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Orszag And The End Of The Dream

Ezra Klein summarizes Peter Orszag's tenure as budget director by, appropriately, focusing on Orszag's central accomplishment of pushing for ways to make health care more efficient:

Where most people assumed that controlling health-care costs would eventually mean confronting the dread specter of "rationing," Orszag, taking his cue from reams of research showing that states that spent a lot of money on per capita Medicare spending didn't have better outcomes than states that spent much less, argued that a substantial portion of each dollar we spend on health care is wasted. The answer wasn't cutting care, he said, but amassing much more evidence on what worked and what didn't, and then integrating that data into a health-care system armed with electronic medical records and software to help doctors make evidence-based decisions. That was a strategy politicians could support without seeing their careers flash before their eyes. ...

On a policy level, Orszag was wildly, even improbably, successful. A bill was passed. The Congressional Budget Office, now under the watchful gaze of Doug Elmendorf, certified it as deficit-reducing. Orszag's two top priorities—an independent commission empowered to aggressively reform Medicare and a tax on high-value insurance plans—survived the process.

But on a political level, he lost the argument: polls showed that few Americans thought the legislation would reduce the deficit. The conversation has turned to long-term deficit reduction without even a breath spared for the long-term deficit cuts that Orszag muscled into the bill. In the most recent Washington Post/ABC poll, 56 percent of Americans disapproved of the way Obama has handled the deficit. The health-care bill itself is not popular, and the No. 1 concern is cost.

It's worth teasing out the politics of this a bit. It was very hard for most people to follow the details of the health care debate, and most Americans took their cue from elites. And on this issue conservative elites played an extraordinarily cynical role. I wrote earlier today about the "highbrow-lowbrow" combination of right-wing attacks, whereby one group of conservatives would trash health care for going too far in controlling costs, and the other would trash it for not going far enough. It's not just there there was a Goldilocks problem, and too few conservatives thought the administration had it just right. Rather there were two sets of propositions on the table:

1. Should the government try to squeeze savings out of health care?

2. Does the Affordable Care Act contain provisions that do so?

Among moderate and liberal health care wonks, the consensus answer to both questions is yes. Of course, there's nothing surprising or inherently cynical about the fact that conservatives would disagree with this consensus. The suspicious thing is that conservatives break sharply into two groups: Those who favor cost savings but insist the Affordable Care Act failed to do so (the highbrows), and those who oppose cost savings and believe the Affordable Care Act does include them (the lowbrows). Every conservative who's a yes on 1 in no on 2, and every no on 1 is yes on 2.

These are logically separate positions. If I told you that, say, half of the conservative pundits would favor savings restraint, and half would believe Obama included such restraint, you'd assume that around a quarter of the conservative pundits would generally favor Obama's approach on health care. But in fact nobody on the right favored Obama's position.

So, for instance, today you have Mary Katherine Ham of the Weekly Standard describing a video which she claims shows Orszag confessing to have imposed health care rationing:

Here's one of Orszag's greatest hits, in which he explains that Obamacare must and will require rationing by an unelected board, despite the fact that Obama claimed it wouldn't:

Now, this is a laughably paranoid interpretation of Orszag's comments. The underlying problem is that it's hard to squeeze waste out of the health care system because every dollar of waste is a dollar of somebody's income. The Medicare Commission is a way to allow health care experts to introduce more efficient medical practices into Medicare. Its advice can be overruled -- and if the commission were actually rationing care in the way right-wingers like Ham suspect, it would create a public backlash and Congress would presumably be eager to overrule its changes. But forcing Congress to vote to overrule the reforms, and the president to sign such a law, makes it harder for smaller special interests to protect wasteful payments, as they currently do.

Anyway, the point is, if you actually believe the paranoid interpretation of Orszag's role, then he'd have smuggled into law a secret plan to have government experts slash Medicare spending by hundreds of billions of dollars. Aren't there at least some conservatives who favor that plan?

Orszag is, in some ways, the technocratic face of Obama's ideology. His central project has been an area where, in theory, conservatives and liberals ought to be able to cooperate. And yet, while the policy has succeeded, the politics have fallen into the maw of intense polarization and a conservative movement running off the ideological rails. Obama has largely abandoned the post-partisan hopes that infused his presidential campaign, and is instead drawing sharp contrasts with the radicalism and blind partisanship of the GOP. Orszag's departure is a fitting cap to the end of a naive hope, one that I shared, that Obama could find common ground with the opposition.