Event Information

An American Enterprise Institute-Brookings/USC Schaeffer Initiative Event
 

For most of the last five decades, the most-discussed finding by the Medicare trustees has been the insolvency date, when Medicare’s trust fund would no longer be able to pay all of the program’s costs. Last year’s report projected that the hospital insurance trust fund would be depleted by 2030 – just 14 years from now. The report also predicted a more immediate and controversial event: the Independent Payment Advisory Board (IPAB), famously nicknamed “death panels,” would be required to submit proposals to reduce Medicare spending in 2018, with the reductions taking place in 2019. Do we remain on this path to automatic Medicare cuts next year?

The American Enterprise Institute and the Schaeffer Initiative for Innovation in Health Policy, a collaboration between the USC Leonard D. Schaeffer Center for Health Policy & Economics and the Brookings Institution, hosted a discussion of the new 2016 trustees report on June 23. Medicare’s Chief Actuary Paul Spitalnic summarized the key findings followed by a panel of experts who discussed the potential consequences of the report for policy actions that might be taken to improve the program’s fiscal condition. You can join the conversation at #MedicareReport.

Video

• Introduction and keynote address
• Panel discussion

Audio

• The 2016 Medicare Trustees Report: One year closer to IPAB cuts?

Event Materials

• AEI TR16 final
• 20160623_medicaretrusteesreport_transcript

HHS Secretary Kathleen Sebelius may lose the most from the Senate’s rule change on the filibuster—and the Affordable Care Act may be healthier for it. I wrote last month on the FixGov blog that “Republicans are the Reason Secretary Sebelius Won’t Resign” (or be fired). That argument is no longer valid. My claim—the president’s inability to get her successor confirmed because of filibustering Republicans—is nullified by the Senate’s rule change, and the benefits may reach far beyond Obamacare.

The Implications of Filibuster Reform for Healthcare

Problems exist in HHS. No one denies it. However, for many appointees in the Department, the Senate rules served as a life preserver in a torrent of poor implementation, managerial failures, and bad PR. So long as the president faced the prospect of long-term vacancies among appointees overseeing ACA, the HHS leadership would be spared.

Today, that all changed. Moving forward, President Obama needs the support of only 51 Senate Democrats to replace top-level political appointees throughout the executive branch. This offers the president substantial breathing room. Nominees no longer need the support of every Democrat and a scarcely identifiable five Republicans. Instead, nominees can draw the ire of as many as four Democrats and still be confirmed.

Maybe Kathleen Sebelius is not to blame for the botched healthcare marketplace roll out. Maybe her Office did not give the thumbs up for the President to repeat “if you like your plan you can keep it.” Maybe she did not contribute to the poor salesmanship of the legislation from the start. However, if she was to blame (and perhaps if she wasn’t), her days in the president’s cabinet may well be numbered. The same may be true for deputies and other administrators in the Department who oversaw the weaker areas of the roll out of this law.

By repositioning HHS personnel or breathing new life into a Department facing continued struggles, the president may well ensure the administration of his signature legislation accomplishment improves. The right appointees can coordinate and communicate policy needs and goals up and down the bureaucratic hierarchy. Rather than settling for a program that meets or falls short of expectations, there is an opportunity to build an effective ACA.

Good Governance beyond Obamacare

The first half of October showed us that political actors in Congress contributed to a broken legislative branch. The second half of October showed us that political actors in the Administration contributed to a broken executive branch. Now is the time for the president to start anew and fix one branch, in the shadow of a Senate trying to fix itself.

In my piece from last month, I also argued that the filibuster rules in the Senate allow for the continuation of poor management and governance. If weak appointed personnel are causing policy problems, communication miscues, and other headaches for the president, the ability to replace them with something other than the word “ACTING” was limited by the 60-vote threshold.

President Obama, who has faced a string of personnel and management issues over the past year, now has greater freedom not simply to oust problematic appointees, but to install talented, effective leaders. With this ability comes a tremendous opportunity to jumpstart an administration that is sputtering.

The campaign for the 2016 Presidential nominations has shaken the political kaleidoscope, and the pieces are still moving. The populist surge of both Donald Trump and Bernie Sanders has torn the carefully crafted campaign strategies of other candidates into tatters. Populism is trumping realism. Political nostrums – like how Evangelical Christians or women will vote – are being challenged almost daily. The political establishment looks like the Wizard of Oz, with feeble powers inside giant machines.

There are, then, many losers in 2016. But perhaps the biggest loser of all is public policy. Policy used to matter quite a lot; the very term “policy platform” implied a solid structure, on which candidates would stand. Today, the strength of a candidate’s policy prescriptions and the strength of their political support seem unrelated. Or if there is a relationship, it is an inverse one. Trump provides the most vivid example of the sundering of policy from politics. But the policies of Sanders don’t come close to adding up either. Trump’s ideas are wacky – but Sanders’ are weak.

Trump’s proposals (when clear enough to be assessed) have been judged to be wholly impractical by every expert who is not certifiable. You cannot, in fact, force a sovereign nation to pay for a 2,000-mile, $20-billion wall you are building to keep their people out. You cannot enact a “total and complete shutdown of Muslims entering the U.S.” You cannot impose a 45 percent tariff on Chinese goods. You cannot cut taxes, ignore entitlements and wipe out the national debt. You cannot deport 11 million people. To be clear, I mean “cannot” here in the narrow, policy sense, rather than in legal or moral terms.

But cries of foul from the policy analysts have fallen on deaf ears. Each time Trump makes a ludicrous suggestion, these experts fill the airwaves with their reasoned arguments against it, Trump ignores them, and his poll ratings go up. Every time an establishment expert attacks one of his proposals, his anti-establishment credentials are burnished.

Meanwhile, the uber-wonk of the Republican field, Jeb Bush, became a piece of political marginalia. He produced some thoughtful and sensible policy ideas, on student financing, economic growth, health care, energy, school reform, and so on. Look where that got him.

Trump has grasped an important truth about politics in the digital age. Policy statements do not need to be serious proposals. They are merely ways to signal to the electorate what your instincts are, and what kinds of things you care about. It doesn’t matter if they don’t pass muster in the DC think-tank community. They are essentially a long list of the candidate’s likes and dislikes – politics in primary colors.

At his rallies, Trump announces his plan to build a wall on the southern border of the U.S., and asks: “And who’s gonna pay for it?” Then he holds out the mike to the crowd. They dutifully shout back: “Mexico!” It’s not true, and it can’t be true, but it doesn’t seem to matter. If Trump wins and appoints Ben Carson, the U.S. will have a Secretary for Education who has wondered aloud if Joseph built the pyramids.

Over on the Democrat side, Hillary Clinton, a wonk to match Bush, continues to fight a nervously close battle against a man who seems to design his policies on a blank sheet of paper, never allowing the facts on the ground to dilute the purity of his vision.

To be clear: I’m not saying that Sanders and Trump are equivalent. Trump plays on fear and loathing; Sanders indulges utopian idealism. But like Trump, the main purpose of Sanders’ policies is to signal a broad set of values, rather than chart a realistic way forward. Even the most progressive analysts of health care policy, like my Brookings colleague Henry Aaron, consider the Sanders plan for a single-payer health care system to be a pipe dream. As Aaron writes: “We know that single-payer mechanisms work in some countries. But those systems evolved over decades, based on gradual and incremental change from what existed before. That is the way that public policy is made in democracies.” Indeed. But not the way public policy is being made on the campaign trail.

Likewise, Sanders’ fiscal policies simply do not stack up, even if he can make the economy grow like it’s the ‘60s (the 1860s, that is). But don’t take my word for it: ask ultra-liberal economist Paul Krugman. Or indeed the four Democrat former chairs of the president’s Council of Economic Advisers who jointly wrote to warn of the fuzzy math at the heart of Sanders’ tax and spending plans. Sanders is playing fantasy fiscal policy.

But just as the unhinged ideas from Trump are doing nothing to dampen his fans, so the unrealistic ones from Sanders are not putting off his core supporters. And just as the scorn of the establishment helps Trump, so the attacks from experts on the mainstream left on Sanders’ ideas bolster his image as a revolutionary idealist, refusing to accept the status quo.

We should be honest: it is only in exceptional circumstances that policy is likely to be the central ingredient of politics. The personality, vision and message of the candidate, and the efficiency of a political operation, are typically more important. We should also be honest that the aspirational nature of campaign pledges very often puts them well beyond reasonable reach. Remember Hoover’s “chicken in every pot and a car in every garage?” Presidents can’t make that kind of change happen.

But even if policies declared on the campaign trail have often been a stretch, they have at least been a stretch in the right direction. Even if they were aspirational, they were not bonkers. The capacity to propose sensible policy has historically been a necessary test of political candidates, with scholars and serious journalists acting as examiners. Good policy may not often win you an election, but really bad policy could lose one. Now, in a fragmented media market, this basic test of policy seriousness may no longer disqualify a candidate.

Most successful Presidential candidates have, once in office, attempted to follow through on most (75% according to one study) of their campaign promises. Obama tried for 80%, according to Politifact. But many of those being made this year cannot be taken seriously, even perhaps by the candidates themselves. They are positioning devices, rather than proposals.

For a scholar working in a public policy think-tank, these are of course disheartening trends. What use is there for policy analysis when it seems as if politicians barely need policies at all? But there are deeper dangers here. If policy and politics separate entirely, the people who end up in office are likely to have little regard for policies, or even the skills required to make them. This will reduce the chances that policies will be implemented successfully, or that they will be effective, and therefore make them even less relevant to an electorate already concerned that our governance system is broken. Worse, the careless disregard for facts, laws, costs, and even basic math is corrosive to the democratic process. It is too much, perhaps, to expect politicians to seek to make voters better informed about the key issues. But I think it is reasonable to hope they will not misinform them.

I hope that I am wrong. I hope that policy will make a political comeback. But I’m not holding my breath.

Editor's note: This piece originally appeared in Bloomberg Government.

The final months of Obama’s historic terms of office as America’s first black president are taking place against the backdrop of an ugly Republican nominating race, and to the sound of ugly language on race from Donald Trump. Progress towards racial equality is indeed proceeding in faltering steps, as the president himself made clear in a commencement speech, one of his last as president, to the graduating class of Howard University.

“America is a better place today than it was when I graduated from college,” the president said. But on the question of progress on closing the race gap, he provided some mixed messages. Much done; more to do. The president picked out some specific areas on both sides of the ledger, many of which we have looked at on these pages.

1."Americans with college degrees, that rate is up.”

The share of Americans who have completed a bachelor’s degree or higher is now at 34 percent, up from 23 percent in 1990. That’s good news in itself. But it is particularly good news for social mobility, since people born at the bottom of the income distribution who get at BA experience much more upward mobility than those who do not:

2. "We've cut teen pregnancy in half."

The teen birthrate recently hit an all-time low, with a reduction in births by 35 percent for whites, 44 percent for blacks, and 51 percent for Hispanics:

This is a real cause for celebration, as the cost of unplanned births is extremely high. Increased awareness of highly effective methods of contraception, like Long Acting Reversible Contraception (LARCs), has certainly helped with this decline. More use of LARCs will help still further.

3. "In 1983, I was part of fewer than 10 percent of African Americans who graduated with a bachelor's degree. Today, you're part of the more than 20 percent who will."

Yes, black Americans are more likely to be graduating college. And contrary to some rhetoric, black students who get into selective colleges do very well, according to work from Jonathan Rothwell:

Three worries on race gaps

But of course it’s far from all good news, as the president also made clear. 

1. "We've still got an achievement gap when black boys and girls graduate high school and college at lower rates than white boys and white girls."

The white-black gap in school readiness, measured by both reading and math scores, has not closed at the same rate as white-Hispanic gaps. And while there has been an increase in black college-going, most of this rise has been in lower-quality institutions, at least in terms of alumni earnings (one likely reason for race gaps in college debt):

2. "There are folks of all races who are still hurting—who still can’t find work that pays enough to keep the lights on, who still can’t save for retirement."

Almost a third of the population has no retirement savings. Many more have saved much less than they will need, especially lower-income households. Wealth gaps by race are extremely large, too. The median wealth of white households is now 13 times greater than for black households:

3. "Black men are about six times likelier to be in prison right now than white men."

About one-third of all black male Americans will spend part of their life in prison. Although whites and blacks use and/or sell drugs at similar rates, blacks are 3 to 4 times more likely to be arrested for doing so, and 9 times more likely to be admitted to state prisons for a drug offense. The failed war on drugs and the trend towards incarceration have been bad news for black Americans in particular:

Especially right now, it is inspiring to see a black president giving the commencement address at a historically black college. But as President Obama knows all too well, there is a very long way to go.