The Future of Healthcare

Since healthcare is the topic du jour, but Paul Ryan's Medicare plan doesn't really include enough detail to allow more than obvious critiques, here's a short post on an entirely different healthcare topic.

Ryan's budget document contains the chart on the right. Scary! It's based on CBO data, and it's a pretty standard fixture in healthcare debates. Basically, it shows Medicare spending rising at 8% a year forever, which means that eventually it overwhelms everything else and the country is broke. But how likely is that?

I don't mean likely in just the Steinian sense that, eventually, costs will be reined in simply because they have to be. I mean that I wonder if we've been brainwashed by the exploding costs of healthcare over the past 40 years into thinking that exploding costs are somehow inevitable in the healthcare field forever. Are they?

I can think of lots of technological revolutions that were pretty costly at first but eventually reached a point where they leveled out and then became cheaper. In fact, pretty much all of them. But perhaps healthcare is different in some ways from previous technological revolutions? For one, it's fairly labor centric and likely to stay that way. For another, costs really have been going up for a long time and there's not much relief in sight. By now, you'd think we'd be nearer the cusp of the curve where costs start going down, but we sure don't seem to be. New pharmaceuticals are as expensive to develop as ever. Cancer treatments keep getting more costly, as the construction of $100 million proton therapy centers demonstrates. And overall per capita healthcare costs just keep climbing inexorably.

Still: do we really think this is going to keep up forever? If it does, it will be pretty much the first time in history. I'm enough of a technological optimist (and a believer in the power of markets) to guess that someday — 10 years? 20? 30? — things like gene therapies, personalized pharmaceuticals, medical AI, and so forth are finally going to revolutionize medicine. And when that happens, costs will plateau at first and then drop. The curve simply won't keep going up forever.

Now, granted, we can't plan on that. There are no guarantees, after all, and maybe medicine will end up being an exception to the usual rule of technological progress. What's more, folks like Paul Ryan could plausibly claim that this makes voucher plans like his more reasonable: if costs don't come down, then we'll have little choice but to cap them bluntly the way his plan does. And if they do come down, then his caps won't have a serious impact.

I don't really have a position here. I'm just musing out loud about the likely future trajectory of healthcare, and whether we're really looking at it through the right lens. Right now we're tacitly assuming that what's happened in the past will inevitable keep happening into the far future. But there's really not much reason to think that's true. Is there?

Obama's Disappearing Act

A friend of mine who's fed up with Obama emailed to respond to my suggestion that Obama's real intentions remain fairly enigmatic:

I agree completely that Obama is enigmatic, but at some point, it doesn't really matter whether he gave away something he really believed in or never believed it in the first place. Does it matter in practical terms whether he's pathetically weak or just a bald-faced liar? After this long, I have a really, really, really hard time believing his heart is in what I'd call the right place on any of this stuff since no matter his brave words when he was angling for the nomination, he's basically given it all away, one thing after another.

This critique of Obama I don't really get. Sure, Obama's not the second coming of FDR (though FDR himself wasn't really the first coming of FDR either), but he got a fair amount done in his first two years, and if the healthcare reform bill was a dog's breakfast of concessions to special interests, well, that's the way Washington works. Obama was never going to change that in the space of 18 months. And I just don't see the case for lying. He's failed to get his way on some things, he's compromised other things away, and yes, he's occasionally just plain done an about face. But if I had to judge, I'd say he's done the latter less than most presidents, not more.

But then there's this critique from Ezra Klein, which strikes me as very much on the mark:

The battle over funding the government for the rest of 2011 has gone on for months, but the most involvement we’ve seen from Obama was a few phone calls placed to negotiators over the weekend....With negotiations breaking down, Obama has invited congressional leaders to the White House to hammer out a deal — but at this point, the question is simply how bad the final agreement will be.

But perhaps more disappointing are the times the president has shown up. Last week, Obama laid out his first major energy plan since the campaign....[It] was a terrible disappointment. Forget the ambitious cap-and-trade proposal that candidate Obama pushed in 2008. President Obama’s energy plan undershot the cap-and-trade plan that John McCain and Sarah Palin pushed in 2008.

And the less said about the State of the Union and the subsequent budget, the better. “Winning the future” has come at the expense of a plan for the present....Something has gone wrong in the Obama administration. And the candidate we need to step forward and point it out isn’t whichever Republican manages to limp shamefacedly out of the primaries after agreeing to call Obama a Kenyan anti-colonialist who kowtows to big business and Karl Marx and believes in both radical Islam and dogmatic atheism. It’s the Barack Obama who ran in 2008. The one who believed in “the fierce urgency of now,” rather than “after the election, we hope.”

Obama has long followed a strategy of letting other people fight pitched battles for a while and then parachuting in toward the end to act as peacemaker. And there's a case to be made for that sometimes. He did it with healthcare because Bill Clinton tried it the other way in 1993 and got his hide nailed to the wall, and in the end Obama's strategy worked. Would a more active intervention have worked better? Maybe, but there was a pretty good case to be made for doing it the way he did.

But over the past year this trait has become almost pathological. Maybe the power of the bully pulpit is overrated, but Obama seems unwilling to even try to move public opinion or take a leadership role in his own caucus. At this point, I really have no idea what he thinks of taxes, the deficit, Medicare cuts, or much of anything else on the domestic agenda. I guess he's figuring that if his political opponents insist on digging themselves into a hole, he might as well stand back and let them. But if he keeps this up much longer, there's going to be nothing left of his presidency except "Well, I guess he's better than the wingnuts from the other party." That may win him reelection, but it won't do much more.

Paul Ryan's Non-Proposal

Just a quick note about Paul Ryan's Medicare plan, since I don't really have enough detail to do the kind of wonky dive that I know everyone is dying for. It's this: Ryan may or may not be the kindest, bravest, warmest, most wonderful congressman on Capitol Hill, but everyone realizes that his Medicare proposal is basically just a PR document, right? It has zero chance of being enacted, and there's pretty much zero chance of anything like it being enacted. It's just a conversation starter, not a serious attempt to produce a workable piece of legislation.

Everyone does understand that, don't they?

So Where's the Medicare Plan?

So I figured I'd wait until today to get the details of Paul Ryan's Medicare plan, but this is pretty much all that his proposal says about it:

Starting in 2022, new Medicare beneficiaries will be enrolled in the same kind of health care program that members of Congress enjoy. Future Medicare recipients will be able to choose from a list of guaranteed coverage options, and they will be given the ability to choose a plan that works best for them....The Medicare premium-support payment would be adjusted so that wealthier beneficiaries would receive a lower subsidy, the sick would receive a higher payment if their conditions worsened, and lower-income seniors would receive additional assistance to cover out-of-pocket costs.

....Health plans that choose to participate in the Medicare exchange must agree to offer insurance to all Medicare beneficiaries, to avoid cherry-picking and ensure that Medicare’s sickest and highest-cost beneficiaries receive coverage....While there would be no disruptions in the current Medicare fee-for-service program for those currently enrolled or becoming eligible in the next ten years, all seniors would have the choice to opt into the new Medicare program once it begins in 2022.

Is that it? Am I missing something? How is anybody supposed to analyze how this would actually work with no more detail than this?

For now, I'm going to assume that I'm missing something. There must be a more detailed document around somewhere that I haven't found yet. There has to be, right?

The Courageous, Serious, Gutsy Paul Ryan

David Brooks on Paul Ryan's long-term budget proposal:

Today, Paul Ryan, the Republican chairman of the House Budget Committee, is scheduled to release the most comprehensive and most courageous budget reform proposal any of us have seen in our lifetimes....His proposal will set the standard of seriousness for anybody who wants to play in this discussion....This budget tackles just about every politically risky issue with brio and guts....Paul Ryan has grasped reality with both hands. He’s forcing everybody else to do the same.

Courageous. Serious. Gutsy. I imagine that within a few days this will be the consensus view of the entire Beltway punditocracy. A plan dedicated almost entirely to slashing social spending in a country that's already the stingiest spender in the developed world, while simultaneously cutting taxes on the rich in a country with the lowest tax rates in the developed world — well, what could be more serious than that?

I think I'm going to be sick.

Caving in to the Mob

Jane Mayer on Attorney General Eric Holder's decision to try Khalid Sheikh Mohammed and other 9/11 defendants in military tribunals instead of civilian courts:

Today’s news that K.S.M. is slated now for a military trial in the naval base at Guantánamo Bay, rather than facing a criminal trial in the civilian justice system that Holder believed was more fitting, may indeed be the defining moment for the Obama Justice Department, defining it, unfortunately, as incapable of standing up to to the political passions still stirred by the threat of terrorism.

....“History will show that the decisions we’ve made are the right ones,” [Holder said last year.] After telling me that he regarded the trial as a defining event, he added, “Between now and then I suspect we’re in for some interesting times.” At his press conference today, he said, “I have to deal with the situation as I find it.”

It's a cowardly decision, and not just from Holder and Obama. There was cowardice and demagoguery aplenty in this entire sorry episode.

Mitt Romney, Scared of His Own Shadow

Considering the clown show he's part of, I'd say that Mitt Romney is probably the least bad Republican candidate for president running right now. But that's a pretty low bar, and Romney's almost pathological fear of being on the wrong side of an issue — any issue — was on full display over the weekend in a speech that slammed Obama's foreign policy:

Yet Romney was silent on Libya, where the U.S. And its NATO allies are enforcing a no-fly zone as rebels try to oust Libyan leader Muammar Gaddafi from power. Asked after his speech what his position is on Libya, Romney refused to take questions from reporters. Instead he and his wife Ann walked away and escaped up an escalator at the Venetian hotel-casino where the event was held.

“I’ve got a lot of positions on a lot of topics, but walking down the hall probably isn’t the best place to describe all those,” Romney said as he walked away with half a dozen journalists trailing him.

Silent on Libya! It's not as if this is the most critical foreign policy issue of the moment or anything. This comes via Daniel Larison, who comments:

Romney seems unable to stake out a foreign policy position until after the Republican consensus has formed, and he then adapts himself to whatever that consensus happens to be....[It's] just another reminder that Romney doesn’t hold foreign policy positions so much as he mimics those who do. There was fairly broad agreement in the GOP that the arms reduction treaty was flawed. It didn’t matter whether the criticisms were valid or not. Romney saw an opportunity to become a vociferous critic of the treaty to ingratiate himself with most of the party. Libya is a contentious issue, and the party is evidently split over which position to take, so Romney predictably cannot take one. For someone who is so fond of mocking Obama’s leadership or lack thereof, it is revealing that when Romney has to stake out a position one way or the other on a controversial question he is unable to show any leadership at all.

Hey, I think Libya is a tough issue. But I'm still willing to articulate a position (namely that intervention was a mistake), and I'm not even running for president. It's pretty hard to believe that even two weeks after it started, a guy who wants to sit in the Oval Office still can't think of anything intelligent to say about it. Obama might have made the wrong decision about Libya, but at least he made a decision.

Paul Ryan's Voucher Plan for Medicare

I imagine that we're going to spend a fair amount of time this week talking about Paul Ryan's plan to cut corporate taxes and slash Medicare, but I think I'll wait until tomorrow to jump in. I'd rather react to the plan itself than to the Sunday chat show version of what the plan might be.

But I'll just say this in advance: I'm pretty sure that Ryan is going to loudly and relentlessly insist that his Medicare proposal isn't a voucher plan. I'm not sure why, but I assume that "voucher" must have polled poorly in some recent Frank Luntz poll or something. But if it walks like voucher, talks like a voucher, and quacks like a voucher, then it's a voucher.

And it does, and it is. So don't let Ryan pull the wool over your eyes on this. You can like or dislike the plan all you want, but it's based on giving you money and then sending you into the private market to buy your own health insurance. That's a voucher, no matter how many times Ryan says it isn't. What's more, I'm pretty sure it isn't even a very good voucher plan. But I guess we'll know for sure tomorrow.

Mike Huckabee's Memory Hole

I can't really think of anything to actually say about this, but I'm sort of gobsmacked by Siddhartha Mahanta's piece today informing us that Mike Huckabee physically erased and crushed all the hard drives in his office when his term as governor of Arkansas ended:

In February, Mother Jones wrote to the office of Arkansas Gov. Mike Beebe seeking access to a variety of records concerning his predecessor's tenure, including Huckabee's travel records, calendars, call logs, and emails. Beebe's chief legal counsel, Tim Gauger, replied in a letter that "former Governor Huckabee did not leave behind any hard-copies of the types of documents you seek. Moreover, at that time, all of the computers used by former Governor Huckabee and his staff had already been removed from the office and, as we understand it, the hard-drives in those computers had already been 'cleaned' and physically destroyed."

....What do the Huckabee files hold? The records could provide details on any number of unsettled controversies involving a governor that faced at least 15 ethics complaints concerning, among other things: his failure to report gifts and outside income, his alleged use of state funds and resources for political and personal purposes, and the pardon of a convicted murderer and rapist who went on to kill again once released.

A former high-ranking Arkansas Republican who was once close to Huckabee and who requested anonymity told Mother Jones that the destruction of the hard drives puzzled him. "I don’t know what that was about, if they had things to hide or not," he says. But, he adds, the episode fits with Huckabee's general reticence when it comes to public disclosure. "Huckabee just absolutely doesn’t trust anybody. In my experience, if you don't trust people, it's because you're not trustworthy. We see the world through our own eyes."

Apparently this came up briefly during Huckabee's 2008 presidential run, but died away quickly. And I assume that Arkansas doesn't have a law requiring gubernatorial records to remain public. But still: wow. Just wow.

Dan Eggen and Perry Bacon Jr. report on the start of Obama's fundraising campaign for 2012:

Facing an energized Republican Party and deep-pocketed conservative groups, President Obama is kicking off his 2012 reelection campaign with a concerted push for help from wealthy donors and liberal groups unbound by spending limits.

....Obama frequently points with pride to the role that smaller donors played in his 2008 election, when his campaign also openly discouraged spending by outside organizations. But now Obama finds himself seeking out the kind of big-money donations he has often criticized while encouraging independent groups to raise and spend unlimited money on his behalf.

Obama’s campaign manager-in-waiting, Jim Messina, has asked the party’s biggest supporters to raise $350,000 each this year, to be shared by Obama’s campaign and the Democratic National Committee, far higher than goals set during the 2008 cycle.

I suppose that soon we'll be able to do away with even the charade that anyone with a net worth of less than a million bucks matters in the slightest. Given Obama's obvious deference to the rich over the past two years, this was probably sadly inevitable.