I think Ezra Klein

OMB director Peter Orszag's position--which Orszag

and in

responding to Virginia Postrel (who argued that if there's so much money to be saved in health care, as demonstrated by waste in Medicare, why doesn't the administration start by eliminating the waste in Medicare?). Klein writes:  

The cost reforms, by contrast, are being done cautiously, cooperatively, and with a focus on Medicare. ....

Which is why it's a bit bizarre to read Postrel writing that "if more-efficient government management can slash health-care costs by addressing all these problems, why not start with Medicare?" When it comes to cost, they actually are starting with Medicare. They hope that the efficiencies work and are voluntarily adopted by private insurance. But there's no actual mechanism to make that happen.

My impression (which could be wrong!) is that there are two sorts of cost savings Orszag has in mind. 1) A bunch of "scoreable" Medicare and Medicaid cuts** that will save $5-600 billion over 10 years and (along with some revenue increases) pay for expanding health coverage over that period; and 2)  A collection of more ambitious "game changer" reforms*** that aren't part of that next-10-year calculation but will "lower the rate of health care cost growth" in the long run. These game changer reforms are not limited to Medicare and Medicaid , as I understand it--indeed, I think it is Orszag's position that you can't do them if you limit them to Medicare and Medicaid.

This latter assertion appears to be a central pillar of "Orszagism," which is defined the claim that (as Ryan Lizza puts it ) "health-care reform is deficit reduction,"-- that without Obama's sweeping health care reforms we just can't "bend the cost curve" down enough in the long run. If the "game changers" could simply be limited to Medicare and Medicaid, you could simply implement them without reforming the rest of the health care system--Postrel's point--thereby more or less totally undermining Orszagism. Expanding health care coverage and cutting long-term federal health-related budget costs would be two distinct, separable policy initiatives (one reliably expensive, one seemingly speculative ).

The assertion--that you can't just do the cuts in Medicare-- isn't really defended in Orszag's recent posts , though he promises more dialogue in the future. Orszag also has to convince people that a) his "game changers" actually will cut costs--in Medicare, or anywhere b) without compromising health or medical progress and  c) without engaging in the nasty treatment-denying behavior HMO's got in trouble for a decade or so ago. ... Update: I forgot d)-- and they'll cut costs so much that they'll more than compensate for the obvious ways universal health insurance will increase long-term health costs (i.e., by increasing the number of consumers demanding medical services and enabling them to exert political pressure, not necessarily illegitimate, to pay for particular expensive treatments, including treatments Orszag's various cost-conscious reforms might deny). ... Best of luck to him.

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** As described in a recent presidential letter , these "scoreable" shorter-term cuts include

reducing overpayments to Medicare Advantage private insurers; strengthening Medicare and Medicaid payment accuracy by cutting waste, fraud and abuse; improving care for Medicare patients after hospitalizations; and encouraging physicians to form "accountable care organizations" to improve the quality of care for Medicare patients ....

Plus "another $200 to $300 billion" in Medicare and Medicaid savings to be announced soon. ...

***--The "game changers," as described by Orszag, include

steps such as health IT, research into what works and what doesn’t, prevention and wellness, and changes in incentives so that Americans get the best care not just more care. 

2:42 A.M.

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It's Pedal to the Metal for the New Chrysler! Obama spokesperson: "We are delighted that the Chrysler-Fiat alliance can now go forward, allowing Chrysler to re-emerge as a competitive and viable automaker." [E..A.]  Viable? Competitive? Hello? We are writing this down. Words like that will be remembered in two years, if Chrysler even makes it that far. ...     2:41 A.M.

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Arianna vs. the Anti-Objectification Cheesecake Police : All the best fights are intra-left these days. ... P.S.: kf last month , City Paper this month. ...   2:27 A.M.

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John Dickerson : "Did Google do it for Deeds?" No. ... 2:18 A.M.

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GM Design Chief Ed Welburn did not not not accuse a HuffPo blogger of racism (sorry TTAC ). ... But he did cite his grotesquely cheesy, cartoonish new Camaro as an example of what can be created in GM's "cutting edge 21st century environment." ... Welburn seems like a nice guy. But I would say the Camaro is a firing offense (though,, if he's a UAW member, it will take 6 unexcused Camaros). ... 2:16 A.M.

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