Jeff G Factually incorrect. When defining what is a "driver" of debt, look not only at magnitude of spending but the rate of growth. No sector of govt spending should ever grow faster than GDP overall, let alone inflation -- save for one-time strategic adjustments by policymakers. http://www.washingtonpost.com/wp-srv/special/politics/30-years-spending-priorities-federal-budget-2012/ The one sector that stands out in terms of acutely excessive rate of growth is Medicare -- by far. Please see the info-graphic linked above and click on the brown box labeled 'Medicare' on the right side. Then click on Defense and other sectors for comparison.
Jeff G By the way Sal, I did write an article previously where I tried to give some details on why U.S. health spending is increasingly inefficient and how it's the main factor in driving up chronic deficits. A little down into the weeds in terms of policy minutiae but hopefully illustrative, and points the way towards possible reforms for Medicare (which doesn't rely on so-called "cutting" of benefits or sacrificing quality). http://www.policymic.com/articles/5945/30-slides-that-get-you-up-to-speed-on-u-s-health-care-policy
Jeff G That's absolutely the commitment that govt should and must make to improve or restore a basic level of confidence. My main assessment is it's easy to do objectively for programs that have a small overall profile and only a niche constituency. It's much harder to do for programs attracting more publicity and larger constituencies, e.g. certain areas of defense spending and healthcare. It takes a better partnership amongst both policymakers and the agencies they oversee, as well as the broader community and electorate.
Jeff G Sal, "The federal government desperately needs help determining which social programs are no longer effective, and ones that have stopped benefiting those originally targeted." Wholeheartedly agree with the whole paragraph. There are a few agencies that do a spectacular job of this, putting rigorous independent evaluation of impact and learning from experience as the central pillar of their mission -- but this ethos needs to spread through all of govt, and policymakers need to heed the results when published. Also, policymakers often scuttle results of evaluations impacting politically salient programs, so sometimes they'll intervene in negative ways, even if an agency has been up front about a program's weaknesses (or lack of cost-effectiveness).
Jeff G Jay, my article answers your question. Medicare's growth in spending is not commensurate with a dollar-for-dollar increase in value of care, nor number of people served. It's becoming increasingly less cost-effective each year while driving up deficits and depleting its assets.
Jeff G Great article, Rick. I've put out a piece that gets further into the weeds with Medicare. The bottom line is the projected, excessive rises in spending aren't making anyone any healthier, aren't due to population aging, and aren't necessary to preserve or maintain quality of care. i.e., they can be avoided -- by reforming the program. Policymakers on both sides need to hear from their constituents about this, and be prodded into action. http://www.policymic.com/articles/5945/30-slides-that-get-you-up-to-speed-on-u-s-health-care-policy
Jeff G Dee, I'm sure the further-right leaning pundits are more than able to point out many (or most) of the line items of govt with which they disagree and would like to see drastically scaled back. However, taking that as a starting point isn't likely to lead to anything productive - just a line-by-line set of items where no one can agree on the respective value of different spending priorities. What would make the most sense in terms of approaching it is to start by reforming the one area of spending that's the biggest cost-driver in terms of our chronic, structural deficit - then live to fight another day about every other part of govt. My article on healthcare cost inflation and its relationship with Medicare's unsustainable growth rate tries to describe this a bit more fully - i.e. why healthcare spending is becoming progressively less cost-effective each year. http://www.policymic.com/articles/5945/30-slides-that-get-you-up-to-speed-on-u-s-health-care-policy
Jeff G Sal, just about every point in this article hits the nail on the head, esp. #1 exactly as stated - also #11. I think moderates would abandon the R/D's and flock to this party in droves. Getting real about climate change would also be a value added.
Jeff G On that very last point, consider the question this way ~ why would a moderate/independent voter -- who wants to see a solution implemented for the structural deficits driven by entitlement growth -- also be in support of an approach that makes indiscriminate cuts across the whole of govt, in particular areas that are (a) not responsible for excess spending growth, and (b) something moderates typically support? These non-defense, discretionary spending priorities are already being crowded out by increasing pressure from entitlements and interest payments, as I've argued repeatedly. In other words, why would a moderate support cuts to the area of this budget that constitutes only 8% of spending (as illustrated here for the year 2020), and is viewed as both important and already threatened by entitlement growth? http://money.cnn.com/2011/01/21/news/economy/spending_taxes_debt/index.htm
Jeff G The bottom line here is that, in regards to the question 'why I identify moderate' -- you may be right in arguing that the left has/will distort the policies that Romney proposed, but as I've outlined above you've also distorted (or omitted simply by mistake) details on the policies that Obama has proposed. Having evaluated the policies put forward by both sides, neither one is altogether terrible, nor altogether perfect. There are good reasons to support either, while different preferences will arise partially out of differing philosophies. There's no one way to skin a cat. That said, perhaps the biggest thing for you to wrap your head around is the idea that, just as it's not true that Romney's proposals were awful and Obama's perfect, neither is the exact opposite true. Lastly, given the known facts about entitlement spending as the main source of our structural deficit, the GOP approach of cutting govt across the board is baffling, particularly as a moderate.
Jeff G Obama actually *has* proposed (and partially enacted) some plan for dealing with Medicare costs, although by the way he's been so subtle in talking about it, you'd be forgiven for not knowing it. The speculation is he wants to bring down costs but doesn't want to make it a signature issue, perhaps not to scare seniors. You can read and compare the Obama vs. Romney plan for Medicare here: http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/08/13/the-white-houses-medicare-plan-isnt-that-hard-to-find/?hpid=z2 In addition, you may have missed the article I wrote on the issue of growing healthcare costs -- rather than compare the two approaches, I talked about the main drivers of cost growth. I mention a few basic provisions that can address them, which are alternately related to different elements of the plans promoted by both camps. http://www.policymic.com/articles/5945/30-slides-that-get-you-up-to-speed-on-u-s-health-care-policy
Jeff G Your second question can be answered by way of responding to your points about entitlement reform and spending reform. I've observed on this site that moderate voices are pretty under-represented, and to the extent they exist, it's pretty much a spectator sport of watching the conservatives like yourself butt heads with the further-left leaning folks (a la the Alexrods of PM)... much like in the "mainstream media." just an editorial note. As for Romney's entitlement reform vs. Obama's. You'll be surprised to know I didn't think Romney's plan was so *terrible* nor Obama's "great." I actually agree Romney's plan (e.g. Ryan's) could have brought down cost growth over time and may have protected quality of care. Surprisingly one thing I didn't like about it is it waited too long (10 years) to actually make any changes to Medicare. However, as to your contention that "Obama-Biden proposed … nothing," you're actually mistaken... cont.
Jeff G John, while the first half of your article contained mostly blame-shifting, I can appreciate the questions you find yourself wanting to ask self-described moderates. To the extent I fit that bill (and I fit it fairly well), I'll throw in my 2 cents. 1, where do I get my news. For the most in-depth analysis, I go to the Economist, which I believe actually comes from a center-right position, and has provided extensive critiques of the past 4 years' performance - yet, not sure if you noticed, it still came out and (reluctantly) endorsed Obama over Romney (http://www.economist.com/news/leaders/21565623-america-could-do-better-barack-obama-sadly-mitt-romney-does-not-fit-bill-which-one?fsrc=scn/fb/wl/pe/whichone) I also occasionally read Ezra Klein, as he does good analysis of H/C & entitlement issues and the economy. cont.
Jeff G Thanks John, I remember seeing that a while back and really liking it. Singapore has a HC system very much modeled on the use of medical savings accounts, and it's a top-rated system. Here's mine, http://www.policymic.com/articles/5945/30-slides-that-get-you-up-to-speed-on-u-s-health-care-policy
Jeff G 1 - generally, sure (and PPACA is bringing Medicaid reimbursement rates more in line with Medicare rates, which ought to ameliorate that). Of course, it's still better than getting 'no' care. 2 - other industries sure, but look at the healthcare sector across other countries. Prices are categorically lower, despite having higher access than in the US. Grant points out growth rates have been higher elsewhere, but not by much - could be statistical noise. We pay nearly twice that of the OECD median. So *insofar as* govt is involved in procurement of care, there are better ways to finance/organize it than what we've got. And we could (and should) move in the direction of pulling prices down, without worrying about decreasing quality at this point -- we're too far at the extreme of high prices, while quality is comparable.
Jeff G The other point is that usually when people use the term 'rationing,' that implies that not only is govt making the price/allocation decisions for people, but that it's making those decisions while providing far too limited quality/quantity of the thing being provided for it to useful to people, nor allow suppliers to adequately meet demand. In the case of the US, I've repeatedly argued that US govt policy is far unbalanced in the opposite direction: making those price/allocation decisions in a way that's far exacerbated price escalation, providing little valued added for consumers (in terms of health) but certainly helping suppliers (e.g. pharma/device manufacturers) turn a healthy profit.
Jeff G Agreed, to the extent it comes down to 'who' is making those allocation/price decisions - individuals or govt. I was mainly suggesting that even if prices are held lower due to govt policy (as opposed to individual choice), it doesn't necessarily follow that quality of care goes down. In general there are a lot of misconceptions when it comes to the r/ship between Cost, Quality, and Access when it comes to healthcare. There's a belief that if Access is subsidized, prices necessarily go up -- a possibility but not an inevitability. Or if Access is subsidized and Cost is held down via govt rate-setting, Quality necessarily suffers -- again, a possibility, but not really supported by the data.
Jeff G Thanks Grant, I hadn't previously seen data on relative rates of growth (as opposed to comparative overall costs). I might view it as an issue of overall fiscal mgmt of healthcare, and to an extent the US is in a worse off position, treating Medicare is mandatory spending with no formal/set budget. As contrasted with Canada's Medicare, which does have a budget that must be held to (though Canada isn't the greatest model to emulate). At a certain point there will need to be a ceiling put onto the rate of growth in costs, both in the US (under Medicare) and in other countries, but there are different routes to achieving that.
Jeff G By the way, prices in a normal market are themselves a rationing device for the allocation of goods/services. But it's only referred to as "rationing" (in quotation marks) when govt is involved in the purchase and any decisions about price. However govt "rations" in just about every contract it engages in with the private sector -- ever heard of competitive bidding, lowest price technically acceptable? No rational person would insist that we pay Raytheon double the price of the newest weapons system compared to a fair market price, nor thinks of that as rationing.
Jeff G Gary, rationing in the context you're using it is very ill-defined. You could define it as simply the act of procuring healthcare by any govt entity and determining some policy on how to value and pay for that care, regardless of price. Yet we know that the US spends drastically higher per capita on HC than other countries, yet this doesn't buy us any better outcomes. It seems that this rhetorical device about "rationing" is unwittingly helping pad the profits of device manufacturers and pharma companies whose products aren't helping us beyond any generic alternative. Actually they couldn't possibly have cooked up a better PR scheme to persuade us to continue paying the ridiculous high prices that we do. http://www.washingtonpost.com/opinions/matt-miller-the-real-medicare-villain/2012/08/24/bb18f572-ede8-11e1-b0eb-dac6b50187ad_story.html
Jeff G Grant, what empirical data do you have showing that costs can't be controlled under universal healthcare? On the contrary, the US has far and away the highest costs among OECD countries, while others where govt is much more involved in direct procurement of care for the whole population have held costs down. These other systems have very comparable health outcomes and quality of care to the US. http://www.oecd.org/health/healthpoliciesanddata/49084355.pdf
Jeff G I'll also throw out a pitch for open primaries. That could get more moderate candidates into the process on both sides, which will get better quality choices (hopefully more willing to compromise) for the general election.
Jeff G Jeanne (and Jeff), spot on. The one thing that's changed is the election is now history, so it's time for constituents to make sure their reps/senators (of both parties) to not let them hear the end of calls to get back to work - get on their case to start doing their jobs and make compromises and get things done.
Jeff G Thanks Tami. I'm definitely interested to see whether or how PPACA may affect HSAs, though it's hard to see any scenario where they'd be somehow banished altogether; I could see how they'd be impacted by the MLR provision. Even FEHBP (federal health plan) offers an HDHP/HSA option (see bottom 2 options): http://www.opm.gov/insure/health/planinfo/types.asp
Jeff G Thanks John. Looks like that report was from late last year - am definitely interested to see what the current status might be. Based on other things it seems the administration has been relatively accommodating of state-level innovations like this. Would be very interesting to see how the HIP program plays out in a medicaid population as well.