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Ball of Confusion

David Brooks wants to save your employer coverage by eliminating your employer coverage. In an article called A Choice, Not a Whine, David Brooks wants us to see that there is a plausible Republican alternative to Obamacare. He begins, of course, by softening up the opposition. "The case against Obamacare is pretty straightforward." he says. Obamacare centralizes power (by which he means centralized Federal power, not centralized state power). There will be lots of new Federal offices; no one knows how many, but there will be lots. Obamacare has led to 4,103 pages of regulations, which is supposed to sound like a very large number, even for a national overhaul of the entire healthcare system. He is also worried that "The law also creates the sort of complex structures that inevitably produce unintended consequences. The most commonly discussed perverse result is that millions of Americans will lose their current health insurance."Good lord, did I hear that right? Is he saying that millions will become uninsured under Obamacare?

He goes on. "A report by the House Ways and Means Committee found that 71 of the Fortune 100 companies had an incentive to drop coverage... a Congressional Budget Office study this year estimated that 20 million could lose coverage under the law."It's hard to tell, but he is not actually saying that people would lose their coverage and join the ranks of the uninsured. What is is saying is that 20 million people could lose their coverage at work and instead begin to get their coverage on the state exchanges. The "incentive" for the 71 Fortune 100 companies is that it might be cheaper for them to pay their workers directly to buy their own insurance. (To be honest, that 71 sounds low; everyone knows that business wants to get out of the health benefits business. I'd expect that aside from the insurance companies themselves the number would be closer to 100.)But 71 big companies. 20 million workers. Big scary numbers. Do the Republicans have a plan to stop this? But of course.Brooks cites an essay to be found in National Affairs called How to Replace Obamacare by James C Capretta and Robert E. Moffit. According to Brooks, Capretta and Moffit "lay out the basic Republican principles."The first principle kicks off with a cliche - "patients should have skin in the game... they should bear a real share of the cost." (And here I thought that with years of reduced benefits, higherco-pays, deductibles, and coinsurance consumers were already feeling some dermal soreness.) How would the Republicans make people have more skin in the game? By eliminating the current tax exemption that businesses (alone) get for providing health benefits. Instead, the consumer would get a tax credit to use to buy their own insurance on the market. Having each person shop for their own insurance would force people to buy high quality, low premium plans. Why business is supposedly not shopping this way themselves is laid out in the Capretta and Moffit article. Since business gets a tax exemption on employee benefits, it has an incentive to keep them as rich as possible.Unfortunately, business doesn't know that it's supposed to be doing this. Instead it has been cutting benefits and transferring costs to their employees for years. Now, however, Brooks wants business out altogether. It wouldn't be 20 million people losing their employer coverage. It would eventually be everyone.To be fair to Capretta and Moffit, they believe that this transfer of risks and benefits should be legged into starting with employers of 200 workers or fewer. The really large employer groups, seeing what a good deal this is (and the workers too, delighted at having potentially more skin in the game; in fact, their entire pelts) would eventually come aboard too. Obamacare problem solved.Brooks is full of other great ideas too. Defined contributions for Medicare which would amount to each enrollee getting a fixed amount they would spend on (presumably) private insurance plans to get a minimum level of benefits that they could then supplement out of their own pockets. And a rule that says "any new spending would be offset with cuts so that healthcare costs do not continue to devour more and more of the federal budget." This would put a zero sum cap on federal medical spending so that if, say, 77 million baby boomers came into the system, or Medicaid was eliminated for a voucher system, benefits would be reduced for everyone in order to compensate.Sounds like a choice to me.


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David Brooks ought to contract an incurable pre existing condition and then have him shop around for health insurance. The market will take care of him.

Every time I hear Republicans talk about "empowering seniors" by giving them tax credits (no big whoopdeedo for those who take in so little in Social Security, they rarely pay taxes) or cash to purchase private insurance, I wonder why they never mention Medicare Advantage plans, which operate more or less this way now (using an individual's Medicare allotment to pay for private insurance). These plans are the Trojan horse of privatized Medicare, and they've made entering the Medicare system one of the most daunting hurtles facing American citizens of any age. Virtually every senior entering the system needs a professional counselor to explain the pros and cons of what turn out to be about 60 or so different plans in total, including 12 comparatively similar options offered by each of the major private insurers (United Healthcare, Humana, Cigna, etc.). Traditional Medicare A & B serves as your default plan if you never can decide, or should you conclude -- as most still do -- that the traditional way remains the better option. Of course, if you do choose traditional Medicare (as 75% of seniors do), you may want to add, at your own expense, a private supplemental plan to cover whatever Medicare doesn't, but that's a whole other deal....and yet more options. Why do more choose traditional Medicare than choose any of the Advantage plans? I can't speak for others, but having researched and compared as thoroughly as most probably ever can, I went with traditional Medicare because of its tried-and-true track record (all those I knew who'd been on it for a time seemed to like it), and because the Advantage plans, including the "Cadillac versions," for which pay out of your own pocket to get a little more, all turned out to be just a little too reminiscent of the private, employer-based plans I'd had issues with over the years. There's just no way around the fact that these plans are operated by for-profit businesses. Why would I consciously sign on with what I'd been hoping to escape? If Obamacare had included a public option, it might have worked a lot like the current Medicare system. In that case, I suspect most Americans would have eventually gravitated toward the public option, just as most seniors prefer the public form of Medicare today.

No, no rationing.There is probably enough money running through the system right now to sustain it for everyone. If this is not the case, we might need to revisit some national priorities. Do you know that the United States is responsible for almost 41 percent of total world military spending? Maybe we need to ration that.

Assume for the moment that there is now a single provider which pays all the bills submitted, and everyone works. Does that average worker earn enough over his life-time to afford full, excellent coverage for himself? Put another way, would the average worker have enough money left over after paying for his other necessities to pay for excellent medical care? The *average* person just doesn't make that much money.So, David Smith, I fear you're right about rationing.

Does Obamacare make it more or less likely we'll one day have Medicare-for-Everybody? Is it a step in that direction, or an obstacle to making it happen?

That question is still up in the air. What Obamacare does is make it more likely that we will be able to insure everybody. It's a movement (technically speaking) towards one pool of risk (everybody in the same risk pool, which by actuarial standards is the best, most efficient way to spread risks and costs) with multiple commercial providers. The Swiss have been doing this for years and their case it works but has not led to a single payer system.Politically, I don't think we are ready for a single payer system of any sort (however good an idea it might be). But I think we can work with Obamacare.

It has long baffled me why businesses -- large ones, in particular -- would not support some much more robust form of public health insurance or care, especially since their major competitors in other countries mostly don't have to worry about it. American firms were at a competitive disadvantage, plus they had the frequent task of having to haggle with their employees over the level of coverage, who pays for what, etc. etc. I suppose their reluctance stemmed from fear of much higher taxes. The Republicans had plenty of chances to devise (and pass) their own plan, but instead sat on their hands for years and years. When the Clinton administration proposed (a truly byzantine) plan, the Republicans countered with something very like "Obamacare". Now, suddenly, a few years later when the Democrats revived the old Republican plan (in a bid to get it passed with bipartisan support and lower the level of hostile debate, I suppose), cries of "socialism" and other such things emanate from the right side of the aisle. In fact, the Republicans now have in place a model which is far from neat and tidy, but does meet a lot of their goals. For example, there can be differences among states in the plans offered; and Obamacare keeps insurance companies in the loop (for better or worse). It's similar to the German and Swiss plans, as I understand them. On the other hand, I doubt if the "Obamacare" model is a stable one in the USA. Especially if the Republicans manage to undo it, the next iteration (it seems to me) will be a single-payer plan, uniform across states (if the Supreme Court will allow). Unfortunately, given our national penchants for litigiousness and fraud, it is unlikely that we will have a system which anyone thinks is much good. Too many bureaucratic checks and balances to prevent fraud (most of which won't work), too many mechanisms to restrict care, at least for the poor and working-class members. Still, it may be the case that "Obamacare" (which I support) will at least cause the medical "industry" to get rid of its truly bizarre accounting methods. Since they will receive payment for nearly every patient they treat, we shouldn't have to see wildly inflated bills for some in order to cover the costs of the uninsured, the way we do now. Once we know what the REAL costs are, we may have a shot at reducing the galloping inflation in health care costs. But then, I'm an optimist. In any case, if it survives for a few years, "Obamacare" is a step in the right direction, bringing many more Americans under the health care umbrella and reducing the level of anxiety we all now face if we suffer a catastrophic illness. Next, we've got to tackle the shortage of health care providers.

Michael Cassidy - if Republicans do somehow manage to undo Obamacare, I think it will be a political third rail for another generation.

David Smith,I was not arguing about the morality of socially responsible decisions of Catholics. That comes under the social teachings of the Church that according to Ratzinger-Benedict XVI does not require Catholics to vote for a political candidate based on "one issue". Ratzinger-Benedict XVI appropriately taught that Catholics should exercise the principle of proportionality to social-moral decisions because of the multitude of issues that define a candidate. One political candidate may be pro-choice and against same-sex marriage; for the definition of a religious organization according to Obama but against abortion and stem cell research. The list goes on.Freedom of Religion, in particular the definition of a religious organization exempt from federal and state insurance mandates, is a complex issue and it falls, fortunately or unfortunately, into the legal arena. That does not mean it does not have a moral component; nor does it mean that a Catholic cannot vote for a political candidate based on one issue. I hate to put all my trust in a dramatic experiment called ObamaCare or the PPACA when I don't know the details (neither did the Democrats who voted for it). I wish someone would develop a simple comparison table with narrative that showed ObamaCare versus the current system, and honestly addressed the benefit as well as the many cost issues already discussed by myself and others on this blog. We may have to wait until the Presidential debates to get some insight. I am for comprehensive healthcare of all Americans that is affordable.