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The Affordable Care Act, One Year Later

A year ago this week, Capitol Hill was full of noise as the House of Representatives debated, and then voted, on the Affordable Care Act. But one of the most vivid memories of that experience for me was an extended moment of silence.

It came very late on Sunday evening–after the floor speeches, the votes, and the press conferences had ended. The galleries had long since emptied and the Capitol building itself was virtually unoccupied, so that it was possible to walk the entire length of the building, on the ground floor hallway that stretches from the House all the way to the Senate, without hearing so much as a single conversation.

It felt more than silent. It felt peaceful and, yes, satisfying. A prolonged, difficult debate had finally ended. It was time to move on.

Except that we haven’t moved on. We are still having arguments about health care reform. In fact, we are still having the same arguments about health care reform. The Affordable Care Act is law of the land now, yes, but its critics are determined to change that. And while the prospects of repealing it legislatively remain relatively slim, the prospects of repealing at least part of it judicially seem far more realistic than they did in the spring of 2010.

So perhaps it is worth taking a step back, just for a moment, and remembering how we got to this point–why this debate started in the first place and why it led to the enactment of this law.

It’s really not that complicated. Around one-fifth of the non-elderly population, or somewhere in the neighborhood of 50 million people, have no health insurance. Many millions more have insurance with major gaps or limitations, leaving them at risk of financial or medical catastrophe. Notwithstanding legitimate debates over exactly how many people go bankrupt or suffer physical hardship because they can’t pay their medical bills, virtually nobody denies that the human toll is real and significant.

These problems are the product, in part, a dysfunctional health insurance system that evolved haphazardly during the 20th Century. They also the product of a medical system as inefficient as it is costly. The United States pays more–far, far more–for health care than any other developed nation. But the care does not seem to be better overall, to say nothing of the fact that it is patently less available.

The goal of reform was really two-fold: In the short term, to make sure everybody can afford to pay for medical bills without financial distress; it the long term, to make the health care system as a whole more efficient, so that it no longer applied such a crushing financial burden on society. A single-payer system, like the ones in France or Taiwan, would have accomplished this. So would a scheme that turned health insurance into a regulated utility, as the Dutch and Swiss governments have done.

Political compromises, dating back to the earliest days of the 2008 presidential campaign, left the U.S. with a second-best–or, more accurately, a third- or fourth-best solution. It bolsters two existing insurance arrangements: Employer-sponsored coverage for workers in most companies, Medicaid for the very poor. It creates a new, regulated marketplace–insurance “exchanges”–for everybody else. Then, through a combination of tax changes and alterations to Medicare, it tries to reengineer medical care itself, wringing out administrative waste and focusing resources on the treatments, and care styles, that provide the most bang for the buck.

It’s easy to find the flaws–and to figure out who’s responsible for them. Doctors, hospitals, drug manufacturers, and device makers fought changes in the delivery of medical care that might affect their incomes; unions lobbied against tax reforms designed to discourage overly generous insurance; everyday Americans resisted changes to plans they already had. All of this blunted the Affordable Care Act’s efforts at cost control, which explains why, ten years from now, the best projections suggest we’ll have spent roughly as much on health care–as a government and as a country–as we would have if the law never passed.

At the same time, political conservatives fought to limit the bill’s expanse, demanding that the new outlays not exceed a $1 trillion, give or take. They had extra power, thanks to the filibuster, and were able to make the demand stick. As a result, the expansion of insurance coverage–via Medicaid and subsidies for private insurance–will not begin until 2014. Even then, somewhere around 20 million people, or 8 percent of the total population, will remain uninsured. And for some of the insured, the coverage will remain meager.

But the law’s shortcomings should not tarnish its many virtues. Eight percent uninsured means 92 percent insured, or around 95 of residents here legally. Or, to put it another way, more than 30 million additional people will have health insurance because of this law. The coverage, if not always as generous as it should be, will be enough to keep many if not most of the newly insured out of bankruptcy–and it will be available to almost everybody, regardless of pre-existing condition or insurance status.

The cost picture is also encouraging. The official projections suggest that, as of 2021, government spending (and, apparently, the country’s total spending) on health care will not be rising as fast as it is now. This is the critical distinction, because it’s the long-term burden of health care that threatens to bankrupt us. Critics doubt that officials will enforce planned changes to health care financing, but today’s lawmakers have no way to force action by their counterparts in the future. All they can do is put laws on the books–and that’s what they have done.

Are there better alternatives? Of course. But the loudest critics of the law, from the right, don’t have them. For all of their screaming, they have yet to put forward a credible plan that can do as much, let alone more, for less money. Their plans, stripped of misleading rhetoric, generally involve covering far fewer people, dramatically reducing the coverage that people have, or some combination of the two. Their dispute is not with the means Democrats have used to make health care affordable to all. It’s with the goal itself.

No, the way to improve the law is to build upon it–to bolster the insurance coverage, reach those Americans the law as written will not reach, and to strengthen the experiments in cost control that work. The best analysis of the law remains the one Senator Tom Harkin gave: The Affordable Care Act is not a mansion. It’s a starter home. But it’s got a solid foundation, a sturdy roof, and room for expansion.

A year from now, the presidential campaign will be well underway and the debate about the Affordable Care Act will likely be, if anything, more acrimonious than it is now. But perhaps after the election and, hopefully, after 2014, the country really will move on.

By: Jonathan Cohn, The New Republic, March 23, 2022

March 23, 2011 Posted by | Affordable Care Act, Congress, Health Care Costs, Health Reform, Insurance Companies, Medicaid, Medicare, Politics, Public, Single Payer, Under Insured, Uninsured | , , , , , , , , | Leave a comment

The US Chamber of Commerce: Reliably, Irredeemably Wrong

What if I told you I’d found a political group that for a hundred years had managed to be absolutely right on every crucial political issue? A political lodestone, reliably pointing toward true policy north at every moment.

Sorry. But I have something almost as good: a group that manages to always get it wrong. The ultimate pie-in-the-face brigade, the gang that couldn’t lobby straight.

From the outside, you’d think the US Chamber of Commerce must know what it’s doing. It’s got a huge building right next to the White House. It spends more money on political campaigning than the Republican and Democratic National Committees combined. It spends more money on lobbying that the next five biggest lobbyists combined. And yet it has an unbroken record of error stretching back almost to its founding.

Take the New Deal, which historians have long since credited as saving capitalism in the U.S. FDR was dealing with a nation ruined by Wall Street excess—a quarter of the country unemployed, Americans starving and hopeless. He gave his first fireside chat of 1935 on April 28, and outlined a legislative program that included Social Security. The next morning , a prominent official of the Chamber of Commerce accused Roosevelt of attempting to ‘Sovietize’ America; the chamber adopted a resolution “opposing the president’s entire legislative package.”

Fast forward to the next great challenge for America. FDR, having brought America through the Depression, was trying to deal with Hitler’s rise. In the winter of 1941, with the British hard-pressed to hold off the Germans, FDR proposed what came to be called the Lend-Lease program, a way of supplying the allies with materiel they desperately needed.
Only 22% of Americans opposed the Lend Lease program—they could see who Hitler was—but that sorry number included the Chamber of Commerce. The lead story in the New York Times for February 6, 1941 began with the ringing statement from the Chamber’s president James S . Kemper that “American business men oppose American involvement in any foreign war.”

It’s not just that this was unpatriotic; it was also plain stupid, since our eventual involvement in that “foreign war” triggered the greatest boom in America’s economic history. But it’s precisely the kind of blinkered short-sightedness that has led the US Chamber of Commerce astray over and over and over again. They spent the 1950s helping Joe McCarthy root out communists in the trade unions; in the 1960s they urged the Senate to “reject as unnecessary” the idea of Medicare; in the 1980s they campaigned against a “terrible 20” burdensome rules on business, including new licensing requirements for nuclear plants and “various mine safety rules.”

As Brad Johnson, at the Center for American Progress, has detailed recently, the US Chamber has opposed virtually every attempt to rein in pollution, from stronger smog standards to a ban on the dumping of hazardous waste. (They’re hard at work as well trying to relax restrictions on US corporations bribing foreign governments, not to mention opposing the Lily Leadbetter Fair Pay Act). If there’s a modern equivalent of World War II, of course, it’s the fight against global warming. Again a majority of Americans want firm action, because they understand the planet has never faced a bigger challenge—but that action’s been completely blocked in Washington, and the US Chamber is a major reason why. They’ve lobbied against every effort to cut carbon, going so far as to insist that the EPA should stay out of the fight because, if the planet warmed, “populations can acclimatize via a range of range of behavioral, physiological, and technological adaptations.” That is to say, don’t ask a handful of coal companies to adapt their business plans, ask all species everywhere to adapt their physiologies. Grow gills, I guess.

There’s a reason the US Chamber always gets it wrong: they stand with whoever gives them the most cash (in 2009, 16 companies provided 55% of their budget). That means that they’re always on the side of short-term interest; they’re clinically, and irremediably, short-sighted. They recently published a list of the states they thought were “best for business,” and the results were almost comical—all their top prospects (Mississippi!) ranked at the very bottom of everything fromn education to life expectancy.

But that doesn’t mean that business is a force for evil. Though the US Chamber claims to represent all of American business, their constituency is really that handful of huge dinosaur companies that would rather lobby than adapt. Around America, the local chambers of commerce are filled with millions of small businesses that in fact do what capitalists are supposed to do: adapt to new conditions, thrive on change, show the nimbleness and dexterity that distinguish them from lumbering monopolies. As Chris Mead, in an excellent history of the local chambers, makes clear, there are a thousand instances where clear-sighted businesspeople understood the future. Who lured the first movie producers to southern California? The LA Chamber, which sent out a promotional brochure in 1907. Why was the Lindbergh’s plane called “The Spirit of St. Louis”? Because the St. Louis Chamber of Commerce raised the money—that was a pretty good call.

That’s why thousands and thousands of American businesses concerned about our energy future have already joined a new campaign, declaring that “The US Chamber Doesn’t Speak for Me.” They want to draw a line between themselves and the hard-right ideological ineptitude that is the US Chamber. Some of those businesses are tiny—insurance brokers in southern California, coffee roasters in Georgia, veterinarians in Oklahoma—and some are enormous. Apple Computer, for instance, which has…a pretty good record of seeing into the future.

There’s only one reason anyone pays attention to the US Chamber, and that’s their gusher of cash. But the Chamber turns 100 next year, and it’s just possible that a century of dumb decisions will outweigh even that pile of money. If you’re trying to figure out the future, study the US Chamber—and go as fast as you can in the opposite direction.

By: Bill McKibben,, March 22, 2011

March 23, 2011 Posted by | Corporations, Lobbyists, Politics, Small Businesses, Social Security, U.S. Chamber of Commerce | , , , , , , , | Leave a comment


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