Tag Archives: ACA

Fun With Numbers

The Affordable Care Act  maintained existing Medicaid coverage for low income children. Whether or not their parents will have coverage is being left up to the states.
In Indiana, that’s a problem.
As a recent report from the Institute for Working Families explains, right now, Indiana only covers working parents who make up to 24 percent of the poverty line, which comes to $4,581 a year for a family of three. The Medicaid expansion provision in the Act encourages coverage for these low income adults by expanding Medicaid to 133 percent of the poverty line ($25,390 for a family of three).  According to a recent study by the non-partisan Kaiser Commission on Medicaid and the Uninsured–a study which is consistent with Congressional Budget Office’s estimates– 215,803 previously uninsured Hoosiers would have access to care by 2019–if Indiana implements that provision of the Act.
And why wouldn’t we?  The Act provides 100 percent federal funding for the expansion of Medicaid for its first three years, phasing down after that to 90 percent federal funding by 2019.  According to the same study by Kaiser, this will cost Indiana $478 million from 2014-2019 (an average of $79 million each fiscal year).
Interestingly, in a study commissioned by the State of Indiana, the estimated cost (2.58 billion) is approximately 5 times greater than the cost shown by the non-partisan Kaiser study (478 million).
What the Indiana study evidently ignores are the savings involved: Medicaid expansion would save the state substantial amounts we now pay for uncompensated care for the uninsured. We pay those costs two ways: through our tax dollars, and through higher premiums charged to those who are insured. (In fact, according to Kaiser, during the 2014-2020 time period, each insured Hoosier will otherwise pay over $2000 to subsidize the uninsured.)
Let’s try an analogy: let’s say you’ve been taking a bus to work, and you and a couple of friends buy a car. Your share of the car expenses will be 150. a month. The cost to you will thus be 150 per month minus the 40 bucks a month you’ve been spending on the bus. This is a concept called net cost. 
If the state refuses to expand Medicaid, people with incomes between 100 percent and 400 percent of the poverty line will be eligible for subsidies to help them afford coverage in the new health insurance exchanges.  But people below the poverty line won’t receive coverage at all, since the Affordable Care Act assumes they’re covered by Medicaid.
That seems deeply unfair–even immoral.
My question is: why is depriving these people of coverage so important a goal that the Daniels Administration is willing to issue a deceptive analysis of the costs involved?
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It’s a Penalty! It’s a Tax! It’s Unprecedented!

I have been bemused–and occasionally amused–by all the posturing over the provision in the Affordable Care Act requiring people to purchase health insurance.

How dare they!!

If you listen to the right-wing blogs and talking heads, you’ll come away believing that such a mandate is unprecedented. The government has never required us to do something, or penalized us for failing to do something.It’s unAmerican to penalize inaction. That evil Obama  is introducing an entirely foreign element into American law. (The fact that Romney did exactly the same thing in Massachusetts is obviously different….)

Of course, this line of attack is entirely fanciful.

As a legal scholar recently noted, the very same week it upheld the ACA, the Supreme Court affirmed a law requiring sex offenders to register their whereabouts, employment and appearance with local authorities. If they fail to do so, the law in question imposes a penalty of ten years in prison–a bit more draconian than the ACA’s fine. The Court made it clear that this mandatory registration was not punishment for a crime –the individuals subject to the requirement have already paid their debt to society for those transgressions (a contrary construction would run afoul of the Ex Post Facto prohibition).

Courts upholding this particular type of mandate–and there have been several–have explicitly said that the only conduct being punished was the “inactivity” of failing to register.

There are many other examples–so many that a Professor at John Marshall Law School has actually written an essay on “The Incredible Ordinariness of Federal Penalties for Inactivity.”

As I have repeatedly noted, there is nothing wrong with faulting provisions of this particular approach to healthcare reform. What I find absolutely astonishing, however, are the  logical contortions opponents will go through in order to attack the legitimacy of any attempt to  extend access to healthcare. I have been absolutely stunned by opponents’ self-righteous denunciations of such efforts, and by their evident willingness to simply let the uninsured suffer and die.

A recent editorial in the Journal of the American Medical Association is worth quoting.

That editorial began “Physicians and hospitals have a moral duty to provide acute care and emergency care to those who need it.” Proceeding from that expressly moral premise, the editorial concluded that individuals “have an enforceable moral duty to buy sufficient health insurance to cover the costs of acute and emergency care…requiring individuals to buy health insurance is consistent with respect for  individual liberty because individuals have a duty to mitigate the burdens they impose on others.”

We don’t talk much about the morality of policy. We should.

Yesterday, every single House Republican voted to take away health coverage for young adults staying on their family plans, raise prescription drug prices for seniors, end protections for those with pre-existing conditions, reinstate lifetime insurance caps, scrap tax breaks for small businesses, raise the deficit, and take benefits away from 30 million Americans. Pundits reporting the vote generally noted that it was one of a series of such votes, and that it stood no chance of ultimate passage. They spent a lot of time analyzing the politics of the GOPs message and speculating on its electoral effect.

To the best of my knowledge, none of them pointed out how utterly immoral it was.

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Absence of Trust

In the wake of the Supreme Court’s decision to uphold the Affordable Care Act, I was once again reminded of how painful it has become to watch what passes for political discussion/debate in this country.

We have always had disputes about policy, about the proper role of government and the reach of the federal courts. We always will have those disagreements, and that’s how it should be. What is qualitatively different about our current discourse is the degree of suspicion and paranoia that characterizes it.  Americans simply do not trust the motives of those in government, and as a result of that distrust, we are unwilling to grant that honorable people of good will can come to different conclusions about the problems we face.

In Distrust, American Style, I investigated the sources and consequences of that distrust. The sources were easy enough to identify: for the past two decades, we’ve seen massive betrayals by businesses and Wall Street, scandals in institutions ranging from churches to major league sports, obscene amounts of money being spent on lobbying for legal advantage and more recently, poured into Super Pacs. There are undeniable reasons for our current levels of cynicism and distrust.

The problem is, when citizens don’t know who they can trust, they don’t trust anyone, and politics becomes impossible.

Yes, there are bad corporate actors–but there are also scores of good corporate citizens. Yes, there are politicians who are “on the take” and/or beholden to those who finance their campaigns, but there are also many, many good public servants who genuinely are trying to do the right thing. Yes, there are judges whose ideology drives their decision-making, but there are many more who divorce their policy preferences from their responsibility to faithfully apply the law.

Wholesale distrust makes for toxic politics.

It is one thing to disagree with President Obama’s priorities and policies–quite another to suggest, as “commentators” on Fox News and others regularly do, that he is a Kenyan Muslim Socialist who wants to destroy the United States. It’s one thing to disagree with Senator Lugar, quite another to suggest that his ability to work with Democrats on national security issues makes him unfit to hold office. You may disagree with the Court’s analysis of the healthcare law (although very few people seem to know enough about the actual law to form a reasoned opinion), but to suggest that Chief Justice Roberts is a “traitor” or (more bizarrely) that his opinion was flawed because he takes epilepsy medication is to embrace paranoia.

We have reached such levels of derangement that we no longer believe anything we don’t want to believe–and thanks to technology, we can choose to inhabit media environments that reinforce our most unhinged conspiracy theories.

We don’t trust the “lame stream” media (or what is left of it). We don’t trust businesses or unions. We don’t trust the courts. We don’t trust the President, Congress or the Supreme Court. Increasingly, we don’t trust each other.

This is no way to run a country.

It won’t be easy, but rational people need to insist on measures that will make our governing institutions trustworthy again–beginning with more transparency and more control of money in politics. If we can restore a measure of basic trust in the good will of those we elect, perhaps we can begin to calm the crazy and actually talk to each other again.

Failing that, maybe Prozac in the water supply??

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