“Discover the obvious,” Jonathan Cohn said on Monday.
Cohn is one of the nation’s foremost health care journalists and the keynote speaker of the journalism portion of “Hearsay or Fact: A Symposium on the Communication of the Affordable Care Act,” hosted by the Center for Healthcare Research and Transformation.
A senior editor at The New Republic and author of Sick: The Untold Story of America’s Health Care Crisis—and the People Who Pay the Price, Cohn decided to use his time to give five rules about reporting on the Affordable Care Act (ACA). His first rule was an admission that people who follow the everyday tribulations related to Obamacare — like wonks in every field — often assume they don’t need to report on “the obvious” and thus fail to report on the issues that matter most to the public.
He pointed to the success of fellow panelist Stephen Brill’s Time magazine cover story “Bitter Pill: Why Medical Bills Are Killing Us” that illuminated the outrageous variation in medical prices and profits from one hospital and one patient to the next, a well-known fact to experts that came as a shock to many Americans.
What’s obvious to everyone about the debate over Obamacare is that the public is confused. Nearly two-thirds of Americans didn’t know in late September that the health care exchanges were opening on October 1 and 67 percent of the uninsured said “they don’t have enough information about the law to know how it will impact their families,” according to the Kaiser Health Tracking Poll. The uninsured, of course, make up this law’s key demographic. They are the people this law is designed to help most, and their participation in the health care marketplaces will determine if the law is a success.
Why are people so confused? Much of what should be “obvious” has become obscured — intentionally.
Democrats passed the ACA with only Democratic votes — and Joe Lieberman. Republicans have responded with an unprecedented effort to scare voters, starve implementation and sabotage the law, an effort that helped doom the launch of Healthcare.gov, which the White House has to own as a greater act of self-sabotage than anything Republicans could have pulled off themselves.
The political battle over the law has overwhelmed any pertinent policy discussion. So it’s no wonder that people can’t even agree on the basic premises that made health reform necessary and an improvement over the current system, with 56 percent of Americans saying they’ve heard more about the politics and the controversies of the law than any discussion of its practical impact.
Here are five “obvious” premises that every American needs to understand so we can begin to have a rational debate on health care reform.
Photo: BU Interactive News via Flickr
Before The ACA, America’s Health Care System Was Already ‘Socialized’
You should know by now that the United States spends more than any country on health care, even though approximately 50 million citizens have no insurance whatsoever. This is how we ended up with the 46th most efficient health care system in the world.
The Affordable Care Act attempts to fix this in a number of ways, including health care exchanges, subsidies, Medicaid expansion and regulation.
Since 2011, the government has set how much insurance companies have to spend on actual care — 80-85 percent depending on their size — and the minimum standard for the policies they can offer, among several other regulations. So even though private insurers remain in business and the government hasn’t taken control of the medical industry as it has in the United Kingdom, Republicans argue that it’s “a government takeover” of the health care system. Based on this standard, health care has been “taken over” by the government and even “socialized” for decades.
Since 1965, Americans over 65 and under the poverty level were guaranteed basic care, though it took until 1982 before the last state, Arizona, accepted Medicaid. This left America with a single-payer system, with a giant hole mostly made up of Americans under 65 with jobs, and their families.
In 1986, President Ronald Reagan signed a bill that tried to plug that hole — the Emergency Medical Treatment and Active Labor Act. This law states that any hospital that accepts any federal funds — which basically every hospital in America does — cannot turn away any patient, regardless of his or her ability to pay. As this bill provides no reimbursement for this care, the costs of those who can’t pay get passed on to those who can.
In 1996, Congress passed and President Clinton signed the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which mandated guaranteed renewability for all health insurance plans, requiring that an insurer has to offer you renewals of your policy without charging you any more based on any new information it has about your health.
These are three of the key “government takeovers” that helped lead to the broken health care system that we are now attempting to fix, while maintaining a private insurance industry.
The ACA clearly isn’t a one-size-fits-all solution, health economist Thomas Buchmueller pointed out at Monday’s symposium.
That would be a two-page bill that said, more or less, “Everyone is now on Medicare.”
Rich People Get Their Health Care Subsidized By Taxpayers
Single payer is a simple, proven system that would insure all Americans, save lives and cut costs. And it will likely never happen in America as long as the filibuster exists in the Senate. Still, liberals will not stop offering this ideal solution whenever Republicans complain about costs or cancellations.
The right has its own fantasy solution that is about as improbable as single payer: getting rid of the tax exclusion of premiums for employer-sponsored insurance.
As a result of an accident of history, employers and employees do not have to pay taxes on costs of health insurance policies.
Conservatives hate this. “We call the tax exclusion for ESI a tax ‘break,’ but when you think about it, it operates more like a tax hike,” writes the Cato Institute’s director of health policy Michael F. Cannon, another symposium participant. “It coerces workers into handing control over $11,000 of their earnings to their employers, who then choose the workers’ health plans for them.”
John McCain campaigned for president on ending this “tax break,” which costs taxpayers more than the costs of all the subsidies and Medicaid expansion in the ACA, according to symposium participant Dr. John Z. Ayanian. This will never happen because it would be far more disruptive than Medicare for All and — unlike effective single-payer systems around the globe — it has never been proven to work, anywhere.
As a result, taxpayers will continue to help subsidize takers like Ted Cruz, whose family’s $40,000-a-year insurance policy from Goldman Sachs entitles them to a subsidy large enough to put a family of four on Medicaid, though the Cruzes are clearly able to afford their own health insurance.
Photo: Patrick Feller via Flickr
Republican Arguments Against Obamacare Are Opportunistic And Contradictory
Republicans fought the passage of the ACA by conjuring images of “death panels” pulling the plug on grandma and a “government takeover” that would destroy America.
The problem with these warnings was that approximately 80 percent of Americans get their health insurance through their employers. Most of these people haven’t and likely won’t notice much of a change in their coverage whatsoever, unless they’ve gone in for preventive or reproductive health care and discovered that they didn’t have to pay a co-pay for it.
That’s why Mitt Romney’s continual assertion that President Obama was embracing “European” solutions never made sense to most Americans. It was an uniquely American solution born in Massachusetts, in fact.
Republicans didn’t seize on the president’s now-disproven promise “If you like your insurance, you can keep it” until late 2013, though it was clear that it never jibed with his other promise to make sure insurance policies met minimum standards.
Now their fixation on cancellation notices boxes them in, in two ways. First, it ignores that their plot to repeal Obamacare would result in as many as 137 million cancellation notices. Second, right-wing policy proposals would force cancellations that target far more than the estimated 5 percent of Americans who are having their plans changed by the ACA.
“Even if free-market health care reformers were able to pass the plan of their dreams — which would involve tweaking the tax code to end the bias in favor of employer-sponsored insurance — it would likely mean a lot of people would get dropped from their current plans,” the Washington Examiner’s Philip A. Klein notes.
The Republicans’ advantage is that they’re so stuck on the “repeal” part of “repeal and replace” that they’ve never actually passed an ACA replacement. Their rhetoric, and the fact that the only real conservative alternative to single payer requires an individual mandate, means any plan they pass would likely end up generating the same criticisms they’re lobbing at the ACA.
Photo: Adam Glanzman via Flickr
We Can’t Go Back To The Pre-Obamacare Health System
Dr. Ayanian pointed out that though the ACA may not be embraced by a majority of the American public, three key policies have: young people staying on their parents’ plans until age 26, closing the Medicare Part D prescription-drug donut hole, and the ending of concerns about pre-existing conditions.
The Republican Study Committee Obamacare replacement plan, which the House has not voted on, provided pre-existing conditions protections, but only for those who are already insured.
The Washington Post’s Jonathan Bernstein puts it simply — repeal “is dead”:
No one is ever going to kick young adults off their parents’ insurance (or change the law so that insurance companies are allowed to do it). No one is going to bring back the various limitations in pre-ACA insurance policies. Some trimming of the new Medicaid rolls might be possible. But no one — no politician who has to face reelection, at least – is going to just toss all those people off their insurance with nothing to replace it.
Beyond all this is simply the Humpty Dumpty-ness of the situation: The old system has been slowly pushed off the wall for three years now, and by this point it’s really beyond repair, whatever the merits or politics of the situation. Garance Franke-Ruta captured some of this in making the point that delaying things would be impractical at this point, but it really goes beyond that. Too many people have already done too many things to make a full reversal even remotely plausible.
Before the ACA became law, millions of Americans lost their insurance, rates were rising faster than the rate of inflation and the federal government was absorbing more and more health care costs. Repealing it would be a nightmare in that it would reveal a broken health care system badly in need of some type of fix.
AFP Photo/Karen Bleier
Republicans Are Hurting Themselves, Their States And The Working Poor To ‘Punish’ Obama
Because the Supreme Court gave them the chance to do it, about two dozen — all Republican — states have completely rejected the Medicaid expansion in the ACA, even though the government will cover 100 percent of the costs of the expansion for the first three years. States could then opt out of the coverage or continue it with the feds’ contribution decreasing to 90 percent by 2020.
Medicaid expansion should be a huge transfer of wealth from rich blue states to poorer red states, as most of America’s public assistance programs are. Instead Texas, with the largest uninsured population in the nation, has rejected expansion, but will still contribute to helping to insure Californians.
By rejecting Medicaid expansion, just four states — Florida, Texas, Georgia, and North Carolina — will leave 5 million poor people with jobs uninsured. This will result in more emergency room visits that the uninsured cannot afford, and higher rates for the insured in those states.