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Sunday, March 25, 2012

Waiting for the test results

by digby

Gosh, this is awfully helpful:

Grilled about her support for the Affordable Care Act, Sen. Claire McCaskill (D-MO) told a home state radio interviewer that the law’s core structure is “exactly” like the House GOP Medicare privatization plan that conservatives support and liberals detest.

“The irony of this situation is that these are private insurance companies people will shop to buy their insurance. It’s not the government,” she told KMOX of St. Louis on Wednesday. “It’s exactly what Paul Ryan wants to do for Medicare.”

“It’s subsidized by the government — premium subsidies — which is exactly, this is the irony,” continued McCaskill, who faces a tough reelection battle this fall. “You think what Paul Ryan wants to do for seniors, you think it’s terrific. But when we want to provide private health insurance for people who don’t have insurance with subsidies from the government, you think it’s terrible.”

It will be an amazing irony if the ACA ends up being the logic behind privatizing Medicare. And McCaskill isn't alone in this analysis by any means. Here's Ezra yesterday:

Republicans’ long-term interests are probably best served by Democratic success. If the Affordable Care Act is repealed by the next president or rejected by the Supreme Court, Democrats will probably retrench, pursuing a strategy to expand Medicare and Medicaid on the way toward a single-payer system. That approach has, for them, two advantages that will loom quite large after the experience of the Affordable Care Act: It can be passed with 51 votes in the Senate through the budget reconciliation process, and it’s indisputably constitutional.

Conversely, if the Affordable Care Act not only survives but also succeeds, then Republicans have a good chance of exporting its private-insurers-and-exchanges model to Medicare and Medicaid, which would entrench the private health-insurance system in America.

That’s not the strategy Republicans are pursuing. Instead, they’re stuck fighting a war against a plan that they helped to conceive and, on a philosophical level, still believe in. No one has been more confounded by this turn of events than Alice Rivlin, the former White House budget director who supports the Affordable Care Act and helped Ryan design an early version of his Medicare premium-support proposal.

“I could never understand why Ryan didn’t support the exchanges in the Affordable Care Act,” Rivlin says. “In fact, I think he does, and he just doesn’t want to say so.”
Actually that's a very foolish assumption. What Ryan supports is an unregulated, private insurance market in which the old, the sick and the poor would buy sub-standard coverage because that's all they will be able to afford. And if they can't afford any at all, or are too expensive to cover, the insurance companies and the health care providers will be allowed to turn those irresponsible looters and moochers out into the street. As Ron Paul famously said about a sick, uninsured citizen,“What he should do is whatever he wants to do and assume responsibility for himself. That’s what freedom is all about, taking your own risk. This whole idea that you have to compare and take care of everybody…”

That's what the Ayn Rand acolyte Paul Ryan believes too. But until he can achieve total freedom for John Galt, he'll be glad to use Obamacare to degrade and destroy the guaranteed old age health care we currently have, however he can. And the good news is that Democrats are apparently going to help him.

Ezra's analysis yesterday was a dispassionate look at the political strategies of both Parties to explain where this argument would logically lead. And the upshot is that the GOP would be smart to get onboard with Obamacare if they want to destroy Medicare because otherwise the crazy liberals will somehow ram through single payer. (Why he thinks that's going to happen, I don't know. The last I heard from all the Very Serious People was that the ACA was the last chance for health care reform for a generation.) This is an expansion of an earlier post in which he argued that privatizing Medicare and medicaid along the lines of Obamacare is a win-win for everyone:

If Republicans can make their peace with the Affordable Care Act and help figure out how to make the Affordable Care Act's exchanges work to control costs and improve quality, it'd be natural to eventually migrate Medicaid and Medicare into the system. Liberals would like that because it'd mean better care for Medicaid beneficiaries and less fragmentation in the health-care system. Conservatives would like it because it'd break the two largest single-payer health-care systems in America and turn their beneficiaries into consumers. But the implementation and success of the Affordable Care Act is a necessary precondition to any compromise of this sort. You can't transform Medicaid and Medicare until you've proven that what you're transforming them into is better. Only the Affordable Care Act has the potential to do that.
This is why I'm afraid to say that #IlikeObamacare. Ezra's arguing that if Obamacare works great everyone will want to extend it to Medicare. My feeling is that in this political environment it's far more likely that everyone will just extend Obamacare to Medicare, regardless of whether it works well. Indeed, if it doesn't work well, it may even make it more likely. After all, if the costs come down because the Medicaid expansion is whittled away, I could quite easily see Democrats strutting around and counting that as a great success. (At least that's what they usually do when they agree to massive, painful spending cuts.)

Sorry -- I don't trust anyone on this issue. If Obamacare is upheld and gets implemented and it eventually results in universal, affordable health care in this country I will consider it a success. Until then, I don't even want to hear a whisper about rolling the sickest and most vulnerable members of the population -- the elderly -- into it. I just have a sneaking suspicion that Paul Ryan isn't quite as dumb about this as everyone seems to think he is.

Update: Howie writes:

Blue America has endorsed two doctors running for the House, Lee Rogers (CA) and David Gill (IL)-- and neither is ecstatic about Obamacare, although they both think it's a step in the right direction. Here's Lee Rogers, who's running against anti-healthcare fanatic Buck McKeon in a newly redrawn swing district that covers Simi Valley, Santa Clarita, Porter Ranch and the Antelope Valley northeast of Los Angeles:
It's understandable why congressional leaders wanted to reform our health care system after President Obama took office. But the Affordable Care Act is far from an ideal system like a single payer plan or "Medicare-for-all," as some have put it. Certainly there are good parts of Obamacare, like forcing insurance companies to spend 85 cents of every dollar on actual health care, eliminating pre-existing conditions as a determinant for coverage, and allowing adult children to stay on their parent's insurance until age 26.

But there are sections that are not good for patients or providers. Accountable Care Organizations (ACO) will function like HMOs for Medicare patients, potentially limiting access to providers and services. The Independent Payment Advisory Board (IPAB) is an executive branch appointed group that will legislate reimbursement rates for Medicare, but to be overruled, it will take a 3/5th majority of Congress. While pre-existing conditions can't be used to deny you coverage, there are no caps on what insurance companies can charge you. So you could be effectively priced out of the market. Overall, Obamacare was a step in the right direction, but there are many areas that need to be refined and reformed until we have a law that promotes affordable, quality care. We still have a long way to go and that's why we need elected officials who understand the system of health delivery to help shape the future of health care.
Dr. David Gill won his primary in Illinois Tuesday and we just moved him over to the mail Blue America page today. He's a longtime single payer advocate and last night he explained his feelings about the Affordable Care Act:
"The ACA was but a first little baby step toward meaningful health care financing reform here in America. There are some good provisions within the bill, but it leaves intact the basic paradigm of reliance on a private health insurance industry whose primary goal is the maximizing of profit.

"What we must do, instead, is to expand and improve Medicare. Uncle Sam runs Medicare at an overhead of 2-4%, while the private health insurance companies run up overhead and profit-taking of 10 times that amount. Uncle Sam is not in the Medicare business to make money, which is the fundamental difference between Medicare and the private carriers.

"We currently throw away up to 40% of our "health care" budget-- nearly $1 trillion per year-- on a health insurance industry whose primary goal is not the well-being of people. We can do so much better. It is a moral failure to stand by while an American citizen dies every 12 minutes just because they lack health insurance-- we are a better people than that. We will be far healthier and far wealthier as well, when we finally abandon the private health insurance industry and put in place a single-payer system."
Dr. Gill and Dr. Rogers both know how to make meaningful healthcare reform work for their patients and for the system. Blue America is backing them both for winnable congressional seats. And now they're both on the same page.

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