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Health Care and the Waiting Room

Republicans have been waiting for seven years to repeal and replace the hated Obamacare law, and it looks as if they’ll have to wait a while longer. The Senate’s majority leader has postponed a vote on a Republican alternative until after the summer recess, which will likely include some encounters with constituents that won’t make them any more eager to take up the matter when they return.
The Republicans have a president in the White House and a large majority in the House of Representatives and a slight majority in the Senate, the same advantage the Democrats held back when they rammed Obamacare through without a single Republican vote, but their revenge was never going to come easy. That Republican president ran on promises of no cuts to Medicaid and coverage for everybody, that House majority is largely comprised of more doctrinaire conservatives, and slim Senate margin includes both doctrinaire conservatives and more pragmatic sorts of Republicans from purplish states. Although they all ran on promises of repeal and replacement, the Republicans never did agree on what that should look like.
Back when the Democrats had the House and Senate and the White House they were all in general agreement on the basic principles that the government should be interfering more thoroughly in the health insurance market, consumer choices should be restricted, and more government spending should be allotted, so they had an easier time getting their bill passed. Even with a president boasting approval ratings in the 60s and plenty of support from support from the establishment media, however, the Democrats took until just before Christmas and had to resort to some bare-knuckle politics to ram through what was already an unpopular law.
Although the eponymous President Barack Obama won re-election three years later, the Obamacare law was unpopular enough that it was largely responsible for a Republican president and Republican majorities eight years after his supposedly transformative election. Such are the consequences of ramming unpopular legislation down the public’s throat on a strictly partisan vote, along with all the skyrocketing premiums and punitive mandates and other pains that have been inflicted on so many Americans, so the Republicans should count themselves luck for the delay.
Obamacare remains unpopular yet, and even its more honest defenders are admitting that some serious tweaking is required, both the House bill that was passed after an embarrassing delay and the Senate bill that’s currently delayed are polling far worse. Both cut back on planned increases in Medicaid, and they not only don’t cover everyone but leave an estimated 22 million looking for other options in coming years, and there’s no getting around that the tax implications tend to favor the wealthier taxpayers, so the politics is at least as tricky as the policy.
To our old-fashioned Republican way of thinking both the House and Senate bills represent a slight improvement on Obamacare, but come nowhere near the long-promised full repeal and replacement, we expect that whatever compromise version they might reach and pass on a partisan vote will prove unpopular enough to arrive at a Democratic president and a Democratic majority in at least one house in just three years or so. There’s a conservative case to be made for the the Republican bills, and a conservative case to be made against them, but the Republican president who promised no cuts to Medicaid and coverage for everyone and the free-market ideologues and the more pragmatic sorts of Republicans seem likely to persuade the public.
All of them promised their voters something like a repeal and replacement of Obamacare, though, and all of them are itching for something they can call a legislative win. We hope they get it, but we hope they take their time about it, and come to some agreement on the true principles that underlie a free and efficient health care system, and make that hard-to-explain case to the American people, and use the impending implosion of Obamacare to get recruit a couple of symbolic Democratic votes. They’ll probably take some short-term hits for that, but it’s the best plan for the long run, which will take a lot of time.

— Bud Norman

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The Boring Bureaucrats of the CBO Score

The Congressional Budget Office is back in the news, what with all this fuss about repealing Obamacare and replacing it something or another that in any case isn’t to be called Trumpcare, and we’re heartened to see their reassuring initials again. Back when political news was mostly a boring affair about arcane accounting questions the boring bureaucrats of the CBO were always in the lead or at least third paragraph of every story, but that was before the political news became more entertainingly about the latest “tweets” and the accusations of treason being flung from both sides, so lately we find ourselves missing the old days.
That good ol’ CBO finds itself back in the news because of its long-awaited “scoring” of the first of three promised phases of repeal of Obamacare and replacement with something that nobody is calling Trumpcare. The report contains plenty of argumentative ammunition for the Democrats who are unanimously opposed to the plan, possibly enough to scare some of the Republicans with whetted thumbs against the political winds, and a few big numbers that speak well for the first phase of the scheme but might embolden its conservative critics. All in all it was the desultory conclusion that you’d expect from a numbers-crunching bunch of boring bureaucrats, which is what the CBO is paid to be, and within a certain margin of error involved in all human undertakings we’re inclined to accept their findings.
One finding is that 24 million fewer Americans will have health insurance over the next decade if the current proposals of repeal and replace are enacted, which is a number hard for the most pro-reform media to spin, and which the anti-reform media gleefully headlined. The pro-reform forces therefore questioned the supposedly boring objectivity of the bureaucrats at the CBO, rightly noting its past errors in overstating the benefits and understating the costs of Obamacare, but they’ve conveniently forgotten how that happened. We were among the anti-Obamacare voices who noted that the CBO was diligently “scoring” those costs and benefits according to the pie-in-the-sky assumptions and spreadsheet legerdemain that the Democratic administration and Democratic majorities in Congress had described, and that the CBO had made that disclaimer quite clear, and when you take into account that the CBO’s forecasts couldn’t have taken into account subsequent Supreme Court decisions and other events they did about as well as anybody. If the current Republican administration and Republican administrations in Congress didn’t offer such helpful guidelines we can hardly blame those boring bureaucrats as the CBO.
Even without any helpful guidance from the Republicans the CBO has concluded that the first part of more or less Grand Old Party’s three-phase plan would lower federal deficits by a not insignificant $337 billion, given the nation’s poor fiscal health, and would eventually reduce the average American’s health insurance premiums by 10 percent, which by the now the average American would not consider an insignificant sum. The Republicans should be able make some political hay out of those numbers, but at the moment they’re busy discrediting everything the CBO says, and the eventual part will only play out long after the next election cycle and just before the president’s reelection race. The CBO’s past miscalculations were based on the garbage-in-garbage-out assumption of the Democrats who front-loaded their carefully planned Obamacare with early benefits and defrayed costs, while the CBO’s current calculations reflect the Republicans’ longstanding preference for paying up front, and although that makes for good policy we can’t fault the CBO if it makes for lousy politics. If the American public isn’t taking a longer range view of the situation, neither can we fault the CBO for that.
So far as we can tell from the CBO reports and everything else we read and hear and see this Obamacare thing has made things better for some people and worse for others and on the whole worse all around, and we’re quite sure this three-phased real and replacement with something that won’t be called Trumpcare might prove better but surely won’t be perfect. We’re holding out hope that nuns won’t be forced to pay for contraceptive coverage and monogamous married couples won’t have to fork out for sexually transmitted disease plans and teetotaling types aren’t hit up for alcoholism treatment, and that the the youngsters who only need catastrophic care can pay on the cheap, and that the daredevils can continue to defy the actuarial tables, but by now we have to admit that the benefits won’t come without costs, that those costs are actually figured in the long term that people rarely consider, and even those boring bureaucrats at the CBO can’t make any reliable predictions.
We always liked those old-fashined Republicans who used to acknowledge such uncertainties, but these days the party is represented by President Donald Trump and his campaign promises that everyone was going to be covered and the government would pay for it and premiums would go down and care would go up and everything would be great. He was never clear about the details, and being a big picture guy he seems to have left those details up to those Republican establishment guys he ran against, and they seem to have some old-fashioned ideas about paying up front and letting some number of Americans that might approach 24 million go without health insurance, and although there are philosophical arguments to made for that which the CBO can’t score he doesn’t seem able to make it, and this repeal and replace thing seems to be the very first time in his life that he doesn’t want his name on something.
As bad as Obamacare was we’ll still expect something better, but not matter what happens we won’t blame those boring boring bureaucrats at the CBO.

— Bud Norman

Dueling Opinions on Obamacare

Two separate federal courts hearing two separate cases issued contradictory opinions Tuesday regarding the legality of subsidies being provided to people in states with federally-run health care exchanges, and Obamacare and all its embarrassments are back in the news. It’s all very complicated, as is the case with everything Obamacare, but well worth delving into if only for the comic relief.
The dispute in both cases arises from a few words among the 2,000-plus pages of the hilariously named Affordable Care Health Act, which state in unusually clear language that the subsidies shall be made to those who are eligible by their lack of income and had enrolled in exchanges “established by the State.” Only 14 states were willing to go along with the Obamacare boondoggle by establishing their own exchanges, so in the other 36 states the law as written would stick those under-funded suckers who signed up with the full cost of their over-priced plans, which would cause many of them to stop paying their premiums and pay the much smaller fine instead, thus leaving the insurers with a sicker and less profitable pool of customers, thereby raising the poor folks’  ire and everyone else’s premiums and further endangering the already unpopular law’s chances of political survival.
The United States Court of Appeals for the District of Columbia, in a two-to-one ruling in the Halbig v. Burwell case, insisted that the law says what it says and should be enforced accordingly. A few hours later the Fourth Circuit Court of Appeals ruled in the King v. Burwell case that the law doesn’t really say what it says, and in no case should be enforced according to something so silly  as the law’s  plain text. The unfortunate Burwell, whoever he or she might be, seems headed to the Supreme Court for a final resolution.
Until then, it will be amusing to hear Obamacare’s dwindling number of defenders argue that it is the most brilliantly written legislation in American history while simultaneously arguing that it should not be read as written because of its absurdity. The oxymoronically named White House Press Secretary Josh Earnest helpfully explains that “You don’t need a fancy legal degree to understand that Congress intended for every eligible American to have access to tax credit that would lower their health care costs regardless of whether it was state officials or federal officials who are running the marketplace,” but it takes an especially fancy legal education to conclude that is not what Congress wrote into the law. Some argue that the language was quite deliberate, and intended to force recalcitrant Republican governors into starting state exchanges or face the wrath of their dependent class voters, although the estimated four to five million people being subsidized are hardly a formidable voting bloc when spread across 36 states, and far outnumbered by the voters being asked to pick up the tab for the subsidies, but if the Democrats now want to insist that it was just one of those typographical errors that are bound to happen when you’re hastily ramming an unpopular law down the public’s throat in the literal dead of night without a single vote from the opposition party they are free to do so. The D.C. Court of Appeals rejected the government’s argument that the plain text of the Affordable Care Act “renders other provisions of the ACA absurd,” which seems reasonable given that the absurdity standard would render most of the Obama administration’s actions illegal, and any Republicans who insist that the law should be enforced according to what it says are also free to do so.
We’re not such reckless gamblers that we would wager any amount of the final resolution of this matter, but we hopefully note that Professor Laurence Tribe of the impeccably fancy Harvard Law School has said “I wouldn’t bet the family farm on this coming out in a way that preserves Obamacare.” The good professor probably doesn’t have a family farm, and even if he does we can’t imagine him plowing its fields, so we take his comment as merely allegorical, but it’s heartening nonetheless. Even if the argument that a law shouldn’t be enforced as it is written just because it’s written that way does prevail, it will be nice to at last be done with the archaic pretense that the law has any meaning other than what the president wants it to mean.

— Bud Norman

The Debate is Over

The debate about Obamacare is over, according to a presidential pronouncement, and it seems a shame. There was a lot more grousing about it that we’d plan to do, now we’ll have to cancel that sarcastic skit we’d written for the upcoming “Gridiron” show, and the public is stuck with a spectacularly stupid law.
Perhaps the debate will rage on, despite the president’s protests, but he does seem to have an eerie power to end any arguments that he’s losing. The Benghazi scandal disappeared from the news shortly after his Secretary of State declared “What difference, at this point, does it make?” The Internal Revenue Service’s harassment of conservative non-profit groups has been similarly ignored after the president dismissed it as a “phony scandal,” even though the woman at the middle of it of all has quite genuinely invoked her Fifth Amendment right against self-incrimination. The arguments about fiascos from Fast and Furious to Solyndra to whatever happened to all that stimulus spending have all been as abruptly truncated.
All those cancellations of policies and increases in health insurance bills and the death panels passing judgment on grandma and the rest of it will make Obamacare harder to ignore, but the left’s power to put an end to losing arguments should not be underestimated. Even with the coldest winter in memory stubbornly stretching into April after a decade-and-a-half of global cooling the debate about anthropogenic global warming has been declared over, and most of the media have obediently obliged. A relatively recent bout over the five millennia-old tradition of marriage has also been stopped on a technical knock-out, and the half of the country with lingering doubts has effectively been banished from the mainstream of contemporary society. Any debate about the social acceptability of white racism has been thoroughly ceased, which is a good thing, but some very non-racist debate about affirmative action and inner-city crime and other issues that have baleful effects on minorities have also been stopped.
Around the time of the president’s first election Time Magazine declared on its cover that “We Are All Socialists Now,” and that seems to have settled that. If America isn’t quite yet socialist by consensus, we’re at least far enough along that the Majority Leader of the United States Senate can confidently slander the Koch brothers as “un-American” for their pro-capitalism activities and anybody with concerns about that $17 trillion of debt is easily dismissed a radical anti-government kook. Arguments about the basic assumptions of the New Deal welfare and regulatory state were declared over more than 60 years ago, with even such a stalwart Republican as Ronald Reagan being unwilling to do more than try to retain their old limits, and they’ve been barreling towards their illogical conclusions ever since.
We think that these debates never really go away, though, even if they have to be revived by catastrophe. We’d also like to think that Americans still have a stubborn unwillingness to submit to stupid laws, and that enough argument can avert catastrophes, but that’s debatable.

— Bud Norman

What’s the Symbol for Hate?

Every now and then during our drives about town we will spot a bumper sticker on another vehicle exclaiming that the motorist loves Obamacare. A heart-shaped symbol substitutes for the word “love,” as if scanning the four letters would take too much time out of our busy days, and of course there’s no room at all for an explanation of this uncommon affection.
Which is a shame, because we’d love to hear these proudly Obamacare-loving drivers state their reasons. It was easy enough to understand the enthusiasm back when the so-called Affordable Health Care Act was being pitched to an unwary public, and it was going to provide coverage to every single citizen and perhaps even a few non-citizens while allowing everyone who was satisfied with their existing plans to keep them, somehow help the employers who would suddenly be stuck with reams of new regulations, and cost the public treasury a trifling $980 billion, and lower everyone’s premiums to boot. Only the hard-hearted skeptics didn’t love that, but now that they’ve been proved right in every regard those bumper stickers are hard to comprehend.
By now those drivers should know that at least four million of the uninsured will choose to pay a fine cheaper than insurance and remain uninsured, at least seven million people with insurance will be forced off their plans whether they like them or not, employers are hoping to reduce their newly imposed costs by limiting workers’ hours, the Congressional Budget Office’s estimated tab after the budget gimmicks expired has now swelled to $1.85 trillion, and in the latest bit of vindication for the skeptics a Society of Actuaries report says the price of an insurance premium will continue to rise for most Americans. Health and Human Services Secretary Kathleen Sebelius admits that at least part of the rise is directly attributable to Obamacare, telling a group of reporters on Tuesday that “These folks will be moving into a really fully insured product for the first time, and so there may be a higher cost associated with getting into that market.”
The secretary was quick to add that some people will see their insurance costs go down and that subsidies will be available for many lower-income Americans to help them with the cost of their newly-mandated coverage, and others with a heart-on for Obamacare will no doubt find other silver linings. There seems to be an awfully dark cloud within those silver linings, though, particularly for the now-quite-lower-income Americans who will be paying both higher premiums and higher taxes as a result of the subsidies, and Obamacare’s more realistic fans are already talking about the latest round of revisions and refinements. We anticipate that they’ll find all the problems are caused by the pesky remains of a free market insurance system and that even more government control is required, and if the problems persist they’ll prescribe more of the same.
Some conservatives have argued all along that Obamacare was meant to fail to such an extent that the public would at last demand a full-fledged single payer system such as can be found in the more fashionably socialized countries. They’ve been dismissed as paranoid right wing crackpots, of course, but we knew quite a few left-wingers who giddily espouse the very same theory as the reason for their support of the bill. Those who love Obamacare for its faults tell us that fully government-run health will be wonderful, but they’re hard-pressed to explain why something that’s so obviously a good idea can’t be sold to the public without mucking things up first, and they don’t seem to have planned for the possibility that a public fed up with higher premiums and worse care might turn to Republican congressional candidates disinclined to go the Swedish route, but they’re the only ones who seem pleased with the way things are going.

— Bud Norman