Last week’s State of the Union speech was notable because the President hardly mentioned the new health care reform law.
Avoiding what is supposed to be the centerpiece domestic accomplishment of President Obama’s first term stuck out like a sore thumb.
He said almost nothing because the Obama team simply doesn’t know what to say.
The fact is the Affordable Care Act (ACA) is generally unpopular, and its best-known provision, the individual mandate, is wildly unpopular.
Two years after passage and, the implementation of the law’s first steps all designed to build support, the public’s opinion of the law is unchanged and not good. The just out January 2012 Kaiser Health Tracking Poll leaves no doubt:
Only 37% of those surveyed have a favorable view of the law.
44% have an unfavorable view of the Affordable Care Act.
But even some of those who don’t like it don’t like it because it didn’t go far enough—31% of all of those surveyed want to expand the current law while 19% want to keep it in its current form. That’s a total of 50% that want to keep or expand it.
22% want it repealed outright and another 18% want it replaced with a Republican alternative—a total of 40%, fewer than want to expand it or keep it as it is.
On the individual mandate, 67% have an unfavorable view of requiring everyone to buy coverage, while 30% have a favorable view of the requirement.
While a total of 50% of those surveyed think the law should be kept or expanded, 54% say the Supreme Court should throw the mandate out, while only 17% say they think the mandate should be upheld.
So, let’s summarize. Only 37% have a favorable view of the law and 67% don’t like the mandate. But 50% think the law should be kept as it is or even expanded. No wonder Obama and his political team can’t figure out how to play this.Continue reading…
Experimentation in how states would move toward universal health care coverage was written into the DNA of the Affordable Care Act. The law allowed any state to petition for a waiver that would enable it to enact its own brand of reform — including versions that did not include an individual mandate to purchase coverage or penalize employers who didn’t provide it – as long as their plans met the basic criteria of the law in terms of covering most people, providing comprehensive coverage, being affordable, and not increasing the federal deficit.
President Obama yesterday offered to move up the date for states that want to pursue their own visions of reform from 2017 to 2014. Stories in today’s press billed this as an effort by the administration to assuage conservative critics who’ve filed suit against the law and governors from both political parties who fear its economic impact. Medicaid expansion accounts for about half of the newly covered people under reform. Even with the feds picking up 90 percent of the tab, many states in today’s fiscal environment are wary of any new obligations — even one where they’re only on the hook for 10 percent.
As I wrote last month, leaving states to implement reform provides Americans with a classic example of federalism in action, one that may or may not lead to a common system across the U.S. In the early part of the 20th century, states began setting up unemployment and workers compensation insurance systems. The former became a shared federal-state responsibility with common features across the U.S. The latter remained unique to each state. Ohio, for instance, has a single-payer workers compensation system and insurance companies are prohibited from selling policies in the state.Continue reading…
The tone on Capitol Hill during Tuesday’s debate was more civil, the partisan rhetoric less harsh than previous exchanges on the House floor. But there’s little doubt that the Republican-led House will vote later today to repeal President Obama’s signature health care reform law.
That largely symbolic vote – there’s almost no likelihood the Democratic Senate will follow, nor would the president sign the bill – signals the start of a two-year campaign by newly empowered Republicans in the House to undermine the new law. Proponents of “repeal and replace” will next turn to eliminating the most unpopular elements of the law—including the individual mandate – and to cutting off funding for implementation.
But the administration won a powerful set of centrist allies on Tuesday as it scrambled to set in motion reforms that it believes will be popular with the American people once its key provisions go into effect. The new law, signed by Obama last March, is designed to provide about 32 million previously-uninsured Americans with coverage either through Medicaid or subsidized private insurance sold through state-based insurance exchanges. The total cost of the program of about $900 billion will be paid for by a combination of tax increases and slower growth in Medicare spending. The law also places consumer-friendly restrictions on insurance carriers, funds Medicare pilot models in alternative care delivery, and creates a government-run long-term care insurance program.
Tomorrow night the House of Representatives will debate the repeal of the Patient Protection and Affordable Care Act (ACA), what many call “ObamaCare.” Some critics complain that this is a futile exercise because there is little chance of short-term success. But that’s the wrong way to look at it.
At the time of its passage, most members of Congress had no idea what was in the ACA. Nancy Pelosi was more correct than she realized when she said, “We have to pass it to see what’s in it.” Even now, we don’t know half of “what’s in it,” but we know enough to have an intelligent debate. Ideally, tomorrow night’s proceedings will be educational — in a way that the debate last spring was not.
In anticipation of the event, representatives from the National Center for Policy Analysis, the Heritage Foundation, the American Enterprise Institute, the Cato Institute and the American Action Forum will conduct a briefing on Capitol Hilltomorrow at noon. Our goal: to discuss ten structural flaws in the Affordable Care Act. We believe each of these is so potentially damaging, Congress will have to resort to major corrective action even if the critics of the ACA are not involved. Further, each must be addressed in any new attempt to create workable health care reform.
This week’s House health care repeal vote is little more than a political stunt–everyone knows the effort will die in the Senate.
But, when the day is done the only way for the Republicans to do anything with the new health law will be to work out a compromise—repeal before the 2012 elections is impossible and it isn’t very likely after the 2012 elections. Even if the Republicans sweep the White House and both houses of Congress in 2012, it is highly unlikely they will have the 60 Senate votes needed for a full repeal.
So, in the end, a compromise will be needed.
During the past week, more than one Democrat has indicated an interest in at least looking at compromise amendments to the health care bill—particularly on the individual mandate. But so far, Republicans are showing no signs of being interested in fixing what they say is a bill so bad it should only be repealed.
The House vote will take place against a backdrop of increasing debt and enormous fiscal challenge. In recent days, the national debt passed the $14 trillion mark—that is $45,300 for every person in the country!
Half of our national debt was added in just the last six years. The debt was “only” $7.6 trillion in January 2005 and $10.6 trillion the day President Obama was inaugurated just two years ago.
“The primary ethical issue of modern medicine and public health is the outcome gap,” write Paul Farmer and Nicole Gastineau Campos in an essay published in 2004. Entrenched in “growing social inequalities,” this gap is immediately evident to every physician: poverty is inversely proportional to health. “The growing gap,” they elaborate, “constitutes the chief human rights challenge of the 21st century.” The proliferation of people who never experience abuse of their civil rights, but lack access to medical care, has damaging societal implications: “what does it mean when an African-American neonate does not have ready access to a neonatal intensive care unit?” The answer is that “[w]henever more effective technologies are introduced there will be, in the absence of an equity plan, a growing outcome gap.”
Around the country, this gap is exploding. Surviving an illness may sometimes depend on the good will of kids. I kid you not. Carlos Olivas, Jr., a 12 year-old boy, in view that Arizona’s cuts to Medicare meant certain death to a man who he had never met named Francisco Felix, decided to help, raising money in the street. Carlos’ empathy toward Mr Felix―at least in part―originates from the thought of finding his father (who has cirrhosis) in a similar situation.
A sense of responsibility toward others, as exhibited by this young man, is the foundation of all societies. Carlos is an exemplary citizen, proof that the Social Contract is an intuitive concept. His behavior is strictly rational: today, I’m strong and can help the weak; tomorrow, when I’m not as strong, someone will help me.
Republicans pledged to do it as part of their manifesto during the midterm election campaigns. And House Speaker John Boehner, less than a day after the elections, vowed that the GOP would “do everything we can to try to repeal this bill and replace it with common sense reforms to bring down the cost of health care.”
But why was this such a high priority? The lack of cost controls? Unfunded state mandates? Questions surrounding federal funding of abortions? Well, yes, but the go-to critique of health care reform can be summed up in one word:
Recently, as part of a response to the FDA revoking its approval for a late-stage breast cancer drug, several key Republicans criticized this kind of rationing, but set their sights on a much bigger target:
“Unfortunately, this is only just the beginning,” they continued. “The new health reform law — the so-called Patient Protection and Affordable Care Act — creates 159 new boards, commissions and agencies that will destroy the doctor-patient relationship and replace it with federal bureaucrats deciding who gets care and what treatments they can receive,” The Hill’s Jason Millman reported.
When it comes to health care, Republicans should be careful what they wish for.
Their upcoming vote to repeal the health-care law will be largely symbolic — they don’t have the votes to override President Obama’s certain veto. The real thing happens later, when they try to strip the Department of Health and Human Services of money needed to implement the law’s requirement that all Americans buy health insurance. This could easily precipitate a showdown with the White House—and a government shutdown later this year.
On its face it’s a smart strategy for the GOP. The individual mandate is the lynchpin of the heath-care law because it spreads the risks. Without the participation of younger or healthier people, private insurers won’t be able to take on older or sicker customers with pre-existing medical conditions, or maintain coverage indefinitely for people who become seriously ill. The result would be to unravel the health-care law, which presumably is what many Republicans seek.
At the same time, the mandate is the least popular aspect of the law. According to a December 9-12 ABC/Washington Post survey, 60% of the public opposes the individual mandate. While they want help with their health-care bills, and over 60% want to prevent insurers from dropping coverage when customers become seriously ill, most Americans simply don’t like the idea of government requiring them to buy something. It not only offends libertarian sensibilities, but it also worries some moderates and liberals who fear private insurers will charge too much because of insufficient competition in the industry.
The Republicans who will take control of the House this January have made it clear there are two things they hate: deficits and President Obama’s healthcare reform. They’ve promised to reduce the first and repeal (or at least hobble) the second. But if you’re worried about deficits, repealing the Obama plan won’t do any good unless you’ve got a better idea. In fact, the numbers say repealing it could make the government’s budget problems worse.
Despite the outrage over spending on the Wall Street bailout, the stimulus or the Iraq war, at least these costs are temporary. But the combination of an aging population and health costs that keep rising faster than inflation means that spending on Medicare, Medicaid and Social Security are going up – – and they’ll keep going up for years on end. With an aging population, there will be more older people eligible for these programs. The health care they need will cost more on top of it.
When people argue about the costs of an aging America, they often lump Social Security and Medicare together like they were the identical twins of public policy. If they are twins, they’re more like the 1980s movie Twins, featuring Arnold Schwarzenegger and Danny DeVito as the world’s most improbable pair of brothers. Maybe you remember the iconic movie poster. It shows the two dressed alike, but with an enormous Schwarzenegger looming over DeVito. In the budget world, Medicare and Social Security are both problems, but Medicare is definitely played by Arnold. Here’s why.
Health care spending has been rising faster than the inflation rate for decades. In 2007, the Consumer Price Index went up 2.8 percent, and health spending went up 6 percent. In 1997 inflation went up 2.3 percent, and health spending went up 5.4 percent. In 1990, when inflation was 5.4 percent, health spending climbed nearly 11 percent.
Next week starts the new Congress, and with it the Tea Party conservatives. What’s their strategy? What will they rally around?
They’ll grouse endlessly about government spending but I don’t think they’ll use any particular spending bill to mobilize and energize their grass roots. The big bucks are in Social Security, Medicare, and defense, which are too popular. And their support for a permanent extension of the Bush tax cuts will make a mockery of any argument about taming the deficit.
Nor will they focus on the debt ceiling. Their opposition to raising it will generate a one-day story but won’t rally the troops or register with the public. Most Americans aren’t particularly interested in the debt ceiling, don’t know what it means, and don’t feel affected by it.
Instead, I expect their rallying cry will be about the mandatory purchase of health care built into the new healthcare law. The mandate is the least popular, and least understood, aspect of that law. Yet it’s the lynchpin. Without it, much of the rest of the law falls apart: It’s impossible to cover all high-risk Americans, including those with pre-existing conditions, unless those at far lower risk are required to buy insurance.
Knowing they don’t stand a chance of getting a direct repeal of the mandate (even if they could get a majority in the House for it, they won’t summon 60 votes in the Senate, and have no possibility of overriding a presidential veto), they’ll try to strip the federal budget appropriation of money needed to put the mandate into effect. This could lead to a standoff with the White House over government funding in general, and a possible government shutdown.