Friday, April 15, 2011

Judging the Medicare Flip-Flop

I'm still sort of astonished at the audacity of the GOP flip-flop on the Medicare cuts from ACA. Let's see if we can run this down...

1. Prominence: ACA was obviously one of the top Republican issues in 2010, and the Medicare cuts were a major issue within that in campaign materials and ads. Candidates, of course, make lots of commitments that few know about and then flip once in office...a flip is a bigger deal, presumably, the more you campaigned on it. Very high score.

2. Rapidity: We're three months into the new Congress. Not a record for flips, but pretty quick. Very high score.

3. Lack of intervening events: George W. Bush was against nation-building and for a humble foreign policy...until the September 11 attacks. Now, the idea that those attacks changed everything as far as the actual world is concerned was always pretty dicey, but Bush apologists aren't entirely wrong if they want to claim that he had good reason to break his promise. I can't think of any relevant intervening events since the election. Budget and economic projections now are basically similar to what they were then. Perfect score.

4. Lack of compromise or defeat: It's a raw deal to blame a pol for breaking a promise if he or she is defeated (as with Obama on some -- but not all -- of his torture/detention promises), or if the promise is broken as part of making as deal, as with Obama and the tax extensions in fall 2010. That's not happening here; the House GOP budget was entirely their doing, and supported by almost the entire conference. Perfect score.

5. Degree of flop: Did the pol modify the old position (again, see Obama and detention), or completely reverse it? Here, on the Medicare cuts, it's a total reversal, as far as I can see. Perfect score.

Really, this is an outstanding, impressive, flip-flop. Am I missing any categories?

[Updated, link added]


  1. Ryan's plan for Medicare also has a lot in common with ObamaCare. If you just landed from another planet, you'd probably mistake RyanCare for a compromise.

  2. If there's a category you missed, it's for not caring. In what word has it seemed that either party has really cared what analysts have said? Sometimes I think my mistake was getting a poli-sci degree more than a decade after it was relevant.

  3. And even with all those high scores... I wasn't aware that Republicans campaigned against cutting Medicare. Death panels, I noticed. So this didn't stand out as a flip-flop to me. They can pretty much get away with anything, I think.

  4. @Noumenon---for what it's worth, folks in districts that Republicans successfully flipped last November report ads and campaign literature everywhere (TV, radio, online, in the mail) about Democrats cutting "your Medicare" to pay for "Obamacare".

  5. @Couves, Brian Beutler of quoted Senator John Cornyn saying on Thursday, "It's exactly like Obamacare. It is. It's exactly like it. Which strikes me as bizarre that you're seeing so much pushback [from Democrats]."

    Ezra Klein at observes, "Cornyn is, of course, on record favoring that ObamaCare be repealed and declared unconstitutional."

    I disagree with your statement for the following reasons:

    *Ryan's proposal repeals the ACA.

    *The net effect of "Obamacare" is to expand social insurance by extending health care to cover 30 million currently uninsured Americans.

    *The net effect of "Ryancare" would be to remove social insurance for all future elderly Americans who are now under the age of 55 (in addition to removing it from those 30 million currently uninsured working-age adults and their families).

    *Ryan's proposal weakens Medicaid; the ACA strengthens Medicaid.

    *Klein notes, "there’s some truth to what Cornyn is saying — RyanCare uses exchanges that are very similar to the exchanges the Affordable Care Act". However, as Klein further notes, after repealing the ACA's exchanges, Ryan sets up exchanges as a replacement for Medicare recipients---a patient population that is

    1 - more likely to need emergency care,
    2 - less likely to be able to make informed decisions (due to the rate of dementia among the elderly), and
    3 - using a price-setting mechanism that is less market-based than the ACA (see for this last point).

    *Obamacare reduces the federal deficit over the next 10 years; Ryancare increases it (as did the last major health reform---Medicare Part D---endorsed by Rep. Ryan.

    *Klein concludes that Ryancare is more like Romneycare---in that both have health care exchanges without delivery-system reforms (which is why Massachusetts is now trying to deal with controlling health care costs).

    *Even Klein's comparison to Romneycare is, in my view, unfair to Romney. The Massachusetts law he signed as governor expanded health insurance coverage to 98% of the state's residents. As noted earlier, Ryan's proposal begins by eliminating coverage of 10% of Americans (and continues by slashing coverage for those expecting to depend on Medicaid or Medicare).

  6. massappeal,

    The criticism of Republicans for flip flopping is fair. But what about the Democrats? They had previously supported cuts to Medicare and now that they are opposing cuts to Medicare. Maybe they dislike the mechanisms Ryan employs, but they happen to be a lot like what you'll find in Obamacare. I agree with some of the distinctions you draw between the two plans, but I was responding to the assumption underlying JB’s point, which is that they are similar in an important way.

    Personally, I find it hard to take this line of thinking seriously because I suspect that the Democrats will never really cut Medicare and the Republicans were disingenuous when they had previously criticized the Dems for cutting Medicare. The Dems needed to "cut" Medicare to make Obamacare's numbers add up. The Republicans then attacked Democrats for cutting Medicare in a desperate attempt to stop Obamacare.

  7. @Couves (8:34 am) Thanks for your response.

    I think I can pretty fairly give Democrats credit for including some systemic reforms in the ACA that cut health care costs overall, allowing them to project spending less on Medicare (and using the savings to spend on health care for insurance exchange subsidies). This would fall under the category of "mending Medicare, not ending it".

    There's nothing intellectually inconsistent (on the Democrats' part) between voting to preserve (albeit cutting) Medicare in 2010 and voting to oppose Ryan's abolition of Medicare (for those under 55) in 2011 (not to mention his repeal of most of the ACA).

    I agree with your view that "the Republicans were disingenuous when they had previously criticized the Dems for cutting Medicare". The modern Republican party never liked Medicare (see Reagan, Ronald circa 1964) and yesterday's vote demonstrates a renewed desire on their part to end it.

  8. massappeal: True, you certainly can't expect Democrats to vote to repeal ACA, but they should be more open minded about Ryan's Medicare overhaul. I know the Dems want to root out "waste, fraud and abuse" in Medicare, but it's hard to imagine that will make a dent in the program's $36 trillion in unfunded liabilities. More radical reforms need to be looked at, but in this case the Democrats' ideological commitments prevent them from considering real change.

  9. Couves,

    What Democrats will say is that it isn't a Medicare problem -- it's a health care costs problem. Shut down Medicare entirely, and you still have the same sized problem, just changed the bookkeeping.

    As long as we collectively don't intend to just watch old people get sick and let them suffer, I think that's correct (note: there are some who are OK with the "let them suffer" plan, and in fact I find the case for that coherent, although I don't subscribe to it. But the truth is that it's a fringe minority position).

    ACA *does* have several things that may make health care cheaper. Ryan doesn't appear to have anything, or at least nothing that ACA doesn't also have. And, really, I just find it hard to take Ryan seriously at this point...the Heritage numbers are just *that* bad.

  10. Jonathan,

    Ryan's plan gives extra support for the very sick and the indigent but middle and upper income recipients will bear more of the costs themselves. This is where the budgetary cost savings are. It may also help control healthcare costs by incentivizing patients to choose cheaper health care options when they are available… but the primary effect is to shift costs from future workers to future retirees. People won't be dying on the streets, but because it will hit the pocketbooks of elderly voters the political prospects of the plan are highly dubious. On the other hand, increasing taxes to pay for exploding Medicare expenses isn’t an attractive option either. We’ll probably be forced to employ both options when this reaches the level of a debt crisis.

  11. Couves,

    See Ezra Klein yesterday -- if Ryan's plan would work, then that implies that ACA would work far better than Obama, Waxman, etc. think it would.

    Beyond that -- that's what I'm saying; you can't "fix" Medicare without fixing health care in general. And it seems highly unlikely that Ryan's plan would fix health care in general.

  12. Jonathan,

    In theory, we should be able to fix Medicare by shifting costs to future retirees who have resources, as Ryan proposes. Whatever comes of Ryan's plan, I think it's inevitable that Medicare will become more of a safety net and people with money will be increasingly expected to pay for their own care. Medicare as it currently stands is unsustainable.

  13. The "cuts to Medicare" are quite real. The ACA phases out the subsidies to the Medicare Advantage plans. The MA plans were originally a pilot program that was designed to demonstrate that the insurance industry could provide the same care as regular government run Medicare but more efficiently. You can guess which party came up with that idea. Unhappily, the MA plans were actually receiving a 14% subsidy (reduced to 11% this year). The "cuts" to Medicare were actually cuts to Blue Cross, United Healthcare, and their slimy ilk. You can guess why a certain party has got their political panties in a twist over that. However, the cuts are absolutely real and, surprisingly, included in the Ryan Road to Ruin plan.

    Wikipedia "Medicare Advantage" to learn more.

  14. As Anon points out, most of the Medicare cuts in the ACA were to a part of Medicare that essentially IS a forerunner to Ryancare. So cutting that and opposing Ryancare are not inconsistent positions, nor does that make Ryancare something Dems should be particularly "open-minded" about. Indeed, leaving a segment of society subject to the tender mercies of the free market when that segment is particularly ill-suited to participate in that market is pretty much the antithesis of Democratic policy thinking.

    Assuming arguendo that a debt crisis is imminent and implicates Medicare, that doesn't mean we need to hop on the first plan someone throws out there.

  15. Anon and Colby -- Thanks for the information. From what you say, it sounds like neither the Democrats nor the Republicans are being inconsistent.

  16. Couves, the Republicans screamed that cutting the subsidies for the Medicare Advantage plans was "gutting Medicare" and had my senior patients (the FNC watchers and usually the ones who, ironically, were not in an Advantage plan) terrified that their Medicare was "going to be cut". Now the Rs are not only talking about cutting the same subsidy for the over-55s but also phasing out straight Medicare altogether for those of us under 55.

    The Medicare Advantage plans have been around for more than a decade and they are less efficient than Medicare. They cost more. In fact, they cost quite a bit more. Ryan's plan is to gradually pay less than the cost of Medicare for something that already costs substantially more. I would hardly call that "consistent" when last year the MA subsidy phase out was called a "gutting".

    Noumenon may not have noticed the discussion about reducing the subsidies for MA plans, but believe me, the seniors did. They were all riled up last year. They were quite convinced that "Obamacare" was already denying them needed care any time I tried to explain that they didn't need useless screening tests. I even had one teabagger daughter explain to me that "doctors don't take regular Medicare anymore" -- which was news to me! Apparently the giant primary care medical group that I belong too isn't chock full of, er, doctors.

  17. Anon, you seem to be looking at the subject very fairly. I'm sure the "teabagger daughter" would agree!


Note: Only a member of this blog may post a comment.

Who links to my website?