Sunday, October 06, 2013

What Obamacare does, and what the shutdown does

(A friend asked me for my thoughts on the Affordable Care Act. Thought I should turn my answer into a blog post.)

The quick summary: I support the Patient Protection and Affordable Care Act (ACA, or Obamacare). It's a far, far cry from perfect legislation and has a lot of flaws, but it's much better than the previous status quo. Even if I opposed it, however, I would not support shutting down the government over it. I'm no expert, but I am a well-read news junkie and political professional, and I've included a lot of links and sources in this post you can follow for more information.

The details: The ACA can be summarized -- warning, gross oversimplification coming -- in three buckets. The first two are very popular. The third is where most of the controversy lies, but is what makes the first two possible. On that note, it's worth pointing out right at the top that though most people say they oppose the law, some of those same polls show they also don't know what's in it. And when they're asked if they support this specific policy or that specific policy, they do, without realizing they're part of the ACA. (Indeed, Obamacare has a 46-29 approval rating and the ACA is at 37-22 in a recent CNBC poll, but one's a nickname for the same legislation.)

(Rather than cite every single fact of the ACA contents I'm about to list, though I cite many, here are two other summaries: Ezra Klein and the Kaiser Family Foundation).

First, the ACA forces some reforms of insurance itself. The biggest piece here is that it bans insurance companies from turning away new customers who are already sick -- ie, who have a "pre-existing condition". That kind of discrimination made sense for someone who gamed the system by waiting to buy insurance until they were sick, but what about someone who got sick when they couldn't afford insurance and can now never get it, or who lost their job & insurance while already sick? Equally importantly, one such "pre-existing conditions" was being a woman, because you might get pregnant and cost the insurance company more, so women often paid 50% more than men for an equal product. That's now illegal. Other reforms include a ban on lifetime caps, allowing younger people to stay on their parents' insurance until they're 26, Medicare cost cutting measures to help lower the cost curve (if not actual cost) of health care (yes, it may lead to rationing, but if one opposes that, it's worth noting that the insurance corporations already do it)(this is what Palin called the death panel, but it's for whole policies, not individual grandmas), requiring the inclusion of maternity care and birth control in policies (some conservatives, especially Catholics, argue that this is an assault on religious freedom, not just for religious organizations -- I might agree -- but also for religious small business owners -- I don't), requiring insurance companies to spend a certain % on actual care rather than overhead, and more. Because of some of these cost-cutting and efficiency-increasing reforms and a few other provisions (fees on those who opt out, more efficiency in certain Medicare programs, and a few other small taxes and fees), despite a big price tag, the law actually REDUCES the deficit.

The second bucket: It expands insurance coverage. What launched this month are these exchanges or marketplaces where people can browse many different health insurance plans. The bill also includes subsidies for folks up to 400% of the poverty level (how much you can get is tied to your income). So all of a sudden, better insurance at a lower price than ever before is available to many of the nation's 47 million uninsured legal residents. Just this week, many now-former opponents are finding they can save lots of money and get better care.

Third, the only way to make this work is to require everyone to get insurance -- the individual mandate. By bringing in more young and healthy consumers, the insurance companies are able to afford everything I outlined above; otherwise, it would be a huge burden for them. But, it's not just a revenue necessity if you want the above. It's also good policy -- when someone without insurance gets sick and can't pay their hospital bills, one of two things happens. Either the price for everyone else goes up, like with shoplifting, or the government picks up the tab. And of course, preventive care or catching diseases early is much cheaper than waiting until you're really sick. So requiring everyone to have health care will both make all of the above possible and lower costs. BUT, this is the most controversial provision, more so even than rationing, requiring birth control coverage, or even new taxes. Libertarians and right-wing conservatives say it's an assault on our freedom -- that the government shouldn't be able to force us to buy something we don't want. I disagree for at least three big reasons: The benefits far outweigh the costs; my freedom to swing my fist ends where your nose begins (quoting Justice Holmes), hence the second point in this paragraph; and if we can require driver's insurance for getting a car, why can't we require health insurance for using health care -- and how could we morally block the uninsured from using it? We'd be a country of people bleeding in the streets.

One other mandate is that businesses with at least 50 employees must give insurance to their employees or pay a small fine. (Another attack on our liberties, I guess.) This is blunted by the facts that new tax credits will help small businesses and that 96% of businesses over 50 employees already offer health care anyway. Some, like Trader Joe's and Home Depot, have even decided to cancel existing insurance for part-time employees because they can get better insurance for less on the exchanges. (There has been a drop in workers' hours lately that many blame on the cost of the employer mandate, but other economic factors may also be at play.)

In no way is any of this socialism, ie, where "the ownership and control of the means of production and distribution" are held by the government. The ACA does not force anyone to have government-run insurance like Canada; in fact, it doesn't even give anyone new that choice via a "public option." Instead, this actually forces people into doing business with the PRIVATE insurance companies. This is indeed a MARKET-BASED solution based on ideas from… wait for it… Republicans in 1989 and again in 1993. Small wonder the one governor to do something similar at a state level was the business-minded Mitt Romney in 2006.

So yeah, I support it. I tried to mention some of the opposition's arguments in order to be fair, but I think these trade-offs are worth it. It's certainly not ideal, for many reasons, I acknowledge that. A public option would save money and be more efficient. It's more focused on expanding coverage than it is lowering costs, but we need both. There are still many, many problems left to solve, including that: insurance and care shouldn't be for-profit or tied to employment; the Medicare "doc fix" that costs doctors a fortune unless fixed annually still exists; many GOP governors are turning down the law's paid-for Medicaid expansion on principle and thus some poor folks will remain uninsured; and for-profit hospital systems will still order way too many unnecessary tests because they know insurance companies will pay for them, thus driving up costs for all of us. But despite these flaws, some problems are fixed and the new ones that have been created are smaller than the ones that were fixed, for a net gain.

Yes, like with any new law, it has not just gaps but glitches and failures -- the website rollout has highlighted a few. No big new law is perfect, but as implementation exposes flaws, Congress usually fixes them -- look how many times Medicare's been overhauled. That's not happening now; the GOP refuses to let those bills pass. Either live with the broken law and suffer the political consequences or repeal all of it, they say, which hurts Americans. Not to be overly partisan, but just looking at the facts, I can't help but believe that's spiteful, harmful, and perhaps even unpatriotic.

But even if I didn't support the ACA, I would still be opposed to shutting down the government over it. When the government shut down in 1995, it was because Congress and the president couldn't agree over HOW to fund it. This time, they're saying we'll only do X if you do Y on a separate issue, even though we basically all agree on X. The votes exist to pass a straightforward spending bill, but the Speaker of the House won't bring it tothe floor. Instead, he's putting party before country and bowing to a majority of his caucus -- a majority of the majority, but a minority of the chamber -- that says don't fund the government unless a recently re-elected president agrees to defund or delay his biggest accomplishment. And it's not just a majority of our elected lawmakers who would support a "clean" funding bill if they could vote on it, but a majority of Americans. 72% oppose halting the government over health care (Quinnipiac) -- but no vote is allowed. Can you imagine anything more undemocratic (lower-case d)?

The law was passed and signed. Obama then campaigned on it and was re-elected by a comfortable margin, Democrats expanded their Senate majority and won a plurality of the popular vote for the House (but thanks to gerrymandering, not a majority of seats), and the Supreme Court ruled the law Constitutional. And now a reduced GOP majority in one half of one branch won't do their jobs and fund the government unless the other side gives up their entire agenda? That kind of tactic is unprecedented in modern history. Don't get me wrong; I wouldn't ask the GOP to stop trying to change or even repeal Obamacare -- that's what they stand for (or rather, against) -- but there's a huge tactical middle ground between shutting down the government and giving up. Shutting down the government means 800,000 workers without paychecks; a hit to the small businesses near their offices like lunch delis and Walgreens; no EPAenforcement of clean air or clean water; a potential suspension of the WIC program that helps 9 million low-income moms feed their children; shuttered National Parks (that's not just ruined vacations, but a huge economic blow to park-border towns like West Yellowstone, MT or Forks, WA); a suspension of safety inspections for food, new drugs, and new consumer products like toys and cars; a suspension in science and cancer research funds; a slimmed-down FEMAand National Weather Center just as another hurricane barrels through the Gulf; kids with cancer being turned away from new treatment at the NIH; no veteran's benefits or disability checks; a halt to the CDC flu program at the beginning of flu season; no processing of new mortgages or small business loans; and so on and so forth. How the hell is that worth fighting expanded access to affordable health care, no matter what the law's specific provisions may be? And like I say, the votes exist to end this shutdown right now. The Senate can't pass the House bill, but the House can pass the Senate bill; Boehner just won't give it a vote. Also, this.

I have problems with the Democrats too, but this is not "a pox on both your houses." Some of the best lawmakers we've ever had were Republicans, but they're sure not in office right now.



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