Thursday, May 31, 2012

Republicans Against ACA

I have a post up at Post Partisan today noting that the new Crossroads ad against Claire McCaskill that hits her on ACA -- but, I note, the substantive problems identified with "Obama - Claire" are all about Medicare cuts.

To flesh it out a bit...I looked through the web sites of the Republican Senate candidates (this is my group of the 16 candidates most likely to become United States Senators in this cycle) to see what they had to say on the issue. As expected, it's a popular talking point still during this election cycle; all but one had something about  it (if George Allen does, I couldn't find it). Of those 15, only Linda Lingle of Hawaii wasn't clearly for repeal; she only had concerns about it. I should also add that "repeal and replace" has faded, with only two candidates holding that position. The rest were just for repeal.

Ah, but what did they think was wrong with Obamacare? Mostly, they didn't feel it was necessary to explain. About half didn't really say anything substantive at all. Of the rest, Medicare cuts were mentioned by three candidates; cost by two; the mandate by two, and at least one general complain that it's unconstitutional.

I guess one can make of that whatever one wants. Is ACA (thought to be) so unpopular that just mentioning it is enough? Are Medicare cuts the single most common complaint by Republican politicians about ACA? Is Medicare just one of several issues that Republicans think will work?

I believe that someone collected evidence of what was in the 2010 health care reform attack ads; anyone remember that?


  1. Romney is also pretty vague about exactly why he wants to eliminate the ACA and what "common sense health care reform" he intends to replace it with.

    In conversations with Republicans I've tried to get a sense of what, exactly, it is they think is so terrible. These have not been very informative conversations.

    Even when the legislation was being written, I don't recall the objections being very substantive ("It's too big to read!").

    I put most of the opposition down to partisanship. If the GOP actually regains power, I wonder if their opposition will fade.

  2. I think its fair to say that this sort of ambiguity and contradiction is a result of the main GOP position on the idea of health care reform. Other than a few things about reducing malpractice awards and the curtailing the ability of states to regulate insurance companies they have just don't seem to have one, they just want to return to a sort of pre-ACA status quo ante. Seems kinda weird to a progressive but it makes sense in terms of the overall policy stance that the gop/conservative movement has on health care in general, that is its a privilege that should be reserved for people who "deserve" or "earn" it. Theda Skocpol recently wrote a great book about this based on intensive ethnographic research where tea party activists repeatedly saw themselves and the US besieged by parasitic Democrats, young people and immigrants receiving things they didn't deserve like healthcare. Thus their really isn't a position on health care policy other than repeal the horror of Obamacare and nothing to say substantially about health care policy in general because they don't want to fix problems like the uninsured or how we spend more and get worse results than any other developed country in the world.

    1. typical libertarian a-holeMay 31, 2012 at 3:48 PM

      The omnipotent and benevolent invisible hand of the marketplace will take care of everything just as soon as those dirty minority government employee regulators get their greedy paws out of it.

  3. Health care is a positional good.

    My inadequate health care is suddenly great, if yours is non-existent.

    And since health care provision for most of us is a function of employment, it behooves employers to keep things that way. Less and less can be made to magically seem like more and more. Try that with salary.

  4. Who are your 16? Was there a post listing them that I missed?

    1. No, I haven't listed them, but glad to:

      Mourdock, Dewhurst, Cruz, Flake Cardon, Fischer, Allen, Lingle, Rehberg, Wilson, Berg, Thompson, Neumann, Fitzgerald, Akin, and Steelman.

  5. My suspicion is that the talking points for criticizing ACA over cuts to Medicare became moot points when the Ryan budget became a talking point.

    The mandate and constitutionality of ACA await the SC's reveal of their decision; so I'm guessing that GOP candidates are really waiting on that before they gin up a new round of complaints.

    More interesting will be how they respond to that decision. I suspect it may be the right's equivalent to Roe V. Wade when it comes to talking about the importance of holding the presidency in your party.

  6. This is such a weak point for the GOP, that the Dems can just hammer the GOP on this. The GOP basically has no reasonable answer for what to do instead, since healthcare accounts sound even lamer now. The weakness for the Dems in ACA are cost (lack of believability that it won't end up being a huge federal expense) and that the Dems will just overdo it and make it too bureaucratic and expensive. I don't think there are a lot of voters left to sway on this point, unfortunately. Of course, I'm counting on the whole "crammed it down our throats" meme having worn off.

  7. You know what's terrifying about the ACA? The Medicare Sustainable Growth Rate. That was a machination of the 1997 Republican Congress; the attached Wikipedia link shows that the whole thing was rather technical and formulaic and stuff; also at the time a rather small decline in doctor Medicare reimbursement as part of the 1997 Balanced Budget Act.

    While the Republicans no doubt attributed credit to their clever legislation in the face of the tech revenue bubble that followed, doctors were not surprisingly unhappy about losing money in the face of the glorious Republican Act. So Congress patched it, again and again and again, until a small issue has now grown into a $300 B problem.

    If anyone actually read the ACA legislation, they may sense that the document is a lot like the linked SGR overview: formulaic, rational, logical, and sure, imposing a bit of pain, but what shallow group would prioritize their own needs over glorious legislation? The SGR was a couple billion dollar issue that not surprisingly blew up when the doctors didn't play along. Again, in this mostly liberal forum, the proposition that the government would limit citizen consumption of psychoactive drugs was met with a similar resistance that the doctors expressed toward the doc fix. Only the public health cost of psychoactive drugs is about 100X the scale of the Doc Fix. Which suggests the inevitable problem following from inability to limit psychoactive drug consumption will be about 100 times as big.

    This thread gives the standard liberal defense of the ACA: if the legislation is so bad, why don't the Republicans have a better idea? (Answer: because one doesn't exist). Its my impression most liberals generally haven't come to Anastasios' place that the ACA represents a journey that, while arguably necessary, will nevertheless be incredibly destructive.

    Well, Anastasios, and perhaps, President Obama. Arianna reports that Obama warned fundraisers that they may have to start over on HC after the SCOTUS decision. Perhaps he was just underpromising and overdelivering. OTOH, maybe he was expressing a deep wish, since an ideological dream is rapidly turning into a practical nightmare.

    1. Oh, I do suspect that HC will have to be done over again -- I don't think ACA will survive SCOTUS. Pity, as I've said. But there you have it.

      I will quibble a little bit with you, CSH, in that the problem isn't so much the ACA as such. It is that any HCR that really comes to grips with the roots of the problems we have will be difficult and necessitate a lot of pain and controversy (I would not say destruction, necessarily, although some might experience it as such).

      About twenty years ago a health policy expert put it to me this way: the ideal health reform would put in place a system that is 1)universal; 2)cost neutral; and 3)possessed of quality and insurance coverages acceptable to the current American middle class. The problem, which even then health policy experts and interested politicians were quietly admitting among themselves, is that in the real world you can have two out of the three. Thus if we are really serious about universality we have to pay for it in either higher total cost or restricted access. Given that total cost is already untenable, we really only have one choice.

      Now, restricted access doesn't mean the horrors of right wing fantasy. But sooner or later, to choose an example, end-of-life care costs must be brought into line with world standards. The citizens of countries with universal care systems have, over the past couple of generations, become accustomed to cost-benefit calculations in such circumstances. Our elderly citizens have a different set of beliefs about the relative weight of various priorities. Dealing with that is an absolute necessity, and will also be an absolute nightmare.

      No, we don't need death panels. But we do need rational decisions as to whether an octogenerian with arterial disease, hypertension, and a myriad of other ailments is a viable candidate for expensive and difficult surgery to save his lower extremities when amputation is a cheap, safe alternative. That is easy to say in this forum. In Europe, it is a painful discussion that medical professionals nevertheless are trained to have with families with the weight of the medical system and social expectations on their side. In America, even case-hardened experienced surgeons have a hard time with those kinds of situations.

      I understand why conservatives (and yes, many liberals) flinch from this. But it is not patriotism and a concern for freedom, but rather denial of current reality and future disaster looming, and a deep seated emotionalism about either the possibilities of collective action (for liberals) or the possibilities of personal responsibility and free markets (for conservatives). No conservatives, the free market will not save us, free individuals and families will not prosper in this case, and ultimately you are going to lose this fight: if you don't believe me, just look at the current demographic trends and insurance coverage tables. No liberals, government control and intervention is necessary, but it won't be easy or painless or even beneficial in ever specific instance. If you don't believe me, try talking with people from Europe and Canada about the real decisions and problems of universal health care systems. Yes, they are better than what we have. No, they aren't sunshine and sweetness (they really do have waiting periods, and people really do die while they are on the list, and this really is a controversy, even if conservative propaganda greatly exaggerates the problem).

      Life can be a horrible, painful thing. If you don't believe that, try working in a hospital.

    2. Anastasios - thanks for the honest, thoughtful and true comment.

    3. @CSH

      Your point on the "Doc Fix" is legit. There will be resistance to controlling medical costs. But I don't see how this amounts to a criticism of the ACA.

      Even if you think attempts to control costs are doomed to failure, why be terrified of the attempt? Why be critical of serious efforts at cost control? Wouldn't your criticism be better directed at the legislators and institutions trying to prevent or undo those cost controls?

    4. Thanks for the excellent comments, particularly in response to my grumpiness. To swain's questions, well, your points are well-taken - my criticisms are more directed at the people and the process in control of the legislation. Sorry if that wasn't clear - actually, while my ideology runs more toward price discovery driving efficient markets, the thing that makes Anastasios' vignette about the Old Man and the Non-Amputee so powerful is that price discovery is clearly no solution at all to that very vexing problem. Though the ACA is not my ideological preference, its also best not to follow ideology off a cliff, and so the ACA is probably not bad. If it survives.

      Anastasios' post is wonderful, I might quibble a bit around the edges because our politics are not the same, but essentially I think he gets right to the heart of the matter. Indeed, if his post were posted on the doors of all the city halls in America, like a postmodern 95 theses, I'd probably feel a lot more confident about how manageable the ACA was - the people would have much more realistic expectations if they thought of this in the frame Anastasios uses.

      The problem is that Congressmen, perhaps sensitive to their own tenuous positions, put way too rosy a spin on everything. In this particular case I'd probably cut them slack, since universal HC has been a progressive ambition for a long time. The choir they were preaching to was especially receptive to the message.

      What's especially noteworthy about the doc fix problem is that it shows that this trait, currently on display from the left, is universal, since the right equally indulges it. I can't recall firsthand, but I'm sure right-wingers trumped their Balanced Budget Act as glory and wonder and reflective of their own personal awesomeness (particularly when the Tech Bubble subsequently balanced the budget). If there were risks buried in the Balanced Budget Act - like, you know, the eventual multihundred billion cost of the Sustainable Growth Rate - I'm sure those righty congresspeople didn't discuss them, and their partisans no doubt took the cue.

      In summary, if we all lived in Anastasios world, the transition to ACA would be quite a bit less frightening, as we would know what we were getting ourselves into and could plan more effectively. As it is, we're all pretty much crossing our fingers and hoping for the best.

  8. Anastasios -

    Great comment. As someone from New Zealand, I find the HC debate in America slightly baffling.

    A quick quibble:
    I think that it is important to note that rationing in a single-payer system only applies to stuff the government funds. As far as I'm aware, there is no law in any country banning expensive surgeries for terminal patients. You just can't expect the government to pay for it.

    Hence the "rationing! death panels!" conservative critique strikes me as strange. It's almost like conservatives are saying "I don't want this government program to exist. But if it must exist, it needs to pay for every single procedure an individual desires, necessary or otherwise."

    1. Rationing and death panels are okay if they are in the public sector rather than the private sector. Because government is bad and corporations are good.

      This is the cognitive level of conservative philosophy.

  9. "... the ideal health reform would put in place a system that is 1)universal; 2)cost neutral; and 3)possessed of quality and insurance coverages acceptable to the current American middle class."

    This "ideal" is counter to every other good and service... even if possible. The actual ideal health reform would lead to 1)quickly falling prices, 2)speedy innovation, 3)wealthy people acting like Guinea pigs, and 4)focus on what actually fixes problems. In other words: HSAs, lessened licensure, transparent pricing, medical tourism, ending the employer advantage for purchase of medicine. The fraction of deadbeats left over could be mere easily covered because of a market not deformed by gov.

    There's a reason we use markets instead of gov for everything.

    1. @backyard, you don't offer a path to your actual ideal health care reform because ... why, exactly? Maybe because it hasn't a snowball's chance in hell of happening, since you have very few people volunteering to give up their employer-based insurance. You can present your vision as an ideal, but everyone else knows it's a pie in the sky libertarian fantasy.

    2. In fairness, everyone is allowed their fantasies. And I suppose we can imagine a scenario where the employer based system collapses under its own weight. But we have already seen something like that with the collapse of traditional pension systems. The result has not been a move to libertarian practice, but a greater shift toward government based systems. Add to that that any such deterioration of the employer health systems would almost surely affect minorities in a disproportionate way (as the pension collapse has) and with current demographic trends and given that libertarian theory is an overwhelmingly white pastime ... well, as the French would say, Mon Dieu!

    3. ModeratePoli,

      People don't like being stuck with an employer to keep their health insurance. Employers should not have that kind of power over employees. When the tax treatments are equalized, things will change.


      "Add to that that any such deterioration of the employer health systems would almost surely affect minorities in a disproportionate way"

      AAs and "Hispanics." Not Jews or Asians. But I like the argument that the feds need to destroy capitalism because whites are relatively better off. Cuts right to the heart of the Progressive project and the liberal love of immigration from Mexico.

      But it doesn't matter. An actual market for medicine would lower prices and focus energies on what actually works (dietary changes) instead of on treatments for diabetes, etc. Works for everything else, just as the iPhone (toy of the rich) begat the Android pseudo clone and now they're becoming ubiquitous and transformative at all wealth levels.


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