“Not A Bad General Election Issue”: Should Democrats Press The Public Option?
There’s no question that the Affordable Care Act’s rollout has been “rocky,” to borrow the common parlance of the Beltway. The Web site troubles and shifting health coverage for some Americans, despite over-assurances from President Obama during the 2010 political debate, have naturally turned off some people. A much-ballyhooed poll from CNN yesterday shows that support for “Obamacare” has dropped to an all-time low.
But conservatives toasting the apparent turn in public opinion ought to look a little closer at the polling data. It’s true that only 35 percent of Americans favor the law, while 43 percent oppose it. But there’s a crucial third group: 15 percent oppose the ACA because it’s “not liberal enough.” That means that 50 percent of Americans either support the law or want policy changes that shift leftward.
Looking at the polls in that light suddenly shifts the political calculus. Republicans who want to repeal and “replace” the legislation — with measures that have never been entirely clear, especially when it comes to the most popular provisions of the ACA — are suddenly facing an uphill battle with the public.
This presents a pretty clear road map for Democrats worried that the biggest legislative achievement of the Obama era might turn against them. The CNN/ORC poll didn’t press people on what, exactly, “not liberal enough” meant, but it’s not hard to imagine what those people might want. Recall that while the legislation was being crafted, the public broadly supported a “public option” in the bill that would allow people purchasing insurance on the exchanges to select a federal health insurance plan.
So what if Democrats pushed for it? A public option would save $100 billion over 10 years, according to the Congressional Budget Office, and could offer respite from the plan cancellations and rate hikes that still persist with private insurers with the ACA in place.
There’s essentially no chance President Obama will take another bite at the health-care apple, especially with so many other priorities to tackle: his professed desire to combat climate change and income inequality before he leaves office, along with getting comprehensive immigration reform passed. But strategists on 2016 presidential campaigns ought to take heed.
Imagine a candidate who comes out early, and strong, for adding a public option to the ACA exchanges. It could become a signature issue with the liberal grass roots during the primaries, and it wouldn’t be a bad general election issue either — the polls in 2010 showed support for a public option among Republicans and independents as well as Democrats. As Ezra Klein has noted, the sudden disappearance of the public option from Democratic politics has been “a bit curious,” but perhaps its day is coming.
By: George Zornick, The Plum Line, The Washington Post, December 24, 2013
“Extending The Hardship Exemption”: You Can Still Have Weak Health Insurance Under Obamacare, For Now
If you liked your old skimpy health plan, you may not be able to keep it. But now you can get a new, somewhat skimpy health plan instead, at least for a little while.
That’s a rough translation of an Obamacare policy change that the Administration announced on Thursday. The change, first reported by Louise Radnofsky of the Wall Street Journal, represents yet another effort to help people about to lose their existing insurance policies, usually because those policies do not comply with the Affordable Care Act’s standards for benefits and pricing. Those old policies left out major benefits, were sold only to people without pre-existing conditions, and so on.
As you know, plan cancellations have been a source of tremendous controversy—and, for the president, immense political grief. Some estimates have suggested several million people received these cancellation notices. The vast majority of those people have already found new coverage, either directly through insurers or through one of the Obamacare exchange websites, according to the Administration. While some are paying more money, others have discovered that the new policies are cheaper—or, at least, are grateful for the extra protection. Lucia Graves of National Journal wrote about some of their stories the other day.
But some people still haven’t found insurance. Administration officials think, based on conversations with state regulators and insurers, that about half a million people fall into this category. That’s half a million people who could, because of the individual mandate, face tax penalties because they have declined to get affordable coverage.
Now, however, people with cancelled policies have a new option. The individual mandate has always contained a hardship exemption: If you qualify for it, you don’t have to pay the penalty and you have access to the cheaper, slightly less comprehensive catastrophic insurance plans otherwise available only to people under 30. The only question with the hardship exemption has been who gets it. The law gives the administration flexibility over that question and, on Thursday, Health and Human Services Secretary Kathleen Sebelius announced that it would apply to people who just lost their policies and are unable to find replacements that cost the same or less money.
HHS made the announcement by posting a guidance and sending a letter to a half-dozen more conservative members of the Senate Democratic caucus. And neither document answers all of the relevant questions, like how strictly the government will apply the new criteria or for how long this exemption will last. (Administration officials say it will be temporary.)
Conceptually, making the change is not so different from allowing more people to have grandfather protection for their existing coverage—after all, it’s basically telling people who have bare-bones coverage now that they can take out bare-bones policies next year. And imposition of the individual mandate was always supposed to be a gradual process. The financial penalty starts out relatively low, but will increase in 2015 and 2016. The administrative flexibility over the hardship exemption was designed to give the administration some leeway over enforcing the mandate, particularly early on, in order to ease the transition to a new and reformed insurance market. (The Massachusetts reforms, which were a model for the Affordable Care Act, also included a hardship exemption and called for increasing penalties over time.)
Administration officials don’t seem to think many people will take up this new option. They are probably right about that. Catastrophic policies aren’t dramatically different in coverage from the “bronze” policies, which cover 60 percent of the typical person’s medical expenses and comply with all Obamacare requirements. But if you buy a catastrophic policy, you’re not eligible for federal tax credits. If you buy a bronze policy, you are. As a result, most lower- and middle-income people would probably still find the bronze policies a better deal.
Still, some people—primarily, the ones who don’t qualify for subsidies—will opt for the catastrophic policies because they will be moderately cheaper. And some people will opt not to get insurance at all. That will mean fewer people in good health paying premiums for the exchange policies. That’s a potential problem for insurers, who count upon those premiums to offset the medical bills of people in poor health. (For health policy wonks: The catastrophic policies are an independent risk pool, separate from other policies in the exchanges. So for every person who selects one of those policies, that’s one fewer person putting premiums into the larger pot of money for the exchange policies.) There’s also a danger that, as Ezra Klein points out, the administration will come under more pressure to pull back on the mandate for other people. “This latest rule change could cause significant instability in the marketplace and lead to further confusion and disruption for consumers,” said Karen Ignani, president of America’s Health Insurance Plans.
Yes, insurers say those sorts of things all the time. And this singular change probably won’t cause serious, irreparable harm, any more than any of the previous ones did. The number of people whose behavior changes is likely to be small and the new system is more resilient than most people realize. But even minor changes can become major if there are enough of them.
Note: This item has been updated. As a friend reminds me, even the catastrophic plans under Obamacare aren’t that skimpy. They still cover all essential benefits, for example, and the actuarial value really isn’t much different from bronze plans.
By: Jonathan Cohn, The New Republic, December 21, 2013
“What Obamacare Death Spiral?”: So Sorry Republicans, The Rumors Have Been Greatly Exaggerated
Supporters of the Affordable Care Act have been terrified for months now that a combination of a botched online enrollment system, terrible press, and Republican sabotage could send the individual market part of the new system into the much-discussed “death spiral” where a disproportionately large population of older and sicker enrollees would produce very high premiums, which would in turn repel younger and healthier eligibles even more, creating a self-perpetuating disaster.
At Wonkblog today Sarah Kliff reports some research from the Kaiser Family Foundation indicating that fears of a “death spiral” are significantly overblown:
The rumors of an Obamacare death spiral have been greatly exaggerated. So say Larry Levitt, Gary Claxton and Anthony Damico, experts at the Kaiser Family Foundation who have put together a new brief analyzing what would happen if young adults snubbed the Affordable Care Act. Even if young people sign up at half the rate the administration hopes for, it would nudge premiums up only by a few percentage points, their report says.
“When you do the math, it matters, but not nearly as much as the conventional wisdom suggests,” Levitt says….
If young adults (those under 35) were 25 percent less likely than the rest of the population to sign up for Obamacare, they would represent 33 percent of exchange enrollees — rather than 40 percent. This means there would be fewer young people to subsidize older insurance subscribers. To make up that difference, the experts estimated, insurers would need to increase premiums by a terrifying … 1 percent. Yes, exactly 1 percent.
Levitt, Claxton and Damico also tested a scenario where young adults are half as likely as older shoppers to enroll. In that case, the younger enrollees would make up only a quarter of the exchange market. Premiums would fall 2.5 percent short of covering subscribers.
Wow. If these numbers are accurate, the widespread assumption (particularly among happy Republicans) that there’s nothing ahead for exchange enrollees beyond “sticker shock” forever could give way to the expectation that Obamacare will eventually be self-stabilizing, at least for most enrollees. That in turn would upset GOP calculations that they can perpetually benefit from Obamacare’s problems without coming up with their own credible “replacement” proposal (the ones we’ve seen so far, which rely on destructive gimmicks like interstate insurance sales and state-run high-risk pools, while vastly disrupting employer-based coverage, just aren’t credible once you get beyond the slogans).
A whole lot of GOP strategery for 2014 and 2016 depends on an Obamacare crash. They might want to start seriously considering a Plan B that isn’t even worse than the pre-Obamacare status quo ante.
By: Ed Kilgore, Contributing Writer, Washington Monthly Political Animal, December 18, 2013
“Running On Empty”: Republicans Can’t Repeal Or Replace Obamacare, And They’re Too Scared To Fix It
More than three million people have already signed up for health insurance as of last Friday through the exchanges set up by the Affordable Care Act (ACA). That number is growing rapidly, with 15,000 new enrollments a day in California alone.
And the Republican plan to deal with Obamacare generally remains what it has been since 2010 — repeal.
This means the millions of men, women and children covered under plans could either see their plans invalidated by insurance companies no longer required to cover pre-existing conditions or have their Medicaid coverage completely erased. Republicans who spent the last three months screaming about how terrible insurance cancelations are would have to explain what happens next for millions of uninsured Americans.
Repeal is a fantasy, a fundraising opportunity that all Republicans — except the few who take Senator Ted Cruz (R-TX) seriously — know would never happen. And if it did, they would end up owning every aspect of a crumbling health care system the same way Democrats are currently responsible for every splinter in every tongue depressor.
The Washington Post‘s Greg Sargent looks at recent polling and finds that though Americans are largely dissatisfied with the rollout of the Affordable Care Act, they generally support the federal government’s taking a role in getting people affordable health insurance. More importantly, most are still willing to give the law a chance.
“Only 37 percent support repealing Obamacare entirely,” he writes, “while 53 percent say there are good things in the law and that changes are needed to make it work better.”
Republicans are now in what Sargent calls “The GOP Repeal Trap,” which essentially requires them to vow repeal and pray that somehow the law collapses on its own.
While it may seem absurd to those who care about governing, it makes perfect sense strategically because ”replace” is an even bigger fantasy than repeal.
Until it became socialism incarnate, the ACA was the conservative reform to the health care system. So to replace it completely, conservatives would need to go further to the right and destroy the entire employer-provided health insurance paradigm that provides about 85 percent of working adults with their coverage.
That’s what the proposal John McCain ran for president on in 2008 would have done, canceling the insurance of about 20 million Americans, four times the number who had to find new coverage under Obamacare.
Are there conservative fixes that could be made to the ACA that Democrats would be willing to trade for reforms of their own?
Health economist Austin Frakt has listed more than a dozen possible conservative-leaning fixes for the law, starting with their all-time favorite, tort reform, which actually would do very little to lower health care costs but would be a huge win for the right in their never-ending war against trial lawyers.
So why doesn’t some brave Republican — say Governor Chris Christie (R-NJ) — step forward with a set of conservative reforms to the ACA?
The answer is easy: Republican primaries.
Michigan Senate candidate Terri Lynn Land suggested that the law would be fixed and was forced to flip-flop on that position in less than 24 hours, likely in fear that she might end up with a Tea Party challenger. Georgia Senate candidate Rep. Jack Kingston did nearly the exact same thing.
Christie is already saddled with being the only 2016 GOP frontrunner who accepted Medicaid expansion. If he became the face of fixing Obamacare, he would be appealing to the majority of voters but antagonizing if not actually declaring war on those in the base who refuse to accept that Obamacare is here to stay, and also refuse to consider any candidate who tells them what they do not want to hear. (Even if the governor could win the primary backed by the business and more independent wings of his party, he could end up inspiring a Tea Partier to run as a third-party candidate, virtually guaranteeing a Democratic victory in 2016.)
For the foreseeable future, Republican candidates — even those in states and districts President Obama won — are stuck running in the general election with the “problematic” stand of wanting to take health insurance from millions, some of whom may actually show up to vote.
And if they win, they can return to blaming President Obama for never making their repeal fantasy come true. It’s the only safe move.
By: Jason Sattler, The National Memo, December 19, 2013
“No Way Out”: GOP Eyes “Obamacare Trap” Warily
Rep. Marlin Stutzman (R) held an event in his Indiana district this week, at which health care was a major topic of conversation. According to a local press account, not everyone in this Republican area necessarily opposes “Obamacare.”
But Stutzman seemed to realize at the event that simply condemning what he doesn’t like won’t be enough. “What are you replacing it with? That’s what everybody is asking right now,” the congressman said, adding, “There’s several Republican plans that are competing with each other right now just internally. After the first of the year, we are going to try to sort through that.”
That last part was actually rather newsworthy – we didn’t know that House Republicans are planning to finally present their alternative to the Affordable Care Act sometime in 2014. In fact, Byron York reported that intra-party talks are still underway.
[I]n private discussions, House Republicans stress their differences over the details of an Obamacare alternative. For example, there’s no agreement on precisely how to fix the tax inequity for people who don’t receive health coverage at work. There are similar disagreements over all sorts of other points of policy. “Getting unanimity is a tall order for a divided, leaderless party,” says the GOP aide.
As Democrats can attest, getting unanimity is a tall order for a united party with strong leaders, too.
Regardless, while York describes an “Obamacare trap” in which Republican lawmakers struggle with whether to fix or destroy the existing system, the circumstances lead me to believe a very different kind of trap is set.
Let’s say, after five years of effort, House Republicans finally emerge from behind closed doors with a health care reform package they’re proud of and willing to present to the public. What then? The GOP plan will be subjected to some policy scrutiny, which is where the party is likely to run into some trouble.
It’s easy to imagine a side-by-side comparison, in which the Affordable Care Act is tested against the Republican alternative. Which covers more uninsured Americans? Which reduces the deficit more? Which offers the stronger consumer protections? Which is more effective in controlling long-term costs?
I’d bet good money that on all of these questions, the GOP plan will lose – not because Republican policies are necessarily worse than Democratic policies, but because Republicans have already said their approach to health care would eschew regulations and public investments. And while it’s possible to create a health care plan without spending or safeguards, it’s not possible to create a good health care plan without them.
Ultimately, that’s the “trap” GOP officials need to be mindful of. On the one hand, they can continue to offer nothing in the way of an alternative, effectively telling the public they’re not serious about the issue and they prefer to take cheap shots rather than govern. On the other, they can build a consensus around an Obamacare alternative that almost certainly won’t be nearly as good as the ACA. (Remember, the basic framework of the Affordable Care Act was the Republican policy up until a few years ago.)
The trap is set. The question isn’t whether Republicans will fall in, but rather, whether they can get out.
By: Steve Benen, The Maddow Blog, December 18, 2013
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