Who Died And Made The CBO Boss?

The CBO has been given a reputation throughout the health care debate as being the unassailable arbiter of the facts. If you submit them a plan, they will tell you to the letter how many people it will cover, how much it will cost, and whether it will drop overall costs for the nation and the federal budget. Give them a program for emphasizing prevention? They say sorry, it doesn't save any money. Give them a plan for an Independent Medicare Advisory Council to use best practices in Medicare to bring down overall costs and hopefully provide a path for the overall health care system? Sorry, not much savings there either.

What rarely gets discussed, at least in the traditional media, is whether or not the CBO should be trusted with so much power over the details of any legislation, let alone health care reform, where they appear to have a poor track record.

Put most simply, the CBO’s track record in predicting the effects of health legislation is abysmal. Over the last two decades, the CBO has routinely overestimated the costs of expanded government health care benefits and underestimated the savings from program changes designed to reduce expenditures. Most recently, it overestimated the five-year cost of Medicare Part D — the prescription drug benefit -— by more than 35%. Even more dramatically, the CBO’s estimates of the Medicare savings from the Balanced Budget Act of 1997 underestimated the impact, on average, by a full 100%. That’s right: In the BBA’s first three years, Medicare spending fell fully twice as fast as the CBO had projected.

Doug Elmendorf, who has been criticized by former CBO Director and current head of the OMB Peter Orszag, has veered perhaps too closely into a role of playing favorites over his preferred options in how to handle health care reform costs rather than the neutral, just-the-numbers arbiter of what certain plans would mean in dollars and cents. Heck, in the "Gang of Six" meetings in the Senate Finance Committee, the furthest to the right in the whole Congress, Elmendorf has been an active participant.

Now, this may be less of a slam on the Congressional Budget Office itself as much as a political and media process that privileges their judgments as if they were gospel and not the often-conservative estimates of an organization loath to over-promise.

I don’t really think the CBO should change its methods. You need the CBO do be methodologically conservative in terms of what it’ll score or else all kinds of monkeybusiness can start flying through congress. Instead, let me join Ezra Klein in saying we should leave the CBO as it is and just discourage people from wildly misrepresenting the significance of CBO findings.

What you actually need is for politicians to step up and make independent judgments about what they want to do. Doug Elmendorf has decent reason for not wanting to promise that MedPAC reform will lead to vast savings. But members of congress actually serve in congress, and it would be eminently reasonable for them to reach the conclusion that the CBO is underrating how dramatically the proposed reforms would alter congressional behavior. The point is just that if members of congress want to reach that conclusion, they ought to do so under the banner of their own names and own judgment about the politics and policy.

Politicians are notoriously small-c conservative creatures themselves, in that they'd rather be armed with independent evidence before going out on a limb. And the CBO has come to represent that independent arbiter, used for political cover. Only it's a small-c conservative outfit as well. And so the entire debate gets pushed in a conservative direction because politicians will only counter the CBO when it comes to handing out tax breaks for rich people.

...the New York Times op-ed page makes largely the same point:

The budget office provides vitally important guidance to Congress, but focuses primarily on how new legislation might affect federal spending and federal deficits. The office gives only a cursory glance at how reforms might cut costs for the overall system and yield savings for employers, families and state and local governments, the issue that concerns most people.

Moreover, the office makes middle-of-the road estimates of cost and more pessimistic estimates of savings. That makes sense (lawmakers and government agencies routinely exaggerate the virtues of their proposals), but it makes it harder to evaluate proposed innovations.

Respected analysts who are not bound by the C.B.O.’s conservatism have projected significant savings from reforms that the C.B.O. scores poorly. The Commonwealth Fund, a research organization, and David Cutler, a Harvard health economist, separately estimate that an array of reforms could save the government hundreds of billions of dollars in the first decade and the health care system even more. These estimates, coming from advocates of reform, may be too rosy, but underscore the point that the C.B.O. may undervalue savings.

More Health Care And The Campaigns

Obama actually released a second ad on McCain's Health Care Tax today.



While this is definitely effective, it treats McCain's tax as a tax, when if you fully explain it out, it's worse than that.

In year one, you'll have to pay that tax, and the tax credit will roughly offset it. But the tax credit grows with inflation. Health spending grows much more quickly. By year five, your tax credit will have shrunk. Sharply. But health spending will be up, and so your tax increase will have expanded. Substantially. With every passing year, you pay more in taxes and receive less from the tax credit. The plan's savings -- minimal already -- are frontloaded and its costs are delayed. It's a pretty dirty trick.

That's the perfect Republican squeeze play. And if you have a pre-existing medical condition - forget it. Go sign up on a long sheet of those hoping to get the state to help you with your coverage. McCain's plan is a disaster.

What I didn't realize is that Obama released an ad about his own health care plan this week as well.



I know I'm not the target audience for this spot and that it's designed for swing-state independents, but it infuriates me. It shows that Obama is committed only to tinkering around the edges on health care. Eliminating pre-existing conditions would be a big step forward, as would mandating that a high percentage of premiums go to treatment. And preventive care is nice and all. But this keeps us very firmly in the status quo, with the insurance industry and its army of lobbyists in the lead. "Bring down costs" is thrown in there but cost control is not explained or even presented in his plan. And the public option, which is what I'm hanging my hat on in Obama's plan, goes unmentioned, which is a tell that it could go away.

This gives me little hope of Obama's seriousness about this issue, and Congress will have to take the lead here. I know there's a bias toward people liking what they have in health care, but I don't even know how true that is anymore. And his "common sense" solution makes little sense at all.

Ugh.

Dying For Coverage

Advocacy group Families USA has put out a shocking report (PDF), "Dying For Coverage," detailing how Californians are impacted by a lack of health insurance. The number "47 million" that designates Americans without health insurance is too abstract and detached from meaning. Californians are dying because of their inability to afford or acquire insurance.

• Families USA estimates that more than eight working-age Californians die each day
due to lack of health insurance (approximately 3,100 people in 2006).

• Between 2000 and 2006, the estimated number of adults between the ages of 25
and 64 in California who died because they did not have health insurance was
nearly 19,900.

•Across the United States, in 2006, twice as many people died from lack of health
insurance as died from homicide.

The factors that lead to death include: 1) a lack of preventive care and screening, 2) unnecessary delays for medical care because of affordability concerns, 3) no access to care outside an emergency room, and more.

Some of our Democratic members of Congress have commented on the report.

"This new Families USA study highlights a sad statistic that more people in our country died from lack of health insurance than from homicide between 2000-2006," U.S. Rep. Pete Stark (D-CA) said today. "In California alone, nearly 20,000 people in that time frame died because of being uninsured."

"Our nation has more people in jail than anywhere else in the world in its effort to combat crime," Stark said. "Yet, we allow 47 million people to go without health insurance-which translates into going without needed medical care-each year. It's time to take action and combat the real killer in our country-the lack of universal health care."

"It is appalling and irresponsible that more than eight working-age Californians die due to lack of health insurance each day," U.S. Rep. Hilda L. Solis (D-CA) said today. "In California , 60 percent of the uninsured are Latinos, which means that nearly five Latinos die each day because we cannot ensure access to quality, affordable health care."

"I am fighting in Congress to improve the health of communities of color and strongly support improving access to health care for all populations," Solis said.

When Republicans talk about "cost control" in medical care, they want a world very much like this. They believe that the problem with health insurance is that people have too much of it. They would rather it be limited and used only when necessary, and they would rather Americans hold out and comparison shop when they are ill or infirm. In other words, the conservative vision of health care aligns with the for-profit insurance company vision which directly leads to 8 dead Californians every single day.

As we pick up the pieces from the failure of health care reform from earlier this year, this powerful report shows the dire need to repair the broken system and ensure affordable care for everyone.

The Sickening Of America

The number of stories I'm seeing about the obstacles you have to traverse in your daily life just to remain relatively healthy are going up and up. Certainly there are occupations that are increasingly dangerous, as multiple tours of duty are making our soldiers go deaf, and our good friends at Halliburton are paying no attention to contaminated drinking water. But you don't have to be serving in Iraq to have your drinking water filled with all kinds of contaminants.

A vast array of pharmaceuticals -- including antibiotics, anti-convulsants, mood stabilizers and sex hormones -- have been found in the drinking water supplies of at least 41 million Americans, an Associated Press investigation shows.

To be sure, the concentrations of these pharmaceuticals are tiny, measured in quantities of parts per billion or trillion, far below the levels of a medical dose. Also, utilities insist their water is safe.

But the presence of so many prescription drugs -- and over-the-counter medicines like acetaminophen and ibuprofen -- in so much of our drinking water is heightening worries among scientists of long-term consequences to human health.

This is actually a function of the society just being completely overmedicated. The drugs get into the bloodstream and eventually into the sewer system and the reservoirs, and not all of them are cleansed. Forget a lot of drugs in the water, there are a lot of drugs in people, to a level that we really don't know the residual effects.

The sickening of America comes in all forms and fashions. Whether it's coming from treatment at clinics that aren't sufficiently sanitary or well-managed, or tainted drugs that we allow into the country, we don't have a handle on what we ingest. Basic health care costs so much money, $225,000 for every retiring couple, money that is so scarce that we're rationing health insurance like it's a lottery, and offering health care like it's charity. This is like a feedback loop. We're more sickened, we're more medicated to cover the sickness, that makes us more sick, it costs more money to medicate, and the system breaks down.

It's easy to get caught up in this primary fight and lose sight of why we need more effective leadership to repair all these systems that are so terribly broken. We need more than a health care system that doesn't rely on charity or the lottery, we need a medical system that doesn't use drugs like a band-aid and doesn't have a Food and Drug Administration that is practically nonexistent. The last thing that anyone wants is a collapsed system; even the health insurers understand that. But a system of care that is so hurried and sloppy and unconcerned with individual treatment that it becomes nothing more than "take two of these and call me in the morning" doesn't work either. A world-class health care system is focused on prevention and promoting proper diet and exercise, not supplements and substitutes and work-arounds. Otherwise, we're all bound to get sickened, and we'll all be paying for it.