With Bipartisanship Like This, Health Care Doesn't Need Enemies

When you hear about an organization that calls itself the "Bipartisan Policy Center", what's the first question that comes to mind? If I spot you this essay, might it be, "I wonder how they bankroll themselves, whose policy positions they're pushing under the guise of 'bipartisanship'"? No real surprise - when you are willing to offer a big enough paycheck, you can get people from both sides of the aisle to sign on to your clients' positions.

So, then, what's the basic premise of this special interest front group?

What we learned is that, until better care is prioritized over more care, our nation will continue to face a problem with health-care costs. The good news is that, through thoughtful policy, health-care practitioners can be encouraged through rewards to focus far more on what is best for their patients and less on the number of tests and procedures they can order. The even better news is that such a health-care vision can not only produce better care but also cost less.

So... Bill Frist has given up his habit of diagnosing medical conditions from the Senate floor, then insisting that their lives be prolonged indefinitely no matter what the financial cost to the country or emotional cost to their family? Was it the "bipartisanship" that brought him around, or the paycheck, because... You'll please excuse my skepticism that Tom Daschle and Bill Frist couldn't see eye-to-eye on what was good for the nation when they were being paid by the taxpayer to do so, but fell into a warm mutual embrace of their employer's policy position the second they entered the private sector.

Well, they claim that we can pay less and get better healthcare. So how do they, the admitted beneficiaries of the best health care our nation has to offer, far better than the average American can presently hope to obtain, propose to give us this "higher quality and greater efficiency" at a lower cost?

To address these, we seek to promote coordinated and accountable systems of health-care delivery and payment, building on what has proved successful in the private and public sectors. Organized systems of care emphasize the value of care delivered over the volume of care. These systems are often better able to meet patients’ needs and desires and are able to effectively reimburse providers and practitioners for delivering high-quality care.

That sounds like... obfuscation. It would be helpful if they would start by identifying the systems that have "proved successful in the private and public sectors", but... I know, far too much to ask. Besides, if they were to approach that issue honestly they would have to praise the efficiency and popularity of Medicare and the single-payer V.A. system, as well as the fact that every other industrialized nation has managed to offer an overall quality of care comparable to that of the U.S. at a considerably lower cost.

So, if they cannot identify even one of the "coordinated and accountable systems of health-care delivery and payment" they used as their model, perhaps they can help us by giving us examples of that coordination and accountability. You know, of the sort of measures that will result in better care for less money.

• They propose to "Preserve the promise of traditional Medicare while adding more choices and protections for beneficiaries, including accountable systems of care and a stronger, more competitive Medicare Advantage program." So "keep Medicare but with added buzzwords" - and then magically create a "stronger, more competitive Medicare Advantage program"... does that mean, one that won't require massive subsidies to attract even a single consumer to migrate from standard Medicare? Just asking.

• They propose to "Strengthen and modernize the traditional Medicare benefit, including adding a catastrophic cap, rationalizing cost-sharing and premiums and expanding access to assistance programs for those with low incomes" - in case you're not paying attention, what they're saying here is that they want to cost-shift from the Medicare program to its beneficiaries. So... their two leading ideas have nothing to do with improved systems or providing better care. Should we hold our breath and expect things to get better?

• They want to "Reform the tax treatment of health insurance to limit the taxfavored [sic] treatment of overly expensive insurance products" - In other words, if you have really great coverage (like the kind they, personally enjoy) they want to increase the tax burden on your employer so that your employer will offer you lesser coverage. Once again the entire focus is on shifting the cost of care from insurance to the consumer, and has absolutely nothing to do with improving care or efficiency.

• They propose to "Empower patients by promoting transparency that is meaningful to consumers, families and businesses, and streamline quality reporting" - which, if they have actually studied the issue, they know translates into meaningless twaddle. But heck, it sounds like it came right out of a mission statement generator, so odds are you never thought it was anything but meaningless twaddle. The most charitable reading is that they propose to give consumers more information so that they can make their own decisions about their healthcare instead of deferring to their doctors. Oh, you thought you were going to hear about things that work, things that improve care and lower costs, rather than the usual tired nonsense about how consumers can learn to manage the intricacies of their own medical care? Well, guess again!

• They're going to "Advance the nation’s understanding of potential cost savings from prevention programs, through support for research and innovation on effective strategies to address costly chronic conditions" - because, you know, telling people, "If you don't smoke, lose weight, eat better, and exercise more, you'll be healthier", has been such a successful strategy to date. Because so many people have yet to hear that sort of hectoring.

• Back to twaddle, "Offer incentives to states to promote policies that will support a more organized, value-driven health-care delivery and payment system, such as supporting medical liability reform and strengthening their primary-care workforce." In the real world, "medical liability reform" - that is to say, denying victims of malpractice effective redress through the courts" - has not resulted in cost savings. But clearly it's something that their employer's clients want, so there it is! And what does "strengthening the[] primary-care workforce" mean? Clearly it doesn't mean "hiring more primary care physicians", as so far this proposal is about anything but encouraging people to see their doctors when they're sick.

They pat themselves on the back,

All of these policies are designed to improve the quality and value of our nation’s health care. That is where every health-reform effort should start.

Sure, if we pretend that "improve the quality and value of our nation’s health care" is synonymous with "improve the bottom line of the industry groups that fund our organization". Given that none of the proposals as stated has any realistic chance of either improving the quality of care or improving the efficiency of the provision of care, but can be guaranteed to raise both cost and risk for the consumer, it's difficult for me to believe that they're fooling anybody with this other than the guy on the Washington Post's editorial board who approved the essay. I joke - the editorial board and its members push this sort of editorial with some regularity, knowing full well that they're at best pushing a half-truth and at worst pushing something that's good for the bottom line of the insurance, pharmaceutical or hospital industry even if harmful to consumers.

By presenting this report to federal, state and private-sector leaders, we hope to promote a collaborative dialogue and a shared understanding of strategies to put our nation’s health system, as well as its economic outlook, on a sounder, healthier and more sustainable path.

No, really, they don't. All four of the authors had the opportunity to do what was right for the nation when they held elected office, or when they worked in the public sector. Their unified front comes not from a realization of how obtuse and destructive they were when they couldn't agree, but from the fact that they won't keep their jobs if they don't push their employer's agenda. How about a little bit of honesty?

The "Debt-Reduction Sales Tax"

Fareed Zakaria recently ribbed Darrell Issa over Issa's use of euphemisms, suggesting that politicians' use of euphemisms is cowardly, and that those who use them are either lying or at best trying to hide the truth. For some reason this came to mind when I read about the lastest "budget task force" proposal from Pete Dominici Alice Rivlin, and its "debt-reduction sales tax".

We would dramatically simplify the tax system, establishing individual tax rates of 15 and 27 percent (from the current high of 35), cutting the corporate tax rate to 27 percent (from 35 today), ending most deductions and credits while simplifying the rest, and ensuring that nearly 90 million households no longer have to file returns. To reduce the debt, we would supplement our spending cuts with a 6.5 percent "debt-reduction sales tax."

I tracked down a longer version of the report and, although it found room for four pages of photos and bios of the contributors, it omitted any hard numbers.

Correct me if I'm wrong, but I believe if we kept income taxes 0.5% higher - that is, reducing them to 15.5% and 27.5% (they would eliminate intermediate brackets) the tax revenue raised would be substantially greater than that which would be raised through a new national sales tax. So why not keep things simple and impose a 0.5% or even a 1% "deficit reduction surtax" on income taxes until the deficit disappears? Or, more honestly, just set those tax brackets at the slightly higher rate because it's not as if we're really going to eliminate the national debt, is it....

Seriously, if they want to make a policy case for why we should create a new, regressive national sales tax system, imposing significant costs of tax collection and remittance on the nation's businesses, rather than setting the income tax at a slightly higher level, let them make it. Their use of a euphemism suggests either that they can't make a compelling case for the sales tax, or that they don't want to approach the issue honestly. I personally see no sign of honesty in their choice of euphemism because, contrary to what its name implies, I simply don't see that such a tax will ever go away.

No, We Don't Need Another Perot....

Michael O'Hanlon and a Alice Rivlin take on domestic politics and the budget.

We hear that Ralph Nader is running again, but the third-party candidate we need is Ross Perot. In 1992, with his squeaky voice and endless charts, Perot focused attention on the rising federal deficit. His warnings helped keep the major-party candidates from talking budgetary nonsense.

Well, whatever credit we can extent to Perot for bringing attention to the budget, it's not like the deficit and massive national debt are a state secret.

For now, let's play along and assume that the Perot candidacy was truly about balanced budgets, and not about dissatisfaction with the major parties. We can overlook the fact that the poorly articulated Perot platform allowed voters to project their own wishes and desires for the country onto Perot, as evidenced by the collapse of the "Reform Party" pretty much the moment it tried to form a coherent platform. And of course, we'll overlook the fact that Perot didn't win.

For all of their impressive qualities, this year's presidential candidates are woefully short on fiscal prudence. And the next president will face two daunting budget problems. The winner will inherit a large deficit resulting from a weak economy, an expensive war and the persistent political inclination to spend more and tax less. The bigger challenge? Promises made to the growing population of retirees as health-care spending continues to soar.

So they want to resurrect a 1992-era candidacy that promised health care reforms and could lead to a balanced budget? That (despite the failure of his attempt at health care reforms) was Bill Clinton, not Ross Perot. As for promising tax increases, how did Alice Rivlin, view tax increases back in 2001? She saw George H.W. Bush's tax increases as having constituted "political suicide". That's political suicide after being elected, in contrast with Walter Mondale's politically suicidal promise to raise taxes during an election. Like it or not, the odds of having a viable candidate emerge and promise tax increases to cover O'Hanlon's favorite expenditure, the military, plus the cost of trying to stabilize health care cost and (for the two of three candidates who care about the issue) broadening health insurance coverage to most or all Americans? About zero percent.

I'm not entirely clear on what O'Hanlon and Rivlin see as the solution, other than a massive tax increase. It's reasonable to assume that O'Hanlon, a leading cheerleader of the Iraq war and a long-time proponent of military spending, would oppose saving money by ending the war or limiting military spending. They don't say, "candidates should promise to slash Social Security, Medicare and Medicaid, and continue to decline to invest in the nation's crumbling infrastructure", another platform pretty much guaranteed to bring about a crushing defeat in November. What effect do they believe a new Perot would have on this election?

As for trying to elicit a promise not to make the deficits worse, Rivlin has previously noted that deficit spending can boost a troubled economy - I'll grant that she's been arguing that the Bush Administration has been fiscally irresponsible, but is it truly best to demand restraint now, such that yet again we see a Reagan/Bush/Bush-style massive deficit coupled with massive accumulation of wealth among the richest Americans, followed by the tired excuse the minute the Democrats take power, "We can't afford to help you."

I'll also share an annoyance about analysts like O'Hanlon, who seem to want fiscal responsibility only when their own budgetary priorities are not at stake. He's happy to tell us that we can't afford health care reform without a massive boost in tax revenues, but where's his column explaining how we similarly can't afford to toss $120+ billion per year into the fiscal black hole commonly known as the Iraq War?