The Best Short Summary of the Affordable Care Act (ACA) Situation You’ll Find

In a blog post called “There Will Be No Obamacare Replacement”, Paul Krugman quotes himself from seven years ago. What he says deserves to be quoted at length and shared widely.


“You may be surprised at the evident panic now seizing Republicans, who finally — thanks to [FBI Director] James Comey and [evil dictator] Vladimir Putin — are in a position to do what they always wanted, and kill Obamacare. How can it be that they’re not ready with a replacement plan?

That is, you may be surprised if you spent the entire Obama era paying no attention to the substantive policy issues — which is a pretty good description of the Republicans, now that you think about it.

From the beginning, those of us who did think it through realized that anything like universal coverage could only be achieved in one of two ways: single payer, which was not going to be politically possible, or a three-legged stool of regulation, mandates, and subsidies. Here’s how I put it exactly 7 years ago:

Start with the proposition that we don’t want our fellow citizens denied coverage because of preexisting conditions — which is a very popular position, so much so that even conservatives generally share it, or at least pretend to.

So why not just impose community rating — no discrimination based on medical history?

Well, the answer, backed up by lots of real-world experience, is that this leads to an adverse-selection death spiral: healthy people choose to go uninsured until they get sick, leading to a poor risk pool, leading to high premiums, leading even more healthy people dropping out.

So you have to back community rating up with an individual mandate: people must be required to purchase insurance even if they don’t currently think they need it.

But what if they can’t afford insurance? Well, you have to have subsidies that cover part of premiums for lower-income Americans.

In short, you end up with the health care bill that’s about to get enacted. There’s hardly anything arbitrary about the structure: once the decision was made to rely on private insurers rather than a single-payer system — and look, single-payer wasn’t going to happen — it had to be more or less what we’re getting. It wasn’t about ideology, or greediness, it was about making the thing work.

[Still quoting the professor here] It’s actually amazing how thoroughly the right turned a blind eye to this logic, and some — maybe even a majority — are still in denial. But this is as ironclad a policy argument as I’ve ever seen; and it means that you can’t tamper with the basic structure without throwing tens of millions of people out of coverage. You can’t even scale back the spending very much — Obamacare is somewhat underfunded as is.

Will they decide to go ahead anyway, and risk opening the eyes of working-class voters to the way they’ve been scammed? I have no idea….”

End Quote.

The Affordable Care Act really was the “conservative” approach to universal health insurance, a variation on the plan signed into law by the Republican Governor of Massachusetts, Mitt Romney. But the Republican Party decided to oppose everything President Obama did. That meant they had to oppose the ACA too. Now they’re stuck trying to replace a major law they should have been in favor of all along. 

Almost final word from Prof. Krugman:

…if Republicans do end up paying a big political price for their willful policy ignorance, it couldn’t happen to more deserving people.

I’d change that last sentence to read “pay a big political price for playing extremely partisan politics with the health and well-being of the American people”, but the part about the “more deserving people” is perfect.

It Should Be Unbelievable, But Isn’t

As reported this afternoon on the NY Times website:

Senator Harry Reid of Nevada, the majority leader, called House Speaker John A. Boehner of Ohio on Wednesday to commit to negotiations on a long-term deficit reduction deal, but only after the House passes the Senate’s bill to reopen the federal government without policy strings attached.

[Reid called Boehner on the phone and also sent this in a letter:]

“Before the House you have the Senate-passed measure to reopen the government, funded at the level that the House chose in its own legislation. I propose that you allow this joint resolution to pass, reopening the government,” Mr. Reid wrote. “And I commit to name conferees to a budget conference, as soon as the government reopens.”

The speaker’s office dismissed it as a surrender demand.

“The entire government is shut down right now because Washington Democrats refuse to even talk about fairness for all Americans under Obamacare,” said Michael Steel, a spokesman for Mr. Boehner. “Offering to negotiate only after Democrats get everything they want is not much of an offer.”

Wait a minute. “After the Democrats get everything they want”? It’s what the Democrats and the rest of us already have! Except for the federal government being on life support, and presumably most Republicans want that little problem to be fixed too.

The Affordable Care Act has gone into effect. It’s not going away. It’s not something that has to be renegotiated. There was an election. The Supreme Court approved it. People are already signing up (although there is so much interest, the new websites are having trouble keeping up with the demand). 

Get over it, Boehner spokesman, and move on to the next crisis!

Earlier today I read a comment from a Republican at the Boston Herald site. She said that delaying the entire ACA for one year was “reasonable”, since some parts of it have already been delayed. She also said it was o.k. to delay it because the thing doesn’t work anyway (the evidence being that thousands of people who visited the websites yesterday had trouble getting through, because thousands of people were trying to get through).

This is the problem we’re having in this country. There are many among us who live in a different reality and use words like “reasonable” in a different way. “Extortion” becomes “negotiation”. As a result, communication becomes terribly difficult. Ideology can certainly cloud your perception of the world.

PS — Someone just left a comment on the previous post asking why it’s bad for the Republicans to want to delay the ACA. That’s their right, of course. The question is how they try to achieve that goal. See the comments on the post below if you’re interested, including a link to another opinion piece.

In the meantime, I’m going to watch some soccer.

Patience and the Affordable Care Act

It’s always bothered me that the Obama administration didn’t come up with a catchy name for the health insurance provisions of the Affordable Care Act. We’ve got “Social Security”, “Medicare” and “Medicaid”, so why couldn’t the administration come up with an equally helpful name for this thing, instead of leaving an opening for it to be called “Obamacare”?

I bet if Saint Ronald was still President, one of the first things on his agenda would have been to give his pet program a great name that would help sell it to the American people. But Obama apparently thinks he’s above such things.

Nevertheless, the important thing is that this landmark legislation is going into effect two days from now, regardless of what any misguided, foolish, cowardly and/or evil House Republicans do in the meantime.

I know people (including myself) who will probably be taking advantage of the ACA in the relatively near future, so I’ve been wondering how much it’s going to cost. Unfortunately, there are reports in the media that suggest what “average” premiums will be. There was one such unhelpful article in the New York Times today: “‘Affordable Care’ or a Rip-Off?”.

The problem is that you can’t know what a person’s or a family’s costs will be until you factor in where they live, how old they are and, especially, what their income is. Many or most people in this country, not just the poorest among us, will be eligible for subsidies from the government. In fact, if you’re eligible for a subsidy, you won’t even have to wait for the IRS to send you a check. The subsidy will be applied right up front when you pay your insurance premium (which means that some people won’t have to pay anything at all).

There is good news here. The health insurance premiums being discussed so far are generally cheaper than what people would pay for private health insurance today, and the premiums are going to be lower, often much lower, for many of us after the subsidies are applied.

So maybe everyone who’s interested should wait a couple days and then go to to see the real numbers (and also see the pretty young woman with a big smile on her face). I’m sure we can all wait a couple more days.

Here’s today’s New York Times editorial on the importance of the ACA and the subsidies:

If you’re in the mood for even more good news, take a look at this column from Nicholas Kristof. Here’s his conclusion, supported by statistics from the World Bank, the Gates Foundation and the U.S. Agency for International Development:

So let’s acknowledge that there’s plenty of work remaining — and that cycles of poverty in America must be a top priority at home — yet also celebrate a triumph for humanity. The world of extreme poverty and disease that characterized life for most people throughout history may now finally be on its way out.