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Rules For Commenting On The CBO's Judgments

In the least surprising revelation of the day, the Congressional Budget Office doesn't see much in the way of savings coming from health-care reform in the next 10 or so years. This is because the bills under consideration do not save much money in the next 10 or so years.

I would, however, like to propose a couple of rules for commenting on this story. Politicians who are going to use this CBO report against the existing health-care reform proposals must do some combination of the following:

a) Support, as the CBO says you should, the eradication of the tax exclusion that protects employer-based health-care insurance;

b) Support, as Lewin and Commonwealth say you should, a public insurance option that can bargain at Medicare's rates;

c) Support, as the Office of Management and Budget and every health-care wonk in town says you should, one of the various policies floating around to give MedPAC authority to continually reform and modernize Medicare;

d) Support some form of aggressive cost-sharing that would make people extremely angry because it will save money by reducing their access to health-care services;

e) Support comparative effectiveness review that can judge not only the effectiveness but also the cost-effectiveness of various treatments, and give the federal government authority to use that data when deciding reimbursement rates.

I would also like to propose a related rule: any reporters who receive a quote from a politician referencing this CBO score should be required to ask the politician which of these policies -- or which alternative cost-saving policies -- they support. And that should be on the record. I think it's perfectly legitimate to criticize health-care reform for not saving enough money. In fact, I think it's important. Health-care reform should save more money. But it's not legitimate to do that if you also oppose any and all measures for saving money.

(Oh, and to play by my own rules, I support a, b, c, and e.)

By Ezra Klein  |  July 16, 2009; 1:53 PM ET
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I agree. Have you talked to the Post's healthcare journalists?

Posted by: Castorp1 | July 16, 2009 1:56 PM | Report abuse

Typo in rule (b). It should say Lewis and Commonwealth "say" (singular). OK, I feel better now.

Posted by: MarkJ2 | July 16, 2009 2:06 PM | Report abuse

Mostly agreed, but with the caveat that CBO's scoring of something as saving the federal government money (or not) is not necessarily completely the same thing as whether it saves the economy money (or not). There are certainly policies where the greatest impact is felt in the private sector, or that act to reduce costs but have the effect of shifting more costs to the feds.

And vice-versa, too -- ending the employer tax exclusion would probably have a reasonable impact on national health spending (though I haven't seen firm estimates), but it's a gigantic saving to the federal government.

Anyway, point being that it's true that for the most part CBO-scored savings will be correlated with overall cost savings, but there's not 100% overlap.

Posted by: Mike_Russo | July 16, 2009 2:35 PM | Report abuse

I support a, c, e and a much smarter version of d. Not impressed by b, as there are few policy experts that believe that price inflation, versus increase in volume utilization is the issue.

More importantly, I propose another rule for those that would dismiss this report under the "coverage now, cost control later" theory. At least acknowledge that Obama's continual leading claim that the proposed reform will control health care costs is probably the most dishonest part of his Administration so far. Lay a few building blocks? Sure. Control costs? Um, no.

Posted by: wisewon | July 16, 2009 2:43 PM | Report abuse

How about we just greatly ramp up people's access to nurse practitioners for primary care. That would seem to lead to a tremendous cost savings. I'll put the nurses in this country up against the primary care physicians in many other countries.

Posted by: spotatl | July 16, 2009 2:50 PM | Report abuse

I think that if we can get the mainstream media to stop reporting that the CBO score for the House health bill was $1.5T rather than $1T, it would be a good enough victory for one day.

Posted by: smhjr1 | July 16, 2009 2:54 PM | Report abuse

LoL. Yeah, I bet you'd like to define the rules of debate on this. I am not an advocate for doing nothing, but the simple fact of the matter is that healthcare spending would actually be LESS over the next 10 years under current law. And likely over the next 20 years as well.

This is because Democrats have tried to sell a plan for subsidizing healthcare coverage for 30+ million Americans as a way to REDUCE costs. No amount of budget trickery can accomplish this.

Posted by: morgen-vs | July 16, 2009 3:14 PM | Report abuse

When I used Kaiser-Permanente in Oregon a few years ago, routine visits were always to a nurse-practitioner. In three years, the only physicians I saw were a dermatologist (who popped into the nurse's office at her request) and a knee specialist, who confirmed that the nurse's little photocopied handout booklet (which he had written) was providing tghe right advice.

Posted by: DaveoftheCoonties | July 16, 2009 3:25 PM | Report abuse


Comments are only permitted if you accept as a given that universal healthcare (of some sort) be passed? Lovely. How about another option.

f) Since we cannot demonstrate how to significantly reduce costs, the government should avoid becoming more involved (Medicare and Medicade are bad enough) in providing health insurance. Let the admittedly broken system continue to muddle along until either (i) we do come up with ideas for real savings or (ii) face the fact that we cannot afford to spend millions of dollars giving everyone limitless healthcare (e.g. we might actually have to die instead of spending $10mm to obtain an extra month of life).

Posted by: WEW72 | July 16, 2009 3:51 PM | Report abuse

Mr Klein adds more untenable rules to overwhelm the CBO statement.

Posted by: jdcw | July 16, 2009 3:53 PM | Report abuse

Morgen-vs: that's not a fact, that's the confusion I mentioned above. Reform will increase federal outlays on health care. But done right, it will bring down total system costs. The House bill could be stronger on this, but it's still going to help reduce costs.

Lewin Group estimates that a public plan along the lines put forward by the House. could help save the health care system $800 billion or more over the next decade (if it paid at Medicare rates, that number would be almost $2 trillion).

A strong program of comparative effectiveness research -- which is better in the House version than the Senate -- can likewise save hundreds of billions, with most of the benefits accruing to folks who are not the federal government.

Even covering the uninsured via subsidies helps reduce some private costs by reducing the cost shift for uncompensated care.

Posted by: Mike_Russo | July 16, 2009 3:55 PM | Report abuse

WEW72: "Comments are only permitted if you accept as a given that universal healthcare (of some sort) be passed?"

That would be a nice rule, since health insurance industry hacks like you are merely out here spreading lies and disinformation. Unfortunately, that's not the rule Ezra proposed. He merely said that if you are going to use the CBO reports to support/attack an issue, you must be consistent and use them even when you don't like the consequences.

Posted by: edta | July 16, 2009 4:14 PM | Report abuse

Stay classy edta. I like my insurance. Is that a crime? In a single payer system, I clearly lose my insurance.

Explain to me how the following logic errs with respect to a public option:
-The current systems shifts costs from the uninsured, and Medicare, to the privately insured.
-A public option (especially at Medicare rates), will make that shifting more pronounced, as more excess costs will have to be covered by fewer privately insured.
-Some employers will immediately opt for a cheaper "public option", because it is cheaper.
-Other employers will shift at a later date, as private insurance costs shift upward.
-In the end, an inherently monopolistic public option kills my private insurance.

No thank you. I do admit though that, in the long run, costs will probably come down. That happens in single payer systems over time (whether we go there directly or indirectly), as capacity eventually moves to match the fixed price (instead of actual demand).

Typically, the health service provided by a single payer systems is inferior to that received under GOOD private insurance plans, partially because of such capacity issues. There also will have to be a shift in research to the public sector (from the private sector), as the evil pharmaceutical companies have less money to play with.

What truly untenable (under any proposals to date), is to have the service levels of "good" insurance plans available for everybody, without massive increases in costs. Only massive costs savings (other than adjusting capacity) can make that workable The CBO essentially is saying there is no credible data that current plans produce such savings.

Posted by: WEW72 | July 16, 2009 4:33 PM | Report abuse

Klein, when you are elected president, you can make the rules as you want. Otherwise, those of us who don't share your Pollyanna view of health care reform will be happy that the CBO is there to inject some common sense and non-partisan analysis into the mix.

Posted by: WashingtonDame | July 16, 2009 5:56 PM | Report abuse

trillion dollar deficits for life under the obama plan, and this bill makes that substantially worse according to the CBO, and your reaction is to 'make rules' for discussing how bad this is?


Posted by: Spencer99 | July 16, 2009 5:58 PM | Report abuse

Spencer99: CBO has not yet scored the revenue side of the bill, which are designed to cover all of the new spending. Everybody has committed to a budget-neutral bill; it will not add a penny to the deficit and even if it's got weaker cost reforms than it should, likely those will still reduce deficits from where they otherwise would be, under current law.

Posted by: Mike_Russo | July 16, 2009 6:07 PM | Report abuse

Mike, the CBO Director was talking about the score for the House's bill. And based on the CBO's analysis, the public plan would include only 10-12 million people by the end of the first 10 years. And any savings to the federal government were in theory already scored.

Are you saying that the fact that a whopping 10-12 million people are in a public plan by 2019 will result in $800B in savings in healthcare spending outside of the federal government over this period?

I don't possibly see how this could be the case, even factoring in the reduction in emergency care services that might have otherwise gone unpaid. Are you sure the Lewin Group analysis was not based on a more "robust" version of the public plan?

Posted by: morgen-vs | July 16, 2009 7:38 PM | Report abuse

WEW72: "Stay classy edta."

I don't feel obligated to treat liars with class.

WEW72: "I like my insurance."

I'll bet you do. You work for them, after all.

WEW72: "Is that a crime?"

Unfortunately, misrepresenting yourself and lying is not a crime unless you're in a situation where you're under oath. However, that doesn't mean I can't call you out for it. All of your "logic" is a pack of lies, mere fear tactics that the health insurance industry's hired hacks are paid to spread. Having a public option will not do a single thing you claimed it would.

Posted by: edta | July 16, 2009 11:51 PM | Report abuse

It is clear that severe tax increases have or will be taking place in the US on both state and federal level. It is also clear that tax increases have a multiplier effect on GDP contraction (one dollar tax increase will translate roughly into 3 dollars drop in GDP.) There is of course a delay before the tax shock translates into GDP contraction. It is entirely possible that with the temporary impact of stimulus, we may be looking at a prolonged "W" type recovery that is far more protracted than many currently estimate.

Posted by: SoberLOOK | July 17, 2009 1:40 AM | Report abuse

Was it cost effective for the private insurance plan paid for by the taxpayer to fund expensive neurosurgery and rehab for 80 year old Senator with brain cancer? I am sure liberals like Ezra Klein want health care "cost effectiveness" for everyone else but libs and themselves. Is it cost effective to provide sex change operations? Who decides - Nancy Pelosi?

Posted by: Cornell1984 | July 17, 2009 8:11 AM | Report abuse

Thanks to Mickey Kaus, the internet is laughing at Ezra Klein and the Washington Post in general for its continued "selling" of the health care debate -- propaganda and it didn't cost us $25,000 to meet with administration officials! Who is Ezra Klein to make up "rules" for how people discuss an issue? This coincides with the censorship of VP Joe Biden's continued gaffes (We need to spend money to keep from going into bankruptcy????) and lack of coverage of the Treasury Department putting out a bid to make Secretary Geittner laugh by drawing cartoons for him and his Goldman Sachs friends.

I wonder what happens if we don't follow Ezra Klein's rules?

Posted by: Cornell1984 | July 17, 2009 8:31 AM | Report abuse

Ezra's rules? Emily's Reasons Why Not have more utility. Why would anyone feel informed reading a UCLA poli sci grad who never had a job in his life other than writing far left propaganda?

Posted by: RezkoLot | July 17, 2009 10:28 AM | Report abuse

Here is another rule. Obama and the democrats lied again and got caught again.
Their promise that their health care plan would reduce costs is now as credible as their stimulus plan would create jobs.

Klein"s idiotic suggestions are exactly what scares people away from health reform, tax benefits, ration care, have the government decide what treatment you will get and cut medicare.

You have a loser liberals.

Posted by: robtr | July 17, 2009 10:42 AM | Report abuse

Rules? In a knife fight? No rules!

Posted by: WalterSobchak1 | July 17, 2009 10:42 AM | Report abuse

Ezra - If you want to be honest you need to include another option above F) Do nothing. It's a legitmate position for those of us who fear deficits and increased gov't spending to advocate for the status quo. If the system is broken i think there's a lot we could do to fix it before adding trillions to the budget. Just for starters - means test Medicare, end employer tax deduction for health care (and lower income taxes by a commensurate amount), allow insurers to sell policies across state lines and even set up a non-governmental comparative effectiveness group to make non-binding recomendations to Medicare and private sector.

Posted by: mbp3 | July 17, 2009 10:51 AM | Report abuse

Let me see if I understand correctly. WEW72 is willing to let 90% of the country suffer just so 10% can have the best health care in the world. Or maybe is 99% and 1% or 99.9% and 0.1%

Well, that kind of thinking has certainly held sway for most of human history. His problem is that he was born in the 20th century, not the 12th.

Posted by: lensch | July 17, 2009 12:52 PM | Report abuse

I support healthcare reform.

1. No medical care for old people (>60). They are not worth it.
2. No medical care for fat people. They made their problem.
3. No medical care for pregnancy. We have too many babies.
4. No medical care for blacks or Hispanics or Jews. They have too many inherited diseases and chronic lifestyle diseases.
5. No healthcare for drinkers and smokers or people who don't use a helmet when cycling.
6. No healthcare for northern Europeans. They suffer too much depression.
7. No healthcare for immigrants. They cost too much.
8. No chronic care of any sort for anyone. This includes: diabetes, arthritic, congestive heart failure, sickle cell disease, Tay-Sachs disease, etc. etc.
9. No curative treatment for cancer of any sort.
10. No treatment for venereal disease, AIDS etc. This is all self inflicted.

This may seem like a joke but how far off the mark is it really. We can't afford this so let's not pay for it.

Posted by: aloysius1 | July 17, 2009 3:10 PM | Report abuse

"I would, however, like to propose a couple of rules for commenting on this story."


I don't recall any "rules for commenting" on any of Bush's proposals.

You don't like what the report has to say, so you're trying to do damage control. Nice to see the Washington Post is still a fully operational part of the Obama Campaign... less Fourth Estate than Fifth Column.

Posted by: malclave | July 17, 2009 4:32 PM | Report abuse


The healthcare reform bill released by the House Of Representatives is an excellent bill as I understand it. It's a bill with a strong, robust, government-run public option, and an intelligent, reasonable initial funding plan to cover almost all of the American people. It is carefully written, and thoughtfully constructed, informed, prudent and wise. This bill will save trillions of dollars, and millions of your lives. It is also now supported by the AMA.

This is the type of bill that all Americans can feel good about. And this is the type of bill that has the potential to dramatically improve the quality of healthcare for all Americans. Rich, middle class and poor a like. Democrats, Republicans, Independents, and all other party affiliations. This bill has the potential to dramatically improve the quality of life of every American.

The house healthcare bill should be viewed as the minimum GOLD STANDARD by which all other proposed healthcare legislation should be judged. All supporters of true high quality healthcare reform should now place all your support behind this healthcare reform bill released by the United States House Of Representatives, as the minimum Gold standard for healthcare reform in America.

You should all now support this bill with all your might, and all of your unrelenting tenacity. This healthcare bill is a VERY, VERY GOOD! bill for all of the American people. Fight tooth, and nail for every bit of this bill if you have too. Be aggressive, creative, and relentless for this bill.

From this time forward, go BIGGER and DEEPER with the American people every day until passage of healthcare reform with a robust, government-run public option.

FIGHT!! like your life and the lives of your loved ones depends on it. BECAUSE IT DOES!

It should also be noted that Ron Wyden's "Free Choice Proposal" in the senate is a highly intriguing proposal and possibly a brilliant idea. And an Idea that should be strongly looked into as a way of increasing consumer choice, and consumer access to a government-run public option.



God Bless You

Jack Smith — Working Class

Posted by: JackSmith1 | July 17, 2009 5:24 PM | Report abuse

I have only one hard and fast rule for a 'public' option. All government employees, including Senators and Representatives MUST be enrolled in that plan and only that plan.

Will this save money? NO. But it will prevent our political masters in Washington from forcing the rest of us into a plan that is not good enough for them.

Posted by: goldfinch | July 17, 2009 9:34 PM | Report abuse

If only every citizen could take this quiz.

If the majority would answer 'a' to the following question, we would have Universal Health Care:

"Are you willing to contribute 15% of your income so that you, your family and every American can have access to quality health care?"

I personally would JUMP at the chance to pay only 15% instead of the 40% of my income that now goes to premiums. My company dumped our health insurance so I'm out in the real world...and beware that you may be too.

Posted by: lmoor1 | July 19, 2009 1:20 PM | Report abuse

I'm just a pipsqueak 62 year IRS agent in Kansas City. However I was slack-jawed after reading Mr. Klein's "rules" for discussing the CBO estimates for health care reform. Seems to me the proponents of this frantic top-down Soviet bureaucracy take-over of 1/6th of the nation's economy are the ones who ought to be subject to the rule of basic reality. The same power-mad folks whose incompetence and cupidity can't get Medicare and Medicaid under control are in no position to dictate "rules."

Some of the earlier commenters think they are going to get almost free health care provided by the "rich." These folks must not be nearing retirement. Part of the cost of health care "reform" is achieved by cutting back Medicare spending by $500 billion. I've got high ground in the Lower 9th Ward to sell, if you really think these spending cuts will be achieved from pie-in-the-sky efficiencies. No, the savings will be achieved by cutting back on actual care. Grandma, get ready to get thrown under the bus. It's not "efficient" to treat you.

Posted by: dturnerc | July 19, 2009 11:56 PM | Report abuse

Okay...I think Ezra needs to create one more major rule: those opposed to doing anything ACTUALLY like this broken, near collapse health system. What sort of individual would actually defend this system? Well, simple really, these are the sort of people who think markets self correct, that the economy collapsed because of too much government intervention and also think getting rid of all income taxes would make for a sustainable society. So in other words, people who live well outside of reality. People who are so selfish they'd pull the plug on a loved one if it meant some savings...that's who. Now onto this debate...of course creating a public plan costs money....but it also saves money. Currently we spend around 17% of our GDP on health care and we live shorter lives than any other industrialized country, we suffer from illnesses more often and longer, we're fatter (type III obesity going on the rise actually coincides with lack of insurance...big shock) and to top it off...our infant mortality is MUCH higher than every other industrialized country. So in other health system in the world! if conservatives didn't spend all of their time trying to convince the norms why we should never change anything or ever move forward they'd have more time for...oh wait, Mark Sanford shows us what conservative do with their time that should be spent working...oh who I am kidding, conservatives in government don't do anything but enrich themselves and their fellow travelers who fund their campaigns. Good to see the insurance industry is so successful it doesn't even have to pay certain people (you know who you are) to schill...they're crazy enough to do it voluntarilly. Let's ignore the fact that single payer countries like canada spend 10% of their GDP on health care leaving them money to actually live their lives or that health care bills continue to be the #1 reason american's file for bankruptcy...this system works for the few remaining conservatives...the rest of us can die off, leaving only the healthy left...good idea WEW. You stay classy conservatives, once we get you out of the way this problem will finally be solved once and for all. As FDR once said, the only thing we have to fear is fear itself...well that, and the Republicans getting control ever again.

Posted by: ClearPolicies | July 20, 2009 2:26 AM | Report abuse

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