We last talked about the Affordable Care Act/Obamacare in July 2013 (great links!), as parts of it were still being rolled out. Three years later all of its major provisions have begun to operate and experts are starting to get an idea of where the law has been successful at achieving its goals and where results have been disappointing and why.
Non-experts like us have a hard time getting any sense of it at all. Obamacare is only dimly-understood by most Americans. The law had to be grafted onto the existing, highly-complex American health care system, so it is very complex. The law’s affects also are nearly invisible to most Americans, largely by design. Complexity and invisibility left a huge opening for clever propagandists to trash the law and attribute every negative development as the beginning of Obamacare’s imminent collapse.
This is a bummer for a lot of reasons, not the least of which is it makes it hard for us to see through the complexity and opacity to draw our own conclusions about the law’s good parts and bad parts (both exist). To help us out a bit, I will start our meeting on Monday evening by reviewing two key contextual points:
- The major problems/shortcomings of the status quo ante health care system that Obamacare was designed to fix; and
- How the ACA was supposed to do that.
Then, we can go one of several ways. We could discuss each major part of Obamacare in turn, such as the state insurance exchanges, the law’s many new consumer protections, and Medicaid expansion. As we talk I can sketch out some of the latest good news/bad news in each area. Or, we could go big picture and explore whether the ACA has succeeded so far at its three big, broad goals: Achieving near-universal health insurance coverage, controlling health care costs, and improving the quality of medical care. Very ambitious goals.
As we talk, I think it is very important for us to do two things that news stories on Obamacare implementation almost never do.
- Look at the entire law – not just some piece of it that has experienced recent good or bad developments; and
- Compare its results to a realistic alternative – either one based on where our health care system was heading before Obamacare or to Republican alternatives (to the extent they even exist – see links).
If you want we can get into GOP alternatives and Hillary’s plans to protect Obamacare’s gains and fix its flaws or expand it. And, yes, there is yet another lawsuit probably heading to the Supreme Court that is aimed at one of the ACA’s major provisions and bringing the whole thing crashing down.
There’s one more thing. The ACA’s shortcomings are particularly tragic, and not just because health care matters so much. Unlike other laws Obamacare cannot be amended at all because Republican lawmakers will not allow it. They want the ACA to collapse so they can “repeal and replace it.” To my knowledge, no major law has ever been held to this standard, expected to work perfectly in its first iteration. Major laws are amended all the time to correct mistakes and adapt to new conditions and unanticipated or even unanticipatable problems. For example, Medicare’s basic fee structure was completely overhauled less than 10 years after its 1965 passage because it wasn’t controlling costs very well, and the program has been modified thousands of times since then.
So, however brilliant or dumb the Affordable Care Act is, we are stuck with it as is. Any insufficiencies in the law (or unexpected adaptation by consumes and businesses) must either be addressed administratively or left to fester, or, if a GOP-controlled Congress is elected, solved or ignored their way.
DISCUSSION QUESTIONS –
- Review: How was Obamacare supposed to solve the major problems in our health care system?
- The Parts: How has implementation of each major moving part of Obamacare gone? What caused any failures and how was implementation of the law adjusted to compensate?
- The Whole: Can we declare overall success or failure (or making good/bad progress) on the 3 major goals of ACA: Helping the uninsured, making HC more affordable, improving quality of care?
- The Divide: Do liberals and conservatives define “success” differently?
- The Future: What’s next in U.S. HC reform?
- Latest GOP lawsuit.
- Dem/HRC plans to fix/expand?
- GOP plans to repeal/replace?
SUGGESTED BACKGROUND READING –
- A tutorial on ABCs of Obamacare.
- NYT in 2014: Yes ACA is working, but with some caveats. Recommended.
- The ACA is succeeding. The evidence keeps piling up. Either.
- It’s doing way more for the poor than expected.
It’s a mixed bag or it’s failing:
- Progress has been mixed. Recommended. The state exchanges are worryingly fragile.
- It has failed (Conservative POV):
The Future –
- Your must-read! In this month’s JAMA Obama himself outlines progress made to date and next steps in HC reform. (I’m sure Donald Trump’s journal of the AMA article will be published shortly.)
- Key point: Liberal and conservative goals for HC reform are fundamentally different (click thru here to access recommended WSJ article).
- GOP alternatives:
NEXT WEEK: Does the “historical Jesus” matter?
Did you know that October is National Disability Employment Awareness Month and that 2015 is the 25th anniversary of the Americans with Disabilities Act? Me neither, when I chose this topic. I picked it, with its specific focus on government spending on the disabled, because the rapid rise in the number of Americans on disability in the last 25 years has made the disabled into another political football to be kicked around. Conservatives point to the increase in spending as evidence of widespread fraud and/or some sort of runaway “entitlement society” mentality. As Paul Krugman said, the disabled have become the new welfare queens. Progressives are outraged, etc.
Yet, it’s a complicated issues. The sharp rise in the number of Americans on federal disability income supports is mostly explainable by benign demographic factors, like an aging population. A lot of the money state and local governments spending on the disabled is intended specifically to reduce society’s burden of caring for them by helping them get an education and a place to live so they can find work and stay employed. But, when you add up all of these costs it is fairly expensive for our society to provide the full range of services that allows disabled Americans to survive and thrive. There may be legitimate issues here.
Which ones should we discuss Monday night? Like last week’s meeting on the transgendered, my first goal is a little education. I’d like us to learn some basic facts on who in America is disabled, why, and what is done for them at public expense. We could then get into how well these programs work and whether more should be done or less. Also, last week’s big budget deal that prevents national debt default (but not, BTW, a govt shutdown, which is still likely) included some reforms to Social Security Disability Insurance. I will briefly explain those changes in my opening.
As always, I expect (and encourage!) us to debate the core philosophical concern at issue: What is our moral responsibility to act as a community to care for the least fortunate among us.
Discussion Questions –
- WHAT: What does it mean to be “disabled?” How do the govt and others define the term? How many Americans are disabled and how and why? What are the trends here?
- GOVT: What assistance with living do disabled Americans need? What government programs exist to provide it? How much does it all cost and who pays for it?
- EFFECTIVENESS: Do these programs/services “work?” Big gaps, wrong focus, vary by state, etc.?
- TOO MUCH? Why have the disabled rolls grown sharply in the last 25 years? Are the reasons innocuous or have these programs turned into a de facto safety net?
- TOO LITTLE? Alternatively, do we spend too little helping the disabled and/or should more be done to support their ability to work?
- ADA: How effective has the Americans with Disabilities Act been? At what cost?
SUGGESTED BACKGROUND READING –
- Basic facts about disabled-Americans. (Note: 1 in 5 have a disability, but most are elderly or working. Only 1 in 20 Americans age 25-64 are too disabled to work.)
- ABCs of the two main federal disability programs: SSDI + SSI. Recommended skim.
- These programs are abused and overused. Conservative news media are really, really outraged about it. Recommended.
- No, they are NOT being abused:
- UPDATE Sunday: I did not mean to imply there are no problems in disability programs. Here is one: Lack of work incentives.
- Are disability programs responsible for the shrinking U.S. labor force?
- Optional since I’ll explain: The big budget deal tweaks SSDI to lower its costs a bit without cutting benefits.
- The ADA at 25:
Next Week: Do we need more or less government regulation of business?
Bruce, our group’s doctor, will take the lead on this topic. (Bruce is a neurologist. CivCon probably needs a psychiatrist, but nobody wants that job.) The topic I had in mind had to do with our – probably – growing problem of prescription drug over-prescribing and abuse. But, Bruce may prefer to take us a variety of directions, such as:
- Pain medications: The recent sharp rise in opioid addiction in the Unt4ed States, related to the widespread prescribing of Oxycodone. The big issue, aside from just reducing addiction, is how to balance the need to treat chronic pain with safety issues.
- Psychiatric drugs: Their alleged overuse by both adults and children.
- Illicit use of prescription drugs by teenagers and children.
- Whether widespread legalization of marijuana would make our addiction problems better or worse.
Below are some articles on these and other “are we an over-medicated society” issues. I will add others that Bruce brings them to my attention. I’ll see everybody on Monday night.
- We’re an overmedicated nation:
- No, we’re not over-medicated as a country:
- We’re both: We’re an under- and over-medicated nation. (Psych Central) Some groups, like poor kids and the elderly are badly over-medicated.
- America’s biggest drug problem is its doctors. Recommended.
- 100 Americans die from an overdose every day. How do we stop it? (WP) Recommended
Next Week: Are Americans Too Deferential to their Military? ?
Oops. I may have used the wrong term in the title of this topic. I meant for us to discuss the Right To Die movement, the movement to pass “assisted suicide” and “physician-assisted suicide” laws. An assisted suicide is just what it sounds like: Suicide with help from another person. In an assisted suicide, someone helps, but the person to be killed administers the instrument of their own death themselves. It becomes euthanasia only when a doctor directly commits the killing. No U.S. state allows for euthanasia.
However, the assisted-suicide movement has become more popular in recent years. We all remember Terri Schiavo, the brain-dead coma patient from 10 years ago that the U.S. Congress tried to interfere with (link below). Since then, five U.S. states and several countries have adopted versions of assisted suicide in cases of terminal illnesses – and, in some cases, when an illness is not terminal. I thought the many ethical and practical issues raised by assisted-suicide would make for a good Civilized Conversation.
I don’t know much about this issue, so my opening remarks will just be a brief framing. I’ll probably just summarize the U.S. state laws and the Dutch and Swiss statutes on assisted suicide and explain what they do and do not allow. Then, I’ll try to make sure that our discussion covers the major moral and medical and political issues surrounding assisted suicide.
DISCUSSION QUESTIONS –
- What are the general pros and cons of assisted suicide and euthanasia?
- Five U.S. states allow assisted suicide, and six other countries allow either it or euthanasia. What do these laws do? What have their effects been? Are their publics happy with the laws?
- Do you support these laws? If so, under what restrictions should they operate? How could any such laws be written so as to address opponents’ religious and moral objections?
- Is lousy end-of-life medical care a part of the problem? How could end-of-life care be improved in the United States?
- ABCs of this issue (some are by pro- or anti-euthanasia groups)
- Pros and cons:
- Supportive of it.
- Opposed to it.
Next Week: The Future of Marriage in the United States.
When does having a strong moral objection to the law allow you to refuse to obey it? Not very often – try it next time you’re stopped for speeding. But, “conscience clauses,” provisions in law that allow people to refuse to obey it if they have a religious objection, have been around for years. This is as we’d expect in a religious country founded on secular governing principles. But, conscience clauses are making a big comeback, thanks to conservatives. GOP-controlled states are stampeding to pass laws that carve out religious objection exceptions to laws concerning contraception access, GLBT equality, and other areas where the religious right is losing the broader culture war argument.
This topic has been in the news a lot lately. Some employers have sued over the Obamacare requirement that their health plans cover contraception. Some religious employers already are exempt from the requirement, but not enough are to please many conservatives. I’ll explain what’s going on. But, just being in the news is not enough to merit being a weekly topic in our group. I think conscience clauses have a bigger importance than just how they relate to Obamacare implementation. I believe that the idea that people should be exempt from some requirements of laws they don’t like is edging towards becoming a core belief of modern conservatism. To me, this idea that some duties of citizenship are kind of, well, voluntary, is a real slippery slope. That’s why I wanted conscience clauses on our schedule.
On Monday, I’ll open by explaining (1) what conscience clauses are and their history; and (2) the latest developments in this area (it’s not just Obamacare). Then, I’d like us to discuss whether today’s conservatives really are trying to redefine the notion of citizens’ responsibilities, or if it’s just the old federalism philosophy being dusted off for an era when they don’t control the national government.
DISCUSSION QUESTIONS –
- What is a conscience clause? What is the history of this legal idea and its justification?
- What is the latest in the fight over conscience clauses? What is causing the renewal of interest in them? Is it just Obamacare and contraception, or is something else going on? Will the courts side with conservatives on this?
- More broadly, do conservatives view the duties of a citizen to obey the law and contribute to the well-being of their fellow citizens differently than do liberals? Are conscience clauses a part of this, or are they just a sui generis thing related to reproductive issues?
- Is there common ground to be found on any of this?
- Wiki “conscious clauses.” The basic idea.
- Conscience clauses have a long and honorable history (e.g., Jehovah’s Witnesses refusing to obey flag saluting laws), quickly summarized here. I recommend.
- The latest on the Obamacare contraception mandate issue:
- State conscience clauses are everywhere these days:
- States have begun to use conscience clauses to restrict the reach of GLBT equality laws.
- Many states (pdf) have them for emergency contraception. An Oklahoma doctor and hospital recently denied a rape victim emergency contraception and a rape kit!
- Virginia and North Dakota may allow private adoption agencies to turn away parents based on sexual orientation or religious and moral beliefs.
- Texas wants to subsidize companies that defy the ACA’s contraception mandate!
- Basic pros and the cons:
Welcome to the heart of the 2012 presidential campaign! Both the Obama and Romney campaigns swear that they want to protect Medicare and the other side wants to gut the program. The one that persuades the public wins the White House (probably).
So, who’s telling the truth and who’s lying? Or, is the truth somewhere in between? One thing that’s not in dispute is that Medicare faces serious financial problems down the road unless real cost-cutting reforms are put in place. (Note: Medicare is NOT “going bankrupt.” That language is highly misleading, as this explains).
Obamacare tried some Medicare cost-cutting measures. These reforms include the famous $716 billion in “cuts” that Republicans keep hammering on. The House Republican (a.k.a., Paul Ryan) budget would have made even more drastic changes, turning Medicare into a voucher to buy private insurance. Romney, always hard to pin down, has embraced a somewhat less drastic plan for Medicare’s future.
On Monday I’ll open with a short lecture on the basics of what we’re talking about here. I’ll quickly explain :
- What Medicare does, how it’s funded, and why it’s going broke;
- How Obamacare will change Medicare; and
- The fundamentally different way(s) that the GOP would reform the program.
Remember – you can hate the Republican proposals all you want to and call them all liars (I think there’s a lot of truth in that). But, at the end of the day, someone has to do something to control Medicare’s cost growth. The question is how to do that in ways that would (a) work, (b) be fair, and (c) attract public support.
DISCUSSION QUESTIONS –
- What does Medicare actually do and how is it funded? Why is the program running out of money?
- Democrats and Republicans seem to have chosen drastically different ways to fix Medicare. What are the two basic approaches and why were they chosen? Is the GOP way just a covert attempt to privatize Medicare? Is the Democrats’ way realistic?
- Obamacare: What changes did Obamacare make to Medicare, especially the $716b in cuts to providers? Why did they do this?
- GOP ideas: How would the Ryan budget have altered Medicare? What is Romney’s plan? Is this privatization? Is it fair?
- What is the evidence that increasing competition in medical care for seniors would be more efficient and lower costs without gutting quality?
- [Newly Added: A 1-pager, what-is-Medicare explanation.]
- A basic guide to both side’s Medicare plans, from a liberal health policy expert. I recommend either this one, or this one (which probably is a little more balanced).
- Simple explanation of the Obamacare $716 billion in “cuts” to Medicare. I recommend.
- Who really plans to raid Medicare? Guess.
- A general comment on how the two sides’ different approaches to reforming Medicare are fundamentally different.
- The Medicare Bind: Why the program is in trouble and how to save it in the long-run. I recommend.
- Why vouchers and other conservative plans to use private markets to lower Medicare costs probably would not save as much money as Republicans claim (by a former OMB director).
I don’t want to spend the entire night debating numbers. What really matters here, IMO, is that Left and Right have a profound philosophical differences on whether government-guaranteed health insurance should even exist! Let’s debate that, too.
The Supreme Court did not rule on Obamacare today, but could do so Thursday or next Monday or the Next. FYI, here’s a good refresher of what’s at stake and how they might decide.
After the decision, I’ll be sure to link to some of the better commentaries I find. This could be one of the most important SCOTUS decisions in history. Not sine the 1930s has the Court struck down a president’s signature accomplishment. The money quote:
If the court does overturn the mandate, it’s going to be hard to know how to react. It’s been more than 75 years since the Supreme Court overturned a piece of legislation as big as ACA, and I can’t think of any example of the court overturning landmark legislation this big based on a principle as flimsy and manufactured as activity vs. inactivity. When the court overturned the NRA in 1935, it was a shock — but it was also a unanimous decision and, despite FDR’s pique, not really a surprising ruling given existing precedent. Overturning ACA would be a whole different kind of game changer. It would mean that the Supreme Court had officially entered an era where they were frankly willing to overturn liberal legislation just because they don’t like it. Pile that on top of Bush v. Gore and Citizens United and you have a Supreme Court that’s pretty explicitly chosen up sides in American electoral politics. This would be, in no uncertain terms, no longer business as usual.
Also, the idea that the Commerce Clause of the Constitution does not allow an individual mandate to buy health insurance was considered a fringe position just a few years ago.