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“A Vague Hand-Waving Promise Is Not A Plan”: The Republican Plans To Replace Obamacare Have Been Tried, And They Failed

Before Obamacare, the individual insurance market for people who could not get health care through their job was a nightmare. The only way for insurers to make money was to avoid getting stuck with customers who would rack up high medical bills, forcing them to expend enormous time and expense to screen potential customers for preexisting conditions. Even people who could find plans with affordable premiums had to sign contracts loaded with fine-print exclusions leaving them responsible for unexpected costs. Obamacare overhauled that market, eliminating insurers’ ability to screen out healthy customers. In the new, regulated individual markets, people buy plans regardless of their prior health status. This has been a godsend to those unable to obtain coverage before.

Republicans would repeal all these new protections. But never fear, conservatives insist. In their place will be new protections. Ramesh Ponnuru, writing in National Review, points to two protections put in place by Scott Walker’s proposal, which is the prototypical Republican “see, we do too have a plan to replace Obamacare” plan.

Ponnuru mentions two protections. The first is a provision that would “bar insurers from charging higher prices to sicker customers provided they had maintained continuous coverage.” Republicans have taken to using this line a lot, because it sounds to the average person tuning in a lot like a promise to protect people with preexisting conditions, but the last six words are crucial. Maintaining continuous coverage is really hard. We know this because Congress passed a law in 1996 letting people who have employer-provided insurance keep their plan if they maintain continuous coverage. It has proven nearly useless. Maintaining continuous coverage is really hard for people who have financial distress, and it’s harder if the insurance company has every incentive for you to miss a payment or fail to dot one of your i’s or cross one of your t’s, so they can kick you out. And, of course, in a market where insurers can charge higher prices to sicker customers, “maintaining continuous coverage” means buying insurance that’s really expensive and can deny you coverage for lots of treatments you need.

The second provision is high-risk pools. This is a special market for the customers with the most expensive medical needs. Many states have tried high-risk pools. They also work really, really badly. There are all sorts of practical barriers that make it hard to operate a special insurance system for people with the most expensive conditions. For instance, how do you determine eligibility? Tens of millions of Americans have something in their medical history that makes them a less than perfect risk, from the insurance company’s standpoint. Where do you draw the cutoff for eligibility? And how do you keep insurance companies from skimming the high-risk pools, too — after all, they’ll want to cover the least costly people in the high-risk pool, not the most costly ones.

Even if it is possible to devise solutions to these problems, the biggest single impediment is that high-risk pools cost money. There’s no magic secret in a high-risk pool that makes insurers able to sell affordable insurance to people who need lots of medical care. And where would Republicans get the money to finance the high-risk pools? They don’t say. And they all have signed the Grover Norquist pledge that they will never raise taxes under any circumstances — even if aliens come to Earth and threaten to destroy humanity unless the president agrees to raise taxes by a single penny.

The funding problem is not ancillary. There’s an old joke in which a chemist, a physicist, and an economist are trapped on a desert island, and some cans of food wash up onshore. The physicist devises a plan to smash open the cans. The chemist comes up with a plan to heat them open. And the economist says “assume a can opener.” This is the problem not just with the high-risk pools, but the Republican health-care plans as a whole. They assume the availability of funding, but the party is theologically opposed to raising revenue of any kind. Like having a can opener, if the Republicans were able to overcome their fanatical opposition to revenue, the problem wouldn’t exist in the first place. Any reform that assumes Republicans will find a way to fund it is assuming a can opener. It’s premised on a fantastical assumption. That is why, in the absence of some concrete way around the no-taxes-ever problem, a vague hand-waving promise can’t be called a real plan.

Before Obamacare took effect, different measures were tried to reform America’s cruel and dysfunctional individual health-care marketplace. The continuous-coverage protection and high-risk pools both failed. One thing that succeeded was tried in Massachusetts, by Mitt Romney. The Obama administration decided to build that model out nationally, and it has worked very well — premiums have actually come in well under projections. But since it was Obama’s plan, Republicans oppose it. But since Obamacare is working, they need to have something they can say they’ll replace it with, and they’ve turned to the things that have already failed.


By: Jonathan Chait, Daily Intelligencer, New York Magazine, August 21, 2015

August 22, 2015 Posted by | Affordable Care Act, Health Care, Republicans | , , , , , , , | 1 Comment

“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

July 10, 2014 Posted by | Health Insurance, Hobby Lobby, Women's Health | , , , | Leave a comment

“Feigning Outrage”: The GOP’s Health Reform Playbook

The last thing Republicans want right now is to repeal the Affordable Care Act.

They may claim it is destroying the country, but they need it, and desperately, to rebuild their party. They even have a detailed playbook to exploit it, outlining how and when to stage attacks against Democrats who support it in order to inflict maximum damage in the months before the 2014 midterm elections.

As Jonathan Weisman and Sheryl Gay Stolberg reported in this morning’s Times, House Republicans have been organizing their strategy behind closed doors for the last month. They began by capitalizing on the gifts given them by the White House in the form of the malfunctioning health care website and President Obama’s false promise that no one need lose an insurance policy. Then they moved on to claims that personal data is insecure on the insurance exchanges.

Next, according to the playbook, will come criticism of premium price hikes, and breast-beating about changes to Medicare Advantage plans, as well as the possibility that people will lose their doctors under some policies.

Republicans will also hold hearings, and come armed with anecdotes from outraged citizens who suddenly find their new health insurance options aren’t perfect.

Reform has given new life to a party that was in the depths after the shutdown debacle just last month.

This deep concern about Americans’ access to quality insurance is entirely new and utterly insincere, of course. Nearly one in 10 people on Medicare — 4 million people — are dissatisfied with that program, according to surveys, but you don’t hear their complaints broadcast at hearings or at Republican news conferences. In 2010, long before the health reform law took effect, 20 percent of people on employer-based insurance expressed dissatisfaction with their plans, as did a third of people on the individual market. They complained about high deductibles and constrained networks of doctors and hospitals, just as many of them will under the new system. And they complained about cancelled policies.

Republicans never cared about those concerns before the Affordable Care Act came around, and they don’t really care now, even though they’re doing a great job of feigning outrage. They’re simply using these grievances, magnified by anecdotal media coverage, to batter Democrats who are still standing up for the president’s program.

Some of those Democrats are fighting back. They’re pointing out, as the White House did yesterday, that the growth in health care costs is slowing significantly. They’re trying to highlight people who are saving money on their new policies, or who can buy insurance even if they are sick. And they will try to broadcast the voices of the previously uninsured, who have never appeared in a Republican diatribe and never will.

But the most attention, as always, will be paid to the shrillest critics. Just remember, as their attacks pick up in volume in the months to come, that they were prepared long in advance, as cheap as canned laughter.


By: David Firestone, Editors Blog, The New York Times, November 21, 2013

November 22, 2013 Posted by | Affordable Care Act, Republicans | , , , , , , , | Leave a comment

“More Than Just A Message”: The Origins Of “If You Like Your Health Insurance, You Can Keep It”

There are good reasons why President Obama’s leading message on health care during the 2008 campaign, often repeated since, was “if you like your health insurance, you can keep it.” That message was created to overcome the fear-mongering that had blocked legislative efforts to make health care a government-guaranteed right in the United States for a century.

Our health is of central importance to our lives, deeply personal to our well-being and that of our loved ones. That concern has translated politically; for decades, people have told pollsters that health care is a top concern. It is why every 15 to 20 years – from 1912 to 2008 – the nation has returned to a discussion about whether and how the government should guarantee health coverage, the debate rising phoenix-like from one spectacular defeat after another. A big reason for those defeats has been that opponents have exploited those deep feelings to scare the public about proposed reforms.

As one of the people who engaged early on in building the effort that led to the passage of the Affordable Care Act, I am keenly aware of this history. I wrote in 2003 that debates over health care turn dramatically when they move from the problem to the solution. Almost everyone agrees there’s a problem, but when a solution is proposed, people’s first question will be, “how will it impact me?”

The extensive public opinion research we conducted from 2006 to 2008 emphasized that same point: people would look closely at how any proposed reforms impacted their lives. Yes, Americans are worried about high health care costs and alarmed at the prospect of losing coverage. Yes, they may be unhappy with the quality and security of the coverage they have. But at the same time, they are desperate to hold on to it, because at least it’s something.

We also knew that those who wanted to block health care reform would play on people’s fears, a lesson learned most recently in the 1993-1994 fight over the Clinton health plan, in which opponents made wild claims about government bureaucrats coming between you and your doctor and denying you coverage.

In that context, it was essential to assure the 85 percent of Americans with health coverage that reform would not be a threat. Hence, “If you like your health care, you can keep it.” That message reassured people and let them be open to the rest of the message: proposed reforms would guarantee quality, affordable coverage to everyone and fix the real problems people were facing. After all, the first part of that sentence, “if you like it,” implies that lots of people would love to improve their coverage by making it more affordable and secure and by ending insurance company abuses.

Hillary Clinton’s campaign understood this early on, and she used the message consistently when she talked about health care reform during the Democratic primaries. Soon after she dropped out, Obama made it a key part of his health care message. But the promise that you could keep your health care was more than just a message; for almost everyone, it was an accurate description of the almost identical reform policies proposed by Clinton and Obama, which became the foundation for the Affordable Care Act.

The ACA preserves (with small but important improvements) the current system of health care financing for the vast majority of Americans: employer-based coverage, Medicare, and Medicaid. Those are the 94 percent of people with coverage for whom the “if you like it, you can keep it” promise is true.

For the 6 percent of insured who buy coverage on their own, the more accurate message would have been, “If you have good insurance and you like it, you can keep it.” The ACA reforms a corrupt individual insurance market. No longer can insurers turn people down due to a pre-existing condition or raise rates and drop people because they get sick. The ACA bans the sale of plans with such skimpy benefits and high-out-of-pockets costs that they are worthless if someone gets seriously ill.

As we predicted, the opponents of reform used fear-mongering – death panels, government takeover of health care, and on and on – to try to kill the Affordable Care Act. They are still at it, including cynically jumping on the website’s enrollment problems and now insurance companies sending letters to customers which hide the fact that companies are being forced for the first time to sell a good, reliable product.

The opponents of reform have used reckless, baseless charges to try to kill reform. I’m glad that President Obama used a slight exaggeration to finally provide secure health coverage for all Americans.


By: Richard Kirsch, The National Memo, November 4, 2013

November 5, 2013 Posted by | Affordable Care Act, Health Insurance Companies, Obamacare | , , , , , , | 1 Comment

Do Republicans Really Oppose Making Health Care Insurance Cheaper?

The health-care debate has a cyclical nature, and I don’t want to keep writing the same posts over and over again. So rather than write a whole new piece on the GOP’s rediscovery of the Congressional Budget Office’s estimate that the health-care law will reduce the labor supply (which they recast as “destroying jobs”), I’ll just link to the long post I did on the subject in January.

In case you don’t want to click over, though, the short version is this: If you make health-care insurance cheaper and make it harder for insurance companies to deny people coverage, then a certain number of people who would like to leave the labor force but can’t afford or access health-care insurance without their job will stop working.

To understand why, imagine a 62-year-old woman who works for IBM and beat breast cancer 10 years ago. She wants to retire. She has the money to retire. But no one will sell her health care under the status quo. Under the health-reform law, she can buy health care in an exchange because insurers can’t turn her away due to her history of breast cancer. So she’ll retire. Or imagine a 50-year-old single mother who wants to home-school her developmentally disabled child but can’t quit her job because they’ll lose health care. The subsidies and the protections in the Affordable Care Act will give her the option to stop working for awhile, while under the old system she’d need to stick with her job to keep her family’s health-care coverage. That’s how health-care reform can reduce the labor supply. If either case counts as a destroyed job, then so does my winning the lottery and moving to Scotland in search of the perfect glass of whiskey.

Moreover, this would happen for any health-care reform that reduced costs and improved access. So when Republicans say that they want a better health-care reform bill that does even more to reduce costs, they’re calling for legislation that, according to them, would “destroy” even more jobs than the Affordable Care Act. If they’re against all legislation that might destroy jobs in this way, then they’re against making health care cheaper. In fact, by that logic, we could just jack the price of health-care insurance up and make it easier for insurers to turn individuals away. Then even more people would have to stick with their employers. Job creation!

By: Ezra Klein-The Washington Post, February 11, 2011

February 12, 2011 Posted by | Affordable Care Act, Health Reform | , , , , , , , , , , , , , | Leave a comment


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