The GOP’s ObamaCare Dilemma
They hate the program but have no viable alternative.
WSJ (“Republicans Relive Healthcare Nightmare as Midterms Loom“):
Republicans suffered through a recurring nightmare this week: their inability to replace or at least unwind the Affordable Care Act, President Barack Obama’s signature healthcare program.
For the past decade, President Trump and the party have raged against the 2010 law, only to see legislative attempts to decouple it from the American economy fail. This week was no different, as a Republican proposal to replace ACA subsidies with sending federal funds directly to some households for out-of-pocket healthcare costs failed to advance in the Republican-controlled Senate.
[…]
A separate Democratic proposal to extend the enhanced Covid-era ACA subsidies for three years also failed to pass in the Senate Thursday, despite the support of four Republicans—Sens. Lisa Murkowski and Dan Sullivan of Alaska, Susan Collins of Maine and Josh Hawley of Missouri. Combined, the failed votes increase the likelihood that millions of Americans will see their healthcare costs rise next year, during a pivotal midterm campaign season.
Democrats say they plan to make the issue a centerpiece of their effort to flip both chambers of Congress. House Republicans hold a narrow 220-213 majority, while senators hold a balance of 53-47. Sixty votes are needed to advance most legislation in the Senate.
[…]
The focus on health-insurance premiums has moved the political discussion onto one of the few topics on which Democrats have an advantage. Americans’ approval of the ACA edged up to a new high of 57% in December, according to a Gallup poll. An NBC poll in October found that Democrats hold a 23-point advantage among registered voters over Republicans on the party best equipped to deal with healthcare.
[…]
Republicans are caught between the belief among many GOP lawmakers that markets, rather than expensive government programs, should play the leading role in providing coverage and the fact that many GOP voters have come to rely on coverage from the law, often called Obamacare.
The GOP plan for health savings accounts could help with out-of-pocket costs for people with eligible insurance plans, but it doesn’t address the fundamental problem for individuals who are unable to afford insurance. It is also unlikely to be adequate for many insured people who need expensive care. Insurance plans that are paired with HSAs can be very skinny, with high deductibles, which could force some enrollees to pay more than $10,000 next year before coverage kicks in. That cost would far surpass the up to $1,500 the Republican bill would put into accounts to cover out-of-pocket expenses.
[…]
Republican opposition to Obamacare still runs deep. The law, described by Republicans as government overreach, helped fuel the tea party movement and Republicans’ successful effort to reclaim a House majority in 2010. Trump made it a central part of his 2016 presidential campaign. By the time Republicans had enough power in Washington to repeal the law, it had become more popular. Americans didn’t want to lose protections for pre-existing conditions, or the ability to keep adult children on their insurance until age 26, key provisions of the law. Republicans came close in 2017 but failed, with then-Sen. John McCain (R., Ariz.) delivering a decisive thumb’s down in one critical vote.
Jonathan Chait (“Obamacare Changed the Politics of Health Care“):
Fifteen years after its passage, the ACA is a gigantic political pain point for the GOP. You would think Republicans would have made their peace with the law by now and turned their attention to other issues. But unlike pretty much every other conservative party in the industrialized world, where the legitimacy of universal health coverage is largely a given, the GOP seems resigned to bleed out on health care.
Alargely unspoken article of faith for Republicans is that access to medical care is a matter of personal responsibility. They don’t generally advertise this belief, because it is not popular—a growing share of Americans believe that it is the government’s duty to ensure all citizens have health-care coverage, according to Gallup. So the party’s strategy instead was to fight proposals to expand coverage. Until the ACA, this proved effective.
[…]
The ACA broke through decades of gridlock by keeping the employer-based system intact and building up coverage options for people who couldn’t access it. Low-income workers, whose jobs mostly didn’t provide health care, would get Medicaid. People with higher incomes who didn’t have access to employer coverage would get subsidized coverage on individual exchanges, which would have to sell plans to customers regardless of health status.
[..]
[Republicans have not] fully assimilated how the politics of health insurance have changed since the law’s passage. It was easy enough for Republicans to block health-care reform when a program to expand coverage didn’t exist. Taking insurance away from people who have it, or jacking up the price they pay to get it, is a completely different matter.
I opposed ObamaCare from the outset, not because of any ideological opposition to government involvement in healthcare, but because trying to preserve the private insurance model while glomming a welfare system on top of it was in many ways the worst of both worlds. I would have preferred—and still prefer—simply expanding Medicare.
The problem is that Democrats at least acknowledged that there was a problem—access to medical care in this country is incredibly expensive and mostly dependent on employer subsidy—while Republicans whistled past the graveyard. They opposed ObamaCare but never came up with a viable alternative.
And Chait is of course right: once people get used to a government subsidy, they expect it to continue indefinitely. (Republicans use the same tactic: a “temporary” tax cut’s expiration will be painted as “raising taxes” as leverage to force its renewal.)
Rather than subsidize insurance companies, just cut out the middle man and give people healthcare.
********************@
Yep. Good summary of the problem.
And the “solution” that Speaker Johnson trotted out last night is full of ancient, unworkable nonsense that Republicans have been half-heartedly suggesting for DECADES. How do I know this? Because I remember the “association plans” from my time in government…THIRTY YEARS AGO.
As many have pointed out, the big problem Republicans have with being anti-Obamacare is that Obamacare IS RomneyCare, AKA, the Republican solution. They wanted to keep money flowing to insurance companies. They didn’t want to expand the government option, say by allowing 50 and up into Medicare.
The smartest way forward is to allow people to buy into Medicare, while encouraging private insurers to design add-on plans with benefits that augment Medicare. (This is what you can do in many European countries, you’re covered by the national system which is basic, and then you can buy private policies to enhance your coverage.)
Republicans backed themselves into a corner by opposing Obamacare, when they COULD have taken credit for the idea.
I fear we are close to a systemic collapse, because Republican lawsuits have hacked away at the foundations of Obamacare. They’ve damaged the best chance they had to preserve the existing system.
FAFO.
One of the fears of Dem moderates regarding medicare for all is forcing those on employer paid plans to give them up. No one embraces change ya know. The answer to that is let the employers stop sponsoring plans so the villain isn’t government but the employer.
If employers are paying a payroll tax to support M4A, they’ll quickly begin dropping insurance as a benefit, except perhaps, as a M4A add on.
Expecting the same people who want to do away with Medicare to expand Medicare is just silly.
Then there is the biggest impediment for MAGA, it makes perfect sense.
The party currently running things believes in nonsense, not good sense.
They are the “lowest common denominator” the founders feared.
@Daryl: While MAGA rejection of reality is certainly enabling, I expect insurance company lobbyists have more to do with Republican intransigence. The drafters of Obamacare put a lot of effort into drafting a plan to help the uninsured that the insurance companies wouldn’t actively fight. Improving Obamacare is probably the best we can aim for without massive re$i$tance from the insurance companies.
Medical care is inherently a non market activity. A market means open access for providers; in an open market for tomatoes, anyone can set up a stand and sell their tomatoes. Medical care requires licensing and credentialing which automatically limits the number of providers. I don’t think that a system where anyone can call themselves a neurosurgeon without limits would work. On the client side, an open market requires the ability to pick and choose and to walk away freely. Medical problems create duress, and you can’t exercise free choice when you’re having chest pain, break your leg, or go into active labor. Can you imagine the following open market discussion, “Hi, I just got shot. What do you charge for a blood transfusion?”
The customer is under duress plus the provider has to be certified. The result is not a market. Never a market. We do not live in a cloud-cuckoo land where the libertarian fantasies of 20 year old undergraduates work! We will have a mess as long as we refuse to recognize reality.
Of course, realistic answers don’t result in electability, and that’s the problem.
@Slugger:
“Looks like you’re having atrial fibrillations. The gunshot treatment package you purchased doesn’t cover a defibrillator. Would you like to add a cardiovascular option to your treatment package? We have several options.”
Republicans caught between their beliefs and the facts would explain the situation for the GOP on all manner of topics for around 3 decades now.
Healthcare is one of those instances where no amount of gaslighting can alter citizens’ lived experience. If one doesn’t venture into big cities, it is easy to convince them there is rampant urban crime when there isn’t. But, almost everyone has seen a hospital bill first hand.
The other thing is that it’s hard to shop around for medical services, because doctors, surgeons, hospitals, etc. don’t post their rates online. You’d have to make a bunch of calls, or send text messages and/or emails, and then compare everything. It’s not like buying an appliance. And even for non-emergency care, you want to have it soon. You can’t spend months looking for the lowest price and best quality for a hip replacement, for example.
Endorse.
@Slugger: Plus, you can’t value shop when your kid falls out of a tree and breaks a leg or if your spouse goes into cardiac arrest.
Or even if you have a bad case of strep throat.
The notion that “the market” can provide acceptable health care outcomes is simply wrong. I mean, yes, the market can create an economically efficient healthcare system, but one in which a lot of people die and suffer and the very rich get good health care (and I mean the very rich).
Comrade Chait alleges
In many countries, the conservative party has been trying to whittle away their government backed universal coverage — at least in the English speaking ones where I can read the local press. The esteemed Mr. Chait is presumably working with a different definition of “the legitimacy of universal health coverage is a given”, or is projecting his own views onto conservative parties around the world.
@Jen:
I’m a little surprised that at no point have they crafted a Republican solution that is basically ObamaCare, but with vouchers which people can either hand to their employer or use to get insurance on the exchange. Vouchers becoming a massive giveaway to businesses that employ people*. The goal not being to do anything useful on health care availability, but to get people used to “vouchers” and then build support for school vouchers to defund education.
And then get the uneducated people this new education system creates to vote to kill universal health care.
It would take a generation, but it could be a big, big win on a lot of issues.
——
*: businesses that employ people are not the preferred businesses of the Republican Party, but they are an important part of the Republican coalition.
Having direct experience with NHS England, I can tell you that, with a few major caveats, it’s far superior to the US bullshit system.
Caveats:
1. Both the U.S. and UK ration care. The US rations care by making it either unaffordable and/or control of religious fundamentalist Christians. The UK rations care through bullshit austerity and unconscionably long waiting lists. I was told that I would have to go on a mental health waitlist before I could START the process of getting back on ADHD meds. The waitlist was 4 years. I was told I should feel good cause it was down from 6. I told them that I’d be dead before then at my own hands. They shrugged.
2. The continuing effects of austerity and Brexit are making the whole system fragile. The whole NHS just needs more money and resources. Beyond that Kier Starmer gets a tingle up his leg at the thought of hitting an immigrant nurse over the head with a truncheon. The Tories and Labour are in an all out war on immigrants that will fall hard on drs, nurses, and carers. They claim to be doing this to protect the NHS from Reform. Those two parties will be significantly crippled after the next election.
3. The waitlists are also used to prevent people from accessing care that the government and elites dislike. The two I’m most familiar are trans care and ADHD care. The anti-trans bigots are working on garbage human Wes Streeting to make access to ADHD meds impossible. Mental healthcare is also incredibly difficult to access. Get on a waitlist and hope you get care before you walk in front of a train.
3A. Because of the disfavored nature of the care I need I am in constant terror that some asshole is going to revoke my meds. I take both Vyvanse (Elevance) and Wellbutrin (Zyban*). I need both those meds or the chances I will kill myself go from like 50% (manageable) to 99%. I was without Vyvanse for about 3 weeks recently and I woke up on Tuesday and immediately thought “I should kill myself today.” Because I am scared of losing access to necessary medication I am lying to drs and avoiding them like the plague. Not a good idea for someone pushing 50. I was exceptionally candid with my U.S. drs. That made my care significantly better.
At this point I am absolutely convinced that the entire US healthcare system and huge chunks of the NHS are simply giant human rights violations. It’s simply a way to impose scarcity on the populace while enriching rent seeking assholes. Now, I understand that the UK can’t print money like the U.S. can. But in both cases there is more than enough money and resources to allocate to making people’s lives better and healthier. But both governments are “all stick, no carrot” in service of making rich assholes more money. Can’t have the minorities and plebs rising above their place.
I should go piss on Thatcher’s grave.
ETA* Wellbutrin isn’t prescribed for depression here. It’s marketed as Zyban an anti-smoking medication. The only reason I was able to get it was showing an extensive record of being on it and the fact that many drs don’t seem to understand that not all depression meds are SSRIs. Those you have to ween off carefully. You don’t with a SNRI like Wellbutrin. The ancestors told us to lie to the drs so we lie to the drs.
I’m a bit surprised that our billionaire class isn’t getting involved.
If I were a trillionaire transphobe from South Africa with a huge platform and a fondness for meddling in US government and politics, I could probably craft and promote any number of health care reform plans that completely and vindictively screw over trans people. And maybe even reintroduce phrenology*.
And there are other billionaires with different axes to grind. And access to health care is an excellent axe grinder.
Instead, they’ve somehow let RFKJr have more influence and it’s all about promoting measles.
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*: “based on your skull shape, we think the best treatment for your breast cancer is watchful waiting.”
@Gustopher:
Oh, they’ve been wildly successful against trans people. That’s why they’re trying to replicate their success with vaccines, autism and ADHD. Just wait, in like 6 months to a year Joanne is going to start ranting that ADHD isn’t real, we’re just lazy drug addicts.
@Beth:
See, this is what I’m talking about @here. Our bigoted billionaires are really just leaving tools to hurt the people they hate on the ground, unused.
They could have so much more control if they were just willing to use a bit more of their money and influence effectively. To “better” the world, as it were.
But, I guess measles is happy.
And people said smoking was bad for you…
@Slugger:
We’ve known this at least since a famous article by economist Kenneth Arrow in the 60s. But conservatives continue to say we should apply the magic of free markets to everything including health care. That’s almost a religious belief, albeit supported by a lot of lobbying money.
There is no free market in healthcare, even “private” healthcare provided through employers is government subsidized by making the premiums tax exempt. A market intervention one suspects insurance companies just love.
Back in the first half of the 90s when Hilary was in charge of putting together a healthcare finance plan, one of the prominent conservatives (Kristol, maybe?) said something like, “It is critical that we kill healthcare finance reform NOW. Global experience is that it’s so popular that once in place it will be impossible to kill.”
First of the higher premium payments for millions of people are due Jan 1.
This is a myth. Here’s what actually happened.
There were four Senate bills claiming to repeal Obamacare in 2017. The first one McCain supported, but there were enough other Republicans voting against it that it failed. The second one, McCain voted against, but it failed by a wide enough margin that his vote didn’t singlehandedly make the difference.
Following these two failures, the Senate tried another tactic. They crafted a bill that did nothing more than eliminate the individual mandate penalty and a few taxes–that was it, the entire ACA was otherwise left untouched. The bill was dubbed “skinny repeal,” and the plan was to pass it so that it could go to the conference committee where they would come up with a new comprehensive repeal bill that would be acceptable to both houses. “Skinny repeal” was expected to pass the Senate, with only Collins and Murkowski coming out against it. It was that bill where McCain did his sudden, unexpected thumbs-down at the last moment. But the bill he killed was not anything close to a full repeal of the ACA, and if it had passed, there was no guarantee that whatever they came up with in conference committee would have enjoyed any more success than the first two comprehensive bills.
A few months later, Lindsay Graham and Bill Cassidy crafted a new comprehensive repeal bill, which got such a poor reception in the Senate that McConnell didn’t even bother bringing it to the floor.
They did end up eliminating the individual mandate penalty–the essence of the skinny repeal bill–as part of the tax bill, so McCain’s involvement in stopping even that very small reduction in the ACA was rendered moot.
At best you can say that McCain prevented us from finding out if the third time really was the charm. Since we’ll never know what they would have hashed out in conference committee or whether it would have passed, and given that we do know what happened to the three actual comprehensive repeal bills (the two prior to “skinny repeal” and the Graham-Cassidy one several months later), it’s very possible that McCain’s famous “thumbs-down” made no difference whatsoever to the fate of their repeal efforts, and that the real culprit was simply that the GOP lacked the nerve to pass such bills. But the notion that it all came down to one man makes for a nice story, and it’s one that’s been repeated uncritically across the political spectrum, where McCain is either the angel or devil, depending on one’s point of view.
@Steven L. Taylor:
I will ultimately bring this back to healthcare.
One thing that crossed my mind wrt to SNAP benefits during the shutdown was I kept seeing the number of affected Americans rendered as a percentage. Moreover, even if I saw the actual number, it still seemed rather abstract.
Moving away from a reduction of SNAP benefits or Obamacare subsidies, I think one thing that gets lost is that whether given as a percentage or a number in the millions, if the goal is impression, the numbers need context.
For example, ~12.3% of the population is receives SNAP. That actually seems small to many. I mean, 88.7% seems pretty damn good.
Render it as 41.7 million, it sounds high, but to me, still lacks a real impact. Add the context that it exceeds the total population of California, and I think it may make a larger impression.
For those firmly on the Left—thinking of the DSA or the AOCs in office now—it’s almost impossible to reach the point of getting the average person to question the morality of the structure of a society wherein 40 million people need assistance to get something to eat. Much less getting the average person to ask whether that society is truly free or equal or equitable or whatever.
The problem with healthcare: it is even further abstracted than food. Sure, everyone needs healthcare at some point. And often lifestyle or habits provide an avenue for the meaty part of the curve to rationalize away the problem. They can just say, “Don’t smoke” or “eat better” or any number of things.
And if they have insurance, they have no idea what it costs an uninsured person to seek medical care.
To me, the best example to use are procedures like appendectomies, because they are not linked to lifestyle choices and they are life threatening emergencies. An uninsured patient will face 5 figure bills in that case. It is yet another bill to pile onto those who can barely make ends meet; the negotiated monthly payment is so small that the person will die before even half of it is paid off; or it goes unpaid, the person has to pay more for everything else because their credit is score is fucked and all the participants in the system pay for it.
A note: you know I am largely with you on the efficacy of campaign messaging. But I think it is worth considering that messaging in any given cycle is the end point of a much longer process.
Campaign messaging is built upon accumulated assumptions, beliefs, and experiences of targeted voters.
A specific example: DeSantis meddling in education of all levels. The short con is getting people’s backs up about gender or race in the current election cycle to get votes; the long con is to embed assumptions (indoctrinate, let’s be honest) about the meaning and promise of America by ‘educating’ via myth.
GOP messaging about healthcare or SNAP benefits leverage beliefs about America’s relationship to free markets, work ethic, government intervention, personal responsibility, etc. Those beliefs have been instilled in the population via well-funded and specific propaganda since at least the late 19th century. It has been consistent, and many of the organizations who designed the propaganda still exist, run by the descendants of those who founded them.
@Steven L. Taylor:
Aye, but that “just” is bigly misleading. The real world has vested interests and those interests can not be ignored. I suspect the two systems currently running in the world that have the best shot in the US are the German and Swiss models, in which the insurance companies are allowed to exist but with restrictions so tight that, effectively, their only arena of competition is administrative efficiency.
But therein I commit the same crime: I pretend the insurance companies wouldn’t fight like hell to prevent themselves from becoming as bland* as the German and Swiss insurance companies are. They will fight only slightly (if any) harder against extinction.
*To their shareholders and currently ridiculously well compensated execs.
@Kurtz: Putting things in units of California is probably a mistake, as 50% of America has been trained to hate California and will not hear past that. They want California to hurt. Whatever you say after that, they want whatever is worst.
I’d say same for Texas, Florida and New York. Not sure what the right unit is, but it isn’t California.
Might as well say “5 times the number of Jews killed in the Holocaust”
How many dog owners are in America? People love dogs.
ETA: “It’s 12 times the number of people in the KKK” “Let them die!”
@Kylopod: Skinny repeal had to be skinny because they were operating under reconciliation rules. Reconciliation lets you change numbers, but not do “substantive” legislation. Like changing all of the insurance regulations included in the ACA. There was nothing they could do under reconciliation that wouldn’t have outraged the insurance companies.
@Michael Cain:
Sorry, that’s mistaken. The term “skinny repeal” had nothing to do with the fact that they were operating under reconciliation rules. All four of the bills used reconciliation, but only one of them was called “skinny repeal.” Notice that I never said any of the bills would have actually eliminated the ACA, I wrote that they were all “claiming to repeal Obamacare.” They all kept the structure of the law in place, but they aimed to defund a lot of the programs, which would have thrown millions of Americans off health insurance and made it more expensive for millions more. The “skinny repeal” was called skinny because it did essentially nothing to the ACA except remove the penalty for the individual mandate–which wasn’t insignificant, as the mandate was part of the funding mechanism, but it wasn’t anywhere near what the other bills aimed to do, and in any case this policy change ended up passing anyway, under the tax bill. So McCain’s famous “thumbs down” did nothing to stop the policy change being voted on, all it did was prevent Republicans from making a third attempt at a more far-reaching bill after the first two had failed.
@Gustopher:
I’m not sure that matters as much as you think. Though, it did remind me of this scene:
4 times the population of Georgia?
13 times the population of Pennsylvania?
The problem with using any other state is that no one has any idea how many people live there.
What people do know is that California has a large population.
If your claim is salient, Texas would be the choice because the average GOPer probably has a positive image of Texas. Dems are more likely be open to some sort of big reform, and less likely to need this sort of persuasion.
As far as Texas, it is somewhat its own fault, because they have long marketed themselves as and behaved as if they are their own country. California has a bit of that as well, but it isn’t woven into its identity the way it has been in Texas.
One last thing: the states with the most annual domestic tourism are consistently California, Florida, and New York. Florida is a meme state, and not for good reasons. All three draw a lot of vitriol, but people still visit the other two, and it ain’t all from blue states.
@Gustopher:
I’m not sure that matters as much as you think. Though, it did remind me of this scene:
4 times the population of Georgia?
13 times the population of Pennsylvania?
The problem with using any other state is that no one has any idea how many people live there.
What people do know is that California has a large population.
If your claim is salient, Texas would be the choice because the average GOPer probably has a positive image of Texas. Dems are more likely be open to some sort of big reform, and less likely to need this sort of persuasion.
As far as Texas, it is somewhat its own fault, because they have long marketed themselves as and behaved as if they are their own country. California has a bit of that as well, but it isn’t woven into its identity the way it has been in Texas.
One last thing: the states with the most annual domestic tourism are consistently California, Florida, and New York. Florida is a meme state, and not for good reasons. All three draw a lot of vitriol, but people still visit the other two, and it ain’t all from blue states.
@Gustopher:
I’m not sure that matters as much as you think. Though, it did remind me of this scene:
4 times the population of Georgia?
13 times the population of Pennsylvania?
The problem with using any other state is that no one has any idea how many people live there.
What people do know is that California has a large population.
If your claim is salient, Texas would be the choice because the average GOPer probably has a positive image of Texas. Dems are more likely be open to some sort of big reform, and less likely to need this sort of persuasion.
As far as Texas, it is somewhat its own fault, because they have long marketed themselves as and behaved as if they are their own country. California has a bit of that as well, but it isn’t woven into its identity the way it has been in Texas.
One last thing: the states with the most annual domestic tourism are consistently California, Florida, and New York. Florida is a meme state, and not for good reasons. All three draw a lot of vitriol, but people still visit the other two, and it ain’t all from blue states.
@Gustopher:
I’m not sure that matters as much as you think. Though, it did remind me of this scene:
4 times the population of Georgia?
13 times the population of Pennsylvania?
The problem with using any other state is that no one has any idea how many people live there.
What people do know is that California has a large population.
If your claim is salient, Texas would be the choice because the average GOPer probably has a positive image of Texas. Dems are more likely be open to some sort of big reform, and less likely to need this sort of persuasion.
As far as Texas, it is somewhat its own fault, because they have long marketed themselves as and behaved as if they are their own country. California has a bit of that as well, but it isn’t woven into its identity the way it has been in Texas.
One last thing: the states with the most annual domestic tourism are consistently California, Florida, and New York. Florida is a meme state, and not for good reasons. All three draw a lot of vitriol, but people still visit the other two, and it ain’t all from blue states.
A sidenote:
Recent analyses on the decline of relative “lower middle class” living standards in the US seem to indicate that the two largest non-optional causes are massive inflation of house prices and healthcare.
Which in turn drives political discontent.
Therefore, keeping both in check seems an obvious objective for political success.
It seems odd that Republicans fail to grasp that point re healthcare.
(On housing, it’s more complicated: probably needs both more, denser, building; and providing an alternative to house property as the primary safe long-term savings option)
@Kurtz: @Kurtz: @Kurtz: @Kurtz: Jesus! Calm down! I get it already!
(Our hosts’ creaky little website is kind of adorable with its random repeated posts)
@Gustopher:
If it’s worth saying once … 😉