“Tolerating Poor People”: Republicans Explore New Moral Depths On Medicaid
As the lawsuits challenging the Affordable Care Act worked their way up to the Supreme Court, I always found the challenge to the expansion of Medicaid to be the strangest part. Quick context: the program provides insurance for poor people, splitting the cost between the federal government and the states. But the current rules say that each state gets to set its own eligibility standards, which meant that if you live in a state run by Democrats and you’re poor, you can get Medicaid, but if you live in a state run by Republicans, you have to be desperately poor to get Medicaid. For instance, in Mississippi, a family of four has to have a yearly gross income below a princely $9,828 to qualify. Because if a family is living high on the hog with their $10,000 a year, they aren’t really poor, right?
Fortunately, the Affordable Care Act fixed this, by changing Medicaid so that everyone with up to 133 percent of the federal poverty level ($30,657 for a family of four) would qualify. And to make things easier on the states, the bill provided that the federal government would pick up almost all of the tab. The federal government pays 100 percent of the cost of paying for the new enrollees through 2016, 95 percent in 2017, 94 percent in 2018, 93 percent in 2019, and 90 percent from then on. In other words, the federal government is saying to states, “Here’s a bunch of free money to insure a whole lot of your citizens, which will make them healthier and more productive.” And almost every state run by Republicans replied, “How dare you do such a thing to us! It’s unconstitutional! We’re suing!”
And unfortunately, the Supreme Court gave them the right to turn down the money, so each state gets to decide whether it wants to accept the expansion. The irony is that this change in Medicaid is much, much more valuable to the states that have been the stingiest with Medicaid up until now. Massachusetts, for instance, already sets Medicaid eligibility at 133 percent of the poverty level, so they get no new money. It’s the Republican states with Scroogian eligibility who will get the most benefit, insuring millions of their citizens at little cost. But they’re the ones who don’t want it.
It’s pretty obvious that many Republicans wish there was no such thing as Medicaid at all. But if they have to tolerate poor people getting health care, they want to make sure as few of those poor people get it as possible. Because after all, if you can take your kids to the doctor whenever they get sick, how are you going to learn that being poor proves how sinful you are?
When this all comes down in 2014, the Republican governors and legislators who choose to opt out of the Medicaid expansion shouldn’t be allowed to claim that it’s a budgetary issue, because it isn’t—it’s free money, as far as their state budgets are concerned. They’re already trying. Here’s Phil Bryant, the governor of Mississippi, saying that the state doesn’t have the money to cover the estimated 330,000 people in the state who would get insurance paid for by the federal government. Here are Republican officials in Florida, where around a million people could get coverage under the Medicaid expansion, pleased as punch that the Court gave them the opportunity to say “No coverage for you!” to those poor Floridians.
So these Republican officials will be saying to their own citizens, “The federal government is offering to give you free health insurance, but we won’t let you have it. Your health is less important than us making a statement about how much we hate the welfare state and how much we hate Barack Obama and everything he touches.” They believe that it’s better for a person to have no insurance at all than to get insurance from the government. That position is morally vile enough in the abstract, but when they’re actually confronted with a choice to make about whether to allow their citizens to have health insurance, some of them are going to say no. I struggle to find words to describe how despicable and cruel that is.
Now, it’s possible that once that money is actually being offered, the states will all say yes. That’s what Nancy Pelosi argued yesterday. But that depends on the Republican leadership of those states actually giving a crap about their poor citizens. Let’s just say we should believe it when we see it.
By; Paul Waldman, Contributing Editor, The American Prospect, June 29, 2012
“An Act Of Human Decency”: The Real Winners Of The Affordable Care Act Are Ordinary Americans
So the Supreme Court — defying many expectations — upheld the Affordable Care Act, a k a Obamacare. There will, no doubt, be many headlines declaring this a big victory for President Obama, which it is. But the real winners are ordinary Americans — people like you.
How many people are we talking about? You might say 30 million, the number of additional people the Congressional Budget Office says will have health insurance thanks to Obamacare. But that vastly understates the true number of winners because millions of other Americans — including many who oppose the act — would have been at risk of being one of those 30 million.
So add in every American who currently works for a company that offers good health insurance but is at risk of losing that job (and who isn’t in this world of outsourcing and private equity buyouts?); every American who would have found health insurance unaffordable but will now receive crucial financial help; every American with a pre-existing condition who would have been flatly denied coverage in many states.
In short, unless you belong to that tiny class of wealthy Americans who are insulated and isolated from the realities of most people’s lives, the winners from that Supreme Court decision are your friends, your relatives, the people you work with — and, very likely, you. For almost all of us stand to benefit from making America a kinder and more decent society.
But what about the cost? Put it this way: the budget office’s estimate of the cost over the next decade of Obamacare’s “coverage provisions” — basically, the subsidies needed to make insurance affordable for all — is about only a third of the cost of the tax cuts, overwhelmingly favoring the wealthy, that Mitt Romney is proposing over the same period. True, Mr. Romney says that he would offset that cost, but he has failed to provide any plausible explanation of how he’d do that. The Affordable Care Act, by contrast, is fully paid for, with an explicit combination of tax increases and spending cuts elsewhere.
So the law that the Supreme Court upheld is an act of human decency that is also fiscally responsible. It’s not perfect, by a long shot — it is, after all, originally a Republican plan, devised long ago as a way to forestall the obvious alternative of extending Medicare to cover everyone. As a result, it’s an awkward hybrid of public and private insurance that isn’t the way anyone would have designed a system from scratch. And there will be a long struggle to make it better, just as there was for Social Security. (Bring back the public option!) But it’s still a big step toward a better — and by that I mean morally better — society.
Which brings us to the nature of the people who tried to kill health reform — and who will, of course, continue their efforts despite this unexpected defeat.
At one level, the most striking thing about the campaign against reform was its dishonesty. Remember “death panels”? Remember how reform’s opponents would, in the same breath, accuse Mr. Obama of promoting big government and denounce him for cutting Medicare? Politics ain’t beanbag, but, even in these partisan times, the unscrupulous nature of the campaign against reform was exceptional. And, rest assured, all the old lies and probably a bunch of new ones will be rolled out again in the wake of the Supreme Court’s decision. Let’s hope the Democrats are ready.
But what was and is really striking about the anti-reformers is their cruelty. It would be one thing if, at any point, they had offered any hint of an alternative proposal to help Americans with pre-existing conditions, Americans who simply can’t afford expensive individual insurance, Americans who lose coverage along with their jobs. But it has long been obvious that the opposition’s goal is simply to kill reform, never mind the human consequences. We should all be thankful that, for the moment at least, that effort has failed.
Let me add a final word on the Supreme Court.
Before the arguments began, the overwhelming consensus among legal experts who aren’t hard-core conservatives — and even among some who are — was that Obamacare was clearly constitutional. And, in the end, thanks to Chief Justice John Roberts Jr., the court upheld that view. But four justices dissented, and did so in extreme terms, proclaiming not just the much-disputed individual mandate but the whole act unconstitutional. Given prevailing legal opinion, it’s hard to see that position as anything but naked partisanship.
The point is that this isn’t over — not on health care, not on the broader shape of American society. The cruelty and ruthlessness that made this court decision such a nail-biter aren’t going away.
But, for now, let’s celebrate. This was a big day, a victory for due process, decency and the American people.
By: Paul Krugman, Op-Ed Columnist, The New York Times, June 28, 2012
“Attack And Distract Strategy”: Mitt Romney’s Empty ObamaCare-Repeal Rhetoric
Mitt Romney strode out to respond to the Supreme Court ruling behind a podium that read “Repeal and Replace.” His response focused on the first verb and ignored the second.
Right off the top, Romney delivered one of the tightest lines of his campaign: “What the court did not do on its last day in session, I will do on my first day if elected president of the United States. And that is, I will act to repeal Obamacare.”
It went downhill from there. Careful to repeat the word “Obamacare” some 18 times throughout his brief remarks, Romney was careless with the facts in his rebuttal.
Maybe it is the inherent awkwardness of the fact that Romney’s major governmental accomplishment is an individual mandate-driven health-care plan, but his response was fear- rather than fact-based. This is consistent with the “attack and distract” strategy he has deployed when it comes to policy during his general-election campaign.
At least three claims Romney made in his speech deserve particular scrutiny:
First, Medi-scare: “Obamacare cuts Medicare—cuts Medicare by approximately $500 billion.” Medi-scare is a classic fear-mongering technique usually deployed by Democrats against Republicans, most vividly by the television ad depicting Paul Ryan pushing grandma off a cliff. The Affordable Care Act does try to rein in Medicare costs by slowing the rate of growth and ending the Medicare Advantage program, but that should be consistent with Republican values of increasing efficiency and reducing waste, fraud, and abuse. Moreover, the Ryan plan, which Romney endorses, would cut at least that amount but redirect the savings to reducing the deficit. Playing the Medi-scare card is low and discredited, but hearing it from a Republican nominee is more than a bit surreal.
Second, the deficit-bomb card: “Obamacare adds trillions to our deficits and to our national debt.” Deficit and debt make up one of the Obama administration’s greatest weaknesses among independents. It is ultimately a form of generational theft. But the nonpartisan Congressional Budget Office scored the ACA and determined that it actually would reduce the deficit by more than $100 billion in the next 10 years. I agree that government estimates almost always lowball the eventual costs, especially in the realm of entitlements, but the CBO scoring can’t just be ignored in favor of a partisan narrative. And of course, one of the arguments for health-care reform in general is that it will reduce costs in the long run with our aging population and improve American industry competitiveness.
Third, “Obamacare puts the federal government between you and your doctor.” This is always the emotional kicker, directly connected to the oft-repeated talking point that the ACA is a “government takeover of health care.” That would be scary indeed, but keep in mind the liberal critique of the Obama health-care reform is that it is too insurance-industry-friendly. After all, there was never even a public option, let alone the single-payer fantasy. The current system is far from perfect and far from free market. I happen to believe that third-party-payer problem is a big part of what drives up costs. But the Big Brother dystopian fantasy captured by this instant classic in the paranoid style typed by Ben Shapiro—“This is the greatest destruction of individual liberty since Dred Scott. This is the end of America as we know it. No exaggeration.”—is just that. A paranoid exaggeration.
Other specters offered up by Romney include the estimate that an unspecified 20 million Americans will lose health insurance under the ACA and that the law represents a $500 million tax increase. (Keep in mind that the penalty/tax would only be paid by people who refuse to buy health insurance and therefore continue to freeload off the rest of us when they go to the emergency room for urgent care.)
Of course, this law will not solve all the problems in American medicine, and it almost certainly will create some new ones. But aspects of the bill—like coverage of children up to age 26 and stopping insurance companies from denying people insurance due to preexisting conditions—are justly popular and improvements over the status quo.
Republicans beyond Romney were also quick to hoist the “repeal” banner—calling a vote in the House on July 9. They believe this ruling could be a political benefit in terms of getting out the vote in November. The Romney campaign claimed that they raised more than a million dollars online in the hours after the decision. This could be the boost the Romney camp needs for the Tea Party to overlook the ironic inconsistency of the GOP nominee on this core issue. Republicans may very well get a base boost from this decision, reflected in both dollars and votes.
But if you’re actually interested in governing as well as in winning, the impulse to scream “repeal” has to be followed by a plan to “replace.” There are plenty of good Republican policy proposals on how to reduce costs and increase individual choice in health care, but Mitt Romney still needs to decide which specific policy plan he would enact. Unclaimed ideas range from medical-malpractice reform to expanding health savings accounts to allowing insurance purchases across state lines to generic-drug importation. There might even be some degree of bipartisan support for a few these reforms. Then again, the individual mandate once had bipartisan support as well.
Bottom line: simply making up stats for the sake of soundbites is beneath a serious nominee. There is an obligation to propose as well as oppose if you are running for president.
By: John Avlon, The Daily Beast, June 29, 2012
“An Implausible Argument”: Mitt Romney’s Other Health-Care Contradiction
In vowing this morning to do what the Supreme Court didn’t—repeal Obamacare—Mitt Romney trotted out all his arguments against the newly constitutionally sanctioned health care law. Among them were these two points: First, that Obamacare would cause 20 million Americans to lose their health insurance, and second, that it would be a job-killer to boot.
Problem is, these two arguments directly contradict each other.
The 20 million Americans who presumably would lose their health insurance would do so because their employers would decide to cease offering it, letting their employees fend for themselves on the health-insurance exchanges. Why would these employers opt to do that? The only conceivable reason is that it would be cheaper for them to do that. And if it was cheaper for them to do that, they’d then have more money to hire more employees, creating rather than killing jobs.
You can argue, with serial implausibility, that Obamacare will cause millions to lose their health insurance or that it’s a job-killer. You can’t argue both.
With today’s ruling, the fate of Obama’s health-care reform will be up to the voters in November’s election. For voters who hate Obama and all he stands for, that’s one more reason to go to the polls—but those voters are probably going to the polls in any event. If Romney decides to ride this issue, it’s not clear he’ll gain any more votes than he already has locked up. He may motivate some Republicans who don’t particularly care for him but will vote out of their hatred of Obama to care for him somewhat more. (Polling shows that a higher percentage of pro-Obama voters support the president because they like him than pro-Romney voters like Romney.) But I doubt that raising his positives among voters who are already determined to vote for him anyway matters.
Republicans will doubtless exploit the court’s upholding the mandate under the Congress’s power to tax rather than under the Constitution’s commerce clause. There’s that t-word again! It’s unlikely that more than a couple percent of the American people, those with incomes adequate enough to decline to buy insurance, will ever be subject to that tax, but you can count on Republicans to depict it as a mass confiscation worthy of Lenin. Obama and the Democrats need to be able to counter this with real numbers—in Massachusetts, the one state that has already adopted a similar law, just 1 percent of taxpayers are subject to the penalty—even as they focus on the benefits most Americans will derive from the law, which was the tack the president took in his statement this morning.
By: Harold Meyerson, The American Prospect, June 28, 2012
“A Deal Too Good To Pass”: Why It’s Still In States’ Interests To Expand Medicaid
For supporters of the Affordable Care Act, it was hard to hear—over the cheering—anything besides the fact that the Supreme Court today kept the law almost entirely intact. But the Court did make a slight change to a crucial part of the ACA: Medicaid expansion. Under the law, by 2014, states are supposed to extend their Medicaid programs to cover people under 65 with incomes up to 133 percent of the federal poverty line. An analysis from the Center on Budget and Policy Priorities shows that means 17 million more people would have access to health care over the next 10 years. Before today, it looked like states didn’t have much choice in the matter. If they didn’t make the necessary expansion, they would lose all federal Medicaid dollars. In their brief, states argued that wasn’t much of a choice—federal Medicaid grants simply constitute too much money to lose. Back in February, Timothy Jost had a very helpful explanation of the states’ argument on this point in Health Affairs. As he wrote:
A state that refuses to expand its Medicaid program will under the ACA lose all Medicaid funding. Medicaid is the single largest source of federal funding to the states, accounting for 40 percent of all federal money dispersed to the states. States do not really have a choice to walk away from federal Medicaid funding, they argue. The states do not, therefore, really have a choice to refuse to participate in the Medicaid expansions. This coercion, the states contend, is unconstitutional.
According to SCOTUS Blog, the Supreme Court basically agreed: The feds can’t cut all Medicaid funding for states that refuse to expand. Now, states that choose not to extend benefits will forgo the money they would have received for doing so—but they won’t lose the money they’re already getting for current Medicaid services. But while states can now avoid the extension more easily, there’s still no practical reason to go down that path. “It’s still an incredibly good deal for the states,” says Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities. Already the federal government pays, on average, 57 percent of Medicaid costs. But the ACA gives states much higher levels of funding when it comes to extending benefits. As a CBPP report in March noted, the feds will pay a whopping 93 percent of the costs of expansion over the next nine years:
Specifically, the federal government will assume 100 percent of the Medicaid costs of covering newly eligible individuals for the first three years that the expansion is in effect (2014-2016). Federal support will then phase down slightly over the following several years, and by 2020 (and for all subsequent years), the federal government will pay 90 percent of the costs of covering these individuals. According to CBO, between 2014 and 2022, the federal government will pay $931 billion of the cost of the Medicaid expansion, while states will pay roughly $73 billion, or 7 percent.
That means, all in all, states will only see a 2.8 percent increase in what they would have spent on Medicaid if there was no health-care bill. The expansion is also in the interests of health-care providers. The ACA was meant to vastly decrease the amount of health care hospitals have to provide with little or no compensation. It was for that reason, Park says, that providers agreed to reductions in Medicaid and Medicare rates. But without the Medicaid expansion, working adults who are too poor to afford health care but not poor enough to qualify for Medicaid could still be left without coverage in some states. “Now there’s going to be a donut hole in the middle if the state doesn’t proceed,” says Park. That’s bad business for hospitals. There’s another factor that states will have to consider: the savings they will realize as populations begin to get healthier. According to the CBPP report, there will be 33 million fewer uninsured people by 2022. Uninsured people are expensive; they often rely on expensive emergency-room care, rather than getting preventative and early treatment which is ultimately cheaper and more effective. The Urban Institute reports that in 2008, $10.6 billion in state and local dollars went toward hospital care for the uninsured—20 percent of the total costs. The percentage is even higher when it comes to mental-health services. With the expansion, those costs will likely go down dramatically. States may have the option now to forgo the Medicaid expansion. But the results won’t be pretty.
By: Abby Rapoport, The American Prospect, June 28, 2012
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