Tag Archives: ACA

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.


There’s Talking and Then There’s Doing….

Over at Talking Points Memo, Josh Marshall makes a really important point. In a post reflecting on the various reasons that the rollout of the proposed healthcare overhaul has been going so badly, he points to the important role of a President in the passage of complex or controversial legislation.

True, the health-care bill has numerous glaring defects. As Marshall also points out, the defects should have been expected, since the GOP has been promising to do something that is basically impossible–continuing to cover people while offering more carrots and employing fewer sticks.

Even though Republicans control both houses of Congress and the Presidency, the bill faces formidable obstacles. Major stakeholders hate it,  Republican lawmakers are divided, and the bill won’t get a single Democratic vote. Faced with significant opposition, what is needed is what Marshall calls “the mix of formal and informal powers, favors and threats, public presence, the ability to protect or punish” that only a President can bring to bear.

This is something President Trump has shown virtually no interest in doing. We’re at roughly a month and a half into the administration. The GOP has unified control of the government and yet no significant legislation has moved at all. That is a stunning reality which the storm and chaos of Trump’s short presidency has largely obscured. But it is an almost unprecedented development. Some of this may be an inherent limitation because the President came into office as a minority President. But as I argued a month ago, the President simply has no appetite for the hard work of passing laws. He has defaulted to rolling out executive order after executive order, in most cases Potemkin decrees with vaguely legalistic language and limited actual impact. Like so much with Trump, it’s a mix of authoritarianism on the one hand and impatience and flimflam on the other. The upshot isn’t so much a poor man’s as a lazy man’s authoritarianism.

I think it is deeper than Trump’s obvious aversion to actual work. It is equally obvious that he has not the faintest understanding of how government actually works–and even less interest in learning what he doesn’t know. He is used to running a family business where he issued orders and people who were related to him and dependent upon his largesse obediently followed them. He wasn’t even the typical CEO of a publicly-traded company who would at least have to answer to a Board of Directors and shareholders.

A diligent and intellectually curious person with Trump’s background would be disadvantaged by that lack of relevant experience.  Trump is neither diligent nor intellectually curious (judging from his vocabulary and spelling of his tweets, he isn’t even very bright). Several of the skills that Marshall identifies as critical to the passage of legislation are simply beyond his capacity to acquire or exercise, and his self-obsession  precludes any engagement in the sorts of “schmoozing” required to cajole recalcitrant lawmakers. (It is impossible to imagine Trump strategically stroking the egos of crucial legislators.)

Ironically, the very traits that make Trump so manifestly unqualified for the Presidency  may end up saving healthcare….

Fingers crossed.

The Unarguable Benefits of Universal Healthcare

As political posturing over the Affordable Care Act (aka “Obamacare”) continues, the fiscal and social benefits of expanded access to healthcare become steadily more obvious.

The journal Health Affairs recently reported an 8 percent increase per year in the number of early-stage colorectal cancer diagnoses since passage of the ACA. Extrapolated across the country, the researchers estimate the ACA led to approximately 8,400 additional early-stage colorectal cancer diagnoses among seniors between 2011 and 2013.

A 2015 study published in JAMA found that the ACA had increased the number of early-stage cervical cancer diagnoses in women aged 21 to 25.

Early diagnosis doesn’t just increase the likelihood of successful medical intervention; it significantly reduces healthcare costs. When cancer is caught earlier, it is cheaper to treat.

America’s healthcare costs have long been far higher–and our outcomes considerably worse-– than in countries with universal systems. The lobbying clout of Big Pharma and Big Insurance continue to make a cost-effective “Medicare for All” politically impossible, but even with its problems, the ACA has vastly increased the number of Americans who are insured while significantly slowing the rise of healthcare spending; last June, Fortune Magazine reported

The United States will save about $2.6 trillion on health care expenses over a five-year period compared to initial projections made right after the passage of the Affordable Care Act.

While health spending spiked briefly in 2014, evidence shows that it has once again slowed down and will help save Americans trillions between 2014 and 2019, according to a new study by the Urban Institute and Robert Wood Johnson Foundation.

Spending declines will happen across both private health insurance as well as Medicare and Medicaid. Centers for Medicare and Medicaid Services actuaries predicted that total Medicare spending between 2014 and 2019 would be $455 billion lower than the ACA baseline forecast. Projected Medicaid spending over the same time period is expected to be $1.05 billion lower than previous ACA estimates, while private insurance spending projections declined by $664 billion.

I simply do not understand the Republicans’ hysterical opposition to the ACA. Both health outcomes and cost controls have improved, and problems with the program can be fixed with relatively minimal tweaking. The program’s popularity has also improved. (According to survey research, approximately half of those who do remain unhappy with Obamacare complain that it doesn’t go far enough–they would prefer a single-payer system.)

It isn’t just the ACA. Paul Ryan and the GOP are threatening to dismantle both Medicaid and Medicare–programs with low overhead and proven effectiveness– and they are intent on defunding Planned Parenthood, which delivers critical medical services to millions of poor women.

It isn’t as though a free market system could work for healthcare. Market transactions require a willing buyer and a willing seller, both of whom are in possession of all information relevant to the transaction. Equal bargaining power doesn’t describe real-world doctor-patient relationships. In that real world, insurance companies have virtually total control over the options available to those fortunate enough to have coverage.

It seems inconceivable that Ryan, et al, simply do not see the multiple fiscal and social benefits of universal–or at least expanded–access to healthcare. So what accounts for their persistent hostility to programs that have proven their effectiveness? Why are they intent upon substituting block grants for Medicaid, turning Medicare into a “voucher” system, destroying Planned Parenthood and eviscerating the ACA?

If the answer to that question is what I think it is– slashing social programs that benefit millions of Americans will allow them to subsidize the insurance and pharmaceutical industries even more generously and deliver more tax cuts to their wealthy patrons–I wonder how they sleep at night.

Why Do They Hate the ACA?

Yesterday, I noted the anger directed at the Chief Justice by Republicans furious that he failed to strike down the Affordable Care Act. It was yet another aspect of Republican fury over any effort to extend access to health insurance.

The Capitol Times, a Wisconsin newspaper, recently ran an article about the GOP’s fixation on repealing the hated “Obamacare.”

What is this Republican obsession about what was once so derisively called Obamacare?

It makes no difference if it’s a supposedly enlightened Republican like Paul Ryan or an over-the-top right-winger like Ted Cruz. Neither can get through a speech without blaming the Affordable Care Act for all of the nation’s problems and insisting that it be repealed — yesterday, if not sooner….

Evidence continues to pour in that Obamacare has dramatically changed for the better the lives of millions of Americans. None of that fazes the Republicans in Congress or those on the presidential trail.

Let’s be honest. If opposing Medicare wasn’t so politically damaging, most Republican conservatives would advocate its repeal, too. I’m old enough to remember the hysteria and outrage that accompanied passage of Medicare, and the dire predictions that it would erase incentives for people to go to medical school–after all, why spend all that time and money learning to heal people if you couldn’t make out like a bandit once you established a practice?

Apparently, people are still going through medical school, and Medicare has worked well enough that it has joined the “third rail” political status enjoyed by Social Security. Not so the Affordable Care Act, aka “Obamacare.” At least not yet.

The real question–to which I have no answer–is why every attempt by government to expand access to basic medical care meets with such deeply-seated animosity from conservatives.

Let me be very clear: objecting to the way a particular program is fashioned, disputing whether this or that provision is likely to achieve its goals, concerns over cost-benefit ratios and the like are perfectly appropriate matters for debate. To the extent that arguments about the ACA are “deep dives” into the policy weeds–legitimate differences of opinion about the best way to achieve a goal–they are both reasonable and productive; they can only help improve the law.

But no one who has actually followed the GOP’s multiple efforts to repeal Obamacare could conclude that the party’s objections are based upon anything other than a visceral rejection of the very idea that government has a role to play in extending access to health insurance to people struggling to afford it. That rejection is sometimes clothed in policy pretenses, but the pretense is obvious. Probably the most honest exchange was at the GOP Presidential debate that included Ron Paul (not Rand); when a moderator asked him how he proposed to make healthcare available to poor people, he basically said “let them die.” 

And the audience, if you will recall, applauded wildly.

“Let them die” is at the bottom of this frantic rejection of the ACA, and it’s what I don’t get. Any psychiatrists or psychologists out there who can explain this particular lack of humanity and compassion?

The United States is the only modern western democracy that does not have universal access to healthcare. Our refusal to implement a single-payer system doesn’t just allow poor people to die, as I have previously explained, it actually costs us much more money and impedes economic development.

What’s wrong with us?