In tonight’s first presidential debate, Governor Romney and President Obama will spend 15 minutes discussing healthcare. This is a perilous topic for both, but whoever wins this debate within the debate will take a big step to winning on November 6th.
The Affordable Care Act, or ObamaCare as both candidates now call it, will be center stage. The president will offer his standard defense, saying it helps middle-class families by making insurance more affordable and more secure.
But the president knows a full-throated defense will not work. A majority of Americans have consistently supported repeal since day one.
Rather than defend the indefensible – higher costs, higher taxes, Medicare cuts, government expansion – the president will attack.
First, he will tie together ObamaCare and the reform law Gov. Romney signed in Massachusetts, arguing that they are the same.
Gov. Romney should stipulate that there are some policy similarities between the two, but that the differences are what matter. He can deflect this attack and return the spotlight to the president’s unpopular law by clearly saying:
“I did not raise taxes. You raise taxes by $500 billion.
“I did not cut Medicare. You cut Medicare by more than $700 billion to pay for a new entitlement that the public opposed. Your cuts jeopardize seniors’ access to care.
Let’s take a look at Mitt Romney’s Health Care plan using his own outline (“Mitt’s Plan”) on his website.
Romney’s approach to health care reform summarized:
“Kill Obamacare” – There seems to be no chance Romney would try to fix the Affordable Care Act––he would repeal all of it.
No new federal health insurance reform law – There is no indication from his policy outline that he would try to replace the health care reform law for those under age-65 (“Obamacare”) with a new federal law–his emphasis would be on making it easier for the states to tackle the issue as he did in Massachusetts.
Small incremental steps – His approach for health insurance reform for those under age-65 relies on relatively small incremental market ideas when compared to the Democrats big Affordable Care Act–tort reform, association purchasing pools, insurance portability, more information technology, greater tax deductibility of insurance, purchasing insurance across state lines, more HSA flexibility.
Getting the federal government out of the Medicaid program – He would fundamentally change Medicaid by putting the states entirely in control of it and capping the annual federal contribution–“block-granting.”
Big changes for Medicare – Romney offers a fundamental reform for Medicare beginning for those who retire in ten years by creating a more robust private Medicare market and giving seniors a defined contribution premium support to pay for it.
Since 2010, when the Affordability Care Act was signed into law, the American mainstream media has insisted that President Obama’s bill provides the most at-risk Americans, low income families and seniors, with better health care. And that must mean, by any logic, better access to doctors, more access to the modern tools of diagnosis and treatment, and ultimately better health outcomes. That poor Americans benefit greatly from the ACA, and that seniors will be more secure under the president’s law, has seemed so obvious to the left-leaning news outlets that this fact has yet to be critically examined by them.
President Obama’s ACA law purports to provide new health coverage to upwards of 16 million low income Americans by way of Medicaid. We already see in the wake of the Supreme Court decision that many, if not most, states simply cannot be burdened with massive increases in their Medicaid outlays, regardless of the promise of financial support from the federal government (itself a financially unsustainable funding source).
But President Obama’s assertion about new insurance for the poor and all it brings is, in fact, a grand deception. We know that 55 percent of primary care physicians and obstetricians already refuse all or most new Medicaid patients (about four times the percentage that refuse new private insurance patients), and only half of specialist doctors accept most new Medicaid patients. Clearly, granting poor people Medicaid is not equivalent to providing access to doctors.
Now that Mitt Romney has picked Paul Ryan to be his running mate, a major national debate on Representative Ryan’s so-called ‘premium support’ plan has become certain. Ryan’s plan would replace the current Medicare program for workers under the age of 55. When eligible, they would receive a flat dollar amount—or voucher—that would cover part of the cost of a health insurance plan. The value of the voucher would be adjusted annually according to a pre-specified index. If health care costs increased faster than that index, enrollees would have to pay the added cost themselves or accept narrowed insurance coverage.
Because that plan would not apply to anyone age 55 or older, supporters claim that older Americans don’t ‘have a dog in that fight.’ For reasons I explain below, that isn’t true, even if one looks only at Representative Ryan’s Medicare proposal. Other elements of the Romney/Ryan health care program have even larger implications for older Americans, but let’s start with the Ryan Medicare plan.
Costs for Seniors Could Rise
The claim that the Ryan plan leaves American’s over age 55 unaffected is untrue because it is likely to raise the amount they have to pay out-of-pocket for insurance. The reason is technical, but easy to understand. The premium for those who stay in traditional Medicare under the Ryan plan would be calculated as under current law, but the average cost of serving those who remain in traditional Medicare would go up as private insurance companies market selectively to those with relatively low anticipated costs.
I’ve never seen a week in health care policy like last week. The media reports have to be in the thousands, all trying to make sense of the furious debate between Obama and Romney over Medicare.
As someone who has studied this issue for more than 20 years, it has also been more than exasperating for me to watch each side trade claims and for the press to try to make sense of it.
This blog post is quite long because the subject matter is complicated. If you want to cut to the chase, see my conclusion and summary at the end of this post.
Allow me to list a few of the questions people are asking and give you my take on it.
Will current seniors suffer under the Romney-Ryan Medicare plan?
No. Let me start by saying something that will likely surprise you. If I could be king for a day, I would prohibit anyone over the age of 60 from voting in this election. This election is really about the future and the big decisions on the table are about the long-term government spending and entitlement issues that should be made by younger voters who will have to pay for them and will benefit or suffer from them.
Those in their 60s and older are almost surely going to cruise to the end with the benefits they now have.
Whether its Obama’s Medicare plan, based heavily on the Medicare cost control board imbedded in his health reform bill (which doesn’t begin to impact hospital costs until 2020), or the Romney/Ryan Medicare premium support plan (that has no effect on anyone now over the age of 55), today’s seniors’ benefits are insulated from this issue.
In 1932, the Committee on the Cost of Medical Care identified rising medical costs as a threat to the financial security of millions of Americans. In a series of studies that created the field of health services research, the Committee recommended several strategies for cost containment that reads like a blueprint for today’s cost containment efforts: prevention, price controls, capitation, elimination of unnecessary care, and integration. If it sounds like a précis of my previous two blogs – cut prices and cut quantities – it should. We have known for a long time that those are the only ways to cut spending. And yet here we are, 80 years later, facing a spending crisis that threatens to take down the entire economy.
In my lifetime, we have been subjected to a steady drumbeat of rising medical costs. There have been respites – for a couple of years after Medicare introduced DRGs and for about five years in the 1990s during the heyday of HMOs. While DRGs and HMOs shifted costs down, they did not seem to reverse underlying growth trends, although HMOs did not thrive for long enough to be certain.
Not for lack of trying have medical costs continued to increase. We promote prevention, regulate prices, capitate providers, and review utilization to eliminate wasteful spending. We have seen horizontal integration that led to market power and higher costs, and vertical integration that more often than not created unmanageable bureaucracies. Most of today’s proposals for cost containment can be encapsulated by two words: “Try harder.” The Affordable Care Act gives us free preventive care, stricter price controls, ACOs, and the Comparative Effectiveness Institute. We need radical change but all we get is creeping incrementalism. I will take creeping incrementalism over the do-nothing approach of the previous decade, if only because we could use another respite. But the ACA is no permanent fix.
Republican Vice Presidential pick Paul Ryan isn’t the only one Democrats are piling on this week. The knives have come out for Senator Ron Wyden, the Oregon Democrat.
I guess that isn’t a surprise. If Ron Wyden is right on Medicare then so are Paul Ryan and Mitt Romney.
The fundamental problem here is that the Democrats have decided that their best path to victory in the November elections is to say that the Republicans want to destroy Medicare as we know it and that the Democrats can preserve it.
The truth is that no one can preserve Medicare as we know it. There isn’t a prayer that your father’s Medicare will be around in 10 years. There is a legitimate policy debate going on about the direction we will have to go with it.
There is just plain going to be less money to spend on senior health care than there would have been if we let the program continue on its present unsustainable track. Health care providers and patients are going to have less money.
Last week, I noted the significant differences between Paul Ryan’s proposals, from his 2012 budget to Ryan-Wyden to his 2013 budget. I also noted that while it would be tempting to campaign against the 2012 budget, which massively shifted costs onto seniors, his later proposals did that to a far lesser extent.
Or did they?
Governor Romney has endorsed Paul Ryan’s latest plan, which is specific in that it will reduce future Medicare spending by unleashing the power of the free market through competitive bidding. But what if that doesn’t happen? Well, just like the ACA, his law backstops the growth of Medicare spending at GDP + 0.5%.
The ACA is explicit about what will happens if growth goes above that amount. The IPAB will make recommendations on how to cut it. Congress will have to override those recommendations to stop them, and have their own ideas that save just as much. It’s likely those recommendations would involve reducing provider payments. But it’s the hope of those who support the ACA that other provider-based changes, like ACO’s and the excise tax, will keep the IPAB from having to act.
The wanna-be congressman appeared with his neat hair and pressed suit, a competent yet compassionate expression on his face. ”The first thing I am going to do when I get to congress is to work to repeal Obamacare,” he said, expression growing subtly angry. ”I will do everything I can to give you back the care you need from those who think big government is the solution to every problem.”
My wife grabbed my arm, restraining me from throwing the nearest object at the television. I cursed under my breath.
No, it’s not my liberal ideology that made me react this way; I’ve had a similar reaction to ads by democrats who demonize republicans as uncaring religious zealots who want corporations to run society. I am a “flaming moderate,” which means that I get to sneer at the lunacy on both sides of the political aisle. I grew up surrounded by conservative ideas, and probably still lean a bit more that direction than to the left, but my direction has been away from there to a comfortable place in the middle.
It’s not the ideology that bugs me, it’s the use of the “us and them” approach to problem solving. If only we could get rid of the bad people, we could make everything work. If only those people weren’t oppressing us. If only those people weren’t so lazy. It’s the radical religious people who are the problem. It’s the liberal atheists. It’s the corporations. It’s the government. All of this makes the problem into something that isn’t the fault of the person making the accusation, conveniently taking the heat off of them for coming up with solutions to the problems.
The fight is on — again. Mitt Romney, Scott Brown, and Republicans across this country are doubling down against President Obama’s health care reform law. Now that the Supreme Court has said that most of the new law passes constitutional muster, the Republicans are running for office pledging to repeal every aspect of the health care reforms.
For millions of people this isn’t a political issue, it’s a personal one. Their health depends on it.
Massachusetts has led the country in health care reform. Most of us — 98 percent — have health care coverage, and our state leads the country in tackling head-on the ever-growing costs of health care. That is why President Obama used our law as a model for health care reform. But the national Affordable Care Act adds some important elements that improve care even here in Massachusetts.
For seniors, health care reform means expanding Medicare coverage to pick up the costs of prescription drugs. As the donut hole closes, the average Massachusetts senior has so far saved about $650. But Mitt Romney, Scott Brown, and their fellow Republicans want to take that away.
For young people, health care reform means staying on their parents’ insurance plans until they are 26. So far, more than 20,000 young people here in Massachusetts have taken advantage of this. But Romney, Brown, and their fellow Republicans want to take that away.