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The Dull Reality of Change


The so-called "pep talk" the president gave a few minutes ago could have benefited from a bit more pep. Barack Obama seemed tired, almost somber. The early word was that he would use the unscheduled address to reignite excitement over health-care reform. Instead, he gave a detailed explanation of where we are in the health-care reform process. The emphasis wasn't on excitement or persuasion, but reassurance. This prompted an incensed, semi-coherent tweet from Sen. Chuck Grassley, who specializes in such things:

Obama speech on healthCareReform Absolutely nothing new Waste of time saying we are going to get that done Baucus and I know that But doRITE

So writes the guy who's supposed to be writing heath-care reform. Confidence-inspiring, innit? But this question of, as Grassley so eloquently put it, "doRITE," is an interesting one. Insofar as there was anything new in Obama's speech, it was his full-throated advocacy of the Independent Medicare Advisory Council (IMAC) (formerly known as MedPAC). This really is a good idea. But it's an idea that probably makes Grassley mad.

The theory underlying IMAC is that Congress cannot do health-care reform, err, RITE. It is too captured by special interests and too baffled by technical arguments and too paralyzed by partisanship. Leaving the continual tweaks and hard decisions that will bend the curve over the long term up to Congress is a bit like asking JD Salinger to blog: It might happen occasionally, but it's not a safe bet. The IMAC proposal substantially removes Congress from the process. The letter that Peter Orszag sent to Nancy Pelosi explained how it would work:

This draft bill would establish an Independent Medicare Advisory Council (IMAC), which would have the authority to make recommendations to the President on annual Medicare payment rates as well as other reforms. Both the annual payment updates and the broader reforms would be prohibited from increasing the aggregate level of net Medicare expenditures. This proposed legislation would require the President to approve or disapprove each set of the IMAC’s recommendations as a package. If the President accepts the IMAC’s recommendations, Congress would then have 30 days to intervene with a joint resolution before the Secretary of Health and Human Services is authorized to implement them.

In a way, this seems small. But it's what cost control looks like in practice. It's Congress recognizing that it's a process, and a process for which it is ill-suited. It's an expert body able to continuously evaluate the data and make changes to Medicare that will increase the program's effectiveness and decrease its costs. There has been a theory, for many years now, that the health-care system's cost problems would eventually be solved all at once when some popular president and some large congressional majority finally got serious about the issue and made the big, hard decisions.

Well, that's happened, and what we're seeing is that they can barely pull off the easy stuff, much less the hard stuff. There will be no big, wrenching concessions. We will not have an exciting, thrilling, satisfying conclusion to our health-care woes. Not for the foreseeable future, anyway. Instead, we'll begin doing things a bit differently. Making things a bit better with each year rather than a bit worse. Putting a process like IMAC into motion is one way to do that.

Photo credit: AP Photo/Jae C. Hong>

By Ezra Klein  |  July 17, 2009; 5:10 PM ET
Categories:  Health Reform  
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I believe he was less than full throated regarding strong Public Option? True choice in the exchange for everybody?

Posted by: DrSteveB | July 17, 2009 5:41 PM | Report abuse

Why do Sen. Grassleys of the world feel sad about it? Our respected Senators are elected to do the honorable job of 'making laws' and we do not want their precious time spend in mundane things like setting Medicare fees. Let that job be done by someone else and let free these lawmakers on the big sky projects - meat grinding of law making...

Posted by: umesh409 | July 17, 2009 8:26 PM | Report abuse

He cannot sound persuasive about the rush he is demanding on something so massive and transformational, because there is no legitimate sounding reason for this to be done in eight or nine days. It's just a dictator like assertion of will at this point.

Posted by: truck1 | July 18, 2009 9:06 AM | Report abuse


Health care reform must a process, not an event.

As Gawande has said, you have to do it in phases. You can't flip a switch and turn a $2.6 trillion industry.

The House Bill makes it clear that it will be a 3 1/2 year process, with subsidies and the public option not kicking in until 2013.

The legilsation passed this year should be broad. Then they work out the details.

MedPac is key--and quite possibly empowering MedPac will pass in a separate bill--Jay Rockefeller's bill.

I'm quite certain the public option will be in the bill passed in October.
Blue Dogs who do not go along with the public option will not receive White House support when they run for re-election.
They may even find themselves in a primary.

That's how important the public optoin is--not just to social policy and healthcare, but to the economy.

Posted by: mahar1 | July 18, 2009 12:44 PM | Report abuse

"The so-called "pep talk" the president gave a few minutes ago could have benefited from a bit more pep."

Now Ezra, shouldn't we all realize by now that whenever President Obama does ANYTHING, there is always a sound reason behind it? Just because we aren't aware of the reason doesn't mean he hasn't accomplished whatever he intended to do.

Besides, I have the feeling his press conference on Wednesday night will have all the pep" you desire!

Posted by: NoBillary1 | July 18, 2009 1:04 PM | Report abuse

I'm not hearing anything about the 800lb. elephant in the room. Did somebody do TORT REFORM while I was on the toilet? What about the ILLEGALS? Have they stopped clogging up the EMERGENCY ROOMS at the Hospitals? What about, READING the bills? Has EVERYBODY read the bill? Has ANYBODY read the bill? Is this President a bigger LIAR then the last Democrat that was in there? Is it smart to put the HEALTH of our Families, in to the hands of the same people who have Bankrupted SOCIAL SECURITY and MEDICARE? The same folks that run AMTRAK, and The POST OFFICE? The same people -(CHRIS DODD and BARNEY FRANK) - who ASSURED US that "everything was alright"?, that "FANNIE and FREDDIE were sound"? All the while, they were recieving MONEY from these two outfits. Just like they recieved MONEY from COUNTRYWIDE, and BANK OF AMERICA, and CITI. Their wives, and, (in Barneys' case) their boy friends, sitting on BOARDS in these companies, drawing paychecks. 535 of the most CORRUPT, DISHONEST, ARROGANT, MONEY GRUBBING LIARS on the face of the planet. And you want them to TAKE CARE OF US? They only take care of THEMSELVES. They only do what's in THEIR interests. And their LEADER is the WORST of the bunch. The man who "sought out the MARXIST Professors" when he got to college. The man who started his political career, in the living room of a man who used to blow up BOMBS at the PENTAGON, and POLICE STATIONS. A man who sat in a RACIST, ANTI-SEMETIC CHURCH for 20 years, listening to a BIGOT espouse his HATRED for anything that wasn't BLACK. His HATRED for AMERICA. This is your guy? THESE are your GUYS? I've said it before, and I'll say it again...If you've ever wondered what the FALL of the ROMAN EMPIRE looked like? It looks like NOW.

Posted by: GoomyGommy | July 19, 2009 8:26 AM | Report abuse

Thank you for that rant. loved it. The only word you really needed in caps, though, is MONEY. The huge rush on this, alone, indicates suspicious motivation. The rushing, hustling behavior on the part of the administration is nothing less than frightening. People who are good stewards of the country simply don't behave like this.

Posted by: truck1 | July 19, 2009 8:44 AM | Report abuse

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