Game Changer for Medicaid Debate

William A. Hazel: bearer of bad tidings

William A. Hazel: bearer of bad tidings

by James A. Bacon

The debate over Medicaid expansion took a major left turn yesterday when the McDonnell administration revealed that the VCU Medical Center and the University of Virginia Medical Center will lose about $500 million in federal funds to offset uncompensated care between 2017 and 2022.

The Affordable Care Act (Obamacare) will phase out the financial aid on the theory that hospitals won’t need it anymore because, thanks to an expanded Medicaid program and a new state health exchange, most Virginians will have health coverage and uncompensated care will no longer be a problem. But the authors of Obamacare didn’t bargain on the fact that the U.S. Supreme Court would allow states to opt out of Medicaid expansion. Worried about significant fiscal liabilities for the state down the road, Virginia, Republicans are largely opposed to expansion; Democrats, including Gov.-elect Terry McAuliffe, favor it.

The disclosure by William A. Hazel, secretary of health and human resources, that VCU and UVa could lose a half billion dollars changes the debate. Either the state will have to pony up the difference, about $100 million a year, hospitals will have to eat the cuts, or the pain will be spread between the two. Not surprisingly, hospitals are crying bloody murder. The cuts would be “disastrous,” VCU CEO Sheldon Retchin told the T-D. “It’s going to look like Calcutta. It’s going to be bad.”

However the pain is allocated, $100 million in lost federal funds roughly equals the $1.1 billion over 10 years (beginning 2019) that Virginia could be expected to save from opting out of the expansion.

Now, Obamacare supporters can point to the billions of federal dollars that will flow into the state as a reason to support expansion, while foes (of whom I have been one) are deprived of our argument that the state cannot afford it. Whether Virginia expands Medicaid or not, the state gets fiscally hosed either way, so why not at least reap the benefits of it?

This leaves only one substantive argument against expansion: the fear of what would happen if the federal government were no longer able to live up to its obligations and, at some time in the future, shifted financial obligations back to the states. Virginia would face intense pressure to take up the slack rather than abandon a program upon which hundreds of thousands of citizens were then dependent. Democrats and progressives, of course, mock the possibility of the federal government ever reneging on its political obligations. By contrast, some of us regard such a default as nearly inevitable.

Bacon’s bottom line: I’m of two minds. On the one hand, the American hospital industry threw its political support behind the Obamacare legislation in exchange for provisions that would limit competition from physician-owned facilities. You helped foist this abomination upon the American people, you rent-seeking scum, now you own it. If things didn’t turn out like you expected, that’s your tough luck. You made your bed, now sleep in it.

On the other, the loss of half a billion dollars over five years would indeed hit the VCU and UVa medical centers hard. VCU’s FY 2012 net operating revenue was $1.3 billion in FY 2012 and its net income was $122 million in 2012, according to Virginia Health Information data. The impact on UVa would be even greater. Its revenues were $1.2 billion and profits only $88 billion in FY 2013.

Would that “look like Calcutta”? I’m dubious. Clearly, profitability would suffer. Yet both hospital systems would remain profitable. The real impact, I would conjecture, would knee-capping the ability of both hospitals to expand. That’s a legitimate issue to discuss, but let’s make sure we discuss that issue rather than some apocalyptic scenario. Regardless, there’s no denying that the nature of the debate is very different today than it was a week ago.

32 Responses to Game Changer for Medicaid Debate

  1. If there is a taxpayer bailout from any source, administrators’ salaries at the affected institutions and/or holding companies must be capped at SES rates.

  2. re: ” The disclosure by William A. Hazel, secretary of health and human resources, that VCU and UVa could lose a half billion dollars changes the debate. Either the state will have to pony up the difference, about $100 million a year, hospitals will have to eat the cuts, or the pain will be spread between the two. ”

    well.. that’s not a “disclosure”. It was stated up front and well known and even states like Ohio decided it was DUMB to reject MedicAid expansion because it would actually harm hospitals and people.

    nothing was “revealed” or “disclosed”.. it was in plain site from the get go.

    but you do have to ask yourself – if McDonnell and the General Assembly knew this from the get-go – and there is ample evidence they did – and do ,
    then you have to wonder how much they are willing to sacrifice over pure partisan ideology.

    All along – it’s been said that people who don’t have insurance, go to the ERs and the ERs are reimbursed by the govt for those losses (and also allowed to cost-shift).

    One of the goals of ObamaCare was to insure these folks so they can go get regular periodic care from a lower cost source instead of the ER. The regular care would also do screenings to find and detect disease and treat it before it went untreated and became a huge expense to hospitals when the sick eventually did go the ERs.

    so this is a game of choosing to be stupid on purpose so you can toe the right wing partisan positions… even GOP governors in other states were not willing to be THAT stupid.

  3. Larry is right, there was no news in this — although I think the cost number is a bit more detailed. It was clear all along that the hospitals would lose this revenue whether or not Virginia expanded Medicaid eligibility.

    It is a difficult choice. This federal takeover of medical care will eventually lead to unsustainable financial distress (taxes and debt) or drastic rationing or both (the Veterans Administration health system only bigger and worse). But should Virginia ride the gravy train until the crash, or should it stay off the train and stand by until the crash? The crash will get us either way. I can see an argument for joining in what is in effect a hurricane party.

    I was looking over the tax charts for 2014. I think that is when most of the Obamacare taxes really kick in. The tax on medical devices. The 0.9 percent income tax surcharge on couples with an AGI above $250,000. The 3.9 percent tax on unearned income for couples with an AGI above $250,000. For shorthand I’ve taken to calling $250,000 AGI by a new name: “One Obama”. If you have one Obama of income next year, here it comes.

    So, yes, it is hard to argue that the Virginia’s paying all those new taxes should see the money spent elsewhere and not in Virginia.

    • Especially since most of them, as noted in another string, are from Northern Virginia! :)

    • re: ” This federal takeover of medical care will eventually lead to unsustainable financial distress (taxes and debt) or drastic rationing or both (the Veterans Administration health system only bigger and worse). ”

      we need to recognize that every other OECD country in the world – has the dreaded “Federal takeover” and “rationing” problem and despite the fact the govt is running them and there IS rationing (as there is here but we pretend otherwise)… the bottom line is all those other countrie pay 1/2 what we do and live longer.

      There are no countries in the world that have free market health care that is better than OECD health care – none and we’re talking about 150 countries out of 200 total.

      Even with the overwhelming evidence, I’m willing to listen to a different plan from those convinced we can do it a different way.

      but at some point- you must start to recognize that the right’s infatuation with the free market is more wish than reality.

      It’s unconscionable that the right would fiddle and fart around with unproven philosophies while at the same time opposing anything else.

      We’re talking about real people dying and living lives of hopelessness while the GOP apparently could care less… because it violates their “free market” sensibilities.

      how can you be more concerned about a philosophy than people?

      so let’s change the rules so that no Congressman can have no govt health care of any kind as long as we have people who don’t have health insurance.

      Let the Congressmen do health insurance the “free market” way…and prove to the rest of the country that you don’t need no stinkin govt doing health care.

  4. so I’ll return the compliment. Breckinridge has actually read SOME of what funds ObamaCare. Congrats!

    additional money comes from REDUCING the too-generous subsidies for Medicare Advantage especially to those who are earning more that 85K in retirement income.

    However – if we reduce funding to hospitals and instead use that money to fund MedicAid – are we increasing spending? Perhaps that’s why CBO says it does the opposite.

    As far as “taxing the rich” – let me ask – are we taxing them more than Reagan did?

    I would have LOVED to see the GOP propose a better plan for this – both at the National level and at the Virginia level but the reality is the GOP is AWOL from all of this.

    they don’t like ObamaCare but they also have nothing else to offer…

    and you cannot win by opposing something and not offering an alternative.

    This time next year – it’s going to be interesting to see how the landscape has changed (or not). I’m especially interested in seeing the alternatives offered by those seeking office that are opposed to ObamaCare and a new promise to replace the ” you can keep your insurance” … “lie” .. will it be ” hell no, you cannot keep your insurance under ObamaCare”?

    I’m not a staunch defender of ObamaCare.. it’s basically the result of a tortured process when changes were made to satisfy objectors.. but I have no admiration at all for those who oppose and have no alternative – and I do not count individuals “ideas” as an alternative. I count something that has substantial legislative support from those who are opponents.

    It does not “count” if you are opposed and have “ideas” but the opponents themselves cannot agree on an alternative they support as a group.

    this is the state of the country these days when it comes to health care, immigration, same sex marriage, gas and lesbian rights, etc…

    we have opposition. we do not have unified support for alternatives.

    to me that is the essence of effective governance and leadership.

    agreeing to disagree and agreeing to do nothing – is not leadership nor governance.

    • I agree that the GOP’s opposition to all this is weakened by its lack of consensus on a reasonable alternative. We were in big trouble and headed for bigger trouble before this bill passed. I don’t now about marginal income tax rates over time without doing some research, but I do know that the imposition of the Medicare tax on investment income is entirely new, as is the medical device tax. Once you get to One Obama of income, the tax on that next marginal dollar is 36.8 percent for earned income and 18.3 percent for dividends, plus whatever the state tacks on (5.75 percent in VA). At Two Obamas of income, the tax on additional income is 43.4 percent and the tax on dividends 23.8 percent, plus state taxes.

      But then, it has also been clear from the beginning that income redistribution was also a main goal of all this. (And yet the subsidies still are not high enough to be the uninsured to sign on.)

      • I’m no defender of Medicare. it has totally unreasonable subsidies for people of significant means. Neither Medicare nor MedicAid were meant to subsidize people with 85K retirement incomes and a million in assets yet it does and because it does – we say we cannot afford to help people who are truly in need.

        I dislike Obama’s approach to taxing the rich .. it’s wrong and it plays very badly even among those who are not rich.

        but where is the principled alternative that would tell the truth about the current subsidies for Medicare and MedicAid (nursing homes for folks with 500K homes)?

        so Obama is wrong but so is the GOP for showing almost no leadership on the inequalities in the current system that unfairly benefit those who have some wealth at the expense of those who have none.

        we could cover the MedicAid expansion right now if we made the tough decisions about subsidizing those who want to give their homes to their sons and daughters instead of paying for their nursing care. I don’t blame them for doing it but it wrong and it’s adding so much cost to Medicaid that all taxpayers in Va have to pay for it (see the budget) and at the same time – because of the pressure on the budget – people who really need the help – and people who use the ERs – that we also pay for – cannot get cheaper and more cost-effective health care that would benefit taxpayers and those in need.

        we’ve got ourselves in a bad situation with our entitlements and neither the Dems nor the GOP have the cojones to step up and tell the truth.

        I have great sympathy for those who need nursing care later in life.. I might well be one some day but in a country where we won’t give health care entitlements to people because we say it is “socialism”, I think it’s worse than socialism to provide entitlements to those with some financial means and then use that as an excuse for why you cannot afford to help those of even lesser means.

        I’m also not looking to make every “equal”..either.. I do not think anyone is truly “entitled” to something they did not earn but if we are going to do it.. then please, let’s do it on a true safety net basis.. and not some hypocritical back-door subsidy to people who do have money.

  5. Let’s see Mark Warner and Tim Kaine propose legislation reducing Medicare subsidies for higher-income seniors. Oh wait, the Democrats regularly blast Republicans for trying to dismantle Medicare. Shouldn’t McAuliffe figure out how to pay for Medicaid expansion for his constituents?

  6. right now, Virginia has the ability to require those who have assets to pay for nursing home care but they do not require it.

    Is that a subsidy for those who have assets? If we got rid of that subsidy, how many truly poor could be served without increasing the costs overall?

    • Let’s see if Warner and Kaine take on this issue nationally and McAuliffe on a statewide basis. McAuliffe could still propose this change when he makes revisions to McDonnell’s submitted budget. McDonnell revised Kaine’s proposed freeze of the LCI.

      I don’t expect any of these three gentlemen to propose this change. If not, doesn’t the unfair subsidy belong to them going forward?

  7. Just one more reason to cut your losses and get the heck out of Dodge.

  8. wait! the Dems are already invested in ObamaCare.. why would you think they would do something different now?

    it’s the other side that is not satisfied and claims the ObamaCare does not reform the entitlements…

    we have leadership on one side (that you don’t agree with, fair enough) but where is the leadership on the other side?

    this chart shows exactly what our current status quo problem is:

    http://anticap.files.wordpress.com/2013/11/health-spending.jpg

    and some folks will say.. well yeah. .. because we got these folks that don’t have insurance….. DUH !!!!

    The Dems are okay where we are. The GOP is not. why would you expect the Dems to do something the GOP refuses to do?

  9. re: ” If not, doesn’t the unfair subsidy belong to them going forward?”

    it’s been going on a while through both Dem and GOP administrations.

    Why is the GOP excluded from doing anything since they are the ones who keep saying that entitlements are killing the budget?

    at some point – if you really believe this (and I DO) then what is the principled position of the GOP?

    you cannot keep saying that entitlements are killing the budget without getting to some specifics.

    If you are afraid of getting voted out of office for telling the truth – then you lack conviction of your beliefs and principles and why would we would folks in elected positions who cannot or will not honestly tell the truth about the issue?

    I’m not absolving the Dems of this either but they are not the ones who are saying that we are turning into a socialist country and giving entitlements we cannot afford…

    this is my disappointment with the GOP these days. The RINOs were, in fact, forthright enough to talk honestly about entitlements but the guys that have replaced them are not. They are not running on specifics. They are running on a something not forthright and honest but rather along the lines of “elect us” and then we’ll decide what to actually do.

    it’s a totally wacko way of thinking about governance.. “elect me and find out what I ‘ll do”…

    how many voters are going to actually elect someone on that basis?

    • Larry, let me be brutally candid. By and large, the people who vote for the GOP have health insurance coverage. By and large, the people who don’t have Medicaid coverage” vote for the Democrats if and when they vote. Your proposal to whack higher income Medicare recipients probably would make a difference in the ability to expand Medicaid. Also, every time the GOP has proposed entitlement reform, the Democrats have attacked the GOP, which, in turn, has generally lost seats in Congress. E.g., the Senate in 1986.

      Why, under these “facts” should the GOP propose to cut Medicare for its constituents to expand Medicaid for the Democrats’ constituents? That seems very foolish. Shouldn’t Warner and Kaine be willing to touch the third rail?

  10. why? because it’s the right thing to do – the principled, fiscally conservative thing to do and a principled elected person connects with voters when they sense he/she is honest even if they don’t like the message.

    Just like Democrats could never increase the gas tax but the GOP could – the GOP can be an honest broker about the entitlement problem – if they tell the truth and they advocate changes even if it affects those whose benefits might be affected.

    I have absolutely no problem recognizing that Medicare has way too rich benefits for people who make 85K a year in retirement and really should pay more than 100.00 a month.

    by the same token, Virginia , not the Feds, has the ability to re-do their MedicAid policy that allows people to divest themselves of 500K homes before they go into a nursing home that Uncle Sam is to pay for.

    We need truth tellers and not knee-jerk defenders of the status quo and people who are unfairly getting entitlements who should not be.

    I vote for people who are honest about the issues and work to find ways to go forward – as opposed to blockading the other side.

    I do not think I’m alone. I counted on the RINOs to bring some common sense compromise to the tax&spend proclivities of the Dems but now that they are gone – we have two really awful choices – both of which are on paths to failure because both sides have this attitude of “wait until we take over” and ” in the meantime we’ll do our best to checkmate your efforts”.

    I don’t care if they have a D or an R next to their name. If that is their perceived mission – they need to be voted out and replaced with folks that are going to seek solutions.. less than perfect and flawed solutions but solutions not gridlock.

    I vote for the guy that offers that .. and I vote against those that promise gridlock.

  11. Larry, I would agree with you were you to argue the Rs need to jump on board in the event the Warners and the Kaines of this world took on the issue of Medicare/Medicaid at the federal level and if McAuliffe were to make it a legislative priority. Otherwise, we are just grandstanding.

    But, just as Nixon (a guy who makes my skin crawl) had to go to China, the Ds need to lead on entitlement reform and McDonnell needed to act on taxes for transportation. If the Rs were to lead, Warner would use stealing from Medicare and taking away what you earned as a reelection weapon. You know that and I know that.

    Entitlement reform is Lucy and Charlie Brown with the football. Lucy represents the Democrats and Charlie the GOP. Lucy always pulls the ball at the last moment. Charlie cannot trust her. Charlie needs to hold the ball and Lucy kick it. And Charlie cannot replicate Lucy’s bad behavior. But I think Lucy would rather see Charlie fall on his &&& than kick the ball.

  12. re: ” If the Rs were to lead, Warner would use stealing from Medicare and taking away what you earned as a reelection weapon. You know that and I know that.”

    nope. If the R’s put forth a REAL and comprehensive proposal and not just anti-entitlement talking points – it would be politically powerful and give people like me respect for a real position even if I did not agree with all of it and I thought the R’s were willing to work compromises and I think Warner and Kaine would do the same.

    but you cannot win when you have virtually no position other than ideological talking points and your position is to not only not compromise but to obstruct.

    “Entitlement reform is Lucy and Charlie Brown with the football. Lucy represents the Democrats and Charlie the GOP. Lucy always pulls the ball at the last moment. Charlie cannot trust her. Charlie needs to hold the ball and Lucy kick it. And Charlie cannot replicate Lucy’s bad behavior. But I think Lucy would rather see Charlie fall on his &&& than kick the ball.”

    well not totally true. What did Obama get hammered for on Medicare?

    he “cut” Medicare right? but did the GOP talk about what he cut instead of talking about him throwing granny under the bus?

    He cut the subsidy for Medicare Advantage for those with higher incomes.. and he and Warner and Kaine would go further on means-testing if they felt like there was a counter proposal from the other side and that compromise was the intent.

    you have to admit – the GOP has done nothing. they’ve not even tried to come up with their own principled position. Their basic approach is opposition and obstruction – hoping to get a majority come the next elections…

    You can move the Dems off the dime if you actually have a proposal that has merit… you can move the Dems anywhere when the GOP sees any/all concessions as weakness… to be exploited.

    you’re backing the wrong guys TMT… they have no agenda to govern.

    • When Obama cut Medicare – it was the perfect opportunity for the GOP to agree and to urge more cuts using the same logic…the Medicare is far too rich an entitlement for people who have 85K in income and own a million dollars worth of assets.

      That was the opportunity for the GOP to SUPPORT what Obama did and encourage a wider examination and discussion of trimming the more excessive of the entitlement give-a-ways.

      but instead they demagogues him ,, they accused him of death squads and throwing granny under the bus.

      that’s not a principled position that deserves respect.

      that’s pure partisan politics and obstruction.. that goes nowhere and was not intended to go anywhere… just another opportunity to attack.

      you want to cut entitlements? you need to either cut national defense (or raise taxes to pay for it) also. where is the conversation?

      where is the REAL budget proposal from the GOP?

      you cannot begin to solve any of these problems if “compromise” essentially means you are violating your “principles”.

      in other words – no compromises…

      how can you condemn Kaine and Warner on what the “might” do when the other side has already said what they won’t do?

      • Obama’s health care reform proposal had damn little in it for those who tend to vote Republican. There was nothing in it for me. And every time, the GOP proposed any cut in entitlements, the Ds used it as an election issue – and won seats. So why would you expect the Rs to throw themselves under the bus to help Obama?

        What you want is for the GOP to propose a plan that cuts benefits for the middle class to give benefits to those who don’t have them in the name of principled government when the leader of the Democrats repeatedly lied and told the middle class they did not have to give up anything to expand health care. Obama is the kid who wandered away from camp and found himself in the bear’s den.

        Health care reform is about taking from the haves and giving to the have-nots. It’s a suicide mission and that’s why Obama lied over and over and over again. If he wasn’t even willing to tell the truth – you guys and gals need to give up something so I can give it away to someone else — why would anyone expect the Rs to help him?

        There are no cost savings with health care reform. The law didn’t contain a 10% cut in premiums because everyone would be covered and the amount of uncompensated care would shrink to near nothing. When Obama wouldn’t admit this, why would expect the GOP to support something that would not benefit their voters?

        Health care reform doesn’t help millions of people. They are worse off with the ACA than without it. And Obama knew it. Now those millions have realized they are getting screwed and that’s why Obama’s numbers are falling. (Some of my good D friends think that had the GOP not screwed up with the government shutdown, the Obamacare blowup would likely have cost McAuliffe the election.) But you want the GOP to bail out Obama and screw people who are likely to vote R. It doesn’t make any sense.

        Good, bad or indifferent, the political reality is that most people with insurance are not willing to pay more or give up coverage to expand coverage to those who don’t have it. And to reform it, you need losers to balance the winners. I’m not sure anyone could pull off health care reform.

        • Re: there was damn little for me. but there was… you are currently paying for ER care and taxes for MedicAid one of the largest parts of the Virginia budget and you are paying twice as much for health care as others do in other countries – and if you every get sick or get a pre-existing condition – you may well be on your own completely. There by the grace of God goes you.

          I call for the GOP to do what they did with the transportation tax – to actually do something rather than demonize others for trying. You have considerable disrespect for others guy .. you think they don’t vote for reforms.. if they are convinced. I think if a person or a party makes a principled argument and uses facts and does not demonize others that they gain respect even from people who normally vote the other way. I am one of those people. I have voted GOP in the past and would vote again if they had an an actual principled proposal rather than these ignorant and divisive wedge issues they engage in.
          I’d vote GOP for an immigration plan – if they themselves could even agree on one. I’d support real health care and entitlement reform if they would actually agree as a party and propose ones but I’m not going to vote for the sound bite that has no substance and just churn the political waters for no good reason other than perceived political gain.

          re: ” There are no cost savings with health care reform. The law didn’t contain a 10% cut in premiums because everyone would be covered and the amount of uncompensated care would shrink to near nothing. When Obama wouldn’t admit this, why would expect the GOP to support something that would not benefit their voters?”

          but you’re wrong because you’re only believing the GOP talking points. Virginia hospitals will lose millions of dollars of assistance to reimburse them for uncompensated care. Tell me who was paying those millions…

          While it is true that Obamacare does not fix it all AND that what they’re doing really is prospective with no certainty of outcome – it was intended to BEGIN reforms and they expect more changes – to make mid-course corrections and to look downstream for more changes.

          you say it does nothing for you but you pay twice as much for health care than some guy in Singapore, or Canada or Australia does.

          and some day you’ll likely need MediCare because no insurance company will sell you affordable insurance because of your age. You may well enjoy insurance now that you would not have if it were not for tax-free employer provided that gives you one rate and does not discriminate on conditions – something you would not have if you were unlucky.

          re: ” Health care reform doesn’t help millions of people. They are worse off with the ACA than without it. And Obama knew it. Now those millions have realized they are getting screwed and that’s why Obama’s numbers are falling. (Some of my good D friends think that had the GOP not screwed up with the government shutdown, the Obamacare blowup would likely have cost McAuliffe the election.) But you want the GOP to bail out Obama and screw people who are likely to vote R. It doesn’t make any sense.”

          it helps millions of people that did not have insurance. It does adversely impact others. You cannot have reform of our dysfunctional system without it because some people are currently getting something as a result of preferential treatment in the tax code and law that others cannot get.

          I don’t expect the GOP to bail out anyone. I expect them to produce their own competitive version. Why do you think doing that helps Obama? Obamacare has problems in fact BECAUSE the GOP chose to do nothing just like they are doing with immigration.

          you sound like you don’t want the GOP to do anything on these tough issues… what do you really expect from them – gridlock?

          when you say losers … yes.. when someone who is over 65, gets 85K in income and gets full coverage health insurance for 100.00 a month while others much younger can’t touch that kind of insurance for less than a thousand dollars a month – you worry about the “loser” being the Medicare recipient?

          you’re basically opposed to trying to do something and you vote for those who gridlock?

          that seems to be a pretty selfish and cynical view that sounds just terrible.. to me.. I’m agast… We’re voting for people to send to Washington and we want them to do nothing other than gridlock reform efforts?

          Using the criteria being used here.. we would never ever have passed social security or Medicare or MedicAid because it would “create winners and losers”. But we can have tax-free employer-provided insurance and insurance for seniors for 100.00 a month and that does not create winners and losers?

          How do the winners today get to be winners and how did the losers today get to be losers?

  13. The Dems will never back entitlement reform on a large scale because reform requires cutting back on the middle class, not just those nasty rich people. Cutting back on the middle class invites a hostile response and opens the Ds to the charge of being the give-away, welfare party. In other words, means testing would need to go a lot lower on the income/wealth scale to bring about any real savings. We still have enough Calvinism in this country such that society distinguishes between the deserving and the undeserving poor. That’s not a winner for the Ds. Warner and Kaine aren’t stupid.

    Larry, one of the reasons the Rs aren’t doing anything on health care is that most of their constituents are happy with what they have. Most changes will screw those who already have insurance and are basically happy with it. Obama is the guy who wants to give to his constituents — the ones who don’t have insurance and, even there, I suspect he would have settled for an expansion of Medicaid over a broad expansion of insurance.
    The big political problems with health care reform remain: you need to create a bunch of losers to create some winners; and, when push comes to shove, today’s winners aren’t willing pay much to expand health care for others. That’s why Obama’s lie is so atrocious. He told the people that, outside of some taxes that rich people will pay, the average Joe or Jane will not need to give up anything to expand health care coverage. And that was a price Joe and Jane were willing to pay — next to nothing.

    Had Obama said, to expand health care for those who don’t have it, people already with health insurance are going to pay more for less, the ACA would not have passed — period. This is not D or R. This is the reality of American society.

  14. The DEMS WILL back significant entitlement reform if there is a real proposal that is not some cynical demonization to exploit a wedge …

    when the GOP produces nothing and engages in divisive politics and gridlock, blaming the Dems for not being willing … well that’s pretty partisan guy.

    re: the GOP’s constituents are happy. that’s bull feathers.. they complain mightily about paying increasing taxes for entitlements and a hard deficit and boomergeddon.. and they want to do what? Do they want to figure out how to provide medical care entitlements in a more cost-effective manner – nope. they dream ..and the word is DREAM about cutting entitlements and paying less taxes.. by just kicking people off entitlements all together.

    how reasonable and rational is that attitude ? it’s dumb and ignorant and fails from the get go and will not get better for the GOP as they shed more and more people who are not old white guys and do not like what old what guys want.

    re: winners and losers. what you are saying is that we can never have reforms.. and you are wrong.. and you are one of the reasons the GOP is losing.

    When we say we are going to fix the cost of living for social security what are we doing?

    are we creating losers? if the original cost-of-living calculation was too rich and actually paid more that was intended – is fixing that really creating losers?

    If you are paying higher taxes for MedicAid to reimburse hospitals for uncompensated care – and more and more people without jobs start going to ERs and taxes go up to pay for it – are you a winner? Do you think the answer is to stop letting people go to ERs?

    If you neighbor or a family members gets a pre-existing condition and cannot get insurance, does that make you a winner and if we do something to rectify the damage to others, we become losers?

    TMT – you’re going to lose on this for two reasons 1. it immoral to justify gridlock and no reform because of perceived “winners” and “losers” and 2. – because too many others know it’s wrong policy and if we don’t fix it – the country is going to go broke pretending 40 million people can be uninsured “losers” and not cost the “winners” more money.

    I am horrified by your position but explaining it has helped me to better understand the GOP and why they have no ideas and tend towards gridlock.

    it’s become the party of naysayers… and I’m truly dumbfounded that they think they’re going to win future elections…. when their constituency is shrinking – with their help…

    • Larry, would you agree or disagree that some Americans, including those covered by a collective bargaining agreement, have better health care plans as part of their overall compensation? In your view, are they obligated to give up some of what they have to help fund coverage or better coverage for other Americans? And is it wrong for elected officials to fight for those people so that they don’t have to give up what they have?

      Would you agree or disagree that some Americans have somewhat lesser coverage, but like it for the premium level vis a vis coverage. I’d agree some don’t. In your view, are those, who are happy, obligated to give up some of what they have to help fund coverage or better coverage for other Americans? And is it wrong for elected officials to fight for those people so that they don’t have to give up what they have?

      I’m just trying to narrow the issues here. Bottom line, are you arguing winners have an obligation to give up some of what they’ve earned and some of what they like so as to extend coverage to at least some of those who have no or lesser insurance coverage? I want to go one step at time so we aren’t talking past each other, which is what I think both of us are doing.

      • Larry, would you agree or disagree that some Americans, including those covered by a collective bargaining agreement, have better health care plans as part of their overall compensation? In your view, are they obligated to give up some of what they have to help fund coverage or better coverage for other Americans? And is it wrong for elected officials to fight for those people so that they don’t have to give up what they have?

        well first i do not agree when they pay about twice as much, can lose their insurance through no fault of their own or non-payment and get a tax free benefit that those who also work don’t have.

        both John McCain and Mitt Romney advocated getting rid of empoyer-provided tax free insurance and let every see their own on the market.

        the increased cost of employer-provided health care has eaten up every bit of productivity that people would have gotten as additional compensation. People lose their insurance when they change jobs and cannot get it back – will often not get hired somewhere else is they have a pre-existing condition, etc.

        what people “like” is a mirage. As long as they are not touched personally they are “happy” but many, many others are not and they themselves are not immune from the increasing cost of health care.

        we have a bad system of winners and losers and more and more losers are being created.

        “Would you agree or disagree that some Americans have somewhat lesser coverage, but like it for the premium level vis a vis coverage. I’d agree some don’t. In your view, are those, who are happy, obligated to give up some of what they have to help fund coverage or better coverage for other Americans? And is it wrong for elected officials to fight for those people so that they don’t have to give up what they have?

        if you’re talking about catastrophic, it’s not real insurance. It’s like having auto insurance that only covers a million but nothing less.

        when you say give something up – do you think that someone that has a tax-loophole should not have to give it up? Do you think when someone receives a $400.00 a month health insurance subsidy they should not have to give it up?
        flood insurance? crop insurance? sugar price supports? etc.

        what guarantees preferential treatment that you did not earn and that others cannot get? when you say “give up “.. are you talking about the subsidy they have? that they have a subsidy and it cannot be shared with others?

        “I’m just trying to narrow the issues here. Bottom line, are you arguing winners have an obligation to give up some of what they’ve earned and some of what they like so as to extend coverage to at least some of those who have no or lesser insurance coverage? I want to go one step at time so we aren’t talking past each other, which is what I think both of us are doing.”

        did you EARN tax-free health insurance?

        what I appreciate is your ability to talk the issues and stay on point even if we disagree and continue the dialogue on a civil basis. that’s not so easy these days and I highly value it and thank you and would continue the discussion.

        I just do not think people “earned” some of the subsidies and tax benefits they have and when we both agree that, for instance, it’s wrong to give insurance subsidies or tax preferences to people for flood insurance or mortgages.. do you think they “earned” them and are “entitled” to keep them ?

        how many people would want the ability to buy insurance other than what the employer provided – if they had to pay taxes on the cost of it?

        how many people pay for medical care out of their own pocket because they cannot get insurance and they pay for it with taxed money not tax free money ?

        what do some people have access to subsidies and preferential tax treatment and if we try to give the same deal to others – it’s taking yours?

        • Larry, I agree there are reasons for people to buy ACA insurance. Some of the existing policies have significant limitations. Tying insurance to employment does limit career choices. Insurance companies do cancel insurance coverage. Even the young and healthy run some risk of serious and expensive illness and accident. Instead of engaging in open fraud and lies, Obama could have tried to sell the ACA on that basis. But he and the other supporting Democrats knew not enough young and healthy people would join the pools based on these risks. The premiums were too high and reflect the need to cover risks for the sick and elderly. So the Democrats lied. Knowing the ACA would not let people keep their insurance unless it provided subsidies for the risks faced by sicker and older people, Obama and others, including Mark Warner, flat-out lied to the American public. Fraud – pure and simple.

          I also agree the tax code is a mish-mash and treats some better than others in many areas, not just health care. Congress and Reagan simplified the tax code, cut rates and eliminated tax preferences in 1986. And Congress and other presidents have complicated the tax code, raised rates and created zillions of tax preferences ever since. I also try to take the best advantage of the tax laws and regs to minimize my taxes. I’d like to pay less tax and am more concerned about any reforms increasing my tax bill than I am about other people. Selfish? Probably, but I also note elected officials D & R alike never touch people at the very top. Michael Bloomberg and Mark Zuckerberg don’t feel guilty enough to pay more in taxes. I leave guilt to others.

          Tax free health insurance. I see myself taking advantage of the tax law like many others do. I have absolutely no guilt in taking advantage of the law. I believe that employers’ payments of health insurance premiums or self-funding of claims is compensation for workers.

          If Congress wants to eliminate flood insurance, close an unneeded military base or weapons system, support for the sugar industry, electric cars, and use it to fund health insurance, I probably wouldn’t care. I would object strenuously to eliminating the mortgage deduction, as I use it. Ditto for taxing my wife’s health insurance. I’m already paying higher taxes to fund Obamacare. I don’t like that and I’m not willing to pay any more period. I’m far from alone.

          Your arguments are not crazy by any means. But I also think they are losers. Most people are not willing to pay more or give up what they have to expand health insurance coverage. That’s why Mark Warner and Tim Kaine are not making your arguments and are, in fact, back-peddling on the ACA.

          • why didn’t the GOP propose a real alternative when they knew that ObamaCare was flawed and he “lied”?

            re: ” I have absolutely no guilt in taking advantage of the law. I believe that employers’ payments of health insurance premiums or self-funding of claims is compensation for workers.”

            the tax preference is “compensation”? why do you take the tax preferences but resent others getting them?

            do you think your tax preferences don’t come from other people?

            do you want your tax preferences that unfairly benefit you over others but you are opposed to others get tax benefits that work the other way around?

            re: ” the argument about people who have special preferences keeping them while at the same time opposing tax preferences for others for fear it will cost them money.

            that’s the hypocrisy of this TMT.

            how could the GOP truly offer a viable alternative without falling into the same trap?

            so are you essentially saying – you want to keep the status quo because it benefits you even though you know it disadvantages others and that’s a fatal”Flaw” in any reform (Demor GOP) that will kill the reform no matter who offers it?

            be honest here..

            is that the argument?

  15. so two more questions TMT:

    1. – what would happen to US tax revenues if everyone without insurance could get a refundable tax credit for their out-of-pocket?

    are you aware of the other refundable tax credits that people already get?

    2. – what would happen if the money spend on health care by those with employer-policies was taxed so if you had a $15,000 operation, you would be taxed on that amount?

    see my questions here relate to potential tax preferences or penalties and go to the bigger question of what you “deserve” or have “earned” vs what you have not “earned”.

    does the US – use tax policy to create winners and losers – to reward certain kinds of economic activity and to penalize other kinds of economic activity with regard to health care (and actually many other things – like mortgage insurance, college loans, refundable credits for college expenses, no tax on imputed rent or carried interest, etc.

    when people utilize these credits – do you see that as taking something away from you?

  16. Larry, you make good conceptual arguments and many have a basis in equity and fairness. And I would agree many, if not most, Americans like the idea of expanding health care insurance. But I think the evidence is that few are willing to pay more for their insurance or accept less coverage or higher deductibles in order to fund the expansion. I think many would support having the “rich” pay for it. But, as we all know, there aren’t enough “rich” people to pay for any big program. The middle class needs to fund the expansion of health care. And the middle class would not knowingly accept that burden.

    That’s why I maintain Obama’s lie was so terrible. He certainly knew that the middle class had to make significant sacrifices to expand heath insurance and that the middle class was not willing to do so voluntarily. So Obama said, “If you like what you have, you can keep it.” That statement, repeated over and over by Obama and many other Democrats, told the middle class they would not be forced into subsidizing the expansion of health insurance.

    Are there reasons why people without insurance or with insubstantial coverage could benefit from participating in the ACA? Sure. Even the most healthy person can have a stroke or get hit by a car. Having coverage is worth something. Moreover, having policies that cover more services, etc., has value. Some young and healthy people are going to purchase coverage for these and other reasons. But for many, the added price is not worth the added benefits. Some feel they won’t need the covered services. Some would like the coverage, but cannot or will not pay the price. Some people simply don’t care about health insurance (they may need it the most). In sum, there are many reasons why younger and healthy people don’t want to buy ACA insurance.

    I don’t think Obama (or any president) has the political leverage to coerce the American public into purchasing higher-priced insurance to generate the subsidies necessary to expand coverage to the extent proposed. Ditto for forcing everyone out of what they have into single payer. I’m not even sure that could be done by grandfathering everyone who has a policy by date X and going to single payer after that.

    • re: ” Larry, you make good conceptual arguments and many have a basis in equity and fairness. And I would agree many, if not most, Americans like the idea of expanding health care insurance.

      I want to reiterate how much I appreciate being able to dialogue on this in a civil and respectful manner.. a rare thing these days sometimes.

      “But I think the evidence is that few are willing to pay more for their insurance or accept less coverage or higher deductibles in order to fund the expansion.”

      If that is the way it gets framed – I agree with you. I question whether or not it’s right, accurate or fair to characterize it in that way though.

      we have “winners” created by arbitrary tax preferences that those who got them did not do anything to deserve them and those that did not – also did not do anything to not deserve them. That’s inequity in our laws.

      ” I think many would support having the “rich” pay for it. But, as we all know, there aren’t enough “rich” people to pay for any big program. The middle class needs to fund the expansion of health care. And the middle class would not knowingly accept that burden.”

      I’m not that cynical. I think the ordinary person just wants to be able to get treated for cancer before they die from it or have their kid receive care when he/she needs it and/or not go bankrupt from bad luck. I do not think they want the rich to pay for it. I think they look at the other advanced nations with universal care and wonder why we cannot also have it – why we have excuses for not having it.

      “That’s why I maintain Obama’s lie was so terrible. He certainly knew that the middle class had to make significant sacrifices to expand heath insurance and that the middle class was not willing to do so voluntarily. So Obama said, “If you like what you have, you can keep it.” That statement, repeated over and over by Obama and many other Democrats, told the middle class they would not be forced into subsidizing the expansion of health insurance.”

      there is no question that he lied.. either knowingly so or cluelessly so but you don’t repeat it numerous times without at some point realizing it’s going to be exposed as a lie.

      that’s a SEPARATE issue from all the other aspects of ObamaCare.

      Here’s the problem. They wanted to expand coverage but they also wanted the health care plans to meet certain standards – and that second thing they were not honest about but I also question why it had to be bundled into the entire law as without it -you could have achieved something still significant. that was a fail..and before this is all over with – that part may be undone.

      “Are there reasons why people without insurance or with insubstantial coverage could benefit from participating in the ACA? Sure. Even the most healthy person can have a stroke or get hit by a car. Having coverage is worth something. ”

      well .. differentiate between catastrophic coverage versus the minimum standard coverage… meant to “cover” basic things that truly are not “insurance” in a real sense – at least not like a serious illness that could bankrupt you.

      “Moreover, having policies that cover more services, etc., has value. Some young and healthy people are going to purchase coverage for these and other reasons. But for many, the added price is not worth the added benefits.”

      not getting standard screening tests – like for diabetes – is not smart though. It’s a gamble that some might not need and others do – and the result of not getting tested early enough is cardiovascular disease and amputation of limbs. The question is – who pays for those much more expensive illnesses if you don’t have insurance or don’t get screened?

      “Some feel they won’t need the covered services. Some would like the coverage, but cannot or will not pay the price. Some people simply don’t care about health insurance (they may need it the most). In sum, there are many reasons why younger and healthy people don’t want to buy ACA insurance.”

      you are right. but these are the same people who would not buy auto insurance – for the same reasons.. and would not buy fire/casualty insurance for a mortgaged house unless the mortgage company required it.

      the question is – when you go “bare” – and something does happen – who pays?

      “I don’t think Obama (or any president) has the political leverage to coerce the American public into purchasing higher-priced insurance to generate the subsidies necessary to expand coverage to the extent proposed. Ditto for forcing everyone out of what they have into single payer. I’m not even sure that could be done by grandfathering everyone who has a policy by date X and going to single payer after that.”

      the question is – if you gamble on insurance and lose – do you pay the price or do other people have to pay for your irresponsibility?

      If you do not get a colonoscopy. get cancer, and have no insurance or crap insurance, who is going to pay for your treatment?

      In Virginia, you can get an uninsured vehicle registration for 500.00. If that guy rus into you and he has no assets what happens? Well.. for most of us, we have to make sure we have extra coverage in case we end up with the cost… so WHO is paying for that guy not having insurance? You are. right? That’s what is going on in health care also.

  17. Larry, I agree that the American system does provide some incentives for people not to buy insurance and those incentives need to be diminished. It’s not fair to the people who follow the “rules” for those who don’t to be bailed out on a regular basis. My opposition to the ACA does not extend to forcing government to provide incentives for Americans not to be insured.

    I’ve urged a phase-down of the free emergency care law. I also think it would be useful for Uncle Sam to reexamine how the ACA is set up. I do think people must be allowed to keep what they have if they like it. But that doesn’t mean there cannot be incentives for people to purchase better insurance and share the risks with more people. But what does not seem to work, is to develop insurance plans that provide massive subsidies to those who are older and sicker. What should have been done was to look at pools that would be attractive to people in their 20s and 30s, with some level of catastrophic coverage, some level of coverage of preexisting conditions. A pool that goes partway in covering older and sicker people that also attracted younger and healthier people might have been a good start. In other words, instead of basing the ACA on forcing young and healthy adults to participate at levels that would fully cover the older and sicker people in a “hope and change” world, Obama and Congress should have worked to create insurance reform that provided positive incentives to join even though the reform gave less to those without.

    Achieving 25% or 33% of the goal might have been doable, and doesn’t that beat the fiasco that is the ACA today?

    Finally, I cannot accept your argument that reform will provide benefits to all in the form of lower premiums (at least in real dollars). If that were the case, why is no one tying expansion under the ACA to mandatory premium cuts? Why, because they know damn well health care reform will be higher spending on health care and higher insurance premiums just like in Massachusetts.

  18. re:

    ” Larry, I agree that the American system does provide some incentives for people not to buy insurance and those incentives need to be diminished. It’s not fair to the people who follow the “rules” for those who don’t to be bailed out on a regular basis. My opposition to the ACA does not extend to forcing government to provide incentives for Americans not to be insured.”

    the question is how do you make whole those who did not receive the tax preferences and subsidies? How can you provide special treatment to some people then say you cannot to others?

    “I’ve urged a phase-down of the free emergency care law. I also think it would be useful for Uncle Sam to reexamine how the ACA is set up.”

    not ONE opponent of the ACA has said that to my knowledge much less a group of legislators who say there are better solutions than the ACA.

    ” I do think people must be allowed to keep what they have if they like it. But that doesn’t mean there cannot be incentives for people to purchase better insurance and share the risks with more people. But what does not seem to work, is to develop insurance plans that provide massive subsidies to those who are older and sicker. What should have been done was to look at pools that would be attractive to people in their 20s and 30s, with some level of catastrophic coverage, some level of coverage of preexisting conditions. A pool that goes partway in covering older and sicker people that also attracted younger and healthier people might have been a good start. In other words, instead of basing the ACA on forcing young and healthy adults to participate at levels that would fully cover the older and sicker people in a “hope and change” world, Obama and Congress should have worked to create insurance reform that provided positive incentives to join even though the reform gave less to those without.”

    when you have “pools” for people who are 65 and older and you can provide them with health care for about 500.00 per subscribe – why can you not achieve the same thing for younger people? i.e. “medicare for all”?

    “Achieving 25% or 33% of the goal might have been doable, and doesn’t that beat the fiasco that is the ACA today?”

    I don’t think the ACA is “done” myself but I admit it’s in big trouble.

    “Finally, I cannot accept your argument that reform will provide benefits to all in the form of lower premiums (at least in real dollars). If that were the case, why is no one tying expansion under the ACA to mandatory premium cuts? Why, because they know damn well health care reform will be higher spending on health care and higher insurance premiums just like in Massachusetts.”

    we KNOW that every other advanced economy govt on the planet can provide health care for al their people for 1/2 what we do.

    why can we not equal that?

    we actually DO equal that for Medicare…if every other OECD country can do it why can’t we?

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