'Obamacare' can mean anything you want it to

Whatever it is, it's an outrage.

Visiting someone last weekend in a short-term nursing home, I heard a man being checked into the room’s other bed. A nurse gave him the usual questions to determine his state of mind: “Do you know where you are?” “What day is it?” The last one was “Who’s the president?” Not only did he get that one right, he launched into an angry speech about how Barack Obama has “ruined” Medicare, for reasons I couldn’t follow. I briefly thought it would be a good idea to replace “Who’s the president?” with a less stressful test of universal knowledge, but I feared it would come from sports or reality TV, leading to my being diagnosed as completely out of it. Better to stick with the president question, which can also be used to check blood pressure.

Just under a year ago, a lot of people thought the Affordable Care Act (“Obamacare”) would doom the Democratic Party in the 2014 midterms, in which turnout is sure to be higher among older citizens like the one who could barely stand to utter the president’s name. But its sludgy website has been improved, and the ACA has expanded health insurance coverage to millions. TPM’s Sahil Kapur writes that Republican candidates are backing away from a complete repeal of the ACA:

The shift has been crystallized in contentious Senate races this fall. Senate Minority Leader Mitch McConnell (R-KY) recently signaled that Kentuckians benefiting from the state's Obamacare exchange and Medicaid expansion should be able to keep their coverage. Senate GOP candidates Joni Ernst of Iowa, Tom Cotton of Arkansas, Scott Brown of New Hampshire and Terri Lynn Land of Michigan have all refused to call for rolling back Medicaid expansion in their states. The number of television ads attacking the law have plummeted in key battleground states since April, and now even vulnerable Democratic Sen. Mark Pryor of Arkansas is touting his vote for protecting Americans with preexisting conditions under Obamacare.

This does not mean that the label “Obamacare” is any more popular. A Kaiser Family Foundation poll taken in August found that a record 53 percent of respondents had an unfavorable view of the ACA, and I’m sure that what I heard in the nursing home—an indictment of Obama for every bit of red tape involved in getting health care in America—is as common as ever. Obama owns health care, and he’ll be credited or blamed by Americans every time they get a phone call or a piece of mail having to do with insurance for the next decade.

That’s what so brilliant about a plan floated in August by Manhattan Institute senior fellow Avik Roy, which would reshape the ACA more to the Republicans’ liking while keeping in place the law’s name and its insurance exchanges (the ones that frustrate so many people trying to choose a plan). Obama will surely oppose the changes, but if they’re enacted, presumably after he leaves office, he’ll still get the blame for them.

Roy’s plan would drop the ACA’s individual mandate to purchase “government-certified” insurance, ending the nightmare of healthy young men being forced to buy policies that help subsidize the costs of cancer wigs and maternity care. Roy writes that his plan also “expands the flexibility of insurers to design exchange-based policies that are more attractive to consumers, because they are of higher quality at a lower cost.”

One example of this flexibility (see page 26, in the chapter “Emancipating the ACA Exchanges,” in the full Manhattan Institute report) would be allowing insurance companies to charge their oldest policyholders up to six times what they charge their youngest policyholders, up from the 3-to-1 ratio under the current ACA. Older Americans would surely howl at their increased premiums, but many would blame “Obamacare,” and not the revisions made to it.

The Manhattan Institute plan would also allow individuals to forego the comprehensive policies now mandated by the ACA and instead combine high-deductible catastrophic coverage with health savings accounts (“that allow individuals to save for their own expenses” and also provide “a powerful economic reward for maintaining their health through routine preventative measures”). This alternative would work out for many healthy people; those who choose wrong and end up with insufficient coverage for unexpected medical expenses will, yes, blame Obamacare.

But the most audacious element of change in the Manhattan Institute plan involves an expansion of the ACA exchanges. As Roy asks in a column for Politico, “what if we used Obamacare to reform Medicaid and Medicare, by gradually migrating future retirees and Medicaid recipients onto a reformed version of Obamacare’s exchanges?”

Focusing on Medicare, the idea is that the current system is wasteful (a “kludgeocracy,” says Roy in his full report; see my earlier post for a definition) and unfairly redistributes resources from younger workers to older, and often wealthier, retirees. Shifting Medicare recipients into the ACA exchanges (through a slow rise in the eligibility age for Medicare) would supposedly cut health care costs dramatically. Future retirees are not likely to approve of this shift, since they would face a lot more paperwork and guesswork than under the single-payer Medicare system—and comparing the costs and benefits of various health insurance plans is not something that people look forward to doing every few years until they die. But if they don’t like being on the Obamacare exchanges, they can blame Obama, even if the Democrats fight like hell to keep Medicare the way it is.

Reason’s Peter Suderman marvels at the “clever compromise” that Roy’s plan introduces to the public debate: “leaving much of Obamacare’s basic infrastructure, including the exchanges, in place but altering them substantially and using them, in a kind of ju-jitsu move, as a vehicle to reform the rest of the entitlement system, which is ultimately a much bigger fiscal problem.”

One irony is that this compromise implicitly admits that the ACA is, indeed, a market-based reform instead of the creepy, socialist horror show its harshest critics have made it out to be. But no one expects consistency here. If Roy’s plan goes through (a long shot, dependent on GOP control of Congress and a new president unconcerned with the current president’s legacy), I expect to hear a lot of yelling from senior citizens about that cold-hearted bastard, “Scrooge” Obama.

Image from fact-filled "Opt Out of Obamacare" ad.

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