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“Skeletal Descriptions Of Planlike Concepts”: How The Presidential Race Is Making The GOP’s Health Care Ideas Even Worse

Every major national Republican is sure that they want to repeal the Affordable Care Act. They are much less clear about what, if anything, they would do after stripping insurance from millions of people. Two plausible Republican nominees for president — Scott Walker and Marco Rubio — issued health care plans this week. And…let’s just say there’s a reason Republicans spend a lot more time on the “repeal” part of the “repeal and replace” equation.

Indeed, to call these positions “plans,” as opposed to gestures in the direction of having a policy alternative, is probably too generous. As Jon Chait of New York puts it, they are “not so much plans as skeletal descriptions of planlike concepts.” Still, even in larval form, Walker’s plan contains several elements that are common to most Republican health care proposals, and that if enacted would result in horribly unpopular policy disasters. Here are the main features:

End the individual mandate

Most individual components of the Affordable Care Act are popular; the requirement that people carry insurance or pay a tax penalty is not. And since the mandate was very nearly the lever that gave a conservative Supreme Court majority a pretext to declare the ACA unconstitutional, Republicans have also convinced themselves that it is one of the greatest threats to liberty ever seen. So it is inevitable that any Republican proposal will advocate eliminating it, as Walker’s does.

The problem is that the popular parts of the ACA can’t be divorced from the mandate. If people are permitted to free-ride, the health insurance market can’t work. Multiple states tried to initiate ACA-like reforms without a mandate, and it was a disaster — young and healthy people decline to buy insurance knowing they can get it if they fall sick, premiums increase, more people drop out, and the market collapses. This is why President Obama — who pandered during the 2008 primaries by putting forward a plan without a mandate — recanted as soon as he was in a position to actually try to get a law passed.

Make state regulations ineffective

Whenever conservatives have a policy they would prefer not to defend on the merits, the language of federalism comes in handy. In health care, virtually all Republican plans argue for permitting the purchase of insurance across state lines. Walker’s is no exception: “My plan would allow individuals to shop in any state to find health insurance that covers the services they need at a price that fits the family budget.”

In the abstract, a policy of permitting people to shop for insurance across state lines sounds attractive. In practice, it would be a regulatory race to the bottom. Insurance companies would gravitate to the states that place the fewest regulations on insurance industries. It would therefore become easier for insurance companies to deny claims, rescind insurance (or refuse to give it in the first place), and impose hidden costs. If you think credit card companies should be a model for health insurance companies, then Walker’s plan might sound like a good idea. If you’re thinking more clearly, it’s obviously a terrible one.

Make it easier to sell junk insurance

Walker’s plan would reduce federal regulations as well. The Affordable Care Act’s requirement that insurance actually cover things would be eliminated, as would other provisions such as the popular requirement that children be allowed to stay on their parents’ plan until age 26. Other provisions of the ACA, like the ban on discrimination based on pre-existing conditions, would be seriously weakened. So at the same time as Walker’s plan would effectively eliminate many state regulations, it would also leave the insurance companies mostly unsupervised by federal regulations as well.

Conservatives would defend this awful idea by posing a choice between “regulation” and “competition.” But the problem is that health care simply lacks the features of a competitive market. There’s a reason why other liberal democracies have more state intervention into health care than the United States, not less. And by the way, they all cover more people for significantly less money.

Attack the poor

Walker’s politics are not about small government. After all, he thinks that abortion should be illegal even when necessary to save a woman’s life, and he just approved a $250 million gift of taxpayer money to hedge fund billionaires to build a basketball stadium. Rather, his politics are about assisting the rich and powerful at the expense of the poorer and less powerful.

His health care plan is no exception. Like the ACA, Walker’s plan would offer tax credits to allow people to purchase insurance. But Walker’s tax credits would be distributed on the basis of age, not income. The result, as Jeffrey Young and Jon Cohn demonstrate, would be a disaster for the non-affluent, as insurance would become unaffordable for many people at any age. And in addition, Walker also advocates savage cuts to Medicaid. The callousness Walker showed in refusing the ACA’s Medicaid expansion in Wisconsin is reflected in his health care plans.

So Walker’s plan would be an utter disaster if implemented. But it’s not just about Walker. Amazingly, some conservative candidates and pundits attacked Walker’s plan from the right. A spokesman for also-ran candidate Bobby Jindal accused Walker of collaborating with Bernie Sanders to create a plan that would make health care far less accessible to the non-rich.

Essentially, Republicans look at the state of health care circa 2009 — in which more than 16 percent of Americans were uninsured, and in which insurance companies could abuse consumers in a number of ways — and argue that even fewer Americans should have insurance and the quality of the insurance should be much worse. This is one of the many reasons that the contemporary Republican Party is simply unfit to govern at the national level.

 

By: Scott Lemieux, The Week, August 21, 2015

August 23, 2015 Posted by | Affordable Care Act, GOP Presidential Candidates, Health Reform | , , , , , , , , | 2 Comments

“The Equivalent Of Thinking The Iraq War Would Be A Cakewalk”: Why The GOP Presidential Candidates Can’t Reform Health Care

In the last few days, Scott Walker and Marco Rubio released health care plans, and other Republican candidates are sure to follow soon. Most will probably be pretty similar, even if some are more fully fleshed out than others.

But they’ll all share one feature, the thing that tells you that they aren’t even remotely serious about this issue: they will take as their starting point that the entire Affordable Care Act should be repealed.

I say that that shows they aren’t serious not because I think the ACA has done a great deal of good, though I do think that. I say it because it shows that they’re completely unwilling to grapple with both the health care system as it exists today, and how incredibly disruptive the wholesale changes they’re proposing would be. Walker’s plan even says, “unlike the disruption caused by ObamaCare, my plan would allow for a smooth, easy transition into a better health care system.” This is the health care equivalent of thinking the Iraq War would be a cakewalk.

The reality is that repealing the ACA now that it has been implemented would mean a complete and utter transformation of American health care. Republicans have often lamented that the law was so terribly long and included many different rules and regulations — yet now they act as though the law amounts to just a couple of rules here and there that can therefore be tossed out without too much trouble. But they were right the first time: the law is indeed complex, and has brought hundreds of changes big and small to American health care, not just in how people get insurance but in how Medicare and Medicaid work, how doctors and hospitals are paid, and in all sorts of other areas.

The ACA established health care exchanges. It brought millions of people into Medicaid, it closed the Medicare prescription drug “doughnut hole.” It gave subsidies to small businesses. It funded pilot projects to explore new means of providing and paying for care, it imposed new regulations on insurance companies. It created new wellness and preventive care programs, it provided new funding for community health centers. It did all that, and much more. You can argue that each one of these was a good or a bad idea, but you can’t pretend that unwinding them all would be anything resembling a “smooth, easy transition.”

We know why every Republican health care plan has to start with repealing the ACA: politics. Republicans have spent the last five years telling their constituents that they’re going to repeal it any day now, and they’ve held over 50 repeal votes in Congress. They’ve refused to admit that a word of it has any merit, even as they try to incorporate some of its more popular reforms (like protections for people with pre-existing conditions) into their own plans. So they’ve backed themselves into a corner where whatever any Republican offers has to start with repeal.

Which is why all their plans, the ones that have been released and the ones yet to come, are absurdly unrealistic. They pretend that it will be no problem to completely transform the American health care system — and there will be no losers in such a transformation, only winners — which shows that they have no intention of actually doing so. In fact, I’d go so far as to say that if a Republican gets elected next November, he’ll be relieved when his health care plan dies in Congress.

Let’s contrast that with how Democrats acted in 2008, when there was a vigorous debate in the presidential primary over health care. The three leading candidates, Barack Obama, Hillary Clinton, and John Edwards, all had very similar plans, similar because they reflected the Democratic consensus on health care reform that had evolved in the decade and a half since Bill Clinton’s reform effort failed. One major disagreement was over whether there had to be an individual mandate — Clinton’s plan had one, and Obama’s didn’t — but when he took office, Obama accepted that the mandate was necessary to make the entire plan work. It wasn’t a fantasy plan that just pandered to liberal hopes, it was something that could actually pass and be implemented.

Whenever liberals told Obama that a single-payer health plan would be far superior to what he was proposing, he would respond that if we were starting from scratch, that would probably be true. But, he’d say, we aren’t starting from scratch, so the ACA has to accommodate itself to the health care system that already exists. The result was a gigantic kludge, new complexity layered on top of an already complex system in an attempt to solve its varied shortcomings. Like all kludges, it seemed like the realistic option given the situation we confronted, but it left us with something that was far from perfect.

A Republican who actually wanted to pass real health care reform would have to approach the problem the same way: by saying that for better or worse, the Affordable Care Act has already affected the system in profound ways, so any realistic plan has to understand what those changes are, and find the most efficient way to keep the ones that are working and change the ones that aren’t. That doesn’t mean that repeal is impossible, just that it would be a spectacular upheaval, one that I promise you Republicans have no genuine appetite for. Remember all the screaming and shouting they did over the people on the individual market whose previous plans didn’t qualify under the new regulations, and who had to shop for new plans? Multiply that by ten or twenty times, because that’s how many people would likely lose their existing coverage if you repealed the ACA in one fell swoop.

And that would be only the beginning. So when any Republican candidate says he or she has a plan to reform health care, take a close look. If it starts with repealing the ACA — and it will — then you’ll know it isn’t serious and it’s never going to happen.

 

By: Paul Waldman, Senior Writer, The American Prospect; Contributor, The PlumLine, The Washington Post, August 20, 2015

August 21, 2015 Posted by | GOP Presidential Candidates, Health Reform, Obamacare, Republicans | , , , , , , | 1 Comment

“King v. Burwell And Jindal’s Real Leverage”: Interfering With The Signals Other Republicans Are Trying To Send To The Supreme Court

Well, fate may have given Bobby Jindal his heart’s desire: a way to exert real leverage on the GOP via his aborning presidential campaign.

He sure needed some help. His efforts to be a holier-than-anyone ally of the Christian Right were probably doomed to failure against competition with the credentials of Mike Huckabee, Ted Cruz, Ben Carson and Rick Perry. And his record in Louisiana–increasingly criticized by Republicans as well as Democrats–is becoming a real millstone.

But thanks to a proposal on health care he first tossed into the mix last spring, Jindal is well-positioned to argue against any Obamacare “replacement” that relies on the basic structure of the Affordable Care Act, or that incorporates its budgetary assumptions, or that can be said to “compete” with the satanic instrument of socialized medicine by treating people well.

The Washington Examiner‘s Philip Klein thinks this is potentially a very big, and not necessarily (for Republicans) very good deal:

Louisiana Gov. Bobby Jindal has laid down a marker on conservative alternatives to President Obama’s healthcare law that could shape the 2016 Republican presidential race — even if he doesn’t win.

On Tuesday, Jindal wrote a letter to Congress, putting members on notice: “(C)onservatives need to focus on truly conservative health reforms — and not merely a slightly-less-liberal plan.”

He followed this up with a speech in Washington, D.C., where he took a swipe at Senate Majority Leader Mitch McConnell, R-Ky., and House Speaker John Boehner, R-Ohio.

“If the whole point of this election was simply to give John Boehner and Mitch McConnell nicer offices, let’s give them back,” Jindal said, as reported by my Washington Examiner colleague Jason Russell. “What is the point of having a Republican Party if it’s only going to become a second liberal party?….”

One Republican alternative plan, first unveiled last year but re-introduced for this Congress on Thursday by Sens. Orrin Hatch, R-Utah, Richard Burr, R-N.C., and Rep. Fred Upton, R-Mich., does lean on the current Obamacare baseline. And it includes a tax increase on employer-based health insurance that helps finance generous subsidies for low-income Americans to purchase coverage.

But Republicans have another option. They could wipe out Obamacare completely, return tax and spending levels to where they would have been if the law had never passed, and build a free market alternative from scratch. This is the approach that Jindal favors and that he took when he released his own healthcare plan last year.

Going this route would mean that Republicans couldn’t spend much on subsidizing health coverage, opening them up to attacks that they’re stripping away Obamacare without offering a sufficient life raft for its beneficiaries. Jindal argues that Republicans shouldn’t fall into the trap of competing with Democrats on coverage totals and that they should instead focus on reducing costs.

Whatever the policy debate, politically speaking, it’s clear to see how Jindal’s position could influence other candidates in the Republican presidential primary. Though Jindal hasn’t been among the leaders in early presidential polls, he’s still viewed as an important policy voice among conservatives, especially on healthcare.

But there’s an even more immediate way Bobby’s attacks on any Obamacare replacement plan that seeks to “compete” with Democratic beneficence could cause problems: by interfering with the signals other Republicans are trying to send to the Supreme Court that they can avoid chaos if the Court knocks out the ACA’s subsidies in states using a federally created exchange. As reformicon Ramesh Ponnuru notes in a column criticizing Jindal’s proposal, it doesn’t just fail to avoid disruption of insurance markets and coverage–it promises a whole lot of it. And if other presidential wannabes pick up on his line of attack, the fiction that Republicans can be expected to behave responsibly in the aftermath of a shocking Supreme Court decision would vanish once and for all.

Yeah, in some respects it would be nice if Bobby just went back to his Muslim-bashing.

 

By: Ed Kilgore, Contributing Writer, Political Animal, The Washington Monthly, February 6, 2015

February 9, 2015 Posted by | Bobby Jindal, Health Reform, Republicans | , , , , , , | Leave a comment

“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

February 7, 2015 Posted by | Affordable Care Act, GOP, Health Reform | , , , , , , , | Leave a comment

“A Walk Down Memory Lane On Republican Obstruction”: A Consciously Thought-Out Strategy To Create Dysfunction

For some of us its pretty galling to hear Sen. Majority Leader Mitch McConnell suggest that the way to end dysfunction in Washington is for President Obama to move to the “middle,” or to have to listen to a Republican presidential candidate opine about the lack of “adult conversations” in D.C.

For the record, here’s a little walk down memory lane of Republicans talking publicly about their strategy for obstruction:

1993Bill Kristol writes a memo outlining a strategy for Republicans on President Clinton’s health care reform proposal.

Faced with forceful objections in the past, the [Clinton] Administration has generally preferred to bargain and compromise with Congress so as to achieve any victory it can. But health care is not, in fact, just another Clinton domestic policy. And the conventional political strategies Republicans have used in the past are inadequate to the task of defeating the Clinton plan outright. That must be our goal…

Simple, green-eyeshades criticism of the plan…is fine so far as it goes. But in the current climate, such opposition only wins concessions, not surrender…

Any Republican urge to negotiate a “least bad” compromise with the Democrats, and thereby gain momentary public credit for helping the president “do something” about health care, should also be resisted.

2003Governor Deval Patrick recalls Grover Norquist’s comments on plans for a “permanent Republican majority.”

At our 25th college reunion in 2003, Grover Norquist — the brain and able spokesman for the radical right — and I, along with other classmates who had been in public or political life, participated in a lively panel discussion about politics. During his presentation, Norquist explained why he believed that there would be a permanent Republican majority in America.

One person interrupted, as I recall, and said, “C’mon, Grover, surely one day a Democrat will win the White House.”

Norquist immediately replied: “We will make it so that a Democrat cannot govern as a Democrat.”

2009 – As Michael Grunwald reported, these two ideas coalesced into a Republican plan on how to respond to the election of President Barack Obama.

…the Republican plot to obstruct President Obama before he even took office, including secret meetings led by House GOP whip Eric Cantor (in December 2008) and Senate minority leader Mitch McConnell (in early January 2009) in which they laid out their daring (though cynical and political) no-honeymoon strategy of all-out resistance to a popular President-elect during an economic emergency. “If he was for it,” former Ohio Senator George Voinovich explained, “we had to be against it.”

2010 – Having implemented that plan in response to President Obama’s proposal to reform health care, former speech-writer for President George W. Bush – David Frum – is ejected from the party for writing this:

At the beginning of this process we made a strategic decision: unlike, say, Democrats in 2001 when President Bush proposed his first tax cut, we would make no deal with the administration. No negotiations, no compromise, nothing. We were going for all the marbles. This would be Obama’s Waterloo – just as healthcare was Clinton’s in 1994…

Could a deal have been reached? Who knows? But we do know that the gap between this plan and traditional Republican ideas is not very big. The Obama plan has a broad family resemblance to Mitt Romney’s Massachusetts plan. It builds on ideas developed at the Heritage Foundation in the early 1990s that formed the basis for Republican counter-proposals to Clintoncare in 1993-1994.

Barack Obama badly wanted Republican votes for his plan…Too late now. They are all the law.

2011 – Former Republican Congressional staffer Mike Lofgren explains the strategy.

A couple of years ago, a Republican committee staff director told me candidly (and proudly) what the method was to all this obstruction and disruption. Should Republicans succeed in obstructing the Senate from doing its job, it would further lower Congress’s generic favorability rating among the American people. By sabotaging the reputation of an institution of government, the party that is programmatically against government would come out the relative winner.

So let’s be clear…this was a consciously thought-out strategy by Republicans to create dysfunction in Congress that never fit the “both sides do it” meme embraced by much of the media.

As I’ve pointed out before, President Obama has engaged a lot of different strategies to deal with this obstruction that have each had various amounts of success at different times. But as we head into the next presidential election, we’re likely to hear a lot about how Washington doesn’t work.

That will be the big challenge for the Democratic nominee in 2016. I only wish it was possible for them to take Paul Waldman’s advice.

So imagine if a candidate in the general election, or a president in his inaugural speech, said, “This is my program. I realize that the folks in the other party don’t like it. There may be a few places where we can compromise, and if so, that would be terrific. But I’m going to treat the voters like adults and tell them that I’m not expecting a whole lot of cooperation. I’m going to fight for what I promised to do when I ran, and if you don’t like the results, you can turn me out in four years.”

That would at least be honest, and nobody would be disappointed when the result is partisan fighting.

Of course he’s right when he says that would be honest. The question is…are American voters ready for honesty?

 

By: Nancy LeTourneau, Political Animal Blog, The Washington Monthly, February 1, 2015

February 2, 2015 Posted by | GOP Obstructionism, Health Reform, Mitch Mc Connell | , , , , , , , | Leave a comment

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