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"simply Dishonest." Obama? Or Bob Samuelson?

"Naive, hypocritical, or simply dishonest?" That's Washington Post columnist Robert Samuelson talking about the Obama administration and its pursuit of health care reform. His argument in a nutshell: Health care costs too much money and Obama isn't serious about trying to take care of that problem.

I agree wholeheardtly with the first premise. It's the second one I don't get. It's true that, in the world of health care reformers, there are those who focus on coverage almost exclusively. But Obama very clearly is not one of them.

In literally every speech I've seen him give on health care--and I think I've seen or read just about every one--Obama has made cost a primary focus. He talks about the way medical bills are crippling indivdiuals, businesses, and the economy. He talks about the long-term financial burden medical care is imposing upon our society, characterizing it as one of the greatest threats, along with climate change, to our economic viability. Obama is fluent in the underlying problems behind rising medical epxenses--the disorganization of care, the wildly varying treatment patterns across the country, the lack of incentives for quality. And he's spotlighted an advisor, Budget Director Peter Orszag, who is positively obsessed with the subject.

To be perfectly honest, my real worry about Obama is that, in his determination to reduce cost, he'll cut a deal that won't do enough to expand coverage.

Samuelson, though, isn't convinced. It's all just rhetoric, he says: "Obama hasn't confronted [cost]. His emphasis on controlling costs is cosmetic." He then goes on to say

The place to start would be costly Medicare, the nation's largest insurance program serving 45 million elderly and disabled. Of course, this would be unpopular, because it would disrupt delivery patterns and reimbursement practices. It's easier to pretend to be curbing health spending while expanding coverage and spending. Presidents have done that for decades, and it's why most health industries see "reform" as a good deal.

Tough stuff, that. And what would reforming Medicare do? According to Samuelson, it would pave the way for much bigger changes:

What's needed is a fundamental remaking of the health-care sector--a sweeping "restructuring"--that would overhaul fee-for-service payment and reduce the fragmentation of care.

The trouble with this argument is that this is exactly what Obama is talking about doing. He has said all along that he was going to alter payment within the Medicare plan, both to reduce the program's own cost and, over the long run, to drive changes throughout the rest of the health care system. (Medicare is such a big program that, when it makes a change, it can force the entire health care system to respond.) The very explicit goal of these reforms is to move away from payments for episodic treamtents--that is, fee for-service--in order to improve the coordination of care, reduce overtreatment, and reward good outcomes.

And, yes, those are just words. But Obama has embraced concrete proposals to realize these goals. Just this weekend, Obama unveiled a series of specific reductions in Medicare and Medicaid, adding up to more than $300 billion.

I haven't had the chance to scrutnize these proposed cuts and, I'm sure, they're not perfect or sufficient. But the hospital industry is already complaining about them--which, by Samuelson's own criteria, would suggest they are meanigful. And this comes on top of other proposals Obama has embraced, including a proposal to give the Medicare Payment Advisory Commission (MedPAC) more influence over policymaking--a move most experts agree would make health care better and less expensive.

Samuelson's on more solid ground later in the column, when he questions whether Congress will show similar enthusiasm for cost control. While some lawmakers seems serious about cost control, others aren't. But then why attack Obama? Shouldn't Samuelson be championing Obama's proposals and pressuring Congress to embrace them?

In fairness to Samuelson, he may be a victim of unlucky timing. He probably files his column before Friday, when the administration began briefing reporters on the Medicare/Medicaid proposal. Still, I am not sure this weekend's announcement would have changed his views. He's been dismissive about health care reform for years, finding one reason after another to argue it's either unnecessary or downright destructive.

I used to think Samuelson believed this simply because he was so worried it would make the cost problem worse. That's a legitimate--if, in my view, wrong-headed--point of view. But now he's got a president focusing on cost, embracing precisely the proposals Samuelson says are necessary. And Samuelson still isn't happy, which makes me think his real problem may be that he just doesn't care about the problems of the uninsured and underinsured. 

That's Sameulson's prerogative, as a columnist and a member of the voting public. But maybe next time he can drop the pose of high-minded crusader for fiscal responsibility. To be quite honest, he's giving the cause a bad name.

(By the way, I wasn't going to post this until tomorrow. But Andrea Mitchell just cited this article in her commentary after Obama's speech in the AMA. So I'm putting it out there now.)

--Jonathan Cohn