Fwd: qotd: Was the ACA "politically feasible"?

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-------- Original Message --------
Subject: qotd: Was the ACA "politically feasible"?
Date: Fri, 31 Jan 2014 10:32:02 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



The Washington Post
January 5, 2014
The group that got health care passed is packing up and going home
By Harold Pollack

Harold Pollack: [S]ingle-payer folks ... might ask: "Wouldn't we have a
better system if we had a single payer? Why didn't HCAN [Health Care for
America Now] and its friends push for that?"

Richard Kirsch [chief executive of HCAN]: What's the expression: "If
wishes were horses, beggars would ride?"

Yes -- if we could wave a magic wand and design a rational health-care
system that would control costs while providing much better access, we
wouldn't design our current one. The ACA was the best that we could get
through the American political system. The fact that we failed in every
previous instance in the past 100 years reflects the reality that there
hadn't been a reform designed to deal with the realities of American
politics....

http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/05/the-group-that-got-health-reform-passed-is-declaring-victory-and-going-home/

****

Health Affairs
January 2014
Implementing health reform: Four years later
By Timothy Jost

How did things go so wrong [for the Affordable Care Act]? Why is there
so much bad news?....

More devastating for the future of the ACA, however, were the 2010
midterm elections. Republicans picked up sixty-three seats in the House,
swinging control of the chamber from the Democrats to the Republicans.
Before the 2010 elections, Democrats controlled fifty-two state
legislative houses and the Republicans thirty-three; after the
elections, Republicans controlled fifty-three and the Democrats
thirty-two. Before the 2010 election there were twenty-six Democratic
and twenty-four Republican governors, and after there were twenty
Democrat and twenty-nine Republican. Many saw the election as a
referendum on the ACA.

http://content.healthaffairs.org/content/33/1/7.full


Comment by Kip Sullivan, JD

Was the Affordable Care Act politically feasible? Was it "the best"
America could do in 2009 and 2010? Was single-payer legislation more or
less feasible than the ACA? It is still too early to pronounce on the
fate of the ACA, but it is not too early to discuss the political
feasibility question. We have much to learn from looking back at the
muffled debate about that issue among universal coverage advocates prior
to the enactment of the ACA.

Since the modern American single-payer movement was formed in the late
1980s, many supporters of universal coverage have claimed that
single-payer is not politically feasible. Those who made this argument
(Bernstein and Marmor refer to them as "political yes buts"
http://healthaffairs.org/blog/2008/08/28/medicare-for-all-why-we-should-say-yes-not-yes-but)
never explained why multiple-payer "solutions" would be more feasible
than single-payer. In the worldview of the "yes buts," only single-payer
proponents had to answer that question. If, on any given day,
single-payer proponents could not point to 60 votes in the US senate or
majority votes in the US House or in state legislative chambers, the
conversation was over: Single-payer was not politically feasible and had
to be taken off the table to make room for more "realistic" legislation.

This simple counting-noses definition of "political feasibility" avoided
two issues that many observers inside and outside the single-payer
movement consider paramount: Any legislation that proposes to achieve
universal coverage, or even to cut the uninsured rate substantially, is
not politically feasible, or at minimum is no more feasible than
single-payer legislation, if

(1) it doesn't simultaneously reduce health care spending or
(2) is so complex it cannot be implemented within a reasonable period of
time.

This definition of feasibility asks not merely whether a given
legislative body can be pushed into enacting a given bill. This
definition asks as well, once the bill is enacted, is it politically
sustainable? By this more realistic definition of political feasibility,
a bill might have enough votes to pass a given legislative body, but if
the bill can't contain costs or can't be implemented within a reasonable
period of time, it shouldn't be assumed to be politically sustainable
and therefore should not be assumed to be more politically feasible than
other approaches.

Sustainability depends ultimately on how the public perceives
legislation after it is enacted. If the public punishes lawmakers who
voted for the putative "universal coverage" legislation and rewards
legislators who are hostile to government doing anything to help the
uninsured and to lower health care costs, the legislation may die on the
vine or be repealed.

One would think that this definition of political feasibility would have
appealed naturally to the Democrats and their supporters who pushed the
ACA because it asks them to take into account the impact of the ACA on
voters' perceptions of Democrats. In other words, it asks Democrats to
consult their own self-interest in the course of picking a solution to a
problem. It is a noble thing to suffer retribution at the polls for a
bill that does good things for people when you know it's going to work.
But it is foolish to suffer retribution for a bill you suspect, or
should suspect, will fail, or at minimum, will perform far below the
expectations your rhetoric about the bill has created.

When in June 2009, congressional Democrats unveiled the health care
"reform" bills that would become the ACA, I and many others were filled
with apprehension. Our concern was not that some version of these bills
might not pass. To the contrary, our concern was that it might pass (and
thereby demonstrate it was "politically feasible" in the narrow sense of
the phrase) but not be politically sustainable. In a June 2009 comment
on this blog entitled, "Democrats' hype about health care reform will
hurt them," I said:

"President Obama and Democratic congressional leaders are playing a
dangerous game with health care reform. They are raising the public's
expectations sky high before figuring out how to meet those
expectations. They are promising to give us the moon – significant cuts
in health care costs and universal coverage or something close to it –
but even at this late hour they have failed to publish anything
resembling a detailed plan to do that. And the hints they have given us
about the 'reforms' they are likely to endorse indicate they haven't got
a clue how to cut costs."
http://pnhp.org/blog/2009/06/04/democrats%E2%80%99-hype-about-health-care-reform-will-hurt-them/.

I wanted a real debate about the political feasibility of the Democrats'
multiple-payer solution versus our single-payer proposal, and I thought
the most effective way to make my argument was to appeal to Democrats'
self-interest, not just their altruism. Although I doubted the altruism
of some members of Congress, I didn't doubt the altruism of the vast
majority of ACA supporters -- I knew their desire to minimize the
suffering inflicted on this country by our health care system was real.
What I questioned was their understanding of how expensive and complex
the ACA was going to be. If they didn't understand that, how could they
grasp what a political liability the ACA would be for Democrats? How
could they intelligently evaluate the risk that future Congresses might
not have enough Democrats in them to protect the ACA from underfunding
or outright repeal?

But the debate about political feasibility that I and many others hoped
for never came to pass. The single-payer and multiple-payer wings of the
American universal coverage movement never discussed whether the ACA
would be more feasible -- that is, be more likely to pass AND be more
sustainable -- than a single-payer. We never debated whether the
simplicity and efficiency of a single-payer made it more feasible, or at
least no less feasible, than the costly and insanely complicated ACA.
ACA proponents simply pronounced single-payer "off the table" on the
ground that powerful opponents would have made a majority vote in
Congress impossible. And that was that.

Four years have now passed since the enactment of the ACA. The sky is
clotted with chickens coming home to roost. Evidence that the ACA was
never as sustainable as its proponents implied is all around us. This
evidence includes evidence of the damage the ACA has inflicted on
Democrats. Timothy Jost's article in the January 2014 Health Affairs
contains an excellent summary of the unhappy history of the ACA. One of
the most important paragraphs in his paper is the one quoted above in
which he notes the damage Democrats suffered during the 2010 elections
and that many believe this damage was due in part to the enactment of
the ACA in March of 2010. Jost also predicts more bad news for the ACA
as a substantial portion of the people insured through exchanges
discover their choice of provider has been restricted and their
out-of-pocket payments are very high. We are going to see more
heartwarming stories about sick people finally getting the medical care
they deserve, thanks to the ACA, but it will not be enough to forestall
more damage to Democrats (especially if Republicans manage to nominate
candidates who can refrain from discussing "legitimate rape" and similar
subjects).

None of us have a crystal ball. I don't claim that if Democrats and
groups supporting the ACA had used the opportunity presented to us in
2009-2010 to promote HR 676 instead of the ACA that HR 676 would have
passed by March 2010 or even by now. I'm reasonably sure something good
would have been enacted -- for example, an expansion of traditional
Medicare and Medicaid to more people (Bob Kuttner makes a similar
argument here
http://www.huffingtonpost.com/robert-kuttner/obamacare-republicans_b_4293314.html).

I am, however, absolutely certain about one thing: The universal
coverage movement in America would be in a much better position to bring
the long fight for universal coverage to a successful conclusion than we
are now. There are several reasons why I'm so sure about that.

First, whether we had won big or won some incremental improvements in
2010, the public would have been exposed to a debate about a real
solution to the health care crisis as opposed to a debate about
make-believe cost containment schemes such as exchanges, "accountable
care organizations" and punishing hospitals for "excess" readmissions.

Second, the health insurance industry would be receiving less money from
the taxpayer and would be, therefore, less powerful than they are now.
The insurance industry has been driving away private-sector customers in
droves over the last few decades. If public purchasers -- state and
federal governments -- had long ago stopped throwing money at Aetna et
al. with legislation like the ACA, schemes to overpay Medicare Advantage
plans, and legislation privatizing state Medicaid programs, the industry
would by now be a shadow of its former self and a much less potent
opponent of universal coverage.

Third, the political environment for health care reform would be less
toxic than it is today, not because conservatives wouldn't be leveling
the same extreme charges they level at all forms of health care reform
no matter how innocuous, but because the public would be less vulnerable
to extremism and ultimately less cynical about real reform.

ACA proponents may disagree with my assessment of where we might be
today if they had joined ranks with the single-payer movement and had
fought for HR 676. What they can't deny is they refused to engage in a
real debate about the political feasibility (narrowly defined) AND
sustainability of the ACA versus single-payer. They might have learned
something if they had.