“So make no mistake: Health care reform is entitlement reform.” — Barack Obama, April 14, 2009

“Health care reform is entitlement reform.” — Peter Orszag, OMB Director, February 23, 2009

Whenever Republicans insisted on debating entitlement reform and the looming unfunded liabilities of Medicare and Medicaid, which by some calculations amount to more than $100 trillion over the next few decades, President Obama had one handy answer: we’ve already accomplished it.  ObamaCare, he and his administration insisted, was the entitlement reform that we needed to address the crises in Medicare and Medicaid.  Obama claimed that going into the months-long battle that eventually produced the PPACA, commonly known as ObamaCare even when first introduced shortly after his remarks.  The quote above comes from an April 2009 speech, and the larger context of the quote shows that Obama sold his plan as a complete solution:

Along with defense and interest on the national debt, the biggest cost drivers in our budget are entitlement programs like Medicare, Medicaid and Social Security, all of which get more and more expensive every year.  So if we want to get serious about fiscal discipline — and I do — then we’re going to not only have to trim waste out of our discretionary budget — which we’ve already begun — we will also have to get serious about entitlement reform. Now, nothing will be more important to this goal then passing health care reform that brings down costs across the system, including in Medicare and Medicaid.

So make no mistake: Health care reform is entitlement reform.  That’s not just my opinion. That was the conclusion of a wide range of participants at the Fiscal Responsibility Summit that we held at the White House in February. And that’s one of the reasons why I firmly believe we need to get health care reform done this year.  Now, once we tackle rising health care costs, we must also work to put Social Security on firmer footing. It’s time for both parties to come together and find a way to keep the promise of a sound retirement for future generations.

The same is true for Orszag’s remarks two months earlier, in which we get the familiar refrain of “bending the cost curve downward” as a prelude to ObamaCare:

So, to my fellow budget hawks in this room and in the rest of the country, let me be very clear. Health care reform is entitlement reform. The path to fiscal responsibility must run directly through health care.

We also must recognize that reforms to Medicare and Medicaid will only succeed in the context of slowing the overall growth rate of health care costs.

Improving the efficiency of the health system so that we get better results for less money is therefore not just or even primarily a budget issue. It would also provide direct help to struggling families, since health care costs are reducing worker’s take-home pay to a degree that is both underappreciated and unnecessarily large.

And for many states, health care is increasingly crowding out other priorities like higher education, which, in turn, is leading to higher tuition and painful cutbacks at state universities.

All of this is why the president had said, time and again, that he is committed to reforming the health system this year. And with his leadership and the hard work of everyone in this room, we can reform health care, start to bend the curve on long-term costs, and get our economy back on a path of long-term fiscal sustainability.

Had ObamaCare done what the President and his former OMB Director claimed, then why would S&P downgrade the US over its debt and future liabilities?  Perhaps because, as Philip Klein writes at the Washington Examiner, investors weren’t impressed by supposed entitlement reform that consists of adding to those liabilities:

Defenders of Obama will attempt to pin the blame on his predecessor, President Bush, and on intransigent Tea Party radicals in the current Congress. But that would leave out the part in between. For his first two years in office, Obama’s party controlled both chambers of Congress – for part of that period, he had a filibuster proof majority in the Senate. During that time period, he and his fellow Democrats could have passed his supposedly ideal, long-term, deficit-reduction package — one that represented a “balanced approach” between spending cuts and tax increases. It also could have delayed the deficit reduction for several years, so it wouldn’t have affected the current weak economy or the “investments” he considers crucial. Forget about actually accomplishing serious deficit reduction — he didn’t even attempt it.

When Obama came into office, he argued that we needed deficit spending to boost the economy, so he passed a $800 billion stimulus package. Then, in one of his first supposed pivots to the deficit, he convened a ‘fiscal responsibility summit’ in February 2009. But that actually turned out to be part of a different pivot altogether. It was during that summit that then White House Budget Director Peter Orszag declared, “health care reform is entitlement reform.”

And so, for the next 13 months, Obama spent all of his energies trying to get health care legislation across the finish line. The end product was a plan that, according to both the Congressional Budget Office and actuary for the Centers for Medicare and Medicaid Services, did not bend the health care cost curve down.  Let’s even set aside the argument over the accounting gimmicks that were employed to obtain a CBO score that showed modest deficit reduction. The reality is this: the law used money raised through tax hikes and Medicare cuts that otherwise would have been available for deficit reduction, to instead expand Medicaid by 18 million beneficiaries and create a massive new health care entitlement.

There are clearly other problems to which S&P reacted; Klein mentions the fact that Obama didn’t bother to present the plans of his own deficit commission, for one, or offer any specific plan even after it became clear this year that accelerated deficit spending would not pass Congress.  But it’s an inescapable conclusion that S&P doesn’t consider ObamaCare an effective reform of the largest of the entitlement crises we face.  They have been looking for the US to reform its debt structure — and after ObamaCare, they’re still looking.

In other words, health care reform wasn’t entitlement reform — it was entitlement growth at the precise time we needed entitlement shrinkage.  We need to jettison this new entitlement structure and work on reforming the rest of it in order to eliminate that $100 trillion locomotive bearing down on the US economy, and we need to do it sooner rather than later.

Update: The downgrade on Friday does settle one argument, though.  Had Congress stalled and done nothing, S&P (and probably Moody’s) would have downgraded us at that point — and then the blame would have fallen on the Tea Party.