Tuesday, September 24, 2013
The saga of Obamacare: the reckoning
Politico is out this morning with a history of the health reform implementation called "One blow after another" which brings up a lot of bad memories for people who followed the saga closely back in 2009 --- particularly those, like me, who were supportive of the final bill based on the most liberal piece of it, the Medicaid expansion:
“It’s underappreciated how fundamentally the Supreme Court changed the law when it made Medicaid a state option,” said Drew Altman, president and chief executive officer of the Henry J. Kaiser Family Foundation. “The law that is being implemented is not really the law that passed the Congress.”
The good news is that the blue states have all implemented it, like sane people, and their health insurance coverage is going to reach a lot more people when all is said and done. Sadly, many of the poor people who live at the mercy of Republican assholes will just have to suffer and die. Ain't that America ...
The Congressional Budget Office estimated in 2010 that Obamacare would reach 32 million uninsured over a decade. Now only 25 million people are expected to get covered over the next decade.
As written, the law required states to expand the Medicaid program to cover people who make up to 133 percent of the federal poverty level — or about $31,000 for a family of four. Now there will be a coverage gap for people who are too poor to qualify for federal subsidies to purchase insurance on the exchanges but not poor enough to access Medicaid in states where governors refused to broaden the program.
In Texas, where Republican Gov. Rick Perry is one of the law’s staunchest foes, that decision will have a wide-reaching impact, said David Lopez, president and CEO of The Harris Health System in Houston, one of the nation’s most uninsured cities.
Of the 1.5 million patients who visit his hospitals or clinics each year, about 400,000 would have qualified for Medicaid payments if Perry had expanded the program, Lopez estimates. But now, nearby residents will be forced to pick up the tab.
“If we don’t have Medicaid expansion, the responsibility of the care of those individuals falls back to the local community,” he said.
But never let it be said that some of us didn't predict that this Medicaid expansion for the working poor would be the first to go or that the GOP would work night and day to obstruct implementation. December 17, 2009:
The Medicaid provision is obviously a good expansion of the safety net. But with Ben Nelson an alleged Democrat already arguing for scaling that back along with the inevitable convergence of deficit fever, immigration and tiresome old "welfare" arguments to attack it, I think it's awfully vulnerable as well. (The Medicaid constituency could probably use some ACORN organizing to vote on the issue, but the congress decided to throw them under the bus on the basis of a doctored gonzo video and some shrieking from FOX news.)
There has been no public education about responsibility to buy insurance in all this or any strategy to manage expectations of what people will get with Health Care Reform. And because of that the right is going to have a field day telling everyone that the nanny state liberals are forcing them to give to money to insurance companies and then spending their tax money on poor (brown/black) people. So, again, running around saying "Mission Accomplished" is bad politics.
As for the promise to fix all the problems once the bill is in place, I think people are vastly underestimating the forces that are going to be brought to bear to prevent that from happening. Republicans aren't so disorganized that they forgot that they must stop Democrats from giving people reason to believe in government. In addition to deploying their formidable communications apparatus to present health care reform as a massive failure to the majority who are currently covered by employers and will only see the effects from afar, they are going to strangle improvements in the cradle by any means necessary including leveraging their most valuable new voting demographic in the age of Obama --- the elderly. On top of that, we are entering an era of deficit fetishism and have an industry that has shown it will do everything in its power to protect its interests. It's not impossible, but watching the Democrats operate at the zenith of their institutional power over the past year does not give me any confidence that they want to, much less can, battle all that back.
I never said to kill the bill. I don't actually think it's possible to do it at the hands of liberals. (It's health care.) I was hopeful that it would be better. Now the Democrats are going to have to sell this plan to the public, fight off the deficit scolds and the industry and keep the teabaggers from immolating themselves on the steps of congress just to prove that death panels exist. I think it's going to be a hard sell and the political risks of this particular bill at this particular time are tremendous.
I don't know how this bill will play out politically. It's not what I thought health care reform would be, but it is definitely is better for the working poor if we can hang on to the funding, which I think is dicey. As for the rest, we'll see.
But the first thing Democrats need to do is dial down the end-zone dance and start talking about this bill for what it is. Indeed, if I were them, I'd work hard to lower expectations. I do not believe this legislation will be exempt from repeal or serious whittling away as time goes on nor do I think that the political system will allow the quick fixes that will be necessary to keep people on board while they get the reforms in place, regardless of whether the Republicans come back into power during the implementation period, which they very well could. This just isn't a big New Deal style social insurance program and selling it in those terms is setting the stage for a backlash. It's going to be tough. People should be prepared for that.
Unfortunately, the Democrats in DC were so busy taking victory laps and congratulating themselves for their historic FDR-like statesmanship --- and repeatedly assuring everyone that Miss Bringdowns like me were full of shit because: awesome that they didn't see this coming:
Republicans haven’t even gotten close to repealing Obamacare — Democrats insist they never will. But they’ve made the law exponentially tougher to implement than the White House anticipated.
The extent of the challenge became clear soon after Obama wrapped up the East Room signing ceremony in March 2010.
White House aides quickly got to work on a technical corrections bill to clean up messy language in law. They assumed Congress, as it has done so many times in the past, would send it through. Republicans refused — and that cemented flaws in the law that continue to cause problems.
For instance, workers can opt out of their employer insurance — and go on the exchange — if their share of the premium is more than 9.5 percent of their household income. But the law calculates that based on the worker’s premium, not the whole family’s. Advocates of the law have dubbed that “the family glitch” — one that will limit coverage.
Congressional Democrats had also assumed that most governors, particularly Republicans who consider local control a core party philosophy, would set up and run their own state-based exchanges. Drafters of the law didn’t even add the federal backstop until late in the legislative process.
But only 16 states and the District of Columbia decided to take the lead. Six others are partnering with the federal government. The federal government will run insurance exchanges by itself in the other 28 states.
“I didn’t support Obamacare, but it is the law of the land,” New Mexico Gov. Susana Martinez, a Republican, said in March when she signed a bill to set up an exchange, which later was converted to a state-federal partnership for 2014. “My job is to implement this law in a way that best serves New Mexicans.”
The disparity adds another layer of confusion to the rollout. A recent Pew Research Center survey found consumer awareness about the exchanges is much lower in states that have deferred to the federal government. Only 44 percent of people in those states said they’d have access to an exchange versus 59 percent in places with state-based exchanges or state-federal partnerships.
“Everyone knew it was complex,” said Alan Weil, executive director of the National Academy for State Health Policy. But as the law is actually put into practice, “you see more complexity than anyone thought when the law was passed.”
I would have thought it was obvious to anyone who tried to explain how it was going to work
but again, most political supporters just said that the government had "given" health care to 30 million uninsured and left it at that. It was inevitable that there would need to be many fixes to such a complicated bill even before the courts got hold of it. And it was obvious that the Republicans would not help. Not that this should have stopped them from doing it --- but it should have guided their approach to explaining it at least.
I feel for the bureaucrats who are doing this work. It's not easy. But if you want to see how a state that is committed to making it work has laid it out for the public, take a look at Covered California , the California exchange website. It's certainly no more complicated for the person trying to buy insurance than the current marketplace --- and it's going to result in a lot of middle and working class independent workers getting cheaper, better health insurance. And hopefully, a lot of struggling workers at the lower end will find out that they now are entitled to government health care through Medicaid.
Is it as good as government programs that guarantee health care for everyone like Medicare or the VA? Obviously not. But if it's properly implemented it will be a substantial improvement on the status quo. And I would have thought that anyone who had observed the American right wing over the years would have known they would do everything in their power to ensure that it didn't work. Did they think they were going to take this lying down? They take nothing lying down.
I don't know how fair this Politico article really is. Not only are the reforms complicated, but the story about the reforms is complicated and this is a very village centric piece. But there are pieces of it that are correct just on its face, most obviously the fact that the Democrats seemed to truly believe that simply passing the bill would be enough to insure its success. As with so many other issues, they spent so much time patting themselves on the back that they were taken by surprise when the Republicans managed to mount a successful propaganda campaign against the reforms and the right wing Court dealt it a lethal blow to the most liberal piece of it.
Hopefully, these delays and glitches will work themselves out over time. If states like California succeed in the next few years in getting most of their people insured and rates
stay reasonable, it is likely inevitable that the other states will eventually put omething together to match it. Employers will demand it if nothing else. But a little humility in the beginning would have gone a long way toward preparing everyone for this fight and given Democrats, at least, a heads-up that it wasn't over until it was over. It was all about "putting points on the board" and moving on to the next play. That's sports, not governance.
digby 9/24/2013 09:00:00 AM