In The American Prospect: My Take on Jonathan Cohn's The Ten Year War

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I have a review in The American Prospect of Jonathan's Cohn's inside-the-creators' heads chronicle of the ACA's embattled formation and enactment:

Jonathan Cohn, a leading contemporaneous chronicler of the ACA’s formation and enactment, and now author of The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage, is well aware of these shortcomings and faulty assumptions, as well as of the law’s resilience and partial success, such as reducing the uninsured population by about 35 to 40 percent. The book’s chief value, for me at least, lies in illuminating the creators’ perspectives at various crunch points in the law’s conception and enactment.

Cohn takes us back to a long time ago, in a galaxy far, far away, in which Democrats still hoped to win Republican support for major legislation...

The nuance with which Cohn captures the various players' assumptions and motives, and the pressures brought to bear on them, provides some real retroactive clarity, from what already feels like a substantial historical distance. I hope you'll read the review, which relies on substantial excerpts.

Obama's assumptions about healthcare reform, in 2009 and today

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Jonathan Cohn today published an adapted excerpt from his book about the Affordable Care Act, The Ten Year War, coming out on Tuesday. The article's centerpiece is Obama's own assessment of what went right and wrong in the design, passage, and enactment of the ACA.  Of the ACA's basic design, which had become a consensus Democratic by the time Obama was elected, Cohn notes, "It was a far cry from the government-run insurance plan that Harry Truman once championed, but Democratic leaders embraced it as the best they could get..."

 ― and so did Obama, who repeated in our interview his belief that something like a government-run, “single-payer” system would probably work best, but creating one right away would be too difficult. 

“We have a legacy system that is one-sixth of the economy,” Obama said. “The idea that you could, in some way, dismantle that entire system ― or even transition it entirely ― to a single payer system looked politically impractical and probably really disruptive. ... The best chance to actually get people healthier was going to be to design a system that acknowledged 85% of the American people have health insurance and that plugged the gap for those 15% who don’t.”

Obama's neat foreclosure of other possibilities here reminds me of the technique deployed throughout his memoir, A Promised Land, of showcasing his undeniable rationality within a framework bound by self-imposed limits, or limits imposed by his choice of advisers, or -- sometimes -- by what was politically possible.  I see two fallacies here.

Voters understand Medicare-for-all better than Bernie does

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I would think long and hard about contradicting Larry Levitt (of the Kaiser Family Foundation) and Jonathan Cohn (of HuffPost) together on anything but semantic grounds.  But on semantic grounds...I don't think their framing of the results of a Kaiser poll voters' understanding of "Medicare-for-all" is quite right.

Kaiser asked some 1200 voters what the healthcare system would look like "under a national health plan, sometimes called Medicare-for-all." Majorities, varying moderately by partisan affiliation, assumed:

• Taxes for most people would increase 
• People would continue to pay premiums, deductibles and copays for medical services
• People with private insurance would be able to keep their plans
• Private health insurance companies would not be the primary way Americans can get health coverage*
• All U.S. residents would have health insurance coverage

On Twitter, Larry Levitt alluded to "how confused the public is about Medicare-for-all based on our new poll." Jonathan Cohn, who wrote about the results, tweeted, "Voters like Medicare for All, but there's a catch: They don't understand what it'd do."

I don't think the survey respondents and focus group participants were collectively confused, though they're not informed about current bill specifics. I think they're realistic about the furthest likely extent of next-gen Democratic healthcare reform. Their responses lack coherence only to the extent that "Medicare-for-all" can't be understood to encompass "Medicare access for all," particular in the refracted context of a "a national health plan, sometimes called Medicare-for-all."

Underlying Aetna's ACA pullback: Despair of Congress?

In a major scoop, Jonathan Cohn and Jeffrey Young of the Huffington Post obtained via FOIA a July 5 letter from Aetna CEO Mark Bertolini to the Justice Department spelling out that Aetna would cut back its participation in the ACA marketplace if Justice moved to block the company's pending merger with Humana.

Citing Aetna's losses in the ACA marketplace to date and the costs of a busted merger, Bertolini wrote that if  DOJ opposed the merger -- as it did two weeks later -- Aetna would cancel plans to expand its participation in the ACA marketplace from 15 states to 20, and instead cut back to 'no more than 10 states" --- and probably exit the market entirely in future years.

Cohn and Young provide a balanced view of partisan perceptions that Aetna is, in one view, engaging in regulatory hardball (or blackmail) or, in the other, responding to real losses and difficulty in the ACA marketplace.. Probably a bit of both, as Nicholas Bagley suggests  While Bertolini expressed conditional optimism about the ACA marketplace as recently as an April earnings call, Cohn and Young cite an Aetna spokesman's claim that losses have accelerated since then.

Regardless of the precise mix of Aetna's motives and calculations, Bertolini's response to a question about the ACA marketplace* in the April call, quoted by Cohn and Young, is interesting in retrospect. Below is a longer excerpt from his response, with the portion cited by Cohn and Young bolded.

Let me just give you a different basis to think about our participation in the exchanges. We have 911,000 members on the public exchange as individual. We have 1.2 million members that are exchange or ACA compliant.

If we were to go out and buy those members, it would cost us somewhere around $1.2 billion to acquire them. If we were to build out 15 markets, it would cost us somewhere between $600 million to $750 million to enter those markets and build out the capabilities necessary to grow that membership.

So in the broad scheme of things, we are well, well below any of those numbers from the standpoint of losses we've incurred in the first two-and-a-half years of this program. So we see this as a good investment, hoping that we have an administration and a Congress that will allow us to change the product like we change Medicare every year, and we change Medicaid every year.

But we haven't been able to touch this product because of the politics. But if we can get to that point, we believe we are in a very good place to make this a sustainable program.

While Bertolini's letter to DOJ cites the sunk costs of the merger as a reason to cut losses in the marketplace, this earlier statement cites the costs of getting established in the marketplace as a relative bargain (which would in turn become sunk costs if Aetna exits altogether).

So that's one side of the equation. On the other is Bertolini's rueful closing comment about the politics of the ACA.  He suggests that a public benefits program can't be frozen in amber: it requires constant adjustment. Unspoken: Republicans' rooted enmity against the ACA is making such adjustment impossible.

The same point was made implicitly in a report issued yesterday by Georgetown healthcare scholars Sabrina Corlette and Jack Hoadley, laying out Lessons from Medicare as a source of strategies to stabilize the ACA marketplace. The chief (implicit) lesson: get a Congress willing to fix problems as they arise.

The report usefully illustrates that the price spikes and insurer exits that the ACA marketplace is currently experiencing are far from unique, and are in fact par for the course for insurance markets. Similar gyrations have occurred in the Federal Employees Health Benefits Program, state Medicaid managed care programs, and Medicare Advantage. The history of MA is particularly instructive:

 Between 1998 and 2002, the predecessor to today’s MA program (called Medicare+Choice) faced insurers’ decisions to terminate nearly half of the existing Medicare contracts.13 These terminations meant that between 300,000 and 1,000,000 enrollees annually could not stay in the plans they had selected. Terminations occurred disproportionately in rural counties where payment rates were lower. Total enrollment dropped between 1999 and 2003 from 6.4 million to 4.6 million. When Congress increased payment rates, the market stabilized and enrollment grew rapidly. In 2016, there were 17.2 million beneficiaries in Medicare Advantage...

In the wake of high-profile market exits in the Medicare Advantage program, policymakers were able to entice insurers back into the program by increasing payment rates. The Medicare Modernization Act (MMA) of 2003 changed the method Medicare uses to pay plans to a system in which plans bid against a benchmark price that varies geographically. Overall, the new system led to payments to plans that were approximately 10 percent higher relative  to local fee-for-service (FFS) costs from about 2006 to 2010.

These changes, together with other changes described below, led many insurers to re-enter markets they had departed and brought other insurers into the program. Whereas 31 percent of Medicare beneficiaries had no private plan option available in 2000, by 2006, nearly every Medicare beneficiary had access to at least one MA plan. Enrollment more than doubled from 2005 to 2010.

Fixes are (relatively) easy when no one hates a program. A functional equivalent of raising MA payments to insurers in the ACA marketplace would be to improve the premium and cost-sharing subsidies, which many prospective buyers find too skimpy to render coverage attractive -- particularly those with incomes above 200% of the Federal Poverty Level (FPL), the current cutoff for strong Cost Sharing Reduction (CSR) subsidies. At present, most subsidized buyers with incomes over 200% FPL can't afford a plan with an actuarial value higher than 73%, or over 70% for those with incomes above 250% FPL. The latter generally AV translates to deductibles in the $3000-5000 range. To take an example from the Chicago marketplace: If you're a single mother earning $32,000, you just may be willing to pay $175 for a benchmark silver plan for yourself (with your child placed in CHIP) -- but a deductible of $3,500 or $4,500 may make that plan seem close to useless. Boosting the subsidies is one of Corlette and Hoadley's "lessons."

Subsidies were sweeter in the version of the ACA passed by the House in November 2009, which could not be properly reconciled with the Senate bill after Democrats lost their filibuster-proof majority in January 2010.  In the House bill, the benchmark plan for those with incomes in the 200-250% FPL range would have been 85%, vs. 73% in the enacted ACA, and 78% for those in the 250-300% FPL band, vs. 70% in the ACA. Premium subsidies in the House bill were higher for those under 200% FPL, though not for those much above that threshold (and in fact somewhat lower for those over 300% FPL). For those not eligible for cost sharing reduction subsidies, three levels of coverage were available, at actuarial values of 70%, 85% and 95%.There was no AV 60% tier equivalent to ACA bronze, which carry prohibitively high deductibles and copayments for low income buyers.

Improving ACA subsidies would cost money, of course. A Dec.2009 Urban Institute-RWJF analysis estimated that House-level subsidies would cost about 16% more than those included in the bill introduced by Senate leadership in November 2009, which had a subsidy schedule close to that enacted by in the ACA, though with somewhat weaker CSR.  But part of the cost would be offset by improving the risk pool, helping to prevent steep premium hikes.

Other than being funded adequately, there's a more fundamental way the ACA marketplace could be made more like Medicare Advantage: the federal government could be the ultimate payer. In MA, the government sets a benchmark capitated rate for each region, calculated so that insurers can be profitable paying something close to traditional Medicare rates to providers. MA is therefore really neither a "public option" nor a private one; it's a menu of public-private options.  The great advantage is that provider payment rates are controlled, at one remove, by the government. The same is true -- at lower payment levels -- for managed Medicaid plans, and for the Basic Health Plans run under the ACA by New York and Minnesota. I've argued before (once, twice) that the ACA marketplace should be structured this way.

In addition to proposing subsidy sweeteners, Corlette and Hoadley suggest other incremental reforms, such as easing network adequacy requirements for new entries in a a market, or to create a "fallback plan" for markets left with no regular market entrants, or rendering the reinsurance program permanent.

All of those changes, except perhaps the network adequacy requirements, are premised on a Congress motivated to make the marketplace work better. As Bertolini suggested, the first requirement for a program like the marketplace is that it be treated as a perpetual work-in-progress.  It's hard to see that requirement being fulfilled in the foreseeable future. Perhaps the dominant element in Aetna's exit is political despair.

---
* Posed by Anne Gupte of Leerink 

Why the ACA remains unpopular, cont.

Over at the Huffington Post, Jonathan Cohn has teamed up with pollster Mark Blumenthal for a deep dive into why the ACA's approval ratings remain underwater* and why more people continue to say that the law has personally harmed than helped them (though the gap had narrowed. to 22-19 when Kaiser last polled this question in March).

There are two main takeaways: 1) polling results are overwhelmingly partisan, and Republicans are more passionate in their hatred of the law than Democrats are in support of it, and 2) Americans tend to attribute any changes in their health plans -- usually price hikes or coverage cutbacks -- to the ACA. That's especially true of people with employer-sponsored insurance, a third of whom said they'd been hurt by the law.**

While those conclusions are spot-on, and Cohn and Blumenthal provide a nuanced overview of the ACA's effects on various groups, I'd like to throw one sidelight and add a couple of caveats.

First, the sidelight. Noting that the largest category of those who say the law hurt them say it drove their costs up, Cohn and Blumenthal suggest that the perception is not accurate:

Gruber clips inspire powerful condensed defenses of the ACA

On occasion, I've made my case against opinion writers' "paragraph briefs," which make an omnibus case for something by packing disparate and often dubious assertions in comma-separated series.

An often more powerful variant, though still subject to slipping in slugs and ringers, is the link-packed paragraph brief.  These cite an array of evidence in a way that dares the reader not to take the cited authorities on faith -- each of them, maybe a half-dozen, are a click away. Of course, most of us do take most of them on faith most of the time. But the cards are on the table.

The Gruber brouhaha has driven a lot of progressive policy wonks to retrospection -- reviewing the legislative and political history of the ACA while chewing over Gruber's assertions that the process was deceptive and his apparent early impression that federal subsidies to states that built their own exchanges might not be immediately forthcoming.  That process has given rise to what's struck me as two particularly powerful paragraph briefs.

First, Ezra Klein delivers a short legislative history that rebuts the preposterous Halbig/King contention that the ACA's drafters intended to make premium subsidies available only to buyers in state-run exchanges:

If you like your ACA plan, you very likely won't be renewing anyway

Sam Baker and  Jonathan Cohn have both spotlighted a Milliman briefing paper warning of an important potential glitch looming as the ACA's second Open Season approaches. It's this: while the government is encouraging current customers to renew their current plans via auto-enrollment, many customers may see significant price spikes if the plan they selected last year loses its status as a "benchmark" plan.

Subsidies are keyed to the second cheapest silver plan in each market, deemed the benchmark; subsidized customers who buy a plan more expensive than the benchmark have to pay the whole difference. Thus, if the ACA affordability formula decrees that you should pay $30 per month for a benchmark plan with a base premium of $300, and that plan's premium spikes to $350 and it cedes its benchmark status, you'll now be on the hook for $80 per month rather than $30 if you stick with it. To stay at roughly the $30 level, you'll have to switch to one of the two cheapest silver plans on offer this year. (Additionally, if the benchmark plan price goes up, customers' advanced premiums may also go up if they re-apply rather than auto-enroll.)

I wouldn't dream of downplaying this very important potential glitch. But I think it's worth noting an often-unnoticed market factor that will mitigate its impact somewhat: there's tremendous churn in the individual market, and it's likely that half or more of those who enrolled in private plans in 2014 will be looking to renew. Many will have found jobs that offer insurance; some will become eligible for Medicaid; some will marry or move and need to select a new plan in any case. In November 2013, healthcare scholars Rick Curtis and John Graves estimated (with some caveats) that just 42 percent of Americans eligible for subsidized exchange coverage at end of 2014 (i.e., the upcoming open enrollment season) were eligible in the prior year. That doesn't quite tell us what percentage of those currently enrolled in subsidized exchange plans will not be seeking coverage for 2015, but it gives an idea of the degree of turnover.

The ACA preserved state regulation of health insurance

Yesterday I noted that the state-vs.-federal exchange debate within the Democratic party in early 2010 was focused primarily on which level of government would regulate insurance -- and not, as Halbig proponents are suggesting, on whether the "backstop" federal exchange created by the Senate bill would be enabled to issue tax credits.

Both before and after the Scott Brown earthquake, the question was how the Senate and House bills would be reconciled. The House bill created a federal exchange, with an opt-out for states that wanted to create their own. The Senate bill stipulated that states would establish their own exchanges, with an opt-out for those that chose to cede the function to the federal government.

As it turned out, the reconciliation bill that tacked House modifications on the Senate bill did not substantially alter the Senate bill's state exchange structure -- though it did, by the way, include a tax reporting provision that referred directly to tax credits allocated by the federal exchange, a provision that should lay to rest the Halbig contention that ACA tax provisions preclude the federal exchange allocating tax credits.  And although the federal government did end up running most of the state exchanges, in the sense of running the website processing citizens' applications, regulation of insurance, within the broad coverage parameters set by the ACA, remained mainly in state hands.*

Evidence of that retained state control can be found in the varying steepness of 2015 health insurance premium increases in different states. Overall, the rate hikes are in line with or slightly below the increases of previous years. A heat map by PriceWaterhouseCooper indicates that states that ran their own exchanges, and so more actively oversaw the offerings approved for sale, were on balance subject to more moderate increases (Vermont is an exception). From the data that's come in so far (only about half of the states have so far reported wholly or partly on 2015 rates), Jonathan Cohn extracts an illustrative tale of two states:

Tell me your ACA-shopping story

Always fair-minded, Jonathan Cohn pauses in his celebration of lower-than-forecast ACA premiums (as highlighted by the latest CBO update) to acknowledge:

In the transition from the old system, in which insurers could charge higher prices to the sick or avoid them altogether, to a new system, in which everybody pays the same price regardless of pre-existing condition, some young and healthy people must now pay more for their individual policies

The "and" in "young and healthy" is interesting, because, as the conjunction suggests if you look twice, it's not just the young who are paying more under ACA rules. Some if not most healthy older buyers who were in the individual market in 2013 are now paying more -- that is, if no one sharing the insurance has a preexisting condition.*

If you're in the individual market and you're paying more for your insurance in 2014 than you did in 2013, I'd like to speak to you (or, for that matter, if you're unsubsidized and paying less or about the same).  I'd like some detail about what your prior policy covered vs. what your current one does -- what were the tradeoffs. (I wrote up two such stories last month, and I'd like to do more.)

Between Scylla and Charybdis in a hospital bed

The Commonwealth Fund is out with a report*suggesting that the ACA has the potential to reduce the substantial ranks of the nation's underinsured -- those who currently either spend a percentage of their incomes on premiums deemed unaffordable by ACA formulas or who are exposed to out-of-pocket medical expenses high enough to deter them from getting needed care. Jonathan Cohn overviews the core conclusions here.

While affirming that ACA benefits are well-targeted at those likeliest to be underinsured, the report also highlights ways in which the ACA's Qualified Health Plans  (QHPs) may also underinsure -- chiefly via the high deductibles and out-of-pocket cost limits prevalent in bronze plans, selected thus far by 19% of QHP buyers. That much was not news to me. But then the report flagged another underinsurance hazard that brought me up short -- and brought a memory flash. My emphasis below:

A country struggling to share too-high healthcare costs

Jonathan Cohn today posted a roundup of eight health care experts' prognoses for the Affordable Care Act. Among them is Sean Parnell, author of the book and blog The Self-Pay Patient, information sources for those forced to pay all or most or a good portion of their medical expenses out of pocket. Regardless of whether the ACA "succeeds" or "fails," this part of Parnell's forecast is a near-certainty and worth noting:

There will be more Americans who pay directly for more of their health care. The ACA is projected by the Congressional Budget Office to leave 30 million people uninsured, and tens of millions more will get high-deductible plans through exchanges or their employers. These self-pay patients will demand price transparency and discounts for paying in full at the time of treatment, and innovative entrepreneurs will step up to cater to them while ignoring the traditional third-party payment system.

Many have pointed out the irony of Republicans excoriating the ACA for offering high-deductible plans, which conservatives have long touted as a means to promote patient responsibility and cost control. Some reforms intended to make patients weigh costs could be effective if they include the information required to make an informed choice -- e.g., incentives to choose providers with high performance ratings and transparent pricing -- or reference pricing, where the use of a plan-preferred specialist is fully covered, while patients pay the difference if they want a more expensive provider. 

The Wall Street Journal's narrow view of narrow networks

I have see-sawed back and forth between respect for the Wall Street Journal's healthcare reporters and intimations that WSJ coverage of the Affordable Care Act has been skewed toward the negative.

Today's front-page story by Timothy Martin on the prevalence of "narrow networks" in plans offered on the ACA exchanges certainly emphasizes the negative -- without adequate context, in my view.

First, consider the broader context. News this weekend was full of "ACA signup surge" headlines: 1.1 million people have enrolled in plans via HealthCare.gov, and about 2 million overall have enrolled in ACA plans when state exchange totals (not yet fully tallied for the pre-Christmas surge) are added in.  That's well off original projections but signals a significant recovery and acceleration. Today's front-page Journal story is the first since these numbers came in, and mentions them only in passing.

Fair enough, perhaps. The story is about "narrow networks" -- ACA plans that exclude access to many doctors and hospitals within the coverage area. The narrative is built on a McKinsey study finding that 70% of silver plans offered on the ACA exchanges are "narrow" or "ultranarrow" as defined by the study: offering access to fewer than 14 hospitals.

Children first in the acceptance of same-sex marriage

I may later thicken up this post, which has been stalled by a few reading blocks, but just to get the basic idea down...

When I read Justice Kennedy's reasoning on behalf of the children of gay parents in his opinion striking down section 3 of DOMA in U.S. v. Windsor...

This [federal non-recognition of marriages sanctioned by states] places same-sex couples in an unstable position of being in a second-tier marriage. The differentiation demeans the couple, whose moral and sexual choices the Constitution protects, see Lawrence, 539 U. S. 558, and whose relationship the State has sought to dignify. And it humiliates tens of thousands of children now being raised by same-sex couples. The law in question makes it even more difficult for the children to understand the integrity and closeness of their own family and its concord with other families in their community and in their daily lives...

...I flashed back to Jeffrey Toobin's profile of Ruth Bader Ginsburg, which thanks to dysfunction on the New Yorker website I have not been able to access, subscription notwithstanding. According to Toobin, Ginsburg is at least a bit ambivalent about Roe v. Wade, which she thinks may have brought too much change too quickly. Held up as a counter-example was the low profile manner in which gay would-be parents won adoption rights -- in relatively non-adversarial family court proceedings. I can't recall whether Ginsburg had a hand in this, or simply admired the steady under-the-radar progress.

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)

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:

Breaking: U.S. senior benefits means-tested

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:

Progressive consensus and debt ceiling scenarios

Jared Bernstein has a post that crystallizes an emerging consensus on the left regarding our current budget battles:

• Medium-term deficit reduction (10-year horizon, per Simpson-Bowles etc.) is 2/3 done
  
• The last third requires hard bargaining but isn't brain surgery. Cf. Obama in Monday's presser:
  

  The consensus is we need about $4 trillion to stabilize our debt and our deficit, which means we need about $1.5 trillion more. The package that I offered to Speaker Boehner before we -- before the new year would achieve that. We were actually fairly close in terms of arriving at that number.

  
  So -- so if the goal is to make sure that we are being responsible about our debt and our deficit, if that’s the conversation we’re having, I’m happy to have that conversation. And by closing some additional loopholes through tax reform -- which Speaker Boehner has acknowledged can raise money in a sensible way -- and by doing some additional cuts, including making sure that we are reducing our health care spending, which is the main driver of our deficits, we can arrive at a package to get this thing done.

•  The key to our fiscal future is healthcare cost control. The best course on that front is watchful waiting to see how ACA reforms shake out (coupled, I would add on the basis of Obama's 2013 budget and December negotiations with Boehner, with moderate, incremental trims to provider payments and benefits to the wealthy).

Here's Bernstein's sum-up:

In which Henry Aaron talks himself into supporting a raised Medicare eligibility age

Henry Aaron of Brookings, one of the nation's top healthcare economists, has a rather odd perspective on the current brewing battle over so-called "entitlement reform." On the one hand, he focuses his concern on the older elderly, with their ever-dwindling purchasing power, which leaves him less hostile to raising the Medicare eligibility age than other left-of-center economists who acknowledge a need to trim benefits. He is more distressed by proposals to trim cost-of-living increases, e.g. the so-called chained CPU, which seem to strike most observers as a milder, more gradual mode of trimming benefits. Indeed, in the fullness of time, when the ACA is fully up and running and providing affordable care to the uninsured, Aaron favors raising the Medicare eligibility age to expand the ratio of working to retired adults.

On another front, Aaron at once provides historical and comparative data to demonstrate that U.S. senior health and pension benefits are unduly skimpy, and effectively concedes that given our political culture, we need to plan how best to make them skimpier still. He suggests that only by agreeing to benefit cuts can Democrats forestall more radical proposals to shred the safety net, e.g. via private accounts for social security or voucherization of Medicare. At the same time, he argues for benefits that increase with age, with offsets for lower-income younger elderly for whom raised retirement ages are a burden, and for a variety of formulas to shift costs onto the wealthier elderly (his Medicare reforms look something like those proposed by Senators Lieberman and Coburn: providing catastrophic insurance but ending Medigap as we know it, and making the wealthy elderly pay a much higher percentage of the actuarial value of their coverage).

I find it odd that Aaron argues, in effect, for preemptive concessions -- proposing policy choices he regards as less than optimal as a means of forestalling more radical, Paul Ryanesque attacks on safety net programs: 

You want real deficit reduction? Try this...

Like most progressives, I've been pleased to witness Obama thus far refusing to negotiate with himself in the fiscal cliff battle. With his tax proposals and modest proposed spending cuts on the table -- a package derived from his 2013 budget -- it would seem to make sense to let Republicans detail the deeper entitlement cuts they say they want. As Paul Krugman highlights today, the Republican leadership seems unwilling to go on record proposing deep, substantive cuts to Medicare, Medicaid, and Social Security. So the progressive consensus is clear: let them put up or shut up.

Nonetheless, there remain calls among some Obama supporters -- e.g., natch, Andrew Sullivan -- for Obama to "seize the center" and propose more thoroughgoing plans to restrain long-term spending.  And there may in fact be political opportunity for him in doing so -- on his own terms.

Obama can't quite keep it simple

[11/15: several updates at bottom]

In response to the first 'fiscal cliff' question in his press conference today, Obama seemed to shut the door on any alternative to letting the Bush tax cuts for the wealthiest 2% expire -- that is, to raising the top marginal income tax rate. But there was a little sliver of light along the doorjamb, and when Chuck Todd pushed on it, Obama swung the door open.

First, this seemed all but definitive:

QUESTION: You’ve said that the wealthiest must pay more. Would closing loopholes instead of raising rates for them satisfy you?

OBAMA: I think that there are loopholes that can be closed, and we should look at how we can make the process of deductions, the filing process easier, simpler. But when it comes to the top 2 percent, what I’m not going to do is to extend further a tax cut for folks who don’t need it, which would cost close to a trillion dollars.