Interviewer: Ezra Kline
Published In The Washington Post
In recent weeks, we've talked about the administration's idea for controlling health-care costs by allowing the Medicare Payment Advisory Commission to make Medicare reforms without requiring congressional approval. It's a big, bold idea, that first found expression in legislation from Sen. Jay Rockefeller. Late last week, Rep. Jim Cooper introduced a version of Rockefeller's bill in the House. We spoke about the idea this morning, and Cooper's argument is really worth a read. It's not just an argument for his legislation. It's an argument against a broken Congress that's too riddled with special interests and parochial cowardice to perform its basic functions. Many of his colleagues, he argues, don't even know the difference between Medicare and Medicaid. Should they really be in charge of the two programs?
What follows is a lightly edited transcript of our chat. -- Ezra.
You've introduced the companion plan to Senator Jay Rockefeller's MedPAC reform act, which would make MedPAC an executive branch agency and, following a Federal Reserve model, allow it to implement its proposed Medicare reforms without coming to Congress for a vote. Why?
We need to take politics out of health care. Congress will cave to pretty much any special interest on the subject. Meanwhile, we're facing a financial calamity in the growth of Medicare and Medicaid. The financial safety of America is at risk.
I think the MedPAC people do a great job. I've loved their reports for years. But Congress routinely ignores their findings. I think it's very appropriate to elevate their standing.
Now, this is an opening legislative bid. And Congress would retain ultimate control. But it would relieve Congress of a lot of technical responsibilities. By getting expert help and consumer-friendly help, we can improve the situation. A recent MedPAC initiative was to require physicians to report industry relationships. That's a necessary step. But Congress will never do it on its own. All it takes is a doctor complaint from back home and Congress backs off.
You said Congress would retain ultimate control. How?
We could abolish MedPAC entirely. If Congress wanted to intervene with the Federal Reserve, well, we created the Federal Reserve. We could uncreate it. But would you want Congress regulating the money supply? We'd have drowned in inflation, or gone bankrupt, decades ago.
Why take it from Congress at all? Don't seniors and other constituent groups deserve to have their representatives making these decisions. Isn't that the point of our political system?
You remember, a few years ago, how Congress didn't know the difference between Sunni and Shi'a? Ask folks about the difference between Medicare and Medicaid, you'd be surprised.
Do your colleagues confuse them?
Routinely. for example, a lot of my rural friends will say we can't recruit doctors to rural areas because Medicare pays too little. But Medicare pays pretty much market rate. Medicaid pays much less than that. So I'll say don't you mean Medicaid? Then they'll say that they're not on the Health Committee. But these are the most important programs in the country for their constituents!
I hope you understand my motivations, I'm for keeping these programs strong. I'm not for hurting them or eliminating them. My constituents rely on them. We need to keep them strong. Look at issues raised in [Atul Gawande's] New Yorker piece. Tell me how Congress is going to solve that problem. Probably right now the doctors in El Paso, Texas, are saying they want to be paid as much as the doctors in McAllen! And do you think the congressmen in McAllen are saying, "this is terrible, my doctors are being paid too much?" In Congress, it's all pork, all the time.
You know, Alain Enthoven once said that the perfect weapons program would be built in all 435 districts at once and it wouldn't work. Politically, that would be ideal. For national security, it would be a disastrous outcome.
What about the idea of making it a BRAC-style commission that could get a quick vote from Congress rather than a Federal Reserve-stlye agency?
Someone may offer an amendment to make it BRAC style. I could probably settle for that. But as an opening position, I think the Federal Reserve model makes the most sense.
You know, if you read this year's Medicare Trustees Report, on page 209, the dead last page, you'll see the actuary's letter. It says something like, "the preceding report assumes we will cut physician pay by 38 percent over the next few decades." Basically, this whole report is a lie. That's not cost savings. It's putting physicians out of business. We're not doing that. Congress has never, and probably will never, whack physicians by 38 percent. if you base the report on more realistic assumptions, though, Medicare is in trouble a lot earlier.