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May 30, 2011 8:00 AM What the media establishment refuses to understand

By Steve Benen

It was quite a roundtable on “Meet the Press” yesterday. Viewers got to see a Republican strategist, a conservative pundit, a conservative Democrat, and an ostensibly center-left columnist who thinks that Democrats are big meanies when it comes to Medicare.

It was “Must See TV” for viewers eager to see a soul-crushing discussion.

Consider this exchange between host David Gregory and the Washington Post’s Ruth Marcus — who, remember, was the only center-left voice on the four-person panel. The topic at hand was the Democratic win in the special election in New York’s 26th district this week.

GREGORY: So, Ruth Marcus, what wins here: bold leadership on Medicare and the argument that the Democrats won’t do something courageous, or the Democrats who say, “Hey, those guys want to take away my Medicare”?

MARCUS: I regret to inform you that I think it’s the latter. And I think when you were asking Senator McConnell if Medicare was the new third rail of American politics, I think the question was wrong in a sense because it’s the old third rail of American politics.

GREGORY: Mm-hmm.

MARCUS: This play has been run time after time. If you go back and look at the quotes from President Clinton back when he needed to win re-election, they sound a lot like the quotes from Democrats today about don’t let those Republicans take away your Medicare. The difference is that the debt is bigger, the deficit is bigger, the gap is bigger, and the situation is more dire. But I think that, sadly, the lesson of New York 26 is “mediscare” works.

The transcript doesn’t reflect this, but viewers saw David Brooks — one of the three conservative voices on the four-person panel — nodding in agreement while Marcus spoke.

Sigh.

It’s exasperating, but it’s worth reemphasizing what too many establishment types simply refuse to understand: Democrats are telling the truth. Indeed, Dems are doing what the media is reluctant to do: offering an accurate assessment of the Republican plan for Medicare. If voters find the GOP proposal frightening, the problem is with the plan, not with Democrats’ rhetoric.

I’m at a loss to understand what, exactly, Ruth Marcus, David Brooks, and their cohorts would have Dems do. Congressional Republicans have a plan to end Medicare and replace it with a privatized voucher scheme. The proposal would not only help rewrite the social contract, it would also shift crushing costs onto the backs of seniors, freeing up money for tax breaks for the wealthy. The plan is needlessly cruel, and any serious evaluation of the GOP’s arithmetic shows that the policy is a fraud.

Which part of this description is false? None of it, but apparently, Democrats just aren’t supposed to mention any of this. One party is allowed to present this agenda, but the other party is expected to sit quietly on their hands.

Once again, it’s important that the establishment recognize the difference between demagoguery and ringing an alarm. Demagoguery relies on falsehoods to scare people — it’s about playing on folks’ worst instincts, being divisive in a deceptive sort of way, effectively fooling people into believing something they shouldn’t.

But political rhetoric isn’t “demagoguery” when it’s true. If a political message leads the mainstream to feel scared, it’s not necessarily “scare tactics” if people have good reason to worry.

What Dems are doing is ringing an alarm — Republicans are up to something dangerous, and Democrats want people to know about it. The question isn’t why Dems are on the offensive; the question is why the Beltway media finds it offensive.

Steve Benen is a contributing writer to the Washington Monthly, joining the publication in August, 2008 as chief blogger for the Washington Monthly blog, Political Animal.

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  • bleh on May 30, 2011 8:11 AM:

    I think it's fairly clear. The Dems have NOT (yet) emphasized as loudly and aggressively as they should the aspects of the ACA that are intended to "bend the curve" of health care cost growth. That's what the MSM want to hear, and it would take a lot of the wind out of the Republicans' sails.

    The ACA includes just about every idea for "bending the curve" that has been proposed by healthcare economists in the last few decades. The Dems recognize the problem, have proposed fixes, and have enacted those fixes into law. THAT's their answer.

    Whether to emphasize the Independent Payment Advisory Board is an open question. Republicans will attack it as "big government." Personally, I would do it: it throws the argument back on the Republicans and paints them as hypocrites. And to the question of "big government," I would respond "better than Big Insurance, and that's who the Republicans want to turn you over to. Look how well THAT has worked out."

  • c u n d gulag on May 30, 2011 8:14 AM:

    If it's Sunday - it must be time to "Meet the Republicans."

    And it must be time for the same tired old Conservative pusses spewing out the same bullshit to the public by talking to lazy, ancient or stupid hosts who wouldn't know a good or follow-up question from Quantum Physics.

    The reason it's the same old, same old, every fucking Sunday is that the target audience is ancient, and wants the same easy to digest pablum repeated to them by the same assholes every fucking week just like they've been watching for the past 30 years.

    If it's Sunday - it's no time to wake up the old people.

    And if you wake 'em up by talking about killing Medicare, put on David Brooks, because if he doesn't put you to sleep, he can make killing old people sound like something desirable - even to the near-cadavers watching him talking about throwing them under the bus and then backing over them, all to save tax cuts for people who don't need another Porche, but what the fuck, 12 is just not enough if you can have 13 or 20 of them. And you'll need more garage space, so you're a 'Job Provider,' and not some rich leech sucking the life's blood out of this nation.

    And if any of the hosts, including Amanpour - for whom I held out high hopes - now dashed, actually had some real Liberals on, they wouldn''t know what to talk about, let alone what to ask.
    They'd sit there stammering and stuttering, staring at them as if they were either museum pieces or aliens from another fucking planet.
    The audience would hack Farina out of their noses in shock - and then instantly go into shock.
    Stent's would pop-up open around the country, creating fountains of blood in front of the HDTV's.
    Pace-makers would race so fast, they would make the Indy 500 look like a racing event held underwater.
    And EMS crews around the country would have to triage the dead and terminal cases from those wounded oldsters who might yet be saved to watch another episode of "Meet the Republicans" next week when normalcy is restored, and the DFH's are banished from TV for another 30 years.

    I'd sooner put my private parts in a blender and turn it to 'frappe,' than watch any of the Sunday shows (unless Krugman's on ABC and he says somthing that makes George Will's bow-tie spin like a P-51 propeller - that's the only fun part of "Meet the Republicans" on Sunday worth watching).

  • DAY on May 30, 2011 8:22 AM:

    Excellent comments, bleh, and a message that would work, save that the public has the attention span of a gnat and the IQ of a turnip. Negative political ads WORK.

    So we have "mediscare" instead. Like a recalcitrant mule that needs a 2x4 between the eyes, first you have to get their attention. And nothing gets the geezer's blood aboilin' like "Take Away Something."

    I'd write more, but i need to leave some white space for gulag.


    lingsar idnotab: batting 1.000

  • cainmi on May 30, 2011 8:26 AM:

    The CBO says the Republican plan won't even save medicare, how can the press call it demagoguery when it's not just a matter of sounding scary, but it won't do what it's supposed to do either? Was that even mentioned during the discussion?

  • c u n d gulag on May 30, 2011 8:39 AM:

    DAY,
    LOL!!!

  • j on May 30, 2011 8:41 AM:

    Perhaps we should all read the article on Truthout - Medicare is not the driver of our debt but could be the solution - it is
    a very good argument for Medicare for all and a National health care policy that would save money for the country. Now would be a good time to push for it again, I have always thought that if Obama had a second term he would go for it, if he tried at this point the insurance industry would spend billions to defeat him. Is there any way to put this on a ballot for the next election?

  • R. Porrofatto on May 30, 2011 8:52 AM:

    For politicians and Beltway media whores -- pseudo-liberal or not -- it all comes down to undiluted self-interest. Unlike most Americans, they are part of the class who benefit from right wing economic policies and Ryan's plan specifically.
    They are much more likely to:
    - have gotten a whopping tax cut from George W. Bush and are not about to see that disappear
    - enjoy a of income that would benefit even further from Ryan's tax cuts
    - have investments or dividends whose tax rates would be reduced or completely eliminated under Ryan's plan
    - leave an estate that even under current law could be taxable
    - have a defined pension or benefits and will never actually need Medicare
    - enjoy a relationship with or status within the corporate world that makes them more sympathetic to zero corporate taxes and weakened regulation.

    If the truth might hinder any of that is it any wonder they don't give a rat's ass for it?

  • steve on May 30, 2011 8:53 AM:

    its not hard. the rich don't want to pay higher taxes that will be required to fund these programs now that social security is not producing surpluses to offset the cost. the rich include the beltway media types and Congressional types. no surprise that they think that social programs need to be cut.

    alo -- not enough attention is focused on conservative control of K St. This is where the beltway types get their talking points. During the 90's the republicans made a huge push to get their partisans in control of K St. Its made a huge difference

  • FRP on May 30, 2011 9:14 AM:

    All the right poses are struck and all the phlegmatic foundations built . The vigour one takes for granted from joyous sniping at the surly bonds of a Merrygoround , (the Carousels) , of a mean spirited reality pulling away at us , such darling innocents , the yearning acolytes of goody goody gosh we're good , stroked and petted to a spinning nausea . So wonderfully good that noting and diagramming these surly bonds , conspicuously sans vital points , may be generously overlooked .
    The weight of these stars would make a Dandelion blush , from golden mornings to the nodding heads of wispy grey so shocked into a humiliated crimson . Verily , I say unto you , such a wholesome light must in the heavens lie . A light which never sleeps or blinks , without pause seated in the Olympian councils , and named for what glory it is .

    Money is so yesterday ,
    tomorrow is so far away
    , but ,
    Today , today is joost what I say ,
    Oracular , in rather neat and scornful tone , 'it finds its mettle in just what I choose it to herald — neither more nor less.'

    Orwell is Dead
    Long Live Carrol !

  • exxron on May 30, 2011 9:23 AM:

    No one has mentioned Brooks' comment: "We've got massive problems with the unemployed, we've got massive problems with the middle class, and I'm offering you light rail." To which everyone nodded sagely. After all, how could building green industries possibly help the unemployed and the middle class? How could lowering our collective dependence on oil help business?

    The multi-faceted but coherent approach to the interlocking problems of health care and the economy (both short and long term) that Obama began really needs to be restated slowly. (And it would help if it got a constructive critique from progressives.)


  • Shrillhouse on May 30, 2011 9:25 AM:

    I liked the part were Brooks says he would be afraid to invest in the markets right now, due to all the "fiscal instability." Don't worry, David. Most Americans don't HAVE any money to invest anyways. They're too busy with trivial things like keeping a roof over their head, and putting food on the table for the families.

    And Harold Ford is a gigantic shithead...

  • berttheclock on May 30, 2011 9:40 AM:

    "And Harold Ford is a gigantic shithead"

    And, still positioning himself for a re-run in the very conservative State of Tennessee. Notice Claire McCaskill running scared of the TPers in Mizzou? Scary times ahead. Democratic registration dropping in Pennsylvania, Nevada and other states. RepuG legislatures passing Voter ID laws and shortening polling hours. With Perry, possibly, entering the race later on, he will have Texas and border states locked up in the all important Electoral College. 2012 is far from being a lock for President Obama.

  • worcestergirl on May 30, 2011 9:53 AM:

    Does anyone remember (or have a link to) (during the so-called debate when single payor wasn't even on the table) the CBO scoring for a proposal, with and without the public option?

    As I recall the public option resulted in significant savings, but Republicans and assorted Dems didn't like it because private companies wouldn't be able to compete, or some such nonsense. I remember thinking, wow, this really proves the right wing really doesn't give a rat's behind about controlling costs.

  • Ted Frier on May 30, 2011 9:57 AM:

    As the right-tilting MTP panel indicates, conservatives are able to set the terms for debate in a way that liberals cannot, especially since conservatives keep pretending that the mainstream media is biased in favor of liberals.

    So, with that as background, what conservatives say is that if you take taxes off the table, and if you do nothing to lower the cost of drugs, medical care or health insurance in ways that might be "socialistic," then the only way to "save" Medicare is with draconian benefit cuts or a severe cost shift to the elderly.

    This is how you end up with a conventional wisdom in which the only serious and courageous policy option is to end Medicare as we know it.

  • dsimon on May 30, 2011 10:11 AM:

    I think Marcus's comments were overread. Her use of the term "Mediscare" unfortunate, but there is a valid critique to be had.

    Yes, Democrats are essentially truthful about the Ryan plan. But it's also true that they're appropriately critical without having a strong alternative in place to solve the problem. They do have a weak alternative in place: the ACA does have some programs to help control costs. But any substantial proposals to deal with our long-term budget problems, both within and outside of Medicare, are going to involve decisions which will be unpopular with the public. So the easiest thing to do politically is to criticize the other side's unpopular plan while putting forward as little as possible on your own side. Unfortunately, it's not a policy solution for the long term.

    Yes, the Democrats' numbers add up less badly than the Republicans'. But that doesn't necessarily mean that the Democrats' numbers really add up very well either, and I think that's the point Marcus was (inartfully) trying to make.

  • Ron Byers on May 30, 2011 10:12 AM:

    I think the village, starting with David Gregory and "Meet the Republicans" have bought into the notion that the Ryan Medicare Plan is unpopular because of Democrats. They think that the Democratic message machine (such as it is) has gotten the drop on the Mighty Wirlitzer. They are convinced that the Republicans can change the debate if they turn the volumn up to 11 on their machine. Whether you benefit by conservative policies or not, if you are a member of the village, you and your news organization benefits by such a fight. That is just business. If you are in business to sell soap, you are rooting for the Return of the Media Empire.

    I think a lot of people on this board have bought that line.

    Sorry to burst your bubble, but the Democratic media machine isn't responsible for the public's reaction to Privatizing Ryan. The senior citizens who make up the Republican base have figured it out all on their own. There just isn't any polishing the Republican Turd.

    All the Democrats are accomplishing is to remind Americans of what 80% of them have concluded on their own. Not since Privatizing Social Security and then Katrina has reacted with such a single mind.

  • David V. on May 30, 2011 10:13 AM:

    I miss Tim Russert. I learned from his conversations with the pols on MEET THE PRESS. He usually asked the follow-ups that seemed obvious to ask, David Gregory wants to appear balanced. Tim asked questions on behalf of his viewers, he seemed to understand that the pols on his show were interested in their talking points, they were not there to illuminate; Tim was.

  • Tyro on May 30, 2011 10:17 AM:

    dsimon, when you're in the middle of a crisis, it's best not to get bogged down having a "debate" with someone whose solution to the crisis is to kill you, as if it might be useful to find a "middle ground" of "maim." If Marcus wants to be taken seriously, she needs to stop whining aboutnthendemocrats rightly raising the alarm about the Republican danger about their proposal and she should be criticizing the republicans for presenting an unserious, ultimately destructive "solution," rather than "welcoming" it.

  • Anonymous on May 30, 2011 10:25 AM:

    David V.
    I'm sorry, but I don't share your opinion about Russert.

    To me, as a "jurnalist," he was a useful tool.
    It's only when you stack him up against a POS ignoramous like "Stretch" that he looks like a towering genious.

    It's the same principle that makes Paul Ryan look like the smartest kid in the room. If the room has Pence, Bachmann, both Kings, and Goemert, the table lamp is the brightest thing in the room, and then Ryan.

  • windshouter on May 30, 2011 10:27 AM:

    Any guesses what would happen if the shoe were on the other foot, and the Democrats decided to "start a conversation" on taxes by proposing a maximalist position on taxes? Lets say revenue neutral tax reform assuming current law (tax cuts for all expire), lifting payroll tax on Social Security and a 3 % surcharge on large income. The Republicans would not use this as a conversation starter, and would attack this to death and deny the need for any additional revenue. The media would never coin terms like taxscare for this plan.

  • c u n d gulag on May 30, 2011 10:28 AM:

    Sorry, 'Anonymous' above was me.

    And "jurnalist" is how Gregory might spell it, if he knew what one was.

    I'm sure Tim know how to spell "journalist."

    And now, so do I. :-)

  • berttheclock on May 30, 2011 10:37 AM:

    Russert of the early days, yes. Russert, after making a ton of money on TV and book deals and moving to the island to be one with Big Money, NO.

    Shame what those book and TV deals did to both Russert and Chris Matthews. Loved it when, they attempted to schmooze with one another as "just two guys hanging out in the neighborhood bar". Russert discussed Buffalo and Matthews North Philly. However, what they had become was two swells trying to make nice and co-exist with the Very Rich.

  • nycweboy on May 30, 2011 10:38 AM:

    As dsimon points out, the lack of a Democratic alternative on Medicare is what makes the Ryan plan the only discussion to be had. And making "look how awful the Ryan plan is" into a campaign slogan is only half the job. The rest is... how will Democrats do more to control Medicare and reduce costs? That answer isn't just hard... it doesn't exist. And no expert government panel gets us to the big decisions and hard choices that need to be made. This takes leadership and a more honest conversation with the public. Democrats don't have the resolve for it. At least not these days, I'm convinced.

    As for the whining about "too many conservatives on Sunday talk shows" - this line of discussion is becoming tiring. It's clear that the Democratic Party leaders are avoiding the shows (Pelosi and Reid could get on these things any time they wanted, as could a number of others)/ The reason they're not out there is that they have nothing to say, and because they're convinced that Republicans are doing a nice job wrecking themselves. Does that strike me as terrible strategy? Sure. But I think blaming the bookers of Sunday shows is entirely misplaced. If liberal viewers and voters want to have progressive voices in the discussion... then we need to elect new leaders. That's been clear for a while, and it's depressing that so many lefties will blame everyone but elected Democrats when trying to figure out why progressive ideas don't have a louder voice/

  • Fed Up and Tired on May 30, 2011 10:46 AM:

    Lets stop these foolish wars and then we can talk seriously about spending.
    Congress has approved a total of $1.283 trillion for military operations, base security,
    reconstruction, foreign aid, embassy costs, and veterans’ health care for the three operations initiated
    since the 9/11 attacks: Operation Enduring Freedom (OEF) Afghanistan and other counter terror
    operations; Operation Noble Eagle (ONE), providing enhanced security at military bases; and
    Operation Iraqi Freedom (OIF). This estimate assumes that the current CR level continues through the
    rest of the year and that agencies allocate reductions proportionately.

  • zandru on May 30, 2011 10:49 AM:

    Don't Diss "the public"

    "The public" has been hauling its butt out of the old LA-Z-BOY to town hall meetings to give their Republican representatives the what-for. "The public" filled the streets of Madison, WI for literally MONTHS, protesting FitzWalker's repeal of their collective bargaining rights. "The public" doesn't even watch the Sunday morning "Meet the Republicans" programs anymore.

    There have been several town hall-style policy meetings held here locally, and I've attended as many as I can; without exception, all the folks I met there are considerably more thoughtful and knowledgeable than most of the talking-head DC punditocracy. And without exception, they (and I) have rejected the elitist, cookie-cutter Coolidge-era "solutions" that were put up for debate by the town hall organizers.

    My point is that the public is smarter than many of us assume. Apparently, it takes more than just the proverbial 2x4 across the side of the head to get it moving, unfortunately. But they're moving now, and the intelligent librul or Democrat will reach out to further educate these less-political folks, get them involved in changing the government.

    Blog-readers such as ourselves absolutely MUST NOT wallow in our elitism, or snark about "oh, you just noticed?" The tide is turning; get your board!

  • Tyro on May 30, 2011 11:06 AM:

    the lack of a Democratic alternative on Medicare

    The Democratic alternative to Medicare is Medicare. The republican solution is to destroy it. There is no reason why the Democrats should have a "conversation" where they should propose their solution to half-destroy Medicare and then meet republicans somewhere between that and the Ryan plan. Maybe the republicans should come up with a serious proposal that the public would actually accept.

  • emjayay on May 30, 2011 11:11 AM:

    Since the Sunday am talk shows have been completely dominated by boring Establishment types running through their rehearsed soundbites from the center to the right to the far right for years, I don't think it's because Pelosi doesn't want to be on them. Probably someone has some stats, but does anyone have insider info on the selection process? Anyone ever written anything from the inside? I stopped watching years ago when I realised I wasn't hearing anything beyond boilerplate, and no one (including Russert) was pushing anyone beyond that.

    The other day I saw some Demo (sorry, don't remember who...anyone?) actually mentioning some ways to save a bunch of Medicare money, one of which was "Medicare should bargain nationally for drug prices like the VA does."

    Including the VA (serving military, insert waving flag) in the arguement is exactly the right thing to do. There's a reason that the interstate highway act was called National Interstate and Defense Highways Act of 1956 and student college loans were by way of the National Defense Education Act 0f 1958. Throwing the military/flag into anything is very helpful in passing anything in this country. ACA should have been called the National Defense We're Number One USA USA USA Act.

  • Richard H. Serlin on May 30, 2011 11:15 AM:

    Plus, it's not like, as Marcus falsely implies, the Democrats aren't doing anything about rising Medicare costs. They just passed a bill, the Affordable Care Act, that cut costs by half a trillion. And the Act is loaded with other measures that have big promise in slowing health care increases.

    Marcus is not very left, and she's definitely in the Broder mold.

  • some guy on May 30, 2011 11:21 AM:

    "ostensibly center-left" in terms of the WaPo editorial domain means conservative, center-right in Reality Land.

  • SWENXOF on May 30, 2011 11:22 AM:

    You mean to tell me that the same concentrated, nationalized, news media that rolled over and spent months promoted Bush's Iraq war with Arsenal Hall woo-woo-woo fist pumps is really just a mouth piece for special interests? The same media structure that just recently focused 90% of its energy on 12% of the population wearing tri-cornered hats while shouting down handicap people and blabbering something about "death panels" is now indignant at Democrats calling a plan to privatize and gut Medicare a plan that privatizes and guts Medicare?

    Today's media has lost all mooring. One cable channel is devoted 24/7 to unabashed propagandizing and the rest seem to think it's their job to go out of the way searching for and stretching false equivalencies. Nothing good will come from a democracy this under siege from truth and reason.

  • Will on May 30, 2011 11:25 AM:

    I imagine if David Gregory had instead asked Ruth Marcus what the details of the GOP's Medicare plan actually were, he would have been met with a blank stare. The reason Beltway pundits like Marcus and Brooks offer such blandly stupid opinions in place of facts is that they are famously ignorant of actual policy details, and even more so of how those policy details would actually affect real people.

  • denim on May 30, 2011 11:33 AM:

    I am very disappointed in the Marcus "mediscare" comment. Comming from the Clark Kent School of Journalism, I always felt that exposing Truth, Justice, and the American way were the journalist's main job, if not the only one.

  • karen marie on May 30, 2011 11:57 AM:

    Steve, Steve, Steve, it's only right that the media pour shame on Democrats for scaring voters after all the complaints they got for not pouring shame on Republicans for scaring voters during the health care "debate."

  • TCinLA on May 30, 2011 12:43 PM:

    At least it wasn't as bad as "Face the Nation" where one could listen to that shiny little putz Eric Cantor babbling on about "personalizing" Medicare so everybody can get the program that's right for them.

    Watch for that one - they think "personalizing" will work with Medicare where it didn't work with Social Security in 2005.

    internas ectonA????

  • jjm on May 30, 2011 12:51 PM:

    The push, push, push of women (and indeed of people of all genders) who are incompetent, petty, mean-spirited, stupid, uninformed and just plain out of their depth by the NYT (who just ran a front page article on how kind of darling Rand Paul is as a 'gadfly') is disgusting and frankly BORING.

    How many more vapid, inane, illogical, uninformed and stupid citations of idiots can this country stand?

    In past times, Palin, Bachmann, Malkin, Fox news personalities et al, with their horrendous character flaws, their cattiness and their ignorance would have merited what they deserved: BEING IGNORED.

    But no. They are famous for what? For being made famous by the media who have pushed them to the hilt, very like the way old yellow journalist Hearst discovered the bad powers of the press to do so. (Where would Billy Graham have been without him?)

    I would LOVE to read the careful thoughtful words of Jan Schakowsky, Jackie Speier, and many other Democrats, men as well as women, who are interested in the people, in their needs, and in governing well. Kathy Hochul was one such very articulate and very likeable 'woman' that the NYT minimized in their reporting.

    Instead we get intimate, blow by blow reports on a person of such inferior worth as the half-governor of Alaska, whose entire motivation is greed, and we're supposed to be satisfied?

  • Gary B on May 30, 2011 12:58 PM:

    Great article!

    Of course the moderator Gregory must be counted as a conservative too - so 4 conservatives agains a center-left (but all sides are equal) journalist. Was the outcome in any doubt? Why not a real liberal like Bernie Sanders? People should just stop watching the Fox Light programs like "Meet the Press” and "Face the Nation".

    The Ryan plan is a very scary attempt to transfer dollars from Medicare spending to tax cuts.

  • Ed on May 30, 2011 1:10 PM:

    Yes to most of the above. But let's also face the hard reality of lack of sustained leadership from the top. Obama knows what's up but there is no fighting spirit in him. And lacking that sort of leadership in the face of sustained Pit Bull opposition, it's difficult to blame the Democrats for sometimes not fighting back.

    Thank heavens they appear to be now doing it on Medicare. But watch for Obama to go all bipartisan and undercut them in his quest for the so-called independent vote.

    Remember, it was Nancy Pelosi and even Harry Reid who put up a determined fight for the Public Option, only to have Obama, Rahm Emmanuel, Jim Messina, and Max Baucus jerk the rug out from under them and sell it down the river to PhRMA in the back room.

  • Venice on May 30, 2011 1:25 PM:

    Also notice how Gregory pre-empts the question in such a favorable way to the Ryan plan. "BOLD LEADERSHIP".

    It is so sickening to hear the media pre-empt any talk of the Ryan plan with "you may not agree with it, but at least he made an effort...at least he had the courage...at least he put a plan out.."

    Where were these kind words about the Democrats' Health Care Reform? Nobody ever praised them for "at least having the courage to work on reform" that had eluded president after president for decades.

    Aaagh the media makes me ill!

  • Fr0sty on May 30, 2011 1:35 PM:

    This is a fascinating post. Titled "What the media establishment fails to understand," it is written by a member of the media establishment. The subject appears to be that the (other) media establishment are wrong to think of "mediscare" as a tactic and ought to actually be frightened. Presumably we should all be quaking in our boots because a Republican congressman has proposed that 10 years from now people who become eligible for Medicare should receive vouchers to purchase private health care if they so chose. Whoa, yeah, terrifying stuff.

    In 20 years I will be eligible for Medicare. Coincidentally, that is around the time that the US debt to GDP ratio is forecast to hit 300%, a level that is far above that which necessarily causes massive political, and social destabilization. I don't mind socking away a few bucks to cover my own health care in my old age, especially if it means that I won't contribute to the destruction of the country I love. But hey, that's just me.

  • BT on May 30, 2011 1:37 PM:

    People on TV are selected for their ability to tow the line - to tell lies but sound serious - not for being intelligent and reasoned.

    The quality gap between TV and blogs is stunning.

  • desraye on May 30, 2011 1:49 PM:

    "Remember, it was Nancy Pelosi and even Harry Reid who put up a determined fight for the Public Option, only to have Obama, Rahm Emmanuel, Jim Messina, and Max Baucus jerk the rug out from under them and sell it down the river to PhRMA in the back room."

    What? Harry could even get his own party to vote on the public option. Harry Reid did not do anything.The public option went down because of Ben Nelson of Nebreska, Blanche Lincoln, Kent Conrand, and the rest of the conservdems in the Senate, not because some backdoor deal.

  • Mike Lamb on May 30, 2011 1:59 PM:

    And what happens, Frosty, when you can't get coverage at all with all that money you've socked away? What if the money you've saved isn't sufficient even with the voucher? How did private system for covering the elderly work out prior to the passage of Medicare? What if you are in your late 40's, with a couple of kids heading off to college--how are people suddenly going to re-adjust so that they now have to save for Medical care past 60?

  • Rick B on May 30, 2011 2:20 PM:

    The question isn’t why Dems are on the offensive; the question is why the Beltway media finds it offensive.

    The answer to that question according to George Lakoff's book The Political Mind: Why you can't understand 21st-Century American Politics with an 18th-Century Brain is that the conservatives have framed the allowable possible narratives to exclude the idea that the government can possibly do anything at all without becoming a tyranny. If something does not fit into the narrative society prescribes for a given role then the individual will most often refuse to recognize the exceptions. That's because these narratives, as provided by society, are hard-coded into our brains. Those narratives are how we determine what things "mean."

    People choose the roles they play from an accepted set of roles offered by society, and within each role only certain narratives are permitted. Let me emphasize - anything not fitting into that role is generally ignored unless it becomes extremely pressing. "Designing a successful government program to solve a social problem" is not an allowable narrative if your role is successful Washington reporter.

    For conservatives generally the only acceptable way to get medical care is from private wealth or from current employment. That's their narrative. But it pointedly excludes the idea that the government might use reasonable insurance planning to organize the financing of health care services in advance of need and then let the private market bid to offer those services.

    The answer to the question is that conservatives like the Koch brothers have worked reporters very hard to set the acceptable narratives that successful reporters are allowed to consider. There is no equivalent liberal or progressive effort being planned or conducted.

    Also as Lakoff points out, merely providing the facts does not overcome the hardwired narratives built into the brain. The fantasy that such facts might change the narratives is the 18th-Century brain theory he is demonstrating is false. Frames and narratives are what matters, not facts.

  • Sam on May 30, 2011 2:22 PM:

    What is truly astonishing is that the Beltway press seems to totally disregard the $500 billion Medicare reforms that Democrats just signed into law, that extended Medicare's existence for a decade. To argue that Democrats have done nothing on Medicare is simply false, and it is also disingenuous to accuse Democrats of "Mediscare" tactics, when the GOP spent two years lying about the Affordable Care Act, without any pushback from the press.

  • Mike Lamb on May 30, 2011 2:31 PM:

    Sam--not to mention that the Repubs proceeded to campaign, with great effect, on the $500 Billion in "Medicare cuts"...

  • TheRadicalModerate on May 30, 2011 2:40 PM:

    bleh@5/30-8:11AM:

    ACA is never going to be able to bend the curve. Here's why:

    All of the provisions in ACA rely on some form of cost control. They either rely on effectiveness metrics, or outcome-based pricing, or purchasing economies of scale, etc. Those things are all well and good, and they certainly can be successful at driving down the cost of existing treatments faster than they would otherwise be driven down.

    But the thing that's causing costs--especially Medicare costs--to increase exponentially isn't the cost of the old treatments; it's the new stuff, and especially the new stuff that can further extend the life of the elderly. About 25% of Medicare billings already occur in the last 12 months of life, and I'm guessing that that percentage will continue to increase. Essentially, for each additional year a person lives, the cost of buying an extra year of life increases. When you couple that with a steadily increasing life expectancy, you have a problem that swamps cost controls on the less-than-cutting-edge treatments.

    There are only three ways out of this problem. First, you can "cost-control" the cutting edge treatments. This will effectively stifle the market for these treatments and life expectancy will cease to increase--in other words, people will die sooner than medical science would otherwise have them die. This is effectively where ACA is headed. Second, you can cap the lifetime payments to each individual, forcing them to decide which life-extending treatments suit them best, but eventually cutting off their money. Again, the net result is that people die at an age that's earlier than the best treatments would otherwise have them die. This is essentially the Ryan plan. Or third, you can wait until continued life extension makes the problem so bad that the whole system collapses. This also has the effect of limiting (or, more likely, reducing) life expectancy, and costs will be brought under control.

    Personally, I like the Ryan plan because I'd rather be in charge of getting the most bang for my limited buck than having the government decide which treatments are above and below the line, and I'd especially like to ensure that the cutting-edge treatment market stays healthy indefinitely. I think Ryan is slightly more likely to do that than ACA, but it's certainly an eminently debatable point. Ultimately, though, let's not kid ourselves: in the future, the elderly are going to die because they run out of money, not because medical science can't keep them alive for a little while longer.

    I do agree with a bunch of people on the thread that this debate is incredibly simplistic so far, but I'm guessing that that will (slowly) change as each side gets their issues framed more and more concisely. In the long run, though, I think the GOP has the edge on message over ACA proponents, if for no other reason than allocating a fixed amount of money per person is guaranteed to be actuarially sound, while ACA is a crapshoot. The elderly can only be scared so much in this debate, and they're mostly grandparents, too. When they vote, they not only vote for their pocketbooks--they vote for their posterity, too.

  • Mike Lamb on May 30, 2011 3:14 PM:

    RadicalModerate--is there any information that shows that the extremely high charges for some of the cutting edge treatments actually reflect similarly high costs of the procedure? Isn't it likely that as some of these treatments become more and more main stream that the price will drop?

    And finally, what happens when you can't get coverage as an elderly person under Ryan's plan? Forget about $$--the insurance company flat out denies you a policy because it's more "actuarially sound"?

  • dsimon on May 30, 2011 3:20 PM:

    Tyro: "The Democratic alternative to Medicare is Medicare. The republican solution is to destroy it."

    I agree that there is a huge difference between making Medicare viable for the long term, as Democrats want to do, and abandoning it by throwing everyone into the private market, as Ryan proposed.

    The problem, as I see it, is that Democrats have made some progress on the former but haven't really bitten the bullet. We can reduce health care costs, as shown by just about all our peer countries which spend a third less to half as much as we do on medical expenses and get comparable results. But it's hard to see major reforms flying with the public, which doesn't overwhelmingly support the modest bill which we actually got (though they do support individual provisions within it).

    The Republican "plan" is an abomination. The Democratic reforms have been an improvement. But major steps are always going to be subject to political derision, and so Democrats seem hesitant to give up the advantage that Republicans have given them on this issue. Ryan is right that if nothing is done, Medicare will cease to exist. That's not an excuse for adopting his lousy proposal instead of fixing Medicare (which requires non-"market" solutions so anathema to Ryan and his colleagues). But raw politics makes the easiest road the one which leads to putting off the hard choices until absolutely necessary, because hard choices are not going to be popular.

    I think that's what Marcus was trying to say--not that I've been impressed by her all that often.

  • Rick B on May 30, 2011 3:21 PM:

    to The RadicalModerate:

    You are quite wrong about what is driving the super high cost of American healthcare. Yes new treatments are expensive, but the current medical system does nothing to lower that early high cost and create efficient industrial-society lower costs as the product is more widely sold. Atul Gawande delivered this year’s commencement address at Harvard Medical School and described the medical profession's approach to delivering health care as Cowboys and Pit crews. American doctors are still trained in the same individualistic forms of management attitudes that worked in 1937, but medicine itself has moved on to where it takes an effective team system to deliver effective medicine. The cowboy attitude fails very frequently because system management techniques are not applied. Those management techniques (an example being checklists like airline pilots use) will sharply lower health care costs.

    Another extremely high cost element is the individual administrative systems used by separate insurance companies. They differentiate their administrative systems to make it difficult for health care providers to compare prices or to shift to another provider. It creates local monopolies with the very high prices that monopolies charge. A single national administrative system would bring the power of the market to health care costs.

    Another cost is the way insurance companies work with each other, shifting the burden between companies with each company taking a profit from the transaction before shifting it on to another company. It is estimated that this one set of practices adds as much as 25% of the total end cost to the administrative costs.

    Then your argument assumes that all health care advances come from America. That is certainly no longer true. America is no longer the innovation leader of the world in almost any area and that's especially true in health care. Why does the American system cost over twice per capita of any other health care system in the world and yet provides worse results for the nation than most industrial nations?

    The reason there is such a propaganda attack on the ACA is that they are extremely likely to work, but when they do Wall Street, the health insurance investors and the top (overpaid) executives will find their worthless incomes sharply reduced. So to stave off this attack on the amount of money investors are stealing from the sick and from the taxpayers we get the propaganda line lie "ACA is never going to be able to bend the curve."

  • DavidI on May 30, 2011 3:27 PM:

    Several aspects of Sunday's "Meet the Press" stacked discussion warrent consideration aside from the stacked panel istself.

    First, the notwithstanding the seemingly successful efforts by the Reps to convince the pundits that the Democrats do not have an alternative -- they do. The passage of ACA is the beginning of that alternative. Its already in law and dspite efforts by the Rep House of Representatives to stop it it is being implimented.

    Second, aside from the ACAs goal of providing access to health care for virtually all of our citizens, it begins the effort to attack the rate of increase of health cre costs at its root -- the entire health care system (the appropriate approackh), not just the rising costs of Medicare.

    Third, based on CBO estimates, the ACA pays for itself, begins to address health care cost increases at the level of society, and makes a significant move toward reducing the federal debt. Moreover, the "RyanCare" proposal does almost nothing to reduce the rate of health care cost increases, makes no effort to increase the proportion of the population that has access to affordable health care, and uses cost shifting to individuals as its primary means of contributing to federal debt reduction.

    Forth, most responsible progressives admit that more needs to be done to attack rising health care costs given the reality that health care costs much more in the US than in the rest of the industrialized world and provides not significant increment to either quality of live or longevity relative to those systems. Further, we need to start thinking of health care as a system not a bunch of poorly coordinated health insurance programs. The ACA provides the beginnings of such a set of reforms and in that sense is pretty formidable compared to the Ryan proposal that mainly shifts costs to older Americans who too often have limited resources to cope with the increased costs.

    In summary, the whole issue of the need for Democrats to step up to the plate and put forward an alternative to RyanCare is rediculous given that they already ahd dont that and want to move further to ensure the ACA accomplishes its promise!

    The proper context is to avoid further reliance on a flawed "free" market approach (incentives for unregulated insurance to avoid risky groups) that we already know doesn't work as advertised, and address the flaws to create a market based strategy that does work for the public.


  • Rick B on May 30, 2011 3:30 PM:

    dsimon,

    You are mostly correct, but the Democratic solution is not just to stick with Medicare. The ACA already has a great deal of cost containment built into it, and making the costs more visible and comparable to each other will do a fantastic job of lowering overall costs.

    As I referenced above, just the shift from cowboy medicine (dominated by individualistic practitioners) to pit crew medicine (systems management together with effective comparisons between different teams doing the same procedures and measured by outcomes rather than by just counting up the procedures applied) will go a long way towards lowering the overall cost of health care.

    If America had the cost containment of the German or Canadian systems then the entire nation could be provided health care (universal health care) at less cost than the total price currently being paid by the federal government alone for health care costs. Both of those nations have better overall outcomes than America does.

  • Tyro on May 30, 2011 3:38 PM:

    I think the GOP has the edge on message over ACA proponents, if for no other reason than allocating a fixed amount of money per person is guaranteed to be actuarially sound, while ACA is a crapshoot.

    Medicare and the ACA are variations of the health care systems used by every other wealthy country in the world, while the Ryan plan is a joke concocted by someone who read too much Ayn Rand as a child and took it too seriously. Which plan do you think of those too is a crap shoot? One of them we KNOW works, and the other is just a fanciful invention to give people money to buy already unaffordable insurance.

    Sometimes I think that "The Radical Moderate" is just a persona whose shtick is to adopt these crazy talking points under the guise of moderation.

  • Squeaky McCrinkle on May 30, 2011 4:46 PM:

    that makes George Will's bow-tie spin like a P-51 propeller

    There's probably more wit and creativity in those few words than can be found in David Gregory's entire, miserably pedestrian career.

  • Anonymous on May 30, 2011 5:10 PM:

    Personally, I like the Ryan plan because I'd rather be in charge of getting the most bang for my limited buck than having the government decide which treatments are above and below the line, and I'd especially like to ensure that the cutting-edge treatment market stays healthy indefinitely. -TheRadicalModerate

    So you prefer a plan that puts "you in charge" of a decreasing amount of "limited bucks" on the for-profits screw the patient insurance market so that the wealthy can have a tax break? That's the Ryan plan. That's radical not moderate.

  • neil b on May 30, 2011 5:47 PM:

    Getting to the media issue per se: how much do we know about who actually decides the MTP lineup (and compare elsewhere), what is their background and connections, can they be "targeted" with complaints, etc.

  • TheRadicalModerate on May 30, 2011 6:40 PM:

    @Mike Lamb--

    Isn't it likely that as some of these treatments become more and more main stream that the price will drop?

    Yes--and that's an area where ACA-style reforms can help quite a bit, since prices drop extremely slowly or not at all under the current system. But if the rate of innovation stays constant or, more likely, increases, then the new stuff still swamps the old stuff.

    And finally, what happens when you can't get coverage as an elderly person under Ryan's plan?

    As I understand it, Ryan's plan is a lot like Medicare Part D: To participate, an insurer has to provide guaranteed enrollment, and offer a regulated set of services as part of the plan. That set of services may have a lot of variation in it, but you're always going to be able to get a vanilla-flavored plan for $x, where presumably $x = the $y that the feds will give you in premium supports. But it's unlikely that that plan is going to cover cutting-edge treatments; for that you'll need to kick in more money beyond the premium support.


    @Rick B.--

    I'm not saying that you can't do a huge amount of good with reasonable cost controls. But the problem with these is that they're all one-shot savings, while the introduction of new treatments will continue forever, or at least as long as there's medical progress to be made. And all of these new treatments have the same characteristics:

    1) They're usually chronic, so the cost increases at least linearly with time.

    2) They're patented, so the innovator pretty much gets to charge what the market will bear for the first 10 years or so--sometimes longer.

    3) They're complex, so the amount of patient management is high, with the treating physician often having to fiddle with the treatment to get it right and maintain it safely.

    The only way to prevent these treatments from swamping the budget is to either ration them or forbid them outright, and the path to introduction is so high-risk that small amounts of regulation are likely to lead to sharp curtailments in the rate of innovation. I don't think we want that.

    I can't comment on the percentage of innovations coming from overseas, but note that I was mostly talking about actual procedures, drugs, and medical devices, not systemic innovations in healthcare delivery. Again, I don't dispute that you can probably wring out 15%-25% with prudent, ACA-like reforms--for a while. But the innovation will still swamp the system in the long term. Beyond that, I don't think it really matters where the innovations come from. If somebody in Latvia has a better treatment that lets people live longer, elderly Americans are going to want it, price be damned.

    Truth in argument here: After I wrote the first post, I went data rummaging, and discovered that through the 90's, last-year Medicare expenditures held constant at about 25% of overall expenditures. The big-deal study on this was done in 2003, and I can't find anything newer. If anybody has new data, I'd love to see it. Obviously, if last-year expenditures continued to hold constant, then my thesis is, uh, a bit flimsy.


    @Anon--

    So you prefer a plan that puts "you in charge" of a decreasing amount of "limited bucks"...

    I don't think that there's anything that forces the premium supports to be at a fixed price (although I suspect that the Ryan plan keeps them the same adjusted for inflation). If we as a nation decide that we want to devote more resources as a percentage of GDP to Medicare--cool, let's do it. The important thing is that the payout is not unlimited, which is where we're heading now. Without some limitation, I'm afraid that we eventually get to the point where 105-year-olds can demand to live to be 106 and be entitled to the government shelling out a couple of million bucks to do it.

    That health care system is never going to occur, one way or another. But there is unfortunately a sneaky way for the government to ensure that it doesn't occur: they merely reduce the reimbursements on the 105-to-106 medical treatment to the point where the supply dries up. Or, even worse, they dangle the 105-to-106 treatment out there as an indication of how compassionate they are, but they dry up the supply of the treatment that gets you from 95 to 100, thereby reducing the supply of 105-year-olds to a manageable number. Me, I'd rather buy the policy option that pays for the 95-to-100 treatment and doesn't cover the 105-to-106 treatment. But I want that decision to be mine. Don't you?

  • Rick B on May 30, 2011 7:31 PM:

    @RadicalModerate

    1. if the rate of innovation stays constant or, more likely, increases, then the new stuff still swamps the old stuff.

    2. it's unlikely that that plan is going to cover cutting-edge treatments ; for that you'll need to kick in more money beyond the premium support.

    3. the introduction of new treatments will continue forever, or at least as long as there's medical progress to be made. [...]The only way to prevent these treatments from swamping the budget is to either ration them or forbid them outright, and the path to introduction is so high-risk that small amounts of regulation are likely to lead to sharp curtailments in the rate of innovation. I don't think we want that. [...] the innovation will still swamp the system in the long term. [...] Obviously, if last-year expenditures continued to hold constant, then my thesis is, uh, a bit flimsy.

    4. I don't think that there's anything that forces the premium supports to be at a fixed price (although I suspect that the Ryan plan keeps them the same adjusted for inflation).

    5. Without some limitation, I'm afraid that we eventually get to the point where 105-year-olds can demand to live to be 106 and be entitled to the government shelling out a couple of million bucks to do it.
    Your entire argument is a string of "if...", "It's unlikely...", "I don't think...", "If...", "I don't think...", and "I'm afraid...." Read the commencement address by Atul Gawande to the graduating class of Harvard Medical School. I was born after Penicillin but before the miracle drugs of the 1950's and one line in his address struck me. He pointed out that there were almost zero effective treatments for illnesses in 1937 but "We now have treatments for nearly all of the tens of thousands of diagnoses and conditions that afflict human beings. We have more than six thousand drugs and four thousand medical and surgical procedures, and you, the clinicians graduating today, will be legally permitted to provide them. Such capabilities cannot guarantee everyone a long and healthy life, but they can make it possible for most."

    Tell me. How do the other industrial nations behind which America trails in medical outcomes deal with this at a cost of less than half per person compared to the idiocy here in the U.S.? As I pointed out earlier, if the U.S. had the cost structure of Canada or any of the European industrial nations then every person in America could have access to health care at no out of pocket cost merely from what the U.S. Federal government spends each year right now, and there would be change left to pay down the deficit.

    I won't even attempt to estimate how much more competitive our export industries would be without the burden of employer-paid health care as an anchor on export prices, but our exports would certainly increase and that has multiplier effects through the entire economy.

    Your opposition to this and your support for the Ryan budget in contrast is based entirely on speculation about fantasy negative results in the future.

    The fact is that the American health care "system" is a disaster and does not even deserve the term system. The Ryan plan, like all the conservative plans, depends on changing how much money can be directed towards health care from the limited area of the federal government and it does nothing else. But the problem is the purposely opaque financial system (multiple uncoordinated insurance companies battling it out to each gain monopoly profits in selected protected niches) and an almost total absence of widely spread rules and science in the actual delivery of health care based on the outcomes produced. The Ryan Plan would be ineffective on the financial side and ignores the entire problem of delivery of health services.

    The problem of our health care "system" is not financial. It is a refusal to apply true market systems in a transparent cost structure across all companies and an equal and more indefensible refusal to apply operations management procedures to the actual services provided with inputs evaluated by the effect on actual outputs in terms of public health. There is nothing in the Ryan Plan that even belongs in the same universe as this paragraph. There is simply no connection.

    The Ryan Plan - and your speculations - are nothing more that further FUD agreements designed to prevent anyone from actually being effective at managing the failed American health care system. (FUD = Fear, Uncertainty, Doubt for those of you unfamiliar with the term. It is a strategy often used by Microsoft as the promise new possible products to head off what might be dangerously competitive products from competitors. FUD delays the entry of competitors into a market.)


  • Rick B on May 30, 2011 7:33 PM:

    In the last paragraph above the term "agreements" should have been arguments.

  • Tyro on May 30, 2011 7:38 PM:

    But it's unlikely that that plan is going to cover cutting-edge treatments; for that you'll need to kick in more money beyond the premium support.

    There is nothing to stop you from paying for your own cutting-edge/overpriced/not useful treatments under Medicare. The point of Paul Ryan's plan is to offer a means-tested voucher that is worth less and less money over time to purchase health insurance for the least healthy segment of the population until Medicare effectively ceases to exist.

    You seem to have the idea that Medicare as it exists is going to be some kind of drag on medical innovation. To a degree, I think at the public can mostly make that choice. The Ryan plan pays for health care for the retired by basically levying a 100% tax on the assets of retired people to pay for their treatment beyond what small amounts that private insurers ares required to pay for (if they have any requirements at all).

    I don't see any talk here from you about how countries like Germany, The Netherlands, and Switzerland integrate the retired into their national health care systems. If I had any chronic health conditions and was at serious risk of developing more health problems, "here's a $8,000-$15,000 check. See who is willing to insure you this year," is not a confidence-building policy.

    I see what you're saying about your concerns, but your enthusiasm for the Ryan plan is misguided. If you want to stem health care inflation while preserving innovation, you do that, not come up with a rube Goldberg mechanism which throws seniors out on the open insurance market in the hopes that somewhere along the line you might get the desired result.

    Your problem is the same as the pundits-- just because some crazy guy yelled something about medicare reform, you and the pundits reacted with "this is a serious great idea that I have to embrace and start negotiating over," rather than, "these are the facings of a madman, does anyone have anything useful to say?" Paul Ryan might wear a suit and a nice haircut, but that doesn't mean that I am automatically going to take him seriously, or even that I should.

  • TheRadicalModerate on May 30, 2011 9:28 PM:

    @Rick--

    Oddly enough, I don't think I disagree with any of the reforms you've mentioned, and I certainly don't disagree with any of the the things in the Gawande speech.

    I also agree that the financial aspects of both the Ryan plan and ACA have little if anything to do with the kind of reforms that are required to produce an efficient health care system. But they have a hell of a lot to do with the financial health of the nation. So I disagree with you that the Ryan plan is a non-sequitur. It's not health care reform; it's budget reform. (Note that ACA is billed as both health care reform and budget reform. The most charitable I can say about that is that maybe it really is a dessert topping and a floor wax. I frankly don't know how you'd tell--it's too complex to analyze.)

    So: back to budget reform. In the face of a sudden, effective, highly expensive technological advance that significantly increases lifespan, the current contract where you pay your taxes and in turn the government will pay almost any amount to keep you alive is simply unsustainable. In the face of such a crisis, we will either yank away a major entitlement at the cost of huge social disruption, or the system will simply collapse. On the other hand, if we modify that basic contract--with sufficient lead time--to one where the government promises to devote a fixed amount of resources to your health care, we can still increase the amount we pay per person per year whenever it's prudent to do so. But the system is fail-safe; it's not going to become a victim of medical technology's success.

    As you pointed out, there are a lot of "ifs" and "I guesses" and "maybes" in what I've written. That's because the future is unknowable when it comes to this topic. Maybe 99% of everything we're ever going to be able to do to treat humans has been discovered and the history of the next 50 years is one where health care becomes too cheap to meter. Maybe people can live to be 150 with the application of enough resources.

    We can say one definite thing, though: In 1960, health care expenditures were about .05% of GDP in the US. In 2009, they were 17.6%. That's an increase of a factor of 350. Want to use European numbers instead? They're running about 9.5% of GDP. So the increase is only a factor of 190. Do you really think that any entitlement system can survive in the long term, even if the expenditure growth rate is only a tenth of what it was since 1960?


    @Tyro--

    I'm not worried about the actual numbers in the Ryan plan--I'm much more interested in the architecture. Want to have a big argument about how much we spend per person per year on Medicare price supports? I'd be happy to, and I'll bet we're not as far apart as you might think.

    But the essential element of the Ryan plan acknowledges a very simple, very unpleasant fact: In the future we're not going to be able to afford to pay to keep everybody alive for as long as medical technology might otherwise be able to keep them alive. This is a reality that will force a painful, perhaps even devastating, change in how we value life in this country and around the world. The sooner we understand and internalize this, though, the sooner we can work on producing the most cost-effective, most humane system that's actually possible.

  • Rick B on May 30, 2011 10:21 PM:

    TheRadicalModerate

    The very idea that "...the government will pay almost any amount to keep you alive..." is fantasy. It's not true now and it never will be. Today it's the insurance companies and the health care providers who place a limit on what is spent - and the limit is what is considered practical.

    But today it's based on some physician's gut instinct and experience, probably several physicians who huddle informally. It should be based on scientific studies, and that will provide more cost savings. That's been the case everywhere it is been tried. The problem has been that the financial players do not have the medical expertise to make those decisions and the medical experts don't get the data for large scale reviews.

    My bet is that instead of end of life costs skyrocketing based on some fictional demand not controlled by the costs there will actually be lower costs because the practical aspects will be understood in ways they cannot be right now. My mother went through hospice in her last six months, and it was frankly much less frightening and less expensive than was true for people who had no guidance in how to handle the end of their life.

    People who are dying usually know it, and most realize that they do not want to extend the process unnecessarily. The problem is generally when family members get involved and feel that if they don't force the most extreme measures that they are showing a lack of either love or respect for their parents or other elders.

    The thing is, hospice is a social change and a management change in how to approach dying. It works when the drugs and medical interventions no longer have positive effects.

  • Tyro on May 30, 2011 10:51 PM:

    I'm not worried about the actual numbers in the Ryan plan--I'm much more interested in the architecture

    Then you should be even more upset at the Ryan plan-- the entire architecture is misguided, because it revolves around the hope that a demographic of uninsureable people on a fixed income should be haggling with insurance companies over the price of policies which, by their nature, won't be at all profitable to sell.

    Dollar amounts are a concern only in that the vouchers are designed to be less and less valuable over time-- but it's because the nature of the architecture is so misguided that the Ryan plan is not even to be considered as anything but a juvenile Randian fantasy.

  • Eclectic Observer on May 31, 2011 12:39 PM:

    Ruth Marcus is an idiot. Economics is too difficult a subject for most media types to understand. Also, the pundit class is too much in bed in their own self interest with the economically wealthy. Oh they might be socially liberal but on economics-- they are right wing either from ignorance or pocketbook bias.

    Ruth Marcus is a disgrace but what do you expect from a corporate owned media. The balance "This Week" was also disappointing.

  • TheRadicalModerate on May 31, 2011 1:45 PM:

    Rick--

    I think you may be inaccurately projecting your experiences onto the rest of the public. I, too, have had relatives in hospice and I think it's a much more humane way of dealing with terminal illness. But I've also had relatives that lingered for months in hospitals on PEG tubes because they weren't willing to give up, or because we weren't sure that their condition was actually terminal. Bottom line on this: if the medical staff can't definitively say that a treatment is either useless or deleterious, Medicare's going to pick up the tab.

    And this is going to get much, much worse in the future, when virtually everybody's going to have two or three co-morbidities at the end of their lives. Are you going to deny a mid-stage Alzheimer's patient in heart failure an artificial heart-lung device? How about a stage-three cancer patient who also has diabetic gangrene and needs prosthetic limbs? Or neural motor implants for a stroke victim with severe diabetic neuropathy? How about a patient with mild dementia and stage-three cancer--but where we've got a protocol for the cancer that produces a ten-year survival rate over 75%?

    Finally, I'd like to address your science-based approach to end-of-life decisions. I'm an engineer, so I'm always happy to have lots and lots of data with which to make decisions. And I'd like to think that, if presented with data that told me there was only a 10% chance of surviving another month with treatment x, that I'd forgo treatment x. But the idea of plugging all my data into some algorithm that then forbade me from having treatment x just gives me the whim-whams. Who wrote the algorithm? How good was their science? Were they adequately firewalled from the bean-counters when they wrote the algorithm? I simply don't trust somebody--or something--else to make these decisions for me. And you know perfectly well that the kind of bureaucracy that grows up around these kinds of algorithms severely impacts the ability to pay privately. When the whole system has been set up to perform a certain number of treatments x per week, bumping somebody who's more "deserving" (per the algorithm) with a private pay will be virtually impossible.

    Ultimately, this is why I'd prefer a defined-payment system a la Ryan. I'll gladly accept the government deciding how much they're willing to spend on me. But a rigid, defined-benefit health care system that's going to force on me what it considers as best just scares the hell out of me.

  • Neurologically disordered on May 31, 2011 2:27 PM:

    I don't think the producers of MEET THE PRESS are confident that what COMCAST really wants to see is
    an open debate of the issuss on their air?

  • Ecletic Observer on May 31, 2011 4:14 PM:

    What many seem to miss in their contortions to see some virture in Ryan's plan is that private insurance cost growth has been terrible. Given that, why wouldn't we expect similiar if not worse cost/coverage performance experience. Actually, we'd expect probably much worse. The problem with our health care system starts in our medical education with costs and debts and then moves on to a system based on hubris and greed. No other country in the world wants our system. Sure, some might experiment with how providers and financing work together under a highly regulated environment to get the best outcomes but it's nothing like what we have. The reason we are so over-prescribed and over-tested is not just the tort reform question--though I imagine there is a reasonably balanced way of improving that issue which would require concessions from the malpractice insurance industry-patients and most of all doctors and oversight boards-- but that time and money push those practices. In other words-- greed on the part of the the provider supply chain.

  • Gayle on May 31, 2011 4:53 PM:

    I think it is terrible not to be considering some tax increase for Medicare and Social security, it should be combined with tax savings but to completely not discuss some increase which would really help to save the system is crazy. Also we had higher taxes for the wealthy in the 90's and the economy was growing so maybe reconsider this thinking. I agree with cutting programs and getting expenses down but 2.5 to 3.5 percent increase may be needed also. When you say everything is on the table but not tax increase is just terrible politics.

  • Rick B on May 31, 2011 9:04 PM:

    @TheRadicalModerate

    I've also had relatives that lingered for months in hospitals on PEG tubes because they weren't willing to give up, or because we weren't sure that their condition was actually terminal. Bottom line on this: if the medical staff can't definitively say that a treatment is either useless or deleterious, Medicare's going to pick up the tab.
    Bottom line is actually that when the resources are not there, Medicare is not going to spend them.

    First. Medicare under ACA is shifting to paying a fixed amount for a given illness. The hospital will pick up the cost above that and they will not be willing to go for unlimited amounts.

    Second. Again ACA has the review of the effectiveness of treatment as a major part of the program. It will cause only the most effective treatments to be paid for - at fixed costs per illness. It will cease to be the province of any individual physician to determine how much is spent on end of life situations.

    Third. If the resources are not available then no one is going to authorize spending them. Your relatives died in an era when the resources needed to continue their care were available. I can list about six administrative ways to avoid the excess expenditure, but the most likely is the one that Texas has already passed into law and practices - the law in Texas already states that hospitals are not required to spend unlimited amounts on end-of-life cases.

    This is a brief demolishment of your worst case assumptions so that the predictions you offer of the future simply are not possible.

    Your experience as an engineer explains a lot. I was a physics-math major before switching to economics and am now a social scientist. Though I just completed an AAS in computer science. But I have also taught social science research methods. I will assure you that engineering projections have a limited range of applicability. Outside those ranges social processes take over. One such process is the law, and the concept of stare decisis (legal precedent) sets acceptable ways of dealing with problems that engineering logic avoid because of the absence of reliable data and predictable algorithms. I am also a CPA candidate and can tell you that the rules of accounting are essentially generally accepted estimates that give the needed results. Again, this is outside engineering capabilities. You as an engineer are not going to trust either process, but the fact is those processes are the kinds of things that engineering decisions are embedded in and are the reason why most engineers I know dislike politicians. Because the most obvious limitation on your argument is the behavior of politicians when they get together to make decisions that work to give the results they want whether those results are logical or not.

    Bureaucracy, by the way, is the way organizations organize to break down complex problems so that individual human beings (specialists) can be given limited parts of any given problem to decide on. Human beings have limited mental processing power and cannot deal with large problems individually. (Herbert A. Simon wrote of "Bounded Rationality" and Max Weber described how bureaucracy deals with big problems. No organization with over 200 people can operate efficiently without bureaucracy. The number comes from investors who recognize the problems growing organizations have at that point. Always wait until an organization passes that size before investing. It usually requires a change in leadership.)

    What I am pointing out that your evaluation of my "science-based approach to end-of-life decisions is based on a great deal more science than your engineering view is. Social science can use insurance data; engineering science is a lot less likely to be able to. People do not live - or die - by engineering science alone. That's why there are lawyers and politicians and why every effective engineer works for some able to deal with politics well. Engineers can calculate how to perform a certain number of treatments x per week and apply a system of priorities. Politicians tell the engineers when to change the entire system to something that works.

    I'm on Medicare. It gives me a certainty regarding what I am going to have to pay in order to have access to health care. The Ryan plan removes that certainty. Everyone knows that the certainty will exist when they reach age 65 unless the Ryan plan idiots change it. You may like to remove the certainty that I enjoy because you prefer the certainty of what the government pays out. I'll fight - hard - to protect my certainty of availability of health care services. The government can provide that and should not be allowed to shirk its responsibilities because conservatives don't like it. That's the political reality. Engineers who object will lose.

    By the way, engineers make up a large proportion of libertarians. Does that include you?

  • EastWest on June 01, 2011 5:42 AM:

    Who watches Meet The Press anymore? Certainly no one under 40. Repugs are nervous because the kids of the Boomers are growing up and voting, and they aren't voting for Repugs.

  • John Ahlstrom on June 02, 2011 7:04 AM:

    I agree with Benen completely.

    BUT, where is the Democratic alternative?
    Is it single-payer system?
    Wait, that is what we have now.
    Is it cost-effective, evidence-based treatment?
    Wait, that's what we have to have death panels for.
    If it is some combination of capping costs, increasing the taxable income that must contribute, ... Let's See the Proposals ! !

  • Clevelandchick on June 02, 2011 11:59 AM:

    The GOP wants to gut Medicare to fix the deficit but hasn't proposed any solution toward lowering the cost of health care. In fact they voted en masse against the gov't negotiating lower drug costs which is a HUGE part of why our health care costs are out of control. That was an item they insisted on eliminating from the health care reform act when they pretended they might vote for it.

    When people are using every penny of their disposable income to pay for insurance and health care, then not even getting proper coverage that has a drastic impact on our economy.

    But the GOP could care less if Americans dying without health care or going bankrupt when they get sick. Grayson was right when he said the Republican Health Care plan is 'don't get sick and if you do, die quickly'. They accused him of being a demagogue when he was just telling the truth.

  • hooher tod on September 04, 2011 2:38 AM:

    Yes there should realize the reader to RSS my feed to RSS commentary, quite simply

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