“Insurance And Freedom”: How Many Americans Will Be Denied Essential Health Care In The Name Of Freedom?
President Obama will soon release a new budget, and the commentary is already flowing fast and furious. Progressives are angry (with good reason) over proposed cuts to Social Security; conservatives are denouncing the call for more revenues. But it’s all Kabuki. Since House Republicans will block anything Mr. Obama proposes, his budget is best seen not as policy but as positioning, an attempt to gain praise from “centrist” pundits.
No, the real policy action at this point is in the states, where the question is, How many Americans will be denied essential health care in the name of freedom?
I’m referring, of course, to the question of how many Republican governors will reject the Medicaid expansion that is a key part of Obamacare. What does that have to do with freedom? In reality, nothing. But when it comes to politics, it’s a different story.
It goes without saying that Republicans oppose any expansion of programs that help the less fortunate — along with tax cuts for the wealthy, such opposition is pretty much what defines modern conservatism. But they seem to be having more trouble than in the past defending their opposition without simply coming across as big meanies.
Specifically, the time-honored practice of attacking beneficiaries of government programs as undeserving malingerers doesn’t play the way it used to. When Ronald Reagan spoke about welfare queens driving Cadillacs, it resonated with many voters. When Mitt Romney was caught on tape sneering at the 47 percent, not so much.
There is, however, an alternative. From the enthusiastic reception American conservatives gave Friedrich Hayek’s “Road to Serfdom,” to Reagan, to the governors now standing in the way of Medicaid expansion, the U.S. right has sought to portray its position not as a matter of comforting the comfortable while afflicting the afflicted, but as a courageous defense of freedom.
Conservatives love, for example, to quote from a stirring speech Reagan gave in 1961, in which he warned of a grim future unless patriots took a stand. (Liz Cheney used it in a Wall Street Journal op-ed article just a few days ago.) “If you and I don’t do this,” Reagan declared, “then you and I may well spend our sunset years telling our children and our children’s children what it once was like in America when men were free.” What you might not guess from the lofty language is that “this” — the heroic act Reagan was calling on his listeners to perform — was a concerted effort to block the enactment of Medicare.
These days, conservatives make very similar arguments against Obamacare. For example, Senator Ron Johnson of Wisconsin has called it the “greatest assault on freedom in our lifetime.” And this kind of rhetoric matters, because when it comes to the main obstacle now remaining to more or less universal health coverage — the reluctance of Republican governors to allow the Medicaid expansion that is a key part of reform — it’s pretty much all the right has.
As I’ve already suggested, the old trick of blaming the needy for their need doesn’t seem to play the way it used to, and especially not on health care: perhaps because the experience of losing insurance is so common, Medicaid enjoys remarkably strong public support. And now that health reform is the law of the land, the economic and fiscal case for individual states to accept Medicaid expansion is overwhelming. That’s why business interests strongly support expansion just about everywhere — even in Texas. But such practical concerns can be set aside if you can successfully argue that insurance is slavery.
Of course, it isn’t. In fact, it’s hard to think of a proposition that has been more thoroughly refuted by history than the notion that social insurance undermines a free society. Almost 70 years have passed since Friedrich Hayek predicted (or at any rate was understood by his admirers to predict) that Britain’s welfare state would put the nation on the slippery slope to Stalinism; 46 years have passed since Medicare went into effect; as far as most of us can tell, freedom hasn’t died on either side of the Atlantic.
In fact, the real, lived experience of Obamacare is likely to be one of significantly increased individual freedom. For all our talk of being the land of liberty, those holding one of the dwindling number of jobs that carry decent health benefits often feel anything but free, knowing that if they leave or lose their job, for whatever reason, they may not be able to regain the coverage they need. Over time, as people come to realize that affordable coverage is now guaranteed, it will have a powerful liberating effect.
But what we still don’t know is how many Americans will be denied that kind of liberation — a denial all the crueler because it will be imposed in the name of freedom.
By: Paul Krugman, Op-Ed Columnist, The New York Times, April 7, 2013
“Inside The Anti-Obamacare Resistance”: A Facinating Glimpse Into Warped Conservative Ideology And Tactics
The two largest states that have so far failed to join in the Medicaid expansion provided for in the Affordable Care Act are Florida and Texas, where Republicans control the legislature and the governor’s office. Looking more closely at the intra-Republican battle over how and whether rich new federal funds can be captured without “surrendering” to the hated Obama provides a fascinating glimpse into conservative ideology and tactics.
Florida offers the murkiest situation. Gov. Rick Scott, who was beginning to look rather toasty in his 2014 re-election prospects, roiled conservative circles in his own state and nationally by suddenly coming out for Medicaid expansion in exchange for permission from the Obama administration to move Medicaid beneficiaries into private managed care plans. But Scott’s been stopped cold by GOP legislators, who in turn seem split between outright rejectionists centered in the state House and those in the Senate who want an even better “deal” that would utilize the state’s CHiP program, which is a privatized premium support scheme, instead of Medicaid for the expansion.
A conservative Florida reporter presents the views of the rejectionist camp quite vividly:
Tom Lauder, a reporter for Media Trackers Florida, which is closely following the Florida Obamacaid debate, says House Republicans appear likely to stand firm….
“Grassroots conservatives are particularly upset with Gov. Scott using the language of the left in his efforts to build momentum for Obamacaid,” Lauder explained. “When Scott argues, ‘I cannot, in good conscience, deny the uninsured access to care,’ he asserts that the only time people have access to goods and services is when government gives it to them as an entitlement. Scott has enraged his conservative base by making this big-government argument. This isn’t a question of whether government should give Medicaid to the poor and disabled, because the poor and disabled already qualify for Medicaid.”
At issue, Lauder says, is the rejection of Scott’s argument that federal funding will come without cost to state taxpayers.
“Scott’s conservative base also resents Scott talking about federal funding as if it were free money,” Lauder added. “Even if the federal government kept its promise to fund most of the Florida Medicaid expansion, which many conservatives doubt will be the case, Floridians pay federal taxes in addition to state taxes. Federal dollars flowing into Florida are not free dollars, even for Floridians.
In other words: Florida’s “true conservatives” don’t much care what mechanism is being used to expand coverage; they’re just flatly against it.
In Texas, meanwhile, the rejectionist camp is led by Gov. Rick Perry, as Ron Brownstein explains in a National Journal column:
Republican state Rep. John Zerwas, a health care leader who represents a district outside Houston, says legislators are getting an earful at home from providers and local officials worried about the state rejecting the money.
Against that backdrop, Zerwas and some GOP state House colleagues are searching for ways to steer Texas into the expansion. They assume the state will not move more people into the existing Medicaid program. But they consider it misguided to simply reject the federal money and deny insurance coverage to so many people who could obtain it. “We are not going to make this better … without doing something that substantially reforms how we deliver Medicaid,” Zerwas says. However, “we have to have a solution for this group of people.”
Last week, Zerwas introduced legislation that would authorize state health officials to negotiate with the Obama administration to expand while delivering coverage for the newly eligible through new means. He likes the deal the administration is discussing with Arkansas, which could allow the state to use Medicaid expansion dollars to instead buy private insurance for its eligible adults, and he believes that approach could be “sellable to the governor.”
Many here, though, wonder if Perry would take any deal. The widespread belief is that he intends to seek the GOP presidential nomination again in 2016, and accepting more Medicaid money would smudge his image of Alamo-like resistance to Obama.
This is an interesting scenario given recent efforts from the Perry camp (outlined earlier this week in another National Journal piece by Michael Catalini) to depict the swaggering, gaffe-prone Texan as “ahead of his time” in understanding the need for Republican outreach to Latinos. Notes Brownstein:
[I]f state Republicans reject federal money that could insure 1 million or more Hispanics, they could provide Democrats with an unprecedented opportunity to energize those voters—the key to the party’s long-term revival. With rejection, says Democratic state Rep. Rafael Anchia of Dallas, Republicans “would dig themselves into an even deeper hole with the Hispanic community.”
It’s unclear how this will all play out in Florida and Texas. But nobody recently has lost any money betting on the hard-core conservative approach, particularly on an issue as incendiary to the Right as Obamacare. That rejecting any sort of coverage expansion beyond that absolutely required by the ACA would mean leaving vast sums of federal money on the table would in fact be considered a badge of honor by a lot of the people involved.
By: Ed Kilgore, Contributing Writer, Washington Monthly Political Animal, March 22, 2013
“A Total Howler”: Paul Ryan’s Budget, His Own Facts And Obamacare
Hello, I am back. We will discuss aspects of my vacation in due course, but first, our friend Mr. Ryan.
He’s facing lots of derision for assuming the repeal of Obamacare in his new budget. First of all, credit where it’s due–it was apparently Chris Wallace of Fox News who brought this information to light in questioning Ryan, so good for him.
And second of all, yes, this is a total howler. Repeal of Obamacare? Not going to happen. Could theoretically happen in 2017, one supposes, but by that time, even if there is a Republican president and Republican majorities in both houses of Congress, including the super-majority of 60 in the Senate that would presumably be needed to enact full repeal, states will be getting billions in federal funding to put working poor people on the rolls of their new exchanges. It seems pretty unlikely that broad support for undoing that would exist.
So Ryan’s assumption doesn’t pass any known laugh test. So why does he do it? Well, because of the old saying “that’s my story, and I’m stickin’ to it.” Which is to say…
The Republicans have spent the years since the passage of the Affordable Care Act insisting that it’s a deficit-buster. You heard Mitt Romney say this a thousand times. It wasn’t true, and it isn’t true. In June 2012, Politifact gave Romney a flat-out “false” when he made the claim, writing:
…for claims about deficits, we consider the Congressional Budget Office, often called the CBO, to be the standard by which we fact-check claims.
The CBO said this about the health care law back in 2010: It lowers the deficit, by about $124 billion over 10 years.
And in 2011, when Republicans offered a bill to repeal the health care law, the CBO said that increased the deficit, by about $210 billion over 10 years.
Now, is the CBO infallible? Certainly not. And good questions have been raised about some of the CBO’s methods in accounting for the health care law’s effects. We reported on some of those concerns in great detail in a fact-check of statements from U.S. Rep Paul Ryan, R-Wisc. He said the law was “accelerating our country toward bankruptcy.” We rated that Mostly False.
So Ryan has been telling this lie for a while, as have all Republicans. The month after this Politifact assessment, the CBO issued a second report running some new numbers and finding the same result. And this year, The New York Times reported in mid-February that the deficit was decreasing (and it is, and rapidly; see Krugman today on this) largely because of lower health-care costs, by no means all but some of which could be traced to the ACA.
In other words, in reality land, Obamacare contributes to deficit reduction. By how much, we certainly don’t yet know. But all the signs we have–the experts’ projections and the early evidence–suggest that this is the case.
But in Republican land, it’s an article of faith that the ACA increases the deficit. This being the case, or “the case” as it were, then how in the world could Ryan introduce a new budget to eliminate the deficit in 10 years (the full thing is being unveiled Wednesday) that includes Obamacare? He’d be destroyed by the agitprop machine of the right if his budget did that, both because they just detest the thing and because it “increases” the deficit. They’ve agreed on this! Anyone who says otherwise is guilty of apostasy.
So again, this is our “new” GOP. Making up realities according to how the howling half of the base would respond. That sounds kind of like the old GOP to me.
By: Michael Tomasky, The Daily Beast, March 11, 2013
“Ryan’s Blurred Vision”: What The New Republican Budget Reveals And Conceals
Someone needs to tell Paul Ryan that his party – and the economic platform of austerity and plutocracy he crafted for it – lost a national election last year. Someone also needs to tell the Wisconsin Republican that he still chairs the House Budget Committee mainly thanks to gerrymandered redistricting.
Someone clearly needs to remind him of those realities because the “vision document” he proposed on Tuesday as the Republican federal budget is only a still more extreme version of the same notions (and the same evasions) that he and Mitt Romney tried to sell without success last fall.
Voters decisively rejected that version of Ryan’s “path to prosperity,” with its gutting of the Medicare and Medicaid programs, its additional tax cuts for the wealthiest Americans, and its destructive cutbacks in education, infrastructure, scientific research, national security, and a hundred other essential elements of modern American life – and a decent future – that require effective government.
Indeed, the astonishing initial assessment of the new Republican budget by experts at the Center on Budget and Policy Priorities is that Ryan wants even deeper cuts and even more lavish tax cuts than he and Romney touted in 2012. The CBPP estimates that the new Ryan plan would cut $800 billion over the coming decade from an assortment of vital programs, including Supplemental Nutrition Assistance (SNAP, or food stamps); Supplemental Security Income (SSI) that supports the elderly poor; Pell grants for higher education; and federal school lunches, among others, along with the Earned Income Tax Credits (EITC) and Child Tax Credits that have historically improved standards of living for millions of impoverished working families.
Ryan pretends to admire Ronald Reagan, but the late president — who proudly extended and expanded the EITC — was far too liberal for the likes of him and Romney. Unlike the sunny Gipper, these sulking millionaires resent the working poor – the “47 percent” – who aren’t paying high enough taxes.
But everyone ought to know Ryan well enough by now to anticipate these cruel proposals. They ought to know, too, that Ryan would allow the entire edifice handed down to us by previous generations – highways, bridges, airports, canals, reservoirs, schools, parks, and much more – to crumble into oblivion, rather than increase taxes on the Republican donors whose wealth has multiplied so astronomically in recent years. His voice is the high-pitched drone of a generation of termites, voraciously consuming the nation’s foundations.
What everyone may not know is that Ryan’s vision of the future is quite blurry, since he again refuses to specify exactly how his budget allegedly achieves balance. It says (again) that the severest cuts will be made in domestic non-discretionary spending, but never details how much will be cut from which programs or even categories. It says (again) that tax expenditures will be reduced to balance those tax cuts for the rich, but never details those either. It says (again) that the Affordable Care Act will be repealed, although there is no chance of that happening now. And it says that defense spending – including untold billions in well-known waste – will simply be restored to pre-sequestration levels, while everything else will be cut again, starting at the post-sequestration baseline, much as Romney promised last year.
It says the federal budget will achieve balance within 10 years, but (again) there is no reason to believe its unfounded promises.
This old “new” budget demonstrates that no change is taking hold among the Republicans, except that they seem even more rigid in their ideological obsessions. No basis exists for bipartisan negotiation toward a budget compromise.
Without a massive public reaction to the Ryan proposals, the likelihood is that sequestration will continue and the Republicans will again seek to hold government hostage, as they have done repeatedly since 2009. And the nation will continue to suffer until voters finally decide, in their wisdom, to curtail the power of this truculent and implacable faction.
By: Joe Conason, The National Memo, March 13, 2013
“The Ultimate Seller’s Market”: How Big Medicine Plays Us All For Suckers
Sometimes the best journalism explains what’s right under our noses. In Steven Brill’s exhaustive Time magazine cover article “Bitter Pill: Why Medical Bills Are Killing Us,” it’s the staggeringly expensive, grotesquely inefficient and inhumane way Americans pay for medical care.
“In the U.S.,” Brill reminds us, “people spend almost 20 percent of the gross domestic product on health care, compared with about half that in most developed countries. Yet in every measurable way, the results our health care system produces are no better and often worse than the outcomes in those countries.”
Obamacare or no Obamacare, ever-increasing prices show few signs of abating. For all the fear and uncertainty the president’s health insurance reform will eliminate from people’s lives, it’s almost incidental to the overall question of costs.
Moreover, had the law attempted to seriously restrain profiteering hospital chains, pharmaceutical companies and medical equipment manufacturers that Brill depicts as largely responsible for the current morass, there’s no way it could have passed.
Yes, it’s a fiscal issue. If Medicaid and Medicare paid the same amounts for health care as, say, Switzerland or France—the economist Dean Baker has repeatedly pointed out—the Federal budget deficit would virtually disappear. (Although the two federal programs are infinitely more frugal and efficient than the rest of the system.)
But it’s an economic and moral issue as well. Brill was inspired to research the article after noticing the gleaming spires of the Texas Medical Center in Houston, of which M.D. Anderson is the brand name. It’s a great hospital, dispensing world-class care (at world-class prices). But how exactly, Brill wondered, had hospitals become five of Houston’s 10 largest employers? It’s a pattern repeated nationwide, as hospital chains have come to dominate local economies.
Essentially, he found, by gaming what the article describes as “the ultimate seller’s market”—an economic realm where buyers (i.e. hospital patients) are normally ignorant, often frightened and sometimes literally helpless. And who often think they’ve got adequate insurance, until they examine the fine print.
Granted, nobody bargains over a cancer diagnosis or heart attack. Even so, Brill wondered “why should a trip to the emergency room for chest pains that turn out to be indigestion bring a bill that can exceed the cost of a semester of college? What makes a single dose of even the most wonderful wonder drug cost thousands of dollars? Why does simple lab work done during a few days in a hospital cost more than a car?”
Good questions, all. Brill answers them by taking readers on a guided tour of the Alice-in-Wonderland world of medical billing as experienced by ordinary patients for whom getting the bill became an ordeal equal to and sometimes surpassing the illness itself.
Such as “Steve H.,” who never asked the cost of outpatient treatment for his ailing back because his union-sponsored health insurance plan had $45,000 remaining on its annual $60,000 spending limit. “He figured, how much could a day at Mercy [hospital] cost?…Five thousand? Maybe 10?”
The bill came to $89,000—including $45,000 for an electronic stimulator Brill learns that Mercy Hospital bought from the manufacturer for $19,000, which spent roughly 25% of that amount making and shipping it. (An arbitrator persuaded the hospital to settle for $10,000 of the $44,000 it said Steve H. owed.)
Moreover, as medical markups go, Steve H. got off relatively easy. The “chargemaster” computerized system hospitals use to prepare bills routinely assesses patients 10 times and more what commonly used items like gauze pads and surgical gowns actually cost. If baseball teams treated their captive audiences like that, they’d be selling $40 beers.
At times, Brill’s mordant deconstruction of hospital bills can be grimly funny—even if Alice D., left facing a $900,000 bill for her dead husband’s futile cancer treatment, can be pardoned for not laughing. In the end “her losses from the fixed poker game that she was forced to play in the worst of times with the worst of cards,” persuaded Alice she could never afford to remarry.
Even chemotherapy patients who survive can be staggered to learn that a miracle drug cost Genentech roughly “$300 to make, test, package and ship to M.D. Anderson for $3,000 to $3,500, whereupon the hospital sold it to [patient Steve] Recchi for $13,702.33.”
Ultimately, many of these humongous bills are never collected; the industry average is around 35 percent, although prestigious hospitals like M.D. Anderson collect 50 percent of what they charge. Most are “non-profits” only in the sense of having no stockholders; instead, administrators are paid princely multi-million-dollar salaries. They occupy themselves with building empires.
In the end, Brill concludes that Americans pay an enormous price for refusing to admit that “because the health care market deals in a life-or-death product, it cannot be left to its own devices.”
He and Time have done a great public service.
By: Gene Lyons, The National Memo, March 13, 2013
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