 years; but that's another story.) Put CLASS's $72 billion into the proverbial lockbox and the Senate bill's savings dwindle to $58 billion.
Factor in assorted uncertainties and accounting gimmicks (the Senate bill's spending doesn't start to ramp up significantly until 2014), and it seems prudent to conclude only that the Senate bill would pay for itself. Anticipating this likelihood, a much-cited Nov. 17 letter to the president from 20 prominent economists emphasized not that the bill must reduce the deficit but that it must achieve "deficit neutrality."
Mission accomplished. But that's not bending the cost curve.
I haven't taken into account the various "delivery system reforms" in the Senate bill, much-touted by the Atlantic's Ronald Brownstein in a Web column that was quickly embraced by the Obama White House. These are a variety of measures, many of them pilot programs, aimed at making hospitals and doctors more accountable. The consensus is that these are A) worth trying and B) unlikely to deliver tangible savings in the near term. The CBO has accordingly been hesitant to ascribe to them any significant curve-bending properties. It would be rash to say more than that they may bend the curve in the future. For example, a just-released report by the Medicare Payment Advisory Commission, which the health reform bill aspires to transform into a Fed-like, quasi-independent budget-cutting apparatus, concludes that regional variations in Medicare spending (the subject of a hugely influential Atul Gawande story in the New Yorker this past June) aren't nearly as great as was previously supposed.
If Democrats can't say health reform would bend the health inflation cost curve, what can they say? More than enough to justify its passage. Most important, it would extend health insurance coverage to 31 million of the 45 million people who currently lack it. It would also curb a variety of abuses by insurers (primarily in the nongroup market) that make health insurance unavailable to those who need it most. The bill would achieve these two goals in a fiscally responsible way (which is a lot more than you can say about the last major health bill in 2003, which extended Medicare coverage to pharmaceuticals without figuring out how to pay for them).
Health reform isn't what it could have been, but it's a good bill. Democrats should praise it. But they should stop saying it will bring health costs down in the private and/or public sectors, because there's precious little evidence that it will.
E-mail Timothy Noah at email@example.com.
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