Perhaps Kathleen Parker's Problem is That She Doesn't Understand Honesty

At least if you're a Republican. Penning yet another childish screed about President Obama, Parker whines,

Moreover, people don’t like being insulted and misled, as many feel they have been by this administration. This is not just a feeling but a demonstrable fact, especially vis-a-vis the Affordable Care Act. And it’s not just the far-right fringe who object to the strategic misrepresentations along the way.

If Parker thought you had even a smidgen of intelligence, her next paragraph might cover some of the most outrageous lies about the PPACA. You know... like death panels. Or even some of the lesser Republican lies, like arguing that Obamacare would cover illegal immigrants, cause massive budget deficits, cause massive increases in insurance premiums, or involved the government taking over the insurance industry. Heck -- she, herself, is lying even as she writes about public sentiments toward the PPACA -- she knows that the key elements of the law, save for the mandate, are in fact supported by clear majorities of Americans, that it's the label that drags the law down. She probably giggles about the voters in Kentucky who praise Kynect and express their gratitude that it's not Obamacare, even though... it's simply the name Kentucky gives the exchange through which its residents can enroll in Obamacare.

What are the horrible lies that Parker attributes to Obama?

These obfuscations include telling the American people that they could keep the insurance they had if they liked it and also writing the law in such a way that the ACA’s mandate to purchase government-approved insurance was not a “tax,” despite the Internal Revenue Service’s role in policing its compliance.

Oh, the horror. An overstatement that was made in good faith, and run-of-the-mill machinations designed to get a better CBO rating. Politifact, the "fact-checking" outfit that made the declaration upon which the "lie" accusation is premised initially rated the statement as "true", making me wonder if they're producing a reliable analysis or if they're channeling an Arnold Schwarzenegger movie. Dean Baker has capably responded to those who want to hang their hats on the third (yes, in between declaring the statement "true" and "false", Politifact also rated it as half-true) analysis of the statement.

If Obama's pledge was understood as ensuring that every plan that was in existence in 2010 would remain in existence, then it would imply a complete federal takeover of the insurance industry. This would require the government to tell insurers that they must continue to offer plans even if they are losing money on them and even if the plans had lost most of their customers. This would at the least be a strange policy. It would be surprising if many people thought this was the meaning of President Obama's pledge....

On closer inspection, the claim that President Obama lied in saying that people could keep their insurance looks like another Fox News special. In the only way that the pledge could be interpreted as being meaningful, the pledge is true. The ACA does not eliminate plans that were in existence at the time the bill was approved.

Parker, of course, knows all of this, but anticipates that her intended audience does not.

Similarly, anybody who was following the debate over the PPACA knows that there was an absurd insistence that the law be revenue-neutral. They know that many compromises were built into the law, including significant delays in its implementation, to keep the books nominally balanced. Parker knows that the Republicans she serves would have shrieked like banshees had the mandate been explicitly enforced through a tax, as opposed to a penalty. Parker knows that the penalty is based on income and enforced by, you guessed it, the IRS. Within that context, her feigned surprise that the penalty could be characterized as a tax is quite revealing.

But wait -- there's more. Parker knows that her party and its supporters spent two years and spent vast sums of money litigating against the PPACA, and insisting through that litigation that the penalty was not a tax. If it was so obvious to everybody that the penalty was a tax, why spend years litigation the case, causing taxpayers to pour millions of dollars into its defense, only to reach the inevitable conclusion that it is a proper exercise of Congress's power to levy taxes? Why did the political right attack and vilify Chief Justice Roberts for joining the majority on that issue? What are we supposed to make of the refusal of Scalia, Alito, Kennedy and Thomas to join what Parker tells us was, at all times, a known and obvious fact? Parker later lectures,

This ruling, indeed, was the reason the ACA was able to go forward, which is why so many Republicans were apoplectic with Roberts’ siding with the liberals in a 5 to 4 ruling. In other words, Obama’s obfuscation was simultaneously revealed and rewarded by the court. And the American people were smacked with a health-system overhaul many more would have rejected had they known the truth.

If it is so blindingly obvious that the penalty is a tax, and if Parker truly believes that lying by politicians is a bad thing, why does she implicitly applaud the Republicans for lying about the mandate in order to perpetuate costly and divisive litigation? Why does she implicitly defend attacks on Roberts for accepting what she tells is is an obvious truth, rather than embracing a partisan lie in order to take down the law?

What inspired Parker's attack on the President? If you've been following the headlines, you already know. An economist who worked with the Obama Administration in developing the PPACA made an off-the-cuff comment that has been demagogued into the suggestion that the Obama Administration thinks voters are stupid. As a reference, Parker links to an idiotic screed against the PPACA, but fastidiously avoids introducing the facts -- that the statement she wants to attribute to "the White House" was made in an off-the-cuff manner by economist Jonathan Gruber, a non-politician who is long out of the Obama administration, and who most people wouldn't know from Adam.

Parker follows that absurd attribution with a sentence that starts, "Punditry aside...." It would appear that Parker believes that "punditry" and "demagoguery" are synonyms. Incredibly, after having linked to a diatribe that relies upon Gruber to suggest "", Parker then explicitly invokes Gruber,

Those who feel defrauded by their own government got third-party confirmation recently when remarks by one of the ACA’s chief architects, MIT economist Jonathan Gruber — invoking the stupidity of voters and lauding the political advantage of a lack of transparency in government — went viral.

Parker appears to believe that her readers are too stupid to click the links and find out that there's only one story.

Now, it is no surprise that Parker and her ilk feign deep offense at the most trivial impropriety, real or imagined, by a Democratic President. But really?

We also know that once trust is gone, it’s very hard to restore. Over time, and not just during this administration, we have lost trust in one institution after another. But when we have lost faith in our government, we have lost faith in ourselves.

At their core, the midterms were really about restoring that trust.

To Parker, it seems, having somebody once associated with the Obama Administration suggest that, as many voters aren't always informed on the issues and are inclined to latch onto labels instead of substance (you know, like "death panels"), it can be necessary to construct legislation that avoids certain "trigger words", is on par with Watergate. Parker, it seems, has no problem with such robust honesty as proposing something as a Social Security privatization plan, then objecting to any use of the term "privatization" as an unfair distortion. Or proposing a Medicare voucher plan then objectin to any use of the term "voucher" as an unfair distortion. Because, you know... that's her party. Let's ignore the $millions earned by Frank Luntz, coaching Republicans on how to mislead voters on issues ranging from the "death tax" to "climate change". When it comes to healthcare reform, Luntz kind of takes us full circle:

In the spring of 2009, a Republican strategist settled on a brilliant and powerful attack line for President Barack Obama's ambitious plan to overhaul America's health insurance system. Frank Luntz, a consultant famous for his phraseology, urged GOP leaders to call it a "government takeover."...

PolitiFact editors and reporters have chosen "government takeover of health care" as the 2010 Lie of the Year. Uttered by dozens of politicians and pundits, it played an important role in shaping public opinion about the health care plan and was a significant factor in the Democrats' shellacking in the November elections.

Yeah, that Kathleen Parker is horrified by dishonest politicians, and does nothing but overestimate the intelligence of her readers.....

Obamacare Works, Period

The other day, Reihan Salam was on Real Time, but didn't manage to air all of his anti-Obamacare tropes before the host switched to a different subject. One he did manage to voice is the suggestion that the 74% of Republicans who like their benefits under their PPACA health insurance policies are wrong. I'm not sure how the logic of that argument works, as they either like their benefits or they don't. Perhaps he means that they're wrong in principle, as they should instead prefer the status quo ante or some unidentified alternative program, but endorsing that position would suggest that Salam doesn't think the program represents good policy even if it provides people with what they assert to be good health insurance coverage.

Salam did suggest that the only reason Obamacare is working is because it is subsidized. In a sense that's true, as it is the subsidies that help create the volume of enrollees necessary to create the large risk pools that allow the program to work, enrolling all applicants without regard to preexisting conditions. But outside of that narrow context, Salam is wrong. As somebody who has purchased a PPACA policy without a subsidy, I can attest that I was able to choose and enjoy a policy that provides coverage superior to anything I was able to purchase as an individual consumer prior to the Act's effective date, and that the price of the policy was reasonable even without a subsidy. The manner in which the PPACA's policies are priced for dependents allowed me to obtain coverage comparable to that which I had previously received through COBRA but at a lower price.

Although the pre-PPACA policy I had purchased to cover the period between the expiration of my COBRA eligibility and January 1, 2014, cost less than my PPACA-compliant policy, it also offered far less. I also didn't have to try to remember years of detailed medical information which the insurance company could use to find pretextual reasons to increase my rates or deny care. I recognize that many Republicans, perhaps including Salam, believe that having inadequate health insurance coverage is a feature, not a bug, forcing people to pay a greater portion or all of the cost of certain basic care, mental health care, addiction treatment and the like, and that the ideal health insurance policy involves a HSA and only catastrophic insurance coverage, I would have a greater appreciation for that argument if an appreciable number of its advocates were willing to walk the walk -- legislate or contract away their own health insurance benefits for the inadequate coverage they wish to foist off on the rest of the country.

Salam suggested that there is inequity in having a multi-tiered health insurance system, with Medicare being less attractive than PPACA plans, which he asserted are less attractive than employer-sponsored plans. It's important to note that I've seen employer-sponsored plans that are far less attractive than most plans available under the PPACA, and the plan I purchased was quite comparable to the employer-sponsored plan I had been continuing through COBRA, so I don't find his argument of inequity between employer-sponsored plans and PPACA plans to be particularly compelling. As for Medicare offering less than private health insurance, I see no evidence that the Republican Party at large views that as a problem that needs to be fixed. A party whose governors have largely chosen to grandstand, harming their states and large numbers of their constituents by refusing to expand Medicaid. Inequities exist, but it's not clear that we should prioritize their elimination over other healthcare reforms, or even that the people want inequities removed as opposed to the establishment of a reasonable minimum for what health insurance plans must offer.

Typical Republican alternatives to the PPACA have involved either throwing everybody into the individual market, with low-coverage catastrophic insurance and HSAs, or a voucher system where (if you qualify) you get a voucher or tax credit with which you are to pay for your insurance and fund your uninsured care. Those proposals bring back some of the worst aspects of the former system, at best foisting those previously deemed uninsurable or who would face staggering insurance costs due to pre-existing conditions into government programs -- after all, why should we expect health insurance companies insure sick people when that cost can be borne by the taxpayer? To the extent that the Republicans attempt to bridge the gap between the Gingrich-style plans and the PPACA, including large risk pools and exchanges, but most notably preventing insurance companies from raising premiums for people with pre-existing conditions, the more necessary it becomes to impose some form of mandate -- and even if you automatically enroll people in insurance while using the voucher or subsidy they left unused, such that you can argue that "It's not a mandate", somebody has to foot the bill.

On the whole, Salam is one of the more honest and thoughtful commentators on the Republican side. I would like to see him address the issue of health care in light of his abilities. We can start with the fact that there is no actual Republican health insurance reform that is being seriously advanced within the party. We can add to that, the fact that reforms that will shake the system are likely to cause people to lose their current insurance, whether that occurs abruptly or as a new policy is phased in. In other words, unless the Republican Party wants to take an enormous political risk that implicates all of its anti-Obamacare rhetoric, we're looking at incremental reforms, not the reinvention of health insurance and the healthcare market. Within that context, what reform ideas would Salam propose that have any chance of getting passed by the Republican majority in the House, let alone becoming law? If the answer is, "None", then he's reinforcing what many, and probably most supporters of the PPACA already acknowledge -- as flawed as the law may be, it's the best law that could get through Congress.

Speaking of Geithner, About Those ObamaCare Regulations....

Stephen Brill asks, why is it that Geithner's getting a free pass on the postponement of the employer mandate under the PPACA?

The explanation for the postponement was that the rules, instructions, and reporting forms necessary to implement the requirement could not be written in time. The Treasury Department has responsibility for that paperwork and has had three years and three months to get it done. Geithner was in charge of Treasury for all but five of those 39 months....

Can’t someone tell us why Geithner and his team couldn’t get their homework done in 39 months? Is 39 months too fast to be “thoughtful and careful?” What happened? Why wasn’t the White House staff monitoring them from the day the bill passed to make sure the work was getting done? What about the Office of Management and Budget, which was run during most of those 39 months by Peter Orszag and Jacob Lew (who now runs Treasury) and which is supposed to supervise regulation-writing at federal agencies?

Brill echoes some of Joe Klein's anti-administration rhetoric, but it is a fair question to ask: why couldn't Geithner get the job done, and why wasn't he held accountable for his failure?

In fairness to Geithner, the answer may be political - it may be that the regulations are in place, and the forms aren't all that complicated, but that the Administration was responding to political concerns and pressures and used complexity as an excuse. But as Brill points out, nobody seems to be investigating the issue.

Sure, Let's Break the Tie Between Health Insurance and Employment

Ross Douthat complains that the PPACA does not break the bond between employment and health insurance,

The policy consensus... is that the status quo is actually the problem, and that it deserves to be threatened, undermined and replaced as expeditiously as possible. Wonks of the left and right disagree on what that replacement should look like. But they’re united in regarding employer-provided coverage as an unsustainable relic: a burden on businesses, a source of perverse incentives for the health care market and an obstacle to more efficient, affordable and universal coverage.

Douthat then provides an inaccurate history of McCain's proposal to replace employer tax incentives with an individual tax credit. Douthat pretends that there was something brave in McCain's proposal, and that it played a role in his loss of the 2008 election, but presents no evidence in support of either suggestion. The problems with McCain's proposal did not lie in its severing the tie between insurance and employment, but in his reliance upon dogma - the notion among factions of the Republican Party that the biggest problem we have with health insurance is that people have too much of it - and the fact that he would have thrown working Americans into the individual health insurance market, with some sort of government-run insurance program to pick up the unprofitable applicants, those with pre-existing medical conditions. The problem wasn't that McCain wanted to shift out of the employer-provided insurance model, it was that he wanted to radically redefine the entire health insurance market to the significant detriment of individual workers.

Douthat argues that having insurance exchanges and subsidies constitutes a "center-left alternative to the existing system", never mind that right-wing advocacy groups like the Heritage Foundation had a long history of pushing for exchanges, and that nobody has proposed that a system of exchanges can function without subsidies. Douthat has a point, that much of the rest of the program is designed to perpetuate the status quo, and he's also correct that demagoguery from both political parties makes it difficult to disturb that status quo, but he's implicitly arguing that the exchanges are a superior alternative to employer-provided health insurance. So why no criticism of the Republican factions that are working overtime to impede the implementation of the exchanges, in the hope of crippling individual access to health insurance through the exchanges?

Douthat fails to discuss the Republican Party's lockstep opposition to the PPACA, and how that factored into the eventual legislation. What would be better than an "individual mandate", and a continuation of traditional subsidies to employers that offer health insurance? A tax. Leaving aside for the moment John Roberts' ultimate conclusion that the individual mandate is a tax, why couldn't we fund the PPACA through a tax, again? Many aspects of the bill could have been improved had the Republican Party, or even a handful of Republican Senators, decided that it was better to pass a good reform bill than to try to take down the President. That strategy seemed to be working in 2010, so they doubled down. How many times have House Republicans brought absurd "repeal" votes to the floor, demonstrating their fondness for grandstanding and demagoguery? How many times have they offered to sit down with the Democrats to iron out the bugs in the PPACA and make it a better, more functional bill? Would that be roughly 37:0?

How's this for an idea? Phase out the present subsidies to businesses in favor of subsidies to individuals, but with the subsidy credited toward the cost of any employer-sponsored health coverage, while replacing the individual mandate with a modest payroll tax that is also credited to health insurance purchases, whether through an employer or through the exchanges? If your employer doesn't provide insurance you can take the entire subsidy with you when you purchase through an exchange. If you choose not to obtain health insurance, you don't get anything back - or the government could enroll you in a bare bones catastrophic insurance plan so that should you require medical care following an unexpected accident or illness your care providers can get paid.

Perhaps Douthat should also ponder this: if the tie between health insurance and employment is the huge evil he perceives, it can be wiped away in a heartbeat by implementing a single payer system, or through a system of exchanges in which the consumer picks an approved, privately administered health insurance plan while the government pays the premium.

Robert Saumuelson's ObamaCare Journamalism

If you read Samuelson's column, you know that he's not particularly interested in analyzing the issues of the day, so much as he is interested in advancing a specific, right-wing economic agenda. But he could at least make an effort, couldn't he?

To get some answers, I recently talked with the heads of four “professional employer organizations” (PEOs) — these are companies that act as “human resources” departments for small companies. They provide payroll services and advise on fringe benefits and government regulations. Their customers include construction companies, restaurants, small manufacturers and professional firms. Many of these firms are only now coming to grips with the ACA, because they’d assumed that the Supreme Court would invalidate it or that a Republican White House would repeal it.

That's the first place I would look for answers about the PPACA - a bunch of consultants who were apparently happy to reassure their clients, "Don't worry about ObamaCare because it will be repealed or overturned," or who knew better but were not sufficiently competent to convince their clients to prepare for the possibility that they might actually have to follow the law.

To encourage candor, we talked on a not-for-attribution basis.

As if they would own up to that level of incompetence and then speak with Samuelson on anything but a "not-for-attribution basis".

First, some companies now providing insurance are being hit with huge premium increases. Before Obamacare, said one PEO adviser, his clients typically received annual increases of 6 percent to 12 percent. “This year we’re seeing 30 percent rate hikes,” he said. The surge is blamed, rightly or wrongly, on the ACA’s requirement for more comprehensive coverage and on its formula for calculating premiums (aka “community rating”).

Seriously? Is it that the incompetence of the consultants who spoke with Samuelson reached beyond their failure to advise their clients to prepare to comply with the law, and extended into not even knowing the basic economics of health insurance and premium costs? Or is it that Samuelson didn't ask the obvious follow-up question, "Which is it - rightly or wrongly?" To be fair to Samuelson, I think he knows the answer, but if he said it out loud ("wrongly") his three-point list would as a consequence have only two points.

Second, most companies haven’t made final decisions. Those who have go both ways. Another adviser described a 250-worker car dealership with good wages but no health insurance; it will provide coverage and cut wages to help pay costs. Another example involved a 60-worker manufacturing firm with wages of $12 to $15 an hour. It offered bare-bones policies with steep deductibles. Confronting higher premiums for expanded coverage, the owner will drop insurance. He found the ACA “too complex,” said this adviser.

Should we assume at this point that we're talking about a cause of higher premiums other than those that employers rightly or wrongly attribute to ObamaCare? If so, it's pretty much a given that some employers will choose to drop insurance, pay the penalty, and let its workers seek coverage through the exchanges. They're probably better off than with the "bare-bones policies with steep deductibles" (i.e., "crap") policies Samuelson says their employer previously offered - I think it's safe to assume that Samuelson has a gold-plated Medicap plan on top of his own, government-paid, comprehensive Medicare benefits - the workers who need adequate insurance may be better served by their employer's choice. But seriously? The consultant who is paid to make the process as simple as possible for a client employer can't get his client past, "It's too complex"? And that would be the fault of... somebody other than the consultant?

Third, many firms are revising their business models to minimize insurance costs. One favorite idea: Hold workers below the 30-hour weekly threshold requiring insurance. Many part-time employees who work more (say, 35 hours a week) will lose hours.

I've heard about this little scheme, as well. The fixes are so obvious (e.g., setting the penalty based upon total employee hours) that the only reason that it's worth discussing is that people like Samuelson anticipate that Republicans will filibuster any effort to implement a fix. But you know what? It may not amount to much. When an employee is given a choice between working two jobs because his employer won't give him more than thirty hours, and working one job with decent health benefits, guess which job anybody worth hiring is going to choose?

If Samuelson had any experience working in an environment where employees earn at or near minimum wage, he would have some appreciation for how little it takes to convince an employee to change jobs. Samuelson wouldn't notice fifty cents an hour. Were he making $7.25 per hour, it would become a big deal. If you want to run the business with employees who don't mess up orders, don't waste food, are less likely to steal, are easier to train and supervise, etc., as a general rule you have to pay a bit more than the guy down the street. If my competitor in food service were intent on keeping his employees below thirty hours a week, I would be happily skimming the cream off of his workforce.

Another adviser mentioned a client, an engineering firm with 48 workers, that had deliberately restrained expansion.

This is where I make a coughing noise that sounds a lot like I'm actually saying "bull****". If this engineering firm truly is constraining its size to avoid giving its employees decent health insurance, it's not going to have much luck retaining engineers. They have even better options than the movie theater worker and hotel workers whose anticipated plight was, mere moments ago, giving Samuelson such... is the word, delight?

I would suggest that Samuelson stop "concern trolling" ObamaCare and propose some meaningful solutions, but... as I suggested up front, I see no evidence that he's interested in solving the problems ObamaCare is attempting to address.

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?

If A Case Can Be Made for Ryan's Medicare Vouchers, How About Making It

Sometimes I get a bit tired of how bad analysis can be in a "leading" newspaper. Here's what passes for the work of a "health care correspondent" in the National Journal, on Paul Ryan's latest budget stunt:

The plan would not eliminate traditional Medicare. Democrats have gotten political mileage from accusing Ryan of wanting to “end Medicare as we know it.” That is not the same thing as ending Medicare. Ryan’s plan would give seniors a fixed amount of money that they could use to buy traditional Medicare coverage or a private plan with similar benefits. It would convert the program from a single-payer monolith into a marketplace of competing plans. But unlike his budget of two years ago, it would not remove traditional Medicare from the menu of options. Here’s where the “as we know it” part comes in: Because traditional Medicare would have to compete on price with the private plans, there’s a chance it could become too expensive for every senior who wants it to buy it. The plan, which limits how much the payment can increase each year, could also shift costs to even those seniors who buy the cheapest option in the marketplace.

I think it would be more accurate to say that mediocre reporters have gotten mileage out of snarking at an accurate description of Ryan's Medicare plan which, as any healthcare correspondent should know, has been repeatedly revised due to a recognition that current Medicare recipients would go ballistic if it had been implemented as originally proposed. Seriously, if you buy the conceit that Ryan's privatization plan doesn't change Medicare, but merely gives you ample money to buy full Medicare coverage along with any number of additional private plans, why do you think Ryan continues to be such a coward about the implementation of his plan - pushing off full implementation for a decade? Why wouldn't seniors rejoice at the new choices, rather than being anticipated to recoil with such horror that implementation must be put off into the distant future? If the Ryan plan breaches the promise of Medicare to current recipients, how clueless do you have to be to believe it won't change anything for future recipients? How clueless do you have to be to go along with the pretense that Medicare as we know it could be sustained under his voucher plan?

The author, Margot Sanger-Katz, suggests that under Ryan's voucher plan "there’s a chance [traditional Medicare] could become too expensive for every senior who wants it to buy it". A chance? Could? Is she completely ignorant of the genesis of this plan?

If you believe that the purpose of the Ryan plan is to save money - that Medicare costs too much, and that the voucher plan will significantly curtail spending - how difficult is it to figure out that the savings have to come from somewhere. Ryan and his party engaged in some pretty egregious demagoguery against Obama's cuts to Medicare providers - cuts designed to ensure a consistent level of care for seniors. Those cuts... remain part of Ryan's proposed budget. But that's not enough cutting. From where does Ms. Sanger-Katz believe additional savings will be derived? As should be obvious, Ryan's plan is to ensure that the "fixed amount of money" grows at an artificially capped rate well below the rate of medical inflation.

It's also pretty astonishing that Ms. Sanger-Katz is unaware that the Ryan voucher plan is designed to shift healthier seniors out of Medicare - that is, now that he's willing to allow some form of Medicare to continue to exist. Returning to an earlier point, Ms. Sanger-Katz bashed Democrats for supposedly getting "political mileage from accusing Ryan of wanting to 'end Medicare as we know it.'" If the original plan did not end Medicare as we know it, because his vouchers would happen to be called "Medicare", why is Ms. Sanger-Katz claiming that its the continued ability to buy "traditional Medicare coverage" that keeps Ryan's plan from ending Medicare as we know it? If she believes that to be the case, as is implicit in her argument, then it's time for her to respect the facts and admit that the Democrats were correct

As for the goals of the voucher plan, as should be obvious, healthy seniors with lower healthcare costs are more profitable for private insurers. The sickly, money-losing senior citizens are a population that insurers don't want to serve and have never wanted to serve. Ms. Sanger-Katz would apparently have us believe that she has no comprehension of why Medicare exists in the first place. Seniors who need a lot of medical care will end up on "traditional Medicare" (if they can afford the premium), with the result being that Medicare's per patient costs will rise at a much higher rate than the private plans that are able to cherry-pick from a healthier population. While Ms. Sanger-Katz does not hold herself out as an insurance correspondent, she should still be able to figure out that the operative words are not "chance" an "could".

If Ms. Sanger-Katz knows the basic facts, she should admit them. From there, she could describe the probable impact of Ryan's proposed cuts and voucher plan and, if she nonetheless believes the cuts to be appropriate and a voucher plan to be a reasonable alternative to single payer, lay out the policy case for the Ryan plan. If I give her the benefit of the doubt based upon what she instead wrote, I have to regard her as credulous and lazy - as willing to take at face value representations from hyper-partisan politicians that, if made to a better reporter, would instead inspire a series of probing follow-up questions, or at least the performance of basic research to determine if she's being sold a bill of goods.

The High Personal Cost of End of Life Care

According to Ezekiel J. Emanuel,

IT is conventional wisdom that end-of-life care is an increasingly huge proportion of health care spending. I’ve often heard it said that people spend more on health care in the year before they die than they do in the entire rest of their lives. If we don’t address these costs, the story goes, we can never control health care inflation.

Wrong. Here are the real numbers. The roughly 6 percent of Medicare patients who die each year do make up a large proportion of Medicare costs: 27 to 30 percent. But this figure has not changed significantly in decades.

It seems reasonable to infer that by "figure" Emanual means "percentage", as it is implausible that the dollar figure expended on care during the last year of life has not changed significantly "in decades". So what does that percentage figure mean in terms of dollars?

The Medicare program provides subsidized medical insurance for the elderly and for some disabled people. Spending for Medicare totaled about $555 billion in 2012, providing coverage for about 50 million people.

Let's use the low-end figure, 27%. Emanuel is instructing us that 6% of Medicare recipients consumed 27% of $555 billion - let's round that off to $150 billion for 3 million Medicare recipients, an average of $50,000 per person. That, in contrast to $8,617 on average for everybody else. Let's not forget, also, that many of those patients will be in long-term care facilities for much of the year, subsidized by their savings and, once those are depleted, by Medicaid. While the proportion may not be rising, the dollar amount is rising - faster than inflation - and while the numbers bear out the position that people don't, on average, spend "spend more on health care in the year before they die than they do in the entire rest of their lives" the numbers do suggest an enormous expenditure on medical care for patients who receive little benefit from that care - and perhaps pay an enormous personal price on top of the financial cost.

And the total number of Americans, not just older people, who die every year — less than 1 percent of the population — account for much less of total health care spending, just 10 to 12 percent.

Given that younger Americans are much more likely to die from traumatic injury, it's not really a surprise that when they're included in the picture the percentage declines. But as Emanuel surely knows, although care for traumatic injury can be phenomenally expensive, people are not actually talking about car crashes when they are talking about the high cost of end-of-life care.

Emanuel makes a better point about cost reduction,

The more important issue is that just because we spend a lot on end-of-life care does not mean we can save a lot. We do know that costs for dying patients vary widely among hospitals, which suggests that we can do better. And yet no one can reliably say what specific changes would significantly lower costs. There is no body of well-conducted research studies that has proved how to save 5, 10, much less 20 percent.

That's true in part. There are patients who are clearly terminal, but whose families insist upon additional treatment (sometimes overruling the wishes of their loved one) at significant cost. Also, if you think through the logical implications of a typical voucher plan, there appears to be a significant population of people who would "save" money simply by cutting off payment for treatment. While it remains correct that there's no good way to define, in advance, when the last year of life begins and what approaches to treating a specific medical condition will save money without compromising care, if you're willing to be sufficiently mercenary to ration care and make that $50K figure impossible for the average elderly person to reach, you'll "save" money.

If you want to try to identify means of saving money - approaches to end-of-life care that avoid the cost of hospitals, skilled nursing facilities, and the like - it's necessary to engage in the analysis of available data on approaches to patient care, costs and outcomes. If you want patients to be informed of their options, including the fact that by foregoing the aggressive treatment of what is likely to be a fatal disease they may both live longer and have a better quality of life, you have to actually educate the patient - and as Emanuel notes the last effort to introduce that sort of education on a widespread basis collapsed under Republican hysterics about "death panels".

Emanuel is correct that doing nothing to improve the quality of care for the dying is not an acceptable approach to end-of-lie care, but at the same time he suggests that we're doing very little. Emanuel supports end-of-life counseling for patients (the so-called "death panels"), increased availability and use of palliative care, and revised criteria for admission to hospice care. But we can also do some comparative outcome research, which might help us create better criteria for who truly is approaching the end of life, and what treatments that might represent top notch quality of care for a younger patient may undermine quality of life and perhaps even shorten the remaining lifespan of an elderly patient.

Tying Medicare Reform Into Obamacare

Robert Kuttner comments on Medicare reform proposals:

The White House, however, has dropped hints that Medicare could come in for cuts, specifically an increase in the eligibility age. This is a really bad idea. The administration has already imagined that it will be able to cut Medicare by nearly a trillion dollars without cutting services, in order to finance Obamacare. Republicans railed against these cuts in the campaign. Any further Medicare cuts are a terrible idea.

Long-term reform of Medicare is necessary, and is a daunting project. But it doesn’t belong in this budget deal.

I agree with Kuttner that, as things presently stand, increasing the eligibility age for Medicare is likely to prove to be bad policy. A lot of people hold off on obtaining medical care until they qualify for Medicare, and making people wait a few years longer is likely to both increase the number of people who have unmet medical needs as they enter Medicare and the cost of treating some of those illnesses and disorders. It's not clear that the government would end up saving any money, or at least not an appreciable amount.

Looking at political reality, though, you're going to see any "increase in age" legislated in the same manner as the Romney-Ryan voucherization plan - it will be something that affects a class of future retirees, not those who are presently at or near retirement age. That means first that the change is likely to be scheduled to take effect under a different President, but also that Congress will be staring down the next set of people who are near retirement age when they actually implement the change.

So, how about that "Obamacare" thing?

Let's say that the future deal is that the age for eligibility in Medicare is bumped up by three years. Not so good for unhealthy near-retirees, right? Except if things work out as planned, those near-retirees will have health insurance - likely with companies that would just as soon dump them onto Medicare. If the eligibility age is increased but that class of seniors is permitted to buy into Medicare, those who would presently be left high and dry by a raising of the eligibility age may be able to obtain Medicare courtesy of the subsidies made available through "Obamacare". If the trade is "We'll raise the Medicare eligibility age by three years, starting in [the future], as long as affected seniors can buy into Medicare," most seniors should be reasonably covered through that transition period.

There's also an element of "put up or shut up" involved for the Republicans. If the private markets can compete with Medicare, providing the same or better service at a cost savings to enrollees, then insurance companies should be lining up to serve near-retirees during the years leading up to their Medicare eligibility. If that in fact happens, great! If the Republicans are afraid to go there... well, what does that tell you?

How to Approach Tax Reform and Balancing the Budget

Mark Thoma quotes Robert Reich on "grand bargain" negotiations, with Reich proposing how President Obama could open negotiations by describing a set of tax increases and loophole closures that would balance the budget, without any need to "raise taxes on America’s beleaguered middle class, cut Social Security or Medicare and Medicaid, reduce spending on education or infrastructure, or cut programs for the poor".

Although Reich presents his argument in apparent earnest, I don't think he expects that the President will follow his advice. Thoma presents a more basic suggestion,

Obama should at least reverse the Republican pre-election mantra and insist: raise taxes first, then we'll talk spending cuts.

I think you can take a bit from all three columns. The President could actually use Reich's model to illustrate "This is how we can balance the budget with tax increases," followed by, "Here are the tax increases and loophole closures I actually propose." He can add, I'm not saying these tax increases and reforms cannot be reduced or eliminated but I am saying this: before I'm willing to revisit that part of my proposal we must identify enough spending cuts to balance the budget, and only if we accomplish that can we start talking about additional spending cuts that might offset the revenue we otherwise need to raise through the tax changes I've identified."

I also think he should stick to his guns on Social Security, even if it makes some people gnash their teeth, with the same sort of tweaks that were made in 1982. Change as little as possible, in a manner that will make the CBO happy over a fifty year projection. It's the position he took in the debates, and it's consistent with the notion that Social Security should be self-funding.

Frankly, I think the conceit of the "grand bargain" can get in the way of good policy formation, just as throwing three competing goals (universal coverage, revenue neutrality, reduction of healthcare costs) into healthcare reform unnecessarily complicated the debate and legislation while arguably producing a weaker bill than might have been achieved through separate legislation. Social Security expenditures are increasing, but are not out of control. The federal deficit is not all that bad when you remove Medicare, Medicaid and Social Security from the mix. The real issue is the present cost and projected growth of healthcare expenditures. Ezra Klein summed up the issues a few days ago with a series of CBO graphs.

What these three charts tell you is simple: It’s all about health care. Spending on Social Security is expected to rise, but not particularly quickly. Spending on everything else is actually falling. It’s health care that contains most all of our future deficit problems. And the situation is even worse than it looks on this graph: Private health spending is racing upwards even faster than public health spending, so the problem the federal government is showing in its budget projections is mirrored on the budgets of every family and business that purchases health insurance....

Page 9 of the report includes this remarkable statistic: If we just continue on the way we’re going , then “spending for Social Security, Medicare, other major health programs, defense, and interest payments” will “nearly equal all of the government’s revenues in 2020 and would exceed them from 2022 onward — leaving no revenues to cover any other federal activities, such as income security programs, retirement benefits for federal civilian and military employees, transportation, research, education, law enforcement, and many other programs.”

The projection does not include reforms not yet in effect, i.e., those of the Patient Protection and Affordable Care Act ("Obamacare"), but it's beyond obvious that healthcare costs are the elephant in the room. The cost control measures of Obamacare are not going to fix the problem, but at least they're a starting point. If the Republicans choose to continue to pretend that this is a problem we can fix by repealing the first serious effort to bend the cost curve, or by cutting funds for PBS, they're (still) not serious about balancing the budget. If you recall, when the Democrats proposed a modest measure to help patients understand end-of-life care, something that could conceivably lead to better care and outcomes for elderly patients, the Republicans demagogued about "death panels".

The only Republican reform ideas we seem to be hearing about on healthcare are to turn all public insurance programs into voucher programs, and to strip preventive care out of health insurance and pretty much make everything but catastrophic care self-funded through a MSA. "Let's not look at what is working here, and certainly not at what is working in the rest of the world." If our nation's per capita healthcare expenses were reduced to the levels typical of other developed nations, most of our immediate budgetary problems would disappear - we would still have a cost curve issue, but we would have a much better starting point. The Republicans won't consider emulating even the most market-based foreign healthcare models - not just because ideology trumps balancing the budget, but because it's easier to argue for cuts if you first contrive a crisis.

Healthcare Reform is a Done Deal

This one goes out to David Frum.

You Don't Bend to The Opinion Polls, Yet You Call Yourself a Leader?

If Michael Gerson were an honest man, he would admit that his former colleague, David Frum, made a valid point when he argued that the Republican Party would have benefited from making itself a part of healthcare reform rather than positioning itself as an obstacle. The Republican Party's continuing avalanche of misinformation about the Affordable Care Act is a sight to behold - as was the manner in which a contrived "activity vs. inactivity" distinction was puffed up over the course of two short years into a legal theory that almost defeated the legislation. Having lost first at the legislature and then in the courts, what's a hack like Gerson to do but double down on his party's mendacity.

Gerson was, of course, an important cog in the wheel of the Bush Administration's misinformation machine. The machine for which popular opinion was a meaningless distraction. The public is starting to oppose war with Iraq? "Well then, let's get the invasion underway - the public always comes around when the bombs start dropping." The public opposes privatizing Social Security? "Well then, let's find a different word to use. How does 'private accounts' sound?" The public wants to know who met with Dick Cheney when he was forming the Administration's energy policy? "Well, it's tempting to scoff or laugh, but let's stick with stonewalling for now."

But when it's the other guy in office, Michael Gerson is suddenly all for government by plebiscite. Gerson can't even be honest about public sentiment. He whines about the Affordable Care Act, "Change came in the form of a law that a plurality of Americans opposed", but he knows full well that the opposition was in no small part a result of Republican demagoguery and misinformation. He wasn't the worst of the bunch, but he played an eager and happy role in that misinformation campaign.

He knew then, just as he knows now, that the only significant part of "Obamacare" that polled poorly was the individual mandate - that pretty much every other significant reform element, when people understood what they were asked about, received majority support. He focuses on the bill as a whole because it advances his narrative - the lie he and his party keep telling the nation, not because they believe that the public doesn't like "Obamacare" but because they're terrified that it will succeed.

Yes, that's right, they're terrified of its success. If they believed a tenth of their demagoguery, they would allow the ACA to come into full effect and let people see for themselves how bad it is. It's easy to repeal unpopular laws. They live in abject terror of a popular, successful reform that brings insurance to tens of millions of people who are presently uninsured or underinsured. So their effort has been to keep that from happening - and to tell as many lies as necessary to provoke public suspicion, concern and opposition.

Gerson has good company in today's Republican Party, because his position is essentially that of a coward. If you're trying to advance what you believe to be good policy, or at least the best policy you can implement given political reality, and run into a political headwind, you should abandon ship, run for the hills, scurry off the sinking ship like a terrified rat. Perhaps that's how he perceives his ex-boss's abandonment of immigration reform and Social Security reform, or McCain's abandonment of immigration reform, campaign finance reform, cap and trade.... The ultimate politician is a Mitt Romney, a guy with no core beliefs, a guy who's always chasing the latest poll, a guy who will discard his most significant (and arguably only) significant political achievement in the name of winning an election. I would like to say that nobody in their right mind would confuse Gerson's brand of cowardice with leadership but... while you can't fool all of the people all of the time, Gerson and friends are happy to shoot for 51%.

Listen to Gerson's platitudinous nonsense:

Obamacare matters in the current election not only because its future is at stake but for what its passage tells us about Obama as a leader. He is stubborn, which can be an admirable trait when applied to the public interest. But on health-care reform, Obama combined stubbornness with ideological predictability and partisan ruthlessness — imposing a very conventional liberalism in the Chicago way.

Obama is "stubborn" - a good thing if it means advancing Gerson's political agenda, really that of his party, but a terrible thing if it means advancing any other agenda. To pass legislation with a significant majority in the House, a 60 vote majority in the Senate, and then to reconcile minor differences in the bill based upon majority support in the Senate? That's anti-democratic. Not at all like the Bush-era tax cuts that shot our deficits through the roof and create a lingering hangover for our nation, crammed through the Senate by reconciliation in Bush's first term based upon a series of patently false promises. Who was heading up the team tasked with spinning that sow's ear into a silk purse? Oh, yeah....

For goodness sake, "the Chicago way"? Can't Gerson try to be even a little bit creative, to try to disguise his silly and childish attacks as something other than warmed over Republican demagoguery? Is he unable to conjure up a novel turn of phrase without the help of David Frum? To find fresh poison to inject into the public discourse without the help of Marc Thiessen? (Lord, what a dream team that was.)

Gerson continues to whine that Obama failed to broker a "grand budget compromise in 2011", a failure attributed to his demand that a significant part of the balancing of the budget come in the form of tax increases, then goes on to whine about forthcoming "large issues" - "avoiding the fiscal cliff, reforming the tax code, making entitlement commitments more sustainable". Never mind that the "fiscal cliff" is of little concern to anybody but pundits and demagogues - here in the real world we know that Congress will act to prevent that "cliff" from having any meaningful impact on the economy or defense spending. Never mind that Obama's "grand bargain" proposals included significant entitlement reform, and that the very legislation Gerson rails about, "Obamacare", implements cost-saving reforms - and that it has been Gerson's own Republican Party that has demagogued against the Medicare cuts that are part of that legislation. Never mind that "reforming the tax code" is a meaningless phrase - you may as well whimper that the President hasn't spent enough time reshuffling the deck chairs on the Titanic.

Gerson closes by suggesting that if Obama doesn't "become an entirely different type of leader", by which he apparently means a spineless Republican, we should conclude that "America needs a new one". I guess it's fortunate for Gerson that a man who shares his complete lack of integrity, and endorses Gerson's apparent notion that "presidential leadership" is best demonstrated by following the latest opinion poll, is presently the Republican presidential nominee.

David Brooks, Master Craftsman of Republican Talking Points

Okay... it's really not worth my time to dissent a column this risible, but... today, David Brooks gives a lecture on bipartisanship that, true to his standard, consists of his spin on the latest Republican talking points, recast to appear measured and moderate to those who might be... normally I might say, average to less-informed voters, today I'll say, people who aren't very good at thinking. How many sharks can you jump in a single column?

Brooks starts with a Richard Dawson impression. Survey says.... "viewers loved Mitt Romney’s talk of professionalism and bipartisanship." No need to argue why that is or what it actually means.

In other words, primary campaigns are won by the candidate who can most convincingly champion the party’s agenda, but general election campaigns are won by the candidate who can most plausibly fix the political system.

As any Tea Party member can tell you, there is a difference between "bipartisanship" and what it might take to "plausibly fix the political system". Brooks also knows as a matter of policy, reaching a bipartisan solution can weaken a policy proposal. That's not always the case, but by definition a bipartisan solution is going to be less partisan than, if I need to say it, a partisan solution. If you're looking for purity of ideology, you want partisanship.

Brooks then goes through a Romney-like list of elements he deems essential to "break[ing] through the partisan dysfunction and mak[ing] Washington work". Let's start with what it doesn't take:

1. It "doesn’t take moderation". Brooks points to Ted Kennedy, whom he argues "had the ability to craft large and effective compromises on issues ranging from immigration to education and health care."

   That of course explains why Ted Kennedy won the nomination to be the Democratic Party's candidate back in 1980, sailed into the White House and... oh, right.

   Well then, it explains why David Brooks and the Republicans view Kennedy as a pillar of bipartisanship, a figure they respect and admire, and regard the culmination of his career of work in favor of healthcare reform, the Patient Protection and Affordable Care Act, as what you can achieve through a true bipartisan effort. Oh... right.

   Well, Ted Kennedy did cosponsor the DREAM Act, and that sailed through the... oh, right, the Republicans changed their mind.

   Recall, Ted Kennedy is not only Brooks' best example in support of his point, Kennedy is his only example. I'm not going to dispute that over the course of a very long career Kennedy cosponsored some important legislation with Republicans, but anyone with knowledge of history knows that much of that cooperation occurred during a prior era when the parties were less polarized, when the Republicans didn't see obstructionism as a winning election strategy, and worked in contexts in which the Republican cosponsors saw an opportunity to benefit from attaching their names to the bill. John McCain didn't drop his support for the DREAM Act because Kennedy became less persuasive. He dropped it because he was afraid of losing his seat to a primary challenger.

2. Might doesn't "make right". Brooks lectures that the effective President has to avoid thinking that his position is objectively the correct one, and that he can "win the debate" and get everything he wants simply by "get[ting] the facts out there". Brooks somehow forgets to tell us where "out there" is, or what any of this has to do with passing legislation.

   Were Brooks honest about it, he would admit that he's not talking about what it takes to pass legislation, but what it takes to defend legislation that is not popular. If the opposition party is lying about the legislation and its effects, can you count on convincing people of the truth merely bu putting "the facts out there"? Obviously not.

   As you work through his column, it becomes increasingly clear that Brooks is making little effort at internal consistency. He's instead alluding to right-wing criticisms of President Obama.

3. Don't live in a fantasy world - "distant fantasies almost never come true", so it's better to work for incremental change. What Brooks actually means here is that a President who has the opportunity to pass legislation that Brooks opposes should instead pass something modest, perhaps inconsequential, in the name of "partisanship". Never mind that the actual fantasy would be believing that, after another election, somebody like Mitch McConnell will change his stripes, apologize for setting a legislative agenda around defeating you, and suddenly become a partner for progress.

Of course by now you're wondering, what does it take to be the bipartisan savior - the "governing craftsman" for whom Brooks so hungers.

1. Having a "dual consciousness" - "[T]he governing craftsman has to... distinguish between a campaign consciousness and a governing consciousness." Campaigning involves "simplifying your own positions, exaggerating your opponent’s weaknesses and magnifying the differences between your relative positions", while governing involves doing "the reverse of all these things".

   Needless to say, Brooks offers zero examples to back this claim up.

   Let me give you an example for how presenting complicated positions, attempting to bridge the differences between yourself and the opposing party, and taking up their opposition works in practice. A President might take, say, a health care reform idea that has its roots in the Republican Party and right-wing 'think tanks', and has even been adopted in one state by a Republican governor, attempt to tweak and update it so it will work on a national basis, and repeatedly attempt to reach across the aisle for bipartisan support. Sound effective?

   Now let's consider what "the opposite" looks like. The sort of approach Brooks would surely tell us would be a one-way ticket out of Washington. The opposition leader might sniff that his number one job is to defeat you, not work with you. The opposition might engage in demagoguery about the plan, asserting that it is socialism, a government take-over of health care, that bureaucrats will decide the care that you get, that it will have death panels that can deny you life-saving care.

   Thank goodness we live in a political culture in which "governing consciousness" rules the day, because one would hate to think what might happen a president or opposition leader couldn't get past his "campaign consciousness". The horror.

2. "Being able to count".

   Is Brooks trying to rule out Mitt Romney at this point, based on budget numbers that don't add up? No, Brooks is pointing ot the obvious fact that if a President wants legislation to pass he must gather enough votes in the House and Senate to get it to pass.

3. Being able to "distinguish between existential issues and business issues." Brooks evokes that famous American politician, Winston Churchill, and contents that "Churchill would have made a terrible mistake if he had compromised with the appeasers". That assertion is going to make little sense to a casual reader, but immediately evokes the right-wing tropes against President Obama - Mitt Rommey's demagoguery and his persistent lies about an "apology tour". Brooks, a good Republican to his very core, is articulating a set of rules for others, specifically Democrats, not for himself.

   Brooks has one other example he offers in support of his point, "On the other hand, Dan Rostenkowski and Robert Packwood were absolutely right to compromise to get the tax reform of 1986 passed." Let's see... so far his examples of politicians who live up to his deals are the late Ted Kennedy, the late Winston Churchill, the late Dan Rostenkowski, and the long-politically dead Robert Packwood. As I said, he's describing what happened in an era during which the parties were less polarized, and pretending it carries over into a significantly different era.

   Assuming Brooks is aware that Winston Churchill would be ineligible to run for President, which of the two additional names he's mentioned does he imagine would have been the "craftsman" politician who would have been elected to the presidency in a walk and presided over a golden era of bipartisanship?

   Brooks feigns child-like innocence, that "in the middle of the fight almost every issue will feel like an existential issue, though, in reality, 98 percent of legislative conflicts are business issues". Perhaps Brooks is describing his own confusion, because although I can see plenty of examples of the opposition party turning "business issues" into stumbling blocks - preventing appointments from going through, needlessly obstructing the progress of legislation that it will ultimately support, spreading misinformation about what should be relatively non-controversial passages in new or pending legislation, and the like.
   
   I'm not coming up with an example of a president confusing business issues with existential issues. It's fair to observe, though, neither does Brooks - we know he's attacking President Obama through innuendo, but Brooks knows how foolish he would look if he came right out and made that claim.

4. Brooks offers the brilliant insight, that his bipartisan leader must be "able to read a calendar". Brooks explains that the politician must understand that they cannot postpone their agenda until after the next election in order to act - that it's "usually better to make a small step next month than do nothing in hopes of a total victory next generation".

   Let's imagine then, that the President is facing a large deficit and national debt, and that people are urging a so-called "grand bargain" that will supposedly balance the budget for decades to come. "Never mind the fact that this Congress cannot bind future sessions of Congress", those maximalists might argue, "You can't take seriously any budget proposal that doesn't fix everything for decades - or longer!"

   The David Brooks who wrote the current column might lecture those politicians and peers that they are being absurd, not only due to the fact that the next session of Congress might undo the work, but because it's not a realistic outcome to expect. He might argue, "If you calm down and take a look at the President's tax plan, you'll find that it does a lot to accomplish your stated goals. This isn't an existential issue - it's business. It's what can pass through Congress, right now. Think of it as a first step down a long road."

   But the David Brooks we have come to know and love? He wants none of that incremental stuff.

   Obama would be wiser to champion a Grand Bargain strategy. Use the Congressional deficit supercommittee to embrace the sort of new social contract we’ve been circling around for the past few years: simpler taxes, reformed entitlements, more money for human capital, growth and innovation.

   So guzzle that Kool-Aid and shoot for the moon! But... what if the public resists?

   Don’t just whisper Grand Bargain in back rooms with John Boehner. Make it explicit. Take it to the country. Lower the ideological atmosphere and get everybody thinking concretely about the real choices facing the nation.

   Doesn't that translate into the big "no-no" of thinking, "all I have to do is get the facts out there, win the debate and then I’ll get everything I want."? No, you see, this is completely different - all you have to do is get the facts out there, win the debate, and then David Brooks will get everything he wants. No rules or principles should get in the way of that.

5. Be "socially promiscuous." Brooks argues that a good deal maker will have lots of friends, be constantly glad handing the opposition, "celebrate their anniversaries and birthdays". You know, the sort of thing that helped Clinton have such a smooth, carefree relationship with the opposition party during his presidency.

   Were Brooks an honest man, he would admit that he's merely parroting an Republican talking point that the President does horrible things like... eating dinner with his family when he could be out at cocktail parties glad handing Republicans and lobbyists. Never mind that, by a number of accounts, Mitt Romney is no social butterfly, and came to be detested by pretty much every one of his primary opponents in two consecutive primary seasons. Never mind that many Republicans openly hated him right up to the second they were stuck with him.

6. Be a really good liar, and conspire against your base. Seriously. Brooks lectures,

   It is relatively easy to cut a deal with the leader of the other party. It is really hard to sell that deal to the rigid people in your own party. Therefore, the craftsman has to enter into a conspiracy with the other party’s leader in order to manipulate the party bases. The leaders have to invent stories so that each base thinks it has won.

   On the little issues - the "business issues" - that's relatively simple, politics as usual. A bit of spin, the issues not that important, you make a deal. How in the world, though, does Brooks believe that will work in relation to solving big issues. Might it sound like President Obama, at a debate, telling the public that he and Mitt Romney aren't very far apart on how to fix Social Security? If so, what are the odds that John Boehner and Mitch McConnell are going to get out of the way and allow the passage of a modest reform bill that will fix Social Security's balance sheet for the next 50 - 75 years?

7. Next, you have to compromise in advance - show "substance pragmatism". Your base wants Medicare for all? A public option alongside private health plans? The insurance industry and healthcare industry want to be sure that the reform will not affect their bottom line profits? Insurance companies want to ensure that they will stay in business, perhaps even become more profitable, despite changes that will otherwise reduce their bottom line? A "craftsman" President might do what President Obama did - work with the various industries and their lobbyists to overcome their opposition to any reform, build the reform on the platform of a right-wing, Republican-endorsed system of private insurance, a mandate to purchase insurance, and keeping the reformed system as market-based as possible. He might get a true craftsman like Ted Kennedy to strongly endorse the bill and its passage.

   No, of course that's all wrong. Stop arguing based upon those facts with their icky "liberal bias" - Brooks' column is about advancing Republican spin. What an honest Brooks might describe as the outcome of his "conspiracy with the other party's" leadership to "manipulate the party bases" and "invent stories." Because that's what pundits do when they are approached for help by a "governing craftsman".

Brooks knows he's being dishonest when he argues that voters are demanding "craftsmanship" in advance of the "brutal trade-offs that loom ahead". Were he an honest man, he would note that Romney's new "talk of professionalism and bipartisanship" is belied by his own campaign trail rhetoric and that, rather than addressing any of the "brutal trade-offs" that Brooks sees as inevitable Romney is promising the Sun, moon and stars - tax cuts for everyone, a huge increase in military spending, pain free spending cuts (trust him, even though he only states support for cutting PBS and the unpopular parts of Obamacare), and that he'll cure the nation's woes by magic - why, if people simply believe he's going to be elected, flowers will burst forth from the ground, the stock market will reach uncharted heights... yeah.

Brooks also cannot be so obtuse as to believe that "Voters [were] astonishingly clear. In 2000, they elected George W. Bush after he promised to change the tone in Washington". If Brooks checks his history books, he'll find that if you look at the popular vote the 2000 election was won by Al Gore. Last I checked, losing the popular vote was an "astonishingly clear" message that more people wanted your opponent to win than wanted you to win, even if you carry the electoral vote. Similarly, Brooks might realize that more was going on in 2008 than the Republican's self-proclaimed maverick, campaigning on a claimed record of "reaching across the aisle," lost to a candidate who merely "promised to move the country beyond stale partisan debates". The country I was in was suffering from a profound economic crisis, and McCain's response was not perceived as impressive. Where was Brooks?

Brooks would have done better to have written a column about how politicians will try to sell you snake oil while on the campaign trail, but alas, that would have ended up being a column in support of the wrong party.

How the Media Plays Out its Role in Our Risible Economic Debate

After a couple of opening paragraphs of pure snark, the Washington Post's editorial board criticizes the President for failing to clearly articulate why he is running for a second term. I've previously called for the President to do exactly that, but unlike the Post's editorial board I'm not going feign outrage if the President sets different priorities than I would prefer.

After attempting to trivialize the President's stated second term agenda by pointing to his plan to help states hire more math and science teachers, and his proposal to end certain tax subsidies for the energy industry,

He wants to take away $4 billion in tax breaks from oil companies. (The deficit in the fiscal year that just ended was $1.1 trillion.)

Why am I reminded of Robert Samuelson's notion of what constitutes "pocket change". Have we truly entered an era in which $4 billion in waste is not worthy of consideration, and in which a proposal for its elimination is mocked? If your concern truly is to balance the budget, why not respond, "One $4 billion item of waste down, 224 to go"? If you read the Post you know the answer - that's not the type of government expenditure that concerns its editorial board.

From there the Post gets to the meat of the President's tax proposal,

And he wants to increase tax rates for the wealthy. That would put a serious dent in the deficit, but it wouldn’t solve the fiscal problem, which unaddressed will “lead to a level of federal debt that would be unsustainable from both a budgetary and an economic perspective,” the Congressional Budget Office recently said.

First the problem is the deficit, and cutting waste isn't enough. Next it's, "The President has a clearly stated proposal that will cut the deficit" but, after a bit of sleight of hand, the deficit is no longer the issue.

So now that we're no longer talking about deficits, but are talking about the "level of federal debt", what does the Post have to say?

A solution can come only from restraining spending, especially growth in Medicare and Medicaid, and raising revenue, and not just from the rich.

Let's back up for a moment. The leading reasons we have a significant deficit at the moment are the Bush tax cuts, the Bush Administration's unfunded wars, and the economic downturn. As I recall, the Post supported all of the above. Yes, we would have a substantial deficit right now even without those factors, but principally attributable to revenue reduction from a profound recession and spending measures meant to help us pull out of the recession and to soften its blow on families. The point being, as we pull out of the recession and return to more normal levels of employment, more people will have income and tax revenues will rise.

And yet, when it comes to figuring out how to raise more revenue, creating more jobs, reducing unemployment, reinvigorating a middle class and improving its wages, none of that occurs to the Post's editorial board. It's "Why aren't you cutting entitlements." It's not that they're unaware that growing the economy will raise tax money - it's that they aren't being candid about their own agenda. If the Post's editorial board has a proposal by which tax revenues can be raised without impairing the economy, above and beyond as a result of growth or the proposed modest rollback of the Bush tax cuts, it's high time they shared it. After all, they found the time to chide Mitt Romney for not sharing the details of his secret plan to make revenue neutral his proposed massive tax cuts, so why keep their own secret plan so close to the vest?

You have to love this part. Remember how "A solution can come only from restraining spending... and raising revenue, and not just from the rich"? Seriously, this is the next sentence of the editorial:

Yet Mr. Obama has put forward no plan to curtail entitlement costs, while Mr. Romney at least is willing to say that benefits for wealthy Medicare recipients will have to be cut back.

That is, immediately after acknowledging that the President proposed a tax increase that will significantly reduce the deficit, and poo-pooing that it's not enough because it isn't sufficiently broad-based, they're praising Romney for making an economically meaningless pledge about trimming Medicare benefits for the wealthy. Even if he keeps that promise, the revenue savings will be trivial. So why is it bad for the President to take a serious, effective measure to close the deficit, but laudatory for Romney to make a cynical, hollow gesture? The most obvious inference is that the Post's concern is not with deficits but is instead with entitlements.

The editorial board next returns to its prior snarkiness,

Why the reticence? Maybe, after promising so explicitly four years ago that he would make hard choices and refrain from kicking the can down the road, he’s reluctant to make the same promises again. Maybe the usual Democratic “Mediscare” campaign is so useful he does not want to muddy the waters — or, more accurately, un-muddy them — with budgetary honesty.

You would think that at least one member of the editorial board would remember the Affordable Care Act, including its serious effort to find cost savings in Medicare. You would think that they would remember that the Republicans immediatedly engaged in demagoguery about the ACA, screaming at the top of their lungs about "death panels" and "cuts to the Medicare benefits you paid for." They claim to have watched the debates, so it's difficult to believe that they could have missed the demagoguery from Romney and Ryan about "cuts" to Medicare. Which side is engaged in budgetary dishonesty and is resorting in "Medicare" tactics, again?

Funny, also, how the Post is suddenly unconcerned about Social Security. Which candidate explicitly addressed Social Security and what it would take to make it fiscally sound over the long term? If you need the reminder, it was President Obama. Does the editorial board have the grace our courtesy to say, "At least he has promises to fix this other thing we've been harping about?" Nope. As with discussion of the ACA, any such honesty would undermine the two points they are trying to make, that the President has made no proposals to prevent entitlement costs from spiraling out of control, and that the only possible solution is massive cuts in those programs.

It seems fair at this juncture to ask, how does the editorial board believe that the federal government can cut Medicaid spending? We're not talking in that context about a population with a lot of resources to spare. To the contrary, if you have significant resources you don't qualify for Medicaid. If you cut Medicaid you cut the provision of medical care to that population.

You can, of course, use ACA-type measures to try to identify waste, to evaluate which treatments are the most cost-effective. But in case they missed it, the Supreme Court recently ruled that Medicaid is such a large program, contributing so much money to state coffers, that states must be given the right to opt out of any significantly revised program and be allowed to continue with the status quo. Seriously, does the Post have even one idea it can share? Romney at least came up with PBS and Sesame Street - and the repeal of the cost-saving measures for Medicare that the board wants to pretend Obama didn't sign into law.

As for Medicare, even if they assume Romney is sincere, they know that savings from his proposal to trim benefits for the wealthy would be trivial. They know that his pledge to repeal Obamacare will increase the cost of the program. They know that a promise to do something a decade from now, even if it's something they would applaud (i.e., turning Medicare into a voucher program) is nothing more that irresponsible buck-passing. Within that context, they want the President to promise additional cuts to Medicare - above and beyond the cuts that Romney and Ryan are suggesting will devastate seniors' ability to obtain care?

The Post is right about this: It would be nice if we could have an adult discussion about these issues and how we might mitigate, if not solve them. If the editorial board spent any appreciable amount of time reflecting on the subject, though, they would realize that unless they break with their longstanding tradition they aren't part of that solution. They're not even making an effort.

Fee-For-Service Isn't "Market-Based"?

It's that time of year, when pretty much every columnist is tempted to phone in a column, putting words in the mouth of the President or his challenger that supposedly represent the truth, a message that they are convinced will win the race, or... allows them to easily meet a deadline. Among today's examples was this lazy example by David Brooks, his usual effort to put his own spin on the present set of Republican talking points. It's banal, and I was ready to ignore it until I hit Brooks' criticism of the Obama Administration's attempt to control healthcare spending by evaluating the efficacy of treatments,

The second approach, favored by me, is to scrap the perverse fee-for-service incentives and use a more market-based approach. I think there’s ample evidence that this could work, but, to be honest, some serious health economists disagree.

As expressed, the statement is an incoherent mess. In our market-based economy, if you want goods you pay for them. If you want services you pay for them. What does Brooks imagine to be more market-based than paying the fees required by people who is selling you their services.

In an effort to make sense of Brooks' argument, I headed over to Romney's website, and found this:

• Medicare is reformed as a premium support system, meaning that existing spending is repackaged as a fixed-amount benefit to each senior that he or she can use to purchase an insurance plan....

• “Traditional” fee-for-service Medicare will be offered by the government as an insurance plan, meaning that seniors can purchase that form of coverage if they prefer it; however, if it costs the government more to provide that service than it costs private plans to offer their versions, then the premiums charged by the government will have to be higher and seniors will have to pay the difference to enroll in the traditional Medicare option

In other words, Brooks is distorting Romney's proposal - rendering it incomprehensible in his retelling - to avoid disclosing that what Romney wants to do is replace Medicare with vouchers. Romney doesn't care whether health insurance is offered on a fee-for-service basis or on some other basis - he simply wants seniors to purchase it from private insurance companies, while constructing a premium structure that will discourage seniors from buying - or leave them unable to afford - traditional Medicare coverage.

Brooks goes from incoherent to insipid:

I’m willing to pursue any experiment, from any political direction, that lowers costs and saves Medicare. Democrats are campaigning as the party that will fight to the death to preserve the Medicare status quo. If they win, the lesson will be: Never Touch Medicare. No Democrat or Republican will dare reform the system, and we will go bankrupt.

The Democratic Party worked very hard to reform Medicare, hampered not by a lack of willingness to make the effort but by lockstep Republican opposition. Brooks knows that the Republican hope was that, between demagoguery, obstructionism and , the reform effort would fail. The goal was not to offer a better alternative - that can be seen from the fact that the "best" Romney is willing to do is propose vouchers for a future set of seniors - but to prevent a reform that would strengthen and perpetuate the program. Through "Romney", Brooks whines that "Congress wrote provisions in the health care law that have already gutted the power of the advisory board", but the Republicans in Congress could have prevented that from happening or could help fix that problem right now. Instead they demagogue about "death panels" and "bureaucrats deciding your care."

When it's private plans, the Republican complaint is that Obama's reforms were going to make you change your insurance plan, put bureaucrats between you and your doctor, make you change your doctor.... But when it's Medicare, the goal is to strip seniors of their present plan, Medicare, and subject them to the vagaries of market forces rather than guaranteeing a predefined set of services in the tradition of comprehensive health insurance. There's no attempt at consistency, but that's only a problem if columnists like Brooks aren't willing to post incoherent nonsense to spackle over the cracks and holes in the healthcare policies his preferred candidates want to impose upon the nation.

If the Democrats win, it will be that much harder for the Republicans to voucherize Medicare, but it is absurd to pretend that the only party that displays any serious interest in reform and cost containment will suddenly stop working on those reforms. Given Romney's effort to distance himself from his own health insurance reform plan, there's simply no credibility to Brooks' suggestion that he would "pursue any experiment, from any political direction". The only plan he's openly favored is voucherization, walking it back only when he realized the backlash that plan was about to create. Under Romney, we're not going to be looking at ideas from Japan, Europe or Canada, or even Massachusetts. If he gets his way, we'll be looking at vouchers.

The charitable interpretation is that Brooks is trying to put the best spin - the least offensive mendacity, inconsistency and incoherence - on what Romney might say about Medicare, and that Brooks is not himself attempting to hide the facts of Romney's plan. But given Brooks' history, there's little reason to view his column as anything other than an attempt to burnish Romney.

Update: Dean Baker addresses a number of the factual errors and faulty assumptions Brooks includes in his "speech".