Osler's Razor

The main reason for the opposition is that Obama chose to back the conservative alternative to European-style socialized medicine.

All of the systemic reforms proposed over the last 50 years to address the rising cost of health care fall into three categories. (1) government take over of the entirety, owning the hospitals, employing the doctors, etc., aka socialized medicine. (2) Expanding Medicare to cover the entire population, replacing the insurance industry except as paper processors for the government, aka single payer, a mild form of socialized medicine, with non-government hospitals and doctors in private practice. (3) Mandatory, but subsidized private insurance, with private hospitals and doctors in private practice, which was the conservative alternative to (1) and (2) until Obama decided to support it.

The basics of the Affordable Care Act were originally proposed by a conservative think tank and have been endorsed in the past by Reagan, Dole, Gingrich, Nixon, and many other Republicans of national note. It was only when Obama decided that was the best he could get for the American public and endorsed the idea that it became anathema to the Republicans.

The ACA contains limits on health insurers. They must pay out a set percentage in benefits, and have a set percentage for their work processing the paperwork, executive compensation, etc. If they collect too much in premiums, they have to rebate that to whomever paid it. Even the health insurance industry agreed to this in exchange for everyone having to have insurance.
 

1. Mark, you should have drafted ACA; it sounds so simple when you say it. But, instead, we have a 2700-page law (and now 20,000 pages of regs and counting), and the Nancy Pelosi prophecy ("pass it & you will know what's in it") remains to be fulfilled with the slight modification: "implement it and you will know what's in it and how it works."

2. While I have partly changed my mind from last week (events proved me wrong, and showed the brilliance of Ted Cruz in pursuing a legislative strategy that was bound to fail), I continue to differ with the premise that we should #DefundObamacare. I continue to believe the proper constitutional solution would be to run on reform, win a mandate from the voters, carve out a practicable majority, and get to work legislatively.

2a. In the meantime, I favor actualization of the law. Rather than obsess over innovative schemes to obstruct implementation (hitting a bullet with a bullet in outer space), I prefer to allow ACA to burn up upon entry into the atmosphere. If it is a monstrosity (and I think it probably is), the public will kill ACA.

3. And, just to restate the political problem for Obamacare, and a Waco friend (who should be referred to as Wf--not WF) provides a great history and summary of the options facing us as we attempt to solve the healthcare problem in our future:

The President inherited a failing system on a trajectory to "unsustainability." He could have addressed the real problems or left things alone, but, instead, he tinkered and settled on some half measures and a series of fairly ineffective but complicated and controversial policy ideas from lots of unlikely places AND THEN he put HIS NAME on it!

Now everything that goes wrong with a system already on the wrong track, it is his fault. Literally everything from a higher co-pays to any form of managed care is now the fault of Obamacare (even if it has nothing to do with ACA and continues a trend that goes back decades).

And the legislative process of 2009-10 also served to make the whole project hopelessly partisan. The bill is flawed and the GOP won't help to make it better b/c they have no ownership and no incentive to make it work.

4. And all this serves to reaffirm conservative fears that this system (almost a lock to fail) was merely a way station to a more Euro-style, one-payer system.
 

Waco Farmer--

Which provisions of the Affordable Care Act (including those I didn't list) do you disagree with? That's what I am really trying to get a handle on here.
 

My husband runs a charitable medical clinic in Texas. He gave a presentation to some donors the other night in which he explained that since Gov. Perry isn't expanding Medicaid in Texas and isn't setting up state exchanges, Obamacare will not change life for the patients his clinic sees. He's also concerned that some of the more affordable plans will not have any doctors that will take them in our area, which is 75 miles from a major city.
 

Megan-- From the perspective of that clinic, is it a good or a bad thing that Perry made those decisions?
 

Mark, I thought your question was a clever rhetorical device--but I was not really sure you intended it to be answered. It seems you did.

My answer is pretty much the same. I have not read the 2700-page bill or the 20,000-plus pages of regulations, so I can only go off of what so-called public policy experts (most of whom I suspect have not reading everything either) are saying. And as that analysis often offers contradictory opinions, I again express my reservations based on the legislative process, what I think I know about big-government solutions, and the law of unintended consequences.

As I say, at this point, I favor implementation. Let the program rise or fall on its own success or failure. Let us have our experiment in Obamacare. I think I will (and we all will) have a better sense of what we like and what we don't like in a year or two or three.

I can tell you this, at my college, HR has drastically reduced the use of adjuncts because of what they tell us are ACA restrictions. As many of you know, academics have long bemoaned the use of adjuncts as an unfair labor practice. So, many readers will say that this is a needed reform. But I can tell you that the emancipated adjuncts are not among the chorus singing the praises of the new policy.

But that is just anecdotal.
 

WF--

Yeah, I meant it! I really do want to know which of these provisions people really like or don't like.

As you know, any law which affects existing regulations and tax law end up being huge. We do know what the major points are, though.

I'm confused as to why the ACA would affect adjunct employment, since they are part-timers who don't have a right to employer health care under the law. Unless they are full-time adjuncts-- is that a common practice at your school? Agree or disagree with that, it's not a problem that should be worked out via health care law. Generally, I suppose that if it forces less reliance on full-timers who are treated as part-timers, that is a good collateral benefit, provided that labor needs stay constant or improve and those people can get full-time jobs that then must be created.

 

Yes, Mark. Evidently, everybody over here is pretty confused about it as well. So, don't feel like the Lone Ranger.

From what I can gather it has to do with the 29-hour threshold. So, depending on how you calculate what an adjunct does outside of class, they may or may not be restricted to two classes rather than three.

And, of course, our use of adjuncts at a community college, would look a lot different from adjunct work at a law school.
 

Sorry. Meant to say.

"And, of course, our use of adjuncts at a community college would look a lot different from adjunct work at a law school."
 

As someone who is currently receiving my insurance through COBRA, I am grateful / hopeful for Obamacare and what it will mean for me and my wife. Due to pre-existing conditions, I would be uninsurable once our COBRA runs out if this law had not passed. My greatest fear, however, is that Republicans will manage to block, undermine and otherwise hinder the law until they can undo it entirely. At that point, I, along with millions like me, will be left to the mercy of the insurance companies. All in that position are one bad health event from bankruptcy.
 

I know I should be making a point, multiple points or argue the points given on the subject, but first I still have to wrap my mind around a seemingly very simple fact. ACA, profoundly flawed or not, is a law that has been legitimately passed. To undermine it in any way implies a measure of “above the law” effort that I cannot place and so I stumble. Side note…never thought I’d see the brilliance of Ted Cruz in a context other than glowing arrogance.
 

Isn't Green Eggs and Ham about trying new things, anyways? Like... new health care ideas?
 

Obama did not put his name on it. The opponents of the law chose to call it "Obamacare" and that became so widespread that Obama acceded to it and began using the term relatively recently.

As one in health policy in DC in the late '70s, and who has followed the field since, a cure for what ailed American health care financing would necessarily be a complicated law. Pelosi's remark has been misinterpreted. She was referring to the lies being told about the law (and still being told) and believed that actually having a law would result in fewer lies, but her hope was proved erroneous.

Survey after survey that asks not about the law by name, but about the individual provisions of the law, find that most people support all or most of the provisions, even when they oppose the law by name.
 

The parts I really like about the law: #3 and #5, both of which the insurance companies say they can only do with #1. Sounds fine to me.
Regarding the adjunct question, I'm an adjunct at a community college and a graduate school. The schools have put limits on my hours, despite the fact that I don't need additional health insurance. To be honest, I don't mind giving up hours to get the law functioning for those without health insurance or with pre-existing conditions. The colleges treated me badly as an adjunct long before the new health care law came about, so at least now someone's getting health insurance.
 

Quietly Responding.

For Wf:

In re the real meaning of Nancy Pelosi's almost-Freudian slip, I would say it is BOTH your interpretation and my interpretation (which was meant to be fairly generous in addition to something with which I agree). Truly, we are not going to know everything we need to know about this new, very radically different health care regime until we see it in action.

Obviously, Speaker Pelosi and President Obama and their political cohorts expect the reaction to ACA to follow the Medicare / SS track in which skepticism gives way to gratitude and then fierce devotion. Perhaps. I make no predictions. The above scenario is certainly possible. Although there are reasons to believe things might go a different way this time around considering the law, the scale of the problem, and this particular point in American economic and political history.

And for the record: the President did say numerous times on the campaign trail in 2012 that we were free to call it Obamacare; in fact, he liked it when we called it that. I consider that an encouragement...
 

WF--

I am not sure that the ACA is a very radically different scheme. Single-payer would be. This is a less-radical alternative to that option. (Oh, if Nixon had gotten his way!)

I think it is possible that Democratic leaders are so overconfident that they think " skepticism gives way to gratitude and then fierce devotion." However, it is very clear that Republican leaders deeply fear that outcome, which is why they have fought this so hard without offering an alternative.
 

Hi Mark,

1. While I agree that ACA is not as radically different as a one-payer system would have been, I do not agree that less "radically different" necessarily means not radically different. ACA strikes me as a fundamental change. But maybe that is mostly a semantic argument. We'll see how much change ACA represents in the fullness of time.

2. I never said Dems were overconfident (I don't think). Again, we cannot know whether they are overconfident at this point. We'll see...

2a. Actually the vast majority of GOP leaders are banking on implementation as a positive political development. The #defunders are a small but vocal minority. Most of the GOP graybeards are betting on Obamacare to be the great game-changer going forward in the national balance of power. At the very least, GOP strategist understand Obamacare as the great fuel that will keep the fires burning in Red States (potential fuel for a long-term House majority) for decades to come.

If I had to bet on overconfidence, it might be the vast majority of GOP thinkers who are convinced that Obamacare will be the bridge too far for the Progressive Era. And, ironically, I probably should count myself in that group.
 

WF, you didn't say Dems were over-confident, I did. I think they are, in thinking this half-measure will change the economics of health care much.

However, I don't see how Republicans would see that as a winner long-term, when it gives direct benefits to insurance companies and individuals (the cost, of course, being in terms of more inchoate things like debt).
 

It's a potential GOP winner long-term for reasons I have stated previously: it does not do much to solve the long-term crisis (may in fact make things worse) and it affixes a return address for any and all complaints ("Obamacare").

And, admittedly, this is patently unfair, but our health care system is at once the best care in the world for the vast majority of Americans and it is at the same time too good to be true (unsustainable). Something had to give. Something will give. And, and again this is the unfair part, it will be the "fault" of Obamacare--even when it isn't.

It is a potentially the great gift that will keep on giving for the GOP.
 

And One Last LAST THING (but I think it is very important):

For the GOP there really may not be that much downside to ACA success. Let's say Obamacare is as big a success as Medicare. Following the passage of Medicare in 1965, the GOP won the presidency in 1968, 1972, 1980, and 1984. Ronald Reagan won two of those elections, after making his political bones as an eloquent but sincere opponent of Medicare in 1964.
 

WF, one last question from me: Do you think the provisions I listed in the post are a good idea or a bad idea?
 

I can support 2 & 6 without reservation. The rest of those provisions require and mandate and restrict a lot. So, they feel a little awkward to me.

Frankly, I would be more comfortable allowing the states to do a lot of the heavy lifting on this and compel when necessary.
 

I think that a reasonable line of Conservative thinking would go something like this.

It is not that they disagree with the major provisions, certainly not the well intentioned goals, the list of things you stated. Rather, it is how those pages and pages of regs are implemented and spun for certain constituents.

The biggest example of this is the contraceptive mandate. Rather than requiring that employers provide this, and then only giving a limited exception for some religious employers, an exception that left out organizations like Catholic Charities and most religious universities, they could have instead expanded access to contraceptives through Title X funding, (i.e. government monies that go to organizations like Planned Parenthood, but which can not be spent on abortion.)

This is just one example. When it comes to implementation, imagine if Romney was President and was implementing this, (not shutting it down.) The difference would be that at every turn, and in all the small details, details which matter, Romney would put a right wing spin on it, while Obama puts a left wing spin on it.

And that sets up another key point, how this was passed, both rhetorically, and in the details.

Scott Brown's election wrecked everything. The Senate and the House were supposed to work out a myriad of details in conference committed. But when Brown was elected that did not happen, and whichever house went second, they just slammed through the first ones version. This was a significant reason that so many of the details got messed up.

The solution would be to pass fixes, a common thing the past. Almost all major legislation has required fixes. But the atmosphere is so poisones that it can't happen. Once you put any of it on the table, it is all on the table, and since the goal of the Republicans is to kill the thing, you can't put any of it on the table.

And this goes to the rhetoric side of how this got through. I don't know where one should put the blame on the President's relationship with Congress. I tend to think the "make him a one term President" thing was a big part of it, along with some of the super-right-wing vitriol. However, the President has responded in kind. (Understandably I think.) But regardless of who stated it, the last five years have been instructive in human nature. If you try to do something without any help from the other side. And you vilify many of them along the way, (or just tell the truth about their "pro-life" hypocrisy) they will do NOTHING to help you.

That is why we are where we are. It is not about policy, it is about power and human nature.




 

My response to this line of conservative reasoning is simple. You could have had a seat at the table. But you chose not to.

A number of conservative constituents were on board with this, specifically the health care industry. The President went out of his way to use your plan, the one successfully implemented in Massachusetts. You could have done something great, and with your seat at the table, hammered out an agreement that would have been reasonable to most Amereicans. One that would have spun a number of the details in both your favor and frankly, in everyones favor. You have good ideas.

But you didn't do that. You gave into the rhetoric of your better demons (Rush Limbaugh) and have hated and despised this President from the beginning.

In turn, that hatred has blinded you to the very real pro-life issues involved in healthcare policy. People die from lack of access to insurance and healthcare because they don't go to the doctor till it is too late. This President has sought to do something about that, while you have done nothing.

Don't ever tell me about your "pro-life" values again. You have no credibility!