Hey, You Done Did the Right Thing, Dial Up My Ring Ring

by Eric Martin

I'm reprinting this from an e-mail from a very close friend, D, whose health has seen better days.  Some of you might recall that I took a trip to Toronto* in August to attend a wedding - it was D's wedding.  We've been very close friends ever since serendipity put us in the same dorm room freshman year at NYU.  D has a request:

Friends - please excuse the mass email.  As many of you know, I got quite sick last year.  I spent a lot of time in hospitals and doctor's offices.  I was poked, prodded and scoped.  I am lucky enough to have health insurance.  But even with pretty decent coverage, I still had to pay a lot of money out of pocket.  I am currently on a drug that costs my insurance company upwards of $5,000 every time I go to the hospital for treatment.  I have cost my insurance company more than $100,000 in the last 12 months alone.  For millions of people, the situation I was in would have either bankrupted them or, more likely, caused them to live in constant pain without any chance of being treated. 

You are all likely aware of the health care debate in Congress.  You are all likely as frustrated and angry as I am that this is even a debate at all, or worse still that it has divided our country, our political system, our 24 hour cable news channels, etc.  Whether or not you like the bill, have issues with some of the bill or know very little about the bill, I think we can all agree that giving more Americans access to affordable health care is probably a good thing.  Regardless of your political affiliations providing these services to millions more citizens would be a great start. 

The big vote in Congress is this weekend!...It is imperative that people call their local congress people and tell them to vote yes on health care reform this weekend. 

Here's the number: (202) 224-3121. Just ask for your representative's office (if you don't know who it is, you can find out here: http://house.gov/).  You will need to know your 5 digit zip code + the 4 other numbers that often follow it.  To find that number - go here: http://zip4.usps.com/zip4/welcome.jsp

I wish they made this easier.  But - really, this will take 2 minutes of your time.

Thank you. 

He's one of the most decent human beings I know, and I thank him for sharing his personal story in an effort to improve the lives of others.  But that's his style.

*(Thanks for all the recommendations re: Toronto restaurants, hotels and sites.  Especially those that recommended Rodneys - my brother's fiancee, who grew up in New Orleans, claims they are the best oysters she's ever had. High praise considering the source.)

Comments

[johnt]

Good idea to put the phone # in, though you may not get through due to other types of calls. The "pro" scratch pads, enumerating the support for affordable [?] health care, the kind that will add trillions to our now manageable national debt and currently inconsequential deficits, will have more than ample room for entries. Perhaps a VAT will mitigate these problems, I know we all can't wait.
Yes, debate is frustrating, people just don't know what's good for them and have these cockamamey ideas about the absence of coercion, and even stranger ideas about the efficiency of government, perhaps remembering the stellar performance of the auto clunker program, though there is no shortage of examples.
But let's clear our minds of troubling considerations, let's ignore the previous extension of various government programs, some of which are impoverishing the states,]I know, pass it on to Washington], ignore that rationing is already becoming a feature of Medicare, that doctors are threatening to walk away from practices, a trend that has already started, and in any case who the hell do they think they are?
Let's do it for D.

[Eric Martin]

the kind that will add trillions to our now manageable national debt and currently inconsequential deficits, will have more than ample room for entries.

Um, I think you mean reduce the debt by trillions, right? As the CBO scored?

Yes, debate is frustrating, people just don't know what's good for them and have these cockamamey ideas about the absence of coercion, and even stranger ideas about the efficiency of government, perhaps remembering the stellar performance of the auto clunker program, though there is no shortage of examples.

Yeah, like the ever unpopular Medicare and Medicaid and SChip. And just look at all those other countries with government provided insurance. All those poor, poor souls laboring without bankruptcy or rescission. Yuck!

ignore that rationing is already becoming a feature of Medicare

You realize that without insurance, everything is rationed. Right?

that doctors are threatening to walk away from practices

You got a link to that?

[Carleton Wu]

ignore that rationing is already becoming a feature of Medicare

Got a link?

[Sebastian]

"Um, I think you mean reduce the debt by trillions, right? As the CBO scored?"

Ugh. The gaming in the CBO scoring has been incredibly intense at this point. We are nearing the point where the once useful CBO budgetary analysis has been turned completely into a political tool.

I don't say that because I dislike the health care bill (I'd probably vote for it if I were unlucky enough to be a Congressman), but because it just isn't an accurate forecast anymore, and that is by design of bill makers.

First, the bill designers purposely put a huge percentage of the costs just outside the 10 year CBO window. You can see this in the ballooning cost structure at the end of year eight and throughout year nine.

Second, the excise tax has been moved to 2018, which mean that pretty much no one expects it will really be implemented, but the CBO has to pretend that it will. (for recent similar examples see the near continuous AMT 'adjustments' and decades long Medicare doctor payment 'adjustments').

Third, about $50 billion of the 'savings' is just reallocated Social Security tax revenue which increases the payout on SS in the long run (though conveniently outside the 10 year window). That isn't savings, that is just budgetary move-around.

Fourth, the "we have no idea how were are saving money but we'll assume it in the formula" section grew enormously and without explanation. This is especially revealing because the method most likely to actually spur savings (the excise tax) was moved into 2018 oblivion.

I think it is too bad that CBO gaming has gone this far (which I want to note is not the CBO's fault, they analyze along certain rules, and the Congress is gaming the rules to get the result they want). But there we are.

[Jacob Davies]

The inestimable Ezra Klein on "gaming" the CBO:

Some conservatives are arguing that Democrats "gamed" the CBO in order to get the score they wanted. That's only true insofar as you think going to office hours and working with the teacher is the same as cheating on a test. Both parties go back-and-forth with CBO to try and get their legislation down to a price tag they're comfortable with. But it's not some sort of trick. In this case, Democrats changed their legislation so the subsidies grew more slowly over time and the excise tax would grow faster. In other words, CBO said that they'd need to do hard things their constituents wouldn't like if they wanted to cut the deficit more, and they did them. That's not gaming, it's governing.

As linked from that, there are good arguments to be made that the CBO's estimates of savings are too conservative:

CBO predicted that drug prices would rise following the Medicare Modernization Act of 2003, which added prescription drug benefits to Medicare, estimating that spending on the drug benefit would be $206 billion. Actual spending was nearly 40 percent less than that.

[Tony P.]

"Gaming the CBO" reached its apogee with what Krugman dubbed the Throw Momma From The Train Act of 2001: Dubya and his minions explicitly provided that their hated death tax should revert back to full strength in the 10th year of the budget window, for NO OTHER REASON than to make the CBO score look better. Now that was some good gaming.

--TP

[Sebastian]

Ezra Klein is wrong on this. Moving a huge portion of costs beyond the ten year CBO window is gaming it. There is no way around it.

Moving the difficult excise tax to four elections away isn't "governing", implementing it NOW would be governing not gaming.

Moving the costs to Social Security is gaming.

Inflating the 'savings' for no reason, especially when moving the excise tax into likely oblivion is gaming.

You didn't respond to any of my very concrete gaming complaints.

"In other words, CBO said that they'd need to do hard things their constituents wouldn't like if they wanted to cut the deficit more, and they did them."

But they didn't. They mostly just moved them out of the ten year analysis window and moved the hard parts until four elections from now.

I wasn't general. I was specific.

[Carleton Wu]

Ezra Klein is wrong on this. Moving a huge portion of costs beyond the ten year CBO window is gaming it. There is no way around it.
Moving the difficult excise tax to four elections away isn't "governing", implementing it NOW would be governing not gaming.

Ok, so moving costs into the second decade is gaming the system. But then you say that moving fees into the second decade is *also* gaming the system. And, according to the CBO, the bill saves 1.2T in the second decade- so even if they've hidden upfront costs, the bill is still saving money in the second decade according to the CBO.
Unless Congress disables the excise tax, which you claim is basically a done deal- but you've no evidence for that proposition.

[Sebastian]

But except for the excise tax the savings for the second 10 years are in the speculative "administrative savings" goobledeygook that they btw dramatically increased from their last analysis for no apparent reason.

And the excise tax is a difficult to implement and painful tax. It is being put off for four elections and is incredibly similar in allegedly 'automatic' function to the Medicare cuts for doctors that have been reducing the deficit since the 1990s.

Of course those cuts have not been reducing the deficit since the 1990s, as they have been waived by Congress every single year that they were supposed to take effect.

So I'm not sure what you would take as evidence for the proposition that the tax isn't a serious proposition. It is more noticeable than the doctor payments issue. It is scheduled to affect more people than the doctor payments issue. It is put much further down the road than the original deficit reduction for Medicare was. The political price for it is to be paid 4 elections from now (but of course future Congresses can't be bound). If they put it one or two years off, you'd have a colorable point. But in reality they are trying to put it off past the next presidential election AND the one after that. There is no economic reason to do that. There is no health care system reason to do that. So why are they doing it, Carelton?

The Medicare payments issue is directly instructive. Medicare alone is almost as expensive per capita as the entire NHS in the UK. The CBO always includes the lower payments for Medicare agreed by the deficit reduction packages. Every year we see ten year projections with those savings included. But in reality, Congress has waived it every year for a decade.

So again, Carleton, why are they putting it off for eight years?

[Jacob Davies]

Sebastian: Moving the difficult excise tax to four elections away isn't "governing", implementing it NOW would be governing not gaming.

Are you saying that the major motivation for moving the excise tax introduction out is gaming the CBO score?

How does that work? Moving the excise tax out increases the 10 year cost by reducing revenues. If that's gaming the 10 year score it's a funny way of doing it. Moving the excise tax out is a sop to House members who don't want to upset unions and doesn't have anything to do with the CBO score. The argument that it will never happen seems unsupportable though - the major example that gets cited is the Medicare doctor fix, and the problem there seems to be that they screwed up the original formula in a way nobody really intended. Other phased-in cost-cutting measures have worked as designed and have not been eliminated (it being much harder to get rid of something on the books than to pass it in the first place, especially when doing so means a loss of revenue). Unlike the doc fix, the excise tax isn't going to make a huge difference in anyone's life or in availability of care.

The argument that an explosion of costs waits just beyond the 10 year period doesn't seem to jibe with the $1.2 trillion projected reduction in the 2nd decade. Even if you think some of the cost-cutting estimates are off, you've got $1.2 trillion in catching-up to do before you're even in the red.

As for not including the cost of the Medicare fix in the bill, look, the Medicare fix is going to happen whether or not this bill passes. Like it or not, it's part of the baseline. Forcing them to make a permanent fix in a bill that may or may not pass and count the cost as part of the bill is kind of bogus since it would enable opponents to compare the bill cost (including the fix) with budget projects that didn't include the fix, which would be completely dishonest since said opponents have no intention of letting the fix lapse. It would be nice if we lived in a world honest enough that that wasn't the case, but we don't. If you want to permanently fix the fix, put it in a separate bill and score that on its own.

[johnt]

Much seems to rest on the CBO estimate, as much also depends on the happiness of fairy tales.
The point of the cuts is not to reduce spending, but to allocate the money elsewhere, that is the only way the Government works, e.g. subsidies now to doctors. In any case & worse yet, there are no cuts.
Yes, religious faith can be detrimental, so why place it in government?

[Sebastian]

"Are you saying that the major motivation for moving the excise tax introduction out is gaming the CBO score? "

No I'm saying that the major motivation for the EXISTENCE of the tax at all is to game the CBO score. That if it was meant as a real part of the cost structure it would be implemented sometime in the next one or two electoral cycles. Not 4 away.

"Moving the excise tax out is a sop to House members who don't want to upset unions and doesn't have anything to do with the CBO score."

And it won't be easier to leave it in 8 years from now. Unions will be just as angry, and if Democrats get their way will be even more powerful. Which is arguably fine in theory, but only suggests that the tax is a dead letter.

"The argument that it will never happen seems unsupportable though - the major example that gets cited is the Medicare doctor fix, and the problem there seems to be that they screwed up the original formula in a way nobody really intended."

The original formula was just as cut oriented as intended, but no one has the political will to follow through on it. Just like the excise tax. And the Medicare example isn't the only one. The AMT is the same issue.

There is no reason to put it four elections out except to avoid political fallout, but as we've seen in the past, when you do that, you still have to avoid the fallout when they come in, which means you don't do it then either.

"Unlike the doc fix, the excise tax isn't going to make a huge difference in anyone's life or in availability of care."

It is unless you are positing that few people will be affected, in which case it isn't worth nearly as much money as is claimed. Democrats aren't going to be better positioned to tell aging union members to stuff it and pay a huge tax eight years from now. The only reason unions aren't making a big stink is because they know full well that "phased in eight years from now" means "not really happening". If they didn't strongly suspect that they would scream loudly about it now, because it hurts them just as much then as it would now.

It is EXTREMELY difficult to come up with a plausible scenario where unions who would oppose it if implemented in a year or two are ok with it in eight years if they think it is really going to happen in eight years.

"As for not including the cost of the Medicare fix in the bill, look, the Medicare fix is going to happen whether or not this bill passes.Like it or not, it's part of the baseline. Forcing them to make a permanent fix in a bill that may or may not pass and count the cost as part of the bill is kind of bogus since it would enable opponents to compare the bill cost (including the fix) with budget projects that didn't include the fix, which would be completely dishonest since said opponents have no intention of letting the fix lapse. "

You have this exactly backwards. The CBO always includes the Medicare 'savings' even though everyone knows they aren't really happening. What you call "completely dishonest" is EXACTLY what Congress forces the CBO to do with Medicare projections every year.

[Carleton Wu]

Much seems to rest on the CBO estimate, as much also depends on the happiness of fairy tales.

And the inadequacy of trolls. 'cmon, you ever going to provide cites for your data, or are you just going to go on like the back of an Objectivist cereal box?

[Carleton Wu]

There is no economic reason to do that. There is no health care system reason to do that. So why are they doing it, Carelton?

I don't have to have a theory; Im honestly not following the minutiae very closely here. Maybe it's to give those with such plans the time to negotiate other compensation packages.

[Carleton Wu]

You have this exactly backwards. The CBO always includes the Medicare 'savings' even though everyone knows they aren't really happening. What you call "completely dishonest" is EXACTLY what Congress forces the CBO to do with Medicare projections every year.

I think that's Jacob's point- this has been done over and over again, asking for it to stop & the price to be added to this particular bill, as if it were responsible for it, seems unfair. Aside from both dealing with medical matters, it would make as much sense to demand that this bill fix the AMT issue, since that is also used in the budget projections.

[Jacob Davies]

That is my point and I don't believe I have anything backwards. The baseline is that CBO pretends that Medicare will be cut as planned both with and without the bill. It won't actually be cut whether or not the bill passes - a situation I agree is completely dishonest but is nonetheless the case - and so the only thing that matters is that in the A/B comparison (bill/no-bill) the baseline is the same.

[Sebastian]

"Im honestly not following the minutiae very closely here. Maybe it's to give those with such plans the time to negotiate other compensation packages."

You aren't following it very closely. And that is fine I guess.

But no, it isn't even remotely probable that it is to give those with such plans time to negotiate other packages.

"That is my point and I don't believe I have anything backwards. The baseline is that CBO pretends that Medicare will be cut as planned both with and without the bill."

Yes, and the CBO pretends that the excise tax will be levied 8 years from now in exactly the same manner.

I haven't once said that the Medicare 'cut' impacted the CBO analysis of this bill. I said that the Medicare 'cut' is an illustration of how Congress plays the CBO's rules to game the result. It pretends that it will do politically difficult things, gets the CBO score on that basis and then doesn't do it. Twelve years in a row.

If there was a real willingness to do the difficult political excise tax, they would do it now or soon. Do you believe that they don't want the money? But there isn't a real willingness to do the difficult political excise tax, but Democrats have to pretend that they will in order to game the CBO. Because without the excise tax it is an enormous budget buster.

And I'm not arguing against the bill. I'm arguing that statements like eric's "Um, I think you mean reduce the debt by trillions, right? As the CBO scored?" are either really naive, or deceptive. I'm arguing for truth in analyzing politics. Congress can use the CBO to lie, but we who analyze it shouldn't.

[Eric Martin]

Yes, religious faith can be detrimental, so why place it in government?

Yeah, I mean, the private sector has done such a bang up job of it, and there are no examples anywhere else in the world of government provided health insurance that functions better than our private system. For less money.

You've convinced me!

[Jacob Davies]

Point taken on the Medicare fix, I guess I was misreading you somewhat as complaining that it wasn't included in the CBO score. But what I said earlier about the differences between the doc fix and the excise tax stands - they're quite different, and there is every reason to think that it will take effect, especially if we're looking at a budget outlook anything like the one we have today. For one thing, who's going to repeal it in 2018? We could have any mixture of Rs and Ds in the Congress & White House, and why would the Republicans want to repeal a tax that falls heavily on union workers and can 100% be blamed on Democrats? Why would Democrats care about repealing it and dealing with the ensuing budget shortfall when they can leave it on the books, blame the 2010 Congress for it, and point at the union support for the 2010 HCR bill?

I see no indication that they don't mean it when it comes to the excise tax. You see 8 years out as meaning it will never take effect, I see 8 years out as pretty much guaranteeing that it will take effect since it can be blamed on someone else.

[Marty]

Gosh, aren't these guys smart.

We'll pass a bill that doesn't do much for four years, doesn't cost the taxpayer anything for 8, we can take the credit for HCR and let someone else deal with reality.

I keep wondering why any cynical politician would vote against it.

[johnt]

Hey Wu, If I did cite would you believe it? Of course not. Try the Investors Business Daily if you wish. Other than that use your common sense, would you want the feds coming in and telling you how much you will be paid?
Force sucks Wu, don't ask your god government to do what you don't have the nerve to do yourself, force people to serve you and tell them what they will be paid.
In case you haven't heard there is already a shortage of primary care doctors. That's now, give it a few years.

[Eric Martin]

We'll pass a bill that doesn't do much for four years, doesn't cost the taxpayer anything for 8, we can take the credit for HCR and let someone else deal with reality.

Yeah, except for the changes that take place immediately.

And the politicians voting against it are not opposed because it doesn't do more, sooner.

They are opposed because they do not believe the status quo needs to change.

[Eric Martin]

Force sucks Wu, don't ask your god government to do what you don't have the nerve to do yourself, force people to serve you and tell them what they will be paid.

Wu has a God Government?

Cooool. Where do I get one of those?

[johnt]

Eric, yeah, try Canada. it wasn't to many years ago Britain used to be the model, but that had to be changed. Perhaps you might want also to refer to Greece or Italy as examples of "progressive" welfare states that offer medical care. Better hurry before they default on their debt, or find a way to weasel out of it. Then there's Japan, great thing about their care is you don't have to undress in the exam room, you don't have time.
Eric, can't you find something else to place your faith in, perhaps the Easter Bunny, maybe give zorastianism a whirl, reincarnation, that's it Eric, reincarnation. This way you and other force loving liberals can leave normal people alone, while of course helping to pick up the medical tab for the poor. Bring your friend Wu along with you.

And may I ask, just where did choice and privacy disappear to? You guys did a 180 on those. And remember all the concern with the Bush Deficits? I guess they weren't big enough, they should have been four times the size, right?
Then there's global warming, or is there, or where you fed a bill of goods?
Gee, I'd like to take you guys seriously but after all that it's kind of hard.
Why bother? I've wasted enough time.

[Eric Martin]

Greece? Yeah, pretty much proves your point because of that one country, riddled and rife with corruption, with a political system that has been in turmoil for much of modern history. But yeah, that's a winning argument.

But seriously, I think France does a pretty good job, Canada and the Brits too. The Scandanavians. Most of Europre for that matter. They manage to insure all of their citizens, and none have to worry about pre-existing conditions.

Not so here.

I don't put faith in much. I'm a pragmatist. I'm attracted by what works. In America, there are 45 million uninsured, tens of millions more underinsurged and some number of people that will be rescinded when they need it most.

We pay more, per capita, for health care despite this fact, rely too heavily on emergency rooms, and the outcomes are lower than many nations that spend less.

You have faith in that?

This way you and other force loving liberals can leave normal people alone, while of course helping to pick up the medical tab for the poor. Bring your friend Wu along with you.

Actually, why don't you go Galt? Go to Somalia or some other libertarian paradise where there is no big governmnt to force you to pay taxes or anything like that.

And remember all the concern with the Bush Deficits? I guess they weren't big enough, they should have been four times the size, right?

This bill reduces the deficit, and even if the CBO is off by a lot/gamed, there is a lot of room before it adds to it in any significant way. And it actually provides a service for people in need.

Unlike Bush's wars, and deficit exploding tax cuts.

Then there's global warming, or is there, or where you fed a bill of goods?

No, there is. Unlikely we'll do much about it, but that doesn't change the facts.

Gee, I'd like to take you guys seriously but after all that it's kind of hard.
Why bother? I've wasted enough time.

The feeling is entirely mutual. Again, please, just go Galt already. I'll even chip in for your one way ticket to Mogadishu where you can bask in the paradise of an entirely unintrusive government.

[Carleton Wu]

Hey Wu, If I did cite would you believe it? Of course not.

That's one theory. Kind of makes me wonder what you're doing here then.

Try the Investors Business Daily if you wish.

You mean, the rag that told us how the UK NHS would've put Steven Hawking down because of his Lou Gehrig's disease? Good source.
Do I need to search through every issue to find your source for the 'already existing rationing in Medicare?' And will I need some special glasses to figure out which facts you've misinterpreted to reach that conclusion?

Force sucks Wu, don't ask your god government to do what you don't have the nerve to do yourself, force people to serve you and tell them what they will be paid.

Ahh, a glibertarian. Ought to have known. This is like running into a Scientologist or a Hare Krishna- it makes noises like a debate, but it never quite manages to respond to new data or construct new arguments. Creaky noises from an old machine, nobody home.

[ChrisJ]

"In case you haven't heard there is already a shortage of primary care doctors. That's now, give it a few years."

Yes. And that is entirely an artifact of the perverse way we pay doctors now -- do more (occasionally needless) procedures, get more dough. Listen to folks for an hour and try to solve their problems -- no dough.