Health reform is the signature achievement of the Obama presidency. It was the biggest expansion of the social safety net since Medicare was established in the 1960s. It more or less achieves a goal — access to health insurance for all Americans — that progressives have been trying to reach for three generations. And it is already producing dramatic results, with the percentage of uninsured Americans falling to record lows.
Obamacare is, however, what engineers would call a kludge: a somewhat awkward, clumsy device with lots of moving parts. This makes it more expensive than it should be, and will probably always cause a significant number of people to fall through the cracks.
The question for progressives — a question that is now central to the Democratic primary — is whether these failings mean that they should re-litigate their own biggest political success in almost half a century, and try for something better.
My answer, as you might guess, is that they shouldn’t, that they should seek incremental change on health care (Bring back the public option!) and focus their main efforts on other issues — that is, that Bernie Sanders is wrong about this and Hillary Clinton is right. But the main point is that we should think clearly about why health reform looks the way it does.
If we could start from scratch, many, perhaps most, health economists would recommend single-payer, a Medicare-type program covering everyone. But single-payer wasn’t a politically feasible goal in America, for three big reasons that aren’t going away.
First, like it or not, incumbent players have a lot of power. Private insurers played a major part in killing health reform in the early 1990s, so this time around reformers went for a system that preserved their role and gave them plenty of new business.
Second, single-payer would require a lot of additional tax revenue — and we would be talking about taxes on the middle class, not just the wealthy. It’s true that higher taxes would be offset by a sharp reduction or even elimination of private insurance premiums, but it would be difficult to make that case to the broad public, especially given the chorus of misinformation you know would dominate the airwaves.
Finally, and I suspect most important, switching to single-payer would impose a lot of disruption on tens of millions of families who currently have good coverage through their employers. You might say that they would end up just as well off, and it might well be true for most people — although not those with especially good policies. But getting voters to believe that would be a very steep climb.
What this means, as the health policy expert Harold Pollack points out, is that a simple, straightforward single-payer system just isn’t going to happen. Even if you imagine a political earthquake that eliminated the power of the insurance industry and objections to higher taxes, you’d still have to protect the interests of workers with better-than-average coverage, so that in practice single-payer, American style, would be almost as kludgy as Obamacare.
Which brings me to the Affordable Care Act, which was designed to bypass these obstacles. It was careful to preserve and even enlarge the role of private insurers. Its measures to cover the uninsured rely on a combination of regulation and subsidies, rather than simply on an expansion of government programs, so that the on-budget cost is limited — and can, in fact, be covered without raising middle-class taxes. Perhaps most crucially, it leaves employer-based insurance intact, so that the great majority of Americans have experienced no disruption, in fact no change in their health-care experience.
Even so, achieving this reform was a close-run thing: Democrats barely got it through during the brief period when they controlled Congress. Is there any realistic prospect that a drastic overhaul could be enacted any time soon — say, in the next eight years? No.
You might say that it’s still worth trying. But politics, like life, involves trade-offs.
There are many items on the progressive agenda, ranging from an effective climate change policy, to making college affordable for all, to restoring some of the lost bargaining power of workers. Making progress on any of these items is going to be a hard slog, even if Democrats hold the White House and, less likely, retake the Senate. Indeed, room for maneuver will be limited even if a post-Trump Republican Party moves away from the scorched-earth opposition it offered President Obama.
So progressives must set some priorities. And it’s really hard to see, given this picture, why it makes any sense to spend political capital on a quixotic attempt at a do-over, not of a political failure, but of health reform — their biggest victory in many years.
By: Paul Krugman, Op-Ed Columnist, The New York Times, January 18, 2016
House Speaker Paul Ryan (R-Wis.) delivered a fairly long speech at the Library of Congress yesterday, fleshing out his vision for making America “confident again” through a far-right approach to governing. There wasn’t anything particularly surprising about the remarks, and the Republican leader conceded his vision won’t be implemented so long as President Obama is in office.
But there was one part of the speech that jumped out at me as noteworthy. On health care policy, the new Speaker said “the other side” – presumably, Democrats – opposes giving consumers choices, while Republicans want to encourage “insurance companies to compete for your business.” It’s an odd line of attack, since the Affordable Care Act’s exchange marketplaces were specifically designed to invite insurers to compete for consumers’ business. I’m not sure how he could have missed this detail.
“There are a lot of other ideas out there, but what all conservatives can agree on is this: We think government should encourage personal responsibility, not replace it. We think prices are going up because people have too few choices, not because they have too many. And we think this problem is so urgent that, next year, we are going to unveil a plan to replace every word of Obamacare.”
Let’s just skip the usual points about the efficacy of the ACA, the law’s many successes, and the millions of Americans benefiting from its implementation. Suffice it to say, there’s no credible reason to try – or even want to try, really – to replace “every word” of the Affordable Care Act.
What I found amusing, however, was Ryan’s use of the word “urgent.”
As the Republican leader sees it, there’s no time to waste. The problems in the health care system are so great that the Speaker believes it’s “urgent” for his party to present their conservative alternative – nearly six years after the ACA was signed into law, nearly two years after the ACA was fully implemented. Now Ryan’s serious about his party’s replacement plan.
It’s hard for even the most charitable observers not to laugh. On June 17, 2009, then-Rep. Roy Blunt (R-Mo.), a member of the House Republican leadership at the time, publicly declared that he was helping craft his party’s alternative to the Affordable Care Act. “I guarantee you we will provide you with a bill,” he said six and a half years ago.
The same week, then-Minority Whip Eric Cantor (R-Va.) told reporters that the official Republican version of “Obamacare” was just “weeks away.”
The Huffington Post’s Jeffrey Young has gotten quite a bit of mileage out of a joke, documenting all of the many, many times in recent years GOP officials have said they’re finally ready to unveil their big health care solution, only to quietly fail every time.
We were told 2014 would be different. In April 2014, House Majority Whip Kevin McCarthy (R-Calif.) said his party’s plan was nearly done, but was being delayed “at least a month.” That was 20 months ago.
Then we were told 2015 would be different. Ryan was tasked with personally heading up a Republican “working group” that would finally put together the GOP’s health care plan. Then-House Speaker John Boehner promised Fox News, “There will be an alternative, and you’re going to get to see it.”
That was 11 months ago.
As of yesterday, however, Ryan believes the issue is “so urgent” that we’ll see the Republican “plan” in 2016. And who knows, maybe we will. I wouldn’t bet on it, but anything’s possible.
But revisiting a piece from February, I think we can safely assume that the House GOP alternative to “Obamacare” – if it ever exists – is going to be cover-your-eyes horrible. How can I know that? Because in order to actually reform the pre-2010 health care system – “replacing every word” of the ACA – policymakers have to commit to extensive public investments, expansive government regulation of the insurance industry, and a commitment to help struggling families receive guaranteed benefits.
In other words, to do reform right, Republicans would have to willingly take policy steps that are anathema to everything they believe about government. It’s a safer bet they’ll do reform wrong – if they follow through at all – and when the GOP alternative stands alongside “Obamacare” and consumers are allowed to compare, it won’t be much of a contest.
This point is routinely lost on much of the chattering class, but Republicans don’t actually like health care reform, which is why we’ve waited so many years to see a plan that still doesn’t exist. GOP lawmakers didn’t see the old system – the bankruptcies, the uninsured rates, the deaths, Americans paying more for less – as a problem requiring a solution, which is precisely why they haven’t invested time and energy in writing a detailed reform blueprint.
Ryan seems to think this time will be different.
By: Steve Benen, The Maddow Blog, December 4, 2015
Anyone who has been able to sit through both the Republican and Democratic presidential debates is very well-versed in the chasm that currently exists between the two parties. When all is said and done, the public is going to have a very clear choice between two starkly different directions for our country to embrace in November 2016. That is a good thing – especially for Democrats who seemed intent on watering down the differences in the 2014 midterms.
But Tuesday’s debate also clarified the differences between Clinton and Sanders. Matt Yglesias does a good job of teeing that up.
To Clinton, policy problems require policy solutions, and the more nuanced and narrowly tailored the solution, the better. To Sanders, policy problems stem from a fundamental imbalance of political power..The solution isn’t to pass a smart new law, it’s to spark a “political revolution” that upends the balance of power.
As we know from both the debate and their position statements, Clinton wants to regulate the big financial institutions and Sanders wants to break them up. The argument from the Sanders wing is that we can’t trust the government to be the regulator.
I remember that same argument coming up between liberals during the health care debate. Those who dismissed the ACA in favor of single payer often said that any attempt to regulate health insurance companies was a waste of time. I always found that odd based on the Democratic tradition of embracing government regulation as the means to correct the excesses of capitalism.
This basically comes down to whether you agree with Sanders when he says that we need a “political revolution that upends the balance of power” or do you agree with Clinton when she said, “it’s our job to rein in the excesses of capitalism so that it doesn’t run amok.” Peter Beinart calls it the difference between an insurrectionist and an institutionalist.
Depending on where you stand on that question, your solutions will look very different. That helps me understand why I never thought Sanders’ policy proposals were serious. Someone who assumes that the entire system is rigged isn’t going to be that interested in “nuanced and narrowly tailored policies” to fix it.
But in the end, this puts even more of a responsibility on Sanders’ shoulders. If he wants a political revolution to upend a rigged system, he needs to be very precise about what he has in mind as a replacement to that system. Otherwise, he’s simply proposing chaos.
By: Nancy LeTourneau, Political Animal Blog, The Washington Monthly, October 15, 2015
“Skeletal Descriptions Of Planlike Concepts”: How The Presidential Race Is Making The GOP’s Health Care Ideas Even Worse
Every major national Republican is sure that they want to repeal the Affordable Care Act. They are much less clear about what, if anything, they would do after stripping insurance from millions of people. Two plausible Republican nominees for president — Scott Walker and Marco Rubio — issued health care plans this week. And…let’s just say there’s a reason Republicans spend a lot more time on the “repeal” part of the “repeal and replace” equation.
Indeed, to call these positions “plans,” as opposed to gestures in the direction of having a policy alternative, is probably too generous. As Jon Chait of New York puts it, they are “not so much plans as skeletal descriptions of planlike concepts.” Still, even in larval form, Walker’s plan contains several elements that are common to most Republican health care proposals, and that if enacted would result in horribly unpopular policy disasters. Here are the main features:
End the individual mandate
Most individual components of the Affordable Care Act are popular; the requirement that people carry insurance or pay a tax penalty is not. And since the mandate was very nearly the lever that gave a conservative Supreme Court majority a pretext to declare the ACA unconstitutional, Republicans have also convinced themselves that it is one of the greatest threats to liberty ever seen. So it is inevitable that any Republican proposal will advocate eliminating it, as Walker’s does.
The problem is that the popular parts of the ACA can’t be divorced from the mandate. If people are permitted to free-ride, the health insurance market can’t work. Multiple states tried to initiate ACA-like reforms without a mandate, and it was a disaster — young and healthy people decline to buy insurance knowing they can get it if they fall sick, premiums increase, more people drop out, and the market collapses. This is why President Obama — who pandered during the 2008 primaries by putting forward a plan without a mandate — recanted as soon as he was in a position to actually try to get a law passed.
Make state regulations ineffective
Whenever conservatives have a policy they would prefer not to defend on the merits, the language of federalism comes in handy. In health care, virtually all Republican plans argue for permitting the purchase of insurance across state lines. Walker’s is no exception: “My plan would allow individuals to shop in any state to find health insurance that covers the services they need at a price that fits the family budget.”
In the abstract, a policy of permitting people to shop for insurance across state lines sounds attractive. In practice, it would be a regulatory race to the bottom. Insurance companies would gravitate to the states that place the fewest regulations on insurance industries. It would therefore become easier for insurance companies to deny claims, rescind insurance (or refuse to give it in the first place), and impose hidden costs. If you think credit card companies should be a model for health insurance companies, then Walker’s plan might sound like a good idea. If you’re thinking more clearly, it’s obviously a terrible one.
Make it easier to sell junk insurance
Walker’s plan would reduce federal regulations as well. The Affordable Care Act’s requirement that insurance actually cover things would be eliminated, as would other provisions such as the popular requirement that children be allowed to stay on their parents’ plan until age 26. Other provisions of the ACA, like the ban on discrimination based on pre-existing conditions, would be seriously weakened. So at the same time as Walker’s plan would effectively eliminate many state regulations, it would also leave the insurance companies mostly unsupervised by federal regulations as well.
Conservatives would defend this awful idea by posing a choice between “regulation” and “competition.” But the problem is that health care simply lacks the features of a competitive market. There’s a reason why other liberal democracies have more state intervention into health care than the United States, not less. And by the way, they all cover more people for significantly less money.
Attack the poor
Walker’s politics are not about small government. After all, he thinks that abortion should be illegal even when necessary to save a woman’s life, and he just approved a $250 million gift of taxpayer money to hedge fund billionaires to build a basketball stadium. Rather, his politics are about assisting the rich and powerful at the expense of the poorer and less powerful.
His health care plan is no exception. Like the ACA, Walker’s plan would offer tax credits to allow people to purchase insurance. But Walker’s tax credits would be distributed on the basis of age, not income. The result, as Jeffrey Young and Jon Cohn demonstrate, would be a disaster for the non-affluent, as insurance would become unaffordable for many people at any age. And in addition, Walker also advocates savage cuts to Medicaid. The callousness Walker showed in refusing the ACA’s Medicaid expansion in Wisconsin is reflected in his health care plans.
So Walker’s plan would be an utter disaster if implemented. But it’s not just about Walker. Amazingly, some conservative candidates and pundits attacked Walker’s plan from the right. A spokesman for also-ran candidate Bobby Jindal accused Walker of collaborating with Bernie Sanders to create a plan that would make health care far less accessible to the non-rich.
Essentially, Republicans look at the state of health care circa 2009 — in which more than 16 percent of Americans were uninsured, and in which insurance companies could abuse consumers in a number of ways — and argue that even fewer Americans should have insurance and the quality of the insurance should be much worse. This is one of the many reasons that the contemporary Republican Party is simply unfit to govern at the national level.
By: Scott Lemieux, The Week, August 21, 2015
“A Vague Hand-Waving Promise Is Not A Plan”: The Republican Plans To Replace Obamacare Have Been Tried, And They Failed
Before Obamacare, the individual insurance market for people who could not get health care through their job was a nightmare. The only way for insurers to make money was to avoid getting stuck with customers who would rack up high medical bills, forcing them to expend enormous time and expense to screen potential customers for preexisting conditions. Even people who could find plans with affordable premiums had to sign contracts loaded with fine-print exclusions leaving them responsible for unexpected costs. Obamacare overhauled that market, eliminating insurers’ ability to screen out healthy customers. In the new, regulated individual markets, people buy plans regardless of their prior health status. This has been a godsend to those unable to obtain coverage before.
Republicans would repeal all these new protections. But never fear, conservatives insist. In their place will be new protections. Ramesh Ponnuru, writing in National Review, points to two protections put in place by Scott Walker’s proposal, which is the prototypical Republican “see, we do too have a plan to replace Obamacare” plan.
Ponnuru mentions two protections. The first is a provision that would “bar insurers from charging higher prices to sicker customers provided they had maintained continuous coverage.” Republicans have taken to using this line a lot, because it sounds to the average person tuning in a lot like a promise to protect people with preexisting conditions, but the last six words are crucial. Maintaining continuous coverage is really hard. We know this because Congress passed a law in 1996 letting people who have employer-provided insurance keep their plan if they maintain continuous coverage. It has proven nearly useless. Maintaining continuous coverage is really hard for people who have financial distress, and it’s harder if the insurance company has every incentive for you to miss a payment or fail to dot one of your i’s or cross one of your t’s, so they can kick you out. And, of course, in a market where insurers can charge higher prices to sicker customers, “maintaining continuous coverage” means buying insurance that’s really expensive and can deny you coverage for lots of treatments you need.
The second provision is high-risk pools. This is a special market for the customers with the most expensive medical needs. Many states have tried high-risk pools. They also work really, really badly. There are all sorts of practical barriers that make it hard to operate a special insurance system for people with the most expensive conditions. For instance, how do you determine eligibility? Tens of millions of Americans have something in their medical history that makes them a less than perfect risk, from the insurance company’s standpoint. Where do you draw the cutoff for eligibility? And how do you keep insurance companies from skimming the high-risk pools, too — after all, they’ll want to cover the least costly people in the high-risk pool, not the most costly ones.
Even if it is possible to devise solutions to these problems, the biggest single impediment is that high-risk pools cost money. There’s no magic secret in a high-risk pool that makes insurers able to sell affordable insurance to people who need lots of medical care. And where would Republicans get the money to finance the high-risk pools? They don’t say. And they all have signed the Grover Norquist pledge that they will never raise taxes under any circumstances — even if aliens come to Earth and threaten to destroy humanity unless the president agrees to raise taxes by a single penny.
The funding problem is not ancillary. There’s an old joke in which a chemist, a physicist, and an economist are trapped on a desert island, and some cans of food wash up onshore. The physicist devises a plan to smash open the cans. The chemist comes up with a plan to heat them open. And the economist says “assume a can opener.” This is the problem not just with the high-risk pools, but the Republican health-care plans as a whole. They assume the availability of funding, but the party is theologically opposed to raising revenue of any kind. Like having a can opener, if the Republicans were able to overcome their fanatical opposition to revenue, the problem wouldn’t exist in the first place. Any reform that assumes Republicans will find a way to fund it is assuming a can opener. It’s premised on a fantastical assumption. That is why, in the absence of some concrete way around the no-taxes-ever problem, a vague hand-waving promise can’t be called a real plan.
Before Obamacare took effect, different measures were tried to reform America’s cruel and dysfunctional individual health-care marketplace. The continuous-coverage protection and high-risk pools both failed. One thing that succeeded was tried in Massachusetts, by Mitt Romney. The Obama administration decided to build that model out nationally, and it has worked very well — premiums have actually come in well under projections. But since it was Obama’s plan, Republicans oppose it. But since Obamacare is working, they need to have something they can say they’ll replace it with, and they’ve turned to the things that have already failed.
By: Jonathan Chait, Daily Intelligencer, New York Magazine, August 21, 2015