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“A Dog’s Life Can Be Dizzying”: The Obamacare Opposition Has Finally Caught Its Own Tail

It’s time to pop the champagne and blow the kazoos: the war on Obamacare has officially reached its point of reductio ad absurdum. Two of the opposition’s favored fevered conspiracy theories about the law have clashed, like two asteroids headed for the planet that smash into each other before they can do any damage below.

First, there was the opposition’s demand that members of Congress and their staff be subjected to Obamacare—that they be forced to give up their coverage in the health plans for federal employees and join the new insurance exchanges on the theory that “if Congress was going to impose Obamacare upon the country, it should have to experience what it is imposing firsthand.” This never really made sense from the outset since the exchanges, at least for the foreseeable future, are meant only for people without employer coverage and for small businesses buying coverage for their workers. That is, most of “the country” is not going to have anything to do with the exchanges—they are just going to keep being covered by their employers.

Forcing the incongruous requirement that Hill employees enter the exchanges resulted, inevitably, in a snafu: the exchanges are not designed for employers and employees to share the cost of plans that are selected by workers, since the exchanges are meant for people buying coverage on their own. Congress, like most large employers, covers the lion’s share of their workers’ premiums, but wasn’t going to be able to do so as the law was written, leaving Hill workers with thousands more dollars a year in premium costs than they now pay. To fix this problem—which was never intended even by the members of Congress who wanted Hill staff to share in the burdens of Obamacare—the administration and Congress agreed on a tweak that would maintain the requirement for congressional staff to enter the exchanges, while allowing for the federal government to pick up its share of the costs. Conservatives decried this as an “exemption” from Obamacare, which was flatly untrue: in fact, the Hill is being included in Obamacare to an extent beyond what the law was built to allow for. For a pithy dismissal of the “exemption” trope, see the recent letter to the editor in the Wall Street Journal by the gentleman from Verona.

Meanwhile, opponents of the law have since the early days of its drafting been busy fanning flames on another front as well: charging that the law would allow for federal funding of abortions, which has been barred for years. This line almost managed to stop the legislation in its tracks before supporters settled on a highly unwieldy compromise—plans on the exchanges can cover abortions (as many insurance plans now do) but the abortion coverage must be offered in a supplemental plan, purchased separately from the main coverage, and without the help of the federal subsidies many people will receive to help them buy the plans. This is such a messy arrangement that abortion rights supporters fear that precious few plans on the exchanges will even bother to include abortion coverage. And the law also allows states to pass laws banning abortion coverage, period, from plans in their exchanges, as many states have already done.

Do you see where this is headed? The law forces Congress and its staffers into the exchanges…the law, in theory, allows for plans with abortion coverage to be sold on the exchanges…and, voila, the crash in the skies above. Take it away, Associated Press:

The politics of the abortion debate are always tricky for lawmakers. They may soon get personal. An attempt to fix a problem with the national health care law has created a situation in which members of Congress and their staffers could gain access to abortion coverage. That’s a benefit currently denied to them and to all federal employees who get health insurance through the government’s plan…

Abortion opponents say the regulation would circumvent a longstanding law that bars the use of taxpayer funds for “administrative expenses in connection with any health plan under the federal employees health benefits program which provides any benefits or coverage for abortions.” Unlike many private corporate plans, federal employee plans only cover abortions in cases of rape, incest or to save the life of the mother.

“Under this scheme, (the government) will be paying the administrative costs,” said Rep. Chris Smith, R-N.J., author of the abortion funding ban for federal employee plans. “It’s a radical deviation and departure from current federal law, and it’s not for all federal employees, but for a subset: Congress. Us.” Smith is calling on the Obama administration to specify that lawmakers and staffers must choose a plan that does not cover abortions. The funding ban, in place since the 1980s, is known as the Smith amendment.

This framing is actually off the mark. It’s not “an attempt to fix a problem” with the law that has created this situation. It was the original demand by Republicans (Iowa Sen. Chuck Grassley led the way) that members of Congress and their staff be forced into the exchanges. The administration is downplaying the whole matter, noting that, technically, Hill members and staffers who buy a plan on the exchanges that comes with the abortion coverage will be paying for that part of the coverage out of their own pocket. But yes, in theory, a member of Congress and his or her staff may now be able to have abortion coverage, which was not the case previously. The horror! After all, we know that some members of Congress have a messy track record with abortions—like, say, demanding that their mistresses get one.

So, tiger, how does that tail of yours taste?

By: Alec MacGillis, Senior Editor, The New Republic, August 20, 2013

August 26, 2013 Posted by | Abortion, Affordable Care Act | , , , , , , , | Leave a comment

Is Paul Ryan’s Medicare A Voucher System Or Not: Who Is Demagoguing Who?

During the White House meeting this week between President Obama and the Republican leadership, Rep. Paul Ryan took the President to task for demagoguing Ryan’s proposed Medicare changes.

According to the Congressman, the insistence on the part of the President- and his brother and sister Democrats – that the program is a voucher system rather than the ‘premium support’ program Ryan steadfastly claims the idea to be, is grossly misleading Americans, all for the purpose of political gain.

While Ryan’s confrontation with Obama brought cheers from the GOP freshman class who fill the corridors of Congress these days, the question that needs to be asked is, ”Who is demagoguing who?”

In truth, the concepts behind premium support and voucher programs are fairly close, each with a similar objective – the government helping out the beneficiary by paying a portion of a benefit, in this case an insurance premium.

Rep. Ryan likes to point out that his proposed Medicare program is the same as that employed by the Federal Employees Benefits Program and the Medicare Part D benefit that helps seniors pay for their prescription drugs. Both these programs operate using government premium support, whereby the government contributes towards the payment of the premiums charged by the private insurance carrier to the beneficiary, but makes the government’s share of the premium payment directly to the insurance company issuing the policy.

This direct payment is what is often considered the point of distinction between a voucher and premium support. In a voucher program the government gives the financial support directly to the beneficiaries who are then on their own to do what they will with the money, so long as they don’t look to the government to do anything else for them.

Using this standard alone, Rep. Ryan would have a point.

Indeed, his plan proposes seniors going to private insurers for their health care coverage with the government contributing a share of the premium charges and making the payment directly to the insurance company. This is just as the federal government does in the cases of federal employee benefits and Medicare Part D.

However, there is a more important distinction between premium support plans and vouchers.

In the plan that provides heath care benefits for federal employees, on which Ryan relies to make his premium support case, if a government employee’s premium costs go up –and they always do – the government increases the premium support in lockstep with the increased premium.

Not so with RyanCare.

Ryan’s proposal, that would turn Medicare into a private insurance program with the government providing assistance to seniors on their premium payments, limits increases in that support to the cost of living index – an amount wholly insufficient to cover the extra costs as we know that rising costs of health care and premium charges always exceed annual cost of living increases. Thus, if premiums increase (and of course they will) the costs of these increases will be shifted to our senior citizens who, in most instances, would not appear to have the ability to take on these increased costs on their fixed retirement budgets.

This, by anyone’s definition, is a voucher program.

In a recent piece by Washington Post blogger Ezra Klein, Ezra interviewed Henry Aaron of the Brookings Institute and Bob Reischauer of the Urban Institute. Messrs. Aaron and Brookings are the two gentlemen who originally came up with the term “premium support” to describe their idea for a Medicare system where the program is opened up to competition by private insurers but has safeguards built in to protect Medicare beneficiaries from the very cost shifting program the Ryan plan proposes.

While Ryan has largely adopted this model – the two originators make clear that he has done so without the key cost shifting safeguards that they believe are so essential to it working.

According to Aaron-

If one does the arithmetic, income grows a few percentage points faster than prices. Health-care spending grows faster than income by a couple of percentage points. So we’re looking at linking to an index that grows less rapidly than health-care costs by three to four percentage points a year. Piled up over 10 years, and that’s a huge erosion of coverage. It’s vouchers, not premium support.

Via Washington Post

Clearly, Ryan’s plan bears a far greater resemblance to a voucher program than the premium support programs he looks to as back up for what he is selling.

We can have a debate as to whether we would be better off turning Medicare over to the private markets. While I believe it is an idea fraught with dangerous consequences to our future seniors (those who are not yet 55 years of age), an honest debate to discuss these different ideas cannot hurt.

However, when Ryan and friends continue to play the political game of blaming the President for misleading the public when it is, in fact, Ryan who is attempting to mislead, there will be no honest debate.

It is not the President who is demagoguing on this one – it is Paul Ryan.

 

By: Rick Ungar, The Policy Page, Forbes, June 5, 2011

June 6, 2011 Posted by | Affordable Care Act, Budget, Congress, Conservatives, Consumers, GOP, Government, Health Care, Health Care Costs, Health Reform, Ideologues, Ideology, Lawmakers, Medicare, Politics, President Obama, Public Health, Rep Paul Ryan, Republicans, Right Wing, Seniors, Under Insured, Uninsured, Wealthy | , , , , , , , , , , , , , | Leave a comment

The Democrats Have A Plan For Controlling Health-Care Costs, Paul Ryan Doesn’t

There’s increasingly an understanding that the mixture of cuts and taxes in Paul Ryan’s budget aren’t quite fair, and the underlying assumptions it uses don’t quite work. But it’s left people hungry for a budget that does work, and annoyed that Democrats haven’t provided one. “If Democrats don’t like his budget ideas, they should propose their own,” writes Fareed Zakaria. “The Democrats and Obama now have to offer a response,” warned Andrew Sullivan. “As of this evening, the Democratic policy plan consists of yelling ‘You suck!’” complained Megan McArdle.

I’ve made similar comments. And I think those comments are mostly right. Democrats need to step up on taxes, on defense and non-defense discretionary, on Social Security, and on energy. But there’s one huge, glaring exception: controlling health-care costs. There, the reality is that Democrats have a plan and Ryan doesn’t. But the perception, at this point, is just the opposite.

At the heart of Ryan’s budget are policies tying the federal government’s contribution to Medicare and Medicaid to the rate of inflation — which is far, far slower than costs in the health-care sector typically grow. He achieves those caps through cost shifting. For Medicaid, the states have to figure out how to save the money, and for Medicare, seniors will now be purchasing their own insurance plans and, in their new role as consumers, have to figure out how to save the money. It won’t work, and because it won’t work, Ryan’s savings will not materialize.

Even Ryan’s fans agree you can’t hold health-care costs down to inflation. But even if you grant that Ryan’s target is too low, his vision for reforming Medicare would like miss a more reasonabke target, too. Consider the program Ryan names as a model. He said his budget converts Medicare into “the same kind of health-care program that members of Congress enjoy.” The system he’s referring to is the Federal Employee’s Health Benefits Program, and cost growth there has not only massively outpaced inflation in recent years, but actually outpaced Medicare, too. Ryan’s numbers are so fantastic that Alice Rivlin, who originally had her name on this proposal, now opposes it.

Democrats don’t just have a proposal that offers a more plausible vision of cost control than Ryan does. They have an honest-to-goodness law. The Affordable Care Act sets more achievable targets, and offers a host of more plausible ways to reach them, than anything in Ryan’s budget. “If this is a competition betweenRyan and the Affordable Care Act on realistic approaches to curbing the growth of spending,” says Robert Reischauer, who ran the Congressional Budget Office from 1989 to 1995 and now directs the Urban Institute, “the Affordable Care Act gets five points and Ryan gets zero.”

The Affordable Care Act holds Medicare’s cost growth to GDP plus one percentage point, which makes a lot more sense. It’s the target Ryan’s Medicare plan originally used, back when it was called Ryan-Rivlin. But the target is not really the important part. The important part is how you achieve the target. And the Affordable Care Act actually includes reforms and new processes for future reforms that would help Medicare — and the rest of the medical system — get to where the costs can be saved, rather than just shifted.

The Affordable Care Act’s central hope is that Medicare can lead the health-care system to pay for value, cut down on overtreatment, and cut out treatments that simply don’t work. The law develops Accountable Care Organizations, in which Medicare pays one provider to coordinate all of your care successfully, rather than paying many doctors and providers to add to your care no matter the cost or outcome, as is the current practice. It also begins experimenting with bundled payments, in which Medicare pays one lump-sum for all care related to the successful treatment of a condition rather than paying for every piece of care separately. To help these reforms succeed, and to help all doctors make more cost-effective treatment decisions, the law accelerates research on which drugs and treatments are most effective, and creates and funds the Patient-Centered Outcomes Research Institute to disseminate the data.

If those initiatives work, they head over to the Independent Payment Advisory Board (IPAB), which can implement cost-controlling reforms across Medicare without congressional approval — an effort to make continuous reform the default for Medicare, even if Congress is gridlocked or focused on other matters. And if they don’t work, then it’s up to the Center for Medicare and Medicaid Innovation, a funded body that will be continually testing payment and practice reforms, to keep searching and experimenting, and when it hits on successful ideas, handing them to the IPAB to implement throughout the system.

The law also goes after bad and wasted care: It cuts payments to hospitals with high rates of re-admission, as that tends to signal care isn’t being delivered well, or isn’t being follow up on effectively. It cuts payments to hospitals for care related to infections caught in the hospitals. It develops new plans to help Medicare base its purchasing decisions on value, and new programs to help Medicaid move patients with chronic illnesses into systems that rely on the sort of maintenance-based care that’s been shown to successfully lower costs and improve outcomes.

I could go on, but instead, I’ll just link to the Kaiser Family Foundation’s excellent primer (pdf) on everything the law does. The bottom line is this: The Affordable Care Act is actually doing the hard work of reforming the health-care system that’s needed to make cost control possible. Ryan’s budget just makes seniors pay more for their Medicare and choose their own plans — worthy ideas, you can argue, but ideas that have been tried many times before, and that have never cut costs in the way Ryan’s budget suggests they will.

That’s why, when the Congressional Budget Office looked at Ryan’s plan, they said it would make Medicare more expensive for seniors, not less. The reason the deficit goes down is because seniors are paying 70 percent of the cost of their insurance out-of-pocket rather than 30 percent. But that’s not sustainable: We’ve just taken the government’s medical-costs problem and pushed it onto families.

No one who knows health-care policy will tell you that the Affordable Care Act does everything we need to do in exactly the way we need it done. That’s why Resichauer gave it a five, not a 10. But it does a lot of what we need to do and it sets up systems to help us continue doing what’s needed in the future.

Ryan’s proposal, by contrast, does almost none of what we need to do. It appeals to people who have an ideological take on health-care reform and believe we can make Medicare cheaper by handing it over to private insurers and telling seniors to act like consumers. It’s a plan that suggests health-care costs are about insurance, as opposed to about health care. There’s precious little evidence of that, and when added to the fact that Ryan’s targets are so low that even his allies can’t defend them, the reality is that his savings are largely an illusion.

The Affordable Care Act has taken a lot of hits. It’s not popular, and though very few of the political actors confidently attacking or advocating it can explain the many things it’s doing to try and control costs, people have very strong opinions on whether it will succeed at controlling costs. But the irony of everyone demanding Democrats come up with a vision for addressing the drivers of our deficit in the years to come is that, on the central driver of costs and the central element of Ryan’s budget, Democrats actually have something better than a vision. They have a law, and for all its flaws, their law actually makes some sense. Republicans don’t have a law, and their vision, at this point, doesn’t make any sense at all.

By: Ezra Klein, The Washington Post, April 8, 2011

April 9, 2011 Posted by | Affordable Care Act, Conservatives, Consumers, Deficits, Democrats, Economy, GOP, Health Care Costs, Health Reform, Medicaid, Medicare, Medicare Fraud, Politics, Rep Paul Ryan, Republicans, Uninsured | , , , , , , , , , , , , | 1 Comment

   

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