02 June 2010

Unfocused anger is ineffective

RCentor had a nice little rant about the SGR over at DB's Medical Rants the other day. (On a random note, I've always found it confusing that it's called DB's Medical Rants, when it really ought to be RC's Medical Rants.  Either that or his posts should carry the byline "Dr Bob."  Get on that willya, Dr Bob?) He cited the ACP statement on Congress' repeated failure to fix the SGR:
Yet the fact remains that time-and-time again, too many members of Congress from both political parties have refused to support legislation to prevent the cut and provide long-term stability in Medicare.
And goes on to say:
I really dislike both parties right now.  I hate the political games they play.  We cannot blame one party, because each party has had power and failed to fix the SGR... a pox on both their houses.
Which is mostly true, with one important caveat.  Both parties want to fix the SGR; we all know that it's a train wreck.  But when I meet with our elected representatives, which I have on multiple occasions, they all earnestly commiserate with me at what a terrible situation it is, and say, "we want to fix this, but we have a problem: where are you going to find the offsets?"

For those not fluent in leg-speak, this is the modern way of saying "how is it going to get paid for?"  Offsets are budgetary terms which reflect the fact that there is a fixed pool of revenue brought in by current law and if the SGR fix is not going to be deficit financed, as Bush's Medicare drug benefit was, there needs to be spending reduction on other programs to match the increased expenditures which would result from the repeal of the SGR.  And note that this problem, created in a bipartisan fashion by a democratic president and a republican congress, will not be cheap to fix (the figure $250 billion sticks in my head).

So when I met with the policy adviser for a senior democratic senator I was asked the "offsets" question -- where are they going to come from? I suggested the department of defense and was laughed at.  Not in a mean way; we both knew I was joking.  Cut defense spending? That's unpossible! I then more seriously suggested that there be "new revenues" created to fund this problem.  That's leg-speak for "raise taxes." That also evoked a laugh, but I wasn't joking.  I was informed that there is "no appetite" for new taxes on The Hill.  By which it was meant, "The Republicans are so fanatically opposed to taxes that they would go apeshit and either they would kill the idea or they would beat us to death in the elections for it or, Democratic competence being what it is, probably both."  So the idea was off the table from the get-go.  Not because the Democrats are unwilling to raise taxes (come on, they're Democrats), but because they are terrified to do so.

I asked a Republican Representative (one of the more moderate breeds) the same thing and was rewarded with a lecture on how taxes are already too high and need to be even lower.  This in spite of the fact that the tax burden in the US is at its lowest point in 60 years.

Make no mistake, the fact that tax increases are not an option is currently the sticking point which is preventing a fix to the SGR.  In fact, that is the rationale the GOP has held up to oppose the fixes so far this Congress: they don't want them deficit financed, at least not any more that the Dems are in the majority.  Deficit-financed SGR patches were cool when the Republicans ran Congress.  After a decade of "starving the beast" there just aren't a lot of easy offsets in the federal budget any more.  (The custom, also, is that the spending reductions should come from the department where the new spending is going. With the ongoing explosion in health care costs, the Department of HHS is under pressure to spend more, not less, in almost every avenue, so good luck cutting there, especially when every service line has its own lobby.)  So when you have one party with a religious-degree-intensity opposition to tax increases and the other party so browbeaten and spineless that they pre-emptively concede the point, it's a stalemate.  Either we give in and deficit finance the thing, or we don't find a solution.

So is Dr Bob right?  Are both parties equally to blame?  I think that's a cop-out and a false equivalency.  The fact that one party is entirely given over to a no-tax ideology, consequences be damned, is dangerous and pernicious.  Let it be noted: I respect Reagan and Bush I because they were able to make the very hard compromises and raise taxes when it was necessary, at least some of the time.  With the current crop of Republicans and their tea-party activists, that trait has been pretty thoroughly purged from the GOP and little ground for reasonable compromise exists.  Is there blame to be apportioned to the Dems?  Sure: they are pusillanimous and ineffective and too often lack the courage of their convictions.  But I need to give them some credit: they tackled the bigger problem in health care and got it done.  What's more, they got it done responsibly.  You may not like the reform law, God knows it's not all anybody could have wished, but like it or hate it, it at least is paid for.  And some Dems will lose their seats over it.  That's more courage than the GOP showed in their years in power.  Health care was either ignored or tackled recklessly.

Dr Bob doesn't have a solution, and neither do I.  We are both mad, and I will be happy to join his "blog protest," especially if we get to carry misspelled signs and paper-maché puppets. I think it will be a lot more effective if we take a moment to understand the problem and the obstacles that are faced in developing a solution.  And I have a challenge to all the patients and physicians who are to join us in our blog protest: come with a solution, or at least be willing to stake out a position.  What programs do you favor taking money out of to fund physician compensation?  Are you willing to raise taxes, and if so, on whom?  Do you think that the SGR cut should be allowed to go into effect, and how should we deal with the resulting access crisis in Medicare if it does?

Come join our blog protest!  But come with ideas, and let's communicate our ideas to our legislators, not just our inchoate anger.


2 comments:

Wise Bass said...

Either we give in and deficit finance the thing, or we don't find a solution.

Hmmm. Taking a bit of a cynical point of view, we could do the former. Yields and interest rates on long-term American Treasury Bonds are still very, very low in spite of all the massive guarantees and spending in the past two years, so why not ride the Gravy Train?

Worse comes to Worst, we can always force the bond-holders to take a haircut while finally - finally - adjusting tax rates and spending to match. There's no way they'd let America default, seeing as how our fall would drag down the rest of the World Economy with us.

/Cynical Opportunist

rcentor said...

The fix is scrapping RBRVS and developing a better payment system. I blogged on it today - Medrants: How should we get out of the SGR mess http://is.gd/cEAZZ