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Posted at 3:21 PM ET, 01/21/2011

Towards a better health-care debate?

By Ezra Klein

On the bright side, I do think you can detect some improvement on the quality of the Republican argument against the health-care law, at least if you look at elites. Take Charles Krauthammer's column, where he writes:

I've got a great idea for deficit reduction. It will yield a savings of $230 billion over the next 10 years: We increase spending by $540 billion while we increase taxes by $770 billion.

Or Greg Mankiw, who says:

I have a plan to reduce the budget deficit. The essence of the plan is the federal government writing me a check for $1 billion. The plan will be financed by $3 billion of tax increases. According to my back-of-the envelope calculations, giving me that $1 billion will reduce the budget deficit by $2 billion.

I take this as evidence that the smartest conservatives are finding it increasingly untenable to argue that health-care reform can't possibly reduce the deficit because it also spends money. They can't quite bring themselves to admit that health-care reform reduces the deficit, but these thought experiments are establishing the principle that it's theoretically possible for a bill like health-care reform to reduce the deficit. Baby steps, people. Baby steps.

My hope is that this will lead us toward a more honest debate over health-care reform, where supporters of the legislation argue that spending money to insure 32 million Americans is worth it and this is a pretty good way to do it and the bill's opponents either argue that it isn't worth it or they have a better plan. That's the real debate here. But it's been obscured by a lot of conservative flimflam over CBO scores. There's been a reason for that: The Republican party wants to oppose this health-care reform without being seen to oppose health-care reform in general and also without offering a comprehensive bill of their own. Arguing that this bill is based on lies allows them to do that. But a debate between different bills, or on the question of whether we need a bill, would be a lot more productive.

By Ezra Klein  | January 21, 2011; 3:21 PM ET
Categories:  Health Reform  
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Comments

"I have a novel weight loss plan:

eat an extra hamburger everyday,

and do an extra two hamburgers worth of exercise everyday."

or

"I have a novel weight loss plan:

drink two less beers every day,

and get one less beer's worth of exercise in every day."


You can look at it either way; either way I'm sure people will agree that 'repeal' of either of these programs (to include drinking two more beers every day or cutting two burgers worth of daily exercise out of your life) is a horrible first step toward a better weight loss program.

Reasonable waistline-reducing modifications to one of these plans would either entail cutting out that extra burger or getting that extra beer's worth of exercise.

I'd be very interested in seeing the Republicans come forward with a plan that either only increased the PPACA related taxes, or only decreased PPACA bennies.

Posted by: eggnogfool | January 21, 2011 4:05 PM | Report abuse

Ezra says:
"My hope is that this will lead us toward a more honest debate over health-care reform, where supporters of the legislation argue that spending money to insure 32 million Americans is worth it..."

My hope is that Democrats will be more honest about exactly how much it does cost to insure 32 million Americans, and stop waving around a CBO report that crumbles under any minimal amount of scrutiny.

Posted by: dbw1 | January 21, 2011 4:10 PM | Report abuse

More accurately, a guy who goes out jogging an hour each night feels he isn't getting to spend enough time with his kids. So he cuts a half an hour out of his daily jog, but cuts an hour-jogs worth of calories out of his diet by skipping morning donuts and switching to diet soft drinks.

Posted by: eggnogfool | January 21, 2011 4:12 PM | Report abuse

dbw1 just ropped the donkey! Amare style dunk on Ezra.

Posted by: cdosquared5 | January 21, 2011 4:23 PM | Report abuse

Now, now... the snippet from Krauthammer's begins "Suppose someone - say, the president of United States - proposed the following". Thereafter follows the "I've got a great idea for deficit reduction. It will yield a savings of $230 billion over the next 10 years: We increase spending by $540 billion while we increase taxes by $770 billion." The opinion then concludes that someone making such an argument would "be laughed out of town."

Financial debates aside, there seems to be little or no debate that there are simply not enough providers willing to provide care to those "covered" by the expanded "insurance" "subsidized" by the PPACA. Even the CBO and Ezra Klein have written about the lack of providers. So what's going to happen with all of this "coverage"?

Moreover, what happens if a court reinstates the now-nullified individual mandate and the subsidies are unfunded? Doesn't this mean that a substantial portion of the population will be paying a penalty -- or a tax, as the Justice Department now seeks to call it -- due to their inability to pay for the mandated "coverage"?

Once again, it's important to note that the views of PPACA advocates (a) did not prevail in the last free election, (b) did not prevail in a decisive federal Court case, and (c) continue to succumb to the careful scrutiny of skilled financial analysts.

There is relatively little to debate, as the PPACA is essentially dead law, even if it is never repealed: as Joseph Califano (a staunch Democrat and former Secretary of Health, Education and Welfare) noted during a television appearance with Ezra Klein last year, the PPACA simply lacks the support necessary to make it effective.
It shouldn't have been enacted and, at this point, repeal is necessary before effective replacement legislation can be developed.

Joe Califano has been around the block a few times... and I encourage review of his statements from last year.

Posted by: rmgregory | January 21, 2011 4:24 PM | Report abuse

I find it more encouraging that C. Krauthammer says that Republicans aren't absolved from replacing HCR: "They [Republicans] will and should be judged by how well their alternative addresses the needs of the uninsured and the anxieties of the currently insured." At least addressing the uninsured is on their radar.

And speaking of the uninsured: Wasn't insuring everyone supposed to reduce health care costs in general? I don't see that as one of the deficit reducers in the CBO score. But if insuring everyone reduces health care costs, which is the government's biggest expense, wouldn't it reduce the budget that way too? Am I missing something?

Posted by: lucasblower | January 21, 2011 4:34 PM | Report abuse

By the way, speaking of omissions... a previous post regarding the "Founder's Health Care Mandate" had a number of them.

The reference 1 Stat 605 (July 16, 1798) begins "the master or owner of every ship or vessel of the United States, arriving from a foreign port into any port of the United States, shall, before such ship or vessel shall be admitted to an entry" -- thereby regulating the commercial activity of those who engage in international shipping. In fact, the headnote to the Act states "Twenty cents per month to be deducted from the wages of seamen, COMING FROM A FOREIGN VOYAGE in a vessel of the United States."

To say that the Act regulates inactivity is hogwash.

The Act is a useful example, though, in that it required PREPAYMENT of all federal costs related to the medical care of seamen -- and it's a joy to see Democrats touting prepayment (rather than borrowing) as a health care funding mechanism.

Posted by: rmgregory | January 21, 2011 4:36 PM | Report abuse

I do not recall the Right Wing commenters being so silly or vocal when it came to giving $billions to the Rich for their tax cuts for absolutely zero return.

Maybe I better go back in the archives to check.

Nah.
Not worth the effort.

Posted by: grat_is | January 21, 2011 4:40 PM | Report abuse

"And speaking of the uninsured: Wasn't insuring everyone supposed to reduce health care costs in general? I don't see that as one of the deficit reducers in the CBO score. But if insuring everyone reduces health care costs, which is the government's biggest expense, wouldn't it reduce the budget that way too? Am I missing something?"

lucasblower,

No, it will increase costs via increased demand for health care services.

Premiums for many individuals will go down as:

- Young healthy individuals will be paying the community rate (e.g. $4,500 instead of $1,500).

- Young healthy individuals not currently insured will have to buy it ($4,500 instead of $0).

- Many people will get tax subsidies to offset the cost of the premiums.

But you don't funnel $1 trillion into an industry and expect costs to fall.

Posted by: justin84 | January 21, 2011 4:52 PM | Report abuse

justin84:
"But you don't funnel $1 trillion into an industry and expect costs to fall."

True that, Justin. For example, consider how much taxpayer money has been funneled into secondary education over that past 20-30 years (via Pell Grants, taxpayer-backed student loans, etc), and then look at the cost trajectory of average annual tuition over the same time period. Has it decreased? I say nay.

The more government subsidizes and pours money into an industry, the more prices tend to go UP, not down. To expect this historical experience to magically change with health care reform and believe Democrats and progressives when they say health care costs will decrease the more taxpayer money is put into it....well, it's ludicrous to accept the rationale.

Posted by: dbw1 | January 21, 2011 5:20 PM | Report abuse

There's a reason this was a debate over health reform, and not just health coverage. In order to reform floundering institutions or businesses, there has to be new pilot experiments to be tested, as well as, filling in gaps in existing organizational structure. If a business sees that its IT infrastructure is woefully inadequate to compete in the marketplace, they will hire some IT guys, and sink some money in. The bill's dual mandate of reforming, as well as, extending coverage seems to be frequently missed.

Posted by: RyanS1 | January 21, 2011 6:17 PM | Report abuse

@rmgregory Why is it that the right sees no reason to be skeptical that giving rich people more money will cause the free market to do something good for everyone without specifying what... but when specific money is actually moved to a specific purpose without specifying how the market will move toward that money... they react with assurances that the market is simply too dumb to figure out a way to reach it. I think you either need a little more faith in the free market or a little less.

Posted by: BoringOrange | January 21, 2011 8:40 PM | Report abuse

I don't think we are going to have a serious debate or significant changes to national health care law for another year or so. There are too many lies and nonsensical talking points still floating around to have the serious debate capable of improving it. We don't need to scrap the law and start over to get something better, but I do think we need to scrap the debate and start over with a new debate... which takes time.

The campaign of fanatical fear-mongering nonsense was a winning strategy for the far right only as long as they could speak in generalities, like "repealing the job killing bill" they call "Obamacare." Sounds good, but it won't happen. So, if they really want to gut it, they have to start going after individual components of the law, and that presents a huge problem for them, because that means they have to start debating the individual components at finer and finer levels of detail, and they lose the public debate on the vast majority of those components. So, I suspect this issue will fade away for a little while.

Posted by: BoringOrange | January 21, 2011 8:46 PM | Report abuse

When I read Krauthammer it makes me want to scream. In this case, "Have you never heard of compromise?!"

You combine some cuts with some spending and you can pass a bill that increases the deficit on net while accomplishing goals that people other than conservatives care about too.

They're arguing that it can't reduce the deficit because it doesn't *only* reduce the deficit. They're idiots.

Posted by: zosima | January 21, 2011 10:04 PM | Report abuse

Ezra:

I'll be interested in the Democrats in congress voting against the "doc fix" that they traditionally support every year to take care of medicare cost increases. That is the ongoing assumption in the bill-that some congress down the road will heavily penalize doctors and other health care workers and thereby magically achieve savings.

The bill's logic-let's assume we save $500 billion-and then we'll spend it over here to bring more people into the system.

That assumption is in the CBO scoring, but it won't happen.

Just like it didn't happen last year.

BTW-how's the Journolist work going? Getting ready for the next campaign?

Posted by: Towson_Tiger | January 21, 2011 10:04 PM | Report abuse

When I read Krauthammer it makes me want to scream. In this case, "Have you never heard of compromise?!"

You combine some cuts with some spending and you can pass a bill that reduces the deficit on net while accomplishing goals that people other than conservatives care about too.

They're arguing that it can't reduce the deficit because it doesn't *only* reduce the deficit. They're idiots.

Posted by: zosima | January 21, 2011 10:05 PM | Report abuse

I dont feel like i should be forced to have health insurance, I think everyone would like to have health insurance if they could afford it. If you need affordable health insurance search online "Wise Health Insurance" you dont want to be with out insurance any time.

Posted by: carriemann | January 22, 2011 3:01 AM | Report abuse

I found a site where you can get coupons for restaurant called "printapons" they are on all over the news, search online

Posted by: helenrae | January 22, 2011 3:44 AM | Report abuse

Study basic reading comprehension. Krauthammer is not engaging in a thought experiment, but in sarcasm. His recent column was nothing but an attack on "Affordable" Health Care. A while ago he imagined a poll in which people were asked: would you like an Omaha steak delivered on Monday, flowers every Tuesday, and so on, and they said yes -- until the bill arrived on Sunday. He compared this to the polls about individual features of "Affordable" Health Care reform. He wasn't trying to prepare himself to accept such polling methods, but rather to expose the folly of them.

Posted by: truck1 | January 22, 2011 7:44 AM | Report abuse

this is quite informative, thanks for the post.
http://www.writessay.com

Posted by: write_thesis | January 22, 2011 11:28 AM | Report abuse

"But you don't funnel $1 trillion into an industry and expect costs to fall."

Fundamentally wrong on two counts. (1) This makes it seem as if the money would NOT be spent on this anyhow. The real question is whether we pay it through the front door or through the back door. (2) Smarter spending can reduce cost growth, no question about it -- look at hospital cost growth reduction in Massachusetts, which was not even designed to try to control costs.

Posted by: Lee_A_Arnold | January 22, 2011 11:32 AM | Report abuse

"This makes it seem as if the money would NOT be spent on this anyhow. The real question is whether we pay it through the front door or through the back door."

You really think that a person going from uninsured to comprehensive insurance, or from a catastrophic plan to comprehensive insurance, isn't going to demand any additional health care services? Wasn't that the whole point of this endeavor - increasing "access"?

"Smarter spending can reduce cost growth, no question about it -- look at hospital cost growth reduction in Massachusetts, which was not even designed to try to control costs."

Smarter spending is a nice soundbite, but it's easier said than done. The smartest spending, I might add, is done by individuals with their own dollars.

Do you have a source for the cost growth reduction in Massachussetts hospitals? And if so, does that source account for health care spending growth falling nationally in the wake of the recession? Doesn't it matter a bit that MA is staring off with the highest hopsital costs in the nation, and only seeing a reduction in the rate of growth?

In any case, health care costs are destroying the state budget.

http://www.boston.com/lifestyle/health/articles/2011/01/03/ballooning_medicaid_costs_strain_bay_state_budget/

Massachussetts spends roughly $12 billion/yr on health care - add in local government health care spending, and it is roughly $2,000 per capita, or $8,000 for a family of four. This doesn't include any Medicare spending done by the federal government.

http://www.usgovernmentspending.com/#usgs302a

And look here: primary physician shortages!

http://www.massmed.org/AM/Template.cfm?Section=Home6&CONTENTID=36180&TEMPLATE=/CM/ContentDisplay.cfm

A quick Google search reveals several Massachussetts hopsitals laying off workers. Not a whole lot, just yet, but it's a cummulative process.

Already, the Boston metro area has dreadful wait times (an average of 49.6 days on average for 5 surveyed specialties vs. 27.0 for the next highest metro area and less than 20 on average if you exclude Boston).

http://www.merritthawkins.com/pdf/mha2009waittimesurvey.pdf

If cost control measures actually see some success, expect more shortages to follow.

Posted by: justin84 | January 22, 2011 5:41 PM | Report abuse

"You really think that a person going from uninsured to comprehensive insurance, or from a catastrophic plan to comprehensive insurance, isn't going to demand any additional health care services?"

Basically, yes.

People just want to be well. Very few people want to be a doctor's office or in a hospital.

If we nip things in the bud, then treating them costs less. When they are not covered, we are paying for them anyhow, (and paying more for them), in our own higher insurance premiums and county taxes.

NBER says that after reform, Massachusetts saw reduced hospital cost growth, compared to the rest of the country: Shorter hospital stays, less admissions for preventable conditions, less in-patient admissions from the emergency room. An uptick in request for doctor appointments, but no apparent increase in demand from the newly insured for inpatient care.

http://www.nber.org/digest/nov10/w16012.html

"Doesn't it matter a bit that MA is staring off with the highest hospital costs in the nation, and only seeing a reduction in the rate of growth?"

What is wrong with a reduction in the rate of cost growth?

"And look here: primary physician shortages!"

Do you think we are going to increase the supply of primary physicians by restricting the demand for them?

Posted by: Lee_A_Arnold | January 22, 2011 10:12 PM | Report abuse

There is no escaping the Black Hole of Medical Costs. We hedonistic Americans demand our cake and eat it too and there is no saying NO to AARP, Transplants, Dialysis, Bypasses, Implantable Defibrillators, Pacemakers etc etc. We have the BEST Health Care in the world if you factor in the Hedonistic Quotient. If the rest of the world stops subsidizing us (Our Currency, Paper is our No. 1 export but I mean the green stuff) we'll have to divert funds from the Military and Terrorism Industrial Complex into Healthcare. Sorry.

Posted by: liverkit | January 23, 2011 2:04 PM | Report abuse

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