Kaiser Health Tracking Poll Shows Most Support Fix For Subsidies Under Affordable Care Act

While you can never be certain as to what the Supreme Court would do, I’ve always felt that it is most likely that they would ultimately find that King v. Burwell is a frivolous case. (In other words, the most conservative justices might accept it, but John Roberts will cast the deciding vote against it if needed). This case is the latest Republican attempt to overturn the Affordable Care Act in the courts because of some language in the law, contradicting other portions, which could be taken to mean that subsidies are only available to those who obtain coverage through state exchanges, and not the federal exchange.

As I’ve pointed out in the past, it would politically be bad for Republicans if the court ruled against the Obama administration in this case. If the Supreme Court does accept the absurd argument that subsidies should only be available under the law for policies purchased on state exchanges, the simplest solution would be for Congress to revise a few words in the law to fix the problem. It is rather common for Congress to pass laws after major legislation to fix minor problems, except in this case Republicans in Congress are more interested in repeated, futile efforts to repeal ObamaCare as opposed to making such fixes–with yet another repeal vote now planned.

The Kaiser Health Tracking Poll for January finds that relatively few people are now aware of King v. Burwell, but most people do think that Congress should fix the problem. Among total voters, passing a law to fix this is supported 64 percent to 27 percent. There is similar support among independents, greater support among Democrats, and even a substantial number of Republicans (40 percent) would support such a fix:

King v Burell

If this is not fixed by Congress passing such a law, the second solution would be for states to start their own exchanges. A majority would also support this in affected states. Even Republicans support this, although at lower levels than Democrats and independents:

King v Burell2

I suspect that Republican leaders would much prefer to see the Supreme Court not put them in a position to have to take such action, either in Congress or at a state level. Failure to take such action would make displease the majority of voters, while taking such action would displease their base, who might take revenge in primaries where they dominate.

Update: Hospitals and insurance companies also lose if the subsidies are not continued, and are therefore also defending the subsidies before the Supreme Court.

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CBO Shows ObamaCare Costing Less Than Projected–Ignore Conservative Attempts To Distort The Data

There was more good news from the Congressional Budget Office today regarding the Affordable Care Act. The latest’s estimates significantly reduce the costs of expanding medical care under the law:

 The Congressional Budget Office on Monday significantly lowered its estimate of the cost of providing health insurance coverage to millions of Americans under the Affordable Care Act.

Douglas W. Elmendorf, the director of the budget office, said the changes resulted from many factors, including a general “slowdown in the growth of health care costs” and lower projections of insurance premiums that are subsidized by the federal government.

In March 2010, when President Obama signed the health care law, the Congressional Budget Office estimated that the expansion of coverage would cost the federal government $710 billion in the fiscal years 2015 through 2019, Mr. Elmendorf said.

“The newest projections indicate that those provisions will cost $571 billion over that same period, a reduction of 20 percent,” he said. The Affordable Care Act not only subsidized the purchase of private insurance, but also authorized a major expansion of Medicaid, the federal-state program for low-income people.

As usual, conservatives are cherry picking and distorting the numbers to portray this as a negative. Among other distortions of the facts, they fail to take into account the fact that having a substantial portion of the country be uninsured results in higher costs for both government programs, as well as costs which are passed on to those who do pay for insurance. The bottom line is that, even before these more favorable numbers, the CBO found that the Affordable Care Act results in a reduction in the deficit. Strange that conservatives who place such a high priority on reducing the deficit (which was run up by Republicans during the Bush years) oppose a program which will help reduce the deficit.

Of course if conservatives are unhappy with the cost of the Affordable Care Act, they should keep in mind the fact that costs are much higher due than they otherwise might be due to providing coverage through private insurance companies rather than through a single-payer system modeled on Medicare. Somehow I doubt many conservatives would go for the far more cost effective single-payer model.

Conservatives are also attacking the law because, while reducing the number of uninsured by 27 million people, there will still be 31 million uninsured in 2025. However, when looking at who will remain uninsured, I wonder which group conservatives are complaining about. Of this 31 million, 30 percent are illegal aliens and conservatives would sure protest if health care coverage were extended to them. Another 1o percent are ineligible for coverage because of living in states which did not expand Medicaid–a decision which conservatives support. The remainder are people who will qualify for coverage but choose not to purchase it.

The number of uninsured might fall as more red states go along with the expanded Medicaid program. It was just announced that Indiana is the latest to offer the expanded Medicaid program.

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Conservative Argues That It Is Not A Bad Thing If People Die Due To Repealing Obamacare

If the Affordable Care Act were to be repealed, as most Republicans are calling for, we would see millions of Americans lose their insurance. We would return to past problems, including people being denied insurance when they have medical problems, people once again being forced to declare bankruptcy due to medical costs, and we would see many more deaths than we will otherwise see.  Michael R. Strain of the American Enterprise Institute has an op-ed in The Washington Post under the headline, End Obamacare, and people could die. That’s okay.

Note again that the author is from the American Enterprise Institute and this is published in The Washington Post. This is not just some isolated blogger or conservative shouting out their personal opinion.

Strain’s logic is that “We make such trade-offs all the time.” For example, “Consider, for example, speed limits. By allowing people to drive their cars at speeds at which collisions result in death, our government has decided that the socially optimal number of traffic fatalities is not zero.”

He has other such examples, but they do not apply to the type of trade-off he is advocating. There are good reasons for having a society in which people can drive, and it is an unavoidable fact that this will lead to a certain number of traffic fatalities. The types of trade offs he discussed are not analogous to taking away health care coverage.

While there are reasons for having a society in which people can drive, despite traffic fatalities,  there is no good reason for either having people uninsured or for a system in which insurance companies are allowed to profit by denying coverage to those who become sick.

Strain argues that, “In a world of scarce resources, a slightly higher mortality rate is an acceptable price to pay for certain goals.” This falsely assumes that health care coverage is something which we cannot afford to provide. However every other industrialized nation on the planet, existing in the same “world of scarce resources,” is able to provide health care coverage to its citizens. The Affordable Care Act is a valuable step in the right direction, but it is an incremental step which still falls short of what is provided in the rest of the industrialized world.

There is no good reason why the United States cannot provide the same level of health care coverage as is seen in the rest of the industrialized world. One reason why we have been unable to do this is the unnecessary middleman–private insurance companies making huge profits while making health care more expensive than elsewhere. Perhaps the answer is that in a world of scarce resources, a system of private insurance is an unacceptable price to pay, and we should be thinking in terms of conversion to a far more cost-effective single payer system.

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Will The State Of The Union Address Matter After This Week?

Obama SOTU

I certainly liked Obama’s State of the Union Address while listening to it. In a room dominated by Republicans, Obama was once again the adult in the room–the sensible one interested in governing and not bogged down in extremist ideology. His economic numbers provided real evidence of success, despite Republican obstructionism, and Obama was right in addressing the need to extend the benefits of economic recovery to more in the middle class.

The question is whether the speech, and Obama’s aggressiveness on policy matters, will make a difference matters beyond this week. David Corn summed up some of my concerns:

Barack Obama is very good at getting elected president (two for two!) and pretty darn good at policy (Obamacare; the stimulus; the auto industry rescue; Wall Street reform; ending Don’t Ask, Don’t Tell; Cuba; immigration reform executive action; dumping DOMA; middle-class tax cuts; new EPA limits on emissions that cause climate change; banning torture; downsizing the wars in Iraq and Afghanistan, and killing Osama bin Laden). But there’s one key piece of the job description where he’s fallen short: shaping the ongoing political narrative of the nation.

The president is the country’s storyteller in chief. And despite his inspiring powers of oratory (see Campaign 2008) and his savvy understanding of the importance of values in political salesmanship (see Campaign 2012), Obama, as his aides concede, has not effectively sold the nation on his own accomplishments, and, simultaneously, he has failed to establish an overarching public plot line that explains the gridlock in Washington as the result of GOP obstructionists blocking him on important issues where public opinion is in his favor. With his State of the Union speech Tuesday night, Obama had one last chance to take a swing at forging this narrative. Though he did adopt a muscular stance in presenting a forceful and vigorous vision—going on offense in the fourth quarter of his presidency, as his advisers have put it—the president let the Republicans off easy.

Throughout his presidency, as the GOP has consistently sought to block him, Obama has responded inconsistently. He often has pleaded for reason and looked to craft a deal—frequently (and justifiably) to prevent a hit to the economy. (This was the adult-in-the-room strategy.) At times, he has praised House Speaker John Boehner, while pointing to Boehner’s tea party wing as the cause of the partisan paralysis. And then he has occasionally—but not too often—flashed anger and slammed Republicans for being irresponsible and reckless (the debt ceiling scuffle, the assorted government shutdown showdowns). He has not presented a steady and stark tale in which he stars as the fighter for the middle- and lower-income Americans who are stymied repeatedly by always-say-no Republicans aligned with plutocrats, the gun lobby, corporate polluters, and other foes of progress. Consequently, he has often borne blame for the sluggish economy and the mess in Washington, with the Democratic Party paying the price for the dips in his approval rating.

For this to have meaning, Obama must stick to pushing his views, and the Democratic Party must be there behind him. The reaction of the Democratic Party has been even more inconsistent than Obama’s. Here’s what I thought during the speech:

Of course the general election is an entirely different ballgame than the midterms, and Democrats who thought there was benefit in running as Republican-lite in a midterm election where the big contests were in the red states might act more boldly. Or maybe not.

On the other hand, maybe we should just be happy that Obama had a good speech, the positive results from his policies are real, and that the speech was well accepted. Beyond that, I’m not sure that a State of the Union address ever really matters all that much.

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Commonwealth Fund Shows That Obamacare Has Made Health Care More Affordable

Another study has shown that the Affordable Care Act is exceeding expectations in increasing access to health care to Americans. A Commonwealth Fund survey has found that Obamacare has resulted in a reduction in the number of working-age adults without insurance from 20 percent of the population in 2010 to 16 percent in 2014 (the first year insurance was available through the exchanges) with further reductions in uninsured expected this year. Even more significantly, the number of adults who did not get needed health care because of cost decreased from 80 million people (43 percent) in 2012 to 66 million (36 percent) in 2014.

The percentage who reported problems paying medical bills in the previous 12 months decreased from 30 percent to 23 percent.

The percentage who did not fill a prescription fell from 27 percent to 19 percent. The percentage who did not get needed specialist care decreased from 20 percent to 13 percent.

“These declines are remarkable and unprecedented in the survey’s history,” said Sara Collins, the study’s lead author. “They indicate that the Affordable Care Act is beginning to help people afford the healthcare they need.”

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Goals Of The New Republican Congress: Repeal Obamacare Despite Success In Lowering Uninsured, Declare War On Math, Promote Pseudoscience To Restrict Abortion

Uninsured 2015

While Republicans are probably on the verge of voting yet again to repeal the Affordable Care Act, and will continue to make false claims that it has been a failure, Gallup shows once again how successful the law has been. The uninsured rate has fallen to 12.9 percent, down from 17.1 percent a year ago. The open enrollment period for 2015 remains open making it likely that the uninsured will fall further, especially if there is a last minute surge in people enrolling as last year. The number will further increase if more states go ahead and accept the expanded Medicaid program, and more people are also likely to receive insurance from employers with the trend towards decreased unemployment. Gallup also found that most who have obtained insurance plan to continue coverage, either through the same or a different insurance company.

Even before the inevitable vote to repeal Obamacare, the new Republican controlled Congress has declared war on math, as Jonathan Chait described it, and have introduced a national ban on abortions after twenty weeks. I recently discussed the pseudo-science used by Republicans to justify this, and there is more at Think Progress.

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Red State Republicans Are A Minority Of Population Despite Senate Gains

Congress

The Senate is probably the strongest example of how our political system is (small-d) non-democratic. Each state receives two Senators, regardless of size, and the District of Columbia, with a population greater than several states, receives zero. The difference in size between the smallest and largest states has also increased significantly since this compromise was reached in the writing of the Constitution. A combination of factors including Senate races primarily in red states, the usual problems faced by either party in the sixth year of a presidency (with Republicans even losing control of the Senate under Ronald Reagan), and several tactical errors by Democratic candidates, led to the Republicans taking control. However, Vox has an interesting calculation:

But here’s a crazy fact: those 46 Democrats got more votes than the 54 Republicans across the 2010, 2012, and 2014 elections. According to Nathan Nicholson, a researcher at the voting reform advocacy group FairVote, “the 46 Democratic caucus members in the 114th Congress received a total of 67.8 million votes in winning their seats, while the 54 Republican caucus members received 47.1 million votes.”

Republicans also receive an advantage in the House due to a combination of gerrymandering and the fact that Democratic votes are more concentrated in cities, leading to Democrats winning a smaller number of districts by higher margins, and in some years allowing Republicans to control the House with a minority of the vote.

Republicans will be forced to defend more seats in blue states in 2016 but the magnitude of the Republican pick up in 2014 will make it much harder for Democrats to actually regain control. The Atlantic looked at key election races, pointing out:

Democrats will be benefiting from a favorable landscape, with Republicans defending 24 seats (many of them in blue territory) while Democrats will be defending only 10. To leverage that advantage into control of the Senate, however, Democrats need to net at least four seats (five, if Republicans win the presidency). That requires sweeping out blue-state freshman Republicans in states such as Illinois, Pennsylvania, and Wisconsin while also defeating a couple of brand-name senators, such as Rob Portman or Marco Rubio, in perennial swing states.

Other factors could help Democrats in 2016 beyond the geography. The economy will hopefully be even stronger, unless the Republican-controlled Congress, or even factors beyond political control, create further problems. The Affordable Care Act will be even more established, assuming Republicans aren’t successful in dismantling it in Congress or the courts, and might be less of a divisive political issue. Perhaps most importantly, the Democrats will be running a more national campaign behind a presidential candidate as opposed to running as Republican-lite and hiding from Obama.

The Los Angeles Times reports, Obama to hit the road, selling economic progress:

Eager to stay on the offensive as new Republican majorities are seated in Congress, the president plans to take a more bullish economic message on the road next week in something of an early test drive of his State of the Union message.

During stops in Michigan, Arizona and Tennessee, Obama plans to draw a connection between actions his administration took early in his presidency and increasingly positive economic trends in sectors such as manufacturing and housing.

Officials say he’ll also offer specific new proposals — some that he’ll pursue with Congress and others he’ll advance with his own authority — that are intended to build on that progress, particularly for the middle class.

It’s an approach that upends the traditional White House script to start the year, when new policy rollouts are usually reserved for the president’s annual address to Congress.

But the White House is eager to sustain momentum  it says started to build after November with major actions on immigration and Cuba as Obama began what he calls the “fourth quarter” of his presidency.

Obama, and other Democrats, should have been made the successes of Democratic policies the major point of the campaign, as opposed to running away from their successes. They might have still lost in deep red states, but Democratic turnout would have been better and they would have done better in less red areas. Besides the benefits of running on Obama’s previous record, as a result of Obama’s post-election actions his approval has shot up in the Gallup and other polls.

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Ideological Republican Legislatures Blocking Attempts At Expanding Medicaid By More Pragmatic GOP Governors

Governors are often more pragmatic than other politicians, having to actually run the state government and consider fiscal realities. Accepting Medicaid expansion is an obvious decision for governors, as long as they consider economic factors rather than Republican ideology, as the federal government picks up most of the cost. 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. In contrast, the federal government pays approximately half the cost of the original Medicaid program,with state governments responsible for the rest.

So far some Republican-run state governments have accepted and others have rejected Medicaid expansion. Additional Republican governors would like to participate in the expanded Medicaid system but this is being blocked by more ideological members of the state legislature. AP reports:

Partisan politics have driven states’ Medicaid decisions ever since the Supreme Court ruled in 2012 that expansion was optional, not mandatory, under the new law. Within months, every Democratic governor agreed to expand Medicaid (although Republican legislatures blocked a few of those efforts).

Only nine states with Republican governors accepted the offer…

The law expanded Medicaid eligibility to adults with annual incomes up to 138 percent of the federal poverty level. That will qualify an individual making less than $16,105, and a family of four earning less than $32,913.

So far, 27 states have agreed to expand Medicaid. But several more, including some with Republican governors, now want in. These governors note that their residents pay the federal taxes that fund expansions, so declining to participate amounts to subsidizing other states without receiving benefits.

Several Republican governors and one independent are meeting Republican legislative resistance to their expansion proposals. Some have tried to woo conservatives by adding “free enterprise” provisions, which require federal approval.

Perhaps the most aggressive GOP governor is Bill Haslam of Tennessee, who won re-election in November. Meeting with newspapers and others, Haslam now says Medicaid expansion is “morally and fiscally the right thing to do.”

The full article also reports on Republican legislatures blocking Medicaid expansion in Wyoming and Alaska, as well as reporting that “Arkansas could become the first state to rescind a decision to expand Medicaid.”

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Obama Approval Reaches 48%

Obama Affordable Care Act

Gallup reports that President Obama’s job approval has increased to 48 percent, the highest since August, 2013. This matches his disapproval rate, being the first time this gap has not been negative since September, 2013. They don’t give firm data to explain this improvement, but note that this partially can be explained by an improvement among Hispanics. They further speculate that the increase might be due to improved views on the economy, as well as people being more generous in their ratings around Christmas.

I wonder if other factors are involved, including his recent successes on foreign policy, the disappearance of the Ebola crisis in the United States which Republicans spread considerable misinformation about prior to the midterm elections, and the success of the Affordable Care Act.

As a sign of how desperate conservatives are to deny the considerable success of Obamacare in both expanding insurance coverage and making it more affordable, they are going further in cherry picking and distorting statements from Jonathan Gruber going back to 2009, with many conservative sites falsely calling him both the architect of Obamacare and its leading spokesman. Strangely, they don’t pay any attention to the far greater statements from him on the benefits of the Affordable Care Act. The Tea Party New Network, which is essentially a dishonest propaganda outlet like Fox but more honest about its political position, even defends Sarah Palin for her rants about death panels, and repeats all the other claims greatly distorted by conservatives. Their complaints about Obama’s poorly worded statements about keeping one’s own doctor or insurance are hardly meaningful considering that their policies would greatly increase the likelihood that people would lose their doctor and insurance, while Obamacare (even if unable to guarantee this will never happen in a market-based system) greatly reduces this risk.

Obama’s improvement in the polls could be a consequence of him becoming more aggressive after the midterm elections, no longer being fearful of taking actions which might place Democratic candidates at risk in red states (a foolish plan which backfired when it led to Democrats staying home). I believe that the Democrats would have still lost seats because of the seats which were up for grabs in 2014, but would have done better if they hadn’t run as Republican-lite. On the other hand,  Dan Pfeiffer told Huffington Post that he believes that if Obama had not waited until after the election, his actions would have been overwhelmed by politics.

The big question is whether this is a transient bounce or if this improvement will continue. Either way his approval is certainly far greater than for Congress. The Republican Congress might give Obama an opportunity to gain further public support if the Republicans actually proceed to pass legislation pushing many elements of their agenda which will be unpopular with a majority of American voters.

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End Of Temporary Increase In Medicaid Payments May Impact Treatment In 2015

The Affordable Care Act has been a tremendous benefit to those who purchase insurance on the individual market, but success has been mixed for the working poor who receive coverage from an expansion of Medicaid as opposed to obtaining private plans. While reimbursement varies by state, it is significantly lower than what Medicare and private insurance plans pay, and often insufficient to meet overhead expenses of private physicians. Many people who might benefit from the expanded Medicaid plan were denied coverage in Republican-controlled states which refused to allow the program, despite the vast majority of the costs being paid by the federal government, following a Supreme Court decision allowing them to opt out of the program. There are also concerns as to whether those covered by Medicaid will be able to obtain sufficient coverage.

In order to increase the number of physicians who accept Medicaid patients, the Affordable Care Act provided for an increase in payment to Medicare levels for primary care services for two years. As The New York Times reports, this period ends at the end of 2014, raising questions as to whether as many private physicians will continue to see Medicaid patients. President Obama has recommended an extension of this increased pay but it is unlikely to be approved by a Republican Congress which is more likely to continue to talk about repealing Obamacare as opposed to work to improve upon it.

It is difficult to predict exactly what the impact of the end of the increased Medicaid payment will be. The article does quote one physician of complaining that this was a “bait and switch” tactic. In reality, the federal government was quite open about the two year time frame for the plan, but it is possible that not all physicians paid adequate attention to information available. Private physicians have historically limited the number of Medicaid patients they accept due to the poor reimbursement, among other problems with Medicaid programs, and I doubt that many have taken a significantly larger number in the past two years in response to a temporary plan.

Much of the Medicaid population is treated by clinics and hospital facilities which are paid different from private physicians, with  Medicaid reimbursement representing an improvement over providing free care as in the past. Contrary to claims frequently made at conservative sites, expanding Medicaid does provide significant benefits for many people, but this will not be an ideal situation as long as Medicaid reimbursement is often less than overhead costs for private physicians. Most likely Medicaid patients will continue to be treated by a combination of clinics and by private doctors who take limited numbers of Medicaid patients.

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