“The First Step Of A Long Journey”: Now’s Not The Time For Liberals To Say “I Told You So” About Obamacare
It has been a rough two months for the Affordable Care Act and its defenders. Having spent years fighting ridiculous allegations about socialized medicine and “death panels,” supporters of near-universal coverage now face something different. The performance failures in the rollout of healthcare.gov have triggered cries of “I told you so!” from some liberals. This wouldn’t have happened, they say, if only Obama had supported some form of single-payer plan, such as Medicare for all. The anger over the botched rollout is understandable, but these recriminations are poorly timed—and just plain wrong.
For starters, the ACA is working reasonably well in some places—California, Connecticut, Kentucky, Washington, and the District of Columbia, for example. These under-reported success stories show that insurance exchanges can work, if properly administered. Exchanges are successfully determining applicants’ eligibility for Medicaid or private insurance, enabling consumers to choose among competing plans, and computing the tax credits to which people are entitled. The human benefits are real, from California to Breathitt County in rural Kentucky. These successes make the federal government’s dismal rollout even more embarrassing. Republicans may have done everything within their power to dynamite the ACA, but the administration fell inexcusably short in launching Obama’s domestic-policy centerpiece.
It doesn’t help that health reform is really complicated. The U.S. health-care system is far and away the most complex in the world, one that includes employer-sponsored coverage, Medicare, Medicaid, Tricare, the Indian Health Service, and small-group and individual insurance coverage—and that’s before Obamacare was implemented.
Given that complexity, some on the left say, life would be simpler if only Congress had been willing—which it was not—to scrap all current arrangements and replace them with a single, federally administered health insurance plan. Those on the right regard this complexity and say that life would be simpler if only Congress had been willing—which it was not—to scrap all current arrangements and replace them with income-related vouchers people could use to help pay for private insurance of their choice.
Those positions enjoy loud support in the blogosphere, Twitter, and cable TV, but only niche support at each end of the political spectrum. Although their ideological values could hardly be more different, these polar-opposite camps each disdain the kludgy fixes of incremental politics. And yet, incrementalism is what most Americans want. Most people are reasonably well-insured. They like their coverage, and they want it to remain affordable. They fear legislation that threatens it. Proposals, whether from the left or right, that force most people into radically different arrangements are fated to remain politically marginal in America.
That the right, which predicted Obamacare would mean the death of liberty and ruination of the U.S health care system, feels vindicated by Obamacare’s initial woes is no surprise. But the troubles with healthcare.gov have rekindled attacks from the left, too. Consider a recent essay by American Prospect co-editor Robert Kuttner, in which he writes, “The colossal mess that Obamacare has become reflects both the character of the legislation and that of the president who sponsored it.”
We understand Kuttner’s frustration. We do not share his disdain for the ACA or for Obama. The law ended a century of legislative failures in the search for universal health insurance coverage, and enacted important reforms of our healthcare delivery system. Obama bet his historic legacy on a reform that, however imperfect, brings health insurance to millions, improves its quality, and helps slow spending growth.
The real beef of those who seek a more radical rewiring of our healthcare system is not with the president. It is with the coalition of labor, healthcare, disability, and anti-poverty groups that coalesced during 2007 and 2008 around a health reform model that later became the ACA. Candidates Hillary Clinton, Obama, and John Edwards endorsed similar health plans. They all included Medicaid expansion, regulated markets (health insurance exchanges), premium subsidies, strengthened insurance regulation, and an explicit or de facto individual mandate. Many Democrats would have preferred single-payer, but the candidates and even most single-payer supporters understood that politically this just wasn’t possible.
We wish ACA had gone farther. It could have provided more generous premium assistance and cost-sharing for working families. It could have allowed people near retirement to buy into Medicare. Alas, senators such as Joe Lieberman—not Obama—scuttled these possibilities. The ACA is only the first step in a long journey of needed health reforms.
Kuttner goes on to write: “Medicare for All would be simpler to execute, easier to understand, and harder for Republicans to oppose.” Nancy Folbre, writing in The New York Times, took the same position. Kuttner and Folbre are correct that Medicare for All would be much easier to understand. Perhaps, as Obama among others has said, Medicare for All would be preferable to our current system, were we designing that system from scratch.
But we aren’t. The slogan “Medicare for all” was never incorporated in a well-crafted legislative proposal. Had it been, it would have been even easier than Obamacare for Republicans to oppose. And implementation would have been formidably difficult. Had the transition to single-payer ever been specifically mapped out, it would immediately have become apparent that this process requires wholesale replacement or rewiring of employer-based coverage, major changes in the relations between states and the federal government. Hundreds of billions of dollars in transfers and new taxes would have been necessary. Enterprising constitutional conservatives surely would have identified plausible court challenges. What’s more, a phalanx of providers—hospitals, doctors, insurers, drug companies and device manufacturers—opposed single-payer proposals. Even such incremental moves as the public option evoked profound unease among insurers, community hospitals, and other key parts of the coalition that supported the ACA.
The backlash against the ACA is occurring because it disrupts coverage of several million people in the individual and small-group insurance market. Transition to single-payer would have been far messier, disrupting coverage for hundreds of millions of Americans, with a much larger and more explosive mix of winners and losers.
There was and is no alternative to the messy incremental politics that produced Obamacare. Liberals such as then–House Majority Speaker Nancy Pelosi didn’t make unpalatable compromises because they held pallid aspirations for health reform. They compromised because they knew that they could not impose their will on querulous colleagues, because they needed 60 Senate votes, because millions of Americans needed help, and because it is better to win messily than to lose gloriously.
Much now rides on the government’s ability to fix healthcare.gov. Definite progress has been made. The federal exchange will be better by year’s end, but it will be months, not a few weeks, before the website really works the way it should. The White House’s cautionary messages on enrollment efforts and its one-year delay in online small business enrollment exemplify the many challenges with getting Obamacare off the ground. So these are anxious times. If the ACA fails, hopes for universal coverage will be set back a generation. Now’s not the time for liberals supporters to turn against Obamacare, or against each other.
By: Henry Aaron and Harold Pollack, The New Republic, November 28, 2013
“Those For Whom It’s Always 1938”: The Republican Tirades Sound Rather Familiar
Some of the initial pushback to the Iranian nuclear deal has faded, but for much of the right, the outrage lingers. A few too many conservatives – in Congress, in the media – seriously want Americans to see a good deal as tantamount to Nazi appeasement.
Indeed, for much of the right, the players have been cast in their proper historical roles: Obama is Chamberlain; Iranians are Nazis; and Netanyahu is both Churchill and Abraham Lincoln. (Don’t think about this too much; conservative historical analogies are deeply odd.)
But Peter Beinart raises a good point this morning: the tirades sound rather familiar.
Over the past quarter-century, there’s hardly an American or Israeli leader the Kristol-Netanyahu crowd hasn’t compared to Chamberlain. In 1985, Newt Gingrich called Reagan’s first meeting with Mikhail Gorbachev “the most dangerous summit for the West since Adolf Hitler met with Neville Chamberlain in 1938 in Munich.” When Reagan signed the Intermediate-Range Nuclear Forces Treaty, hawks took out newspaper ads declaring that “Appeasement is as unwise in 1988 as in 1938.”
Then, when Israel moved to thaw its own cold war with the Palestine Liberation Organization, Yitzhak Rabin assumed the Chamberlain role…. Then it was Bill Clinton. “The word that best describes Clinton administration [foreign] policy is appeasement,” explained Robert Kagan and Kristol in 1999. Then, of course, it was the opponents of war with Iraq. “The establishment fights most bitterly and dishonestly when it feels cornered and thinks it’s about to lose. Churchill was attacked more viciously in 1938 and 1939 than earlier in the decade,” wrote Kristol in a 2002 editorial, “The Axis of Appeasement.”
The Munich comparison is offensive on a variety of levels, but Beinart raises an important criticism: those pushing the analogy are also lazy.
For much of the right, there are simple, shorthand responses to almost every question that are intended to end debates in their favor. Can we bring health care security to millions of American families? “No, because it’s socialism.” Can we talk about income inequality and the concentration of wealth at the very top? “No, because it’s class warfare.” Can we talk about expanding investments in education and infrastructure? “No, because it’s big government.”
Can we reduce the nuclear threat – for us and the world – by engaging Iran in constructive diplomacy? “No, because it’s Munich.”
These are knee-jerk responses intended to circumvent thought. But they’ve also become tired and predictable, so much so that when it comes to diplomacy and national security, conservatives keep reading from the same script, making up new Hitlers, new Chamberlains, and new Munichs. The only thing that stays the same is the role of Churchill – a role they hold for themselves.
No one, least of all President Obama, should take the rhetoric seriously, though he can at least take comfort in knowing he’s in good company.
By: Steve Benen, The Maddow Blog, November 27, 2013
“Obamacare’s Secret Success”: Health Reform Is Starting To Look Like A Bigger Success Than Even Its Most Ardent Advocates Expected
The law establishing Obamacare was officially titled the Patient Protection and Affordable Care Act. And the “affordable” bit wasn’t just about subsidizing premiums. It was also supposed to be about “bending the curve” — slowing the seemingly inexorable rise in health costs.
Much of the Beltway establishment scoffed at the promise of cost savings. The prevalent attitude in Washington is that reform isn’t real unless the little people suffer; serious savings are supposed to come from things like raising the Medicare age (which the Congressional Budget Office recently concluded would, in fact, hardly save any money) and throwing millions of Americans off Medicaid. True, a 2011 letter signed by hundreds of health and labor economists pointed out that “the Affordable Care Act contains essentially every cost-containment provision policy analysts have considered effective in reducing the rate of medical spending.” But such expert views were largely ignored.
So, how’s it going? The health exchanges are off to a famously rocky start, but many, though by no means all, of the cost-control measures have already kicked in. Has the curve been bent?
The answer, amazingly, is yes. In fact, the slowdown in health costs has been dramatic.
O.K., the obligatory caveats. First of all, we don’t know how long the good news will last. Health costs in the United States slowed dramatically in the 1990s (although not this dramatically), probably thanks to the rise of health maintenance organizations, but cost growth picked up again after 2000. Second, we don’t know for sure how much of the good news is because of the Affordable Care Act.
Still, the facts are striking. Since 2010, when the act was passed, real health spending per capita — that is, total spending adjusted for overall inflation and population growth — has risen less than a third as rapidly as its long-term average. Real spending per Medicare recipient hasn’t risen at all; real spending per Medicaid beneficiary has actually fallen slightly.
What could account for this good news? One obvious answer is the still-depressed economy, which might be causing people to forgo expensive medical care. But this explanation turns out to be problematic in multiple ways. For one thing, the economy had stabilized by 2010, even if the recovery was fairly weak, yet health costs continued to slow. For another, it’s hard to see why a weak economy would have more effect in reducing the prices of health services than it has on overall inflation. Finally, Medicare spending shouldn’t be affected by the weak economy, yet it has slowed even more dramatically than private spending.
A better story focuses on what appears to be a decline in some kinds of medical innovation — in particular, an absence of expensive new blockbuster drugs, even as existing drugs go off-patent and can be replaced with cheaper generic brands. This is a real phenomenon; it is, in fact, the main reason the Medicare drug program has ended up costing less than originally projected. But since drugs are only about 10 percent of health spending, it can only explain so much.
So what aspects of Obamacare might be causing health costs to slow? One clear answer is the act’s reduction in Medicare “overpayments” — mainly a reduction in the subsidies to private insurers offering Medicare Advantage Plans, but also cuts in some provider payments. A less certain but likely source of savings involves changes in the way Medicare pays for services. The program now penalizes hospitals if many of their patients end up being readmitted soon after being released — an indicator of poor care — and readmission rates have, in fact, fallen substantially. Medicare is also encouraging a shift from fee-for-service, in which doctors and hospitals get paid by the procedure, to “accountable care,” in which health organizations get rewarded for overall success in improving care while controlling costs.
Furthermore, there’s evidence that Medicare savings “spill over” to the rest of the health care system — that when Medicare manages to slow cost growth, private insurance gets cheaper, too.
And the biggest savings may be yet to come. The Independent Payment Advisory Board, a panel with the power to impose cost-saving measures (subject to Congressional overrides) if Medicare spending grows above target, hasn’t yet been established, in part because of the near-certainty that any appointments to the board would be filibustered by Republicans yelling about “death panels.” Now that the filibuster has been reformed, the board can come into being.
The news on health costs is, in short, remarkably good. You won’t hear much about this good news until and unless the Obamacare website gets fixed. But under the surface, health reform is starting to look like a bigger success than even its most ardent advocates expected.
By: Paul Krugman, Op-Ed Columnist, The New York Times, November 28, 2013
“Rooting For Failure”: Hard To Remember A Time When A Major Political Party And Its Media Arm Rooted For Fellow Americans To Lose
I just spent 15 minutes on my local health care exchange and realized that I could save a couple hundred dollars a month on my family’s insurance. Of course, I live in Washington State, which has a very competitive market, a superbly functioning website and no Koch-brothers-sponsored saboteurs trying to discourage people from getting health care.
California is just as good. It’s enrolling more than 2,000 people a day. New York is humming as well. And Kentucky, it’s the gold standard now: More than 56,000 people have signed up for new health care coverage — enough to fill a stadium in Louisville.
This is terrible news, and cannot be allowed to continue. If there’s even a small chance that, say, half of the 50 million or so Americans currently without heath care might get the same thing that every other advanced country offers its citizens, that would be a disaster.
But not to worry. The failure movement is active and very well funded. You probably know about the creepy Uncle Sam character in ads financed by the Koch brothers. Sicko Sam is seen leering over a woman on her back in a hospital exam room, her legs in stirrups. This same guy is now showing up on college campuses, trying to get young people to opt out of health care. On some campuses, he plies students with free booze and pizza — swee-eeet!
The Republican Party started a failure campaign earlier this year, but then the strategy got sidetracked in a coercive government shutdown that cost us all $24 billion or so. With the disastrous rollout of the federal exchange, Republicans now smell blood. A recent memo outlined a far-reaching, multilevel assault on the Affordable Care Act. Horror stories — people losing their lousy health insurance — will be highlighted, and computer snafus celebrated.
Ron Paul, the nuttier of the two political Pauls, recently suggested to a crowd in Virginia that “nullification” of the health care law might be the best way to kill it. I’m not sure what he meant by that, but it sounds illegal.
It’s hard to remember a time when a major political party and its media arm were so actively rooting for fellow Americans to lose. When the first attempt by the United States to launch a satellite into orbit, in 1957, ended in disaster, did Democrats start to cheer, and unify to stop a space program in its infancy? Or, when Medicare got off to a confusing start, did Republicans of the mid-1960s wrap their entire political future around a campaign to deny government-run health care to the elderly?
Of course not. But for the entity of the Obama era, Republicans have consistently been cheerleaders for failure. They rooted for the economic recovery to sputter, for gas prices to spike, the job market to crater, the rescue of the American automobile industry to fall apart.
I get it. This organized schadenfreude goes back to the dawn of Obama’s presidency, when Rush Limbaugh, later joined by Senator Mitch McConnell, said their No. 1 goal was for the president to fail. A CNN poll in 2010 found 61 percent of Republicans hoping Obama would fail (versus only 27 percent among all Americans).
Wish granted, mission accomplished. Obama has failed — that is, if you judge by his tanking poll numbers. But does this collapse in approval have to mean that the last best chance for expanding health care for millions of Americans must fail as well?
Does this mean we throw in the towel, and return to a status quo in which insurance companies routinely cancel policies, deny health care to people with pre-existing conditions and have their own death panel treatment for patients who reach a cap in medical benefits?
The Republican plan would do just that, because they have no plan but to crush the nation’s fledgling experiment. Sometimes they bring up vouchers, or tort reform, or some combination of catchphrases. Here was Sarah Palin, who is to articulate reason what Mr. Magoo is to vision, on the Republican alternative, as she told Matt Lauer:
“The plan is to allow those things that have been proposed over many years to reform a health care system in America that certainly does need more help so that there’s more competition, there’s less tort-reform threat, there’s less trajectory of the cost increases. And those plans have been proposed over and over. And what thwarts those plans? It’s the far left.”
Yes, it is a big and legitimate news story, for a presidency built on technical expertise, that the federal exchange is not working as promised. Ditto Obama’s vow that people could keep their bottom-feeder health care policies.
But where were the news conferences, the Fox News alerts, the parading of people who couldn’t get their lifesaving cancer treatments under the old system? Where was the media attention when thousands of people were routinely dumped once they got sick? When did Republicans in Congress hold an oversight hearing on the leading cause of personal bankruptcy — medical debt?
All of that is what we had before. And all of that is what we will return to if some version of the Affordable Care Act is not made workable. Republicans have a decent chance, in next year’s elections, of killing the dream of progressive presidents going back to Teddy Roosevelt. But they shouldn’t count on it. What’s going against them, or any party invested in failure, is that Americans are inherently optimistic. That alone may be enough to save Obamacare.
By: Timothy Egan, Contributing Op-Ed Writer, The New York Times, November 28, 2013
“News People Can Actually Use”: The Media Needs To Do More To Help People Navigate Obamacare
Yesterday, Tim Noah made a point in an MSNBC appearance that I think deserves a lot more attention. Media outlets have been doing lots of reporting on the problems of the Affordable Care Act rollout. What they haven’t done is provided their audiences with practical information that could help them navigate the new system. Of course, most Americans don’t have to do anything, since they have employer-provided insurance. But for all the attention we’ve been paying to the individual market, media outlets haven’t done much to be of service. “The New York Times has published the URL for the New York exchange exactly twice,” Noah said, “both before October first.”
My experience in talking to journalists about the publication of this kind of thing—unsexy yet useful information, whether it’s how to navigate a new health law or understanding where candidates stand on issues—is that they often think that addressing it once is enough. When you ask them about it, they’ll say, “We did a piece on that three months ago.” The problem is that for it to be effective, they have to do it repeatedly or people won’t get it. What we have seen is that this information can be found somewhere on news outlets’ websites (here’s an example), but it isn’t on the evening-news broadcast or in the print edition of the paper.
Of course, conservatives would allege that if a newspaper writes a guide to getting insurance through the new exchange, it has demonstrated its liberal bias and become an arm of the Obama administration. But it’s the law. As of next year, if you don’t get insurance through your employer, you need to go to an exchange. Media outlets would just be helping people do what they have to do. I suppose conservatives could also argue that if the local paper puts up a tool on its website that helps people find their polling places and tells them what the voting hours are, it’s just trying to boost turnout, and everybody knows that helps Democrats. Or that if it reminds you to file your tax returns on April 15th, then it’s just helping fund big government. Or that if it tells you to set your clocks back for daylight savings, it’s just feeding the Illuminati/Bilderberg time-theft conspiracy.
People sometimes mock “news you can use” because it’s often delivered in forms that aren’t particularly useful (“There’s a silent killer in your refrigerator right now!”). But helping citizens understand and respond to changes in the law is part of any major media outlet’s mission. The fact that a law is controversial doesn’t absolve them of the responsibility.
By: Paul Waldman, Contributing Editor, The American Prospect, November 27, 2013
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