Tuesday, March 27, 2012

Health care reform and its problems

The Supreme Court's review of what even the President is now calling "Obamacare" reminds me again of the policy and practical political problems with the ACA (Affordable Care Act).

Obamacare is the main domestic achievement of this Administration. And the public has more of a negative than a positive impression of it.

Cenk Uygur of The Young Turks is no doubt right in assuming that the Administration's indifferent defense of the ACA in face of non-stop Republican attacks over the last two years has ceded the active opinion-making on the subject to the program's enemies.

The lack of a public option is a huge problem. The public option would have been a major factor to force private insurers to keep their rates restrained. It would also have led in the direction of a single-payer system.

The individual mandate combined with the absence of the public option is seriously problematic. The mandate is necessary. Unless everyone participates, the important goal of restraining health care costs and health insurance cost is undermined. If people are mandated to buy private insurance, without a public option available, and without a low ceiling on deductibles, the insurance companies could wind up selling what for most people would be "junk" insurance, i.e., insurance with such high deductibles that it wouldn't cover most of the costs those covered would use in any given year.

This would damage the effectiveness of the program, because part of the reason for coverage is so that people will go to the doctor early in the stage of being sick, when treatment is more successful and cheaper. If people are stuck with a $5,000 deductible, the program won't provide that incentive. And people who are forced by law to pay several thousand dollars a year without being able to get their actual health expenses in a year covered with understandably be upset and the mandate.

Exemption of undocumented immigrants is also big hole in the ACA, both in basic fairness and in the universality of coverage, which again is a major factor in restraining costs and promoting good health. This is not a hard concept. If parents are afraid to take their kids to the doctor for fear of running afoul of immigration authorities, their kids are more likely to come to schools with contagious ailments, and the parents more likely to go to work with them.

For that same reason and others, it was also foolishness to postpone the implementation of the main part of the ACA until after the 2012 Presidential election. There are lots of people without insurance in this depression and they need access sooner rather than later. The reason was delaying was largely mindless "free market" dogmatism. Postponing the start meant that the 10-year deficit projections sounded lower. Which might have been a political benefit to the Democrats if anyone actually gave a flying flip about the deficit besides our political and media elites.

Instead, the Administration got better deficit projection, which is highly unlikely to drive any votes to the Democrats. And most people won't see the full benefits of the law until after the Presidential election. And if Obama loses, a real possibility, then Republicans will have a good shot at repealing it before it even goes into effect.

So, going into the 2012 election, Obama and the Democrats gets four years of Republicans blasting the ACA. Most of the benefits are postponed. The very popular public option provision was left out. And the Administration has failed to aggressively defend the program, although Obama has started to do so lately. Maybe he at least will continue to do that now that it's an election year.

Progressive Democrats also need to remember that the omission of the public option was a specific defeat for the Congressional Progressive Caucus and one that largely deprived it of effectiveness during Obama's first term up until now. They made inclusion of a public option a red line minimum for them to support the ACA. Dozens of Representatives signed a statement saying they wouldn't support it without a public option. In the end, they did. They also ate the increased abortion restrictions the Blue Dogs and Republicans inserted into it. Yes, Progressive Caucus got far more pressure from the Democratic establishment than the Blue Dogs did. But it still showed the White House that they could be rolled.

Until the Obama Administration has to worry more about opposition from the Progressive Caucus than he does about opposition from Blue Dogs, his Administration will continue to promote neoliberal economics and pre-compromise its proposals for conservative appeal and then compromise them some more.

I haven't followed the legal arguments closely enough to even guess how the Supreme Court decision on the individual mandate might go. Although if the Roberts Court strikes it down, it will be another heavily political decision.

Jonathan Cohn notes in Obamacare on Trial: What the Right Already Won The New Republic 03/26/2012 how the Republicans have used the fight over health care to push their preferred framing, a process facilitated by Obama's continual compulsion to define his own proposals and principles in terms friendly to the Republican framing:

As recently as three years ago, the idea of an individual mandate (the requirement that most people get insurance or pay a penalty) was largely uncontroversial, not only within the Democratic Party but within the Republican Party as well. As late as the spring of 2009, prominent Republican lawmakers like Charles Grassley, ranking minority member of the Senate Finance Committee, publicly embraced the idea of the mandate as part of health care reform. If he or any other leaders of the GOP thought the mandate was an unholy violation of liberty, they kept it to themselves.

The mandate also has a lengthy, bipartisan resume: Among its original architects were researchers at the Heritage Foundation. Among its early supporters were the three top Republicans running for president: then-Senator Rick Santorum of Pennsylvania, then-Speaker Newt Gingrich and then-Governor Mitt Romney of Massachusetts. Romney, of course, enthusiastically promoted the mandate as a way of enforcing individual responsibility—because, as he liked to say, people who can pay for their health care share shouldn’t pass their bills onto others.
But now they changed:

The mandate is health care reform’s least popular element. By focusing on it, rather than more popular elements of the law, Republicans have a useful tool for attacking President Obama—potentially undermining his most significant domestic policy achievement and ending his tenure in office at one term.
I would like to believe that a Court decision striking down the individual mandate would create an incentive for Obama and the Democrats to make a new push for the public option and event to make a more explicit political issue out of the Court's reactionary tilt. But the last three years offer little hope that Obama and the corporate Democrats would respond that way.

One very odd part of Cohn's article is that he mentions Laurence Silberman as one of the group of "well-respected conservative judges". Respected by whom? Silberman is the Republican hack who overturned Oliver North conviction for perjuring himself before Congress and was a big player in the Whitewater witchhunt during the Clinton Administration. This hack accused President Clinton of "declaring war on the United States" because some White House aides had criticized Special Counsel Kenneth Starr, one of the slimiest characters in American history. (See his profile at Right Wing Watch 04/18/2007) I ask again, respected by whom?

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