TRB MAY 5, 2011
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One of the things Republicans seem to have forgotten, in the wake of the introduction and swift passage of their Dickensian budget crafted by Paul Ryan, is their unshakeable commitment to health care reform. Remember that? Throughout the health care debate, they were determined to rally around their own reform plan. And now the House has passed a long-term budget that yanks health insurance away from more than 40 million Americans and neglects to put anything in its place. Maybe it’s just an oversight, like the time in freshman year when I turned in a history paper with no bibliography. But it’s kind of starting to look like the Republicans don’t actually plan to do anything for the uninsured.
The history of the elusive Republican quest for a health care plan dates back at least to 1993. President Clinton had proposed comprehensive reform; the public believed the system to be in crisis. Congressional Republicans came up with a combination of subsidies, market regulation, and an individual mandate that presaged the law eventually signed by President Obama last year.
But as the debate dragged on, Clinton’s plan sunk, and Republicans backed away from their proposal, insisting it was better to start fresh the next year. “We don’t have to do it all this year,” GOP Senate leader Bob Dole announced in 1994. “You know, Congress meets every year.” Republicans promptly took control of Congress but never managed to get around to reforming health care the next year or any of the dozen years in which they ran the place.
That’s where things stood until 2009 when, having regained first the Congress and then the White House, Democrats coalesced around a health care reform plan similar to the 1993 GOP version. Even though voters backed most of its specific elements, they opposed the plan itself. Yet the public considered the status quo totally unacceptable and overwhelmingly favored a sweeping overhaul. Even at the trough of support for reform, Americans, by a 30-point margin, wanted Congress to keep trying to pass a comprehensive plan.
And so, whenever Democrats accused Republicans of trying to deep-six the whole project, conservative lawmakers would respond with indignation at this vicious slur upon their reputation. It’s “ludicrous,” said one. “Completely untrue,” insisted another. Republicans earnestly claimed they wanted to “start over,” so as to expand coverage and control costs without forcing anybody to change anything. A few sad little gestures popped up in Congress, but nothing like a “Republican health care plan” ever emerged.
Taking control of Congress again this year, Republicans immediately set about undoing health care reform. Carefully following the advice of pollsters, however, they insisted their true goal was not to overturn the law but to “repeal and replace.” The effort began with a straight-up vote to repeal health care reform and replace it with, technically speaking, nothing whatsoever. But fear not! “Repeal is the first, not the last step,” wrote Ryan and four other Republican chairmen. “Compassionate, innovative and job-creating health care reform is what’s next.”
Alas, the race to discover this compassionate, innovative, job-creating health care plan has proceeded with all the urgency of O.J. Simpson’s search for the true murderer of his late wife and her paramour. The effort began with earnest proclamations of intent. Take, for instance, Representative Fred Upton, who, as chairman of the Energy and Commerce Committee, held the responsibility for crafting the long-promised legislation. “We recognize that there are reforms that are needed. We’re not going to just sit on our hands and do nothing,” he promised on January 17, two days before the repeal vote. Three days later, he averred, “We will use every tool at our disposal to dismantle this law and develop a better path forward.” That same day, he promised once more, “Today is day one of our effort to replace ObamaCare with something better, a lot better.”
Days two through 106 have passed with no sign of an alternative plan. Congress held hearings lambasting the Affordable Care Act, but made not even a token attempt to craft a substitute. Repeal-and-replace simply morphed into repeal-and-more-repeal.
By the time Ryan unveiled his budget, Republicans had discarded the “replace” pretense entirely. And so they voted for legislation that not only eliminated health insurance for the 30 million Americans covered under the Affordable Care Act, but hacked a staggering $771 billion out of Medicaid’s budget over the next decade, throwing millions more off the insurance rolls.
Was this perhaps some kind of short-term measure designed to clear out budget space for a future health care reform? Oh, no. Ryan didn’t even gesture toward setting aside any funding to cover the uninsured in a budget plan that claims to extend past 2050.
Conservatives adore Ryan’s budget perhaps because it liberates them from the exhausting burden of pretending to care about the uninsured. It begins with the assumption of perfect markets everywhere and dispatches any attempt to correct for market failures—by, say, covering the uninsured—in purely ideological terms. (Subsidizing insurance for those who can’t afford it leaves them “helplessly dependent on their government.”) Inside this snug little loop of reasoning, if the answer isn’t the free market, you’re asking the wrong question.
The truth is that Ryan lacks the courage to spell out his premises. In 2007, he opposed a modest bill to expand coverage to some uninsured children. “We need a more comprehensive fix,” he insisted. In 2010, he argued that comprehensiveness was the whole problem. “Let’s scrap this bill and start over,” he pleaded. “Let’s focus on step-by-step, common-sense reforms that lower health care costs.”
Neither Ryan nor his adoring fans will actually concede that they want to leave tens of millions of Americans uninsured, preferring to overlook the ugliness of the reality for the beauty of the abstract concept. Republican economist Douglas Holtz-Eakin exalted: “Under this plan, there is a vision of small, contained government that supports rapid economic growth, is fair to future generations, and restores America’s exceptionalism.” If Ryan gets his way, America, the sole advanced economy in which citizens who contract treatable illnesses routinely go bankrupt or die of neglect, would retain this exceptional status.
Jonathan Chait is a senior editor at The New Republic. This article originally ran in the May 26, 2011, issue of the magazine.
Follow @tnr on Twitter.
24 comments
Obama and the Senate Democrats need to hold the line on the ACA and against the Ryan/Repub budget proposal. I would agree with those who say that Obama must be more forceful in opposing the Republican budget proposal and in explaining to the voters exactly what it is. The Republicans have been very skillful at persuading many voters that screwing the poor and middle-class in favor of the corporate sector is somehow good for the poor and the middle-class. But once people understand what the Republican agenda is, it will go down in flames. Dhurtado
- NR143296
May 9, 2011 at 7:51am
They need to do more than hold the line. They need to attack the Republican framing relentlessly. Attack, attack, attack them for what they are. Just say out loud, over and over again, that they only thing Republicans have ever proposed is to let Americans, seniors and low-income working families, parents and children, who cannot afford healthcare get sick and die. "That is not the America I know. I don't think that is the country that most Americans want to live in. We did not become a great nation by abandoning our neighbors to a lonely, painful death."
- roidubouloi
May 9, 2011 at 8:13am
There is no evidence that Ronald Goldman was anything more than a casual friend of Nicole Simpson, and he was murdered for no other reason than he was returning some sunglasses. In an article debunking Republican falsehoods, you should show more sensitivity to the truth yourself.
- polijunky
May 9, 2011 at 8:32am
Well, as Chait has pointed out, the Republicans come up with LOTS and LOTS of Health-care plans. That they all share the problem of being unrealistic, cruel, promote the current status-quo, totally Free-Market based, and involve Repeal BEFORE you actually know what they are, is an implementation detail.
- AllanL5
May 9, 2011 at 8:53am
I don't disagree roid. But even holding the line is a bit more than we have seen so foar. Dhurtado
- NR143296
May 9, 2011 at 8:57am
But they are one and the same, dhurtado, because it is not possible to just "hold the line" indefinitely while under attack. If you concede the initiative, the offense, to the other side, your defenses are destined to crumble eventually. In short, the line cannot be held more than temporarily while a counter-attack is mounted; there can only be a successful offensive or the line and the battle will be lost.
- roidubouloi
May 9, 2011 at 10:04am
Actually, as someone who has researched this area, the truth is that the Republicans have never come up with a plan to cover the uninsured. No Republican president has ever proposed a plan and no Republican nominated for president has ever proposed such a plan. The closest they came was the first presidential candidate to call for universal health insurance was Theodore Roosevelt when running as an independent in 1912. Interestingly, Otto von Bismarck put universal health insurance into place in Germany to outflank the Socialists. Our own right-wingers apparently feel no similar need when it comes to "socialist" Obama.
- Millenson
May 9, 2011 at 10:06am
Actually, I believe you can go back even further: Nixon proposed reasonable health reform program, that was rejected by Republicans. As long as the un-educated public follows the lead of the mindless 24-7 news cycle, and the sensible middle lies back and accepts the drivel, health care will not be improved, and we will face deficits that could easily be cured through entirely reasonable tax reforms. When Republicans, and theTea Party minority can get help from the mindless media to convince the middle that a) ACA has no-good features because they object to one feature, and b) that taxing the top 2% more to close the deficit is an "unacceptable tax increase," even though it would not affect the other 98%, progress is not possible. Like it or not, an honest media can get us out of this mess that they, largely, have created!
- namobo
May 9, 2011 at 10:24am
The grotesque irresponsibility of the Republicans has been much in evidence. The irony, of course, is that serious reform of the healthcare system based on universal coverage is really the only way the country will regain its fiscal balance over the long term. Shrinking government services, whatever relative merit that may hold, will never solve the fundamental challenges besetting the federal budget. The essential problem with the GOP is that, rather than committing to the basic structural reforms that are required, it is content to simply be a passive reflection of our dysfunctional, Frankenstein-like healthcare system together with its contradictory profit motives.
- asterix54
May 9, 2011 at 11:36am
Roi & NR.".. it is not possible to just "hold the line" indefinitely while under attack. If you concede the initiative, the offense, to the other side, your defenses are destined to crumble eventually." Exactly the point I have been making for over two years re BHO and the Dems (especially Senate Dems). They have played defense from the get-go when then had close to supermajorities in the Senate. The bases fror our current economic mess are Repub policies and costs (about 2T$ to date) of tax breaks for the wealthy (and some others), an unnecessary war and the unnecessary continuation of an originally-necessary war(also about2T$ total), and the great recession due in large part to lax regulation (over 1T$ and counting to 2T$ and more). Add to that and an inefficient and costly health care system that costs 16-17% of GNP compared to better systems costing 8-11%/ year (many T$'s in a decade) largely due to intactable Repub opposition. I haven't heard that point made consistently and strongly by BHO. I've mostly heard a little bit of grousing. I haven't seen policies proposed to really correct the problems. I've seen at best weak half-measures that often empower those who created the problem in the first place. [Note that the ACA is much more insurance reform than heath care reform, and most of the public have seen few benefits from it.] BHO and the Dems over two years ago had a golden opportunity to reverse much or all of the dsasterous policies described above. They barely tried even to hold the line--- and have empowered an opposition devoted to their demise. Politicians in the Neville Chamberlain mold mean well, but do not handle intractable opposition well--- and Osama bin-Laden aside as a one-off individual with little real power, BHO has not yet shown himself capable of dealing with intractable domestic opposition. It's not a common or popular position, but I hold the populations of Germany and Italy in the '30s, Iraq in the 90's, and Iran, Korea, Libya, Syria, Thailand -- as well as Japan, Ireland, Iceland and the US- today as responsible for their government. Only if under foreign control does a popluace have an excuse the equivalent of "they made me do it". So almost all of y'all agree the US has a problem.. What's a solution? Grouse about it among yourselves? Work to enable BHO and the Dems to continue to enact half-baked policies designed to fail in a few years, rather than a few months?
- drofnats1
May 9, 2011 at 1:46pm
I wish I knew. Despite my occasional fantasies that the Dems should just stand aside and allow the Republicans to destroy the country to the point where people finally figure it out, I don't think we have a lot of alternatives. Mostly just urging the powers-that-be in the Democratic party to do the right thing and scorching them with criticism when they don't.
- roidubouloi
May 9, 2011 at 1:53pm
Here's a real problem - many people - perhaps especially younger people busy leading their own lives - are simply ignorant of what is going on in Washington. Not to overgeneralize but I've been shocked recently by the fact that some of my brightest and best educated young friends have zero idea what the Republicans have already passed in the House budget let alone what they intend over the long run. I don't know how to get more Americans interested and aware in the world around them. But the electorate has to be both informed and concerned otherwise a minority will prevail. One could argue they already have - how many simply didn't bother to vote in 2010?
- Sophia
May 9, 2011 at 1:56pm
Roi. My own assessment is that there is a very good chance the US -- and the rest of the world-- are indeed headed for an economic Armageddon. The pattern of the graphs are different than 1929---but the fundamentals are there. Maybe we'll somehow get lucky and stop the current trajectory leading to an imploding Euro , and a raised the US debt limit and/or a 2012 budget w/o BHO agreeing to budget changes that near-guarantee a continued Great Recession that really will and should be attributed in good part to his actions and policies -- while he celebrates the "bipartisan agreement" as the economic equivalent of "Peace in our time". Its risky, but the only slim hope I see is a crisis produced at this time by NOT raising the debt limit for which Obama and the Repubs get equally blamed. Quite frankly, better a crisis 2-3 years into a Great Recession giving some hope of digging out, as opposed to 6-8 years of a Great Recession with no realistic hope of digging out--- and Progressive economic policies scapegoated for the disaster. We and Britain dodged that scapoegoat solution 80 years ago--Japan, Germany, italy, Poland, USSR, etc, etc did not. However, acceptance of inappropriate scapegoats knows no ethnic, national,or religious boundaries.
- drofnats1
May 9, 2011 at 5:00pm
To those of you who have commented thus far: angry words, contempt, arrogance, cheap posturing, and affected sophistication have marginalized you. You won't make any difference in the health care debate - not that many of you want to or are even able. You lack the knowledge and experience to be effective. You're the Republicans' best friends!
- rgglsg
May 9, 2011 at 7:06pm
That was insightful, rgg. Why don't you tell us how you see things? Tell us how we are going to achieve and maintain a healthcare system worthy of an advanced industrialized nation in the face of the Republican party and the Tea party and Cato, Koch, and the rest of them. Explain what will work, please. I don't think things are quite that bad, drof, but not for want of trying. And you won't get your wish. The debt ceiling will be raised. My biggest fear is that all this spending cutting, which you and I both know is the opposite of what we ought to be doing in a recession/recovery, will push us into a double-dip and cost the election of 2012. If we can get by that, there is perhaps a window. But nothing will be achieved by refusing to join political battle with the Republicans. There is no other way out (until rgg 'splains it to us, that is).
- roidubouloi
May 9, 2011 at 7:17pm
Republicans will come up with a viable health care plan that benefits all citizens when the Derivatives party finally regulates Wall St. All you need to know about the "liquidity trap" and what's reflected in the global economy can be summed up in one factoid: "Consumer credit is actually shrinking (excluding student loans) while margin debt (the amount that speculators borrow to buy stocks) continues to soar." As for the lost decade to come? You've already had one, you're now entering your second: http://finance.fortune.cnn.com/2011/04/20/lost-decade-weve-already-had-one/ "Either way, Arnott estimates, true, wealth-generating U.S. output is at 1998 levels."
- IggyPop
May 9, 2011 at 7:43pm
Roid, I don't quite understand your penchant for pecking at the people who are in the foxhole with you. If you read my post at 7:51 am, you will see that I am not speaking of holding the line in the sense that you a drofnats are speaking of it. I am talking about blocking the Republican agenda regarding the budget in a way that Obama and the Democrats have NOT done with regard to the ACA, the expiration of the Bush tax cuts, or the short term budget, and exposing the Republican agenda for what it is. So I'm not sure how, or even whether, we differ. That said, it is not necessarily true that defense and counter-punching can never be successful. To use boxing as a metaphor, the most successful boxers are in fact boxers; they employ good defense and counterpunching skills, and, at the right time, will unload devastating power punches. Fighters who aggressively go on offense from the start often get KO'd by good boxer-punchers. Dhurtado
- NR143296
May 9, 2011 at 10:09pm
Finally, someone gets it right. Every debate about health care reform starts with the same false premise: both parties want to solve the problem of the uninsured; they just disagree on how to do it. This is complete nonsense, of course, but no one seems willing to believe that the Republicans could be so heartless and morally bankrupt that they would actually support denying health insurance coverage to millions of Americans with pre-existing conditions. But if you listen to what the Republicans are saying, it couldn't be clearer that they see the uninsured as an outcome, not a problem. For Republicans, the source of every problem is government interference and the solution to every problem is the free market. This leaves no room for government action on the uninsured, and if millions of Americans are denied coverage in a "free market," so be it. The only reason the GOP spewed lie after lie about death panels and "government-run" health care was because they wanted to shift the debate away from the ugly truth about people with pre-existing conditions. And shame on the media and the Democrats for letting the GOP get away with it.
- kkamisar
May 9, 2011 at 10:51pm
Liberals, like the Bourbons, have forgotten nothing and learned nothing. In the face of the looming bankruptcy of Social Security, Medicaid and Medicare their solution is to pour good money after bad until the US goes the way of Argentina, Spain, Greece, Italy and so many other countries that have taken the socialist path. Those programs all need major reform but "liberals", who are the real reactionaries of our time, resist the changes that would be needed to make them viable in the future. All this should obvious to anyone reading the above posts. There is no analysis, no understanding of basic economics, so sophistication of any kind. Instead we get name-calling and insults directed at those who dare offer evidence the liberal emperor is butt naked.
- bulbman1066
May 9, 2011 at 11:08pm
typo: For "so sophistication of any kind" read "no sophistication of any kind".
- bulbman1066
May 9, 2011 at 11:10pm
I look in vain for the "analysis" in your post bulbman. The "naked butt" is that of the Ryan plan, which "reforms" Medicaid and Medicare by virtually eliminating them, and which does not seriously address the deficit because it refuses to address the revenue side of the problem. Dhurtado
- NR143296
May 9, 2011 at 11:23pm
roidubouloi - Some 20 percent of Medicare beneficiaries suffer two or more chronic diseases - notably, cancer, Alzheimer’s disease, cerebrovascular disease, heart disease, diabetes, chronic obstructive pulmonary disease, and end stage renal disease - yet they account for approximately 80 percent of Medicare spending. The incidence and prevalence of these diseases will increase substantially over the coming years as the American population ages. But to control the unsustainable yet ever-increasing cost of health care, the cost of chronic disease care must be limited. ObamaCare would do this through public policy decisions that limit what kind and how much care people with chronic diseases could receive. How? ObamaCare will give us "evidence-based” medical care rationing. Here's how it will work. According to the Centre for Evidence-Based Medicine at the University of Oxford, "Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients." In a single payer/limited payer health care system, the government will define "best evidence" based on "comparative effectiveness" studies produced by government agencies and contractors, and blessed by advisory groups of true believers. "Quality care" will be that which is "evidence based". The government will make health care policy decisions based on its "best evidence" and its advisory groups' definitions of "quality care". This will be called "evidence-based policy making". To illustrate. There is clear evidence that as people age they become less productive and more dependent on others. They contribute less, and they consume more. There is irrefutable evidence that people die. Consequently, there is an evidence-based justification for limiting - and even denying - medical care to unproductive people who will die anyway. (Perhaps Scrooge had a point: “Let them die…and decrease the surplus population.”) But RyanCare would would bend the cost curve down by making low benefit, high deductible insurance plans all that the great majority of people could afford to buy. One way or the other, the problem will be solved. Choose your poison.
- rgglsg
May 9, 2011 at 11:29pm
"But RyanCare would would bend the cost curve down by making low benefit, high deductible insurance plans all that the great majority of people could afford to buy. One way or the other, the problem will be solved." RGG...I have yet to see any evidence that Ryan(s)Care would bend the cost curve down. Unless you mean the direct cost to the tax payer. But then when those low benefit, high deductible plans hit their benefit ceiling the elderly and others with chronic disease can just go to the emergency room for treatment where the tax payer is indirectly paying for it. In fact, the irony of those who tout Ryan(s)Care as the real deal point to projections 10 years into the future while simultaneously claiming that the CBO's 10yr projections for cost savings under the ACA are fantasy land wishes. Yet the CBO projects that Ryan(s)Care would do nothing to limit or bend down the cost curve because there is no incentive or dis-incentive to do so by healthcare providers and insurers. Why? Because Ryan(s)Care has nothing in it to provide any sort of incentive. Unless you consider a dwindling voucher value an "incentive." You state in your post that those 20% under Medicare have chronic diseases that require continued care & treatment. Yet by your post, you imply that ACA, will through "evidence-based policy making" will result in the irrefutable evidence of people dying. The purpose of "evidence-based policy making" is not to deny individual care but to set up quality of life vs. cost benefits for particular procedures or treatments that do little to nothing to increase or add quality of life to an aging population other than to drive up costs and keep the medical industry fat with profits. But then...under Ryan(s)Care's low-benefit, high deductible program you can die much sooner because you won't even HAVE the ability to get denied coverage once you've maxed out your benefits with your chronic disease. The difference between the ACA and Ryan(s)Care is that the ACA will guarantee continued treatment but grandma might not get that hip replacement for her 85 birthday, whereas under Ryan(s)Care...granny can go out and shop around hoping that some insurer will pick her up, cover her costs and hope that as her "voucher" drops in its purchasing power, she doesn't go bankrupt under the "magical free-market land" that Ryan(s)Care believes it will provide. IF that were the case, then we wouldn't have needed the ACA in the first place right? I mean, didn't the free market work so well to begin with? What stopped granny from going out and getting her free-market insurance plan? Oh yeah...that's right. Pre-existing, chronic conditions that insurers can't make profits off of. You want to fix the issue? Then make single-payer insurance the default program for every citizen and then if you want additional coverage or opt-out you can go out and buy it. I'm sick and tired of having the discussion with those who think that somehow medical care is privilege in this country.
- singlspeed
May 10, 2011 at 12:23pm
rgg and all, Contra bulbman's foolishness, it is the right that never learns anything and never forgets anything because it has never learned anything in the first place. That is so, however, whether it is publicly or privately paid for. Right now, 17.6% of our GDP goes to healthcare, and rising, whereas in France they spend 11% of a smaller GDP per capita, cover everyone, and have medical outcomes as good as ours. If 20% of our productive capacity is used up for healthcare, that means we have only 80% for everything else. Given the size of our military commitments, in the neighborhood of 5% of GDP, the problem is clear. If we do not control medical costs, we are going bust. There is no question that, unchecked, medical costs are going to ruin the economy. There are, however, two ways, and only two ways, to ration care and control price: by willingness and ability to pay or by fiat. Ryan and rgg want to make the allocation by willingness and ability to pay. If that continues to be by private insurance, costs will not be reined in, as they have not been, because the consumer does not pay directly. At the same time, millions will be denied care, or received care at public expense, as they have been. Ryan proposes basically to eliminate Medicare in favor of a small and declining subsidy. That solves nothing. It does nothing for insurance costs. It simply puts the country in a posture where those who cannot afford health care are welcome to get sick and die.
- roidubouloi
May 10, 2011 at 2:12pm