Tuesday, September 17, 2013

Jonathan Chait explains the curious mixture of dismissive contempt and intensifying panic in the right-wing crusade against Obamacare

Last week Paul Krugman posted an item on his blog that cuts to the heart of current right-wing doublethink about Obamacare:
I’m sure someone else has pointed this out, but there’s a fundamental contradiction at the heart of the right’s anti-Obamacare strategy — I mean, aside from the fact that it isn’t going to work, and may do immense damage both to America and to the Republican brand.

On one side, as Jonathan Cohn points out, inside the right-wing bubble it’s taken as gospel that Obamacare will be an utter, obvious disaster [....]

But if the right really believed this, it should be happy to let Obamacare come into existence, then collapse. The last thing Republicans should want is to let Democrats snatch victory from the jaws of defeat by provoking confrontations over the budget and the debt ceiling before the American people get to experience the nightmare of expanded insurance coverage.

In fact, politically the right is acting as if it fears that Obamacare will, in reality, be highly popular — that once the exchanges and the Medicare Medicaid expansion go into effect, people will decide that they like the new system, and strongly oppose efforts to reverse course. (This is almost surely the more realistic view.) So the law must be stopped at any cost before it goes into effect, and people learn first-hand that the anti-Obamacare propaganda was false.

So which is it? Are Republicans sure that disaster looms, or are they terrified because they suspect that things will be OK? My guess is, both: clear thinking is not exactly a hallmark of the modern GOP, and may indeed be a positive disqualification for career success.

Unfortunately, fear of Obamacare success is in the driving seat right now, and may well lead to government shutdown, debt default, or both.
(The argument here was foreshadowed in a column that Krugman wrote back in July, which has turned out to be very prescient and thus bears re-reading: "Republican Health Care Panic".)

=> One person who has laid out an especially clear and illuminating explanation of these political and ideological dynamics, as well as their practical implications, is the ever-perceptive Jonathan Chait. He did this in his September 15 New York Magazine article titled "The Plot to Kill Obamacare: Why it continues to drive many Republicans to madness". I recommend reading the whole thing, but here are some highlights for a start:
The Republican party has voted unanimously against establishing the Affordable Care Act in the Senate and then in the House of Representatives, then voted some 40 times to repeal or cripple it; it has mounted a nearly successful campaign to nullify it through the courts and a failed presidential campaign that promised to repeal it; and it has used its control of state governments to block the law’s implementation across vast swaths of the country, at enormous economic cost to those states. Yet somehow, in the wake of all this, the party is consumed with the question Have we done enough to stop Obamacare?

This peculiar subject of introspection, as if Joe Francis were lying awake at night cursing himself for his prudery, reflects the deepening mix of terror and rage with which conservatives await the enrollment of millions of uninsured Americans beginning in October. On the substantive merits of the law, only the subtlest variations can be detected in the GOP’s evaluation. Mitch McConnell calls it the “single worst piece of legislation passed in the last 50 years in the country.” Representative John Fleming of Louisiana calls it “the most dangerous piece of legislation ever passed by a Congress” and “the most existential threat to our economy … since the Great Depression.” Virginia gubernatorial candidate Ken Cuccinelli harks back to the Fugitive Slave Acts for a comparative affront to liberty.

Having achieved near consensus on the policy, the party has fallen into intramural squabbling over which extraordinary threats to deploy. Shut down the government? Default on the national debt? (House leaders have wriggled out of demands to do the former by promising to do the latter.) Conservative activists have turned on their leaders as traitors for hesitating to employ the most obviously suicidal methods, affixing John Boehner’s name to the hated program (“Boehnercare”) or accusing McConnell of “empty rhetoric … about ending Obamacare.” These recriminations reprise the hallucinatory attacks by Cold War conservatives like Joe McCarthy and the John Birch Society, which over time migrated from their original targets onto such figures as President Eisenhower and the Army.

The historical echo is fitting in the sense that Obamacare has come to fill the place in the conservative psyche once occupied by communism and later by taxes: the main point of doctrinal agreement. (In constituent meetings, “this is the overriding issue that is being discussed,” one Republican member of Congress explained late last month. “Way more than immigration, way more than the debt.”) The transformation of Obamacare from a close relative of Republicans’ own health-care ideas to the locus of evil in modern life is owing to several things, including the almost tautological political fact that its success would be Obama’s: Permanent health-care reform would define Obama as a Reaganesque transformative figure, rather than the failure conservatives still hope him to be remembered as. The law’s slow rollout has made it a live issue, unlike the already-expired stimulus, and thus the main receptacle for simmering concerns over unemployment and the tepid economic recovery.

Most important, the law has, in its direct impact, opened a fissure over the role of government deeper than any since the New Deal. Obamacare threatens America’s unique status among advanced economies as a country where access to regular medical care is a privilege that generally must be earned. In a few weeks, the United States government, like those of France, or Australia, or Israel, will begin to regard health insurance as something to be handed out to one and all, however poor, lazy, or otherwise undeserving each recipient may be. “We can’t afford everything we do now, let alone provide free medical care to able-bodied adults,” as Missouri Republican Rob Schaaf, author of the state’s harsh anti-Obamacare initiative, put it. “I have a philosophical problem with doing that.”

The Obamacare wars have progressed from the legislative to the judicial to the electoral fronts, gaining intensity at every step. Now they move to a new battleground to secure the law and all it represents, or provoke its collapse. That an implementation battle is taking place at all is a highly unusual circumstance. Major new laws often stagger into operation with glitches, confusion, and hasty revisions, but not sabotage. Obamacare will come online in the midst of an unprecedented quasi-campaign atmosphere, with Republicans waging a desperate political and cultural war to destroy it. [....]
And this brings us to Chait's key points:

Right-wingers may be saying that Obamacare is guaranteed to fail, and that its implementation is a looming "train wreck". But what really frightens them is the prospect that, once it is implemented, it will actually work successfully and will prove to be too popular to roll back. That fear, Chait suggests, is not unfounded.

On the other hand, many people who support health care reform have found it hard to muster a level of enthusiasm for Obamacare that matches the passionate intensity of opposition on the right. And part of the reason is that many of them regard Obamacare—which is really, at heart, a modified and nationalized version of RomneyCare—as an inadequate and hopelessly compromised half-Republican half-solution. They would prefer to see something along the lines of a less complicated and more straightforwardly universalistic single-payer system. (I am one of the people who believes that, if it were a realistically available option, some sort of single-payer system would be better than the Obamacare compromise—not to mention a huge improvement over the existing situation.) Chait argues that many of these skeptics are actually selling Obamacare short. It's certainly imperfect, but it's a valuable step in the right direction that looks workable and promising. He also provides some good reasons to agree with that assessment.
The transformative potential of Obamacare is not a conservative hallucination. It is the resolution of a confounding dilemma decades in the making. The American health-care system is not merely the only one in the advanced world that’s closed off to a large share of the population; it’s also the most expensive by far. The normal structure of a public problem is that the worse the problem, the easier it is to solve—as traffic gets worse, more people support mass transit; the more soldiers die, the more pressure to end the war. American health care has long defied that dynamic. The worse the problem grows, the harder it has gotten to solve. The more waste and inefficiency that sprout through the medical system, the more of an interest doctors, hospitals, and pharmaceutical companies have in maintaining the status quo. The uninsured are diffuse and disorganized, unable to marshal any substantial political support, and the effect of their plight has largely been to make people with insurance fearful of any change lest they join them. [....]

The Affordable Care Act broke through the policy trap by combining solutions to the cost-inflation problem with solutions to the access problem. The medical industry would undergo painful reforms, but in return Washington would supply it with some 25 million new customers.

At the time of its passage, the received wisdom in Washington (and not just among partisan Republicans) deemed Obamacare’s cost reforms pitifully inadequate. [....] In the three years since, a steady accumulation of evidence has amassed to the contrary. Through a thousand tiny nudges, the law has transformed the entire medical field from one that encouraged more, and more expensive, care with no regard for outcome into one geared toward paying for quality. Some of the changes have been blunt and simple. The old pay-for-quantity system rewarded hospitals for doing a bad job, since patients who contracted an infection or received poor treatment would come back for more treatment, bringing in a second Medicare reimbursement. Obamacare created penalties for hospitals with high rates of infection or patient readmission. Lo and behold, this year, Medicare announced that its patient-readmission rates fell—“a feat that long seemed beyond reach,” the Washington Post reported.

Obamacare also imposed a tax on the most expensive insurance plans, and though the tax does not take effect until 2018, employers have already started shopping around to avoid its bite.  [....]  The most dramatic change underfoot is an entrepreneurial wave encouraged in sundry ways by Obamacare.  [....]

All these reforms have added up to a revolution in modern medical economics. Health-care inflation since 2011 has fallen to its lowest level in half a century. The Congressional Budget Office estimates of Obamacare’s costs, widely derided at the time of its passage as too optimistic, have thus far proven too pessimistic. The agency has already cut $600 billion off the expected ten-year spending total for Medicare and Medicaid. If the reforms continue to bear fruit, costs will come in even lower.

And health experts increasingly expect the reforms will bear fruit. “The ongoing slowdown in the health-care growth rate defies historical post-­recession patterns and is likely to be ­sustained,” concluded Price­water­house­Coopers in June. “It appears that the reforms will stick and health-care exchanges and other policies will bring competitive pressure to markets,” says Randall Ellis, a professor of health-care economics. “Although the proof for this point of view is not yet definitive,” reports the Health Affairs blog, “the depth and breadth of change suggest that significant transformation in the nation’s delivery system is under way.” Among health-care wonks, this is no longer a controversial assertion: The evidence thus far suggests Obamacare’s cost reforms are a staggering success.

Now look back at all the quotes in the last paragraph. Every one of them has qualifiers attached: likely, appears, not yet definitive. That, appropriately, is how people in the worlds of academia and economic forecasting express themselves. The future is uncertain by definition.  [....]
And one reason this particular future is uncertain is that the long-term outcomes will depend, in part, on whether the right-wing opponents of health care reform are successful in their efforts to sabotage and derail it.
That Obamacare is both bound to fail and must be destroyed is the premise of conservative-movement thought, the A=A from which every other conclusion springs. In 2010, the American Enterprise Institute fired David Frum after he wrote a blog post questioning the Republican strategy of total opposition to Obamacare. Fealty to the cause of repeal is a sine qua non for any effective participation in the movement. The e-mail ­listserv where conservative health-care-policy wonks gather is called the “Repeal Coalition”—which is to say, anybody not fully dedicated to repeal cannot ­participate in conservative health-care-policy deliberations.  [....]

You might think that this all represents nothing more than another episode of conservative self-delusion of the sort that ended in a dumbfounded Mitt Romney campaign beholding the election returns last November and Karl Rove bleating helplessly at the Fox News decision desk. But unlike with the election, perception and reality cannot be so neatly separated. The final, decisive stage of the Obamacare wars is one in which perception can ­create its own reality. The predictions of a train wreck are intended to precipitate one. [....]
So the political and and ideological wars over health care reform during the next six months or so may turn out to have very significant consequences, one way or another.
It is hard to imagine that the news about Obamacare over the next few months will be good. The rollout of Medicare, and the addition of prescription-drug coverage under George W. Bush, both provoked mass confusion and complaint, and those laws were not fighting off an angry rearguard insurgency. The question is whether the glitches and failures amount, in either reality or perception, to the sort of catastrophic failure that leads panicked insurance companies, potential customers, governors, and state legislatures to pull out.

Conservatives have portrayed their war against the exchanges as a desperate last stand against Obamacare and for freedom as we know it. History is replete with previous examples of last stands. Ronald Reagan warned conservatives in 1961 that if Medicare passed into law, “one of these days you and I are going to spend our sunset years telling our children and our children’s children what it once was like in America when men were free.” The conservative movement sustains itself by constantly disregarding its warnings of the last mortal threat to liberty and redirecting itself onto the next one. Yet it has made opposition to Obamacare completely central to its identity. If the Obamacare train does not wreck—or, to put it more accurately, if conservatives fail to wreck the train—it will be fascinating to see: What will they do next?
With luck, we may get a chance to see. Meanwhile, read the whole piece ... and stay tuned ...

—Jeff Weintraub

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