“An Irreducibly Tangible Question”: What Happens To The Uninsured If Health-Care Reform Is Dismantled?
When the Republican presidential candidates talk about health care, the discussion usually moves quickly toward the philosophical and the abstract.
Take Rick Santorum’s appearance at the Christian Liberty Academy last weekend in this Chicago suburb. Before a raucous crowd, the former senator from Pennsylvania portrayed President Obama’s health-care-reform law as an “affront to freedom.” In Santorum’s telling, the plan is not so much an attempt to reshape the health care system as the worm on a line meant to hook Americans on Big Government. “What tribute won’t you pay to the government if they can promise that if you give them more they will … take care of you?” he asked dramatically.
There’s no question that an ideological chasm over Washington’s proper role in health care separates Democrats and Republicans. And there’s no doubt that some Democratic strategists believe that average Americans will grow more tolerant of activist government if they see it providing them more direct benefits, such as health insurance.
But the debate over health care reform — which will intensify again next week as the Supreme Court hears oral arguments on challenges to the law’s mandate on individuals to buy insurance — involves more than competing philosophies or political strategies. At its core, it raises an irreducibly tangible question: what, if anything, to do about the nearly 50 million Americans who today lack health insurance.
Those millions of uninsured rarely intrude into the promises from GOP congressional leaders and the party’s presidential field to defend liberty by repealing Obama’s plan. But ignoring them doesn’t make them go away. If the 2012 election rewards Republicans with enough leverage in Washington to erase Obama’s initiative, they will face the choice of finding an alternative means to expand coverage or allowing the number of those without insurance to grow, with far-reaching consequences not only for the uninsured but for those with insurance as well.
Without some policy intervention, there’s little question that access to health insurance will continue to decline. Since 2000, the number of the uninsured has jumped from 36.6 million to 49.9 million, about one-sixth of all Americans.
That number would have been even higher if an additional 20 million people over that period had not obtained coverage through Medicaid and the Children’s Health Insurance Program. This growth partially offset the unrelenting erosion in employer-based care: The share of Americans obtaining coverage from their employer has declined every year since 2000, in good times and bad.
Earlier this month, the Congressional Budget Office forecast that, absent the new health-care law, the number of uninsured would rise to 60 million by 2020. That large a pool of uncovered Americans would create enormous strain for the health-care system.
The uninsured themselves would feel the most immediate effect, of course — studies show they are much more likely than those with coverage to defer or entirely forego needed care. But such an increase would also produce upward pressure on premiums for the insured as providers, especially hospitals, raise prices for those with coverage to offset the cost of uncompensated care to those without it. “The idea that repeal [of health-care reform] is somehow going to lower your premium is folly,” says Len Nichols, director of George Mason University’s Center for Health Policy Research and Ethics. More likely, he argues, repeal would increase premiums.
Obama’s health-care law, whatever its other virtues or flaws, represents a serious effort to break this cycle. CBO, echoing earlier projections, estimated last week that it would cover 33 million of the uninsured. No Republican has offered a plan to cover anywhere near so many. In 2009, the Congressional Budget Office estimated that the principal House Republican alternative to Obama’s proposal would cover only 3 million of the uninsured.
Both Santorum and Mitt Romney have proposed unspecified tax credits to cover some of those without coverage. Douglas Holtz-Eakin, president of the center-right American Action Forum, notes that Republicans believe that allowing interstate sale of insurance plans that offer more bare-bones coverage will reduce premium costs and expand access. Even so, he acknowledges, because so many of the uninsured have meager incomes, any tax credit big enough to meaningfully expand coverage still requires “a lot of money.”
But Republicans are proposing to shrink, not increase, federal health-care spending. Both Romney and House Republicans want to convert Medicaid into a block grant and cut federal spending on the program about in half by 2030. Even if those cuts provoked greater efficiency, the Urban Institute has estimated they could swell the number of uninsured by 14 million to 27 million beyond the effect of repealing Obama’s coverage expansion.
Leading Republicans almost all portray the health-care debate as a philosophical turning point between a limited central government and one they see as overweening and even tyrannical. But the debate also represents a much more practical turning point, between a society that attempts to approach universal health coverage and one that accepts millions of people living without insurance — with unavoidable costs for the uninsured and the insured alike.
By: Ronald Brownstein, The Atlantic, March 23, 2012
“The Collapse Of Civilization”: GOP Releases Plan To Save America From The Poor
The House Republicans unveiled their new budget today, complete with a spooky video pressing home the point that only the House Republicans and their leader Paul Ryan stand between us and CIVILIZATIONAL COLLAPSE. Yes, the peril of rising debt is that bad. No, it’s not so bad that it’s worth restoring Clinton-era tax rates to prevent. But so bad that it’s worth throwing tens of millions of people off health insurance? Oh, yeah.
The first place to begin with the House budget is taxes. The plan is to slash tax rates, with the top rate dropping to 25 percent. The budget asserts that it will make up for most of the lost revenue by eliminating tax deductions, but it does not say which ones. This would require them to produce about $6 trillion worth of tax deductions. It would also ensure that, if they succeeded, taxes on the rich would fall, a lot, and taxes on many non-rich people would rise. This probably explains why they are not providing any details, which also explains why this promise would be tricky to fulfill. In any case, the upshot is that they have delineated $6 trillion worth of deficit-expansion, offset by unspecified promises to make it up.
On the spending side, things get somewhat more specific. Medicare would be partially privatized. The basic functions of government, like:
Over the next decade, Ryan would spend 30 percent less than the White House on “income security” programs for the poor — that’s everything from food stamps to housing assistance to the earned-income tax credit. (Ryan’s budget would spend $4.8 trillion over this timeframe; the White House’s would spend $6.8 trillion.) Compared with Obama, Ryan would spend 38 percent less on transportation and 24 percent less on veterans. He’d cut “General science, space, and basic technology” by 20 percent. And, compared with the White House, he’d slash “Education, training, employment, and social services” by a full 44 percent.
Do House Republicans really think the federal government is vastly overinvesting in things like roads and scientific research, or is this merely a gimmick to make their tax cuts appear affordable? It is hard to say.
They do genuinely seem to believe that the federal government spends way too much on the poor and sick, and move to correct that. Poor people, or people who have a family member with a serious medical condition, come in for special abuse here. The Republican budget would repeal the Affordable Care Act, which provides health insurance coverage to 30 million people, and replace it with nothing. On top of that, it would absolutely slash Medicaid and the childrens’ health insurance plan, eliminating coverage from 14-27 million more people (the wide variation reflects the fact that the outcome heavily depends on how states respond to the huge cuts, and the elimination of rules that force states to cover poor people.)
All in all, we have a standard mix of specific benefits for the rich, specific pain for the poor, and a lot of vague promises that would entail pain for the middle class, without committing themselves in a way that could hurt politically.
By: Jonathan Chait, Daily Intel, March 20, 2012
“You Can’t Fix Stupid”: Birth Control Is Different Than Starbucks
The controversy over contraception has faded a bit. Congressional Republicans are rethinking efforts to overturn a requirement that would make birth control coverage a mandatory part of health insurance. Rush Limbaugh has stopped talking about the issue, at least for the moment.
But the issue hasn’t gone away entirely. The administration is still working on ways to accommodate the wishes of some large religious institutions opposed, for reasons of faith, to sponsoring employee benefits that cover contraception. (On Friday, it unveiled a few options and announced it was seeking public comment on them.) Conservatives, meanwhile, continue to press their case.
With that in mind, let’s talk about a conservative argument that isn’t simply about religion or the morality of birth control. It’s the suggestion that birth control coverage simply doesn’t belong in health insurance, because it’s not an expense that all of us should be subsidizing.
Among those making that argument recently was syndicated columnist Mona Charen. After arguing that contraception costs “less than the cost of a weekly trip to Starbucks” and that a variety of programs, public and private, make free contraception available to the poor, Charen draws a distinction between birth control and other types of drugs:
Contraceptives are not a matter of life and death. But even if they were, such as cancer drugs are, is that an argument for forcing insurance companies to provide them free? Why not force free distribution of all medicines? The mandate makes no economic, social or moral sense.
Actually, it makes economic, social and moral sense.
Let’s put aside the question of whether contraception coverage should be “free,” because that’s not really the issue anymore. Republican Senators Roy Blunt and Marco Rubio, along with the Conference of Catholic Bishops, have said they oppose any requirement that forces employers to cover contraception, regardless of whether such coverage requires out-of-pocket expenses.
And, one more time, let’s dispense with this notion that every woman can get birth control for less than the weekly cost of Starbucks. As noted here previously, the cheap drugs at Target, Walmart, and the other big chains are great if you take the standard combination hormonal pills, which combine estrogen and progestin. But some people cannot or should not take those pills. They’re not good for postpartum women who are breast-feeding, for example, and they cause side effects for many others. They may not be as effective, for some women, as methods like intrauterine devices, depo-provera, or surgical sterilization.
How many women fall into those categories? It’s a minority of the population, to be sure. But that’s always the story with health care and health insurance. At any one time, most people don’t require expensive medical care. Only a small number of people do. It’s precisely for the sake of that group – the ones who face high expenses, and could face financial or medical turmoil without assistance – that insurance exists.
Keep in mind that, at some point or another, pretty much everybody falls into that category. Maybe you’re not a woman who needs expensive birth control. You might still be a woman, or a man, who ends up with heart disease. Or allergies. Or a chronic gastro-intestinal problem. Or cancer. Insurance is there to take care of you, so why shouldn’t insurance be there to take care of a woman who needs more expensive forms of contraception?
No, birth control isn’t treatment for an acute condition. It’s routine, preventative care. But that hardly undermines the case for coverage. Think about eye exams for a moment. Or blood pressure checks. Both of these are widely available, for very low cost. In fact, if you do the math, over the course of a year either one would cost less than a year’s supply of even generic hormonal contraception. But insurance typically covers those costs and, under the Affordable Care Act, insurance must cover those costs – because this sort of care keeps people from getting serious medical conditions and, quite possibly, saves money in the long run.
The very same things are true of birth control. Pregnancy is a wonderful thing, but it’s also a serious medical condition that requires serious medical attention. (Those of you unfamiliar with what pregnancy entails might want to consult this page from the American Academy of Family Physicians – or ask a woman who has been pregnant.) Don’t forget, too, that some women take contraception to control their menstrual cycles or for reasons that aren’t really related to avoiding pregnancy.
Some critics insist there’s a difference between screening for hypertension or vision problems, on the one hand, and controlling the timing of pregnancy, on the other. Non-procreative sex, they say, is a purely voluntary act, for which others should not have to pay. “No one is touching your birth control, ladies,” conservative writer Amanda Carpenter tweeted on Friday. “We just don’t want to be forced to pay for it.” But, according to statistics from the Guttmacher Institute, 99 percent of women use birth control at times during their reproductive years. Based on that, I think it’s safe to assume that non-procreative sex is an activity in which virtually everybody engages, at some point or another, and for which a large majority will need birth control.
And so we’re back to the question that’s always been at the very heart of our health insurance debate: Do we think responsibility for medical expenses should lie primarily with individuals, even if that means some won’t be able to afford it? Or is it a burden we wish to spread more broadly, across society, so that everybody can get the care they need, at a price they can afford?
You know where I stand on that question.
P.S. When the administration announced its options for accommodating religious institutions on Friday, it also released a rule about health plans for college students – and, in so doing, revealed that, for legal reasons, it does not have the authority to regulate all the plans. Sarah Kliff has the story. It doesn’t sound like a huge deal, but, as she notes, it’s yet another reminder of how complex insurance regulation is in the U.S.
By: Jonathan Cohn, The New Republic, March 16, 2012
Hurray For Health Reform: “Protecting Those Who Are Falling Through The Cracks”
It’s said that you can judge a man by the quality of his enemies. If the same principle applies to legislation, the Affordable Care Act — which was signed into law two years ago, but for the most part has yet to take effect — sits in a place of high honor.
Now, the act — known to its foes as Obamacare, and to the cognoscenti as ObamaRomneycare — isn’t easy to love, since it’s very much a compromise, dictated by the perceived political need to change existing coverage and challenge entrenched interests as little as possible. But the perfect is the enemy of the good; for all its imperfections, this reform would do an enormous amount of good. And one indicator of just how good it is comes from the apparent inability of its opponents to make an honest case against it.
To understand the lies, you first have to understand the truth. How would ObamaRomneycare change American health care?
For most people the answer is, not at all. In particular, those receiving good health benefits from employers would keep them. The act is aimed, instead, at Americans who fall through the cracks, either going without coverage or relying on the miserably malfunctioning individual, “non-group” insurance market.
The fact is that individual health insurance, as currently constituted, just doesn’t work. If insurers are left free to deny coverage at will — as they are in, say, California — they offer cheap policies to the young and healthy (and try to yank coverage if you get sick) but refuse to cover anyone likely to need expensive care. Yet simply requiring that insurers cover people with pre-existing conditions, as in New York, doesn’t work either: premiums are sky-high because only the sick buy insurance.
The solution — originally proposed, believe it or not, by analysts at the ultra-right-wing Heritage Foundation — is a three-legged stool of regulation and subsidies. As in New York, insurers are required to cover everyone; in return, everyone is required to buy insurance, so that healthy as well as sick people are in the risk pool. Finally, subsidies make those mandated insurance purchases affordable for lower-income families.
Can such a system work? It’s already working! Massachusetts enacted a very similar reform six years ago — yes, while Mitt Romney was governor. Jonathan Gruber of the Massachusetts Institute of Technology, who played a key role in developing both the local and the national reforms (and has published an illustrated guide to reform) has surveyed the results — and finds that Romneycare is working pretty much as advertised. The number of people without insurance has dropped sharply, the quality of care hasn’t suffered, and the program’s cost has been very close to initial projections.
Oh, and the budgetary cost per newly insured resident of Massachusetts was actually lower than the projected cost per American insured by the Affordable Care Act.
Given this evidence, what’s a virulent opponent of reform to do? The answer is, make stuff up.
We all know how the act’s proposal that Medicare evaluate medical procedures for effectiveness became, in the fevered imagination of the right, an evil plan to create death panels. And rest assured, this lie will be back in force once the general election campaign is in full swing.
For now, however, most of the disinformation involves claims about costs. Each new report from the Congressional Budget Office is touted as proof that the true cost of Obamacare is exploding, even when — as was the case with the latest report — the document says on its very first page that projected costs have actually fallen slightly. Nor are we talking about random pundits making these false claims. We are, instead, talking about people like the chairman of the House Republican Policy Committee, who issued a completely fraudulent press release after the latest budget office report.
Because the truth does not, sad to say, always prevail, there is a real chance that these lies will succeed in killing health reform before it really gets started. And that would be an immense tragedy for America, because this health reform is coming just in time.
As I said, the reform is mainly aimed at Americans who fall through the cracks in our current system — an important goal in its own right. But what makes reform truly urgent is the fact that the cracks are rapidly getting wider, because fewer and fewer jobs come with health benefits; employment-based coverage actually declined even during the “Bush boom” of 2003 to 2007, and has plunged since.
What this means is that the Affordable Care Act is the only thing protecting us from an imminent surge in the number of Americans who can’t afford essential care. So this reform had better survive — because if it doesn’t, many Americans who need health care won’t.
By: Paul Krugman, Op-Ed Columnist, The New York Times, March 18, 2012
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