Republicans in Congress have voted somewhere around 40 times to repeal the Affordable Care Act, Obamacare, since 2010. One might have thought that a Supreme Court ruling that the law was constitutional and an electoral drubbing of the Romney/Ryan ticket, with repeal a prominent feature of their campaign, would be enough to quell the GOP zeal for repeal. It wasn't.
Having failed in the courts and in Congress, they're not stopping, convinced that they can continue to keep public sentiment against it, and they've got a new plan for doing that. National Journal explained it in this article about Senate Minority Leader Mitch McConnell's "long ball" legislative game to make affordable health insurance out of reach for millions of Americans once again. He, and his colleagues, will do it by "trying to brand the law as one that costs too much and is not working as promised." They intend to make it a liability for Democrats in 2014 in order to retake the Senate and have another go at repeal in 2015.
McConnell’s office has assembled the law’s 19,842 new regulations into a stack that is 7 feet high and wheeled around on a dolly. The prop even has its own Twitter account, @TheRedTapeTower.
“All you got to do is look at that high stack of regulation and you think, ‘How in the world is anybody going to be able to comply with all this stuff?’ ” GOP Sen. Orrin Hatch, told National Journal. “And I’m confident that the more the American people know of the costs, the consequences, the problems with this law, then someday there are going to be some Democrats who are going to join us in taking apart some of its most egregious parts.”
Congressional Republicans have a coordinated attack and already have the conservative media on board. We'll explore just one example below the fold.
Case in point, National Review Online's Yuval Levin, who is more than doing his part. Consider this story on NRO, subtly titled " The Unaffordable Care Act." Levin's primary premise is that the slowing rate of growth in health care costs, which is actually something that is happening, is illusory and just based on assumption and can't be expected to continue. It could, and likely will, with implementation of Obamacare.
But, Levin argues by making many unfounded assumptions of his own, it can't. The key piece, the argument goes, is the Independent Payment Advisory Board (IPAB), one of "two huge problems with the law’s design."
The first is that, unless health costs grow very slowly and keep the growth of Medicare costs very low, Obamacare’s additional price controls (in the form of the IPAB) would have to kick in, and, because they are only allowed to take the form of across-the-board rate cuts for providers, they would result in drastically reduced access to health care for seniors. The actuaries of the Medicare program (who work for Barack Obama) have projected that this would require payment rates for doctors in Medicare to dip well below Medicaid rates and keep falling. [...]
We know that Medicaid’s low payment rates cause many doctors to refuse Medicaid patients, and therefore make it difficult for many poor Americans to find health care. Taking Medicare rates below that level should have similar, but even more drastic, effects. It’s not even worth trying to think through the details of what that would look like because it would simply never happen—we’ve seen that far smaller cuts than that are undone each year through the “doc fix” and there is no way doctors or seniors would put up with such blunt across-the-board cuts and such a loss of access to care. The only way to really avoid that mess is if health costs just magically remain very low, and that’s basically what the administration (and to some extent the CBO) now project when assessing the law. The CBO assumes, for instance, that the IPAB wouldn’t even have to start doing anything at all until after 2022.
Note that? The sky is falling because of IPAB but it isn't actually falling because doctors and seniors won't let it happen. But it's still a disaster because it's part of Obamacare. Even if it wouldn't kick in until after 2022. What Levin isn't saying about IPAB is that written into the law were myriad ways in which it is constrained by Congress: primarily in the fact that the 15 members it is to be comprised of have to be confirmed by a filibuster-happy Senate.
The truth about IPAB, a potentially powerful check on the rate of increase of health care costs, is best told by an actual health care expert [pdf], in this case Henry J. Aaron.
There are some things the IPAB can do, some things it may do, and some things it is prohibited from doing. It can propose changes in how some providers are paid or how care is organized. Congress may substitute other ways of reaching the spending targets, but if it does not, the IPAB recommendations take effect. The IPAB may suggest ways to change the health care system outside Medicare. But these recommendations have no binding legal force. The IPAB is prohibited from making any recommendations that would result in health care rationing or that would change Medicare benefits, premiums, deductibles, or cost-sharing.The IPAB won't destroy Medicare. It can't destroy Medicare. That's a truth the Levin haltingly, sort of acknowledges, even while laying out every nightmare scenario that could potentially occur. In an alternative universe in which the increase in costs for Medicare weren't slowing down and with an IPAB that actually was a death panel.
If the targets for Medicare spending growth are met, the long-term financing problems of Medicare will be largely solved. The number of enrollees will grow as baby boomers reach age 65, but costs per person will be well controlled. The success of the IPAB is therefore of critical importance.
The same alternative universe assumptions Levin forwards to
The second large design problem that the rosy health-costs scenario allows the administration to ignore reaches even closer to the heart of Obamacare. After the law’s designers got their first real CBO score in 2009, they realized they had to find some way to cut the projected costs of the law’s exchange subsidies if they were to have any chance of pretending the law would cost less than a trillion dollars over a decade. So they inserted a provision that kicks in in 2018 and requires that, if the cost of the exchange subsidies exceeds 0.5 percent of GDP in any given year, the level of subsidy would be cut in a means-tested way. The provision didn’t draw much attention even from health wonks at first, but in 2011 the CBO produced an analysis of it showing that it would cause very significant declines not just in the growth of subsidies but in their nominal value year-over-year for many middle-class families. These families’ out-of-pocket costs would quickly grow larger than the penalty (or tax, for John Roberts fans) they would have to pay for not having coverage, and many could well opt to go uninsured until they needed care. [...]Once again, Levin is speculating about an outcome six or seven years down the road that is a total nightmare but actually isn't going to happen. Beyond that, the Levin is not being very truthful in asserting that the CBO says people will drop out of the exchanges like flies after 2018. Actually, that's not what the CBO said in its projections in the latest report about participation in the exchanges:
Until this year, the CBO has always assumed that these families just wouldn’t drop their coverage, but in its latest score of Obamacare, the agency for the first time projects that the number of people in the exchanges will actually begin to drop after 2018, declining by almost a tenth over the subsequent five years even as the population grows. And since the people who remained in the exchanges would tend to be poorer and sicker, the costs of providing them subsidies would grow very quickly (by almost 6 percent annually), since the exchange pool would become more risky. (And this projection, remember, is still based on rosy expectations about overall health-cost growth.) This nightmare scenario, too, is pretty unlikely to happen, since the people involved would be middle-class families. They’re not going to accept the enormous downside of Obamacare without even the modest upside of exchange subsidies, and they’re not going to like being forced to go uninsured. The politics of this just wouldn’t hold.
All told, CBO and JCT now project that 26 million people will be enrolled in the insurance exchanges in 2022, about 500,000 more than estimated in the August 2012 report.Hmmm.... That's more people in the exchanges than CBO previously estimated. The massive rate of decrease Levin says the CBO is warning about isn't even reflected in the graph form the report they link to:
From the March 2010 baseline to the current baseline, such technical revisions have lowered estimates of federal spending for the two programs in 2020 by about $200 billion—by $126 billion for Medicare and by $78 billion for Medicaid, or by roughly 15 percent for each program.Since that's happening in the actual universe, rather than the alternative one, Levin probably determined it wasn't worth mentioning.
There is a great deal in the implementation of Obamacare that is in the realm of the unknown, dependent as it is on the economy, employment levels, state participation in the exchanges and Medicaid. What we do know is that Republicans will seize upon every hiccup in the implementation, and Republican governors will continue to cause those hiccups to sabotage the law. What we also know is that Republicans and their allies in the media will continue to lie about the law. We also know they'll take those lies on the campaign trail.
Democrats can't be complacent in the fact that the Court ruled (mostly) their way and that the Affordable Care Act is the law of the land. They've been reluctant to really embrace it because Republican attacks on it have been so effective with the public. That's going to have to change to keep this new pack of lies from taking hold in 2014.