“Returning To The Days Of Recalcitrance”: Rubio Demands States’ Right To Ignore The Poor
For a senator who likes to hold himself out as the future of the Republican brand, Marco Rubio has come up with a remarkably retrograde contribution to the party’s chorus of phony empathy for the poor: Let the states do it.
All anti-poverty funds should be combined into one “flex fund,” he said in a speech on Wednesday, and then given to the states to spend as they see fit. He actually believes that states will “design and fund creative initiatives” to address inequality.
“Washington continues to rule over the world of anti-poverty policy-making, with beltway bureaucrats picking and choosing rigid nationwide programs and forcing America’s elected state legislatures to watch from the sidelines,” he said. “As someone who served nine years in the state house, two of them as Speaker, I know how frustrating this is.”
Do-nothing legislators in states like Mr. Rubio’s Florida feel frustrated precisely because most federal safety-net programs are designed to limit the ability of states to refuse to help their less fortunate residents. As Lyndon Johnson knew from personal experience in 1964, when he began the War on Poverty, states could not be trusted to properly address the poverty in their midst. Or, to put it another way, certain states could be trusted to yell and scream and fight to the end for their right to do as little as possible.
One of the great achievements of the War on Poverty programs was to extend the safety net to the South, where white legislators saw little reason to spend taxpayer dollars on the basic needs of poor citizens, most of whom were black. Southern lawmakers in Congress fought for the right of governors to veto grants made possible by the Economic Opportunity Act, one of the centerpieces of the War on Poverty, and Southern governors exercised those vetoes repeatedly. But Sargent Shriver, director of the Office of Economic Opportunity, overrode those vetoes, bypassing the governors and sending anti-poverty money directly to the local agencies and community groups that could do some good with it.
If you think those days of recalcitrance are over, take a look at the map of the states that have refused to expand Medicaid under the Affordable Care Act. The list of 25 includes every one of the states that seceded from the union, with the exception of Arkansas, which is doing only a partial expansion. (Virginia is likely to accept the expansion after its newly elected Democratic governor, Terry McAuliffe, takes office later this week.)
But long before “Obamacare” became a curse word among Republicans, most of those same states were already stingy with their spending on Medicaid, which lets states determine who is eligible for the program. The 16 states that restricted Medicaid to those making half or less of the federal poverty line included the usual cast of characters: Texas, Mississippi, Alabama, Georgia, North Carolina, and Virginia. The most generous states — giving Medicaid benefits to those at the poverty line or higher — were clustered in the Northeast and the upper Midwest, along with California.
That’s undoubtedly fine with Mr. Rubio and other Republicans who see nothing wrong with a country that is a patchwork of generosity and indifference.
“It’s wrong for Washington to tell Tallahassee what programs are right for the people of Florida,” Mr. Rubio said. “But it’s particularly wrong for it to say that what’s right for Tallahassee is the same thing that’s right for Topeka and Sacramento and Detroit and Manhattan and every other town, city and state in the country.”
That battle, though, was fought and lost by Southerners 50 years ago, just as they lost a far bloodier states’ rights battle a century earlier. The country long ago came to the conclusion that economic rights, just like voting rights and criminal rights, had to be uniform. As much as it might frustrate Mr. Rubio, people should not be made to suffer just because they were born in an uncaring state.
By: David Firestone, Editors Blog, The New York Times, January 9, 2014
“The GOP’s Obamacare Obsession Will Sink Them In 2014”: As A Democrat, I Like The Republican Strategy, For It’s Political Suicide
2014 has arrived – an election year. President Obama is surely happy to have 2013 behind him, excited to have a new year ahead to work on issues that the American people care about: immigration reform, the budget, extending unemployment benefits, job creation and raising the minimum wage to name a few.
Republicans are also excited about the year ahead. And their agenda?
Replace, repeal, demonize and continue to oppose Obamacare.
Yes folks, the 47 attempts to repeal this law at your time and expense (literally); weren’t enough.The fact is that the Republicans promised, ‘hey, vote for us, we’ll take over the House and create jobs!’ was a broken, empty promise.
The fact is that Americans still care about the economy (a category into which job creation, extending unemployment benefits and raising the minimum wage fall), still ranks numero uno on their list of must haves for 2014.
The fact is that poll after poll shows that the majority of Americans feel there is a disparity of wages in America, want unemployment benefits extended and support raising the minimum wage to a more livable wage.
The fact is that in the last election, Democrats won landslide victories by hitting home the point of income inequality in America and how it must be changed.
And the fact is that, polls show, the majority of Americans don’t like Obamacare, but do like “The Affordable Care Act” and don’t want it repealed or replaced, just repaired – and they do not want Republicans fighting over it or voting on it anymore. Despite all that, Republicans are still betting that their opposition to Obamacare will help them win and win big in November 2014.
And the machine’s already in motion. It started with the Republican National Committee’s announcement that it would emphasize the Democrats’ support of Obamacare, hoping to gain seats in both the House & the Senate in the next election. RNC Chairman Reince Priebus, said Obamacare is going to be the issue of 2014. As the new year starts, so starts the launch of a multistate radio ad campaign targeting Democrats.
Although Republicans see the continued attack of “if you like your health care plan, you can keep it” comment by the president as their golden egg, I believe it will eventually fall on deaf ears. Those that aren’t Democrats or don’t like the Democrats won’t vote for them, whether they like their insurance, their plan, their doctor or not.
And by November, the website will be fixed, even more people will be insured as millions more will sign up for Obamacare by the end of March and by November rather than death panels we’ll be hearing about how many people were able to have early detection of cancer and get it treated and be cured, rather than die; due to having health insurance and receive preventative care.
We will hear how no jobs were lost due to Obamacare and the economy will continue to improve; despite Republican claims otherwise. In other words, there will be – and Democrats better drive these points home – more success stories and satisfaction with Obamacare than not.
So as a Democrat I like the Republican strategy, for it’s political suicide; oh but it will gain seats in the House and the Senate … for the Democrats.
By: Leslie Marshall, U. S. News and World Report, January 8, 2014
“Obamacare And Emergency Rooms, A Bit Of Perspective Needed”: Oregon Study Doesn’t Undermine Affordable Care Act Claims
Headlines based on a study of emergency room visits by a few thousand Oregon Medicaid beneficiaries undoubtedly gave the Obama administration heartburn last week. Although the study predated the Medicaid expansion authorized by the Affordable Care Act — which began in some states on January 1 — many who wrote about the Oregon study jumped to the conclusion that the millions of newly enrolled Medicaid beneficiaries would make greater — not less — use of the ER for routine care.
I may be going out on a limb, but I for one don’t buy the idea that the Oregon study means emergency rooms are going to get even more crowded. And that’s because more Americans will finally have insurance.
Reform advocates have long suggested that getting folks out of the ranks of the uninsured should cut down on visits to the ER for noncritical medical care. Many people who lack coverage don’t have a primary care physician and all too often make trips to the ER when their illness or injury could have been treated more appropriately and inexpensively in a clinic or doctor’s office.
The Oregon study, which was published in the journal Science, would seem to disprove that theory.
In 2008, two years before the ACA was enacted, Oregon increased the number of Medicare beneficiaries in a novel way: by lottery. Many Oregonians who had been on a waiting list for the state’s Medicaid program got lucky when their names were drawn and they were added to the rolls.
The researchers who wrote the Science article studied the emergency room use of about 25,000 of the successful and unsuccessful lottery participants and found that those who won coverage actually made more trips to the ER over 18 months than those whose names were not drawn.
Headline writers were quick to draw their conclusions: Obamacare would not reduce unnecessary ER visits.
“Emergency Visits Seen Increasing with Health Law,” read the headline above the New York Times story last Thursday.
“Obamacare Medicaid Expansion to Worsen Hospital ER Burden,” said Bloomberg.
And Forbes gave us this: “New Oregon Data: Expanding Medicaid Increases Usage of Emergency Rooms, Undermining Central Rational for Obamacare.”
“For years,” wrote Forbes columnist Avik Roy, “it has been the number one talking point of Obamacare supporters. People who are uninsured end up getting costly care from hospitals’ emergency rooms. ‘Those of us with health insurance are also paying a hidden and growing tax for those without it — about $1,000 per year that pays for [the uninsureds’] emergency room and charitable care,’ said President Obama in 2009. Obamacare, the President told us, would solve that problem by covering the uninsured, thereby driving premiums down. A new study, published in the journal Science, definitively reaches the opposite conclusion.”
There is more than a bit of twisted logic in that paragraph. It is true that those of us with insurance pay considerably more for it because those who don’t have it often can’t pay for their ER care. That’s because the hospital shifts the cost of that “uncompensated care” to its insured customers. Researchers have estimated that people with insurance pay $1,000 more a year for it than they would if this cost shifting didn’t have to occur.
Bringing uninsured people into coverage eliminates much of that cost shifting. And that’s a good thing, considering that the vast majority of Americans with health coverage — even after the Medicaid expansion — get it through private insurance companies, either at work or on their own.
The actual increase in the number of visits per person among the newly insured in Oregon via the Medicaid lottery was 0.41. In other words, each new enrollee made 0.41 visits more on average during the 18 months than the 1.02 ER visits made by those who remained uninsured.
When you look at it from the perspective of those numbers, and the actual amount Oregon spent per person, as University of Chicago health policy expert Harold Pollack did in a healthinsurance.org post, this is far from a “sky is falling” disaster in the making. And it is actually reducing the cost shifting.
Also, as Pollack pointed out, “the emergency departments will be reliably paid for care they provide … (With coverage expansion) providers don’t have to fear the burdens or uncompensated care, and…they don’t need to cruelly pursue low-income patients over bad debts.
It’s also important to keep in mind that private insurers now manage most of the states’ Medicaid populations, and they will be vigilant in their efforts to steer their new Medicaid enrollees away from the ERs and to more appropriate and cost-effective settings. WellPoint subsidiary Amerigroup described in a recent policy brief, for example, how its efforts to reduce primary care-treatable ER visits among Medicaid beneficiaries resulted in a savings of more than 50 percent.
Rather than rushing to conclusions, let’s see how the Medicaid expansion under Obamacare actually plays out in the years ahead.
By: Wendell Potter, The Center for Public Integrity, January 6, 2014
“The Scourge Of The Wingnut Hole”: Coverage Totals Would Be Far Greater If Not For “Red” States Refusing Medicaid Expansion
We have a reasonably good sense of how many Americans have enrolled in the health care system in recent months, signing up for coverage made available through the Affordable Care Act. For a more ambitious tally, Josh Marshall includes exchanges, Medicaid, young adults staying on their family plans, and those who were able to bypass exchanges to buy ACA-compliant policies directly from insurance carriers, for a grand total of about 10 million.
But every time these numbers are culled, it’s worth remembering that the coverage totals would be far greater were it not for “red” states refusing to accept Medicaid expansion.
The original plan, you’ll recall, was to simply mandate the greater access. The U.S. Supreme Court, however, said states must have a choice as to whether or not to accept the good deal. Most Republican-led states, naturally, rejected the policy, leaving millions behind for no particular reason.
But how many million? The Associated Press published a report this week with a striking figure.
About 5 million people will be without health care next year that they would have gotten simply if they lived somewhere else in America.
They make up a coverage gap in President Barack Obama’s signature health care law created by the domino effects of last year’s Supreme Court ruling and states’ subsequent policy decisions.
This coverage gap clearly needs a name. Ed Kilgore started calling it the “wingnut hole” months ago, and it’s certainly a descriptive phrase. Ryan Cooper added the other day:
It’s worth remembering that the federal government will pay 100 percent of the cost of the Medicaid expansion through 2016 and 90 percent of the cost afterward. It could very well work out that refusenik states will not even save money because of additional spending on the uninsured in emergency rooms and elsewhere.
But regardless of the pitiful sums involved, make no mistake: This action is utterly gratuitous.
Quite right. In fact, as we’ve discussed many times, Republicans at the state level who refuse Medicaid expansion generally struggle to explain their position in any kind of coherent way.
What’s more, let’s not forget the irony of the larger context: congressional Republicans spent most of their waking hours complaining about a sliver of the population receiving “cancellation notices” through the Affordable Care Act because of changes to the individual market. Indeed, GOP officials routinely claim this will leave 5 million Americans behind with nothing (a total that appears to have been exaggerated by a factor of 500).
And yet, if their concern were genuine, wouldn’t Republicans necessarily be outraged by these 5 million Americans who are suffering because some red-state policymakers are acting out of petty partisan spite?
By: Steve Benen, The Maddow Blog, January 3, 2014
“The Three Stages Of Obamacare Acceptance”: It’s Increasingly Difficult To See How Repeal Would Work, Even With Full GOP Control
Now that Obamacare is clearly moving forward, Republicans are adjusting to a new reality: it may no longer be a realistic option to simply wait until the law collapses under its own weight and vanishes entirely. GOP lawmakers are increasingly discussing a range of responses, from proposing profound changes to finally embracing a comprehensive alternative.
Which raises a question: Is it possible to envision a future in which Republicans and Democrats do enter into real negotiations over the future of the law and the health system, in which each side gets some changes it wants, in exchange for accepting some of the other’s proposed changes?
Yes, it is. But to get there, Republicans will first have to pass through what might be called the Three Stages of Obamacare Acceptance.
Right now, Republicans entertaining changes or alternatives are still proceeding from the premise that no outcome is acceptable unless it fatally cripples the law or eliminates it entirely. Republicans don’t believe the law can be fixed, since they think that even if it does work according to its own lights, it will still amount to a colossal policy failure. If Republicans want to hold that position indefinitely, there’s not much Dems can do about it.
But if Republicans do get to a point where crippling or eliminating the law is not the only acceptable outcome, there are scenarios under which they might negotiate for certain types of changes to the law, in exchange for changes Dems or liberals want.
Larry Levitt of the Kaiser Family Foundation laid out the types of incremental changes Republicans might pursue. He suggested Republicans might propose various ways of relaxing Obamacare’s regulations, in keeping with conservative policy ideas, that wouldn’t destroy the law. For instance, they could propose allowing insurance sales across state lines so competition drives down prices, something liberals might be willing to accept under certain circumstances if the law’s uniform federal minimum coverage standards are kept (which could theoretically prevent the “race to the bottom” liberals fear).
Or Republicans could propose to make tax deductions available to those over 400 percent of the poverty line who do not qualify for Obamacare subsidies, helping those who see premiums go up (which Republicans have turned into a major issue) and mitigating Obamacare’s redistributive elements a bit. Or Republicans could propose relaxing the limitations on age ratings, allowing insurance companies to charge more than the current three-to-one ratio the law mandates between older and younger people.
In exchange, liberals might ask for subsidies to be expanded to those who fall into the Medicaid gap — making too little to qualify for subsidies but too much to qualify for Medicaid in states that haven’t opted in to the expansion. Or they might ask for more in subsidies for those who currently qualify.
The point is, there are scenarios under which real negotiations over the future of the law could take place. But Republicans would have to be willing to accept something less than its complete destruction. (As Jonathan Bernstein has detailed, a general unwillingness by Republicans to try to get some of what they want on multiple issues has made the GOP into a kind of dysfunctional “post policy” opposition.)
Let’s be clear: It is certainly still possible that over the long term, Obamacare could fail, if, say, the demographic mix is bad, insurers pull out, and the exchanges collapse. If so, Republicans would theoretically be able to simply wait for the law to fall apart in a few years. But some experts are cautiously optimistic that the latest enrollment numbers suggest the law could be on track to work.
And that’s where the Three Stages of Obamacare Acceptance come in — presuming, again, that the law works at least moderately well over the long term:
* Stage One: A dim awareness that there might be some good elements in the law, and that the public might not support returning to the old system. GOP Rep. Jack Kingston, for instance, recently suggested that it might not be “responsible” to simply let the law fall apart, and that lawmakers should be open to anything in it that would help people get coverage. Kingston was immediately slapped down by his primary opponent and quickly reiterated his zeal to get rid of it entirely. Something similar happened to a GOP Senate candidate in Michigan.
* Stage Two: A genuine recognition that large numbers of people are already benefitting from the law, and that this reality needs to be reckoned with — such as by proposing alternatives or changes that purport to accomplish similar goals, even as the elimination or crippling of it remains a paramount aim. GOP Rep. Tom Price has proposed an alternative designed, in part, to cover people with preexisting conditions, but it would probably cover far fewer people, and Price continues to insist on Obamacare’s repeal, maintaining its demise is a certainty.
Meanwhile, Senator Ron Johnson has admitted that “we have to deal with the people who are currently covered under Obamacare,” and to do this, he has proposed keeping the exchanges while getting rid of the individual mandate. The latter, experts say, would fatally undermine the law, and as such this isn’t a serious proposal.
* Stage Three: Republicans accept Obamacare is likely here to stay, abandon the premise that the only acceptable outcome is crippling or eliminating the law, and negotiate to achieve incremental changes they want. This is the scenario outlined by Levitt above. It’s hard to know when this might happen in earnest – certainly not in 2014, and GOP presidential primary politics could also make this difficult next year. But you’re already seeing this a bit with GOP governors who are negotiating with the feds to create their own versions of the Medicaid expansion.
It’s always possible Republicans could win the presidency and both houses of Congress in 2016 and pass legislation repealing the law. And again, if the law fails over time, the above stages could be moot. But it’s increasingly difficult to see how repeal would work in practical terms, even with full GOP control. What’s more, as Jonathan Cohn has detailed, experts think early returns suggest the law is likely to work out. Which means you can begin to imagine Stage Three kicking in. At some point.
“If Republicans were to accept that the law is in place for the foreseeable future, then one could envision tweaks that could move it in a more conservative direction without undermining its goals, while also providing improvements to the law that liberals are looking for,” Levitt says.
By: Greg Sargent, The Plum Line, The Washington Post, January 2, 2014
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