Wednesday, December 29, 2010

For Doing All of the... Light Lifting on Entitlement Reform

Robert Samuelson pats himself on the back for turning 65 and still proposing to roll back Medicare and Social Security:
I've written columns like this for years. Little has changed. Medicare premiums for wealthier recipients (income thresholds: $85,000 for individuals, $170,000 for couples) have increased modestly, affecting about 5 percent of beneficiaries. But politicians fear making major changes. They dread an assault from AARP, the main senior lobby, and the rage of millions of retirees and near-retirees. Public opinion is hostile. It's high on reducing deficits and low on changing the programs that create the deficits.
Let me say this: I'm fine with having those who can afford to do so contribute a greater amount to their health care in the form of premiums, copays and deductibles. The problem, though, is that's not enough - and Samuelson's not willing to tackle the tough issues or to press the tough choices. He's content to pretend that the problem of Medicare can be somehow fixed through increasing the age of eligibility or through increased premiums alone. Let's examine, for example, how hard Samuelson pushed back against the lie of "death panels:
These critics charge that Obama would curtail Medicare benefits or create "death panels" to deprive ill seniors of desirable care. Not only are these charges mainly false (as Obama says), but they wrongly suggest that we put some important subjects off-limits. Medicare represents one-fifth of personal health spending. Why shouldn't we debate what should be covered and who should pay? Similarly, doctors, patients and families should discuss end-of-life care. It's not just that 25 to 30 percent of Medicare spending occurs in patients' last year. Expensive, heroic care often compounds suffering.
From a search of his columns in the Post, that's it. That column reflects that Samuelson understands that end-of-life care and its very high cost is a huge part of the problem with Medicare, but he's unwilling to articulate a solution that would reduce those costs. At sixty-five perhaps he doesn't want to hear it, but everybody dies. Delaying the age of eligibility for Medicare won't change that.

Samuelson also doesn't want to address the fundamental issues that led to Medicare's creation and perpetuation: Seniors (and other people who are at heightened risk of serious or fatal illness) are costly to insure, period. Making people wait longer to become eligible for Medicare won't of itself make alternatives affordable. People who need medical care will still have to obtain medical care. If the idea is that seniors who can afford to pay should shoulder a greater percentage of the cost of their care, so that the burden isn't shifted onto younger taxpayers, great - let's work on that. But Samuelson's reforms seem to be predicated on the notion that it's better to have an increased overall expenditure on health insurance and medical care for the elderly through private payments and private insurance than it is to perpetuate a less costly, more efficient government-run program. That also appeared to be his position on the Affordable Care Act - it's better to preserve massive private profits at the expense of universality and cost containment than it is to look at - and even less consider - the efficiencies created through the national health insurance programs of any other nation.

Samuelson has to be aware of the consistent, highly valid criticism of his notion that you can fix Medicare pretty much by raising the age of eligibility: Not everybody has a cosy sinecure like his, in which you can earn a six figure income for cycling through the same tired series of editorials year after year after year, producing a whopping two columns per week. Most people aren't doctors or lawyers, accountants or bankers. The people who are going to be the most costly to Medicare during their sixties are those least likely to be able to continue to work into their seventies, least likely to be able to afford increased premiums or other contributions, and least likely to be able to afford private insurance. If they cannot get onto Medicare by virtue of age, they will get onto Medicare by virtue of qualifying for Social Security Disability - at an even higher cost to the taxpayer. (And no, that program's not sustainable either.)

Samuelson happily glosses over the primary reason that he and his peers get Social Security, Medicare, and other benefits that they don't necessarily need. They hold disproportionate income, wealth, business and political power. They vote. The "dread assault of the AARP" is really the "dread assault of people like Samuelson." That's not a problem unique to the United States. Senior care, long-term care, and end-of-life care play a major role in healthcare inflation in every developed nation. The developed world does not deal well with issues of sickness and mortality. If you want to "engage and change" public opinion, you have to be courageous enough start with such measures as counseling on end-of-life issues - and you have to be honest enough to call a lie a lie.

It will do nothing to whine about how the world won't change "unless political leaders discard their self-serving hypocrisies" - you might as well wait for the law of gravity to be suspended. You either have to get the overwhelming weight of public opinion behind change, or you have to wait for the crisis. If you want to see the problem in action you need look no further than Samuelson himself - when a massive tax cut for the wealthy adds close to a trillion dollars to the deficit over the next ten years, it's not even worth a passing mention. When massive deficit spending is required to pay for something he supports, it's "pocket change" - and even if he later admits that he underestimated the cost he offers no solution and no retreat.
But I am certain -- now as then -- that budget consequences should occupy a minor spot in our debates. It's not that the costs are unimportant; it's simply that they're overshadowed by other considerations that are so much more important. We can pay for whatever's necessary.
How's that for self-serving hypocrisy?

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