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“Illusions Of Care”: Romney’s Healthcare Plan That Isn’t

If someone asked you to come up with a good reason that Mitt Romney—the boring one-term governor of a state he left with high debt, poor job-creation and low approval ratings—became a credible national candidate, you might have a hard time doing so. The fact that he is wealthy and could self-finance his way into the top tier of Republican presidential contenders helped, as did the fact that he had won in the bluest of states, Massachusetts.

But the main reason, ironically, is that he was associated with a policy achievement—healthcare reform—that he has completely come to oppose. Back in 2007, Republicans still pretended to care about the crisis of 45 million uninsured Americans and costs that keep spiraling upwards. And so they looked to the one Republican who had tackled that problem at the state level and had done so with a program that harnessed the private sector rather than creating a massive new entitlement program. Conservative organs such as National Review, which would later inveigh against the Affordable Care Act (ACA), cited Romney’s experience with reforming the health insurance system as one of his most valuable credentials.

Throughout this campaign Romney has walked a tiny tightrope on healthcare: he attempts to make amends for passing the state level template for the ACA by issuing over the top denunciations of socialist, unconstitutional “Obamacare.” Meanwhile he has studiously avoided saying anything of substance about how he would address the massive market failure that defined the pre-reform American healthcare system.

On Tuesday in Orlando Romney gave a speech intended to create the false impression that he intends to replace the ACA with something that would provide the same benefits through other means. Here is how the Washington Post summarized the speech: “Romney fleshed out a plan he proposed earlier that would apply free-enterprise principles to the nation’s health-care system rather than operate it like a ‘government-managed utility,’ letting competition drive down prices and increase quality.” The “earlier” they refer to is Romney’s big healthcare speech last May that was meant to make it clear how different he is from Obama on the subject.

That was the main thrust again on Tuesday. Romney repeated the usual right-wing shibboleths: that the ACA has hamstrung the economic recovery by placing “unaffordable” cost burdens and new taxes on families and businesses. He has been at this for a while, using misleading anecdotes, such as his blatant misrepresentation of a passage from Noam Scheiber’s book that he claims shows the White House knew healthcare reform would damage the recovery, when it only shows that it knew more stimulus might have been more valuable to the short-term recovery. Of course, had Obama proposed more stimulus spending instead of healthcare reform in the fall of 2009, Romney and other Republicans would have opposed it.

In fact, the Romney campaign appears to disagree with the Post that Romney offered much more substance than he did last May. When I asked for details of what he is proposing, the campaign said he laid it out last year and the program is available on the campaign website.

The healthcare page on Romney’s site does not, in fact, tell you much about what Romney would do. Instead it mostly offers vague, inoffensive sounding principles such as “Ensure flexibility to help the uninsured, including public-private partnerships, exchanges, and subsidies” and “Offer innovation grants to explore non-litigation alternatives to dispute resolution.”

Some of the principles are more blatantly ideological and potentially quite troubling, such as “Limit federal standards and requirements on both private insurance and Medicaid coverage.” Those federal standards and requirements are in place to protect citizens from rapacious companies and miserly state governments that would deprive recipients of necessary treatments. Any given federal requirement might be too costly or unnecessary. But Romney doesn’t specify which federal requirements he would eliminate so as to avoid inviting scrutiny of what his policy would do to the vulnerable.

The few specifics Romney offers could reduce, rather than expand, medical coverage. Romney would turn Medicaid into a block-grant program. That way, if poverty increases the federal government would not be on the hook for covering more Medicaid recipients. It would be the state’s problem. And what would the states do? Reduce the quality of coverage, or tighten eligibility rules to reduce the number of people covered.

The only other major change to the health insurance delivery system Romney offers is this: “End tax discrimination against the individual purchase of insurance.” That’s a euphemism for creating an expensive new tax deduction. That’s pretty hypocritical coming from someone who promises to cut tax rates and somehow magically make up for the lost revenue by eliminating tax expenditures.

Currently employer-provided health insurance is not taxed as income. Consequently, we overspend on health insurance by favoring that compensation over money employers pay to workers and the workers spend on anything else. This is actually not a very good policy for anyone. Employers are stuck with escalating healthcare costs, employees see their wage increases get diverted to healthcare, and the individual insurance market offers inferior, expensive coverage that unfairly disadvantages the self-employed and thus discourages risk taking.

These are all good reasons to get rid of our current system and switch to a universal, single-payer approach, such as making everyone eligible for Medicare. The alternative way to eliminate the current market distortion would be to end the tax deductibility of employer-based health insurance. That’s the program John McCain ran on in 2008. Back then, conservatives made sensible arguments in favor of doing so. For example, the Family Research Council complained in 2007 that employer-sponsored health insurance enjoys the single largest subsidy in our tax code.

But Mitt Romney is not John McCain. He is a coward, who lacks an iota of McCain’s political bravery. Consequently, Romney fears the backlash that would ensue if he took the principled position in favor of removing this inefficiency. So instead he proposes to equalize the treatment by making it also tax-deductible for individuals to buy their own insurance. That’s good for them, but it does nothing for the market. (The advantage to the market of McCain’s proposal was that it would move millions of health working-age Americans into the individual insurance market, much as the individual mandate would.) The ACA creates a flat tax credit for buying insurance. Romney would repeal that and offer a tax credit based on how much you spend on health insurance, so it would disproportionately benefit richer people who can afford more expensive tax plans.

In a similar act of falsely telling voters they can have their cake and eat it too, Romney promises to keep the most popular provision of the ACA, the rule preventing insurers from excluding prior conditions, without explaining how he would prevent the insurance market from a death spiral of cost increases. (The current mechanism for preventing that, the individual mandate, is the core of what Romney promises to repeal if the Supreme Court doesn’t do so first.)

As a freelancer who pays for his own insurance, I stand to benefit. But as American citizens, we all stand to lose.

 

By: Ben Adler, The Nation, June 12, 2012

June 14, 2012 Posted by | Affordable Care Act | , , , , , , , , | Leave a comment

Kicking The Unemployed When They Are Down

Recent highly publicized national jobs reports showing private-sector gains being offset by public-sector losses have drawn attention to the macroeconomic costs of the austerity program already underway among state and local governments, and gaining steam in Washington.  But the effect on the most vulnerable Americans–particularly those out of work–is rarely examined in any systematic way.

At The American Prospect, Kat Aaron has put together a useful if depressing summary of actual or impending cutbacks (most initiated by the states, some by Congress) in key services for the unemployed and others suffering from economic trauma.  These include unemployment insurance, job retraining services, and family income supports.  In some cases, federal funds added by the 2009 stimulus package are running out.  In others, the safety net is being deliberately shredded.

A recent report from the Center for Budget and Policy Priorities notes that the most important family income support program, TANF (the “reformed” welfare block grant first established in 1996) is becoming an object of deep cuts in many states, precisely at the time it is most needed:

States are implementing some of the harshest cuts in recent history for many of the nation’s most vulnerable families with children who are receiving assistance through the federal Temporary Assistance for Needy Families (TANF) block grant. The cuts will affect 700,000 low-income families that include 1.3 million children; these families represent over one-third of all low-income families receiving TANF nationwide.A number of states are cutting cash assistance deeply or ending it entirely for many families that already live far below the poverty line, including many families with physical or mental health issues or other challenges. Numerous states also are cutting child care and other work-related assistance that will make it harder for many poor parents who are fortunate enough to have jobs to retain them.

This is perverse precisely because such programs were once widely understood as “counter-cyclical”–designed to temporarily expand in tough economic times.  Not any more, says CPBB:

To be effective, a safety net must be able to expand when the need for assistance rises and to contract when need declines. The TANF block grant is failing this test, for several reasons: Congress has level-funded TANF since its creation, with no adjustment for inflation or other factors over the past 15 years; federal funding no longer increases when the economy weakens and poverty climbs; and states — facing serious budget shortfalls — have shifted TANF funds to other purposes and have cut the TANF matching funds they provide.

This retrenchment, mind you, is what’s already happening, and does not reflect the future blood-letting implied by congressional Republican demands for major new cuts in federal-state safety net programs–most famously Medicaid, which virtually all GOPers want to convert into a block grant in which services are no longer assured.

If, as appears increasingly likely, the sluggish economy stays sluggish for longer than originally expected, and both the federal government and states continue to pursue Hoover-like policies of attacking budget deficits with spending cuts as their top priority, it’s going to get even uglier down at the level of real-life people trying to survive.  If you are unlucky enough to live in one of those states where governors and legislators are proudly hell-bent on making inadequate safety-net services even more inadequate or abolishing them altogether, it’s a grim road ahead.

By: Ed Kilgore, Democratic Strategist, June 10, 2011

June 11, 2011 Posted by | Class Warfare, Congress, Conservatives, Deficits, Economy, GOP, Government, Governors, Ideology, Jobs, Lawmakers, Middle Class, Politics, Republicans, Right Wing, State Legislatures, States | , , , , , , , , , , , , | Leave a comment

Paul Ryan’s Moral Barbarism

Karl Rove’s column the other day joined the many conservatives expressing their hurt and anger that President Obama would depict Paul Ryan’s budget as harming sick and vulnerable citizens:

Mr. Obama likes campaigning more than governing. And for this president, campaigning means knocking down straw men and delivering a steady stream of misleading attacks. It means depicting opponents as indecent, heartless people who take special delight in targeting seniors and autistic children.

In fact, Obama has never accused Ryan, or anybody, of having a “special delight” in targetting seniors and autistic children. But he has accused them of pursuing policies that would harm, among others, seniors and autistic children. That’s because it’s incontrovertably true. The Center on Budget and Policy Priorities delves into the details of Ryan’s plan to slash Medicaid by more than a third over the next decade, and in half over the next two decades:

  • Seniors:   An overwhelming majority of Medicare beneficiaries who live in nursing homes rely on Medicaid for their nursing home coverage.  Because the Ryan plan would require such deep cuts in federal Medicaid funding, it would inevitably result in less coverage for nursing home residents and shift more of the cost of nursing home care to elderly beneficiaries and their families.  A sharp reduction in the quality of nursing home care would be virtually inevitable, due to the large reduction that would occur in the resources made available to pay for such care.
  • People with disabilities:   These individuals constitute 15 percent of Medicaid beneficiaries but account for 42 percent of all Medicaid expenditures, mostly because of their extensive health and long-term care needs.  Capping federal Medicaid funding would place significant financial pressure on states to scale back eligibility and coverage for this high-cost population, many of whom would be unable to obtain coverage elsewhere because of their medical conditions.
  • Children:   Currently, state Medicaid programs must provide children with health care services and treatments they need for their healthy development through the Early Periodic Screening, Diagnostic and Treatment (EPSDT) aspect of Medicaid, which provides regular preventive care for children and all follow-up diagnostic and treatment services that children are found to need.  A block grant would likely permit states to drop EPSDT coverage, meaning that children, particularly those with special health care needs, would not be able to access some care that medical professionals find they need (because Medicaid would no longer cover certain health services and treatments for children, and their parents wouldn’t be able to afford to pay for that care on their own).
  • Working parents and pregnant women:   Many state Medicaid programs already have extremely restrictive eligibility criteria for parents.  In the typical state, working parents are ineligible for Medicaid if their income exceeds 64 percent of the poverty line (or $14,304 a year for a family of four), and unemployed parents are ineligible if their income exceeds 37 percent of the poverty line ($8,270 a year for a family of four).  Under a block grant, states could cut these already low eligibility levels even further, cap enrollment, and/or require low-income parents to pay more for health services.  States could do the same for low-income pregnant women who rely on Medicaid for their prenatal care, resulting in them forgoing services that are critical to ensuring a healthy pregnancy.

Now, Rove appears to be a pathological liar, or at least so deeply enmeshed in partisan spin it’s not clear that a distinction exists in his mind between objective truth and claims that are useful to his side. But many other conservatives have likewise expressed what has the ring of genuine outrage that Obama would accuse Ryan of snatching medical care away from people in nursing homes, very poor families, special needs children, and so on. I think it reflects, in part, an inability or lack of desire to think with any specificty about the concrete ramifications of imposing extremely deep cuts to Medicaid. Who do they think is on Medicaid? Prosperous, healthy people?

No, Medicaid is a bare-bones program throwing a lifeline to people who are in bad shape. Cutting Medicaid may be the politically easiest way for Ryan to clear budget room to preserve Bush-era revenue levels, as Medicaid patients have little political clout. But it is, well, deeply immoral. I’m actually surprised that conservatives not only can’t seem to imagine (or care about) the consequences of such policies, but they can’t even imagine that people like Obama would actually feel moral outrage at their plan. They can’t imagine a liberal objection as representing anything other than an attempt to score political points. It’s bizarre. I mean, of course Obama finds it morally objectionable to take away medical care to people in nursing homes and children with special needs. That’s why he’s a Democrat.

By: Jonathan Chait, The New Republic, May 3, 2011

May 3, 2011 Posted by | Conservatives, Democrats, GOP, Governors, Health Care, Health Care Costs, Health Reform, Medicaid, Politics, President Obama, Rep Paul Ryan, Republicans, Seniors, States | , , , , , , , , | Leave a comment

The Ryan Plan For Medicaid: Not Good For Low-Income Americans Or State Budgets

With Washington looking for ways to rein in costly entitlement programs and state governments struggling to balance budgets, conservatives have revived an old nostrum: turning Medicaid into a block grant program.

The desire for fiscal relief is understandable. Medicaid insures low-income people and in these tough economic times, enrollment and costs — for the federal government and state governments — have swelled.

Representative Paul Ryan, and the House Republicans, are now proposing to ease Washington’s strain by capping federal contributions. Like his proposal for Medicare, that would only shift the burden — this time onto both state governments and beneficiaries.

Still, some governors may be tempted. His plan promises them greater flexibility to manage their programs — and achieve greater efficiency and save money. That may sound good, but the truth is, no foreseeable efficiencies will compensate for the big loss of federal contribution.

Mr. Ryan also wants to repeal the health care reform law and its requirement that states expand their Medicaid rolls starting in 2014. Once again Washington would pay the vast bulk of the added cost, so states would be turning down a very good deal to save a lesser amount of money.

Here’s how Medicaid currently works: Washington sets minimum requirements for who can enroll and what services must be covered, and pays half of the bill in the richest states and three-quarters of the bill in the poorest state. If people are poor enough to qualify and a medical service recommended by their doctors is covered, the state and federal governments will pick up the tab, with minimal co-payments by the beneficiaries. That is a big plus for enrollees’ health, and a healthy population is good for everyone. But the costs are undeniably high.

Enter the House Republicans’ budget proposal. Instead of a commitment to insure as many people as meet the criteria, it would substitute a set amount per state. Starting in 2013, the grant would probably equal what the state would have received anyway through federal matching funds, although that is not spelled out. After that, the block grant would rise each year only at the national rate of inflation, with adjustments for population growth.

There are several problems with that, starting with that inflation-pegged rate of growth, which could not possibly keep pace with the rising cost of medical care. The Congressional Budget Office estimates that federal payments would be 35 percent lower in 2022 than currently projected and 49 percent lower in 2030.

To make up the difference, states would probably have to cut payments to doctors, hospitals or nursing homes; curtail eligibility; reduce benefits; or increase their own payments for Medicaid. The problems do not end there. If a bad economy led to a sharp jump in unemployment, a state’s grant would remain the same. Nor would the block grant grow fast enough to accommodate expensive advances in medicine, rising demand for long-term care, or unexpected health care needs in the wake of epidemics or natural disasters. This would put an ever-tightening squeeze on states, forcing them to drop enrollees, cut services or pump up their own contributions.

This is not the way to go. The real problem is not Medicaid. Contrary to most perceptions, it is a relatively efficient program — with low administrative costs, a high reliance on managed care and much lower payments to providers than other public and private insurance.

The real problem is soaring medical costs. The Ryan plan does little to address that. The health care law, which Republicans have vowed to repeal, seeks to reform the entire system to deliver quality care at lower cost.

To encourage that process, President Obama recently proposed a simplified matching rate for Medicaid, which would reward states for efficiencies and automatically increase federal payments if a recession drives up enrollments and state costs. The president’s approach is better for low-income Americans and for state budgets as well.

By: The New York Times, Editorial, April 30, 2011

April 30, 2011 Posted by | Affordable Care Act, Budget, Deficits, GOP, Government, Governors, Health Care, Health Care Costs, Health Reform, Jobs, Lawmakers, Medicaid, Medicare, Politics, President Obama, Rep Paul Ryan, Republicans, States | , , , , , , , , | Leave a comment

Governor Walker’s Misleading Claims On Medicaid

Wisconsin Governor Scott Walker painted a misleading picture of Medicaid in his New York Times op-ed on Friday.  Medicaid is neither obsolete nor inflexible and changing it to a block grant, as the House Republican budget that Walker supports would do, would significantly harm the millions of seniors, people with disabilities and children who rely on it every day.

Governor Walker says Medicaid is obsolete because it is biased toward covering people in nursing homes rather than their own homes.  In fact, Medicaid is moving in precisely the opposite direction.  In 1990, just 13 percent of Medicaid spending on long-term care went for care in the community rather than in an institution.  By 2009, the figure was 43 percent.  That’s a great example of how Medicaid is changing with the times.

Moreover, health reform, (i.e., the Affordable Care Act) provides several new options to speed this trend along and continues funding for the “Money Follows the Person” program, in particular, which moves people from nursing homes back to the community.  With health reform’s new options and funding, progress will likely continue.  That won’t happen under the House Republican budget plan, which would sharply reduce funding for Medicaid and convert the program to a block grant.

My colleagues, Edwin Park and Matt Broaddus, have shown how risky a block grant is for states.  If the House Republican block grant proposal had been in place starting in 2000, their analysis shows, in 2009 Wisconsin would have received 40 percent less in federal funds – nearly $1.6 billion in that year alone.  With such a sharp drop in federal funds, the state would have been ill-equipped to deal with a recession or even to meet the ongoing needs of an aging population.

Governor Walker claims the success of the Children’s Health Insurance Program (CHIP) and state Medicaid demonstration projects show that states could do well under a Medicaid block grant, but he’s wrong on both counts:

CHIP, which does operate under a structure similar to a block grant, has a narrower purpose than Medicaid, as noted in a recent brief from the Kaiser Commission on Medicaid and the Uninsured.  It covers far fewer children than Medicaid and covers children in families with higher incomes.  Moreover, in the past, some state CHIP programs did run short of funds and had to freeze enrollment and set up waiting lists.

As to Medicaid demonstration projects, they allow states to cover people who are ordinarily not eligible for Medicaid (such as low-income, childless adults) or services that aren’t usually covered (such as short-term, or “respite,” care for families with children with complex medical conditions) as long as they don’t spend more federal funds than they otherwise would have received.  This is nothing like the Ryan block grant, which would slash the federal funds that states would otherwise get to help them run their programs, not hold federal funds steady.

By: Judy Solomon, Center on Budget and Policy Priorities, April 25, 2011

 

April 25, 2011 Posted by | Affordable Care Act, Gov Scott Walker, Governors, Health Reform, Medicaid, Politics, States | , , , , , , , , , , | Leave a comment

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