Health Care


The Summit of Folly

So much for the pivot to jobs
February 22, 2010

In the latest issue of the Weekly Standard, my colleague Yuval Levin and I have a short editorial on the White House "summit"on health care coming up later this week. Here's a short excerpt:

It is now clear that the “summit” the president has called for February 25 is not intended to consider different approaches to health care financing, but rather to create an illusion of momentum that might just lull disoriented congressional Democrats into ramming the health care bill through the budget reconciliation process....

Leading up to the summit, Harry Reid, Nancy Pelosi, and White House officials aim to produce a bill that bridges not the yawning gap between Democratic and Republican proposals but the technical differences between House and Senate Democrats. The House and Senate bills do differ on some issues—a government insurance plan, the details of tax increases and Medicare cuts—but they agree on the big picture, which would be the essence of a combined bill: a massively ambitious, costly, intrusive, inefficient, and clumsy combination of mandates, taxes, subsidies, regulations, and new government programs intended over time to replace the American health insurance industry with an enormous federal entitlement while failing to address the rising costs at the heart of our health care dilemma.

It would raise taxes in a tough economic time, cut Medicare benefits without putting the program on a sustainable footing, create a new open-ended entitlement as we confront daunting deficits, and displace the insurance arrangements of millions.

The public has had a good look at all this for a year, and has hardly been tentative in its judgments....

One way or another, this ill-advised legislative process is nearing its end. It will either conclude with the Democrats putting their blinkered and misguided proposal aside, at last to pursue genuine, incremental, modest, and practical health care reforms addressed to the actual problems our system confronts, or it will end with the passage of a ruinous bill rejected by the public and likely to exacerbate both the collapse of our public finances and the explosion of health insurance costs.

It is now up to Republicans and the many Democrats in Congress who increasingly see the folly of their leaders’ ways to make sure this process concludes not with the enactment of Obamacare but with the initiation of a real health care debate. Listen to the voters: Scrap this bill and start over.

The full article is available here.

posted by James C. Capretta | 6:02 pm
Tags: White House summit
File As: Health Care

A Roadmap to Better Health Care

Thoughts on Paul Ryan’s Plans for Reform
February 22, 2010

Over at National Review Online, I take a look at Congressman Paul Ryan's "Roadmap" for entitlement and tax reform. The piece focuses on the reforms which are crucial to building a functioning marketplace in the health sector. An excerpt:

Elected Democrats and their allies have also taken note of Ryan’s proposal. Their main interest seems to be, as usual, in scaring seniors about supposed Republican “privatization” plots. In particular, liberals are focusing their anti-“Roadmap” fire on the proposal to convert the Medicare entitlement for those currently under age 55 into a system of fixed contributions toward the purchase of insurance.

Ryan’s opponents are right to highlight this reform. It is a dramatic shift from current law. But they’re wrong to argue that it would do nothing to control health-care costs. These critics claim that Ryan’s plan would simply shift the burden and risk onto individuals, because the government’s financial support for health-insurance enrollment would no longer keep pace with premiums. But that’s the wrong way to look at it. Our goal shouldn’t be to keep pace with premiums, but to bring premiums under control by eliminating the widespread inefficiency that exists in the health-care sector today. That’s the only way to slow the growth of health-care costs without harming the quality of care.

Forget one-off ideas for trimming this or that. What is needed is a continuous, long-term, dynamic process that will lead those who deliver services to want to provide better care at less cost. What can bring that about? Ryan’s emphatic answer is that a functioning marketplace can, and an essential feature of such a marketplace is cost-conscious consumers. Under current law, when costs rise, the federal government pays a sizable portion of the extra costs, thus undermining the incentive to find better and cheaper ways to go about things.

Ryan’s reforms would provide substantial federal support to encourage broad-based insurance coverage and enrollment, but the support would not be open-ended as it is today. A person who buys economical health care would get to keep all of the savings. Conversely, a person who selects expensive health care would have to pay more out of his own pocket. That’s the way the new Medicare drug benefit works, and costs have come in 40 percent below original expectations. To root out inefficiency, improve productivity, and provide powerful incentives for cost-cutting innovation, the entire health-care sector must be transformed into a vibrant, competitive marketplace. And that’s exactly what the “Roadmap” would deliver over time.

The full article is available here.

posted by James C. Capretta | 4:37 pm
Tags: Paul Ryan, Roadmap
File As: Health Care

Health Care and the Debt Commission

February 17, 2010

Over on National Review Online, I have a new Corner post about the politics of President Obama's new Debt Commission. Here's a snippet relevant to the concerns of this blog:

Then there’s the issue of health care. The president and his advisers have said they have no intention of abandoning the health-care bills that have passed the House and Senate, despite overwhelming evidence of intense public opposition. The primary reason for long-term budgetary imbalance is out-of-control spending on health-care entitlements. And so what would the Democratic health-care bills do? Stand up another runaway health-care entitlement, of course. The Congressional Budget Office has said that the new spending commitments in both the House- and Senate-passed bills would reach about $200 billion in 2019 and increase 8 percent every year thereafter. Moreover, if enacted, a health-care bill would dramatically reduce the options available to the new Debt Commission. It would not be possible to seriously consider fundamental Medicare reforms just months after Congress voted to cut payments to Medicare providers by nearly $500 billion over a decade. Nor would Democrats go along with scaling back a new health-care subsidy program they just spent two years getting into law. Team Obama’s plan here is quite obvious:lock in a partisan health-care program over the unanimous objections of congressional Republicans, and then to try to get Republican help to clean up the government’s budgetary mess. That Republicans are resisting this one-sided game should surprise no one.

If any further evidence is needed that the Obama Debt Commission is a farce and should not be taken seriously by Republicans, it can be found in the laughable timeline the Obama White House is pushing for the commission’s recommendations and follow-on congressional action. The plan is to have the commission spend most of this year behind closed doors coming up with the most far-reaching tax hikes and spending cuts seen in a generation. Then, after voters have already cast their ballots in the mid-term congressional elections in November, the commission would make its recommendations known and the lame-duck Congress would take them up and pass them in a matter of weeks, with almost no time for public debate. And politicians wonder why the electorate is cynical.

The entire post can be found here.

posted by James C. Capretta | 2:55 pm
Tags: Debt Commission, health care, deficits
File As: Health Care

Obama’s Very Weak Hand

When all else fails, try bipartisanship
February 12, 2010

Over on National Review Online, I have a new piece about the president’s agenda, the national debt, and the political moment. An excerpt:

After Scott Brown’s stunning victory in the Massachusetts special election last month, it is now clear that the coalition President Obama was counting on to pass his health-care bill and follow-on legislation is in absolute tatters. The strain of the effort to ram health care through despite intense public opposition has taken a very heavy toll. Independent voters remain outraged at the arrogance of it all, and have swung decisively toward GOP candidates in recent contests. Congressional Democrats now know they are in peril, and are behaving accordingly. They are in no mood to take any more tough votes on behalf of a president’s agenda that their constituents have plainly rejected. Indeed, in the current environment, it’s hard to see how the House could pass the same health-care bill that it passed just last November.

This puts the president in a terrible bind, especially given the difficult budgetary choices now confronting him. His 2011 budget submission to Congress shows deficits rising to $1 trillion by the end of the decade and continuing thereafter. From 1789 through 2008, the U.S. government borrowed $5.8 trillion. If the Obama budget were adopted in full, government borrowing would exceed $18 trillion by the end of the decade. Debt accumulation at such a pace would almost certainly precipitate an economic crisis.

In their heart of hearts, most Democrats think the solution to the nation’s budget problem is a massive tax increase; if they had succeeded on health care, some might have been willing to use that momentum to propose one. But in the current environment, with so much distaste for out-of-control government, the White House and congressional Democrats know full well that it would be complete political suicide for them to push a tax increase at this stage.

Which brings us back to the president’s renewed interest in having Republicans share in, as he put it, “the burdens of governing.”

Unfortunately for him, he is now holding a very weak hand as he heads into discussions with his adversaries. His health-care program is so unpopular that Democrats themselves are walking away from it. He promised voters he wouldn’t raise taxes on the middle class, and his Democratic allies want to expand government, not contain or shrink it. So, unless he changes course, he is stuck with presiding over an unprecedented borrowing binge that threatens to cripple his administration.

The whole article can be found here.

posted by James C. Capretta | 2:46 pm
Tags: budget, deficit, bipartisanship, President Obama
File As: Health Care

Facing in Opposite Directions

February 10, 2010 • My EPPC colleague Yuval Levin has written a post that nicely sums up why a bipartisan health-care solution will not be easy to come by. It's not that conservatives and liberals don't both see the shortcomings of today's arrangements. They do. It's that they simply have very different conceptions of what must be done to fix the problems. Liberals believe that more empowered and enlightened government management of the health sector can deliver better results. Conservatives quite rightly are highly suspicious of this contention. The government has been running Medicare and Medicaid for more than four decades, and the result has been bureaucratic regulation and price controls that make the entire health sector less efficient and productive. The conservative solution is to empower cost-conscious consumers in a reformed marketplace that rewards efficiency and value. Given the intensity of the debate over the last year, the odds are long indeed that the two sides will suddenly find an acceptable compromise anytime soon.

posted by James C. Capretta | 5:01 pm
Tags: Yuval Levin, conservatives, liberals
File As: Health Care

The President’s Budget and Health Care Reform

February 5, 2010

I have a new column up at Kaiser Health News this week. An excerpt:

It is now readily apparent that piling up debt at the rates implied by the president’s budget would all but invite an economic crisis. At some point, the flood of Treasury debt instruments worldwide would lead lenders to demand higher rates of return for their loans, or perhaps to runaway inflation — or more probably both. The result could be quite devastating to private-sector business investment, productivity and job growth, making it all the more difficult to get out from under the debt spiral that would ensue....

It’s not that the president and his advisors don’t recognize the problem. They speak frequently about the dangers of business as usual. The problem is that the president’s stated solution will never work.

What the administration would like to do is to have Congress pass the health care bill and then follow it up with a bipartisan deficit-cutting plan, put together by a special commission assigned with assembling a medium and long-term solution to the nation’s budgetary woes.

The first problem with this sequencing is its unrealistic political calculus.... The other problem is the planned timing of the debt commission’s recommendations and congressional action. The president would like the commission to issue its plan after the November congressional elections, and have a lame-duck Congress vote on it between early November and the start of new Congress next January. So the most far-reaching tax hikes and spending cuts in a generation would be recommended by an unelected commission and passed by an exiting Congress, all in a matter of days and weeks, even as newly elected members are set to take their seats. To say the odds are long is quite an understatement.

The whole thing is available here.

posted by James C. Capretta | 3:26 pm
Tags: budget, Obamacare, deficit commission, debt
File As: Health Care

‘Reconciliation’ Talk Reveals Democratic Desperation

January 29, 2010

House Speaker Nancy Pelosi and many of her allies outside of Congress have spent the past week trying to convince rank and file Democrats and others that Obamacare need not be dead if only the party had the will to pursue what might be called the “reconciliation solution.” Indeed, the Center on Budget and Policy Priorities recently circulated a short white paper aimed at bucking up Democrats on the reconciliation option. The authors argue that using the budget reconciliation process — which effectively means legislation can pass in the Senate with a simple majority instead of sixty votes — to approve a massive health-care bill is entirely consistent with prior practice.

And, it is true that the budget reconciliation process has been used to pass significant pieces of budgetary legislation in prior years, including welfare reform, tax cuts, and scores of important changes in the Medicare and Medicaid programs.

But there’s a big difference between what’s been done in past and what Democrats are trying to convince themselves to do this time around. Those reconciliation bills made amendments to current law. What the Democrats are now contemplating is something entirely different and totally bizarre: they want to try to pass a reconciliation bill which amends another bill which has not yet been approved by Congress.

Here’s the scenario they have laid out: The Senate has passed a bill, which is now sitting on the House side awaiting action. As the Speaker has implicitly admitted, in the wake of Scott Brown’s election to the United States Senate, Democrats have run for the hills on health care. There aren’t nearly enough votes in her caucus today to pass the Senate bill as it stands, and there’s a real question about whether they could even pass the bill they already adopted last November.

But the Speaker says today’s impasse need not be the last word on Obamacare. According to this way of thinking, it might be possible to pass the Senate bill a little later this year if the Senate would just agree to first pass a bill providing a series of amendments to the previously-passed Senate health-care plan. Those amendments would be considered under the special rules governing budget reconciliation measures, which means no filibuster. There would be only twenty hours of debate, and then it would come to a vote on final passage. If Senate Democrats could hold just 50 of their 59 Senators (the vice president can break 50-50 ties), they could pass it, or so the theory goes. Once the Senate cleared such a measure, House Democrats would then supposedly feel comfortable going ahead and voting to approve the Senate-passed health-care bill because another bill would be following right behind it to make politically crucial amendments. The president and the Democrats would then get their “historic” signing ceremony after all, only there would be two bills to sign instead of one (more pens for everyone!).

That the White House and congressional Democrats are even thinking and talking this way is an indication of how far they have fallen. They are clearly desperate, so desperate in fact that they are willing to float any kind of half-baked and far-fetched scenario in the press if it has even a remote chance of breathing life into the rapidly expiring corpse of Obamacare.

But this reconciliation gambit is so full of holes and such a perversion of the process that it’s hard to imagine anyone taking it seriously. For starters, the baseline for assessing such a reconciliation bill would be current law, which would not include the Senate health-care plan still sitting in the House chamber. You can’t pretend something is already in law if it isn’t. And so, when the Congressional Budget Office assessed such a bill, they would have to assign costs based on what it would do relative to today’s tax and entitlement structure, not some fictitious baseline that assumes passage of the Senate bill.

Moreover, any provision in a reconciliation bill that does not change tax receipts or budgetary spending can be stricken from it with just 41 votes in the Senate under the so-called “Byrd Rule.” The rule was adopted by the Senate more than two decades ago to limit the kinds of provisions that could ride on a budget reconciliation measure to those that actually make non-trivial changes to the federal budget. But if a reconciliation bill includes numerous amendments to another bill which is not even law yet, the whole bill or large portions of it could be irrelevant budgetarily, and therefore “Byrd”-able. For instance, the Senate-passed health-care bill includes the so-called “Cadillac insurance tax,” which raises about $150 billion in revenue over ten years. House Democrats want to exempt union-sponsored insurance plans from the tax through 2017. But if such an exemption were included in a Senate reconciliation bill, it would not change federal revenues because the underlying tax it is amending would not yet be in the law.

Clever lawyers and budget experts are almost certainly working overtime to see if they can find a way around what would seem to be fundamental obstacles to such a scenario. But even if they could, the idea that the Congress could employ such a distorted process to ram through a government takeover of American health care, in the wake of what happened in Massachusetts, is itself far-fetched. Rank-and-file Democrats have lost their stomach for this fight. They don’t want to push legislation they know their constituents have rejected, and implausible war-gaming by their leadership isn’t going to convince them to change their minds.

posted by James C. Capretta | 6:17 pm
Tags: reconciliation, Cadillac tax, Senate
File As: Health Care

Entitlements, the Budget, and the State of the Union

January 27, 2010

In a new post over on NRO's Corner tonight, I comment on the health care and budgetary aspects of President Obama's State of the Union address:

On health care, he offered nothing new. He is sticking with the plan the public has quite plainly rejected. According to a recent CNN poll, a full 70 percent of Americans want Congress either to start over entirely or to drop the subject altogether. That’s because they recognize that the plan the president has been pushing so aggressively for the better part of a year would be a disaster, for the quality of American medicine and for the nation’s budget outlook. The president claims the bill would cut the deficit, but that’s based on completely implausible assumptions. The bill would stand up another runaway entitlement program, paid for with offsets that will never hold up over time and cost-control ideas that are weak and largely meaningless.

Yesterday, I had another post on the Corner, remarking on the administration's proposed budget "freeze." An excerpt:

In reality, the Obama freeze is a purposeful diversion and sideshow. The nation is rushing headlong toward a fiscal crisis because of runaway government spending, and the Obama administration has no serious plan to head it off. Between 1789 and 2008, the federal government ran up $5.8 trillion in debt. In just the first three years of the Obama administration, CBO expects the debt to increase by nearly another $4 trillion. In 2010, CBO projects total federal spending will exceed $3.5 trillion, more than $500 billion over what was spent in 2008. Further, in 2012 and beyond, with realistic assumptions regarding extension of the Bush tax cuts, relief from the Alternative Minimum Tax, funding for the wars in Iraq and Afghanistan, and restoration of planned cuts in Medicare physician fees, the government is headed toward $1 trillion budget deficits every year for as far as the eye can see. 

This massive run-up in debt is set to occur just as the baby boomers head into their retirement years, pushing up costs in Social Security, Medicare, and Medicaid. Between 2010 and 2030, the population that is age 65 and older will rise from about 41 million to 71 million. CBO expects spending on the big three entitlement programs to rise from 9.8 percent of GDP in 2010 to 14.4 percent in 2030 — an increase of about 4.6 percent of GDP in 20 years. That’s like adding another Social Security program to the federal budget with no plan to pay for it.

So far, the president’s primary response to this looming budget and entitlement crisis is to propose to pile another runaway health-care entitlement program on top of the unaffordable ones already on the books. According to CBO, the federal cost of the health-care commitments in both the House- and Senate-passed health-care bills would reach $200 billion in 2019 and would increase about 8 percent every year thereafter. Meanwhile, the offsets to pay for this new spending are completely unrealistic, and the so-called “bend the curve” provisions are far too weak to make a difference.

posted by James C. Capretta | 11:35 pm
Tags: budget, entitlements, President Obama
File As: Health Care

After Obamacare

January 24, 2010

With my colleague Yuval Levin, I have cowritten a piece in the latest Weekly Standard examining the political landscape for health care reform in the wake of the election of Scott Brown to the United States Senate. After discussing how the Democrats’ ambitious plans have screeched to a halt, we suggest some ideas for health reform that conservatives should take up:

First, they should seek to address the problem of insuring Americans with preexisting conditions through state-based high-risk pools, not cumbersome insurance regulations that try to outlaw basic economics. Risk pools, backed with federal money but nowhere near the scale of Obamacare’s costs, would give those with preexisting conditions more options in the individual market and make a significant dent in the number of uninsured, but without overturning our health care system.

Second, they should propose to help doctors and patients limit some of the burden of rising costs with medical malpractice reform. Sensible caps on punitive damages would not only save money but also help address shortages of medical providers in key specialties, and allow more Americans to afford and access care.

Third, they should argue that the states be given the lead role in developing more detailed reforms of how and where people get their insurance—to cover more people and slow the rise of costs. The overall goal should be to build well-functioning marketplaces in which insurers and providers compete to deliver the best value to cost-conscious consumers. The federal government should remove bureaucratic obstacles to state experimentation on this front, and offer support where possible, but not design one mammoth new program. The regulation of both the practice of medicine and of insurance is done in the states, and their improvement should be too....

Meanwhile, for the longer term, conservatives should make a case for changes in the tax law that level the playing field between employer-provided and individually purchased health insurance, with a gradual transformation of the tax exclusion for employer-based coverage into a credit available to all. A consumer-controlled tax credit would also enhance the benefits of risk-pools, tort reform, and state-based reform efforts.

And they should press the case for real Medicare reform, not to use the program as a pot of cash, as the Democrats tried to do over the past year, but to put it on a sound footing by empowering enrollees rather than bureaucrats to make decisions....

These ideas would not yield a sudden transformation of American health care, but a gradual improvement in the areas that matter most—cost-control, greater access for the uninsured, and greater fairness for those with preexisting conditions—while sustaining the quality and innovation that characterize American health care.

The piece is available in its entirety here.

posted by James C. Capretta | 9:28 pm
Tags: Obamacare, Yuval Levin, tort reform, risk pools, Medicare
File As: Health Care

Health Care and the Deficit

January 22, 2010

The House Budget Committee held a hearing yesterday on "Perspectives on Long-Term Deficits." I was invited to testify. Here is how I concluded my written testimony:

The nation’s long-term budget outlook is bleak in large part because our healthcare entitlement commitments far exceed the revenues available to pay for them. By 2019, the House and Senate-passed health-care bills would add at least another $200 billion per year to those commitments, and unleash pressures for even more spending down the road. Meanwhile, the offsets used to pay this spending would be much less likely to occur, and the cost control provisions are not nearly robust enough to make a difference.

Congress would be well-advised to take a step back and rethink this entire approach. Instead of passing an expensive health-care bill that uses $1 trillion in offsets to pay for more spending, it would be better to craft a sensible, consensus long-term budget plan which has as one of its core elements an affordable, bipartisan health-care program, one that truly does the job on costs and expands coverage as well.

Here's a video of the hearing (my testimony begins at 33:22):

[Video permalink]

posted by James C. Capretta | 5:27 pm
Tags: deficit, debt, entitlements, Obamacare
File As: Health Care

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