“The Long, Long Battle For Health Care Reform”: The Single Defining Goal Of American Progressivism For More Than A Century
So in this week of epochal Supreme Court opinions, even health policy wonks would not claim that King v. Burwell can match Obergefell v. Hodges in terms of its historical significance. There’s a reason the latter is stimulating spontaneous outbreaks of happiness among people who aren’t political and don’t follow constitutional law.
But at Vox today, Dylan Matthews reminds us that of the incredibly long hard path this country has followed to reach even the Affordable Care Act’s first timorous steps towards universal health coverage. Those conservatives who talk as though no one has ever seriously considered such a socialist abomination until now really are betraying their ignorance about history:
National health insurance has been the single defining goal of American progressivism for more than a century. There have been other struggles, of course: for equality for women, African-Americans, and LGBT people; for environmental protection; against militarism in Southeast Asia and the Middle East. But ever since its inclusion in Teddy Roosevelt’s 1912 Bull Moose platform, a federally guaranteed right to health coverage has been the one economic and social policy demand that loomed over all others. It was the big gap between our welfare state and those of our peers in Europe, Canada, Australia, New Zealand, and Japan.
And for more than a century, efforts to achieve national health insurance failed. Roosevelt’s third-party run came up short. His Progressive allies, despite support from the American Medical Association, failed to pass a bill in the 1910s. FDR declined to include health insurance in the Social Security Act, fearing it would sink the whole program, and the Wagner Act, his second attempt, ended in failure too. Harry Truman included a single-payer plan open to all Americans in his Fair Deal set of proposals, but it went nowhere. LBJ got Medicare and Medicaid done after JFK utterly failed, but both programs targeted limited groups.
Richard Nixon proposed a universal health-care plan remarkably similar to Obamacare that was killed when then-Sen. Ted Kennedy (D-MA) walked away from a deal to pass it, in what Kennedy would later call his greatest regret as a senator. Jimmy Carter endorsed single-payer on the campaign trail, but despite having a Democratic supermajority in Congress did nothing to pass it. And the failure of Bill Clinton’s health-care plan is the stuff of legend.
Yes, Obamacare haters may dismiss the experience of virtually every other wealthy country by intoning “American exceptionalism”, as though we have some long-cherished right to die young that’s as essential to the national character as unlimited possession of guns. But this has been a constant issue in our own country, too, and it’s a token of how far our political system has drifted to the right that redeeming the vision of Teddy Roosevelt and Harry Truman and Richard Nixon strikes so many people as a horrifying lurch into socialism.
By: Ed Kilgore, Contributing Writer, Political Animal Blog, June 26, 2015
“Jeb Once Again Turns To His Apple Watch”: A Wrist Gadget As Part Of His Vision For A Replacement Healthcare System
Jeb Bush caused a bit of a stir last week, telling an audience that he intends to destroy the Affordable Care Act, replacing it with a “consumer-driven” system, part of which includes his new Apple Watch.
“On this device in five years will be applications that will allow me to manage my health care in ways that five years ago were not even possible,” he said. “I’ll have the ability, someone will, you know, because of my blood sugar, there’ll be a wireless, there’ll be, someone will send me a signal…. We’ll be able to guide our own health care decisions in a way that will make us healthy.”
Yesterday, campaigning in New Hampshire, the Florida Republican returned to the same subject:
“We’re on the verge of a revolution in this regard, where we’ll be able to know all sorts of things with, you know, devices like this. I got beat up by the left because I showed my, you know, Apple Phone – this device will have the ability to measure your sugar content, to measure your heartbeat, to measure whether you’re taking your drugs in the proper way. And you’ll be able to wirelessly send text messages to your health care provider or to your loved one, or whatever, so that you can get back on track.”
It seems the former governor isn’t entirely clear on why he “got beat up.”
The point isn’t that wearable tech is irrelevant (he said “phone” yesterday, but I assume he meant “watch”). It’s easy to imagine devices that can help people manage chronic conditions like diabetes. Indeed, the Florida Republican makes it sound as if these advancements are on the horizon, but in many instances, the technology already exists.
That’s not the problem. Rather, the area of concern is that Bush intends to scrap the Affordable Care Act, which would eliminate health security for millions of families, and he included a wrist gadget as part of his vision for a replacement system. Sarah Kliff added last week:
Bush endorses the idea of “someone” sending him a signal on his Apple Watch when his blood sugar is low. I like that idea, too! It would help diabetic patients, like Bush, better manage their care.
But here’s the challenge: there is not some army of benevolent people out there monitoring blood sugar. There are health-care providers who do this, and to get signed up for their blood sugar monitoring programs, you typically need health insurance. In this way, the type of consumer-powered health market that Bush describes is one that relies on Americans having access to health services – and using that access to make better decisions about their health care.
Jeb Bush didn’t get “beat up” because he pointed to his fancy gizmo; he got “beat up” because he pointed to his fancy gizmo while making the case against the existing U.S. health care system.
By: Steve Benen, The Maddow Blog, May 22, 2015
“Where Employees Are Treated With Contempt”: Obama Blasts Staples, And Reveals Larger Partisan Divide Over Workplace
Another big interview with President Obama came out today, this one from Buzzfeed, and this section, in which Obama slammed Staples for limiting employee hours, supposedly in response to Obamacare, is creating a bit of buzz:
BEN SMITH: If I can move on to the Affordable Care Act. We reported yesterday that the office supply store Staples is — I’m sure this is an issue you’ve heard about before — is telling its workers that it will fire them if they work more than 25 hours a week. A manager had told a worker we talked to that “Obama’s responsible for this policy,” and they’re putting these notices on the wall of their break room saying that. I wonder what you’d say to the CEO of Staples, Ronald Sargent, about that policy?
OBAMA: What I would say is that millions of people are benefiting from the Affordable Care Act. Satisfaction is high. The typical premium is less than 100 bucks.
SMITH: But this is a specific consequence…
OBAMA: No, I’m gonna answer the question. And that there is no reason for an employer who is not currently providing health care to their workers to discourage them from either getting health insurance on the job or being able to avail themselves of the Affordable Care Act. I haven’t looked at Staples stock lately or what the compensation of the CEO is, but I suspect that they could well afford to treat their workers favorably and give them some basic financial security, and if they can’t, then they should be willing to allow those workers to get the Affordable Care Act without cutting wages.
This is the same argument that I’ve made with respect to something like paid sick leave. We have 43 million Americans who, if they get sick or their child gets sick, are looking at either losing their paycheck or going to the job sick or leaving their child at home sick. It’s one thing when you’ve got a mom-and-pop store who can’t afford to provide paid sick leave or health insurance or minimum wage to workers — even though a large percentage of those small businesses do it because they know it’s the right thing to do — but when I hear large corporations that make billions of dollars in profits trying to blame our interest in providing health insurance as an excuse for cutting back workers’ wages, shame on them.
Obama obviously didn’t know any details of the Staples situation when he was asked the question, but Buzzfeed reported Monday that the company is becoming particularly aggressive in making sure its part-time workers don’t work more than 25 hours a week, now that an Affordable Care Act provision mandating that large companies offer health insurance to employees working over 30 hours is in effect. Staples says that the policy is years old and has nothing to do with health insurance; the employees Buzzfeed talked to say it’s being enforced with renewed vigor.
Regardless of those details, this is another example of the fundamental difference between the approach to workplace issues Obama is trying to move Democrats toward, and the ways that Republicans are pushing back. As I argued a few weeks ago when Obama raised the issue of paid sick leave — which the United States is alone among highly developed countries in not mandating — Republicans essentially want to help people get to the employer’s door, while Democrats want to go inside with the worker and help make the workplace more humane.
The Staples story illustrates the environment of so many contemporary American workplaces, where employees are treated with contempt and suspicion while being told how much they’re loved. The original Buzzfeed story contains a Staples memo threatening part-time employees with discipline up to termination if they clock in for more than 25 hours in a week. The memo ends with, “I appreciate and value you.” I’m sure that warmed the workers’ hearts.
There may be some part-time workers who find that in response to the ACA’s insurance mandate, their employers try to limit their hours in the way Staples is doing. That’s why Republicans want to change the mandate’s definition of full-time employment from 30 to 40 hours. But we should be clear about what would happen if Republicans got their way. Some number of people like those at Staples might be able to work a few more hours (though if Staples is telling the truth, it wouldn’t matter for their part-timers, because they’re adamant about keeping them below 25 hours regardless). But a much larger group — full-time hourly workers — would then be in danger of losing their health coverage.
Right now if a large company (remember, this provision only applies to large companies) wanted to cut a full-time employee’s hours so they wouldn’t have to offer her health insurance, they’d have to cut her all the way down from 40 to 29 hours, which in most cases just isn’t practical. But if the law’s definition of full-time work was 40 hours, they could cut her from 40 to 39 and be able to take away her health coverage, which would be a lot easier. One hopes that few companies would want to do that, and indeed, over nine out of ten large companies were already offering insurance to full-time workers even before the Affordable Care Act. But some would, and the number of employees at risk of losing their coverage would be much higher than it is under the current 30-hour definition.
The populist stance Obama is taking here is undoubtedly good politics; Republicans will try to say that they’re the ones on the side of the part-time workers, but voters generally understand that they’re always in favor of giving employers the power to treat employers however they wish. In any case, this kind of dispute is just one more reason why we should try to move away from a system where most people get insurance through their employers. If we did that, people wouldn’t have to rely on the generosity of their bosses, and we wouldn’t have to argue about who’s part-time and who’s full-time. And neither party has a particular stake in, or ideological commitment to, the employer-based insurance system; it’s an artifact of history. Moving beyond it would be a major change, and we all know by now that when it comes to their health coverage, people fear change. But it would be better for everybody.
By: Paul Waldman, Contributing Editor, The American Prospect; Contributor, The Plum Line, The Washington Post, February 11, 2015
“Give Me Liberty And Give You Death”: How The GOP Embraced Being The Party Of Death
As part of their long-standing war on the Affordable Care Act, conservatives have filed a lawsuit willfully misreading the statute to deny upward of 10 million people subsidies to purchase insurance. This denial of insurance will almost certainly lead to significant amounts of preventable death and suffering.
Michael Strain of the American Enterprise Institute doesn’t deny any of this. Instead, he argues that some suffering and death may well be a price worth paying:
In a world of scarce resources, a slightly higher mortality rate is an acceptable price to pay for certain goals — including more cash for other programs, such as those that help the poor; less government coercion and more individual liberty; more health-care choice for consumers, allowing them to find plans that better fit their needs; more money for taxpayers to spend themselves; and less federal health-care spending. This opinion is not immoral. Such choices are inevitable. They are made all the time. [The Washington Post]
At a high enough level of abstraction, what Strain is saying isn’t wrong. Not all public policy can function on the basis of keeping mortality rates to the lowest possible number. Some lifesaving treatments might help so few people and cost so much that they might not be worth it. Even major infrastructure projects entail some risk of injury or death on the part of workers, but few people would argue that any such risk is unacceptable.
But the fact that the costs of the ACA might theoretically exceed the benefits doesn’t get us very far. What benefits, exactly, would accrue if millions of people were denied medical coverage because the ACA is seriously damaged or destroyed? It’s here that Strain’s argument falls apart.
One potential line against the ACA is the radical libertarian one, holding that any effort by the government to provide health care to the non-affluent represents an unacceptable level of state coercion. The problem here is that the “freedom” to die of preventable illnesses and injuries is not one the vast majority of people value very highly. A Republican Party committed to these principles would be transformed into an electoral coalition that would make Barry Goldwater’s 52 electoral votes in 1964 look robust.
Since the people responsible for the anti-ACA effort know this perfectly well, the constitutional arguments against the ACA have the advantage of not logically requiring the Supreme Court to rule the entire modern regulatory state unconstitutional. The disadvantage is that they ask the court to deny many millions of people health coverage based on liberty interests that are ludicrously trivial.
The litigants challenging the constitutionality of the ACA do not contend that the federal government cannot regulate national health-care markets. Rather, their constitutional argument boils down to an assertion that the government has the authority to assess a tax to compel people to purchase health insurance, but not a penalty. It’s pretty hard to argue that the fate of liberty in America hinges on this formal limitation on federal power.
The more successful federalist argument launched against the Affordable Care Act is similarly unattractive. Chief Justice John Roberts’ inept rewriting of the ACA’s Medicaid expansion allowed states to opt out. Republican-controlled states have eagerly rejected the large amounts of federal money on offer to insure more poor residents, something that is likely to result in the unnecessary deaths of more than 5,000 people a year.
I don’t think this particular protection of state autonomy is worth that many lives (or, indeed, a single life). But here’s the kicker: The Supreme Court’s decision does not even meaningfully protect state sovereignty. Under the court’s theory, Congress could have enacted the ACA’s Medicaid expansion by repealing the pre-existing Medicaid entirely. This, apparently, would be completely constitutional. There may be things worth 5,000 lives a year; an incoherent legal argument that doesn’t even really protect states’ rights isn’t one of them.
Strain’s arguments have similar problems. To his credit, he’s not a libertarian radical who asserts that the federal government cannot play any role in expanding health-care coverage. Rather, “universal coverage should concern itself with the catastrophic expenses associated with serious medical events that will affect a minority of the population.” The affluent, or people with good jobs, can get real medical coverage; the non-affluent might get some protection for disasters, but would have to pay through the nose for common medical procedures. Whether or not one prefers this policy alternative — which I think is far worse — there’s not a lot of meaningful protection of “freedom” going on here. The number of lives worth sacrificing so that people can choose between a few more insurance alternatives — or between the “freedom” to pay for checkups for their children or their electric bill — strikes me as “zero.”
And, of course, even this is too generous to the Republican reformers. The ACA isn’t unpopular because it provides subsidies that are too generous or because the exchanges offer insurance that cover too many things. The Republican alternatives Strain discusses will all disappear should the ACA be destroyed, because the trade-offs involved will outrage many voters. The actual Republican alternative Strain thinks it’s worth killing a lot of people for is “nothing.”
But, hey, the next upper-class Republican tax cut could be even larger, and it’s not going to be elite Republicans who pay the price. As the writer Roy Edroso puts it, Strain’s argument can be summarized as “give me liberty and give you death.” I think we can see why Republicans would prefer for the Supreme Court to do their dirty work.
By: Scott Lemieux, The Week, January 29, 2015
“Who’s Paying The Premiums?”: Health Insurance Is Not A Favor Your Boss Does For You
The debate over the Hobby Lobby case has been plagued by many problematic presumptions, but there’s one that even many people who disliked the decision seem to sign on to without thinking about it. It’s the idea that the health insurance you get through your employer is something that they do for you—not just administratively, but in a complete sense. But this is utterly wrong. You work, and in exchange for that labor you are given a compensation package that includes salary and certain benefits like a retirement account and health coverage. Like the other forms of compensation, the details of that insurance are subject to negotiation between you and your employer, and the government’s involvement is to set some minimums—just as it mandates a minimum wage, it mandates certain components health insurance must include.
Those who support Hobby Lobby are now talking as though mandating that insurance include preventive care is tantamount to them forcing you to make a contribution to your local food bank when you’d rather give to the pet shelter. You can see it, for instance, in this piece by Megan McArdle in which she tries to look at the clash of rights involved in this dispute, but running through the whole piece is the idea that an employee’s health insurance isn’t compensation for her labor but a piece of charity her boss has bestowed upon her for no reason other than the goodness of his heart. Referring to the question of whether the religious beliefs of Hobby Lobby’s owners are being imposed on its employees, she writes: “How is not buying you something equivalent to ‘imposing’ on you?” Then later she refers to “a positive right to have birth control purchased for me.”
But when your insurance coverage includes birth control, your employer isn’t “buying you” anything. Your employer is basically acting as an administrative middleman between you and the insurance company. Your employer isn’t the one whose money is paying the premiums, you are. It’s compensation for the work you’ve done, just as much as your salary is.
This goes all the way back to to the roots of our employer-based insurance system. During World War II, the government imposed wage and price controls, meaning employers couldn’t give raises. So they began to offer health insurance as an alternate form of compensation, and when the IRS decided in 1943 that insurance could be paid with pre-tax dollars, it made it all the more attractive as a form of compensation. And keep in mind that the preferential tax treatment of health insurance (which the self-employed don’t get) is a tax benefit to the employee, not the employer. If you eliminated it, employers’ balance sheets would stay the same (it would still be counted as an expense), but employees would have to pay taxes on the benefit.
You might or might not think that remembering the true nature of the insurance benefit should change the calculation in the Hobby Lobby case. I’m guessing that for the plaintiffs, it wouldn’t; they’d probably argue that even having to think about what sinful harlots their employees are imposes a “substantial burden” on their religious freedom. And as I’ve argued before, we should get rid of the employer-based insurance system entirely. That may happen eventually, but in the meantime, it’s good to remember just whose health insurance it is. It’s not your boss’. It’s yours.
By: Paul Waldman, Contributing Editor, The American Prospect, July 9, 2014
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