There will be two national elections before the new health overhaul is substantially implemented (in 2014) and a third election the year it is supposed to be implemented.
Question: Will the voters reward office holders who supported the Affordable Care Act (ACA), or will they vote for their opponents? In thinking about this question, forget all the public opinion polls. Can you predict the outcome based on what you know about political science alone?
My prediction: Supporters of the new law are going to get creamed. As I explained at my own blog the other day, there are four reasons: The law violates two bedrock principles of coalition politics that have been successful for the past 80 years; it abandons core Democratic constituencies; and it ignores the fundamentals of the politics of the health care sector.
Franklin Roosevelt’s First Principle of Successful Coalition Politics: Create benefits for people who are concentrated and organized, paid for by people who are disbursed and disorganized.
The ACA violates this principle in spades. The main beneficiaries are many (but not all) of the new law are 32 million to 34 million newly insured people who otherwise would have been uninsured. Far from being organized and focused, most people in this group do not even know who they are. Indeed, it is probably fair to say that never in American history have so many benefits been conferred on so many people who never even asked for them!
I watched C-Span through the entire voting process on Sunday night. Socialism? Tyranny? The Republican hyperbole was unhinged from reality.
Democratic claims that the health care reform marked a major milestone in domestic policy were closer to the truth. But billing the legislation as comparable to the advent of Social Security in the 1930s or Medicare and Medicaid in the 1960s simply isn’t accurate.
So many said it would never happen. But now, on Sunday, March 21, 2010, it appears that reformers have the votes. Rep. Bart Stupak, the leader of the anti-abortion hold-outs, has announced that he will vote “yes.” – under the agreement, President Barack Obama will sign an executive order ensuring that no federal funding will go to pay for abortion under the health reform plan. This really doesn’t change anything. Stupak got nothing except face-time on television.
At last, Congress is about to take the first step toward transforming what we euphemistically call our health care “system.” In the years ahead, the laissez-faire chaos that puts profits ahead of people will be regulated, with an eye to providing affordable, evidence-based, patient-centered care for all.
Over the last three years, I have predicted that Medicare reform would pave the way for health care reform, and this bill makes that possible. Under the legislation, Congress will no longer be in a position to thwart Medicare’s efforts to rein in spending by eliminating waste. Not everyone is happy about this. Over at Politico.com former Republican Senator Bill Frist and former Democratic Senator John Breaux register their protest in a column titled “Keep Medicare in Congress’ Hands.”Continue reading…
“This gets back to the fundamental lesson of political survival that Bill Clinton taught me, which is if you make it about the American people’s lives instead of your life, you’re going to be okay.” — Paul Begala
It’s March, 2015. Healthcare reform has now been active for over five years with the majority of reforms kicking in as of January 1, 2014. Several amendments have been proposed and passed in the interim period including the All-Payer Act normalizing reimbursement rates for hospitals between Medicare, Medicaid and private insurance.
The American Family Practice Reimbursement Act promulgated minimum reimbursement levels for primary care providers acting as part of accountable care organizations and included a package of incentives for medical graduates and nurse practitioners to practice primary care. A particular emphasis was paid to establishing federally qualified health centers in urban and rural areas where Medicaid statistics reveal high rates of chronic illness and minimal levels of compliance with requisite preventive care to arrest the erosion of chronically unstable patients into catastrophic illness.Continue reading…
Unmistakably, the mojo has shifted back to the Democrats – it is amazing how a dour and monolithic opposition can cause even Dems to unite for a common cause. Our President has also learned a few lessons, including the importance of symbols, populism, and singing with one’s diaphragm. (We knew we were in trouble a few weeks ago when Rahm started being criticized for not being sufficiently Machiavellian.) With yesterday’s CBO figures showing that the reform plan will save nearly $150 billion, even fence-sitting Democrats now see more political risk in saying No than Yes. That, of course, is the most relevant calculus, and with it more and more of the Blue Dogs are entering the Yes column each day.Continue reading…
Joseph White, a professor of politics at Case Western Reserve University, made this interesting observation in his weekend column in The Fiscal Times:
“On most issues, there is no such thing as a stable “public opinion.” People do have general attitudes, beliefs that they can use to evaluate a choice. But often voters hold different attitudes that would lead to different evaluations of the same choice. How they answer a question depends on which considerations have been raised in their minds most recently.”
Therefore the analysts who predict Democratic defeats in November based on negative survey responses about health care reform now are making a fundamental error. The Republicans have shown great ability to raise considerations that push the evaluation in one direction. Yet some of that effort has been encouraged by the concerns conservative Democrats raised during the debate as they tried to make legislation better fit their preferences. They will not be making those arguments as they run for reelection. In the election campaign there would be far more spending on ads to defend the legislation. The press coverage may focus more on the actual provisions of the bill as opposed to the GOP charges. But focusing on the actual specifics will only be possible if there is a law that passed and can be defended. Democrats have to be able to point to something and say: “this is what we did, this is the truth about it, this is how it would help you.”
The Democrats also have to remember that the “losers who can’t deliver” consideration will be far more prominent in November if they pass nothing now. In short, the battle over interpretation of the health care reform effort has only begun. We do not know how it will turn out in November, but there are good reasons to believe the Democrats are better off fighting it with a new law in hand.”
Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect and The Washington Post. His most recent book, “The $800 Million Dollar Pill – The Truth Behind the Cost of New Drugs ” (University of California Press, 2004) has won acclaim from critics for its treatment of the issues facing the health care system and the pharmaceutical industry in particular. You can read more pieces by Merrill at Gooznews.com.
In popular psychiatry, a classic passive aggressive gambit is “malicious compliance”- intentionally inflicting harm on someone by strictly following a directive, even though the person knows that they are damaging someone by doing so. In Washington, the most skilled practitioner of this dark art is Speaker Nancy Pelosi If health reform craters, Pelosi will disingenuously claim that she did precisely what the President asked of her, and blame the Senate and the President for its failure.
In reality, Pelosi’s “leadership” almost fatally wounded health reform last summer. If the process does collapse, the blame should fall squarely on her shoulders. Her poor political judgment led directly not only to squandering a nearly 80 vote majority, but also exposed embarrassing and ill-timed disunity among Democrats on a signature domestic policy issue. It won’t be the Republicans that killed health reform, but incompetent Democratic Congressional leadership.
Last July 14, Speaker Pelosi unveiled the opening bid in the health reform process- HR 3200, America’s Affordable Health Choices Act of 2009. This bill was drafted largely without input from their Republican colleagues or from important Democratic moderates. It also put into legislative language virtually exactly what the President promised in his campaign, without considering seriously the political implications for the actual passage of the legislation- a political form of malicious compliance. Democratic moderates felt their input had been ignored and they were immediately trapped on the wrong side of this issue.
HR3200 had an immediate polarizing effect on the health reform debate, and the damage control process was on. In a sense, health reform has never recovered. Pelosi’s bill summoned the right wing talk radio demons (and the inimitable Betsy McCaughey) out of their caves, reviving long dormant rhetoric about a “government takeover of the health system”. This label has clung stubbornly to all subsequent versions of the legislation.
Unfortunately, the critics weren’t too far wrong. HR 3200 effectively federalized the employer health benefit. It mandated that employers offer a “one size fits everyone” health benefit to their workers, the benefit precisely defined by federal statute. It imposed an 8% payroll tax on employers who did not provide the benefit, pushing their federal payroll tax to 23% if you include Social Security and Medicare. It also moved the top tax rate for federal income taxes for businesses filing as “subchapter S” to 46%, a level not seen since Jimmy Carter was in the White House.
Given unemployment was climbing toward 10% at the time, HR3200 would have simultaneously diminished corporate cash flow and increased the cost of hiring new workers for firms that did not presently offer health coverage- a recipe for no recovery.
HR 3200 created new health insurance premium subsidy for workers covering and estimated 20 million new people, but without any meaningful brake on future federal subsidies. To enroll these new folk, however, health insurers would have to comply with provisions of a new federal health insurance exchange, whose rules would have effectively ended medical underwriting.
The health coverage gated through the exchange was no longer be “insurance”, but a federally defined health care entitlement financed largely by employers. The bill also created a public health insurance option, which had the effect simultaneously of competing with and financially undermining private health insurers. All of this was to be overseen by a politically appointed Health Choices Commissioner, in effect, a commissar for the health insurance system. This nominally private-sector approach had a distinctly Soviet flavor.
Almost immediately upon HR3200’s release and for the following seven months, the Democrats have been playing defense on health reform and losing. Democrats elected from Red or Purple states ran from the bill as fast as their legs would carry them. They rebelled against the “public option”, the employer mandates, as well as the tax increases required to fund the premium subsidies.
Moderate Democrats also objected to subsidizing private coverage of abortions and to any enrollment of people in the US illegally (roughly 7-8 million of the uninsured). It might have been possible to address these concerns “privately”, e.g. in the initial drafting process, but by the time HR 3200 was released, many After almost four months of contentious negotiations, a revised version of the House bill passed by only five votes, one of which came from a stray Republican.
By the time Democratic moderate concerns had been clumsily and publicly accommodated (in the late fall), the resulting House bill had gravely offended three core constituencies of the Democratic party- women, Hispanics and the single-payer advocates, without materially addressing the critics of a huge expansion of federal power (and spending). The Democratic base lost enthusiasm for the bill while Democratic moderates continued to struggle with the “government takeover” label. By late fall, the legislation had acquired the odor and toxic sheen of a rotten side of tuna.
In the court of public opinion, the ensuing seven months (with a brief blip after Labor Day after a well- crafted Obama defense of health reform), were all down hill for health reform. Opposition to the process, as much as the substance, of health reform hardened, aided materially by a flurry of dealing making around the Senate bill (Medicare or Medicaid carve outs for Florida, Louisiana and Nebraska most visibly).
The late January loss of Ted Kennedy’s seat to an insurgent “Tea Party” Republican, Scott Brown, was an unmistakable warning sign that even formerly unassailable Blue State Democrats were now at risk. Political pundit Charlie Cook, who follows the Congressional races at a microscopic level, wrote recently that the Democrats have been in free fall since August. They lost gubernatorial races in New Jersey and Virginia, county executive races in solidly Democratic Fairfax County (VA) and Westchester and Nassau Counties (NY). A surge of inconvenient scandals- David Paterson, Charles Rangel and Eric Massa- all in New York- have further tarnished Democratic credibility. Cook placed the odds on the Democrats losing the House this November at 50-50 and sliding.
On the eve of the Presidential health reform “summit”, a Newsweek poll revealed that independent voters, crucial to re-election of Democratic moderates, opposed passage of health reform by a stunning 62-29% margin. Despite the White House’s feeling that the President could paint the Republicans into a corner and blame them for halting health reform, a Politico.com reader poll after the summit suggested the Republicans decisively outpointed the President (52%-19%) by stressing the fiscal and economic risks of the bill. There aren’t a lot of undecided voters left on the health reform issue- and strongly “anti-” sentiment outruns strongly “pro-” sentiment by almost two to one.
Now the White House and Democratic leaders are in the final scramble to find votes to send the President something he can sign and declare this endless and divisive process over. Speaker Pelosi suggested last week that, regardless of the damage they may suffer at the polls in November, House Democrats owe her and the President a reaffirmation of their support. Pelosi basically ordered her troops to swallow their reservations about this bill and fall on their swords.
Gloria Borger of CNN reported late last week that a “senior White House aide” characterized the coming vote on health reform as “the last helicopter out of Saigon”, the most unfortunate political metaphor of the Obama era thusfar. (For younger people, that helicopter was ferrying South Vietnamese collaborators with the United States off the roof of the CIA compound before the North Vietnamese Army flooded into Saigon). What did the “senior White House aide” mean? That the Communists are coming and congressional Democrats need to save themselves and run for the hills? It sure doesn’t sound like a clarion call to do the right legislative thing.
It isn’t the Communists that are coming. It’s a lynch mob. And the angry horde is going to discriminate between “progressives” and moderates. They are simply going to find and hang as many public officials as they can get their hands on – incumbent Congresspeople, Senators, Governors, state legislators, county executives. Unfortunately for the Democrats, the majority of those incumbents are Democrats. I’ve not seen such a toxic electoral atmosphere in my lifetime.
If she cannot find the votes to pass health reform, Speaker Pelosi will be deflecting blame and knifing her White House colleagues in the back all the way to the guillotine. If it passes, it will be in spite of, rather than because of, her advocacy. By maliciously complying with the President’s mandate, Speaker Pelosi and her arrogant, tone-deaf management of the legislative process badly damaged the prospect for lasting health reform. She should scramble for a seat on that last helicopter herself.
Humphrey Taylor is Chairman of The Harris Poll. Prior to joining Harris, Taylor worked in Britain where he conducted all of the private political polling for the Conservative Party and was a close adviser to Prime Minister Edward Heath in the 1970 campaign and subsequently to Margaret Thatcher. After a year of debate, in which health care policy was covered in the media almost daily, very few people are even moderately well informed about the details of the proposals for health care reform. But many of them have strong opinions. Most people, our data would suggest, are confused, conflicted, clueless and cranky: confused because of the complexity of the many issues that are on the table; conflicted because they often favor policies that are mutually contradictory; clueless because they don’t know, let alone understand, most of what is being proposed; and cranky because Washington has failed, yet again, to provide a health reform bill they like.
The mind-boggling complexity of the system and the proposed reforms provide plenty of opportunities to attack the proposals, however unfair or unreasonable they may seem to advocates of reform. Critics say the proposed reforms would lead to a government take-over of the system, higher taxes, less choice, lower quality, higher unemployment and rationing.
Confused? One huge problem is that the American health care “system,” as it is euphemistically called, is fiendishly complicated. Health insurance coverage is provided by Medicare, Parts A, B, C, D, Medicare Advantage, Medicaid, employers and their insurance plans, the V.A., D.O.D., FEHBP, SCHIP, WIC, the Indian Health Service, community clinics, HMOS, PPOs, and the individual insurance market. There are state regulated and ERISA plans. Important federal government health care agencies include HHS, CMS, AHRQ , CDC and NIH. There are solo, small and large practices, single and multi-specialty groups, and integrated medical systems. Hospitals and doctors employ huge numbers of people at great expense to figure out how to get reimbursed by insurers, Medicare and Medicaid, and how to deal with uncompensated care.
Physicians are paid on a fee-for-service basis, by capitation, and by salaries, and can receive bonuses and pay-for performance incentives. These payments come from thousands of different health plans, each with its own rules as to what is reimbursed and how.
Complexity of reform proposals
A benign dictator who wanted to reform the health care system might decide to scrap it completely and replace it with a simpler system that would be much easier to understand, much less expensive to manage and much easier to improve. But most Washington watchers who understand the politics of health care policy believe that this is politically impossible. Too many powerful interests are involved. Therefore, most major reform proposals with significant support build on the system we have now rather than replace it. They would keep employer-provided insurance, private sector health insurance, Medicare, Medicaid, the V.A., the D.O.D., and the other third-party payers. They would keep the many government agencies that manage and regulate different parts of the system.
And then, as if the system is not complicated enough, the congressional proposals would add more complexity, new agencies, and new regulations. One or both of the House and Senate bills would create individual and employer mandates, with new subsidies for some employers and low-income individuals, reduced subsidies for Medicare Advantage, a “public option” to compete with private sector insurance, new taxes on “Cadillac plans” and the rich, the barring of medical underwriting based on health status (pre-existing conditions and recision), and health insurance exchanges. Those proposals would encourage, expand and make use of electronic medical records, electronic prescribing, and other health information technologies, comparative effectiveness research, quality measures, price transparency, wellness programs, “medical homes,” patient-centered care, evidence-based medicine and outcomes research.
Another whole layer of complexity relates to the need for fundamental reimbursement reform. Our 2008 survey of health care opinion leaders for the Commonwealth Fund found a large majority who believed that this is the most important step that needs to be taken to improve the efficiency of the system and quality of care. Reimbursement reform means changing “perverse incentives” in the way that doctors are reimbursed, reducing fee-for-service payment and moving to bundled payments, payments for episodes of care, capitation or salaried physicians. Experts argue that this would require many more accountable care organizations (ACOs) and medical homes.
Are your eyes glazing over? There are probably only a few thousand health care policy wonks who fully understand all the complexity of our system and of the proposed reforms.
What most people don’t know or don’t understand
In addition to the unbelievable complexity of the health care system and reform proposals, there are some simple and very important factors that most people do not think or talk about, and probably do not believe.
Most health care economists believe that present cost and coverage trends are not politically or economically sustainable. They believe that we will have to make really tough choices as we try to satisfy potentially infinite demand with finite resources. For how long can health care spending increase 2½ times faster than GDP? How many more uninsured people will we tolerate?
Some political leaders and media seem to encourage this ignorance and the simplistic belief that if only their policies were adopted we could have it all – access to high quality care at an affordable cost with no new taxes, and secure access to all needed services for the rest of our lives. Most people seem to believe that it would be possible for everyone to have access to all the wonders of modern medicine without much higher taxes or other costs. Most people believe that insurers should insure anyone who wants insurance, without requiring the young and the healthy to buy insurance. Adverse selection and moral hazard are not just incomprehensible insurance jargon; few people have ever thought about the concepts.
A recent Pew survey found that only two percent of all adults could correctly answer twelve very simple questions about politics (e.g., how many Senate votes are needed to break a filibuster; who, of four well-known politicians is the Senate Majority leader). One can only speculate as to what percentage of the public would pass a similar test of “health reform literacy.”
Most people believe that the health care system “has so much wrong with it that fundamental changes are needed.” They believe health care costs too much and that everyone should have health insurance. So where’s the conflict? The problem is that many people tend to support contradictory positions. They oppose cutting benefits but don’t want their taxes , their out-of-pocket costs, or their premiums to increase. They believe that everyone should have affordable access to every test, treatment and procedure that they or their doctors want but don’t stop to think what this would cost or how it would be paid for. They favor universal coverage but oppose an individual mandate. They favor an employer mandate but don’t want to make it more expensive for employers to hire people. They favor a “public option” but oppose a “government-run insurance plan.” They believe every patient should have access to high quality care, but don’t think the young and the healthy should to have to pay for it.
It is tough to win public support for proposals when very large numbers of people are misinformed and believe many of the strange criticisms made by those opposing reforms. In recent polls, two-thirds (65%) of the public believed that “the proposed reforms would result in a government-run health care system,” even though the reforms would greatly increase the number of people with private sector insurance. More than half the public believed that the proposed reforms would “reduce the choices many people have now” (55%), that health insurance would be “too expensive for many people to buy” (52%), or “would make it harder for many people to get the care they need “ (51%). A 45% to 30% plurality believed that “the proposed reforms would hurt Medicare.” And more than a third (37%) that the “proposed reforms would create death panels that would decide who should live and who should die.”
The public was split 41% to 41% as to whether health care would be “rationed,” and do not realize that we already ration care by reimbursing or not reimbursing it. Large minorities believed that “Medicare will be phased out” (32%), that the “plan promotes euthanasia to keep costs down (25%), and (where did this come from?) that “the government will be able to access individual bank accounts to help pay for services” (23%).
The polls sometimes mislead their readers by suggesting that people already have opinions when they ask questions about the details of the policy. These polls can be useful; they can test the public’s reactions to issues and policies and the language used to present them. But reactions to a question do not mean that people actually had opinions on the issue (let alone understood it) before they were surveyed. However, most people do have opinions about health care reform, even if they do not know much about what is being proposed.
What is striking now is the contrast between the large 78% majority of the public who thinks that “fundamental reforms are needed” or that the “system needs to be completely rebuilt” and the hostility to the proposed reforms. Attitudes to proposed reforms seem to have much more to do with the popularity of who is proposing them than what is being proposed. In September 2009, we found that a 53% majority thought that President Obama’s proposed reforms were “a good thing” while a 54% majority believe the proposals of the Democrats in Congress were “a bad thing.” But what was the difference between their policies? Since September, support for the president’s proposals has declined along with his job rating. And while the Democratic proposals are unpopular, the Republican proposals (whatever they are) are much more unpopular.
The polling data underline the truth of the advice to “keep it simple, stupid.” Unfortunately, the system we have now is absurdly complicated and health care reform could only be simple if we nuked the system we have and re-built it from scratch. And that won’t happen.
Rhetoric trumps substance. In the absence of a simple, comprehensible reform, it is easy to criticize any package of reforms. People who are misinformed and have little understanding of what is actually being proposed often hold very strong opinions.
The introduction of Social Security and Medicare (which were bitterly opposed at the time) involved relatively simple concepts that could be explained to most people. The health reform proposals now on the table, and some of those proposed in the past, cannot. This helps explain why so many presidents, Democratic and Republican, have failed to pass substantial health care reform that would greatly reduce the number of uninsured and help contain costs.
I’m viewing the latest rumblings in the US health care debate from the confines of a clear but cold Britain, where the big news is that the country is joining the PIGS in entering economic meltdown—or at least being a lot more broke than it thought it was. (PIGS are Portugal, Greece, Ireland & Spain, not farm animals). And yet it appears that health reform is making if not a comeback then at least vigorous palpitations. The reason for this seems to be the strength that the Anthem Blue Cross/Wellpoint premium rises have imbued into the Administration.
Those of you reading THCB over the years will know that I think the individual insurance market is doomed to fail and should be replaced. It has its apologists; for example Cato’s Michael Cannon here criticizes Paul Krugmanwho explained last Friday why the individual market goes into a death spiral. Michael claims that Mark Pauly’s research shows that the individual market works. What Pauly’s work (and I despair at having to read it again, so this is from memory) tends to show is that insurers are incompetent at charging sick people to the full extent that they cost them, but do charge them roughly three times what they charge healthy people. Pauly also said in Health Affairs that the individual market works pretty well for 80% of the people in it, but he seems to think that screwing the remaining 20% is OK. Coming from a tenured Ivy league professor who’s probably never had to buy health insurance in his life, that was pretty rich. But apparently Wellpoint’s latest performance shows that it’s not OK for much of the other 80% either—hence their dropping out, leading to Krugman’s death spiral.Continue reading…
I think health care reform is dead. And the proposed reform was relatively inconsequential anyway, as it would have left in place Medicare as is, Medicaid as is but bigger, employment-based health insurance, and fee-for-service medicine. And with Scotty Brown winning in Massachusetts, and harsh political winds stripping off the Blue Dog votes from the House Democratic majority, it seems that there’s no hope. In that context Obama’s not entirely spirited defense and offer to have a parlay on TV in a couple of weeks doesn’t sound like a recipe for action.
But apparently the public is less happy with nothing than it might appear are politicians. Today’s Washington Post/ABC Poll claims that two-thirds of the population think that we should keep trying—including 56% of the independents who the Dems feared they had lost and even a sizable minority of those claiming to be from the do-nothing party.
Will this poll make any difference? I doubt it, but stranger things have happened. And it does confirm that although Americans may not like the bill or agree on any solution, they know that the health care system is a big problem.