• All CBO score fighting, all the time

    OK, maybe a few other things besides how the CBO scored health reform are being discussed. But it sure doesn’t seems that way. Must we witness another debate on these points again (among others)? I guess so.

    On just that, Jonathan Bernstein disagrees with my take on the CBO’s estimates. And I agree with him disagreeing with me. Here’s him, first quoting me, and then in his own words:

    What interests me, however, is a different argument from Austin Frakt that his entire dispute about CBO scoring “misses the most important message conveyed by CBO estimates.” That is:

    Here’s the state of the debate over these CBO health-reform estimates: which is right, the baseline scenario or the alternative fiscal scenario? It’s the wrong question! It doesn’t matter which scenario you think is right. Likely neither is when examined in any detail, and both are horrible in broad sweep. Choose your poison: massive taxation or massive debt.

    Actually, though, there’s a third option: recognition of the underlying problem and dealing with it.

    The problem is health care costs. They’ll cause budgetary distress with or without health reform. The CBO’s estimates, both of them, show it clearly. Health care costs have been the source of budgetary woes for decades, and there’s no end in sight under any realistic scoring of any serious health reform proposal.

    I understand Frakt’s point, but I think he’s wrong. Yes, it’s quite true that reformed health care is still producing enormous projected future budget deficits. Indeed, that’s just the most obvious problem; it’s an even bigger deal that health care costs threaten to swamp the rest of the economy, which can’t possibly be a good thing.

    I guess the question to ask is whether the problem with health care and future budgets is a policy question or a political question.

    That’s a very good question. The answer is “both.” Bernstein goes on to make an excellent case for the political relevance of the debate over the CBO’s estimates. He’s right. Go read it.

    And then there is the policy. We don’t have good, sustainable health care policy. Moreover, nobody has proposed any alternative that is both politically feasible and likely to do a substantial amount of good. It’s easy to find things that everyone can agree on–at least in principle–that don’t make a dent in health care costs or change things very much. It’s also easy to declare, “Thou shall not raise spending more than GDP + 1 percentage point,” but you’ll not likely get very many successive Congresses to agree to meet that goal.

    When considering a point of debate, I always find it instructive to adopt the assumptions of the opposition and ask, “Then what?” In this case, it doesn’t matter which side you call the opposition. If you adopt its assumptions about the CBO estimates or, in fact, either of the set of assumptions the CBO itself used in two alternative long-range projections under health reform (or, as it turns out, even without that reform), you arrive at the same, horrifying fact. Health care costs are the problem, not how the CBO scores bills. That was my point.

    For evidence, you can look at the charts I posted. For another way to see it, look at the chart in Jonathan Chait’s recent post, which he credits to Ezra Klein. See a big change in health care cost growth between the pre-reform and post-reform lines? Not really? Well, it’s there, it’s just tiny. It is some consolation that it ends up going in the right direction (after some gyrations), but, still, it’s a tiny change. It hardly does the job. That’s not the fault of the CBO, the ACA, the Democrats, or the Republicans. It’s a massive, collective, multi-generational failure.

    Perhaps Bernstein is right, that a first, necessary, step is to stop second guessing the CBO. I concede that. But, let us ask, “Then what?” It’s a good question. Got an answer? Do either of our political parties?

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    • “But, let us ask, “Then what?” It’s a good question. Got an answer? Do either of our political parties?”

      Single. Payer.

      Or perhaps you believe the answer is to continue with the present system that leaves tens of millions of Americans without access to care other than the emergency room, and tens of millions more with coverage that is often found to be inadequate when the bills start getting denied by the insurance company.

      Tens and tens of millions of Americans with no, or inadequate health care is anything but “Exceptional”.

      Single payer, or at least the ‘public option’ will get more coverage to more people in the most economically sensible manner possible.

    • The solution is the one that raised most of the objections and that is a panel that examines the efficacy of various treatments and approves a Best Practices model. If this were in place today situations such as those in McAllen TX would be rare.
      The extreme Right calls this government rationing but it’s a practice that insurance companies deal with every day.
      Another problem is both Party’s seem oblivious to the current Healthcare laws; yesterday on Hardball two politicians were involved in the debate on Healthcare and the Republican representative continually invoked ERISA as existing protection for the American Healthcare consumer.
      ERISA does not dictate benefits, it only rules on Health Insurance claims that fall under its purview. In addition, ERISA is also not applicable at the State level unless the Plan comes under ERISA’s strict provisions. The Supreme Court has lamented the fact that there is no bright line standard for when ERISA supersedes State Regulations.
      Finally, a single payer plan sounds good in theory but unless the plan has built in cost controls as mentioned in my first sentence, single payer will not solve the problem. You could probably achieve the same objective by eliminating for-profit Health Insurance Companies, at least up to a specific level of coverage (German Plan).

    • I think there are a number of ideas which must be looked at. For some reason we seldom examine the health care systems in Japan or Taiwan, which have better outcomes at half the cost.
      There are also other issues besides total costs, America simply has to rid itself of employer negotiated health care. Health insurance legacy costs were a major driver that caused GM’s bankruptcy. Toyota focuses on building cars.
      Personally, I would prefer a flat state payroll tax dedicated to insurance, with each state then negotiating with in state insurers over plans, with everyone guaranteed basic coverage, with a personal option to then buy into more expensive policies. I do not know if it would bring down total costs for health care, but it would reduce business costs and give people choice as they can pick the in state insurer plan and agency they most feel comfortable with.

    • I don’t have a problem with retaining the current system with a public option feature. I suspect that over time, the public option would indeed become a de facto single payer system. (I also think we get there if Republican judges overturn the individual mandate.) Rich folks will always be able to find premium access.

      What I think you, Kirk, and I would agree with is that to hold down overall costs, there has to be some form of rationing. Currently it’s Insurance Companies that do the rationing on the private side, Medicare reforms do the rationing on the public side.

      I’ll grant you that it’s harder to ration on the public side, between pandering to elderly voters, and whackadoodles running around like Chicken Little about “death panels”. But up until now, Insurance company rationing is much worse a problem (pre-existing conditions, benefit caps that run out, procedures not covered). All of the recent Republican proposals appear to save money only in a ‘race to the bottom’ sense – more people will have ‘junk’ health insurance. (Accidental Death and Dismemberment coverage is *not Life Insurance.)

      The new health care law at least moves us in the direction of applying best practices across the national health system. And that’s where you get your costs controlled. I don’t mind paying for a level of government that does useful things, and adequate health care is one of those things which I feel every American rates. It’s plainly silly that the US pays about twice per capita on health care than any other industrialized nation, with decidedly middle-of-the-pack outcomes.