Will Republicans now learn to hate Medicare payment reform?

HHS and CMS yesterday announced a major expansion of efforts to move Medicare payments away from fee-for-service and toward so-called value-based and bundles payments. The ACA seeded this effort with a host of pilot programs, and the administration is looking to build on the momentum generated, as HHS Secretary Sylvia Burwell writes in the New England Journal of Medicine:

As we work to build a health care system that delivers better care, that is smarter about how dollars are spent, and that makes people healthier, we are identifying metrics for managing and tracking our progress. A majority of Medicare fee-for-service payments already have a link to quality or value. Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018. Perhaps even more important, our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018. Alternative payment models include accountable care organizations (ACOs) and bundled-payment arrangements under which health care providers are accountable for the quality and cost of the care they deliver to patients. This is the first time in the history of the program that explicit goals for alternative payment models and value-based payments have been set for Medicare.

One worry about this initiative: phasing out fee-for-service has until now been a bipartisan goal. A bipartisan "doc fix" bill to update and reform the Medicare payment structure foundered only the question of how to pay for it - necessary because the status quo baked an unsustainable "Sustainable Growth Rate," established in 1997 and "patched" with a payment hike every year, into long-term budget projections.  The doc fix would have transitioned doctors to payments based on "performance scores" and, like the HHS/CMS initiative, encouraged formation of ACOs, medical homes and other structures purporting to foster coordinated care.

A prophet not without honor save in his own party

How many political prognostications hold up well nearly five years later?  Give Republican Cassandra David Frum credit for seeing the landscape clearly in February 2008:

John Mitchell, Richard Nixon’s attorney-general, predicted in 1970: “This country is going so far right you won’t recognise it.” His prophecy was vindicated. Now its time is up: 2008 is shaping up to be the first decisive Democratic victory since 1964 – a 1980 in reverse...

In 2002, equal numbers of Americans identified as Republicans and Democrats. In the six years since, Republican identification has collapsed back to the level recorded before Ronald Reagan. The decline has been steepest among young voters. If they eat right, exercise and wear seatbelts, today’s 20-somethings will be voting against George W. Bush deep into the 2060s. Most ominously, US polls show an ideological sea change: a desire for a more activist government, a loss of interest in the tax question and a shift to the left on most social issues (although not, interestingly, abortion).

The real problem with Obama's June 8 press conference

I am not going to opine on whether Obama's "the private sector is doing fine" gaffe will hurt him in the long run.  Sullivan assumed yes, and when I read his lament I jumped immediately for comfort to Jonathan Bernstein, who, right on cue, assured that ultimately it will matter not a whit. 

I am distressed, though, by a more conscious word choice of Obama's in that June 8 press conference below, though -- on that recalls the political summer from hell, 2011.  Wanna guess what I'm thinking?  I will refrain from putting the (repeated) keyword in italics:

Last September, I sent Congress a detailed jobs plan full of the kind of bipartisan ideas that would have put more Americans back to work.  It had broad support from the American people.    It was fully paid for.  If Congress had passed it in full, we’d be on track to have a million more Americans working this year.  The unemployment rate would be lower.  Our economy would be stronger.

A not-entirely-false equivalence of blame between the parties

Primed by James Fallows,  Greg Sargent, and Steve Benen, I'm on high alert for false equivalence -- reporter's language blaming government dysfunction equally on both parties, when it's Republicans who have taken the filibuster and other means of blocking legislative action to unprecedented extremes while opposing and demonizing a host of policies that they've historically supported.  So the radar started blinking when I came across this in a Financial Times editorial:

For the last three years, the country has been paralysed by a political gridlock that has put its future on the line. Both Republicans and Democrats are to blame – 

 But then, I was stopped by the actual "equivalence":

the Grand Old Party for its callous obstruction of all Democratic initiatives and President Barack Obama for his naïve neglect of the need for muscular leadership.

When the Party of Lincoln started stinkin'

One has to take history according to Gore Vidal, marvelous storyteller that he is, with enough salt to store it for the winter. Add a double dose for his jaded fictional narrators.  But this, from Vidal's 1876 diarist Charles Schuyler, a bastard son of Aaron Burr who's pinned his fortunes all but entirely selfish hope on the Democrats, does capture the by-now-all-but-eternal GOP:

...the noble new party that freed the slaves and preserved the Union is the very same party that is now in cahoots with the crooked railroad tycoons and with the Wall Street cornerers of this-and-that, thus making it hard for a noble creature like Bigelow -- like Stedman? -- to confess to the bankruptcy of what only ten years ago was the last or latest, best or better, hope or dream of an honourable system of government (p. 64, Vintage ed).

We all fail if health care reform fails

Reading first Jonathan's Cohn's account of the uphill struggle to muster enough House Democrats to pass the Senate health care bill with a reconciliation fix, and then Amy Sullivan analysis of how the fragile majoirty that passed the House bill may founder over abortion, I heard myself mouthing former Counterterroism chief Richard Clark's words at the 9/11 Commission hearings: "your government failed you...I failed you."

If Congress does not pass a comprehensive health care reform bill this year, that will constitute a massive collective failure in which we all share.

Republicans will have failed in their callous disregard for the plight of tens of millions of uninsured and tens more millions underinsured Americans,and in their willingness to place political gain ahead of the welfare of the people they are elected to serve. They will have failed in their success at scuttling  the country's best hope of bending the health care cost curve and thus laying the basis for a sustainable fiscal future.

Progressive activists will have failed in their refusal to recognize that for all its concessions to industry and to the spending inhibitions of the most conservative senators in the Democratic caucus, the bill that passed the Senate maintains the capacity to transform our health care system vastly for the better. They will have failed to recognize that the bill's limitations were imposed by the constraints of the Constitution and the filibuster and the U.S. electorate, that it could not be more sweeping than the most conservative Democrats would allow.

Obama: Republican budgeting = Wall Street risk management

As Republicans scream "socialist" at Obama, he is outflanking them by tying Republican stewardship of the economy to Wall Street's reckless mismanagement -- and dramatically contrasting his own budgeting practices and priorities.

While Obama spent two years as a candidate contrasting his proposed menu of investments and tax hikes on the wealthy with "the failed policies of the last eight [seven, six] years," his own budget enables a new level of sophistication in the contrast. Now, the Republicans in his telling are poor risk managers -- while Obama is a long-range planner and investor. From today's weekly address:

My administration inherited a $1.3 trillion budget deficit, the largest in history. And we've inherited a budgeting process as irresponsible as it is unsustainable. For years, as Wall Street used accounting tricks to conceal costs and avoid responsibility, Washington did, too.

These kinds of irresponsible budgets -- and inexcusable practices -- are now in the past. For the first time in many years, my administration has produced a budget that represents an honest reckoning of where we are and where we need to go.

It's also a budget that begins to make the hard choices that we've avoided for far too long -- a strategy that cuts where we must and invests where we need. That's why it includes $2 trillion in deficit reduction, while making historic investments in America's future. That's why it reduces discretionary spending for non-defense programs as a share of the economy by more than 10 percent over the next decade -- to the lowest level since they began keeping these records nearly half a century ago. And that's why on Wednesday, I signed a presidential memorandum to end unnecessary no-bid contracts and dramatically reform the way contracts are awarded -- reforms that will save the American people up to $40 billion each year.

While the budget itself proposes huge outlays for stimulus, health care reform, education, alternative energy and infrastructure, Obama here emphasizes so far rather theoretical and distant planned spending cuts and spending-as-percentage-of-gdp projections dependent on optimistic growth predictions. He has skillfully hedged ambitious spending plans with commitments -- and rhetorical emphases --on long-range budget planning. If promises of future frugality seem a bit easy, it's also true that Obama has laid down a marker, imposing ambitious deficit reduction targets on himself by which he will be measured before his term is out.

Meanwhile, he is only too happy to help Republicans tie themselves to the crony capitalism that enabled the bubblenomics of recent years.

Obama: "Republican values we all share..."

In imagining Obama's acceptance speech, I thought vaguely that he might quote Thomas Jefferson, speaking in his first inaugural address at the victorious end of a bitter factional battle: "we are all Republicans, we are all Federalists." But Obama's personal model is Lincoln, so in his appeal for healing and unity, he chose one of Lincoln's great appeals to unity, the unheeded plea in his first inaugural:

We are not enemies, but friends. We must not be enemies. Though passion may have strained it must not break our bonds of affection.

And with supreme grace, enacting what he spoke, Obama credited that sentiment as an expression of "Republican values...we all share." We are all Republicans, indeed. I guess he did quote Jefferson as well.

More on this magnificent speeech tomorrow.

Obama brings it back to earth in Virginia

Obama seems to have responded to warning bells that he was floating off on elevated campaign rhetoric like the Wizard of Oz in his balloon.

At the Virginia Jefferson-Jackson dinner, he led with a straight electability argument, tied to a more down-to-earth version of his change-our-politics argument, and followed by a laundry list of policy promises. None of it was new, but the proportions were changed. By word count, the policy section was approximately 40% of the speech, compared with slightly more than 10% on Super Tuesday. This speech was a business case for a candidate claiming he can win a broad mandate and use it to push through legislation less distorted by lobbying interests than any other.

Obama began by taking on the mantle of nominee presumptive, moving John McCain up from Exhibit B to Exhibit A of Honorable Policymaker Corrupted by Washington Politics. After the obligatory "good man" gesture, he hit him first on policy and then on process, i.e. flip-flopping for political gain:

Now, John McCain is a good man, an American hero, and we honor his half century of service to this nation. But in this campaign, he has made the decision to embrace the failed policies George Bush’s Washington.

He speaks of a hundred year war in Iraq and sees another on the horizon with Iran. He once opposed George Bush’s tax cuts for the wealthiest few who don’t need them and didn’t ask for them. He said they were too expensive and unwise. And he was absolutely right. [McCain has actually spoken of a 100 year troop presence in Iraq, along the lines of our presence in Japan and Korea, with whom we're not exactly at war, but never mind...]

But somewhere along the line, the wheels came off the Straight Talk Express because he now he supports the very same tax cuts he voted against. This is what happens when you spend too long in Washington. Politicians don’t say what they mean and they don’t mean what they say. And that is why in this election, our party cannot stand for business-as-usual in Washington. The Democratic Party must stand for change.

This time Hillary was Exhibit B of Politician Corrupted by Process -- the better to demonstrate that she was like McCain, or maybe a bit worse with regard to politics if not policy:

It’s a choice between debating John McCain about lobbying reform with a nominee who’s taken more money from lobbyists than he has, or doing it with a campaign that hasn’t taken a dime of their money because we’ve been funded by you – the American people.

That allowed a segue to the electability argument - brought home to the local audience:

And it’s a choice between taking on John McCain with Republicans and Independents already united against us, or running against him with a campaign that’s united Americans of all parties around a common purpose.

There is a reason why the last six polls in a row have shown that I’m the strongest candidate against John McCain. It’s because we’ve done better with Independents in almost every single contest we’ve had. It’s because we’ve won in more Red States and swing states that the next Democratic nominee needs to win in November.

Virginia Democrats know how important this is. That’s how Mark Warner won in this state. That’s how Tim Kaine won in this state. That’s how Jim Webb won in this state. And if I am your nominee, this is one Democrat who plans to campaign in Virginia and win in Virginia this fall.

While arguing electability would normally come across as politics-as-usual, Obama's casting his as hardheaded idealism. His appeal to independents and Republicans is not born of triangulation; his policy pronouncements are liberal straight down the line. That's the best argument for his straight-talk pitch: he's succeeding beyond his liberal base in spite of his policies, not because of them.

Next came the policy prescriptions, nicely salted with arguments as to why he'd be able to get them effected -- including past accomplishments (expanding health coverage and passing middle class tax cuts in Illinois), others' endorsements (Kennedy's statement of faith in his health care commitment), quick-draw contrast with Hillary (why mandates don't help), and promises to get things done in a timely matter (health plan passed in first term, yearly minimum wage hikes).

He ended with a deft two-step that syncs up two halves of his argument: that Democrats have the right policy prescriptions, but that Democrats have been almost as corrupted by political process (over some undetermined period of time) as Republicans have. His solution, he admits implicitly (and refreshingly), is as much a product of the historical moment as of his own abilities: because the electorate has swung left, Democrats can come out of their defensive crouch and advance an unabashedly liberal agenda. Dropping the defensiveness is itself a cure for "broken politics," first because it means being less beholden to polling, and second because reducing the power of lobbyists is a natural Democratic platform plank, since Democrats by creed defend the poor and middle class against the monied interests that wield the vast bulk of lobbying power.

Spelling all that out would make for dull speaking. Obama does it by emphasizing that 'this is our moment" and by reminding us that "hope" has been realized by Democratic leaders in other such moments:

This is our moment. This is our time for change. Our party – the Democratic Party – has always been at its best when we’ve led not by polls, but by principle; not by calculation, but by conviction; when we’ve called all Americans to a common purpose – a higher purpose.

We are the party of Jefferson, who wrote the words that we are still trying to heed – that all of us are created equal – that all of us deserve the chance to pursue our happiness.

We’re the party of Jackson, who took back the White House for the people of this country.

We’re the party of a man who overcame his own disability to tell us that the only thing we had to fear was fear itself; who faced down fascism and liberated a continent from tyranny.

And we’re the party of a young President who asked what we could do for our country, and the challenged us to do it.

That is who we are. That is the Party that we need to be, and can be, if we cast off our doubts, and leave behind our fears, and choose the America that we know is possible. Because there is a moment in the life of every generation, if it is to make its mark on history, when its spirit has to come through, when it must choose the future over the past, when it must make its own change from the bottom up.

This is our moment. This is our message – the same message we had when we were up, and when we were down. The same message that we will carry all the way to the convention. And in seven months time we can realize this promise; we can claim this legacy; we can choose new leadership for America. Because there is nothing we cannot do if the American people decide it is time.

This time, Obama managed to make hope seem pragmatic.

Related posts:
Feb 10: Obama decries the 47% solution
Feb. 5: Hillary's Speech was Better than Obama's
Obama's Metapolitics
Obama: Man, those Klinton Kids are Something
Obama Praises Clinton, and Buries Him

Truth and Transformation

The Washington Post's Eugene Robinson has put his finger on how Obama is hitting Bill Clinton's hot button. The nub is that the 'hope' Obama holds out is that his presidency will surpass Clinton's - that he will play Alexander to Clinton's Phillip:

Bill Clinton's brilliance was in the way he surveyed the post-Reagan landscape and figured out how to redefine and reposition the Democratic Party so that it became viable again. All the Democratic candidates who are running this year, including Obama, owe him their gratitude.

But Obama has set his sights higher, and implicit in his campaign is a promise, or a threat, to eclipse Clinton's accomplishments. Obama doesn't just want to piece together a 50-plus-1 coalition; he wants to forge a new post-partisan consensus that includes "Obama Republicans" -- the equivalent of the Gipper's "Reagan Democrats." You can call that overly ambitious or even naive, but you can't call it timid. Or deferential.

In fact, Obama's pitch for voters to join a coalition that could make him a 'transformational' President has grown more focused and explicit as the Clintons have ratcheted up the ferocity of their attacks. On Jan. 5, in the ABC debate, he said that while Bill Clinton deserved "enormous credit" for "balancing budgets," "we never built the majority and coalesced the American people around being able to get the other stuff done." On Jan. 14, he said that Reagan did build that majority ; he "changed the trajectory of America in a way that Richard Nixon did not and in a way that Bill Clinton did not. He put us on a fundamentally different path because the country was ready for it." Finally, last night in the CNN debate, he said in effect that the Bill Clinton could not do this because the Clintons are not in the habit of telling the truth:

Now, this, I think, is one of the things that's happened during the course of this campaign, that there's a set of assertions made by Senator Clinton, as well as her husband, that are not factually accurate. And I think that part of what the people are looking for right now is somebody who's going to solve problems and not resort to the same typical politics that we've seen in Washington...the larger reason that I think this debate is important is because we do have to trust our leaders and what they say. That is important, because if we can't, then we're not going to be able to mobilize the American people behind bringing about changes in health care reform, bringing about changes in how we're going to put people back to work, changing our trade laws. And consistency matters. Truthfulness during campaigns makes a difference.

And then there's the explicit pitch, that Obama can do the transformational:

What I do want to focus on, though, is how important it is, when you talked about taking on the Republicans, how important it is I think to redraw the political map in this country. And the reason I say that is that we have gone through the 2000 election, the 2004 election, both of which were disappointing elections.

But the truth is that we as Democrats have not had a working majority in a very long time. And what I mean by that is a working majority that could push through the kinds of bold initiatives that all of us have proposed. And one of the reasons that I am running for president is because I believe that I can inspire new people to get involved in the process, that I can reach out to independents and, yes, some Republicans who have also lost trust in their government and want to see something new.

So the pitch boils down to: because I don't lie like a Clinton, or polarize like a Clinton, I can be the transformational leader that Bill was not and that Hillary can't be. Yes, that would bring the blood to Bill's cheeks and the bile to his tongue.

Obama is a complex thinker. As the Clintons have ratcheted up their attacks, he has integrated his response into his critique of Clintonism: according to Obama, their distortions of his record demonstrate why Hillary is likely, as Bill did, to fail to win the trust and therefore the support of a working majority.

Hillary: Don't Tread on Me

I wonder if Hillary is not playing in some sense on people's widespread love to hate her. Watching her tear into Obama, I found myself very disturbed but also thinking that not too many people on earth would want to mess with her. Not to get into tailoring gender-based epithets, I wonder if some won't feel toward Hillary something like what FDR said about the Nicaraguan dictator Somoza: he's a son of a bitch, but he's our son of a bitch....

Perhaps, too, in weighing the pros and cons of attacking Obama without any too-tender regard for scrupulous accuracy, the Clinton team decided to send a message to Republicans: don't tread on me. The old egg fry: this is your candidate on Hillary.

The Lying Clinton Meme

Barack Obama seemed hesitant as he went after Bill Clinton on Good Morning America today - lots of blinking, lots of pauses. Still, this carefully measured stop-lying-about-my-record counterattack may well be effective, because without using the word "lie," Obama chimed several times in several minutes on the Clintons-can't-quite-tell-the-truth meme that is lodged, with good reason, in our collective psyche:

You know the former president, who I think all of us have a lot of regard for, has taken his advocacy on behalf of his wife to a level that I think is pretty troubling...He continues to make statements that are not supported by the facts -- whether it's about my record of opposition to the war in Iraq or our approach to organizing in Las Vegas.

I completely understand his wanting to promote his wife's candidacy, and Michelle is out there doing the same thing on my behalf. But I do think think that there should be standards of honesty in any political discourse. That's part of the change I want to bring about. If you have something that just directly contradicts the facts coming from a former president I think that's a problem because people presume that a former president if going to have more credibility. I think there are certain responsibilities that come with that.

I understand him wanting to promote his wife's candidacy. She's got a record that she can run on. But I think it's important that we try to maintain some -- you know, level of honesty and candor during the course of the campaign. If we don't, then we feed the cynicism that has led so many Americans to be turned off to politics."

What I don't want is a situation in which we are so driven to just win that we are willing to say anything, and over time, you know the American people just get turned off because they don't believe what politicians say (my emphasis).

As is usually the case with Obama, his choice of words displays simultaneously his mode of "fighting" - that is, criticizing his opponents - and his mode of "uniting" - acknowledging the element of legitimacy in his opponent's efforts. (As Mark Kleiman points out today, Obama is "perfectly sincere about wanting to make major progressive change without using demonization as a primary political tactic." That goes for Bill Clinton as well as Ronald Reagan.) His tone was more in sorrow than in anger, his stance that of an adult calling timeout when a child's game overheats. Almost every allegation was couched in either praise of (Bill) Clinton or acknowledgment that his support for Hillary is itself legitimate. The rhetoric was masterful; again, I'm not so sure about the delivery. It's that hesitancy that I think made me lean toward Hillary after watching several debates this past fall.

The moment of Clintonian dishonesty that ABC focused on in the aftermath was not that egregious. According to Bill, Obama “said that since 1992, the Republicans have had all the good ideas." Obama actually said, ``I think it's fair to say that the Republicans were the party of ideas for a pretty long chunk of time there over the last 10 to 15 years in the sense that they were challenging conventional wisdom.''

Okay, Obama didn't say the ideas were 'good,' but generally, challenging conventional wisdom is thought to be a good thing. Perhaps Obama got his time frame wrong; earlier in the interview, he had acknowledged that the American people were ready for Reagan's call to shrink government, strongly implying that doing so was a "good idea": "I think they [the American people] felt like with all the excesses of the 1960s and 1970s and government had grown and grown but there wasn't much sense of accountability in terms of how it was operating." (He might have added, but didn't, that "peace through strength" was a good idea, in that our military buildup pressured the Soviets into attempting the reforms that unraveled their economy.)

Obama made his comment more inflammatory by shifting the time frame from the Clinton years to the present--a frame in which the only "ideas" Republicans have acted on are huge tax cuts for the wealthy, government by lobbyists and budgeting by earmarks, and war of choice to preempt imaginary threats.

Obama is on firmer ground calling Bill Clinton out for dismissing his claim to have consistently opposed the war in Iraq as a "fairy tale." There Clinton was engaging in a classic smear-the-Senator maneuver, mis-characterizing up-or-down votes as complete representations of a policy position. Like most Democrats in favor of withdrawing active combat troops from Iraq, Obama did not vote to cut off funding for them while they're there. End of story.