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Posted at 10:01 AM ET, 01/31/2011

Is this what conservatives are reading about health-care reform?

By Ezra Klein

I can't tell whether this column by Mona Charen is an uncommonly sophisticated deception or simply confused:

President Obama has budgeted $635 billion for Obamacare over the next decade. Even those not given to panic, like the CBO, estimate that $1.2 trillion is closer to the mark. But even that is probably way too low. The bill doesn’t really kick in until 2014. From 2014 to 2024, the more likely costs will be $2.5 to $3 trillion.

This isn't just apples to oranges: It's apples to limes to zucchinis to starfruit. It's a number salad, but it's cleverly composed. Most of the numbers actually do come from somewhere. If asked where you got them, you could point to a document, or a report, or an expert. You'd just have to hope the reader didn't actually go look at that document or report or expert.

The $635 billion comes from the 2010 budget, which was released in February of 2009, before the Affordable Care Act was written. It is not the amount Obama "has budgeted" for health care. It was a "downpayment" of money he wanted to put towards health-care reform. The idea was that the president was showing his commitment to paying for the bill by identifying more than $600 billion in funding at the beginning of the process. But this was never intended to pay for health-care reform, nor stand as an estimate of the bill's 10-year cost. As the conservative Heritage Foundation noted at the time, "The budget narrative even says that 'additional funding will be needed.'" The budget now, of course, includes about a trillion dollars in funding for health-care reform over the next 10 years.

The $1.2 trillion doesn't come from the Congressional Budget Office, as Charen says it does. Their estimate of the legislation is easy to find, and it's a shade over $950 billion. Check the table here. The $1.2 trillion is a number made up by opponents of the health-care bill like Cato's Michael Cannon. As he explains, to get to $1.2 trillion, you have to add in "the additional $208 billion that Democrats plan to spend on physicians who participate in Medicare." This, unfortunately, takes us down a whole other rabbit hole: It's not "Democrats" who plan to spend that money. It's "Medicare," with the support of both Democrats and Republicans. That money, in fact, needs to be spent because of something Republicans did in 1997. It has nothing to do with health-care reform, and it's needed even if the bill is fully repealed.

As for the $2.4-3.5 trillion estimate, that took me a little longer to track down. According to CBO, the law spends about $800 billion between 2014 and 2019. Adding five years onto that estimate seems unlikely to more than triple it. So how did Charen get to $3 trillion or so? It seems to come from an unexplained table attached to the end of a March press release from the minority staff on the House Budget Committee. The table appears to include so-called discretionary costs -- which, as CBO has explained, are not in the legislation because they predate it and are already in the budget (i.e., the Indian Health Service) and/or because Congress hasn't actually decided to spend the money -- and the unrelated Medicare spending that Cannon sunk into the legislation. There might be some other Easter eggs I'm missing.

It's also worth noting that the CBO -- who, as Charen says, "is not given to panic" -- estimates that the legislation will reduce deficits by a bit more than a trillion dollars between 2020 and 2029. That information doesn't make it into her column, as you might imagine.

The point here isn't to pick on Charen. The point is that conservatives are being deceived by the people they trust when it comes to the health-care bill. That process of misinformation might also be happening among conservative elites, as you can see in the transmission from Cannon to Charen. Now, I can't say whether Charen knows better and is attempting to mislead her readers by repeating this stuff or is honestly confused. I can say she has at least three factual errors in a paragraph that only includes three facts, that the National Review published it, and that it seems plausible that this is the sort of work that conservatives are using to form their impressions of the law.

By Ezra Klein  | January 31, 2011; 10:01 AM ET
Categories:  Health Reform  
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Comments

There's a third option: Charen and her readers don't care what is factually true or not because they have pre-decided to oppose health care reform based on their conservative ideology and the fact that Obama/Democrats/liberals support it. So columns like this are not actually about the details of health care reform. Instead they are a form of communal hate screaming out, "HEALTH CARE REFORM BAD!"

Posted by: redwards95 | January 31, 2011 10:07 AM | Report abuse

I don't know if the numbers are correct or they're made up but the first thing that came to mind is, Aren't the Chinese ecstatic that we chose to do HCR on THEIR dime? Think about it. That's all borrowed money there. Borrowed from them. No wonder their economy's humming and ours is stagnant.

Its amazing how you can say he's "paying for the bill" and not realize he's paying for it with borrowed money. That's not paying for it. its putting off the inevitable pain of it.


If I owe $50k on my credit cards and take a vacation on a new card I just got it doesn't mean I'm fiscally responsible, it means THE EXACT OPPOSITE.


Posted by: visionbrkr | January 31, 2011 10:14 AM | Report abuse

Mona Charen has been doing this for decades. She's a Republican hack who will say or write whatever the current party "talking points" are. Yes, she lies, and her readers don't care. The point for Republicans is not to find the truth but simply to win the argument.

Posted by: marvyT | January 31, 2011 10:17 AM | Report abuse

visionbrkr -

*sigh* It's not borrowed money. It was paid for by a combination of things, including Medicare cuts that conservatives were for before they were against.

Listen, everyone likes scoring points on internet message boards. But take a step back and think about what you're doing. Conservative critiques successfully maneuvered Democrats into paying for their signature domestic proposal with politically difficult spending cuts.

If, rather than giving them credit, you're now going to go and attack them for it, then what hope does our country have of ever balancing the deficit. Think about what you're doing to our country. And then explain that to your fellow conservatives.

Posted by: CarlosXL | January 31, 2011 10:26 AM | Report abuse

To quote Suzyn Waldman when she saw Roger Clemens show up in Steinbrenner's box at Yankee Stadium, "oh my goodness, goodness gracious!"

Ezra's post here is so full of errors and fallacies I'm not sure where to start. I won't have time to cover them all, so how 'bout some highlights:

"The point is that conservatives are being deceived by the people they trust when it comes to the health-care bill. "

You mean like Ezra and other progressive-honks have been deceiving people for the past year with their indefensible defense of the "CBO score" of the ACA? It's been proven over and over to be chock-full of bad math and unrealistic assumptions (by REAL financial analysts), yet Ezra continues to point to it as gospel, like when he says above....

"It's also worth noting that the CBO....estimates that the legislation will reduce deficits by a bit more than a trillion dollars between 2020 and 2029."

Allow me, for the benefit of those readers Ezra seeks to deceive, post the passage from the CBO regarding this estimate of the impact of the ACA in the 2020-2029 period (which, as you might imagine, didn't make it into Ezra's column):
"Although CBO does not generally provide cost estimates beyond the
10-year budget projection period, certain Congressional rules require some
information about the budgetary impact of legislation in subsequent decades... THE
IMPRECISION OF THAT CALCULATION REFLECTS THE EVEN GREATER DEGREE OF UNCERTAINTY THAT ATTENDS TO IT [emphasis mine], compared with CBO’s 10-year budget
estimates."

And given how much we know now about how far off many of the CBO's projections in the FIRST ten years are, for Ezra to pull out this completely fictitious 'trillion dollar deficit reduction' number for the second decade is stunning in it's attempt to deceive....the very thing he accuses Mona of doing!

Posted by: dbw1 | January 31, 2011 10:31 AM | Report abuse

Carlos,

Ya i get the "story" behind it. but the point I was making was that our deficit right now is what 1.5 trillion or so per year. So if those cuts were to happen then the deficit would be that much less.

How politically difficult were spending cuts that included reduction in payments to insurers (ie Medicare Advantage), reduction in payments to Medicare providers that may or may not happen and tax increases etc.


As far as balancing the deficit I'm all for ending the wars that we shouldn't be in anyway. reduce the pentagon budget dramatically but again that won't be enough either to make up $14 trillion and counting.

But the point is when you're figuratively underwater on your mortgage you don't go out and buy a new second home.

Posted by: visionbrkr | January 31, 2011 10:33 AM | Report abuse

"That money [Medicare doc fix], in fact, needs to be spent because of something Republicans did in 1997."

'Something the Republicans did'? I know progressives are pitiful when it comes to knowing their history of this country, but surely you remember who was President in 1997, right? Didn't Clinton sign that bill?

Sheeshh, Ezra....your column today may take the cake compared to the normal amount of inaccuracies and revisionist history that tend to be hallmarks of your posts.

Posted by: dbw1 | January 31, 2011 10:40 AM | Report abuse

"Listen, everyone likes scoring points on internet message boards. But take a step back and think about what you're doing. Conservative critiques successfully maneuvered Democrats into paying for their signature domestic proposal with politically difficult spending cuts."


But that's not true at all. Nobody has ever paid for Medicaid or unemployment benefits.

Posted by: krazen1211 | January 31, 2011 10:49 AM | Report abuse

redwards95:
"There's a third option: Charen and her readers don't care what is factually true or not..."

I invite you to take the time to scroll back over the message boards beneath prior columns of Ezra's on the ACA. Myself and others have put forth a litany of facts about the inaccurracies in the CBO score of the ACA, yet neither Ezra nor other left-wingers on the boards can address them successfully. Conservatives are more than willing to talk 'facts' about health care reform. What we are not willing to talk about are ficticious assumptions used in the CBO report.

If you can't defend the ACA using facts (which puts you in good company with the other left-wingers on the board) then perhaps you should just move on?

Posted by: dbw1 | January 31, 2011 10:51 AM | Report abuse

Any projection of the 10-year fiscal impact of legislation is a guess. All projections are based on assumptions which almost never hold true for that long. The Republicans will have their guesses and the Democrats will project the opposite. The only really neutral guess is the CBO's.

Posted by: marvyT | January 31, 2011 11:09 AM | Report abuse

@dbw1,

You just don't understand statistics or mathematical modeling at all, and have clearly been mentally overwhelmed by all the conservative hackery you read. That CBO statement you highlighted is true of any temporal model prediction as you predict further into the future, and just represents the CBO being honest about the relative certainty of different parts of their reported predictions. That doesn't change the fact that the best, most honest assessment out there, one which if anything undervalues the savings that could come from the experimental bits of the bill, predicts massive savings, so even if your ideologically motivated ignoring of all but the worst possible and unlikely case turns out correct, then that just means we're in the left tail and we're just not saving money, but still aren't spending more than we would have without the bill.

Posted by: goodepicwashpost | January 31, 2011 11:18 AM | Report abuse

visionbrkr -

I'm afraid you're mistaken.

The money comes essentially from TAXES & FEES

As well, 500 billion in SAVINGS in Medicare costs. Basically, the OVERpayment of subsidies to MORE than compensate Health Insurance COMPANIES. Plus other waste & fraud savings.

That money that is CUT & then REDIRECTED to Health Care, ORIGINALLY comes from taxes to Employees & Employers (MEDICARE PAYROLL TAX)

So 500 billion in SAVINGS from Medicare

& a 410 billion "increase [in] federal revenues (mostly by increasing the
Hospital Insurance payroll tax and imposing fees on certain manufacturers
and insurers)" ( CBO, http://bit.ly/HR2cbo )

For the 2012-2019 period:

500B + 410B = 910B in revenue NOT borrowing

910B - 780B (cost) = 130B to REDUCE our DEBT

PLUS the CBO estimates that Health Care REFORM would "REDUCE federal budget deficits during the 2020s..around one-half percent of gross domestic product (GDP)" ( http://bit.ly/HR4872cbo )

260 Trillion x .5% = 1.3 Trillion

SO through the END OF THE 2020's

Health Care Reform PAYS OFF 1.43 Trillion of our DEBT.


Posted by: OversightOfGovt | January 31, 2011 11:19 AM | Report abuse

@dbw1,

You just don't understand statistics or mathematical modeling at all, and have clearly been mentally overwhelmed by all the conservative hackery you read. That CBO statement you highlighted is true of any temporal model prediction as you predict further into the future, and just represents the CBO being honest about the relative certainty of different parts of their reported predictions. That doesn't change the fact that the best, most honest assessment out there, one which if anything undervalues the savings that could come from the experimental bits of the bill, predicts massive savings, so even if your ideologically motivated ignoring of all but the worst possible and unlikely case turns out correct, then that just means we're in the left tail and we're just not saving money, but still aren't spending more than we would have without the bill.

Posted by: goodepicwashpost | January 31, 2011 11:19 AM | Report abuse

goodepicwashpost:
"You just don't understand statistics or mathematical modeling at all..."

I do statistics and forecast-modeling for a living. I always find it amusing when myself or other conservatives are lectured about 'not understanding math', by left-wingers who (of course) typically include no math whatsoever to defend their position.

But I will be more than happy to indulge you if you care to take up defense of any of the following samples of clear CBO misses (so far, that we know of) in their score of the ACA:

- high-risk pools ($15B-$20B miss...at least; could miss by as much as $125 Billion per a labor-union funded supporter of the ACA [the NIHCR])

- small employer tax credit ($20B-$30B miss Yr 1; could miss $200B-$300B over the first ten years)

- Medicare 'savings' not sticking (at least $100 billion miss, and that's being quite conservative)


The point, goodepicwashpost, is that anyone who 'understands statistics or mathematical modeling' will also understand that the likelihood for accuracy is higher in the near-years, and decreases as you get further out in time.

And, given the monumental misses in the CBO score for just those items we know about in the FIRST year, how any left-winger can continue clinging to what the CBO report says about 5-20 years in the future is the epitome of "idealogically motivated ignoring of all but the BEST possible cases..."

Posted by: dbw1 | January 31, 2011 11:48 AM | Report abuse

@oversight of govt,


ya i get the talking point.

I also get that those numbers are not set in stone and can go either way.


If you understood what I was saying you'd see that I'm saying that any increase in funding (over and above what we take in, in a year) is borrowed.

BTW that means we're borrowing the continue two wars, pentagon funding for projects that the Pentagon said they don't want (because the jobs for those projects are supposedly worth more than what it will cost us years from now to pay off the debt.


@goodepicwashpost,

what you also aren't mentioning is the the CBO only gives its figures based upon numbers coming in. if you really believe you can cover 32 million people more than are being covered now with just some additional taxes, less giveaways to insurance companies and no more doctors than before and have little or no adverse affects on the current healthcare system you really are naive.

Posted by: visionbrkr | January 31, 2011 11:56 AM | Report abuse

dbw1: And your solution to skyrocketing health-care costs & under- or non-covered health-care users would be?.....

Posted by: bigfish2 | January 31, 2011 11:57 AM | Report abuse

OversightOfGovt:
"PLUS the CBO estimates that Health Care REFORM would "REDUCE federal budget deficits during the 2020s..around one-half percent of gross domestic product (GDP)"

Please see my post above that includes the CBO's own disclaimer regarding the high-uncertainty of this projection you cite, and then answer this: name one government entitlement program that either 1) saved MORE than the CBO originally estimated, or 2) cost LESS than the CBO originally estimated.

Find just one example, and perhaps people would be more willing to indulge this silly notion of how much money the ACA is going to 'save' us, and how the nirvana-of-savings will be even more than the CBO estimated in their preference for 'conservatism'.

Posted by: dbw1 | January 31, 2011 11:57 AM | Report abuse

@visionbrkr

I DON'T DISAGREE that if you DON'T PAY for NEW SPENDING, then you're just putting it on the National CREDIT CARD.

HOWEVER, that's NOT the case with HEALTH CARE REFORM.

Think of it as a combination of the DEMOCRATIC budget rule PAY-AS-YOU-GO

and the REPUBLICAN budget rule CUT-AS-YOU-GO.

About HALF was payed w/INCREASED income &

about HALF w/a budget NEUTRAL reorganizing of EXPENSES (think of it as TIPPING LESS in order to PURCHASE more at a RESTAURANT)

Posted by: OversightOfGovt | January 31, 2011 12:13 PM | Report abuse

bigfish2:
"And your solution to skyrocketing health-care costs & under- or non-covered health-care users would be?....."

Well, less federal government involvement would be a good start. Think about this....over the past 20-30 years, whether talking health care, education, or whatever....have costs DECREASED the more the FEDERAL government got involved? Hmmmmm......

I believe the best solutions are localized....states, cities, and municipalities everywhere already had lots of programs and subsidies to help the uninsured get health care. That's why it's been a fallacy from the beginning that lack of insurance = lack of health care. I've posted several times, but would be glad to post again, of several programs/non-profit clinics in my area that have been covering the 'uninsured' for years....but whom Democrats think will be able to see a doctor for the first time thanks to the ACA.

And having relatives who are providers, one of the first things (not last things) any serious effort at health care reform would have done would be to address medical malpractice (and the trial lawyers helped ensure that the Democrat version of 'health-reform' would be anything but serious).

Show me any left-winger who argues medical malpractice reform is insignificant and I'll show you a left-winger who has 1) never seen a P&L statement of a provider to realize how much costs are incurred and passed on to patients to cover their malpractice insurance, and 2) not talked to doctors to understand how much of the 'over-testing' demonized by liberals like Ezra is due to fears of being sued, NOT because of greed to generate more income.

However, I'm guessing if you are like most left-wingers, any solution that does not involve a FEDERAL government program and more bureaucracy is no solution at all.

We all saw that the Democrat solution is to solve a 5% problem by upsetting the apple cart for the other 95% with an intrusive big-government bureaucracy-exploding 'solution' that will do nothing to lower costs, and will increase the deficit.

Posted by: dbw1 | January 31, 2011 12:20 PM | Report abuse

@oversight of govt,


forgetting about more of your talking points (ie cut go vs pay go which are both a load of crap) i'll simply mention that when my wife balances her check book and I balance mine if she's negative more than I'm positive then we're overall negative.

oh and btw when you tip less in order to purchase more in a restaurant the next time you go there you can expect worse service (especially if they know you as a poor tipper)

Posted by: visionbrkr | January 31, 2011 12:33 PM | Report abuse

"about HALF w/a budget NEUTRAL reorganizing of EXPENSES (think of it as TIPPING LESS in order to PURCHASE more at a RESTAURANT)"

But you're putting the whole meal on the credit card, and you are so far in debt you shouldn't be eating at a restaurant in the first place...

Posted by: justin84 | January 31, 2011 12:34 PM | Report abuse

"i'll simply mention that when my wife balances her check book and I balance mine if she's negative more than I'm positive then we're overall negative."

I'll simply mention that analogies to household budgeting generally suck.

Posted by: pseudonymousinnc | January 31, 2011 12:44 PM | Report abuse

@dbw1: Can you name a single piece of legislation that was projected to lower the deficit by over a trillion dollars that ended up increasing it? How about has any tax cut ever resulted in lowering the deficit? Or maybe has voting any Republican into office as President lowered the budget in the past 30 years?

But, even if you assume your premise (which I disagree with, as Social Security has brought in more revenue than spent) that all past 'entitlements' are more expensive than projected, that doesn't equate to all future entitlements will be more expensive than projected. HCR has less in common with Medicaid and Medicare than it does finical reform.

Show me any rightwinger who argues that tort reform is a good thing, and I'll show you a person who believes that we should be limiting the freedoms of individuals to seek redress in legal system. Who are you to state that a person only deserves x amount of money for any kind of medical error.

Do you really believe that a young women who has her set on fire during a cosmetic removal of a mole shouldn't be able to seek damages in court, even though she is scared for life? http://www.lawyersandsettlements.com/features/medical_malpractice/medical-malpractice-negligence.html

Why do you have so little faith in our justice system that a family whose daughter died during a routine outpatient surgery because unqualified, unsupervised individuals were doing what they weren't supposed to do and then the hospital tried to hide the facts should only be able to receive $250,000 in punitive damages? And because of the damage cap, the family couldn't find a lawyer who would take the case, until a firm agree to do it Pro Bono. Any idea how many hours it takes to put a case like this together? http://www.latimes.com/news/local/la-me-ucla-death-20110122,0,5352148,full.story

How much are your family members worth to you? What kind of emotional damages do you think a daughter is worth? Why should law makers be making these decisions?

Or maybe you could explain why Texas's tort reform laws have failed so miserably. Here's a challenge: Name one instance in which tort reform laws have lowered health care costs.

Posted by: DavidCEisen | January 31, 2011 12:56 PM | Report abuse

@pseudo,

oh come on why? because they don't continue your talking point? If we were talking about the Wars in Iraq and Afghanistan (of which I expect we agree that we should not be there, should never have been there) then that analogy would work better for you, no? Come on and call me a shill for old time's sake, ok.

Posted by: visionbrkr | January 31, 2011 12:58 PM | Report abuse

""about HALF w/a budget NEUTRAL reorganizing of EXPENSES (think of it as TIPPING LESS in order to PURCHASE more at a RESTAURANT)"

But you're putting the whole meal on the credit card, and you are so far in debt you shouldn't be eating at a restaurant in the first place..."

But the United States government has a fiat currency, a AAA rating, and pays the lowest interest rates in the world. When you go out to dinner and when the government spends money have nothing in common. Its a nice narrative.

Before anyone starts screaming that eventually we will have too much debt, find I agree, but you don't need to create false equivocations between how the government and you balance your
'checkbooks.' If you could borrow money at the same interest rate the US government can, then you would be an idiot not to borrow as much money as humanly possible asap. (Again not saying the government should, just pointing out the comparison is dumb)

Posted by: DavidCEisen | January 31, 2011 1:04 PM | Report abuse

Any solution to our country's health care problems will require government involvement. No country has successfully implemented a private, completely unregulated health care market with effective outcomes.

It is important to note the specifics of the health care industry before throwing out the typical "less government is always better" talking point. The problem of rising uninsured people was a problem of the private sector's creation. Left to their own devices, they cherry-picked their customers based on pre-existing conditions. They did this because it was profitable. The only exception was the large employer-based pool (which, as it turns out, was more regulated).

It's important to look at the incentives for each of these players and then it becomes clear why there are problems. The economic incentive of the private insurer is to pick the healthiest population and then not pay for anything. They are not going to act in a way that is not profitable unless they are forced to do so. The ACA does this by forcing them to take all comers, but also forcing everyone to buy insurance.

Ask any provider how they rate their dealings with the private insurance industry. Actually, ask them how many people they employ full-time just to ensure they get paid for the services they provide. The overhead alone has been estimated to add 10-12% of our health care costs.

State or local-based efforts have largely failed to either control costs and cover the uninsured. A notable exception is Massachusetts which has done both to some extent, and largely why the ACA was based on it. Texas, which is highlighted by many conservatives as a pillar of deregulation has the nation's highest percentage of uninsured individuals.

Take HR 3400 as an example. This used health savings accounts and allowed people to purchase insurance across state lines while largely preserving the current insurance regulations - as expected the projections were that it would cover an extra 3 million people (not even accounting for population growth during the first 10 years), while proving them with lower quality insurance (a "race to the bottom" if you will). Many of these were low-actuarial-value, high deductible plans, which are almost equivalent to no insurance at all.

It's time we got past these arguments that deregulation is the only answer. Too much regulation is bad I agree, but I don't think we're anywhere near that point. We need smart regulations that protect consumers and align public and private players with the correct incentives. The ACA does take some steps to do that, and it will take time to see how much improvement we can get out of it.

Posted by: kmani1 | January 31, 2011 1:17 PM | Report abuse

Tough Crowd.

Am I detecting some bias in these posts?

nah

Posted by: OversightOfGovt | January 31, 2011 1:19 PM | Report abuse

"But the United States government has a fiat currency, a AAA rating, and pays the lowest interest rates in the world. When you go out to dinner and when the government spends money have nothing in common. Its a nice narrative."

I'd agree that they aren't that similar, but primarily because a going to a restaurant isn't that hazardous to anyone's budget.

The government's spending spree is far more dangerous by comparison.

In any case, the main point is that the ACA's spending is being financed entirely by debt, which has been denied by various liberal commentators here.

Yes, we get that ACA cuts Medicare spending, but that spending was *already on the credit card*.

Posted by: justin84 | January 31, 2011 1:26 PM | Report abuse

"In any case, the main point is that the ACA's spending is being financed entirely by debt, which has been denied by various liberal commentators here."

I'm sorry but this doesn't make any sense. By that logic 100% of what the government does is financed by debt. Even shrinking the deficit is funded by debt, I guess. If you are truly worried about the deficit you should be pissed over the extension of tax cuts, which were financed completely through deficit borrowing.

Posted by: DavidCEisen | January 31, 2011 1:34 PM | Report abuse

"In any case, the main point is that the ACA's spending is being financed entirely by debt, which has been denied by various liberal commentators here."

I'm sorry but this doesn't make any sense. By that logic 100% of what the government does is financed by debt. Even shrinking the deficit is funded by debt, I guess. If you are truly worried about the deficit you should be pissed over the extension of tax cuts, which were financed completely through deficit borrowing.

Posted by: DavidCEisen | January 31, 2011 1:36 PM | Report abuse

We ALL understand that CBO projections are BASELINES used by policymakers to compare the effect of the LAW/BILL against CURRENT LAW.

It's understood that Congress will continue to pass laws & the economy will take unexpected turns; both of which will ALTER the forecast

Predicting the Future is INHERENTLY inaccurate. Everyone knows it! Take weather forecasters for example.

As INACCURATE as we all know that they BOTH are, we rely on them to PLAN for the future NOW.

I'll give one more shot at the ANALOGY, just for FUN:

Think of it as LESS money spent from the MEDICARE FUND on giveaways (subsidies) to Health Insurance Companies

AND using that money to pay for Health Care Reform. (I hope the analogy fits)

NO NEW UNPAID SPENDING (projection ONLY of course)


Posted by: OversightOfGovt | January 31, 2011 1:36 PM | Report abuse

"Yes, we get that ACA cuts Medicare spending, but that spending was *already on the credit card*."

So if you have 50K on your credit card mostly due to doctor bills, you pay for a gym membership/quality food by cutting in your budget elsewhere, get healthy so now you don't have to go to the doctor as often and save money in the long-run, you shouldn't have done any of this because you had 50K on the credit card originally?

::bangs head on table repeatedly::

Posted by: foAGubFB | January 31, 2011 1:43 PM | Report abuse

"No country has successfully implemented a private, completely unregulated health care market with effective outcomes."

Then again, no country has really tried to do so either, so it doesn't really mean much that it hasn't successfully been done. There would never have been a United States of America with that attitude.

"The problem of rising uninsured people was a problem of the private sector's creation. Left to their own devices, they cherry-picked their customers based on pre-existing conditions. They did this because it was profitable."

You do know that the dominance of the for profit insurance model was a direct result of government intervention into the health care market, don't you?

That the employer provided comprehensive health insurance model was a result of government policy?

Posted by: justin84 | January 31, 2011 1:46 PM | Report abuse

I understand the inclination to want to make the argument that Health Care reform is put on the CREDIT CARD, because w/MOST spending, that argument is perfectly VALID.

I use the CREDIT CARD analogy all the time, because it's easier to understand than referring to BONDS.

Money is fungible. The US has a GENERAL FUND. We have MORE bills than we have CASH to pay for it. So we get more CASH w/LOANS(bonds) from China/Japan/us/others.

So you could make the argument that just about any of our bills are put on the CREDIT CARD. (Not EVERY bill at the same time of course)

HOWEVER, it's harder to make that argument w/Health Care Reform since it points to SPECIFIC sources of REVENUE to PAY for it.

It's easy to say that the 13 Month extension of UNEMPLOYMENT Extended Benefits or Medicare PART D were put on the CREDIT CARD, because they POINTED to NOTHING as a payment source.

One more REAL try at the ANALOGY. Say you went to the RESTAURANT w/money you SPECIFICALLY EARNED from your SECOND job getting lousy tips at a BAR where you provide lousy service because of the bad tips. (happy, visionbrkr?)

Posted by: OversightOfGovt | January 31, 2011 2:01 PM | Report abuse

"So if you have 50K on your credit card mostly due to doctor bills, you pay for a gym membership/quality food by cutting in your budget elsewhere, get healthy so now you don't have to go to the doctor as often and save money in the long-run, you shouldn't have done any of this because you had 50K on the credit card originally?"

Actually, you're just cutting doctor bills for one group of people and creating all new doctor bills for a second group.

Eating better and going to the gym would indeed cut down on doctor bills, but the ACA doesn't do anything like that. All it does is provide cost insulation to more people, driving up utilization and prices of health care services. Nice try though.

Posted by: justin84 | January 31, 2011 2:10 PM | Report abuse

DavidCEisen:

You made so many ridiculous points, I ran out of characters trying to point them all out....so I'll just have to limit my critique to a few:

"HCR has less in common with Medicaid and Medicare..."

How does this make any sense at all? The ACA creates a new entitlement which puts taxpayers on the hook for trillions (that's with a 't') of health care costs for the indefinite future. It's actually quite similar to the M/M entitlements in that respect.

"Show me any rightwinger who argues that tort reform is a good thing..."

I'm not sure what you don't understand. It's a fact beyond question that fears of lawsuits cause providers to over-test, which is one of the largest areas of spiraling health care costs. Quoted in that 'conservative-hack' newspaper, USA Today:

"The fear of missing something weighs heavily on every doctor's mind. Many ER doctors say the No. 1 reason is fear of malpractice lawsuits. "It has everything to do with it," said Dr. Angela Gardner, president of the American College of Emergency Physicians."'

The so-called studies that claim medical malpractice costs remain relatively unchanged as a percentage of health care costs over time ignore one fairly important fact: those studies only look at actual malpractice claims and payouts. They ignore the upward cost pressure created by over-testing, to which Ezra was referring as the product of 'greed', but which most doctors will tell you occurs because of malpractice lawsuit fears.

By the way....I noted you failed to produce a single example of a federal entitlement program that has come in with less costs and/or more savings than projected, and instead launched into red-herring anecdotal sob-stories of malpractice victims. Given that my mom went through a horrific case of malpractice two years ago, I don't really need to be told of the realities of real incidents of malpractice.

I'm not an expert on every state, but I know in my state which DOES have tort reform the $250k limit you cite would not apply to the serious case (death) to which you seek to tie it. It only applies in cases where no life-altering long-term damage is done, and therefor creates a great dis-incentive by those seeking to turn any little slight in their care into a lottery ticket.

If you are even a little bit willing to look at the facts of malpractice lawsuits, you will find an inordinate number are frivolous....and THAT is what drives up our medical costs via over-testing.

Posted by: dbw1 | January 31, 2011 2:19 PM | Report abuse

"Then again, no country has really tried to do so either, so it doesn't really mean much that it hasn't successfully been done. There would never have been a United States of America with that attitude."
Incorrect America tried this after Clintoncare failed." The result? The number of people without health insurance went from 14% to around 18%. The amount of premium dollars spent on administration costs increased from 10% to almost 20%.
Another example of America trying to use the free-market to lower health care costs is Medicare advantage. That failed as well, and the hundreds of billions of dollars in wasteful spending it created was cut in order to pay for health care reform.
So like pretty much every conservative you are lying and complete clueless.

Posted by: mynameisblehbleh | January 31, 2011 2:26 PM | Report abuse

As usual, dbw is claiming some very speculative numbers as "clear misses" in the CBO score, which is ironic because he is saying the CBO used bad numbers...

The high risk pools are currently vastly undersubscribed relative to estimates. In fact, some Republicans tried to make this a talking point to bash HCR, claiming that a lack of participation meant that the bill was either poorly designed or not necessary. DBW would have you believe that his speculative numbers are clearly right, but he's given us no reason to believe them over the CBO's, when the only actual fact from is that the CBO overestimated year 1.

For the small employer tax credit, he lazily extrapolates extra year 1 costs. For all his talk about being a finance professional and relying on good math, this is a tremendous error. It is an unfounded assumption, and one that we can see an obvious error in when we note that when small businesses take tax credits to provide insurance to their employees, those same employees will no longer be eligible for subsidized insurance in the individual policy market. An increase in one is more or less an equivalent reduction in the other, so while the CBO may have gotten the balance between the two wrong, the costs wash, and any good accounting (the "math") has to note that.

Third, he basically just assumes that Medicare can't be cut, claiming the CBO is "at least" $100 billion off, also without justification. And before you assume he is correct, notice how much differently PPACA cuts Medicare than the 1997 bill that created the "doc fix" problem. In short, the PPACA cuts are pretty defensible in a world where 60 Senators are needed to overturn them.

Basically, before you buy dbw's claim that the CBO is cooking the books and the numbers he cites are "fact", please know that they are anything but.

Posted by: sanjait | January 31, 2011 2:28 PM | Report abuse

kmani1:
"Texas, which is highlighted by many conservatives as a pillar of deregulation has the nation's highest percentage of uninsured individuals."

1) you do understand that 'uninsured' does not equal 'can't get health care'?

2) how many of the 'uninsured' counted in Texas are illegal immigrants?

Posted by: dbw1 | January 31, 2011 2:29 PM | Report abuse

"Eating better and going to the gym would indeed cut down on doctor bills, but the ACA doesn't do anything like that. All it does is provide cost insulation to more people, driving up utilization and prices of health care services. Nice try though. "
Except for the fact that any analysis of ACA shows that it REDUCES overall health care spending. Nice try though.

Posted by: mynameisblehbleh | January 31, 2011 2:29 PM | Report abuse

"1) you do understand that 'uninsured' does not equal 'can't get health care'?
2) how many of the 'uninsured' counted in Texas are illegal immigrants?"
1) I realize that conservatives think that going to the emergency room means you have access to health care, but here in the real world we realize that that isn't true. But then gain we cant expect you to be basing anything on something you've no clue about.
2) I see so your saying that we should determine the uninsured rate by cherrypicking and not counting every person.
By the way California has almost double the percent of illegal immigrants the Texas and Flordia has about the same rate, yet those states don't have as high of uninsurance rates

Posted by: mynameisblehbleh | January 31, 2011 2:40 PM | Report abuse

A pre-emptive note on why we should believe Medicare cuts in PPACA will stick:

Most of the cuts to Medicare come in two categories, as visionbkr noted before: Medicare Advantage and provider payments.

Medicare Advantage is a program that allows private insurers to manage Medicare cases. Before PPACA, the government gave private insurers a premium over existing Medicare costs for no good reason (other than that insurance lobbyists are very good at what they do). The cuts to this program simply bring MA payments in line with regular Medicare. The program was set up to show how much better private insurers supposedly could do the job than the government bureaucrats at Medicare, and now they get to actually prove that without the crutch of ~20% higher payment from the government. Does this not seem like a politically defensible cut to make?

The reduced payments to providers will give some people visions of the reduced physician payments growth rate in 1997 that led to the annual "doc fix". Obviously, that cut didn't stick, but before you assume all provider payment cuts are equivalent, notice that the PPACA cuts are quite different. They cut payment rates to hospitals rather than physicians. Physicians can select their clientele, so they have a lot more market power. The "doc fix" started happening because nobody was willing to accept the idea of physicians abandoning Medicare payments en masse. Hospitals basically must accept all comers, and Medicare is their biggest customer by far, so their market power is greatly reduced. They cannot and will not refuse Medicare patients. Some people argue they will go broke with reduced payments under PPACA, but this is hooey. To the hospitals, the cuts to Medicare reimbursement rates are more than offset by the decreased rate of non-payment by uninsured individuals (since PPACA subsidizes and forces people to be insured...). Before you assume that hospitals are going to go broke because of PPACA, recognize that all the major hospital trade associations enthusiastically supported the bill.

So why should we believe this cuts can't or won't stick? Especially in a world where 60 Senators are required to pass legislation...

Posted by: sanjait | January 31, 2011 2:44 PM | Report abuse

I'm glad we have dbw1 and his merry band of strawmen here to help us to understand why nothing can get done in this country. Given his rich assortment of friends and relatives who have provided him with keen insight into every aspect of the healthcare debate and who have provided him with sufficient indisputable evidence that each and every provision of PPACA is in error we now know how to proceed.
We should simply ignore all economic and fiscal analysis of providing healthcare in this country and simply institute tort reform that allows for no monetary damages to be awarded. Thus no one will get sick or need treatment since there's no money in it for them or their ambulance chasing attorneys. Apparently this is the sole contributor to the high cost of health care. I'd readily give up my right to sue if it meant that I no longer had to worry about needing medical care.

Posted by: mikemfr | January 31, 2011 2:51 PM | Report abuse

@dbw1: Again, can you name a single piece of legislation that was projected to lower the deficit by more than one trillion dollars, which ended up actually increasing the deficit? Or can you site a single example of tort reform lowering medical costs?

"If you are even a little bit willing to look at the facts of malpractice lawsuits, you will find an inordinate number are frivolous....and THAT is what drives up our medical costs via over-testing."

This argument makes no sense, though. If a lawsuit is frivolous, it will be thrown out of court. A cap on damages doesn't affect this at all. All you are saying is that Washington should set up "Life-Altering Damage Panels," which will job whether or not injuries suffered are serious enough to bring to court. Presumably anyone can try to prove that any damage done to them is life-altering, which, by the way, doesn't prevent individuals from bringing frivolous claims to court.

Posted by: DavidCEisen | January 31, 2011 2:58 PM | Report abuse

sanjait:
"dbw is claiming some very speculative numbers...

Well, let's walk through them then, shall we?

"high risk pools are currently vastly undersubscribed relative to estimates..."

You forgot to add, "but costing more than expected". http://www.washingtonpost.com/wp-dyn/content/article/2010/12/27/AR2010122702343.html
http://www.healthleadersmedia.com/content/HOM-253020/Not-Enough-Money-for-HighRisk-Pools-CBO-Says

"For the small employer tax credit, he lazily extrapolates extra year 1 costs...

True, sort of. The CBO estimated 200,000-250,000 small businesses would take this tax deduction. In the first year, we find out (thanks to Ezra) that nearly 4 million will qualify. If you can come up with a reason why 4 million would qualify for just one year, and only 200k or so will qualify for years 2-10...then I'll rethink my point. But for the time being, I'm assuming that given the eligility rules for claiming the deduction the actuals for years 2-10 will be closer to the 4 million number provided by Ezra, and not the 200k number assumed by the CBO.

"....we can see an obvious error in when we note that when small businesses take tax credits to provide insurance to their employees, those same employees will no longer be eligible for subsidized insurance in the individual policy market. An increase in one is more or less an equivalent reduction in the other..."

This actually false. Quite false. According to the group that Ezra used for his estimate of the 4 million small businesses that would qualify, the majority were already offering health insurance....i.e., there will be little or no change in the number of employees who would qualify for subsidized insurance on one side of the ledger in return for tax credits given away on the other.

"Third, he basically just assumes that Medicare can't be cut, claiming the CBO is "at least" $100 billion off, also without justification."

Again, your point is false. I outlined this more in depth last week, but don't have time to go to the same detail every time I post about the same thing. The CBO used the assumption that 100% of 'efficiency savings' would pass back to the government via them cutting provider reimbursement rates (in spite of the CBO's own disclaimers about this assumption that I copied and pasted previously). Again, how much harder would you work if you knew 100% of the incremental income would go to someone else? Feel free to look back at my post on Ezra's board last week related to this; it was quite lengthy, perhaps a bit boring...but presumably what you must be looking for as 'justification'.

Nice try, sanjait. But once again, facts refuse to join the side of ACA defenders. Next.....

Posted by: dbw1 | January 31, 2011 3:03 PM | Report abuse

mynameisblehbleh:
"I realize that conservatives think that going to the emergency room means you have access to health care....we cant expect you to be basing anything on something you've no clue about."

1) I have a close relative that has run a non-profit clinic for years, providing health services to the poor and uninsured.

2) I have an even closer relative (who lives in my house) that is a provider, and volunteers free time when needed at a local non-profit clinic that takes care of the uninsured.

3) One of the largest hospitals in the country (where my mother was seen in the past couple years) has a plaque on the wall beside the entrance informing everyone up to 200% of the poverty rate to check at the business office as they may qualify for free or subsidized health care in that facility under existing state and local support programs...and that was before ACA was ever passed.

So feel free to figure out what YOU are talking about before chiming in....

Posted by: dbw1 | January 31, 2011 3:11 PM | Report abuse

mikemfr:
"and simply institute tort reform that allows for no monetary damages to be awarded."

Your inability to distinguish between 'tort reform' and 'no monetary damages' should give us a clue as to your lack of comprehension on this issue. Tort reform does not equal $0 paid to victims of real malpractice.

Oh, and I noted you failed to provide a single fact or analysis to refute any points....just more of the name-calling and attack-the-messenger tactics to which left-wingers are usually left to resort when they can't argue with the facts and numbers presented.

Posted by: dbw1 | January 31, 2011 3:22 PM | Report abuse

Dbw1: I noticed you have yet to give one fact supporting the notion that tort reform lowers medical costs and prevents or discourages frivolous lawsuits.

Posted by: DavidCEisen | January 31, 2011 3:25 PM | Report abuse

Dbw1:

Actually can you answer to following questions please:

1) Do you support the limiting of punitive damages in any other industry? How about in the auto-industry? Should Toyoto only have to pay up to a certain amount of money if their automobiles are shown to be faulty?

2) Can you name a single example of medical costs being lowered through tort reform?

3) Can you name a single example of a frivolous lawsuit resulting in more than $250,000 in punitive damages?

4) If you believe their should be exceptions for 'life altering damages,' who would decide whether or not the damages are truly life altering? How would this prevent someone from bringing forward a frivolous claim of life altering damages, and how would this differ from the current system?

Posted by: DavidCEisen | January 31, 2011 3:33 PM | Report abuse

DavidCEisen:
"If a lawsuit is frivolous, it will be thrown out of court. A cap on damages doesn't affect this at all.
...can you site a single example of tort reform lowering medical costs?"

Sure, glad you asked. At this point it's a little dated, but one source I liked to use was from 2004 when the CBO, after studying many of the state efforts on tort reform, stated:
"The most consistent finding in the studies that CBO reviewed was that caps on damage awards reduced the number of lawsuits filed, the value of awards, and insurance costs."

Even more state-level studies are out there if you care to look for them, but time and again just putting in damage caps have reduced frivolous claims....BEFORE the time and taxpayer expense of courts and judges had to be used to 'throw it out'.

"can you name a single piece of legislation that was projected to lower the deficit by more than one trillion dollars, which ended up actually increasing the deficit?"

Have to admit...you got me on this one. I can't think of a single piece of legislation that ever promised to deliver a trillion dollars of savings 20 years after it's passage. Please point me in the direction of such examples for me to look at. Or do you consider lack of any evidence of a bill ever over-promising benefits to the degree the ACA has promised to be all the proof you need that it will indeed deliver?

In the meantime, I see you yet again refuse to answer the previous challenge to provide an example of a government entitlement program that has come in under cost or over-savings estimates. I've answered all your questions, yet you continue to ignore mine. I'm guessing there is a reason for that....

While I can't think of any past bills that meet the challenge of a trillion-dollar-savings promise, there are lots of government entitlements for you to choose from if you care to answer this question I've now asked you three times.

Posted by: dbw1 | January 31, 2011 3:44 PM | Report abuse

http://www.insurance-reform.org/TrueRiskF.pdf
==malpractice claims, have decreased 45 percent since 2000.
==malpractice payouts have been decreasing since 2000
==malpractice insurance is worse then health care. 40% of malpractice costs are due to adminstrative fees.
==Malpractice premiumes have been decreasing the past 5 years.
==Tort reform in states has failed to have positive effect.
In some cases such as Iowa and Missouri, Iowa sa malpractice premiumes fall 6% while missouri saw them increase 1%
even though Missouri had tort reform laws.
==Melpratcie has a 40% payout loss ratio. Single-payer would save 40%, or 5.25 billion a year.

http://www.insurance-reform.org/TrueRiskF.pdf
http://wonkroom.thinkprogress.org/2009/02/09/gop-lawsuit/
==5% of doctors account for 55% of malpractice suits.
Only 2% of people who are effected by misconduct and malpractice sue their doctor.
http://www.centerjd.org/air/pr/AIRhealthcosts.pdf
http://www.joepaduda.com/archives/000243.html
==malpractice accounts for 1% of health care costs

Posted by: mynameisblehbleh | January 31, 2011 3:44 PM | Report abuse

Ezra,

Excellent exposition of the inherent stupidity and flawed logic of most conservative arguments. I have read a few of Charen's columns in years past and have always found her capable of making many stupid arguments. Great work.

Posted by: OHIOCITIZEN | January 31, 2011 3:54 PM | Report abuse

DavidCEisen:
"3) Can you name a single example of a frivolous lawsuit resulting in more than $250,000 in punitive damages?"

No, but I'm guessing I could find at least 1,000 examples of small-dollar frivolous claims that hospitals (and their insurers) had to spend tons of money defending.

Keep in mind, the point all along is not to prevent REAL malpractice lawsuits...it's to limit the frivolous ones that tend to be high-in-volume (read: clog-the-system) even if they are lower in dollar-amounts.

"4) How would this prevent someone from bringing forward a frivolous claim of life altering damages..."

Some states, like Ohio, now require the certification of a medical professional (typically a semi-retired M.D.) who serves as a step between potential victims of real malpractice and those just looking to cash out over any perceived mistreatment. The medical professional is not asked to determine the merits of the potential case; he's simply certifying that the alleged grievance represents potential REAL malpractice.

This step alone discourages the bottom-feeders among the trial attorney spectrum from filing lawsuits they themselves know to be nothing more than money-grabs....because the attorney or his patient has to front the money for the certification. Any attorney who sincerely believes they have a real case of malpractice will have no problem fronting the $5k (give or take) to get the medical certification before proceeding with a lawsuit.

On the other hand, an attorney who is just pushing large volumes of claims hoping for large volumes of small-dollar out-of-court settlements to go away....well, he's going to think twice about filing frivolous claims....

See my last post to answers for your other questions....

Posted by: dbw1 | January 31, 2011 4:01 PM | Report abuse

"Except for the fact that any analysis of ACA shows that it REDUCES overall health care spending. Nice try though."

Pure assertion. Do you have a source? Of course not, because if you did you wouldn't be spouting off such nonsense.

The Centers for Medicare and Medicaid Services (part of the Department of Health and Human Services, clearly a bastion of conservative zealots) had this to say:

"In aggregate, we estimate that for calendar years 2010 through 2019, NHE would increase by $311 billion, or 0.9 percent, over the updated baseline projection that was released on June 29, 2009."

https://www.cms.gov/ActuarialStudies/Downloads/PPACA_2010-04-22.pdf

So even the government thinks that this thing will cost a bit more, though the government appears quite optimistic that we can hold the line on spending growth so that we almost have a free lunch.

Who gives 32 million people increased access to a service, hold the service providers constant and expects total spending on that service to decrease?

It's just economics. Increased demand and constant supply lead to either increased costs or shortages, and when the government is involved it's often both.

Posted by: justin84 | January 31, 2011 7:07 PM | Report abuse

@visionbrkr

The cuts in HCR were part of a political compromise. They never would have happened on their own. To criticize Democrats for not passing the cuts alone is criticizing them for not living in some Tolkienesque apolitical fantasy world.

Posted by: zosima | February 1, 2011 1:00 AM | Report abuse

Ever wonder about all the free stuff you see on the web? It appears like everybody wants to give stuff away for nothing, nada, zilch. But are these items truly free of charge? If so, how can these companies afford to give away all of these coupons and samples? It’s truly all about you, the consumer. We live in a very competitive world marketplace place. The internet has upped the ante in terms of who could be seen and heard via all with the mass media. Now companies need to make lots of noise and this is one way that can do it. One of the best place on the web is called "123 Get Samples" and get your free stuffs

Posted by: marycruz234 | February 1, 2011 4:54 AM | Report abuse

Challenged to cite an example of tort reform lowering medical costs, dbw1 quoted the first sentence of the following paragraph from a 2004 CBO report on the effects of tort reform:

"The most consistent finding in the studies that CBO reviewed was that caps on damage awards reduced the number of lawsuits filed, the value of awards, and insurance costs (see Summary Table 2). One study of automobile-related torts found that caps on noneconomic damages decreased not only the value of noneconomic claims made to insurance companies but also the number of lawsuits filed. Other studies suggested that those caps led to increases in insurers' profitability for both medical malpractice and general liability insurance. (Evidence on whether premiums were affected was mixed.)"

In my view, dbw1's selective quoting from this paragraph is misleading.

Posted by: KennethAlmquist | February 1, 2011 4:00 PM | Report abuse

"1) I have a close relative that has run a non-profit clinic for years, providing health services to the poor and uninsured.

2) I have an even closer relative (who lives in my house) that is a provider, and volunteers free time when needed at a local non-profit clinic that takes care of the uninsured.

3) One of the largest hospitals in the country (where my mother was seen in the past couple years) has a plaque on the wall beside the entrance informing everyone up to 200% of the poverty rate to check at the business office as they may qualify for free or subsidized health care in that facility under existing state and local support programs...and that was before ACA was ever passed.

So feel free to figure out what YOU are talking about before chiming in...."

Getting a doctor visit at a clinic is not the same as health care.

Posted by: Dem_Bones | February 4, 2011 8:10 AM | Report abuse

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