June 23rd, 2017

The debate about the Senate version of the health care insurance reform bill…

…rages on.

I believe the bill will be modified, and has not reached its final form. But in the meantime, I was thinking about the following question to ask the critics who say it’s just Obamacare light: what else would you expect? After all:

(1) The president is not a conservative and would be unlikely to favor, and has not pushed for, a more conservative solution.

(2) Same for Congress, which does have some conservatives in the GOP, but they are not in the majority and not likely to be so any time soon.

(3) American citizens have become accustomed to subsidized medical insurance as a right, just as Obamacare proponents expected them to and planned that they would.

(4) Democrats are more than prepared to portray Republicans as heartless meanies who want to kill people. In fact, they’re portraying them that way right now—but a more Draconian, market-based bill would cause the cries to crescendo even further.

(5) As a thought experiment, consider what the GOP did when they last controlled the House and Senate as well as the presidency. They passed Part D of Medicare. They wanted to get out ahead of the Democrats on this; not that they ever got much credit for it. But I wonder what the GOP might have passed to deal with health care insurance reform prior to Obama’s election (and prior to Obamacare, of course), had they been focusing on the problem. Would it in fact have been something that looked something like Obamacare-lite, even without Obamacare having been previously enacted? I’m using Part D as an indicator.

And now—ta-da!—we have the article I was waiting for: Avik Roy’s analysis of the Senate bill. He is enthusiastic. Here’s an excerpt:

The reason that Medicaid’s health outcomes are so poor is because the outdated 1965 Medicaid law places a laundry list of constraints on states’ ability to manage their Medicaid programs. As a result, the main tool states have to keep Medicaid costs under control is to pay doctors and hospitals less and less each year for the same care. Hence, many doctors don’t take Medicaid, and Medicaid enrollees struggle to gain access to care.

The Better Care Reconciliation Act of 2017 addresses these problems in several ways.

First, the bill repeals Obamacare’s Medicaid expansion, and replaces it with tax credits so that low-income Americans can buy the coverage of their choice at an affordable price.

Second, the bill gives states a new set of tools to make their Medicaid programs…

A third area where the Senate bill does extremely well is in giving states the latitude to come up with new ways to serve their needy populations with better results and lower costs.

We’ve talked already about the new flexibility that states will have with their Medicaid programs. They’ll have even more flexibility to open up their private insurance markets to innovation and competition, through a new set of “Section 1332” waivers in which the validity of the waiver applications will be assumed by the federal government so long as the plan doesn’t increase federal spending…

…[A]ny Republican conservative in the Senate who is thinking of voting “no” on this bill: how many times in your life will you have the opportunity to vote for a bill that fundamentally transforms two entitlement programs? How often will you get to vote for a bill that cuts spending by hundreds of billions of dollars? How often will you get a chance to make a difference for millions of your constituents who are struggling under the weight of rising premiums and exploding deductibles?

Please read the whole thing. One of the main points I take away from it is that the bill would restore a measure of federalism to the entire operation.

Why do I put so much weight on what Avik Roy says? Simply because, in the past, I’ve found him to be the most knowledge and fair writer on health care insurance reform issues, as well as practical and realistic.

I find what he writes about the current bill to be very encouraging—that is, if his voice isn’t drowned out by all the others.

15 Responses to “The debate about the Senate version of the health care insurance reform bill…”

  1. Bill Says:

    I generally think more federalism is a good thing, so that’s a hopeful sign

  2. TommyJay Says:

    I haven’t read Mr. Roy yet but here are my counterpoints.

    1) Mr. Trump, the NYC businessman was a leftist. Trump the campaigner was a hard core conservative. President Trump seems to be a vague (weak?) conservative so far. Who knows what he really thinks about health insurance policy? I am sure he wants a second term and will let Capitol Hill conservatives take the heat, instead of himself.

    3) While this is narrower in scope, the language Neo uses here is strongly reminiscent of the Progressive Party platform that Teddy Roosevelt ran on, and lost. We now have all of that, and Dems work for more.

    I’d guess that this is exactly the group-think of country club GOPe’rs. The expansion of gov. is inevitable, all we can do is slow the rate a bit; why even try, have another G&T.

    You can’t succeed if you never try.

    4) The cries are at volume level 10 now. I’m not sure taking it to a Spinal-Tap 11 will matter much.

    5) Ah,… Medicare part D. Of course, they never get credit for it, and never will for anything else. I believe it is true that part D is the only major entitlement program where costs have come in well below projections. By contrast, the actual cost of Medicare/Medicaid in 1990 came in 7 or 8 times higher than the 1990 projections made during its passage (inflation adjusted).

    About getting credit. A Comedy Central host several years ago asked Bono (of U2) who was the greatest humanitarian of the last couple years. He said G.W. Bush, who had poured at least couple billion dollars into Africa for HIV retro-viral drugs. Gasp! Promptly sent to the dustbin.

    If the GOP Health Insurance bill really is ObamaCare lite, the costs will continue to explode. This will probably lead eventually to the federal partial confiscation of retirement accounts (excluding unions, of course). But if it is more like Med part D, then there is hope. I reject the notion that Med part D and Obamacare are in anyway similar. Markets, incentives, and flexibility matter.

  3. TommyJay Says:

    Agree with Bill. Federalism = Flexibility.

  4. J.J. Says:

    This issue is of utmost interest to our daughter, a small business person who has to buy her individual insurance on the Obamacare exchange. This year she had only one insurance company to choose from. Next year there may be no choice, as has already happened in several states. If that happens, she may have to go naked and rely on EMTALA to get treatment in an emergency room. A ghastly proposition. People in her position curse the ground Obama walks on. Before Obamacare she had her choice of four insurance companies, a doctor she liked, a premium/deductible combo she could afford, and was quite happy. She lost her doctor, her choice of insurance companies, and has unaffordable premiums and deductibles. It has been a nightmare!

    No one seems to care about the people like her who have been so adversely affected. No one even mentions them in the analysis of these bills. It seems to be all about Medicaid. In my opinion those on Medicaid have the least to fear from the new GOP versions. Medicaid needs improving and this offers the opportunity. It also offers the opportunity for the individual insurance to go back to pre Obamacare days.

  5. Mac Says:

    J.J. says: “No one seems to care about the people like her who have been so adversely affected.”

    I had a very eye-opening conversation on Facebook a couple of years ago. I think it started with my saying something critical about the people who were not doing so well under Obamacare. Three liberal friends chimed in to say that it had worked out very well for them. These are all affluent people, one of them I think quite affluent–that one was very happy about the fact that Obamacare had enabled him to retire early. And they seemed doubtful that the stories of hardships created by Obamacare were really genuine, or numerous enough to be significant.

    So then another friend, who is barely getting by, whose husband is past retirement age but they can’t afford for him to retire, chimed in, saying well, I’m one person who was very adversely affected. And she explained how much more sxpensive health insurance had become for them. She also mentioned other people in similar and very non-affluent circumstances who were worse off.

    The response from the affluent winners to the poor loser boiled down to “too bad.” They faulted various third parties but would not acknowledge that Obamacare was in any way to blame for the situation.

    No need for me to gild that lily with snark about compassion, I guess.

  6. Geoffrey Britain Says:

    The problem isn’t that the bill isn’t conservative enough. I’ll bet that it contains no path forward to a return to a healthy private insurance model. If so, the problem is that Congressional conservatives know that the GOP has no intention of progressing past this point. The GOP establishment simply favors a slower march toward the collective.

    “I generally think more federalism is a good thing” Bill

    “Agree with Bill. Federalism = Flexibility” TommyJay

    Thomas Jefferson: “A government big enough to give you everything you want, is strong enough to take everything you have.”

    Jefferson disagreed rather vehemently with Hamilton on this issue. It seems to me that the trick is to achieve a proper balance. If government is too weak, that nation falls to the invader. Too strong and it will strangle liberty. Anyone who thinks that the Federal government did NOT long ago surpass that point of balance is either willfully blind or effectively supports the death of liberty.

    “No one seems to care about the people like her who have been so adversely affected.” J.J.

    There are millions like your daughter J.J. Which begs the rhetorical question, why isn’t the GOP highlighting this issue? Democrats and their MSM propaganda machine are screaming “that millions are going to die!” and the GOP response is silence…

    “The response from the affluent winners to the poor loser boiled down to “too bad.”” Mac

    She doesn’t belong to the right victim group. Liberal progressive’s ‘compassion’ rests upon the degree to which it provides self-validation to the liberal progressive. That’s why there is zero concern among liberals about jobless blue collar white Americans.

  7. mkent Says:

    “The president is not a conservative and would be unlikely to favor, and has not pushed for, a more conservative solution.”

    What I expected from a Republican Congress is to pass the same ObamaCare repeal bill that they sent to Obama’s desk last year. Let Trump veto it, if he does. THEN begin the negotiations.

    What they’ve done now is conceded the loss without even trying.

    “American citizens have become accustomed to subsidized medical insurance as a right, just as Obamacare proponents expected them to and planned that they would.”

    1) Have they? Progressives keep asserting this over and over, but from what I can see, it’s just noise. I understand that this is some kind of holy grail for progressives, but here in flyover country, ObamaCare is the most hated law since the Volstead Act.

    2) It doesn’t matter what most people want. ObamaCare is going to crash — is crashing — spectacularly. California may want single-payer healthcare, but it will crash even more spectacularly. The laws of economics are relentless. If we can’t negotiate a sensible repeal, the best thing to do would be to get out of the way and let it crash, lest we be blamed for it. Maybe then Congress will be more sensible.

  8. AesopFan Says:

    I was thinking about the following question to ask the critics who say it’s just Obamacare light: what else would you expect? …(2) Same for Congress, which does have some conservatives in the GOP, but they are not in the majority and not likely to be so any time soon. – Neo

    Given that the GOP has initiated and supported very progressive policies in the past concerning medical care (among other things), I still don’t understand why the Democrats totally refused to allow them any input and “buy in” on Obamacare, which would have led to both a better bill (circumventing some obvious problems) and more support for it later.

    I’ve heard several theories, including that (a) the D’s didn’t want anyone to notice this was their single payer stalking horse; and (2) they didn’t want the GOP to get any credit for the success of the law. Was there anything else, or are these enough to explain the closed process and midnight vote?

    (I remember reading Bono’s comments about Bush, and thinking that at least there was one honest progressive on the planet).
    (Bush’s ranch in Texas also had a better environmental footprint than Gore’s mansion. Just sayin’.)

  9. AesopFan Says:

    Geoffrey Britain Says:
    June 23rd, 2017 at 9:07 pm

    “The response from the affluent winners to the poor loser boiled down to “too bad.”” Mac

    She doesn’t belong to the right victim group. Liberal progressive’s ‘compassion’ rests upon the degree to which it provides self-validation to the liberal progressive. That’s why there is zero concern among liberals about jobless blue collar white Americans.
    * *
    Check out this article (and you are right on your other points also, I just don’t have a corroborating post readily at hand).

    http://www.nationalreview.com/article/448850/liberal-elite-privilege-noblesse-oblige


    Despite Rosenfeld’s efforts, however, her novel makes clear that the liberal hypocrisy it depicts is no foible but reveals a serious defect: a facile, often brazen combination of self-righteousness and self-advancement.

    Speaking of Orwell, his observation that all leftist political parties are “at bottom a sham, because they make it their business to fight against something which they do not really wish to destroy,” holds up impressively after 75 years.

    Similarly, diversity in education, from preschool to postgraduate, and the resulting holy war on privilege, requires denouncing but not renouncing. Despite its stated intent to subvert unjust hierarchies, multiculturalism facilitates rather than impedes careerism. A degree from a selective college, one racially integrated in a carefully curated way, does wonders for those getting on in the world. “Checking your privilege” never involves transferring to Jerkwater A&M, diverse in ways selective colleges never will be, and thereby surrendering one’s spot in the Ivy League so that it can be filled by a cashier’s or opioid addict’s kid.

    It turns out that “social justice” amounts to noblesse oblige, simultaneously strengthening the obligations and social status of our meritocracy’s credentialed gentry. Literary scholar William Deresiewicz, a self-described democratic socialist, says that the rise of political correctness means that privilege laundering pervades the entire college experience, not just the admissions process. The ultimate purpose of political correctness, he contends, is to “flatter” the elite rather than dismantle it. In effect, socioeconomically advantaged students, professors, and administrators use political correctness to “alibi or erase their privilege,” to “tell themselves that they are . . . part of the solution to our social ills, not an integral component of the problem.” The social-justice warriors’ stridency belies, even to themselves, the fact that their aims are so limited.
    * * *
    I love the phrase “privilege laundering” —

  10. AesopFan Says:

    HotAir’s John Sexton brings up the single biggest argument against Obamacare – and how the Media failed in its journalistic stewardship.

    http://hotair.com/archives/2017/06/23/trump-signs-va-reform-bill-law/

    The CNN report on problems at the VA is being released in the middle of the extremely contentious debate over repealing (or altering) of Obamacare. The VA is a completely socialized health care system, a step beyond single-payer, and it is an ongoing disaster. That ought to be part of the discussion about where our system is going, but for some reason, Democrats are never asked or expected to defend the VA even as they agitate for moving the entire nation in the direction of greater government control over health care.

    I think this is one of those cases where the left is actually hampered, albeit indirectly, by having a national media that seems incapable of viewing some issues from multiple points of view. Franky, if we had a press that wasn’t so simpatico with Democratic goals on health reform, the country could have had a real discussion about the costs as well as the benefits of moving toward a more socialized system. Instead, we got a media that went along with every lie the Democrats told about Obamacare until it was too late to matter. And to this day, most of the media has never admitted that one of the goals of the effort was to slide the country toward single-payer without admitting that was their intent.

    The American people may not have been up on all the details of various proposals but I think they had a good sense they were not being given the truth. That’s why we are where we are now, i.e. on the verge of another major change of direction in health care policy. It probably could have gone differently if the media had worked to keep Democrats honest about their goals and the potential downsides of their plans from the start, i.e. all the things they are now eagerly doing with the Republican plan.

  11. Big Maq Says:

    “the bill would restore a measure of federalism to the entire operation” – Neo

    Seems to be the case for this one part of “healthcare”.

    It is a step in the right direction.

    We’ll see with the rest.

  12. Big Maq Says:

    “The president is not a conservative and would be unlikely to favor, and has not pushed for, a more conservative solution.” – Neo

    Right. About all trump consistently said is “repeal and replace”.

    Oh, and (per your #4), he did say the House version was “mean” (not sure if it was the first iteration or the latest one).

    One thing is for sure, everyone will be selling it as a full repeal and replacement, even if it ends up being mostly a tweaked / modified obamacare.
    .

    That we finally have a GOP POTUS, with a GOP House and Senate, it surely seems that this may well be a lost opportunity to make the kinds of changes that will radically reduce the scope of government, the leviathan, that many here claim they want.

    Ultimately, #3 should be at the top.

    If we are not selling our ideas as superior, gathering support for the changes we think are important, and if we don’t expect more from our elected officials, holding them accountable, how can we expect even our “Royal Flush” win in 2016 to deliver?

    Those kinds of changes to obamacare were doomed from well before Nov 2016.

  13. Big Maq Says:

    A county by county estimate of the impacts, that can interactively by filtered by age and income is here…

    http://www.kff.org/interactive/premiums-and-tax-credits-under-the-affordable-care-act-vs-the-senate-better-care-reconciliation-act-interactive-maps/

    If one is 60 years old (and presumably as they near it in their 50’s too – the filter notches down to 40 only, though), at every income range, it looks like $1000s more net out of pocket.

    At $20K it will be net (after credits) $1K more in western PA for a Bronze plan – 5% of income.

    At $50K, it is $4K+ – 8% of income.

    Looks like a good chunk of the mid-west where this demographic is more likely a trump supporter, the story is much the same.

    Note: it says nothing specifically about deductibles, other than identify plans as Silver or Bronze.

  14. Big Maq Says:

    It seems that what is playing out before us is a consequence of not spending much effort to sell a conservative vision or set of ideas in this area.

    In absence of that, the only thing the GOP could articulate was “repeal obamacare”, with nothing in their back pocket to sell on what the alternative is. All they had / coalesced around were the criticisms of obamacare.
    .

    So now, without having set a foundation for a bolder, more conservative solution, all the GOP can do (or think they can do) is tweak obamacare.

    What is being proposed is fine, as far as “fixing” obamacare is concerned (i.e. mitigating the “death spiral”, and reducing some of its burdens / cost drivers / taxes / etc).

    The long term problem is that this bill is still very much a government centered “solution”, and its inherent problems will be forever linked to the GOP (raising the question / doubt if the GOP even have any “better ideas” to begin with).

    In the near-term (2018, 2020), it seems that it may well hurt many of the swing voters that trump won.
    .

    Seems to me, if one is going to be d*mned either way, might as well go for the solution you really want.

    But, again, that takes selling the proposition, groundwork that hasn’t been done, and, with the timetable they are gunning for, no way to achieve.

  15. Big Maq Says:

    Often times it makes one wonder if some of the commentators out there are coming here to read this blog and its comments section.

    The timing is an interesting coincidence on this piece from Ben Shapiro…
    http://www.nationalreview.com/article/449020/democrats-republicans-agree-health-care-principles-avoid-real-debate
    .

    “Democrats and Republicans apparently agree on health care’s central principles, they just argue over how best to implement them.

    And yet the passions run high.

    We are polarized. And politicians seek to exacerbate that polarization, not alleviate it; they want passions running high all the time. It’s tough to pry a buck from a fellow who thinks you’re busy all day rewriting a statute on Medicaid reimbursement.

    Americans want their politicians arguing over the big issues — we do have big issues to discuss. Politicians have an interest in avoiding big issues while giving the impression that they are at war over big issues. The result: small divisions over policy inflated into be-all, end-all arguments that never even implicate central issues.

    No wonder Americans are frustrated.”

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Previously a lifelong Democrat, born in New York and living in New England, surrounded by liberals on all sides, I've found myself slowly but surely leaving the fold and becoming that dread thing: a neocon.
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