The Senate Deal: The Price of Everything

The CBO finally scored the redrafted Senate health care bill, saying it will cost $871 billion over the next ten years. Not that anybody waited for the numbers before cutting a deal. This was never really about the numbers. It was about coming in below an arbitrary figure and passing the bill by an arbitrary date.

The CBO Director’s Blog writes that  “(t)he changes with the largest budgetary effects include expanding eligibility for a small business tax credit; increasing penalties on certain uninsured people; replacing the ‘public plan’ … with ‘multi-state’ plans  … deleting provisions that would increase payment rates for physicians under Medicare; and increasing the payroll tax on higher-income individuals and families.”

In other words, the bill now has more breaks for business but harsher punishment for uninsured individuals, it eliminates the already-weakened public option, it pays doctors less – and it costs the Federal government $23 billion more.

Hey, what’s not to love?

The idea of raising payroll taxes on higher earners is a good one.  But if you take that new revenue, add the unfair tax on higher-cost benefit plans (studies demonstrate its unfairness), throw in the pay cut for doctors, and toss the higher individual penalties on top of that, it still doesn’t offset the fiscal recklessness behind killing the public option.

Why would the public plan have saved the government money?  Because, as the CBO puts it, “it was expected to exert some downward pressure on the premiums of the lower-cost plans to which those subsidies would be tied. ”  In other words, it would have made other insurance cheaper by creating real competition.  If it’s costing the government this much money to lose the public option, can you imagine what it’s costing the rest of us as individuals?

Remember: the CBO score doesn’t include the personal value of  these policies for each of us. The Senate’s new bill won’t just increase the Federal budget. We’ll also pay higher premiums because we lost the public option, and face more out-of-pocket payments from the excise tax.    Wasn’t it Oscar Wilde who said a cynic is someone who “knows the price of everything and the value of nothing”? It’s pragmatic to take the best deal you can get, but it’s cynical to avoid the battle and then claim it’s the best deal you can get.  The main thing dividing progressives right now is that some see pragmatism and others see cynicism.

Another question:  If Joe Lieberman can single-handedly be credited with most of these changes, is it fair to call him the Twenty Billion Dollar Man?  Maybe.  But remember, it’s easy to hate Joe Lieberman – and it’s a distraction.  The Administration and the Senate leadership made a series of choices that give him this power.

Some say that the public option was always doomed – that the Administration cut a deal in which they’d make a half-heated attempt to fight for it and would then let  it die, placating the always-compliant liberal wing with another mantric repetition of the phrase “we didn’t get everything we wanted, but …” In that scenario Joe’s the Bad Cop to the President’s (and Harry Reid’s) Good Cop.  If Joe Lieberman didn’t exist it would be necessary to invent him.  “Hey, I wanted to help you out – here’s a cup of coffee – but my partner here …”

Think that’s unfair ?  I certainly hope so, but that gets us back to the string-of-blunders interpretation. Reality’s probably somewhere in the middle:  mismanagement and a back-room deal or two. (We know there was a deal with Big Pharma.)

There’s an easy way for the President and Sen. Reid to disprove the Good Cop/Bad Cop Scenario, of course:  They can fight like hell to win concessions in the House/Senate conference, to bring the  final bill more in line with the House version.  That would mean, at the very least, a public option and no excise tax.

Think they will?  Me neither – but I think they should be pressed to do so.  I expect that the House will be put under enormous pressure to cave and accept the bill as it is.  I think the President and other party leaders assume the left can always be counted on to cave in for the good of the country.  I also think that anyone who points out the flaws in this bill will be subjected to another round of scoldings from party leaders and their supporters, charged with not understanding how the world works. Wouldn’t it be better to debate the tactics on their merits instead?

Because that last charge is the biggest miscalculation of them all.  Many of the people being lectured  over this bill are the same people who have been right about matters of both policy and politics for most of the last decade.  (And about the politics – the Democrats are going to get killed if they pass this bill.)  So it was particularly satisfying to see Markos Moulitsas respond forcefully to Chris Matthews for his wave-of-the-hand dismissal to those who saw the last decade’s events more clearly than he did.

That doesn’t necessarily make them right today, of course, but I think they are.  And speaking personally, I’m not talking about “killing the bill” – I’m talking about getting a better bill.  I believe it will take a credible threat  – a “fear factor” – to get that done.

Elmendorf vs. Orszag: A “Teachable Moment”… for Geeks and Nerds

This week a bitter confrontation between individuals from two distinct social groups offered our nation a rare and precious “teachable moment,” an opportunity to grow beyond those things which divide — or unite — us as a people.

Those individuals, of course, are OMB Director Peter Orszag — a geek — and the CBO Director, ubernerd Douglas Elmendorf. Their struggle is our struggle. Through it we can learn not only about ourselves, but about how to understand and talk about … numbers.

That’s right. I said we can talk about numbers. Wait! Don’t go. This doesn’t have to be boring! Numbers can be exciting!

First, the conflict. As NBC’s First Read reported: “Peter Orszag accused Congressional Budget Office Director Doug Elmendorf of ‘overstepping’ in a Web post Saturday … Orszag, a former CBO director, accused Elmendorf of playing into a stereotype that the CBO often overestimates cost and underestimates savings.”

This is war … between two analytical types whose names sound like characters in a Tolkien novel.

And they didn’t just throw down. They did it on blogs. The conflict began when Elmendorf blogged that the new Medicare advisory panel charged with reforming payments was likely to generate a paltry $2 billion in savings over the next ten years. Orszag replied by saying, in effect, that short-term savings was never the point, adding for good measure that the CBO had “overstepped.”

While it ain’t exactly rival rap entourages exchanging gunfire outside a radio station, it’s pretty badass stuff for number-cruncher types. Orszag’s post also suggests that the CBO would be wise to restrict itself to “qualitative” and not quantitative projections over longer periods of time – a polite way of say “you can’t touch – or quantify – this.” (His “qualitative” comment even includes a hyperlink … back to the very post it’s embedded in. Is that kind of head trip? Some ultra-hip, self-referential “meta” critique of the blogging medium itself?)

“Playing into a stereotype”? Those are fighting words in any context. The stereotyping in this case is between Orszag as geek and Elmendorf as nerd. While people consider the two terms interchangeable, here’s the difference: A ‘nerd’ is conservative, number-fixated, and highly rational. A ‘geek,’ while equally bookish and intellectual, is more given to flights of intellectual fancy and wild imagination.

A nerd can count. But a geek can dream.

Each of us can be a nerd or a geek at different times of our lives, of course, or even at different times of the day. But in this fracas, that’s how the social divide breaks down. Why? Perhaps it’s because Elmendorf’s job is to calculate the bottom-line effect of any program on the government and its coffers, while Orszag (who once held Elmendorf’s job) is allowed to project the long-term and systematic change that new ideas (like advisory panels) might have. There may be bigger savings in Orszag’s vision (I think there are), but dreaming those sweet dreams isn’t in Elmendorf’s job description.

For those of us who love our policy by the numbers, it’s heady stuff. It’s hard dollars vs. soft. It’s expenditures vs. imagination. Elmendorf is the stone-faced banker who won’t lend the money, while Orszag’s the inventor holding a prototype of the hula hoop. Elmendorf’s the dour landlord who says “Sorry, kids – the theater’s closed,” while Orszag is Mickey Rooney and Judy Garland saying “Hey, kids! Let’s put on the show right here!”

Orszag is the right brain and Elmendorf is the left. Orszag is the … oh, you get the point.

Does any of this matter? Actually, it does. We need to apply both types of rigor, but policy analysis is no different from judicial analysis. Numerical impartiality can be a mask for ideological leanings and other assumptions. Both Elmendorf and Orszag have important roles to play, but I think Orszag is right to look at a larger and more quantitative picture. Real “healthcare reform” will come in ways we can’t quantify yet.

I was also surprised by the ideology that seemed implicit in Elmendorf’s recent testimony about health reform. It was striking that he noted simply the cost to the Federal government, and not the potential for overall savings. Even more noticeably, according to the Wall Street Journal, he commented on the support many health policy analysts have expressed for taxing health benefits (an idea I’m not crazy about). The vast majority of health analysts believe there are great savings to be had, along with improved health outcomes, from structural reforms of the very kind that the Medicare panel represents. Elmendorf’s selective use of health analysts’ thinking reflects either ideology, a mode of thought, or (to be fair) simply his necessary focus as the “expenditure and revenue guy” on Capitol Hill.

It’s not up to me to adjudicate between these two analysts, whatever my biases. I do think Orszag has the cooler job, and perhaps as a result has a broader outlook. But that may only prove that I’m a geek. As for resolving this throwdown, maybe the President can invite the two of them over for a beer. Or an Ovaltine. They can watch sci-fi movies, chill out, and resolve their differences.

In the end, however, health care isn’t about the numbers at all. It’s about human lives. Numbers are only tools to help us achieve the right ends. If those of us who love numbers remember that, this will have been a true “teachable moment.”