Now that King v. Burwell was decided as it should also have been decided, with rejection and Muntzian laughter, what’s next for healthcare reform.
Legal
There are two sets of legal challenges still out there that could have significant impact on PPACA. The first is a challenge against the funding of the Cost Sharing Reduction (CSR) subsidies. The law authorized the money to be paid, but it was fuzzy if these funds were automatic funding (like Social Security) or discretionary funding. The Obama administration has been paying these funds as if they were automatically funded. To me, this sounds like a political dispute that the courts won’t want to touch.
The second set of legal challenges are the far more common set of challenges. “What does that actually mean…” For instance the law requires all insurance plans to offer reasonable access to all needed providers. Is a single PCP with an open panel 22 miles away from what someone lives, reasonable access? Is the CMS guidance sufficient to fulfill the law? I have no idea, let’s go to court.
Medicaid Expansion
Forty percent of the states still have not expanded Medicaid.
Costs
From a system perspective, Obamacare is part of the policy/economic mix that broke the second derivative of cost increases. This is a massive win at the federal fiscal level. However, part of the win is probably the proliferation of high deductible health plans which make people cut back from needed care. And so far, our pricing per unit of service is still way too high. As commennter Keith G notes:
Now that Obamacare has what seems to be an extended shelf life, we can turn our attention to the next health care battle. Life-saving pharmaceuticals are still priced too god damn high for Americans. This needs to stop. While I can afford the Obama care premiums every month, what I can not afford are the $1000 per prescription (x3 drugs) cost of my monthly stay alive drug supply.
Luckily I have AIDS….
We need to get higher actuarial value coverage to more people and bring down the costs per unit of service at the same time. Some of that will happen with narrow networks, some of it is happening with Accountable Care Organizations, some of that is happening to market pressures. We need to get the Federal Trade Commission more involved with a preliminary stance that most consolidation deals are a net negative to consumers.
Continued Expansion
In the Medicaid expansion states, we’re at about 80% of the probable maximum expansion. We need to get to 100% of probable maximum expansion and hopefully do a Michigan and blow by the coverage expansion goal. In the non-Expansion states, we’re probably at 40% maximum coverage.
Wyden Waivers
Section 1332/State Innovation/Wyden Waivers should be the next big set of discussions. These waivers allow states to meet Obamacare coverage and affordability goals through state customized plans with very few constraints. The Feds will pick up the cost of state experimentation. In a rational political universe, this should be extraordinarily attractive to conservative states as they get to try conservative healthcare solutions (besides dying quickly of course) with federal money. In reality, most of the action on 1332 waivers is coming from Blue states.
Drinking their milkshakes
Peter Suderman (husband of McMegan, and general libeterian dude-bro) had a good point about conservative healthcare policy in a recent Politico article:
Republicans have already lost, because when it comes to larger health policy goals, the party effectively doesn’t have any beyond the repeal of the Obamacare. In the long term, Republicans can’t win this fight because they don’t know what winning means….Obamacare, in other words, was ClintonCare’s second act—the culmination of more than 15 years of work and consensus building. To put it another way: Republicans never started working on health policy; Democrats never stopped.
Policy victories will go to the Democrats on health policy for a very simple reason; they are the only ones with any political backing who are engaged in examining pro-active policies. Republicans can veto and say no, but they can’t advance active changes because their policy translation apparatus from a few wonks to actually writing legislation is broken.
Cervantes
You don’t think it’s just that, when it comes to most of what we call governing, they are completely nihilistic?
Baud
If I were one of the liberal justices, my concurring opinion would have been a picture of Nelson Muntz pointing to Scalia’s dissent.
Obama probably did the right thing going with Sotomayor instead.
Frankensteinbeck
They don’t WANT any. Do not make the mistake of thinking your enemy shares your values.
JPL
@Frankensteinbeck: That’s no quite true.
My representative Tom Price has a plan that Richard was kind enough to dissect and then shred to pieces.
WereBear
No, because they are more than willing to write a law proclaiming capital punishment for public nose picking.
PhoenixRising
Your mouth to…etc…on the CSRs as a political issue. The fact that we got to yesterday scares me badly.
Sorry I missed the cackling, really.
raven
@PhoenixRising: What wouldn’t scare you?
SRW1
Suderman’s point of conservatives not being able to come up with a coherent and workable plan of their own also explains the tardy response of red states towards Wyden waivers.
IGMFY is a hard to overcome disincentive.
JPL
@PhoenixRising: This is from Linda Greenhouse’s column in the NYTimes
Frankensteinbeck
@JPL:
A) It’s hard to feel self-righteous if you say out loud that you like hurting people, and they simply must feel self-righteous. So many conservative positions are about feeling self-righteous.
B) Having an alternative plan is very useful if one of your biggest motivations is a bedrock belief that a black man cannot ever be smarter than a white man, and you want to demonstrate that publicly. Your plan doesn’t have to work or make sense, because you are automatically smarter than the black man.
LarryB
Democrats today occupy the same policy space as the Republicans of the last generation, except browner and gayer. It’s hard to feel like this is a huge win. As for today’s Republicans, we didn’t “break” their policy apparatus so much as co-opt it and that has just driven them batshit. The great irony of the 2012 elections was that Romney had to run away from his signature accomplishment as Mass. gov.
Davis X. Machina
This ain’t over… any more than segregation
Untreated chronic obstructive pulmonary disorder now!
Untreated chronic obstructive pulmonary disorder tomorrow!.
Untreated chronic obstructive pulmonary disorder forever!
the Conster
OT, but big terrorist attacks in France Tunisia and Kuwait happening, killing dozens. Seems coordinated.
Davis X. Machina
@the Conster: Ramadan just kicked off last week.. Some ‘holy month’.
Frankensteinbeck
@LarryB:
This is not true, no matter how often people say it. Democrats are for expansion of civil rights, improving the safety net, improving environmental regulations, improving business regulations, increasing taxes on the rich, increasing domestic spending on all fronts, and limited interventionism. A generation ago, Reagan was doing his damnedest to put as many black men in jail as possible, villainize welfare and cut it back, annihilating (James Watt) the environment, deregulating business (he got us INTO this mess), shifting the tax burden to the poor, telling everyone the government doesn’t work and shouldn’t do anything, and cowboy diplomacy.
What has changed is that Reagan got his way for 35 years, and we’ve got a Hell of a lot of ground to make up to even reach where we were then.
Davis X. Machina
@Frankensteinbeck: You don’t remember? Back in the late Carter administration, we were this close [….] to having Fritz Hollings, Howell Heflin, David Boren, Sam Nunn, and John Stennis usher in a northern European social democracy.
Then Clinton, DLC, school uniforms, etc. etc.
GregB
Besides starting wars, giving tax breaks to their rich friends and jailing and killing US citizens, do the Republicans have an agenda?
Bobby B.
Muntzian laughter and Homerian who-hoo!. My classical education in Bonerland has served me well.
Ayn Randy
I think this was taken care of in the first few posts, but they can’t advance changes because they don’t believe in it.
Steve in the ATL
@JPL: I feel your pain–I live in Tom Price’s district as well. Never thought I’d miss being represented by Cynthia McKinney….
Betty Cracker
@Frankensteinbeck: Thank you. I get tired of hearing that bullshit all the time and usually don’t even bother to refute it, but someone should, every fucking time. Because it’s defeatist bullshit like that that discourages folks from voting.
FlipYrWhig
Isn’t the Republican approach to health policy basically “if you don’t like your health insurance, get a better job” crossed with “welp, buddy, if you think you’ll need a doctor anytime soon, guess you’d better start saving up”? You know, “liberty” and “personal responsibility,” i.e., you’re on your own, loser pays?
Cervantes
@WereBear:
Right, but I wouldn’t include that sort of thing in “most of what we call governing.”
beltane
@Davis X. Machina: A Shia mosque in Kuwait was one of the sites attacked today. Violent fanatics think everything they do is holy.
Redshift
@Frankensteinbeck: It’s also more effective for long-term opposition. Remember, the Heritage Foundation plan (which led to Romneycare and was part of the compromise for Obamacare, though not as much as many people think) wasn’t intended to actually be enacted, it was intended to allow Republicans to claim they had a plan to disrupt the process of building a coalition for the Clinton plan. Just saying no works for a while (longer than I’d like), but it leaves them more vulnerable to shifting political winds; less “both sides” plausible deniability.
RSA
Republicans will work mainly in political rather than policy space. It may be that eventually Obamacare (under some other name) will have as much lip service from Republicans as Social Security and Medicare (but not Medicaid–it’s for the poors), but of course behind the scenes they’ll be working to deregulate and privatize it in the name of freedom.
FlipYrWhig
@Davis X. Machina: Back in the good ol’ days, Democrats were Democrats. Like Richard Shelby.
Cervantes
@LarryB:
Which “Republicans of the last generation,” and what are the general contours of that “same policy space,” as you see it? (Thanks.)
WereBear
@Cervantes: Oh, you’re right. It’s not governing!
Cervantes
@Davis X. Machina:
I can’t tell you how much I miss that lot.
@FlipYrWhig:
I can’t tell you how much I want to miss him.
Redshift
@FlipYrWhig: Don’t forget going to the emergency room, while at the same time being opposed to the requirement for hospitals to provide emergency care and lauding companies that don’t offer meaningful health insurance.
chopper
four boxes.
Kropadope
@JPL:
Link, por favor?
@Frankensteinbeck:
I think the confusion here is because anyone who is serious about governing has moved to the Democratic Party. It’s not just about role and scope of government anymore. It’s about whether you want a government that can provide prosperity for everyone or just a few.
So, what we have is a handful of former Republicans who are now dedicated Democrats and Democrats broadly wiling to accept good Republican ideas (to the extent that such a thing exists) for the sake of consensus building.
Elizabelle
@chopper: Thank you. Logged on to SCOTUSblog. Haven’t ever followed that in real time.
I am thinking of Clementa Pinckney and the Charleston murdered today.
Of course, the world goes on, and we have mass murder abroad too.
Interesting to me that one decapitated in France is “terror”, but NYTimes will never use that for white “primacy” (its word) crimes domestically.
FlipYrWhig
@Redshift: Republicans do seem to like the idea that people might get crushed by medical expenses. If improvident people live longer and healthier than they deserve, moral hazard, no backsies, infinity.
chopper
ssm is up. kennedy’s opinion
chopper
Holding: Fourteenth Amendment requires a state to license a marriage between two people of the same sex.
FlipYrWhig
@Kropadope:
The one area in which Republicans have retained a great interest in governing: uteruses.
chopper
And to recognize a marriage between two people of the same sex when a marriage was lawfully licensed and performed out of state.
5-4
chopper
BAM, MOTHERFUCKERS
chopper
four individual dissents!
Elizabelle
YES! Same sex marriage is a go. Kennedy has the opinion?
the Conster
STATES MUST ISSUE MARRIAGE LICENSES!
What a week!!!
SiubhanDuinne
YES to SS marriage! Way to go SCOTUS!!!!
A Ghost To Most
Same-sex affirmed. Yay!
Great week for America, lousy week for wingnuts
FlipYrWhig
@chopper: w00t
beltane
Not a good week for wingnuts, but at least they have Bristol Palin’s happy news to celebrate.
Cervantes
@Elizabelle:
Yes.
elmo
::crying::
A Ghost To Most
@beltane:
That is the rose on the (wedding) cake.
raven
Blubber Blubber, “We’ll overturn this too”!!!
Cervantes
@beltane:
On the other hand, I can think of three reasons not to discuss that “news.”
chopper
i’m a need to bring an umbrella outside, cause conservative’s heads all asplode.
Elizabelle
@elmo: So happy for you, elmo.
And you and mrs. elmo MUST come to a Balloon Juice meetup this year. We will do Southern Maryland, if it suits.
Mike in NC
Another setback for the GOP 2016 Klown Karavan.
Cervantes
@elmo:
Eleven years almost to the day since those vigils in Massachusetts.
Celebration now, then more work.
A Ghost To Most
Has Fat Tony released his temper tantrum yet?
NonyNony
@LarryB:
This is a lie. An out and out lie. You may have been lied to by others or be lying to yourself but recognize that it is a lie.
Democrats today occupy about the same policy space they did in the 1960s except without the Southern flank of the party. They have always been spread across the political spectrum – the Dems have never been a “liberal” party. They have always been a big tent party that includes liberals, moderates, and even some conservatives (though the Dems in 2015 are substantially less conservative than the Dems of the 1950s, and somewhat less conservative than the Dems of the 1990s).
Ask yourself this – if this policy is what Republicans a generation ago wanted, why wasn’t it in place a generation ago? Why didn’t Nixon push for it? Why didn’t Reagan? And the answer is because they didn’t want it. Republican positioning for legislation like the ACA has always been about positioning – a fake legislation to hold out to Dems to say that they have an alternative.
But make no mistake – Republicans have been against the expansion of government into healthcare for MULTIPLE generations. New Deal era Republicans fought against it. 60’s era Republicans fought against it. 70s era Republicans fought against it. Reagan-era Republicans fought against it. 90s Republicans made it a hill to die on against Clinton. Fighting against any expansion of the government into the healthcare arena has been one of their major policy planks for a hundred years. So stop kidding yourself.
Cervantes
@A Ghost To Most:
Again, yes.
elmo
@Elizabelle: Thanks. SoMD is a cultural moonscape. We could do National Harbor!
FlipYrWhig
@NonyNony: I think there’s a case to be made that 21st-century Democrats are less populist and/or supportive of labor than 20th-century Democrats were. 20th-century millionaires with consciences were Republicans; now Silicon Valley and hedge funds are Democratic interests. So there’s less alignment between rich:poor and Republican:Democrat than there used to be. But that’s also because a lot of hardscrabble people reacted badly to the culture wars and the browning of America and drifted into the Republican fold.
Kropadope
@NonyNony:
Part of the issue is that the left wing of the party has been cowed and/or shut out by leadership. Democrats look more like Republicans to a lot of people because their focus, particularly in the Obama years, has been on meeting policy goals with market-based solutions, not full government control. Socialists have been pretty much shut out. (I think this is a mistake for the D leadership, it’s good to show where all the markers are being lain so that our Represtantives actually look representative of the polity)
Didn’t Nixon try to institute some version of single-payer? Wasn’t it the Democrats who sunk Jimmy Carter’s hopes of single-payer?
ruemara
They need to add in cost of living adjustments. I’m in default — again – at my second attempt to have health care. That extra $175 is killing me, but I have a chronic health condition, which means I need coverage. I’ll be under the gun trying to get things squared away in the upcoming five months, just because this month, I’m trying to spend my money on getting a career underway. The affordable part of the ACA needs to be fixed.
FlipYrWhig
@Kropadope:
You may be overestimating the number of soc1alists in the Democratic Party or who have ever been members of the Democratic Party.
Kropadope
@FlipYrWhig: I didn’t say that there were a lot of them, just that they’re there and have earned a platform to present their ideas. Also, Democrats have put forward single-payer proposals in the past. Not only is single-payer not on the table now, but the law had to be stripped of the public option to pass.
Elizabelle
@elmo: National Harbor would be great! Not been there yet, and easy for Virginians and DC. We will make it happen.
WaterGirl
@ruemara: I’m sorry ruemara, I wish it wasn’t so.
A Streeter
@Elizabelle:
Sadly, no. NH is deliberately designed to capture its audience by, in particular, being almost completely inaccessible other than by car. It is far from Metro and has almost no bus service. As a car-light DC resident,I would not be able to go to a meetup there.
jody in paris
when friends of friends on fb are complaining about how unaffordable their policy is or how they got dropped for being too sick — in general, who/what should they contact? in 2014 there were allegedly people helping with this — are there still, and who? thanks.
Elmo
@A Streeter: ah crap. Never thought of that.
Richard mayhew
@jody in paris: navigators are the helpers and they are still out there. However the dropped for illegitimate reasons complaints should go to either/both state attorney general office and state insurance commissioner plus a CC to the local paper
jody in paris
@Richard mayhew: thanks. i’ve passed the information on. i needed it after i said that the insurance company must have lied …happy to live somewhere where i pay more than i think i should but know it goes towards people who can’t pay so that we’re all covered.