Tuesday, July 15, 2014

Obamacare Works, Period

The other day, Reihan Salam was on Real Time, but didn't manage to air all of his anti-Obamacare tropes before the host switched to a different subject. One he did manage to voice is the suggestion that the 74% of Republicans who like their benefits under their PPACA health insurance policies are wrong. I'm not sure how the logic of that argument works, as they either like their benefits or they don't. Perhaps he means that they're wrong in principle, as they should instead prefer the status quo ante or some unidentified alternative program, but endorsing that position would suggest that Salam doesn't think the program represents good policy even if it provides people with what they assert to be good health insurance coverage.

Salam did suggest that the only reason Obamacare is working is because it is subsidized. In a sense that's true, as it is the subsidies that help create the volume of enrollees necessary to create the large risk pools that allow the program to work, enrolling all applicants without regard to preexisting conditions. But outside of that narrow context, Salam is wrong. As somebody who has purchased a PPACA policy without a subsidy, I can attest that I was able to choose and enjoy a policy that provides coverage superior to anything I was able to purchase as an individual consumer prior to the Act's effective date, and that the price of the policy was reasonable even without a subsidy. The manner in which the PPACA's policies are priced for dependents allowed me to obtain coverage comparable to that which I had previously received through COBRA but at a lower price.

Although the pre-PPACA policy I had purchased to cover the period between the expiration of my COBRA eligibility and January 1, 2014, cost less than my PPACA-compliant policy, it also offered far less. I also didn't have to try to remember years of detailed medical information which the insurance company could use to find pretextual reasons to increase my rates or deny care. I recognize that many Republicans, perhaps including Salam, believe that having inadequate health insurance coverage is a feature, not a bug, forcing people to pay a greater portion or all of the cost of certain basic care, mental health care, addiction treatment and the like, and that the ideal health insurance policy involves a HSA and only catastrophic insurance coverage, I would have a greater appreciation for that argument if an appreciable number of its advocates were willing to walk the walk -- legislate or contract away their own health insurance benefits for the inadequate coverage they wish to foist off on the rest of the country.

Salam suggested that there is inequity in having a multi-tiered health insurance system, with Medicare being less attractive than PPACA plans, which he asserted are less attractive than employer-sponsored plans. It's important to note that I've seen employer-sponsored plans that are far less attractive than most plans available under the PPACA, and the plan I purchased was quite comparable to the employer-sponsored plan I had been continuing through COBRA, so I don't find his argument of inequity between employer-sponsored plans and PPACA plans to be particularly compelling. As for Medicare offering less than private health insurance, I see no evidence that the Republican Party at large views that as a problem that needs to be fixed. A party whose governors have largely chosen to grandstand, harming their states and large numbers of their constituents by refusing to expand Medicaid. Inequities exist, but it's not clear that we should prioritize their elimination over other healthcare reforms, or even that the people want inequities removed as opposed to the establishment of a reasonable minimum for what health insurance plans must offer.

Typical Republican alternatives to the PPACA have involved either throwing everybody into the individual market, with low-coverage catastrophic insurance and HSAs, or a voucher system where (if you qualify) you get a voucher or tax credit with which you are to pay for your insurance and fund your uninsured care. Those proposals bring back some of the worst aspects of the former system, at best foisting those previously deemed uninsurable or who would face staggering insurance costs due to pre-existing conditions into government programs -- after all, why should we expect health insurance companies insure sick people when that cost can be borne by the taxpayer? To the extent that the Republicans attempt to bridge the gap between the Gingrich-style plans and the PPACA, including large risk pools and exchanges, but most notably preventing insurance companies from raising premiums for people with pre-existing conditions, the more necessary it becomes to impose some form of mandate -- and even if you automatically enroll people in insurance while using the voucher or subsidy they left unused, such that you can argue that "It's not a mandate", somebody has to foot the bill.

On the whole, Salam is one of the more honest and thoughtful commentators on the Republican side. I would like to see him address the issue of health care in light of his abilities. We can start with the fact that there is no actual Republican health insurance reform that is being seriously advanced within the party. We can add to that, the fact that reforms that will shake the system are likely to cause people to lose their current insurance, whether that occurs abruptly or as a new policy is phased in. In other words, unless the Republican Party wants to take an enormous political risk that implicates all of its anti-Obamacare rhetoric, we're looking at incremental reforms, not the reinvention of health insurance and the healthcare market. Within that context, what reform ideas would Salam propose that have any chance of getting passed by the Republican majority in the House, let alone becoming law? If the answer is, "None", then he's reinforcing what many, and probably most supporters of the PPACA already acknowledge -- as flawed as the law may be, it's the best law that could get through Congress.

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