When Harry Reid invoked the "nuclear option" last week to permanently prohibit filibustering judicial and executive branch nominees (SCOTUS excepted) he invited a brief surge of ritualistic navel gazing by a class of political pundits who also tend to spend a lot of time worrying about the national debt, and healthcare costs, and the amount of money the country spends on elderly people generally.
These might seem like unrelated issues -- the filibustering of nominees and the trajectory of public healthcare spending -- but they're actually very tightly linked. These fiscal scolds actually owe Reid an enormous debt of gratitude, but their religious devotion to the idea that solutions to big problems aren't worth undertaking if they're not bipartisan has proven to be stronger than their commitment to budgetary restraint.
In a single interview with NewsmaxTV on Monday, Time magazine's Mark Halperin unintentionally exposed the tension between these two precepts, when he allowed his axiomatic hostility to partisan power grabs to overwhelm his concern for the country's fiscal health.
"We do need to do some of that [rationing] in this country because we can't afford to spend so much on end-of-life care," Halperin said. A very high percentage of our healthcare spending is for a very small number of people for the last stages of their life. I'm not saying the system shouldn't allow that, but there's too much cost, judgments have to be made ... As a society we need to have this discussion in an honest and straightforward way because we can't afford every instance that people would like to have."
Halperin got into a little bit of trouble Tuesday, because his comments inadvertently confirmed the premise of a question about the coming "death panels." He ultimately clarified that he was referring to an ongoing political controversy about the Independent Payment Advisory Board -- a cost-cutting panel created by the Affordable Care Act, designed to cap Medicare spending growth.
And here's where we reach the contradiction. IPAB is one of the Affordable Care Act's most significant sources of cost saving potential. It might not ultimately be of much fiscal consequence in the coming years if healthcare inflation remains low, but if and when spending spikes, then a panel of medical and industry experts will be tasked with cutting payments to hold spending at a manageable level, creating an incentive for providers to allocate resources wisely. The board won't and can't directly ration services, but it, or a beefed-up version of it, will probably be the mechanism that keeps federal health spending on a sustainable trajectory without tossing seniors into the private system and letting insurers do the rationing.
But the board is currently vacant, and Republicans probably would have nullified it altogether if Reid hadn't nuked the filibuster. They would have rejected all of its eventual nominees, summarily. A backup mechanism in the law allows the secretary of Health and Human Services to act as a sort of one-woman cost-cutting board, but that power would be much more vulnerable to both politicization and to abolition by Congress than a fully staffed IPAB.
If you care about how the country spends its healthcare dollars, as Halperin says he does, Reid's decision to go nuclear is of enormous consequence. Congress can override IPAB's recommendations, but only by replacing them with different savings of equal magnitude. And if Congress wants to do away with IPAB altogether, it will have to reckon with how to finance the higher relative health spending it will be creating. Higher taxes? Different provider cuts? Much greater cost sharing? Privatizing Medicare? By adding it to the debt?
Republicans, and some Democratic IPAB opponents, characterize it as a rationing board. Most of them steer clear of "death panel" rhetoric. But the question for them once it's up and running will be, Who should be rationing these dollars instead? Should insurers do it, while pocketing a decent profit along the way?
This sounds to me like the honest, straightforward discussion Halperin called for, and all because Reid abolished the filibuster for executive branch nominees. But instead of celebrating Reid's decision, Halperin joined his peers in the assumption that the nuclear option will ultimately prove to be counterproductive because of its partisan nature.
"I don't think the way the filibuster has become so routine, and the way it's used and other things are used to get in the way of Washington's functioning," he said. "I think this [nuclear option] is another thing being done in a partisan way, which both sides have done over the last few years, that's going to make it more difficult for Washington to work well."
Halperin did champion majoritarianism in the interview, and allowed that he's "not all that exercised about the [rule] change itself."
But to the extent that Halperin and others identify "Washington working" with "spending less money on programs like Medicare," there's just no question that Reid's decision will allow Washington to work better. And that's true even if it's thanks to a partisan power grab.