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Health

Former Obama Budget Head Challenges Paul Ryan To Demonstrate How His Budget Would Lower Health Costs

Rep. Paul Ryan’s (R-WI) proposals to control health care spending by slashing the federal government’s contribution to Medicare and Medicaid and shifting that spending on to future retirees or the states, has dominated Washington’s conversation about entitlement reform.

But on Thursday morning, a group of health care economists and former Obama administration officials laid out an alternative approach that could achieve health savings by encouraging providers to deliver care more efficiently.

“Mr. Ryan has had too much running room to go out with proposals that neither will reduce overall health care costs nor will help individual beneficiaries simply because there has not been enough of an alternative put forward by those who believe that we really need to focus on the incentives and information for providers,” Peter Orszag, former director of the Office of Management and Budget under President Obama, told ThinkProgress in an interview at the Center for American Progress.

Republicans have offered a plan that would “shift risk on to consumers” rather than examining whether doctors are prescribing the most effective and efficient treatments. “I would challenge Mr. Ryan and others who support a premium support approach to show an analysis done by an objective entity, like the Congressional Budget Office, in which that type of approach reduced overall health care costs.”

The alternative — which Orszag described as a “centrist proposal” that would “keep the basic structure of the current system” while dramatically improving it — would among other changes, promote privately negotiated payment rates between insurers and providers, increase transparency in prices, and reduce the risk of malpractice claims for physicians. Read the full plan here.

The proposals compliment the delivery system reforms and administrative simplifications included in the Affordable Care Act and have attracted bipartisan support in the past. These changes seek to reimburse providers for delivering care more efficiently rather than paying a separate fee for individual services. They “are all very doable,” Orszag said, adding, “If I had to pick out two or three things to do immediately, I would pick the accelerated towards bundled payments and non fee-for-service payment. We already have the structure in place, the challenge is to kind of ramp it up and accelerate it,” he said. “The second thing, which might be a little more controversial, both substantively and politically is to put forward a more agressive medical malpractice reform.”

“When I go out and talk to heath care groups, if you start out with the fact that you acknowledge that whatever the academic literature says, that it would be beneficial if we could provide more clarity to doctors, the conversation changes. And I think it would be beneficial for supporters of the Affordable Care Act to change the conversation in that way,” Orszag claimed.

Yglesias

Better Institutions Aren’t ‘Less Democracy’

Peter Orszag has what I think is a very good column about the desirability of increasing automaticity in certain aspects of American policymaking that’s been given provocative framing around the idea that America needs “less democracy.”

Provocative framing has a lot of marketing value, but it also provokes lots of people to disagree with you and I saw Orzag’s thesis being subjected to a lot of unwarranted scorn earlier today. I would suggest that people ignore the framing and focus on what he’s actually saying. He seems to have two really concrete suggestions. One is that we should try to enhance the scope of “automatic stabilizers” in American fiscal policy. This is orthodox Keynesian thinking and not something any progressive should have a problem with. The other is that we should strengthen the hand of non-elected boards to make adjustments to Medicare payment rates. Some progressives may have a problem with this on the grounds that cutting spending is a bad idea. But most progressives I know also claim to be admirers of single-payer health care systems that do a better job than America’s of controlling health care costs. The way that they do this is precisely through the sort of technocratic price controls that Orszag is praising.

What I would say on both sides is that framing everything as a conversation around more or less “democracy” is a foolish way to think about institutional design. In a democracy, political authorities are accountable to citizens. That principle is compatible with a wide array of institutional schemes. Electing Supreme Court justices to two-year terms wouldn’t make America “more democratic,” it would make us worse governed. Adopting default rules that strengthen automatic stabilizers wouldn’t be “less democratic,” it would be a good idea.

Yglesias

Peter Orszag Can Defuse Complaints About His Giant Wall Street Payday By Giving The Money Away

Former White House Office of Management and Budget Director Peter Orszag needed a job to do after leaving Washington, and unfortunately for him the only gigs available were high paying jobs for Wall Street banks. And as Orzag makes clear in remarks offered to Gabe Sherman for a New York Magazine profile he’s really upset at the way this paucity of options has left him vulnerable to criticism from people who don’t understand the difficulty of his position. All the man wanted, after all, was a challenge.

What a time it was.

“I could have been totally comfortable doing something easy,” he told Sherman, “going back to academe or a think tank, giving speeches, having a cushy consulting thing—ironically, which would have played off my White House experience much more than what I chose to do. Or I could have done something new, which would be harder.”

You’ve got to respect that. Which is why it’s so tragic that the small matter of his multi-million dollar payday at Citi has turned a man who just wants a challenge into the subject of ire. Fortunately, there’s a pretty easy solution to this problem. Just take the extra money and give it away. Hang on to the salary of an OMB director. Heck, hang on to double the salary of an OMB director and donate the rest of the cash to charity. Maybe give it to a think tank that he thinks is doing good work. Or just hand a check over to the next homeless guy he sees. Oxfam and UNICEF do good work. There are lots of options out there. And in the spirit of self-sacrifice and taking on new challenges, I’d be happy to volunteer to do some research on the subject and write up a memo.

This is all a bit tongue in cheek, but really only a bit. I’ve come to the conclusion that a lot of rich banker types really do feel that all they want is job where they do rigorous, difficult, high-status work and they’re just kind of stuck being despised fatcats who people say mean things about on the Internet. So give the money up!

Media

Orszag and the NYT

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Interesting news:

Peter Orszag, economist and former director of the Office of Management and Budget, will become a contributing columnist for The New York Times Op-Ed page. Beginning Tuesday, Sept. 7, his columns will appear one to two times a month in The Times and online at NYTimes.com/opinion and will cover a broad range of economic and domestic issues, including national fiscal policy, education and health care. In addition to his columns, he will examine these and other relevant issues on The Times’s Opinionator blog.

Orszag has been in jobs where one can’t fully speak one’s mind for several years now and has managed to make a remarkable quantity of thought-provoking on-the-record statements given those constraints so I’m looking forward to this. In a dream scenario, I’d love to see some back and forth and engagement between him and Paul Krugman about some of Krugman’s critiques of the Obama administration but for whatever reason newspapers seem to discourage their writers from actually engaging with one another’s arguments.

Yglesias

Orszag Leaving

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I’m not sure how much there is to say about the reports today that OMB Director Peter Orszag will be leaving next month, but it’s worth observing that this is a high-turnover job. Presidents Clinton and Bush managed to go through eight OMB Directors, one of whom only made it thirteen months.

It occurs to me that one way in which the Obama White House differs from the Bush White House is that many more of its personnel are “characters” each with their own independent profile in DC. So fairly routine comings-and-goings or the inevitable disagreements about policy direction or points of emphasis can wind up looming larger in the media than a comparative context would suggest.

Economy

Baucus And Orszag See ‘Growing Sense Of Inevitability’ For Ending Hedge Fund Manager Tax Break

Sens. Max Baucus (D-MT) and Chuck Grassley (R-IA), and OMB Director Peter Orszag

Sens. Max Baucus (D-MT) and Chuck Grassley (R-IA), and OMB Director Peter Orszag

Last year, the House of Representatives adopted a change (included in the Obama administration’s budget) that ends an inequity in the tax code enabling hedge fund and private equity managers to pay lower taxes on their income. Right now, the percentage of a fund’s proceeds that investors pay to the manager — called the “carried interest” — gets taxed as if it’s capital gains (at a 15 percent rate, instead of 35 percent), even though the manager doesn’t have any money at risk. It’s as if we treated movie proceeds given to a film’s lead actor as investment income.

This long overdue change has yet to be taken up by the Senate, as Senate Republicans have been adamantly opposed to it. “I think it will be difficult [to find 60 votes for the change],” said Sen. Chuck Grassley (R-IA). “A lot of hedge funds have gone belly up,” claimed Sen. Orrin Hatch (R-UT). “Frankly, this administration will raise any tax it can.”

However, Congress has a bunch of very popular business tax credits that it would like to extend, but the extensions need to be paid for, so the carried interest break is looking more likely to disappear. Senate Finance Committee Chairman Max Baucus (D-MT) said this week that there’s “a growing sense of inevitability” about the tax hike occurring, despite heavy lobbying from the financial services industry.

Office of Management and Budget Director Peter Orszag agreed yesterday, predicting that “you’re going to see a change in the taxation of carried interest pass the Senate within the next few weeks.” Orszag then took on the common conservative canard that the tax increase would stifle investment:

Mr. Orszag argued that Wall Street would adjust to a higher tax rate on carried interest, saying he was “unaware of any credible evidence that there would be any significant adverse effect from the increase in taxes”…Mr. Orszag asserted that past tax increases — from those on dividends, capital gains and the marginal income tax rates — did not lead to a big dip in investment and that changes in the tax treatment of carried interest would most likely have a negligible impact on investing.

Hedge fund managers make hundreds of millions of dollars (and often billions) annually. Does anyone really think they will suddenly slam on the brakes if they have to pay the same tax rate as the janitors who clean their offices?

The preferential treatment of carried interest is a bizarre fault in the tax code that only persists because of the power of the financial services industry and Republican resistance to any tax hike at any time. But sooner or later, Congress is going to have to start raising money somewhere, and treating carried interest for what it is — normal income — is a good place to start.

Update

Citizens for Tax Justice released a report today pushing for the carried interest “loophole” to “finally be closed.”

Politics

Orszag: Some who are advocating delay on health care are just trying to kill it.

Late this week, a group of Blue Dog Democrats in the House and six “centrist” Democrats urged their leadership to delay action on health care reform. The White House has been insisting that Congress send him health care legislation by August, a deadline that seems to be fading. CNN’s John King asked White House budget director Peter Orszag about these developments:

ORSZAG: We have to remember: there are some who are advocating delay simply because they don’t have anything to put on the table. The typical Washington bureaucratic game of — ‘if you don’t have a better alternative, just delay in the hope that that kills something’ is partly what’s playing out here.

Orszag clarified that he wasn’t speaking about Blue Dog members or other “members of Congress and Senators who are actually actively participating in the debate.” But, he cautioned, “there are those who are advocating delay just as a desperation move to try to kill this.” Watch it:

A strategy memo authored by GOP consultant Alex Castellanos suggests that “it is crucial for Republicans to slow down what it calls ‘the Obama experiment with our health.’” The memo concludes, “If we slow this sausage-making process down, we can defeat it, and advance real reform that will actually help.”

Yglesias

Orszag on the New CBO Numbers

Responding to today’s new, more pessimistic CBO scoring of the president’s budget in light of the deteriorating economic situation, Peter Orszag was at pains to emphasize that deficit projections are highly sensitive to relatively small changes in assumptions. For example, suppose that first you project revenues of $100 and spending of $103 for a $3 deficit. Then you get some bad news about the economy so projected revenue drops by five percent. Well, suddenly you’re looking at a deficit of $8. The alarming way to put this is that the deficit has nearly tripled. The calm way is that revenue has fallen by 5 percent.

Beyond that, Orszag observes that differences between OMB and CBO projections are normal, observes that CBO’s growth estimate is not only lower than OMB’s, but also lower than the Fed’s and lower than the blue chip forecast. He says that to put the issues in perspective, but “we recognize that the budget resolution will be written off the CBO numbers.” Thus, he reiterates the four main principles that animated the administration’s budget proposal. He doesn’t expect congress to return exactly what they wrote up, but he does expect it to adhere to these principles:

  • “must invest in health care”
  • “must invest in education”
  • “must invest in clean energy”
  • “must cut the deficit in half by the end of his first term”

In general, Orszag downplayed the significance of this report, saying that of course it will be taken into account as congress does its work “it’s not like the process would normally just have them take the budget, xerox it, and vote on it” so we shouldn’t think of congress tinkering with the proposal as being in response to the budget projections as such. “It’s a normal part of the legislative process to take the core things the president wants to get done and then work within those boundaries … beyond that, developments are ongoing and you’ll see the chairman’s marks some time next week.”

Yglesias

Animal Spirits

animal1.gif

For the past few days, I’ve been reading Animal Spirits: How Human Psychology Drives the Economy, and Why It Matters for Global Capitalism by George Akerlof and Robert Shiller. I’ve also been feeling like over the same time span, the Obama administration has shifted its public rhetoric in the direction Akerlof and Shiller would suggest. Turns out this is not a coincidence. Michael Scherer reports:

White House Budget Director Peter Orszag is a numbers guy, a propeller head as President Obama would say. But as David Von Drehle and I write in this week’s print version of TIME, Orszag has been spending his time recently reading not about spreadsheets, but about psychology. In particular, he has been reading a new book by the economists George Akerlof and Robert Shiller called “Animal Spirits: How Human Psychology Drives The Economy, and Why It Matters For Global Capitalism.” [...]

The White House is trying to recreate a sense of confidence by pointing out all the measurements that suggest the sudden loss of confidence may be causing the same irrational result that the confidence bubble created. Of course, the White House must walk a delicate line here, for even the smartest people in the Washington do not know when the markets will stop sinking. No one can predict the animal spirits. As Obama said Thursday, “The market is going to be responding to all this information out there and, you know, the whole issue of animal spirits in the marketplace and when suddenly a rally catches, you know, you guys know that better than I do. But my focus has to be on the long term. And my long-term projections are highly optimistic — if we take care of some of these long-term structural problems.”

Reading: It’s fundamental.

Health

Highlights From The Senate Finance Committe Hearing With Peter Orszag

Today, the Senate Finance Committee held a hearing about President Obama’s Fiscal Year 2010 Health Care Proposals with OMB director Peter Orszag. Below are some highlights.

orszagtestimony.jpg

Orszag on why capitalism and Medicare Advantage overpayments are incomparable:

In a rather heated exchange with Sen. Chuck Grassley (R-IA), Orszag defended the Obama administration’s proposal to eliminate the subsidies provided to insurers participating in the Medicare Advantage. “Capitalism is not founded on excessively high subsidies,” he said.

ORSZAG: I know many people believe that capitalism is founded on private markets, and it is. But I very firmly believe that capitalism is not founded on excessively high subsidies to private firms. That is what this system delivers right now. For every Medicare beneficiary in Medicare advantage, the federal government pays a thousand dollar more than covering the same beneficiary under fee-for-service.

Listen:

Orszag’s approach may have come off as smug or arrogant, but he’s probably right on the substance. It’s unclear why Medicare would pay about 13 to 17 percent more for beneficiaries enrolled in MA Plans, if they’re not providing better quality care (and just pocketing the subsidy.)

And as Orszag points out, for every dollar the federal government provides to Medicare Advantage in additional benefits, it spends $1.30 in costs. “We’re all paying a $1.30 in order to deliver a dollar to a subset 20% of Medicare beneficiaries. I don’t think that’s competition, I think that’s an unwarranted subsidy,” he said.

Orszag on the unintended consequences of the health care crisis:

Many progressives have made the argument that the economic crisis demands health care reform. Chairman Max Baucus (D-MT) asked Orszag about the cost of doing nothing. Orszag checked off the usual talking points but then explained why college students should advocate for health care reform:

ORSZAG: Lots of families are experiencing higher tuition at public universities. Research clearly connects rising tuitions to rising costs of health care in state government budgets, which then means they don’t have room to support public education to the degree they did in the past.

Listen:


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