Saturday, September 25, 2010

The ACA and the USA
I've been thinking recently about how the future of the Affordable Care Act, the health care reform law passed last March, could be read as (not to be too dramatic) the future of American politics itself.

Here's a measure that, warts and all, provides for a massive expansion of coverage to people in need and cost savings that could range from minor to game-changing, depending on the course of implementation. (See here for an excellent examination of how the biggest battles in the health care reform war remain to be fought in the years to come.) Within the context of those goals, it's business-friendly to a fault. Each state has a great deal of leeway in setting up its exchanges and other provisions. It's the arguably more conservative version of what Mitt Romney did in Massachusetts.

And the Republicans, who never engaged in good faith in helping to shape the policy, want to cripple or kill it for reasons they can't even coherently articulate.

For starters, Republicans say they will try to withhold money that federal officials need to administer and enforce the law. They know that even if they managed to pass a wholesale repeal, Mr. Obama would veto it.

"They’ll get not one dime from us,” the House Republican leader, John A. Boehner of Ohio, told The Cincinnati Enquirer recently. “Not a dime. There is no fixing this.”

Republicans also intend to go after specific provisions. Senator Orrin G. Hatch of Utah, a senior Republican on the Finance Committee, has introduced a bill that would eliminate a linchpin of the new law: a requirement for many employers to offer insurance to employees or pay a tax penalty. Many Republicans also want to repeal the law’s requirement for most Americans to obtain health insurance.

Alternatively, Republicans say, they will try to prevent aggressive enforcement of the requirements by limiting money available to the Internal Revenue Service, which would collect the tax penalties.

Republicans say they will also try to scale back the expansion of Medicaid if states continue to object to the costs of adding millions of people to the rolls of the program for low-income people.

In addition, Republican lawmakers may try to undo some cuts in Medicare, the program for older Americans. Many want to restore money to Medicare’s managed-care program and clip the wings of a new agency empowered to recommend cuts in Medicare. Recommendations from the agency, the Independent Payment Advisory Board, could go into effect automatically unless blocked by subsequent legislative action.

The political problem with the ACA is twofold: one, it came along in a moment when everyone is suspicious if not contemptuous of government to start with, and two, its painful components might be better known, and are generally easier to explain ("the government is going to force you to do something!") than its goodies ("states will set up and regulate a series of exchanges through which you can choose among a range of health coverage options"). Knowing this, the Republicans have made "repeal and replace" the centerpiece of the campaign manifesto they released this week.

That this makes absolutely no sense isn't deterring them. They claim to want to keep the candy provisions (for instance, no discrimination by insurers for pre-existing conditions) while cutting the veggies (the individual mandate) that pay for the candy. They boisterously oppose Medicare cost savings less draconian and intrusive than what they put forward a few years back. And they killed provisions that would have saved far more money--the public option, early Medicare buy-in--probably because they knew those components of the reform would be popular and effective, undermining the whole "gummit's no good, so let us run it" argument. Their favored replacement strategies--capping malpractice lawsuits, ramping up Health Savings Accounts, and killing state-based regulation of insurers--would do very little, do pretty much nothing, and make things worse, respectively. (They could have had at least the first two provisions within the ACA if they'd actually negotiated on that legislation rather than trying to kill it for purely political reasons.)

The core premise of Republican health care reform is the same it's always been: their focus is on lowering costs for the relatively affluent who already have coverage, rather than expanding coverage for those who lack it. That this does little to constrain overall system expenditures, because the uninsured will continue to get (much more expensive) emergency room care, continually seems to elude them. At a values level, they seem not to care at all that millions will remain uninsured because they can't afford coverage.

The worst of it? This bottomlessly cynical and real-world counterproductive strategy might work. I don't think they'll get outright repeal, but between their political skill, the Democrats' gutlessness and the nature of how policy debates are covered, they might manage to de-fund the ACA and render it dead on the books. What a triumph that would be: tens of millions still without health coverage, no regime for controlling costs, but at least we'd be saved from some ignoramus's misguided fear of rampant, icky "socialism."

And needless to say, if we can't even get this right, we're never, ever going to be able to grapple successfully with the larger problems of demographically driven busted budgets, declining global competitiveness and potential environmental disaster that are looming just over the horizon.

1 comment:

Anonymous said...

I guess I just don't get exactly why Dems are so demoralized. They passed huge health care reform, financial reform, disavowed an embrace of torture, put two new faces on the Supreme Court, and have taken pretty good steps (if not absolutely heroic ones) to move things in a good direction in Iraq, Afghanistan and the Israeli-Palestinian conflict. I've never considered myself a huge Obama fan, but that's not too shabby, especially given a Republican opposition in the Senate that has more or less concluded that there's no advantage to them cooperating with almost anything. I understand that it's not the New Deal and that Obama has disappointed many on the left by not going "far enough," but I continue to be puzzled by the conventional wisdom and pundits who seem to think that left-leaning voters would rather sit on their hands in November than show up and stop the Republicans from taking back one or both chambers of Congress. As somebody who has an ear tuned to what people of both political persuasions have to say, it seems to me that most right-leaning talking heads are outraged (surprise, surprise) by all the things the Dems have accomplished. Doesn't that count for something with those who voted Obama in?