Iowa's physician shortage

 

Zach Kucharski of the Gazette introduces the panel

Iowa is last in the nation in obstetricians per capita, which is felt most acutely in rural areas where fewer hospitals are offering obstetrics or even pediatric services. Iowa is also third-lowest in the US in retention of physicians. Those are only two data points in an overall shortage of physicians in the Hawkeye State, which was the subject of the latest Gazette Business Breakfast earlier this week. 

Two days later, Iowa earned the infamous distinction of being the first state in the U.S. to shrink its civil rights ordinance by removing gender identity from protection. The action was justified by the legislature's earlier attempts at punishing transgendered people being struck down by the courts as running afoul of this ordinance. Without the pesky civil rights ordinance, our government is free to take whatever potshots at transgendered people that it feels like taking. What an expression of our state's official hostility to difference!

At first glance, these are two different topics. Is it possible, though, that they are connected?

Unity Point Medical District, where your humble blogger gets his doctorin'
(Google Earth screenshot)

At the Gazette event, panelists Dr. Fadi Yacoub (Linn County Medical Society), Dr. Timothy Quinn (Mercy Medical Center), and Dr. Dustin Arnold (Unity Point Health) were interviewed by the Gazette's Zach Kucharski. They referenced two main strategies for improving Iowa's physician retention: improving the doctors' bottom lines, and incentives for Iowa students to do their medical education in Iowa.

Despite Iowa's reputation for low cost of living, Quinn noted physician salaries are not keeping up with increasing levels of medical school debt, and insurance payments relative to cost of living are are comparatively low. Arnold suggested the state should see positive effects of "tort reform," which means the legislature has capped damages for medical malpractice suits. Current legislation (HSB 191) before the Iowa legislature would offer student loan repayment programs for rural doctors, and commission a study of the effects of cutting medical school from four years to three (cf. Murphy and Barton 2025). On the other hand, would-be budget cutters in Washington are looking at Medicaid, which is "essential to medical care in Iowa" (Quinn's phrase) due to the directed payment program.

The legislature is also hoping to improve retention by keeping Iowa residents in the state, creating preferences in medical school admissions. (The University of Iowa, though, is 78 percent Iowan, already near the 80 percent target for schools.) The thought is that people who are close to family and already appreciate the wonders of Iowa will want to stay here. "We don't have pro sports, we don't have concerts, but" Iowa is a state you love, said Yacoub, noting he was "preaching to the choir here." Arnold of Unity Point added Cedar Rapids is a great place to live, "once you're here you want to stay." This may or may not be true, given the state's (not the city's) regressive political culture, but even if we retain 90 percent of Iowa-based doctors the gap between working age doctors and our aging population will continue to increase.

When we take on faith that Iowa is so great you could confuse it with heaven ("Field of Dreams" reference), it precludes serious discussion of our future. When we take on faith that the most important considerations are low taxes, we miss the thousand things that make for quality of life (some of which are paid for with taxes). I'm an urbanist, not a physician, and tend to see things through an urbanist lens. As such I'm probably missing important dimensions of this specific problem. But we want more physicians to move here, so we need to think about how to make it an attractive place, which means attractive for everybody.

Iowa's physician shortage exists in a national context. Quinn noted at the start medical schools nationwide have not kept up with demand, so the whole country must rely on immigration to make up the gap. (Yacoub, who came to the United States in 1989, is one example.) Later he noted the shortage of doctors extends to nurses and support staff as well. 

But it also exists amidst a sociopolitical context in our state that is becoming increasingly hostile to difference. As Richard Florida noted two decades ago, it is openness, not turning inward, that welcomes a variety of people with varieties of talents. Iowa, except for a few larger counties, is shedding population like no one's business. We have managed to combine the worst of northern weather and southern politics: Our policies and public statements are openly hostile to poor people, immigrants, the transgendered, and city dwellers, just for starters. What message does that send to anyone else who might be or feel a little different? 

The physician shortage is making working conditions for current physicians worse. As scheduling gets tighter, there is less space in a physician's life for continuing education or even lunch. I wonder how else working in Iowa might affect a physician's desire to be here? No one mentioned COVID at all, but I remember patients stacking up at hospital emergency rooms at the same time (early 2021) Governor Kim Reynolds was declaring the pandemic over. Evidence of the negative health effects of data centers (Criddle and Stacey 2025) and corn sweeteners is accumulating, but they are the darlings of our economic plans. Meanwhile, Iowa has the fastest-growing cancer rate in the country. It can't be easy to practice medicine in an environment that consistently chooses corporate bottom lines over public health, and hostility to vulnerable minorities over building prosperous and inclusive communities.

I can't say with any precision whether Iowa's official penchant for nostalgia and resentment is exacerbating our shortage of physicians. Some early-career physicians may prefer the Politics of Yesterday, while others may be indifferent. But overall it is unlikely to lure the talent we need.

SEE ALSO: "Iowa: You're on the Menu," 9 May 2023

What should be in the next CARES Act?

Some bars and restaurants have remained takeout-only,
despite the Iowa government's laissez-faire attitude towards the pandemic

None too soon, the U.S. Senate is taking up renewal of the CARES Act this week. Emergency relief for individuals, businesses, state and local governments, and hospitals was passed in March as the reality of the coronavirus pandemic hit America. (See highlights and details here and here.) It's hard to remember March, but it seemed then that the pandemic's unusual virulence required a drastic social shutdown, and that to keep the economy from tanking during the emergency. Paul Krugman compared the response to a "medically-induced coma" to create space for dealing with the virus. To get the patient (all of us!) through, the CARES Act pumped $2 trillion into the economy, and additional legislation added about another half trillion (Amadeo 2020). That's a lot of money... I can remember when one of President Jimmy Carter's budgets in the late 1970s was the first to pass the half trillion mark for the entire year!

Now we're heading into late July. Partial reopenings in May and June brought some flickers of economic life, but only somewhat, and the pandemic continues. Retail sales are back to pre-pandemic levels, but not across the board and unemployment remains high (Maheshwari, Corkery and Schwartz 2020; Rosenberg 2020). "I'm less optimistic today than I was 30 days ago," Marriott chief executive Arne Sorenson told The New York Times. "The virus is in so many different markets of the United States" (Gelles 2020). So, now what do we do?

The coffeehouse across the street from my campus closed March 20,
and now folks are carrying off the pieces.
(It might have gone out of business anyway.)

House Democrats passed a $3 trillion extension to the CARES Act in May called the Heroes Act, extending unemployment benefits at current levels, issuing another round of stimulus checks, providing much more aid (about $1 trillion) to states and cities, and including money for hazard pay for essential worker, testing and tracing, student loan forgiveness, food stamps, housing support, the U.S. Postal Service, and an employee retention tax credit (Werner 2020). Senate Republicans are negotiating this week with President Trump on a roughly $1 trillion alternative likely to include, liability protections for businesses, another round of stimulus checks, school aid conditioned on opening in person, much less aid to states and cities, extended unemployment benefits at a lower level, tax credits to businesses for adaptive measures as well as employee retention, and quite possibly no money at all for additional testing. Trump's desire for a payroll tax cut now seems unlikely to be included (Werner, Kim and Stein 2020; Carney 2020; Pethokoukis 2020). Among other proposals, Democratic Senator and former presidential candidate Elizabeth Warren has suggested support for child care providers, and Black and Latino neighborhoods, along with a national eviction moratorium and anti-corruption provisions (Warren 2020).

What happens to rental housing if renters can't pay?

Back in the day, I worked with Paul J. Quirk of the University of British Columbia on research on the Presidency and Congress using theories of conflict resolution. Paul argued that policy makers ought to maximize joint gains by identifying complementary interests--goals shared by parties to the conflict--and negotiating the remaining conflicting interests. Joint gains solutions are superior to split-the-difference styles of compromise, or to stalemate (Quirk 1989, Pruitt and Warr 2013, Fisher Ury and Patton 2011, Lewicki Barry and Saunders 2020).

Off the top of my head I'd say there are four complementary interests involved in negotiating CARES bills, pretty much the same now as in March:

1. sustain the economy. The economic health of the country is risked by any shutdown, or even specific restrictions or regulations. Production and sales should be preserved as close to ready-to-go until it's safe actually to go. And, while emergencies call for bold measures, government finances should not be so extended by borrowing that normal operations are impossible once the emergency ends.
2. protect public health. It should be clear to all by now that this virus is serious business, and neither wishing it away or yelling at people is going to work. Social activities need to be restricted until some modicum of safety is achieved, even at some (a lot of?) economic cost.
3. enable essential work and schools. Any vital work should be facilitated and, where necessary, protected. This particularly includes, but is not restricted to, those who provide health care, food, and public safety.
4. protect/sustain the most vulnerable. Not everyone can work from home, or have a reservoir of savings to see them through the emergency. If people's work is essential, they need the rest of us not to endanger their health; and if people are laid off, their jobs should be there when it's safe to return, and they should be sustained until then.

There are also conflicting interests. These include ideological conflicts (does aid create a disincentive to work, and is that bad? should we use aid to shape a more climate-friendly future?), economic interest conflicts (do hog farms, airline companies, e.g. qualify for aid under one or more of the criteria above?), and political conflicts (how will these measures affect candidates' political prospects in November?). Generally, the group that wants a solution more has to give more on conflicting interests. For example, in 1991-92 President George H.W. Bush stood to suffer politically from a poor economy (and he did), so had to accommodate congressional Democratic demands for tax increases. It's more difficult to assess the current situation: President Trump's political standing has suffered since March, but even so Democrats may be more concerned than Republicans about who might get cut off from assistance.

These lists of complementary and conflicting interests are pretty much the same now as they were in March. But the context has dramatically changed. Unlike March when a lot of us were thinking in terms of 3-6 weeks of shutdown, it is now four months on and obvious that the pandemic is going to be with us for quite awhile yet. Policies that were successful in other countries--contract tracing, widespread timely testing, and plenteous personal protective equipment (PPE)--are nearly impossible to implement effectively with the disease so widespread. There have been hopeful noises about vaccine(s) in production, but even under a best-case scenario that remains months away. Demagoguery by a frustrated President and his allies in the media have led many people to reject even the most minimal precautions.

Swiped from diazhub.com. Used without permission.

So it's not now practicable to resume normal economic and social activity, nor is it now practicable to shut the economy and society down for the duration of the pandemic. We've had a half-assed shutdown that's made people poor and still potentially contagious.

America, I am... really disappointed in you.

To the content of the bill! Setting priorities involves making choices, deciding who in these desperate times gets benefits, and who doesn't in spite of hardship. It amounts to "picking winners," about which there is justifiable cultural ambivalence. And yet choose we must, in a world where the invisible hand is infected with coronavirus, and government has resources that are substantial (so it has responsibility to act) but not limitless (so it can't fix everything).

In the immediate crisis in which we found ourselves in March, it probably made sense to think only of getting through it, and to shovel money out the door while making as few choices as possible. It probably had some good effects, but clearly was marred by lack of oversight, and the greater ability of those with power to access the resources, leaving the most vulnerable citizens and businesses in the lurch. 

Now we seem to be in it--the pandemic crisis, I mean--for the long haul, so it behooves us to think more carefully about the choices involved in the next round of aid. Who should receive assistance? There are many people who could claim economic losses from the pandemic and the shutdown. We could put them into three categories:

• those who, if they were to lose their job, might bring down the whole society (health care workers, teachers, child care, firefighters, public transit at least in major cities e.g.)
• those who, if they were to lose their job, would have difficulty replacing that income (blue collar and service workers, locally-owned small businesses)
• those who, if they were to lose their job, could hold out until they find another (white collar workers, corporate CEOs)

These are just examples, but my point is the decision-making should resist putting people, however well-connected or sympathetic, into higher categories than where they truly belong. It may be that we can afford to compensate everyone for lost income, but we probably can't, so we should prioritize by need.

Besides assistance to affected individuals, businesses, and governments, there needs to be considerable investment in pandemic mitigation like testing and contact tracing. I don't know how much, but it needs to be enough to change the situation on the ground and move us towards the end of this.

What's the future of the Postal Service?

Finally and most uncomfortably, we're now operating in a time frame where we need to think about the long-term impacts of COVID assistance. Can we still imagine that we are going to put things back the way they were, or are we thinking about what society will look like after the emergency? For one example, Joseph W. Kane of the Brookings Institution argues that resources need to be directed towards making America more resilient to climate change, because state and local governments will be facing increasing incidence of disasters with depleted financial cupboards. He calls, among other things, for small-scale green infrastructure projects, attention to income- and race-based equity, and greater community engagement in planning (Kane 2020; see also Bliss 2020). At the same time, President Trump seems to see the crisis as an opportunity to reshape Social Security and the Postal Service. Should emergency assistance during the pandemic aid be constructed to reform the public welfare system (Rachidi 2020)? As Holy Mountain is all about working towards inclusive, sustainable, prosperous communities, thoughts about the CARES Act inevitably turn to the sorts of outcomes that would help bring them about.

I've avoided specifics on provisions and amounts; what I'm finding, which should make us somewhat sympathetic towards the politicians who must make these decisions, is there's not a firm standard by which to evaluate the competing claims. But these are some principles that can be used to evaluate whatever comes out of the Senate this week, and the Congress as soon as possible after that. Maybe each party could take a billion, with a third billion devoted to pandemic mitigation? Negotiations being what they are, we should expect some flaws and some unhappiness, but I hope there will be some progress towards a common future.

PRINT SOURCES

Fisher, Roger; William Ury; and Bruce Patton. 2011. Getting to Yes: Negotiating Agreement Without Giving In. New York: Penguin, 3rd ed.

Lewicki, Roy J.; Bruce Barry; and David M. Saunders.  2020. Negotiation. Boston: McGraw-Hill Education, 8th ed.

Pruitt, Dean G., and Peter Warr. 2013. Negotiation Behavior. Burlington: Elsevier Science.

Quirk, Paul J.  1989. “The Cooperative Resolution of Policy Conflict.” American Political Science Review 83:3 (September 1989):  905-921.

Visualization by Gabriel Heller:

Why other people's health care matters

Unity Point Health-St. Luke's Hospital, Cedar Rapids
(Source: unitypoint.org)

This week's report from the U.S. Census Bureau showing the percentage of Americans without health insurance increased in 2018 shows that this issue is not going away any time soon (Casselman et al). The increase is the first since the economic recovery began, and the first under the Affordable Care Act of 2010. It occurred despite a decline in the poverty rate and sustained good economic indicators. When the economy flags, health care could become a real mess.

If the extent of health coverage has indeed peaked, it may indicate that President Donald J. Trump is successfully mismanaging the ACA to death, as he threatened to do in 2017. The administration has urged states to crack down on eligibility for Medicaid, which seems to be the biggest factor in the recent decline; it has also threatened immigrants their status would be affected by receiving Medicaid benefits, stopped enforcing the individual mandate, eliminated subsidies for insurance purchases, and stopped publicity and assistance efforts (Casselman et al).

James Morone's culture-centered review of seven decades of health care policy making, published in 2014, shows amidst the technical complexity and interest group influence there have been two strong themes throughout this time (2014: 172-173). Both themes have deep roots in American political culture. One is support for social insurance, the idea that all members of a community deserve a certain level of the stuff necessary for life. From Obama's second inaugural address: We are true to our creed when a little girl born into the bleakest poverty knows that she has the same chance to succeed as anybody else, because she is an American, she is free, and she is equal, not just in the eyes of God but also in our own (quoted at Morone 2014: 187).

The other is aversion to socialism, including what the American Medical Association's public relations firm began calling "socialized medicine" back in the mid-1940s. We are a nation of individuals who believe success (or failure) should depend on our own efforts, and that such success as we are able to attain should not be redistributed away from us by the government to someone whose efforts were insufficient to achieve the same good outcome. As Justice Antonin Scalia said during oral argument in the 2012 case, The federal government is... supposed to be a government of limited powers.... What is left? If the government can do this, what else can it not do?

Put that way, there's no escaping the value choice inherent in health care policy. My previous posts on health care, in 2013 and 2017, while allowing that responsible people could disagree, generally defined the problem as a case of fixable market failure. Morone (2014: 181-184) faults former President Barack Obama for an early focus on technical solutions that lost sight of the values underlying his policy effort.

So, let's talk values. To start with, I've already made explicit my communitarian values on this blog. From the start, I've argued that the problems of the 21st century--economic opportunity, environmental sustainability, social inclusion, and governmental finance foremost among them--point us to a shared destiny. We are a community, and the bell "tolls for thee," whether we like it or not. This has put me on the liberal side of today's American politics, despite my preference for non-partisanship. There's a lot to be said for markets and individualism, but I also believe our most serious common problems require collective solutions. Access to health care is one such problem.

Beyond that, I am a person of faith, at least nominally Christian, depending on your definition. I worship in the Christian tradition, at any rate, and find one particular aspect of Christianity distinctively compelling: the emphasis on redemption. No one, in Christian teaching, is ever so far gone that they can't recover. In fact, apparently nothing gets God off the couch to do the end zone dance of joy like recovering an individual thought to be lost. What do you think? Jesus asked his disciples. If a shepherd has a hundred sheep, and one of them has gone astray, does he not leave the ninety-nine on the mountains and go in search of the one that went astray? And if he finds it, truly I tell you, he rejoices over it more than the ninety-nine that never went astray (Matthew 18:12-13, NRSV).

Children's book version, from Concordia Publishing House

Of course, this story, along with the Good Samaritan and the lost coin and other examples, probably refers to spiritual rather than physical redemption, but as much healing as Jesus did during his lifetime, you'd think the logic could be extended. Sure, we are responsible for our own lives, whatever the hand we're dealt, as well as the consequences our actions have. But it must also be that no one should be allowed to fall so far as to be unrecoverable.

And that's what lack of health insurance--as well as its more obscure relative, underinsurance--do. People live precarious lives, getting sick more and longer, working and earning less, dying sooner, always one event away from financial ruin. This is one area of life where we have to have each other's collective backs, regardless of individual assessments of merit.

This is not to say the Affordable Care Act, even with needed revisions and better implementation, is the only answer to this need, nor is Medicare for All. By all means let's talk about a variety of approaches. That means engaging with the conversation in a serious way that looks for solutions, not ad hominem yipping about "socialism."

And it's even possible that heaven rejoices more over someone who is able to get health care they couldn't otherwise afford than they do over 99 healthy people, even if those people always eat right and exercise.

SOURCES

Ben Casselman, Margot Sanger-Katz, and Jeanna Smialek, "Share of Americans With Health Insurance Declined in 2018," New York Times, 11 September 2018, A1

James Morone, The Devils We Know: Us and Them in America's Raucous Political Culture (Kansas, 2014)

Things have changed

HHS secretary Alex Azar speaks at the American Enterprise Institute

"We've learned from mistakes" is a common theme in recent policy presentations around Washington dealing with long-standing public problems. The solutions offered seem familiar as well, though possibly "Versions 2.0" that address earlier policy failures.

Government should make public policy where problems persist due to market failures i.e. where the private actions of buyers and sellers don't resolve some widespread public need. (Frustratingly, there is no metric for when the market fails. It's a matter of perception. One way of distinguishing conservatives from liberals is where and how often they perceive market failures.) Health care's market failure occurs because consumers lack information about price and quality they need to make informed decisions, because health insurance policies usually mean consumers aren't price-sensitive anyway, and because the traditional fee-for-service model creates incentives for providers to over-treat patients. Infrastructure's market failure occurs because while roads, bridges, sewer pipes and such are excludable in theory, in practice everyone gets to use them so generating profits is impossible. Basic research's market failure occurs because, as Maria Zuber of the National Science Board pointed out at the Bipartisan Policy Council last week, the payoffs are uncertain and occur in the very long term at a time when corporate shareholders have come to expect returns quarterly.

Governments, however, are not always effective in filling the breach when markets fail. Freed from the need to make a profit, political institutions must nevertheless be responsive to the public, or at least to the attentive portion of it. Moreover, without market price signals, it is difficult for governments accurately to perceive returns-on-investment, particularly when officeholders are feeling pressure from the public. No government in the world is flush enough to provide everyone with everything they might need. The amoral market does not allocate health care in any morally-satisfying way, but any health care system has to set limits on coverage, and that's a lot harder when it's as explicit as it is in a policy context. Infrastructure suffers because while new construction can be politically rewarding, routine maintenance is not, so funding is a constant losing battle. Basic research, on the other hand, sounds exotic and often goes down blind alleys, so it makes an easy target for people who target government "waste, fraud and abuse."

"Fixing health care" panel at American Enterprise Institute, 16 May

A panel at the American Enterprise Institute this week promoted private sector initiatives in health care aimed at reducing inflation, which has taken this sector of the economy from 8 percent of U.S. gross domestic product in 1980 to nearly 20 percent today without any observable advantage over other advanced democracies. Two themes that emerged from an energetic and wide-ranging discussion were providing at least primary care through Accountable Care Organizations (ACOs) as an alternative to fee-for-service medicine, and reducing expenditures by catching problems earlier through what Rashika Fernandapulle of Iora Health termed "high-impact relationship-based care." I've been hearing both of these for 25 years or more. Accountable Care Organizations, as defined by Kaiser Health News, are "networks that coordinate patient care and become eligible for bonuses when they deliver that care more efficiently." They are a key cost control tactic of the Affordable Care Act. They sound a lot like Health Management Organizations (HMOs), which were authorized in 1973, and when employer-based plans shifted in their direction on a large scale in the 1990s helped to restrain the growth of costs, but over time became infamous for denial of care. "Some people say ACOs are HMOs in drag," the Urban Institute's Kelly Devers told Kaiser, but there is more flexibility provided to patients in choosing specialists and there are more regulations to ensure the cost savings don't impact the quality of care.

Infrastructure panel at National Association of Counties, 17 May

A panel at the National Association of Counties celebrated Infrastructure Week by exploring the potential of public-private partnerships. John Porcari, a former transportation official now with the consulting firm WSP, suggested that private firms are essential to design and maintenance of infrastructure which are harder for governments to fund. Of course these sorts of partnerships are not new. The panel didn't mention the expansion of Stapleton Airport which was a byword for governmental failure in the 1990s, but they did raise Chicago's 2009 privatization of parking services, which has become a byword for bad contracting (see Kaehny 2009, Cohen and Farmer 2014). Indeed, today's Post reports on malfeasance by a contractor on Metro's Silver line that was reported by a whistleblower. Moderator Adie Tomer of the Brookings Institution raised other problems of the past, including overstretched city staff being outgunned in information and focus by the contractor and unable to do proper oversight, and contractors left in the lurch by sudden policy changes. The panelists noted these problems were widely understood, and could be anticipated in program design and process, as well as through intergovernmental information sharing. They commended value capture as a means of funding infrastructure spending (including ongoing maintenance), and praised its inclusion in the Trump administration's infrastructure recommendations.

(Source: chemistry.stackexchange.com)

Last week's panel at the Bipartisan Policy Council agreed on the need for government to fund basic scientific research; Erik K. Fanning, CEO of Aerospace Industries Association, added the need to educate "a well-prepared dynamic workforce." Again, these are long-standing policies, but our national commitment is being questioned even as "Chinese and Europeans are also making scientific research and development investments." 

• Spending caps for the Department of Defense, the major source of basic research funding, are "coming back with a vengeance in FY20." 
• Education funding at both federal and state levels is under the gun (see Olen 2018 for the U.S. Department of Education, and widespread protests in many states). 
• President Trump has not nominated anyone to head the Office of Science and Technology Policy (see Waldman 2018 on why this matters). 

The United States, says panelist Maria Zuber of the Massachusetts Institute of Technology, "has to decide whether it wants to be a leader or a participant" as other countries adopt "our playbook for economic prosperity." So, needing a means of taking research to the next level in order to maintain our edge, we find ideological game-playing.

The policy panels were optimistic about market mechanisms in health care and public-private infrastructure partnerships, and at least the possibility of more assertive science policy. When pushed by the moderators, several of them were less optimistic that substantive policy could be achieved any time soon. I'd like to think that the reasons for earlier policy failures--including resistance to health care rationing, economic as well as political incentives that conflict with the general public interest, and budget pressures--have been addressed in the current versions of these approaches. I'm still working on actually thinking that, however.

SOURCES

The Bipartisan Policy Council hosted "Investing in the Nation's Future--A Renewed Commitment to Federal Science Funding" on 8 May 2018. Speakers were Erik K. Fanning (Aerospace Industries Association), Mark S. Berry (Georgia Power), John Keller (University of Iowa), Michael L. Telson (General Atomics), Maria Zuber (Massachusetts Institute of Technology and National Science Board).

The American Enterprise Institute hosted "Fixing Health Care: Driving Value Through Smart Purchasing and Policy" on 16 May 2018, co-sponsored with the Brookings Institution, Pacific Business Group on Health, and University of Southern California Schaeffer Center for Health. Speakers were Alex Azar (U.S. Secretary of Health and Human Services), Kevin Bozic (University of Texas Medical School), Rushika Fernandopulle (Iora Health), Mai Pham (Anthem), Jeffrey White (Boeing), Lanchee Chen (Hoover Institution), Chris Jennings (Jennings Policy Strategies), Mark Miller (Laura and John Arnold Foundation), Gail Wilensky (Project HOPE), Joseph Antos (AEI) and Paul Ginsburg (USC Schaeffer).

The National Association of Counties hosted "Collaborate to Build: Modernizing Infrastructure Policies to Advance Public-Private Partnerships" on 17 May 2018, co-sponsored with the Brookings Institution Metropolitan Policy Program. Speakers were Roy Charles Brooks (Tarrant County, Texas, and President of NACo), Elliott Bouillion (Resource Environmental Solutions LLC), Judah Gluckman (DC Office of Public-Private Partnerships), John Porcari (WSP) and Adie Tomer (Metropolitan Policy Program).

SEE ALSO:

James Morone, The Devils We Know: Us and Them in America's Raucous Political Culture (Kansas, 2014). Chapter 3 addresses the need for and political response to health care rationing.

Richard Rose, Lesson-Drawing in Public Policy: A Guide to Learning Across Time and Space (CQ Press, 1993)

The Republicans' tax revolt

Senate Republican Leader Mitch McConnell (R-Kentucky) celebrates passage (swiped from nytimes.com)

There can be no more caviling about the accomplishments of the Republican-led federal government in 2017: the tax bill that cleared December 20, and was signed by President Donald J. Trump two days later, represents major policy change. Unfortunately, in addition to achieving some legitimate objectives the bill pushes policy in some very dubious directions.

First, the good news. The bill includes a long-overdue overhaul of corporate taxation. The U.S. relies to an unusual degree on business taxes, and the complex provisions of the tax code had pushed the top rate (which nobody really pays) far above that of other advanced democracies. The current bill closes some loopholes and reduces the top tax rate from 36 to 21 percent, making American business taxation more transparent and possibly more internationally competitive. Some advocates expect this to result in more hiring with higher wages. (I'm dubious, given that corporate profits have already been doing well for most of this decade, far outpacing wages.) The provision is not revenue-neutral, but could have been offset with higher individual rates. (It wasn't.)

I'm also fine with what's happened to the home mortgage interest deduction: the amount of debt on which interest is deductible was reduced from $1,000,000 to $750,000 for homes purchased after 2017, and nearly doubling the standard deduction drastically reduces the amount of people who will take it. This provision of the code has inflated prices, encouraged communities to sprawl and individuals to over-build (see Zuegel 2017 and Williamson 2017); the presumption that homeowners make better citizens was dubious from the start.

Other positives: Using chained CPI to make year-to-year adjustments should more accurately reflect the impact of inflation on taxpayers, even though it will mean lower benefits from, say, the Earned Income Tax Credit.... The child allowance has been increased for the first time in awhile, to $2000, albeit offset by eliminating personal exemptions. For low income filers, $1400 of that credit can be refunded in a sort of "negative income tax"... And some ideas got removed from earlier versions: reducing or ending tax credits for historic preservation, as well as provisions affecting higher education like taxing tuition benefits for employees of colleges and graduate student fellowships. (Maybe those last are neutrals rather than positives, since nothing was changed.)

If the bill had gone only that far, it might have been more widely supported, in and out of Congress, although that's hard to say given Washington's toxically partisan divide. But the sponsors had to go and:

• skew the individual cuts to the wealthy. In part that's because the wealthy pay most of the income taxes in America, but that's not true of all taxes. (ITEP 2017 shows the distribution of tax payments by income level, and how that would have been affected by an early version of the 2017 tax bill.) This exacerbates an already-widening income and wealth gap in America. The skew does appear worse if you include the expiration of individual cuts after ten years, which was included to make the bill fit under budget caps, so a lot of opposition analysis focuses on 2027 numbers. In fact those cuts may or may not expire, but if they don't, they will clearly worsen the bill's impact on the deficit (discussed below.)
• double the estate tax exemption, which was absurdly high even before Republicans tried to end it in their 2001 tax cut. The ability of the very rich, some but not all of whom got that way by doing socially-productive things, to pass on huge fortunes to their heirs, all of whom got that way simply by coming out of the right vagina, is absolutely contrary to an opportunity society. We're making the world safe for aristocracy, pure and simple. And since whites got several centuries' head start on making money, this approach does racial harm as well.
• expand pass-through provisions, by which individual income can be taxed at the lower business rate. This option is not available to typical working people, of course, only to those in a position to declare themselves independent contractors. A special provision related to real estate partnerships will provide substantial benefits to the Trump family as well as Senator Bob Corker (R-Tennessee), a late convert to the yes column, all of which is giving cynics a field day.
• retain the obscene carried interest loophole, whereby the income of financial wizards is taxed as capital gains rather than income, and therefore at a much lower rate. This has cost the government $18 billion over the last ten years, besides which it irrationally favors financial wizardry over any other work. Hello-o-o, 1 percenters!
• run as much of a deficit as they legally could claim. The official estimate of revenue loss, $1.4+ trillion over 10 years, assumes a substantial economic stimulus effect, which as I said may or may not result, and steady and considerable economic expansion throughout the period. Otherwise the impact on the deficit is substantially worse. Fiscally stimulating the economy at all in the eighth year of a bull market with the country at or near full employment is hard to justify. The capacity of the federal government to deal with future events (natural disasters, security threats, economic downturns, funding for retirement and health care programs, maintaining infrastructure), not to mention regular disruption in our high-tech economy, has been damaged, which is inexplicable. In the near term, higher deficits would trigger funding cuts for Medicare and Medicaid.
• add legislative matters to the bill. Republicans have repeatedly attempted over the years to repeal the individual mandate provision of the Affordable Care Act and open the Alaska National Wildlife Refuge to oil drilling, without success. Both are included in this bill. The ACA change cuts health care policy off at the knees--"We have essentially repealed Obamacare," President Trump proclaimed Wednesday--roiling individual insurance markets, without any recourse for the most vulnerable.
• do all this in an all-fired hurry, without so much as a committee hearing. Senator John S. McCain (R-Arizona) complained last summer about his leadership's abandonment of "regular order" in considering legislation. This bill was a most egregious example, but he supported it anyway.

The tax bill does some good, but considering its effects on vulnerable individuals as well as American society as a whole, it does a lot more bad.

DATA STUDIES
Tax Policy Center: http://www.taxpolicycenter.org/publications/distributional-analysis-conference-agreement-tax-cuts-and-jobs-act/full
Institute on Taxation and Economic Policy: https://itep.org/finalgop-trumpbill/

Reuven S. Avi-Yonah et al.: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3089423

American Planning Association: https://www.planning.org/blog/blogpost/9140260/
US Treasury Dept: https://www.treasury.gov/press-center/press-releases/Documents/TreasuryGrowthMemo12-11-17.pdf 

SEE ALSO:
William G. Gale and Leonard Burman, "Congress Missed an Opportunity to Reform the Corporate Tax," Up Front, 26 December 2017
Alejandro Ortiz and Kathleen Powers, "So, What's in the Tax Bill?" Vote Smart, 13 December 2017

Health care (II)

Senator Mitch McConnell of Kentucky,
principal architect of the Senate Republican health care bill

Senate leaders are trying to get to a vote in the next few days on the latest version of the Republican health care act, dubbed the Better Care Reconciliation Act. The bill is intended to repeal the Affordable Care Act of 2010 ("Obamacare"), while minimizing political damage to Republicans by preserving some of its more popular features.

The Congressional Budget Office (CBO) Monday released its assessment of the effects of the bill: the number of insured Americans will decline by 22 million in 10 years, while the federal deficit will decline by a total of $321 billion. The deficit reduction could in theory be greater, but the bill also repeals the tax increases on upper brackets included in the 2010 law (Kaplan and Pear). The CBO did not to my knowledge assess whether the law would fulfill President Trump's April promise that individual premiums and deductibles, which have risen pretty steadily for more than 30 years, would be "much lower," but a collection of health economists and policy experts consulted by The New York Times predict many people will face substantially higher deductibles, or premiums, or both. Rodney L. Whitlock, a former Senate Republican policy assistant, thought deductibles would reach "almost assuredly five digit" territory (Adelson).

Obamacare was passed after more than six decades of effort to pass a national health insurance bill that had previously yielded government health programs for the elderly (Medicare, passed in 1965) and the poor (Medicaid, also passed in 1965) as well as a series of bloodied presidents who attempted broader approaches. The policy window was open only because Democrats briefly had a "filibuster-proof" Senate majority of 60-40, and because provider groups were willing to negotiate with the administration which they had not been in the 1990s when Bill Clinton was President. A few Republicans were involved in policy talks in the summer of 2009, but withdrew coincident with the rise of the grass roots conservative movement known as the Tea Party.

President Harry S Truman (1945-53) advocated an early national health program

Health care policy efforts were sustained by the persistence of three problems:

1. Lack of insurance. According to the Kaiser Family Foundation, 15 percent of non-elderly Americans lacked insurance in 2013, a proportion that had been pretty consistent dating back to the 1980s. They weren't always the same 15 percent, as people cycled in and out of employment or eligibility for Medicaid, so the percentage of people with inconsistent access to insurance was somewhat higher. Lack of insurance is associated with major health problems, shorter life expectancies, inconsistent care and financial stress.
2. Under-insurance. This is harder to measure, but a large population had health insurance that didn't actually cover what they ultimately needed, due to limits on benefits, exemptions for pre-existing conditions, or what wasn't covered by the policy to begin with. This has contributed to the rise of crowdfunding appeals to pay for unanticipated health care expenses.
3. Rising costs. Health care inflation had been running well ahead of the consumer price index at least since 1980, when health care spending amounted to about 1/12 of U.S. gross domestic product. It is now about 1/6 of GDP, placing financial stress on consumers, businesses that provide health insurance for their employees, and governments at all levels.

The existence of these three problems created substantial obstacles to opportunity in America. In a country that prides itself on meritocracy, the ability to rise is handicapped when accident of birth dooms some of us to inferior health care, not to mention housing, education and so on.

The ACA, for both practical and political reasons, eschewed national health insurance for patches on the existing system (which is not only well-established but fiercely defended by the provider groups that had defeated earlier policy efforts). Roughly based on the approach taken in Massachusetts a few years earlier, it created incentives for employers to offer insurance benefits, virtual markets for individuals in each state ("health care exchanges"), subsidies for individuals and small businesses, and expansion of the Medicaid program. It mandated minimum "essential" coverage in all policies, that everyone have health insurance, that coverage could not be denied for pre-existing conditions, "community rating" for all regardless of age sex or health status, and that children could remain on their parents' health insurance until they were 26. All these emphasized access rather than cost control, though there were some aspects of the bill that sought spending efficiencies.

President Barack Obama, for whom the Affordable Care Act
of 2010 was a primary legislative achievement

Opposition was characteristically virulent, based largely on philosophical and political reasons. Some worried that government would become too large and powerful. There was also reflexive opposition from the Republican Party in Washington and most states that they controlled. Dozens of votes were taken in Congress to repeal all or part of Obamacare, but tellingly, in six years no hearings were ever held on what if anything should replace it once it was repealed. Republicans nationally proved a lot better at winning elections and talking the program down than at designing policy, and thus arrived at their moment of victory quite unprepared.

Serious health care policy makers note Obamacare needs fixing:

1. Costs continue to rise, after a hiatus early in the decade which may have been a fluke, or may have been a temporary effect of the severe recession which dampened demand for just about everything. Health care inflation didn't start with Obamacare, but is unsustainable and will doom the program even if nothing else does.
2. Insurance exchanges have had an uneven record in practice, even after the initial enrollment bugs were worked out. Many counties have one or zero companies offering policies to individuals, which doesn't provide consumers with any benefits of competition. A more stable basis for the program would surely help.
3. Millions of people have been added to insurance rolls, but millions more remain outside. The proportion of uninsured non-elderly Americans dropped from 15 percent in 2013 to 10 percent in 2015, but still, 10 percent. Weak penalties for not buying insurance were probably understandable early on, but the "introductory rate" era is past and they must be strengthened if coverage of the long-term ill is going to be sustainable. (See comments by Dan Mendelson, president of Avelere Health, on Morning Edition Monday.)

A full repeal of the ACA would require 60 votes in the Senate to break a certain filibuster, so Republicans are pursuing only those changes that have budgetary impact in a "reconciliation" approach that cannot be filibustered. The Republican-controlled House passed the Affordable Health Care Act on May 4, 2017, without committee hearings and before the CBO had fully analyzed its effects. It was blocked in the Senate. Senate Republican leader Mitch McConnell revealed the somewhat different Senate version on June 22, also without committee hearings while pushing for a quick vote. Reservations within the Republican caucus, however, have prevented a vote thus far.

President Donald J. Trump has not been involved in the policy making process,
and his statements on health care have been vague and contradictory

The Republican approaches are less overtly assaults on the ACA structure than the "repeal" rhetoric of the last seven years would have predicted, but the dry-sounding policy changes may lead to the same effect. Sarah Rosenbaum of the Milken Institute School of Public Health at George Washington University charges: "A terrible blow to millions of poor people is recast as an easing off of benefits that really aren't all that important, in a humane way" (Ornstein). Rather than ending Medicaid expansion, for example, the current bill phases out the additional national support to states, which along with spending caps would create a strong disincentive for states to continue it. Medicaid spending caps would have the effect of reducing federal spending on that program, which is administered by states although primarily funded by the federal government (Adler, Fiedler and Gronniger).

Ending mandates on policy coverage, having insurance and community rating would lower the costs of policies for some, while driving it up for others. Moreover, without the individual mandate the viability of the mandate for pre-existing conditions would be doubtful, though the Senate bill has added a "lockout" provision requiring a six-month waiting period for getting insurance if one has let previous coverage lapse. What Brookings analysts concluded about the House bill--In general, enrollees who are younger, have higher incomes, or live in low-cost areas are most likely to be better off, while enrollees who are older, have lower incomes, or live in high-cost areas are most likely to be worse off (Brandt et al.)--is probably true of the Senate bill as well.

If access to health care is to remain part of our common life, it requires more than holding the line on repealing the Affordable Care Act. It requires advocates, because the complex set of system patches created by the ACA could be starved of funding more easily than it could be repealed by law. ("Perhaps let OCare crash and burn!" tweeted the President Monday morning, noting repeal is "Not easy!") Ensuring access while controlling costs is surely difficult, though the parties and interests in this ongoing policy process are making it more difficult than it needs to be, given the experience of other industrial democracies. That means seriously addressing the market failures (information, competition, merit goods) endemic to privately-produced health care. I don't know if that's even possible in such a polarized political environment, but signs of unrest in the states offer some hope.

EARLIER POST: "Health Care," 4 May 2013

DATA FROM KAISER FAMILY FOUNDATION
"Health Insurance Coverage of Nonelderly" (2013-2015)
"Premiums and Tax Credits Under the Affordable Care Act vs. the Senate Better Care Reconciliation Act," 23 June 2017

POLITICAL ANALYSIS: Nate Silver, "Mitch McConnell Isn't Playing 13-Dimensional Chess," FiveThirtyEight, 27 June 2017

Deliberation and the shutdown

Last Tuesday night I moderated a discussion among first-year students at Coe College on "Getting American Politics Back on Track." It was fortuitously timed, given the shutdown of the federal government that began with the start of the new fiscal year that very day. (The organizers insisted it was mere coincidence.)

The discussion format was based on James Fishkin's book Democracy and Deliberation (Yale University Press, 1993). After the organizers introduced the format, and I said a little about the issue, the students divided into groups of six-to-eight and discussed the options presented on the two-page issue brief. As a student of political theory as well as American politics, I was as interested in their reactions to the process as much as their thoughts on how to overcome polarization-based governmental dysfunction.

Well, they liked the format just fine, or so they said, though some groups were unable to reach a consensus and fell back on majority rule, and some groups' results felt like lowest-common-denominator compromises instead of creative products of multiple competing perspectives. But since they are required to attend a certain number of these during their first year at Coe, we didn't confront what to me is the biggest obstacle to ideas like Fishkin's or Benjamin Barber's: time. We were there more than two hours after all, counting dinner provided by the school, and that's not insignificant for most adults.

I came to see a couple more obstacles, ways that the system of deliberation could be gamed by those seeking an advantage. I want to be clear that I didn't see manipulation happening Tuesday night. The Coe students mostly knew each other, and for the most part didn't have immediate personal stakes in the issue. But at a town meeting, dealing with issues on which people had strong feelings, you'd really need to trust the people you were deliberating with.

First, without an objective standard of fairness, we are reliant on the perceptions of the participants. While ideally deliberation would take into account all interests and weight them equally, that's unlikely to happen in practice, and even if it did not everyone would see it that way. A comment at the Tuesday forum illustrated this problem as it relates to the current shutdown of the federal government. One young man suggested the shutdown was occurring because of congressional Democrats' unwillingness to compromise. House Republicans keep passing continuing resolutions, he noted, and they keep getting shot down in the Democratically-controlled Senate. "That's the Republicans' story," I laughed, "and they're sticking with it." There certainly are reasons to question whether the House Republicans are negotiating in good faith. For one thing, the continuing resolutions they keep passing have all been variations of the same approach: continuing resolutions for short periods while delaying and/or defunding implementation of the health care reforms. For another, the health care reform law on which the House Republicans have been fixated is a side issue. Democrats can argue, with some justification, that a "clean CR"--a continuing resolution funding the government at current levels, without amendments--is itself a compromise, albeit a lowest-common-denominator one, because it reflects no new legislative priorities from neither side.

Does anyone think the House Republicans are seeking common ground? Well, maybe the Republicans do. House Speaker John Boehner of Ohio, said during debate Tuesday, "All the Senate has to do is say 'yes' and the government is funded tomorrow." Thomas L. Friedman interpreted this as "Give me the money and nobody gets hurt." But the fact remains that there is no clear standard of objectivity. What looks to me like a reasonable compromise, even a patch, might look to you like complete disregard of your priorities. If you believe that the health care reform truly is a fiscal disaster-in-the-making that will create all manner of societal problems besides, then repeated efforts to roll it back are not only eminently reasonable but urgent.

A second problem with deliberation is that a process that relies on achieving consensus is vulnerable to who allege unfairness as a negotiating tactic. The instruction book I used Tuesday night calls for the moderator to solicit ideas from people who feel their voices were not heard in the small group discussions. (I didn't do this, though.) If some participants in a deliberative meeting complain that their voices were not heard, they may truly have been excluded, or they may just be trying to gain a bargaining advantage. I continue to hear, as state health care exchanges open this week, complaints from opponents that the 2010 health care law was passed with only Democratic votes--"rammed through," as some put it. While that is true, I don't know that Republicans can plausibly charge that their views were deliberately ignored. President Obama met repeatedly with people from both parties through the summer of 2009, including Iowa's Republican Senator Charles Grassley. It was Grassley and the other Republicans who withdrew from these talks, in the wake of Tea Party tantrums at local congressional appearances in August 2009. (And then there were those alleged "death panels," and Sarah Palin charging that she would have been forced to have an abortion under the law, ...) I'm certain that Obama would have loved to get Republican votes for the law, or any version of it--the optics would have been way better, not to mention it would have reduced the need for bargaining with provider interest groups. But there were simply no Republican votes to be had.

In spite of the potential pitfalls of deliberative democracy, though, one look at the mess the federal government is in this week is all it takes to know there has got to be a better way than what we're doing.

Health care

(President Harry S. Truman, an advocate of national health insurance.)

It's been a tough week for the Affordable Care Act, the health care reform law passed in 2010 and currently in the implementation phase. A Politico story (see below for link) validated a spurious claim that has been making the rounds in the last year, to wit, that members of Congress are seeking to exempt themselves from provisions of the law mandating purchase of insurance from purchasing exchanges. President Obama is being criticized by members of his own party for lack of leadership and failure to communicate on health care, with Montana Senator Max Baucus saying "I just see a huge train wreck coming down" as the law is implemented. And Friday Caroline Humer of Reuters news agency reported few insurance companies are enrolling in the state-level insurance exchanges, which makes it questionable whether those exchanges will be able to operate as intended.

The exemption falsehood is the latest in a series of fact-free efforts to manipulate public opinion, dating back to Sarah Palin's 2009 crusade against putative "death panels," and even farther back to hoary charges of "socialized medicine." However, unlike death panels, which theoretically could have been in the law even though they weren't, the exemption story is fundamentally absurd. The law doesn't affect people with insurance, as long as the insurance plan itself qualifies. Members of Congress, who have very good health insurance, aren't exempt from a requirement to buy insurance that they're already buying. And even those required to buy insurance aren't required to buy it from exchanges.

So what is giving this lie legs? As should be obvious to anyone, some people really really really want this law to fail. This certainly includes former Pennsylvania Republican Senator Rick Santorum, whose 2011 presidential campaign appearances in Iowa featured lengthy tirades against the law. When I saw him speak at Mt. Pleasant, he claimed that America ceased to be a free country when the law was passed; he wondered why we're helping people get health care when we don't help them get food and housing (um, actually, we do); and raged against longer waiting times in doctors' offices. Swell guy, that Santorum, and no wonder he's pushing the exemption story to the max this week. If you're as angry about it as he is, which hardly seems humanly possible, write an angry letter your representative and send Santorum's group some money.

(Former Pennsylvania U.S. Senator Rick Santorum, whose public
persona is angry, and inaccurate to boot.)

That doesn't explain how the congressional exemption falsehood got into Politico, though. John Harwood of The New York Times points out, "In fact, lawmakers said, the talks the article referred to concerned preserving the same kind of employer-subsidized health coverage for Congressional employees that workers at private companies can receive under the law." I've sent a query to the lead author of the Politico story. He hasn't responded, nor has Politico issued a clarification or correction. I'll let you know if that changes.

The other criticisms are harder to assess. In an ideal world, the Obama administration, and particularly the President, would be noting that we're embarking on quite the grand social experiment, and issuing regular public statements of information and reassurance. But I don't know how reasonable it is to expect that, given that other stuff keeps coming up, like the civil war in Syria or the bombings in Boston, that have to be addressed, too. More basically, I'm pretty sure people overestimate the effectiveness of even focused presidential rhetoric. There is a lot of noise in the world of politics, more and more each week it seems, and even if the President's is the loudest voice in the country it still gets drowned out more often than not. There need to be more people involved in this effort besides Obama and Secretary Sibelius. Is Baucus helping?

It would be nice if the health insurers were feeling confident and enthused, too. Given that we've never done this sort of thing before as a country, some degree of uncertainty is inevitable. Nothing Obama says or does can undo that. Could the government do a better job of cushioning the insurers against whatever it is they're worried about? Maybe. Given that insurers were very much a part of the bill's formulation in 2009--if anything provider groups were too involved in the process, because few members of Congress were willing to negotiate their votes--you'd think this would have come up. But let us grant that at least some of the insurers' concerns are legitimate. Those should be addressed. Insurers should not, however, be indemnified against any conceivable loss or inconvenience. This isn't about them.

Health insurance is important to the central question of this blog: how are we Americans going to live together? Between 15 and 20 percent of adults 18-65 are without health insurance at any given point in time; expanding that point to a year, or two years, the percentage gets larger, as different people get and lose insurance. (Up-to-date numbers from the Kaiser Family Foundation here.) That number would, I'm sure, at least double and maybe triple or more, if we change the subject to underinsurance, that is, having insurance that does not adequately protect a person against medical emergencies. This is not a trivial matter. People without insurance have significantly higher incidence of major health problems, less consistent care, shorter life expectancies, and much more vulnerable finances. (For data see Katherine Swartz's chapter, cited below, and the sources she cites in endnotes 3-10. There is also a 2008 study by the Urban Institute.) Bottom line: Health insurance is critical to equality of opportunity. It matters very much whether people have it or not. It is not, as Justice Scalia suggested in his dissenting opinion, a luxury item that is purchased by people who have made it economically.  It is, for the past 30 years anyway, a significant demarcation between the "haves" in our society and the "have-nots."

Moreover, to the extent that uninsured and underinsured people get their medical care in emergency rooms, it raises health costs for everyone. Did Senator Santorum ever wonder, if they're not paying the cost of emergency care, who is? Did he ever wonder if someone in his family would have a medical emergency and have to wait for uninsured people who got there first?

I support implementation of the Affordable Care Act, if only because it is the only game in town. It is the only means currently available that will address the critical problem of uninsured and underinsured people. Single-payer is not on the table. And Republicans, for all their full-throated opposition to "Obamacare," have offered nothing in the way of alternative methods once they achieve their goal of repealing it. Indeed, several G.O.P. senators, including Iowa's Charles Grassley, who were engaged in health care talks with the administration in 2009, fled as soon as the Tea Party turned up the heat that August. Once in awhile, Paul Ryan or someone will pop up with a suggestion, but do these ever get committee hearings or floor votes in the Republican-controlled House of Representatives? There have been over 30 votes to repeal the Affordable Care Act; how about something of substance?

Moreover, the style of reform enacted in the Affordable Care Act has worked, at the state level, in Massachusetts. Massachusetts is not America, of course; its population is overall better-educated and had a higher proportion of insured people before its health care law was enacted in 2005. Perhaps most importantly, implementation of health reform in Massachusetts was facilitated by cooperation between Republican Governor Mitt Romney, legislative Democrats, and provider groups.

The Massachusetts experience shows that health care reform can work. For sure there will be problems along the way, but those can and will be overcome if people in power work together to overcome them. On the other hand, with enough fear-mongering, misinformation, and foot-dragging, the Affordable Care Act can very well be effectively undermined. Obama's legacy would suffer, people would have even less faith that government can do anything right, insurance companies could do things the hugely profitable way they've always done them, and maybe the rest of us would enjoy shorter waits for doctor visits. Maybe those would all be good things. But those are picayune matters, compared with the opportunity to what we need to do:  make people more healthy, promote economic opportunity, and keep America from becoming even more divided than it already is.

SOURCES

John Bresnahan and Jake Sherman, "Lawmakers, Aides, May Get Obamacare Exemption," Politico, 24 April 2013, http://www.politico.com/story/2013/04/obamacare-exemption-lawmakers-aides-90610.html.

John Harwood, "The Next Big Challenge for Obama's Health Care Law: Carrying It Out," New York Times, 30 April 2013, A10.

Caroline Humer, "U.S. Insurers Wary of Health Reform," The Gazette (Cedar Rapids, IA.), 2 May 2013, 1A, 8A.

Robert Pear, "Obama Says Health Care Law Is 'Working' and Changes Won't Be Widespread," New York Times, 1 May 2013, A15.

Katherine Swartz, "Uninsured in America: New Realities, New Risks," in Jacob S. Hacker (ed), Health at Risk: America's Ailing Health System--And How to Heal It (Columbia, 2008), 32-65.

ALSO WORTH A LOOK...

Linda Bergthold, "Obamacare: Will the Trains Run on Time?" HuffingtonPost.com, 30 April 2013, http://www.huffingtonpost.com/linda-bergthold/obamacare-will-the-trains_b_3189634.html: soberly positive expectations for implementation

Bill Keller, "Five Obamacare Myths," New York Times, 16 July 2012, http://www.nytimes.com/2012/07/16/opinion/keller-five-obamacare-myths.html?src=me&ref=general&_r=0... somewhat dated, but a useful reminder of the junk that was circulating last summer

Glenn Kessler, "Obama's Claim that 90 Percent of Americans 'Don't Have to Worry' about 'Obamacare," WashingtonPost.com, 30 April 2013, http://www.washingtonpost.com/blogs/fact-checker/post/obamas-claim-that-90-percent-of-americans-dont-have-to-worry-about-obamacare/2013/04/30/01414c02-b1f7-11e2-9a98-4be1688d7d84_blog.html: how Obama has exaggerated claims for the benign impact of the Affordable Care Act. Particularly Kessler points out that the underinsured, whom Obama has overlooked in his speeches on the subject this week, will need to get better insurance, which will cost 'em.