I hope my fellow liberals will read what he has to say–not because you will agree with him, but because he offers an instructive and well-articulated vision of what conservative health policies might look like that build on the platform created in ACA.Â I am a firm believer in Mill’s idea that if you only know your own side of the argument, you really don’t know that.
Roy rightly acknowledges that Republicans will not outright destroy ACA at this point. That question was decided by the 2012 election and by the (eventually) successful roll-out of ACA this year. Whatever the polling numbers on “Obamacare,” Â the on-the-ground progress is impressive. Medicaid expansion and the new marketplaces are embedding within the fabric of American life.
Where it gets interesting and disconcerting is to note the generative conservative possibilities opened up by ACA. Roy would limit ACA in various ways. But his real quarrel is with Lyndon Johnson not Barack Obama. Once 64-year-olds are enrolled in the health insurance marketplaces, why the abrupt transition at age 65? Roy would raise the Medicare eligibility age by four months every year, retaining the subsidy structures provided by the exchanges and Medicaid. Over time, this would turn Medicare into much more of a means-tested program with dramatically reduced actuarial subsidies to the top half of the income distribution.
I don’t support this or see it as politically attractive for Republicans. But Roy’s plan raises fundamental questions about what we want Medicare to be and do. Â More here.
Our wide-ranging conversation covered his pride in health reform, his thoughts on how our health care system is changing, Princeton Universityâ€™s high-ranking law school, and his disappointment in implementation screw-ups typified by the flawed rollout of HealthCare.gov.
Cutler was the author of a prescient and scathing 2010 analysis warning of the need for stronger management of information technology (and other matters) in the implementation of health reform. During the darkest days of website malfunction, theWashington Postâ€˜s Ezra Klein labeled Cutlerâ€™s analysis â€œthe memo that could have saved Obamacare.â€
Over at healthinsurance.org, I interviewed MIT economist Jon Gruber on the state of ACA. Â We discussed a huge range of things, ranging from the case for the “Cadillac tax” to lessons of the botched rollout. It was a pretty upbeat conversation. But Jon was characteristically blunt regarding states that have declined ACA’s Medicaid expansion:
Jon:Â I think, Harold, the single thing we probably need to keep the most focus on is the tragedy of the lack of Medicaid expansions. I know youâ€™ve written about this. You know about this, but I think we cannot talk enough about the absolute tragedy thatâ€™s taken place. Really, a life-costing tragedy has taken place in America as a result of that Supreme Court decision. You know, half the states in America are denying their poorest citizens health insurance paid for by the federal government.
So to my mind, Iâ€™m offended on two levels here. Iâ€™m offended because I believe we can help poor people get health insurance, but Iâ€™m almost more offended thereâ€™s a principle of political economy that basically, if youâ€™d told me, when the Supreme Court decision came down, I said, â€œItâ€™s not a big deal. What state would turn down free money from the federal government to cover their poorest citizens?â€ The fact that half the states are is such a massive rejection of any sensible model of political economy, itâ€™s sort of offensive to me as an academic. And I think itâ€™s nothing short of political malpractice that we are seeing in these states and weâ€™ve got to emphasize that.
Harold:Â One of the things thatâ€™s really striking to me is thereâ€™s a politics of impunity towards poor people, particularly non-white poor people that is almost a feature rather than a bug in the internal politics in some of these states, not to cover people under Medicaid, even if itâ€™s financially very advantageous to do so. I think thereâ€™s a really important principle to defeat this politically, not just because Medicaid is important for people, but because itâ€™s such a toxic political perspective that has to be â€¦ It has to be shown that that approach to politics doesnâ€™t work because otherwise, we will really be stuck with some very unjust policies that will be pursued with complete impunity in some of these places.
Jon:Â Thatâ€™s a great way to put it. There are larger principles at stake here. When these states are turning â€“ not just turning down covering the poor people â€“ but turning down the federal stimulus that would come with that.
They are not just not interested in covering poor people, they are willing to sacrifice billions of dollars of injections into their economy in order to punish poor people. It really is just almost awesome in its evilness.
There’s not much more to my post than the headline: I’ve just concluded my sixth phone call with BCBS of Illinois (having been hung up on the first five times by an automated phone tree which sends you directly to an automated service-satisfaction survey without first giving you any service to be satisfied about). This means I spent the better–or worse–part of two hours trying to find out why BCBS sent me a bill for my January premium I’d already paid on-line.
I went straight to Blue Cross to buy health insurance because I don’t qualify for a subsidy and didn’t see any reason to grapple with–or burden–healthcare.gov. But every time you hear that payments made on the government Website might not be transferring properly to the insurers, please remember that payments made on the Blue Cross Website suffer from the same disability. And while there’s a live chat on Healthcare.gov which at least connects you to a person who can explain the problem, Blue Cross has made sure to keep its product completely untouched by human hands. I finally got through by calling corporate headquarters and explaining first to the corporate operator and then to local customer service and then finally to national customer service (after local stayed on the line with me for ten minutes to assure that national actually picked up) that a bill dated 12/12 should have included an electronic payment made on 12/2, and that no, the bill and my payment hadn’t “crossed in the mail.” In the words of the great Eric Clapton, “How many times must I explain myself ‘fore I can talk to the boss?” though by “Forever Man” I doubt he meant “man with whom you have to stay on hold forever.”
In short (I know, other people’s customer service nightmares are a bore while one’s own is fascinating), everyone who complains about the f***-ups of Obamacare ought to take a second a remember the last time s/he had to deal with a private insurer. In fact, the worst thing about the Affordable Care Act is that it leaves the insurance companies in the picture, and us to their continued tender mercies.
We can’t specifically predict atrocities such as occurred in Sandy Hook. Yet the Medicaid expansion in health reform is an important step in addressing violence by mentally-ill offenders.
Me with a long piece in the Washington Monthly:
Itâ€™s a strange thing. Newtown was an atypical crime, committed by an atypical offender, using a murder weapon that I hope will be outlawed but that remains pretty atypical for gun homicides. Even though we may not be able to stop an event like Newtown from happening again, it seems to be moving public policy more than the routine smaller scale tragedies that we could more easily prevent. Newtown has provided a genuine occasion for Americans to think seriously about gun policy, and to consider the very real challenges to our mental health system. We should make the most of this moment.
Itâ€™s naive to believe that we could specifically identify someone such as Adam Lanza before he goes on a rampage, but improved policies could still prevent an unknown, maybe unknowable number of violent deaths. No one policy will dramatically reduce homicides, and the politics and administration of effective mental health policy are both daunting. But making these policies work would provide a fitting memorial to the victims of needless violence across America. While we may not be able to entirely solve the tragedies that occur at the intersection of mental illness and gun violence, surely we can do better than weâ€™re doing now.
During the health reform fight, a handful of people emerged with distinctive voices, who had a huge impact. The best of them combined the policy expertise, empathy, and graceful writing to command public attention as we finally extended health insurance coverage to millions of people.
Jonathan Cohn, senior editor of the New Republic was certainly one of those people. His award-winning 2007 book Sick chronicled the plight of uninsured and underinsured Americans. The New Yorkerâ€™s Atul Gawande called Sick â€œstunningly important â€¦ In one damning true story after another, Jonathan Cohn lays bare the tragedy of our health care system.â€
Jonathan also originated and ran an influential blog called â€œThe Treatment,â€ covering the daily fight over health reform. I was a special correspondent for â€œThe Treatmentâ€ during 2009 and 2010.Â Having Jonathan as my editor there was a just a very special opportunity for me in my midlife-crisis journalism career.
provide tax credits to purchase a catastrophic private health insurance policy, with catastrophic defined as costs above 15% of income (financed by ending the tax exclusion of employer paid insurance; people could purchase additional coverage with after tax dollars)
issue each person/family a “health care credit card” that could be used to purchase care in the deductible amount
A few quick comments about Prof. Feldstein’s proposal and how it compares to mine.
Defining catastrophic as a percentage of income makes conceptual sense, but introduces some technical challenges. All of the issues related to timing, what happens if your income changes, and perverse incentives related to loss of subsidy if your income increases that have been raised with respect to the income-based subsidies in the ACA apply to Prof. Feldstein’s proposal as well (and to just about any public policy that provides a differential government expenditure/subsidy based on income).
Prof. Feldstein’s proposal provides a guaranteed means of financing needed care if someone makes a bad choice in choosing catastrophic coverage only, while mine does not. A huge concern under my proposal is what will persons who choose to only have catastrophic insurance, but who get sick, actually do? Will some avoid the care they need? If so, this will likely increase the catastrophic costs that Medicare will incur down the road if they spend through the catastrophic coverage amount.
A central claim of my bookBalancing the Budget is a Progressive Priority is that slowing the rate of health care cost inflation is a necessary, but not a sufficient condition to our ever achieving a sustainable budget down the road (it will also take a tax increase). Further, it will be virtually impossible to take the very hard steps to address health care cost inflation without both political parties coming up with a set of health care reform strategies that we will actually try, and which make both sides responsible for seeing to the hard work this will take. Health reform is far more difficult than Social Security reform (in a technical sense), for example, because mailing checks is much easier than purchasing health care. We will never be done with health reform and there will be many mid course corrections.
Even though we don’t know what all the steps will be, we desperately need to take some initial ones, and we will soon know what the Supreme Court will say about the ACA. This will be a landmark decision that will have profound political and policy consequences, but in one sense, regardless of what the Supremes say, the next step is to identify a bipartisan way forward on health reform (stop laughing; we have to do it).
Central to my book is a set of health reform policies that I claim represent the type of deal that would emerge if the two sides actually negotiated with one another. For such a deal to emerge, it would take both sides being clear about what their primary interest was in health policy. For Progressives, universal coverage has always been the holy grail and dream deferred, not just of health policy, but really of all social policy. As I noted in this debate with Jim Capretta, I don’t think Conservatives have an interest that is so clear and heartfelt as universal coverage is for Progressives, but if I had to take a stab, I would claim that it is their belief that people don’t have enough “skin in the game.” As an aside, this makes little sense to me, and when I look at empirical data on cost sharing with my more conservative friends, we see different things. In a similar way, when I say that I think the lack of a predictable, universal health insurance coverage scheme is an existential mark against our nation, they don’t get my degree of feeling.
Accepting such differences is an important step, because reaching a deal will mean abiding with one other to reach a compromise.
Greg Sargent noting that in spite of the Affordable Care Act not being overly popular as a whole, focus on health reform during the election could be helpful to the President.
I would agree and go even a bit further, and say that avoiding health reform discussion since passage of the law has enabled Republicans to get away with only being clear about what they are against, and let them off the hook from offering a coherent alternative. The more discussion about health reform during the election the better. If Republicans move toward a plan that attempts to substantially address coverage, cost and quality, it will start to look an awful lot like what they have been against. If they don’t offer a comprehensive plan, then they will have no answer to one of the key issues facing our country.
The Affordable Care Act was a good step because it was a step; we desperately need to take the next one and find some set of health reform policies that we will actually TRY. It will take both sides to do this, and an important step is to smoke Republicans out on what they are really for (if anything). This is a time where the Rove playbook–go on offense around a presumed weakness–should be co-opted by the President, both for policy and political reasons.
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