“Between A Rock And A Stupid Place”: The Medicaid Scandal Of State Level Republicans
As the reality of states refusing the insanely generous terms of the Affordable Care Act’s Medicaid expansion (viz., the Texas legislature’s proactive legislation prohibiting the state from participating), begin to sink in, with it comes the realization that a completely perverse situation will now prevail in these states. The New York Times‘ Robert Pear explains for anyone who hasn’t heard:
More than half of all people without health insurance live in states that are not planning to expand Medicaid.
People in those states who have incomes from the poverty level up to four times that amount ($11,490 to $45,960 a year for an individual) can get federal tax credits to subsidize the purchase of private health insurance. But many people below the poverty line will be unable to get tax credits, Medicaid or other help with health insurance.
You will occasionally hear that people left exposed by states refusing to expand Medicaid are “covered” by Obamacare health insurances exchanges, and that’s true for what little it’s worth. The subsidies designed to make coverage affordable for the working poor (and a big chunk of the middle class), however, don’t kick in until a beneficiary’s income is above the federal poverty line. That’s because it did not occur to the Affordable Care Act’s sponsors that the Medicaid expansion provisions covering all Americans up to the poverty line would become voluntary for the states. And you know what? Had they known the Supreme Court was going to so rule, they probably would have thought no state would hate its own poor people enough to turn down the fiscal deal represented by the expansion (that was certainly the assumption a lot of otherwise smart observers made when the Court’s decision came down). Turns out as many as 25 states may in fact go in that stupid and malevolent direction, leaving up to 5.7 million Americans at the very heart of Obamacare’s intended coverage population without meaningful access to health insurance.
Now normally you’d think a Court-created “hole” in a legislative plan of this size would lead to a legislative “fix,” wouldn’t you? But that is for sure not happening until such time as Democrats regain control of the House and of 60 Senate seats–the temporary majorities that made enactment of the Affordable Care Act over the united opposition of the GOP possible in the first place.
The scandal of state-level Republicans leaving so much federal money on the table and so many poor people in the lurch may well become a campaign issue in 2014. But while this treachery is very likely to become a long-term political issue for Republicans in the affected states–particularly in the South, where its racial dimensions are impossible to ignore–the overall landscape going into the 2014 midterm election is hardly promising for Democrats there or nationally.
So putting things right and holding the happy architects of this wildly unfair situation may take a good long while. But payback’s hell.
By: Ed Kilgore, Contributing Writer, Washington Monthly Political Animal, May 28, 2013
“Reverse Sticker Shock”: Reality-Based Evidence On Obamacare In California Amidst All The GOP Hysteria
For months now we’ve been told that the Affordable Care Act would produce a cataclysm of skyrocketing health insurance premiums, particularly in the individual insurance markets that the law most affects. Earlier this week alarms were raised particularly in California with the news that three major insurance companies had decided against participating in the health care exchanges that would offer Obamacare coverage.
So it’s a bit of a shock–sort of a reverse sticker shock–today to learn that preliminary assessments of the cost of the new, improved (because subject to new minimum coverage requirements) policies in California once the exchanges are up and running will in most cases be lower than what citizens of this high-cost state are accustomed to paying. TNR’s Jonathan Cohn summarizes the news:
Based on the premiums that insurers have submitted for final regulatory approval, the majority of Californians buying coverage on the state’s new insurance exchange will be paying less—in many cases, far less—than they would pay for equivalent coverage today. And while a minority will still end up writing bigger premium checks than they do now, even they won’t be paying outrageous amounts. Meanwhile, all of these consumers will have access to the kind of comprehensive benefits that are frequently unavailable today, at any price, because of the way insurers try to avoid the old and the sick.
Sarah Kliff of Wonkblog has more details:
Health insurers will charge 25-year-olds between $142 and $190 per month for a bare-bones health plan in Los Angeles.
A 40-year-old in San Francisco who wants a top-of-the-line plan would receive a bill between $451 and $525. Downgrade to a less robust option, and premiums fall as low as $221.
These premium rates, released Thursday, help answer one of the biggest questions about Obamacare: How much health insurance will cost. They do so in California, the state with 7.1 million uninsured residents, more than any other place in the country.
Multiple projections expected premiums to be relatively high.
The Congressional Budget Office predicted back in November 2009 that a medium-cost plan on the health exchange – known as a “silver plan” – would have an annual premium of $5,200. A separate report from actuarial firm Milliman projected that, in California, the average silver plan would have a $450 monthly premium.
Now we have California’s rates, and they appear to be significantly less expensive than what forecasters expected.
On average, the most affordable “silver plan” – which covers 70 percent of the average subscriber’s medical costs – comes with a $276 monthly premium.
Such numbers, it is important to note, do not reflect the actual cost to the estimated 2.6 million Californians who will qualify for Obamacare tax subsidies (available to those with incomes up to 400% of the federal poverty rate).
One of the “horror stories” we’ve been hearing from Obamacare opponents for years now is that the whole scheme will collapse once healthy, low-income young people realize they’ll face large news costs for the kind of minimum high-deductible catastrophic coverage they actually need. They’ll bail, it has been suggested, not only from Obamacare (screwing up the broad-based risk pools that make affordable coverage for older and sicker people possible), but from Obama’s political coalition as well. So this comment from Kliff about the California numbers is worth noting:
For a less robust “bronze” plan, which covers 60 percent of the average beneficiary’s costs, the tax credit could actually cover the entire premium for low-income twenty-somethings.
None of this should really be that surprising; the idea that a broader pool plus competition and guaranteed benefits would provide a better bargain (plus vastly greater security) for consumers in the individual market was central to the entire Affordable Care Act architecture. But it’s taken a while for facts to catch up with all the negative agitprop. It won’t keep House Republicans from voting to repeal the entire law a 38th or 39th or 40th time before the bulk of the Affordable Care Act becomes effective next year. Still, it’s nice to see some reality-based evidence amidst all the hysteria.
By: Ed Kilgore, Contributing Writer, Washington Monthly Political Animal, May 24, 2013
“Panic Is Just What Republicans Want”: Democrats Shouldn’t Take GOP’s Bait On Obamacare Implementation
The notion that Obamacare’s implementation could become a major liability for Democrats in 2014 is gaining widespread currency, and today it’s the subject of a big New York Times piece reporting on confident predictions by Republicans that implementation problems will give them a powerful weapon against Dem candidates. Obama is set to do a series of events designed to educate the public on the challenges of implementing the law, beginning with one on Friday where he’ll promote the law’s benefits for women.
It strikes me that GOP Obamacare implementation triumphalism is a tad premature.
Here is how the Times characterizes the sentiment in Dem circles about the coming war over implementation:
Democrats are worried about 2014 — a president’s party typically loses seats in midterm years — and some have gone public with concerns about the pace of carrying out the law. Senator Harry Reid of Nevada, the majority leader, told an interviewer last week that he agreed with a recent comment by Senator Max Baucus of Montana, a Democratic architect of the law, who said “a train wreck” could occur this fall if preparations fell short.
The White House has allayed some worries, with briefings for Democrats about their public education plans, including PowerPoint presentations that show areas with target populations down to the block level.
“There’s clearly some concern” among Democrats “that their constituents don’t yet have all facts on how it will work, and that Republicans are filling that vacuum with partisan talking points,” said Representative Steve Israel of New York, head of the House Democrats’ campaign committee. “And the administration must use every tool they have to get around the obstructions and make it work.”
Quotes like these are widely held up as evidence that Republicans are right that Obamacare implementation is shaping up as a major problem for Dems. But this amounts to a fundamental misreading of what it is these Dems are actually saying. Democrats are simply doing exactly what they should be doing — that is, calling for care and caution in the implementation of Obamacare, and calling for a serious effort to educate the public about the challenges and potential pitfalls it entails. This is not tantamount to running away from the law wholesale; nor is it a concession that implementation will amount to a major political albatross.
As Jonathan Cohn has detailed at length, it’s very possible there will be real problems with the health law’s implementation. If that happens, Republicans will relentlessly try to tie Dem candidates to those difficulties, in hopes for a rerun of 2010. But in 2010, public reactions to the new health law were largely suffused with deep anxiety about the severe economic crisis and uncertainty about the new president’s ability to cope with it. Republicans and allied groups made the assault on Obamacare central in 2012, in the presidential race and in many Senate contests, with absolutely nothing to show for it.
Will implementation make things different in 2014? By all means, the problems could be very real, particularly with Republicans intent on subverting implementation wherever possible. Dems should remain vigilant and prepare for turbulence. But they needn’t fret this too much. For one thing, as Josh Barro has noted, implementation is likely to be most keenly felt among those who currently lack insurance, who will naturally see getting insurance as a preferable outcome to nothing at all, even if it proves logistically difficult.
Dem candidates can strike a balance here: They can call for careful implementation and criticize it when it goes awry, while standing squarely behind the law’s overall goal of expanding coverage to the millions of Americans who lack it. What’s more, they can continue to remind the public that Republicans are offering no alternative of their own and simply want to return the country to a pre-reform free-for-all that nobody, particularly the large ranks of the uninsured, wants. This position is the correct one to take, substantively and politically, and it shouldn’t be that hard to get the balance right. After all, whatever the unpopularity of Obamacare, offering nothing in the way of reform isn’t exactly a winning message, either. Major reforms are not easy, and Dems can say so, while pointing to the endless GOP drive to repeal the law to reinforce the notion that Republicans have no interest in actually addressing the country’s most pressing problems.
Dems should refrain from displays of political panic, since panicking is exactly what Republicans want them to do. “A lot of this is psychological warfare,” is how Dem strategist Doug Thornell recently put it. “I would tell Dems not to take the bait.” So would I.
By: Greg Sargent, The Plum Line, The Washington Post, May 7, 2013
“Unconscionable But Irrelevant”: Florida GOP Legislature Puts Politics Over People
It seemed like a breakthrough moment. In late February, Florida Gov. Rick Scott (R), who had made hating “Obamacare” his raison d’etre, announced his support for the Medicaid expansion policy in the Affordable Care Act. The Republican governor said at the time, “I cannot, in good conscience, deny the uninsured access to care.”
It was an open question whether Scott’s principal concerns were with the uninsured or the state hospitals he’s been friendly with in the past, it was nevertheless welcome news for health care advocates. Florida’s governor, an unlikely ally, had cleared the way for bringing health care access to 1.3 million Americans, expanding the reach of Obamacare to new heights.
At least, we thought so at the time. What was unexpected was Rick Scott’s own legislative allies ignoring the governor’s wishes and punishing Florida on purpose.
Scott wouldn’t be the one to “deny Floridians” a part of the health care law — but the Florida legislature had other plans. Lawmakers adjourned Friday after passing a budget that does not include funding for a Medicaid expansion. Unless the Republican-controlled legislature comes back for a special session later this year — which some Democrats are calling for — Florida will not expand Medicaid in 2014.
In Florida, where one in five non-elderly residents lack insurance coverage, the consequences are especially large: An estimated 1.3 million Floridians were expected to gain coverage through the Medicaid expansion. About a quarter of those people — Floridians earning between 100 and 133 percent of the Federal Poverty Line — would still be eligible for tax subsidies on the health insurance exchange.
As we talked about in March, Scott isn’t the only Republican governor in this boat. In Ohio and Arizona, GOP state lawmakers remain reluctant to accept Medicaid expansion, regardless of its benefits, and regardless of the wishes of their Republican partner in the governor’s office.
But the move in Florida is especially jarring given the circumstances — the state has an enormous Medicaid-eligible population, and was poised to receive $66 billion in federal funds over the next decade. What’s more, Florida already has struggling public hospitals, which will now be in even worse shape.
A Democratic state senator called the Medicaid decision “unconscionable,” which is true, but apparently irrelevant to state GOP lawmakers.
By: Steve Benen, The Maddow Blog, May 6, 2013
“Managing Expectations”: How Conservatives Are Helping Obamacare
Yuval Levin, among other conservatives, has made an offer to liberals: Let’s delay the implementation of Obamacare for a year and make everybody better off:
Congressional Democrats surely want to avoid being blamed for a meltdown of American health care during a congressional election year, the people implementing this law at every level could certainly use the time, and Republicans believe that more time would not make Obamacare more popular but would allow them to further develop and articulate their alternatives (and allow another election to intervene earlier in the rollout process, making a replacement more plausible).
Liberals, wisely, are saying no. What’s funny about this conversation is that conservatives have been accidentally managing expectations for implementation: By harping constantly on what a disaster the rollout is going to be, they will make what actually happens look good by comparison.
Jonathan Cohn has a good piece in the New Republic arguing that implementation won’t be as bad as people are saying. This is his really important observation:
Notice that the worries about implementation chaos apply strictly to people who would otherwise be uninsured or at the mercy of the existing individual insurance market, in which plans are inconsistently priced, full of coverage holes, and of unpredictable reliability — and in which financial assistance for buying private coverage is not available at all. Even if it takes these people a while to get insurance, and even if finding that coverage is a maddening experience, they’re going to end up with something they don’t have now: Coverage that meets more of their needs and is available to them, with substantial financial assistance. Don’t forget: Today, people with pre-existing medical conditions frequently cannot get any coverage on the individual market.
This is something that has been lost in the discussion of Obamacare implementation difficulties:
Implementation won’t much affect the 78 percent of Americans currently covered through Medicaid, Medicare, or employer group health plans. It will make some people who currently buy individual coverage worse off. But only 5 percent of Americans get insurance through the individual market, which is already hugely dysfunctional. Three times as many Americans are currently uninsured, and they can only stand to gain from Obamacare implementation, even if it does not go smoothly.
For those 5 percent who buy individual coverage now, the new law will be a mixed bag. Some people will probably have frustrating bureaucratic experiences with the new exchanges that they didn’t have buying directly from insurers. And some people (particularly young and healthy people) will see their premiums go up. But others will see their premiums go down, either because they currently pay a lot because of age or health status, or because income-based premium subsidies will more than offset any premium increase.
There will also be people who lose group health coverage, when premium subsidies make it attractive for their employers to send them to shop in the exchanges. (Others will gain group coverage if employers decide it is better to offer it than to pay a penalty for uninsured workers.) But neither this effect nor any problems faced by people with existing individual insurance is likely to create a clamor for repeal that is any more effective than the din of the last three years.
That is because the most obvious way to fix the problem of those who have trouble in the health exchanges will be to fix the exchanges, not repeal them. Let’s say your employer dropped group coverage and you’re having trouble with the exchange. Will you want the whole law repealed in the hope that will lead your employer to reverse course and offer a group plan again? Or will you want the exchange fixed so you are guaranteed access to coverage?
Cohn looks back to Medicare Part D and the Children’s Health Insurance Program and argues that those programs got through their rocky implementations in large part because benefits obtained with bureaucratic difficulty are better than no benefits at all. He’s right, and this is why conservatives are “magnanimously” offering to delay implementation of Obamacare. They realize that once people have guaranteed access to health coverage, they won’t want to give it up, even if there are implementation problems.
The political landscape is already dire for those who still hope to repeal Obamacare, and they’re actually making their position worse by talking constantly about what a nightmare implementation is going to be. This fall, as the exchanges come on line, tens of millions of people are going to find they can get health coverage they never could before. They are likely to be quite happy about that, especially if they’ve been hearing for months in advance that it will be a mess.
By: Josh Barro, Bloomberg, April 29, 2013
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