“Don’t Pick Out Hymns For Its Burial”: Still Plenty To Watch For In Health Care Debate
I have a few quick thoughts on this week’s Supreme Court hearings and what it will mean for our coverage of health reform.
Most people in the courtroom (or people who, like me, listened to audio, read transcripts, wrote and edited a ton of copy and couldn’t avoid Jeff Toobin) ended up with the gut feeling that health reform is in deep trouble – that the court is likely to toss the individual mandate, some of the insurance provisions, and maybe a whole lot more. Maybe all of it.
But of course, we don’t really know what the court will do. Tough questions in public certainly let us know that all nine justices are not exactly the law’s biggest boosters. But what they will do, as they mull and debate behind closed doors, is not a sure thing. We can guess, but we don’t know. And we won’t know for about three months. (There’s a chance that it will be sooner – but traditionally big rulings come out at the end of the term. And this is a big, big ruling).
Remember the “Conventional Wisdom” was wrong before – wrong from the beginning. The CW didn’t think Obama was going to push for comprehensive health reform. The CW didn’t think he’d be able to enact health reform – particularly not after Scott Brown’s election. The conventional wisdom didn’t think there would be a fight about the mandate. Or that the mandate would end up in the Supreme Court. Or that it would be in deep, deep, deep trouble once it got there.
So what do we do for the next three months?
First of all, we are going to get spun – and the negativity about the oral arguments is going to help the anti-health law camp of spinners. (The “hey it’s hunky-dory, it’s all fine” advocacy world rings a little hollow at the moment – although they may turn out in June to be right.) Keep an eye out for that “the law is dead so let’s get real” drumbeat because if things are said often enough, in a media or political context, they can start becoming the new conventional wisdom and affecting how we report and write.
We might get pushed by editors to be more forceful about predicting the demise of the law (or the mandate) than we are comfortable with. Push back – you can certainly say there are real questions about the law’s survival. You can’t pick out hymns for its burial.
Watch your state. Are officials slowing down implementation? Not submitting grant applications for exchange planning when they were before, or not putting out bids for exchange IT teams, etc.? Are the implementers slowing down – and are the non-implementers freezing? How much catching up will they have to do if the statute is upheld – and they have to meet some exchange certification deadlines by Jan. 1, 2013.
Is the court situation affecting state politics – local, congressional, presidential. How?
Is anyone talking about state initiatives to fill in if the parts of the federal plan are punctured? For instance, if the federal mandate fails, there’s nothing to stop a state from passing its own mandate; the federal constitutional questions don’t apply. I suspect few states will do this – but I can think of a handful that might. (If this does start to bubble up in your state, please email me your coverage.)
What are the hospitals’ and insurers’ and physician groups’ contingency plans? Are delivery system reforms and innovations on hold – or is the assumption that they can either proceed without the federal law, or that the relevant sections of the law will survive
And does the public know what it wished for? It wanted health reform when it didn’t have it. Then it decided it didn’t like health reform when it got it. Do Americans really want to go back to March 22, 2010 (the day before President Obama signed it)? And do they realize they can’t; that the health system has changed? Do they understand that people who are getting benefits under the first phases of the law’s implementation could lose them? And that costs will rise, the numbers of uninsured (now somewhere around 50 million) will rise, and Congress – so polarized that it has trouble doing much more than renaming post offices these days – is not going to come swooping in with a pain-free bipartisan fix-the-problems-with-no-cost-or-dislocation make-everyone-happy solution.
By: Joanne Kenen, Association of Health Care Journalists, March 29, 2012
“Exotically Countercultural”: The Unhappy Triumph Of The Marketplace
This objection to Obamacare’s individual mandate, by Jonathan Adler at the libertarian Volokh Conspiracy website, grabbed my attention:
“Virtually everyone” may acquire health care—but “virtually everyone” is not “everyone.” Most people may purchase health care at some point in their lives, but some will not. Some people will refuse to purchase health care for religious reasons. Some will not purchase health care because they are lucky enough not to need such care before a sudden death. Still others may decide not to purchase health care because they have chosen to remove themselves from commerce—consider a survivalist or other person who decides to live in a shack, growing their own food, and not engaging in commerce with others.
Consider Adler’s latter example: It strikes me that the vast majority of Americans would find the idea of “not engaging in commerce with others” to be exotically countercultural at best, possibly antisocial or even deviant. Such a reaction is symptomatic of the fact that the marketplace has long enjoyed pride of place in Americans’ moral psychology. “The chief business of the American people is business,” as President Calvin Coolidge famously said.
This ethos has made proper small-l liberals of us, hasn’t it? Americans have been taught by the libertarian right and the Clintonian middle to believe that a commercial relationship between nations—trade—is the only way to achieve lasting international harmony. At least before the great stock market crash of 2008, CEOs were like cult heroes in the popular imagination. From the pluckiness of Horatio Alger’s heroes to the theology of Joel Osteen, success in the marketplace has been seen as an outward confirmation of inward virtue and divine blessedness.
So it’s with some sense of schadenfreude that I see conservatives of the classical liberal variety chafing at the requirement to buy health insurance, calling it an attempt by Congress to “create commerce.” I’m fully aware of the contractarian basis for this objection: that a forced purchase is not a legitimate commercial exchange.
But the paleocon in me responds this way: This is the antitraditional bed you’ve made for us. Now lie in it.
By: Scott Galupo, U. S. News and World Report, March 27, 2012
“National Solutions To National Problems”: The Affordable Care Act Is Much More Than Politics
The law is a commonsense solution to our country’s broken healthcare system and is clearly constitutional. It eliminates insurance company abuses, makes coverage more affordable for seniors, families, and small businesses, and creates rules that stop insurers from denying care to the sick and jacking up premiums anytime they please.
The logic of the law is that we can make coverage more affordable and fair if everyone has insurance, including the young and healthy and those who don’t expect to get sick. That lowers costs by spreading the risk more broadly.
Our system is fundamentally out of balance. Many people don’t get the care they need, and others only get care at everyone else’s expense—and usually at an emergency room where services are far more expensive than at a doctor’s office. As a result, at least $43 billion in uncompensated care is provided every year, paid for by a $1,000 “hidden tax” in the premiums of every insured person in the country.
Today most people have insurance. Most of the 50 million uninsured want coverage but either can’t afford it or are excluded by insurers because of pre-existing conditions. When the law is fully implemented, families unable to afford coverage will get tax credits to put it within reach. The truth is that the individual responsibility provision, also known as the mandate, will affect only the 2 percent of Americans who have access to affordable coverage but refuse it. That’s what this fight is about: the 2 percent who reject rules that will allow the rest of us to get better, more affordable coverage.
The Supreme Court has consistently ruled that the Constitution gives Congress the ability to develop national solutions to national problems. If the court were to bow to political pressures to strike down the law, it would essentially put regulation of healthcare, which accounts for nearly 18 percent of our economy, beyond the reach of Congress. That is plainly absurd.
The case against the health law is an extension of a transparently partisan political mission to tear down this milestone law as a way to turn President Obama out of office in November. What the partisans selfishly refuse to acknowledge is that there is so much more than politics at stake.
By: Ethan Rome, U. S. News and World Report, March 26, 2012
What If “The Bogeyman Disappears”: How High Court Ruling Could Backfire On GOP
At WaPo’s ‘The Fix,’ Aaron Blake has an interesting read, “On health care, Supreme Court loss could be electoral win.” Blake believes the GOP’s glee about the upcoming Supreme Court ruling on the ACA could backfire — in an unexpected way. Blake explains:
…Some Republicans are worried that their big challenge to Obama’s health care law could backfire come election time.Obama, of course, does not want to see his signature initiative overturned by the Supreme Court, which holds oral arguments on the bill next week and should render a decision by late June. And Republicans who have long railed against the bill would certainly be overjoyed to see the bill struck down.
But in an electoral milieu (yes, we just used that word) in which winning is often based more on voting against something rather than voting for it, losing at the Supreme Court may be the best thing that could happen to either side — and particularly Democrats.
“In a perverse way, Obama is helped if it is overturned, because then he can use it to rally his base,” said GOP pollster Glen Bolger. “If it is not overturned, then Republicans have a frying pan to bash over the Democrats’ head…”
That last point may be a bit of a stretch. It’s just as easy to imagine the GOP looking like whiners, grumbling about a pro-Republican court saying the law is sound. Plus it may be overstating the intensity of opposition to the mandate — many who don’t like it may be willing to at least give it a try, especially if the High Court says it’s OK.
In addition, don’t forget that polls indicate many who opposed the bill wanted a stronger role for government. Asked “What, if anything, do you think Congress should do with the health care law? Expand it. Leave it as is. Repeal it.” in a Pew Research poll conducted March 7-11, 53 percent said “expand it” (33 percent) or “leave it as it is” (20 percent), with just 38 percent supporting repeal.
Blake is on more solid ground, however, in arguing:
Republicans already hate the law, and if it gets struck down, there’s nothing to unite against. Obama may pay a price from his political capital for enacting a law that is eventually declared unconstitutional, but all of a sudden, the bogeyman disappears, and the GOP loses one of its top rallying cries.The Democratic base, meanwhile, would be incensed at the Supreme Court, which has generally tilted 5-to-4 in favor of conservatives on contentious issues, and could redouble its efforts to reelect Obama so that he could fill whatever Supreme Court vacancies may arise.
Blake argues less persuasively that Republicans will still put energy into repealing the law, even after the Supreme Court’s ruling. Seems to me that this would be a huge loser for the GOP. The public was tired of the legislative debate a long time ago. I would agree with Blake’s assessment, however, that Dems may “have more to gain than Republicans do” in terms of the election — even with an adverse ruling.
By: J. P. Green, The Democratic Strategist, March 23, 2012
Hurray For Health Reform: “Protecting Those Who Are Falling Through The Cracks”
It’s said that you can judge a man by the quality of his enemies. If the same principle applies to legislation, the Affordable Care Act — which was signed into law two years ago, but for the most part has yet to take effect — sits in a place of high honor.
Now, the act — known to its foes as Obamacare, and to the cognoscenti as ObamaRomneycare — isn’t easy to love, since it’s very much a compromise, dictated by the perceived political need to change existing coverage and challenge entrenched interests as little as possible. But the perfect is the enemy of the good; for all its imperfections, this reform would do an enormous amount of good. And one indicator of just how good it is comes from the apparent inability of its opponents to make an honest case against it.
To understand the lies, you first have to understand the truth. How would ObamaRomneycare change American health care?
For most people the answer is, not at all. In particular, those receiving good health benefits from employers would keep them. The act is aimed, instead, at Americans who fall through the cracks, either going without coverage or relying on the miserably malfunctioning individual, “non-group” insurance market.
The fact is that individual health insurance, as currently constituted, just doesn’t work. If insurers are left free to deny coverage at will — as they are in, say, California — they offer cheap policies to the young and healthy (and try to yank coverage if you get sick) but refuse to cover anyone likely to need expensive care. Yet simply requiring that insurers cover people with pre-existing conditions, as in New York, doesn’t work either: premiums are sky-high because only the sick buy insurance.
The solution — originally proposed, believe it or not, by analysts at the ultra-right-wing Heritage Foundation — is a three-legged stool of regulation and subsidies. As in New York, insurers are required to cover everyone; in return, everyone is required to buy insurance, so that healthy as well as sick people are in the risk pool. Finally, subsidies make those mandated insurance purchases affordable for lower-income families.
Can such a system work? It’s already working! Massachusetts enacted a very similar reform six years ago — yes, while Mitt Romney was governor. Jonathan Gruber of the Massachusetts Institute of Technology, who played a key role in developing both the local and the national reforms (and has published an illustrated guide to reform) has surveyed the results — and finds that Romneycare is working pretty much as advertised. The number of people without insurance has dropped sharply, the quality of care hasn’t suffered, and the program’s cost has been very close to initial projections.
Oh, and the budgetary cost per newly insured resident of Massachusetts was actually lower than the projected cost per American insured by the Affordable Care Act.
Given this evidence, what’s a virulent opponent of reform to do? The answer is, make stuff up.
We all know how the act’s proposal that Medicare evaluate medical procedures for effectiveness became, in the fevered imagination of the right, an evil plan to create death panels. And rest assured, this lie will be back in force once the general election campaign is in full swing.
For now, however, most of the disinformation involves claims about costs. Each new report from the Congressional Budget Office is touted as proof that the true cost of Obamacare is exploding, even when — as was the case with the latest report — the document says on its very first page that projected costs have actually fallen slightly. Nor are we talking about random pundits making these false claims. We are, instead, talking about people like the chairman of the House Republican Policy Committee, who issued a completely fraudulent press release after the latest budget office report.
Because the truth does not, sad to say, always prevail, there is a real chance that these lies will succeed in killing health reform before it really gets started. And that would be an immense tragedy for America, because this health reform is coming just in time.
As I said, the reform is mainly aimed at Americans who fall through the cracks in our current system — an important goal in its own right. But what makes reform truly urgent is the fact that the cracks are rapidly getting wider, because fewer and fewer jobs come with health benefits; employment-based coverage actually declined even during the “Bush boom” of 2003 to 2007, and has plunged since.
What this means is that the Affordable Care Act is the only thing protecting us from an imminent surge in the number of Americans who can’t afford essential care. So this reform had better survive — because if it doesn’t, many Americans who need health care won’t.
By: Paul Krugman, Op-Ed Columnist, The New York Times, March 18, 2012
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