The Agenda

Brief Thought on Gruber

I recall raising my eyebrows when I read this passage in Ron Brownstein’s much-cited take on the Senate health bill.

When I reached Jonathan Gruber on Thursday, he was working his way, page by laborious page, through the mammoth health care bill Senate Majority Leader Harry Reid had unveiled just a few hours earlier. Gruber is a leading health economist at the Massachusetts Institute of Technology who is consulted by politicians in both parties. He was one of almost two dozen top economists who sent President Obama a letter earlier this month insisting that reform won’t succeed unless it “bends the curve” in the long-term growth of health care costs. And, on that front, Gruber likes what he sees in the Reid proposal. Actually he likes it a lot.

“I’m sort of a known skeptic on this stuff,” Gruber told me. “My summary is it’s really hard to figure out how to bend the cost curve, but I can’t think of a thing to try that they didn’t try. They really make the best effort anyone has ever made. Everything is in here….I can’t think of anything I’d do that they are not doing in the bill. You couldn’t have done better than they are doing.”

(Briefly, I’ll note that this strikes me as obviously false and strangely over-the-top. Harold Luft’s proposal for a Major Risk Pool struck me as politically viable and clearly more effective as a way to restrain costs, and that’s just one of many examples.) 

Indeed, Gruber has been consulted by both parties. But he has also been, as I noted at the time, a prominent advocate of the Massachusetts reform model, and that he has argued, in The New Republic and elsewhere, for an approach that places coverage expansions first and cost controls second as an explicit political strategy. I’m sorry to say that I can’t find his piece on TNR’s website, but here is Gruber in aninterview with Ezra Klein.

That’s also because the people who mainly care about coverage now have something they need to protect from health-care costs, right? If costs aren’t controlled, you can’t keep the coverage.

The same thing happened in Massachusetts. We passed our bill. The lobbying group Health Care for All was incredibly important in that. But they were primarily about coverage. But then they realized that they would lose all this coverage they’d gained if it didn’t control costs. So they got behind real cost-control measures. A global budget, even.

People say you can’t do coverage without cost control. I think it’s the opposite. You can’t do cost control before coverage. We would do a huge amount for the cause of cost control just by covering people.

Jonathan Cohn noted the popularity of the Massachusetts reforms, and rightly so. Yet the cost control mechanisms haven’t taken effect quite yet. One wonders if the popularity of the Massachusetts model will remain similarly stratospheric.

I mention Gruber’s political argument because it is, well, a political argument, and it deserves to be evaluated as such. One of the reasons so many conservatives opposed Medicare Part D is because of it’s cart-before-horse structure. But it worked politically! For a while, at least. 

Reihan Salam is president of the Manhattan Institute and a contributing editor of National Review.

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