Can there be a constructive entitlement debate?

Something must be done about entitlements – specifically Medicare and Medicaid. Smart, informed, forward looking people like David Walker, former comptroller general of the United States, have been sounding the alarm for years. It took the shock of trillion-dollar deficits (ironically almost entirely unrelated to entitlement spending) for their calls to be heeded.

Unfortunately for America, the calls are being heeded at a time of unprecedented partisan bickering and gridlock, meaning the potential for a constructive debate about what to do to rein entitlement spending is somewhere between slim and none.

This was driven home while I was reading a post by Ross Douthat on his New York Times blog last week discussing the dicey politics of the Republican plan. As Douthat said, “the constituency most resistant to Paul Ryan’s Medicare reforms seems to be conservative-leaning blue collar voters — what the Pew Research Center, in a recent report, calls the ‘Disaffecteds.’ ”

Losing this segment of the populace could cost the Republicans dearly. Douthat noted there are essentially two ways to deal with this political problem:

One is what you might call the cynical Sam’s Club strategy, which involves attacking the Democrats as big-government socialists from one corner of their mouths while promising to defend entitlements (the real driver of government’s growth, of course) to the death from the other corner. This was the Republican approach during the health care debate, and it’s a reasonably effective strategy — so long as you don’t actually care about limited government or the looming fiscal dégringolade.

Douthat said the better, less cynical, more productive approach “is to champion entitlement reform in a way that reassures blue-collar voters, and addresses their (entirely valid) economic concerns.” As Douthat said, the Ryan budget – “packaging a sweeping Medicare reform together with something that looks like just another supply-side tax cut, with a repeal-but-don’t-replace health care bill thrown in for good measure” – probably doesn’t fit that bill. He then pointed to a David Brooks column and an earlier column of his own that both suggested a different sort of plan, one that spread the pain more evenly while still adhering to conservative, small-government principles.

A budget more completely informed by small-government egalitarianism might try to make the recent payroll tax cut permanent, rather than just cutting income tax rates. It might attack handouts for oil and natural gas companies as well as those for alternative energy, and slash agricultural subsidies more dramatically than the Ryan budget does. While thinning out the maze of tax deductions, it might expand the earned-income tax credit and the child tax credit, both of which make it easier to earn a decent living and form a stable family. While trying to repeal Barack Obama’s health care plan, it would insist on replacing it with the kind of universal tax credit that Ryan himself has previously championed.

That’s when it struck me: The Republican Party today is far, far more likely to engage in the “cynical Sam’s Club strategy” – however hypocritical and ineffective – than it is to offer up genuinely constructive solutions of the type outlined by Douthat, especially if those genuinely constructive solutions might be portrayed by Tea Party radicals in any way, shape or form as tax hikes.

Today’s Republican Party is no more concerned about fiscal responsibility than the party that nearly doubled the federal debt during the last period it controlled both Congress and the White House. Indeed, Dick Cheney’s “deficits don’t matter” seems to remain the governing mantra. Deficits don’t matter; only cutting social spending does. The Pentagon remains sacrosanct. Utterly failed tax cuts for the wealthy must be preserved. For Republicans, the cause is spending they don’t like, not deficits.

And, America, it doesn’t take a genius to realize that, the shameless “we’ll save Medicare” pandering of the 2010 election cycle aside, Republicans don’t like Medicare spending.

America needs have a grown-up discussion about what to do about Medicare costs – which, unless you want to throw granny to the wolves, means having a grown-up discussion about how to curtail health care inflation. So far, Republicans are absent from that discussion. President Obama has proposed the Independent Payment Advisory Board, which grown-ups who actually know quite a lot about health care policy think will make a difference. The GOP has proposed vouchers for seniors to buy private insurance – vouchers that would cover less than the cost of care – with no mechanism beyond the vaunted “private marketplace,” which has proven less than adequate at restraining health care inflation, to actually lower prices.

You can only have a grown-up debate when both sides are acting like grown-ups.

Call it ‘Medi-scare’ if you like, it’s still true

Apparently, Republicans have a new definition of demagoguery: Telling the truth about what Republicans want to do.

After Democrat Kathy Hochul won a special election in New York on Tuesday largely by attacking the Republican plan to privatize Medicare championed by Rep. Paul Ryan, Ryan said this:

And what they do in this particular case with Medicare, they are shamelessly demagoguing it and distorting this — we call it Medi-scare — to try and scare seniors.

Yglesias had a good post yesterday pointing out the long pedigree of the term “Medi-scare.” William Safire accused Bill Clinton of engaging in “Medi-scare” when he attacked then-House Speaker Newt Gingrich for a plan to slowly privatize the program. Gingrich, remember, admitted that his plan and hope was for Medicare to “whither on the vine.” Pointing that out was decried as demagoguery. Bob Dole hit the same note during the 1996 campaign:

Instead of working with Republicans and with the Democrats to try to secure, preserve and strengthen Medicare, the President chose to engage in a campaign to scare American seniors. We call it Mediscare! Mediscare! Mediscare! All the ads you see in Florida, all the ads you see in Florida, are negative Mediscare ads!

Again, the Republican plan wasn’t to secure, preserve or strengthen Medicare. It was to see it whither on the vine. To be fair to Gingrich, his plan was far less radical than Ryan’s. He would have preserved traditional Medicare while instituting a private option that he hoped would make the public option look unattractive. As a cost-savings mechanism, however, that approach has been pretty well proven not to work.

So, is it still Medi-scare if it’s true? For all of Ryan’s complaints about demagoguing and distorting, Democrats have been doing little more than describing what the plan would actually do: Replace Medicare’s guaranteed health coverage with vouchers for private insurance – vouchers almost guaranteed not to cover the full price of care. Now there’s been some silliness from usually reliable fact-checking organizations about whether ending Medicare as we know it is the same thing as ending Medicare, but the basic outline of Ryan’s plan is indisputable – and pretty well understood by the public, it seems to me. And the public hates it.

That’s not demagoguery.

Obamacare is exceeding estimates already

Though it doesn’t take full effect until 2014, the Affordable Care Act is already decreasing the number of uninsured, and it is doing so in ways that should help lower the cost of insurance for everyone, says Rick Ungar at Forbes. Provisions in the law allowing grown children to stay on their parents’ insurance until age 26 has brought hundreds of thousands of young people into the ranks of the newly insured.

As Ungar says, this is very, very good news:

Because the under 26 crowd tends not to get sick, adding them to the insurance pools helps bring the very balance that was intended by the new law.  The more healthy people available to pay for those in the pool who are ill (translation- the older people), the better the system works and the lower our premium charges should go.

Of course, this is the entire idea behind the Affordable Care Act. If everyone is insured, the pool will be large enough, and full of enough healthy people, to truly spread the risks and the costs and make care more affordable for everyone.

Note that this is the exact opposite of what Republicans are trying to accomplish with their approach to Medicare. There, they want to foist a pool of older, sicker Americans onto a private market that no one has any reason to believe wants them – and they want to give seniors vouchers to pay for that insurance that they know won’t cover even current health care costs.

Obama’s approach is working. The Republican plan is a disaster waiting to happen.

Everything you need to know about Ryan’s Medicare plan in one sentence

In a speech attempting to defend his widely panned budget plan – even Newt Gingrich called it radical – U.S. Rep. Paul Ryan, R-Wisc., revealed perhaps more than he intended about his attitude toward his main target: Medicare.

As he discussed the steps he believes are necessary to keep Medicare solvent and that he believes will rein in health care costs, he said this: “As we strengthen welfare for those who need it, we propose to end it for those who don’t.”


Most seniors, who have been paying into Medicare their entire lives, do not consider Medicare coverage “welfare.” Redefining it as such, which – like similar attempts with Social Security – makes it easier to cut a program that just about every senior citizen depends upon today. Ryan’s plan would turn a single-payer plan that guarantees coverage into a privatized voucher program that guarantees seniors will pay far more for health care coverage than they do now. Somehow, this is supposed to lower costs – though his plan depends on the willingness of the insurance industry to cover the oldest, sickest, poorest segment of the population.

Medicare is not welfare. It is a plan to cover those private insurance doesn’t want to cover. It is in trouble mainly because health care costs are rising out of control. Ryan’s solution will do absolutely nothing to rein in those costs. Instead, it will shift them onto those in our society who can least afford them.

Gingrich was right to call this plan “radical” and “right-wing social engineering.”

Why the mandate is constitutional

The luck of the draw wasn’t kind to Virginia Attorney General Ken Cuccinelli: The three-judge appellate panel randomly assigned by computer to hear the appeal of his suit challenging the constitutionality of health care reform came up with three judges appointed by Democrats. If recent history is any guide, they will find uphold the individual mandate as constitutional. So far, every judge appointed by a Democrat has ruled in favor of the mandate; every judge appointed by a Republican found the mandate unconstitutional.

That’s an unfortunate partisan breakdown from the judicial branch, which should be insulated from politics.

But while luck was against Cuccinelli, so is the law. The individual mandate is constitutional, and the key of the argument for it can be found in Cuccinelli’s own comments in a news conference following the hearing:

The insurance mandate penalizes people for not engaging in commerce.  In other words, you can get fined for doing nothing.

But the fact is that it is impossible to choose not to engage in the health care market. You can hope you won’t need health care. You can pray you won’t need it. You can save and scrimp so that you can pay routine health care bills yourself. But the way the current system is set up, only incredibly wealthy Americans can guarantee they will never need more health care than they can afford.

The individual mandate, then, does not penalize people for choosing not to engage in commerce. It penalizes people for expecting society to cover their costs if they unexpectedly fall ill or are involved in a serious accident.

No one argues that the health care market is not subject to congressional regulation under the Interstate Commerce Clause. And when the argument is correctly framed, it is also pretty clear that the individual mandate is a rational and proper exercise of that regulatory authority.

Republicans acknowledge health care reform repeal is dead

Well, it only took five months, but House Republicans finally realized that, on their own, they cannot undo a bill passed by Congress and signed into law last year by President Obama.

Of course, anyone with any sense and a marginal understanding of how the U.S. government works (which apparently does not include the House leadership) understood on the day after last year’s elections that Republicans didn’t make enough gains to actually carry out their promise to repeal the most significant health care reform law in a generation. They regained control of the House by a significant margin, but fell short in their bid to retake the Senate. That meant they controlled one-half of one-third of the federal government.

That didn’t stop House Republicans from making their first act when taking over the House passage of the most juvenile and incorrectly named bill I’ve ever seen: “Repealing the Job-Killing Health Care Law Act.” Never mind that private sector job growth had been plugging right along, especially in the health care field, since the bill passed. The entire exercise was futile, of course, because a repeal was dead in the Senate and would face a certain veto by President Obama if it passed.

Rep. Dave Camp, R-Mich., chairman of the powerful House Ways and Means Committee, finally acknowledged what everyone else has known for months: “Is the repeal dead? I don’t think the Senate is going to do it, so I guess, yes.”

Yeah. Duh.

Camp said his inclination was to work instead on repealing the most controversial portion of the reform bill: the individual mandate. The constitutionality of the mandate is being challenged in the courts. The problem, of course, is that the mandate is a keystone of the law. The reform act prohibits insurance companies from denying coverage because of pre-existing conditions. Without some sort of mechanism to keep people from waiting until they need insurance to buy it, that provision could bankrupt insurance companies.

There are alternatives to the mandate (which was originally a Republican idea, let us not forget), but most of them have serious drawbacks if the goal is to actually ensure Americans have health care coverage when they need it. For instance, there could be open enrollment periods. If you don’t get insurance during one of those periods, you would either be ineligible to get it later or would have to pay a late-enrollment penalty. So, if you find yourself needing insurance, you’d either be out of luck or have to pay a significant fine, even as you’re facing a serious illness. Other proposals would require proof of health care insurance to receive certain government services or have lack of coverage be considered by credit rating agencies.

But let’s have a discussion about reasonable alternatives. In fact, let’s have a reasonable discussion about the best way to achieve the goals of health care reform: Universal coverage and a sustainable rate of increase in costs. It would have made more sense to have that discussion back when the bill was being debated, but Republicans were too intent on ensuring the final bill had absolutely no stamp of bipartisan approval. President Obama would have welcomed the debate back then, and there’s no reason not to have it now, especially if Republicans truly comprehend that repeal isn’t an option.

Ending the plan to end Medicare as we know it

The fat lady appears to have sung on Paul Ryan’s radical proposal to end Medicare as we know it and replace guaranteed health care benefits with completely inadequate vouchers for private insurance. Even House Speaker John Boehner seems to realize that the proposal won’t survive budget negotiations.

But America won’t forget that House Republicans supported this disastrous proposal, and even passed it as part of a budget that did little for the deficit, raised taxes on the middle class and gave the wealthy huge tax breaks.

And if the American people are inclined to forget about this, something tells me Democrats won’t let them.

In the meantime, even though Medicare may be safe, Ezra Klein reminds us that Republicans still want to destroy Medicaid and have a shot at succeeding – which would have disastrous consequences for millions of vulnerable Americans.

The Republican crusade against abortion

You know, there’s a lot going on in this nation and the world that could use attention from Congress. The economy is sputtering. The long-term debt is out of control. Coal mines aren’t safe places to work. Port security isn’t what it ought to be (let’s not let down our guard just because Osama bin Laden is dead). So what did House Republicans take time out of their busy schedule to do today: Pass a restrictive anti-abortion bill that has zero chance of becoming law.

The bill would enshrine in permanent law the Hyde Amendment, which for years has prohibited spending federal money on abortions through Medicaid and most other federal programs. The Hyde Amendment must be reapproved occasionally. This law would be permanent.

But, naturally, it goes further. The No Taxpayer Funding for Abortion Act prohibits health insurance policies that cover abortion from receiving federal tax credits through the Affordable Care Act. Such credits, after all, act as an indirect subsidy of abortion. It also prohibits deducting the cost of an abortion as a health care expense.

Not only that, if the health plan you’re covered by includes coverage of abortion – even if you would never think about getting an abortion – you lose the ability to deduct all your health care premiums from your taxes. This is huge and would inevitably result in most major insurance plans dropping coverage for abortions.

This is how Republicans believe the world ought to be: No individual mandate to require people buy insurance, but a federal mandate ensuring that the insurance people do buy does not include coverage for a medical procedure they disagree with.

Again, there are more important things happening in this nation that demand congressional attention. This is the party the American public gave control of the U.S. House to last November. Buyers’ remorse yet?

Why health care needs to be fixed

Ezra Klein had a must-read post yesterday about health care in America featuring three graphs that show why health care in the United States is driving this nation off a fiscal cliff. The most telling of the three graphics is this one showing the increase in costs in the United States and other nations:

As you can see, other nations are seeing increasing costs, too, but the curve in the U.S. is far sharper. That is the single largest driver of our structural deficit problem. In fact, without this increase, and its projected continuation, the United States doesn’t have a structural deficit problem. If the deficit is the main issue we ought to be concerned about (I know I’m sounding like a broken record here, but it’s not), then health care is the area of that issue we need to concentrate on the most.

President Obama got a start on that with the Affordable Care Act, which Republicans are doing their best to overturn – even though doing so will make the deficit worse.

The report that Klein cites shows, once more, that the United States pays far more for health care than any other nation – twice the GDP of the United States is devoted to health care spending as it is in Great Britain even while 50 million Americans aren’t covered by insurance. Our system is inefficient and fragmented to the extreme. As Klein pointed out, “we’re spending more on government-provided health care than most countries where government-provided health care is pretty much all there is.”

Even though the Affordable Care Act was painted as an extreme socialist plan, the plain fact is that it didn’t go nearly far enough. The United States cannot afford the path it is on. It’s way past time to find a new one.

Yglesias on the sensible conservative alternative to health care reform

Matt Yglesias gets this exactly right this morning: The sensible conservative alternative to the Affordable Care Act is the Affordable Care Act:

If you simply do what Ponnuru and Levin propose, every insurance company will be competing to make a profit that’s attractive to young men with no chronic health problems and unappealing to everyone else. To turn this idea into an idea that actually works for people with medical needs you need to do three things. One, you need to prevent firms from turning customers away because of their health status or demographic characteristics. Two, you need some kind of regulatory definition of the minimum benefits that need to be offered in order to qualify as “health insurance” that’s eligible for the tax credit. And three, you need some kind of penalty for failing to enroll yourself in a plan to ensure the existence of a viable risk pool. What you need, in other words, is the Affordable Care Act and its regulate/subsidize/mandate tripod structure.

I don’t think it can be reiterated enough: Despite the fact that conservatives smeared the Affordable Care Act as some sort of socialist takeover of the health care system, it is, in fact, a very conservative, free-market oriented approach to health care reform – and it’s full of ideas that conservatives not only should love, but many ideas that conservatives actually developed: including the now-reviled individual mandate.

Had the Affordable Care Act been introduced by Republicans as a response to a single-payer proposal from Obama – something that could honestly be called a “government takeover of health care,” conservatives undoubtedly would have embraced it.