Friday, September 23, 2011

"Obamacare" is More Like the Apology Tour Than ACA -- Fortunately For Mitt

Jonathan Chait has been saying for months that he just can't see how Republicans can nominate Mitt Romney, given that his signature accomplishment in his brief time in office was passing a bill that was basically identical to the core substance of Barack Obama's health care reform. After watching the the Republicans debate last night, the fog is finally beginning to lift for him:
These [audience] expressions clearly reflect the straightforward policy implications of conservative principles. At the same time, I don’t think they ought to be taken purely at face value...Yes, conservatives have developed a series of policy stances — say, that subsidizing and regulating private health insurance is the greatest threat to freedom in American history. Rather than treat this as a principled view, Romney simply treats it as an atavistic expression of hostility toward Obama. He defends his Massachusetts plan by pointing out that it involves private insurance. That makes it exactly the same as Obama’s plan, but Romney probably figures most conservative voters don’t know that, and he’s probably right. 
That's exactly right (and, really, what some of us have been emphasizing for a long time). Conservatives simply don't have a lot of hostility to the program that Mitt Romney supported in Massachusetts; what they are hostile to is "Obamacare," which functions more or less on the same level as Barack Obama's (entirely fictional) apology tour foreign policy. That there is also an actual policy -- a law -- that corresponds to "Obamacare" is more or less coincidental.

Paul Waldman makes this point really well in a post today concentrating on Herman Cain's claim that he'd be dead if Obamacare had been enacted earlier (his emphasis):
I have no doubt that the typical Republican voter actually believes that when the Affordable Care Act is implemented, every time one of the nation’s nearly one million practicing physicians wants to perform a procedure or prescribe a medicine, they’ll have to literally place a call to Washington and get permission from some stingy bureaucrat...Why do they believe that? Because people like Herman Cain keep telling them so. I don’t know whether Cain is an ignoramus or a liar, but it has to be at least one, maybe both. He stood on a stage, looked into the camera, and told people that under the ACA, doctors will have to get permission from government bureaucrats for every procedure, and treatment of illnesses will proceed not according to the recommendations of medical professionals but on “the government’s timetable.”
 Exactly.

Now, the question I'm interested in is whether, in fact, most of the candidates on the stage last night, and most Republicans in the House and Senate, are actually on the "ignoramus" side of that. Not all -- Mitt Romney certainly knows very well what the ACA is -- but a lot of them. I'll say this: both I (in my Plum Line recap) and Andrew Sprung last night noticed that Romney had left open a huge hole in one of his health care answers, and no one up there on stage was able to take advantage of it. Of course, there are lots of reasons why that might be the case (not their strategy, didn't get called on, etc.), but it seems perfectly plausible to me that for at least some of them the problem is that they really do believe that "Obamacare" consists of some new huge government agency that is going to be making day-to-day decisions about whether people can get surgeries or not.

One more thing: I've watched seven Republican presidential debates so far, and I've yet to hear even a mild suggestion that the non-Romney candidates could describe what Obamacare actually will do.

Once again, the necessary disclaimer: I'm not saying that Romney will win the nomination; not every policy works this way for Republicans. And if GOP elites turn against him, they're apt to express it through health care. But I just don't think health care will cost him the nomination.

17 comments:

  1. Now that GOP media voices are panning Perrys debate performance, I'm really hoping Perry finally starts ripping into Mitt. This nomination contest is getting boring!

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  2. It's been obvious since early 2009 that the GOP hysteria regarding health care is based on tribalism, not facts. (And it thrived on incitement from the Rush/Drudge/Fox noise machine.) And that means Romney can play fast and loose with the facts to make it seem like he's a loyal member of the tribe, without any ill effect among GOP primary voters.

    But this seems like a dangerous game to play in the general election. If Romney gets the nomination, he will need to play up his anti-Obamacare rhetoric in order to keep the GOP base energized; otherwise, with his moderate background, Tea Partiers are likely to view him as "Obama-lite" and may go third party or sit out. But the more he plays that up, the more it gives Obama and his surrogates the opportunity to explain how Romneycare and Obamacare are virtually identical.

    That will likely have the twin effects of (1) alienating right-wing Tea Partiers that are convinced ACA = Death of Freedom and (2) signaling to anti-Obama independents that perhaps ACA isn't so bad after all.

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  3. I think JB is exactly right.

    If Mitt wanted to keep Obamacare, he could remove the medicare cutoffs and increase mandate penalties. Then call it Rand-care of something.

    Again, the mystifying part of the ACA is why wait for so long to kick in,and not create a few champions. For example, a public option for people under 30. Or for long term disability.

    But yes, I doubt anyone can tell you what Obamacare really is. I doubt Obama could, either.

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  4. Charlie: "I doubt anyone can tell you what Obamacare really is."

    I know I can't. That doesn't mean that I'm opposed; it's just that, after all that debate, I'm still not real clear on the mechanics. For example: who makes decisions regarding which procedures (or drugs, or devices) are covered? More to the point, is there going to be some mechanism in place to ensure that such decisions are insulated from political influence?

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  5. I'm sorry - I didn't realize that I had asked such a difficult question. No one knows?

    Anyone out there?

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  6. I've argued the following previously, but the hard thing to figure about the ACA is how to transition from the current US healthcare system (~3/4 of us have high quality, high cost health care, and ~1/4 of us get basically nothing) to the post-ACA world (all of us have access to high quality, high cost health care) and still save money. There are many proposed mechanisms for these savings, while the moose on the table, which no one cares to discuss (rationing), lingers like a bad odor.

    Its the specter of rationing that those candidates channel last night when they mention a bureaucrat coming between you (with your world class health care currently) and your doctor. Not a part of ACA, but plausibly a part of the US health scene post-ACA. (To be fair, regardless of whether the ACA passed.)

    Occurs to me today that this explains why the painful journey to universal coverage had to happen in a Democratic Administration. Sure Republicans back to Nixon had plans to close the coverage gap, and Romney's Massachusetts plan or Bush's Med D share characteristics with ACA, but the inevitable specter of rationing in going full national with an already-way-too-expensive US health care system was always going to be a problem in the journey. Had to happen in a Democratic Administration, whose supporters were less likely to focus on the negative implications of things like rationing.

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  7. @Sullivan; this is good breakdown of what "ACA" is.

    http://thinkprogress.org/yglesias/2011/09/23/327178/what-to-expect-from-repeal-and-replace-efforts/

    @CSH; yes, the fear of rationing is a real one. It will happen. In fact, it already does happen a lot.

    But to ignore ACA for a bit, the point about JB's post is there are no "high-information" voters. High information doesn't mean you know anything, it just means you are more in the loop for gossip.

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  8. Charlie: "High information doesn't mean you know anything, it just means you are more in the loop for gossip."

    A lot of truth there.

    Thanks for the link.

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  9. Ok, I know a bit more about ACA now, but I still don't know who decides what's covered. I find it implausible that we will be mandating coverage of pre-existing conditions but not mandating treatments for those conditions.

    "I'm sorry, Mr. Smith. We do cover AIDS, but we just don't go in for those newfangled drugs. What you need is a good daily multivitamin. Take it with plenty of water!"

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  10. But the anonymous bureaucrat coming between you and your doctor already exists for most people in the U.S. The bureaucrat just doesn't work for the government. She (or, more rarely, he) works for a large insurance company. Go check your statement of benefits for your employer-provided health insurance. Search for the word "preauthorization". Any time you see that word, it means your primary care doctor has to call a bureaucrat and justify the decision to, for example, put you in the hospital because you are about to die.

    [Full disclosure: My wife is a primary care doctor and this is her biggest complaint about the health care debate. The anonymous bureacrat is already here.]

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  11. Yes, we all realize that the evil (and I'm not being sarcastic) insurance companies regularly deny coverage for all sorts of things. It just amuses me the way that some ACA advocates seem to want to pretend that a government-managed system is going to cover everything. If it does, we're in real trouble.

    (Note that I'm not opposed. In fact, I suspect that a "public option" - though far from a perfect answer - may be where we need to end up.)

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  12. Under Obamacare, isn't it the same insurance bureaucrat who will be making the authorization decisions?

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  13. Speaking of rationing, there are HMOs that not only forbid certain expensive treatments, they also forbid the doctor to tell you that such treatments exist and or to tell you that the HMO forbids them.

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  14. I'd say on the question of stupid, corrupt or evil, it's a combo of all three ... but mostly the latter two. The Republican Party is about power, plain and simple. If that means lying, cheating, stealing elections, telling voters that ObamaCare will kill your grandmother, etc. then that is what they will do. And I'd so pretty much everyone on that stage last night knows that, and they don't care. Michelle Bachmann could care less if there's no such thing as a FEMA re-education camp or if Gardasil causes brain damange. Some lady told her that and that's good enough for her, because truth doesn't matter, results do.

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  15. The way the ACA works is that the state will basically certify that insurance plans meet minimum threshholds. They have to cover preventative care, for example, and can't have lifetime maximums, and have at least some actuarial value. Basically, this is to make sure that the insurance available on the exchanges doesn't suck. The prices will be more competitive than individual markets now because of larger risk pools. But once you have insurance, it is basically the same stuff most of us have through our work now.

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  16. RomneyCare helped doom Mitt in 2008, when he lost decisively to an extremely weak McCain... who NOBODY liked... except a fawning lefty media who turned on their fav maverick just as soon as he was nominated.

    It almost doesn't need to be said, that nobody's watching this besides we geeks, and I didn't even bother with last night's nonsense much, other than to catch Johnson's debut.

    But when people start paying attention... when it comes to the rat killin'... ObomneyCare is gonna be what dooms brother Mitt.

    Now, can Perry stand up and grab the ring? That's the question. He's got his own problems and is quite flawed as well.

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  17. Curtis: "The way the ACA works is that the state will basically certify that insurance plans meet minimum threshholds."

    Thank you - an actual answer to my question! I'm assuming, however, that the state certification is just for the exchanges. How do we ensure that adequate coverage is provided by the national insurance carriers that are now required to cover all sorts of pre-existing conditions? Who sets their standards of coverage?

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