The latest Kaiser Family Foundation tracking poll on the health care reform law is out and, as usual, it includes some intriguing findings.
Public approval of the law had dipped conspicuously in October, for no apparent reason. But now approval is back to where it has been for most of the last two years, dating back to the law’s enactment in March of 2010. Overall, according to the survey, public opinion on the Affordable Care Act is divided almost evenly: 41 percent of people hold a favorable view of it, while 43 percent hold an unfavorable view.
For the law’s supporters, such as myself, that’s good news but not great news. And it confounds a prediction that many of us made about the law: That, over time, it would become more popular. The lack of enthusiasm is particularly frustrating given that law is finally delivering some clear benefits.
The Centers for Disease Control recently announced that the number of young adults without insurance fell by 2.5 million in the last year. That almost certainly is a result of the law, which requires that insurers allow parents to enroll children under 26 on their policies. Meanwhile, about 2.65 million seniors have saved an average of $500 on their prescription drug costs and 24 million seniors have had free preventative care visits. The reason, again, is the Affordable Care Act.
These gains are small compared to what the law will eventually do: When the Affordable Care Act has taken full effect, 30 million additional people will have health insurance while many more will benefit from the protection of still-to-be-written consumer regulations. But that won’t happen until 2014.
So can anything boost the law’s popularity before then? Perhaps.
Maybe you’ve been too busy following the Republican presidential campaign to shop. Maybe you were waiting to make sure Congress passed the payroll tax break. Or maybe, like me, you’re just a chronic procrastinator. Whatever the reason, you still have time to buy gifts for the policy wonk in your life, particularly if they like books.
Below are a few recommendations. I know most of these authors, so I may be biased. But the books come highly recommended by independent sources, too.
Obamacare as history: Today’s home page features an article by Paul Starr, a professor of sociology at Princeton. His 1982 tome, the Social Transformation of American Medicine, is the definitive history of health care in America. His new book, Remedy and Reaction, starts with that history but ends with the Affordable Care Act. For the big picture of view of how the law came to be, what the law seeks to do, and how it’s likely to play out, you can’t do much better.
Obamacare as Policy: But you’re a wonk, so you want all of the details, right? For that, I highly recommend John McDonough’s Inside National Health Reform. McDonough is a true insider: He played a key role in the Massachusetts health reforms. In 2008, the late Senator Ted Kennedy recruited McDonough to join the staff of the Senate Health, Education, Labor and Pensions Committee – where he helped craft the legislation that President Obama eventually signed.
Obamacare as Cartoon: Jonathan Gruber’s graphic novel (official title: Health Care Reform: What It Is, Why It’s Necessary, How It Works) is basically health care reform for dummies, although it isn’t really for dummies. It’s for anybody who wants a more visual, and more entertaining, guide to the law. Like McDonough, Gruber is an insider: He was an advisor and technical consultant to reformers in Massachusetts and Washington. He’s also a character in the book, thereby achieving cartoon book immortality -- something public intellectuals rarely achieve.
Politifact is getting a ton of grief from the left today. And deservedly so. The independent fact-checking organization has selected, as its "lie of the year," the claim that House Republicans want to “kill” or “end” Medicare. Like Steve Benen and Paul Krugman, I think Politifact got this one very, very wrong. And that's no small matter: It's the lead story, with a massive headline, on the front page of today's St. Petersburg Times – an influential newspaper in a key election state loaded with senior citizens.* In the coming months, Politifact's finding is sure to appear prominently in campaign advertising.
Let's review the facts: In 2022, were the House Republican plan to become law, new retirees would no longer have the option of enrolling in the traditional government-run insurance program. Instead, retirees would get a voucher, which they could use to pay for a private insurance policy within a regulated marketplace. The voucher’s value would depend on a formula pegged to the general inflation rate. If it were not enough to pay for a health policy – and most experts, including the Congressional Budget Office, believe it would not be – seniors would have to make up the difference on their own.
One likely consequence is that insurers would begin offering cheaper, but skimpier, benefit plans: Seniors might still be “insured” but they would no longer have comprehensive benefits. Many would simply not be able to pay for their medical care, much as seniors did routinely before 1965, when Medicare came into existence.
Does that amount to ending Medicare? Politifact says no, for two reasons. First, the organization says, Democratic and kindred groups have run ads featuring people who look very old. Since the proposal would only affect people 55 and younger, Politifact argues, that’s misleading. Second, Politifact says, the Republican proposal would leave in place a program that provides the elderly with both financial assistance and access to insurance. Ergo, Medicare would still exist.
Politifact's first claim doesn't stand up to scrutiny. If the House Republican proposal were to become law, it’s possible (some experts would say likely) that today’s elderly would suffer, because the risk pool for Medicare itself would get sicker and sicker. That would require ever larger subsidies from outside the system. But as the constituency for traditional Medicare shrunk, as elderly beneficiaries died, the political will to make those subsidies would likely ebb.
Besides, Medicare is a program for senior citizens. It would make more sense to illustrate it with children?
Ron Wyden and Paul Ryan got everybody’s attention last week when, together, they endorsed the idea of turning Medicare into a voucher scheme. But exactly how similar are their visions? I’m starting to wonder.
In interviews with Igor Volsky of Think Progress and with yours truly, Wyden was emphatic about protecting traditional Medicare and what it offered seniors. “I would never do anything to shred it, or weaken it, or harm it in any way,” Wyden had told me. Later, he said this scheme was “absolutely not … the end of Medicare as we know it.” But Ryan, in an interview with James Pethokoukis of the American Enterprise Institute, struck a different tone: “We are stopping the open-ended, defined benefit system,” Ryan said.
It might not be immediately apparent, but the quotes from Wyden and the quote from Ryan are not consistent with one another. If anything, those quotes highlight the extent of ideological disagreement between left and right over Medicare's future.
Contrary to popular perceptions, the debate is not simply over whether public sector insurance programs are more efficient than private sector alternatives. And it is not simply over whether competition can lower the cost of medical care more effectively than regulation. It is also whether our society should make a solemn guarantee to seniors – and, more precisely, what that guarantee should be.
Today, Medicare is a guarantee to the elderly that, upon retirement, they will get a comprehensive set of health benefits that will be within their financial means. The guarantee does not come free: Seniors pay premiums for Part B and Part D, the portions of Medicare that cover outpatient services and prescription drugs. Medicare also has cost sharing, in the form of deductibles and co-payments, just like any other insurance policy. But seniors pay far less in premiums and out-of-pocket expenses than they would if they were buying insurance on the open market. That’s because they’ve paid into the system for the entirety of their working lives, via the payroll tax, and because present-day taxpayers pick up the tab for whatever is left over.
And that's a wrap. The Republican presidential candidates are done debating, at least until the caucuses and primaries begin. Who won Thursday night's event in Iowa? Who lost? I have no idea, as I'm neither an Iowan nor a Republican. But here are five semi-informed (and perhaps semi-intelligent) observations on what transpired.
1. Proof that Newt Gingrich is in trouble. Go back and pay attention to Mitt Romney’s answers on Thursday night. He talked about the economy and his experience in the private sector. When pressed about his conservative credentials, he hit the usual talking points but made a point of stressing the importance of bridging partisan divides. These are not the answers of somebody desperate to shore up his support with the base. These are the answers of somebody who’s in the lead, expects to stay in the lead, and is thinking about positioning himself for the general election. On Twitter, ABC’s Jake Tapper noticed the same thing and speculated that Romneys’ internals must look awfully good right now. I bet he’s right, although I'm far from discounting Gingrich – or anybody, really. This race is just too unpredictable.
2. Romney's good fortune. It’s amazing that in Iowa, of all places, Romney has not gotten more scrutiny for his change of position on abortion. He’s acknowledged that his views used to be different and I am perfectly willing to believe politicians (like writers!) can have honest changes of heart. But Romney’s story on this just doesn’t pass the smell test. Romney’s former support of abortion rights wasn’t ambiguous: He spoke frequently about a family member who’d died from an illegal abortion and, when challenging Ted Kennedy for the Senate in 1994, vowed “you will not see me wavering on this.” Years later, supposedly, a meeting with scientists about stem-cell research led Romney to have an epiphany – and a conversion to fully pro-life politics. Is it possible Romney’s explanation is truthful? Sure. It is likely? No. Salon has the full accounting of his positions, if you want to judge for yourself.
3. Maybe Rick Perry isn't finished after all. He’s looked confident in the last two debates. He’ll never be a world-class intellectual, but he gives coherent answers now and I am starting to see some charisma. Experience obviously makes a huge difference. If he’d had even a little more exposure to serious media scrutiny previously in his career, he’d likely be in a very strong position now. He’s not, obviously: Those early performances really diminished him, in the eyes of the elite and, apparently, the voters. But he has money and, supposedly, he’s good at the kind of retail politics that make a difference in Iowa. If Newt really is in free fall, could Perry benefit? After the debate, the Fox News panel certainly seemed impressed. And the most reliable authority, Nate Silver, thinks a Romney-Perry race is still possible.
Senator Ron Wyden has an unofficial fan club and I consider myself a charter member. I joined in late 2006, right after the midterm elections, when a newly energized Wyden introduced a serious proposal for universal health care. The idea was elegant -- in many ways, a policy wonk's dream. And while it never became the template for reform, it had a catalytic effect on the debate. If not for the political conversation that Wyden's proposal started, the Affordable Care Act might not exist today.
I suspect Wyden is trying to reprise that role now, with a new proposal he unveils Thursday. But this time Wyden is focusing more narrowly on reforming Medicare and reducing deficits, rather than reinventing the entire health care system from scratch. Wyden is a true believer in bipartisanship and his 2006 bill reflected that: Its co-sponsor was Senator Robert Bennett, a thoroughly conservative Republican from Utah. The new Medicare proposal also comes with a Republican endorsement, but it's an even more unlikely one: House Budget Chairman Paul Ryan.
Yes, this is the same Paul Ryan who, less than a year ago, introduced a radical plan that would have eliminated the traditional government Medicare insurance plan altogether. In its place, Ryan envisioned a voucher scheme with competing private plans – one in which the government no longer guaranteed all seniors could get comprehensive coverage at affordable prices. Critics called it a scheme to end Medicare as we know it. Ryan and his allies bristled, but the description was accurate.
The plan Ryan and Wyden will unveil formally on Thursday is less radical and less threatening to seniors. It also starts with a voucher scheme but, at least on paper, it would preserve traditional Medicare as an option.
And that's not the only difference. Ryan’s original proposal called for the government to spend far less money on the elderly. That was its chief source of budget savings and a major source of danger: Seniors would end up individually responsible for a dramatically larger share of their individual medical expenses. The new Wyden-Ryan framework does not call for these severe reductions in spending, theoretically sparing seniors the hardship Ryan's old proposal would have unleashed.
But if the Ryan-Wyden plan improves upon the original Ryan plan, does it also improve upon Medicare? Would seniors really be better off? Would the government save a lot money? I think the answer to all three questions is no.
The economy remains weak and health insurance keeps getting more expensive, but the number of young adults without health insurance fell by 2.5 million this year.
How could that be? Simple. President Obama and the Democrats passed health care reform. And, by all accounts, it's starting to do some good.
A lot of good.
As Ricardo Alonso-Zaldivar of the Associated Press first reported on Wednesday, the Centers for Disease Control is releasing new data that shows the number of young adults, ages 19-25, without private insurance fell from about 10.5 million to 8 million between 2010 and the middle of 2011. The number of Americans in other age groups, including those between 26 and 35, went up in the same period. See the graph below, which Igor Volsky has reproduced from the administration's analysis.
Why would adults younger than 26 be so much more fortunate than those who are older? The only possible explanation, according to administration officials and most health care experts I know, is the Affordable Care Act. One of the first provisions to take effect is a requirement that insurers offering family coverage include dependents up through the age of 25.
This isn’t the first time we’ve heard about that provision having an impact: Previous estimates, public and private, had suggested at least half a million people and possibly many more had gotten health insurance thanks to the young adult provision. These latest numbers from the CDC, according to the administration, are more precise than those previous reports. (Even if subsequent analysis suggests the 2.5 million figure is high, it's clear large numbers of young people are taking advantage of this provision.)
Critics of the law, which they (and I) like to call "Obamacare," have suggested that its expansions of and improvements to health insurance are not worthwhile because of the expense they inevitably impose. And it's certainly true that requiring insurers to cover more services or more people will, on its own, force the insurers to raise premiums. Recent private sector estimates have suggested that the law’s new requirements have raised premiums by 1 to 2 percent.
Newt Gingrich’s past endorsement of an individual mandate has drawn fire from conservatives. But that's not his only health care heresy.
In 2008, Gingrich made the case for another idea that became part of Obamacare and, in due time, the focus of right-wing attacks. Worse still, at least from the standpoint of conservatives, he did so by writing an op-ed for The New York Times.
Oh, and did I mention he had some help? Gingrich had a co-author: John Kerry, the Democratic senator and former presidential nominee.
The title of the article was “How to Take American Health Care from Worst to First” and it was actually a collaboration by Gingrich, Kerry, and Billy Beane. If you follow baseball or read (or saw) Moneyball then you are familiar with Beane. He’s the revered general manager of the Oakland Atheletics who helped pioneer the use of "sabermetrics."
Over time, Beane was able to get better players for the A's, at a cost his financially limited team could afford, by using more finely tuned statistics. And in the Times op-ed, the writers suggested that doctors and hospitals could apply a similar approach to medical care, using statistics to provide treatments that did more for less money. The only problem, Gingrich and his collaborators pointed out, was the lack of good data:
Remarkably, a doctor today can get more data on the starting third baseman on his fantasy baseball team than on the effectiveness of life-and-death medical procedures. Studies have shown that most health care is not based on clinical studies of what works best and what does not — be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition.
A few innovative health care organizations have been able to create, and apply, their own data. Among them is the Intermountain Health Care in Utah. Intermountain has won acclaim for producing high-quality care at costs that are about one-third less than the national average.
Gingrich, Kerry, and Beane cited Intermountain as proof that data could boost efficiency, but they also acknowledged that ultimately the private sector couldn't solve this problem on its own. More action was necessary, they said, and that action had to come from government:
