Nov 062013

MNsure, Minnesota’s insurance exchange, released its October enrollment numbers today. Nearly 11,000 people have enrolled in coverage; over 9,000 have enrolled in Medical Assistance or MinnesotaCare. This is consistent with enrollment data from other states indicating Medicaid enrollment that far exceeds enrollment in private health plans. It’s too early to draw conclusions from one month of enrollment data, but it will be interesting to see whether the trend persists. It could be that low-income people are more motivated to enroll in coverage and that these numbers will even out as the enrollment deadline approaches. It may also indicate that the Medicaid expansion is more critical than we first realized. The data also raises questions about increasing health care disparities between states. A low-income family in Minnesota will have much better access to health care than a low-income family in South Dakota.

Oct 292013

Having failed in their efforts to repeal the Affordable Care Act, conservatives are now trying to blame Obama for the health plan cancellation notices that are now going out to customers. They point out that Obama previously stated that people who liked their current plans could keep them and that those statements must have been either deceitful or ignorant.

First, Obama and Democrats have never been great at explaining the details of the law. Politicians generally aren’t wonks and they don’t like making wonkish qualified statements like “Most people will be able to keep their current plans.” Second, the cancellation of these plans is a feature of the law, not a bug. These plans didn’t comply with the ACA because they didn’t offer certain essential services or they had excessive cost-sharing requirements. The ACA-compliant plans will offer richer benefits and stronger cost-sharing protections. Yes, some people may end up paying higher premiums than they do now, but this seems like an acceptable trade-off to me. It’s not as if most people on the individual market were terribly happy with their current individual plans.

If people want to argue that we should be allowed to pay for crappy coverage, that’s fine. It’s just not a terribly compelling argument.

Oct 032013

We Americans like to think that our form of constitutional democracy is the best form of government ever invented. But what if the Constitution is actually contributing to the current government shutdown and political standoff? That’s the thesis of a fascinating Wonkbklog essay by Dylan Matthews. Matthews points out that our separate executive and legislative branches were designed to serve as checks on one another, but this strategy doesn’t work as well when the branches are controlled by opposing hyper-polarized political parties. As polarization increases, so do the odds of an irreconcilable standoff like what we’re seeing today. And the Constitution doesn’t provide a tie-breaker.

Voters also have a difficult time determining whom to hold responsible when things go wrong. Is the shutdown the fault of the House? The Senate? The President? In most other democracies, the majority party controls both the executive and legislative branches, so it’s easy for people to register their approval or disapproval of the government. Here, we punish or reward whoever happens to be up for election in that cycle.

I’m not arguing for a wholesale reinvention of American government. But it’s difficult to ignore the increasing dysfunction in Washington and perhaps it’s time to consider some tweaks to our system. Despite claims to the contrary, the Constitution is not a holy text and treating it as such may lead to our downfall.

Sep 252013

While Ted Cruz and his fellow conservatives mount yet another doomed effort to derail Obamacare, Canadians are pointing at us and snickering. Even the super-wealthy Canadians can’t understand why a relatively modest set of reforms provokes such conniptions among American Tea Party types. Compared to the single-payer systems found in Canada and much of Europe, Obamacare preserves the status quo to an almost embarrassing degree.

The Affordable Care Act has plenty of flaws and shortcomings that should be addressed. It’s too bad that Republicans can’t engage in a reasonable discussion about how to improve the law, but the Tea Party has rendered the opposition incapable of discussing policy. Their willingness to shut down the government and risk a debt default in order to deny people health insurance isn’t just conservatism run amok. It’s a deeply reactionary response to a rapidly changing world, mixed in with some not-so-subtle racism for good measure. I’m not sure how you persuade people with that mindset to accept reality. And that’s why I’m more than a bit worried about what the next few weeks will bring.


Sep 182013

Even after a Supreme Court ruling and a presidential election, Republicans remain fixated on dismantling Obamacare. Their latest strategy is to defund Obamacare by holding the federal budget or the debt ceiling hostage. Jonathan Chait’s recent piece on the ongoing plot to destroy Obamacare provides keen insight into the fears driving this last, desperate rearguard action by conservatives. Despite making nonstop proclamations that Obamacare is already a failure, conservatives rightly worry that Obamacare will successfully provide affordable health coverage to millions at affordable prices. It could redefine the role of government in a key component of both the economy and daily life, a prospect that most conservatives simply can’t abide.

These last-minute hijinks will come to nothing. The President and Congressional Democrats will never agree to anything that delays or defunds the most significant social legislation of the past forty years. It may take a government shutdown or a flirtation with financial ruin to bring Republican leaders to the realization that their Tea Party colleagues must be abandoned in the wilderness for their party to survive.

Sep 112013

Politicians love to compare the federal government to a typical American family whenever the subject of spending cuts comes up. They argue that families must live within their means and so should the federal government. The argument is ridiculous and akin to comparing apples to airplanes, but it always generates a cheer at political rallies. Over at Wonkblog, Brad Plumer shows how odd a family might look if it spent like the federal government:

– The Smiths would spend 20 percent of their income, or $10,440 each year, on an arsenal of guns, tanks and drones to defend their house against threats or invade the occasional neighbor over lawn-pesticide disputes and access to the gas station.

– The Smiths would spend another third of their income financing retirement and health care for Grandma and Grandpa. Part of that would have been prepaid by money that Grandma and Grandpa socked away while they were working, but some of it would be paid for by the parents and kids who are chipping in.

– Actually, come to think of it, the Smiths spend nearly half their money — 43 percent — operating a massive insurance conglomerate whose main beneficiaries are family members.

The article probably won’t change any minds, but it illustrates how lazy and inaccurate some analogies can be.

Jul 032013

The Obama administration announced yesterday that it would delay implementation of the employer insurance mandate until 2015, which prompted Republicans to squeal in glee and remind Americans yet again that Obamacare will be the nation’s downfall. The mandate requires employers with more than 50 full-time employees to provide health insurance or pay a penalty. Ezra Klein points out that the employer mandate is an ill-conceived policy that encourages businesses to reduce worker hours to dodge the penalty.

The mandate is largely symbolic and delaying it won’t undermine the law’s core purpose: to provide health coverage to the uninsured. It’s easy to view this as a cave to the business community, but the administration may have decided that it’s better to ensure that the exchanges are running smoothly before focusing on less critical provisions of the law.

Nobody talks much now about the rocky implementation of the Medicare prescription drug benefit a few years ago. I expect the same will hold true of Obamacare.

Jun 042013

Those Republican governors who still refuse to participate in the Medicaid expansion may be inflicting long-term financial damage on their states. A new RAND study finds that not only will these states will pay out nearly $1 billion more in uncompensated care and forfeit several billion more in federal Medicaid dollars, but they will also have more uninsured residents. Some conservative governors have concluded that expanding Medicaid is the best option for both their constituents and their budgets, but others (Texas Governor Rick Perry, for instance) remain committed to blocking the expansion on ideological grounds.

The RAND probably won’t persuade any of these leaders to change course. Not in the short term, anyway. But once 2014 arrives and other states implement the expansion without much fuss, the holdouts may decide the practical benefits of joining them may outweigh any political considerations. And if they don’t, their beleaguered local hospitals and medical providers will ramp up their lobbying efforts. That kind of political pressure may be difficult to resist.

May 032013

Conservatives are seizing upon a new study that shows Medicaid recipients tend to consume more health care while their overall health remains unimproved as proof that the forthcoming expansion of Medicaid under the Affordable Care Act is a waste of money. It’s a willfully stupid conclusion for the following reasons:

  • People on Medicaid have low incomes. People with low income tend to have more chronic health conditions. So it’s no surprise that they would consume more health care once they receive access to affordable health care.
  • The study in question tracked people for only two years. It’s unlikely that a huge improvement in a chronic condition is going to show up after a couple years. And some conditions may never improve. Does that mean health care is wasted on such people? Is it wasted on me?  If we focus only on measurable improvement as the yardstick for justifying public health care expenditures, we’d better be prepared to have some really difficult conversations with our elderly and disabled.
  • The study did show that Medicaid recipients were substantially less likely to experience depression, which can be as debilitating as any physical impairment.
  • That lower incidence of depression might be related to the finding that Medicaid recipients experience far less financial stress.

Expanding Medicaid is undoubtedly a cost to society. But this study does nothing to undermine the basic assertion that Medicaid makes a real and positive difference in people’s lives.

Apr 172013

In what may be a sign of things to come, Senator Max Baucus delivered a stern warning to Health and Human Services Secretary Sebelius for not doing enough to educate people about what the Affordable Care Act means for them. He has a legitimate point; the feds need to step up their public relations efforts soon if they hope to get people enrolled in health coverage beginning in the fall. But Baucus should be more concerned about the implementation of the federal exchange that will be serving over thirty states. The success of health care reform hinges upon the work of anonymous programmers and web designers who must construct a website that is stable and functional on a massive scale from day one. Getting the word out is important, but it won’t matter much if the exchange website is overwhelmed or difficult to use.

The feds are certainly capable of pulling this off, but I wonder if elected officials really understand how much technical wizardry is necessary to make health care reform a reality. And I wonder how many other Democrats will start predicting failure as a means of political damage control.