Obamacare’s tenth life

This post is cross-posted at Medium.

Back in January, I recounted the Affordable Care Act’s many trials and tribulations in anticipation of what was poised to be its toughest battle yet. From Scott Brown cracking the Democrats’ filibuster-proof Senate majority in 2010, to John Roberts turning gun-shy before obliterating the individual mandate, through Ted Cruz’s government shutdown, Obamacare had more than its share of close calls.

Yet the law defied death again and again. “[F]or eight years, center-left health reform has prevailed against constant slings and arrows because its moral foundations are strong,” I wrote at the time. “Obamacare’s tendency to survive may just be what spares it again.”

And survive again it has. Trumpcare is dead, and Obamacare is alive. The GOP’s seven-plus year charge of repeal and replace went down in flames on Friday, having barely even made it out of the starting gate. And when it comes to the core of Obamacare, Republicans hardly even put up a fight.

That’s because the GOP long ago gave up on contesting the basic moral foundation of Obamacare: the notion that everyone is entitled to healthcare as a right. It was a quiet concession, drowned out by years of chest-thumping cries to repeal Obamacare, but the right implicitly acquiesced to Obamacare’s new normal years ago. That, more than anything, doomed the effort to repeal it.

Republicans tried to resist the moral force of universal healthcare by tarring it as “socialized medicine” and a government takeover of health insurance. But since Obamacare began delivering real benefits to real people, the center of gravity within Republican opposition shifted toward a more practical, less ideological critique about high premiums and inadequate coverage. Underneath the howls for repeal, the conservative objection increasingly moved from universal healthcare itself to the outcomes and mechanisms Obamacare employed to approximate it.

Donald Trump formalized this concession. Just days after his election, he announced that he intended to keep Obamacare’s popular guarantee of coverage for people with pre-existing conditions. Even earlier, Paul Ryan’s “Better Way” proposal agreed to preserve this protection, too. But to insure the sick, you must also insure the healthy — insurance markets cannot function any other way. And when it comes to universal healthcare, insuring both the sick and healthy is more or less the whole ballgame.

To keep protections for the sick in place, the Republicans would have to produce a plan that looked a lot like Obamacare. Under this constraint, the only way to differentiate it — and thus the only way to realistically claim to “repeal” Obamacare — would be to design a version of the law that was meaner, stinger, and outright worse.

That’s ultimately just what the GOP did, but only after abandoning their first strategy: so-called “repeal and delay.” This plan — to give Republicans the political catharsis of an immediate Obamacare repeal vote, but delaying the effective date of repeal for several years — implicitly conceded two important points: First, that it was unjust and untenable to simply repeal and toss people off of their healthcare. And second, that Republicans had no idea how to actually replace the law.

After it became clear that repeal and delay too would cause chaos on insurance markets, that half-baked plan was scrapped once enough leading Republicans (Trump included) clamored for simultaneous repeal and replace. And that course correction produced the monstrosity that was the American Health Care Act.

The bill was a horribly constructed, unloved mess from the day Ryan announced it from behind his smirk. But it was really its Congressional Budget Office score that did it in, for the CBO confirmed what everyone suspected: that AHCA grossly offended the prevailing moral principle of universal healthcare. In pursuit of that principle, Obamacare had normalized a baseline of widespread and affordable coverage. AHCA did immense violence to each of these, threatening to throw 24 million people off their insurance and jack up rates on millions more of the oldest and more vulnerable Americans.

With that, it was only a matter of time before AHCA collapsed in a heap. There were other factors, of course: The Republican Party was in a defensive crouch from the get go, and couldn’t coalesce around a replacement plan. A public enraged by the elevation of Donald Trump to the presidency and terrified of the threat to life and limb posed by repeal galvanized to mount a fierce resistance. But the common thread through all of them was the potent moral force of universal healthcare.

Granted, Obamacare hasn’t yet achieved the goal of universal coverage. But it made a major down payment toward that goal, lowering uninsured rates to historic lows. With the failure of AHCA, the country is refusing to turn back from those gains.

So for the second consecutive Republican presidency, grand conservative designs to gut a pillar of the welfare state have crumbled. When George W. Bush decided to spend his second-term political capital privatizing Social Security, his plan made it through the summer before being pronounced dead. What is remarkable about Obamacare repeal is that it fell apart so fast.

But like Social Security reform, AHCA crumbled under the weight of poor policy design, Republican factionalism, and public resistance. Call it loss aversion, status quo bias, third-rail entitlements — the welfare state has demonstrated an impressive staying power.

And it all comes back to the foundational moral basis for government forging ahead to better people’s lives and provide a sense of security. That’s the brick wall that Ryan’s now-aborted “rescue mission” ran into headlong. Universal healthcare is right and just, and that’s why Obamacare has survived yet again — and perhaps for good.

Social democracy as the answer to Trump

I’ve been reading Tony Judt’s Ill Fares The Land, his 2010 plea for social democracy in the last days of his life.  It turns out that Judt presciently anticipated the appeal of Trumpian authoritarianism in our insecure age — and offered social democracy as our best hope to withstand it.

obit-judt-articleinline

Tony Judt (New York Times)

Judt was a steadfast if begrudging admirer of social democracy–a political ideology that “does not represent an ideal future; it does not even represent the ideal past.  But among the options available to us today, it is better than anything else to hand.”

Social democracy is the true center of modern political thought.  Where socialism outright rejects capitalism, social democracy accepts it.  Social democracy aims to harness the engines of capitalism while tempering its rough edges, crafting the institutions and guardrails necessary to balance capitalism’s chaotic dynamism with a measure of ordered security.

That sense of security is dangerously amiss today, roiling much of the West with anxiety.  “We have entered an age of fear,” Judt wrote.  “Insecurity is once again an active ingredient of political life in Western democracies.”  This is the insecurity of terrorism, of technological change, of globalization, of economic inequality, of the prospect of job loss.  “And, perhaps above all,” Judt wrote, “fear that it is not just we who can no longer shape our lives but that those in authority have also lost control, to forces beyond their reach.”

This combination — an electorate both gripped by fear and inflicted with skepticism of their leaders’ ability to do anything about it — produces anti-democratic movements that offer stability by turning aggressively inward.  “If we can have democracy, we will,” Judt observed.  “But above all, we want to be safe.  As global threats mount, so the attractions of order will only grow. [. . .]  Outsiders, however defined, will be seen as threats, foes and challenges.  As in the past the promise of stability risks merging with the comforts of protection.”  That’s the lure of Trumpism that Judt saw coming.

The fearful society craves stability.  This stability can be provided one of two ways: First, it can be anti-democratic stability.  This is the order promised by a strong man — one who exploits this insecurity by vilifying the weak and the “other.”  One who looks at blighted communities cast to the margins of the American story and declares “I alone can fix it.”  One who assures those forgotten communities that he will “give you everything. I will give you what you’ve been looking for for 50 years.”

“Unless the Left has something better to offer,” Judt warned, “we should not be surprised to find voters responding to those holding out such promises.”

Fortunately, the Left does have something to offer — Trumpism isn’t the only answer to insecurity.  Stability can also be provided through democracy by crafting institutions to truly protect people from the risks of modern life.  “Social democracy in Europe, the New Deal and the Great Society here in the US, were explicit responses” to challenges and threats wrought by previous eras of insecurity, Judt wrote.  Where Trumpism offers recriminations in response to insecurity, the Left must offer reassurance.

What does that reassurance look like?  By and large, it means insuring individuals against commonly-shared risks in the twenty-first century.  Political scientist Lane Kenworthy laid out a full agenda for a Social Democratic America, including wage insurance to protect workers from cuts in pay, sick leave to insure workers in case of illness, a child benefit to insure parents against the costs of child rearing, and other social insurance programs.  It might also include an aggressive program of targeted government investment to stimulate stagnant communities, coupled with a federal works program, to function as a form of insurance against creative destruction discarding whole regions of the country.

Of course, a program of that scale and ambition will directly confront a public with ever-diminishing expectations in the capacity of its civic institutions and their leaders.  As Chris Hayes wrote in The Twilight of the Elites, we face a crisis of authority in the United States after a generation of catastrophic elite failure at every turn across virtually every pillar of society. This makes for a receptive audience for the authoritarians promising anti-democratic stability that bludgeons these very institutions, and a much more doubtful audience for those looking to achieve democratic stability through better and more comprehensive institutions.

Which means the Left’s message and messenger matter.  A compromised center-left version of social democracy in the hands of a leader closely tied to decades of institutional failure won’t be compelling.  While Hillary Clinton pushed an agenda packed with progressive technocratic reforms and programs, her institutional ties were too unshakable and her ambition to restructure the American economy too trimmed to compete with the vociferous anti-democratic stability offered by Trump.

The Left will need an outsider insurgent that can credibly lay claim to moving the country in the direction of social democracy.  Barack Obama pushed a centrist progressive agenda, but did so as an outsider reformer offering hope and relief from the failures and disappointments of the previous generation.  Bernie Sanders positioned himself as an outsider to the political class vowing social democratic revolution of the country’s institutions, but lacked the inspirational and heroic appeal of Obama that cut across all core Democratic constituencies.  Some combination of the two is what’s called for.

Moreover, a social democratic response to Trump isn’t necessarily about specific policies.  Rather, it requires making an unabashed positive case for the role of government to better citizens’ lives; for the capacity of a democracy to craft institutions to guard against threats new and old; for the ability of elected leaders to chart a course that enlivens struggling communities and ensures that prosperity is broadly shared.

Even if Trump’s presidency crumbles under the weight of chaos, incompetence, and scandal, the resonance of his dark message won’t necessarily follow suit in four years.  As the closest approximation of the Left in mainstream American politics, Democrats will only defeat Trump by offering voters their own vision of how to achieve security in the twenty-first century.  In an age of fear, the hostile illusion of security of the Right can only be matched by a hopeful communal security of the Left.

The Constitution is a sanctuary from Trump’s executive order

Last week, I published a column at Syracuse.com (my hometown news org) arguing that Donald Trump’s attempt to de-fund sanctuary cities is unconstitutional.  In short, progressive federalism for the win:

The Trump administration would like to shift the burden and cost of carrying out its political agenda of rounding up immigrants on to local cities, their police forces and their taxpayers. Unfortunately for the White House, the Constitution was devised to limit Washington’s powers, protecting states and cities from exactly this kind of federal encroachment.

Read the rest here.

A supreme theft

This week, Donald Trump announced his nominee to fill the Supreme Court vacancy that arose after Justice Antonin Scalia’s death during President Obama’s second term in office.  The nomination is the result of stolen goods that Senate Republicans housed for ten months and then giftwrapped for Trump upon taking office.  The coming Supreme Court fight is thus a bridge between the radical insurgent GOP of the Obama years to the vengeful and autocratic Trump regime taking shape—a fight that, for good or ill, will bind Trump and the GOP more than ever.

On March 16, 2016, President Obama nominated Merrick Garland to fill the Supreme Court seat vacated after Justice Scalia’s death.  Garland was the widely respected, long serving Chief Judge of the U.S. Court of Appeals for the D.C. Circuit, the second highest court in the land.  An ideological moderate, Garland had previously gained acclaim from influential senators on both sides of the aisle.

The Republican-controlled Senate refused to even hold a hearing or give Judge Garland an opportunity to make his case.  Instead, the Senate kept the vacancy open, denying Obama his constitutional prerogative to appoint a justice, and held onto the seat on the off-chance a Republican won the presidency in 2016.  This was an unprecedented abdication of the Senate’s constitutional duty to advise and consent upon the president’s nominee.

So the vacancy that Trump is now filling is the result of plunder committed by the GOP against the country’s first black president.  And that plunder was the culmination of a relentless effort to brand that president as illegitimate.  As Obama took office in 2009, Senate Republicans cast into minority opposition seized on their base’s fear and revulsion to Obama’s politics and identity and molded it into a legislative strategy.  Senate Republican leader Mitch McConnell vowed total resistance to the president’s supposed radical socialist agenda.  McConnell sought to deny Obama any stamp of bipartisanship, sullying the president’s popularity and lifting the Republicans’ chances to reclaim majority status in Congress.

Congressional Republicans did the work of tarring Obama as an ideological outsider.  Meanwhile, Trump was busy stoking fears of Obama as an ethnic outsider with a fraudulent birth certificate.  This all served to cement fear and paranoia in the minds of GOP voters that the White House was in illegitimate hands—even though that president was twice elected with a popular vote majority free of any foreign or law enforcement interference.  The Republican Senate’s theft of Obama’s last Supreme Court nominee was the final malfeasant act of eight years of delegitimization.

That is the legacy of Trump’s Supreme Court inheritance: one of theft and deceit.  The process for filling a seat on the country’s highest court is no longer governed by law or custom—and certainly not by the Constitution—but instead by raw power.  The operative principle now is that if Republicans have the power to deny a Democratic president a Supreme Court pick, they will do so.  It’s about power and nothing more.  Any other claimed principles—about letting the people have a say in the presidential election, etc.—are backward-manufactured rationales to justify a power grab.

Senate Democrats must now decide how to react.  Rightfully furious about their Republican colleagues’ egregious mistreatment of Garland, many are predisposed and ready to side with the demands of the party’s base to resist Trump at every turn.  Other Democrats worry about being blinded by rage and tripping into a fight that the party simply cannot win.

It’s true, Democrats will ultimately lose this nomination fight.  The left must understand the brutal math.  But that’s beside the point.  If Democrats think Senate Republicans will hesitate to nuke the filibuster on the next Supreme Court nomination if Democrats let this one go, they are deluding themselves.

This Court battle is not about the merits of the nominee.  And Democrats cannot to take the high road in a doomed attempt to save Supreme Court nominations from becoming a partisan race to the bottom.  Republicans are already running that race, and made clear with their treatment of Garland that the Supreme Court is no different from any other political contest.  Democrats have no choice but to engage in this fight or else make Supreme Court vacancies a one-way rightward ratchet where Democrats play by an old set of rules and norms that Republicans systematically obliterate.

If Democrats need a principle to justify fighting Trump’s nomination, here’s one: appointments should be required to get support from each party.  It’s hardly an unreasonable position—after all, Elena Kagan and Sonia Sotomayor both attracted bipartisan support.  And it wasn’t that long ago that Justice Ruth Bader Ginsburg was confirmed by the Senate 96-3.  This would call for a widely-approved consensus nominee—someone in the mold of, say… Merrick Garland, of whom Republican Senator Orrin Hatch once said would be a “consensus nominee” who had “no question” of being confirmed.

But here we are.  One way or another, Donald Trump, a popular-vote loser of dubious electoral legitimacy and of whom a growing majority of Americans disapprove, will fill the Supreme Court seat heisted by Senate Republicans from Barack Obama.  This joint operation binds Trump and the GOP closer than ever, as Republican senators gush over the credentials and qualifications of his pick, seemingly oblivious to the impeccable credentials and qualifications of the man they spurned, Merrick Garland.

This linkage is about more than just a single Supreme Court confirmation, however.  There is a direct line from a conservatism that once sought small government to one that increasingly vilified government—that sowed distrust in institutions and then actively worked to weaken those institutions, creating the vacuum of authority that is ripe for Trumpism.  For an ideology that once prided itself on restraint, respect for tradition, and deference to preexisting institutions, conservatism has clearly lost it way.  When followed to its extreme, the endpoint of conservatism is Trump.  It is eminently possible that in the long run, the strain of revolutionary conservatism that has prevailed on the right since 1980 is outright incompatible with liberal democracy.

Stalemate-and-delay: the future of the Obamacare fight?

The fight over Obamacare is poised to dominate much of President Trump’s first year in office.  Republicans are dead set on following through on years of political attacks against the law.  Democrats are equally adamant about saving President Obama’s signature achievement and the millions insured under it.

The problem is that congressional Republicans look increasingly unprepared to follow through on their rhetoric about replacing the law.  Yet they and the Trump administration is convinced the law is failing.  This leaves the GOP in a real bind.

But there may be a way out.  When it comes to Obamacare, the best outcome for everyone may be a stalemate.

As a basic matter of math, Republicans need Democratic support to replace Obamacare.  They could repeal the law with a bare majority in the Senate, but will need eight Democrats to go against the party and overcome a filibuster to enact a replacement.  Republican leadership, including Trump and House speaker Paul Ryan, has backtracked from the repeal-and-delay misfire, and has since come to promise that repeal and replacement will occur near simultaneously.  That requires Democratic votes.

The core question for Trump and the GOP is how to get them.  Trump believes that he is negotiating from a position of ever-increasing strength.  He thinks the law will crumble on its own, even telling congressional Republicans gathered in Philadelphia that he had thought about “doing nothing [on healthcare] for two years, and the Dems would come begging to do something” after “catastrophic” price increases.  Ryan has the same forecast for the law, repeatedly (and falsely) asserting that Obamacare’s individual marketplaces are in a “death spiral.”

Trump has hinted at this scenario before.  Earlier in January, Trump tweeted that the GOP needed to “be careful” about repealing Obamacare, because Democrats would be to blame when the law “fall[s] under its own weight.”  There is clearly a side of Trump that sees political advantage to continuing to hang Obamacare around the necks of Democrats—a side of him that splits from Republican leadership in Congress on the immediate urgency to erase the law from the books.  By sitting back and waiting, Trump suspects he could get a better deal.

Democrats, on the other hand, are confident that Obamacare is succeeding.  They point to the 20 million people insured under the law and signs that its marketplaces have stabilized.  Democrats are determined to resist GOP repeal efforts, and are increasingly drifting toward a strategy of all-out opposition to Trump across the board.

From the Democrats’ perspective, there’s no reason to disabuse Trump of his notion that Obamacare is a ticking time bomb with their names attached to it.  Suppose Democrats stick together as a uniform bloc in opposition to repeal and replace.  A frustrated Trump might see the Democrats as “ungrateful” for the GOP’s efforts to save them from their supposed healthcare mess.  Trump might then decide to wait until carnage from Obamacare’s “collapse” starts to hit in order to exact a better deal out of desperate Democrats at that time.

For Democrats, this result keeps Obamacare on the books, delaying the repeal fight until a day when Trump may be on even weaker ground in public approval, and a day that is that much closer to the 2018 midterm elections.  At that point, Democrats could spark a wave election to take back the House or Senate, stopping Trump’s agenda altogether.

But stalemate-and-delay makes sense for Republicans, too.  If Trump gets fed up with congressional gridlock over healthcare and with how much of his first year in office the issue has consumed, he may want to shelve repeal—especially if he expects to pin down the Democrats into agreeing to more favorable terms down the road.  But would the repeal-obsessed GOP Congress go along with this?  Almost certainly.  Trump owns the GOP now, and the party will largely do as he says.  If Trump says build a border wall, Ryan asks how high (while writing a $15 billion check, to boot).  There’s no reason to think the party would subvert him if he tired of the Obamacare battle.

Trump and other leaders take the position that even though they could wait and let the law implode on its own, they have a duty to come to the rescue of those suffering under the tyranny of Obamacare.  By postponing the repeal push, Republicans get to blast obstructionist Democrats for perpetuating the hellish suffering inflicted on the American people under Obamacare.

This relocates the Obamacare debate back into the Republicans’ comfort zone.  Republicans are most at ease using healthcare as a political piñata against Democrats.  But now that they have the power to decimate Obamacare, they have no plausible plan to put the piñata back together again.  At the GOP’s Philadelphia retreat this week, one member of Congress said that the party’s leaders have offered “zero specifics” on an Obamacare replacement so far.  A leaked recording of that retreat shows Republican members of Congress ill at ease with the party leadership’s lack of strategy and clarity on healthcare.

So for Republicans in Congress, postponing repeal buys more time to devise a replacement plan, while allowing them to continue to use Obamacare as a political battering ram to rally their base going into the 2018 midterms.  Even though they’ve spent seven years railing against the law, Obamacare repeal is a fight that the GOP is not ready for.  Republicans are animated by political opposition to Obamacare as an avatar for big government liberalism.  But they still aren’t equipped or prepared to translate that political opposition into policy language.  Stalemate-and-delay allows them to reap the benefits of the former while avoiding the embarrassment of the latter.

Conversely, it also avoids Republicans taking ownership over the country’s healthcare system going into those elections—something many in the party are loath to do.  “We’d better be sure that we’re prepared to live with the market we’ve created” with repeal, said Rep. Tom McClintock of California.  “That’s going to be called Trumpcare. Republicans will own that lock, stock and barrel, and we’ll be judged in the election less than two years away.”

There are risks in this gambit for Democrats, but those risks are tolerable.  The key is for Democrats to stick together in total opposition to GOP repeal efforts.  And they will be sticking together to defend a wounded healthcare law—one that the Trump administration will weaken to the fullest extent of its executive authority.  Trump already issued an executive order instructing his administration to relax enforcement of the law “to the maximum extent permitted by law.”  White House adviser Kellyanne Conway even suggested the administration may refuse to enforce the law’s controversial individual mandate.  And Trump also canceled planned advertising for the law’s individual marketplace plans in the final days of open enrollment in an apparent attempt to reduce sign-ups.  These are all attempts to loosen the screws on Obamacare’s three-legged stool.

But these risks were always going to be the case under a Republican administration.  Republican sabotage was inevitable, but it beats wiping the law off the books entirely.

So perhaps Obamacare’s future looks much like its past: a political lightning rod perpetually on the chopping block, but never actually chopped.  Trump can rationalize stalemate-and-delay as standing pat until a later day when he can bend Democrats to his will.  Republicans can keep rallying their base on the promise of repeal were it not for those obstructionist, big government Democrats.  And Democrats can appeal to their base having successfully fought Trump and continuing to stand up to Republicans intent on gutting Obama’s signature achievement.

And that might be Obamacare’s political sweet spot.  Democrats want to save Obamacare, and Republicans need an off-ramp from repeal.  For both parties to win, the solution might just be to stalemate.

The case for federalizing Medicaid

If Donald Trump ever moves on from bickering over the size of his inauguration crowd to actually governing, one of the first orders of business will be churning out a promised “terrific” Obamacare replacement plan. While we don’t yet know the exact details of Trumpcare, Trump adviser Kellyanne Conway confirmed this week that block granting the Medicaid program to the states will be a big part of it.

This isn’t a surprise. Republicans like Speaker Paul Ryan and health secretary nominee Rep. Tom Price have called for kicking Medicaid down to the states for years. Unfortunately, it’s the exact wrong direction we should be going toward.

Medicaid provides health insurance to nearly one hundred million people, including children, pregnant women, nursing home residents, people with disabilities, and low-income Americans. For over fifty years, the program has been managed jointly by the federal government and the states. Washington finances at least half of the program’s costs, and often substantially more in poorer states. Obamacare expanded Medicaid to cover those just above the poverty line, and even offered to pick up the entire tab for the first years of the expansion. Still, nineteen conservative-led states turned down free money, causing a Medicaid “coverage gap” currently ensnaring 2.5 million people that would have otherwise gained insurance.

Conservatives in Washington want to drastically change this arrangement by simply cutting a check to the states and letting them run Medicaid. Conservatives like this idea for a few reasons. For one, a block grant creates more predictable (and lower) costs for the federal government. It gets the federal government off the hook for covering a share of whatever costs program enrollees incur, and instead just subsidizes state Medicaid programs. A block grant transfers most of the commitment of insuring vulnerable populations from the federal government to the states.

The problem, of course, is that this is a barely-concealed way of cutting healthcare funding for the poor. The only way for block grants to save the federal government money is to systematically lowball the amount of the grant. For example, the block grant plan pushed by Price and other House Republicans would slash Medicaid spending by $1 trillion — nearly 25 percent — over the next decade. A similar plan offered by Paul Ryan in 2012 would have caused up to 20 million Americans to lose their coverage.

This leaves it to individual states to pick up the slack, but it’s far from guaranteed that they are willing or able to do so. Medicaid is already one of the costliest expenditures for states, consuming on average nearly 20 percent of their budgets (second only to K-12 education). Making up for a $1 trillion funding gap would be a stretch even during relatively good economic times. But during a recession, block granting would be a disaster. While the federal government can take on debt to finance deficit spending, almost every state is required to keep a balanced budget. When revenues dry up during a downturn, states take an axe to social spending to make up the difference. These cuts inevitably come disproportionately from low-income programs. So the end result of block-granting means Medicaid will get cut to the bone just when more and more people will need it.

Block-grant proponents want to give states more of a role to experiment with Medicaid. But just as some states may seize on new flexibility to experiment upward with better, more generous programs, others will ratchet Medicaid downward by providing stingier benefits. Those nineteen states refusing the federal Medicaid expansion in particular have political cultures deeply hostile to insuring the needy. In Texas, for example, childless adults are ineligible for Medicaid regardless of how poor they are, and even parents are “too rich” for coverage if they earn more than 18 percent of the poverty line — $2,118 a year.

Even though national Republicans package Medicaid block granting as an exercise in states’ rights, it’s not clear how many states want the privilege of taking the primary lead in running Medicaid. Even some Republican governors worry that block grants will reduce the effectiveness of their safety nets. Medicaid block grants could easily follow the pattern of welfare reform — another safety net program devolved to the states during years of economic growth that has since shriveled away due to chronic underfunding.

Instead of block-granting Medicaid to the states, a better course is to do the exact opposite: have the federal government assume full responsibility for Medicaid. This would eliminate harsh state-based eligibility restrictions like in Texas, and would guarantee coverage for all who qualify. Because the federal government can run budget deficits, it is better situated to protect the program during economic downturns. And federalizing Medicaid would relieve the states of a massive fiscal burden, freeing up money for education, infrastructure, tax cuts, and other state projects.

Putting Medicaid entirely in the hands of the federal government may also better tame the program’s costs. As Greg Anrig of the Century Foundations writes, “taking 50 separate state bureaucracies out of the picture would be a meaningful step in the direction of reducing confusion and wastefulness.” Congress and federal agencies would also be better able to experiment with cost-containment strategies without the states in the mix.

Federalizing Medicaid could also yield tax relief for low- and middle-income Americans. While new federal revenues would need to be raised, the states would be free to cut taxes. And because the federal tax code is more progressive than the states’, most of the new financing for Medicaid would come from the wealthy. The net result would likely mean lower taxes for most Americans.

Federalization is not a new idea, nor a partisan one. As Anrig points out, Ronald Reagan proposed federalizing Medicaid in 1982 in exchange for giving the states over other safety net programs. Even earlier, in 1979 Jimmy Carter proposed federalizing Medicaid as part of his health reform pitch.

On the campaign trail, Donald Trump promised that he would not cut Medicaid. That’s a promise he cannot keep while also block-granting the program. Instead of pawning Medicaid off on the states, the federal government should lift it off of their shoulders entirely. That would give the states real flexibility.

Note: This post is cross-posted at Medium.

A Red State Option on Steroids for Obamacare

The Affordable Care Act came under existential attack the minute it was signed into law.  Almost immediately, a slew of Republican state attorneys general rushed to the court house to have the law struck down on the grounds that its individual mandate to purchase insurance was unconstitutional.  Less noticed but just as consequential was a sidecar challenge to the law’s mandatory Medicaid expansion, arguing that it violated states’ rights.

When the case (known as NFIB v. Sebelius) reached the Supreme Court, it split the polarized justices.  Four conservatives were ready to toss out the law entirely, four liberals were bent on saving it.  In an apparent tacit compromise, Chief Justice Roberts agreed to provide the fifth vote to uphold the mandate as a tax, while liberal Justices Breyer and Kagan joined the majority in striking down the mandatory Medicaid expansion.

This was hailed as a victory for Obamacare, but the under-noticed Medicaid ruling has had dire consequences.  The Court’s decision opened up a “Red State Option,” and nineteen conservative-led states have opted not to expand their Medicaid programs to cover the near poor, ostensibly out of sheer partisan spite.  This has blocked 2.5 million people from obtaining insurance.

I point this out because a pair of Republican senators are proposing a large-scale version of the Supreme Court’s compromise today.  In order to replace Obamacare, Sens. Susan Collins of Maine and Bill Cassidy of Louisiana would create a sort of Red State Option on Steroids, allowing states to opt out of Obamacare entirely if they so choose.  As Vox’s Sarah Kliff explains:

The Patient Freedom Act would, as described by Sens. Cassidy and Collins, give states three options:

  1. Continue to run the Affordable Care Act as is without any changes
  2. Switch to a different health insurance expansion that emphasizes auto-enrolling all uninsured residents into a federally subsidized catastrophic plan
  3. Offer no coverage expansion at all, and the state would lose the money it currently receives for insurance subsidies and Medicaid expansion

Under Option 1 (let’s call it the “Blue State Option”), progressive states such as California and New York that like Obamacare can keep it.  Or at least, they can keep most of it—Cassidy-Collins would impose a 5 percent cut on subsidy payments to Obamacare enrollees.

Under Option 2 (the “Red State Super-Option”), conservative states like Texas and Kansas can ditch Obamacare entirely and opt into a not-yet-fleshed-out conservative replacement plan.  Cassidy and Collins haven’t yet fully formed what this replacement looks like, but it will involve auto-enrollment of the uninsured into high-deductible catastrophic insurance plans attached to health savings accounts.  The money that would have been spent on Obamacare subsidies in these states will be redistributed into these HSAs based on each individual’s age, rather than income.

Option 2 will tend to disadvantage low-income individuals, because it abandons Obamacare’s means-tested subsidies.  And it also undercuts the GOP’s current main objection to Obamacare: its high out-of-pocket costs.  With high-deductible plans, enrollees aren’t really insured at all until they first rack up thousands of dollars in medical expenses, and must self-fund everything else with their own savings.  This will aggravate healthcare-induced financial strain, not alleviate it.  For that reason, HSAs tend to be virtually useless to all except the wealthy.  Even so, Option 2 is a revealing look at the true conservative impulse of what right-leaning health reform would look like.

Option 3 is essentially a State of Anarchy Option.  As health economist Aaron Carroll says, “I have no idea why any state would choose [this option].”  This option would appeal only to states looking to mindlessly blow up the healthcare coverage expansion (there may be some…), but would otherwise seem to solely exist to prod states toward choosing one of the other two options so as not to lose federal money.

Under all three options, the ACA’s taxes are left in place—a concession sure to rankle congressional Republicans.  Annual and lifetime limits will stay, too, as will the ability of children to stay on their parents’ insurance until turning 26, and the prohibition on insurers excluding patients with preexisting conditions.

The Cassidy-Collins plan is plainly meant as an attempt to craft a bipartisan way out of the Obamacare repeal fight.  Republicans need eight Democratic votes to enact any replacement plan, and Sens. Cassidy and Collins hope that Democrats might settle for kicking the Obamacare decision down to the states.

For Democrats, the only reason to support this idea is because saving Obamacare in blue states is better than not saving it at all.  It’s a sort of second-best option that at least protects individuals in Democratic-led states.

But Cassidy-Collins will also amplify healthcare polarization from state to state.  The Medicaid expansion has already shown that some states will almost certainly not make this decision based on legitimate policy considerations around how best to expand health insurance.  The issue of healthcare has become too partisan, with the ACA serving as an avatar for anti-Obama resistance.  Perhaps that resistance will finally defuse now that Obama has left office, but Cassidy-Collins certainly gives the states the opening to widen the geographic gulf in our healthcare system.

And of course, the most vulnerable will be the ones who suffer.  As Topher Spiro of the Center for American Progress writes, “It’s unconscionable that access to quality health care would depend on where you happen to live.”  Cassidy-Collins puts the decision about who deserves health coverage in the hands of state elected officials, who are disproportionately conservative Republicans skeptical of universal healthcare in much of the country.

Perhaps the most significant outcome of Cassidy-Collins is that it signals that there is a cohort of Republican senators who are serious about committing to a replacement plan before killing Obamacare altogether.  Collins has already said that Republicans must have at least a “detailed framework” for a replacement before repealing the law.  Her vote is one that Republicans need in order to move in any direction on healthcare.

But Cassidy-Collins is also telling in other ways.  By punting the repeal fight to the states and presenting them with a menu of healthcare options, the proposal creates a sort of Choose-Your-Own-Adventure Federalism.  In a country growing increasingly divided by politics, Cassidy-Collins embraces polarization in policy.

Contrary to Obama’s 2004 convention speech, there clearly are Red States and Blue States when it comes to health policy.  Federal health policy ought to serve as a floor to guarantee certain rights and benefits regardless of state politics.  But the so-called “compromise” bill in the Senate would abscond from that duty and instead only heighten our political divide.  Whether or not it is a tenable compromise, the fact that such an outcome is viewed as a plausible off-ramp speaks volumes about the state of our politics.

The agonized are organizing

New post at Medium:

One day into the Trump administration, millions of those horrified by his presidency put that mantra into action, taking to the streets to peacefully defend their rights and values. The Women’s Marches were a historic display of civic resistance, but on their own, they will not be enough. The bursting energy on display from the marches’ grand scale must now be channeled into an equally fierce but targeted resistance to specific actions and policies promoted by the Trump administration.

Fortunately, there are early signs that this is already happening. Trump and congressional Republicans have vowed to roll back Obamacare — an act that would rip health insurance away from 32 million people while causing premiums to double for millions more, according to the nonpartisan Congressional Budget Office. The political anxiety countless Americans feel about a Trump administration is converging with a real and imminent bodily anxiety millions dread from the Republican Congress’s insistence on shredding health reform. The result is a percolating resistance to the new administration’s top legislative priority.

Read the rest here.

How Obamacare repeal sets the table for the entire GOP agenda

President-elect Donald Trump and his Republican allies in Congress are ready to press ahead with Obamacare repeal come January.  The effects of repeal will be devastating enough.  But repeal also triggers problems that help the GOP justify the rest of its agenda.  By repealing Obamacare, Paul Ryan and company will try to bootstrap in drastic changes across government in the name of reducing deficits and stabilizing federal programs like Medicare.

Republican plans to repeal Obamacare would exact a massive human toll.  Repeal could throw upwards of 30 million people off of their health insurance, doubling the current uninsured rate.  And if Republicans gut the law’s protections for those with pre-existing conditions, 52 million people would struggle to find affordable insurance.

The human carnage of repeal is meant to coerce Democrats into going along with a right-wing replacement bill.  Republicans will have 52 votes in the Senate in 2017.  They can repeal most of Obamacare with 51 votes for a reconciliation bill.  But to enact new legislation replacing the law, they’ll need eight Democratic votes to overcome a filibuster.  The thinking is that creating an Obamacare cliff with massive human disaster on the other side will compel cooperation from Democrats.

Never mind whether this scheme can actually work without provoking a stampede of insurers out of Obamacare’s marketplaces during the transition period leading up to the cliff.  Like the hostage-taking expeditions during the Obama administration—the debt ceiling fiasco, the fiscal cliff, the government shutdown—this is another instance of the GOP manufacturing a crisis in order to strong-arm its policy priorities through Congress.

Conveniently for Republicans, Obamacare repeal opens the door to far more of the conservative agenda than just upending the individual insurance market.  According to a new report from the Brookings Institute, repeal would also jeopardize the solvency of Medicare.  Obamacare included a 0.9 percent payroll tax on incomes above $200,000 to help shore up Medicare’s finances.  This extended the solvency of the program’s trust fund until at least 2028.  Without this tax, Medicare could go broke in less than eight years.

It’s impossible to imagine conservatives restoring any of Obamacare’s taxes on the wealthy.  (Indeed, cutting these taxes is part of the appeal of Obamacare repeal for Republicans.)  And by repealing the law, Republicans also drag Medicare closer to crisis.  It’s easy to picture Ryan and others seizing the opportunity to warn that Medicare cannot be sustained without drastic changes along conservative lines–the type of reform Ryan has spent years pursuing.  The conservative vision would terminate our commitment to Medicare as a government-run insurance plan, and replace it with a voucher payment to seniors to shop on their own for private insurance plans.

So by repealing Obamacare, Republicans worsen Medicare’s financial position and thereby tee up the case for privatization.  But that’s not all.  The passage of Obamacare has corresponded with a marked slowdown in the growth of healthcare costs over the last several years.  The U.S. is currently on pace to spend $2.6 trillion less on healthcare than we expected before Obamacare was passed.  It’s difficult to assess how much Obamacare contributed to these savings, but it undoubtedly played a part.

If this slowdown is reversed by repeal, and healthcare costs begin to balloon again, the GOP could well use it as an excuse to pass the rest of its radical policy prescription across the entire gamut of American insurance options.  These reforms range from block-granting Medicaid to capping the tax exclusion for employer-provided insurance to promoting higher deductibles for more people.

Repeal could even give Republicans space to shoehorn in their desired policies outside of healthcare.  The Brookings report also found that Obamacare repeal will worsen long-term deficits.  Republicans will also undoubtedly pursue massive tax cuts near simultaneously with Obamacare repeal.  This combination will cause deficits to explode.  And as the Congressional Budget Office begins projecting larger and larger deficits, Republicans will have a ready-made excuse to justify austerity politics and massive cuts to safety net programs and other domestic spending.

We’ve seen this story before: the GOP leverages a crisis of its own making to push through its chosen policy prescriptions.  Even with a congressional majority, Republicans won’t be able to quit governing through crisis mode.  Their policy agenda will be painful for millions of Americans, and deeply unpopular because of it.  Republicans need a pretext to bolster the political necessity for making sweeping changes to our safety net.  Repealing Obamacare unlocks a whole host of rationales to help the GOP do precisely that.

But this also allows Democrats and other Obamacare defenders to lay out the full stakes of repeal.  Obamacare repeal doesn’t just rob insurance from the millions who have gained coverage under the law.  Repeal also jeopardizes the financial sustainability of Medicare for future retirees.  Repeal threatens to ignite higher healthcare inflation, raising premiums and eroding employees’ take-home pay.  Repeal erodes the financial standing of a whole host of programs for low-income Americans that are vulnerable to arbitrary budget cuts.  The implications of repeal are simply massive.

By repealing Obamacare, the GOP is trying to tee up its entire legislative agenda.  Liberals have an obligation to shout from the mountaintops about the full harm of this conservative exercise in bootstrapping.

The team quietly building a child allowance

I have a new post up at Medium based on a conversation with professor Hiro Yoshikawa, and work he and others are doing to build out the theoretical and empirical case for a child allowance in the United States:

It’s a distant thought now, but someday liberals will again get the chance to advance a progressive agenda on the national stage. And in the grim shadow of November’s electoral defeat, the future of progressive thought is already being hatched. Academics and researchers are quietly building the case for a bold new policy to support American families in cities across the United States: a universal child allowance.

Read the rest here.