On Over-Promising in Health Care Reform
It appears I have to clarify a post I wrote earlier today in light of this Chris Bowers riposte. I was generally making a claim about the student loan bill being an unequivocal progressive victory, a statement with which he agrees. However, he argues that the claim of nothing being progressive about the health care victory is misguided:
However, the claim that there is nothing progressive about the health insurance reforms that passed into law doesn’t add up. Because of this legislation, it is estimated that 16,000,000 additional low-income Americans will receive public health insurance than they would have under previous law (CBO report, PDF, page 21). Millions of low-income, uninsured Americans received public health insurance is a straight-up, undeniable progressive victory.
Further, by moving much more of the cost of Medicaid to the federal level, the program becomes much more stable, and difficult for right-wing state governments to cut, over the long-term.
Yet further, the $11 billion in additional funding, over five years, for Community Health Centers in the legislation will, at current rates of service, provide primary health care to an additional 17.8 million low-income patients a year. (Current funding of $2.5 million a year (PDF, page 6) treats 20.27 million patients, so funding of $4.7 billion annually projects to 38.11 patients).
It’s possible that I’m being presumptuous in thinking this targets me. Because I’ve been writing about the Medicaid expansion and particularly the community health centers, which I called a revolutionary universal care program for low-income Americans back in December, for quite a while. I would throw in the CLASS Act, a voluntary, government-run long-term care insurance program, as a very progressive element.
I don’t think anywhere in that post I argued about this or that element of a very comprehensive health care bill. I argued that the student loan win was a more unequivocal victory. I like getting insurance for 32 million people. I like federal expansions of Medicaid to make that system palatable and viable. I like universal care, medical-home programs for the less fortunate.
But perhaps the larger point is the casual throwing around of the phrase “largest progressive victory in 45 years” attached to a bill that supporters have to then backtrack on and call a moderate effort that Republicans offered as a counterpoint to Clintoncare in 1993. Regardless of the pretzel logic that suggests anything that makes America somewhat better in outcomes than Nigeria, or something, can be reasonably described as progressive, the fact is that there are not only some really painful compromises in this bill, but the overall structure is by no means assured as an enduring policy triumph. Jon Cohn outlines just a few of the issues that will need to be wrestled with in implementation today:
DELIVERING THE DELIVERABLES President Obama promised that some of the benefits of reform would appear in the first year. For starters, within 90 days the Department of Health and Human Services must set up a high-risk pool as a temporary source of insurance for people who have pre-existing conditions.
Some of the new consumer protections will take effect within six months; first, though, federal officials have to translate that law into regulation. The government is also supposed to provide a new, easy way for consumers to compare benefits from insurer to insurer.
EDUCATING THE PUBLIC It’s one thing to create a health insurance program and quite another to get people to sign up for it. Today, many more people are eligible for Medicaid than actually enroll, in no small part because some states — wary of adding too many people to the rolls — make it hard to apply for and stay in the program.
That said, more than 97 percent of people in Massachusetts now have insurance, thanks in part to an aggressive public relations campaign that enlisted the Red Sox to raise awareness about the state’s own health care overhaul. A similar effort to increase public knowledge and to undertake direct outreach to individuals will be necessary. While states and nonprofit organizations will play vital roles, the federal government should probably take the lead.
These, and more of what Cohn describes in his article, are all good points. But I submit that it makes it exponentially more difficult to deliver positively on such issues when the liberal infrastructure keeps backslapping and telling everybody what an enormous progressive triumph this all is. There’s a tension between using the passage of the Affordable Care Act as an electoral tool, hyping it up, and the reality of delayed implementation, and potentially weak enforcement, and the pitfalls of exchange design, and everything else that can go wrong.
I think Claire McCaskill is absolutely right here:
The Missouri Democrat said her party has probably oversold the legislation that just became law.
“The side on which I’m on, that voted for the bill, probably is overpromising, [has] not been clear enough about the fact that this is going to be an incremental approach over time, [and] the benefits aren’t going to be felt by most Americans immediately,” McCaskill told MSNBC’s Morning Joe.
Nevertheless, the Republicans have been over the top in demonizing the health bill, McCaskill said.
Let’s just be honest about all this, OK? Student loan reform is smart and 100% defensible in concept. The Affordable Care Act involved legislative compromise and must be watched carefully to ensure it achieves the promise that many liberals are touting this week. Rather than labeling it, we have to work to make it actually operate properly.