Wednesday, September 7, 2016

Brooks on Obamacare, continued

Harold Lloyd at Coney Island in Speedy (1928), via gastrocinema.
David Brooks ("The Incredible Shrinking Obamacare"), I was saying, has an extremely weak understanding of what's in the Affordable Care Act, and it strikes me that it might not be a bad idea to kind of go over that briefly, because (a) it's got a very complex surface, but it's pretty simple on the inside, (b) the administration still hasn't explained it all that clearly, as is unfortunately the case with so much of what it does, and (c) the daemonic right wing has kept us all off balance with its perpetual Gish Gallop of facts, pseudo-facts, and lies, forcing us to spend all our time saying what it isn't as opposed to what it is.

The Patient Protection and Affordable Care Act is in the first place a broad program to bring the nation to universal access to good quality health care on the basis of actuarial principles.

The good quality, for everybody who has health insurance, was to be created by a general reform of the insurance business emphasizing preventative care (through no-copay checkups and such), holistic treatment (cutting into the fee-for-service model), reduction of stupid rent-seeker costs (which didn't go over too well with the pharmaceuticals industry), and a revolution in the way premiums are assessed, making it strictly on the basis of age and not taking the customer's health state into account (including the preexisting-condition rule). The universality would be attained through the very large-scale expansion of two things that already existed in 2009 and the introduction of a third thing that didn't:
  • your standard employer-supplied health insurance for people working for decent employers, which was to become a legal requirement (employer mandate) for all companies with 50 or more employees instead of just a gift presented by the fancy firms competing for high-value employees or a victory won by unions in the shrinking pool of people who have unions to represent them;
  • your traditional Medicaid covering poor people, which was to be extended from people who were poor by federal definition to a larger group of people who were not that poor, or a little over a third less poor, from a rating of 1 on the federal poverty scale to a rating of 1.38; and
  • a new mechanism to get health insurance to people who aren't poor but who can't rely on employers to take care of it for them, whether because their workplaces are too small (fewer than 50 employees) or because they're self-employed, and require them (individual mandate) to buy it in a state-run or federally-run Marketplace.
These three strategies for dealing with uninsurance were aimed at maybe 13% of the population in 2013, which was far too many people, 42 million or so, but a lot fewer than the total of those who were already covered, the 155 million or so on employer-sponsored health insurance, 14 million on the individual market such as it was at the time (it was pretty terrible, and when Obama said, "If you like it you can keep it", he really had no idea there was anybody dumb enough to claim they liked it—he was talking to those of us on normal group plans), 55 million on Medicaid, and the 41 million on Medicare.

Brooks is missing, for one thing, a sense of the proportions involved when he writes,

During the debate over Obamacare, both supporters and opponents assumed the giant law would transform the American health care system. The supporters argued that the system would help Americans purchase health insurance through carefully regulated state exchanges. President Obama envisioned a day when consumers could shop for health coverage “the same way you’d shop for a plane ticket on Kayak or a TV on Amazon.”
Those first two links, by the way, aren't references to any evidence that his statements are true but general Times information links; the third to the blog of Craig Bannister, who is not exactly a health policy expert but the media relations, PR, and marketing manager for the Christianist news service CNSNews, not that the quote is inaccurate, but Brooks's appropriation of it misses a couple of points: that Obama was not "envisioning a day" but welcoming the day, October 1 2013, when the Marketplace exchanges went online for the first time (it would take a couple of months before it was really working, as we know, and it's still not quite as easy as Amazon); and that the exchanges were not aimed at "Americans" or "consumers" in general but at the fairly well-defined subgroup of that 13% that was working but not in a relatively large company.

The new law really was aimed at transforming the American health care system, at improving health care and making it universally available, but the exchanges were a very narrowly targeted part of the program. The idea that all Americans would go out and shop for their own health insurance was actually a long-nurtured conservative dream—the well-known "Heritage plan", whose goal was to free bosses from buying insurance for their workers and move the entire burden to the workers themselves—and entirely at odds with the ACA, which made it a requirement that employers (of a certain size) must buy employees' insurance. I always feel it's a central aim of conservative critics to hide this essential point.

Anyway, Obamacare just really isn't "incredibly shrinking"—it's working more or less as planned.

That's the part I wanted to cover. There's more on Brooks's misunderstanding of what kind of revolution the ACA was supposed to bring from Jonathan Chait (h/t Driftglass); and on his failure to realize the huge importance of some of the broad reforms, in particular ending discrimination in premiums for less healthy people, from Dean Baker.

There's a lot to say, too, about the reasons the ACA is not working as well as we hoped it might by this time (even though it's cut the number of uninsured in half already, and open enrollment starts up again in a couple of months). For example, there's the way Republicans (like Senator Rubio) seeking to deny Obama a success and insurance companies seeking regional monopolies (like Aetna) have worked to sabotage the workings of the ACA by preventing competition. Above all, there's the refusal of Republican governors and state legislators to expand Medicaid thanks to the dreadful Roberts decision in the National Federation of Independent Business v. Sebelius case, which has had a much greater effect in keeping the number of uninsured too high than any problems in the Marketplace have had.

But there's no use in arguing with Brooks, because he doesn't in the end know what he's talking about. He's parroting the work of his secret masters on the one hand and his research assistant on the other, but he really doesn't understand.

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