Dean,

You have written at length about the price of drug. Did you read yesterday's USA Editorial about the drug prices? They talked about many insurance company has four tier of drug prices. Some of the drugs in the Tier four could cost someone with health insurance paying up to 100,000 even the drugs are covered.

Don't think this only affects very few people. The number of drugs labeled in Tier four has increased significantly in recent years.

Another compelling case for more efficient financing of drug R&D.

I meant USA Today.

Dean,

Does 'outsourcing your healthcare system' mean that the U.S. and the Europe plans to suck even more trained health professionals from poorer countries?

The statistics on the number of health professionals leaving Africa each year are well known.

Maybe the U.S. should consider fixing its own health system? Rather than pulling even more resources from the rest of the world.

Albert @ Open Budgets

Dean,

I'd love your take on this Forbes article "The New Unions" http://www.forbes.com/leadership/forbes/2008/0225/100.html

I've been thinking for some time that the only effective US unions in 2008 = licensing requirements for a FEW careers such as physicians, air traffic controllers, actuaries, lawyers, etc

Last month I read your "Conservative Nanny State", this only confirmed my hypothesis.

Now the corporate media like Forbes has a take on licensing, what's your counter-take?

Albert,

unless you're going to shoot health care professionals from developing countries if they practice in rich countries, you will not keep them in their home countries. The obvious answer is to have some payment to the developing countries so that they can afford to train and keep more health care professionals.

It is much cheaper to train professionals in developing countries than in rich countries. There is no reason not to take advantage of this fact to the benefit of both sides. We just should make sure that payments are made to the poor countries -- it is much easier and more humanitarian than shooting people who want to cross borders.

Unfortunately this right wing talking point is spreading. MN Governor Tim Pawlenty, often thought of as a likely veep under McCain has been talking like this for years.

It is how he justifies not raising taxes when there is a deficit in the state budget. I heard McCain use this same frame on ABC This Week.

For those of you who don't know Pawlenty (especially since you may learn more about him if selected veep), he didn't win either statewide election for governor by more than 50 percent, his rap name is Less than 50 cent. He also maintained his no new tax pledge by raiding the tobacco settlement money. And the 35W bridge feel down on his watch, with his Lt. Gov as head of MN DOT.

Dean,

Re: "Of course, the reason why the costs of these programs are projected to explode is that health care costs in the United States are projected to explode."

According to this analysis http://www.concordcoalition.org/facing-facts/2007/ff-1220-demographics.pdf demographics account for a very large portion of the projected increase in cost of Medicare -- 46.2% of the increase by 2030 and 36.9% of the increase by 2050 -- the balance of the growth due to excess cost growth of healthcare.

If you disagree with their conclusion, where do you think their analysis has gone wrong in terms of specific assumptions and/or methodology?

thanks.

Brooks,

The figures you cite, and the bit about "the balance of the growth due to excess cost growth of healthcare" works out so that 53.8% of the (projected) increase in healthcare costs as of 2030 and 63.1% as of 2050 will be due to "excess cost growth" rather than demographics. We probably don't want to solve the demographic problem (it would require a solution much like the one proposed for keeping medical personnel in poor countries), but more than half the problem can be addressed without resorting to extermination. We just need to control costs.

Brooks,

You can take a look at CBO's long-term budget projections. It's very clear that most of the cost growth is in Medicare and Medicaid, which is obviously due to health care costs, since people don't get any older in these programs than they do in SS [http://www.cbo.gov/ftpdocs/88xx/doc8877/12-13-LTBO.pdf]. You might find Figure 2-4 especially helpful.

Anonymous,

I wasn't arguing against seeking to reduce excess cost growth of healthcare, just asking Dean to explain the discrepancy between the assertion he, Orszag/CBO and some others have made that demographics play only a very small role in our Medicare problem, something that the Concord Calition analysis contradicts, and to explain why Concord is wrong.

Dean,

I know what CBO said. That's exactly what the Concord Analysis claims to refute. That's why I'm asking you about one vs. the other.

So again, according to this analysis http://www.concordcoalition.org/facing-facts/2007/ff-1220-demographics.pdf demographics account for a very large portion of the projected increase in cost of Medicare -- 46.2% of the increase by 2030 and 36.9% of the increase by 2050.

If you disagree with their conclusion -- if you think demographics is only a small factor in projected Medicare cost growth (as CBO concludes) -- where do you think their analysis has gone wrong in terms of specific assumptions and/or methodology?

Dean, I think you have a "Hostile Student"....

http://c2.com/cgi-bin/wiki?HostileStudent

No, Dean, you needn't shoot them. The government need only earn the enmity of the US government and suffer an embargo. It then becomes very difficult for their medical professionals to immigrate. Thus is the medical care system saved.

Or the Third World country could charge the country to which the medical professional is immigrating a fee to cover the cost of education and training, as well as a restocking fee.

Dean

you are right, but there is another aspect of this people need to try to think about clearly.

even if health care costs are not controlled, the extra cost of Medicare will not be a cost of government. it will be a cost of health care.

if we are going to be living longer and consuming more expensive health care, we are going to need to pay a higher percent of our income for retirement and medical care in old age.

whether we pay that as a "tax" or as "private insurance" we will still pay it.

acting as though we, or the country, can save that money by cutting entitlements is just dishonest, or stupid.

i think it might make some sense to cap the medicare tax and raise the rate as medical costs increase. but i can already see how that would play out politically.

Duncan,

Re: "Dean, I think you have a "Hostile Student""

Nice snark. No, just a student who is hoping to get an actual answer to a staight-forward question. If Dean doesn't wish to take the time to look at the Concord Coalition analysis and tell me where he thinks it goes wrong, fine (disappointing, but whatever). In the past on this blog I've pointed out the discrepancy between Concord's conclusions and those of CBO and Dean on this matter and asked Dean to point out what he considers wrong about the Concord analysis http://www.prospect.org/csnc/blogs/beat_the_press_archive?month=02&year=2008&base_name=bill_moyers_goes_off_the_deepe#comment-6155707. I didn't get an answer then, so I asked again here, although this time I didn't mention CBO. Pointing me to the CBO analysis, while I'm sure Dean intended it to be helpful, is obviously not an answer to my question if I'm asking what he sees as wrong with Concord's analysis and why he considers it wrong.

So...I asked my question again, hoping for an answer this time. Crime of the Century in your book, I guess.

Mr Duncan wrote, Dean, I think you have a "Hostile Student"....

Exactly. From the link you posted: "A hostile student is someone who will say PleaseDoMyHomeworkForMe ... OR ELSE!!"

Which is exactly what Brooks does.

Brooks wrote, In the past on this blog I've pointed out the discrepancy between Concord's conclusions and those of CBO and Dean on this matter and asked Dean to point out what he considers wrong...

Yes, and in the past I've pointed you to the exact section in the CBO analysis which has mathematical formulas explaining how they got their results. But you don't know enough mathematics to evaluate those formulas, so all you can do is point at the Concord Coalition's argument, instead of actually trying to understand the substance yourself.

And as Mr Duncan implies, when Dean or other commenters here refute your position with evidence, you just ask another question because either you can't figure it out yourself or you refuse to.

coberly wrote, if we are going to be living longer and consuming more expensive health care, we are going to need to pay a higher percent of our income for retirement and medical care in old age.

But the problem is with the assumption that health care has to be more expensive. A big, easy way to save money would be to nationalize health insurance (aka "single payer"). Another important way to save money, but which people don't talk about much because it would offend one of the few genuine priestly castes in our secular society (viz, physicians) would be to do away with the crazy, utterly bizarre health care system we have now (where doctors are basically organized as a medieval guild) and replace it with a modern, rational structure.

liberal

i agree. just making an additional point because i think it is important that people understand that the "huge government expense" is not exactly a government expense.

it's not the same as saying 'we all benefit from government spending'

it's a very different thing when your money comes directly back to you.

in the case of SS it is almost certain that you will get your money back, or if you die someone you love will get your money back.

in the case of Medicare you may get your money back, or a lot more than you paid, or not... just like any insurance policy.

you are just using the United States of America as your insurance company because it offers the best rates.

There are 3 fundamental issues with the U.S. health care system that nobody wants to discuss.
1. The cost of education
2. Greed of doctors
3. Kickbacks by Big pharma to doctors.
I truly don't understand why every doctor feels like they deserve to be paid like CEO's of multi billion dollar corporations, but they do.
We should get rid of the AMA and prosecute doctors who take kickbacks from pharmaceutical companies.
My wife worked for a doctor in VA who was making 30,000 per month from his practice and another 14,000 in kickbacks from pharmaceutical companies(second set of books).
He and most doctors should be in jail and the AMA dismantled. The only pupose for the AMA is to limit the number of doctors and to increase their incomes.

Dean,

Agreed, lets leave the shooting to the U.S. government.

The WHO estimates that in Canada, New Zealand, the United Kingdom and the United States, a quarter or more of all physicians have been imported from other countries. Still keen to talk about reimbursing training costs?

And remember that you were talking about getting more than the 25% that you already have.

And just to give a little context (WHO numbers again): The Americas have 10% of the global burden of disease and 42% of the health workers. Sub Saharan Africa has 3% of the health workers and 25% of the burden of disease.

So when you obsess about the state of the U.S. health service, one wonders whether you value African and U.S. lives equally.

A major piece of the bad future is the medicare part B drug benefit passed by the "permanent republican majority" under Bill Fritz and Tom Delay. Bug exterminators make good national policy makers and legislators, right ?

I agree with Bruce Bartlett: The worst piece of legislation ever enacted.

At some point in time, we as a people have to realize that the republican agenda is about bankrupting the country to throw off "New Deal" socialist programs. We are in the midst of a class war in the US.

Albert,

i know the numbers on foreign doctors -- I have written dozens of times that i want to reimburse training costs. The U.S. comes out way ahead in this story by any measure. What do you think the costs of med school is in Uganda or Kenya, $5k per year, maybe $10K? You could double these sums and still end up way ahead if the U.S. paid its doctors what West European countries did.

btw, on valuing African lives, maybe you should take note of the fact that Uganda, Kenya and the other countries losing health care professionals to the U.S. are getting nothing for this loss now. I am proposing a system that gets them something where they would otherwise get nothing. tell me how that devalues their lives.

Brooks,

i have a more than full-time job. Unless someone can show me a reason to think that CBO did their calculations wrong (I have done the same calculations) I don't have the time to spend chasing down all the work that investment banker Peter Peterson funds with our tax breaks.

To reduce costs we could import doctors. But we could also make it easier to travel to those countries to take advantage of lower prices there. The travel and hotel costs are small compared to the procedure costs for many procedures.

Travel would lower costs much more quickly than importing doctors because competition between doctors would impact only those costs and would take many years to reach a full effect. Travel would immediately lead to specialty hospitals with lower overhead.

BTW: My approach to universal health care would also immediately lower costs due to increased competition within whichever legal framework applied. It's at www.plan.bipartisanhealthplan.com

Dean,

Sorry I had not read your "Medicare Choice Plus" before commenting above.

Having read it ... perhaps I missed it ... but you suggest granting vouchers so that seniors could participate in the health plans of other countries.

Do you envisage those companies setting up contracts and institutions in the US; or must US seniors travel to those countries for the service?

Dean,

Re: "i have a more than full-time job. Unless someone can show me a reason to think that CBO did their calculations wrong (I have done the same calculations) I don't have the time to spend chasing down all the work that investment banker Peter Peterson funds with our tax breaks."

I realize you are a busy person and I didn't mean to come across as presumptuous regarding what your priorities should be. And apparently you dismiss a priori what Concord has done because you think they lack integrity and are pursuing an agenda set by Peterson to benefit him personally (I'm sensing that in your comment -- If I'm wrong, please correct me).

But, with all due respect, given how important the question is -- how much of the projected Medicare costs are due to excess cost growth of healthcare vs. due to demographics -- and how often you repeat your conclusion as fact, I would think it would be worth taking 10 minutes to read the analysis to which I linked, and another 10 or 20 minutes to state what assumptions of theirs are erroneous and why. Again, I don't want to sound presumptuous, but I'm just saying that if you're spending a good deal of time blogging -- and I'm glad you are and I'm appreciative of it -- then this would seem to be worth addressing. And your choice not to do so makes me question the defensibility of your (and CBO's) conclusion, and therefore its validity. Perhaps the most valid conclusion is somewhere in between yours/CBO's and Concord's. I don't know. That's why I've asked for your help with this very important question.

Dean,

As follow-up to my comment above, for convenience I'll paste here the relevant portion of the Concord Analysis (relevant to my question, that is). There is a useful table on page 2 that accompanies the text below (I provide link in comment upthread). If you have a few minutes to tell me what you think is wrong with their assumptions or methodology and why, I'd appreciate that help.

Below the dotted line is excerpt from the Concord analysis.

---------------------------

According to the Medicare Trustees, who prepare the most widely accepted long-term projections of Medicare spending, the program’s cost will rise from 3.2 percent of GDP in 2007 to 6.5 percent in 2030 and 9.0 percent in 2050…

How much of this growth is due to demographic aging and how much to “excess growth” in health costs? To answer this question, we need to take into account two distinct demographic drivers: the growth in the number of elderly relative to the total population, or what we will call the “age wave effect,” and the rising average age of the elderly themselves, or what is often called the “aging of the aged.” The growth in the number of elderly as a share of the population adds to spending by increasing the relative number of federal beneficiaries. The rising average age of the elderly also adds to it by increasing average costs per beneficiary. It does so because per capita health costs rise steeply with age, even among the elderly themselves.

We must also agree on a neutral benchmark for future growth in average costs per beneficiary at any given age (that is, in the age-adjusted cost per beneficiary). The most common benchmark, used by both the Trustees and the CBO, is the rate of growth in per capita GDP. One justification for the benchmark is that much of health-care spending consists of labor-intensive services, and so can be expected to increase along with income. Another is that, in a population with a stable age structure, health-care spending
will remain unchanged as a share of GDP if the age-adjusted per capita cost rises at the same rate as per capita GDP.

With this benchmark, assessing the impact of demographic aging is a simple matter of arithmetic. (See technical note [below]) We calculate that it will add 1.5 percent of GDP to Medicare’s cost by 2030 and 2.2 percent of GDP by 2050. Demographic aging thus accounts for 46 percent of the total cost growth the Trustees project through 2030 and 37 percent of the growth they project through 2050.

In Medicare, all of the demographically driven growth between now and 2030 is attributable to the age wave effect, that is to the surge in the number of beneficiaries as Boomers cross the threshold of old age. The aging of the aged plays only a minor role—and indeed, initially pulls down growth as the wave of newly enrolling Boomers actually reduces the average age of Medicare beneficiaries. After 2030, the growth in the number of beneficiaries slows dramatically. However, as the outsized Boomer cohorts age into their high-cost 80s and 90s, the rapid rise in the average age of the elderly also begins to push up spending, partially offsetting the slower growth in enrollment.

Technical Note

All of our calculations use the demographic and economic projection scenarios underlying the 2007 Trustees’ report. Age specific per capita spending data for Medicare are from the 2005 Health Care Financing Review Statistical Supplement.; data for Medicaid are from the 1999 Medical Expenditure Panel Survey.

Our results were obtained using standard compositional analysis. For Medicare, we use the official Trustees projection; for Medicaid, we generate a long-term projection using the same age-adjusted per capita rate of “excess cost” growth assumed by the Trustees. We isolate the impact of demographic aging by comparing the long-term cost projections with the growth that would occur due to the following three demographic changes alone: (1) the change in the number of elderly (aged 65 and over) relative to the nonelderly (age 0-64); (2) the change in the age composition of the elderly; and (3) the change in the age composition of the nonelderly. We make two minor simplifying adjustments: We treat disabled Medicare beneficiaries as “elderly” in calculating the relative change in the number of elderly; and we combine the change in the age composition of the nonelderly, whose impact is very small, with the change in the age composition of the elderly. Neither adjustment materially affects the results.

Brooks,

without checking the Peterson methodology, the numbers do look about right. In the next 42 years, they project that Medicare's costs will increase by 2.2 percentage points of GDP due to aging. CBO has the costs of Medicare and Medicaid together increasing by 2.5 pp of GDP as a result of aging.

By comparison, the costs of these two programs increased by 4 pp of GDP in the last 42 years. I'm not sure why we are supposed to be scared.

I doubt that anyone at the Concord Coalition including Peterson is motivated by venal desires, instead their motivation is largely ideological and driven by a disdain for the New Deal and the theoretical underpinning of the Great Society.

That is it seems they are working back from their conclusion: Social Security bad, Medicare bad. In doing so they simply ignore data that doesn't assist their model. As examples if we examine either Social Security or Medicare as the numbers actually came in since the mid 90's we have a clear trend towards increased solvency in both systems. Which is not to say that we can just ignore the problem, but instead should try to measure the size of this trend and establish the reasons that year in and year out their model fails in the same direction

I don't see Concord or anyone associated with the 'Entitlement Crisis' narrative discussing alternative economic and demographic assumptions or even acknowledging that such things exist. They don't even raise them to dismiss them, they simply refuse to go there at all.

The reason I don't trust Concord or Cato is that they have been proven over the years to not be trust worthy or particularly intellectually honest.

No one I know has successfully refuted the central thesis of 'Phony Crisis':
"Now add this: most of the people who say they want to fix the roof actually want to knock holes in it."
When I see Peterson or someone from Cato coming my direction with a hammer I am not about to grant them the assumption that all they are really concerned about is roof integrity. That is because I have examined some of their past work in this area and been less than impressed by the shoddiness of their work.

"A major piece of the bad future is the medicare part B drug benefit passed by the "permanent republican majority" under Bill Fritz and Tom Delay. Bug exterminators make good national policy makers and legislators, right ?"

Well I don't agree with Bruce Bartlett on Medicare Part D (Part B is out patient) mainly because his opposition is largely ideological and driven by his opposition to big government. This doesn't come out clearly when he is posting to Economics blogs but is clear as a bell when visiting the archives of his (now defunct) blog Bartlett's Notations. He is a down the line Movement Conservative Republican that happens to write well-informed pieces on economic topics.

Medicare Part D was an excellent innovation that was simply ineptly implemented in a way that deliberately benefited Big Pharma. The previous setup was ridiculously inefficient, designing a health system where you can only get paid for medication is during hospitazation was kind of crazy.

Properly structured the preventive care available by having drugs available through Part D offers at least the chance of significant cost savings on the Part A (Hospital) side. Imagine if we had everyone in America on the right combination of blood pressure and cholesterol control medications, potentially we could shut down whole wards.

Now that it exists Part D is fixable and can prove to be part of the solution rather than being seen just as part of the solution. Medication is an integral part of modern medical care in a way that it maybe wasn't in the 1960s, excluding it from a government medical program is just bad medicine.

Dean,

Thank you for your answer.

Re: "without checking the Peterson methodology, the numbers do look about right."

Well, their numbers say that "demographic aging ... will add 1.5 percent of GDP to Medicare’s cost by 2030 and 2.2 percent of GDP by 2050. Demographic aging thus accounts for 46 percent of the total cost growth the Trustees project through 2030 and 37 percent of the growth they project through 2050."
(1) So you agree, then, that demographics are very far from an inconsequential factor in the projected growth in Medicare cost as a percent of GDP, and are an even larger factor in the projected growth in entitlements as a whole including Social Security, which is not due at all to excess cost growth of healthcare, and is driven obviously by demographics*, right?

(2) Therefore, don't you think that it is at best a gross overstatement to say what you said in quote below?

"Robert Samuelson has yet another diatribe talking about the budget breaking cost of "Social Security, Medicare and Medicaid." As CBO director Peter Orszag has tried to teach those willing to learn, the problem is health care, not aging." http://www.prospect.org/csnc/blogs/beat_the_press_archive?month=01&year=2008&base_name=the_post_attack_on_social_secu#comment-6144154

Or to use the word "the" in your statement in the post of this thread when you say "the reason why the costs of these programs are projected to explode is that health care costs in the United States are projected to explode"

Re: "By comparison, the costs of these two programs increased by 4 pp of GDP in the last 42 years. I'm not sure why we are supposed to be scared."

First, per the Concord document, the Medicare Trustees project Medicare's cost to "rise from 3.2 percent of GDP in 2007 to 6.5 percent in 2030 and 9.0 percent in 2050". Needless to say, this is projected to coincide with very substantial growth in Medicaid and Social Security as percentages of GDP, which is obviously imnportant context.

(3) So, are you suggesting that we have no huge problem of projected long term fiscal imbalances under current policies, and that growth in Medicare is not the (or even "a") major component in the growth of these imbalances over the next several decades?

* Per The Concord Coalition analysis: "Including all three major entitlement programs—Social Security, Medicare, and Medicaid—demographics will add 3.5 percent of GDP to the federal budget by 2030 and 4.4
percent of GDP by 2050, accounting for 57 percent of total spending growth over the first period and 45 percent over the second, assuming a per capita GDP cost neutrality benchmark. The corresponding figures assuming a per worker GDP benchmark are 63 percent and 50 percent."

Bruce Webb,

You've made it clear that you don't trust Concord and you think they are being dishonest in pursuit of their supposed agenda.

If you wish to address what, if anything, you see as invalid in their analysis, by all means please do so. In other words, if you can, it would perhaps be helpful if you would address their argument rather than just stating your suspicions of their motive and lack of integrity.

Brooks, they like you simply refuse to enter into a data infused debate that would open Intermediate Cost assumptions to discussion.

Because their economic and demographic model can be and have been shown to be crappy time and again. I don't have to examine their methodology. Their work is subject to the GIGO problem, Garbage in yields Garbage out.

If you can point to something Concord published that explicitly defends using Intermediate Cost assumptions I will be glad to take a look at it. But in more than a decade of posting on this I have yet to see any rigorous analysis of the actual numbers in the data table in relation to the fact that IC assumptions are consistently off and in the same direction.

We had a string of years from 1997 to about 2003 where actual average performance fell outside the confidence interval with the result of depletion pushed out from 2029 to 2041. When I read the 1998 Report and saw the dramatic improvement in outlook in a single year, two questions popped into my head. One what caused this one year change to a 75 year outlook? Two is the process likely to continue? Well I answered those two questions to my satisfaction and in the ten years since have been asking them of everyone else only to have them, like you simply refuse to engage on the actual data.

To repeat: their analysis is invalid because it relies on a bad model. Concord either has not examined the assumptions underlying their analysis, which makes them incompetent hacks. Or they have and decided to shade their analysis in a predetermined direction, which makes them dishonest hacks.

Bad models yield bad results. People who make solvency arguments that end up in 'crisis' have an obligation to explain why the consistent improvements we have seen over the last ten years should not continue. They have not in fact even raised the issues brought forth by the continual improvements in the date of depletion and continual shrinkages in the projected payroll gap. Instead they duck the whole set of obvious questions. As do you.

Look you would have to be blind to study Social Security and not notice that the numbers were changing in a way that suggest medium term outcomes better than Intermediate Cost assumptions and so a much better ultimate result. Which leads me to believe these people are willfully blind hacks.

Brooks,

Do you have your answer? Essentially, in predictions, both methodologies can be sound, and yet one will be a better prediction. Dean's methodology assumes control over costs, either by rationing or by lowering input cost, will solve the Medicare riddle, because the demographic bubble can be handled by prioritizing taxing and spending. Simply put, Medicare will not be able to sustain crazily-increasing healthcare costs, and neither will the private insurance system. (If you haven't noticed.)

The concord methodology assumes that we won't ever get those costs under control. But it should be obvious that they have no interest in any scenario that isn't doomsday for Medicare. Therefore, why bother with their analysis? The CBO has pessimistic forecasts as well.

Here are some more facts, and I expect you to provide thorough research and analysis if you plan to question them:

1. At the present rate, severe rationing will take place soon anyway. Private insurers do a lot of rationing now, and they will be doing even more as they lose ratepayers. Medicare rationing will be easier to stomach if it is similar to what's going on in the private sector.

2. The Medicare part of the equation can be vanished by moving to universal, single-payer coverage. This would unify the books, give everyone a stake in the current state of the program, and "save" social security in one fell swoop because the Medicare problem won't be rolled into the numbers.

Does anyone know offhand (I'm not expecting research here) what the total cost of medical care as a percentage of GDP would be over the same period, assuming no change in the overall system?

Bruce Webb,

Re: "Brooks, they like you simply refuse to enter into a data infused debate that would open Intermediate Cost assumptions to discussion."

Like me? When did I refuse to enter into such a discussion? Which assumptions are appropriate for projecting the degree/length of SS "solvency" is certainly irrelevant to the point I've made previously regarding SS "solvency". In other words, I could grant you, arguendo, that your assumptions and your projections are correct (and that others are overstating SS cost in their projections), and it wouldn't have anything to do with my point.

As for the Concord analysis, when you refer to Intermediate Cost assumptions, does that pertain only to SS or to Medicare as well? If only the former, I'm still left without any refutation of their analysis and conclusion regarding Medicare (and Dean said regarding their Medicare numbers "the numbers do look about right"). So if your disagreement with their use of Intermediate Cost assumptions pertains only to SS, do you see anything erroneous in their analysis and conclusion regarding Medicare, which is the focus of my query?

liberal,

I don't want to get into another unproductive, uncivil exchange with you, so I won't respond to your insults.

Re: "in the past I've pointed you to the exact section in the CBO analysis which has mathematical formulas explaining how they got their results."

I can usually find in a CBO document where their mathematical forumulas are. But you are simply misunderstanding my question. Dean and Orszag/CBO seemed to be saying that demographics (as opposed to excess cost growth in healthcare) are only a very minor factor in projected Medicare growth and even in overall entitlement growth. The Concord analysis reached a strikingly differenct conclusion. I've asked Dean (and anyone else) to point to what, if anything, is wrong with Concord's assumptions or methodology, and why those assumptions/methodology are invalid. If you think referring someone to the mathematical formulas used by CBO constitutes an answer to that question, again, you are simply misunderstanding the question.

Please drop the insults, or if you just can't, at least couple them with valid, relevant points or useful questions.

yes, i have been absolutely 100 percent correct in saying that there is no reason for people to fear the problems to the budget from demographic change. they are no different than what we have seen in the past and they are dwarfed by the problem of rising health care costs, both in the private an dpublic sector.

The Concord Coalition is trying to mislead people by mixing the two. If we fix health care, then the demographic issues are easily dealt with. If we don't fix health care, then we are totally screwed so there is no reason to worry about the demoggraphics.

It's sort of like worrying about termites when your house is on fire. Thats' probably being a bit too generous to Pete Peterson and the Concord Coalition.

By the way, as budgetary matter it is misleading to count SS an increased cost until after 2046 when its trust fund is projected to be depleted. Under the law, its additional costs are debt repayment, not SS spending.

Mr. Duncan (and Dean),

Thanks for offering a possible explanation.

Re: "Dean's methodology assumes control over costs, either by rationing or by lowering input cost, will solve the Medicare riddle...The concord methodology assumes that we won't ever get those costs under control."

If that is what accounts for the difference in their projections (essentially that one scenario assumes fundamental changes in our healthcare system that will very substantially lower costs, and the other scenario does not), it would be helpful if Dean would say so himself. I don't know if that is or is not the explanation for it. And Dean has said about Concord's Medicare projections "the numbers do look about right", which implies that there is no discrepancy to explain (between CBO's breakout of the impact of demographics vs. the impact of excess cost growth of healthcare). Yet CBO and Dean assert or strongly imply that CBO's and Dean's own analysis prove that demographics (aging) is not a major factor in projected Medicare cost growth. So:

1) Regarding how much of projected Medicare cost growth is due to demographics vs. due to excess cost growth of healthcare, is there or is there not a large difference between what Concord is saying vs. what Dean and CBO are saying?

2) If the answer to # 1 is "no", and then, given that Concord's projections attribute a substantial portion of the cost growth to demographics (46% through 2030 and 37% through 2050), isn't it wrong for anyone to assert or imply that demographics is not a major factor in this growth?

If the answer to # 1 is "yes" (as I think it is, which is largely why Concord wrote the piece, although they also addressed Medicaid and SS), perhaps your explanation accounts for the difference. I really don't know, which is why, if that's it, it would be helpful if Dean would say so (but it seems he's already answered "no" to question # 1, which would mean there is no significant difference to explain).

Based on reading the excerpt below from the Concord report, it's not at all clear to me that your explanation is the answer (I'm not saying it isn't; just that I don't know). They seem to start with the methodology of CBO and the Trustees, and then apply what (on the surface at least) seem to be straight-forward calculations. Excerpt below:

"We must also agree on a neutral benchmark for future growth in average costs per beneficiary at any given age (that is, in the age-adjusted cost per beneficiary). The most common benchmark, used by both the Trustees and the CBO, is the rate of growth in per capita GDP. One justification for the benchmark is that much of health-care spending consists of labor-intensive services, and so can be expected to increase along with income. Another is that, in a population with a stable age structure, health-care spending
will remain unchanged as a share of GDP if the age-adjusted per capita cost rises at the same rate as per capita GDP."

"With this benchmark, assessing the impact of demographic aging is a simple matter of arithmetic. (See technical note [below]) We calculate that it will add 1.5 percent of GDP to Medicare’s cost by 2030 and 2.2 percent of GDP by 2050. Demographic aging thus accounts for 46 percent of the total cost growth the Trustees project through 2030 and 37 percent of the growth they project through 2050."

"Technical Note"

"All of our calculations use the demographic and economic projection scenarios underlying the 2007 Trustees’ report. Age specific per capita spending data for Medicare are from the 2005 Health Care Financing Review Statistical Supplement.; data for Medicaid are from the 1999 Medical Expenditure Panel Survey."

"Our results were obtained using standard compositional analysis. For Medicare, we use the official Trustees projection... We isolate the impact of demographic aging by comparing the long-term cost projections with the growth that would occur due to the following three demographic changes alone: (1) the change in the number of elderly (aged 65 and over) relative to the nonelderly (age 0-64); (2) the change in the age composition of the elderly; and (3) the change in the age composition of the nonelderly."

Later in the document, addressing the discrepancy between their results and those of CBO, they write the following, which actually seems to be the opposite of your contention that the explanation lies in an assumption by Dean (and CBO) that there will be greater cost containment than assumed (apparently) by Concord (and by the Medicare Trustees).

"Many of those who assert that demographics only account for a small portion of the future growth in entitlement spending do so on the basis of partial and misleading measures... The CBO, whose recent study concludes that aging accounts for only one-quarter of the growth in federal health spending through 2030 (and much less than onequarter thereafter), also fails to take all of the demographic dynamics into account. Surprisingly, it entirely overlooks the impact of the aging of the aged on Medicaid. Its conclusions contradict earlier CBO analysis, whose larger estimates are completely consistent with our own.*"

"Some adherents of the new budget school also minimize the importance of demographic aging by assuming
rates of excess per capita growth that are much higher than those used in the Trustees’ projections, especially in the long run. The CBO, for example, closely follows the Trustees through 2030, but assumes a higher rate thereafter."

"* See The Long-Term Budget Outlook (CBO, December 2003) and The
Long-Term Budget Outlook (CBO, December 2005)."
Re: "But it should be obvious that they have no interest in any scenario that isn't doomsday for Medicare."

Why do you assume that they want to eliminate Medicare? Based on what? Can you point me to something they've said/written that advocates or implies such a position? Or are you saying they keep that goal hidden? If so, I still ask, on what basis do you attribute such a radical agenda (elimination of Medicare) to them? There must be something more than the document to which I linked to justify such an assertion about them, right?

Re: "1. At the present rate, severe rationing will take place soon anyway. Private insurers do a lot of rationing now, and they will be doing even more as they lose ratepayers. Medicare rationing will be easier to stomach if it is similar to what's going on in the private sector."

I'm not well-informed on healthcare policy, but based on the enormous, unsustainable fiscal imbalances we face over the next several decades, it seems inevitable that we will spend much less on entitlements, including Medicare, than current projections (even with tax increases, which are also inevitable). Even if we can achieve systematic, cost-saving change in our healthcare system and reduce or even eliminate excess cost growth, given that a large part of the growth in entitlements, including in Medicare, is due to unavoidable demographics, yes, that will mean "rationing", probably in a variety of ways -- reduced medical coverage, means-testing, etc.

Re: "2. The Medicare part of the equation can be vanished by moving to universal, single-payer coverage. This would unify the books, give everyone a stake in the current state of the program, and "save" social security in one fell swoop because the Medicare problem won't be rolled into the numbers."

I'm not sure what you mean by "vanished", and I'm not sure what you mean by "sav[ing]" Social Security, not do I understand what you are asserting in that statement.

Dean,

Re: "It's sort of like worrying about termites when your house is on fire."

Using your metaphor, do you really think one factor accounting for about 40% of a problem can be thought of as "termites" and the other factor accounting for 60% of the problem as "fire"? (Concord's analysis, the number of which you said "do look about right", concludes that "Demographic aging thus accounts for 46 percent of the total cost growth the Trustees project through 2030 and 37 percent of the growth they project through 2050.")

Re: "By the way, as budgetary matter it is misleading to count SS an increased cost until after 2046 when its trust fund is projected to be depleted. Under the law, its additional costs are debt repayment, not SS spending."

From the standpoint of our fiscal imbalance and it's implications for taxation, spending and impact on everyone's standard of living, that's a distinction without a difference. And it's not even a completely appropriate distinction. It would be if none of the ongoing cost of SS were financed by ongoing taxation (only from repayment of the bonds currently in the "trust fund"), but as you know, much of SS spending will indeed be financed through ongoing taxation.

But more importantly, and back to my point that it's a distinction without a difference, I'm concerned with our projected long-term fiscal imbalances and the need to reduce them to a sustainable level (of publicly-held debt-to-GDP, to be precise) one way or another. If projected SS spending is X or is X+10, and there is no money in the bank saved for it, what difference does it make what we call it?

I realize people have paid in and have been promised a particular level of benefits, so from that perspective, I understand why the "repayment of debt" distinction has meaning, although I think it is itself misleading, as I've asserted above, but if we're talking about the problem of our long-term fiscal imbalance, how bit it is, what would mitigate it, etc., that technical, semantical (and somewhat misleading) distinction is not very meaningful.

Brooks,

the fire is what the broken health care system is doing to the economy. It is utterly absurd that the Peterson crew effectively has the country worried about what a nuclear war will do the budget, and therefore trying to adjust its tax and spending to make it affordable, rather than preventing nuclear war.

The problem is a broken health care system. The costs associated with aging are easily affordable (we paid them in the past), and if people like Pete Peterson didn't have so much money and power, no one would be worrying about them.

Dean,

(1) If about 40% of projected Medicare growth and about 50% of total entitlements growth is due to demographics, then even if we substantially reduced excess cost growth of healthcare, we'll still have huge growth in entitlements, right?

I don't think anyone serious -- certainly not Concord Coalition -- denies that cost-saving structural changes to our healthcare system will be necessary (in fact, if you read that short document to which I linked, you can see Concord saying that such changes will be needed), but the point they (and I) are making is that painless changes in our healthcare system will not even come close to achieving sufficient savings to solve the problem of our enormous long-term fiscal imbalance, nor will such savings combined with tax increases be sufficient, so we will need to make real sacrifices on the spending side as well as increasing revenues via tax increases.

(2) Do you disagree? In other words, do you think that it is both desirable and politically feasible to try to solve our long-term fiscal imbalance solely through relatively painless changes in our healthcare system, combined with tax increases and (I presume) cuts in the Defense budget, as opposed to all of the above plus real sacrifices in entitlement spending (reduced eligibility and/or reduced benefits)?

Brooks wrote:

"do you think that it is ...feasible to try to solve our long-term fiscal imbalance **solely** through relatively painless changes in our healthcare system, combined with tax increases ...[without] real sacrifices in entitlement spending ...?"

Not for one minute!! But I would also be interested in learning how you would go about quantifying entitlement reductions in a way that best preserves social justice.

Brooks,

yes, i absolutely think that if we fix our health care system then we can afford the projected increases in the cost of the entitlement system, just as we did over the last 40 years. People on average will have far higher after-tax incomes, even if we do it all on the tax side.
i have never seen a serious case why this would be a problem -our tax rate in 2050 would still be far lower than in most European countries today. what is the problem in this story?

Dean,

First, thanks for a straight answer.

As for your answer, you are saying that "yes", you think that it is both desirable and politically feasible to try to solve our long-term fiscal imbalance solely through relatively painless changes in our healthcare system, combined with tax increases and (I presume) cuts in the Defense budget, as opposed to all of the above plus real sacrifices in entitlement spending (reduced eligibility and/or reduced benefits).

You are an economist and I am not. Nor do I know much about healthcare policy and the potential savings from changes in our healtchare system, whereas you have done considerable analysis on that subject.

Having said that, while I, as a layperson, looking at the size of the projected imbalance, think intuitively that the answer is "no" rather than "yes", what carries more weight in my book is the consensus of economists and other relevant experts across the political spectrum, which seems consistent with my "no" and at odds with your "yes".

To the best of my knowledge, your view is extremely contrarian, outside the consensus of even "progressive" policy experts (e.g., from Brookings). Do you agree?

And have you seen this paper http://www.brookings.edu/~/media/Files/rc/papers/2008/04_fiscal_future/04_fiscal_future.pdf before? If you haven't, I'd appreciate any comment you may have. It seems to be the result of experts across the political spectrum trying -- and managing -- to at least find a few things they can all agree on, things that are apparently obvious to everyone. Yet you disagree with some of the key things on which they can all agree. In that light, with all due respect, hopefully you can understand why I'd be very skeptical of your view. Is there something they are all just getting way wrong that you are getting right? And if so, why would they all miss what you see?

Straight Talker,

Re: "I would also be interested in learning how you would go about quantifying entitlement reductions in a way that best preserves social justice."

I don't have the expertise to "quantify" the ideal level of various entitlement reductions. Of course it must be done compassionately. We face tough choices and major sacrifices, and we have to choose among bad options, all of which harm people -- different groups of people to different degrees. I think means testing is one appropriate policy BECAUSE of my concern that we cut spending compassionately. Given that we face scarcity and a choice of who gets harmed how much, I'd rather see a millionaire go without a Social Security check than see EVERYONE get a smaller Social Security check (just as an example).

Brooks wrote:
"Having said that, while I, as a layperson, looking at the size of the projected imbalance, think intuitively that the answer is "no" rather than "yes", what carries more weight in my book is the consensus of economists and other relevant experts across the political spectrum, which seems consistent with my "no" and at odds with your "yes"."

Did you listen to this "consensus" of economists regarding whether or not there was a housing bubble?

Brooks,

i think it is primarily a matter of politics -- they don't like entitlements.
Europe pays much higher tax rates now than we would in 2050. Many European economies are doing as well or better than ours. None of these economists would argue any of these facts with me.

Are you saying that the people of Brookings are not being honest, and that they are agreeing to those points in that paper simply because "they don't like entitlements"??

Is that really your answer?

If that's NOT what you're saying, then I ask again, why would all these policy experts, including the ones from Brookings, agree on key points that, to you, are obviously wrong? Why would they all miss what you see?

And again, let's stay focused on what my question was rather than shifting it.

You answered "yes", confirming that you think that it is both desirable and politically feasible to try to solve our long-term fiscal imbalance solely through relatively painless changes in our healthcare system, combined with tax increases and (I presume) cuts in the Defense budget, as opposed to all of the above plus real sacrifices in entitlement spending (reduced eligibility and/or reduced benefits).

The experts at Brookings clearly disagree with you on THAT point. That's what I'm asking you about when I ask why they would all be completely wrong (along with just about every other policy expert on this matter whose views I've read/heard) while you are right? Do you have any theory on why they would all be missing what you see so clearly? Or is it really that you think the Brookings experts (and just about everyone else) secretly share your view, but are being dishonest because "they don't like entitlements"?

Dean,

Re: "People on average will have far higher after-tax incomes [if we fix health care], even if we do it all on the tax side."

On the tax side, how much of an increase do you have in mind? How would it be apportioned? How would it be collected? And would you rule out adding new fees of any kind under any circumstance?

On the health care side, do you think it is humane and just to extend Medicare coverage beyond the current 90-day limit for skilled-nursing care? Or to put it another way, is forcing a chronically-ill person to spend down their assets (thus denying their issue, if any, to benefit from them) before qualifying for Medicaid coverage, something you would still want to remain in place (presumably to keep health care solvent or its costs affordable)?

Brooks,

Yes -- they are not being honest and several very prominent policy people largely agree with me on the entitlements story, so I am not alone (e.g. Peter Orszag, CBO director, and henry Aaron, Brookings honcho).

Frankly, i wouldn't give a damn if I was alone. Almost no economists saw the housing bubble, almost no economists saw the stock bubble, almost no economists questioned the Boskin Commission's claim that the CPI hugely overstated inflation. Economists have a very good record of being completely wrong. I would worry if most agreed with me.

Straight talker, if we increase average taxes on the order or 2-3 pp of income we could probably deal with the issues of aging long into the future. A huge amount will depend on how we deal with health care, if nearly all economists were not protectionists, and therefore opposed to opening health care to international competition, we could see dramatic reductions in HC care costs by taking advantage of more efficient systems elsewhere in the world.

Just to be clear, you are saying that Peter Orszag and Henry Aaron agree with you that it is both desirable and politically feasible to try to solve our long-term fiscal imbalance solely through relatively painless changes in our healthcare system, combined with tax increases and (I presume) cuts in the Defense budget, as opposed to all of the above plus real sacrifices in entitlement spending (reduced eligibility and/or reduced benefits).

That certainly seems to be what you're saying, but PLEASE CONFIRM.

If you can provide links or can direct me in any way to comments from them indicating their agreement with you on that point, please do so.

Dean,

Re: "if nearly all economists were not protectionists, and therefore opposed to opening health care to international competition, we could see dramatic reductions in HC care costs by taking advantage of more efficient systems elsewhere in the world."

If you can refer me to a link explaining how this might work -- especially, something you've written on this topic -- I'd appreciate it.

Re: "if we increase average taxes on the order or 2-3 pp of income we could probably deal with the issues of aging long into the future."

On what are you basing this estimate?

Also I would like to know what you think the percentage increase for universal HC would amount to for those NOT on Medicare/Medicaid.

Thanks.

Straight Talker,

here are a few papers for you:

on the benefits of trade in health care:

http://www.cepr.net/index.php/publications/reports/medicare-choice-plus-the-answer-to-the-long-term-deficit-problem/

http://www.cepr.net/index.php/publications/reports/professional-protectionists-the-gains-from-free-trade-in-highly-paid-professional-services/

on the budget

http://www.cepr.net/index.php/publications/reports/the-forty-four-trillion-dollar-deficit-scare/

Thanks for the links. This is an interesting proposal. What have your most critical reviewers cited as weaknesses in this plan and how have you responded to them?

Demographs, as you assume, may not be the greatest threat to future debt imbalances. However, the authors of the 2005 bbok The Coming Generational Storm see it otherwise and have constructed a way of understanding (primarily U.S.) government economics, and they forecast a demographically-driven economic collision between old and young.

They dedicate this work to their 10 grandchildren who they predict will encounter a country whose collective population is older than the current population of Florida. And that this situation will be prevalent throughout much of the industrialized world, including China; that we will have a population age profile that reflects "the greatest demographic change in human history"; changing from forever young to forever old; that a new segment has emerged which is the fastest growing population segment; people over 85 years of age. They rely on Bureau of the Census figures that forecast growth of the 85+ segment - from 4,259,000 in year 2000 to 13,552,000. in year 2040. This, and other population trends, will change the ratio of gold-ages to "kids" from 1.8 to 3.0, with all the consequences of supporting an aging population with fewer workers contributing to social programs that were built on a completely different set of assumptions.

The U.S. social programs we have today are largely a creation of a time when "old people" were expected to die shortly after retirement. The basic assumption was a high ratio of working people to retired people. This high ratio made possible a transfer system where each working generation supported the retirement of prior generations. Kotlikoff and Burns report on the reduction in the ratio of workers to beneficiaries: 16.5 to 1 in 1950 down to 3.4 to 1 in 2000. By 2030, they project, there will be only two workers for each beneficiary.

Dean,

Again, please just confirm (per my request in my previous comment above).

Since I was clear on what the question was, and that on THAT question the Brookings folks and other experts I've seen disagree with your answer, and you responded that Peter Orszag and Henry Aaron agree with you, it certainly seems that you were claiming that they agree with you on your answer to THAT question.

In other words, they agree with you that it is both desirable and politically feasible to try to solve our long-term fiscal imbalance solely through relatively painless changes in our healthcare system, combined with tax increases and (I presume) cuts in the Defense budget, as opposed to all of the above plus real sacrifices in entitlement spending (reduced eligibility and/or reduced benefits).

Again, PLEASE CONFIRM that THAT is what you are claiming they agree with you on. I want to make sure there's no shifting going on regarding what you're claiming they agree with you on despite the clarity of the question and the apparent clarity of your claim. I'm just asking you to take LITERALLY JUST A FEW SECONDS to confirm explicitly that that's what you're claiming. PLEASE do.

thanks.

Dean,

By the way, of the 16 policy experts who produced the paper to which I referred* and linked, 11 are from "progressive" think tanks (7 from Brookings, 3 from The Urban Institute, and 1 from The Progressive Policy Institute). So, if anything, the deck was stacked to the "progressive" side. Yet, as I said, they all managed to agree on a few basic, key assumptions, and you disagree with them on some of them.

* Taking Back Our Fiscal Future http://www.brookings.edu/~/media/Files/rc/papers/2008/04_fiscal_future/04_fiscal_future.pdf

Brooks asks Dean:

[Are you claiming] "it is both desirable and politically feasible to try to solve our long-term fiscal imbalance solely through relatively painless changes in our healthcare system ..."?

No. That's not what Dean has been saying or what he has said in the past.

If you read Dean's articles (see above) -- particularly Medicare Choice Plus, p. 4 -- you will see that although he knows HC reform is preferable, it is not likely to happen in the near term, due to the power of interest groups. So ... as opposed to doing nothing, Dean puts forward his Medicare Choice Plus plan as a stopgap measure.

If you want to take Dean to task on his proposal, then you might want to focus on the credibility of his statement that reform of the HC system is not necessary to "achieve substantial savings." As I see it, if you beyond this you are merely attacking a straw man.

Newcomer,

I often have this problem with Dean: I ask a question, and I get either an answer to a different question, or an answer that is somehow vague with regard to my question. In the latter case, I ask for clarification or confirmation of my interpretation of what he said, and often I don't get one. I get either more of the same or nothing at all. While I respect Dean and appreciate this blog and any time he offers to me, the above dynamic is quite frustrating.

You are correct that there is a difference between what set of policies one prefers vs. what they think is politically feasible or likely. That would have been a useful distinction for Dean to make if it applies to his position. But instead, his answer to my question was "yes, i absolutely think that if we fix our health care system then we can afford the projected increases in the cost of the entitlement system, just as we did over the last 40 years. People on average will have far higher after-tax incomes, even if we do it all on the tax side." He doesn't say "I think we could do it and it's preferable, but I don't think it's realistic politically", which is the distinction you are making (I think). If that's what Dean is saying, I wish he would say it himself. I still would express skepticism that it is preferable or perhaps even that it is possible in practical terms, but at least that would be a useful distinction.

And you cannot rightly say that I am "attacking a straw man". I asked if Dean believes A and B. He said "yes" to my question, and then added something akin to a presidential signing statement (i.e., he said "yes" to my question, but attached that yes to a statement that gave the impression that he may have been answering a different question -- the practical feasibility question only, not the political). So I have sought clarification/confirmation (repeatedly). He has not said "I'm saying 'yes' to A, but 'no' to B", so my request for confirmation that he's saying "yes" to A and B or my interpretation that his "yes" in response to my question about A and B was indeed a "yes" to A and B and my subsequent points and questions based on that interpretation cannot rightly be called "attacking a straw man".

As someone who is often frustrated by others who erect straw men, I can assure you that I would never want to do so myself. All I ask for are direct, straight-forward answers to straight-forward, relevant, legitimate questions and points. And of course, I hold myself to the same standard.

Brooks,

Sometimes it’s possible to learn a lot about the validity of person’s assertion by noting what they choose not to reply to. For example, after thanking Dean for supplying links clarifying his position, I asked him “what have your most critical reviewers cited as weaknesses in this plan and how have you responded to them?” My query was met with deafening silence. My conclusion? Dean’s proposal doesn’t hold up well to peer review! Otherwise, Dean would have provided a link documenting his critics’ comments and his responses to them.

Here’s another example. Dean wrote: "People on average will have far higher after-tax incomes [if we fix health care], even if we do it all on the tax side." I wrote: “How much of [a tax] increase do you have in mind? How would it be apportioned? How would it be collected? And would you rule out adding new fees of any kind under any circumstance? Dean answered: “If we increase average taxes on the order or 2-3 pp of income we could probably deal with the issues of aging long into the future." I then asked: “On what are you basing this estimate?” Interestingly, Dean chose not to reply. As much as I respect Dean’s professionalism, I am forced to conclude – in this instance -- he simply pulled these numbers out of the air.

You wrote: “All I ask for are direct, straight-forward answers to straight-forward, relevant, legitimate questions and points. And of course, I hold myself to the same standard.”

Have you read any of Dean's three essays – particularly, Medicare Choice Plus; especially, page 4?

Straight Talker,

You may be right re: the implications of a conspicuous absence of a response, particualrly when it seems to be a habit on someone's part, and that that may apply to Dean. In my case, as I've said, I've often either received no response from Dean or a response to a different question than the one I asked, which, if deliberate, is a straw man argument. The possibilities in the latter situation are (1) that he did so deliberately (answering a different question than the one I asked in order to set up and knock down a straw man rather than deal with my more challenging actual question or (2) that he lacks sufficient interest in my comment containing my question to take a moment to really pay attention to what I actually wrote. I'll leave it up to others to decide which they think is more likely the case. In any case, in addition to being frustrating and a lost opportunity for teaching/learning and for stimulating discussion, his tendency to avoid tough questions either by ignoring them or by responding to unasked (straw man-type) questions in lieu of the actual question is somewhat ironic considering that Beat the Press is kind of a watchdog site, calling out those in the press who supposedly present half-truths or distortions and who deserve to be called on it publicly.

I do want to say this: Unlike many -- perhaps most -- partisan bloggers (e.g., Mark Thoma, Brad Delong, RedState), Dean does not ban people or delete comments that challenge the "truths" and talking points of his "side". He allows a free discussion/debate, and for that he deserves much credit. It should be the norm rather than the exception, but it isn't.

And of course, he provides this forum and serves up interesting and important food for thought, for which I'm appreciative. And he often makes what seem to me to be sound and important arguments, even though he generally does so only in service to a partisan agenda rather than holding both "sides" to the same standard and calling out either "side" when they distort matters (and calling out the press when their bias or sloppiness benefits either "side").

I'm making the above compliments not to kiss butt but rather because I'm criticizing the host, so I think it's appropriate for me to also point out some important things for which he deserves substantial credit.

Re: "Have you read any of Dean's three essays – particularly, Medicare Choice Plus; especially, page 4?"

I had not read those papers, but in response to your question I just read page 4, as well as parts of The Forty Four Trillion Dollar Deficit Scare (co-authored by Dean), which was a source cited in a footnote on page 4 of the other paper.

Do you have a point or question regarding what's on page 4 or anything else in that paper?

As I've noted more than once, I don't know much about healthcare policy or about alternative systematic changes ("reform") and their potential cost savings, impact on quality and access/availability, etc., so I'm not sufficiently informed to critique papers on the subject. I therefore rely on the views of various experts (of various political orientations, views of economics, etc.) and on whatever scrutiny I can muster. Which is why, when I see experts across a broad span of the political spectrum agreeing on some fact or assumption, and I see a strong partisan rejecting it, I try to find out (1) if the contrarian agrees he is one, (2) the basis for his contrarian conclusion, and (3) why he thinks just about every other expert is missing what he sees. But of course, it's hard to find out these things when the person is not responding to my questions or at least not doing so directly and straight-forwardly.

Brooks,

Re: "Do you have a point or question regarding what's on page 4 or anything else in that paper?"

The short answer is Yes. And as I suspected, since you admit to not reading Dean's definitive statements on this topic -- and because I assume he likewise is not reading the links you have posted -- are guys a only talkiing past each other. (At least that is what I have observed in your brief exchange with one another. But more on that later -- perhaps?!)

Given it's near my bedtime here on the East Coast, I'll have to get back to you tomorrow sometime to answer your question more fully.

In the meantime, if you don't mind answering a personal question on this public forum, what is/was your profession? And just to 'prime the pump', I'll go first. I'm a group family child care provider.

Sorry Brooks. The "anonymous" contributor is really me.

Anonymous,

First, are you Straight Talker? When I forget to put my name in the "Name" box, it shows up, of course, as "Anonymous", so I'm wondering if you just made that mistake.

Re: "as I suspected, since you admit to not reading Dean's definitive statements on this topic -- and because I assume he likewise is not reading the links you have posted -- are guys a only talkiing past each other. (At least that is what I have observed in your brief exchange with one another."

That is not at all a fair characterization of my side of my exchange with Dean. First of all, he provided those links in a comment he addressed to YOU, in response to YOUR comment, not to ME in response to MY comment. Second, and even more to the point, I have simply asked straight-forward, relevant, legitimate questions, but I have not received straight answers. Even if -- repeat IF -- the answers to my questions exist somewhere in a paper to which he linked, particularly if those links were offerred in a comment addressed to someone else, that does not constitute a direct, straight-forward answer to a simple, straight-forward question. If Dean had asked me a question or responded directly to my question, I assure you I would have listened, thoughtfully considered his question or point, and responded directly, substantively, and as clearly as I could. I have no interest in talking past someone or in shutting my ears when he is responding to my questions or arguments. That is the exact opposite of what I'm seeking here, and what I seek generally when I'm discussing or debating some matter with someone. I wish to engage substantively and in doing so to learn and to perhaps help others learn. If you think I'm the kind of guy who likes to talk but not listen, to just voice his opinion but not consider those of others and explore with them their opinions and my own, you've got me completely wrong.

However, having said all that, if you want to elaborate on your "observations" and if you have any suggestions for improving my approach to such exchanges, I'm all ears.

Straight Talker,

ok, I see you made the same "Anonymous" mistake that I've made many times.

I forgot to tell you my profession. I'm a (strategy) management consultant.

Your profession seems to me to be very noble, and I presume rewarding despite probably being tough at least at times. Those are just assumptions of mine; I know nothing about it except a bit from TV/movies (e.g., Fresh, a movie I think is quite good http://www.netflix.com/Movie/Fresh/524745?lnkctr=srchrd-sr&strkid=1101808044_0_0 ).

Feel free to drop me an email if you want to discuss any stuff (economic/political policy, work, or whatever) offline. I'm at BrooksBud@aol.com

Straight Talker,

By the way, I'm also "B Rational" on SwordsCrossed.org, which I highly recommend even though the diary and comment posting frequency is not nearly as great as some other political community blogs. The concept of SwordsCrossed is for people across the political spectrum to engage substantively, as opposed to the echo chambers of right and left, respectively.

Anyway, you may like it. And if you want to see me engaging enthusiastically and substantively with people -- of right, left, and "other" -- with whom I disagree, you can find plenty of examples there.

Straight Talker,

i just quickly read one of your comments. My 2-3 percentage points of income tax increase estimate is based on my memory of various papers that I have done over the years. I believe that you can get a more careful estimate out of my $44 trillion deficit scare.

As far as the response of other economists, they generally say that it will be politically difficult to fix health care and tend to view it as almost politically inconceivable that we would do something like Medicare Choice Plus (allowing people to buy into foreign health care systems). Many also say that they don't want to see taxes go up and that it would be politically difficult to raise them.

I never had any economist question the basic numbers -- we are all using the same numbers -- they just have a different political agenda.

Straight Talker,

Just a note regarding another "observation" you should probably make, if you haven't already made note of it:

Why do you know that, prior to your question, I had not read the papers at those links? Answer: Because I told you, in a direct, clear response to your question in which I made a good faith effort to provide you with such an answer, even though I knew that you (or someone else) might criticize me (fairly or unfairly) for not having read them.

You asked: "Have you read any of Dean's three essays – particularly, Medicare Choice Plus; especially, page 4?"

I could have ignored that question and just responded to the other parts of your comment.

I could have given a vague answer like "Yes, I have", leaving unclear (1) whether or not I had done so prior to your asking the question, and (2) if I was referring to just page 4, to that entire document, or even to all of all three documents.

But instead, again, I made a good-faith effort to answer your question directly, clearly, and fully, even if it might draw criticism. And a point I've made on this thread is that I wish others, including Dean, would do the same.

Dean,

Re: "As far as the response of other economists, they generally say that it will be politically difficult to fix health care.... Many also say that they don't want to see taxes go up and that it would be politically difficult to raise them."

Perhaps this is why you don't seem willing to discuss the essay Brooks cites (above) -- Taking Back Our Fiscal Future. Because, as Brooks put it "all [16 policy experts] managed to agree on a few basic, key assumptions, and you disagree with them on some of them." (See pages 4-5 of this report.)

re: "I never had any economist question the basic numbers -- we are all using the same numbers -- they just have a different political agenda."

"Figures don't lie, but liars figure." - Samuel Clemens.

As you appear to be suggesting, it all depends on the political perspective one is advancing -- including your own, of course. ;-)

Brooks,

Re: "I know nothing about it except a bit from TV/movies..."

I can 'see' that. :)

This one -- Daddy Day Care -- is the real deal; right down to the regulations and personality stereotyping of on-site inspectors.

http://www.netflix.com/Movie/Daddy_Day_Care/60027689?lnkctr=srchrd-sr&strkid=1039744505_0_0

Brooks,

Re: "[H]aving said all that, if you want to elaborate on your "observations" and if you have any suggestions for improving my approach to such exchanges, I'm all ears."

Mea culpa (my fault). I never intended to challenge your integrity; but I did (past tense) question your (presumed) methodology.

I hope you will accept my public apology. I like your suggestion to take our conversation off-line. I'll contact you soon.

Straight Talker,

Thanks. I look forward to your email.