by Max Brantley
Will Arkansas Republicans really deny fellow citizens health care financed by the federal government?
The question on implementation of Obamacare is no more complicated than that.
Early returns from the usual bomb throwers is that, yes, Republicans value preservation of their capital more than the health of their fellow citizens.
Ezra Klein of the Washington Post has heard the same noise — extremist Republican (redundant, I know) governors in Florida, Wisconsin and Louisiana are leading the charge to be modern-day George Wallaces, standing in the hospital doors. Social Darwinism today. Social Darwinism tomorrow. Social Darwinism forever. (The economically fit live, the poor and sick die.)
Klein thinks the red states will come around. You can see a glimmer of possibility in this in occasional half-temperate remarks from the handful of reasonable Arkansas Republican legislators. They want to study a bit before declaring they, too, are modern-day George Wallaces. But then you have the Jon Hubbards and John Burrises of the world, with wild exaggerations on impact (Hubbard invoked Pearl Harbor) and cost ($250 million in state administrative costs, Burris pulled from somewhere the sun don't shine.) Klein's counsel:
Ignore them. The deal the federal government is offering states on Medicaid is too good to refuse. And that’s particularly true for the red states. If Mitt Romney loses the election and Republicans lose their chance to repeal the Affordable Care Act, they’re going to end up participating in the law. They can’t afford not to.
...But, somewhat perversely, the states that get the best deal under the law are states like Texas, which have stingy Medicaid programs right now, and where the federal government is thus going to pick up the bill for insuring millions and millions of people. In states like Massachusetts, where the Medicaid program is already generous and the state is shouldering much of the cost, there’s no difference for the federal government to pay.
That is to say, the less you’ve been doing on Medicaid so far, the more the federal government will pay on your behalf going forward. And that gets to an irony of the health-care law: Red states have, in general, done less than blue states to cover their residents, so they’re going to get a sweeter deal under the terms of the Affordable Care Act.
Of course, you can still elect Mitt Romney and a Republican Congress and tell a significant chunk of the American people who have no way to pay for basic health care — tough.
ALSO: Ernest Dumas explains in his Times column this week why there are benefits for all in the health legislation, not just for those low-down deadbeat children of the working poor with their hands out for free diagnosis of an ear infection.
All the fury over Obamacare and the U. S. Supreme Court’s decision upholding its constitutionality suggests that the law will drastically alter the lives of all Americans.
That is one of the many ironies of this epic battle, now in its fourth year. For the most part, the 15 percent of Americans who will be directly and significantly affected by the Affordable Care Act because they are not now insured seem to rather like the law’s controversial provisions or accept them. It’s the other four-fifths—the 170 million who are already fully insured by employer or individual policies and the nearly 100 million who are covered by one of the government programs—who are ready to storm the ramparts, for or against it, if you believe the polls.
Yet many, perhaps even most, of insured Americans think they will never be affected in a direct way, unless the law does succeed in one of its goals, which is to slow the growth of medical costs for one and all. Some are skeptical that the government will take the steps prescribed in the Affordable Care Act to get costs under control because many providers will oppose them. But it remains a hope.
For tens of millions of the currently insured, there are direct benefits. The law directs insurance companies to send rebates to policyholders each year when the companies spend more than 15 or 20 percent of people’s premiums (depending on the size of the insurance pool) on administration, profits and executive bonuses rather than medical care.
This summer, some 115,000 Arkansans who have individual or employer insurance will get about $7.8 million in rebates for insurer overcharges in 2011. Most of them will cash the checks not knowing it resulted from the Affordable Care Act, and they will go on cursing Obamacare and the Supreme Court.
Indirectly, everyone who is insured now will benefit if everyone else becomes insured and his or her medical care is paid for, as the law intends. That will end or dramatically reduce the unreimbursed care at hospitals and clinics and end the cost shifting to the premiums of the insured.
That part of the law—the so-called mandate for people who are not insured and who earn more than 133 percent of the federal poverty line to buy insurance with government help—is the one that has caused the fury. It was the basis of all the suits challenging the constitutionality of the law on the theory that the commerce clause didn’t expect government to ask people to buy insurance. (The government has been requiring people to buy insurance since 1935, when everyone was mandated to buy Old Age, Survivors’ and Disability Insurance, and 1965, when they had to buy old age and disability health insurance.
If you are young and healthy, you have a reasonable case for being sore that the country will ask you to buy insurance now rather than wait until you get sick. If your pay is not so swell, the government is going to pay a hefty part of the monthly premium for you—nearly all of it if your family income is very low.
But if you are insured and you and your employer are paying hefty premiums, don’t you also have a case for being sore that all those people have gotten a free ride at the hospitals and clinics and that the costs are passed along every year to you in the form of another premium increase?
I referred to all the ironies of the Affordable Care Act battle. The most perverse is that the mandate that people buy insurance is the conservative and Republican formula. It was hatched by Ronald Reagan’s think tank, the Heritage Foundation. It was the soul of the Personal Responsibility movement, embraced by Reagan and Bush I and then by Republicans in Congress in the great healthcare battle of 1993-94, lost by Bill and Hillary Clinton. Clinton reportedly wanted to join with the Senate Republicans on the private mandate but Hillary had too much invested in her plan, and the whole thing died. Monday, Mitt Romney, whose Massachusetts mandate law was the template for Obamacare, disagreed with his party and the Supreme Court and said the little penalty in the law for not buying insurance ($99 in 2014) was not a tax. It was not a tax when he prescribed the same thing in Massachusetts eight years ago.
You can see why tea partiers and others on the right would be upset about the other big feature of Obamacare, the expansion of Medicaid to cover most poor adults. That is government spending on the poor. Up to now, Republicans in Congress have been champions of Medicaid, but now that it is part of Obamacare they are forced to be against it.
Republican legislators in Arkansas, like those in Congress and in a few other states, were saying over the weekend that they would block state participation in the expanded Medicaid, which the Supreme Court said states could choose to skip without penalty.
At least for Arkansas, skipping it would be unimaginable: billions of dollars for Arkansas health care and the economy, none of it costing the state government a dime until 2017 and after 2020 costing the state ten cents on the dollar.
You may wonder why Arkansas hospitals supported the law, joined last week by the chancellor of the state’s medical school and hospital. For 2010, the last year for which figures are available, the uncollected bills and charity care at Arkansas hospitals totaled nearly $1.3 billion—people who were not insured and did not pay for their treatment. At the state medical center at Little Rock, the uncompensated care for the uninsured last year came to $175 million. Arkansas taxpayers picked up most of the bill for them through state and federal taxes.
Under Obamacare, Medicaid and the insurance mandate will end nearly all that cost shifting in 2014. Does that sound like something we should turn down?