While Washington wonks continue to bicker over health policy, positive change is occurring outside the Beltway.

Last week, the Altarum Institute, a research organization based in Ann Arbor, Michigan, reported that the moderation in the growth of health-care costs we have seen over the past few years is continuing: Total health spending rose by less than 4 percent from February 2011 to February 2012. And it’s encouraging to see the progress that doctors, hospitals and other providers are making to improve the value of care — by cutting back on unnecessary procedures, for example, expanding their use of information technology, and switching from fee-for- service to compensation schemes aimed at maximizing the quality of treatment.

Instead of examining these changes and finding ways to encourage them, the Washington policy discussion continues to demonstrate its ability to, well, it’s not clear exactly what it does. The most senseless bloviating recently came from Charles Blahous, a senior research fellow at George Mason University, in Arlington, Virginia, and a former official in the George W. Bush White House. He claims to have shown that the 2010 health-care reform act will substantially increase the budget deficit, despite official estimates to the contrary. The Washington Post decided this warranted prominent coverage.

What Blahous actually did was play a trick. His analysis begins with the observation that Medicare Part A, which covers hospital inpatient care, is prohibited from making benefit payments in excess of incoming revenue once its trust fund is exhausted. He therefore argues that the health reform act is best compared to a world in which any benefit costs above incoming revenue are simply cut off after the trust-fund exhaustion date. Then, he argues that since the health-care reform act extends the life of the trust fund, it allows more Medicare benefits to be paid in the future. Presto, the law increases the deficit by raising Medicare benefits.

Double Standard

Yet Blahous only partially adopts his own novel approach. When discussing the nation’s fiscal outlook, he writes of the “federal government’s untenable long-term fiscal outlook under current law.” But the long-term deficit projections are so dire primarily because we assume that benefits will continue to be paid in full even after the Medicare and Social Security trust funds are exhausted. If no benefits beyond incoming revenue can be paid after the trust funds are exhausted, then the fiscal outlook really isn’t untenable.

You can’t adopt one perspective to argue we have a massive long-term deficit and then another to argue that the health bill expands the deficit.

While we’re at it, since Blahous is enthralled with basing his deficit projections on such a strict interpretation of the law, he is being far too modest. The government is not legally allowed to issue any debt above the statutory limit, so Blahous should have assumed the deficit would disappear when we reach that limit at or around the beginning of next year.

(In case there’s any doubt about his disingenuousness, Blahous subsequently defended his article by claiming that it was subject to a “double-blind peer review process, which means that I did not know who was reviewing the paper, and the reviewers did not know who had written it.” Yet the text of the paper itself, at footnote 26, states that the author is one of the public Medicare trustees. There are only two, and as any competent reviewer would have known, the probability that the other trustee, Robert Reischauer, would have written it is effectively zero.)

Another study receiving some recent attention is a much more serious one — which is why it didn’t get a whole lot of attention. Joseph Doyle, a professor of economics at the Massachusetts Institute of Technology, and his co-authors examined whether high-cost hospitals in New York deliver better care than low-cost ones do. The design of their study is clever, and the authors conclude that the higher-cost hospitals have lower mortality rates. This challenges an array of evidence, most associated with researchers at Dartmouth College, suggesting that higher costs don’t mean higher quality.

The Doyle study, though, included emergency patients only, and not all of them. As a result, it examined only about 5 percent of the admissions (who account for less than 10 percent of total costs) at the relevant hospitals. Furthermore, as the authors note, even for that 5 percent of admissions, there appeared to be no additional benefit to higher spending at the hospitals whose costs were in the top 15 percent of all hospitals in their sample. The conclusion from the Doyle study is thus not, as some in Washington have argued, that there are no opportunities for lowering costs without impairing quality. It’s only that for certain types of emergency care, higher-cost hospitals seem to deliver better results — and only up to a point.

This brings us back to the progress being made beyond the Beltway toward a better combination of cost and quality in health care. Consistent with other evidence that points to a deceleration in cost pressures is a Congressional Budget Office report earlier this month showing that Medicare spending has risen less than 3 percent over the past year.

In a future column, I will explore the debate over whether this slowdown is purely temporary. On the one hand, the Great Recession has restrained health-care spending. On the other, many changes in health-care delivery — for instance, the recent decision by nine physician groups to eliminate 45 unnecessary tests and procedures — suggests the slowdown is at least partly structural. The question then becomes how to continue it. That’s what Washington should be debating.

Peter R. Orszag is the vice chairman of global banking at Citigroup and an adjunct senior fellow at the Council on Foreign Relations. He was President Obama’s director of the Office of Management and Budget. This post first appeared at Bloomberg.

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23 Responses for “Washington Stuck Fighting Wrong Health-Care Battle”

  1. Nate Ogden says:

    “You can’t adopt one perspective to argue we have a massive long-term deficit and then another to argue that the health bill expands the deficit.”

    Why not, PPACA is the biggest contradiction ever passed.

    It’s a tax until it isn’t a tax

    http://www.nytimes.com/2012/04/14/opinion/ducking-the-medicare-crisis.html

    About 65 percent of the cost of the Obama health care law is supposed to be met by Medicare expense reductions and tax increases totaling roughly $1 trillion over 10 years. The deficiency with this plan is that it amounts to double-counting, using urgently needed Medicare economies to finance the new law.

    Given that context, the government’s accounting practice — counting $748 billion of cost savings and $259 billion of revenue increases toward both Medicare and the cost of the Obama plan — is particularly troubling. Moreover, this problem is largely hidden from public view.

    Under Washington’s delusional rules, budget crunchers in both the White House and Congress credit this $1 trillion twice: once in calculating that the care law will generate more revenues than costs, and again in concluding that the Obama plan will chip away at the Medicare problem.

    “And it’s encouraging to see the progress that doctors, hospitals and other providers are making to improve the value of care — by cutting back on unnecessary procedures, for example, expanding their use of information technology, and switching from fee-for- service to compensation schemes aimed at maximizing the quality of treatment.”

    Exactly which programs are you referring to that were big enough to restrain cost in our 2 trillion dollar system? Those encouraging signs you mention haven’t even saved pennies in our 2 trillion of spending. So if it wasn’t the programs you try to credit what really drove those reductions in inflation?

  2. Paolo says:

    I walk down the street and find a $20 bill on the sidewalk. I pick up the bill and put it in my pocket. All of a sudden I am $20 richer. I go back home and tell my wife. She says that the family is now $20 richer.

    In the meanwhile, my math-challenged neighbor observes the story and claims that one of us is lying. According to him, it’s not possible that both I AND the family are richer by $20. He claims it’s double counting.

    I try to argue that this is very simple: I am part of my own family. Therefore, if something increases my net worth, it also increases the net worth of the entire family. But he won’t have any of it and keeps saying that my accounting rules are delusional and that I’m double counting.

  3. Nate Ogden says:

    United States District Court Judge Vaughn R. Walker overturned Proposition 8 on August 4, 2010 in the case Perry v. Schwarzenegger, ruling that it violated both the Due Process and Equal Protection clauses of the United States Constitution.[11] Walker issued an injunction against enforcing Proposition 8 and a stay to determine suspension of his ruling pending appeal.[12][13] The Ninth Circuit Court of Appeals continued the stay, keeping Walker’s ruling on hold pending appeal.[14]

    On February 7, 2012, in a 2–1 decision, a Ninth Circuit Court of Appeals panel affirmed Walker’s decision declaring the Proposition 8 ban on same-sex marriage to be unconstitutional.[15] The panel also unanimously affirmed Judge Ware’s holding that Walker was not obligated to recuse himself from the case because he is gay.[16] Still, the panel continued a stay on the ruling, barring any marriages from taking place pending further appeals.[17]

    So when they are liberal policies it is OK for the court to overrule a majority of the public.

    PPACA, which a majority of the public opposes on the other hand should be left to stand.

    In the words of a not very wise man;

    “How do they differ?”

  4. Nate Ogden says:

    Simpletons really do struggle to comprehend the value of polls. Let me help you out BobbyG;

    http://www.youtube.com/watch?v=s9CjeZ1Mod0

    • BobbyG says:

      You were the one touting the will of “majorities.” None of which are to-the-person population opinion enumerations, they are all necessarily samples. I certainly don’t need you to lecture me on statistical methods.

      Again, “It gets to be like citing bible verses.”

      • Nate Ogden says:

        Yes you and the baby clearly have it under control, you have staked your ground and we all know exactly how you feel. Please don’t start throwing ceral as well though.

        No idea what your repeative anti bible rant has to do with the role of courts nor why you suddenly want to cite bible verses.

  5. Peter1 says:

    Nate, when do you decide that the courts should have sway over public opinion and when do you decide when public opinion should have sway over the courts? Is it when one or the other simply gives you what you want?

    When is public opinion just mob rule?

    • BobbyG says:

      Google “factitious majorities” Madison Federalist.

      e.g.,

      “Majority will cannot form and act outside of a process that favors long- term, broadly distributed majority. And such majorities arguably have goals and arrive at conclusions about what rights a constitution should recognize that are different than the goals pursued and the conclusions about rights reached by factitious majorities. Furthermore, the Bill of Rights restricts the popular sovereign in the making of law. ”

      http://repositories.lib.utexas.edu/bitstream/handle/2152/2412/dehartp80970.pdf?sequence=2

      BETER THAN THEY KNEW: THE CONSTITTION’S IMPLICIT MORAL DESIGN, Paul Robert DeHart, PhD. The University of Texas at Austin, 2005

      Look at the 20 pg bibliography as well as well.

      And, as I wrote in 1998 in my more modest grad work:

      “James Madison and his co-founders of the new American nation quickly learned that continued exercise of the rights and freedoms they risked their lives for would require a vigilance codified into constitutional constraints focused on far more than any anticipated excesses of a neo-monarchical executive. As recounted by Stanford University constitutional historian Jack Rakove:

      “Americans entered the Revolutionary crisis confident that they knew what their rights were; after independence, they modified these ideas only modestly. What did evolve, far more dramatically and creatively, were their ideas of where the dangers to rights lay and of how rights were to be protected. At the outset Americans believed that arbitrary acts of the Crown and its colonial officials, including judges of the higher courts, posed the greatest threat, and they accordingly treated the rights of representation and trial by jury as their chief securities against arbitrary rule. It took a decade of experience under the state constitutions to expose the triple danger that so alarmed Madison in 1787: first, that the abuse of legislative power was more ominous than arbitrary acts of the executive; second, that the true problem of rights was less to protect the ruled from their rulers than to defend minorities against factitious popular majorities acting through government; and third, that agencies of central government were less dangerous than state and local despotisms.” (Jack N.Rakove, Original Meanings: politics and ideas in the making of the Constitution, 1996, Alfred A. Knopf, NYpp. 289-290)

      SCOTUS won’t be submitting the PPACA question to the CNN/Bloomberg/Fox/APUSA Today et al polls du jour. Read the Rakove cite closely. From it you can cherry-pick your federal Branch Bogeyman of choice.

      • Peter1 says:

        “It took a decade of experience under the state constitutions to expose the triple danger that so alarmed Madison in 1787: first, that the abuse of legislative power was more ominous than arbitrary acts of the executive; second, that the true problem of rights was less to protect the ruled from their rulers than to defend minorities against factitious popular majorities acting through government; and third, that agencies of central government were less dangerous than state and local despotisms.”

        That is brilliant. The frothing at the mouth of politicians eager for election unleashes their ability to elbow their way to the front of the mob.

        California’s Prop 8 and NC’s vote this May 8th cementing bigotry (much of it religious) into the state’s constitution against gay marriage are good examples.

  6. I commented that I discovered a new website to keep growing in all areas of health and where we can create free profiles to share information with our physicians, patients, laboratories and medical students.

    http://www.dr-faceb.com

    Discuss it with others and obtain maximum benefit from these tools that are an ideal complement to our Blog.

  7. BobbyG says:

    See and raise:

    “I recognize that many persons believe the health mandate is very bad legislative policy. But the appropriate judicial response to such a complaint has long been clear. The Court was admirably forthright about the point in its ruling in Munn v. Illinois in 1876: “For protection against abuses by the Legislature, the people must resort to the polls, not the courts.”

    http://www.tnr.com/article/politics/102685/conservative-defense-obamacare-affordable-care-health

    We The People remain free to revise or repeal PPACA via, well, democratic means.

    Q: “freedom and liberties”

    I always love that. How do they differ?

  8. Nate Ogden says:

    Why wasn’t Roe v Wade left to the polls? Ah that’s right becuase the majority of people don’t support it.

    How about Affirmative action, courts have greatly expanded that.

    Prop 8 in CA the courts have overruled popular votes numerous times.

  9. Nate Ogden says:

    TNR link, what is that 50/50 chance it wasn’t made up or plagerized? What are you going to link next DailyKoz comments to prove your point?

  10. BobbyG says:

    http://www.law.columbia.edu/fac/Henry_Monaghan

    Harlan Fiske Stone Professor of Constitutional Law

    Email him.

    But, hey, what can HE possibly know relative to our resident know-it-all?

  11. BobbyG says:

    Quinnipiac University Poll. Feb. 14-20, 2012. N=2,605 registered voters nationwide. Margin of error ± 1.9.

    “Do you think that health insurance plans should cover birth control as preventive care for women or not?”

    71% Yes
    _

    ABC News/Washington Post Poll. March 7-10, 2012. N=1,003 adults nationwide. Margin of error ± 4.

    “Do you think health insurance companies should or should not be required to cover the full cost of birth control for women?”

    61% Yes
    _

    ABC News/Washington Post Poll. April 5-8, 2012. N=1,003 adults nationwide. Margin of error ± 4.

    “All in all, considering the costs to the United States versus the benefits to the United States, do you think the war in Afghanistan has been worth fighting, or not?”

    66% No
    _

    Bloomberg National Poll conducted by Selzer & Company. March 8-11, 2012. N=1,002 adults nationwide. Margin of error ± 3.1.

    “Do you believe birth control should or should not be part of the national political debate?”

    77% No
    _

    ABC News/Washington Post Poll. March 7-10, 2012. N=1,003 adults nationwide. Margin of error ± 4.

    “Organizations known as super PACs can raise and spend unlimited amounts of money on behalf of candidates they support. Supporters say this is a form of free speech, while opponents say this allows groups or wealthy individuals to have unfair influence. Do you think it should be legal or illegal for these super PACs to operate?”

    69% No
    _

    Quinnipiac University Poll. Feb. 14-20, 2012. N=2,605 registered voters nationwide. Margin of error ± 1.9.

    “In general, do you agree or disagree with the 1973 Roe v. Wade Supreme Court decision that established a woman’s right to an abortion?”

    64% Yes
    _

    I could continue.

    But, then, so could you. It gets to be like citing bible verses.

    Why even have courts? Just go by plebiscite on everything. ‘eh?

  12. Nate Ogden says:

    I can’t tell from his bio when he has ever actually praticed law…..

  13. BobbyG says:

    Right. Avoid the question.

    I can’t tell for from your screen name anything about your credibility either (though the spelling provides clues).

  14. Nate Ogden says:

    What question? Your the one arguing we shouldn’t have courts, the legislature should be free to do as they please.

    Why have courts you ask, ok, so they can strike down unconstitutional laws like PPACA. Any more questions?

  15. BobbyG says:

    Really? Ever heard the phrase “rhetorical question”?

    What’s “unconstitutional” is what SCOTUS decides. Neither nor my opinion counts.

  16. Nate Ogden says:

    yes rhetorical questions are not meant to be answered……so why did you cry that I didn’t answer your question?

    “Right. Avoid the question.”

    was it rhetorical or not? I ignored it as rhetorical and you cried so I answered it and you cried. At least the baby made some sense.

  17. BobbyG says:

    “I recognize that many persons believe the health mandate is very bad legislative policy. But the appropriate judicial response to such a complaint has long been clear. The Court was admirably forthright about the point in its ruling in Munn v. Illinois in 1876: “For protection against abuses by the Legislature, the people must resort to the polls, not the courts.”

    - Henry Paul Monaghan

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