The Insider: Wishful Thinking
Wishful Thinking Part One: The Vanishing Voter Mandate for Repeal After a pause to remember those who were killed or wounded in Tucson, Congress is set to resume work this week, and the first order of business is a House vote to repeal the Affordable Care Act (read Community Catalyst’s statement opposing repeal here). As they move to take up repeal, the House leadership claims a popular mandate for repeal. A closer look at public opinion reveals that this “mandate” is nothing more than a figment of their imagination.
Unfortunately, polling questions that lack nuance will yield misleading results. Simple questions about repeal tend to track overall numbers for oppose/support. For example, a recent Gallup poll reported 46 percent supporting repeal and 40 percent opposing. These numbers fail to capture the significant percentage of the population who say they are opposed because they don’t believe the new law goes far enough.
When pollsters make the effort to dig deeper into public attitudes it turns out that repeal is much less popular. According to a recent ABC News poll, only about 15 percent of the population actually supports total repeal. Similarly, a recent Marist poll, while finding a larger percentage (30 percent) favoring total repeal, found that more people support expanding the law even further (35 percent).
If lawmakers were really listening to their constituents, they would give the ACA a chance to work rather than wasting time with a symbolic vote meant as a sop to the far right.
Wishful Thinking Part Two: Public Opinion-based Budgeting Aside from claiming a mandate that doesn’t exist, Congressional Republicans have taken the radical step of replacing the CBO with the “Congressional Polling Office,” or CPO. Instead of relying on independent fiscal analysts to evaluate whether the ACA saves money, Republicans will determine whether the legislation raises or lowers the deficit based on what people believe. Other important economic effects, such as the effect of the ACA on job creation, will also be determined by public opinion rather than analysis. Using CPO estimates instead of those pesky numbers from the CBO, which show that repeal will increase the deficit by $230 billion over the next ten years, spares the new majority the embarrassment of having to disregard their own newly enacted rules that require legislation that raises the deficit to be “paid for.”
Cost Containment: There’s a right way and a wrong way The recent report on national health care spending issued by the CMS Office of the Actuary highlights the importance of not disconnecting efforts to contain health care costs from the mission of revamping the health care system. The report shows growth of health care spending slowed during the 2009 recession. The biggest reason was that fewer people had health insurance. Reducing the number of people who have insurance saves money, but does it the wrong way: by undermining the goals of health insurance, which are to protect people against the cost of illness and facilitate their access to care.
The ACA, in contrast, tackles the problem of cost containment in the right way. Initially, it expands coverage without increasing costs. Over the longer run, it reduces health care spending by improving quality and efficiency.
While we’re on the subject of the right and wrong ways to reduce costs, it bears repeating that the wrong way to reduce federal health care spending is to decouple it from efforts to reduce the rate of growth of health care overall and instead substitute arbitrary spending caps. This was an idea that was advanced in the Rivlin-Dominici report on deficit reduction. We can expect efforts to revive the idea in the context of the upcoming debate over lifting the debt ceiling. It is important not to lose sight of this debate because, while many activists are gearing up for a fight to protect Social Security, it is health care (Medicare, Medicaid and the ACA affordability credits) that pose a greater long-term challenge to the federal budget and are at greater risk of being undermined.
Caution: Mad Scientists at Work States are called the laboratories of democracy, but sometimes those labs can give birth to bad ideas as well as good ones. Two bad ideas being promoted at the state level are a call to eliminate the ACA ban on reducing Medicaid eligibility (known as the “Maintenance of Effort” requirement or MoE) and legislation being introduced in several states to criminalize implementation of the ACA.
Eliminating the MoE is a “wrong way to contain costs” idea a number of Republican Governors are embracing. It would lead to further reductions in the number of people with health insurance and increase cost-shifting onto the private sector. At the same time, it would fail to do anything to improve the way our health care system operates. Also, if states go backward on eligibility now, they will face increased implementation costs in 2014, making implementation more difficult.
Criminalizing the ACA A number of legislators have filed legislation making it a crime to enforce the provisions of the ACA . See, for example, this proposal from Maine. (While such legislation, were it to pass, would likely be found unconstitutional, its purpose, like many other state nullification efforts, is not to make policy but to rally the opposition.) An effective response requires supporters to engage on the issue of what we want our health care system to look like on our own terms. Check out Community Catalyst’s list of the top 10 things activists can do in 2011 to keep the pressure on for quality affordable health care.
— Michael Miller, Policy Director