“The Obamacare Plaintiffs And Medicare”: Maybe They’d Love Obamacare If The Hated President’s Name Wasn’t On It
Politico‘s Jennifer Haberkorn scored a bit of a scoop by convincing the chief plantiff in the King v. Burwell litigation, David King, to let her into his Fredericksburg, VA living room, apparently because he didn’t want to leave her shivering on his front doorstep. Most of what she tells about him, though, seems to come from his recent social media expressions rather than from anything he said to her in person:
The man who could cripple Obamacare isn’t shy about telling the world that he thinks the president is an “idiot,” posting altered images of the first lady in Middle Eastern clothing and expressing his hatred for the “Democraps” who enacted the health care law.
Greg Sargent, however, finds something more interesting to examine about King and a couple of his co-plaintiffs:
[I]t’s fascinating that King is less than a year away from qualifying for Medicare. As it happens, Politico reports that two of the other four challengers are 64 and 63, also putting them very close to qualifying. Remember, this lawsuit is all about the plaintiff’s objection to being subjected to the individual mandate’s requirement that they get insurance. The plaintiffs are claiming injury because Virginia is on the federal exchange, which, they say, means they should not be getting the subsidies which are necessary under the law to require them to get insurance under the mandate. Yet three of the challengers are very close to having the mandate canceled for them by Medicare. (One, it should be noted, is 56 years old.)
It would be really interesting to know what these challengers think of Medicare, given their role in a lawsuit that could go a long way towards gutting the coverage guarantee for millions of Americans.
Unfortunately, we cannot answer Greg’s question yet, if ever. Maybe these folk share the not uncommon belief of seniors that Medicare is an “earned benefit” (at most half-true) in contrast to the “welfare” nature of Obamacare (again, at most half-true). Maybe they don’t like Medicare as it is but would like to “reform” it–though the most common Republican proposal for “reform” is to convert Medicare from being a defined government-provided benefit to a means-tested system of public subsidies for private insurance purchases like Obamacare. Maybe they’d love Obamacare if the hated president’s name wasn’t on it. It’s hard to say. But whatever their reasons, they’re willing to force millions of people who aren’t on the brink of qualifying for Medicare into a health care wilderness. No wonder they don’t want to give interviews.
By: Ed Kilgore, Contributing Writer, Political Animal, The Washington Monthly, February 6, 2015
“The Supreme Court At Stake”: Overturning Obamacare Would Change The Nature Of The Supreme Court
In the first Affordable Care Act case three years ago, the Supreme Court had to decide whether Congress had the power, under the Commerce Clause or some other source of authority, to require individuals to buy health insurance. It was a question that went directly to the structure of American government and the allocation of power within the federal system.
The court very nearly got the answer wrong with an exceedingly narrow reading of Congress’s commerce power. As everyone remembers, Chief Justice John G. Roberts Jr., himself a member of the anti-Commerce Clause five, saved the day by declaring that the penalty for not complying with the individual mandate was actually a tax, properly imposed under Congress’s tax power.
I thought the court was seriously misguided in denying Congress the power under the Commerce Clause to intervene in a sector of the economy that accounts for more than 17 percent of the gross national product. But even I have to concede that the debate over structure has deep roots in the country’s history and a legitimate claim on the Supreme Court’s attention. People will be debating it as long as the flag waves.
But the new Affordable Care Act case, King v. Burwell, to be argued four weeks from now, is different, a case of statutory, not constitutional, interpretation. The court has permitted itself to be recruited into the front lines of a partisan war. Not only the Affordable Care Act but the court itself is in peril as a result.
At the invitation of a group of people determined to render the Affordable Care Act unworkable (the nominal plaintiffs are four Virginia residents who can’t afford health insurance but who want to be declared ineligible for the federal tax subsidies that would make insurance affordable for them), the justices have agreed to decide whether the statute as written in fact refutes one of the several titles that Congress gave it: “Quality, Affordable Health Care for All Americans.”
If the Supreme Court agrees with the challengers, more than seven million people who bought their insurance in the 34 states where the federal government set up the marketplaces, known as exchanges, will lose their tax subsidies. The market for affordable individual health insurance will collapse in the face of shrinking numbers of insured people and skyrocketing premiums, the very “death spiral” that the Affordable Care Act was designed to prevent.
It seems counterintuitive to describe a statutory case as having implications as profound as a constitutional one, but this one does. It hasn’t received the attention it deserves, probably because the dispute over phraseology that the case purports to present strikes many people as trivial or, at least, fixable if the court gives the wrong answer. Actually, it’s neither. (Has anyone noticed that the House of Representatives voted on Tuesday for the 56th time to repeal the law?)
The precise statutory issue is the validity of the Internal Revenue Service rule that makes the tax subsidies available to those who qualify by virtue of their income, regardless of whether the federal government or a state set up the exchange on which the insurance was bought. The challengers’ argument that the rule is invalid depends on the significance of two sub-clauses of the act that refer to “an exchange established by a state,” seemingly to the exclusion of the federally established exchanges.
But other parts of the complex and interlocking description of how the subsidies work suggest no such limitation. They point strongly in the opposite direction. For example, if a state chooses the option not to set up its own exchange, an option 34 states have exercised, the law requires the United States Department of Health and Human Services to “establish and operate such exchange within the state.” (Justice Antonin Scalia loves to quote dictionaries, and the government’s brief obliges him by quoting the definition of “such” from Black’s Law Dictionary, a standard legal reference: “that or those, having just been mentioned.”) The government argues that in this exercise of “cooperative federalism,” the federal government simply acts as the state’s surrogate; functionally, the federal exchange “is an exchange established by the state.” The law’s other relevant sections support that interpretation. For example, one section provides that any “applicable taxpayer,” defined by income, will be eligible for the subsidy, making no reference to where the taxpayer purchased the insurance.
I could go on about the intricacies of the statute, but the intricacies aren’t my point. Statutory interpretation is something the Supreme Court does all the time, week in and week out, term after term. And while the justices have irreconcilable differences over how to interpret the Constitution, they actually all agree on how to interpret statutory text. (They do disagree on such matters as the legitimacy of using legislative history, or on what weight to give a law’s ostensible purpose; I’m referring here to how they actually read a statute’s words.)
Every justice subscribes to the notion that statutory language has to be understood in context. Justice Scalia said it from the bench just last month, during an argument about the proper interpretation of the federal Fair Housing Act. “When we look at a provision of law, we look at the entire provision of law, including later amendments,” Justice Scalia said. “We try to make sense of the law as a whole.” (Justice Scalia was addressing a lawyer for the state of Texas, who was arguing for a very narrow reading of the Fair Housing Act. The justice’s skepticism toward the state’s statutory argument has been, in my opinion, widely misinterpreted to mean that Justice Scalia will rule for those seeking to preserve the law’s current broad meaning. I believe, rather, that Justice Scalia will accept the broad statutory reading and then go on to find that the Fair Housing Act so interpreted is unconstitutional. That important case is Texas Department of Housing and Community Affairs v. the Inclusive Communities Project.)
Across the ideological spectrum, the court’s opinions are filled with comments like Justice Scalia’s. Justice Clarence Thomas wrote in a 1997 opinion that in a statutory case, courts have to look at “the language itself, the specific context in which that language is used, and the broader context of the statute as a whole.”
Chief Justice John G. Roberts Jr., arguing for contextual interpretation in a 2009 opinion, observed that “the sun may be a star, but ‘starry sky’ does not refer to a bright summer day.”
Justice Anthony M. Kennedy wrote in a 2006 opinion that an interpretation of a single statutory provision “is persuasive only to the extent one scrutinizes the provision without the illumination of the rest of the statute.”
These examples all come from a brief filed on the government’s behalf by a group of law professors who are specialists in statutory interpretation, administrative law or constitutional law. One is Charles Fried, a law professor at Harvard who served as solicitor general during the second Reagan administration. (Another signer of this brief is my Yale colleague, William N. Eskridge Jr., one of the country’s leading authorities on statutory interpretation.)
Readers of this column may recall my expression of shock back in November when the court agreed to hear King v. Burwell. A three-judge panel of the federal appeals court in Richmond, Va., had unanimously rejected the challenge to the law, and the plaintiffs’ appeal didn’t meet the normal criteria for Supreme Court review. A defeat for the government — for the public at large, in my opinion — seemed all but inevitable.
While I’m still plenty disturbed by the court’s action, I’m disturbed as well by the defeatism that pervades the progressive community. To people who care about this case and who want the Affordable Care Act to survive, I have a bit of advice: Before you give up, read the briefs. (Most, although not all, are available on the website of the American Bar Association. ) Having read them this week, I’m beginning to think for the first time that the government may actually prevail.
The challengers have submitted a bunch of me-too arguments from the usual ideological suspects that offer various versions of the narrative concocted to validate the acontextual reading of the law that eliminates subsidies on the federal exchanges. That narrative depicts a highly implausible scenario in which the states — which under the Constitution couldn’t actually be compelled to set up their own exchanges — were given a powerful incentive: Set up your exchange or, if you exercise your choice to default to the feds, your citizens will lose their right to the tax subsidies that will enable them to afford insurance.
The problem for the challengers is that the statute itself nowhere says that, and no one in a position of power appears to have believed at the time that the law would do any such thing. In recent weeks, supporters of the law have had a great deal of fun digging up old statements and video clips demonstrating the contemporaneous belief of prominent Republicans that the subsidies would be available to everyone. The website Talking Points Memo posted one such revelation the other day about Representative Paul Ryan, who at the time was the ranking Republican on the House Budget Committee.
Beyond what various people hoped or expected, there is a deeper issue that the challengers ignore but on which the government’s briefs are utterly persuasive. A fascinating brief filed in support of the government by an unusual coalition of 23 red-state and blue-state attorneys general (some from states with their own exchanges and others from federal-exchange states) maintains that the challengers’ narrative would “violate basic principles of cooperative federalism by surprising the states with a dramatic hidden consequence of their exchange election.”
This brief, written in the Virginia attorney general’s office, continues: “Every state engaged in extensive deliberations to select the exchange best suited to its needs. None had reason to believe that choosing a federally facilitated exchange would alter so fundamental a feature of the A.C.A. as the availability of tax credits. Nothing in the A.C.A. provided clear notice of that risk, and retroactively imposing such a new condition now would upend the bargain the states thought they had struck.”
There are abundant Supreme Court precedents that require Congress to give states “clear notice” of the consequences of the choices a federal law invites them to make. Justice Samuel A. Alito Jr. invoked that principle in a 2006 case interpreting the Individuals With Disabilities Education Act, a case cited by the 23 attorneys general. The government’s own brief, filed by Solicitor General Donald B. Verrilli Jr., observes that “it would be astonishing if Congress had buried a critically important statewide bar to the subsidies under this landmark legislation” in technical sub-clauses.
To accept the challengers’ narrative, the government’s brief asserts, “the court would have to accept that Congress adopted that scheme not in a provision giving states clear notice of the consequences of their choice, but instead by hiding it in isolated phrases.” The court should interpret the statute “to avoid the disrespect for state sovereignty” inherent in that unlikely account.
Among the two dozen other “friend of the court” briefs filed on the government’s behalf is one from a group of small business owners (significant because the earlier case against the Affordable Care Act was brought by a small-business federation) and several from the health care industry. The Catholic Health Association, representing 600 Catholic hospitals, along with Catholic Charities, filed a brief explaining the significance of the Affordable Care Act for health care providers that serve, as the Catholic hospitals do, a high proportion of low-income patients.
So will the Affordable Care Act survive its second encounter with the Roberts court? I said earlier that this case is as profound in its implications as the earlier constitutional one. The fate of the statute hung in the balance then and hangs in the balance today, but I mean more than that. This time, so does the honor of the Supreme Court. To reject the government’s defense of the law, the justices would have to suspend their own settled approach to statutory interpretation as well as their often-stated view of how Congress should act toward the states.
I have no doubt that the justices who cast the necessary votes to add King v. Burwell to the court’s docket were happy to help themselves to a second chance to do what they couldn’t quite pull off three years ago. To those justices, I offer the same advice I give my despairing friends: Read the briefs. If you do, and you proceed to destroy the Affordable Care Act nonetheless, you will have a great deal of explaining to do — not to me, but to history.
By:
“Bait And Switch”: Introducing Obamcare Lite; What The New GOP Health Reform ‘Alternative’ Really Tells Us
Plainly wounded by the Plum Line’s mockery, some congressional Republicans have finally unveiled a plan to replace the Affordable Care Act with their own health care reform. Is it serious? It’s certainly serious enough to examine and judge on its merits. Will it become the plan around which Republicans will unite? I doubt it, just because it’s hard to imagine Republicans ever uniting around a plan to do anything proactive on health care, though that’s always possible.
What’s really remarkable about this plan is that for all the claims we’ll hear about how it undoes the tyrannical horror of Obamacare, the Republicans’ version of health care reform has accepted most of the fundamental goals and regulatory paths of the law they so deeply despise. This plan — authored by Senators Richard Burr and Orrin Hatch and Rep. Fred Upton — is little more than Obamacare Lite. Though the devil is in the details — and there are some devilish ones — this tells us that Barack Obama has for all intents and purposes won the health care argument, at least as far as it concerns government’s role in health care.
Here are some of the provisions, which I’ve copied from their synopsis:
- Ensure NO ONE can be denied coverage based on their pre-existing condition;
- Prohibit insurance companies from imposing lifetime limits on a consumer;
- Adopt an age rating ratio that limits the amount an older individual will pay to no more than five times what a younger individual pays (5 to 1) as a baseline, unless a state affirmatively elects to have a different ratio;
- Require health plans to offer dependent coverage up to age 26, unless a state opts out of this provision;
- Ensure guaranteed renewability for patients to be able to renew their coverage;
- Create a new “continuous coverage protection” that rewards individuals moving from one health market to another — regardless of whether in the individual, small group, or large employer markets — by allowing them to get a similar plan at a similar cost and not be rated on health status.
In addition, they would reduce the availability of subsidies from their current 400 percent of the poverty level to 300 percent of the poverty level, and repeal the Medicaid expansion but allow poor people not on Medicaid to get subsidies. The subsidies also would no longer be tied to the actual cost of insurance, and they’d be a tax credit instead of a direct subsidy at the point of sale. There’s also a provision replacing the “Cadillac Tax” on high-value plans with a provision removing the deductibility of employer health care plans that cost over a certain level.
If all that’s making your eyes glaze over, consider it this way: Again and again in the Republican plan, what they do is take a provision or principle in the Affordable Care Act and essentially say, “We want to do that too, we’ll just do it a little less generously.” No denials for pre-existing conditions? It’s in there, but there are some important caveats (which I’ll get to in a moment). No lifetime limits on coverage? In there. Young people up to age 26 can stay on their parents’ plan? Yes, but a state could opt out. Subsidies for middle-class people? In there, just up to 300 percent of the poverty level. Coverage for the poor? Yes, just up to 100 percent of poverty instead of 138 percent. Tax on high-value plans? Yep, just in a different way. Government-set limit on how much insurers could vary premiums by age? Yes, but the ratio would be expanded from 3-1 up to 5-1. A mandated list of “essential health benefits” for all plans? Yes, but the states would determine the list instead of the federal government, with more flexibility.
In all these cases, they aren’t looking for some free-market alternative that will supposedly deliver even better results. They’re accepting government’s role in both regulating insurance and in helping people pay for it; they just want to make the benefits not so attractive.
There are a few exceptions. They would repeal both the individual and employer mandates, which by now even Democrats are not particularly enthusiastic about (at this point I think most Democrats would be happy to junk the employer mandate if they got something in return, though the individual mandate could be a different story). And most significantly, the plan abandons the fundamental coverage guarantee the Affordable Care Act provides, while essentially trying to convince you that’s not what it does.
This is a critical point. Under the ACA, no one will ever be denied coverage because of a pre-existing condition. Ever. Medical underwriting, in which insurers comb through your history to see if they don’t want to cover you or if they should charge you huge premiums, is over. The Hatch-Burr-Upton plan is presented as though it does the same thing. Note that bullet point above: “Ensure NO ONE can be denied coverage based on their pre-existing condition.” In their executive summary, this point is the one sentence in the document that is highlighted in bold.
But actually, it’s not quite true. Their plan has a one-time open enrollment period for the uninsured; if you don’t get coverage during that time, you’re out of luck, and insurers will be free to deny you coverage. If you have coverage now but lose it, say because you lost your job, you’d have a limited amount of time (they don’t specify how long) to enroll in a new plan; if that time expired, you’d also be out of luck.
They would probably argue that they’re putting the responsibility on individuals, and all they have to do is take advantage of it. But that’s a very different thing from a guarantee. And that may be the biggest difference between the Affordable Care Act and this plan. The ACA tries to achieve universal coverage, and this plan doesn’t.
Frankly, that isn’t all that surprising, because universal coverage was never a goal conservatives had for health care. In recent days some of them have been arguing for something similar to this plan — see Michael Strain or Ramesh Ponnuru — and what they say about the subject is that they want universal catastrophic coverage, meaning everyone should have access to a bare-bones plan that will cover them not for ordinary medical expenses but only when a major illness or accident brings those expenses to a level that almost no one could afford. Those catastrophic plans are usually paired with Medical Savings Accounts for people to pay for everything else — a more market-based approach.
But the Hatch-Burr-Upton plan says nothing explicitly about catastrophic plans, and it doesn’t claim universal coverage as a goal. Its approach is that coverage will be there if you’re on the ball enough to get it at the right time. And if you aren’t, tough luck.
So there is something of a bait-and-switch going on. On provision after provision, this Republican plan promises to give all the benefits of the ACA, at least the ones that score highly in polls. It accepts that government will regulate health insurance and help people pay for it, even if that help is substantially less helpful. Looking at that, we might say that Republicans have accepted the ACA’s foundation, and that part of the health care argument is over. But they still aren’t willing to move substantially toward universal coverage. The ACA doesn’t achieve universal coverage either (the reasons why are a topic for another day), but it tries much harder to move down that road. So the new GOP “alternative” to Obamacare tells us that some Republicans, at least, have ceded a whole lot of ground in the broader debate over government involvement in health care, but it appears that’s one bridge they aren’t yet willing to cross.
By: Paul Waldman, Senior Writer, The American Prospect; Contributing Writer, The Plum Line, The Washington Post, February 5, 2015
“Deadly Consequences”: Public Health Experts Have Estimated How Many Americans Will Die If The Supreme Court Repeals Obamacare
When conservative American Enterprise Institute scholar Michael Strain published an article last week titled, “End Obamacare, and people could die. That’s okay.” he made two critical errors: He embedded a genuinely extreme view into a banal one, and then demanded absolution for both without defending the former.
Strain’s larger point is so uncontroversial, it barely needs reprising: Obamacare was not the final word in U.S. health policy, and if Republicans want to replace the Affordable Care Act with a different, less redistributive set of reforms, they should be able to try, without necessarily catching hell for preferring a system that tolerates marginally more avoidable deaths than Obamacare does (especially if they ply fiscal savings into different programs that alleviate poverty, or improve general welfare).
This is an unobjectionable point. Had Strain argued that the Republican presidential nominee should make an Obamacare alternative the centerpiece of his 2016 platform, nobody would have called it immoral. But the premise of his article is that conservatives (including himself, presumably) will be pleased if the Supreme Court intervenes to gut Obamacare, because it would provide Republicans the missing leverage they’ll need to impose a replacement through the political branches.
First comes god from the machine, and only then comes an Obamacare replacement.
If such a dramatic predicate carried no consequences, Strain’s cost-benefit argument would stand on its own. But when you account for the damage the Supreme Court would incur in order to provide Republicans their missing leverage, it collapses completely.
In a brief to the Supreme Court, dozens of public health scholars, along with the American Public Health Association, detail the harm the Court would create by ruling for the challengers in King vs. Burwell. Most of their analysis is rooted in the basic point that stripping insurance away from eight million people would dramatically impede their access to the health system. But they also flesh out the corollary argument that an adverse ruling would have deadly consequences, and ballpark the number of avoidable deaths such a ruling would cause.
“Researchers found that, in the first four years of the [health care reform] law in Massachusetts, for every 830 adults gaining insurance coverage there was one fewer death per year,” the brief reads. “Using the national estimate that 8.2 million people can be expected to lose health insurance in the absence of subsidies on the federal marketplace, this ratio equates to over 9,800 additional Americans dying each year. Although the specific policy context and population impacts of any policy cannot be directly extrapolated from one setting to another, the general magnitude and power of these findings from the Massachusetts study demonstrate that even when approached cautiously, these earlier findings carry enormous public health implications for withdrawing subsidies and coverage from millions of Americans.”
The Massachusetts story wouldn’t unfold precisely in reverse everywhere the subsidies disappeared, but the experience there suggests the Supreme Court ruling would have measurable mortality implications. These costs (read: deaths) couldn’t be paired against the benefits of increased spending on anti-poverty programs. These are the costs conservatives are eager to inflict on others simply to gain the leverage they need to advance an alternative that the status quo forecloses.
Responding to critics in a followup article, Strain brushes this all aside by stipulating that Republicans would never allow all this suffering. “I think it’s very likely that the congressional GOP would enact some sort of replacement if the Supreme Court strikes down Obamacare,” he writes. “They would very likely take measures to address the needs of those who lost their subsidies as a result of the Court’s action.”
To back up his suspicions, he cites a suspiciously limited set of news reports, quoting Republicans who claim to be working on such a plan—or, at least “talking about how to build consensus on a replacement.”
He does not quote from this Wall Street Journal article titled, “Republicans to Block Legislative Fix to Health-Care Law,” or this article by TPM’s Sahil Kapur titled, “Republicans Are At A Loss On What To Do If SCOTUS Nixes Obamacare Subsidies.”
For those who haven’t been keeping score all along, Republicans have spent the past several years cyclically promising and then failing to deliver an Obamacare alternative. They didn’t have an alternative prepared in 2012 when conservatives asked the Court to declare Obamacare unconstitutional. They didn’t have an alternative prepared later in the year, when Mitt Romney was their presidential candidate. They didn’t have an alternative prepared when they shut down the government as part of an ill-fated effort to defund Obamacare. They didn’t run on an Obamacare alternative in 2014. And they don’t have an Obamacare alternative prepared this week, though they’re scheduled to pass another repeal bill on Tuesday.
The story’s a little different today in that the subsidies really could disappear by fiat, harming millions of people, under GOP control of Congress. Republicans genuinely haven’t encountered a motivating force this strong in the five years since Obamacare became law. If in defiance of such a remarkable pattern, Republicans manage between now and June to come up with a workable plan or a stopgap—one that President Obama will sign—they will have filled the hole in Strain’s argument. Five months might seem like a long time in politics, but remember: It took Democrats more than twice that to pass Obamacare, and almost 10 times as long thereafter to implement it.
By: Brian Beutler, The New Republic, February 2, 2015
“An Iron Determination”: Revisionist History On Obamacare Subsidies
As we drift toward a potentially disruptive Supreme Court decision on the subject of whether Congress in the the Affordable Care Act intended to withhold insurance purchasing subsidies from people in states that declined to set up their own exchanges, the large and ever-increasing evidence that nobody in the states making such decisions thought they were risking subsidies is becoming a potential factor in how the Supremes come down. At the Plum Line this morning, Greg Sargent collects a variety of statements from Republicans involved in state-level exchange decisions, and concludes with this compelling quote from University of Michigan law professor
Nicholas Bagley:
[T]he challengers say that Congress clearly threatened the states with the loss of tax credits if they didn’t set up their own exchanges. But the states read the ACA very carefully, and they didn’t see any threat.
It’s the worst kind of revisionist history to claim that the ACA put states on notice of the harsh consequences of failing to establish an exchange. The states had no idea that tax credits hung in the balance. And the Supreme Court has said time and again that statutes shouldn’t be read to impose unexpected burdens on the states. That basic principle — the idea that states must have clear notice of the consequences of their decisions — protects the rights of the states in our federal system. And it cuts hard in favor of the government.
That’s going to be an argument that only an iron determination to mess up implementation of the Affordable Care Act can overcome.
By: Ed Kilgore, Contributing Writer, Political Animal Blog, The Washington Monthly, January 27, 2015
Share This Blog
Unknown Feed- An error has occurred; the feed is probably down. Try again later.
mykeystrokes.com 