Tuesday, November 13, 2012

Rooting for the ACA’s Failure?

Beyond stating what now should be quite obvious—that ObamaCare is here to stay—what does the 2012 election mean for health care reform?  On one hand, the voters have spoken, re-electing a Democratic president who is committed to full implementation of the law over a Republican candidate who promised to repeal it on “Day One”—while expanding Democratic control over the Senate and reducing the Republican majority in the House.   As a result, there is no realistic scenario where there will be the votes in Congress to roll back the law.  Also, exit polling suggests that just one-quarter of voters favor complete repeal of the Affordable Care Act.  On the other hand, it would be a gross misreading of the election to say that voters have enthusiastically embraced ObamaCare.  The same exit polling shows that voters are split nearly down the middle on the law’s future, with slightly more (47%)  being in favor of keeping or expanding it compared to the 45% who said they thought it should be fully or partially repealed.

In other words, complete repeal is off the table, at least for the next four years. But the proponents of ObamaCare haven’t yet won the hearts and minds of a solid majority of voters.  That likely will only happen if the law is successfully implemented at the federal and state levels, and voters find from their own actual experience that it is a good thing.  But if its implementation is messy, confusing, uneven, unsatisfying, and/or too costly, then the public could yet render a judgment against it. 

What worries me is that the ACA’s opponents, having failed in their “three year war against ObamaCare”, will decide that their best remaining option is to do their darndest to make implementation confusing, uneven, unsatisfying, and/or too costly for the public.  Then they can say “we told you so” and hope that the public agrees. 

So, for instance, a large number of conservative states might decide not to set up the  state health exchanges through which federally-subsidized insurance will be sold to qualified residents, hoping that it simply is too much work for the federal government to effectively set the exchanges up and run efficiently for millions of persons in (potentially) dozens of states.  They might decide not to accept federal dollars to expand Medicaid to their poorest residents, as at least a half dozen states are threatening to do, thereby ensuring that implementation will be at best uneven, leaving behind many of the most vulnerable people who were supposed to get coverage under ObamaCare.  Also, under the ACA, hospitals and other safety-net clinics will get fewer federal dollars to offset the costs of treating indigent patients because they were supposed to be fewer of them as Medicaid is expanded.  But if their state doesn’t agree to the expansion, those same safety net institutions still have to treat the indigent patients that will be denied access to Medicaid, but with a lot less funding—potentially forcing them to close or at the very least resulting in cost-shifting to those with insurance.  And then the politicians in those states could say, see, it is all ObamaCare’s fault, even though it was their own opposition to the Medicaid expansion that made the law untenable for their safety net clinics!

And setting up the law to fail in the states that oppose it is precisely the advice being offered by some ObamaCare critics.    Arguing that the federal government can’t “competently operate dozens of exchanges. . . Republican governors should allow the feds to live with the mess they created rather than clean up for them” writes Philip Klein in the Washington Examiner.   And, at the federal level, the House GOP could again try to use its leverage over spending to try to deny the administration the funds it needs to implement the law, although this wasn’t very successful in the outgoing 112th Congress, and will likely be even less so in the new one.

If the critics of ObamaCare decide to do everything they can to undermine its implementation, they are essentially putting patients at risk to make a political point.  States that refuse to set up the exchanges or agree to the Medicaid expansion will be making it harder for their residents to get access to health insurance.  By refusing to lending a hand to the federal government’s effort to make the law work in their states, they may succeed in making it more confusing for the public and less likely to achieve the law’s goal of facilitating enrollment in qualified health plans, but how can it be good public policy to make it harder for people sign up for coverage?

There is a better way, which is to get over the polarized, ideological and hyper-partisan political debate over ObamaCare, accept that it is here to say, to acknowledge that a majority of voters could have elected a President and Senate committed to its repeal but didn’t, and instead seek bipartisan avenues to improve it.  USA Today reports that some Republicans and Democrats are beginning to talk about ways to “come together and fix it” rather than continuing the fight over killing it on one hand or keeping it exactly as is on the other.   History reminds us that this is what happened when Medicare and Medicaid were enacted in 1965: after initially being fiercely opposed by conservatives, and after several election cycles where voters chose the candidates that favored continuing those programs rather than the ones promising to repeal it, the cries for repeal faded, the efforts to disrupt implementation ceased, and repeated Congresses and administrations found a way to enact bipartisan legislation to make them work better. 

Isn't it time for the country to come together to try to make the Affordable Care Act work, including fixing things that are wrong with it, rather than rooting for (and even trying to facilitate) its failure in delivering on the promise of accessible, affordable health insurance for all?

Today’s question: How would you answer the above question?


ryanjo said...

Hmm..not a very democratic attitude, Bob.

So -- having re-elected a President based mostly on a weakly recovering economy, we 45% of Americans who have some issues with the ACA (which Mr. Obama skirted at every chance) -- we should go quietly into the shadows? Not going to happen, not at all! This is a law that even ACP says will destroy my private practice. It may also bankrupt our economy. (http://www.bloomberg.com/news/2012-06-13/health-care-spending-to-reach-20-of-u-s-economy-by-2021.html).

But I guess Henry Clay gave that same speech to the Abolitionists after the Fugitive Slave Act was passed, and Andrew Volstead told opponents after he orchestrated the override of President Wilson's veto of Prohibition: "Give it up, it's the law now...you have lost". We all know how those turned out -- the most destructive war in our history and a generation of lawlessness. Sometimes, our politicians come up with such terrible ideas. Now to simply accept them...that would be a real failure.

BDoherty said...

Come on, comparing a law to extend coverage to slavery is a bit over the top even offensive, don't you think? And ACP has never said it will destroy private practice. Tell that to the 500 practices getting paid more under the Comprehensive Primary Care Initiative. Or how about the 10% bonus and Lifting Medicaid rates to MedicRe also mandated by the ACA? It is one thing to use the democratic process to persuade people to oppose the law, another for states to try to impede or nullify a law that has been duly enacted by Congress and upheld by the Supreme Court.

Steve Lucas said...

There are plenty of current arguments about Obamacare without reaching far into the past for issues from a different time and place. Let us look at what will happen under the current process. Passing a law sounds so simple, but the reality is very different.

There are all ready thousands of new regulations associated with Obamacare. After the federal government sets rules each state then must develop its own set of policies to interrupt those rules. This will take years given the volume of federal regulations. This whole mash up must then be moved into the public domain and we then deal with the never ending new rules that will surely follow.

I am personally annoyed to hear such words as “mandate” and “the American people have spoken” coming after an election where the President won by 2%. I am also mystified by the constant drum beat of “tax the rich.” The numbers are just not there, it will take a balanced effort to solve our financial issues and that will include reducing spending.

Quoting past tax rates is also a nonstarter since inflation and the tax code at the time drove behavior. Part of the success of the Laffer curve was due to the inefficiencies of our economy. The desire of every business deal was to have free cast flow while showing a tax loss.

In an interview after his meeting with the President Tuesday the head of the NEA was asked what he would reduce to balance the budget, over and over, staying on point, his response was “cut the tax breaks of the rich.” Sorry, but the rich already pay more taxes than the poor both in real dollars and in percentages of income. I do not see any future lowering of rates and additional limits on deductions will be the way forward. We have two viable plans that accomplish this; we just need the political will to make a choice.

Obamacare was never going to be repealed; it does need to be streamlined. Here is one doctor’s take on the situation:


Steve Lucas