Republican Extremism Gives Democrats The Edge

Jonathan Chait looked at demographic and political trends to consider whether the trend towards the Democratic Party is likely to continue. Much of what he wrote is a recap of the conventional wisdom these days, with some disagreeing. He considered multiple factors including the tendency of the young and minorities to vote Democratic. To some degree this could be offset by an increased trend for white voters to vote Republican out of a backlash against the increase in minorities. While Democrats are expected to dominate in presidential elections, there certainly can be exceptions if there is a major occurrence favoring Republicans as the party out of power. Plus Republicans should continue to maintain a sizable portion of Congress due to the higher turnout among Republicans in off year elections as well as structural advantages in each House. Republicans have an advantage in the House of Representatives due to gerrymandering and the greater concentration of Democrats in urban areas, giving Democrats victories by larger margins in a smaller number of states. Republicans have an advantage in the Senate due to smaller Republican states having the same number of Senators as the larger Democratic states. Republicans therefore have a reasonable chance of controlling each House, or come close as is now the case in the Senate, despite a larger number of people voting for Democrats to represent them.

The key point which gives us our status quo, and gives the Democrats the edge, is that the Republican Party is now firmly in the hands of a radical fringe which will always have difficulty winning a national election, but which is unlikely to change in the foreseeable future:

My belief, of which I obviously can’t be certain, is that conservatism as we know it is doomed. I believe this because the virulent opposition to the welfare state we see here is almost completely unique among major conservative parties across the world. In no other advanced country do leading figures of governing parties propose the denial of medical care to their citizens or take their ideological inspiration from crackpots like Ayn Rand. America’s unique brand of ideological anti-statism is historically inseparable (as I recently argued) from the legacy of slavery. Whatever form America’s polyglot majority ultimately takes, it is hard to see the basis for its attraction to an ideology sociologically rooted in white supremacy.

Jonathan Bernstein sees the United States as remaining more of a 50:50 nation as in 2000, also citing George Bush’s victory over John Kerry in 2004. However the Democratic advantage in the electoral college has increased tremendously since 2000 when George W. Bush was able to come in a close enough second to take the presidency due to irregularities in Florida and a friendly Supreme Court. This victory in 2000, along with the 9/11 attack, gave Bush, as an incumbent during time of war, an edge which future Republican candidates are unlikely to enjoy.

The current political divisions won’t last in their current form forever. At sometime there is likely to be a major event which shakes up the current divisions. Chait noted that this might have been the 9/11 attack if the Republicans hadn’t squandered their political advantages by their disastrous invasion of Iraq. I would add to that being on the wrong side of far too many other issues prevented the Republicans from becoming a long-term majority party.

Most likely at some point in the future the far right will lose their grasp on the Republican Party as those who actually want to be able to win an election eventually regain control. Perhaps this will come as a newer generation rejects the most extreme ideas of the current conservative movement. If the Republicans don’t change, eventually a third party might challenge them, as difficult as it is for third parties to compete in our current political system. We might also see the Republicans persisting in their current form as a southern regional party as others battle for political control in the rest of the country.

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New CBO Report Shows Medicaid Expansion Is A Better Deal For The States Than Previously Predicted

The trend continues. We have seen predictions regarding costs and benefits of the Affordable Care Act and then receive further data which shows that Obamacare is working even better than expected. The latest news comes from a new Congressional Budget Office report on Medicaid expansion.

Congressional Budget Office (CBO) estimates released last week show that health reform’s Medicaid expansion, which many opponents wrongly claim will cripple state budgets, is an even better deal for states than previously thought.[1]  CBO has sharply lowered its estimates of the costs to states of adopting the Medicaid expansion.

  • CBO now estimates that the federal government will, on average, pick up more than 95 percent of the total cost of the Medicaid expansion and other health reform-related costs in Medicaid and the Children’s Health Insurance Program (CHIP) over the next ten years (2015-2024).
  • States will spend only 1.6 percent more on Medicaid and CHIP due to health reform than they would have spent without health reform (see Figure 1).  That’s about one-third less than CBO projected in February.[2]  And the 1.6 percent figure is before counting the state savings that the Medicaid expansion will produce in state expenditures for services such as mental health and substance abuse treatment provided to the uninsured.

The federal government pays 100 percent of the cost of Medicaid expansion for the first three years with this gradually dropping to 90 percent in 2020. Republican governors opposing Medicaid expansion have claimed that ultimately paying 90 percent will strain their budgets while supporters argue that using this money to care for the uninsured will help the economies in these states and save money in other areas by having the currently uninsured receive coverage.

Republicans have also argued that one result of offering the expanded Medicaid program is that people eligible for the original program but who have not applied will apply for Medicaid as a result of the publicity surrounding the expanded Medicaid program. This would cost the states more as the federal government will continue to match funds for those who qualify for the original Medicaid program at current levels which average 57 percent. This tells a lot about how these Republicans think, seeing it as beneficial for the poor to not receive benefits they qualify for. The CBO has decreased its estimates as to cost to the states as fewer people who qualified for Medicaid but remain unenrolled are now enrolling than projected.

Despite the significant benefits from the expanded Medicaid programs, some Republican states remain determined to block the program. Bills have recently passed in Georgia and Kansas to make sure that they do not wind up with a Democrat getting elected governor and deciding to accept the federal funds to expand Medicaid. This changes the law so that approval would be needed by the state legislature and a governor could not expand Medicaid without their vote.

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Increased Health Care Spending Just Might Be Buying Higher Quality Care

altarum_cost_graph

Jonathan Cohn has looked at what appears to be a recent increase in health care spending (national health expenditures in the above graph) after a period of decline. Most likely this is due to a variety of reasons, and I don’t find it surprising that a period of decreased spending would be followed by increased spending. This is partially a sign of an improving economy as people are less likely to put off spending on medical problems when they have more money available. The increase in people covered by insurance this year due to the Affordable Care Act should lead to a further increase in spending, but this spending is desirable

Cohn looked at a variety of possible causes but didn’t hit on the key point that increases in medical spending might not necessarily be a bad thing until late in the article:

It’s not always the case that spending more on health care is a bad thing. New or more treatments might alleviate suffering, reduce disability, or extend life—all of which have value. Providing insurance to more people, so that they are more secure financially, also has value. The reason to worry about high health care spending is that the extra money America spends doesn’t actually seem to buy America better health care. But, over the long run, the real goal of health care reforms should be a combination of restraining costs and improving quality.

Traditionally it has been true that we could not see benefits from increased spending compared to other countries, but there are factors in health care which could currently be causing increased spending compared to previous spending in the United States as well as increased quality. There has been a push for Medical Homes, increased payment for primary care services, and for increased attempts at payment of doctors based upon performance as opposed to fee for service alone. If doctors are given incentives to screen more for elevated cholesterol and do more to treat diabetic patients this would lead to increased spending, with this spending being beneficial.

Contrary to the argument that we were not seeing quality for our past spending, The New England Journal of Medicine reports this week that complications among diabetic patients have decreased between 1990 and 2010. The Annals of Internal Medicine also reports that between 1999 and 2010 the number diabetics has increased, with a decrease in the number who have the disease but are undiagnosed, and that treatment has improved. Both having more diabetic patients and providing treatment which results in better control is going to cost more money. It is too soon to have any data to see if there is a correlation between increased spending over the past year and quality of care, but I do wonder to what degree the trends I noted in the above paragraph are contributing to higher costs and how this might correspond with further improvements in the quality of care.

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Republicans Will Soon Regret Being The Party Of Repealing Obamacare

The Affordable Care Act has exceeded expectations where ever we have measurements, such as in people signing up, despite the Congressional Budget Office reducing their prediction after the computer problems in October. The Republican horror stories have been debunked whenever the facts have been examined. There are no death panels, and the Republican predictions of doctors refusing to see Obamacare patients or long waits have turned out to be false. Health insurance companies desire to increase participation in the exchanges, and premium increases are projected to be far less than Republicans have predicted. However, despite the success, the debate over Obamacare is unlikely to end soon. Far too many Republicans suffer from Obamacare Derangement Syndrome.

This includes a degree of short term memory loss. The individual mandate, selling insurance through exchanges, and high deductible plans to discourage spending are all conservative ideas which most Republicans supported up until the Affordable Care Act was nearing passage in Congress. This year Republicans will continue the attacks on Obamacare because of the intensity of opposition among Republican voters. Elections, especially off-year elections, have become far more about motivating the base to get out to vote as opposed to convincing undecided people to vote for your party. Repeating the same lies about the Affordable Care Act will motivate their voters to get out to vote. If Democrats, who at times are almost as inept at campaigning as Republicans are at governing (and predicting the effects of Obamacare), continue to cower in fear over their own accomplishments, there will be little to motivate as many Democrats to get out and vote.

However the realities will change over time, as First Read explained:

It’s easy to explain why the GOP doesn’t want to move on. Health care is the issue that fires up the base; it unites a party that’s divided on other issues; and the law remains mostly unpopular in most public-opinion polls. Obama even recognized this when he talked about possible bipartisan fixes to the health-care law during his news conference yesterday. “My suspicion is that probably will not happen until after November, because it seems as if this is the primary agenda item in the Republican political platform.”

That’s a short-term winner but a long-term problem

That political platform looks like a short-term winner in the upcoming midterm elections, with the GOP having an excellent opportunity of winning back the Senate. But it raises other long-term challenges. What do you do with the eight million Americans who now have insurance on the exchanges, and with the 24 million Americans who are projected to be on the exchanges by 2017 (the next time there’s the possibility of a GOP president)? What about the millions more who have insurance via expanded Medicaid or via their parents’ insurance? And how do you advocate repeal and replace when you don’t have a detailed legislative alternative (that’s scored by the Congressional Budget Office)? Come 2015 and 2016, Republican presidential candidates could very well find themselves in an unsustainable position — having to campaign on a repeal message in the primaries (because that’s what GOP voters want), but then having to face a general electorate that’s more hostile to the idea (because repeal doesn’t poll well outside the GOP).

Americans will not want to repeal Obamacare when they consider what this means. We cannot take away health insurance from millions, and place many more at risk of losing coverage should they become sick. In the near future, to argue to repeal Obamacare will sound as absurd as arguing to repeal Medicare. Of course those who think that Republicans have really moved beyond wanting to repeal Medicare haven’t paid enough attention to the Ryan budget which Republicans have repeatedly voted to support.

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Success Of Obamacare Might Translate Into Political Success

The number of people signing up for private insurance coverage under the Affordable Care Act has now reached eight million. While primarily symbolic, it does represent a victory after initial projections of seven million were reduced to six million due to the problems when the exchanges opened. We know that if they failed to meet these projections, Republicans would be making a big deal of them. In addition, late enrollees included a high percentage of young people.

Good news means more positive head lines, such as National Journal writing that Obamacare is on a Winning Streak. The political climate is changing, with some Democrats now being more willing to run on its success.  I think it is essential that they do this to reduce the risk of the loss of a large number of seats this November. The evidence shows that Obamacare is a success but if Democrats don’t defend it, voters will only hear Republican attacks. Hiding from Obamacare will only make Democrats look weaker, and will not protect them from voters who vote against Democrats based upon Republican misinformation.

Ezra Klein writes that the right suffers from Obamacare Derangement Syndrome, being unable to admit that it is working:

Republicans used to talk about Bush Derangement Syndrome. Washington Post columnist Charles Krauthammer defined it as “the acute onset of paranoia in otherwise normal people in reaction to the policies, the presidency — nay — the very existence of George W. Bush.” Republicans like Krauthammer understood that BDS helped the Bush administration in two ways: it fired up their supporters and it distracted liberals from more modest, but effective, critiques.

Today, the right struggles with Obamacare Derangement Syndrome: the acute inability to see Obamacare as anything but a catastrophic failure that the American people will soon reject. For those suffering from ODS, all bad Obamacare news is good news, and all good Obamacare news is spin. In this world, delays of minor provisions in the law prove that the entire structure is collapsing, while surges of millions of people enrolling in insurance don’t prove anything at all…

But it’s coming at a moment when Obamacare’s successes are getting tougher and tougher to deny. The law signed up more than 7.5 million people in the exchanges, more than 3.5 million people in Medicaid, and it led millions more to get health care through their employers or directly through insurers. Premiums are lower than the Congressional Budget Office predicted when the law passed, and insurers are already thinking about how to compete for applicants in 2015. The White House has a much better story to tell than anyone — including me — thought possible in December.

For Republican pundits it might not matter that Obamacare is a success. Republicans show more intensity in their views, and very little concern for the truth. Campaigning against Obamacare might still motivate Republicans to get out and vote.

Andrew Sullivan might be a bit overly optimistic about the political effects of the success of Obamacare, but I hope he is right:

There’s simply no denying that the law has been rescued by an impressive post-fiasco operation that did to ACA-opponents what the Obama campaign did to the Clintons in 2008 and to Romney in 2012. Obama out-muscled the nay-sayers on the ground. I have a feeling that this has yet to fully sink in with the public, and when it does, the politics of this might change. (Since the law was pummeled at the get-go as something beyond the skills of the federal government to implement, its subsequent successful implementation would seem to me to do a lot to reverse the damage.) There are some signs that this is happening. A new Reuters/Ipsos poll finds the following:

Nearly one-third of respondents in the online survey released on Tuesday said they prefer Democrats’ plan, policy or approach to healthcare, compared to just 18 percent for Republicans. This marks both an uptick in support for Democrats and a slide for Republicans since a similar poll in February.

That’s mainly because of renewed confidence and support from previously demoralized Democrats. But it’s also a reflection, it seems to me, of the political vulnerability of Republicans who have failed to present a viable alternative to the law, and indeed seem set, in the eyes of most voters, merely to repeal ACA provisions that are individually popular. And this bad position is very likely to endure because of the intensity of the loathing for Obama/Obamacare among the Medicare recipients in the GOP base. It seems to me that right now, the GOP cannot offer an alternative that keeps the more popular parts of Obamacare without the air fast leaking out of their mid-term election balloon. And so by the fall, the political dynamics of this may shift some more in Obama’s direction. By 2016, that could be even more dramatic. One party – the GOP – will be offering unnerving change back to the status quo ante, and the other will be proposing incremental reform of the ACA. The only thing more likely to propel Hillary Clinton’s candidacy would be a Republican House and Senate next January.

It’s that long game thing again, isn’t it? Like the civil rights revolution of the Obama years, it seemed a close-to-impossible effort to start with, and then was gradually, skillfully ground out. It also seems true to me that the non-event of the ACA for many, many people will likely undermine some of the hysteria on the right. The ACA-opponents may be in danger of seeming to cry wolf over something that isn’t that big a deal. Yes, they may have premium hikes to tout as evidence of the alleged disaster. And every single piece of bad news on the healthcare front will be attributed to the ACA, fairly or not. But the public will still want to know how premiums can go down without people with pre-existing conditions being kicked out of the system, or without kids being kicked off their parents’ plan, and so on. I think, in other words, that the GOP’s position made a lot of short-term political sense in 2010 and even 2012. But it’s a much tougher sell in 2014, let alone 2016. Once again, they have substituted tactics for strategy. Every time they have done that with Obama, they have failed.

Sullivan described how he has benefited from the Affordable Care Act and concluded, “Yes, I am just one tiny, and rare example. But for me, at least, Obamacare has over-delivered and over-performed. If my experience is replicated more widely, then I suspect the polling and politics will shift yet again.”

Cross posted at The Moderate Voice

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Insurance Companies Plan To Increase Policies Offered On Exchanges Following 2014 Success, And Other Health Care News

The first year of enrollment for insurance under the exchanges is largely for first getting our feet wet, with more people projected to sign up in the future. It certainly exposed problems in the computer system and allowed for them to be fixed (although further testing before October was clearly needed). Insurance companies got to see whether this was a profitable market they would want to enter. In the past one or two insurance companies dominated in most areas on the individual market. One of the benefits of selling coverage through the exchanges was the hope that multiple companies would now begin to offer coverage.

Even conservatives who oppose the Affordable Care Act should agree with the benefits of having more companies offer insurance, including the likelihood of competition leading to lower prices. Actually exchanges, along with mandates, were originally supported by Republicans until they opposed the plan when supported by Barack Obama.

So far we are receiving good news following the initial IT problems. The Affordable Care Act now looks like a good policy which just got off to a rocky start. Enrollment is estimated at 7.5 million, exceeding predictions made even before they were adjusted downward with the early computer problems, with more healthy young people signing up at the last minute. Politico reports that insurance companies are happy with what they are seeing and want to get in:

Health insurers got their first taste of Obamacare this year. And they want seconds.

Insurers saw disaster in the fall when Obamacare’s rollout flopped and HealthCare.gov was a mess. But a strong March enrollment surge, along with indications that younger and healthier people had begun signing up, has changed their attitude. Around the country, insurers are considering expanding their stake in the Obamacare exchanges next year, bringing their business to more states and counties. Some health plans that skipped the new marketplaces altogether this year are ready to dive in next year.

At least two major national insurers intend to expand their offerings, although a handful of big players like Aetna, Humana and Cigna, are keeping their cards close for now. None of the big-name insurers have signaled plans to shrink their presence or bail altogether after the first rocky year. And a slew of smaller health plans are already making moves to join more states or get into the Obamacare business for the first time.

“[W]e see 2014 as just the beginning for exchanges,” said Tyler Mason, a spokesman for UnitedHealth Group, one of the nations’ largest insurers. “As the economics, sustainability and dynamics of exchanges continue to become clearer, we believe exchanges have the potential to be a growth market with much to offer UnitedHealthcare and other insurers and consumers.”

Nurturing this growth and health plan participation will be one of the first tasks of Sylvia Mathews Burwell, assuming she is confirmed to succeed Kathleen Sebelius as secretary of Health and Human Services.

The article reviewed plans by many of the larger insurance companies and also noted that several smaller companies now want to start selling insurance. Being able to offer their plans on the same computer site as the larger companies will allow small companies to compete for sales more easily than in the past, further increasing choice for consumers.

It is not only insurance companies which see the Affordable Care Act as succeeding. The latest Reuters/Ipsos poll shows the number of people who prefer Democrats over Republicans on health care has increased:

Americans increasingly think Democrats have a better plan for healthcare than Republicans, according to a Reuters/Ipsos poll conducted after the White House announced that more people than expected had signed up for the “Obamacare” health plan.

Nearly one-third of respondents in the online survey released on Tuesday said they prefer Democrats’ plan, policy or approach to healthcare, compared to just 18 percent for Republicans. This marks both an uptick in support for Democrats and a slide for Republicans since a similar poll in February.

Not surprisingly, Gallup has found a greater decrease in the uninsured in states which have embraced the Affordable Care Act, such as by setting up their own exchanges and taking advantage of the expanded Medicaid program.

Having Gallup survey the number of uninsured is of value as the Census Bureau is changing how it is surveying the uninsured, with Gallup providing a second set of numbers for comparison. Many Republicans see a conspiracy to make Obamacare look good. Actually this looks like a change to get more accurate results, which might actually show a greater number of uninsured. The changes also started with 2013 so we will still be able to compare the year prior to the exchanges to subsequent years. Sarah Kliff explained further at Vox.

Cross posted at The Moderate Voice

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Coverage Of The Success of Obamacare And Debunking Republican Lies

Obamacare Winning

Reading liberal versus conservative columnists give entirely different views of the Affordable Care Act. Liberals have been writing about its success while conservatives continue to spread misinformation. Here’s a few examples of liberal views on the topic (which are the fact-based articles):

Tim Dickenson of Rolling Stone (source for the above graphic) writes that Obamacare is working. Instead of the fake conservative horror stories, he linked to stories which show how the Affordable Care Act is helping people. He described the successes, and pointed out that “Republican Party sabotage has also impeded enrollment.” Rather than back away  from calling a lie a lie as many journalists will, Dickenson directly addressed Republican lies as lies as he debunked them:

GOP LIE No. 1: THE NUMBERS DON’T MEAN ANYTHING
Over the course of the open-enrollment period, Republicans labored to argue that Obamacare did far less good than advertised because an estimated 4.7 million Americans received letters in the fall warning that their current policies could not be renewed, as they failed to comply with new coverage requirements. They point to these “cancellations” to argue that few of the folks being counted as ACA enrollees previously lacked insurance.

There are three glaring flaws to this argument. First: Many if not most of those whose plans were canceled were automatically transferred into similar policies that complied with the new law. One of the nation’s largest for-profit insurers told House investigators that it had issued fewer than 2,000 outright cancellations.

Second: Through executive orders, Obama gave roughly half of those who received a letter – 2.35 million – the chance to stay in their existing coverage. CBO estimates suggest that just 1.5 million actually continued in their grandfathered plans, as many could find cheaper and/or better coverage on a subsidized exchange or qualify for Medicaid. It’s telling that the Michigan leukemia patient featured in Koch-funded ads intended to convey the horror of these cancellations has found a compliant poicy on the exchange that still covers her oncologist and cut her monthly premium in half.

Giving the Republican argument every benefit of the doubt, this would leave a potential pool of about 3 million people who changed, rather than gained, insurance. This leads to the third flaw in the argument: Obamacare sign-ups were always going to include millions of people who already had insurance. In its latest estimate, the CBO showed just two-thirds (4 million of 6 million) of exchange enrollments coming from people who were previously uncovered. And the limited hard data available from the states suggests the CBO is closer to the mark than the GOP: In New York, nearly 60 percent of buyers were previously uninsured. In Kentucky, it’s even higher: 75 percent.

GOP LIE No. 2: THEY HAVEN’T PAID THEIR PREMIUMS YET
GOP critics point out that the administration hasn’t tracked how many enrollees are actually paying their insurance bills. The complaint about transparency is fair, but the concern is misplaced. Figures from state exchanges and insurers themselves show that between 80 and 95 percent of enrollees are paying their bills.

GOP LIE No. 3: OBAMACARE WILL COLLAPSE UNDER ITS OWN WEIGHT
One legitimate concern as Obamacare ramped up was that it could enter a “death spiral.” This would happen if the number of older, sicker people on the exchanges far outnumbered the young and the healthy. Premiums would spike, year over year, with each increase driving more healthy folks out of the pool – making the exchange unsustainable. While reaching 7 million enrollees is a huge win politically, it doesn’t ensure Obamacare’s viability as an insurance program. “I do think there’s too much focus on the overall number,” Karen Ignagni, a top insurance-industry lobbyist, told reporters. What matters far more, she said, is the insurance pools’ “distribution of healthy to unhealthy.”

The administration wanted 18- to 34-year-olds to make up nearly 40 percent of enrollees. By March, however, only 25 percent of the mix was under 35. That sounds dire. Yet even pools with just 25 percent of younger people would not create a tailspin, forcing premiums to rise by just 2.4 percent, according to the Kaiser Family Foundation.

Additionally, the convoluted structure of Obamacare eliminates systemic risk. Even the 27 states that relied entirely on the federal exchange will end up with state-specific insurance pools. What this means is that if a death spiral were to develop in, say, Ohio, that failure would not pull down neighboring states. What’s more, safeguards within the ACA mean states don’t have to get the mix right in Year One. For the first three years, ACA has shock absorbers to prevent premium spikes in states with problematic pools. Over that same period, the penalties for not buying insurance step up – which should drive younger, healthier people into the market, balancing the risk profile. We lack hard data to get a clear picture of all state pools. But private insurers are sending optimistic signals to investors that all is well. Case in point: Insurance giant WellPoint just raised its earnings forecast.

GOP LIE No. 4: “OBAMACARE IS THE NUMBER-ONE JOB KILLER IN AMERICA”
That’s what Texas Sen. Ted Cruz told a Tea Party convention in Dallas last summer. Since then, the GOP has been making two ACA-connected job-loss claims, both demonstrably false. First, they twisted a February CBO report to claim that Obamacare will cause 2.5 million Americans to lose their jobs. What the CBO actually found is that Americans will be able to work a little less thanks to lower health-care costs, voluntarily scaling back work hours between 1.5 and 2 percent through 2024, or the output of 2.5 million full-time workers. The other GOP lie is that Obamacare is causing employers – who will be responsible for insuring employees who work more than 30 hours a week – to either scale back the hours of full-time employees or hire only part-time workers. This, too, is hogwash. While the share of part-time employment remains historically high, it has actually been in decline since 2010, when Obama­care became law.

I have discussed many of the above points, with links to the evidence, in previous posts on health care reform.

I was also happy to see that he concluded with the same opinion I have expressed that Democrats must take the offensive on health care:

House Republicans have learned the hard way that even nibbling around the edges of Obamacare can backfire. In February, the GOP pushed a bill to tweak the mandate that businesses offer health care to all employees working more than 30 hours. Switching to the GOP’s preferred 40-hour standard, it turns out, would add $74 billion to the deficit by 2024 and cause nearly 1 million Americans to lose coverage. That’s the kind of move that would play right into Democratic hands. Says Greenberg, “Democrats do very well when they hit back at Republicans on what people lose.”

Until recently, Greenberg had been advising Democrats to move beyond Obamacare and turn to bread-and-butter issues like jobs and the minimum wage. “The strongest attack on Republicans,” he says, “is that they’re obsessed with Obamacare instead of critical issues like dealing with the economy.” But his new poll has Greenberg rethinking that counsel. “Until now, this is an issue where the intensity has been on the other side,” he says. But defending Obamacare, he adds, has emerged as “a values argument for our base.” Greenberg now believes Democrats “ought to lean much more strongly” to campaign on the virtues of Obamacare as a means of boosting progressive turnout. “Not apologizing for Obamacare and embracing it actually wins the argument nationally,” he says. “And it produces much more engagement of Democratic voters. That’s a critical thing in off-year elections.”

Eugene Robinson also wrote about the success of Obamacare:

A new report by the nonpartisan Congressional Budget Office estimates that, despite all the problems with the HealthCare.gov Web site launch, 12 million people who previously lacked insurance will obtain coverage this year. By 2017, the year Obama leaves office, the CBO predicts that an additional 14 million uninsured will have managed to get coverage .

Why was the Affordable Care Act so desperately needed? Because without it, 54 million Americans would currently have no health insurance. Within three years, according to the CBO, Obamacare will have slashed the problem nearly in half.

We should do better, and perhaps someday we will. Most industrialized countries have some kind of single-payer system offering truly universal coverage. But if you have to work within the framework of the existing U.S. health-care system — which involves private health insurance companies and fee-for-service care — the Affordable Care Act reforms are a tremendous advance.

Many Republican critics of Obamacare know, but refuse to acknowledge, that the reforms are here to stay. Does the GOP propose to let insurance companies deny coverage because of preexisting conditions, as they could before the ACA? Does the party want to reimpose lifetime caps on the amount an insurer will pay? Tell young adults they can no longer be covered under their parents’ policies?

He concluded by also recommending that Democratic candidates take advantage of the success of Obamacare:

To do well in the fall, Democrats have to infuse their most loyal voters with similar enthusiasm. The success of Obamacare will help. Already, polls are showing upticks in support for embattled Democratic incumbent senators in Louisiana, Arkansas and Alaska. Democrats control their own destiny in November: If they can get their voters to the polls, they’ll win.

In the long run, no matter what happens in the election, I’m more convinced than ever that the Affordable Care Act will be seen as landmark legislation. With minimal immediate impact, the ACA does two tremendously important things.

First, it shifts the incentive structure in the health-care industry in ways that promise to hold down rising costs. And second, it establishes the principle that health care should be considered a right, not a privilege.

Of course it’s not perfect. It’s a thing of beauty anyway. We have liftoff. It’s working.

Paul Krugman described Obamacare as the unknown ideal:

The current state of public opinion on health reform is really peculiar. If you’ve been following the issue at all closely, you know that the Affordable Care Act is one of the great comeback stories of public policy: after a terrible start, it has dramatically exceeded expectations. But hardly anyone seems to know that.

He blamed Fox and Rush Limbaugh for all the misinformation they have spread, the Obama administration for doing a “lackluster job so far in getting the word out,” and “a persistent anti-ACA tilt in news coverage.” He pointed out how factual stories on the success of Obamacare are often buried in the back pages of newspapers.

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New CBO Report Projects The Affordable Care Act Will Cover More People And Cost Less Than Previously Projected

CBO Affordable Care Act Revised Cost

A new report from the non-partisan Congressional Budget Office projects that the Affordable Care Act  increase the number of people covered, help reduce the deficit, and will cost $104 billion less than previous forecasts::

Relative to their previous projections made in February 2014, CBO and JCT now estimate that the ACA’s coverage provisions will result in lower net costs to the federal government: The agencies currently project a net cost of $36 billion for 2014, $5 billion less than the previous projection for the year; and $1,383 billion for the 2015–2024 period, $104 billion less than the previous projections

Here is the update regarding projections of number of nonelderly people covered (with the elderly already having coverage under Medicare):

CBO and JCT estimate that the insurance coverage provisions of the ACA will increase the proportion of the nonelderly population with insurance from roughly 80 percent in the absence of the ACA to about 84 percent in 2014 and to about 89 percent in 2016 and beyond (see Table 2). CBO and JCT project that 12 million more nonelderly people will have health insurance in 2014 than would have had it in the absence of the ACA. They also project that 19 million more people will be insured in 2015, 25 million more will be insured in 2016, and 26 million more will be insured each year from 2017through 2024 than would have been the case without the ACA.

Projections for the cost of the Affordable Care Act have been reduced due to a combination of factors including less money being spent on subsidies than projected. The report also found that premiums are lower than expected and the CBO does not project a significant increase in premiums in 2015. They project that premiums will increase by about $100 for silver plans in 2015 and subsequently project annual increases of 6 percent per year. There have often been double digit increases in premiums in the individual market in the past.

One reason for premiums being lower than previously projected by the CBO is that more people are purchasing plans with greater restrictions than the CBO had previously predicted. For the benefit of the vast majority of the country who, despite all the attention the topic has received only represent a small percentage of the entire country, here is a brief explanation of the choices available. Plans offered differ based upon how high the deductible and co-pays are, with those having lower out of pocket expenses having higher premiums. Some insurance companies also offer different plans in each category which differ based upon how restrictive they are. For example, I had the choice of a few Blue Cross plans. The most expensive (which I purchased) offers access to all physicians who accept Blue Cross and is the traditional non-HMO insurance plan. There were also less expensive plans offered which correspond with the HMO products they have available. They cost less but also restrict which doctors can be seen, and typically pay out less. The least expensive option was a new plan which, while sold under the Blue Cross name, is actually run by a local hospital network and (with some exceptions) restricts coverage to doctors and hospitals in their network.

In the past, employers have had comparable choices to offer to their employees. There has been a push back as many people have been unhappy with the restrictions from HMO’s . While some employers have continued to offer more restrictive HMO plans, many others have changed to more expensive but less restrictive plans.

The CBO originally projected that insurance purchased through the exchange would mirror the employer plans. I do not find it all surprising that instead there were greater sales of the more restrictive plans. Those new to insurance coverage would not have had bad experiences with restrictive HMO’s. Many people who were denied insurance in the past were happy to have any coverage. As they were paying out of their own pocket, even if receiving subsidies, it is also to be expected that consumers would purchase the less expensive HMO plans unless they have experienced reasons to purchase the more expensive and less restrictive plans.

Some see this as evidence that the Affordable Care Act has been more successful then it actually has been in cutting expenses. It is likely that over time there will be more people who will choose a plan without the HMO restrictions. The CBO does predict that “the differences between employment based plans and exchange plans will narrow as exchange enrollment increases. That pattern will put upward pressure on exchange premiums over the next couple of years, although CBO and JCT anticipate that the plans’ characteristics will stabilize after 2016.” Again, their projections are for a 6 percent annual increase, which still remains less than has often been seen in the past. This includes increases due to expected consumer demands for less restrictive policies but the CBO is not able to code potential decreases in costs from future improvements in cost control, leaving hope that the increases might be less than this.

Update: Coverage Of The Success of Obamacare And Debunking Republican Lies

Cross posted at The Moderate Voice

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Quote of the Day: Bill Maher on The Ryan Budget And Obamacare

“Game of Thrones returns this weekend on HBO. I’m sure you know it as a magical fantasy where you’re never quite sure who’s going to live or die. Or maybe I’m thinking of Paul Ryan’s budget.” –Bill Maher

Bonus Quote:

“Obamacare hit its numbers. Despite all the initial problems, Healthcare.gov surpassed the enrollment goal, over 7 million. Now the Republicans are saying that they’re going to repeal the Internet.” –Bill Maher

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Newly Insured Able To Find Doctors Despite Republican Predictions Of Shortage And Long Waits

With people actually becoming enrolled in health insurance due to the Affordable Care Act, we have further evidence that the Republican scare stories are not coming true. There are no death panels. The government has not taken over health care. Enrollment in plans sold through the exchanges have met earlier projections despite the initial problems with the computer system. While it is too early for final numbers, it appears that the number of people who do not receive insurance due to failing to pay premiums will be lower than earlier projections. Now we have additional data debunking claims that physicians would not accept patients enrolled through the exchanges, there would be doctor shortages, and long waits for medical services.

The claims from Republicans that doctors would not accept patients enrolled under Obamacare were never taken seriously by those who understand how the Affordable Care Act works. Despite Republican misinformation, Obamacare is not a separate government health care plan. People obtaining coverage through the exchanges purchase private insurance which doctors would find indistinguishable from anyone else with private insurance. There is not a big red stamp saying “Obamacare” on their insurance cards. If they are to accept patients based upon coverage, medical practices give preference to patients with private insurance as it pays significantly more than government programs, and there are less collections problems compared to the uninsured.

The Journal of the American Medical Association published a study in which people called physician offices to see if they would be able to obtain an appointment. Kaiser Health News summarized the results:

Researchers posing as nonelderly adult patients made nearly 13,000 calls to primary care practices across Pennsylvania, New Jersey and eight other states between fall 2012 and spring of last year.

What they found may provide some comfort amid growing concerns of doctor shortages, especially as more people gain coverage through the Affordable Care Act, potentially straining the health system.

Dr. Karin Rhodes, from the University of Pennsylvania and a lead author on the study published this week in JAMA Internal Medicine, says when researchers said they had insurance, they were able to make an appointment about 85 percent of the time — on the first try, no less.

“Capacity exists. I think this is a very optimistic message,” Rhodes says, adding that researchers were usually able to get scheduled within a week. The median wait in Massachusetts was about two weeks.

Medicaid pays significantly less, often less than a third of what private insurance plans pay for physician services and it would be expected that fewer physicians would accept new Medicaid patients. As fewer doctors accept Medicaid patients, and those who do only accept a limited number, only sixty percent accept of researchers identifying themselves as Medicaid patients, as opposed to 85 percent saying they have private insurance, were accepted on the first call. As is currently the case withe Medicaid patients, I would expect that those in the expanded Medicaid programs will have to make multiple calls to find physicians willing to accept them and/or go to clinics which receive higher reimbursement than private physician practices.

To attempt to improve access for those with Medicaid, including those in the expanded Medicaid program, the Affordable Care Act  does increase reimbursement for primary care services to Medicare levels for Medicaid patients for two years, and there is talk of extending this period. While Medicare also pays less than private insurance, the payment is more reasonable and most doctors will accept Medicare, while Medicaid payment is often insufficient  to meet overhead in private practice without the temporary increase.

In other health care news today, The Los Angeles Times reports that the number of people covered under insurance from their employers has increased under the Affordable Care Act (contradicting further Republican claims):

In addition to gains in insurance coverage as a direct result of the Affordable Care Act, the number of Americans covered by employer-provided insurance also has increased in the last year, according to newly released data from the Rand Corp.

As previously reported by my colleague Noam N. Levey, Rand estimated that the number of Americans with health insurance rose by about 9.3 million as of mid-March. The group’s researchers note that the number probably has increased as their survey missed much of the final surge of enrollments in the online marketplaces created by the healthcare law, also known as Obamacare.

The share of Americans aged 18 to 64 who lack coverage dropped from 20.5% to 15.8% by Rand’s calculations.

The 9.3-million increase in coverage, which takes into account people who lost coverage, includes people who enrolled in plans on the marketplaces, those who bought a plan directly from an insurer and those who became eligible for Medicaid. About half the states have expanded Medicaid under the law’s provisions.

But the full Rand report, released Tuesday, notes that the figure also includes a significant increase in employer coverage. That increase contradicts predictions made by both opponents of the law and some of its supporters who had expected employer coverage to drop when the 2010 healthcare law took effect.

Joan McCarter wrote more on the increase in the number of newly insured.  Adrianna McIntyre also looked at the recent RAND study, including how some conservatives try to play games with numbers they don’t like.

The New York Times reports that, as would be expected, sicker people enrolled earlier. It is not surprising that those with medical problems, many of whom were denied coverage due to pre-existing conditions in the past, would be more motivated to obtain health care coverage as soon as offered while healthier people were more likely to procrastinate until the March surge. The early enrollment of those with serious medical problems is another indication of the value of the Affordable Care Act.

There is also considerable attention being paid today to reports from Medicare regarding payment to physicians. In some cases, those receiving the highest payments might be those with the largest volume of Medicare patients doing high-cost procedures, while in other cases there may be indications of Medicare fraud. Medicare has already been placing those receiving the highest reimbursement under increased scrutiny.

Cross posted at The Moderate Voice

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