Friday, September 11, 2009

Shining a Dim Light on Healthcare Reform

David Brooks comes not to praise Obama, but to... damn him with faint praise? I expect that some on the right will claim that Brooks' latest reflects a continuing infatuation with Obama, but I think Brooks' history belies the notion of infatuation. If I were wrong, I would expect Brooks to direct happy sunbeams at Obama, the way he did with so much of Bush's (bad) policy. But instead we get the dim glow of an intellectual nightlight.

Speaking of Obama's promise not to raise the deficit as a "Dime Standard", Brooks opines that it "kills off" the House Bill in favor of a less expensive Senate Bill, and as setting "off a political cascade".
Since the Congressional Budget Office is the universally accepted arbiter in such matters, the Democrats have to produce a bill that the C.B.O. says is deficit-neutral, now and forever. That means there will be a seller’s market for any member of Congress, Republican or Democrat, who has a credible amendment to cut costs. It also means the Democrats will have to scale back coverage and subsidy levels to reach the fiscal targets.
Or maybe it means none of that. I recall when CBO's optimistic projections were being used to sell Bush's tax cuts. What happened when the economy tanked, again? Did Brooks call on Bush to issue a mea culpa and restore prior tax levels? Hardly. This is Brooks applying his usual double standard, albeit in a less obvious manner than Gerson: it's only Democrats who have to keep their promises, and only Democrats who have to strive for fiscal sanity.

Nothing's wrong with advocating fiscal sanity. But in my opinion, if you wish to be taken seriously on the issue, you have to apply the same standard to both parties' tax and spending policies.

What's likely is that the CBO will project an optimistic and pessimistic ten year projection, paving a path for the passage of any bill that (by whatever math is being used) falls somewhere between the two extremes. As so many aspects of healthcare reform aren't quantifiable, tremendous heat may later be directed at the question of whether or not healthcare reform was deficit-neutral, but nobody will be able to provide an accurate, meaningful balance sheet. Also, this year's bill isn't next year's budget. If Congress decides next year to increase subsidies, that doesn't mean that this bill isn't revenue neutral. If it sounds like I'm describing a big game, well, yeah. I'm just surprised Brooks doesn't yet understand (or pretends not to understand) how the game is played.

Brooks continues by describing how Obama has endorsed a "backdoor and indirect version of the cap" on the tax exemption on employer-provided health benefits, and thus in his view has "no principled argument to reject" a direct cap. You know what? If that's what Congress passes, I wouldn't expect Obama to even try to reject the explicit cap. And if the Republicans want to advance a clear-cut tax increase on the middle class in advance of next year's midterm elections, I applaud their courage for being honest about the effect of a cap. So which Republican wants to sign up first?

Brooks provides some standard tropes on tort reform:
Third, the president accepted the principle of tort reform to reduce the costs of defensive medicine. Once again, the specific proposal Obama mentioned is trivial. The important thing was the concession on principle. There are already amendments being drawn up to create separate malpractice courts and to otherwise reform the insane malpractice system. The president is going to have a hard time rejecting these amendments just because they might reduce campaign donations from tort lawyers to the Democratic National Committee.
I keep forgetting the number of states in which evil trial lawyers have successfully battled back tort reform. Is it... zero? Yeah, that sounds about right. Also, Earth to David Brooks, most tort lawyers don't practice in the area of medical malpractice - that's a boutique practice, made even more so by tort reform efforts to date that have massively increased the cost and complexity of litigating a malpractice case.

But more to the point, while it's easy to repeat "tort reform" propaganda about the legal system (the worst sin of which, at least according to this NEJM study, is it's frequent wrongful denial of compensation to genuinely injured plaintiffs), there are a couple of things to consider. First, nobody is really riding the "tort reform" horse at this time. While Brooks is the first to abandon the CBO as a "gold standard" when its findings contradict his platitudes, malpractice spending (including, of course, the bulk of that spending - the cost of the defense against valid claims and of paying the victims of those claims) is less than 2% of healthcare costs.

If Brooks would defer to the CBO's projections on how money much various "reforms" would save, my guess is that most would be revenue-neutral (tort reform, even as sweeping as the near-immunity granted in Texas and Florida) has had no apparent effect on healthcare costs or inflation) to increasing the cost. Even if we assume that "defensive medicine" exists, there is no evidence that even the most sweeping "tort reform" measures will limit its "practice". The CBO has "found no statistically significant difference in per capita health care spending between states with and without limits on malpractice torts".

Further the CBO finds no relationship between so-called "defensive medicine" and healthcare inflation:
Other factors such as defensive medicine (which refers to medical tests or procedures of little or no clinical value that are ordered by physicians primarily to avoid lawsuits) and physician-induced demand (which refers to spending that is brought about at least in part by providers’ desire to augment their own income) do not appear to explain a significant part of the growth in spending, according to published analyses
It's not clear what Brooks envisions in terms of "separate malpractice courts", or how he thinks their creation will affect anything about the present tort system. Like other "tort reform" advocates who bandy about similar ideas (such as "health courts"), the specifics are always lacking.

Brooks next states that, by suggesting that he'll pass a bill that has effective reform even if it does not include a public option, the President has killed off the possibility of a public option. In fact, what he did was make clear that he will sign a healthcare reform bill that does not include a public option, if that's all that the Senate will give him. Sure, some would have preferred that he express that he would veto a bill without a public option (including some on the right who would want to see him set himself up for failure), and it's likely that any sort of public option that gets through would be implemented only if certain triggers are met. But unless Brooks knows of some way that a President's speech could have magically won him a filibuster-proof majority in the Senate to back a pubic option, Obama was acknowledging political reality, not creating it.

Brooks then talks about Presidential support for "game changers" without really being clear on what he has in mind. Brooks takes umbrage at this suggestion,
Since health care represents one-sixth of our economy, I believe it makes more sense to build on what works and fix what doesn't, rather than try to build an entirely new system from scratch.
The only risible parts of the speech came when Obama said that parts of the system work (they don’t; they’re unsustainable) and when he said he would be the last president to take on health care (we still await a president willing to take on fundamental perversities in the system).
Is Brooks serious? He thinks that there are no parts of the present system that work? I would love to read his series of editorials explaining how he would tear the system down and rebuild something entirely new, while convincing the nation's people, doctors and hospitals to obligingly trust his better judgment. But if anybody's accused Obama of arrogance, following any such series they'll have nothing on Brooks. Seriously, Brooks expected that Obama could go before the nation and state, "All proposals to date are too modest, nothing works, and so we're going to tear down the system," and have any chance of subsequently getting any sort of reform bill passed?

Also, Obama didn't say "he would be the last president to take on health care". He said "I am determined to be the last". If Obama believes he can or will be the last, that's risible. But he was actually describing his level of determination, not his actual expectations. Rhetorical excess? Sure. But hardly what Brooks pretends.

I think it's a fair criticism to state that Obama "has decided to expand the current system, not fix it." But that's because he lives in the real world, and is addressing the political realities of our system of government. Alas, David, sometimes even a capable President cannot make the pie higher.


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