Thursday, March 09, 2017

The debate over Obamacare is not a debate over economics, its really about ideology

The GOP has finally released their bill to overhaul Obamacare. Though some key elements of Obamacare will remain, it is clear that the GOP is uncertain just how to undo Obamacare without facing serious political repercussions in the 2018 mid-terms. Given the onslaught of legislative initiatives working through Congress now, it would seem to me that Republicans in Congress now have enough rope to do themselves in for the next midterm election.

The American Health Care Act, as introduced by Republicans in Congress, is the bill that the GOP has been working on for weeks behind closed doors. The key features of the bill show that allowing parents to keep their kids on the plan until age 26, banning discrimination based on pre-existing conditions, and even the Medicaid expansion will survive for now. The bill has serious changes for much later baked into it so that the current Congress has a chance to survive the midterms. That's cute.

At the Washington Post, they've noticed that opposition to the bill is fairly universal from the industry the bill purports to regulate. Organizations representing doctors, hospitals and even insurers have expressed surprise at the contents of the bill mostly because they were not invited to offer input on the bill. Afraid of offending their donors and their voters, Republicans in Congress seem to be mum about their true objectives, even in this bill.

Economist Dean Baker suggests that the GOP Congress will top 50 million uninsured once this bill becomes law. Here is one very interesting observation Baker makes about how people use Medicaid:
For example, the plan leaves in place the expansion of Medicaid through 2020. This should be long enough so that most currently serving Republican governors will not have to deal with the effect of the elimination of this provision. After 2020 people benefiting from the expansion will be allowed to remain on Medicaid, but new people will not be added. Since people tend to shift on and off Medicaid (something rarely understood by reporters who cover the ACA), after two or three years the vast majority of the people who benefited from the expansion will no longer be getting Medicaid. By 2025, the impact of the expansion on the number of the uninsured will be trivial.
This is something I did not know: people go on and off Medicaid. Once enrollment is frozen for Medicaid, the people who were on it once, will find that they cannot return after 2020. Great for Republicans in elected office who are already set with gold-plated insurance, bad for people who need the help.

Numerous critics have requested a scoring of the bill by the Congressional Budget Office (CBO) for the reason that no one knows the true cost of the bill. This is interesting considering that many Republicans claim to be fiscally conservative. Why wouldn't they wait to find out? Perhaps their objective is not the repeal of Obamacare. Their objective is repeal of the taxes imposed by Obamacare that would result in a nice, tidy windfall for the wealthiest of Americans who run very large businesses, but can't wait to externalize the cost of health care for their employees.

I suggest here, that the debate over Obamacare, and health care in general is not about economics. It's about ideology. Conservative rhetoric maintains that people should be responsible for their own health. In a perfect world, that might be true, but this world is far from perfect, at least with humans in it. What conservative talking points miss is that business does the majority of the polluting, while funneling most of the income generated by the business to the top 1%. 

Business creates pollution. Ordinary people minding their own affairs do not even come close to the effluvia created by business. Business sells things that pollute and people buy them. From plastic doo-dads of all manner, shapes and sizes, to electronics that need to be properly recycled, to vehicles that spew CO2 and particulate matter into the air for us to breathe, to oil spills, and coal ash spills.

All of that pollution has an effect on the health of the people who use products and services created by the very businesses that seek to escape the costs that businesses can impose on everyone else. This is the argument missing from the debate. There are a few more arguments missing, too. Like how doctors have engineered a shortage of doctors to prop up their incomes relative to everyone else. Or how drug patents now cost Americans roughly $360 billion a year. Or how lawyers game the courts with torts to increase the cost of protection for doctors.

The entire game is about shifting costs from one party to another. This is how they keep us divided. This is what the GOP plan to replace Obamacare is about. It's time to bring everyone together, into a system that keeps everyone in, everyone covered, and lets nobody out. After all, we're stronger together, right?

Enter now, the bill now in Congress that is nowhere to be seen in the news, H.R.676 - Expanded and Improved Medicare For All Act. This is a universal health care act. This requires everyone to pay in and everyone to be covered. Based on my reading so far, there is very little way that I can see, for any single group to externalize or shift the costs of health care onto another. Here is the bill summary:
This bill establishes the Medicare for All Program to provide all individuals residing in the United States and U.S. territories with free health care that includes all medically necessary care, such as primary care and prevention, dietary and nutritional therapies, prescription drugs, emergency care, long-term care, mental health services, dental services, and vision care.
Only public or nonprofit institutions may participate. Nonprofit health maintenance organizations (HMOs) that deliver care in their own facilities may participate.
Patients may choose from participating physicians and institutions.
Health insurers may not sell health insurance that duplicates the benefits provided under this bill. Insurers may sell benefits that are not medically necessary, such as cosmetic surgery benefits.
The bill sets forth methods to pay institutional providers and health professionals for services. Financial incentives between HMOs and physicians based on utilization are prohibited.
The program is funded: (1) from existing sources of government revenues for health care, (2) by increasing personal income taxes on the top 5% of income earners, (3) by instituting a progressive excise tax on payroll and self-employment income, (4) by instituting a tax on unearned income, and (5) by instituting a tax on stock and bond transactions. Amounts that would have been appropriated for federal public health care programs, including Medicare, Medicaid, and the Children's Health Insurance Program (CHIP), are transferred and appropriated to carry out this bill.
The program must give employment transition benefits and first priority in retraining and job placement to individuals whose jobs are eliminated due to reduced clerical and administrative work under this bill.
The Department of Health and Human Services must create a confidential electronic patient record system.
The bill establishes a National Board of Universal Quality and Access to provide advice on quality, access, and affordability.
The Indian Health Service must be integrated into the program after five years. Congress must evaluate the continued independence of Department of Veterans Affairs health programs. (emphasis mine, text of bill here
Note that private insurance is effectively cut out of the basic health insurance business. An enormous, confusing bureaucracy of multiple private insurance companies will be replaced by one federal agency, with one neck to grab in November. No one gets out from paying the taxes to support the program, which means that there can be no cost shifting for profits. Increase the burden on party at the risk of increasing the burden for all, and anyone who tries to do that will be found and made known.

Taxes are imposed at numerous sources, including securities transactions like the sale of stocks and bonds. That means those with lofty incomes who engage in high frequency trading might have to do something more productive with their time and computers. Everyone pays in for their mutual benefit.

I note with interest that Bernie Sanders is not a cosponsor of the bill. I wonder if he has an opinion of it. In 2011, Sanders introduced a similar bill, but the Physicians for a Single Payer Plan liked HR 676 better.

This is our moment. HR 676 is a far better plan and does not set one generation or even one faction against another as the Republican plan does. If everyone pays in, the costs are nominal for all. Under the current system and worse, with the GOP plan as proposed, burdens are shifted and concentrated on the people who are least able to afford it.

So let your Congressperson know that you know about HR 676. Let those who oppose HR 676 explain why the people should not be united in the pursuit of quality health care that is already enjoyed by every other industrialized country, as a right. We have an alternative to the GOP plan. Let's talk about that.
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