Sunday, October 13, 2013

As the latest manufactured crisis drags on ... we sometimes need to remind ourselves that the Republicans have proposed NO serious alternative to the Affordable Care Act

In a few items I posted back in mid-September, I considered what was then a looming question, "Will Congressional Republicans shut down the US government or blow up the economy?" It's clear in retrospect that I should have added the phrase "or both?"
As I noted yesterday, there is a very strong possibility that the near future the Congressional Republicans, not content with doing everything they can to sabotage the painfully slow recovery from the economic crash of 2008, will once again threaten to send the US government into default and disrupt the world economy by using a manufactured crisis over the debt ceiling for purposes of crude and irresponsible political extortion. Some analysts are predicting that this time around the Republican leadership will find a way to avoid a destructive full-scale crisis—not because it would be harmful to the country, but because they worry that it might be politically damaging to the Republican Party. But as I also noted, there are good reasons to worry that those predictions will turn out to be wishful thinking.
Wishful thinking, for sure. The Republicans did (partly) shut down the federal government, they did provoke a totally unnecessary and extremely dangerous crisis ... and they may wind up actually forcing the US government into default, with potentially disastrous consequences.  (As it is, they've already done real damage to the credibility of the "full faith and credit" of the US government.)

If some way is found to avoid this particular disaster on this particular occasion, it will only be a reprieve, not a real solution to the increasingly alarming pathologies of American national politics. As long as the Congressional Republicans continue to regard these blackmail threats as a promising and legitimate tactic for routine politics, and as long as they don't suffer any decisive political costs for doing so, then we can expect this series of cliffhangers to continue indefinitely.  In 2011 they used the threat of a blowing up the economy to demand contractionary fiscal policies whose predictable consequences were to sabotage the economic recovery.  This time, they have used this threat in order to undermine or destroy health care reform (along with pressing for a collection of other goodies from the right-wing wish-list).  Next time, it will be something else.  One can't help thinking of old-time movie serials like "The Perils of Pauline". But a better title for this long-running series that might be "Why the US Republican Party Has Become a Threat to the Republic" ... or perhaps, more mildly, "Let's Face It, The Republicans Are the Problem".

This latest crisis generated by the Congressional Republicans (let's not pretend that either Obama or the Congressional Democrats share any of the blame) brings together so many unpleasant, bizarre, and depressing elements that it's hard to deal with them all at once.  So for the moment I'll just focus on one aspect of the issue ostensibly driving this confrontation.  The Republicans have partly shut down the federal government, and are threatening to force the US government into default for the first time in our history, as tactics of political extortion in order to force Obama to cripple, or even abandon, the health care reform passed in 2010—technically called the Patient Protection and Affordable Care Act, colloquially known as Obamacare.  Some of the main provisions of the Affordable Care Act just began going into effect, and Tea Party zealots of the Republican far right, dragging the rest of the Party with them, saw this as the moment for an apocalyptic last-ditch fight to prevent health care reform from being implemented by "defunding Obamacare".

=>  In the last few days there have been signs that at least some House Republicans, including figures in the Republican leadership like Paul Ryan and Eric Cantor who are certainly dangerous right-wing extremists but who don't have the kamikaze inclinations of Tea Party true believers, have begun to worry that this overreaching may have been a tactical error.  One factor that undoubtedly caught their attention was a series of recent polls showing widespread public disapproval for what they've been doing, leading them to fear that the government shutdown could turn into a public-relations debacle for the Republican Party (on an even bigger scale than the Gingrich shutdown in the 1990s).  Some House Republicans may be in the process of deciding that, in terms of their re-election chances, they are more afraid of voters' anger about the government shutdown than of the threat of a Tea Party primary challenge from (even further to) their right.  There have also been indications that some key figures of the plutocratic right were beginning to wake up to the potential dangers of the Tea Party Frankenstein monster they had helped to create.  So the Republicans began to get public warnings from figures like the Koch brothers, and even from op-eds in the editorial section of the Wall Street Journal, the premier propaganda organ of the plutocratic right, warning them that playing Russian roulette with the threat of a US government default "invites catastrophe".  (The Wall Street Journal's own editorials, which had previously been encouraging the Congressional Republicans to weaponize the debt ceiling and threaten to use it as a tool of political extortion, have recently been expressing such concerns in more coded language.)

So at least some of the Congressional Republicans may be looking for ways to get out of the corner they've painted themselves into.  But it would be wrong to feel prematurely optimistic about this.  The latest offer they've presented to the Obama administration and the Senate is un-serious and un-constructive to the point of absurdity.  They still refuse to pass a "clean" Continuing Resolution to re-open the federal government without attaching partisan conditions.  And they propose to lift the debt ceiling for just six weeks, while adding a provision that would deny the Treasury some of the flexibility necessary to delay default the next time this happens, and with a further debt-ceiling extension conditional on negotiations with the White House—which would mean that within a few weeks we would be back in this same blackmail/crisis situation we're in now, under even worse conditions.

The only reasonable solution to the crisis would be for the Republicans to agree to a long-term, unconditional raising of the debt ceiling.  (It would be nice if this were accompanied by a promise never to play with dynamite this way again, but I'm not holding my breath.)  And it would be reprehensibly unwise and irresponsible for Obama to agree to any deal short of this.  On the other hand, from the Republicans' perspective this reasonable solution to the crisis they've manufactured would look like "unconditional surrender" (to quote a phrase recently used by House Speaker John Boehner), and that's certainly a charge that will be hurled against the Republican leadership by the Tea Party and much of the far-right propaganda machinery.  So I think it's quite possible that they will choose to push the country into default rather than losing face.  That's what Saturday's news suggested.  We'll see.

=>  Meanwhile, back to the central pretext used by Congressional Republicans for this latest round of brinksmanship, "defunding Obamacare".  Let's put aside, for the moment, the fact that the Republicans are (once again) using extraordinary, irresponsible, and dangerous tactics in this fight that should not be accepted as legitimate or regarded as part of normal politics.  Do their hysterical criticisms of Obamacare, which they are using to justify their actions, actually raise valid substantive concerns.  The simple answer is no.  The more fleshed-out answer is even more damning.

Let's begin by recognizing that the health care reform embodied in the Affordable Care Act does have various flaws, limitations, and aspects that might be improved. Actually, some of the reasons for that have to do precisely with the moderate, limited, and insufficiently ambitious character of the reform that was actually enacted in 2010.  It is at heart a modified and nationalized version of RomneyCare—a half-Republican compromise solution in many respects.  Those compromises, which include retaining a key role for (profit-seeking) private health insurance companies and a very gradual phasing-in of some key provisions, account for some of the features that make the resulting package so complicated and so hard for many Americans to understand.  Some people would prefer to see a less complicated and more straightforwardly universalistic single-payer system. I'm one of those people.  It seems likely to me that, if it had been 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.  But the hard fact is that this was not a realistically available option, and under the circumstances something along the lines of Obamacare was probably the best package that could actually have been enacted.  (Though I do still wonder sometimes whether the White House gave up too early on the possibility of adding on a public option.)

But all that is hypothetical.  Do any of the criticisms of Obamacare actually being made by Republican politicians and pundits and the right-wing propaganda machine actually hold water?  No.  For example, they have been endlessly repeating the line that Obamacare is a "job killer" which will be catastrophic for small businesses and devastating to the economy—in fact, many right wing politicians and pundits have been claiming lately that Obamacare is already destroying the the economy, even though most of its provisions haven't even been implemented yet.  Is there any reason to take any of these claims seriously?  Not really, as James Surowiecki carefully explains in the latest New Yorker.  In reality, "Obamacare may well be the best thing Washington has done for American small business in decades."  (If we want to speak frankly, the biggest "job killer" in this country for the past four years has been the Republican Party, which has, in effect, been doing everything it could to sabotage the economic recovery and prevent unemployment from coming down.)  How about those "death panel" scares we kept hearing about a few years ago, the skyrocketing insurance premiums that Obamacare would produce, and so on?  All bogus.  And I haven't even touched on the wildest and most alarmist claims that have been flying around lately.

Of course, it is legitimate to ask whether, in principle, an alternative health care reform plan might be designed that is better than the one that emerged from the legislative sausage-grinder in 2009-2010 (in the face of monolithic and unremitting Republican obstructionism, sabotage, and mendacity).  I'm sure that, in principle, the answer is yes.  But as I've already noted, whether there was any realistically available alternative that had any politically credible chance of getting passed is a different question.  In practice, the alternative to passing the Affordable Care Act, in something close to its actual form, was almost certainly enacting no health care reform at all.  And that, in turn, would almost certainly have meant that for another decade or more no one would have been willing to make another serious effort to reform our highly unfair, costly, wasteful, and otherwise dysfunctional health care system—as happened after the defeat of Clinton's health-care initiative in the 1990s.

But it's important to emphasize that all these considerations of whether it might be possible to design a health care reform that would be better than Obamacare are, once again, purely hypothetical.  In the real world, neither the Congressional Republicans nor any other Republican figure of any consequence have ever proposed any serious, concrete alternative health care reform plan.  Yes, various right-wing think tanks and policy intellectuals have occasionally tried to come up with alternative plans and approaches intended to look serious and constructive, though none of them really looks very convincing.  (And if any elements from these plans were ever accepted by the Democrats and had a chance of getting passed, we can presume that the Republicans would then reject them—just like the right-wing bait-and-switch on the "individual mandate", an idea originally pushed by Republicans and right-wing think tanks that they now they now denounce as unconstitutional and tyrannical.)  But the point is that, so far, all this has remained in the realm of idle speculation and the occasional op-ed.  In the decades since the defeat of the Clinton health care reform, the Republicans have never actually proposed a concrete health care reform plan of their own.

I think this fundamental point needs to be re-emphasized, since Republican politicians and pundits sometimes try to pretend (or insinuate) otherwise.  The Republicans have proposed no serious alternative to the Affordable Care Act.  For a while they tried to obscure this embarrassing fact by claiming that they wanted to "repeal and replace" Obamacare.  But the "replace" part of that claim turned out to be empty, and in practice many of them found it difficult to keep pretending otherwise.  One especially revealing moment was provided by Senate Minority Leader Mitch McConnell in a TV interview in July 2012.  McConnell, who had been regurgitating the standard propaganda talking-points against Obamacare, was repeatedly pressed by Chris Wallace of Fox News, no less, to explain what the Republicans would do instead, if they controlled the White House and Congress, to provide health care coverage "to the 30 million people who are uninsured".  McConnell ducked the question several times, trying to run out the clock on the interview, and finally blurted out, "That is not the issue."  This gave the game away.

Later that month a column by the dissident conservative Republican Josh Barro (who has increasingly been turning into an ex-Republican) incisively spelled out the implications.  People who believe, or who try to pretend,
that undermining Obamacare is part of a long game to get a better health reform are mistaken. If there is Republican enthusiasm for "a health system reform that seeks to contain cost growth through progressive cost-sharing, deregulation designed to facilitate business-model innovation, and other market-oriented measures," [JW: Barro was quoting from a piece by  Reihan Salam that tried to concoct a speculative pseudo-sophisticated defense of Republican governors who were blocking Medicaid expansion to poor people in their states] then where was that reform (or even serious legislative action toward such a reform) when Republicans ran the federal government between 2001 and 2007?

The alternative to PPACA is nothing. Mitch McConnell’s comments last weekend were instructive -- Republicans in Congress have no meaningful plan to replace Obamacare and think that 30 million uninsured Americans is “not the issue.”

Conservative health wonks will object to my characterization. They will say they have many plans to use markets to drive down costs so that affordability is less of an issue. They may even advance plans that spend money to subsidize some sort of coverage for some expanded group of Americans. But Republicans have not taken them up on those plans when they have had the chance. That’s partly because expanding coverage costs money, and Republicans aren’t willing to spend money on it. And it’s partly because achieving significant cost control, even though market mechanisms, goes against the interests of groups that support Republicans, such as doctors and seniors.

There’s a reason Representative Paul Ryan’s plan to cut Medicare costs doesn’t even start affecting anyone for 10 years. The Republicans’ best electoral strategy on health care is to talk a good game but not implement reform with meaningful effects. If Republican governors refuse expanded Medicaid, those federal incentives won’t change.

This is a shame, because Reihan is right about one thing: There's a lot that’s undesirable about the PPACA model. [....]

Those are all things Republicans could have gotten if they had been willing to play ball on reform. But instead, they hunkered down and decided to throw everything they could at the law. [....] Turning down the Medicaid expansion [JW: as many Republican-controlled state governments have done] would be just another component of the obstruct-everywhere strategy.

Republicans might succeed in throwing enough wrenches in the law to prevent it from working, though that looks less and less likely following last week’s court decision. But nobody should fool himself into thinking the endgame is a sleeker, better reform that expands coverage and controls costs. If Republican lawmakers in the states decide to turn down Medicaid funds, the main effect will be many of their constituents going without health insurance.
=>  And that brings us back to the current crisis.  The great cause for which the Congressional Republicans have decided to engage in political blackmail and extortion, for which they are willing to bring the country to the edge of a constitutional crisis and to risk damaging not just the US economy but the whole world financial system, is to deny adequate, affordable, and reliable health care coverage to millions of Americans who currently don't have it.  That's really what's involved.  It's not that the Republicans have a better plan for reforming the health care system, a superior alternative to Obamacare.  There is no serious Republican alternative to Obamacare.

It's true that from time to time Congressional Republicans still try to go through the motions of pretending that they have a concrete alternative, or that they are working on coming up with a concrete alternative.  But whenever they do, the things they say turn out to be unserious and incoherent.  Back on September 17 Matt Yglesias noticed, and skewered, one particularly comical example:
Rep. Steve Scalise, R-La., is supposedly ready to unveil House conservatives' long-awaited replacement for the Affordable Care Act. Based on this description, I'm very curious to see what they come up with:
“We address that to make sure that people with pre-existing conditions cannot be discriminated against,” he said.

He promised, however, that it would not “put in place mandates that increase the costs of health care and push people out of the insurance that they like.”
So here's one example of the kind of costly mandate that a free marketeer might want to avoid—a mandate that insurance companies not discriminate against customers with pre-existing conditions. Insuring a sick person, after all, is a lot more expensive than insuring a healthy person. So normally you want to charge sick people more. Discriminate against them, as it were. But if that's not allowed, then you'll have to raise prices across the board. And yet those higher prices are going to push people out of the insurance they like, leaving you with an even sicker group of people in your pool. That's the famous insurance "death spiral" that the Affordable Care Act is supposed to break with the injection of subsidies and penalties.

My strong suspicion is that Rep. Scalise is not in fact some kind of public policy prodigy who's thought his way out of a dilemma that's gone unsolved by the governments of all 50 U.S. states and every industrialized country on the planet. But maybe I'm wrong and we're all about to learn that 100 percent of the thorny political difficulties of Obamacare can just be waved away. That'd be nice.

Matthew Yglesias is Slate's business and economics correspondent. He is the author of The Rent Is Too Damn High.
We can laugh, and we should, but the joke may be on us.  The Republican Congressional leadership now seems to be trying to erase the bit about "defunding Obamacare" from the ransom note they presented with their blackmail threat.  But they've backed themselves into a corner they may not be able or willing to get out of—so in the end they may blow up the economy after all.  Stay tuned ...

—Jeff Weintraub