The Virtuous Social Egalitarian Circle:
Whether or not it's accurate
, Scott Gottlieb's op-ed on whether you'll be able to buy your way out of Obamacare (
answer: only if you're willing to pay 100% cash for treatment) made me feel better about our impending health regime
. Why? 1)
Gottlieb argues that the upper middle class will be stuck in the system. Assume he's right. The upper middle class has a lot of political power. It will not allow itself to be screwed by cost-saving federal bureaucrats!
(Exhibit A: Mammmograms!) 2)
Gottlieb charges the system will likely have the same sort of restrictions on buying private supplemental insurance that Medicare has. Is the upper middle class unhappy with Medicare? No. If Medicare started denying treatments right and left, would they be unhappy? Yes. And they would rebel on election day. Which is why Medicare doesn't
deny payments right and left. When it comes to protecting my insurance, whom would I rather rely on--angry affluent aging boomers or Aetna adjusters? It's not even close
The same political dynamic should serve as a check against setting Medicare payments so low that all the good doctors leave the system and go private. Of course, that's already happening to some extent. (The top hip-replacement guy on L.A.'s West Side just stopped taking Medicare.) But I don't think voters will let it go much further, to the point where they are routinely denied access to the docs they want to see. (Exhibit B: The doctor's fee cut, which Congress repeatedly refuses to OK). 4)
The very egalitarian impulse that Gottlieb ridicules--the desire to prevent the system from becoming a "lower-end benefit" like Medicaid--will force the government to keep benefits generous enough that the second-to-top decile (and the third, and fourth) don't bolt.
That serves both the anti-rationing cause (you think the top 40% will stand for 'death panels'?) and the social-egalitarian cause (rich and non-rich in the same waiting room). The enemies of this generous approach won't be the "egalitarians." They will be the cost-cutters. They will lose.
Doesn't that mean we'll spend more and more on health care, without reducing federal outlays by "bending the curve"? Did somebody say something about "bending the curve"? Really? Social egalitarians should not want to bend the curve. (We should want to find a way to pay the bill. One idea here .)... 3:07 P.M.
Nobody Expects the Pong! Reader C. asks a good Question: Many people--e.g., Paul Starr , Bill Galston , me--have urged the House to just pass the Senate bill intact, word-for-word, which would have the effect of sending it immediately to the President and avoiding a House/Senate compromise that would then require a second Senate vote. It doesn't look like the House is going to take this approach--there are going to be negotiations on a compromise, negotiations that may extend into February. But what if the negotiations bog down? Can the House just go back and pass the Senate bill? Or is the "pong" strategy somehow voided once House-Senate negotiations start? ... Specifically, what if it begins to look as if Obama won't get the necessary 60 votes the second time around? (Suppose, for example, that Sen. Nelson gets such an earful back in Nebraska that he says he won't vote for the bill a second time.) If the Senate looks like it's changing it's mind, can the House just pass the existing Senate bill and end the game anyway? ... Even better, if the Senate actually tries and fails to pass a new House-Senate compromise, can the House then go back and just pass the original Senate bill? ...I don't know the answer, but some parliamentary experts out there probably do. ... 2:22 P.M.
Brings 'Da Noise!
Jonathan Chait declares
hat the Fed-like "Medicare advisory commission holds the greatest potential to drive transformation of the system, but that "[i]n its official budget estimates, CBO credits these experiments with virtually no budget savings."
[E.A.] The implication: CBO's projection of a deficit decline is conservative--there's likely to be even more
savings once the unelected experts on the advisory commission start denying payments for "wasteful" treatments and medical devices.
But Chait is wrong, I'm pretty sure. The CBO credited the Medicare advisory commission with large savings. Indeed, the reason the final Reid bill (the "manager's amendment") was originally deemed to have greater savings than the first Reid bill was, according to the CBO, precisely because the "manager's amendment" seemed to fix the trigger that causes the less-than-democratic Medicare advisory commission to swing into action. Then the CBO read the fine print and discovered that the trigger was only half-fixed--it comes unfixed in 2019--and as a consequence CBO corrected its original estimate from "a broad range around one-half percent of GDP" to "a broad range between one-quarter percent and one-half percent of GDP." In other words, it cut the lower bound of its already incredibly vague estimate by half.
Obviously, if the CBO revised its savings score from the Medicare commission downwards that means, contra Chait, there were savings there to begin with. Lots of savings-- a potential quarter percent of GDP. Half of all the savings in the bill
Where did Chait get his bogus assertion? 1) He was going off the CBO report of the old Reid bill; 2) He heard it on JournoList!
P.S.: Chait declares "totally false" the GOP argument that Congress' unwillingness to carry out cuts in doctors' salaries might presage unwillingness to make other scheduled Medicare cuts. He then cites a report from the Medicare actuary , Richard Foster, to show that--contra Republicans--if the Medicare cuts are approved, the "rate of growth" in health care spending will slow. But this same Medicare actuary, Richard Foster, worried in that same report that Congress' unwillingness to carry out cuts in doctors' salaries might presage unwillingness to make the scheduled Medicare cuts ( see page 9 ). Doesn't that suggest that the original GOP argument wasn't "totally false"? Maybe had a germ of truth!
That's the trouble with Chait. GOP claims are always "totally false" or "thoroughly debunked pseudo-factoids." Republicans always act in venal bad faith--they never have even a half-a point. It's why I don't trust him. ... 2:07 P.M..