Respect for the ACA

Over 7 years the Affordable Care Act took its hits. Its passage cost the Democrats their majorities in 2010. It’s been dinged and sabotaged by the likes of Marco Rubio. The GOP voted countless times to repeal it. And even Bernie Sanders — to be sure, a good guy who always voted to increase coverage — says to keep our sights on single-payer instead of getting too wrapped up in defending Obamacare.

I’d like to offer some support for those beleaguered politicians, staffers, activists and other “stakeholders” who made the ACA happen in the first place. It was hard work. I don’t think anyone — certainly not those of us on the left — ever thought it was going to make everything perfect. It included, as even its proponents acknowledged, some pretty bitter pills: The continuation of the private insurance system. The personal mandate. This wasn’t the kind of cradle-to-grave health care that one would envision from scratch.

It was, expressly, a kluge that could get through a very big-tent, very fractious Democratic Congress in 2010; made politically palatable (supposedly) by being minimally disruptive to the health insurance people already had. It was based on the Massachusetts plan, which was designed to appeal to a moderate-conservative Republican governor. When it went national, even this accommodation was politically perilous: The bill barely survived passage, and many Democrats did not survive the subsequent elections.

But for all its shortcomings, have we noticed that the Overton window changed drastically? That for all their criticisms, people really don’t want to go back to what was the norm, pre-ACA? And that Republicans were prepared only to smash the whole thing, not to actually improve upon it.

Watch the Republicans flounder, with their catastrophic CBO score of 24 million losing coverage. You knew this was going to happen, because every criticism they ever offered was shallow, opportunistic and unrealistic. Led by Trump — no outlier among Republicans on health care — they promised their plan would somehow cost less and cover more, but be more … free-market-ish. Trump upped the ante at every opportunity.

What are the GOP’s objections, or plans for better health care?

  • Free market solution! Yeah, thought of that. They’re called exchanges.
  • Mandated coverage is bad! Insurance needs to insure. It has to be worth something. We didn’t know we needed seat belts in cars either, but I’d be dead a couple times over without them.
  • Personal mandate: The Dems, and Romney, considered the problem of adverse selection — that you don’t “need” insurance until you need it. So they  included the mandate.
  • With Thursday’s PowerPoint, Paul Ryan seemed to attack the very idea of cross-subsidization – in other words, insuranceThe young shouldn’t have to pay for the old! Welp, ask the old how they like jacked-up, unaffordable premiums. Thought of that. (Cf. Men shouldn’t have to pay for lady-stuff like pre-natal care — as if women got pregnant on their own.)
  • Screw the poor! Always, always in GOP-land, the underserving poor should be abased and reviled. Well, they end up in ERs when they get sick, and cost a lot more that way. [It's also really cruel and mean -- ed.] This is one reason why states and hospitals really like the Medicaid expansion. Thought of that, thanks so much.

The Democrats had an understanding of the issue and its inherent tensions, and had staff expertise to hash through it. The GOP apparently has little of either, and is driven by a propaganda culture actively hostile to knowing about such things.

In other words, the Republicans are screwed. They’re screwed if they don’t pass their hideous bill; they’re triple-screwed if they do. And as with everything, so are we. So are we.

So for a brief moment I’d like to salute the 2009-2010 lawmakers, wonks, and advocates who actually understood that there would be really hard trade-offs; that the policy of health care is really complicated, and always politically dangerous — and has been for over a century. I’d like to salute those lawmakers who were good Democratic Party soldiers, and got shellacked due partly to unfair and deceitful attacks (“death panels”, etc) — but also simply because of those difficult trade-offs: Even as it did a great public service, there was something for everyone not to like. C’est la vie.

What we’re seeing now is that the poor unloved ACA was basically doing its job: Providing a modicum of justice and convenience in the health care market; a little bit of breathing room from those who have suffered illness; helping people see doctors when they’re sick; and curbing the worst, greediest and most misanthropic abuses of the insurance industry.

It is not enough — no health care advocate, no compassionate person would claim that. We are still at the mercy of an industry — one-sixth of our economy — that ruthlessly leverages human need and inelastic demand for its own profit. In a sane world, we’d regulate that and find ways to reduce costs. We’d probably have to introduce price controls; and if you thought the ACA was a political donnybrook, you can imagine what instituting price controls would be like. Currently that’s impossible, when one party is dead set on sabotaging and killing the bill, as well as allergic to any kind of heavy-handed market regulation.

The ACA was not the Make Everything Perfect For All Time bill. But it was in many respects a courageous (QED) and extremely thoughtful piece of legislation. In other words, a real step forward. And the public is not going to consent to go back to what we had before.

Update: John McDonough, formerly of Health Care For All in MA and Ted Kennedy’s point man on the ACA, on the Republicans exchanging working-class lives for more money for rich people. “All for a little bit of money”



Discuss

50 Comments . Leave a comment below.
  1. It's working so well some conservatives propose single payer

    Customer service, wait times and usability are much improved in 2017 from my 2013 experience.

    I got steered to a bronze plan with similar co-pays to a pricier silver by a very helpful and knowledgeable staffer on the phone. And they’ll call you back instead of leaving you on hold. I’m paying a little more out of pocket by saving more in the long run with lower premiums.

    And someone in Newsmax actually proposed killing ACA and putting all the uninsured into Medicaid instead-aka a public option. The politics of healthcare have become far more favorable for progressives.

    • more government, please

      Many folks who don’t like the ACA think it doesn’t go far enough. Price controls. Public option. etc.

      Even Trump — very sensibly! — suggested negotiating with drug companies for better prices, which was the Dems major objection to Medicare Part D.

  2. CAMPAIGNING IS EASY, GOVERNING IS HARD...

    as the ideological / political schism between Trump and Congressional Republicans is now proving.

    Fred Rich LaRiccia

  3. A bit too glowing

    Because something is hard does not mean taking the easy way out. The insurers had too big a role in fashioning the ACA. Karen Ignani, their chief lobbyist for insurers(HIP), had a big hand in writing regulations. The mandate came about since they would be depending on larger risk pools.

    Max Baucus who headed the legislation through the Senate put the kibosh on more efficient cost lowering plans. I know this because I attending a meeting with David Himmelstein after he had met with Baucus, and would not bring SP to the floor for debate.

    It is ironic that the ACA was compromised deeply towards what the GOP insisted on. Then they voted against it.

    • With all respect

      To you and the merits of single-payer, it does not shock me that Himmelstein didn’t have a nice meeting with Baucus. Himmelstein has been one of the “doesn’t play well with others” SP advocates (unlike, say, Sanders).

      Meanwhile the ACA has saved actual lives, while DH would not have sullied by being involved in such a corporate sellout.

      I like single payer. I think Himmelstein’s political strategy is … Doomed to fail.

      • "easy way out"

        And respectfully, I think after 100+ years of advocacy for universal health care of some kind, and the resultant political fallout, I would not refer to the ACA as “the easy way out”. I think it’s rather easier to declare oneself to be on the right side of an issue, as Himmelstein does, without actually digging into a give-and-take legislative process which is *designed* to disappoint.

        • Well,

          when you let a HIP lobbyist write the law, and refuse to even have a debate on the merits of ACA with the success staring you in the face, you got much less than second best with premiums rising out of sync with the growth of the country, executives earning multi-million dollar salaries, and being sold on the stock exchange, this is a recipe for failure. In fact, in spite of surviving it is on life support and has changed the party make up of Congress.

          David HImmelstein had a very respectful interchange with Max Baucus. The Senator even admitted he though Canada had an impressive health insurance system(called Medicare by the way), but still would not add it to the debate. The major problem with the ACA as indicated above was the heavy hand of the insurance lobby. Too many legislators were recipients of their largess to the detriment of the American people.

          I was interviewed shortly after the ACA was passed by Kevin Cullen of the Globe. You can read it here.

    • WOULDA, SHOULDA, COULDA...

      talk about beating a dead horse.
      ACA was the easy way out ? Really ?
      We did not have the votes for single payer! Hello ?
      Oh, the lights are on but there’s no one home. Got it.

      Fred Rich LaRiccia

      • I'm not sure we tried very hard.

        No, I don’t think ACA was the easy way out either. If anything single-payer might have been since it can simply be explained as Medicare For All, and has the twin advantages of being ethically superior AND financially most efficient. At one point this had 80 House cosponsors. If the President had decided to put the WH behind it that would have been the discussion and I can easily see it working.

        • My frustration was that we didn't do a little bit of SP or consolidation

          I felt like we missed an opportunity to do some consolidation and SP in conjunction with the ACA.

          We could have made Medicare an at-cost option for health insurance for those under 65. We could have merged Medicaid into Medicare — just make the Medicaid customers eligible for Medicare and eliminate the duplicity. We could have lowered eligibility for Medicare to 62 or 60 or 55. We could have said that all pregnant women, postpartum women, and newborns were on Medicare because we all love the unborn and the newly-born.

          We could have added to the rolls of the insured and added to the rolls of Medicare at the same time.

          This isn’t to say I disagree with charley — I don’t. We’re better with the ACA than we were without out.

          • The silver lining

            Is a majority of both Trump and Clinton voters now want the government to do more, not less with healthcare. I don’t think it was the intention of either Obama or Clinton to call ACA the end of healthcare reform. If anything, it was the end of the beginning. A foundation to build on. And one that has proven to be more durable than supporters or critics anticipated since, given a few years now, most people who use it like it-most people who don’t need it aren’t affected by it-and it’s going to eventually be pretty easy to make policy fixes to the architecture it created.

            Absolutely merge Medicaid and Medicare and expand Medicare eligibility. I think adding comprehensive child health care will be enormously popular-kid insurance-especially for newborns-is really freakin expensive. And nobody in any party wants to pay for it.

            I am willing to make a small ideological concession to the right an argue that for working age adults having health insurance is a personal responsibility-and ACA does that with the mandate the right now wants to take away. By keeping the mandate but offering an opt in public option we can start getting cost controls while also giving adults a choice between free market or public healthcare. I think they will vote with their feet to the Medicare program, but those who really love their market insurance can keep it.

            • free market public option

              When you mix the two the maze of regulations can become more confusing than things already are. Google “Debbie Hirst cancer patient” and you’ll read the story of a women in England who wanted to pay on her own for better drugs than she was going to get from the government to treat her cancer, and was then told if she did she would lose all her treatment options from the wonderful single payer European style plan.
              A friend’s father in Poland was recently diagnosed with cancer in his spine and at 62 he is being told he is too old for treatment. 55 is the cutoff point. She is trying to get him into this country.
              Personally I believe we need “death panels” and more older people (myself included) who are willing to die gracefully. If I ever need to wear a diaper and be fed with a spoon, I’ll blow my brains out. People who contribute to their own demise (ex smokers) should not be allowed to burden the system.
              Free health care for kids until they graduate high school or turn 18. It can be coordinated with some sort of expanded clinic at the individual schools.

              • Questions

                Your comment about “people who contribute to their own demise (ex smokers)” leads me to ask a few questions.

                Would you also deny coverage to people who eat themselves into morbid obesity? Would you deny coverage to recovering alcoholics? How about people who contribute to their own demise by choosing sedentary lifestyles? Who, in your opinion, should decide what these rules are how strictly they are enforced?

                Oh, and so long as you’re advocating “free market” health care, how do you feel about the current proposal to allow employers to demand genetic testing of prospective employees, and to insist on getting genetic testing of their dependents?

                While it is possible to cherry-pick failures of pretty much any system, such an approach all too often blinds us to the larger picture.

                The current US health care system is abysmal. The changes being driven by the GOP will make it dramatically worse. That it is the reality.

                • current US health care system is abysmal?

                  We always hear about the public option as if it is magical. I’m not cherry picking, England is having problems. And if Medicare is so great why do we need “Medicare supplement” plans.
                  ” By Kate Holton | LONDON
                  Britain’s health service is engulfed in a “humanitarian crisis” that requires the support of the Red Cross to use Land Rovers to transport patients, the charity said on Saturday.
                  Founded in 1948, the National Health Service (NHS) is a source of huge pride for many Britons who are able to access free care from the cradle to the grave.
                  But tight budgets, an ageing population and increasingly complex medical needs have left many hospitals struggling during the winter season in recent years, prompting headlines about patients being left to wait on trolleys for hours or even days.”

                  I understand any system has it’s problems but it’s not like we are Calcutta. Where I worked had good coverage (non union) and we had to contribute to it’s cost. The company provided incentives for people to lead healthier lifestyles (if you stopped smoking, went for yearly physicals, had colonoscopies, etc) and would reward that behaviour with lower premiums.
                  Even you would admit we shouldn’t give a lung transplant to a 90 year old who smoked all their life, right?
                  I haven’t formed an opinion about the genetics aspect of things, though it’s intriguing and how it’s being used to fight cancer is great. But for now we’ll call it a pre-existing condition and coverage should be available.

                  I’m OK with making whatever we come up with being the ONLY plan available to government employees though, Congressman and Senators will work much harder on it then.

                  • In a word, yes

                    It is abysmal because we collectively pay a far greater share of our GDP to health care costs — especially health care administration costs — and we get far worse outcomes, pretty much any way those outcomes are measured.

                    We pay for a Rolls Royce and get a 1964 Corvair.

                    You miss the point about the proposed legislation regarding genetic testing. It means that any employee AND THEIR DEPENDENTS can be forced to take genetic tests, and the results of those tests disclosed to employers (and insurance companies from that point onward).

                    The result is that new-born child of an employee will, under this regulation, have its full genome disclosed to insurers for the rest of its life. That’s not a “pre-existing condition”, that is sentencing infants who may carry a set of genetic markers to a life of NO health coverage (or employment).

                    You are, in fact, cherry picking while ignoring the mountain of evidence that already rebuts your opinion.

          • And the part about...

            …pregnant women, postpartum women, and newborns would be a nice way to put on record who among us are truly pro-life.

            • I wish I shared your optimism

              I long ago concluded pro-life legislators were more concerned about telling women what to do than actually helping them bring those unexpected babies to term. We’ve seen massive reductions with pilot programs in education and adoption that are literal drops in the budgetary bucket-but this new budget eviscerates PP which prevents far more abortions than it performs
              and makes deep cuts to HHS for the very services you ask for.

              I honestly think our side needs to do a much better job framing this issue beyond just protecting choice. It pains me to know a few devout people who routinely hold their nose for Republicans on this single issue. If more of them knew just how much our party’s policies promote the choice to have the child-we’d be in much better shape.

      • We did not have the votes for single payer! Hello ?

        Yup,
        And since we controlled the house & senate….why did we not have the votes? Hello?

        • We don't have consensus on single payer

          I’m not sure we ever did.

          • We had Democrats who voted against single payer

            Because their campaigns were being funded by special interests who fought against it. This is the problem when you take the attitude that “the money HAS to come from somewhere”.

            • Yes and no

              I agree that that attitude is the problem, but you go too far when you attack the integrity of everyone who voted against single payer. Some people are sincerely more conservative than us, to state the obvious.

              • If one is truly conservative...

                …from a fiscal standpoint they should be first in line to support SP. If they are of the religious conservative persuasion they should re-read what the Bible has to say about caring for those who need it.

            • Voted against?

              Has single payer ever been put up for an actual vote? If so I had forgotten.

            • You're not wrong

              But if you hold up your purity card and don’t take donations from people who work in any industry that has any power…

              you won’t make it farther than state rep.

              • Or the Senate and nearly the Democratic nomination

                Small donors put a socialist in the Senate and nearly sent him to the White House. I disagree with your fatalism-but also agree there is call for flexibility in evaluating how the bad money influences a politician. I think it’s far more difficult to eschew corporate dollars and take office-but I’ll add that progressive politicians who do walk that walk have a far easier time winning over independents. As a veteran of the 08′ caucus-It was a big part of Obama’s Iowa appeal.

                • Exception that proves the rule?

                  Small donors put a socialist in the Senate

                  Sure — but that’s an edge case.

                  For one thing, he ran for state-wide office in 1972, 1974, 1976, 1988, 1990, 1992, 1994, 1996, 1998, 2000, 2002, 2004, 2006, and 2012. Fourteen times. And, of course, he also ran for may of Burlington in 1980, 1982, 1984, and 1986.

                  For another, his 2012 senate race cost him a whopping $3.2M. Total. His opponent spent $132k; Sander certainly could have spent less. What about 2006? Sanders spent $6.6M; his Republican opponent spent $7.3M. In 2000, Jim Jeffords won the seat spending $2.1M. The other senate seat in Vermont saw Leahy spend $4.9M in 2016, $4.1M in 2010, and $1.9M in 2004. Historically, you don’t need an awful lot of money to win a US Senate seat in Vermont, certainly relative to other states.

                  I recognize that VT went from GOP to Dem, but it managed to do so relatively quietly and conflict-free. We’re simply not seeing that in many other states — the races are fiercer and more expensive, and don’t allow for a candidate who has run for office state-wide fourteen times.

                  • I wasn't arguing that

                    But MA could be VT if we tried just a little bit harder and held our local players to a higher standard. The People’s Pledge worked both times it has been tried and it’s something we should continue to emulate going forward. I agree it’s not a deal breaker for me when candidates I like don’t use small donors. I look at relying on small donors as a value added proposition for a candidate-its a plus. When candidates rely on wealthier donors it’s not necessarily a minus for me-I’m reality based-it’s just not a plus. And within a primary it makes a bigger difference for me than in a general.

                • ehh...

                  Small donors put a socialist in the Senate and nearly sent him to the White House.

                  …I’m not really comfortable with normalizing the general idea that money == votes and even less so with the more specific notion that one source of money is better than another source.

                  The saving grace of small donors, I guess, is the diffusion (dare I use the word ‘competition’?) of ideas such that unity only really happens in the broadest possible terms: the ‘wisdom’ of crowds is, strangely enough, both rather blunt and altogether squishy…. But individual donors, be they rich or poor, are equally likely, whatever the specific amount of their donations, to be wrongheaded on any given issue…

                  And I find it clearly ridiculous that anything “nearly sent” Sen Sanders to the White House. He had a good run, but I don’t think he came nearly as close as you think he did, if he did come anywhere close, at all.

  4. Question for all Democrats, especially those in office:

    What the HELL is an “affordable” right?

    Are my rights, as a citizen “for sale”? Must I purchase my “rights” at the local mall, on line, or at a flea market?

    The ACA is dead, or will be soon. Time to push for health care as a right.

    • All this means is "taxpayer funded"

      And, since the poor don’t pay taxes at all, and even at progressive rates, there aren’t enough rich people to raise the kind of dough this would take, that means “funded by middle class taxpayers.”

      So, the result would be some savings on insurance premiums that are completely wiped out by a giant tax hike, and for this bargain I would wind up with downgraded coverage.

      I would have been OK with the government option, to see how things work, but had they gone full single payer, I would have jumped on and stayed on the Sen. Brown bandwagon.

      • I think you are wrong about your second paragraph.

        My understanding is that any additional payroll tax for Medicare to cover everyone won’t even come close to completely replacing your premium in terms of cost. That’s the beauty of government health care – it covers everyone AND is more financially efficient.

      • HIT THE TOP 1% WITH A 10% SURTAX FOR 10 YEARS

        and you wipe out the national debt. Save hundreds of billions in yearly interest payments.

        And that’s how you pay for the social safety net.

        See how easy that was. Next question ?

        Fred Rich LaRiccia

        • But they will move....!

          Actually, they will not move, but that’s the argument against taxing them.

          • THE RICH WILL NOT MOVE IF THEY ARE TAXED MORE

            I know because I talked this over with my millionaire brother years ago.

            He laughed when I raised this very concern with him saying he and his millionaire friends SHOULD pay more tax to help working families and the poor.

            He echoed what billionaire Warren Buffett has been saying for years.

            Fred Rich LaRiccia

        • Numbers don't add up.

          There are simply way, way more people in the middle group, within a few standard deviations of median– even though income inequality has risen sharply. The result is that put a huge tax hike on a few tens of thousands in the “1%” and you raise some money, but if you have a more modest tax hike on a hundred million people, you get far, far more money.

          The result is that, when a plan such as this is is proposed, the proposal always provides that it can be paid for by progressive taxation of the wealthy. Then, when the cost of the program actually becomes clear, things shift to “geez, we need a lot more money to pay for this” and you have to tax the middle in addition to the top. And suddenly people like me aren’t (politically) “middle class”– we’re just rich, and have to pay our share.

          It is like the laws of gravity. It always goes like that.

          Even the 2010 ACA went this way. If you are poor and had no insurance, it was great! I can get subsidized coverage! If you were already paying for health insurance, your costs went up, a lot, to pay for all these new insureds. And because we had to keep costs down overall, the coverage got worse.

          Obamacare might save money in some big picture, but for middle class taxpayers, it cost A LOT of money.

          • ah... ehrm.... you are 'right'...

            Even the 2010 ACA went this way. If you are poor and had no insurance, it was great! I can get subsidized coverage! If you were already paying for health insurance, your costs went up, a lot, to pay for all these new insureds. And because we had to keep costs down overall, the coverage got worse.

            …in that something is not adding up.

            If the costs of the already-insured were raised to cover the cost of the newly-insured, what was the point of the government subsidies for the newly-insured?? From the point of view of the insurers the amounts, per patient are the same, tho the sources differ: for example, patient X (already-insured) contributes the total premium of M dollars… Patient Y (newly insured), contributes M’ and the government makes up the difference such that Y(M) equals X(M).

            The cost increase is real however, but has nothing to do with the number of new enrollees or the fact they are subsidized: it is derived from the fact that the newly insured and subsidized are one of the unhealthiest cohorts in the population: this is because of previous care denial. So the surge in price was expected, but also expected to level out over time as that cohort transitions from unhealthy to less-healthy and then to healthy.

            And it is precisely because RyanCare aims to allow insurers to arbitrarily dump patients to the curb that Ryan can present such a cheap plan.

      • The poor don't pay taxes at all?

        Really? No sales tax, tax on gas? No tolls? Is this the infamous 47%?

    • FOX POLL SHOWS 54 % OPPOSE TRUMPCARE

      and Sen. Susan Collins (R-ME) just said she will vote NO on it, effectively killing it in the Senate.

      It’s dead.

      Fred Rich LaRiccia

  5. TRUMP - SCARE CUTS CANCER RESEARCH 16 %

    As a cancer survivor, I am only alive today because of cutting edge stem cell transplant.

    Fred Rich LaRiccia

    • NIH funding cuts

      Robert Gallo, working at the National Cancer Institute, one part of the National Institute of Health, was one of the co-discoverers of the co-discoverer of HIV. Trivia time, he’s married to my cousin and attended their wedding when I was six years old.

      Trump wants to cut funding to this department.

      • woops

        Need to read before I post “send”

        Robert Gallo, working at the National Cancer Institute, one part of the National Institute of Health, was one of the co-discoverers of HIV. Trivia time, he’s married to my cousin and I attended their wedding when I was six years old.

        Trump wants to cut funding to this department.

  6. ACA as "job killer"?

    Unemployment is under 5% nationally and under 3% in Massachusetts.Prior to Obamacare, unemployment was over 8%. In Massachusetts, where the forced mandate was implemented years before Obamacare, unemployment is well below the national average and yet, Republicans call the forced mandate a “job killer”.
    Why journalists or prominent Democratic office holders do not shout this over and over and over again is a mystery to me.

  7. It's disappointing that no one is asking Ryan if . . .

    . . . there is anywhere in the world where health care is provided more efficiently than under the ACA, and, if so, what reforms from those countries are incorporated into the GOP plan.

  8. I'LL BET TRUMP SCARE LOSES TOMORROW

    in the House with 22 pukes voting NO.

    Any takers ? Lobsta Dina.

    Fred Rich LaRiccia

« Blue Mass Group Front Page

Add Your Comments

You must be logged in to post a comment.

Fri 24 Mar 2:13 AM