THE TREATMENT JANUARY 8, 2010
Marcy Wheeler, who has written a lot of smart things about health care at her blog Emptywheel, has a series of new posts today about the work of MIT economist Jonathan Gruber. If you read my blog, you're certainly familiar with Gruber, as both a frequent source of analysis and occasional outside contributor of items. Wheeler's posts today raise questions about both some of Gruber's arguments and Gruber's intellectual independence. First I'll address the arguments--or one of them, anyway. Then I'll talk about the independence issue.
The argument I want to address is one that's come up a number of times in the last few weeks: The fact that, in Massachusetts, around a fifth of all residents still report finding health care unaffordable. This is relevant to the national debate because Massachusetts is three years into a reform plan that, roughly speaking, is a good proxy for what we'll try nationally if something like the Senate bill becomes law. Gruber fits into this because he was an architect of the Massachusetts plan and remains on the board overseeing it.
It's true many people in Massachusetts still struggle with their medical bills. It's one reason those of us applauding the progress in Massachusetts never say the success there is unqualified. But it's important to put that failure in context. The figures Wheeler cites come from a study conducted by Urban Institute researchers and subsequently published in the peer-reviewed journal Health Affairs. Those figures, current through late 2008, show clearly that people got better access to care--and had less trouble paying their bills--as a result of reform.
For example, in fall of 2006, 17.0 percent of people reported skipping medical care because of costs. By fall 2008, it was down to 11.3 percent. The figure stabilized in the second year, but that's to be expected, given the economic trends. As people lose their jobs and incomes suffer, they're bound to have more trouble paying their medical bills. The fact that the numbers didn't get markedly worse in that time period--and remained better than they were at the outset of reform--suggests strongly that the reforms significantly improved people's lives.
Again, is that good enough? No. Is it better than the status quo? Absolutely. Not coincidentally, that's the same argument Gruber and others, myself included, have made about reform nationally.
OK, let's move on to the second part: Gruber's intellectual independence.
The big news that started this discussion was the disclosure that, over the last year, Gruber has had a contract with the administration to do analytical work. For this, he was paid $300,000. Wheeler says:
Even assuming that Gruber is the only one in the world who can run these simulations, don’t you think it’s rather, um, dubious that the guy evaluating the heath care reform–for $300,000–is also the package’s single biggest champion?
And no one has been transparent about this contract?
Gruber responded by telling Politico's Ben Smith, who wrote about the controversy, that he has been open about his role when asked and that he mentioned it in a disclosure form for the New England Journal of Medicine. As for the work itself, he explained it thusly:
Throughout this year I have provided technical assistance to the administration and to Congress with my micro-simulation model, as well as based on my experience as a member of the Massachusetts health connector board. But NONE of the work I have done in public, or any public declarations I have made, has been in any way funded by the Administration. That funding was strictly for internal work that I did for the administration and, via the administration, for congress. All externally visible work and comments, such as my editorials or public reports, have been done on my own time.
Moreover, at no time have I publicly advocated a position that I did not firmly believe--indeed, I have been completely consistent with my academic track record.
Gruber's role as an adviser to the administration and Congress was hardly a secret. I have written as much on several occasions. (Here's one instance and here's another.) I don't remember asking him whether he was getting paid, but I assumed he was, at least for the technical work using his model, as any consultant would be. There are only a handful of models out there and his is widely considered among the very best, rivaling that of the Congressional Budget Office itself. But running the model for all of the possible iterations of reform is a hugely consuming task with its own set of expenses (research assistants, etc.). I would have been surprised if he weren't getting paid.
Having said all that, Wheeler's criticism gave me some pause. (While I don't always agree with her, I've always found her to be fair.) On some occasions, I've cited Gruber without mentioning that he was an adviser. I assumed readers knew that because I'd mentioned it before and because, at least within policy circles, it's widely known. But, of course, not everybody reads every item I write. And not everybody follows this debate that closely. In the future, I will mention Gruber's role as an adviser every time, not just some of the time. Readers are entitled to that information, so that they can make their own judgments.
For what it's worth, one of the reasons I cite Gruber frequently is that, in my experience, he's sincere to a fault. As he says, his views have been consistent, going back many years. And, more than most experts I know, he is willing to call out friends and allies when his projections suggest they are wrong. That doesn't mean he's always right, of course. (He and I differ over some more subjective questions, like how much cost-sharing is excessive; I like single-payer systems and he, I think, doesn't.) But, like so many of my colleagues, I trust him to tell me what he really thinks--and, more important, to use numbers at which he's arrived honestly.
Update: Wheeler quotes Princeton economist Uwe Reinhart making the same point I do above. Of the relatively few private models available, Reinhardt says, Gruber's is among the best. She also notes that Reinhardt has a more skeptical take on cost-sharing. (A point on which Reinhardt and I agree.)
One more thing: I see, from reading other items on this around the web, other journalists writing on health care were not aware that Gruber was doing projections for the administration. Obviously this was not as widely known as I thought, which means that Wheeler deserves credit for publicizing Gruber's work--and that I should be diligent about mentioning it in the future.
OK, one more thing: I agree with everything in Karen Tumulty's post.