“We’ll Never Stop Arguing About It”: Obamacare Is Helping A Lot Of People. Not Everyone Thinks That’s Good News
In politics there are some issues where liberals and conservatives share the same goal, but disagree about how to achieve it — we all want to have as little crime as possible, for instance, but there are different ideas about how to accomplish that. Then there are issues where the two groups have different goals — liberals want to preserve women’s reproductive rights, and conservatives don’t. And sometimes, there are issues we think fall in the first category, but actually belong in the second.
Health care may just be that kind of issue, where we talk as though we all have the same fundamental goals, but we actually don’t. There’s an interesting article in the New York Times today on a major success of the Affordable Care Act that demonstrates why we’ll never stop arguing about it. Here’s how it begins:
The first full year of the Affordable Care Act brought historic increases in coverage for low-wage workers and others who have long been left out of the health care system, a New York Times analysis has found. Immigrants of all backgrounds — including more than a million legal residents who are not citizens — had the sharpest rise in coverage rates.
Hispanics, a coveted group of voters this election year, accounted for nearly a third of the increase in adults with insurance. That was the single largest share of any racial or ethnic group, far greater than their 17 percent share of the population. Low-wage workers, who did not have enough clout in the labor market to demand insurance, saw sharp increases. Coverage rates jumped for cooks, dishwashers, waiters, as well as for hairdressers and cashiers. Minorities, who disproportionately worked in low-wage jobs, had large gains.
Before we go farther, we should remember that the ACA is a complex piece of legislation that affects every area of American health care, but for now we’re going to talk just about insurance coverage. When liberals see a report like this one, they say, that’s terrific — some of the most vulnerable people in America, and those who had the hardest time getting covered before, now have health insurance. They offer this as practical evidence of the law’s success.
But conservatives (not all conservatives, but many of them) don’t see that as a success at all. If the government is helping an immigrant who washes dishes for a living get health coverage, then to them that means that government is redistributing tax money from deserving people to undeserving people. The two groups look at the same practical effect, and interpret it in opposite ways.
That isn’t to say that the ACA didn’t give benefits to everyone, because it did. Millions of middle-class and even upper-class people were hurt by the fact that insurance companies used to be able to deny you coverage if you had a pre-existing condition, but the ACA outlawed that. And if the payment reforms in the law bring down overall health spending, we all benefit. But the most visible and dramatic parts of the law relate to the tens of millions of Americans who used to be without health coverage but now have it.
This is why Republicans continue to call the ACA a “disaster” and a “catastrophe” despite the good it has done. Liberals hoped that once the law was implemented and its practical effects became clear, the law would become hugely popular. Instead, views of the law divide closely on ideology and partisanship, and that hasn’t changed and won’t change.
That’s because there’s a fundamental clash of values at work, which means that liberals and conservatives will always judge it according to different standards. Because the law did a large amount to bring coverage to those who couldn’t afford it (through both the expansion of Medicaid and subsidies), and because it included a raft of new regulations meant to solve a variety of problems within the health care system, conservatives will always oppose it, whether it succeeds on its own terms or not. To doctrinaire conservatives, a government regulation that accomplishes what it sets out to isn’t a success at all; it’s a moral failure by definition. That’s why liberals will never convince them to support the ACA by pointing to its practical successes.
That isn’t to say that conservatives don’t make practical arguments against the ACA, because they do. But they’re mostly window dressing placed atop their moral objections to government involvement in health care. So yes, they predicted that Obamacare would destroy the economy, and cost millions of jobs, and lead to fewer people with health coverage, and balloon health care spending, and make premiums skyrocket. When they turned out to be wrong about all these things, conservatives didn’t say, “Well gee, I guess this law was a pretty good idea after all.” Because the fundamental moral objection remains, whatever the practical impact.
You can see it in the decision to accept or reject the law’s expansion of Medicaid. The federal government offered states a huge pot of free money to provide coverage to their poor citizens, and though some conservative governors tried to argue that it would be too expensive, those arguments were laughably weak. As one independent analysis after another has shown — from groups like the Rand Corporation, not exactly a bunch of lefties — taking the expansion leads to healthier state finances and better economic growth, on top of helping your state’s constituents. But for many governors, insuring poor people isn’t a moral good at all; just the opposite, in fact. So they were even willing to incur economic damage in order to avoid it (and to give Barack Obama the finger, of course).
Where this all leaves us is that the ACA will never become something we agree on, no matter what it does or doesn’t do in the real world. But even that’s not the whole story, because there are political factors at work. Smart Republicans understand that with each passing year, the law becomes more and more entrenched and harder to unwind, no matter how much they hate it. It’s one thing to keep people from getting insurance, but it’s something quite different, and far more politically dangerous, to take away insurance people already have — and if they really repealed the law, that’s what they would be doing, not just to a few people but to 20 million or so.
That’s why Republicans have so much trouble coming up with their “repeal and replace” plan. It’s not because there aren’t conservative health care wonks who could give them an outline. It’s because any real repeal would be so spectacularly disruptive to the system that it would a political nightmare. Just today there’s an article in The Hill on the efforts of the Republican task force charged with producing the new repeal-and-replace legislation, under the title, “GOP group promises ObamaCare replacement plan — soon.” If you’ve been following this issue, you know that title is a joke. As the piece says:
Coming up with a plan to replace ObamaCare has been an aim for the Republican Party for so long that it’s become a laugh line even in conservative circles. Despite voting more than 50 times in the House to repeal the law, the GOP has not once voted on legislation to take its place.
But every couple of months, they say that they’ll be releasing their plan any day now.
If Republicans actually took the White House and held Congress, my guess is that they’d pass something they called “repeal and replace” but which would leave the ACA largely intact. Just as they propose to privatize Medicare but rush to tell seniors who love it that their own coverage wouldn’t be affected, it would be some kind of time-delayed change that would avoid kicking people who now have insurance off their coverage. And if Hillary Clinton gets elected in the fall, it’ll be another four or eight years before they could even try this. No matter what happens between now and then, conservatives won’t ever decide that the ACA has worked out well, whether it actually did what it was designed to do or not. As far as they’re concerned, the design itself was the problem. But they may decide, as they did with Medicare, that doing away with it isn’t worth the bother — at least not worth bothering to to try all that hard.
By: Paul Waldman, Senior Writer, The American Prospect; Contributor, The Plum Line Blog, The Washington Post, April 18, 2016
“Cleaning Up Another Republican Mess”: Louisiana Ready To Make Big Gains Through Medicaid Expansion
Few states need Medicaid expansion more than Louisiana, which made it all the more difficult to justify former Gov. Bobby Jindal’s (R) refusal to consider the policy. By all appearances, the Republican made a plainly political decision without regard for the state’s needs: Jindal wanted to be president (yes, of the United States), so he took a firm stand against “Obamacare.”
Louisiana’s current governor, Democrat John Bel Edwards, ran on a platform of Medicaid expansion through the Affordable Care Act, won his election fairly easily, and immediately adopted the policy. The Times-Picayune in New Orleans reported yesterday that the governor went directly to the legislature to explain why this was the smart move for Louisiana.
Medicaid expansion is estimated to save Louisiana $677 million over the next five years and more than $1 billion over the next decade, Department of Health and Hospitals officials told Senate Health and Welfare Committee members Monday (April 18).
The cost estimates came after Gov. John Bel Edwards testified before the committee about his decision to expand Medicaid eligibility to about 375,000 people between July 1 and June 30, 2017. DHH officials will make an effort in the coming weeks to educate legislators about the benefits of Medicaid expansion and what they said was misinformation given to the Legislature to justify not expanding Medicaid under former Gov. Bobby Jindal.
“I believe the folks in the prior administration who said we couldn’t afford Medicaid expansion, they took the worst case scenario on every variable,” Edwards told lawmakers in the GOP-led legislature. “If you look at what we’re doing in light of experience in other states … we know we’re going to save money.”
And he knows this because it’s true.
I can appreciate why this may seem a little counter-intuitive. Ordinarily, when state policymakers recommend expanding benefits to struggling families, critics will respond, “We’d like to help, but we can’t afford it and we’re not willing to raise taxes.”
But Medicaid expansion is one of those policies in which states get to do both: participating states receive federal funds to implement the program, while expanding coverage for low-income families who would otherwise go uninsured. At the same time, hospitals’ finances are strengthened as medical facilities see fewer patients who can’t pay their bills.
Since implementation of the Affordable Care Act began, how many states have found Medicaid expansion hurt state budgets? None. Republicans will be quick to argue that someday, maybe, in the future, the fiscal challenges will become more acute, but given pre-ACA reimbursement rates, there’s no reason to believe they’re correct.
It’s exactly why every governor with access to a calculator – including plenty of red-state Republicans – have found the arithmetic undeniable.
As for Louisiana in particular, as we talked about last week, the state really is having an “elections have consequences” moment right now. Gov. Edwards, the region’s only Democratic governor, hasn’t been in office long, but he’s already making strides to clean up the Republican mess he inherited.
By: Steve Benen, The Maddow Blog, April 19, 2016
“Who Hates Obamacare?”: Progressives Should Not Be Trash-Talking Progress And Impugning Motives Of People On Their Side
Ted Cruz had a teachable moment in Iowa, although he himself will learn nothing from it. A voter told Mr. Cruz the story of his brother-in-law, a barber who had never been able to afford health insurance. He finally got insurance thanks to Obamacare — and discovered that it was too late. He had terminal cancer, and nothing could be done.
The voter asked how the candidate would replace the law that might have saved his brother-in-law if it had been in effect earlier. Needless to say, all he got was boilerplate about government regulations and the usual false claims that Obamacare has destroyed “millions of jobs” and caused premiums to “skyrocket.”
For the record, job growth since the Affordable Care Act went fully into effect has been the best since the 1990s, and health costs have risen much more slowly than before.
So Mr. Cruz has a truth problem. But what else can we learn from this encounter? That the Affordable Care Act is already doing enormous good. It came too late to save one man’s life, but it will surely save many others. Why, then, do we hear not just conservatives but also many progressives trashing President Obama’s biggest policy achievement?
Part of the answer is that Bernie Sanders has chosen to make re-litigating reform, and trying for single-payer, a centerpiece of his presidential campaign. So some Sanders supporters have taken to attacking Obamacare as a failed system.
We saw something similar back in 2008, when some Obama supporters temporarily became bitter opponents of the individual mandate — the requirement that everyone buy insurance — which Hillary Clinton supported but Mr. Obama opposed. (Once in office, he in effect conceded that she had been right, and included the mandate in his initiative.)
But the truth is, Mr. Sanders is just amplifying left-wing critiques of health reform that were already out there. And some of these critiques have merit. Others don’t.
Let’s start with the good critiques, which involve coverage and cost.
The number of uninsured Americans has dropped sharply, especially in states that have tried to make the law work. But millions are still uncovered, and in some cases high deductibles make coverage less useful than it should be.
This isn’t inherent in a non-single-payer system: Other countries with Obamacare-type systems, like the Netherlands and Switzerland, do have near-universal coverage even though they rely on private insurers. But Obamacare as currently constituted doesn’t seem likely to get there, perhaps because it’s somewhat underfunded.
Meanwhile, although cost control is looking better than even reform advocates expected, America’s health care remains much more expensive than anyone else’s.
So yes, there are real issues with Obamacare. The question is how to address those issues in a politically feasible way.
But a lot of what I hear from the left is not so much a complaint about how the reform falls short as outrage that private insurers get to play any role. The idea seems to be that any role for the profit motive taints the whole effort.
That is, however, a really bad critique. Yes, Obamacare did preserve private insurance — mainly to avoid big, politically risky changes for Americans who already had good insurance, but also to buy support or at least quiescence from the insurance industry. But the fact that some insurers are making money from reform (and their profits are not, by the way, all that large) isn’t a reason to oppose that reform. The point is to help the uninsured, not to punish or demonize insurance companies.
And speaking of demonization: One unpleasant, ugly side of this debate has been the tendency of some Sanders supporters, and sometimes the campaign itself, to suggest that anyone raising questions about the senator’s proposals must be a corrupt tool of vested interests.
Recently Kenneth Thorpe, a respected health policy expert and a longtime supporter of reform, tried to put numbers on the Sanders plan, and concluded that it would cost substantially more than the campaign says. He may or may not be right, although most of the health wonks I know have reached similar conclusions.
But the campaign’s policy director immediately attacked Mr. Thorpe’s integrity: “It’s coming from a gentleman that worked for Blue Cross Blue Shield. It’s exactly what you would expect somebody who worked for B.C.B.S. to come up with.” Oh, boy.
And let’s be clear: This kind of thing can do real harm. The truth is that whomever the Democrats nominate, the general election is mainly going to be a referendum on whether we preserve the real if incomplete progress we’ve made on health, financial reform and the environment. The last thing progressives should be doing is trash-talking that progress and impugning the motives of people who are fundamentally on their side.
By: Paul Krugman, Op-Ed Columnist, The New York Times, February 5, 2016
“Health Reform Realities”: A Simple, Straightforward Single-Payer System Just Isn’t Going To Happen
Health reform is the signature achievement of the Obama presidency. It was the biggest expansion of the social safety net since Medicare was established in the 1960s. It more or less achieves a goal — access to health insurance for all Americans — that progressives have been trying to reach for three generations. And it is already producing dramatic results, with the percentage of uninsured Americans falling to record lows.
Obamacare is, however, what engineers would call a kludge: a somewhat awkward, clumsy device with lots of moving parts. This makes it more expensive than it should be, and will probably always cause a significant number of people to fall through the cracks.
The question for progressives — a question that is now central to the Democratic primary — is whether these failings mean that they should re-litigate their own biggest political success in almost half a century, and try for something better.
My answer, as you might guess, is that they shouldn’t, that they should seek incremental change on health care (Bring back the public option!) and focus their main efforts on other issues — that is, that Bernie Sanders is wrong about this and Hillary Clinton is right. But the main point is that we should think clearly about why health reform looks the way it does.
If we could start from scratch, many, perhaps most, health economists would recommend single-payer, a Medicare-type program covering everyone. But single-payer wasn’t a politically feasible goal in America, for three big reasons that aren’t going away.
First, like it or not, incumbent players have a lot of power. Private insurers played a major part in killing health reform in the early 1990s, so this time around reformers went for a system that preserved their role and gave them plenty of new business.
Second, single-payer would require a lot of additional tax revenue — and we would be talking about taxes on the middle class, not just the wealthy. It’s true that higher taxes would be offset by a sharp reduction or even elimination of private insurance premiums, but it would be difficult to make that case to the broad public, especially given the chorus of misinformation you know would dominate the airwaves.
Finally, and I suspect most important, switching to single-payer would impose a lot of disruption on tens of millions of families who currently have good coverage through their employers. You might say that they would end up just as well off, and it might well be true for most people — although not those with especially good policies. But getting voters to believe that would be a very steep climb.
What this means, as the health policy expert Harold Pollack points out, is that a simple, straightforward single-payer system just isn’t going to happen. Even if you imagine a political earthquake that eliminated the power of the insurance industry and objections to higher taxes, you’d still have to protect the interests of workers with better-than-average coverage, so that in practice single-payer, American style, would be almost as kludgy as Obamacare.
Which brings me to the Affordable Care Act, which was designed to bypass these obstacles. It was careful to preserve and even enlarge the role of private insurers. Its measures to cover the uninsured rely on a combination of regulation and subsidies, rather than simply on an expansion of government programs, so that the on-budget cost is limited — and can, in fact, be covered without raising middle-class taxes. Perhaps most crucially, it leaves employer-based insurance intact, so that the great majority of Americans have experienced no disruption, in fact no change in their health-care experience.
Even so, achieving this reform was a close-run thing: Democrats barely got it through during the brief period when they controlled Congress. Is there any realistic prospect that a drastic overhaul could be enacted any time soon — say, in the next eight years? No.
You might say that it’s still worth trying. But politics, like life, involves trade-offs.
There are many items on the progressive agenda, ranging from an effective climate change policy, to making college affordable for all, to restoring some of the lost bargaining power of workers. Making progress on any of these items is going to be a hard slog, even if Democrats hold the White House and, less likely, retake the Senate. Indeed, room for maneuver will be limited even if a post-Trump Republican Party moves away from the scorched-earth opposition it offered President Obama.
So progressives must set some priorities. And it’s really hard to see, given this picture, why it makes any sense to spend political capital on a quixotic attempt at a do-over, not of a political failure, but of health reform — their biggest victory in many years.
By: Paul Krugman, Op-Ed Columnist, The New York Times, January 18, 2016
“The Problem Is The Politics”: Sanders’ Single-Payer Plan Is A Distraction
If you’ve successfully landed on the beaches, but your forces are still taking heavy fire, what do you do? Do you concentrate on trying to hold the line and make further advances or do you sit in a circle and design a better landing craft?
The problem with Bernie Sanders’ health care vision isn’t the vision. His raw outline for a greatly simplified and less expensive health-care system is excellent in theory. The problem is the politics — the reality of which battle-scarred Hillary Clinton clearly has the better grasp.
This was the message Clinton tried to convey in the Sunday Democratic debate. Her most potent point on health-care reform centered on recalling the “public option” fiasco during the fight for the Affordable Care Act.
The public option was to be a government-run health plan competing with the private offerings in the health-care exchanges. It was a no-brainer to keep the insurance companies on a shorter leash. But, as Clinton noted, “even when the Democrats were in charge of the Congress, we couldn’t get the votes for that.”
John E. McDonough, a health policy expert at Harvard, has also been through the health-care wars. As a Massachusetts state legislator, McDonough led an unsuccessful campaign to bring single-payer to his liberal state. In a recent New England Journal of Medicine article, he explained why a similar effort in Sanders’ own state of Vermont failed.
Vermont was the great hope for we fans of single-payer. (I was waving pompoms.) The state is progressive and one footstep from Canada. Gov. Peter Shumlin was totally onboard. He spent four years trying to make a single-payer plan happen. Three major-league studies showed that it was economically feasible.
But even in Vermont, a clear public mandate for single payer never materialized. A rebellion against it almost cost Shumlin the governor’s job.
Asked about this on Sunday, Sanders took a swipe at Shumlin (who has endorsed Clinton).
“Let me just say that you might want to ask the governor of the state of Vermont why he could not do it,” Sanders responded. “I’m not the governor. I’m the senator from the state of Vermont.”
Yes, and as senator from Vermont, Sanders introduced several single-payer bills that went nowhere. The most recent one, the 2013 American Health Security Act, attracted not a single co-sponsor.
The plan Sanders released two hours before the debate remains too sketchy for a reliable independent analysis, according to McDonough. But lack of detail isn’t his biggest concern. It’s opening a new front in the battle to defend Obamacare.
“Republicans sent a bill to the President’s desk last week that would eliminate health insurance for 22 million Americans by 2018,” McDonough wrote me. “This is not beanbag. It’s the real deal, and we have to focus where it matters the most.”
“Bernie wants to lead us on a distraction tour while Republicans want to kill the progress we have made.”
How far have we come? Thanks to Obamacare, almost 18 million formerly uninsured Americans now have health coverage. A report just out of Georgetown University has the rate of uninsured Hispanic children falling to a historic low.
Insurers can no longer turn down people with pre-existing conditions. And important politically, Obamacare has demonstrated that universal coverage is doable without creating mass unemployment or “exploding” deficits. On the contrary.
Making Obamacare more Medicare-like through incremental steps may not feed the romantic urge to reinvent health-care reform from scratch, but there’s no other road, not in the America of 2016. Finally, let’s not forget that vanguard of reform is still on the beaches and taking fire.
Correction: The health policy expert at Harvard is John E. McDonough, not Thomas. We regret the error. This article has been updated to reflect that change.
By: Froma Harrop, Featured Post, The National Memo, January 19, 2016
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