Earlier this week, HILFY asked a good question:
how the Obamaites were able to create the ACA so cleverly that Trump’s vandals still have not been able to kill it?
I am reluctant to ascribe detailed and granular levels of intentionality to the ACA authors regarding anti-sabotage design.
At the highest levels, the political theory was that people would like the benefits of the ACA and provide a growing set of invested constituencies that would rally to the defense of the ACA if need be. And we have seen that at the highest levels. People now expect per-exisiting conditions to be covered and they expect guaranteed issue. Medicaid expansion has not been completely rolled back even in Kentucky despite a governor that campaigned on rolling it back. At the highest level of interest group politics, there is intentionality.
At lower levels, I don’t know. I really don’t. I think the key decision to make the US federal government the prime risk holder for individual market premium spikes was a key decision that has insulated the subsidized market has acted as a systemic counter-sabotage buffer but I don’t believe that decision was made for that purpose.
One of the key things that we need to remember is that the ACA as signed into law was a cobbled together contraption of various things that no one expected to be the final say on the issue.
I’m working with a great set of co-authors on a non-related piece that should be going out next week. I created the skeleton for the combined writing plan. The initial version had sections titled: “Explain the strangeness” and “Something awesome happens here” with bullet points and key references to explain the strange and the awesome. We then filled it in a bit more before handing it off to the publisher where they then did a nice edit with a bunch of questions. We then polished the piece, accepting all of the suggested edits and tweaked a few things that on a second read needed to be explained and had a nice long discussion on the implications of a comma. And then we sent the piece back to the publisher who will make it go live next week.
The ACA as signed in March 2010 was past the skeleton stage. It was not the final, finished, polished product of a regular process. The House bill passed with the belief that a Senate bill will also pass where the final details and polishing would happen in a conference committee. That did not happen due to the election of Scott Brown (R-MA) as the Senate GOP caucus promised to filibuster the appointment of conference committee members. So we got the rough draft Senate bill that passed 60-40 on Christmas Eve as the ACA.
If Democrats in 2009 were trying to repeal proof the bill, they would have extended subsidies to everyone, they would have insisted on a single national risk pool instead of state based risk pools and they would have enriched subsidies so that someone making $100,000 would be paying $200-$300 a month in out of pocket premiums for a $1,500 deductible plan.
The decision to make the federal government the partial risk holder for premium increases has been a major shock absorber over the past two years but I don’t know how much intentionality can be attributed past that decision?
EveryDayIHaveTheBlues
Resilience?
Baud
I was at dailykos when Brown was elected and there were many diaries on the wreck list cheering the result because it would teach Dems a lesson.
Planetpundit
It could be said ACA is repeal-proof because the Dems took the best ideas from Repub health care (such as there were and what there was of them) pounded them into a more humane workable form and subsidized them to the degree that was politically viable at passage. There is no functional scalable system by going anywhere “right”. Leftward sends you into what was then the shoal strewn shallows of single payer. Which is where we lay drifting today. All future viable plans will be from the “left”. Of course, sane health care programs HAVE no ideologies.
Joe Falco
Could it also be because some of our enemies who are in the best position to damage the ACA the most are a bunch of twits? Twits that through a combination of “failing upward” and a lack of talent and/or expertise couldn’t craft legislation to get them out of a wet paper bag?
O/T
I was listening to a story on NPR today that Scott Pruitt’s EPA, despite Pruitt trying his best to be a super villain straight out of Captain Planet, couldn’t even write up a set of new rules to replace Obama-era regulations that could pass muster in court. The sad part of the story was that Pruitt is *gasp* learning from these early missteps and putting in the hard work to demolish EPA rules.
gene108
Heh….not bad for a rough draft…
MomSense
@Joe Falco:
They have damaged it, though. 3.2 million people have lost health insurance since 2017. That’s a lot of people. How many of them won’t be diagnosed when it is early enough to save their lives? How many people will lose their homes, lose everything because they did get diagnosed with something or had even a minor emergency and can’t pay those bills?
Joe Falco
@MomSense: Whatever that number turns out to be, it won’t be enough for those Moloch worshippers.
MomSense
@Joe Falco:
It’s so disgusting and I get so angry that they are never called on it by our media.
sheila in nc
Would love to have the cite when your piece appears.
David Anderson
@sheila in nc: I’ll brag about it here…
azlib
The one thing that always puzzled me in the ACA was the sharp divide between the subsidized population and the non-subsidized one. Do Congress critters not understand smooth functions?
dnfree
Yes, please do pass it on. I hadn’t thought in quite some time about the circumstances under which it had to be passed, and consequently that it really wasn’t the final version. I have also been very interested in your analysis of how some things done in the current administration have turned out to have the opposite effect of what Republicans had intended. But as you also point out, there has been real damage done. I wish there were some way to bring together a bipartisan consensus to fix it.
Ruckus
@azlib:
There is so much that many members do not understand that getting them to smooth functioning is almost a fools goal. Now some of that is self desired not understanding and some is just inability to understand anything past the 4th grade.
The Other Bob
@MomSense:
I am not sure 3.2 million people have “lost” insurance. I bet a bunch of them just feel it’s OK to not have it because there is no longer a penalty to being a freeloader. I am sure the price increases have pushed some out of the market and we are all paying more because of freeloaders who show up at the ER without insurance.
I am open to being corrected on my assumptions.
efgoldman
SURPRISE!
I am covered by Medicare Advantage.
Mrs efg, however, is nine year younger than I, and dependent on ACA subsidies of several hundred dollars/month until July 2019.
The subsidy amounts are reported on IRS form 1095, as many know.
The total amount of $$ shown on form 1095 is reportable and taxable as income!
Took us from ~$1200 refund to owing ~$600.
They out it in one pocket, take it out of another.
I’m sure it’s just the way Granny Starver planned it.
HILFY
Thank You!
HILFY
One of Obama’s few faults was that he thought “at the highest level” too often, being a superior type of guy.
Those of us with some down and dirty experience would expect the deplorables to act deplorably.
Tho I could never have expected anyone as thoroughly bad as Trump.
David Anderson
@dnfree: No it is not a history piece of the ACA, it is a “what if proposal XYZ is tweaked in a way to make it work better” piece…. I was just describing the combined writing process used between me and my co-authors.
David Anderson
@efgoldman: Go talk to an accountant as the subsidies are a tax credit and not a cash grant. That seems very odd to me.
Kelly
@efgoldman: I’ve never paid tax on the tax credit.
https://www.healthinsurance.org/faqs/if-i-get-an-obamacare-subsidy-in-the-exchange-is-the-subsidy-amount-considered-income/
Bob Hertz
David: Your second to last paragraph on what could have been done in a final effective bill is one of the best summaries I have encountered of the last 8 years.
Also worth noting is that the 2010 election results, driven by death-panel drivel and false fears of Medicare cutbacks, is why necessary improvements to the ACA became politically impossible.
Bob Hertz
Quick question David:
In your opinion, would the anti selection and death spirals happened anyways if we had better subsidies and a national risk pool? Hard for me to say. Guaranteed issue nornally leads to a death spiral in the absence of a mandate, but very large subsidies could postpone this outcome.
bob hertz
Chet Murthy
David, this sounds like nirvana. And honestly, while I’d love this, it also sounds like something people in that bracket shouldn’t expect and don’t deserve. Health care is 10% of the economy; I think it would be unfair for me to not pay 10% of my income in insurance premiums + deductibles, yearly. So …. I guess what I’m saying is, wow, I can see why the GrOPers worked so hard to block this — it’d have been electoral dynamite to their position.
David Anderson
@Bob Hertz: We’ll find out with Silver Loading.
Hypothetically $0 net of subsidy premium plans would be very attractive to healthy people but I really don’t know.
I think the national risk pool instead of the state wide risk pool eats up a lot of the idiosyncratic risk that 12 million people can eat but 40,000 can’t so it would have helped and made the partisan sorting reaction far less strong.
Bob Hertz
you are utterly actuarially correct about the national risk pool. Did anyone propose this in 2009, or was the federalism silliness dominant at the time?
It is absolutely no accident that California has had pretty stable premiums, whereas almost all smaller states have been a wreck.