Ramesh Ponnuru has a long piece at National Review imploring conservatives to come up with a health-care plan they can swiftly put in place when Obamacare inevitably collapses under the weight of its disastrous big-government delusions. Though I disagree with almost every point Ponnuru makes along the way, from his analysis of what will happen with Obamacare to his recommendations of what a conservative health-insurance system should look like (the fact that anyone, even a free-market dogmatist, thinks catastrophic coverage plus high-risk pools would work out great is just incredible), I’ll give him credit for trying to get his ideological brethren to come up with a proposal to solve what they themselves keep saying is a terrible problem. But alas, his effort is doomed to fail. Why? Because when it comes to health care, conservatives just don’t care. I’ll elaborate in a moment, but here’s the crux of Ponnuru’s argument:
Opponents of Obamacare should plan instead for the likelihood that in its first years of full operation the law will fail in undramatic and unspectacular ways. Premium increases, cost overruns, and the like may keep the law from becoming popular, but they will not prompt the third of the public that supports it to switch sides, or even get its many soft opponents fired up about it. Meanwhile, the administration will spend millions of taxpayer dollars to advertise the law’s benefits. The law’s dogged defenders will explain away all the disappointing developments, and the polls, as the result of continuing opposition in red states. A few conservative lawmakers have speculated that the law will crash so badly that the Democrats will themselves demand repeal in the next couple of years. That is not the way to bet.
Republicans’ confidence that Obamacare will collapse has contributed to their lassitude in coming up with an alternative. It is a perverse complacency. If the program were going to collapse in the next three years, it would be all the more important for Republicans to build the case for a replacement for it. We can be sure that the Left would respond to any such collapse by making the case for a “single payer” program in which the federal government directly provides everyone insurance.
The biggest problem with this kind of appeal is that he will never, ever get anything beyond a tiny number of Republicans to invest any effort in coming up with a health-care plan. That would involve understanding a complex topic, weighing competing values and considerations against one another, and eventually getting behind something that will be something of a compromise. And let me say it again: They. Just. Don’t. Care.
That isn’t to say there are no conservatives who care about health care, because there are a few (like the folks at the Heritage Foundation who came up with the individual mandate!). But they are few and far between on the right. Your typical Republican, on the other hand, cares deeply about issues like taxes and defense policy, and works hard to understand them and come up with ideas for where they should go in the future. But had President Obama not passed health-care reform, they would have been perfectly happy to let the status quo continue indefinitely. They donned their fervent opposition to Obamacare like a new jacket, for reasons of politics, not policy. Sure, it was in many ways a conservative plan, much of whose complexity comes from the fact that it works to expand coverage within the private market. But it was big and important, and it was Obama, and it was a way to articulate their anti-government philosophy, and so they got fired up about it. But it isn’t because health-care policy is something they’re passionate about. Republicans care about taxes whether or not at the moment we happen to be having a big public debate about taxes. But if we weren’t debating health care, they wouldn’t be staying up nights coming up with interesting solutions to health-care problems, because it just isn’t their thing.
Ponnuru doesn’t allow for the possibility that Obamacare will turn out to be something less than a total failure, and he says that conservatives all believe the same thing (though he does differ from some of his allies on whether it will collapse dramatically or simply limp miserably along). But let me suggest another possible scenario: It ends up working pretty well. It doesn’t turn America into a health-care paradise, and there are some implementation problems here and there, and we still have to pay more for our system than other countries do. But people like the fact that their coverage is guaranteed, and the doomsaying turns out not to be borne out. Critically, the middle class and wealthy people who collectively hold political influence discover that their lives haven’t really been changed all that much, except in some ways that are positive. And it becomes hard to get voters too angry about Obamacare.
What will Republicans do then, if the issue doesn’t seem to have much political potency? Will they keep working to come up with new health-care proposals more in line with their values? Or will they move on to some other issues that seem to offer better opportunities to gain political advantage? If you think it’s the former, you’re dreaming.
By: Paul Waldman, Contributing Editor, The American Prospect, June 13, 2013
House Republicans are launching a coordinated campaign against Obamacare, hoping to emphasize the negative effects of the health law to their constituents at upcoming town hall meetings. At the same time, however, they’re fully prepared to tell those same constituents to enjoy all the benefits available to them under health reform — ultimately taking advantage of Obamacare funding in their home districts.
As Politico reports, several of the GOP members of the new coalition — called the “House Obamacare Accountability Project,” or HOAP — went on the record to confirm they will help their constituents figure out how to get the benefits funded through the health reform law. The Republicans said that if they’re asked, they will help people get access to the insurance premium subsidies or the Medicaid coverage that’s available to them under Obamacare. “That’s an important part of constituent services,” Rep. Kevin Brady (R-TX) explained.
They’re not the only lawmakers who have advocated for getting rid of the health law even while simultaneously enjoying its benefits. As Lee Fang reports in the Nation, several anti-Obamacare Republicans like Sens. John Cornyn (R-TX) and Rob Portman (R-OH) have requested grants funded through the health reform law for their districts. GOP lawmakers who decry Obamacare in public have requested Obamacare money to bolster their states’ health clinics, extend health services to uninsured residents, and launch public health campaigns.
In their letters requesting Obamacare funds, Republican lawmakers have praised the positive long term effects of the health reform law’s initiatives. Cornyn wrote that a grant from the Affordable Care Act would “improve the health and quality of life of area residents.” In reference to the same grant, Rep. Michael McCaul (R-TX) called the effort a “crucial initiative to achieve a healthier Houston/Harris County.” Rep. Aaron Schock (R-IL) praised a local nonprofit for winning Obamacare funds that will help give “people the tools to live healthier and longer lives.”
That reflects a larger trend when it comes to Obamacare: Although Americans may say they oppose the health law as a whole, they support its individual provisions. That seeming contradiction may partly be thanks to GOP-led initiatives like HOAP. Since political controversy has swirled around the health reform law for the past three years, Americans remain confused about what Obamacare actually does — and over 40 percent of the public isn’t even sure whether it’s still law.
By: Tara Culp-Resseler, Think Progress, June 7, 2013
House Republicans have voted 37 times to repeal ObamaRomneyCare — the Affordable Care Act, which creates a national health insurance system similar to the one Massachusetts has had since 2006. Nonetheless, almost all of the act will go fully into effect at the beginning of next year.
There is, however, one form of obstruction still available to the G.O.P. Last year’s Supreme Court decision upholding the law’s constitutionality also gave states the right to opt out of one piece of the plan, a federally financed expansion of Medicaid. Sure enough, a number of Republican-dominated states seem set to reject Medicaid expansion, at least at first.
And why would they do this? They won’t save money. On the contrary, they will hurt their own budgets and damage their own economies. Nor will Medicaid rejectionism serve any clear political purpose. As I’ll explain later, it will probably hurt Republicans for years to come.
No, the only way to understand the refusal to expand Medicaid is as an act of sheer spite. And the cost of that spite won’t just come in the form of lost dollars; it will also come in the form of gratuitous hardship for some of our most vulnerable citizens.
Some background: Obamacare rests on three pillars. First, insurers must offer the same coverage to everyone regardless of medical history. Second, everyone must purchase coverage — the famous “mandate” — so that the young and healthy don’t opt out until they get older and/or sicker. Third, premiums will be subsidized, so as to make insurance affordable for everyone. And this system is going into effect next year, whether Republicans like it or not.
Under this system, by the way, a few people — basically young, healthy individuals who don’t already get insurance from their employers, and whose incomes are high enough that they won’t benefit from subsidies — will end up paying more for insurance than they do now. Right-wingers are hyping this observation as if it were some kind of shocking surprise, when it was, in fact, well-known to everyone from the beginning of the debate. And, as far as anyone can tell, we’re talking about a small number of people who are, by definition, relatively well off.
Back to the Medicaid expansion. Obamacare, as I’ve just explained, relies on subsidies to make insurance affordable for lower-income Americans. But we already have a program, Medicaid, providing health coverage to very-low-income Americans, at a cost private insurers can’t match. So the Affordable Care Act, sensibly, relies on an expansion of Medicaid rather than the mandate-plus-subsidy arrangement to guarantee care to the poor and near-poor.
But Medicaid is a joint federal-state program, and the Supreme Court made it possible for states to opt out of the expansion. And it appears that a number of states will take advantage of that “opportunity.” What will that mean?
A new study from the RAND Corporation, a nonpartisan research institution, examines the consequences if 14 states whose governors have declared their opposition to Medicaid expansion do, in fact, reject the expansion. The result, the study concluded, would be a huge financial hit: the rejectionist states would lose more than $8 billion a year in federal aid, and would also find themselves on the hook for roughly $1 billion more to cover the losses hospitals incur when treating the uninsured.
Meanwhile, Medicaid rejectionism will deny health coverage to roughly 3.6 million Americans, with essentially all of the victims living near or below the poverty line. And since past experience shows that Medicaid expansion is associated with significant declines in mortality, this would mean a lot of avoidable deaths: about 19,000 a year, the study estimated.
Just think about this for a minute. It’s one thing when politicians refuse to spend money helping the poor and vulnerable; that’s just business as usual. But here we have a case in which politicians are, in effect, spending large sums, in the form of rejected aid, not to help the poor but to hurt them.
And as I said, it doesn’t even make sense as cynical politics. If Obamacare works (which it will), millions of middle-income voters — the kind of people who might support either party in future elections — will see major benefits, even in rejectionist states. So rejectionism won’t discredit health reform. What it might do, however, is drive home to lower-income voters — many of them nonwhite — just how little the G.O.P. cares about their well-being, and reinforce the already strong Democratic advantage among Latinos, in particular.
Rationally, in other words, Republicans should accept defeat on health care, at least for now, and move on. Instead, however, their spitefulness appears to override all other considerations. And millions of Americans will pay the price.
By: Paul Krugman, Op-Ed Columnist, The New York Times, June 6, 2013
Sen. Marco Rubio (R-FL) proposed a constitutional amendment Tuesday that, if approved, would nullify Obamacare’s individual mandate. The amendment is the latest in a string of failed GOP attempts to repeal Obamacare, which many Republicans still view as unconstitutional.
The “Right to Refuse” amendment would make any laws that tax Americans who fail to purchase goods or services unconstitutional, targeting the Affordable Care Act’s stipulation that nearly all Americans must purchase health insurance. The amendment was introduced by Rep. Steven Palazzo (R-MS) in the House in February.
In a press release, Rubio cited the recent Internal Revenue Service scandal as one of his reasons for introducing the bill:
“ObamaCare is a disastrous policy that is not only destructive to job creation, it will also unleash the corrupt and scandal-ridden IRS on taxpayers simply for not buying health insurance,” said Rubio. “We should put our faith in the American people to decide what goods and services they want to buy, not have Congress dictate it and have the IRS empowered to harass Americans to make sure they do it.”
The Supreme Court ruled in 2012 that Obamacare’s individual mandate could be considered a tax, and therefore was upheld under the constitution. But that hasn’t stopped many Republicans from claiming Obamacare is unconstitutional — the act has survived at least 37 repeal attempts since Republicans took control of the House in 2011, the most recent repeal vote occurring in mid-May. Since news broke in May that the IRS flagged certain conservative groups applying for tax-exempt status for additional scrutiny, several Republican leaders have used the scandal to question whether the IRS can be trusted to implement Obamacare.
Constitutional amendments are far more difficult to pass than bills — amendments proposed by Congress require a two-thirds majority vote in the House and Senate. With a Democrat-controlled Senate, Rubio and Palazzo’s amendment would have difficulty achieving even a simple majority. Rubio has been billed as a rising star in the Republican party and likely 2016 presidential candidate, but his fervent opposition to Obamacare — along with several other positions — show that his views don’t stray far from the status quo of the Republican party.
By: Katie Valentine, Think Progress, June 4, 2013
Imagine you went to Best Buy and found a great deal on a plasma television set. I want to be clear here: You didn’t find a great television set. This television set is actually a bit crummy. The picture is fuzzy. Consumer Reports says it breaks down a lot and it’s expensive to fix. But it’s really cheap. The price tag reads $109.
When you take it to the counter, the saleswoman tells you that the set will actually cost you $199. And count yourself lucky, she confides in a conspiratorial whisper. There are customers whom Best Buy won’t sell it to at any price. You ask her which customers those are. The ones who need the TV most, she replies.
So here’s the question: Does that television really cost $109?
Best Buy, of course, would never do this to you. If they say you can buy a television set for $109, you can buy it for $109. Plus, they’re handsome, and their customer service is great, and I hope they advertise in The Washington Post forevermore, amen.
But this is actually how the individual health-insurance market works. And understanding why is crucial to understanding a lot of what you’re going to read about health reform in the next year.
Last week, California released early information on the rates insurers intend to charge on the new insurance marketplaces — known as “exchanges” — that the state is setting up under Obamacare. They were far lower than anyone expected. Where analysts had anticipated average premiums of $400 to $500, insurers were actually charging $200 to $300. “This is a home run for consumers in every region of California,” crowed Peter Lee, director of the state’s exchanges.
The Affordable Care Act’s critics saw it differently. Avik Roy, a conservative health writer at Forbes, said Lee was being “misleading” and that “Obamacare, in fact, will increase individual-market premiums in California by as much as 146 percent.” Obamacare, he said, would trigger “rate shock,” the jolt people feel when they see higher rates. That doesn’t sound like a home run at all.
Who’s right? In typical columnist fashion, I’m not going to tell you just yet. But stick with me, and you’ll be able to parse the next year of confused and confusing Obamacare arguments with ease.
Here’s the first thing to know: We’re talking about a small fraction of the American health-care system. This isn’t about people on Medicare or Medicaid or employer-based insurance. It’s about people joining Obamacare’s insurance exchanges. That’s people who buy insurance on their own now, as well as some of the uninsured. In 2014, 7 million people, or 2.5 percent of the population, is expected to buy insurance through the exchanges. By 2023, that will rise to 24 million people, or 8 percent.
So we’re talking about a small portion of the market. Worse, we’re talking about that small portion of the market all wrong.
Roy got his 146 percent by heading to eHealthInsurance.com, running a search for insurance plans in California and comparing the cost of the cheapest plans to the cost of the plans being offered in the exchanges. That’s not just comparing apples to oranges. It’s comparing apples to oranges that the fruit guy may not even let you buy.
I ran the same search Roy did. I looked for insurance in Irvine, Calif. — my home town. The average monthly premiums of the five cheapest plans is $114. So I took the middle plan, HealthNet’s IFP PPO Value 4500. It’s got a $4,500 deductible, a $2,500 deductible for brand-name medications, huge co-pays and a little “bestseller” icon next to it. And it’s only $109 a month — if they’ll sell it to you for that price.
That’s the catch, and it’s a big one. Click to buy the plan and eventually you’ll have to answer pages and pages of questions about your health history. Ever had cancer? How about an ulcer? How about a headache? Do you feel sad when it rains? When it doesn’t rain? Is there a history of cardiovascular disease in your family? Have you ever known anyone who had the flu? The actual cost of the plan will depend on how you answer those questions.
According to HealthCare.gov, 14 percent of people who try to buy that plan are turned away outright. Another 12 percent are told they’ll have to pay more than $109. So a quarter of the people who try to buy this insurance product for $109 a month are told they can’t. Those are the people who need insurance most — they are sick, or were sick, or are likely to get sick. So, again, is $109 really the price of this plan?
Comparing the pre-underwriting price of this plan to those in Obamacare’s exchanges is ridiculous. The plans in Obamacare’s exchanges have to include those people. They can’t turn anyone away or jack up rates because of a history of arthritis or heart disease.
They also have to offer insurance that meets a certain minimum standard. Under Obamacare, for instance, the out-of-pocket limit for someone making 100 to 200 percent of the poverty line is $1,983. Under the Value 4500, you could spend up to $9,500 before the out-of-pocket limit kicked in. Obamacare also has subsidies for people making up to four times the poverty line. The poor pay next to nothing. The rich pay full freight.
“We as a society have never really said here’s what reasonable insurance is,” says Larry Levitt of the Kaiser Family Foundation. “It’s just been anything goes. For the first time they’re setting a minimum about what reasonable insurance should be.” They’re also setting a minimum about who should be able to get it, and at what cost. Now it really will work like Best Buy, where the price on the tag is the price everyone actually pays.
Some people will find the new rules make insurance more expensive. That’s in part because their health insurance was made cheap by turning away sick people. The new rules also won’t allow for as much discrimination based on age or gender. The flip side of that, of course, is that many will suddenly find their health insurance is much cheaper, or they will find that, for the first time, they’re not turned away when they try to buy health insurance.
That’s why the law is expected to insure almost 25 million people in the first decade: It makes health insurance affordable and accessible to millions who couldn’t get it before. To judge it from a baseline that leaves them out — a baseline that asks only what the wealthy and healthy will pay and ignores the benefits to the poor, the sick, the old, and women — well, that is a bit shocking.
By: Ezra Klein, Wonkblog, The Washington Post, June 1, 2013