What price will Republicans extract for CSR funding and reinsurance?

If the current glimmers of bipartisanship in healthcare legislation take on any sustained shine, the primary agenda for Democrats is obvious: appropriate funding for Cost Sharing Reduction payments and for some kind of reinsurance program to replace the program that expired in 2017.

The first is simply a matter of ending sabotage: CSR is integral to the structure of the ACA marketplace and incorporated in its budget baseline. Republicans have simply exploited a drafting error to destabilize the individual market. As for reinsurance, Republicans made its necessity manifest by including generous "stability funding" in the main House and Senate "healthcare" bills -- in fact, overly generous funding designed to compensate for their various disfigurements of the market (e.g., repeal of the individual mandate and measures to reintroduce medical underwriting and non-comprehensive insurance).

To have any real hope of getting these measures passed in a Republican Congress, however, Democrats are going to have to face up to the question: What pound of flesh will they let Republicans extract as payment for these essential, common-sense fixes? It's a foregone conclusion from a progressive point of view that changes Republicans will demand will not improve the market. What concessions might actually win passage and do less harm than the fixes will do good?

"Not losing, choosing"? - Avik Roy turns up the gaslight on the BCRA

Two weeks ago, I took on the argument of various BCRA proponents that most of the 22 million people forecast by CBO to lose insurance coverage should the bill become law would be "choosing, not losing." That write-off of legions of uninsured was founded on CBO's assertion that most of the first-year coverage loss of 15 million would occur "primarily because the penalty for not having insurance would be eliminated."  Expect to hear more of this, I forecast.

In brief, I suggested that argument depended on  1) conflating the forecast immediate effect of mandate repeal in 2018 with the ten-year effect; 2) ignoring the extent to which, in CBO's own telling, the mandate interacts with other changes in the marketplace and Medicaid; and 3) pooh-poohing the obvious and stated purpose of the mandate, which is to boost the ranks of the insured and reduce premiums by improving the risk pool -- which CBO clearly assumes it has accomplished in some measure.

Now here cometh Avik Roy, chief healthcare apologist for the Republican establishment, making the "choosing not losing" argument in detail.  Roy's addition to the argument hinges mainly on a rather breathlessly presented look at CBO's unpublished estimate of 10-year coverage losses attributable to mandate repeal under the BCRA (provided to Roy by a Congressional staffer). This estimate closely tracks CBO's published December 2016 analysis of the effects of repeal of the mandate alone, with the ACA left otherwise intact. CBO forecast that straight mandate repeal under the ACA would result in a ten-year coverage loss of 15 million, as compared to CBO's forecast that 22 million will lose coverage under the BCRA. Here's CBO's breakout of the losses under straight mandate repeal:

Does Avik Roy want to preserve or privatize the Medicaid expansion?

Conservative healthcare wonk Avik Roy, unlike Republicans in Congress, wants health insurance to be affordable for all Americans. But his proposal for an amended AHCA has an enormous hole in it: Medicaid.

Roy favors income-adjusted tax credits, which the AHCA maintains on an interim basis until 2020, with age-based adjustments to the ACA schedule. In 2020, a credit that adjusts only for age (and not sufficiently for that) takes over. Here's Roy's suggested amendment:

If the Senate were simply to remove the House bill’s uniform tax credit and continue the hybrid model past 2019 through 2020 and beyond, the bill would most likely get a better coverage score from the C.B.O. The Senate would be able to direct more financial assistance to those who need it, whether because of old age, ill health or low income. Indeed, the Senate could tweak the exact formulas for age and income adjustment, to maximize the number of people with health insurance in the most cost-effective way.

Under the 2018-19 subsidy schedule that Roy wants to make permanent, enrollees with incomes "up to" 133% of the Federal Poverty Level pay 2% of their income for a benchmark plan.The ACA specifies, however, that eligibility for credits begins at 100% FPL -- and the AHCA does not repeal that provision (and uses the same "up to 133" language in its subsidy schedule).. In states that accepted the ACA Medicaid expansion (after the Supreme Court made it optional for states in 2012), adults with incomes under 133% FPL (138% FPL in practice, because of a 5% deduction), are eligible for Medicaid. What happens to them under Roy's plan? Or to those with incomes under 100% FPL in non-expansion states, who currently are left out in the cold?

"Redemption" threatens the ACA marketplace (and Medicaid and Medicare)

In the post-election nightmare we're now living in, existing Republican blueprints to "repeal and replace" the ACA are newly relevant. Perhaps the most comprehensive plan was published by the American Enterprise Institute in December 2015 and prepared by an all-star cast of conservative healthcare wonks including James Capretta, Yuval Levin, Ramesh Ponnuru  and Avik Roy.

Reading this plan today, I was struck with deja vu stemming from my slow read, nearly complete,  of Eric Foner's Reconstruction: America's Unfinished Revolution, an epic chronicle of the failure of post-Civil War Republicans' efforts to endow the South's freedmen (and pre-war free blacks) with a modicum of political representation and civil rights. Over time, as Republican willingness to enforce those rights militarily waned, the resurgent white oligarchy used terror and violence to disenfranchise African Americans and regain total political control. The toolbox for maintaining that control over decades sounds very contemporary:

Fiscal retrenchment went hand in hand with a retreat from the idea of an activist state meeting broad social responsibilities. “Spend nothing unless absolutely necessary,” Gov. George F. Drew advised the Florida legislature in 1877, and lawmakers took his advice to heart, abolishing the penitentiary, thus saving $ 25,000, and abandoning a nearly completed Agricultural College, leaving the state without any institution of higher learning, public or private. Alabama’s Redeemers closed public hospitals at Montgomery and Talladega and Louisiana’s were “so economical that … state services to the people almost disappeared.” Similar reductions affected provisions for the insane and blind as well as appropriations for Southern paupers, despite the lingering effects of the economic  depression. South Carolina Democrats tightened collections from blacks owing mortgages to the state land commission, producing a “pell-mell rout of Negro settlers.” Public education— described as a “luxury” by one Redeemer governor— was especially hard hit, as some states all but dismantled the education systems established during Reconstruction. Texas began charging fees in its schools, while Mississippi and Alabama abolished statewide school taxes, placing the entire burden of funding on local communities. Louisiana spent so little on education that it became the only state in the Union in which the percentage of native whites unable to read or write actually rose between 1880 and 1900. School enrollment in Arkansas did not regain Reconstruction levels until the 1890s. Blacks suffered the most from educational retrenchment, for the gap between expenditures for black and white pupils steadily widened (Kindle locations 11077-11089).

McKinsey's really important finding: the still-uninsured don't know about ACA subsidies

McKinsey & Company is out with a new survey -- conducted online and in English only -- of participants in the 2014 individual market for health insurance. One headline stat seized on by ACA skeptic Avik Roy (see note below) is that of those who purchased ACA-compliant plans, just 26% reported themselves uninsured in 2013.  That number is apparently at wild variance with HHS' report that of the 5.18 million Healthcare.gov enrollees who applied for financial assistance (95% of the total), 87% reported being uninsured at the time of application.The huge difference is due in large part to these factors:

1) HHS asked those applying for financial assistance whether they were insured at the time of application. McKinsey asked whether they were covered through most of 2013.

2) McKinsey's numbers include people who bought off-exchange -- and people not eligible for subsidies* (as Charles Gaba has noted).

3) McKinsey's respondents were self-selected via an online survey, and the survey was conducted in English only.

The truth probably lies somewhere in between. Charles Gaba estimates that about half of ACA exchange signups were previously uninsured. The question of who was previously uninsured is in any case complex, given the high volatility of the individual market for insurance (and of the job market). According to an estimate by healthcare scholars Rick Curtis and John Graves, less than half the people who will be eligible for ACA enrollment at the end of 2014 will have been eligible a year prior. According to Graves and Jonathan Gruber, 7.6 million people lost health insurance in 2012; approximately the same amount must have gained it.  That kind of churn is perpetual.

While the questions, "how many signups were uninsured?" and "how many paid?" suck up all the political air, the real import of the McKinsey survey (to the extent that it is representative) lies elsewhere, in my view. The survey indicates pervasive ignorance among the subsidy-eligible of what the ACA had to offer them.

Republicans wouldn't scrap the main driver of ACA rate shock

As the reality that millions have benefited from full implementation of the Affordable Care Act takes hold, more and more Republicans are resorting to what Ezra Klein has dubbed Fauxbamacare: propose to repeal the hated law, replace all its popular components without providing any details.

Progressives counter that if you claim you want to make health insurance affordable to all, unless you come out in favor of a single payer system there is no real alternative to the basic structure of the ACA: guaranteed issue (that is, no variation in health plan price based on a person's medical history), an individual mandate or equivalent* to offset the influx of sick people into the risk pool, and subsidies (or Medicaid) for those who can't afford the premiums.

While that's mostly true, it's also true that some plans crafted to current conservative specs look significantly if not radically different from the ACA. The vast majority of Republican elected officials have shied from putting forward such a plan -- or ignored the one put forward by Senators Coburn, Burr and Hatch --  since such alternatives require tough tradeoffs. The main difference is that conservative schemes give insurers more leeway to sell plans with skimpier benefits and lower premiums. They eliminate or vastly reduce the Essential Health Benefits (EHBs) mandated by the ACA. They loosen the allowing "age banding" of premiums -- the degree to which older buyers can be charged more than younger ones -- from the ACA-mandated 3-to-1 to the pre-ACA norm of 5-to-1.

It's true that for healthy people who were buying insurance in the individual market prior to the ACA, the law's coverage rules substantially drove up the premium price. Rate shock is a real phenomenon. As the complaints poured forth, the EHBs were a prime attack point.  "I'm 55 -- I don't need childbirth coverage." "I'm of sound mind -- I don't need mental health coverage."  Limited age-banding was also a rallying point, since the 5-to-1 ratio was based on actuarial calculations.  Why should a 23 year-old pay more so that a 58 year-old can pay less?

These complaints have some legitimacy. The EHBs and age-banding limits involve tradeoffs that can be argued from either side. But they are not the prime drivers of the rate hikes caused by the ACA.

If Republicans win it all, what will they do to the ACA?

I want to make a foray into reporting and ask some healthcare wonks what they think Republicans will do to the Affordable Care Act if they win both houses of Congress and the presidency by 2016.

While Republicans gleefully anticipate the ACA's implosion, ACA supporters assure themselves that repeal is a dead dream, as the ACA has already provided insurance to millions and rewritten coverage rules (e.g., guaranteed issue) in ways that will be impossible to take away. That may be true. But it does seem to me that Republicans in control of Congress and the presidency could ruin the law without repealing it outright.  They could do so out of a combination of antipathy to a law that (colloquially) bears Obama's name and sincere belief in principles such as consumer choice and deregulation.

What Avik Roy won't tell you about healthcare in Switzerland and Singapore

Avik Roy so despises the Affordable Care Act that he wants it to swallow Medicare and Medicaid.

According to Roy's latest sketch of a conservative plan to offer universal health insurance, Medicare and Medicaid are the chief culprit in the United States' uniquely expensive healthcare system -- notwithstanding that they pay less per procedure than private insurers and patients, and that most experiments in alternatives to fee-for-service payment are located within them.

In Roy's free-market healthcare vision, Medicare and Medicaid patients would be transitioned onto deregulated health insurance exchanges, where insurers would be free to offer even skimpier insurance than the current exchange bronze plans, designed to cover just 60% of average patient costs. They might also be free to expand the ACA's age-rating, which limits the ratio of older patients' premiums to young patients' to 3-to-1, and be freed from offering the ACA's minimum essential benefits.

To flesh out this vision, Roy touts the virtues of his two favorite national systems: those of Singapore, which features mandatory individual health savings accounts (HSAs), and  Switzerland, in which everyone buys insurance on private exchanges (subsidized for about a third of the population). But as is his wont, Roy fails to mention the feature that enables each of these systems work: strong government influence over pricing.

Take first Roy's sketch of Switzerland's free market system:

Free market visionary foresees healthcare apocalypse

Free market fundamentalist John H. Cochrane gave himself a Christmas gift on the Wall Street Journal op-ed page on Dec.25, allowing himself to anticipate the Affordable Care Act's certain imminent demise. Then, like a Left Behind acolyte imagining the apocalypse, he moved on to a vision of the new healthcare heaven and earth (liberally adorned with those free market halos, stock tickers):

We need to permit the Southwest Airlines, LUV -0.18% Wal-Mart, WMT +0.42% Amazon.com AMZN +0.95% and Apples of the world to bring to health care the same dramatic improvements in price, quality, variety, technology and efficiency that they brought to air travel, retail and electronics. We'll know we are there when prices are on hospital websites, cash customers get discounts, and new hospitals and insurers swamp your inbox with attractive offers and great service. 

The Affordable Care Act bets instead that more regulation, price controls, effectiveness panels, and "accountable care" organizations will force efficiency, innovation, quality and service from the top down. Has this ever worked? Did we get smartphones by government pressure on the 1960s AT&T T +0.30% phone monopoly? Did effectiveness panels force United Airlines and American Airlines to cut costs, and push TWA and Pan Am out of business? Did the post office invent FedEx, FDX +1.01% UPS and email? How about public schools or the last 20 or more health-care "cost control" ideas? 

In which Ezra Klein shorts Avik Roy

ACA supporters are naturally ticked off that conservatives are now carping at the high deductibles and out-of-pocket maximums in many ACA insurance plans, most notably the bronze ones. Ditto for "narrow networks" -- a limited choice among doctors and hospitals.  The Dish has a precis of complaints from Jonathan Chait, Jonathan Cohn, Kevin Drum and Ezra Klein. Here's Ezra:

What's confusing about this line of attack is that high-deductible health-care plans -- more commonly known as "health savings accounts" -- were, before Obamacare, a core tenet of Republican health-care policy thinking. In fact, one of the major criticisms of Obamacare was that it would somehow kill those plans off. "Obamacare may be fatal for your HSA," warned the Heritage Foundation on 2010. "Health Savings Accounts Under Attack" blared Red State....

Obama's pledge that "if you like your doctor, you can keep your doctor" is also under fire. The issue here is that insurers entering the competitive health marketplaces are tightening their networks in order to cut costs and improve quality. It's worked: Premiums in the marketplaces are far lower than was expected when Obamacare passed.

 This, too, is a success for a longtime conservative health-policy idea..."Narrow networks are not some cruel attempt to limit patient choice foisted upon us by the insurance industry," write economists David Dranove and Craig Garthwaite. "Instead, these plans may provide our best opportunity for harnessing market forces to lower prices."

Fair enough. However, when Klein asks his old healthcare sparring partner Avik Roy to explain the apparent hypocrisy, he lampoons Roy's response without engaging its substance, which is perfectly consistent with Roy's longstanding attack line against the ACA. There are, I believe, internal contradictions in that attack line, and Klein has dealt with them elsewhere. But not here:

The ACA as a framework for (further) conservative healthcare reform

Austin Frakt does AEI's James Capretta the honor of seriously considering* elements of Capretta's attempt (with Douglas Holtz-Eakin) to fill in the long-empty "replace" blank in Republicans' purported "repeal and replace" program for the Affordable Care Act. After spotlighting various lacunae as well as potentially workable elements in Capretta's "decentralized, market-diven alternative to the PPACA," Frakt comes to a core point, implicitly questioning whether conservative healthcare wonks are acting in good faith:

6...Democrats are well aware of the limitations and problems with the Affordable Care Act. Some are so troubling that the administration is considering some interesting proposals that would require Congress to act. Point being, there is leverage for some negotiation on some aspects of the law. And, crucially, some of the things Capretta has proposed fit within the structure of the ACA, such as allowing Medicaid enrollees to buy exchange plans (see Arkansas), capping the employer-sponsored insurance tax subsidy (see the Cadillac tax), or making exchange plans more catastrophic. But that brings me to …

No, 93 million Americans will not lose their health plans under Obamacare

Avik Roy is within his conservative pundit rights in spotlighting the grievances of the estimated 3 percent of the population who may be subject to higher health insurance premiums when the ACA takes full effect in 2014 than they currently pay for plans in the existing individual market.  He descends into partisan hackery, however, in suggesting that tens of millions more will "lose" their coverage as employers' "grandfathered" plans fall by the wayside, as they are bound to do -- and that therefore, "93 million Americans will be unable to keep their health plans under Obamacare."

Roy purports to find a nuclear bomb in interim final regulations for group health plans issued in the Federal Register in 2010:

Contrary to the reporting of NBC, the administration’s commentary in the Federal Register did not only refer to the individual market, but also the market for employer-sponsored health insurance.

Could a "doc fix" have a bigger impact on U.S. healthcare than the ACA?

Two interrelated features of the U.S. healthcare system are probably the primary causes for the uniquely high cost of healthcare in the U.S.: weak government control over pricing, and the fee-for-service payment model.

These interrelated weaknesses are exacerbated, as a weekend Washington Post exposé showed, in that Medicare pretty much lets doctors determine the rates at which they paid, by leaving it to the AMA to produce estimates of how long each procedure takes. Surprise! The doctors' chief trade group massively pads the estimated times required for most procedures. 

Even if procedure prices were based on accurate time estimates, free-for-service incentivizes providers to perform a high volume of the most expensive procedures. Nonetheless, countries in which the government imposes monopsony price control -- i.e., every other wealthy country in the world -- generally manage to deliver universal healthcare at two thirds to half the cost per capita of healthcare in the U.S.  Government control over pricing, as Ezra Klein recently forced healthcare free market evangelist Avik Roy to admit, is the sine qua non of effective heathcare cost control.  And we in the U.S. don't have it, as a study published in Health Affairs ("It's the Prices, Stupid...", Gerard F. Anderson et al., 2003) explains:

"Government-run healthcare," Singapore style

In his long rhetorical war against the Affordable Care Act, Avik Roy likes to hold up Singapore's healthcare system as a shining counter-example. He quite rightly points out that Singapore spends far less on healthcare than the U.S. (4% of GDP vs. 18% for the U.S.), and with better outcomes. How do they do it? Roy -- while acknowledging one aspect of the government's heavy hand --  credits free-market magic:

The key to the Singapore system is mandatory health savings accounts: again, something that libertarians and many conservatives wouldn't like. Matt Miller of the Center for American Progress describes Singapore as "further to the left and further to the right" than the American system--something that could also be said of Switzerland.

In which Ezra Klein makes Avik Roy acknowledge why U.S. healthcare costs are so high

Avik Roy and Ezra Klein had a long --very long -- conversation about Roy's beefs with the Affordable Care Act. They covered "rate shock,"  minimum coverage standards, and Roy's dreams of a more fundamental system overhaul that would push everyone onto healthcare exchanges by privatizing Medicaid and Medicare and ending the employer tax deduction for health care benefit provision. 

Roy has been a relentless critic of the ACA. Having read some of his writings about it but by no means all, I was surprised to learn, as Klein probed his reaction to feature after feature, that he "do[esn't] have* a problem with standardizing benefits" and that "guaranteed issue [no refusals or cost bumps for preexisting conditions]is fine." His objections really boiled down to three: 1) he objects strenuously to "community rating," i.e., the ACA's limiting of the price differential between the youngest and oldest age cohorts to 3-to-1, as opposed to the roughly 6-to-1 ratio that Roy says the market would dictate.  2) He would like the exchanges to offer plans that cover even less than the lowest cost plans in the current design -- plans covering, say, 40% of a member's average yearly costs rather than the 60% that the exchange's lowest-run "bronze" plans are designed to cover. 3) As mentioned above, he would like more radical reform -- health exchanges for everyone.

As Klein eventually made Roy implicitly acknowledge, though, none of his favored solutions get at the root of the United States' disproportionate healthcare inflation.

Who might suffer "rate shock" under the Affordable Care Act?

Avik Roy's much-debated screed implying that the launching of the ACA exchanges will trigger widespread "rate shock" among legions of healthy young people who could previously by insurance more cheaply relies on misleading comparisons, as Ezra Klein, Jonathan Cohn and Rick Ungar charged. None deny, though, that the price of the most minimal available insurance will rise for a subset of healthy young adults

In an essay suggesting that rate shock is real, Will WIlkinson recounts that for a brief time a year or so ago he was paying about $100 a month for a catastrophic plan that he found through the Freelancer's Union (presumably a more honest broker than the scammy online broker Roy relied on).

I clicked through and tried the union's plan-finder with random zip codes in the northeast, south and west; it wasn't until  my fifth try that I found a zip code -- 27108, in Winston-Salem, NC -- in which a UnitedHealth quote was available. If I were my 22 year-old son, I could get a plan for $79 a month with a $10,000 deductible and 70% of expenses paid after that, with a total out-of-pocket expense cap of $15,000 (except that if I were my son I couldn't, because he had hip labral surgery this year, which would doubtless jack up his rate if he were searching now -- see Ezra Klein on this.) For $105 per month, I (or 22-me) can get the same deal with a $5,000 deductible and $10,000 annual cap on my out-of-pocket expenses. (Of course, that's a posted plan from just one provider in one market, and comparing ACA offerings to the current individual market is not just comparing apples to oranges, but 50 different fruits to hundreds of other different fruits. But the offering is roughly in line with what Roy found on eHealthInsurance.com)

Look what the GOP can get for $300 billion

In July 2011, Obama was reportedly ready to sign off on a grand bargain for deficit reduction that would include $800 billion in new revenue and somewhere in the neighborhood of $3 trillion in spending cuts over ten years. David Brooks said that Republicans would be crazy not take such a deal.  And that decision may pay off for them.

If Republicans can stomach the sequester and withstand pressure from defense contractors and other constituent groups, they can close the books on ten-year deficit reduction with some $2.7 trillion in spending cuts and the measly $600 billion in new revenue that Obama unaccountably settled for on Jan. 1 (plus additional interest savings).

The double catch is that even Republicans profess to dislike the sequester's indiscriminate swing of the meat ax, and Republicans also purportedly want to cut and "reform" entitlements -- though they would prefer to induce Obama to do the dirty work on that front.  And the funny thing is that he will -- if Republicans would only give ever so little on revenue. My educated guess is that if they would agree to say $200 billion worth of tax loophole closures or tightenings, Obama will go quite far in altering the structure of Medicare, Medicaid and Social Security.

There's one other catch. Republicans would have stop doing their utmost to strangle Obamacare in the crib. That's their ticket to privatizing Medicaid and Medicare.

Consider the Rubicon on Medicaid that's been stealthily crossed in the last month. Sarah Kliff explains:

Learning to love Obamacare, cont.

Recently, conservative healthcare policy commentator Avik Roy pivoted from a long history of denouncing the Affordable Care Act to acceptance of its status as law of the land and thence to a happy vision of a marriage between Obamacare and Ryancare, whereby seniors are progressively migrated onto the ACA's exchanges, and Medicare's remaining "public option" (traditional Medicare) becomes available to non-seniors on the ACA exchanges.

This pivot highlights the Heritage Foundation pedigree of the ACA: Democrats embraced "premium support" and healthcare exchanges because the combo seemed the only form of universal healthcare provision that Republicans could support; Republicans promptly demonized the effort even as they proposed migrating its structure into Medicare. In any case, the ACA exchanges should indeed serve as a proving ground for the dubious notion that managed competition among insurers will reduce healthcare costs.

A recent article by two partners at Mercer Health and Benefits, a major HR consultant, highlights another effect of the ACA that should cheer conservatives.  The ACA's coverage mandates, Tracy Watts and Eric Grossman assert, have raised the cost of coverage and so led more employers toward a form of health insurance that shifts more costs to policyholders and possibly lowers them overall:

Medicare for all, or Obamacare for seniors? Or both?

Many have noted that the Medicare reform plan included in Paul Ryan's 2012 budget, though sketchy in detail, looked a lot like Obamacare for seniors plus a public option -- the public option being traditional Medicare, which would compete with private plans on an ACA-like exchange.  Throughout the presidential campaign, Ryan emphasized that his plan would not affect current seniors, only kicking in for those under 55 when the plan was enacted.

This year, to meet the GOP target of balancing the federal budget within ten years, Ryan is reportedly planning to move the migration age up.

That possibility has led Avik Roy, the most vocal spox for conservative health reform ideas, to stop worrying, love the ACA, and envision its fusion with Ryancare:

There has been an important development since last year’s House budget: the reelection of President Obama. Obama’s victory means that Obamacare will be implemented, warts and all, making it politically impossible to repeal, even if Republicans are fortunate enough to retake Washington in 2017.

About that conservative soft spot for means-testing

[reposted from 2/22]

Jonathan Cohn had some fun this afternoon with this tweet and article:

‏@CitizenCohn Huge scoop: White House endorses means-testing for Medicare. http://www.newrepublic.com/article/112506/david-brooks-obama-and-medicare …

--  the joke being that Obama's 2013 budget, released a year ago, proposed modest increases in the already-higher premiums that wealthy seniors pay for Medicare Parts B and D.  Legions apparently retweeted Cohn without pausing to note that the "scoop" was a year old and based on information that the White House publicized.

Cohn's post was prompted by David Brooks lambasting Obama for not offering serious entitlement cuts, such as means-testing, in current negotiations to replace the sequester (see Cohn's post for links).  Which highlights a rather odd fact: means-testing Medicare and Social Security has been a Republican talking point throughout the budget wars. They use it either, I imagine, for cover -- see, we're not just about cutting benefits for the poor -- or as a stalking horse for cutting benefits for everyone else. More on that later.

The funny thing about means-testing is that it's functionally equivalent (if arguably less efficient in some cases) to raising taxes on the wealthy, which is anathema to the GOP.  Another funny thing: people don't realize the extent to which benefits for the elderly are already means-tested -- or, if I'm using that term imprecisely, more expensive for the wealthy (and in one case, available only to the poor).  A few facts, then, about our core elderly benefits: