Trying to Understand the Current State of Health-Care Debate. And Failing…: Focus
Can someone point me to something Stuart Butler has written in the past three years that has turned out to be correct?
I mean, it seems to be blinkered, partisan, wrong–and obviously wrong at the time, both in its analysis of the political forces and of the policy substance. Am I wrong? Take a look:
…[because of] the continuing problems with the federal budget deficit and the national debt and the worrying long-term weakness of the economy…. 2013… a year for buyer’s remorse in Congress and around the country…. Employers[‘]… concerns about mandatory benefits are slowing their hiring… lower-wage employers are moving towards hiring part-time employees to avoid the ACA’s penalties. These patterns will only grow…. The possibility of larger-than-expected enrollment in health insurance exchanges will sharply increase the budget costs… force Congress to reopen key ACA coverage provisions….
It’s also hard to imagine the expansion of Medicaid proceeding as planned… even the short-term prospect of Washington picking up expanded Medicaid costs is not likely to prevent a strong pushback by states….
The prospects for serious Medicare reform are actually on the rise. The Ryan version of premium support…. Obama’s initial large lead as the best defender of Medicare slid to just 5 points by the election…. Romney… won the senior vote…. Relying on the Independent Payment Advisory Board (IPAB) of experts in health care economics and the health care system to crack down on physicians and hospitals is hardly going to make the ACA more popular among seniors…
…as a deal that no sensible governor and state legislature can refuse and to think that doing so would harm the state and its clinicians and health care facilities…. Some Republican governors, such as Rick Scott… say there is no sense in leaving federal money on the table. Still, others are balking… Bobby Jindal. Are they lacking common sense?…
Most states taking the deal would still have to dig deep into their already overstretched budgets in the future…. A recent Heritage Foundation simulation… makes it clear that although most states will enjoy a net budget gain for the first 3 years, they will be experiencing a rapidly escalating trajectory of state costs by the end of the period…. The Medicaid expansion could be much more costly to states…. There is no guarantee that the deficit-burdened federal government will be able to maintain its funding promises….
Fearing that the ACA’s design of Medicaid expansion could end up as a Faustian bargain for state budgets… there are far better ways to approach this particular group of the uninsured than simply expanding Medicaid….
Pressing states to participate in the expansion of Medicaid is a bad idea…. The ACA’s approach threatens future state finances and locks in an approach that makes it less likely to ensure Medicaid coverage that will be affordable to future federal and state taxpayers while providing adequate health services to beneficiaries.
…‘One swallow does not make a summer.’ Three years of slow health spending growth is welcome, but it would be unwise to open the champagne just yet. This is definitely not the time to ease up on seeking reforms in Medicare and Medicaid to limit the unfunded obligations on our children and grandchildren. And it is no time to cease challenging the new entitlements and cost-reduction wishful thinking of the ACA.
I mean:
- The combination of interest rates and even a subnormal posture made for a much more optimistic budget picture in 2012 than Butler claimed…
- The claim that ACA exchange subsidies would turn out to be an unexpectedly-large budget buster was simply wrong…
- I look monthly for disemployment effects from the ACA, and if I look really hard I can find things that might be very small ones…
- No, there were no politically-viable prospects for serious Medicare reform…
- The Heritage Foundation “simulation” that states would benefit budgetarily from Medicaid expansion for only the first three years–I haven’t heard anyone repeat that lately…
- The claim that the federal government was likely to renege on its Medicaid-expansion funding promises seemed deaf to the real politics at the time and seems even deafer now…
- The Republican argument that expanding Medicaid would be a bad idea for a state looked bad at the time and looks worse and worse with every passing day…
- Expanding Medicaid has not locked anybody into an unsustainable policy path…
- The cost-reduction thinking of the ACA does not, at least now, look wistful…
- If it is not now time to open the champagne at the improvement in the health-care spending-path trajectory, when would it be time?
And when I look at what Stuart Butler is writing today, I see no talk about how his root-and-branch opposition to Medicaid expansion, unwarranted budgetary and health-care spending-growth pessimism, and belief that the politics were still favorable for ACA repeal were all misjudgments. I see no talk about how the fact that the world has turned out to be a different place from what he claimed it was back in 2012 and 2013 has led him to rethink. I read, instead:
: Two Cheers for the GOP’s Burr, Hatch and Upton Alternative to Obamacare: “It’s high time for the GOP to move away…
…from going-nowhere votes to repeal the Affordable Care Act (ACA or ‘Obamacare’)… adopt the strategy of achieving a more conservative vision of health through structural–and potentially bipartisan–amendments to the ACA…
Shouldn’t this denunciation of a GOP pursuing “going-nowhere… repeal… [of] ObamaCare…” come with, at the very least, an admission that this is a reversal-of-field on Butler’s part as well? Especially as the politicians Butler wants to praise today–Burr, Hatch, and Upton–are still pursuing that will-o’the-wisp forcefully, so that Butler asks us to:
Put aside… the lawmakers’ statement that the first thing to do is to repeal the ACA… the important thing is to focus on the core elements of the proposal as potential vehicles for broad-based reform…
where I take “broad-based” to be a synonym for “bipartisan”.
And why no mention anywhere that Burr-Hatch-Upton’s plan is a minor reworking of last year’s Burr-Coburn-Hatch proposal? Why the pretense that this is a new offer, rather than an attempt to revive something that did not get traction with the leadership of either party last year?
And why call for two cheers for a plan that Butler says has these features:
- “The specific [health-care insurance] credit design is imperfect…”
- “Regrettably, the new plan raises the cap [on the deductibility of employer-sponsored health insurance] above the thresholds even for the badly designed ACA ‘cadillac tax’ on high-cost plans…”
- “The GOP plan could have moved much more decisively towards state-led reform… within the ACA itself is a provision that allows states to propose radical changes…. Rather than seek to repeal… §1332, the plan sponsors would have been much wiser to have proposed strengthening it…”
- “The proposal has attracted liberal criticism, with some critics raising design concerns that need to be addressed…”
And yet his bottom line is:
The Burr-Hatch-Upton plan is an important proposal from leading GOP lawmakers and includes approaches that contain the basis for agreement. If the White House and congressional Democrats are willing to look seriously at several of its central provisions, they will see opportunities for addressing the impasse over the ACA and achieving health coverage goals that are widely shared.
But why does Butler say this is superior to the ACA? He says its steps away from incentivizing employer-sponsored insurance are inferior to the ACA’s. He doesn’t see the point of the Dingbat Kabuki involved in not building on §1332. It has serious design flaws. And its tax-credit design is “imperfect”. And Butler seems to me to give us no reason to prefer it to the ACA save one:
- It is a proposal by Republicans.
Well, the core design of the ACA was once a proposal by Republicans too. As Jon Gruber likes to say, ObamaCare is RomneyCare. Why not simply stick where we are and see how the policy bets we have placed with ObamaCare turn out, so that we actually learn something about what does and does not work?