The Obamacare Direct Mail Campaign

The Affordable Care Act, often labeled (derisively) as Obamacare, has never been an incredibly popular piece of legislation at least not when pollsters ask about the overall legislation. Individual elements do poll quite favorably. ACA has become the domestic achievement for this White House for good or for ill and I think a recent letter I received could help to change the perception of the ACA and make the title "Obamacare" a positive descriptor.

About two weeks back I had a curious voice mail from my health insurance company about an issue I should really call them back about.  I didn't because typically when my health insurance company needs to talk to me about something, it's not a good something.  Not this time.  A few days later I received a letter in the mail. There were two sheets and on the second sheet in large, plain type it read: "A rebate will be paid to your employer due to new requirements outlined in the Federal Healthcare Reform regulation." A rebate you say?  On the other page was more of fine print:

The Affordable Care Act requires [my employer's provider] to rebate part of the premiums it received if it does not spend at least 80 percent of the premiums [my employer's provider] receives on healthcare services...No more than 20 percent of premiums may be spent on administrative costs...This is referred to as the "Medical Loss Ratio" standard or the 80/20 rule. The 80/20 rule in the Affordable Care Act is intended to ensure that consumers get value for their health care dollars.

So let me get this straight, my employer will receive a check from our insurance provider because our insurance provider didn't meet the 80/20 rule, and the letter goes on to describe how my employer can distribute the rebate, provided it's a non-Federal governmental plan.

1. "Reducing premiums for the upcoming year; or"
2. "Providing a cash rebate to employees or subscribers that were covered by the health insurance on which the rebate is based."

My employer's insurance provider is a large one, covering over 3 million people. While the 80/20 rule is determined state to state--basically my provider didn't meet the standard in DC, but might have in Virginia--there are potentially a couple million people just from my provider that are primed to see a tangible benefit from the 80/20 rule and they all got a letter telling them they would get a tangible benefit.  You can't buy this kind of positive publicity for legislation.

Now, I'm not here to debate the wisdom of this rule.  I'm simply suggesting a piece of legislation that has elements a majority of people clearly favor just picked up what will likely prove to be a net positive in an election year.  Obviously Romney has been reluctant to come out too strong against Obamacare because, well Obama aped Romneycare, but potentially there are independents who weren't too excited about Obamacare that have now seen as many as three direct benefits from legislation that doesn't even take full effect until 2014. They've seen insurance companies can't deny them coverage, they've seen their children receive continued coverage until age 26, and they've seen a letter about a rebate.

Now perhaps I'm overestimating the impact and I haven't seen other pundits talk about this much, but this seems like a piece of good news for Obamacare and by transitory properties, a good piece of news for the president.


UPDATE: I've been informed by a friend at Doctors for America that I got one of the policy points wrong. Insurance companies can still deny coverage to people over 18 due to pre-existing conditions. This protection isn't set up to take place for a bit longer. Right now only those 18 and under cannot be denied coverage due to a pre-existing condition. If someone over 18 is denied coverage due to a pre-existing condition and can't get coverage for 6 months, they are eligible for a high-risk buying pool through the federal government. Full details available at www.healthcare.gov.

Medicaid Does Make People Healthier

Planet Money, a special program on NPR, had an episode last week exploring the research recently released by Katherine Baicker, a health economist at Harvard.  Her research has begun to lay to rest at least one argument against expanding Medicaid, but it's also called into question an oft cited rationale people use when they are to expand Medicaid.  You can listen to the whole thing here (which also goes into the methodology of the research), but here are some of the key takeaways:

• Across a similar socio-economic level, people on Medicaid reported better health than people not on Medicaid (reliant on faith-based, charitable, emergency room, i.e. non-government based healthcare).
• Respondents on Medicaid were 40% less likely to go into debt collection.  Basically, we see positive spillover benefits from Medicaid coverage.  People don't rack up a lot of medical debt, so they have less debt overall so they are much more likely to be able to service the debt they have and not slip into collection.
• Respondents indicated feeling more healthy within a month of being on Medicaid, even though it took many of them much longer to really engage with the system.  Basically, without the threat of catastrophic health costs hanging over their heads people instantly felt better, less stressed.

All of these are positive things.  But there are a couple caveats to note.  First, this is based on survey results, credit reports, and various other non-biological data (though the study does include some health records).  The researchers have actually taken blood samples from many of the people surveyed and when those results get released you could have definitive medical evidence of improved healthcare outcomes for people on Medicaid.  The second caveat is perhaps a bigger issue:

• The group on Medicaid actually spent 25% more on procedures than the group not on Medicaid during the first year of the program.

One of the biggest economic rationales for expanding Medicaid is that it will pay for itself.  As people have access to preventive care the overall cost would come down and the expansion would pay for itself.  In the first year of research this didn't prove to be true.  

I would speculate (and I acknowledge it's speculation) that you might be see a binge effect.  People have gone from famine to feast and as they see primary care doctors, those doctors find problems that may have been ignored for a long time.  And the research indicates that most of procedures undergone by Medicaid recipients were scheduled, which would support my speculation.  The researchers are still tracking this group and will report out year two results soon.  I wouldn't be surprised to find that in year two the costs of the Medicaid group drop substantially as people level off into a steady, healthy state.

For now, Baicker says rather eloquently, we have two definitive pieces of information.  One, people on Medicaid have better health outcomes.  Two, having people on Medicaid is more expensive (so far).  So policy makers have to make the cost-benefit analysis for themselves.  What's the value of a healthier populace?  Does it exceed the cost?  I think you all know where I come down on this, but I'm sure there are those that would disagree.

Meaningful Limits

Colin received quite an honor today. After leaving a comment on a blog by Connor Friedersdorf's blog yesterday, Connor took an entire post to elevate and explain Colin's comment--even preemptively defending it in the face of "liberal commentators." In Colin's comment, he makes a point about the text of the Commerce Clause--the clause of the Constitution that vests Congress with the power to regulate commerce between the States. Colin rightly notes that 

[t]he Commerce Clause does not say that Congress has the power to regulate trade with foreign countries, the Indian tribes, and -- oh by the way -- also do whatever it pleases so long as it even tangentially has anything to do with commerce.

Connor, for his part, then launches into a discussion of whether liberals are wrong to cast aspersions of partisanship on the conservative judges for striking down ACA. He rightly defends the intellectual honesty and consistency of Thomas's position but then says this about the other conservative justices: 

The rest of the conservative justices face a more difficult decision. All are to varying degrees supporters of both stare decisis and the notion that a core function of the Constitution is to divide power among the federal government and the states, putting meaningful limits on Washington's power. Weighing in on the Affordable Care Act, they're inevitably going to undermine at least one value in which they earnestly believe.

But Connor's dilemma is false. The doctrine of stare decisis and the desire for "meaningful limits" on the Commerce Clause are not in conflict. In fact, the Court could--and should--uphold the ACA while observing both stare decisis and reinforcing meaningful limits on the Commerce Clause. As Professor Koppelman wrote in Salon last week:

But there already is a pretty big limit on the commerce power:  United States v. Lopez, a well-known 1995 decision that invalidated a federal ban on handgun possession near schools. Justice Breyer nicely summarized its holding: “Congress cannot get into local affairs, particularly where they are noncommercial.” With that decision on the books, the No Limits argument is like saying that unless you buy my rickshaw, you will have no way to move from place to place. You have legs.  Everyone can see them. Lopez placed limits on federal power.  Everyone can see them. The claim that there will now be no limits is weird. It denies the existence of what is there in plain sight.

What's more, Lopez interacts with another well known Commerce Clause case from the 1990s, Morrison v. Olson, to set a hard boundary on the extent of the Commerce Clause power. These cases, then, provide us with a meaningful limit on the power of Washington and they provide precedent. Upholding the ACA would violate neither of these and would adhere to an even more venerable Commerce Clause case (satisfying stare decisis) while not dismantling the existing limitation on Congress' Commerce Clause authority (satisfying the meaningful limits requirement).

Healthcare and David Brooks

David Brooks had his usual column in The New York Times yesterday, where he believes the great philosophical debate between Democrats and Republicans will be defined by the Medicare debate.  Namely, should there be a centralized panel of experts/technocrats that decide optimum courses of care that would be funded (which is what Democrats have argued for and has worked in other countries) or do we give individual patients the power of choice and let the markets drive down costs (which is what Republicans have argued for and what Rep. Ryan's voucher program would equate to).

In the column he notes, rather well, a typical Democrats argument for a centralized panel:

Democrats tend to be skeptical that dispersed consumers can get enough information to make smart decisions. Health care is phenomenally complicated. Providers have much more information than consumers. Insurance companies are rapacious and are not in the business of optimizing care.

The trouble is he never addresses these objections.  Instead he cites how various studies have been off on the cost or enrollments, and ignored the data in the previous link I added above.  That's a pity.  My largest complaint about healthcare solutions in the vein of Rep. Ryan's and other Republicans is the failure to address information asymmetries in healthcare.  As Matt Yglesias reminds us, buying healthcare is not like buying shoes.  

And before someone jumps all over me for failing to think my fellow citizens have the capacity to make good healthcare choices, let me add I don't trust myself to make the right healthcare choices.  That's why I go to the doctor.  If chicken soup and Advil (or is it Tylenol, I don't know) don't work I go to a doctor and do what he or she says. Would it be better doctors, not insurance companies, were the decision makers in healthcare?  Absolutely, but that's not the case in our current system, and that still doesn't put the power with the consumer, because doctors are simply going to know better.

I get so frustrated with the illusion of the discerning senior with the time, energy, and intellect to competently choose the right medical care for themselves and that such a discerning senior can, through aggregate market forces, drive down costs without driving down quality.  At the very least a centralized government panel won't be driven to decide a course a treatment by considering profit margins.  The same can't be said for private insurance adjusters.

Healthcare - File under "Captain Obvious"

Matt Ygelsias called my attention to this story out of Vermont, where Harvard healthcare economist William Hsiao was hired by the Vermont legislature to find new designs for Vermont's healthcare system.  Hsiao has offered a single-payer system.  Hsiao outlined in the report that, "getting one entity to process claims, reforming medical malpractice and taking other steps would save $2.1 billion in health spending by 2025."  My initial thought was "Well, duh."  I then rolled my eyes and tossed my hair back dismissively.

Healthcare if Different

In the comments section of this blog healthcare has been a much debated topic. Austin Frakt writes why healthcare is different, and why the solution can't simply be increased individual choice.

It's a complex problem and simply "liberating" the market won't work on its own.

Stimulus != War in Iraq

Today, in an article discussing Pres. Obama's legislative success yet "unpopularity," Sheryl Gay Stolberg of the New York Times compares the passage of the stimulus package, comprehensive healthcare reform, and financial regulation to Pres. Bush's taking the United States into an unnecessary war. No, really:

It is an argument that sounds eerily similar to the one Mr. Obama's predecessor, George W. Bush, made to justify an unpopular war in Iraq as he watched his own poll numbers sink lower.

Just because two presidents claim that their unpopular actions are in the best interest of the country does not make the actions themselves equivalent. The war in Iraq was predicated on nonsense. The stimulus package, financial reform, and comprehensive healthcare reform--what ever you think of the policy choices themselves--were reactions to actual problems, actually doing harm to the United States.

Rep. Cantor's Magic Bullet

Much has been made recently of threats and acts of vandalism perpetrated against Democrats that voted for health care reform over the weekend. Those Congressmen and women have spoken up about this intimidation and that his has no place in American politics. That all sounds reasonable enough, except....

House Minority Whip Eric Cantor thinks the Democrats are making too much political hay of these acts. Then he drops the supposed bombshell publicly disclosing, "A bullet was shot through the window of [his] campaign office in Richmond this week." Of course, here's the problem. It doesn't match the facts. From the Richmond Police Department it appears a bullet was fired into the air, fell back toward the earth (as gravity is want to make objects do) and broke through a window pane in the same building that Cantor's office is housed in. It broke the window pain, but not the blinds and it fell at a downward trajectory.

That seems like a gross overstatement on Cantor's part and a false comparison as opposed to lawmakers that have face thrown bricks and cut propane lines.

HCR Passage Popular?

First post-Healthcare Reform Gallup Poll finds 49% of the American people think passage of the Healthcare Reform Bill is a "good thing" compared to 40% of Americans viewing it as a "bad" thing. Democrats are predictably thrilled about its passage while Republicans are just as predictably not thrilled. Independents split basically even.

Process may have been the problem after all.

Monday Round-Up

• Happy Health Care Reform Day. Last night, the House passed both the Senate Health Care Reform Bill and a Reconciliation Bill. Meanwhile, a Thomson Reuters report finds that, despite the Great Recession, Healthcare costs increased last year.
  
• Jane Mayer takes on Marc Thiessen's new book in the New Yorker. We've addressed Thiessen here and here recently.
• The internationally supported Transitional Federal Government reiterated its now stale vow to launch an offensive and take control of Somalia.
• The Times Online reports that Iran is training Afghan Taliban fighters in small unit tactics. If true, this is notable because Iran initially supported US/NATO intervention in Afghanistan.
  

Health Care Reform and the American People

Joel Beneson looks at recent polling and makes a point that I've been hammering away at for some time: the American people are not opposed to Health Care reform and that not passing the bill will damage the Democrats' midterm election prospects.

CBO Marks-Up the Senate Bill

The Congressional Budget Office predicts the Senate Health Care bill will reduce the deficit by $118 billion over 10 years.

Also, you can now follow D.C. Exile on Twitter.

Again with the Doing Stuff

Nate Silver has a good post over at FiveThirtyEight that looks at slight boosts Democrats received after passing the House and Senate versions of Healthcare reform last year. Polling disclaimers aside, I think this goes to a point I was trying to make a couple weeks ago in the comments in a debate with Colin (here and here). It was my contention that Democrats will pay a political price in the autumn for Healthcare reform regardless of whether they pass a bill or not. I further argued that, on balance, getting something done was of greater political value than not getting anything done.

Lucy and the Football

After a day or so of wide-ranging praise for the Lecturer-in-Chief following his performance at the GOP retreat on Friday, the theme driving the news cycle has become one of “engagement.” Headlines like, “Obama Engages,” or “Obama Continues Policy Outreach to GOP” have proliferated. But this is not new.

In fact, Obama’s first year is the story of relentless, futile attempts at bipartisanship. The President has repeatedly reached across the aisle and allowed Republican influence on bills only to see the GOP vote in unison against that bill. The effect of these efforts has been that the President not only ends up with watered-down bill (see, e.g., the Stimulus Package) but he ends up simultaneously throwing away political capital and angering his base. It has been, quite simply, a year of Lucy and the Football.

Yet, there seems to be something different here. Since the State of the Union, and including last week’s Q and A session with the GOP, the President has aggressively communicated his efforts at bipartisanship. Rather than being victimized by his constant, quixotic attempts to invite Republicans into the tent only to have them burn the tent down, he’s put the GOP on its heels. He has made it clear, vocally and repeatedly over the last week, that the door is open to the Republicans, that they can come in, but they’re going to have to compromise. He is doing his very best to convert the Grand Old Party into the Grand Obstructionist Party. For this, I applaud the President.

Rather than castigating himself on the altar of bipartisanship, the President is going to make the Republican Party pay the price, politically, for their nihilism. The President should keep up his vocal, aggressive challenge to the GOP that they participate in government. Good on ye, Mr. President.

Now, go pass Healthcare.

More HC Process versus HC Substance Evidence

From the Massachusetts Special.

Passing the Bill

Colin and I have been going back and forth in comments here. Below is my argument for passage.

The crux of what I'm saying is: Healthcare reform is not unpopular; the healthcare reform process is unpopular. The two are difficult to disaggregate which is part of the reason why I discount the polls that say Healthcare reform is unpopular. Given the wide agreement that the healthcare system in this country is too expensive and broken to a greater or lesser degree, I think that the passing the bill and putting some reform in place may ex post facto render Healthcare reform popular. I may be wrong and, whether it becomes popular will depend on the ability of its proponents to present it convincingly in a popular light, but three things are true today: 1. The healthcare reform process is unpopular; 2. the duration of the healthcare reform process has hurt the Democrats politically; and 3. healthcare reform is necessary. If the Democrats are going to pay a political price regardless of its passage—and they will—then passing something, giving them the opportunity to change the conversation and demonstrate an ability to govern, is the better tactic.

UPDATE: David Plouffe writes in today's Washington Post:

[P]olitically speaking, if we do not pass [healthcare reform], the GOP will continue attacking the plan as if we did anyway, and voters will have no ability to measure its upside. If we do pass it, dozens of protections and benefits take effect this year. Parents won't have to worry their children will be denied coverage just because they have a preexisting condition. Workers won't have to worry that their coverage will be dropped because they get sick. Seniors will feel relief from prescription costs. Only if the plan becomes law will the American people see that all the scary things Sarah Palin and others have predicted -- such as the so-called death panels -- were baseless. We own the bill and the health-care votes. We need to get some of the upside.

Healthcare Reform Comparison

House staffers have put together a handy comparison of the House and Senate bills. You can view it here.

The Republic, Moral Imperatives, and The Golden Rule

Senator Tom Coburn has an illuminating profile in yesterday’s New York Times. I say illuminating because it makes plain his disdain for Congress, his colleagues, and basically anything he doesn’t like. Indeed, the reporter does not address and Sen. Coburn does not provide an explanation for seemingly chronic obstructionism except to imply that someone has to do it.

Beyond stifling the democratic process and abusing the privilege of his position he also makes at least one ridiculous statement. Towards the end of the article, in explanation for his opposition to healthcare reform, he says, “If you look historically, every great republic has died over fiscal issue. That is the biggest moral issue of our time.” If he expounds on this statement the reporter declined to include it. I dare say the reporter couldn’t include any exposition on the statement because it’s patently false as Coburn has framed it.

To my knowledge no republic has gone broke and suddenly died. There have been crises, massive loans, and rescues but not sudden death. Much to the contrary republics have “died” because of the income polarization of the haves and have-nots. Two prime examples include the French Revolution and even, to a lesser degree, the American Revolution. When the wealth of a nation is to consolidated in the upper rungs of the income ladder. When the poor get poorer, and when the government refuses to address this inequity you get revolution. Anyone would be hard pressed to say that one’s level of income has no connection to the level of healthcare they receive. Sen. Coburn would have you think that providing healthcare to the have-nots would lead to the end of our republic, when history teaches us that the exact opposite is true.

Sen. Coburn also calls this the “biggest moral issue of our time.” Now it’s unclear if he means the fiscal issue is the greatest moral issue or if he means the survival of the republic, a survival he falsely sees threatened by healthcare reform, is a great moral issue. What is clear is that for him there is not morality involved as it relates to ensuring basic healthcare to all US citizens. This seems entirely backward to me.

I balk at anyone suggesting the survival of our republic is a moral imperative. It implies a level of hubris regarding out own form of democracy that is dangerous and untethered from the reality of the imperfections in our system. It also assigns a kind of spiritual superiority to our system of government which complicates compromise. Of course, it’s not as if Sen. Coburn spends much time worrying about compromise anyway.

Instead, if one were to bring morality into the healthcare debate, it is the morality spoken of so eloquently by the late Robert F. Kennedy. Our moral imperative is to our fellow man, our fellow citizen. We are obligated by our interconnection as people to do what we can to provide for our neighbor when he or she can not provide for themselves. Why is this a moral imperative? Why in our hyper-capitalist society, built on ferocious individualism should we care for our neighbor? Because there could come a day where any one of us falls on hard times and needs a helping hand. I’m not a tremendously religious person. I don’t attend Bible study every Sunday as Sen. Coburn does, but I remember the golden rule. Treat others as you, yourself would like to be treated. Perhaps if Sen. Coburn heard "no" as much as he said "no" he would be a more humble public servant and more compassionate elected representative of this republic.

re: The President's Healthcare Speech

Bret wrote a good post discussing the impact - or lack thereof - of the President's healthcare speech before he delivered it last week. While it is too early to tell what if any impact that speech has in fact had on the healthcare reform debate in Congress, several polls since the speech have measured a notable bump in the President's approval rating, both generally and for healthcare reform specifically. You can find the most recent poll, conducted by CNN/Opinion Research, here.

UPDATE: Shorter Nate Silver: the American people are confused. (h/t Bret)

Meet Joe Wilson

Representative Joe Wilson (R-S.C.) hails from the 2nd District of South Carolina. Wilson has served the good people of the 2nd District since winning a special election in 2001 following the death of Congressman Floyd Spence.

Rep. Wilson is also the gentleman who interrupted Pres. Obama during his address to a joint session of Congress on September 9, 2009. Mr. Obama, while attempting to dispell the myriad lies - yes, lies - propogated by the likes of Chuck Hagel, Sarah Palin, and the Wall Street Journal, noted that his plan would not provide health insurance to illegal immigrants. Rep. Wilson responded by shouting through the gallery, interrupting the President, "You lie!"

Rep. Wilson's outburst is indefensible. Wilson breached protocol by interrupting the President, shouting in the gallery, and labeling the President a liar. Sen. McCain has already called for Rep. Wilson to apologize. But apology is not sufficient. Even the Republican party, which continues to coddle partisans who adhere to such absurdities as denying President Obama's citizenship, must recognize there is no place for such behavior. The President and the Presidency are deserving of respect, at least as much respect as is shown for their colleagues in the House and the Senate, and in those august chambers.

Rep. Wilson should apologize. He should be shunned by his colleagues. He should be censured by the House.

UPDATE: Bret notes in comments that Wilson's outburst has been described as unprecedented -- I certainly have no living memory of anything like this happening. Former Congressman, now Chief of Staff, Emanuel claims it is unprecedented. Sen. Leahy notes that nothing like Wilson's shouts has occurred in his 35 years in the Senate.

Wilson has released a rather weak and, in my view, insufficient apology. As Scherer says, Rep. Wilson has apologized for the tone rather than the substance, and not at all for the incredible disrespect he showed the Presidency.

Rep. Wilson's website has crashed.

Wilson's Democratic opponent for 2010's website has crashed: RobMillerforCongress.com