What’s Behind the Fixation on Obamacare?

October 7, 2013

I’m having withdrawal symptoms. Not symptoms that my body is craving formerly-abused substances. Rather, symptoms that I want to withdraw from following what’s going on — and not — on Capitol Hill.

I’m tired, as I’m sure you are, of the day-by-day, blow-by-blow reports and commentary on who said what, what’s really on their minds, who will do what next, what they should do instead, etc.

And I’m anxious because I can’t persuade myself that this is all a lot of kabuki theater staged to ensure that Republicans up for re-election don’t lose their primaries to candidates more radically right-wing than they.

This may be simply because I’m prone to worrying — one of the things I do best, in fact.

Wonkblogger-in-chief Ezra Klein thinks the government shutdown is really a fine thing because it makes default on the debt less likely. And bad as the shutdown is, everyone knows default would be a whole lot worse.

Noam Schrieber at The New Republic arrived at a similar conclusion, based on the political calculations he supposes House Speaker John Boehner will make.

On the other hand, Howard Gleckman at the Tax Policy Center says that for many House Republicans, Obamacare is the white whale, a.k.a. Moby Dick, that so obsessed Captain Ahab.

The end result, as you may recall, was that he and all but one of his crew members died in a futile effort to kill the creature, who wouldn’t have harmed them if left alone.

There is, to me, something apt in this analogy. Obamacare clearly isn’t just a program Republicans don’t like — different somehow from the many, many other items the House leadership planned to include in its debt ceiling bill.

It’s a symbol for diverse antipathies — not the least of which is Obama. At any rate, I don’t know how else to explain what’s appearing more and more like an obsession.

Bill Moyers & Company’s Joshua Holland, among others, argues that right-wingers feel they’ve got to stop Obamacare now because otherwise Americans will soon find out that it delivers meaningful benefits.

It will thus “provide solid evidence that government can improve people’s lives.” So, Holland says, it’s “an existential threat” to the Tea Party types, who rail against “big government.”

Also, not coincidentally, against the taxes we pay for such public goods as education, clean air and water and what we’ve got by way of a safety net.

Eduardo Porter at The New York Times also refers to “an existential threat.” For him, it’s the distinct possibility that a “large slice of the middle class” will shift its allegiance to Democrats because of the benefits of Obamacare.

In short, a shrewd political calculation, rather than “only some folks gettin’ their crazy on,” in Jared Bernstein’s priceless words.

But there is some deep hostility to social programs here.

Thus, we have Washington Post columnist George Will comparing the insurance subsidies to a heroin drip that will make Americans “instant addicts” — just as we’ve become addicted to other entitlements like Social Security.

See also Senator Ted Cruz, who alleges that the President plans to get as many of us as possible “hooked on the subsidies, addicted to the sugar.”

Ah, well. Taking the most optimistic view of things, the economy will be rescued from the devastating consequences of default. And Obamacare will continue to roll out, as the law provides.

But that doesn’t mean the hard-core opposition hasn’t done damage. Some examples in my next post.


Young Adults Cannon Fodder in War Against ObamaCare

August 22, 2013

I thought I’d exhausted my reserves of outrage, but that was before some far right-wing organizations plumbed new depths of outrageousness.

FreedomWorks and allies are urging people to opt out of the opportunity to purchase health insurance through the exchanges that will open in October, thanks to the Affordable Care Act, a.k.a ObamaCare.

The campaign is targeting young adults — and presumably those toward the bottom of the income scale, since most relatively high-earners have employer-sponsored health insurance plans.

Young adults — liberally defined as under 40 — are told they should burn their (fabricated) ObamaCare cards and pay the fine for having no health insurance.

Not to worry, they’re told. You can always get care in a hospital emergency room — or health insurance when you actually need it.

True for the ER. Mostly not for the insurance — unless, as Wonkblogger Sarah Kliff explains, you have a “major change in life circumstances” and manage to have it at just the right time.

What’s meant by “major change in life circumstances” seems not to include having a serious car accident or developing symptoms of diabetes — or a serious mental illness like schizophrenia, which is commonly first experienced in late adolescence or early adulthood.

But FreedomWorks isn’t worried about the well-being of young adults — or older adults either, for that matter.

Its aim is to crash ObamaCare because efforts to kill it outright have failed. Doesn’t mean Congressional Republicans won’t take another stab at crippling it one way or the other, of course.

What with all the talk about defunding and delaying, we’re seemingly heading toward another hostage-taking effort.

Congress has already agreed to a spending package that shorts the U.S. Health and Human Services Department on funds needed to maximize enrollment — more than the agency would have needed if 26 states hadn’t decided to leave the whole exchange business to the fed.

Getting the uninsured — and under-insured — signed up won’t be easy. Only 57% of uninsured Americans even know they will soon have to buy health insurance or pay a fine, according to a recent Gallop poll.

And only 62% of all Americans know that they may be eligible for subsidies to buy it on an exchange, another recent survey found.

It may be especially hard to get young adults into the system. About a quarter think they don’t really need the insurance because they’re “healthy enough.” And many of the much larger number who want it may think they can’t afford it.

Yet everyone agrees that the long-term success of the ACA hinges on getting young adults into the insurance exchange pools. They tend, by and large, to need less health care. So the costs of insuring them offset the costs of insuring older, sicker people, who can no longer be denied coverage or charged inordinate rates.

If there aren’t enough of the healthy sort, insurance premiums will rise, which will drive more of them away, which will drive premium costs up even more. Next thing you know, you’ve got what the experts call a death spiral.

All it would take is 3 million opt-outs and “ObamaCare falls apart for good,” FreedomWorks says. Over-promising a tad, but the administration itself has put a top priority on enrollling at least 2.7 million young adults next year.

It’s nevertheless true that a small fraction — maybe 3% — of young adults who have non-group health insurance now could see premium increases because their incomes will put them over the threshold for subsidies.

The threshold for a single person would be nearly $46,000 if the exchanges were open now. Economist Jonathan Gruber, who helped design the ACA, puts the price tag for these relatively fortunate young people at $1,600-$2,000 a year. And though that may be more than they’re paying now, they’re likely to get better coverage.

FreedomWorks, however, tells all young adults that the health insurance they’ll be able to buy “in most cases will cost more than it’s actually worth.”

I seriously doubt that someone earning upwards of $46,000 a year will decide to risk bankruptcy — not to mention inadequate health care — just because s/he’ll have to pay somewhat more than if health insurers could pick and choose the way they used to.

But the message could resonate with young adults further down the income scale, including the 9 million or so who’ve got no health insurance and and may not know they could get a subsidy to buy it.

Fact of the matter is that health insurance bought on an exchange is a good deal for them. In California, for example, a single minimum wage worker would pay nothing for the lowest cost plan and as little as $44 a month for a plan that’s significantly better.

Declaring freedom from ObamaCare, as FreedomWorks urges, would cost the worker $95 initially, but $250 more in 2015 and even more every year thereafter — something FreedomWork omits from its messages.

The bigger issue, of course, is that no one — not even the so-called young invincibles — can count on freedom from a major accident or illness.

Would the folks at FreedomWorks chose the high-risk course they’re advocating for themselves or their offspring? Of course not.

I hope International Steelworkers President Leo Gerard is right when he says that young uninsured Americans won’t either.

But all concerned parties have a lot of work to do to reach them and bring them into a program that right-wingers are carelessly (in the literal sense) doing their best to wreck.


Medicaid Saves Lives, Though New Study Doesn’t Show It

May 16, 2013

My mother-in-law has just been released from the hospital, where she hastily checked in with what turned out to be a case of pneumonia and a related blood infection.

Serious for anyone, but especially someone like Mom, who’s approaching her 94th birthday.

I’ve been wondering whether she’d have gone to the hospital so fast if she hadn’t had Medicaid to supplement her Medicare benefits.

Would she instead have waited to see if the cough subsided and the breathing got easier, knowing she’d have to cover a deductible — and perhaps “coinsurance,” i.e., a copay — she couldn’t afford?

I doubt this would have crossed my mind if I hadn’t been reading responses to the recently-published study of the effects of expanded Medicaid coverage in Oregon.

As you may know, the researchers compared certain health-related measures for low-income Oregon residents who’d won and lost out in a lottery the state used to expand its Medicaid program.

No seniors like Mom in either group because Oregon, like all other states, provides some Medicaid coverage for all low-income Medicare beneficiaries who’ve also got quite limited savings and other financial assets.

So the researchers were comparing two groups of people between the ages of 19 and 65 — all quite poor, some insured by Medicaid and some with no health insurance.

Not surprisingly, they found that lottery winners used health services more, including for preventive care. Prescription medications as well.

They had virtually no catastrophic out-of-pocket expenses — also significantly less occasion to borrow money or skip paying other bills to pay those for their health care.

More surprisingly perhaps, they had significantly reduced rates of depression. (Any relationship here to relief from plaguing financial worries?)

On the other hand, the researchers found no significant effects on several basic health measures — diagnosis and treatment for high blood pressure and elevated cholesterol levels.

And though Medicaid apparently increased probabilities for diabetes diagnosis and medication, it had no significant effect on a measure used for diabetics’ blood sugar control — at least, not within the study timeframe.

This relatively small, highly technical study has proved a Rorschach test of people’s views of the Affordable Care Act, as a borrowed headline on The Incidental Economist says.

ACA opponents jumped on the findings, of course. The libertarian Cato Institute immediately saw “a huge ‘Stop’ sign” in front of Medicaid expansion.

Washington Post columnist Robert Samuelson found confirmation for his view that the ACA has been “oversold” as a measure to improve health — as indeed, has health insurance generally.

New York Times columnist Ross Douthat concluded that the study tended to support health insurance that covers only catastrophes because more comprehensive insurance doesn’t deliver better health, as ACA supporters said it would.

ACA proponents jumped on the findings too, arguing in part that protection from medical bankruptcy is a good enough reason to expand Medicaid, as the law initially required.

That, however, as they pointed out, isn’t the only benefit the study found. Many references to what one of the researchers called the “astounding finding” on improved mental health.

Some progressives also jumped on opponents for misunderstanding — or perhaps deliberately misusing — the health measure findings.

Kevin Drum at Mother Jones does a nice job here. As he explains, “significant” is used in its statistical sense, not as we commonly use it to signal something meaningful or important.

The study did find “fairly substantial improvements” for measures like high blood pressure, as Drum’s annotations of one of its tables shows. But the sample size was too small for these to meet the statistical test — a 95% confidence level.

Nearly lost in the back-and-forth on the latest paper are some findings from an earlier study by the same research team.

This one looked at several health measures, including what we might consider the most determinative — mortality rates.

Samples were large enough to get statistically significant results because the team was comparing rates in three states that had expanded their Medicaid programs with rates in three¬† that hadn’t.

Lo and behold, mortality rates went down in the expansion states — by 6.1%. That’s 2,840 fewer deaths a year for every 500,000 people who gained access to affordable health care through Medicaid.

Which brings me back to Mom, who might not be alive if she hadn’t gone to the hospital when she did.

And who probably wouldn’t be back in her own place now if Medicaid weren’t covering the costs of a home aide and a physical therapist to help her get more steady on her feet.

This isn’t statistically significant, but it’s pretty damn significant to me and others who love her.


The Message Behind the Messages in Ryan’s Budget Plan

March 18, 2013

This year I vowed not to pick apart Congressman Paul Ryan’s budget plan — the refurbished, but barely changed Path the Prosperity.

A path it certainly is. And it’s worth attending to because it shows where right-wing Republicans want to take us — if not all at once (highly improbable), then step by step. Or should I say manufactured crisis by crisis?

Specifically, as Washington Post columnist Michael Gerson indicates, they view “civil society as an alternative to government.” This should set off alarm bells among nonprofit service providers and all of us who care about the work they do.

Like last year’s plan — and the plan the year before — it purports to strengthen the safety net by block granting Medicaid and SNAP (the food stamp program), thus giving states “flexibility” to manage increasing diminished federal funds.

Except that they’d have to time-limit SNAP participation, since that worked so well for former — and now desperately poor — families dumped out of the safety net by “welfare reform.”

Retirement would be secured by converting Medicare into a modified voucher program that would jack up the per person cost of traditional Medicare, thus building a fiscal case for killing it.

Meanwhile, seniors would have to pay increasingly more for their insurance because the premium support they’d get from the government wouldn’t keep pace with rising health care costs.

And the Affordable Care Act would be repealed, including the federal incentives for Medicaid expansion. So an estimated 40-50 million more low and moderate-income people too young for Medicare wouldn’t have any health insurance whatever.

Something (unspecified) would be done to cut Social Security spending. The plan cites misleadingly over-simple life expectancy increases. So we can infer that Ryan wants the eligibility age increased again.

Also “less generous benefits.” We know by now that this is code for pegging Social Security cost-of-living adjustments to the chained CPI, which rises more slowly than the price index used now.

But the plan itself merely directs the President and Congress to propose reform legislation — a profile in courage, as one advocate remarked.

But I said I wasn’t going to write about these things. And here I am off on a tear.

The combination of what Robert Greenstein at the Center on Budget and Policy Priorities calls “reverse Robin Hood policies” and the euphemisms used to describe them does that to me.

Well, the Path will die in the Senate, just like the previous plans. So the most we can say about it as a genuine budget blueprint is that it sets the stage of another partisan standoff.

What actually struck me about the plan was the introductory justification — not the lead-off hysteria about the imagined debt crisis, but the celebration of community.

The budget, Ryan says, “makes room for community — for the vast middle ground between government and the person.” People find happiness “through friendship, … in their families, their places of worship and youth groups.”

“While we belong to one country, we also belong to thousands of communities.” They encourage our personal growth. “So the duty of government is not to displace these communities, but to support them.”

Who could argue with that? Only someone, I suppose, who thought that the federal government was — or should be — the source of our personal happiness, sense of “belonging and self-fulfillment.”

The explicit message is that our communities — and our families — face many dangers, i.e., “rising health costs, a stagnant economy, massive debt, an uncertain world.”

The federal government can do something about these, but it shouldn’t play the leading role because its proper business is to “secure our individual rights and protect … [community] diversity.”

The unspoken message is that Ryan and his right-wing colleagues aim to divest the federal government of core responsibilities for the health, well-being and economic opportunities of the population as a whole.

The proposed Medicaid and SNAP block grants wouldn’t merely shift funding responsibilities to the states — by shrinking the federal cost shares over time.

They would ultimately shift feeding and tending to the medical needs of low-income people onto local communities because it’s wholly unrealistic to believe that states would — or even could — continue to absorb the costs of retaining these critical safety net programs intact.

Nor make up for deeper, as-yet-unspecified cuts to non-defense programs that depend on annual appropriations, e.g., education, transportation, public safety, housing assistance.

They’d be billions larger than those the current law requires because the Ryan budget would shift all further mandated cuts in defense to those other so-called discretionary programs.

States could also lose funds for school meals, other child nutrition programs and Temporary Assistance for Needy Families because another $800 billion would be taken from programs that don’t depend on annual appropriations — in addition to those, like SNAP and the major health care programs, that the plan specifically names.

We would, in other words, return to some long ago time when faith-based and other local community organizations cared for the poor in their communities as best they could, with no government help whatever.

Many communities today have strong networks of nonprofit organizations that both supplement and serve as channels for federal spending on both safety net programs and others that meet vital human and economic needs.

But not all communities have such organizations.

And I doubt you could find a nonprofit anywhere that would say that it — and others in its network — could meet the needs of all low-income community members if the federal government backed out of its anti-poverty commitments.

In short, the budget plan presents a clear contrast between the right-wing Republican vision for our society and the vision President Obama campaigned on — that “we are greater together” and that government is a way we come together to help give life to values we commonly share.

Well, most of us anyway.


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