I often wonder why the Republicans chose the name “Obamacare” in their attempts to ridicule Barack Obama’s “Patient Protection and Affordable Care Act.” After all, the first half, “Obama,” merely gives credit to the person who orchestrated the passage of the legislation and “care” is a benign word, even a pleasant word. Maybe they liked it better than the “Make the Rich Pay for Poor Children’s Medical Treatment Act.” Or maybe they thought that people hate “Obama” so much that just by saying his name it will make them angry. The bottom line is that it seems to be a lot like the phrase “Yankee Doodle,” originally meant as an insult, but adopted and even embraced by the target of the taunt.
Now that the new law has mostly survived, what does it mean for real-life Americans? There are many articles, like this one, that point out some things and make a few predictions, but no one seems to know the answers to two basic questions that are on my mind. What kind of insurance will ordinary Americans be able to purchase with regard to A) Quality of Care and B) Cost of Care? I’m not convinced that the new act has meaningful price controls on premiums or that the quality of care will be well-regulated. In fact, I will predict that the insurance companies will essentially take the following position: “Sure, you can have all of those new bells and whistles demanded by the Act, but you’re going to need to pay for it.” Here are some of those bells and whistles. And then the American public will likely not be witness to the intense behind-the-scenes lobbying that will result in 20% premium increases every year. I hope not, but I’m not optimistic.
Here’s another issue. Take a look at the numbers thrown around by many conservatives. Many conservatives are squawking that this is supposedly one of the biggest tax increases in the history of America. And see here. Many articles that claim that the Act requires $500 billion in new taxes; if you actually read the articles closely, though, they are talking about $500 billion over the next ten years, which equates to $50 billion per year. This means that “Obamacare” is only going to cost HALF as much, per year, as the American military adventure in Afghanistan. It amazes me how most conservative don’t care about how much their wars cost. Wars are sacred and one must never question that American wars are actually working to protect Americans, even though it is more likely that an American will get killed by a piece of furniture falling on her than by a terrorist. And this has no connection with the fact that we are blowing up poor people in desolate areas for $2 billion dollars per WEEK. In other words, the corrupt and disgraceful Afghanistan war is costing twice as much as a program that will do some good for many people.
And when are we going to find out what happened behind closed doors at the United States Supreme Court. It sounds like Justice Roberts had a Darth Vader moment. My guess is that after having to bear the ideologue right wing of the Court for years, he decided he was tired of being associated with those guys. I’m merely suggesting that although he was under intense political pressure to fall in line for another 5-4 conservative wing victory, he bolted. I suspect he had an epiphany. Maybe he wanted to be invited to cocktail parties hosted by more open-minded sorts of folks. Maybe he’s taken endless shit for many of his other votes and this was the case where he wanted to try to prove that he had a heart to go with his smile. Maybe he’s thinking about building a respectable legacy for himself. There’s a many fascinating hints that the process was highly acrimonious. There’s even evidence that Roberts switched his vote at the last minute and that he even authored what turned out to be the dissent. We can only hope that this was a divorce rather than merely a disagreement, and that the right wing will need to earn Roberts’ vote from now on.
Obama’s new certified program leaves open too many question for me to celebrate much. That will be the way I see it until I get a straight answer as to how much my policy will cost and how good my health care will be under that policy. And how well the government can control the cost of premiums into the future. These are the sorts of basic questions I would demand answer to before buying anything else. Would you buy a TV without knowing these things? A washer or dryer? This conspicuous lack on information is why I’m not celebrating much, even though Obama’s program has some excellent provisions (e.g., portability). I’m not optimistic in the long run that Obama’s version of a health insurance plan will survive. I believe, along with Dr.Margaret Flowers, that the long-term answer lies is single-payer:
Medicare and Medicaid must be left out of the discussion entirely until leadership has the courage to address the real reasons why our health care costs are rising, the toxic environment created by investor owned insurances and the profit-driven health care industry.
Health care spending in the United States is the highest in the world and in some cases is two times higher than spending in other industrialized nations, which achieve nearly universal coverage with better health outcomes than the U.S. Our soaring health care costs outpace our growth in GDP, inflation and wages. By any measure it is an unsustainable situation.
Willard Romney’s reaction to the SCOTUS decision is very revealing. He calls it bad law, yet much of it parallels law he supported when he was MA governor. The “individual mandate” in Obamacare came straight out of the Heritage Foundation, a conservative thinktank, and had the blessing not only of George H.W. Bush, but of Romney himself (he called it “individual responsibility”). Moreover, in his very next breath after ranting against the new law, Romney declared that “his” healthcare reform law would: (1) exempt pre-existing conditions; (2) let people keep their doctors; and (3) make health insurance more affordable — all of which are things that have already been included in the new law. So, once again, Romney has managed to take both sides of the issue — both opposing and supporting Obamacare. What a sleaze.
In regards to Roberts, he wanted to maintain the integrity of the court, but he also wanted to rein government in in the future, and he accomplished both. While ACA is upheld, it was upheld on a technicality. It was ruled impermissible under the Commerce Clause, which means that along with Lopez and Morrison, the Commerce Clause boundaries are now well established, whereas prior to Lopez, the limits were only theoretical. In addition, the decision is a victory for federalism because it struck down the federal government’s ability to addict the states to federal funding then threaten to pull it away if the states don’t do DC’s bidding. And that was a 7-2 decision, which means it’s a precedent that is unlikely to ever be undone.
I think what happened is that Roberts played good cop. “See those other four guys there? They are going to strike down the entire law. But I’d like to uphold it. I just need a few things from you.” And the liberals on the court gave it to him. Which is why the purely political conservative heads are exploding, but the legal conservatives and libertarians are rejoicing. This decision was a huge victory for libertarian legal scholars.
Adam: I agree with you that Roberts’ opinion set the stage for further invocation of the commerce clause as a reason to strike down further federal laws.
Over at Reason.com, Nick Gillespie is not optimistic that Obamacare will rein in health care costs:
“[T]he “Affordable Care Act” has virtually no cost control mechanisms in place and a recent analysis by the firm Bradley Woods projects that insurance premiums will rise about 7.5 percent annually under the law.”
Here’s how he sums up the law:
1. Government is still unlimited.
2. Mitt Romney is still lame.
3. Health care costs will still soar.
I recently brought my 2 year old to the ER via ambulance after a sudden and unexpected seizure. Scary experience for a parent, but fortunately it is a benign condition that occurs in young children- febrile seizures- with fever spikes. My husbands employer (he is a humble electrician) provides our insurance and by the end of the year we will pay almost $5000 in premiums alone, before we see any Dr. Our deductible is $3000/individual, which was almost met through her experience. I am having another baby in August, using a midwife because I believe homebirth is safer and less invasive, which is an out of network expense. To sum it up, \”Obamacare\” has increased our premiums already from last year, our out of pocket has skyrocketed, and it would be much cheaper if we held no insurance at all with a baby born this year and an emergency room visit. Most years, this is not the norm as we stay active, eat healthy and make proactive decisions about taking care of ourselves.
I have the same questions you have Erich about the costs and the quality of care this reform will truly bring. Mostly I disagree with Justice Ginsburg comment splashed throughout the news media that it is not an option to participate, everyone will eventually need healthcare. Not everyone chooses to use the healthcare system that is insurable: acupuncture, homebirth, homeopathy. I take the model of my friends mother who was diagnosed with cancer and chose hospice instead of never-ending hospital treatments which would have cost her family time, energy, tears, and money over vasts amount of time. She is a hero in my mind for understanding that this illness would kill her and to take it in stride and end her life meaningfully rather than in a hospital bed with machines and lack of power to make her own decisions.
Healthcare as they define it is a choice, not an inevitability. It is a mindset that we “need” all of the services that are provided, often times without consent. Like the catheter they gave my 2 year old daughter for $1086, without my and knowledge before I got there to consent.
Erich, as a result of the ACA, Missourians (both businesses and individuals) will be receiving $64 million in premium refunds after August 1, 2012 under the provision of the law which requires either 85/15 or 80/20 (depending on numbers of persons getting insurance)of premiums be used for the actual delivery of health care services.
Nationwide the amount of premium refunds due after August 1, 2012 under the ACA will top $1 billion!
So, in my answer to your questions;
First, as insurers are more and more required to account for the actual delivery of services to policyholders, coverage will be expanded to maintain prices, prices will moderate or the refunds will become an annual event. If the refunds become an annual event, insurers and their sycophantic supporters will have more and more consumer ire directed at them with resulting regulatory or legislative action being taken to keep prices down. It may also be possible that insurers would, as intended under the ACA, compete as to pricing and rates go down but, I find this highly unlikely due to the present market structure of the industry (oligopoly)in the various states. The insurance exchanges set up under the ACA, either by the states or mandated by the federal government (as in Missouri-we passed a law prohibiting the creation of one! Oh, and passed up millions in grant monies), are designed to promote competition in pricing and coverage.
Second, the various electronic record keeping provisions and the changes from fee for service delivered type reimbursement pricing to quality of care delivered reimbursement will drive providers to improve care while driving down costs. To a limited degree, this has already happened. Hospitals will no longer get federal monies just for piling on whatever is done for patients. Comprehensive internal record keeping will allow any treating physician or other treater to know exactly what is recommended and what is done to provide individual care. Immediate review of all patients’ records will allow for more efficient delivery of care as there will be comprehensive records available immediately to rule out certain conditions or the necessity of certain treatments so as to reduce unnecessary testing and services (also so-called “defensive medicine”). Outcomes will affect reimbursement, including penalties and nonpayment for faulty care requiring patients to be re-admitted.
The combinations of the various provisions of the ACA to create and drive better and more cost efficient delivery of patient care are what allowed the non-partisan Congressional Budget Office (CBO) scoring of the legislation to show decreases in the cost of delivery of services by some $500 billion over the next 10 years. Most of those monies will be saved in Medicare delivered services and payments from the federal government and are the source of the Republican canard that Obamacare cut Medicare or raise taxes by $500 billion.
Erich, I hope this provides some answers to your questions. As for what exactly the ACA does for you individually, it’s not the “Erich Vieth knows what price for what quality of care act.” You and I will have to wait and see if the designed results are delivered under the ACA.
One of the big questions hanging over the act is participation. The primary distinction between using the tax power vs. the commerce power is that the commerce power brings the power to regulate, and to punish violations of the regulations. The tax power grants the power to tax, and that’s it. As long as the tax, or penalty, or whatever they choose to call it is paid, the citizen is in full compliance with the law. if the government wishes to compel the purchase of health insurance, they have no levers other than the penalty. Also, there’s a psychological difference for citizens. Under the original reading of the ACA, citizens were in violation of the law if they did not have health insurance. But since the law is only justified by the tax power, the decision to not carry insurance is as morally neutral as the decision to not buy a hybrid car and forego the tax benefits of the car. In addition, states need not fear Medicaid dollars being pulled from them. So many governors may not participate. Then there’s the exchanges, which the feds are supposed to set up if the state governments won’t, except they kinda forgot to appropriate the funds to do that. Oops. So the Republicans and citizens who object still have a ton of leverage to sabotage the ACA, and Democrats have only themselves to blame.
Actually Adam,
By reasoning the mandate as constitutional as a function of tax policy, a precedent is set that will allow more government mandates for private services.
Through this opinion, Roberts flung open wide the door to a corporate takeover of government.
Erich,
One part of the high cost of health care has come as the result of the insurance companies avoiding competition through their contracting with large employers. Seldom do the employees have a choice between two insurers. The PPACA has provisions that attempt to re instate competition within the industry through health insurance exchanges.
Personally, I would like to see a portion of the insured’s total premiums transferable if he changes insurance companies. This would give some incentive to the insurance companies to compete for customers.
Roberts did open the tax door wider while closing the commerce door shut a little, quite true. But the tax power is actually a very limited power because it cannot be used to outlaw things or require things. It can only give financial incentives to do things. The penalty is really just a reverse tax credit, if they’d raised everyone’s taxes $1000 and then said you get $1000 back if you buy insurance, it would have been easily found constitutional. Roberts probably just figured it wasn’t worth striking it down when they could just rewrite it. Closing off the commerce power route to mandates will have more far reaching consequences.
It seemed to me that Roberts SLAMMED the commerce clause door shut. There are now five justices clearly on record for using the commerce clause to limit the scope of federal power considerably, potentially to dismantle many existing federal programs.
The Lopez, Morrison, and ACA decisions don’t threaten any current programs or regulations. The federal government’s power to regulate commerce is pretty much unlimited. So long as it is commerce and actually exists. Those three decisions simply said that Congress cannot regulate things that are not commerce, nor can they create commerce in order to regulate it. That still leaves the commerce power incredibly broad, but it at least limits it to actual commerce.
The Medicaid decision is actually far more consequential, because the government kept on trying to reach activity they couldn’t otherwise reach by trying to commandeer the states. The Medicaid decision, supported by seven justices, makes that much harder to do.
Adam: Consider that healthcare, which constitutes 17% of the entire economy, has been declared to NOT be commerce capable of being regulated. http://www.upi.com/Top_News/US/2010/02/04/Healthcare-spending-17-percent-of-economy/UPI-26041265295497/
It has been. The justices just said that people not participating could not be made to do so by force of law.
However, they can be encouraged to do so through the tax code. Which really should be sufficient. Candidate Obama was right the first time when he said he didn’t think people needed to be forced to buy health insurance. They don’t. If it’s a good enough deal for them, they’ll buy it. Most people, such as me, take workplace insurance because it’s a great deal. The employer pays like 75% of the premiums. If the subsidies pick up that much of the cost on the exchanges, the vast majority of people will want it. The only ones who won’t will be a few more well off people who only need help with catastrophic costs and will get an appropriate, but non-qualifying, insurance plan for them.
Adam,
Robert’s rationalization clearly doesn’t represent the opinions of the rest of the SCOTUS. The other conservatives insisted on striking down the PPACA in its entirety, while the liberal justices upheld the act on the basis of the commerce clause.
The problem with striking down a penalty for non compliance in favor of a tax is the resulting tax burden. The burden of a tax is always placed on those who cannot pass it on by raising prices.
It doesn’t really matter. Five justices said it violated the commerce clause. That’s a binding precedent. The federal government may only regulate actual commerce that exists.
I didn’t get the statement about the problem with the tax power. The financial effect is the same whether it’s called a penalty or a tax, isn’t it? The only thing that’s different is the legal and moral implications. A tax is morally neutral, whereas a penalty implies a violation of the law, with potentially escalating consequences should violation continue.
I see the brilliance of the decision (that the Romney campaign apparently has bumbled mightily…I need to read up on how that is true…only caught the tail end of an NPR discussion) as twofold:
1) The commerce clause as noted above, is in serious jeopardy.
2) By framing this as a tax issue, Roberts tossed a softball to the “right”wingers and Republicans. “If you guys can’t use this to win the election, then you’re just plain incompetent.”
Adam,
by linking an individual mandate to tax authority, Roberts has opened a Pandora’s box of future anti consumer legislation.
Considering that Senator Chuck Grassley, Republican Senator from Iowa, advocated boycotting companies that dropped support for the American Legislative Exchange council, how long before these ALEC shills start passing mandates that impose consumption quotas and tax people who don’t buy a new car, TV, and Home computer every two years, citing the ruling of the Roberts ruling as a precedent?
Imagine the effect of being unable to afford a new car, maybe even being unable to drive, and having to pay for one, perhaps as a way to stimulate the economy.
BTW, the penalty provision was not ruled a violation of the commerce clause, as I understand it, but the Republican justices ruled that the Commerce clause did not support the penalty. Not the same thing. Also, as a tax, it would be subject to various convolutions in the tax code, so that large employers like WalMart, can continue their back-door subsidies that put many of their “associates” on Medicaid and Medicare.
The original House reform bill specifically identified large employers refusal to provide adequate health care benefits to employees as a means of increasing profits, and proposed addressing this problem with penalties against the employers.
But, I guess, Adam, you would rather your tax money go toward supporting the profits of large corporations.