“Kicked To The Curb”: Republicans’ Self-Hatred Swells To The GOP Vs. Its Own Base
Does any modern political party besides the GOP hold a huge segment of its base in contempt? I’ve written a lot about how Republicans have failed to make inroads with Latinos, young voters or women since their 2012 defeat, but what’s really interesting is the way they continue to deride many of their older, white, working-class voters, too.
When Mitt Romney insulted “the 47 percent” of Americans who pay no federal income taxes, he failed to notice that the vast majority of them are white, most of them white seniors, the most reliably Republican voters in the country. A large portion of the people Paul Ryan describes as “takers” – vs. productive “makers” – are likewise older whites. And although Ryan and his party want to turn Medicare into a voucher program – run by exchanges, much like the Affordable Care Act – they tried to hide that fact during the 2012 race because it was hugely unpopular with their base.
The latest insult came from former senator and 2012 presidential runner-up Rick Santorum. On CNN’s “State of the Union” Sunday Santorum complained that the Affordable Care Act has meant that “sicker, older” people are getting health insurance (h/t Crooks and Liars.) Santorum told Candy Crowley and former Gov. Howard Dean:
Well, let me just add that one of the solutions that President Obama tried to accomplish was to let people keep their own insurance. It turns out that a lot of insurance companies are actually allowing that to happen, and that could cause even more problems for Obamacare, because that means fewer and fewer people getting into the exchanges. And the ones who, at least to date, it’s just facts Gov. Dean, the ones in the system are much older.
I talked to one insurance company today, a third of their enrollees are over sixty years of age. That is not how an insurance system would work, but those are the people signing up and the folks who can keep their plans because they’re more customized and lower cost, will now. And the folks who are going to get into these exchanges are going to be probably sicker, older, and as a result, premiums are even going to go higher.
First of all, it’s not clear Santorum is right about this. Some states are seeing unexpectedly high proportions of younger people sign up for coverage. In Kentucky, 41 percent have been under 35; in California, it’s 22 percent, which is proportionate to their share of the population. Still, the enrollment rate in California is highest for people over 55. That’s not surprising, or permanent: Based on the experience of Massachusetts, older people tend to sign up for coverage first; younger enrollees do it closer to the deadline.
But assuming that Santorum isn’t wrong (admittedly a leap), what is he saying? That people over 60 who don’t have coverage shouldn’t be able to get it? We know these people are white, and presumably – since they’re not eligible for Medicaid, which covers many of the poor and unemployed — they’re working people. But Santorum says “that’s not how an insurance system should work.”
Luckily Howard Dean was there to disagree. “I think it’s great that we’re insuring people who can’t get insurance that are over 55 and 60,” he told Santorum and Crowley. “That’s what this is supposed to do.”
Of course, if insurers are unhappy with their older customers, Rep. Alan Grayson has an answer: his “Medicare for All” bill, which would allow anyone who wanted to to sign up for Medicare instead of a private insurance plan. Back during the ACA debate many liberals wanted to see that option, but it was vetoed by insurance interests. Opening up Medicare to people 55 and older would help stabilize the program – although they’re the older edge of the ACA pool, they’d be younger and healthier subscribers in the Medicare pool – and provide an alternative for those priced out of or under-served by the private market.
Still, the big news this weekend was that the federal website that lets most people access insurance exchanges, Healthcare.gov, is mostly fixed. That’s why Santorum was reduced to railing against those takers in the GOP base. On Fox News Sunday, Chris Wallace attacked the ACA as “income redistribution.”
And, of course, Santorum insisted that the ACA’s troubles raised questions about “the president’s competence.” Dean wasn’t having that either.
“That’s right-wing talking points against this president,” Dean replied. “From day one, they’ve tried to undermine him as a human being … I lose my patience with this nonsense. I do believe that the facts are going to be determined by what happens on the ground. Three months from now, a lot more people are going to have health insurance, and a lot more people are going to be happy with all this.”
By: Joan Walsh, Editor at Large, Salon, December 2, 2013
“The First Step Of A Long Journey”: Now’s Not The Time For Liberals To Say “I Told You So” About Obamacare
It has been a rough two months for the Affordable Care Act and its defenders. Having spent years fighting ridiculous allegations about socialized medicine and “death panels,” supporters of near-universal coverage now face something different. The performance failures in the rollout of healthcare.gov have triggered cries of “I told you so!” from some liberals. This wouldn’t have happened, they say, if only Obama had supported some form of single-payer plan, such as Medicare for all. The anger over the botched rollout is understandable, but these recriminations are poorly timed—and just plain wrong.
For starters, the ACA is working reasonably well in some places—California, Connecticut, Kentucky, Washington, and the District of Columbia, for example. These under-reported success stories show that insurance exchanges can work, if properly administered. Exchanges are successfully determining applicants’ eligibility for Medicaid or private insurance, enabling consumers to choose among competing plans, and computing the tax credits to which people are entitled. The human benefits are real, from California to Breathitt County in rural Kentucky. These successes make the federal government’s dismal rollout even more embarrassing. Republicans may have done everything within their power to dynamite the ACA, but the administration fell inexcusably short in launching Obama’s domestic-policy centerpiece.
It doesn’t help that health reform is really complicated. The U.S. health-care system is far and away the most complex in the world, one that includes employer-sponsored coverage, Medicare, Medicaid, Tricare, the Indian Health Service, and small-group and individual insurance coverage—and that’s before Obamacare was implemented.
Given that complexity, some on the left say, life would be simpler if only Congress had been willing—which it was not—to scrap all current arrangements and replace them with a single, federally administered health insurance plan. Those on the right regard this complexity and say that life would be simpler if only Congress had been willing—which it was not—to scrap all current arrangements and replace them with income-related vouchers people could use to help pay for private insurance of their choice.
Those positions enjoy loud support in the blogosphere, Twitter, and cable TV, but only niche support at each end of the political spectrum. Although their ideological values could hardly be more different, these polar-opposite camps each disdain the kludgy fixes of incremental politics. And yet, incrementalism is what most Americans want. Most people are reasonably well-insured. They like their coverage, and they want it to remain affordable. They fear legislation that threatens it. Proposals, whether from the left or right, that force most people into radically different arrangements are fated to remain politically marginal in America.
That the right, which predicted Obamacare would mean the death of liberty and ruination of the U.S health care system, feels vindicated by Obamacare’s initial woes is no surprise. But the troubles with healthcare.gov have rekindled attacks from the left, too. Consider a recent essay by American Prospect co-editor Robert Kuttner, in which he writes, “The colossal mess that Obamacare has become reflects both the character of the legislation and that of the president who sponsored it.”
We understand Kuttner’s frustration. We do not share his disdain for the ACA or for Obama. The law ended a century of legislative failures in the search for universal health insurance coverage, and enacted important reforms of our healthcare delivery system. Obama bet his historic legacy on a reform that, however imperfect, brings health insurance to millions, improves its quality, and helps slow spending growth.
The real beef of those who seek a more radical rewiring of our healthcare system is not with the president. It is with the coalition of labor, healthcare, disability, and anti-poverty groups that coalesced during 2007 and 2008 around a health reform model that later became the ACA. Candidates Hillary Clinton, Obama, and John Edwards endorsed similar health plans. They all included Medicaid expansion, regulated markets (health insurance exchanges), premium subsidies, strengthened insurance regulation, and an explicit or de facto individual mandate. Many Democrats would have preferred single-payer, but the candidates and even most single-payer supporters understood that politically this just wasn’t possible.
We wish ACA had gone farther. It could have provided more generous premium assistance and cost-sharing for working families. It could have allowed people near retirement to buy into Medicare. Alas, senators such as Joe Lieberman—not Obama—scuttled these possibilities. The ACA is only the first step in a long journey of needed health reforms.
Kuttner goes on to write: “Medicare for All would be simpler to execute, easier to understand, and harder for Republicans to oppose.” Nancy Folbre, writing in The New York Times, took the same position. Kuttner and Folbre are correct that Medicare for All would be much easier to understand. Perhaps, as Obama among others has said, Medicare for All would be preferable to our current system, were we designing that system from scratch.
But we aren’t. The slogan “Medicare for all” was never incorporated in a well-crafted legislative proposal. Had it been, it would have been even easier than Obamacare for Republicans to oppose. And implementation would have been formidably difficult. Had the transition to single-payer ever been specifically mapped out, it would immediately have become apparent that this process requires wholesale replacement or rewiring of employer-based coverage, major changes in the relations between states and the federal government. Hundreds of billions of dollars in transfers and new taxes would have been necessary. Enterprising constitutional conservatives surely would have identified plausible court challenges. What’s more, a phalanx of providers—hospitals, doctors, insurers, drug companies and device manufacturers—opposed single-payer proposals. Even such incremental moves as the public option evoked profound unease among insurers, community hospitals, and other key parts of the coalition that supported the ACA.
The backlash against the ACA is occurring because it disrupts coverage of several million people in the individual and small-group insurance market. Transition to single-payer would have been far messier, disrupting coverage for hundreds of millions of Americans, with a much larger and more explosive mix of winners and losers.
There was and is no alternative to the messy incremental politics that produced Obamacare. Liberals such as then–House Majority Speaker Nancy Pelosi didn’t make unpalatable compromises because they held pallid aspirations for health reform. They compromised because they knew that they could not impose their will on querulous colleagues, because they needed 60 Senate votes, because millions of Americans needed help, and because it is better to win messily than to lose gloriously.
Much now rides on the government’s ability to fix healthcare.gov. Definite progress has been made. The federal exchange will be better by year’s end, but it will be months, not a few weeks, before the website really works the way it should. The White House’s cautionary messages on enrollment efforts and its one-year delay in online small business enrollment exemplify the many challenges with getting Obamacare off the ground. So these are anxious times. If the ACA fails, hopes for universal coverage will be set back a generation. Now’s not the time for liberals supporters to turn against Obamacare, or against each other.
By: Henry Aaron and Harold Pollack, The New Republic, November 28, 2013
“Obamacare’s Secret Success”: Health Reform Is Starting To Look Like A Bigger Success Than Even Its Most Ardent Advocates Expected
The law establishing Obamacare was officially titled the Patient Protection and Affordable Care Act. And the “affordable” bit wasn’t just about subsidizing premiums. It was also supposed to be about “bending the curve” — slowing the seemingly inexorable rise in health costs.
Much of the Beltway establishment scoffed at the promise of cost savings. The prevalent attitude in Washington is that reform isn’t real unless the little people suffer; serious savings are supposed to come from things like raising the Medicare age (which the Congressional Budget Office recently concluded would, in fact, hardly save any money) and throwing millions of Americans off Medicaid. True, a 2011 letter signed by hundreds of health and labor economists pointed out that “the Affordable Care Act contains essentially every cost-containment provision policy analysts have considered effective in reducing the rate of medical spending.” But such expert views were largely ignored.
So, how’s it going? The health exchanges are off to a famously rocky start, but many, though by no means all, of the cost-control measures have already kicked in. Has the curve been bent?
The answer, amazingly, is yes. In fact, the slowdown in health costs has been dramatic.
O.K., the obligatory caveats. First of all, we don’t know how long the good news will last. Health costs in the United States slowed dramatically in the 1990s (although not this dramatically), probably thanks to the rise of health maintenance organizations, but cost growth picked up again after 2000. Second, we don’t know for sure how much of the good news is because of the Affordable Care Act.
Still, the facts are striking. Since 2010, when the act was passed, real health spending per capita — that is, total spending adjusted for overall inflation and population growth — has risen less than a third as rapidly as its long-term average. Real spending per Medicare recipient hasn’t risen at all; real spending per Medicaid beneficiary has actually fallen slightly.
What could account for this good news? One obvious answer is the still-depressed economy, which might be causing people to forgo expensive medical care. But this explanation turns out to be problematic in multiple ways. For one thing, the economy had stabilized by 2010, even if the recovery was fairly weak, yet health costs continued to slow. For another, it’s hard to see why a weak economy would have more effect in reducing the prices of health services than it has on overall inflation. Finally, Medicare spending shouldn’t be affected by the weak economy, yet it has slowed even more dramatically than private spending.
A better story focuses on what appears to be a decline in some kinds of medical innovation — in particular, an absence of expensive new blockbuster drugs, even as existing drugs go off-patent and can be replaced with cheaper generic brands. This is a real phenomenon; it is, in fact, the main reason the Medicare drug program has ended up costing less than originally projected. But since drugs are only about 10 percent of health spending, it can only explain so much.
So what aspects of Obamacare might be causing health costs to slow? One clear answer is the act’s reduction in Medicare “overpayments” — mainly a reduction in the subsidies to private insurers offering Medicare Advantage Plans, but also cuts in some provider payments. A less certain but likely source of savings involves changes in the way Medicare pays for services. The program now penalizes hospitals if many of their patients end up being readmitted soon after being released — an indicator of poor care — and readmission rates have, in fact, fallen substantially. Medicare is also encouraging a shift from fee-for-service, in which doctors and hospitals get paid by the procedure, to “accountable care,” in which health organizations get rewarded for overall success in improving care while controlling costs.
Furthermore, there’s evidence that Medicare savings “spill over” to the rest of the health care system — that when Medicare manages to slow cost growth, private insurance gets cheaper, too.
And the biggest savings may be yet to come. The Independent Payment Advisory Board, a panel with the power to impose cost-saving measures (subject to Congressional overrides) if Medicare spending grows above target, hasn’t yet been established, in part because of the near-certainty that any appointments to the board would be filibustered by Republicans yelling about “death panels.” Now that the filibuster has been reformed, the board can come into being.
The news on health costs is, in short, remarkably good. You won’t hear much about this good news until and unless the Obamacare website gets fixed. But under the surface, health reform is starting to look like a bigger success than even its most ardent advocates expected.
By: Paul Krugman, Op-Ed Columnist, The New York Times, November 28, 2013
“When Ideology Collides With Reality”: Irrational Republican Exuberance Over Obamacare’s Problems
In these days of hyper-polarization, some readers may wonder why I always treat with great respect the findings and analysis of conservative number-cruncher Sean Trende of RealClearPolitics. I don’t always agree with what he says, but he’s willing to say uncomfortable things to people on his side of the barricades when data and history so indicate, as he did in a column today pouring ice water on the popular conservative idea that a collapse of Obamacare would lead to some sort of “existential crisis” for liberalism or “the welfare state.”
I’ve said before that our press corps suffers from histrionic personality disorder, and this is but the latest example. Wasn’t it just weeks ago that we were told the government shutdown could cost Republicans the House? But elections and the ideological orientation of the country don’t turn on such immediate, short-term events. The arc of history is long. Both parties, and both ideologies, have plenty of wins ahead of them, and neither is likely to suffer a knockout blow.
Let’s start by observing that we’re barely 50 days into Obamacare’s launch. While the program is clearly in much graver political danger than was the case a month ago, it’s still unclear that the ship won’t eventually be righted. Maybe the so-called “young invincibles” will sign up in droves, or maybe they won’t and the program will go into a death spiral. We just don’t know yet.
But even if the Affordable Care Act does collapse, I’m not sure that the liberal project will be kneecapped, much less destroyed. Americans have very short memories, and the pendulum will swing back quickly if Republicans mess up their next opportunity to govern.
Trende then goes through a long series of historical examples (dating back to 1890) of big political calamities for one party or the other that was followed in relatively short order, and sometimes almost instantly, by a big recovery, often because the other party over-estimated its advantages and overreached. And he notes that even in specific policy areas a misstep or defeat doesn’t necessarily take issues off the table:
Even the last failed attempt at health care reform, in the early 1990s, didn’t actually spell the end of reform efforts for the next two decades, as many suggest. It just proceeded incrementally, with some fairly significant steps. Congress in 1996 passed the Kennedy-Kassebaum bill, which established health insurance portability. The following year, Republicans helped to establish the State Children’s Health Insurance Program, which today provides health care for almost 8 million children. In 2001, before the 9/11 attacks, Congress was consumed with a debate over the Patient’s Bill of Rights, with the only major disagreement involving whether plaintiffs should be able to collect punitive damages while suing their HMO.
Sean even suggests an Obamacare “disaster” could produce an even more ambitious Democratic health care initiative:
[E]ven if Obamacare does collapse, the most liberal aspects of the American health care system — Medicare and Medicaid — will still be around. Democrats have already been pretty straightforward about what their “Plan B” will be: Medicare/Medicaid for all. Both programs are still very popular, and the Democratic standard-bearer in 2016 would almost certainly campaign on expanding them, perhaps to those over 55 for Medicare and under 25 for Medicaid. I’m not sure that would be a losing issue, even with an Obamacare collapse. In 10 years, I think it’d be a winner.
That is indeed the “silver lining” that a lot of single payer advocates have been seeing in the troubles involving the Obamacare exchanges, which are complex and hard to administer in no small part because of their reliance on a managed competition model many liberals never favored in the first place.
Trende thinks the major lesson here is that the ideological clash of ideas that activists often perceive in political events just isn’t shared by that many voters:
The American electorate is not intensely ideological, and is more motivated by things such as the state of the economy, whether there is peace abroad (or whether we’re winning a war), and whether the president is suffering from a major scandal.
I would agree in part, but would go further to say that today’s radicalized Republican Party has goals that have never commanded a majority of the electorate, and are even less likely to do so in the future. It is capable of making big gains when Democrats screw up, but is determined to risk them immediately to pursue an unpopular agenda. If the worst (or from their point of view, the best) happens and conservatives gain the power to implement that agenda, then the odds are extremely high they will, as Trende puts it, “mess up their next opportunity to govern.” And in that respect, ideology really does matter–when it collides with reality.
By: Ed Kilgore, Contributing Writer, Washington Monthly Political Animal, November 20, 2013
“A Major Obamacare Success Story”: It’s Increasingly Clear That The Affordable Care Act Is Significantly Bending The Cost Curve
The anger over the botched rollout of the Affordable Care Act’s federal health insurance exchange — and over the conflicting explanations about whether people can keep their coverage — has been bipartisan and well-deserved. The administration needs to make personnel and management changes to get enrollment back on track. But the focus on insurance coverage obscures other parts of the ACA that are working well, even better than expected. It is increasingly clear that the cost curve is bending, and the ACA is a significant part of the reason.
The law has two overarching goals: Cover almost everyone, and slow the growth of medical care costs. The goals are equally important. Too little coverage, and premiums in the exchanges will be unaffordable; too rapid a cost increase, and the federal government will not be able to afford the subsidies.
Even as coverage efforts are sputtering, success on the cost front is becoming more noticeable. Since 2010, the average rate of health-care cost increases has been less than half the average in the prior 40 years. The first wave of the cost slowdown emerged just after the recession and was attributed to the economic hangover. Three years later, the economy is growing, and costs show no sign of rising. Something deeper is at work.
The Affordable Care Act is a key to the underlying change. Starting in 2010, the ACA lowered the annual increases that Medicare pays to hospitals, home health agencies and private insurance plans. Together, these account for 5 percent of the post-2010 cost slowdown. Medicare payment changes always provoke fears — in this case, that private plans would flee the program and that the quality of care in hospitals would suffer. Neither of these fears has materialized, however. Enrollment in private plans is up since the ACA changes.
The law also emphasized that payments should be based on the value, not the volume, of medical care. In a value-based system, compensation is made for the patient as a whole, not for specific services provided. As a result, eliminating services that are not needed is financially rewarded. The reaction to this change has been rapid: Hospital readmissions, which used to bring in substantial dollars, are now penalized.
Unsurprisingly, the readmission rate in Medicare is down 10 percent since 2011. Similarly, hospital-acquired infections used to bring in additional dollars, but now they do not. One program to cut infections, encompassing only 333 hospitals, saved more than $9 billion. Both of these changes improve patient health even as they reduce spending.
The accountable-care movement — which aims to make providers more accountable for the cost and quality of care — has blossomed far beyond expectations. There are nearly 500 Accountable Care Organizations (ACOs) nationwide, half in Medicare. Ten percent of Medicare beneficiaries are in ACOs, and many others are in payment systems that put together all reimbursements for a procedure, such as a hip replacement or cardiac stent insertion. Leaders of medical systems routinely report that they expect, and are preparing for, a move to value-based payments.
Evaluations of recent ACO programs show quality improvements among all participating organizations and financial savings for many. This is not a surprise. The Institute of Medicine has been reporting for more than a decade that a third or more of medical spending could be eliminated while increasing patient health. The only surprise is how fast the system has moved in this direction.
The ACA does not account for all of the recent cost slowdown. New medical technologies are coming online more slowly than they used to; none of the 10 best-selling drugs on the market today were developed in the past decade. Similarly, patients with high deductibles are deferring elective procedures. Many insured families today owe more from a hospital visit than they have in the bank. Each of these factors is contributing to the reduction in health-care spending. But noting that factors beyond the ACA are important does not deny the importance of the law.
Cost savings induced by the ACA are particularly beneficial because they could increase quality while they lower spending. The reduction in technology development means lower costs but also fewer ways to treat sick people. People with high deductibles use fewer valuable services as well as fewer less-valuable ones. Only by eliminating unnecessary care can we ensure that everyone benefits from saving money in health care.
Governors and legislators in red states are almost universally opposed to the ACA. But these states are still seeing cost savings from the law — and they are participating in other ways.
Six states, including places as diverse as Arkansas, Massachusetts and Oregon, are using ACA-appropriated funds to help shift medical care to a higher-quality, lower-cost system . Nineteen other states are planning similar changes. And many of these states are solidly red.
States’ successes can feed back to federal policy. A recent Senate proposal, for example, calls for replacing the broken payment system that Medicare uses to compensate physicians with a system of payments based on value.
Before he was criticized for his statements about insurance continuity, President Obama was lambasted for his forecasts of cost savings. In 2007, Obama asserted that his health-care reform plan would save $2,500 per family relative to the trends at the time. The criticism was harsh; I know because I helped the then-senator make this forecast. Yet events have shown him to be right. Between early 2009 and now, the Office of the Actuaries at the Centers for Medicare & Medicaid Services has lowered its forecast of medical spending in 2016 by 1 percentage point of GDP. In dollar terms, this is $2,500 for a family of four.
Looking ahead, there is every reason to believe that costs will continue to grow slowly, maybe even more slowly. A study in Massachusetts showed that ACO savings increase over time as organizations move into more areas that can slow cost growth. An analysis of exchange premiums estimated that insurance costs in the exchanges are 16 percent below what was forecast two years ago; the lower costs were attributed to competition from new entrants in the market.
If cost growth continues at its low pace, the cumulative savings to the federal government would be more than $750 billion over the next decade. Such savings are likely to dwarf anything that comes out of Congress this year.
Many Americans are rightly upset with the Obama administration’s rocky rollout of the insurance exchange. Failing at such a major project is inexcusable. But if the early indications are any guide, we should be pleased with how the new health law is affecting what we pay for care. If the Web site is fixed and enrollment can catch up to expectations, the ACA could yet become a major policy success.
By: David Cutler, The Washington Post, Opinions, November 8, 2013
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