The Real Threat to Seniors: Single Payer

No sooner had the president’s budget arrived on Capitol Hill last Monday than the demagoguery began. Within hours of the budget’s release, Sen. Brian Schatz (D-HI) tweeted that “One party wants to expand Medicare and Medicaid and the other wants to cut them.” The facts, however, show a different contrast—one party attempting to keep a promise to seniors, and another abandoning that promise to fund other priorities.

First, the budget would not “cut” Medicare. As multiple administration officials explained during congressional hearings on the budget, Medicare spending would continue to rise every year under the president’s proposals. Only in a government town like Washington could lawmakers say with a straight face that a reduction in projected spending increases constitutes a “cut.”

Third, the budget proposals would yield tangible benefits to seniors through lower Medicare cost-sharing. A proposed rule released in July found that one of these changes would lower beneficiary co-payments by $150 million in one year. If enacted in full, seniors would see billions of dollars in savings over the ten-year budget window.

Fourth, and most importantly, legislation Schatz supports wouldn’t “expand” Medicare and Medicaid, it would eliminate them. Sen. Bernie Sanders’ single-payer bill, which Schatz has co-sponsored, would, in addition to ending Medicaid, liquidate the Medicare trust funds, using the proceeds to finance the new government-run program. As I noted last year, that makes Sanders’ bill, as well as similar legislation introduced in the House last month, not “Medicare for All” but “Medicare for None.”

That raid on the Medicare trust funds represents not just an accounting gimmick, but a statement of Democrats’ priorities—or, rather, the lack of them. Medicare has long-term funding problems, which the president’s budget attempts to address. But in using the Medicare trust funds as a piggy bank to finance a single-payer system—the full cost of which Democrats have no idea how to fund—the party shows how, in trying to provide all things to all people, it will abandon the most vulnerable.

Perhaps the best rebuttal to “Medicare for None” came from, of all people, Rep. Steny Hoyer (D-MD). In a speech on the House floor in September 2009, Hoyer said:

At some point in time, my friends, we have to buck up our courage and our judgment and say, if we take care of everybody, we won’t be able to take care of those who need us most. That’s my concern. If we take care of everybody, irrespective of their ability to pay for themselves, the Ross Perots of America, frankly, the Steny Hoyers of America, then we will not be able to take care of those most in need in America.

Therein lies the true flaw in the left’s logic. Whereas the president’s budget would work to protect Medicare for vulnerable seniors, Schatz, Sanders, and their supporters would liquidate the Medicare trust fund to finance “free” health care for Mark Zuckerberg and Elon Musk. The choice between the two paths seems as obvious as it is clear.

This post was originally published at The Federalist.

Congress’ Bipartisan Spending Addiction

Did you hear the joke that circulated around the Capitol over the holidays? It’s called Congress’ ability to control government spending.

Shortly before departing for their Christmas break, lawmakers of both parties voted to waive provisions of existing law that would have led to spending reductions over the coming decade. The move represented but the latest instance of the bipartisan addiction to federal spending that plagues our nation’s capital.

Because the final tax bill increased the deficit by nearly $1.5 trillion on a static basis—that is, not taking into account the economic growth that tax relief will produce—the PAYGO law would have required commensurate automatic reductions in spending in the coming years had Congress not enacted a waiver. However, as I noted last month, while a $1.5 trillion reduction in spending sounds large, it would represent less than 3 percent of all federal spending over the next decade.

Empty Democratic Threats

Prior to passage of the tax bill, Democrats threatened that statutory PAYGO would result in spending reductions to government programs. In August, the liberal Center for American Progress published a list of all the programs potentially subject to sequester spending reductions. In November, House Minority Whip Steny Hoyer (D-MD) used a Congressional Budget Office analysis he requested to decry “the complete elimination of all funding to dozens of mandatory programs next year” if Congress enacted a deficit-increasing tax bill.

Hoyer added that “while it is possible to avoid the PAYGO enforcement cuts triggered by their added deficits, Republicans would need Democratic votes to do it, requiring them to abandon their go-it-alone partisan strategy.” On that count, Hoyer needn’t have worried. On the spending bill that waived the PAYGO spending reductions, 14 Democrats voted for the measure in the House, and 18 Democrats voted for the bill in the Senate.

However, Senate Democrats could have insisted on the removal of the PAYGO waiver as their price to allow the spending bill to overcome a Senate filibuster. They did not do so. In fact, every Senate Democrat voted to “waive all applicable budgetary discipline” for the spending bill. That motion passed the Senate on a 91-8 vote, with Republicans providing all eight of the nays.

The PAYGO Law Is a Joke

For all their willingness to talk a big game before Republicans passed their tax measure, Democrats folded like a cheap suit on applying statutory PAYGO spending reductions to the tax bill. Earlier in December, their threats rattled moderate Republicans like Sen. Susan Collins (R-ME), who before voting for the tax measure forced Republican leaders to pledge that the spending reductions would never go into effect.

But Republican leaders could only make such a pledge—which, as Hoyer rightly noted in November, required Democratic votes—because they knew Democrats would never follow through on their empty threats to let the spending reductions occur. Liberals love government spending, and their saber-rattling over statutory PAYGO amounted to empty rhetoric towards Republicans: “Don’t pass a tax cut, or we’ll shoot ourselves in the foot by cutting programs we like!”

Only eight of 51 Senate Republicans voted against waiving budgetary discipline for the spending bill, and only two of those, Kentucky’s Rand Paul and Utah’s Mike Lee, voted against the bill’s final passage. Likewise, only 16 Republicans voted against the spending bill in the House, and several of those voted no not because the bill cancelled automatic spending reductions, but because the bill didn’t spend enough on federal defense programs.

The press critics who claim the death of bipartisanship should have watched the debate on waiving PAYGO. Both they and federal taxpayers would benefit from more closely examining the bipartisanship on display in waiving any semblance of fiscal discipline.

This post was originally published at The Federalist.

Are Cost-Sharing Reductions Subject to the Sequester?

Sen. Susan Collins (R-ME) thinks she has a deal with Senate Majority Leader Mitch McConnell (R-KY) to attach two provisions to a short-term spending bill later this month: The Alexander-Murray legislation to appropriate funds for cost-sharing reduction (CSR) payments to insurers, and a separate bill she and Sen. Bill Nelson (D-FL) have developed regarding reinsurance proposals.

Collins also thinks these two provisions will have a “net downward effect on premiums,” even after repealing Obamacare’s individual mandate as part of the tax bill the Senate is currently considering. However, it appears that Alexander-Murray and Collins-Nelson’s net effect on premiums could end up being a nice round number: Zero.

Cost-Sharing Reductions and the Sequester

The statute that created the budget sequester applies a list of programs and accounts not subject to sequestration spending reductions. For instance, the law exempts refundable tax credits, like those provided to low-income individuals who buy coverage on Obamacare’s exchanges, from sequestration reductions.

However, neither cost-sharing reduction payments nor reinsurance would qualify as refundable tax credits. They are paid directly to insurers, not individuals, and are not part of the Internal Revenue Code. Also, neither cost-sharing reductions nor reinsurance are on a list of other accounts and programs exempted from the sequester.

The Obama administration previously admitted that cost-sharing reduction payments were subject to the sequester, in a sequestration report to Congress in April 2013, and in testimony before the House Energy and Commerce Committee in August of that year. In a separate 2014 report, the Obama administration also admitted that Obamacare’s transitional reinsurance program (which expired in 2016, and which senators Collins and Nelson effectively want to re-create) was subject to the sequester.

However, last year Judge Rosemary Collyer ruled these actions unconstitutional, because the treasury lacks a valid appropriation to pay out CSR funds. The Trump administration last month stopped the CSR payments to insurers, citing the lack of an appropriation. While the Alexander-Murray bill would appropriate funds for the CSR payments, it would do so through the Centers for Medicare and Medicaid Services, not the treasury—meaning that the sequester would apply.

Statutory PAYGO and the Sequester

Earlier this month, the Congressional Budget Office (CBO) released a letter to Rep. Steny Hoyer (D-MD) indicating that legislation increasing the budget deficit (on a static basis, i.e., not accounting for economic growth) by $1.5 trillion would result in a sequester order of approximately $136 billion for 2018. The existing statutory formula would deliver a 4 percent, or approximately $25 billion, reduction in Medicare spending, followed by about $111 billion in reductions elsewhere.

However, because the sequestration statute exempts many major spending programs like Social Security and Medicaid, CBO believes that only about $85-90 billion in existing federal resources would be subject to the sequester. This means an additional $20-25 billion in mandatory spending, if appropriated, would immediately get sequestered to make up the difference.

On the one hand, conservatives who oppose paying CSRs to insurers may support an outcome where insurers do not actually receive these payments. On the other hand, however, some may view this outcome as the worst of all possible worlds: Having surrendered the principle that the federal government must prop up insurers—and Obamacare—without receiving any actual premium reductions, because the payments to insurers never get made.

This scenario, when coupled with repeal of the individual mandate, could result in a legislative outcome that raises premiums next year—a contradiction of the promises Republicans made to voters.

This post was originally published at The Federalist.

Paul Ryan and “Regular Order”

Last week, Politico published an article talking about how the Republican House of Representatives under Paul Ryan’s speakership set a new record for the number of bills approved under closed rules—which prohibit members of Congress from offering amendments. Although the Politico story didn’t use the term, it echoes the complaints of Sen. John McCain (R-AZ) surrounding Obamacare “repeal-and-replace” legislation this past summer: “I want the regular order.”

McCain’s comment invites a question: What exactly constitutes “the regular order” in Congress? Why do people keep calling for it? And if so many people keep calling for it, why doesn’t Congress just restore “the regular order” already?

‘Deem-and-Pass’

Politico quoted House Rules Committee Ranking Member Louise Slaughter (D-NY): “Under Speaker Ryan’s leadership, this session of Congress has now become the most closed Congress in history.” To call Slaughter’s complaints about a closed process ironic would put it mildly.

Seven years ago, when she chaired the Rules Committee, Slaughter proposed having the Democratic House enact Obamacare into law without voting on it. The House could merely “deem” Obamacare approved as a result of passing some other measure.

While the House has repeatedly used this “deem-and-pass” strategy under both Republican and Democratic majorities, the optics of passing such a massive and prominent piece of legislation using such dodgy procedural shortcuts led Democrats to abandon the gambit, but not before conservative bloggers noted that Slaughter, Rep. Steny Hoyer (D-MD), and others attacked the “deem-and-pass” maneuver when Republicans controlled the House in the 2000s.

Republican Manipulation

In proposing the “deem-and-pass” strategy, Slaughter looked to protect House Democrats from taking a tough vote on the unpopular health-care bill Senate Democrats approved on Christmas Eve 2009—the one with the “Cornhusker Kickback,” “Gator Aid,” “Louisiana Purchase,” and the other backroom deals that made the legislation toxic in the minds of many. When in the majority themselves, Republicans have used the same tactics, using procedural blocks to avoid politically difficult votes.

In 2015, the appropriations process ground to a halt in mid-summer, when Democrats offered an amendment preventing federal funds from being used to display the Confederate flag in national cemeteries. The amendment, offered by Rep. Jared Huffman (D-CA), originally passed by voice vote, but some Republicans pledged to vote against the bill if the amendment remained in it.

Republican leaders didn’t have the votes to strip out the amendment, and didn’t have the votes to pass the bill with the amendment in, so the Interior appropriations bill got shelved—as did the entire appropriations process, because Republicans feared Democrats would offer Confederate flag-related amendments to any spending bill that came to the House floor.

House Freedom Caucus

Yet on several occasions over the past few years—including the Confederate flag flap—conservatives and HFC members have looked to leadership to squelch debate on amendments. Earlier this year, moderate Republicans and Democrats combined to defeat an amendment that would have prohibited federal funding of soldiers’ gender-reassignment surgery. Conservatives responded a few weeks later by demanding that leadership insert such a funding prohibition into the defense spending bill—without a direct vote, via the “deem-and-pass” strategy—even though the provision would have violated the will of the House as expressed in a vote weeks before.

While the executive ultimately decided the transgender issue—at conservatives’ behest, President Trump issued an executive order prohibiting transgender troops from serving, making the House procedural dispute moot—it illustrates the problems inherent with a move to “regular order.” As with Slaughter and Democrats, conservatives support an open process in the House only up until the point when it detracts from their desired policy outcomes, at which point the legislative process quickly devolves into a game of ends justifying means.

If it wanted to, HFC could easily demand a more open floor process out of Ryan. It could vote down the rules governing floor debate on individual bills unless and until the Republican leadership allowed an open process and more amendment votes, at which point the Republican leadership would have no choice but to acquiesce to pass legislation through the House. However, a more open process would require conservatives to accept policy outcomes they might not like—federal funds being spent on gender-reassignment surgeries, for instance.

These strictures require leadership to use all manner of procedural shortcuts and chicanery to cobble together legislation that can command a majority of votes. It’s no way to run a railroad. But until members’ desires for “the regular order” are strong enough that they will vote down bills on process grounds alone, it will remain the way Washington works—or, in many cases, doesn’t.

This post was originally published at The Federalist.

Yes, Obamacare Really Does Disadvantage Individuals with Disabilities

My article last week regarding disability groups’ political and policy views prompted some comments and criticisms on Twitter. Rather than trying to explain detailed subjects in bursts of 140-character tweets, I considered it best to compile them into a longer-form article.

To summarize my prior work: Obamacare provides states with a greater incentive to expand Medicaid to able-bodied adults than to cover services for individuals with disabilities. States receive a 95 percent match this year (declining to 90 percent in 2020 and all future years) to cover the able-bodied, but a match ranging from 50-75 percent to cover individuals with disabilities, while more than half a million are on waiting lists to receive home or attendant care.

Many of the responses I discuss in greater detail below attempt to obscure two separate and distinct issues: The question of the amount of funding for programs versus the priorities within those programs.

As a conservative, I’m likely to disagree with liberals on the ideal size of many government programs, but I thought I would at least agree with them that individuals with disabilities should receive precedence within those programs. However, Obamacare actually tilted Medicaid’s preference away from individuals with disabilities, which makes disability groups’ silence on that front surprising.

There Is No Correlation Between Waiting Lists and Medicaid Expansion

The timeliest rebuttal comes from a story on a long-term care report none other than AARP released yesterday. Susan Reinhard with that organization—no right-wing conservative group, by any stretch—said that

Many states have struggled to expand home- and community-based options for Medicaid enrollees needing long-term care because that is an optional benefit. Nursing homes are mandatory under federal law. While states focus on Medicaid coverage for children and families — as well as non-disabled adults covered by the Medicaid expansion under the Affordable Care Act — adults with disabilities have received less attention. ‘Long-term care is a stepchild of the program and not a top focus for states,’ she said. (emphasis mine.)

That statement notwithstanding, several people cited two different analyses that compare states’ decisions on expansion to the able-bodied and their waiting lists for home-based care for individuals with disabilities. But each of those “studies” (based on only one year of data available) take an overly simplistic approach, and therefore don’t get at the core issue of the extent to which the skewed incentives Obamacare created have encouraged states to prioritize the able-bodied over those with disabilities.

A state’s decision to expand Medicaid to the able-bodied, or reduce its waiting lists for individuals with disabilities, depends on myriad factors. For instance:

  • A wealthy state with a greater tax base would have more resources both to expand Medicaid to the able-bodied and to reduce its waiting list of individuals with disabilities, while a poorer state with a smaller tax base might not have resources to do either;
  • A state with “bad” demographics (e.g., an older and sicker population), or higher costs for health and personal care services, might have more difficulty reducing their Medicaid waiting lists;
  • A state may face other fiscal pressures—controversy over school funding, a natural disaster, a pension crisis—that could affect overall Medicaid spending.

Numerous variables affect states’ budget choices, and therefore their Medicaid waiting lists. The “studies” controlled for exactly none of them. They examined whether a state expanded Medicaid and the total number of people on a state’s waiting list, and that’s it.

Moreover, under Obamacare, all states receive the same (higher) federal match to cover able-bodied adults—another change in policy (prior to Obamacare, all Medicaid match rates were based on states’ relative income) skewing the balance in favor of wealthier expansion states. Yet, as noted above, the analyses claiming no correlation between expansion and Medicaid waiting lists didn’t even attempt to control for these variables—or any other.

Therefore, in the absence of a quality study examining the issue, I’ll go with something far simpler: Common sense. If you’re a state that wants to spend more money on Medicaid, and you can do something (i.e., cover the able-bodied) that gives you 95 cents on the dollar, or something (i.e., reduce waiting lists for individuals with disabilities) that gives you 50 cents on the dollar, which are you going to do first?

I thought so. The incentives in Obamacare strongly favor coverage of the able-bodied over coverage for individuals with disabilities. And no number of crude analyses attempting to provide retroactive justification for this bad policy can hide that fact.

Waiting Lists Are Worst In Two Non-Expansion States

This comment reinforces the crudeness of the analysis being cited. All else being equal, as the second- and third-largest states in the Union, Texas and Florida would be expected to have a larger number of people on its waiting lists for home- and community-based services than a smaller expansion state like Connecticut. All else isn’t equal, of course, but did the analysts attempt to control for these kinds of factors? Nope. They examined raw waiting list numbers, rather than waiting lists as a percentage of the population.

But just suppose for a second that the commenters above are correct, and there is no correlation between expansion to the able-bodied and waiting lists for home-based care. That means that the greater incentives Obamacare gives to states to cover the able-bodied—and while the advocacy community might not want to admit it, Obamacare clearly does give states greater incentives to cover the able-bodied—didn’t affect state behavior, or decisions about whether to reduce disability waiting lists at all.

In that case, why has the disability community expressed such outrage about the impact of per capita caps or block grants on Medicaid beneficiaries with disabilities? If states make decisions without considering federal incentives—the point of the claims that there is no correlation between expanding Medicaid to the able-bodied and longer waiting lists for individuals with disabilities—then why also claim that “cost-shifting to states will force massive cuts in Medicaid services?” Why wouldn’t states shift around resources to protect individuals with disabilities—what the disability community claims that states did to reduce waiting lists even while expanding Medicaid under Obamacare?

There are really only two credible possibilities:

  • States are affected by incentives, therefore Obamacare—by giving states a higher match to cover the able-bodied—encouraged discrimination against individuals with disabilities; or
  • States are not affected by incentives, and therefore the per capita caps—which generate a comparatively small amount of savings in the House repeal bill—will have little impact, because states will re-prioritize their budgets to protect the most vulnerable.

It’s therefore worth asking why some appear to be trying to argue both sides of this question, and doing so in a way that neatly lines up with partisan lines—trying to ignore Obamacare’s skewed incentives, while roundly castigating the House Republican bill for incentives that will “force massive cuts in Medicaid.”

Republicans’ Bill Would Cut Program Helping People Live at Home

This is a true statement: Section 111(2) of the American Health Care Act, House Republicans’ “repeal-and-replace” bill, would sunset the enhanced match for the Community First Choice program on January 1, 2020. That option provides states with a 6 percent increase in their federal match for home- and community-based services, including to individuals with disabilities. But here again, raising this issue demonstrates the inherent disconnect between the incentives being offered to states, and the disability community’s responses to those incentives.

  • Obamacare provides states with a match ranging from 20-45 percentage points higher to cover the able-bodied than individuals with disabilities: “No correlation between expansion and waiting lists for individuals with disabilities!”
  • Obamacare provides states with a 6 percentage point increase for home-based services: A “huge change to improve HCBS [home and community-based services] care.”
  • The Republican alternative to Obamacare would reduce Medicaid spending for traditional (i.e., non-expansion) populations by a comparatively small amount: “Massive cuts to Medicaid services.”

Isn’t there a slight contradiction in these responses—both in their tone and in their logic? And isn’t it worth noting that these contradictions all happen to align perfectly with the natural partisan response to each of these issues?

This Is A Political Problem, Not a Policy Problem

Claiming that the greater federal match to cover able-bodied adults than individuals with disabilities stems from a “political history problem” deliberately obscures its roots. This “history” did not take place half a century ago, at Medicaid’s creation, it took place in the past few years, as part of Obamacare.

When crafting that legislation, Democrats could have come up with other policy solutions that expanded Medicaid to the able-bodied without discriminating against individuals with disabilities in the process. They could have proposed increasing the federal match for coverage of individuals with disabilities, in exchange for states covering the able-bodied at the existing federal match rates. Congress enacted a similar type of “swap” in the Medicare Modernization Act. The federal government took over the prescription drug cost of Medicare-Medicaid “dual eligibles” in exchange for a series of “clawback” payments from states.

Democrats in Congress could have considered other ways to expand Medicaid without giving states a greater match to cover the able-bodied than individuals with disabilities. To the best of my knowledge, they chose not to do so. President Obama could have insisted on a more equitable Medicaid formula, but he chose not to do so. And the disability community could have pointed out this disparity to the president and leaders in Congress, but chose not to do so.

Agree or disagree with them, these were deliberate policy choices, not a mere historical accident.

How Can You Support Lower Funding While Complaining About Access?

The argument about lower funding levels misses several points. First, while the Congressional Budget Office has not released estimates of how much the per capita caps (as opposed to changes associated with scaling back Obamacare’s Medicaid expansion) will reduce federal spending, multiple estimates suggest a comparatively small amount of savings from this particular change—at most 1 or 2 percent of spending on traditional Medicaid populations over the coming decade.

Second, if given sufficient flexibility from Washington, states can reduce their Medicaid spending, rendering the discussion of “cuts” under the caps moot. Rhode Island’s Global Compact Waiver, approved in January 2009, actually resulted in a year-on-year decline of Medicaid spending per beneficiary. Moreover, the non-partisan Lewin Group concluded that Rhode Island’s waiver reduced that spending by improving beneficiary access and care, not by denying medical services.

Third, if caps on Medicaid are so harmful and damaging, then why did Obamacare cap spending on Medicare—and why did disability groups remain silent about it? Current law imposes a per capita cap on Medicare spending, one enforced by Obamacare’s Independent Payment Advisory Board (IPAB) of unelected bureaucrats.

What’s more, Obamacare imposes an annual inflation adjustment (gross domestic product growth plus 1 percent) likely to be lower than the inflation adjustment for disabled populations included in the House-passed bill (medical inflation plus 1 percent). Yet a critique of the Medicare payment caps or IPAB appears nowhere in the disability community’s 14 pages of comments regarding the bill that became Obamacare.

So the question to the disability community is obvious: Why does a Democratic proposal to impose per capita caps on Medicare raise no objections, but a Republican proposal to impose (potentially higher) per capita caps on Medicaid guaranteed to prompt “massive cuts in Medicaid services?”

Let’s Just Pay More for Everyone

This comment attempts to obscure the distinction between the amount of funding and the priorities for that funding. I might disagree with liberals about the overall level of funding for the program—not least because efforts like that in Rhode Island demonstrate the potential for Medicaid to become more efficient—but I should agree with them about the need to prioritize care for the most vulnerable. Unfortunately, Obamacare’s Medicaid expansion goes in the opposite direction.

In thinking about the important distinction between overall program funding and priorities within a program, I’m often reminded of a speech that former House Majority Leader Steny Hoyer (D-MD) gave on the House floor in September 2009: “At some point in time, my friends, we have to buck up our courage and our judgment and say, if we take care of everybody, we won’t be able to take care of those who need us most. That’s my concern. If we take care of everybody…then we will not be able to take care of those most in need in America.”

Yes, Hoyer’s speech discussed Medicare, not Medicaid, and he voted for Obamacare (and its Medicaid expansion) six months after giving it. But the speech raises an important point about the need to prioritize entitlements, one that the notion of giving higher reimbursement rates to all populations ignores.

That’s what’s wrong with focusing solely on the question on the amount of funding for a program. Reasonable people can (and will) disagree about where to draw the funding line, but it has to be drawn somewhere. “Solving” the question of funding priorities by increasing reimbursements for all populations—the equivalent of promising everyone a pony—will, by failing to choose wisely now, cause even tougher fiscal choices for generations to come.

Disability Groups Have More Important Priorities

Yes, I have worked with disability groups. For one, in 2013, I served on the Commission on Long-Term Care Congress created in the wake of the CLASS Act’s failure and repeal. We took many hours of public testimony from disability groups and others, and received dozens of other written comments—many from dedicated and passionate parents or caregivers of individuals with disabilities, and all of which I made a point to read. I won’t claim to have made disability policy my life’s work, but my jobs over the years have intersected with the disability community on several occasions.

By claiming that disability groups have “way more priorities than comparing their FMAP [i.e., their federal match rate],” this comment actually makes my point for me. The January 2010 letter by the Consortium of Citizens with Disabilities (CCD) setting out priorities for what became Obamacare was 14 pages in length, amounted to over 5,500 words, and included (by my count) 73 separate bulleted recommendations regarding the legislation. All that, and yet not one word on the bill prioritizing coverage of the able-bodied over individuals with disabilities? Frankly, the issue seems quite conspicuous by its absence.

Just Interview Someone From This Consortium

I received a series of tweetsculminating in a dramatic “Shame on you”—attacking me for not having contacted any members of the Consortium for Citizens with Disabilities (CCD) prior to writing my piece. It is correct that I didn’t reach out to any CCD member groups before printing the article. I didn’t need to because I had already spent years working with them.

The charge that I never spoke to “ONE SINGLE CCD MEMBER” is false—and demonstrably so. For nearly four years, from the spring of 2004 until the end of 2007, I worked as a lobbyist for the National Association of Disability Representatives (NADR). During that time, I spent many hours in CCD task force meetings, interacting both directly and indirectly with CCD members. The commenter’s accusation that if I had reached out to CCD members, I would know about the lengthy adjudication process for many Social Security disability claims holds no small amount of irony—I handled those issues over a decade ago.

In reality, my time working with CCD members while representing the disability representatives prompted me to write my article last week. While attending CCD meetings, I saw firsthand how some meeting participants—several of which remain in their current positions and active in CCD activities—made offhand comments of a rather partisan nature. Not everyone joined in the political commentary, but several felt comfortable enough to make clear their partisan affiliations in open discussions, even if I and others did not.

Similarly, I recall how the disability community fought against George W. Bush’s idea for personal accounts within Social Security almost uniformly, and even before Congress and the administration had an opportunity to fully develop their proposals. At the time, my client, the National Association of Disability Representatives, took an agnostic view towards the personal account concept, focusing more on the specifics of whether and how it could work for the disability community.

For instance, NADR wanted to ensure that any personal account proposal would hold the Social Security Disability Trust Fund (separate from the Old Age and Survivors Trust Fund) harmless, and that people who spent time receiving disability benefits would not be financially harmed (e.g., lack the opportunity to save wage earnings in a personal account, yet have their retirement benefits reduced) for having done so.

By contrast, most CCD members opposed the proposal from the get-go, often coordinating with Nancy Pelosi, Sander Levin, and other Democrats for events and strategy meetings. Archives on the disability coalition’s website from that era appear incomplete, but a 2005 August recess “Action Alert: Efforts to Privatize Social Security Continue!” gives a sense of the message coming from most CCD members, and the organization as a whole.

At this point any liberals still reading might applaud the disability community for having come out so strongly against the Bush proposal. But that idea focused on the Social Security retirement system, not the disability program, and the Bush administration and Republicans in Congress wanted to engage with disability groups to ensure any reforms held the disability community harmless. So how did failing to engage them—choosing instead to oppose from the outset—help the disability community?

In truth, early and vocal opposition to personal accounts may have put the disability community at greater risk had the personal account proposal been enacted without disability groups’ technical expertise on how best to structure it. And given both the partisan comments I heard from at least some CCD members at CCD meetings, it’s worth asking whether partisan or ideological concerns—separate and distinct from the interests of the disability community—unduly or improperly influenced the organization’s collective judgment back then.

Their inherent contradictions in the current debate—remaining silent about Obamacare’s unfair Medicaid match rate disparity and Medicare payment caps, while strenuously objecting to Republican attempts to impose payment caps on Medicaid—reinforce those concerns about undue partisanship.

It isn’t always easy stating inconvenient truths—pointing out that laws one doesn’t like should be enforced along with every other law, or where policies proposed by lawmakers with whom one might ordinarily be aligned fall woefully short. But such truth-telling remains an essential ingredient to authenticity and credibility. As I argued last week, I don’t think the disability community has done that in this case. I wish they had.

This post was originally published at The Federalist.

Obamacare Did NOT Fix Medicare — It Made It Worse…

Politico reported this morning that House Minority Leader Hoyer defended Obamacare as “fixing” Medicare: “We believe that the health care bill — and very frankly CBO believes the health care bill will do something that Medicare very badly needs, and that is to constrain price escalation in health care.”  Where to begin with this statement…?

  • First, a CBO study released just last week found that prior Medicare demonstration programs designed to control costs – along the same lines as those included in Obamacare – did not work at controlling costs.  What’s more, CBO added that Medicare’s fee-for-service system presents “inherent” obstacles to reducing cost growth.
  • Second, the projections that Leader Hoyer said will “constrain price escalation” are based on arbitrary payment reductions that CBO and virtually every other non-partisan expert has concluded are unrealistic.  For instance, the Medicare actuary found that provisions in Obamacare “are unlikely to be sustainable on a permanent annual basis.”  Likewise, CBO concluded that the Medicare reductions will be “difficult to sustain for a long period.”
  • Third, the Medicare “savings” have already been spent – not to improve Medicare’s solvency, but to create Obamacare’s new entitlements.  Medicare actuary Foster noted that the Medicare provisions in Obamacare “cannot be simultaneously used to finance other Federal outlays (such as the coverage expansions under the PPACA) and to extend the [Medicare] trust fund,” and CBO agreed, writing that the Medicare provisions in Obamacare “would not enhance the ability of the government to pay for future Medicare benefits.”  Even President Obama, in an interview with Fox News, admitted that “You can’t say that you are saving on Medicare and then spending the money twice.”

So in sum: The demonstration projects designed to save money likely won’t work, the arbitrary payment reductions can’t be sustained – and even if either of the first two scenarios hold, the money saved will not actually help Medicare, because it’s already been spent to pay for Obamacare’s new entitlements.  That’s not saving Medicare – that’s making it worse.

New Poll: 60% of Americans “Deem” Democrats’ Tricks a Parliamentary “Slaughter”

I wanted to alert you to a new poll released today by the Center for Medicine in the Public Interest, which revealed that six in ten Americans believe that House Democrats’ “Slaughter Solution” to avoid a vote on the Senate-passed bill is “unfair.”  Given that Majority Leader Hoyer asserted yesterday that “real Americans” would not “make a distinction” between a vote on “deeming” the bill passed and a vote to pass the bill itself, House Democrats may wish to re-assess their strategy to avoid an up-or-down vote on passing the Senate bill.  Either that, or they can continue making statements implying that three out of five of their fellow citizens are not “real Americans…”

The poll also shows significant opposition to the substance of the Democrat bills, as well as the process.  Significant majorities oppose raising taxes and cutting Medicare benefits to pay for new insurance subsidies (76%), having government panels recommend medical procedures (87%), and government involvement in deciding the “acceptable” level of health coverage (81%).  Conversely, Republican solutions to allow individuals to buy insurance across state lines (84%), let people save for health needs through tax-free Health Savings Accounts (78%), and allow premium discounts for individuals who participate in healthy behaviors (85%) receive widespread support.

“Stand Up and Vote” in the Senate — But Not the House…

Democrats’ confusion about their health care bill tactics continues apace.  Senate Majority Leader Reid attempted to lecture Republicans today to “stand up and vote” on health care.  But House Majority Leader Hoyer attempted to defend that chamber’s strategy of NOT voting on the Senate bill, because “I don’t think any American – real American – out there is going to make a distinction” between a vote on “deeming” the Senate bill passed and an actual up-or-down vote on the measure.  If that’s the case, why doesn’t the House Majority Leader follow the lead of his friend the Senate Majority Leader and force House Democrats to “stand up and vote” on the Senate bill?

It’s also worth asking where exactly is this long-promised bill that Republicans are supposed to “stand up and vote” on, and why it hasn’t yet appeared.  Are Democrats continuing to negotiate backroom deals with their “Big Pharma” friends, or still working to keep the special deals they negotiated for themselves back in December?

House Democrats Want to Enact Legislation WITHOUT Voting on It

This morning’s article from CongressDaily reveals that, despite the rumors surrounding the Senate’s consideration of a reconciliation bill, House Democrats are continuing to embark upon their “Slaughter Strategy” of enacting the Senate bill into law without ever voting on it.  This would of course violate the President’s repeated demands for an “up-or-down” vote on his health proposals—and it would classify as the parliamentary “trick” promised by Speaker Pelosi’s office weeks ago.

Given these developments, many may ask exactly what in the Senate bill House Democrats find so offensive that they are afraid to take an up-or-down vote on passing the measure – is it the “Cornhusker Kickback,” the “Louisiana Purchase,” “Gator Aid,” and all the other backroom deals assembled to obtain votes for the bill?  Is it the “Cadillac tax” on health plans that their union constituents find offensive?  Is it the bill’s federal funding for insurance plans that cover abortion, and for abortions performed at community health centers?  Or is it the very notion of a $2.3 trillion government takeover of health care?

 

Dems Dispute GOP Claims On Order Of Reconciliation

Friday, March 12, 2010
by Anna Edney with Dan Friedman contributing

A Republican claim said to be based on advice from the Senate parliamentarian does not throw Democrats off plans for how to pass a healthcare overhaul, according to aides and sources.

On Thursday, Senate Republicans pushed the idea that the $871 billion Senate-passed overhaul bill must first be signed by the president before the Senate could vote on a reconciliation bill that will include changes to the upper chamber’s bill.

“The Senate Parliamentarian’s office has informed Senate Republicans that reconciliation instructions require the measure to make changes in law,” a GOP aide said.

Senate Budget Chairman Kent Conrad was under the same impression, but the House is not worried.

A House leadership aide said Thursday the House has different rules and is safe with the choices it has to proceed. That includes a rule that would declare the Senate bill passed upon passage of the reconciliation package, in effect helping House Democrats avoid an uncomfortable vote on the Senate-passed bill.

The aide then said the president would sign the Senate-passed bill before the Senate votes on reconciliation. It would appear that could cause a problem with House members who distrust the Senate to actually pass the reconciliation bill, but the aide said the House is good with proceeding that way.

At the same time, Senate Republicans’ characterization of what the parliamentarian relayed to them leaves out a second part.

The reconciliation package cannot directly amend the Senate bill if it is not law, but Republicans were also told the reconciliation package can be written to tweak existing law or create a law. That means if written carefully, the Senate bill does not have to become law before reconciliation comes up, though it is difficult.

A Republican aide confirmed the parliamentarian told them the additional information.

Meanwhile, the House Rules Committee will make a decision on how to proceed after CBO numbers come in on a final reconciliation bill. Rules could meet as early as Wednesday. The House Budget Committee will meet on the reconciliation bill Monday, meaning CBO scores should come before then. Budget Committee Republicans plan to hold a press conference today to push back against reconciliation.

House Majority Leader Hoyer‘s office will brief staff on health legislation at 10 a.m., following a 9 a.m. Democratic Caucus meeting. Hoyer’s office did not answer whether the discussion will be on the final reconciliation bill.

House and Senate leaders met Thursday evening with White House Chief of Staff Emanuel and health reform czar Nancy-Ann DeParle but exited with no updates.

Leaders were still determining whether student loan legislation should be part of the reconciliation package. But a leadership aide said opposition appeared to have “changed dramatically.”

Following a Senate Democratic Caucus meeting Thursday afternoon on putting student loan legislation in the reconciliation package, Senate Majority Whip Durbin said the caucus is leaning toward its inclusion. Senate Health, Education, Labor and Pensions Chairman Tom Harkin made a presentation at the meeting in favor of including the student loan bill, while Conrad made one that was not totally opposed, according to senators.

Meanwhile, the healthcare effort is affecting efforts to renew dozens of tax breaks for businesses and individuals, extend benefits for laid-off workers and prevent a drastic cut in Medicare physician payments. The Senate passed its $140 billion measure Wednesday, but used nearly $40 billion in offsets the White House has set aside for the healthcare bill.

“I think health care will be the priority, which means that some of the offsets [in the extender bill] may have to be replaced,” Durbin said. “I think we’ll find things.”

Creating a Market by Abolishing It?

Leader Hoyer just suggested that Democrats want to create an open and transparent health care marketplace.  Perhaps he should review Section 202(c) of H.R. 3962 (page 100 of the House-passed legislation), which notes that beginning in 2013 (when the exchange comes online in the House version) “individual health insurance…may only be offered” through the national, government-run exchange.  How does prohibiting the purchase of private individual insurance—and forcing people into a government-run exchange—constitute the creation of an open marketplace, except in the most Orwellian vision of health care?