“Obamacare Is Here To Stay”: Kentucky Is Emblematic Of The States That Have Received Substantial Assists From Obamacare
You’ve heard of Obamacare, right?
It’s that disastrous, costly and intrusive policy that President Obama and his fellow Democrats rammed down the throats of Congress back in 2010 — a failed plan that conservative Republicans have pledged to “repeal and replace.” According to its critics, it is un-American; it destroys the health care system; it burdens businesses; it hollows out Medicare. Right?
Ah, wrong. Despite what you may have heard and despite the caprice of electoral campaigns, the changes wrought by the Affordable Care Act are here to stay. That’s because it accomplishes much of what it set out to do — and its beneficiaries mostly like it.
Don’t expect Republicans to try to turn back the clock. Oh, some of them will continue to bash Obamacare and to blame it for any negative effects on the country’s dysfunctional health care “system” — including rising costs. And some will even go so far as to continue to insist that it ought to be repealed.
Take Senate Minority Leader Mitch McConnell, who expects to lead the upper chamber if Republicans claim a majority. In a debate last month with his Democratic rival, Alison Grimes, McConnell suggested that he would repeal the Affordable Care Act but leave in place Kentucky’s popular state exchange program.
“… The best interest of the country would be achieved by pulling out Obamacare, root and branch,” he said. “Now, with regard to Kynect, it’s a state exchange. They can continue it if they’d like to.”
McConnell’s pronouncement was a tour de force of dissembling, a virtuoso performance of fabrications and disinformation. The Washington Post’s fact checker awarded him three Pinocchios.
That’s because the state’s health care exchange, Kynect, is a part of Obamacare, made possible by the 2010 law. If Obamacare is ripped out “root and branch,” the state exchanges could not continue to exist. (The GOP has continually pledged to find a mechanism to replace Obamacare, but its warring factions have failed to agree on any plan that would leave state exchanges in place.)
Here’s the rub: Kynect is very popular with Kentucky’s residents, many of whom are enjoying health insurance for the first time in their lives. They have been primed by Republican politicians to hate the president and any policy he endorses — including his signature health care plan — but they don’t want to give up Obamacare’s benefits.
Kentucky is emblematic of the states that have received substantial assists from Obamacare. It is largely rural and is among the poorest states. It has also long ranked near the bottom in several health indicators, including obesity and smoking rates and cancer deaths. Obamacare has been a boon for its residents, cutting the rate of uninsured in half.
According to The New York Times, people who live in rural areas are among the biggest winners from the Affordable Care Act. Other groups who have reaped substantial benefits are blacks, Latinos, women and younger Americans between 18 and 34.
Here’s another reason that Obamacare is here to stay: Its expansion of Medicaid is a boon to the states that have taken advantage of it. After the Supreme Court ruled that Medicaid expansion was optional, most Republican governors vowed to resist it — even though the federal government will pay 100 percent of the cost for the first three years and 90 percent thereafter.
But some of those GOP governors are now having second thoughts as rural hospitals are forced to close down for lack of funds and poor people are sidelined by preventable illnesses. Several GOP governors have already expanded Medicaid — which provides health insurance for the poor — and others are considering doing so.
Last month, Ohio’s Republican governor, John Kasich, advised his GOP colleagues to stop fighting the Medicaid expansion. The opposition, he said, “was really either political or ideological. I don’t think that holds water against real flesh and blood, and real improvements in people’s lives.”
Some Republicans have trouble admitting that on the campaign trail, but they all know it’s true.
By: Cynthia Tucker, The National Memo, November 1, 2014
“Who Knew?”: Obamacare Is Such A Disaster That Even More Insurers Want To Be Part Of It
There are still plenty of days when Obamacare looks bad. Tuesday wasn’t one of them.
The Department of Health and Human Services announced that more insurers were joining the Affordable Care Act’s new marketplaces—you know, the places where people can buy coverage on their own and, depending on their incomes, qualify for subsidies. How many more insurers are participating? Quite a few, it turns out. According to HHS, the net increase is more than 25 percent. That should translate to more options for people buying coverage. The increased competition should also help keep premiums relatively low.
The data is preliminary, based on 44 states for which HHS had information. And of course the sheer number of insurers offering coverage is just one sign of how the law is doing. If you’re actually buying insurance, you don’t simply want choices. You want good choices. You want to know that the insurance will give you access to doctors and hospitals when you need them. You want to know that the coverage pays your bills adequately. And so on.
Still, Obamacare critics hadn’t predicted the markets would evolve this way. On the contrary, they expected that young and healthy people would stay far away from the new marketplaces, because the new coverage would be pricier than what they were paying before. Without enough business, the argument went, insurers would get skittish and withdraw. At best, the marketplaces would all become oligopolies and monopolies, with just a handful of insurers continuing to sell policies. At worst, the whole scheme would fall apart. That quite obviously isn’t happening.
Trouble could still arise. By design, Obamacare includes a series of provisions designed to insulate insurers from major losses in the first three years. I usually describe them as “shock absorbers.” Many other policy wonks refer to them as the three Rs, for reinsurance, risk corridors, and risk adjustment. Two of the three, risk corridors and reinsurance, are temporary measures set to expire in 2016. More knowledgeable critics of the law, like Bob Laszewski and Megan McArdle, have warned that more insurers could abandon the market or at least jack up their premiums once those measures expire.
I can’t tell you with certainty whether they are right or wrong. Always in motion is the future, as a famous prophet once said. But keep in mind that gloomy, even dire, predictions about Obamacare’s marketplaces are nothing new. One of my favorites was an op-ed that ran in the Wall Street Journal at the end of last year. The author was John Cochrane, a professor of finance at the University of Chicago. The headline was “What to Do When Obamacare Unravels”—not “if,” mind you, but “when.”
At the time, with unexpected plan cancellations and the website problems very much on people’s minds, betting against the program working probably seemed like a good idea. Who wants to make that kind of bet now?
By: Jonathan Cohn, The New Republic, September 24, 2014
“Collaborating With The Enemy”: Can Republicans Be Convinced To Help Improve The Affordable Care Act?
When the Affordable Care Act was passed in early 2010, people made lots of predictions about how its implementation would proceed, in both practical and political terms. While the law’s opponents all agreed that it would be a disaster from start to finish, the law’s supporters were slightly less unanimous, if nevertheless optimistic. Most figured that though there would probably be problems here and there, by and large the law would work as it was intended, enabling millions of uninsured Americans to get coverage and providing all of us a level of health security we hadn’t known before.
And that’s what has happened. But there was one other assumption among the supporters that’s worth examining anew, now that most of us agree the law isn’t going to be repealed. Like every large and complex piece of social legislation, it was said, the ACA would have to be tweaked and adjusted over time. For instance, when it was passed in 1935, Social Security excluded agricultural and domestic workers, just coincidentally shutting most African-Americans out of the program. Those workers were added later on, and other changes were made as well, like adding cost of living adjustments to account for inflation. Medicare, too, has undergone changes both large (like adding a prescription drug benefit) and small. So what are the possibilities for adjusting the ACA in the near future? In the current atmosphere—one not just of intense partisanship, but one in which one party has made venomous opposition to this law the very core of its political identity—can we hope to actually fix the things about the law that might need fixing?
The administration has already made some changes to the law using its executive authority. Most notably, it has delayed the employer mandate; as it stands now, the mandate won’t fully take effect until 2016. As it happens, few people are particularly enthused with the employer mandate in its current form; conservatives have never liked it, and more than a few liberals have their doubts about it. As Mike Konczal recently explained, there’s an alternative:
The employer mandate has been another major roadblock for the ACA. The current “Obamacare” plan requires employers with more than 50 full-time workers to pay a part of the health care costs for employees who work more than 30 hours a week, or pay a fine. This is unpopular with employers, and it fuels larger worries that workers are getting their hours capped or that expanding businesses are hitting a major road bump the moment they reach 50 employees.
As the Roosevelt Institute’s Richard Kirsch writes, the way the final House bill tackled this issue was much smarter: Under the House plan, employers that didn’t provide health care to their employees would pay a percentage of payroll as a tax to cover health care. Consequently, there would be no incentive to juke the number of new hires or their hours. Also, current health insurance premiums don’t vary according to an employee’s income, which discourages employers from hiring lower-wage workers. Charging a percentage of payroll for coverage would help companies cover the costs even as the system moves towards the exchanges.
If you were a Republican who cared about this issue, this would be a perfect opportunity to change the law in a way you’d like. It wouldn’t be giving up something to get half a loaf, it’d be giving up nothing to get half a loaf. Democrats and Republicans could agree to change the mandate, whether it’s to more closely resemble the original House version of the bill, or something else. I’m sure that creative legislators could come up with any number of ways to produce the maximum number of people with employer-sponsored coverage—or even, now that the exchanges seem to be working quite well, devise a new way for employees to use them without employers just getting off the hook for providing coverage.
But we all understand the present reality, which is that no Republican is willing to work with Democrats to improve the ACA, even in ways that address particular complaints conservatives have about the law, because that’s considered collaboration with the enemy and would guarantee you the wrath of the Tea Party and a primary challenge from the right. Within the GOP, changing the law for the better is actually thought to be a terrible sin, while making futile gestures in opposition to the law while tacitly accepting its existence in its current form is thought to be the height of ideological integrity.
It’s possible that over time, as the repeal fantasy looks more and more ridiculous, Republicans will begin to grow more open to legislation making changes to the ACA to improve its operation. That’s what logic would dictate, but anything other than fist-shaking opposition to the ACA may remain politically toxic for a long time in the GOP.
But maybe there’s something Democrats can do to affect that conversation. It’s easy for them to just say:
“If Republicans really cared about improving people’s lives they’d join with us to make improvements, but instead they’d rather just have talking points.” It’s even true. But that doesn’t get you anywhere. So perhaps Democrats could try getting more specific. They could come up with whatever they think is the best way to deal with a weakness in the law, like the current form of the employer mandate. Turn that into a bill. Start moving it through the legislative process in the Senate. Force Republicans to answer specific questions about it, like: “Congressman, you’ve criticized the current employer mandate. Tell me why you think this new proposal isn’t an improvement.”
I’m not naïve enough to think that all Republican opposition to improving the ACA is going to melt before the power of those questions. But it only helps Republicans if they can stay vague in their discussions of the law. The more specific the discussion gets, the harder it is for them. And at least you could introduce the idea of Republicans joining with Democrats to improve the law, which is something barely anyone has brought up until now.
By: Paul Waldman, Contributing Editor, The American Prospect, September 8, 2014
“Grappling With Their Shortsighted Rejection”: The Tough Politics Of Medicaid For Republicans
In the world of Republican politics, there is no surer bet than opposing ObamaCare. But conservative obstruction to the health care overhaul may finally be catching up with a handful of Republican governors running for re-election. Their rejection of ObamaCare’s expansion of Medicaid — the federal health assistance program for the poor and disabled — has been them losing both the argument and voters.
Princeton political scientist Sam Wang recently published an analysis of polling data from this year’s gubernatorial races. It found that Republican incumbents who resisted ObamaCare’s Medicaid expansion — including Wisconsin’s Scott Walker, Pennsylvania’s Tom Corbett, and Kansas’ Sam Brownback — are in much tighter races than those who accepted it. “Republican governors who bucked their party’s stance and accepted the policy are faring better with voters — in these races, an average of 8.5 percentage points better,” Wang discovered.
This shouldn’t be surprising. Setting aside the incendiary politics surrounding ObamaCare and its alleged freedom-killing agenda, the simple truth is that Republican governors have blocked health insurance for nearly six million citizens. And they’ve done so despite the fact that under ObamaCare, the federal government covers all the cost of expanding Medicaid for the next six years, and at least 90 percent of the cost in 2020 and beyond.
Why have Republican governors spurned this incredibly good deal? Their ostensible justification has been disbelief that the federal government would hold up its end of the bargain, leaving states to pick up the tab.
But researchers at the Urban Institute threw cold water on this argument in a study last month. They found that the federal government has almost never reduced funding to the states for Medicaid. In fact, it has not done so since 1981, when President Reagan and Congress imposed a temporary funding cut.
Indeed, Congress has been far more likely to increase funding for state Medicaid programs. It has done so twice in recent memory — in 1997 and in 2005 — boosting state funding even while making other cuts to the program.
The sanctity of the federal commitment to Medicaid has only grown in recent years. As evidence of federal faint-heartedness, conservatives point to an administration proposal floated during 2011 budget negotiations that would have reduced federal Medicaid funding to the states.
But this bad idea was dropped after the states got newfound bargaining power from the Supreme Court’s 2012 decision making the Medicaid expansion entirely voluntary. With the expansion now optional, the administration can ill afford to weaken the financial carrot for red states to buy in. This has also made the administration agreeable to some conservative twists on traditional Medicaid, like using public dollars to enroll people in private health plans in Arkansas and Iowa.
The Urban Institute also quantified how much intransigent red states are losing by resisting ObamaCare. They’re turning down $400 billion in free federal money over 10 years. They will have missed out on over 172,000 new jobs in 2015 alone. And they’ve cost their hospitals $168 million, enough to completely offset ObamaCare’s reimbursement cuts to hospitals for Medicare and Medicaid.
And, of course, these states have also frozen themselves at pre-ObamaCare rates of high uninsurance. “While the number of uninsured in other states fell by 38 percent since September 2013,” the researchers explain, “non-expanding states experienced a decline of just 9 percent.”
As the midterm elections approach, Republican candidates are discovering that the politics around health care reform are becoming unexpectedly complicated. Trailing badly in the polls, Gov. Corbett announced last month that Pennsylvania will expand its Medicaid program. In states that have already expanded their programs, pro-repeal conservative candidates are stumbling to explain how they would handle new Medicaid enrollees.
But this is what happens when you engage with the actual policy implications of health care reform. Conservatives can whip up fear and hostility over an abstract big-government monolith called ObamaCare. But the actual programs contained therein (like expanding public health insurance for the poor) tend to be pretty appealing to voters.
As their arguments are rendered hollow, obstructionist Republicans are paying the electoral price for thwarting these types of programs. When they picked a fight against expanding Medicaid, conservatives chose the wrong bulwark for massive resistance against national health care reform.
By: Joel Dodge, The Week, September 9, 2014
“The Campaign For Liberty”: The War On Obamacare Has Become A War On Minorities And The Poor
Like many eleventh-hour strategies, the right’s final offensive against the Affordable Care Act has a last-gasp quality to it. Where better-laid plans to defeat the ACA in Congress and via Constitutional challenge were fraught with ideological purpose, the challengers in Halbig v. Burwell are engaged in something much smaller. Their argument is merely that if you read a poorly drafted section of the statute out of context, it appears that the law doesn’t contemplate subsidies in states that availed themselves of the federal government’s backstop, Healthcare.gov. Millions of people would lose their health insurance in service of teaching Congress a lesson about the importance of legislative draftsmanship.
That’s not a very becoming political argument, though, so the Halbig supporters have stapled a grandiose claim to their core challenge. Because many of the people who would lose their insurance would also qualify for an exemption from the law’s insurance coverage mandate, they frame it as a principled campaign for liberty.
But many is not all. It’s probably not even most. As University of Michigan law professor Nicholas Bagley noted on Tuesday, a conservative victory in Halbig would eliminate subsidies for everyone, but the hardship exemption would only apply to a subset. Many, many people—those above about 180 percent of the federal poverty level—would still be required to purchase insurance. It would just become more expensive for them. The exemption—the escape hatch to freedom—would only be available to those whose coverage costs more than eight percent of income: the poor, and near-poor. These are the people whose liberty conservatives claim to be fighting for—the people who were only able to purchase insurance because the subsidies made it affordable. The people who, as Bagley writes, would “be free to decline coverage that, without tax credits, they can’t afford anyhow.”
This kind of post hoc appeal to liberty long predates the Affordable Care Act, but it has become particularly salient in the fight against Obamacare as enrollment has grown and weakened traditional tools of opposition. When the Supreme Court made the Affordable Care Act’s Medicaid expansion optional back in 2012, it vouchsafed an old but typically losing conservative argument that using federal spending as an incentive to force state action can be unconstitutionally coercive—a freedom-crushing blow against states’ rights. But the freedom the Court upheld two years ago looks, in effect, an awful lot like the freedom the challengers in Halbig claim to be fighting for. In both cases there’s something conspicuous about the people to whom these strange conceptions of liberty apply.
As of early April, per this Kaiser Family Foundation map, 19 states remained fully unwilling to consider Medicaid expansion. In the weeks since, Wyoming and Tennessee joined Utah and Indiana among GOP-controlled states working toward expanding Medicaid. So the chips are slowly falling. But they are falling along fairly predictable racial and income lines.
Tennessee was a genuine surprise, in that it isn’t lily white, and has fairly high rates of poverty. But the GOP-controlled states that have expanded Medicaid, or are considering Medicaid expansion, are pretty white relative to GOP-controlled states where expansion is out of the question. Deep Southern states, where poverty is most concentrated and black population rates approach 30 percent, aren’t calling up the Department of Health and Human Services in Washington to negotiate a conservative Medicaid expansion compromise. To the contrary, that’s probably where resistance to the expansion runs strongest.
The story won’t be much different if conservatives get their way and ACA subsidies disappear in Healthcare.gov states. If you haven’t caught on by now, the conspicuous thing about the Medicaid freedmen and those who would be freed from the individual mandate is that they’re disproportionately black and poor. ACA rejectionism isn’t enhancing their liberty at all.
But there’s something conspicuous about the Obamacare opponents posing as tribunes for liberty, too. They’re nearly all affluent white people, who take their own health insurance for granted and probably wouldn’t consider themselves liberated if a court or legislature took aim at it for any reason. And though their rhetoric suggests otherwise, they’re waging the final Obamacare battles against poor people and minorities, not on their behalf.
By: Brian Beutler, The New Republic, September 4, 2014
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