Tag Archives: ACA

Deconstructing The Rhetoric

A week or so ago, an Indiana legislator–a Republican– posted a comment to Facebook about the current effort to “repeal and replace” the Affordable Care Act. I know this particular Republican to be thoughtful and well-intentioned; he’s not one of the mean-spirited or rigidly ideological partisans who populate our Statehouse.

His “logic,” however, defied reality.

He began by saying that we are not debating healthcare–we are debating access to health care via insurance coverage and that government  should “let the insurance market work.”  (Why he thought the distinction significant mystifies me, but okay.)

I am a huge proponent of markets–in areas of the economy where they work. Most people recognize that healthcare is an area where markets do not work; market transactions require a willing buyer and a willing seller both of whom are in possession of all information relevant to the transaction. That definition doesn’t characterize doctor-patient interactions, and it also doesn’t characterize the health insurance “marketplace.”

Even if you assume that all citizens understand the complexities and “fine print” of the policies offered by health insurers, that they all understand the technical terminology employed and are able to make considered opinions about the nature and extent of their desired coverage, you are left with several major problems that cannot be solved by “market magic.”

First of all, most Americans get their health insurance through their employers. They don’t get to participate in the choices involved. (This coupling of insurance and employment is problematic for lots of reasons unrelated to the subject of this post; for one thing, it makes American businesses less competitive in the global economy. But that’s a subject for another day.)

Second, significant numbers of people who do not get their insurance through their jobs–either because they don’t have jobs or their employer doesn’t offer it–cannot afford the coverage they need. (That’s why we have Medicare and Medicaid.) In the U.S., non-governmental health insurance policies are priced to cover expenses that include not just the expected payouts to providers, but the costs of marketing, profits and taxes. Private insurance overhead also includes very substantial salaries paid to insurance companies’ management, costs not incurred by Medicare and Medicaid. Last time I looked, Medicare overhead averaged around 3% while private insurance overhead averaged around 24%.

Third, and most important: markets, by definition, are voluntary. (That “willing” buyer and seller…). Insurance works by spreading risk. If younger, healthier people decide they aren’t “willing” buyers–if only the elderly and sick and people with pre-existing conditions participate in the market–the whole system comes crashing down. Insurers have to charge higher and higher premiums, and policies become more and more unaffordable. That’s why the ACA’s mandate was an essential part of the law.

If we accept the premise that access to healthcare is a human right–and I am well aware that most Republicans do not accept that premise–then people who cannot afford insurance must be subsidized. For the reasons I’ve listed, providing access through “market forces” would add enormously to the costs of the insurance and thus to the amount of the subsidies.

There is a reason other developed nations have pursued a variety of ways to nationalize health insurance; it’s the only way to make universal access cost-effective.

When you deconstruct Paul Ryan’s rhetoric about giving people the “freedom” to go uninsured, and the GOP’s reverential references to “market economics,” what you get is what the Congressional Budget Office described: millions of Americans losing insurance entirely, and millions of others paying much more for much less coverage.

Eventually, Americans are going to have to decide between a system like “Medicare for All,”  that pays for actual healthcare, and our current, unsustainable and immensely more expensive insistence upon subsidizing the bottom lines of Big Insurance and Big Pharma in the name of “the market.”

The purchase and sale of health insurance in today’s U.S. can be called many things, but a genuine market isn’t one of them.

 

The Closer You Look, The Meaner It Is

If your eyes glaze over at the prospect of getting down “in the weeds” of the Senate healthcare bill, Josh Marshall’s summary really tells you everything you need to know:

It has always been crystal clear for numerous reasons that the Senate health care repeal bill would be the like the House bill, both versions, just as it will be like the final bill that emerges from a conference committee. McConnell and Ryan knew that ball hiding about scores and legislative language would prevent reporters from saying this: Around 24 million Americans will lose their coverage, everyone will go back to the era of pre-existing conditions restrictions and lifetime limits. The freed up money will go to a big tax cut for the very wealthy. You didn’t need to see the legislative language to know this. It’s been a failure of journalism to pretend otherwise.

If, however, you want several specific compelling reasons to oppose this travesty, there are any number of reports and commentaries that can help. For example, we learn about several “buried” provisions from an article in the LA Times, in a column that describes the bill as a “poorly-disguised massive tax cut for the wealthy, paid for by cutting Medicaid — which serves the middle class and the poor — to the bone.” Then there’s this:

States will have more authority to reimpose lifetime and annual benefit caps and eliminate essential health benefits. This may be the most insidious provision of the repeal bill, and certainly is the most deeply hidden.

As several Governors–including Republican Governors– have noted, this grant of authority to the states will almost certainly be used, because the deep cuts in Medicaid and other federal funding will leave the states no choice.

The Affordable Care Act also had state waivers designed to allow for innovations, especially in state Medicaid programs. But under the ACA, those waivers could not  lead to fewer people being insured, or to the imposition of higher out-of-pocket expenses. The Senate bill repeals those limitations.

Under the measure, the secretary “must” approve a waiver request as long as it won’t increase the federal deficit. As a result, states would be able to eliminate the essential health benefits that all health plans must provide under the ACA — including hospitalization, prescription coverage, maternity care and substance abuse and mental health treatment. Since only essential health benefits are subject to the ban on lifetime and annual benefit limits, high-cost patients such as cancer victims and sufferers from chronic diseases could permanently lose their benefits in the course of their treatment.

And then there’s pre-existing conditions. As the Times reports,

Protection for people with preexisting conditions is destroyed. Senate Republicans claim in their talking points that the measure protects people with preexisting conditions from being denied coverage or priced out of the market. Don’t believe them…The Senate bill will open the door to states forcing people with preexisting conditions into segregated markets that will lead them to pay far, far higher costs than everyone else….This bill will bring the country back to a system in which insurance only works for the healthy, and the sick can’t afford the coverage they need.

There’s lots more. Older Americans will get hosed; under this bill as currently drafted, older Americans could be charged five times what younger, healthier Americans will pay. Meanwhile, the biggest tax cut for the rich is retroactive; a millionaire who already had booked a $1-million gain on a stock sale, for example, would collect a $38,000 benefit.(Even the Wall Street Journal was aghast at that one.)

And most despicable of all:

In fact, all the measure’s tax cuts taken together, valued at about $700 billion over 10 years, would be almost entirely paid for by the bill’s elimination of Medicaid expansion in the 30 states and the District of Columbia that accepted it.

The bill defunds Planned Parenthood. It cuts Medicaid so drastically that hundreds of thousands of elderly Americans will no longer be able to go to nursing homes, and rural hospitals that depend upon Medicaid will close. It will strip coverage from more than twenty million people, and take us back to the days when people had no choice but to use emergency rooms for primary care. The medical cost curve, which had been coming down under the ACA will once again rise more rapidly than the rate of inflation.

And why? To further enrich the already wealthy–and not so incidentally, to destroy the legacy of America’s first black President.

 

Anticipating Unanticipated Consequences

These are horrific political times. It’s hard not to be depressed–every day, it seems, we wake up to a new assault on what we thought were American values, new evidence of deplorable behaviors and attitudes we thought we’d left behind, new efforts to roll back hard-won progress.

But.

We need to remind ourselves that the turbulence and upheaval we see around us is not a new phenomenon. Times of social transition are typically unsettled and contentious. (Think of the Sixties, not to mention the Industrial Revolution, the Civil War…). The question is: what comes next? What are we transitioning to? 

My own prediction–based on history and a lot of hope–is that the election of Trump will prove to be a turning point, that the resistance and increased activism we are already seeing will grow more pronounced, and the political pendulum will swing back toward sanity and concern for the common good. The problem is, in the meantime, Trump and the Congressional GOP are doing incalculable damage to the environment, to the rule of law, to the economy and to America’s place in the world.

Yesterday, McConnell finally unveiled the Senate’s Trumpcare bill, and it is even worse than the House version; it proposes to take health care from millions of struggling Americans in order to give a huge tax break to the rich.

Despicable as it is, I’m not the only person who sees potential for eventual progress lurking in short-term disaster. Take Ezra Klein’s recent article for Vox, “Republicans are about to make Medicare-for-All Much More Likely.”

On Friday, McConnell reportedly “delivered a private warning to his Senate Republicans: If they failed to pass legislation unwinding the Affordable Care Act, Democrats could regain power and establish a single-payer health-care system.”

History may record a certain irony if this is the argument McConnell uses to successfully destroy Obamacare. In recent conversations with Democrats and industry observers, I’ve become convinced that just the opposite is true: If Republicans unwind Obamacare and pass their bill, then Democrats are much likelier to establish a single-payer health care system — or at least the beginnings of one — when they regain power.

And if the GOP successfully unwinds Obamacare, the Democrats are far more likely to regain power in 2018. As Klein says,

The political fallout from passing the American Health Care Act — which even Donald Trump is reportedly calling “mean” — will also be immense. In passing a bill that polls at 20 percent even before taking insurance away from anyone, Republicans will give Democrats a driving issue in 2018 and beyond — and next time Democrats have power, they’ll have to deliver on their promises to voters. Much as repeal and replace powered the GOP since 2010 and dominated their agenda as soon as they won back the White House, if the American Health Care Act passes, “Medicare for all” will power the Democratic Party after 2017.

The bubble that Congressional Republicans occupy has become so divorced from the reality of American life and opinion–so in thrall to a (shrinking) base that is itself divorced from reality–that they no longer connect with most Americans. And presumably, the Democrats will have learned some important lessons from their experience with the ACA.

If Republicans wipe out the Affordable Care Act and de-insure tens of millions of people, they will prove a few things to Democrats. First, including private insurers and conservative ideas in a health reform plan doesn’t offer a scintilla of political protection, much less Republican support. Second, sweeping health reform can be passed quickly, with only 51 votes in the Senate, and with no support from major industry actors. Third, it’s easier to defend popular government programs that people already understand and appreciate, like Medicaid and Medicare, than to defend complex public-private partnerships, like Obamacare’s exchanges….

Obamacare was the test of the incrementalist theory, and, politically, at least, it’s failed. Democrats built a law to appeal to moderate Republicans that incorporated key ideas from Mitt Romney’s Massachusetts reforms, and it nevertheless became the single most polarizing initiative of Obama’s presidency. All the work Democrats did to build support from the health care industry has proven to be worth precious little as Republicans push their repeal plan forward. And the complex public-private design of the Affordable Care Act left the system dependent on the business decisions of private insurers and left Democrats trying to explain away premium increases they don’t control. The result is a Democratic Party moving left, and fast, on health care.

“I have been in contact with a lot of Democrats in Congress,” says Yale’s Jacob Hacker, who is influential in liberal health policy circles, “and I am confident that the modal policy approach has shifted pretty strongly toward a more direct, public-option strategy, if not ‘Medicare for all.’”

As bleak as our current political environment is, Klein and others see Ryan, McConnell and our clueless President unwittingly sowing the seeds of fairer and more cost-effective policies.

The accuracy of that prediction, of course, depends upon the strength, savvy and persistence of the Resistance.

When The Emperor Has No Clothes…

Yesterday, the Republicans’ much-hyped replacement of the Affordable Care Act went down in flames.

There are multiple lessons to be drawn from the legislative fiasco we’ve just witnessed, although I am doubtful the people who most need to learn those lessons are capable of doing so.

The first–and most obvious–is that Donald Trump presides (in the words of David Gergen, who has served both Republican and Democratic Presidents) over an incompetent and delusional Administration. “I actually think this may be the worst hundred days we’ve ever seen in a president.”

As one wag commented, William Henry Harrison had a better second month.

Political commentators have repeatedly catalogued the myriad ways in which Trump is unsuited for the Presidency–including but not limited to his emotional and mental instability, lack of intellectual curiosity and ignorance of the structures and operations of government. Those deficits translate into an inability to understand that Presidents–unlike CEOs of closely-held corporations–cannot simply issue orders to Congress, a co-equal branch of government, and expect compliance.

The art of a legislative “deal” is distinctly different than the art of developing a parcel of real estate. A successful Presidency requires skills that Trump neither possesses nor understands.

Then there is Paul Ryan, who has long been lauded as the Republicans’ policy wonk. The lesson here is that in a group of midgets, even a short guy looks tall. Ryan has had seven years to craft a replacement for Obamacare; clearly, he spent none of that time considering what such a replacement should look like. Ryan has been “defrocked”–shown to be all political posturing and no policy chops. The bill he tried to peddle to his fractious caucus was an abysmal piece of legislation–a “steaming pile of excrement” in the words of one Republican lawmaker.

Even if Ryan had possessed the skills credulous pundits have attributed to him, however, it probably would not have been possible to bridge the deep divides within the GOP. The aptly-named “lunatic caucus” wants nothing less than a government retreat from any participation in healthcare, including Medicaid and Medicare. The moderates–mostly elected from more competitive districts– understand that such a retreat is neither possible nor desirable, and wanted legislation that they could have described as improving upon the ACA.

The only thing the two factions agreed upon was that they were being asked by a President with a 37% approval rating to vote for a measure supported by 17% of voters.

Congressional Republicans are hopelessly divided between the radical ideologues produced by 2011’s extreme gerrymandering (who don’t give a rat’s patootie what their party’s leadership wants) and the GOPs (somewhat) more traditional representatives.

The third lesson, then, is that It will only get worse.

The Party of No is no longer capable of getting to yes.

It’s Not Just Complicated…

Trump generated a lot of well-deserved criticism–not to mention sarcasm–for his recent expression of surprise at the complexity of health policy, saying “Who knew it was so complicated?” The universal response was “Apparently, everyone but you!”

Which brings us to the bill currently before Congress.

Virtually every headline about Paul Ryan’s proposed ACA replacement has been negative: NBC’s said bluntly “Experts: The GOP Healthcare Plan Just Won’t Work.”

While their objections vary depending on their ideological goals, the newly introduced American Health Care Act (AHCA) is facing an unrelenting wave of criticism. Some experts warn that the bill is flawed in ways that could unravel the individual insurance market.

Among other problems, the article pointed out that the bill is almost certain to reduce overall coverage and result in deductibles increasing. It will also phase out Obamacare’s Medicaid expansion. Older, sicker and lower-income patients will be the bigger losers.

The headline of the Washington Post’s Plum Line was equally direct: “The New Republican Health-Care Plan is Awe-Inpiringly Awful.”  

Noting that Trump had campaigned on a promise to replace the ACA with “something terrific,” Paul Waldman, who authors the Plum Line, observed that the bill is

so far from terrific that there doesn’t seem to be anyone other than House Speaker Paul D. Ryan (R-Wis.) himself who thinks this bill isn’t a disaster. It’s being attacked not just from the left but from the right as well. Heritage Action and the Club for Growth, two groups that exist to browbeat Republicans into upholding hard-right principles, have just come out against it.

Waldman marveled that

House Republicans have accomplished something remarkable: They have written a bill that would make every problem they’ve complained about much, much worse. If there’s any saving grace, it’s that almost no one will be happy about it, except for the wealthy people to whom it gives a gigantic tax cut.

So… Republicans are going to drastically reduce the number of Americans with health insurance while increasing costs pretty much across the board:  individuals, state governments and the federal government will all pay more. According to insurance experts, the bill will also do enormous damage to the insurance market. The GOP is evidently willing to inflict all that pain in order to give rich people a tax cut.

The problems with the bill range from the ludicrous to the outrageous, and you can all decide for yourselves which parts you find more horrific or ridiculous, but as a number of observers have pointed out, the promises of a genuine Republican replacement for Obamacare were always impossible to keep.

Today’s GOP is an increasingly uncomfortable amalgam of true believers who oppose the very notion that government has an obligation to provide access to health insurance, and who are working frantically to eliminate Medicare and Medicaid, and the party’s realists, who know that taking health insurance away from Americans who finally have been able to access it–not to mention Medicare recipients– is political suicide.

That’s a political fence that can’t be straddled.

What Ryan and his minions are trying to do is square the circle: drastically reduce coverage while pretending they are doing no such thing.

Some day–if and when sanity and a modicum of honesty return to American government– the United States will join virtually every other first-world country and provide universal coverage. I’ve previously posted about the multiple benefits and clear superiority of Medicare for All.

In 2006, the Economist—hardly a leftwing publication—had this to say about the U.S. healthcare system:

“America’s health care system is unlike any other. The United States spends 16% of its GDP on health, around twice the rich country average, equivalent to $6,280 for every American each year. Yet it is the only rich country that does not guarantee universal health coverage. Thanks to an accident of history, most Americans receive health insurance through their employer, with the government picking up the bill for the poor (through Medicaid) and the elderly (through Medicare).

[…]

In the longer term, America, like this adamantly pro-market newspaper, may have no choice other than to accept a more overtly European-style system.”

Obamacare was a step in the right direction, but America still spends more per person on healthcare than any other country–and we still rank 37th in outcomes. (If our infant mortality rate was as good as Cuba’s—Cuba’s!—we would save the lives of an additional 2,212 babies every year.)

Other countries have opted for more efficient–and more humane– national systems.

In 2017 America, we are still arguing over whether healthcare should be viewed as a right (or at least a utility), or whether we should continue to treat it as a consumer product, available to those who can afford it and “tough luck” to those who can’t.

That circle can’t be squared.