Moment of Blather

By James Kwak

David Brooks’s commentary on Paul Ryan’s “budget proposal” is entitled “Moment of Truth.” Brooks falls over himself gushing about his new man-crush, calling it “the most comprehensive and most courageous budget reform proposal any of us have seen in our lifetimes.” “Ryan is expected to leap into the vacuum left by the president’s passivity,” he continues.

Gag me.

First of all, Ryan’s plan is not “comprehensive” by any stretch of the imagination. Ryan’s plan does limit taxes to 19 percent of GDP and outlays to 14.75 percent of GDP by by 2050, producing a huge surplus. How does he achieve this budgetary miracle? In part, he does it by waving his magic wand. This is what the CBO has to say (emphasis added):

“The proposal specifies a path for all other spending [other than Medicare, Medicaid, and Social Security] (excluding interest) that would cause such spending to decline sharply as a share of GDP—from 12 percent in 2010 to 6 percent in 2022 and 3½ percent by 2050; the proposal does not specify the changes to government programs that might be made in order to produce that path.”

If you look at Table 2 of the CBO report (p. 16), you’ll see that the extended baseline scenario already shows non-entitlement spending falling from 12 to 7.5 percent,* so Ryan is pulling 4 percentage points out of thin air. But if you go back to Table 1 (p. 3), you’ll see that those 4 percentage points are all it takes to balance the budget in 2040 and 2050. So if I can use the same magic trick as Paul Ryan, I can balance the long-term budget right now, without touching Medicare or Medicaid.** In other words, if you believe Paul Ryan, there is no Medicare crisis (at least not through 2050).

So, without further ado, here’s my budget proposal: Leave everything the way it is, except that non-entitlement spending will do whatever Paul Ryan says it will do. Let’s see if David Brooks calls me a courageous leader.

Now, the Ryan plan is not completely devoid of details. It would be more accurate to call it a Medicare-Medicaid proposal, because that’s the main area where the plan actually says anything substantive. In particular, it converts Medicare into a voucher program. Beginning in 2022, 65-year-old beneficiaries would receive a voucher to spend on private health insurance. The value of that voucher would be set at the amount that the government is currently projected to contribute toward Medicare for a 65-year-old beneficiary in 2022. After that point, an individual beneficiary’s benefit would go up each year by the percentage by which health care becomes more expensive because of aging. All vouchers would also go up by the amount of the consumer price index.

The result is that government health care spending in 2050 falls to 4.75 percent of GDP instead of rising to 12.25 percent — a difference of 7.5 percentage points. But let’s think about how this has happened.

There are two ways that government spending on health care can go down. Either health care itself is getting less expensive, or the government is just paying for less of it. Hint: it’s not the former.

“A private health insurance plan covering the standardized benefit would, CBO estimates, be more expensive currently than traditional Medicare. Both administrative costs (including profits) and payment rates to providers are higher for private plans than for Medicare. Those higher costs would be offset partly but not fully by savings from lower utilization. . . . Moreover, CBO projects that total health care spending for a typical beneficiary covered by the standardized benefit under the proposal would grow faster than such spending for the same beneficiary in traditional Medicare under either of CBO’s longterm scenarios.”

So instead, what’s happening is the government is just paying for less health care. It’s doing this because the vouchers are designed to grow in value more slowly than the cost of health care. That’s where all of the cost savings come from.

Think about it. Does this accomplish anything? Yes, we have added a positive amount to the government’s fiscal balance. But we have done it by taking a larger amount from our aggregate household fiscal balance.

Let’s try an example. Today, we pay $100 in taxes; Medicare pays $5 in expenses and buys us $95 in health care. (That $5 in administrative expenses is just to have a round number, not a real estimate.) Let’s say that buys us all the health care we need.

The “Medicare crisis” is that thirty years from now, taxes will grow to $150, but to get the future-world equivalent of $95 of health care, the government will need to spend $200: $10 on expenses and $190 on health care. In other words, we’ll have a shortfall of $50. Because Medicare is an entitlement program, that shows up as a $50 government deficit.

Under the Ryan plan, we still pay $150 in taxes, only now we get back a voucher worth $150 that we can use to buy health insurance. Voilà! No government deficit. But to get a plan that is equivalent to what Medicare would have been, we now have to pay $210 to a private insurer, which will spend $20 on expenses and $190 on health care.

In other words, we’ve taken a $50 government deficit and replaced it with a $60 household deficit.

This is the problem with thinking of everything in terms of “taxes” and “spending.” The categories make sense if the government is buying things we would not have bought individually, like national security. But if we’re talking about things we would have bought anyway, the direction of the cash flows is irrelevant. All that matters is the bottom line. And the Ryan plan makes the bottom line worse.

Now, this is a simplification. Under the Ryan plan, we will not buy exactly the same health care that we would under Medicare. The Ryan plan will affect health care consumption, because poor seniors won’t be able to afford the health care they get now. So it will reduce overall spending on health care — but exactly by depriving people of care they would have had under Medicare. I think that’s called “rationing.” Now, I am in the camp that thinks that health care is already rationed today and will always be rationed, and we need to be honest about it so that we can ration it in the way that does the most good for the most people. But rationing it based on income is just about the worst way I can think of.

The other thing the Ryan plan does is it eliminates part of the insurance component of Medicare. Some insurance against being poor is still there: the funding comes via payroll taxes, but everyone gets the same benefit. (Actually, the benefits are a tiny bit progressive, since the top 8 percent by income get smaller vouchers.) But there’s no insurance against volatility of health care costs. If health care grows more slowly than projected, beneficiaries will be better off than if it grows as projected (but probably still worse off than under traditional Medicare); but if it grows faster than projected, they will be even worse off. In other words, we’ve taken the risk of health care inflation and transferred it to households. Cost certainty for the federal government sounds great, until you realize it is exactly balanced by uncertainty for real people.***

So let’s try to boil down the Medicare plan this way:

  • If everyone buys the same health care they would otherwise, it makes us all worse off, because our bigger household deficits more than balance the smaller government deficit.
  • People may buy less health care, but only because the poor will have to.
  • On top of that, we’re shifting risk from the government to individual households.****

And remember, if Ryan’s magic “plan” for discretionary spending is to be believed, all of this is unnecessary.

There is really only one surprising thing about the Ryan plan: why is Social Security spared? The plan leaves Social Security benefits completely untouched while gutting Medicare and national defense at the same time (there’s no way we get non-entitlement spending down to 3.5 percent without slashing defense budgets). Social Security is widely believed to be considerably easier to fix than Medicare, and prominent Democrats like Peter Orszag have come up with their proposals.

The only answer I can come up with is that it’s pure politics: Ryan didn’t want to be seen as attacking both pillars of support for the elderly with one blow. Yet frankly I would rather see modifications in Social Security than in Medicare. With Social Security, lower benefits are bad, but they are predictable (and indexed to an appropriate index). With Medicare, beside the fact that vouchers will be capped below the rate of health care inflation, there are other major risks: the risk that the private insurance market will not develop affordable plans for seniors (look what a great job they’ve done with the non-employer market so far) and the risk that health care costs will grow even faster than projected.

Yet Ryan decided to go after Medicare. And, according to David Brooks, “His proposal will set the standard of seriousness for anybody who wants to play in this discussion.”

No. Seriousness means doing something about health care costs themselves — not transferring the fiscal problem to households. And while we may not all agree with the details, the Obama administration’s health care reform bill took a serious swipe at those costs. And the Ryan plan would largely cripple health care reform’s efforts to ensure universal, affordable coverage, mainly by eliminating the individual mandate and subsidies for poor people. Instead of being serious about health care costs, Ryan’s plan just tries to make them vanish, hoping we won’t realize that they’ll show up in our own household budgets.

But my daughter doesn’t believe in magic. And she’s only four years old. So neither should you.

* The drop from 12 percent is because 2010 government spending was high because of the stimulus bill.

** I’m referring to the extended baseline scenario, not the alternative scenario, which is more accurate in some ways. But I think this is appropriate here. The problem with the extended baseline scenario is that it is not politically feasible (i.e, we expect Congress to change current law because the extended baseline scenario is politically unpleasant). But the same problem applies to Ryan’s proposal.

*** I’m also not sure if the Ryan plan preserves insurance against poor health. I believe there is a prohibition against medical underwriting, a requirement that plans charge the same amount to all members, and a risk-spreading mechanism that shifts money between plans. These should limit cherry-picking, although obviously not as well as the current single payer system.

**** You could say that this is irrelevant because the government’s tax base is those same households, but you would be wrong. The government can shift burdens among income groups or even among generations to cope with sudden shocks (e.g., the post-World War II generations paid for World War II, and no one complained about that), while households can’t.

79 thoughts on “Moment of Blather

  1. Amen. No – amen squared. No. Amen to the nth power. Brooks’ piece is why I believe pundits should be licensed like drivers, with penalty points for fatuity, wrongheadedness, being plain wrong factually etc. X points and you are banned from talk shows and Op-Ed pages for a specified period. Community service equals shutting up.

  2. I agree that most of Ryan’s plan is politically infeasible fluff, but the Nedicare voucher idea seems like the least infeasible of available options. We both know that medical care will need to be rationed much more in the future, due to demographics and all of the new expensive medical wonders that will be developed. But I don’t see how the government can directly ration care, if a cancer drug gets cut, highly motivated special interest groups will lobby congress to get it back. Vouchers would seem to eliminate this problem. Not a perfect solution, but I haven’t heard of anything better.

  3. James, I was cheering you on right up until the point where you said “the Obama administration’s health care reform bill took a serious swipe at those costs.”

    The ACA’s cost control mechanisms are no more real than Ryan’s magical 4%. The difference between the ACA and Ryan’s proposal is the difference between a mirage and a fantasy, nothing more.

    The ACA’s approach to cost control consists of:

    1) pilot and demonstration programs at alternate methods of health care delivery–which have been going on anyway since the 1980’s and just generate reports gathering dust. Why will that change?

    2) encouraging accountable care organizations and patient-centered medical homes. This too is old wine in new bottles: a repackaging in new names of concepts that have been touted since the 1970’s but have ever taken hold on any large scale. Why will that change?

    3) comparative effectiveness research. This might actually change things if it were done right, but the funding for this is controlled by a trust whose board of directors is dominated by (in fact consists almost exclusively of) representatives of Big Pharma, the Hospital Lobby, and Organized Medicine. My guess is your four-year old daughter knows better than to believe that one either.

    4) reductions in payments to doctors. Which have been written into existing law since the mid-90’s (the so-called Sustainable Growth Rate formula), but which, since 2000 have been deferred by Congress every year but one when the AMA rattles its sabres. Why will that change?

    All the while, the ACA injects huge amounts of new money into the system by forcing nearly everybody to buy health insurance. What effect will that have on costs? Hint: it won’t decrease them.

    Nobody in Washington has put forward serious proposals to rein in health care costs. If we do not get this under control, the Medicare crisis will, indeed, be quite real, and will be accompanied by a more or less simultaneous crisis in the private insurance markets as health care inexorably devours ever larger shares of our GDP. You know we all talk about how international companies are outsourcing low-skilled jobs to China and South Asia to take advantage of cheap labor. But did you know they are also outsourcing skilled jobs to, of all places, Germany to try to escape the crushing burden of health care costs in the US?

    The health care system is a cancer on the American economy, both public and private sectors. Not only is it killing us economically, a portion of the people who receive unnecessary health care (1/3 of all health services, by conservative estimates) are injured or maimed in the course of that, too. It requires radical change. Nothing remotely up to the task has been proposed by anybody in Washington.

  4. I find it to be, not ironic, ironic is an adjective that doesn’t seem to do it full justice, “disingenuously simpleton”????—that Republicans are always going on and on and on about the evils of fiat money. But David Brooks, Paul Ryan, Sarah Palin, Newt Gingrich etc.., think that if you pull a voucher out of your butt it will solve every social problem under the sky.

    And I’m not even starting on how asinine it is that Republicans think the way to balance the budget is to cut revenues. I wonder how long Paul Ryan thinks Microsoft would stay in business if they offered products below cost, and yet that’s what Ryan and his idiot constituency wants the U.S. Government to do.

    Unfortunately Government agencies can’t threaten, and put into action, moving facilities and jobs overseas (and turning their back on their native country) like Cisco and GE do (and have done for years) when things get tough.

  5. I second Steven’s comment that Ryan’s plan is politically infeasible fluff. But this fluff, incredible as it is, will shift the Overton window even further right. And to even come out with such a plan is bold for two reasons: it opens up the right to the same sort of attacks that they made against the left during the healthcare debate, and makes even more clear what the longterm goals of the right are in terms of actual policy. The question is what will be done about those two things.

  6. I hope The Donald is keeping in touch, if I were him I would be shakin in my boots right now after readin this.

  7. You missed the one Elephant-sized reason Ryan didn’t go after Social-Security: Bush already tried it and failed miserably. If Ryan pitched a plan like this about social security, a plan that was very similar to Bush’s, it would be 2005 all over again. Unless Obama approved it, and then it would be a weird situation.

  8. I simply do not understand the criticism of the ACA in terms of attempting to reduce costs by a variety of different means based on delivry systems.

    Will all of them work? Of course not.

    Will all of them fail? Of course not.

    But the simple fact of the matter is that without reducing the costs of medical delivery systems, any and all plans like Ryan’s can only “succeed” in shifting the cost of healthcare(in this case Seniors’ healthcare) from one entity to another, as is clearly pointed out by Mr. Kwak’s post.

    I fail to understand how people can be anything but horrifed by the idea of shifting a cost burden onto people who simply do not have the money. Let alone celebrating the author of such an act as “courageous”.

  9. A few observations:

    1. The premise that the federal government should provide healthcare for everyone or anyone is wrong headed to start with. Why would cutting what the fed government covers not be good a thing?

    2. The magic the liberals are trying to sell as usual is that if to offer to give something to everyone and blame the republicans for any apparent cuts.

    3. All Ryan is trying to do is get spending back to 2008 levels, which was already way too much by the federal government.

    4. The federal government under Obama is running an annual deficit of over $1.3 trillion. Ryan’s budget is only for $70 billion in cuts. Not counting what the Fed is doing with POMO.

    5. I agree this is not comprehensive budget plan. It should cut more.

    6. What would you propose to cut?

  10. I agree with James but would take it a step further: it’ about time someone gagged David Brooks. The Ryan proposal does not address inflation of cost but shifts any future financial burden to the recipients of care. Private insurers have not been able to deal with the ever rising cost of Health Care so I don’t see how adding them as middlemen helps Medicare in the long run. The 2003 Medicare reform act was written and enforced by the Republican majority- and we still pay for it. Look what PhRMA is lobbying FOR and you get a pretty good idea what needs to be fixed in order to get a handle on rising costs. There’s some truth for as change.

  11. James – Good points. Ryan is thinking too much like an accountant. He needs to think like an economist to truly solve the healthcare cost issues.

  12. I’m surprised that no one has pointed out the blatant hypocricy of Ryan in proposing to cancel the individual mandate to purchase private health insurance (because it’s “unconstitutional”), while at the same time forcing seniors to purchase private health insurance (instead of Medicare).

    Perhaps he plans to avoid this charge of hypocrisy by saying that seniors won’t be FORCED to buy the subsidized private insurance he favors. So is he willing to let me wait until I get sick and then buy into the insurance market? Will he enforce a preexisting conditions rule (what senior doesn’t have preexisting conditions??). Unless he forces people to buy in one way or another, his plan isn’t going to work. So isn’t he basically proposing an individual mandate for seniors? What’s his back up plan if the Supreme Court says this is unconstitutional?

  13. “3. All Ryan is trying to do is get spending back to 2008 levels, which was already way too much by the federal government.”


    This is wrong in so many ways it beggars description.

    “1. The premise that the federal government should provide healthcare for everyone or anyone is wrong headed to start with. Why would cutting what the fed government covers not be good a thing?”


    Would you be happy in a country where you could walk down the street and step over a sick person dying from lack of healthcare? Melodramatic? Yes, it is. But it is the truth.

    “6. What would you propose to cut?”


    I am more interested in cutting the inflation rate of healthcare via changing delivery systems.

    I am interested in cutting tax breaks for corporations who have seen their taxes decrease by 2/3’s since the 60’s. I am more interested in cutting the tax breaks for the Top 400 whose latest tax rate was less than 17%(and that is on AGI).

    I am intersted in cutting tax breaks for trust fund babies/gene pool winners who are taxed at lower rates than labor.

  14. Until the government admits that it does in fact subsidize big pharma with research and study finding, we are letting our dollars flow out of our coffers freely. In this context, a major revision of the intellectual property laws (i.e., drug patents) is in order to bring some benefit back to the government which so generously subsidizes the cost of bringing drugs to market, and then refuses to adopt sufficiently tough stances in negotiating competitive pricing for the very drugs that tax dollars paid to bring to market in the first place. Myopia? Insanity? Legislative capture?

    Again, there are some things that our current version of the ‘free’ market doesn’t do well. For instance, the AMA limits the number of doctors to keep demand and therefore salaries high. Therefore, the AMA is a non-free-market entity, but I don’t hear any of the champions of capitalism complaining about their monopoly on the supply of doctors.

    And the HMO that decides it can gouge that much more from the folks that simply have to have health care (I suppose they could choose to just die…that is a viable option) is another fine example of how our medical services field could stand better regulation or, dare I say it, socialization.

    If we examine those countries with the very best health care, we might learn a thing or two from them. Heaven forbid we might pay any sort of homage to the French or the Canadians or the Swedes…

  15. The main problem with Ryan’s plan is that in the long-run it won’t actually save any money anyway, that’s all fantasy. Look at the Doctor fix currently in Medicare that was supposed to save money by cutting the re-imbursements that go to Doctors for certain procedures. Every year there is a Doc fix, and those cuts never actually manifest themselves (even though they are assumed in future budgets, making the future deficits actually worse than projected.)

    So what will actually happen if this voucher system goes into effect? Each year as health care costs go up, and those future seniors don’t get enough money to cover their costs – but still vote in higher numbers than young people – Congress will simply pass the “voucher fix” so the vouchers keep up with the costs and there is no actual savings at all.

    Rationing and brining down the rate of health care cost increase are the only things that will actually save anybody any money – total unseriousness by the GOP again, except this time disguised better then ususal.

  16. “… rationing .. based on income is just about the worst way I can think of.”

    How about we just limit the benefits to people Paul Ryan likes?

  17. It is worse, far worse than people think.

    ” this is one of the main take aways of the Congressional Budget Office’s (CBO) analysis of the plan proposed by Representative Paul Ryan, the Republican chairman of the House Budget Committee. Representative Ryan would replace the current Medicare program with a voucher for people who turn age 65 in 2022 and later. This voucher would be worth $8,000 in for someone turning age 65 in that year. It would rise in step with with the consumer price index and also as people age. (Health care expenses are higher for people age 75 than age 65.)

    According to the CBO analysis the benefit would cover 32 percent of the cost of a health insurance package equivalent to the current Medicare benefit (Figure 1). This means that the beneficiary would pay 68 percent of the cost of this package. Using the CBO assumption of 2.5 percent annual inflation, the voucher would have grown to $9,750 by 2030. This means that a Medicare type plan for someone age 65 would be $30,460 under Representative Ryan’s plan, leaving seniors with a bill of $20,700. (This does not count various out of pocket medical expenditures not covered by Medicare.)

    According to the Social Security trustees, the benefit for a medium wage earner who first starts collecting benefits at age 65 in 2030 would be $32,200. (This adjusts the benefit projected by the Social Security trustees [$19,652 in 2010 dollars] for the 2.5 percent annual inflation rate assumed by CBO.) For close to 70 percent of seniors, Social Security is more than half of their retirement income. Most seniors will get a benefit that is less than the medium earners benefit described here since their average earnings are less than that of a medium earner and they start collecting Social Security benefits before age 65.

    Furthermore, the portion of income going to health care costs will increase through time according to the CBO analysis. This is due both to aging of individuals and to increasing health care costs through time. As noted insurance for older beneficiaries will cost more than insurance for younger beneficiaries, but Representative Ryan’s voucher would still only pay the same amount for their care. This means that if the average 80-year-old cost twice as much to insure as the average 65-year-old, then the premium that would come out of a seniors’ pocket would be twice as large. This implies that if the program had been in effect for 15 years in 2030 then the average senior would be paying $41,400 for a Medicare equivalent insurance package in 2030, 25 percent more than the medium earner’s benefit in that year.

    The other reason that Representative Ryan’s plan will lead to rising health care costs for seniors through time is that the voucher payment does not keep pace with health care cost inflation. As costs continue to rise relative to the voucher, seniors will be required to pay a larger portion of their health care costs themselves. It is worth noting that 2030 is only 8 years after the voucher program kicks in.”

  18. @engineer27: “How about we just limit the benefits to people Paul Ryan likes?”

    Isn’t that the Paul Ryan program? I thought that was the program.

  19. So if I am correct Ryan’s plan would casue the following.

    Take good ol’ Bob and Jim. Two people with the exact same income over their working lives; the same exact savings; the same exact contributions to Medicare; living next door to each other.

    Bob is one year older than Jim. He is guaranteed Medicare. Jim goes into the voucher system.

    In 2030, Jim will pay $41K for health insurance. Bob will pay nothing.


  20. I response to DH, sick care must be available for every person without bankrupting them. Otherwise USA cannot be considered humanitarian and democratic. Every developed country in the world has government support. What a mess USA sits in !

  21. Excellent post Mr. James Kwak, Bravo!

    A month ago or longer[?], “Tippy Golden Press” put up a couple of links regarding the progressive, and pragmatic approach that the “State of Vermont” is about to implement involving a mandate/law[?] on “Single-Payer Health Care”.
    I hope that he is listening, an will provide once again those fantastic links to “Baseline Scenario”.
    Ref: “Vermont Health Care for all”
    Ref: “In Vermont, single-payer healthcare in a single state” (I know its a small state – it’s a prototype – a litmus test of what can be, and what can’t be in real life)
    Ref: “Vermont’s Health Care reform”

    Please note that Vermont, and other states aren’t standing idly by waiting for miracles to happen in D.C. for the “Fix” regarding Obama’s Medicare Program – but, what there doing is realistic, while trying to minimize the pain for its[their] citizens into the future. It’s called good government!
    God bless you, “US Senator, Bernie Sanders (I,Vt.)”
    Thankyou James, and Simon
    Where’s Tippy when I need him,…:-))

  22. I have completely given up on Brooks seeing reality through the haze of being a DC insider invited to all the parties and clubs etc. He no longer has credibility and should take some advice from his fellow Times oped writer Frank Rich who refuses to move to DC because he fears his inability to resist the temptations that Brooks has so pliantly succumbed to.

  23. When I listen to David Brooks on PBS Newshour he seems to be a reasonable intelligent man with more than a little bit of compassion for his fellows. His grasp of macroeconomics is not up to the task. The U.S. wage earners are so far underwater employment-wise and our current accounts balance is so negative that we should stop talking about deficit reduction. It is a bad idea guaranteed to make life worse for all of us.

    One path to reducing medical costs is to vastly increase the number of doctors and nurses. We can pay for medical school for every qualified student. That will reduce the number of 500K+ doctors, but none of use can afford the continued scarcity. We have fiscal policy options and we should use them. Passing the GOP budget limitations proposal is nuts. OBTW, we don’t need anymore quants. Let’s pay smart people to do useful work like teach students and treat sickness.

    This needs to be said repeatedly until it is understood. Read writings by the MMT theorists and then make some adult decisions.

  24. Not sure I understand JK’s special hatred for Brooks. “Gag-me”…”Man-crush”…Really? Brooks isn’t even really all that conservative–why not go after Pat Buchanan, George Will, or Krauthammer.

    And doesn’t Ryan get at least some props for, as JK says, “gutting defense.” If anything needs gutting, it’s defense. Or what about Ryan’s tax reform proposal, which apparently eliminates a large number of tax loopholes to collect the same revenue with lower overall individual rates. Isn’t that a fairly non-partisan approach?

    It’s way too easy to be dismissive of proposals to fix health care costs because the problem is so politically intractable. JK comes across as way more of a know-it-all in this post than David Brooks EVER has.

    Castigating the Ryan plan is just a cheap shot in the absence of any comprehensive proposals on entitlement reform from the democratic leadership.

  25. I see vouchers as simply a way of dissolving any concept of ‘bulk discounts’ once all services thus financed are in the hands of private companies & corporations.

    Please tell me I’m wrong! I’m losing faith in this countries abilities to deal with both large & small problems.

    I’ll be at the bar.

  26. There is a certain elegance to the political benefits this proposal will produce. No one will be injured until well in to the future so the present office holders will not have to deal with the irate Seniors while they are in office. The voters who will be greatly injured are smaller in number and more concerned about their take home pay today than having to buy health insurance at age 65 from the Rip-Off Price Fixing Free Enterprise Health Industry.

    If these guys and gals really have gonads they should implement it in 2013 so the next election can be run as a voter referendum.

  27. not sure but does any body really believe that insurance companies will even want to participate? the reason Medicare and Medicaid exist is because private insurers weren’t interested in insuring the elderly. and there is little wonder as to why. insurance companies make their money by charging premiums and investing the money from premiums. their costs are claims and administration costs. with the elderly there will be no time between premium being paid and a claim. and it will not be a low cost claim. and it will happen often. human bodies always break down as we get older, irrespective of how we act, as DNA will over rule even good habits. so an insurer is guaranteed a loss every time for all of their policy holders. this is why they got out of the market for the elderly.

  28. @EMichael
    “I am interested in cutting tax breaks for corporations who have seen their taxes decrease by 2/3′s since the 60′s. I am more interested in cutting the tax breaks for the Top 400 whose latest tax rate was less than 17%(and that is on AGI).

    I am interested in cutting tax breaks for trust fund babies/gene pool winners who are taxed at lower rates than labor.”

    RIGHT! About one-half of all the “deficit cutting” in the Ryan proposal is going to finance tax cuts for corps and wealthy individuals. In other words, it’s the same old Repug BS in a new coat.

    It’s simply stunning how the MSM can be taking this seriously. It’s a “let them eat cake” moment in the US.

  29. Not to get to far off the beaten path, but didn’t the Federal Reserve actually bail out Wall Street with QE1 & QE2!
    Something is missing here regarding common sense, and it stinks to high hell! What I can decipher through the maze of deception was a (approx.)couple of trillion dollars off-loaded onto the average citizens backs that should never been allocated as a bailout for a nefarious bunch of crooks through the derivatives[?] market!
    Money that could be used to pay down the debt on Medicare…but what do I know?
    Ref: “QE2 through the Lens of QE1” (9/29/10)

    “Is this a one dimensional vortex? That is to say a “Black Hole” for the poor, children, elderly, crippled(etc.), and middle class – a vivid nightmare about to become a reality?”

    God Bless You, Julian Assange :-))

  30. @rayw “That will reduce the number of 500K+ doctors…”

    too late, the MD ex-CEO of United Health Care gave himself a 1.8 BILLION (no typo, that’s a B for BILLION)

    “package” in 2005….

    And what do quarterbacks get for a season – millions to throw a ball…?

    yup, we sure are having an adult conversation now about the right incentives…

    I really thought I would never have my breath taken away by yet another diabolic stunt by the Rethug Wrecking Crew, but I guess “god” wants me to be aware of the true nature of iniquity in this war…

    that dog and pony graph that they’re all running around showing the trajectory of health care costs if we don’t start letting people walk around discount supermarkets with oozing diabetes wounds while buying cat food for themselves with food stamps and, hopefully, dying within the year,

    that big wad of blood red on the graph is EXACTLY the cost of militarism – it’s the “war” that wasn’t on the books on the books as “health care costs”…

    damn that’s harsh, eh?

    Macro thinkers NEVER forget to keep their eye on “who”, or in this case more of a “what” since its so sub-human,

    walks off richer AFTER a “war” than they were before….

    “…we’ve never been more powerful (AKA “richer”)…” – the classic line after Davos…


    Use the USA military “over there” to wipe out the citizens “over here”….

  31. Very, very nice job, James. This is why yours is still one of the few blogs that I still visit from time-to-time.

    I’d like to believe that pro-social aspirations will prevail, and that a measured, serious debate is all that is needed to steer us onto the right course.

    In my view, the reality is that the SS/Medicare “crisis” is rigorously agenda-driven, and that agenda is all about consolidating power and wealth among already entrenched interests. There is no need for debate, and reason will not prevail. Round up the usual suspects.

    There is simply no other way to explain the prominent media perch provided to a mediocrity like David Brooks.

  32. @EMichael

    “I simply do not understand the criticism of the ACA in terms of attempting to reduce costs by a variety of different means based on delivry systems.

    Will all of them work? Of course not.

    Will all of them fail? Of course not.”

    Yes, they will all fail. They will all fail because they are _designed_ to fail. The ACA is a huge fraud: it is nothing more than a giveaway to the insurance and health care industries. In my earlier comment I quickly summarized the four major cost control mechanisms it includes. Three of them have been in place for over a decade, some for several decades, and accomplished nothing. The fourth, comparative effectiveness research is new. And, as I stated earlier, I believe it could help if done well (although the fact that it can take 2 decades for medical practice to change in response to well-done research is not encouraging on this note either). But if you read the details of how they have implemented it, the foxes have been appointed to guard the chicken coop. The funding is controlled precisely by those whose interests lie in assuring that it fails. And they will so assure. The ACA looks like it has cost reduction provisions if you don’t examine the details. But none of stands up to scrutiny. That is why I refer to it as a mirage.

    Even a “bold step” like a single payer system probably won’t, by itself, work because the industry has already captured the potential single payer. As long as we have fee-for-service and for-profit hospital care and an effectively unregulated health care system, the health care industry will continue to suck more and more resources out of our economy. A new regulatory power that is independent of those interests and amply supported by knowledgable people is needed to redesign the entire system head-to-toe. I don’t imagine that falls in the realm of the politically feasible, which is why I see such a bleak long-term outlook for our economy.

    All of that said, I definitely agree that the Ryan plan is simply disgusting.

  33. “And doesn’t Ryan get at least some props for, as JK says, “gutting defense.” If anything needs gutting, it’s defense. Or what about Ryan’s tax reform proposal, which apparently eliminates a large number of tax loopholes to collect the same revenue with lower overall individual rates. Isn’t that a fairly non-partisan approach?”


    Could you direct me to the part where Ryan is “gutting defense” I cannot seem to find it.

    And if you think for one second that lower rates and less deductions will lead to equal tax revenue, you have missed the last thirty years.

    Lower rates lead to lower rates.

  34. @RayW
    “One path to reducing medical costs is to vastly increase the number of doctors and nurses.”

    Maybe. But there have been studies previously suggesting that in medicine there is a phenomenon of supply-induced demand. That is, if you create more doctors and nurses, they will simply do more tests and “treatments” to sustain their incomes and costs will go up.

    Look, we have tried to use “market mechanisms” in health care since the 1980’s and failed. When will we acknowledge that the fundamental principles underlying competitive markets simply don’t apply to health care. Patients are powerless in the health care system because they lack the knowledge necessary to make rational decisions about the use of health services. They do not know what the implications of their symptoms are in terms of diagnosis. They do not know what their diagnoses imply in terms of prognosis. They do not know which treatments work best (or if any work at all) under what circumstances. And it is nearly impossible for them to find out what anything costs because nobody in the health care system gives straight answers to those questions.

    So why don’t we come to our senses and accept what the rest of the industrialized world has known all along: health care cannot be sensibly allocated by market mechanisms. And let’s look at some of their successful approaches and try them here. But in order to do that, we will have to break the stranglehold that the health care and insurance industries have on government.

    Everybody who has looked at the issue has concluded that at least 1/3 of all health care in this country is useless or worse. I’m not saying it is always possible to identify exactly which is which. But with that large a target, we should be able to substantially reduce our costs without sacrificing the health benefits our system does provide. To make it economically sustainable might require additional rationing beyond that that removes things that are not entirely useless but produce only minuscule benefits at great cost. But it has to be guided by in-depth understanding of what works and what doesn’t, and we can’t allow it to be taken over by those who profit from the existing system. “Market mechanisms” that do not directly interfere in the provision of care will never get us there. At best, like much of what we have tried in the last 30 years, they will be useless. At worst, like the Ryan plan, they will lead to needless sickness and death.

  35. Not that I want to defend Ryan, but what exactly does Social Security have to do with the Budget?

  36. @CBS

    Are you telling me there are no programs to change and/or imoprove delivery systems in the ACA?

    That changing from fee-for-service to another method is not in play?

  37. Wonderful article, James. Brooks is amazingly superficial about almost everything, preferring superficiality to honesty OR analysis. David is plenty bright, but, let’s face it, highly partisan. So, all things considered, poking holes in Brooks’ article is sort of a cheap shot, however well deserved.

    From my perspective, there are really three keys to overcoming the severe future world consequences of our present budgetary mindset.

    First, we must find a way to collect more in taxes. There are lots of philosophies to that, but most of those include fully reforming the tax code to realign incentives toward education and innovation, and away from wealth accumulation and carbon. For instance, the way to give the wealthy a tax break is to make them (through the tax code) pay for all medical education (not hard to imagine, since the top 1% could pay to educate every future doctor and nurse out of their petty cash!!).

    Second, we must completely revise our approach to national security. That would take a 50% cut in military spending, and a similar cut in other national security (currently 15 agencies which can’t communicate).

    And, lastly, simply institute Medicare for all (single payer) such that the government has complete control over medical pricing and delivery. This isn’t socialized medicine, but removes the entire gamut of presently disincentivized providers, manufacturers, pharmaceutical companies and health insurance providers. Single payer is not the only way, but probably the simplest and most effective other than the government doing what the Netherlands does and set all premiums, and all pricing, and not allow any exclusions (it works well there).

    If nothing is done about these three things, nothing will solve the problem. Since none of these things will be done, Ryan and all the other “smoke and mirror” advocates (that’s all 545 in Congress and one President) won’t do what it takes to save us from collapse.

    Watching this reminds me of Nero and massive bonfire celebrating the end of another great power. It’s happened throughout history, and is going to happen here. Sadly, the Tea Party should be renamed the Mad Hatter party, since they only know one thing: how to say “no” louder than their other Republican cohorts.

    Check out:

  38. @EMichael “That changing from fee-for-service to another method is not in play?”

    It’s “in play” in a very casual way. It will be studied in demonstration projects. But there have been demonstration projects for alternatives to fee-for-service going back to the early 1980’s. (In fact, the very first health insurance program in the United States goes back almost to 1900. It was the Kaiser Health Plan, the ancestor of Kaiser Permanente, and it was a staff model HMO with salaried physicians and capitated community-rated premiums.) It doesn’t need to be studied any more. (OK, it may be necessary to study how to make it work in certain special circumstances such as rural areas with very few providers.) It needs to be _done._ And the ACA doesn’t call for anything to be _done._ And I am enough of a health system insider to know that if it isn’t mandated, it isn’t going to happen. Organized medicine and the hospital and insurance industries will strangle it in the crib.

    And, perhaps I am too cynical, but I do believe that the ACA intentionally stops short of actually doing anything, and deliberately sabotages the comparative effectiveness research. That way the Democrats could say to the public that they did something wonderful while winking at their health industry paymasters and reassure them–don’t worry, nothing’s going to happen that changes your predatory business model.

  39. “There are two ways that government spending on health care can go down. Either health care itself is getting less expensive, or the government is just paying for less of it. Hint: it’s not the former.”

    Right. The problem with Medicare and Medicaid is not special to them. The problem is the spiraling cost of medical care as a whole, without concomitant benefits. For three decades the US has paid an increasingly greater proportion of its GDP than any other advanced economy, except for the Clinton years. That is the problem that we have to address. If we get medical costs under control, we will probably get Medicare and Medicaid under control. Trying to fix them without fixing the general problem is futile.

  40. “There is really only one surprising thing about the Ryan plan: why is Social Security spared?”

    Who knows? But that is sensible. Social Security is neither broke nor broken. Any projected problems with Social Security are well within the margin of error. You can’t take these long term projections as prophecy.

  41. @CBS: “And, perhaps I am too cynical, but I do believe that the ACA intentionally stops short of actually doing anything, and deliberately sabotages the comparative effectiveness research.”

    I think it is impossible to be too cynical about the “Affordable Care Act” or, in fact, anything proposed by either the “Democrats” or the “Republicans.”

    We need a sea change. Apparently, we are satisfied to to let the Koch Bros. – financed Tea Party provide it.

    For shame, America.

  42. @earle.florida

    Yes, the folks in Vermont are refreshing in their common sense and decency. Dr. Hsaio is somewhat pedantic but perhaps a living treasure. He says he has given up on the United States and now works mainly with countries outside the U.S. who thus enjoy the benefits of his wisdom and learning.

    p.s. you are mistaken about my gender :)

  43. This is not directly related to Paul Ryan’s phony and disingenuous attempt to reconcile the federal budget with health care costs, but I thought this was worthy of bringing Mr. Kwak’s readers’ attention to. If Republicans had passed the Affordable Care Act sooner, instead of stalling and spreading lies about non-existant “death panels” (courtesy of the illiterate Sarah Palin) this young gentleman in the LA Times story below would currently have health insurance.,0,5042640.story

  44. One thing I don’t understand about the American healthcare insurance system is why they make it so difficult for people who are sick and dying (children and adults included) to get medical care when they need it. These are the people who need it the most.

  45. Bayward Waterbury writes: “we must completely revise our approach to national security. That would take a 50% cut in military spending…”

    Reducing military spending would definitely reduce America’s debt. But what would happen to the military, the soldiers, the people who work in the defense industries? What would they do for a living? There would be a national crisis if they suddenly lost their jobs. A Republican president described the American economy as a military-industrial complex. I’m not saying it cannot be done, reducing military spending, but it would be a profound exercise to do so.

  46. James,

    You have to understand what it means to be a Republican:

    I’ve got mine, I’m doing just fine. I’m a winner. To hell with you neighbor. You Loser.

  47. @Paul Cohen: “You have to understand what it means to be a Republican: I’ve got mine, I’m doing just fine. I’m a winner. To hell with you neighbor. You Loser.”

    Paul, I say you have to understand what it means to be a Democrat: “I’m on your side. I’m doing what’s best for the people. But behind your back, you can count on me to sell you out to the Republican power structure every chance I get.”

    The Democrats SAY they’re for the common good, but they take that campaign cash from the banks and insurance companies just as fast as they can, then scratch those backs behind closed doors.

    These two “parties”: tweedle-dee and tweedle-dum — operate in very effective lockstep to deceive and rob the people of this country.

    What will it take to change the situation? That is the great unknown.

  48. @ tippygolden press

    My mind is as open as the universe;
    there are no differences between the end and the begin, the alpha, and the omega;
    the near eastern sunrise, too the furthest western sunset other than benevolent thoughts;
    there is no ambiguity between my womanhood and mankind other than the altruistic fact that it is woman that binds the universe as one”

    Sorry “tippygolden press” for the assumed gender mishap, I’m such a nerd at times :-))

  49. @ RCarla…

    “What will it take to change the situation? That is the great unknown.”

    Remember the “Tea Party”, kinda like remembering the Alamo other than the fact that the Alamo brought Texas into the United States. Whereas the former was solely that of a predestined captured malocclusion…a twisted sister drugged into willing submissive, and subverted into the mercenary sub-culture of the nefarious bellicose Republican Party!
    What the “American People” need is a true “Independent Party, period! Yes, easy to say, but this long winded fragmented movement has been growing, as such, that of a metastasized incoherent inculcation. Gaining grassroots acceptance throughout the United States, with much to do about ambiguity already washed of its arrogant fatalities! We, all of the collective as free people, must put our ideas together as a singularity, pulling ourselves out of this political morass! jmho

  50. In the words of Harold Meyerson, the Republicans – Ryan included – want to repeal the 20th century. Ryan didn’t propose a Medicare reform plan. He proposed to dismantle Medicare and substitute an insurance industry subsidy plan. This is a man more concerned about industry profits than peoples’ health. Period.

  51. It seems that research improves the quality of medical care and anables prevention which lowers cost. The %of GDP that is spent on research is small. The NIH budget is on the order of a rounding error for defense or education or transportation or agriculture. So transferring 3% (an arbitrary example) of large department budgets to NIH might increase the NIH budget enough to produce enough innovation to improve quality and effectiveness of care and reduce costs through prevention. At that point the standard of acceptable care would rise.

  52. Of course Brooks favors Ryan’s plan enthusiastically, they are each the worst sort of system-serving filth, Ryan in his capacity as the quintessential lobbyist lickspittle, Brooks in his as regime mouthpiece extraordinaire. The real danger here, of course, is in allowing oneself to be drawn into the debate at all, envisioning – as Quack would have us do – the proposals of Democratic opposite numbers as somehow more bearable or meritorious. Its part and parcel of regime strategy, of course, to give off the appearance of meaningful difference between the two political factions when none actually exists. We will be done with the Brookes, Ryans and Obamas only when the events of Cairo are replicated in the United States.

  53. @Lavrenti Beria
    (yes, I remember who he was)

    I grasp your impatience with the jokers in DC, but about Cairo, be careful what you wish for. We don’t yet know how that will shake out, and history shows that such things usually take a long while to settle. Most common pattern is that any real revolution takes a full generation or two to know how it will turn out.

  54. In candor, Brooks and Ryan are two total tools, they make me wanna barf every time I see their ugly republican puss on the boob tube.

    anyway, Bayard, good post, as always, and I checked out your blog, and enjoyed reading there, as well.

    Annie, you go….you’ve got this down to both an art and a science…rock on you special human…that idea of diabolic at the end of your post = brilliant.


    I apologize if I gave you the impression that I think Democrats are any better.

    Both parties speak to the needs of Ordinary Americans but serve only one constituent: Money.

    “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. — That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, — That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness. Prudence, indeed, will dictate that Governments long established should not be changed for light and transient causes; and accordingly all experience hath shewn that mankind are more disposed to suffer, while evils are sufferable than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security.”

  56. But rationing it based on income is just about the worst way I can think of.

    That’s because you’re not ideologically committed to the idea that the interests of very rich people are the only interests that matter. If you look at it from that perspective, Ryan’s proposal makes perfect sense — you won’t have to wait in line behind hoi polloi at the doctor’s office if they can no longer afford to go there, and you get another huge tax cut, too.

  57. Ryan’s plan is not Ryan’s, it’s from Heritage and other “thinktanks”, i.e. PR outfits. The plan is bogus, it’s just a tool to push through the agenda of the plutocracy; its numbers are merely to fool enough of the public to allow this agenda to get through Congress. David Brooks is just another hack (well paid) participating in the scam.

  58. @jakepgh,

    You’ll know that Quack and Johnson will have reached maturity when they no longer pose topics here that unconsciously embrace ruling class control mechanisms, namely that the only way to envision a question is to do so within the confines of a conventional, Republican/Democrat perspective. To escape these strictures seems to me the only possible way forward for serious political conversation in the United States. I mean if you keep buying food at the company store ….

  59. Whew – let me catch my breath – I dug out a $20 bill to pay for groceries and I’m exhausted from the exertion – so much easier for them to scan the chip on my forehead…

    @tippy – I think your Big Giant Head gave you the wrong reading list for understanding the human species – USA has a continuous history of beating plowshares into swords and then the swords back into plowshares – google “infrastructure” federal programs in USA after WWII – and how many MONTHS (not 20 years or more) it took to ramp up the metallurgic production to fight WWII – yes I am taking you backwards through the space time continuum :-)

    Today the *diabolical* psychological anti-insurgency campaign is in full swing – we’re all getting to watch the Washington DC version of “A Streetcar Named Desire” – Stanley Kowalski crawling into Blanch DuBois’s fragile psyche – yessireeebob – millions of newly-minted Blanches who are new to poverty need (tea-drinking) Stanleys to finish off them off…no planning for you…

    Yup, the nice ladies are shell-shocked…ah, but the men – ’bout time they got into slamming Stanley around…

  60. Yes, Ryan’s plan is mostly a Medicare and Medicaid plan, but isn’t that appropriate? That’s where the unsustainable costs lie. Ryan’s plan doesn’t claim to solve the health care problem; it just solves the federal budget problem. It does so transferring the “excess” costs to individuals (for Medicare) and the states (for Medicaid). That’s one way to do it. How does President Obama and/or Democrats in Congress plan to solve the budget problem? The PPACA takes meaningful steps to broaden health insurance coverage but its attempts at cost control are pitiful and dubious.

  61. Medical care cannot be a profit-making business, because properly taking care of sick people costs more money than it can bring in. Although only 10 percent of us may be ill or injured at any given time, that could be you or me when one of us has a heart attack or gets hit by a runaway bus.

    Or it could be your little child who is born with a genetic disease and needs regular medical attention for the rest of her life.

    Today, U.S. “medical care” is a cartel. It is a closed system with thousands of middlemen profiting on the inefficiences of a hodge-podge of payment systems; sky-high prices for drugs that are developed mostly with taxpayer money from the National Institutes of Health; incredibly expensive television commercials for prescription drugs; hospitals vying for insured patients while trying to dump the uninsured.

    We need to cover everyone equally, cradle to grave. It’s the only way we will achieve real health care and bring per capita costs into line with other industrialized countrie. How to pay for that?

    With your favorite method: tax those who have been paying a smaller and smaller share to support their exalted position in this society: first the mega-wealthy, then the very wealthy, then the corporations.

    That would be the liberal plan.

    Too bad we don’t have any liberals left to stand up to the medical cartel and put forward realistic, humane and workable solutions to the problems that face us.

  62. Big picture – Any and all economic systems are all about the relationship between the human species and everything material on planet earth.

    Big picture – the *ever-present* danger to the human species are bacteria and viruses. That means “health care” is a constant cost which includes sanitation, medicine and human intelligence.

    Now how *focused* is anyone on those two basic fundamental realities of life-maintenance?

    I’m going to ramp up the time and activity I dedicate to snipping off all the different ways the “C” students can bring me down with their willful ignorance and mean-heartedness. I consider it a personal moral obligation to do limit the damge they can do to me – PERSONALLY – by accessing cherished institutions of civilization – especially at this point in time. It’s a *war*.

    Now, back to shooting UP (with the gracefullness of deadly accuracy) – place your bets, oh global billionaires – “who” is going to “win” in the USA?

    Let me get out my crystal ball :-)

    Yup, perpetual war in the ME until the oil runs out with which they fuel up and then their almighty hardware will lay there longer than the pyramids….

    But how to shut down the health insurance and mortgage and bank enronistas in USA….?

    Whatever plan anyone has in whatever position in the meat grinder you find yourself trapped in since 2001 – borrow from their books all of the counter-insurgency tactics – ALL of them – economic disobedience, flood the internet with LIES about everything personal, and just say NO to every demand they make on you to HURT someone else in order to keep your “job”…

    We the People can shut down “the government”…


    And for those globalists in other countries who made deals with people operating from within the USA that did not have the POWER to deliver what they promised – you’re welcome to come here and take them off to your hard labor prison camps to work off the trillions in vapor derivatives….

  63. @Adam Washington

    “Ryan’s plan doesn’t claim to solve the health care problem; it just solves the federal budget problem.”

    Where does this thought come from? It does not do anything remotely close to that, and that is based on the totally fictional Heritage computations(several of which have already been withdrawn by Heritage after they caused an outbreak of uncontrllable laughter in every economist, accountant and anyone with a 10th grade or higher competency level in math.

    The only thing we do not know is exactly how badly it would increase the deficit, as Mr. Ryan gave no reasons whatsoever on how he would increase his revenue base. He just made it up.

  64. @ Annie

    Get it all out my fair lady! For the site is beginning to dim quickly (why?)? The volume of traffic (eyeballs) has precipitously fallen off in the last couple of months, and the outlook is bleak. Is it redundancy, impracticality, or subject matter thats run its course…etc.,etc.,(or esoteric powers that be)?
    Main Stream Media (MSM) still rules with an “Iron Fist[?]” while juxtaposed to the blogsphere is analogous to a cat plying with a shredded ball of “Yarn”!
    It’s time to get really over the top (controversial, but certainly not anarchist) and bring some thought provoking discourse, rather than the classical “Power of Suggestion” that is linear with only one ending…”A Dead End”!

  65. @earle – I’m sorry, *who” has been utilizing the *anarchists*….?!

    Seems to me like the ones who walk off as trillionaires after a decade of war…

    Their “Iron Fist” is a Stanley Kowalski character with a bible – that would be a “D” student…

    But you’re right about one thing, brown-nosing Nihilists is a dead end…

    No one will ever take out a mortgage
    No one is putting their small cash reserves in any kind of “bank”…
    And looks like a lot of people are going to employ war tactics – mimicking the success stories of those at the top

    Keep shooting down, earle…

  66. @Adam Washington

    “Ryan’s plan doesn’t claim to solve the health care problem; it just solves the federal budget problem.”

    The CBO disagrees(until after 2022):

    “The nonpartisan Congressional Budget Office’s initial analysis of the House GOP budget released today by Rep. Paul Ryan (R-WI) is filled with nuggets of bad news for Republicans.

    In addition to acknowledging that seniors, disabled and elderly people would be hit with much higher out-of-pocket health care costs, the CBO finds that by the end of the 10-year budget window, public debt will actually be higher than it would be if the GOP just did nothing.

    Under the so-called “extended baseline scenario” — a.k.a. projections based on current law — debt held by the public will grow to 67 percent of GDP by 2022. Under the GOP plan, public debt would reach 70 percent of GDP in the same window.”

    Of course, the CBO has to take Ryan’s revenue projections at face value, so the deficit would undoubtedly be larger than the CBO currently states.

    And finally, the reduction in the deficit starts when the Congress allows Ryan’s voucher program to start in 2022.

    Think about that. For Ryan’s budget to start reducing the deficit, in the years leading up to 2022, Congress is going to have to not change a law that requires a 65 year old to pay $10,000 more(hopefully) a year for health insurance equal to Medicare(if he can even find it) than those over 65.

    Not to mention that Congress is going to have to ignore not just the newly turned 65 year olds, but the 64s, 63s. 62s, etc., who can see the Damocles Sword of health care costs descending upon them.

    There simply is no chance of any part of Ryan’s actual deficit reducing part of his budget ever happening.

    So basically his “cause” amounts to lowering taxes on the rich and corporations, cutting off some poor peoples’s benefits, and adding an untold amount to the Federal deficit.

    “Courageous” is not the word that should be used for this Randian fantasy.

  67. To put that in perspective. Try and come up with a list of Congressmen in 2012 that would vote for a program that increases healthcare costs for every American senior citizen by $6900.

    Not a chance.

    And therein lies the reason Ryan’s deficit cuts “start” ten years down the road.

  68. @CBS

    You wrote: “I do believe that the ACA intentionally stops short of actually doing anything, and deliberately sabotages the comparative effectiveness research.”

    There are some real conceptual issues with CER, because it is based on a scientifically flawed model of why treatment effectiveness varies among individuals. I have written about the alternative view of “personalized Medicine” in The Scientist. A brief excerpt:

    “So long as evidence-based medicine rests on the assumption that variations in efficacy and side-effects in a trial population are random statistical fluctuations without testing if they are the result of scientifically comprehensible causal relationships, the ‘evidence-based’ paradigm will be on the wrong side of history.”

  69. @jakepgh

    If you research who introduced the concept, and why, you’ll find that it was part of the risk management in a business model that, theoretically, was able to extract profit from research budgets before the research produced any product. I kid you not.

    Science has nothing to do with it and is even scorned by statistics.

    Which brings us back to the made-it-all-up aspect of the “budget”…there is no data available from which to discern what the real cost is of the real and present danger to the health of the human species – viruses and bacteria….infant mortality is shooting up – pneumonia – check the stats – the industrialized era’s tenement dwelling killer – poverty is always accompanied by lack of sanitation infrastructure…

    Corps aren’t paying any taxes and continue to get taxpayer subsidies…at least make them pay for the infrastructure they access more than all households in the 5 mile radius combined – but when you do, like some states tried, they move to where people crap and wash clothes in the river outside their plush corner office…

  70. One other deliberately unknown “stat” in the Gen X against all other Gens *war* – the 40-somethings need *now* the old-age tune ups that the 70-somethings need *now* – so that should tell you something about that imaginary health care cost curve (which is really militarism costs until oil runs out) – are the 40 somethings going to make it to 70?

    Just a few years ago they could not stop buying even bigger SUVs – think they’re rational about anything “sustainable”?

  71. @annie

    It isn’t only the poor who suffer from the present US system. The data say that high income inequality (among nations, or among US states) correlates with poorer physical & mental health status for both rich & poor. See Wilkinson & Pickett, “The Spirit Level”. Current data show the US has one of the most unequal societies on earth, with respect to both incomes and wealth. We could probably improve everyone’s health and welfare by leveling incomes — say, back to where we were in 1980.

  72. To frame this in any kind of “god’s work” spiritual context is completely wrong.

    This is about the absolute power of militarism and those who hunger and thirst for it. Autocratic and cruel. And even 30% of a population striving for it indicates widespread genetic degeneracy.

    This is about creating the *power* to put people in a place to make a “Sophie’s Choice”.

    And the same people are getting rich off of this decade of war – they are getting richer and richer with each choice that each one of us as a Sophie will be told to make – first in “theory”, of course.

    As for main street media – they’re an unfunny Monty Python skit – that “Bring out your dead” skit done as a *professional* propaganda-control of the main street conversation…

    Read it – “Sophie’s Choice”.

    And then tell me we are safe or free to love one another under this “economy”

    Constitutional Convention and BURN THE PATRIOT ACT.

    Where’s their budget cut for spying on everyone only to figure out how to steal EVERYTHING from you because of the “choices” you make?

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