The meaning of success

How should we define the success of the Affordable Care Act (ACA)? In recent months, news reports focused on the number of new enrollees as a key test of the law. Although the troubled performance of the healthcare.gov website during October and November delayed enrollment for hundreds of thousands of potential subscribers, Obama administration officials and Congressional Democrats hailed a surge in enrollment at the end of the year as proof that the law would fulfill its promise of providing affordable coverage to millions of uninsured Americans.

To date, enrollment numbers paint a decidedly mixed portrait of the ACA’s impact. Speaking on September 30, 2013, HHS Secretary Kathleen Sebelius declared that “success looks like at least 7 million people having signed up by the end of March 2014.” By late December, however, Sebelius hailed the fact that 2.1 million people had signed up for coverage through the new exchanges as evidence that the law was now working well. Earlier in the month, President Obama cited the increased pace of enrollment as proof that “the demand is there, and the product is good.” Even the most optimistic estimates, however, suggest that signups continue to lag far behind the administration’s own goals.

Obama administration officials responded to criticism about the widespread cancellation of individual insurance market policies in late 2013 by exempting millions of Americans who faced “unexpected natural or human-caused events” that prevented them from obtaining coverage from the individual mandate. Ironically, this decision, which sought to mollify Congressional critics and their outraged constituents, further undermines the prospects for meeting its enrollment targets and exacerbates an already serious credibility gap for Democratic candidates in the upcoming Congressional elections. Democrats continue to emphasize a “moving average” approach to measuring the success of the health insurance exchanges, pointing out that the pace of enrollments increased steadily once the website’s “glitches” were ironed out in late November. However, a failure to meet the administration’s own goal of 7 million new enrollees by the end of March 2014 will provide Republicans with a new policy story just in time for the 2014 campaign season.

Unfortunately for Congressional Democrats, increased enrollments did little to rehabilitate the image of the ACA in the eyes of the public. In a CNN poll released in on December 23, support for the law fell to 35% – a new low – despite significant improvements to healthcare.gov as a result of the “tech surge” in late November. The new polls highlight a troublesome trend for Democratic candidates who heed President Obama’s call to close ranks behind the ACA. Core Democratic constituencies now oppose the law, including 60% of women. Furthermore, in an ironic twist, 63% of those polled expected to pay more for health care after the implementation of the Affordable Care Act. In its current form, the ACA promises to be a millstone around the necks of vulnerable Congressional Democrats in 2014. Unless the Obama administration and other supporters of reform can reassure a doubtful public about the problem-solving capacity of American political institutions, the ACA may prove to be a classic Pyrrhic victory. In short, administration officials may win small battles over improving the performance of website, but lose the larger war over public support for government-led health care reforms.

The continued unpopularity of ObamaCare more than three and a half years after its enactment reflects a much deeper concern than simply website snafus or insurance cancellations. As I’ve argued elsewhere, ObamaCare has done little to restore public faith in the ability of government to solve social problems. Unless and until the administration begins to meet its own targets, the political fallout of the ACA will cast a long shadow over the 2014 elections … and beyond.

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Mental Health Loses Funding As Government Continues Shutdown

In the months leading up to World Mental Health Day, DC has been shaken by a series of violent events that ended with innocent lives lost and our country’s mental health services called into question. During this same time period, Washington, DC has been consumed by a government shutdown, with lawmakers and policymakers trying to determine how to rein in our country’s financial burdens and overspending. Unfortunately, as federal and state governments look to cut budgets at every turn, mental and behavioral health services are often on the chopping block first. Financial cuts, compounded with US stigma often applied to mental health troubles and disparate access to services across the county, mean that those who need services most are often those left without proper care.

August though October brought DC into the spotlight for many reasons, the saddest of which is the violence that was covered by mass media as two shootings occurred. In one case, Aaron Alexis, a 34-year-old, perpetrated a mass shooting that left 12 people dead, in Washington’s Navy Yard. Previous to the shooting, it was reported that Mr. Alexis was treated at the VA for mental health issues including sleep disorders and paranoia, but had not lost clearance.

Miriam Carey, also 34, reportedly had an unhealthy obsession with the White House when she drove her car into the White House gates and led police on a chase around DC before being killed. Although she had no reported psychosis or supposed violent intent, it was noted in the months leading up to the incident she believed that the President had beenstalking her and might have suffered from postpartum depression. When killed by authorities on Pennsylvania Avenue, she had her 18-month-old child in the car.

Budget Cuts

Although societal stigma and knowledge of where to access behavioral and mental services are often barriers to care, budget cuts continue to make seeking care more difficult. Whether this be through decreases in available services, lack of providers due to poor reimbursements or less preventative actions in communities, the impact of mental health funding shortages is great. According to the National Alliance on Mental Illness, “increasingly, emergency rooms, homeless shelters and jails are struggling with the effects of people falling through the cracks due to lack of needed mental health services and supports.”

In the last five years, significant budget cuts have befallen mental health programs and services. From 2009 to 2011, states cut mental health budgets by a combined $4 billion- the largest single combined reduction to mental health spending since de-institutionalization in the 1970s. In Chicago alone, state budget cuts combined with reductions in county and city mental health services led to shutting six of the city’s 12 mental health clinics. These closures, along with other public and private center closures in Chicago, have eliminated vitally needed services, especially on the south and west sides where they are indispensable.

Threats of sequestration in 2013 had a significant impact on people’s ability to access mental health services and programs, including children’s mental health services, suicide prevention programs, homeless outreach programs, substance abuse treatment programs, housing and employment assistance, health research, and virtually every type of public mental health support. The Substance Abuse and Mental Health Services Administration(SAMHSA) claimed it alone would be cutting $168 million from its 2013 spending, including areduction of $83.1 million in grants for substance abuse treatment programs.

Consequences

Despite the need to balance budget and make all health care services more efficient, many argue that society has better long-term outcomes if more federal and state dollars are allocated to mental and behavioral health care. This includes preventative services as well as mental health testing and treatment.

Because individuals with untreated mental illness often find themselves in emergency rooms, homeless shelters and prisons, the societal cost of prevention and treatment may be exponentially less than funding those other outlets and catchment areas. This is especially true in the case of children, who face cycling in and out of the system throughout their lives if left untreated.

These costs can be exceptionally large over the lifetime given that the National Institute of Mental Health (NIMH) estimates that two-thirds of children with lifetime mental health problems never receive treatment. This takes substantial emotional and financial tolls on individuals and families, as well as the broader society. However, programs that address the mental health needs and provide services for youth show better outcomes in health and education that carry over the lifetime. For example, in the University of Chicago’s Crime Lab, therapy is being used to curb youth violence, especially amongst those with behavioral and mental health care needs.

Additionally staining on the mental health care system is that during times of recession and budget cuts the caseload for mental health actually increases. It has been estimated that during this most recent recession, the caseload of community mental health services alone has increased almost 50 percent. This increase has most notably been seen in the Native American community, where suicide prevention is an essential part of the cultural health care demands.

Everyone Benefits

The NIMH contends that one in 17 people suffer from a “seriously debilitating mental illness,” we as a society are accountable for ensuring that those in need have resources for care. Not only does access to quality mental and behavioral health care ensure that individuals are being properly treated, but that America as a whole saves money and resources caring for those in need in other, more expensive settings. It may further prevent violent acts like those in DC from happing.

On this World Mental Health day think about the ways in which access to and support of mental and behavioral health care can be improved in your community.

 

President Obama Fails To Explain Tech Glitches And Solutions In ACA Speech

Monday at 11:30am EST, President Obama spoke in the Rose Garden about the recent troubles with health insurance exchange enrollment and websites. With a team of young people standing behind him and Janice Baker at his side, the first person in the state of Delaware to successfully enroll in the exchange, President Obama said he was speaking to every American wanting to get affordable health insurance. He claimed that in the last three weeks, despite the horrific technological problems with the websites, that “half a million consumers across the country have submitted application through federal and state marketplaces.” He further touted that the “federal site alone has been visited 20,000,000 times” in the last three weeks. Unfortunately for those American’s who are really interested in signing up on the exchange sites, he glossed over the depth and breadth of the current troubles, giving a speech that sounded more like a State of the Union address with small-business examples and reading letters written to the White House.

President Obama also alleged that no one wants to see the exchange sites improve more than the federal government, noting that, “the website has been to slow, and people have been getting stuck during the process.” He also said that it is the mission of the administration to make them “more better,” with visible cringing from the audience, but claimed failures were due to response rates. He said the public response was “overwhelming, which has aggravated the underlying problems.”

However, he failed to go any further to explain what those other underlying problems were or when specifically they will be fixed. He did say that while HHS and contractors such as CGI Federal are working out the “kinks,” American’s should be patient. He claimed that “if the product is good, [American people] are willing to be patient,” suggesting that there will not be a delay for the individual mandate.

Nevertheless, he followed this by assuring the public that unlike Black Friday sales, the insurance plans will not run out like purchasing a new PlayStation – adding to the list of items the administration has compared exchange sites to, including iPhones and travel websites.

Despite his promises of improvements and putting the “best and brightest” on the job, CNN and other sites have insisted that the inherent technological and platform problems with Healthcare.gov will not be resolved anytime soon. This begs the question, that if the federal government is now searching for the best and brightest to correct the estimated 5,000-5,000,000+ lines of coding that need to be fixed on the federal site alone, who was working on the original platforms?

As he continued his speech, the President reminded the American public that although the websites for enrollment are not as, “quick, consistent or efficient as we want,” that the exchange sites are far more than “just a website.” He noted that many pieces of the Affordable Care Act (ACA) are already in place and being utilized by millions of Americans. He addressed pre-existing conditions, youth under the age of 26 and several other provisions that are already being rolled out by federal law, and the successes they have seen there.

He noted more examples of ACA triumph in Oregon, where he maintained that the exchange, “has cut the number of uninsured people by 10% in three week,” which is about “56,000 more Americans” with health insurance coverage.

During the speech, President Obama also tried to clarify the exchanges or marketplaces by describing them to the public as becoming part of a “big group plan… that bargains on your behalf for the best deal in health care.” He said that by doing so, insurance companies have created new products and options that strengthen market forces, leading to better deals.

He went on to say that without a doubt, “prices have come down,” further claiming that “when you add the next tax credits (those not yet implemented)… then the prices come down even further.”

The President rounded out his talk by noting the Republican party’s opposition to the ACA and how willing they were to “shut down the global economy” to fight against the ACA. A move, he claimed, that shows just how unwilling Republicans are to negotiate on legislation intended to, “free families from the pervasive fear that one illness one injury will cost you everything.”

While that may be the goal of the Affordable Care Act, the underlying technological and coding problems may prove to make that impossible.

 

Primary Care Deserts Do Not Disappear With Nurse Practitioners

In coming years the US could see growing shortages in the availability of primary care physicians (PCPs). With the number of individuals seeking care increasing and the current medical system continuing to incentivize physicians to specialize, the number of available PCPs will decline proportional to the population. To fill that gap, Ezra Klein and others have asserted that expanded scope of practice will allow nurse practitioners (NPs) to serve as viable substitutes for primary care shortages.

While NPs serve a vital role in the system and meet need, the argument that they are a 1:1 substitute for PCPs (but for the greedy doctors and pesky regulations holding them back) is singular and shortsighted. The argument also fails to address broader policies that influence both NP and PCP behaviors. Policies that unjustifiably lead to the unequal distribution of caregivers, location or expertise, inherently parlay into unequal care for patients. Sadly, a broader scope than “freeing nurse practitioners” is necessary to meet primary care needs, as NPs are complements, not substitutes. Policy must address the need for more primary care and assist to realign the system to meet our country’s basic care and equality through redistribution.

Primary care is the foundation of the evolving health care system, with equal access the intended goal of the ACA. Along the way to meeting future demand for primary care, NPs can be increasingly utilized to meet the needs of Americans and improve the health of the nation. And let it be known I am a strong proponent and supporter of nurse practitioners and all non-physician providers and coordinators. However, the argument that most NPs practice in primary care and will fill the primary care gap, estimated at about 66 million Americans, is inaccurate. It isn’t a 1:1 substitute, especially given that models of the solo practitioner are vanishing in lieu of complementary and team-based care.

The US, unlike many western countries, does not actively regulate the number, type, or geographic distribution of its health workforce, deferring to market forces instead. Those market forces, however, are paired with a payment system whose incentives favor high volume, high return services rather than health or outcomes. These incentives are reflected in where hospitals steer funding for training, and in the outputs of that training.

Throughout the US there are geographic pockets that fail to attract medical professionals of all kinds, creating true primary care deserts. These deserts occur in part due to the unequal distribution of practitioners in the health care system, with our medical schools and salary opportunities producing low numbers of generalists across the board. We have even continued to see shortages in nurses throughout the US.

In fact, 2012 residency matching rates not only show continued unfilled positions in primary care, but that the rates of graduating minorities are highly skewed from programs. This contributes to even greater problems with finding primary care providers that reflect the populations they serve. Sadly, this is also true for nurse practitioners, where only 4.9% are African American, 3.7% are Asian or Pacific Islander and 2% are Hispanic. Further, the geographic distribution of NPs and physicians assistants alike is close to that of physicians. A June 2013 assessment found that the distribution for urban, rural and isolated rural frontier primary care providers is within a few percentage points for NPs and PCPs.

Ezra Klein was not wrong in his assessment that physicians are often influenced by income. However, it seems likely that financial incentives are drivers for many professionals in the health care sector, including nurse practitioners, registered nurses and physicians assistants (PAs). Dr. Andrew Bazemore, Director of the Robert Graham Center for Policy Studies in Primary Care in Washington, DC has done significant research in this area. His perspective is that, “The suggestion that runaway health system costs could be contained simply by replacing higher salaries of physicians for lower salaried substitutes with less training misses the point – that cost containment will most likely result from optimizing primary care functions such as prevention, population management, care coordination, and avoidance of unnecessary referrals, procedures, ER use and hospitalizations of primary care providers.” Dr. Bazemore asserts that, “Achieving that level of effectiveness likely involves teams that include primary care physicians, NPs, PAs, behavioral and community health workers, and other important components, operating in a transformed practice setting.”

It is also correct that regulation on NPs is onerous and sometimes oppressive. Across the nation, regulation on NPs is exceptionally disjointed and often results in unnecessary hurdles for all involved, called scope-of-practice laws. Although impediments are common in the health care system, it is extensively difficult for NPs and similar non-physicians to break into a system that is deeply rooted in tradition.

However, by honing in on one piece of the puzzle, Mr. Klein missed the bigger picture. The principals of substitution do indicate that on the supply side, NPs stepping into roles for PCPs would better meet demand. But that is not the real world outcome. The broader landscape shows us that instead of a 1:1 substitution, nurse practitioners are compliments in the overall care system, important roles that fulfill many primary care needs.

Therefore, policy changes are still needed to improve patient health outcomes and forge a team-based relationship between care providers. Incentives to enter primary care and needed across the disciplines, as are models of team-based training that build on the strengths of each in managing whole persons and populations. Ezra Klein fails to note that most primary care shortage estimates implicitly include NPs and PAs already working in primary care while not accounting for the fact that NPs and PAs are choosing specialization over primary care for the same reasons as physicians.

Instead of an environment where NPs and PCPs are positioned to compete with one another, federal and state legislators should spend more time crafting policy that equalizes the distribution of care providers across the system. That redistribution means incentivizing, monetarily or otherwise, primary care clinicians to stay in general medicine and work in tandem with other providers. Whether it be the reformation of medical school, constructing a more honest approach to population health or restructuring pay scales and incentives, team-based medicine with improved access and outcomes should be the real discussion.

 

Four More Years of Health Reform

While the last news I saw this morning before leaving the house still had Florida as “too close to call,” the outcome in that state has become irrelevant, with Obama securing enough votes in the electoral college (303 at last count) and claim another term as President of the United States. Importantly, Obama also won the popular vote by about 2.5 million votes. While the contest was close until the end, and our nation clearly remains divided, I am thankful that we do not find ourselves confronting the legitimacy question that can arise when the winner of the electoral college loses the popular vote. (Think Bush v. Gore.)

So, what awaits us in Obama’s second term? Well, I think it’s clear what needs to be done: More action needs to be taken to improve the nation’s economy. The Obama administration has made some gains in this area with the stimulus and the auto bailout, but there is more work to be done. For me, the question is: Will the Republicans in Congress work with him at all? For four years they’ve played obstructionist politics, with the goal, one would assume, of creating a one-term president and capturing the White House in 2012. That’s why none of them voted for the Affordable Care Act, why they refused to vote on the President’s jobs bill, and why they pushed our country to the brink of default by playing games with the debt ceiling. All of these things were done not because they were the best for our country, but because they were the worst for the President. And, in spite of that, Obama was able to prevail.

This morning, we now know that the Affordable Care Act, better known as “Obamacare,” will have the opportunity to be fully implemented in 2014. We know that tens of millions of Americans without health insurance will soon have affordable coverage. We know that there will soon be an option for individuals to shop for health insurance in a more transparent and competitive system of health insurance exchanges, with a government-sponsored option among the available choices. And we know that our nation’s elderly and disabled will continue to depend on Medicare, rather than facing the possibility of being given a voucher to go out and shop for coverage on their own.

This election has given us four more years of health reform. In that time, perhaps the public will warm to the program the way they have grown to love Medicare and Social Security. Perhaps we’ll see some real improvements in health and health care. Perhaps this will be the impetus for additional reform efforts in the future. But we’re not out of the woods yet. Republicans still control the House, while Democrats cling to a narrow majority in the Senate. It is possible that, through the budget process, Republicans can interfere with the implementation of the Affordable Care Act. It is even possible that, if they make large gains during the 2014 mid-term elections, they could find themselves in the position to repeal the ACA by overriding President Obama’s veto. And, while I hesitate to bring it up so soon, there’s 2016, when we will once again elect our President. Obamacare will only have been fully implemented for a couple of years, and if the economy hasn’t fully recovered, you can bet that the rhetoric of repeal and replace will be on full display. But, for the moment, we can breathe a little bit easier, knowing that we just bought Obama–and Obamacare–a little more time.

 

America, “We’ve Lost a Pod”: What Romney and Obama Didn’t Say…

While polls immediately following Wednesday’s Presidential debate in Denver suggested that Mitt Romney came out of the contest way ahead of Barack Obama, the real winners were clearly America’s fact-checkers and policy wonks. Sure, Romney may see a bump in his poll numbers after his performance, but it’s the detail-oriented folks—some might say experts—that really get to delve into the content as they aim to correct and rationalize the multitude of competing arguments and “data”. By contrast, the evening’s losers were: Michelle Obama, who spent her 20^th wedding anniversary watching the debacle; everyone on Twitter disinterested by politics; and moderator, Jim Lehrer, who “lost a Pod” due to poor facilitation. That’s right. After a full 90-minutes of debate, Lehrer was unable to keep the candidates’ comments concise enough and we missed out on what might have been the most exciting part of the debate: an open back-and-forth between Obama and Romney.

Nevertheless, health care comprised a large portion of the debate with both candidates touching on everything from the origins of ObamaCare—a label for the Affordable Care Act that Romney apologized to Obama for using, but one which Obama said he actually welcomed—to insurance premiums and a discussion of the Medicare Independent Payment Advisory Board, or IPAB. Still, given all the misinformation put forth by both Romney and Obama during the second Pod, it appeared by the end that neither had actually read the Affordable Care Act and that both needed new accountants.

But perhaps we should give the candidates the benefit of the doubt. Maybe, just maybe several important and highly anticipated topics were not simply forgotten or purposefully overlooked by the candidates, but were rather innocent victims of the last, lost Pod. Had the last Pod not become a casualty of debate, we might have heard about the following:

The Supreme Court Decision on the Affordable Care Act. Given the numerous amicus briefs, intense public emotions and extensive media coverage surrounding the President’s signature bill, it was shocking that neither President Obama nor Romney touched on the case. With the next four years offering an enormous opportunity to dramatically alter the landscape of the Court, and the highly partisan spin taking place during the debate, it was surprising that we didn’t hear either candidate discuss the case. Obama could have pointed to the ruling to give more credibility to health reform, while Romney could have capitalized on the close 5-4 decision arguably rewritten by Chief Justice Roberts to make the claim that ObamaCare— particularly the unpopular individual mandate—isn’t the best way to implement reform. We could have heard that, but we didn’t.

Then there was the diabolical 47 percent. Seriously. This was a softball lobbed right down the middle for President Obama. It hung there in the air in front of him for a full 90 minutes, untouched, while he took swings at several other topics and missed. Obviously, this gaffe isn’t one that Romney would be expected to draw attention to himself, but why on earth didn’t Obama go after the low-hanging fruit? Was he worried that he’d come off as too attacking? Perhaps. But the President never brought it up, and he should have. You can bet that Romney was ready with a prepared response on the topic. Too bad we never got to see him use it.

Reproductive rights. This past year has seen monumental coverage of reproductive rights as the Affordable Care Act and state legislatures have gone head-to-head over funding. Planned Parenthood and Susan G. Komen Foundation have clashed over support, Plan B became a battleground for HHS and the FDA, and politicians have made one gaffe after another (think “putting an aspirin between your knees for birth control” and “legitimate rape” for starters). Yet, once again, President Obama didn’t bring up a topic where he enjoys a lot of popular support for his position on the issues. Romney and the GOP have been behind most of the chaos and it would have been very easy for Obama to associate Romney with Todd Akin and the lack of women’s rights many women associate with the GOP. This was certainly a missed opportunity for Obama as women will undoubtedly be the deciders of this election.

A humanizing glimpse of Mitt Romney. It’s well known that Romney’s wife, Ann, has Multiple Sclerosis.It’s also been pointed out repeatedly that the Romney campaign has shied away from discussing the disease and its impact on their family. However, in last night’s debate, Governor Romney spent a lot of time and effort to come across as compassionate and in touch with the average American. In fact, he essentially led off his comments talking about health care and the economy, telling personal narratives about the impact of our broken system and the Great Recession on Americans. He focused on others, but he never focused on himself. Although I’m sure many would advise him to stay away from any topics that associate him with money, disease and his personal experience would have endeared him to so many. In a recent interview Ann said her husband’s response to the disease had been, “He said to me, ‘I don’t care how sick you are. I don’t care if you’re in a wheelchair. I don’t care if I never eat another dinner in my life. I can eat cereal and toast and be just fine. As long as we’re together, everything will be OK.’” That paints the picture of a man who actually cares about others, which is an image Romney desperately needs to convey to undecided voters. Perhaps he was just waiting to be accused of his comments about the 47% before unleashing this most personal secret weapon. Alas, America, we lost a pod, and the world may never know.

 

Unraveling the Hypocrisy of Mitt Romney, Education, and Big Bird

Last night’s presidential debate between Barack Obama and Mitt Romney was difficult to watch for two reasons: First, Mitt Romney said a lot of things that were misleading at best, blatantly false at worst, or otherwise devoid of details the rest of the time. Second, President Obama did very little to directly object to these half-truths and untruths. As one colleague of mine put it, the President was playing a prevent defense–not trying to score points, just trying not to make any terrible gaffes while hoping that Romney didn’t score enough points to win the debate and perhaps the election.

On that score, polling shows that Romney handily won last night’s debate. Now, history is less clear on whether the results of that single debate will have much of an effect on the outcome of the election, but at issue for me is a larger point: I feel compelled to speak up where the President did not. Unfortunately, I cannot do so for every issue that was discussed last night, nor do I have any misgivings that I will reach even a respectable fraction of the people who saw last night’s debate. Rather, for me, this is about principles. In particular, it’s about not letting misleading information be peddled to the American public as if it were true. It’s about respecting you to much to let you be pandered to. And, it’s about helping Big Bird keep his job.

Last night, both President Obama and Governor Romney extolled the virtues of education. They both agreed that America’s education system is lacking and that this creates deficiencies in our young people that ultimately have a negative effect on our economy as jobs are shipped overseas and new technology is developed elsewhere in places where math and science curricula are pursued relentlessly. The difference of opinion came about when each candidate spoke of their specific plan to improve education.

President Obama said that he would create a program that would produce 100,000 new math and science teachers (which also creates jobs, coincidentally). He said that he would work to keep college tuition more affordable, and he has actually backed this up with action already: introducing a special student loan consolidation program that puts a little extra money back in the pockets of people just like me, who have accumulated debt from pursuing higher education.

Governor Romney, on the other hand, said we need to improve American education, but then gave no specifics of how he would do so. Later in the evening, however, as he was addressing the federal deficit, he cited funding for the Corporation for Public Broadcasting, parent company of PBS Television as an example of the type of program he would cut. When he realized that the debate’s moderator, Jim Lehrer, works for PBS, he was quick to indicate that he likes both Big Bird and Newshour (Lehrer’s show). There are three problems with this.

First, only about 15% of PBS funding comes from federal support, with the other 85% coming from private donations. This means that even if Romney had his way, and pulled all federal funding for the network, it’s not clear that PBS would have to resort to selling advertisements, as Romney has suggested they should. A small increase in private donations could be enough to offset the lost support. Second, the amount of federal funding to PBS represents less than 0.01% of the federal budget. This is problematic because Romney is citing the proposed cuts to PBS as a way of reducing the deficit and balancing the budget. Something that’s less than one one-hundredth of a percent isn’t going to do that. He could cut PBS 100 times and it would only be 1% of the budget. Deficit reduction will require two things: generating additional revenue, and reducing spending of large programs, like Medicaid, Medicare, and Social Security. Governor Romney wants to do all of that, too, (well, not the revenue-raising part) but he didn’t mention it, because he knows those cuts are unpopular. Of course, Big Bird is popular, too, but fortunately for Romney, children can’t vote.

Finally, and most importantly, it’s problematic because it provides some insight into Governor Romney’s policy positions on American education. On the one hand, he says the system needs to be improved. On the other hand, he’s willing to cut all federal funding for PBS, which is an important component of early childhood education in this country, even though it stands to have next to no impact on reducing the deficit. So, does he really care about improving education for the American public as a whole? I don’t think so. I think he sees education as he sees everything else, including health care: If you work hard and are successful (i.e., wealthy), you can buy all the education and health care you want. If you’re lazy, unsuccessful, or weren’t born with a silver spoon in your mouth, you don’t deserve an education or health care. In all of this, Romney seems to be forgetting that his own father was once on welfare, and that his mother credited that program with giving them the solid foundation and the support they needed to become successful. I guess it’s easy to take it all for granted if that’s all you’ve ever known. Maybe if he would have watched Sesame Street as a child, he could appreciate just how important it–and programs like it–are to American children. Especially the ones who will never have the opportunity to go to a nice Ivy League university on their daddy’s dime.

 

What Obama’s Done For You Lately: Lower Insurance Premiums

The number of people who love health care reform plus the number of people who hate health care reform is considerably larger than the number of people who actually understand health care reform. John and Jane Q. Public were outraged that Congress voted on a bill that “they hadn’t even read” although Mr. and Mrs. Public didn’t read it, either. It’s unfortunate, because the Affordable Care Act, despite some of its shortcomings, actually does a lot of wonderful things. One of those things is put some regulations in place on the health insurance industry.

In particular, the ACA requires insurers to be more transparent about how they’re spending your premium dollars and places caps on the rate at which insurers can increase your premiums. This might not seem like a huge deal to you at first, because most of us get our insurance through our employers, and our employers pick up the majority of the tab, but according to the Department of Health and Human Services, these regulatory provisions are adding up. According to a recent report, the ACA has saved consumers $2.1 billion over the last year.

The savings come from two different provisions of the law. First, insurers are prevented from raising their premium rates by more than 10% without submitting public justification for the rate hike and receiving approval from state insurance departments. This, according to HHS, has slowed premium growth and saved $1 billion since September 2011. Second, the ACA requires insurers to devote at least 80 cents of every premium dollar to providing health care. This also provides an incentive for insurers to hold rates down, but more importantly, it puts money back into consumers’ pockets. If an insurance company doesn’t meet the 80% threshold, they have to refund the difference to their beneficiaries. This, according to HHS, adds up to another $1.1 billion since September 2011.

Of course, most of us probably won’t be getting a refund check in the mail, but those who do can expect it to average around $151. So, what has Obama done for you lately? Well, for many of you, go look in your mailbox, because his administration may just have arranged for you to get a refund check from your insurance company. If there’s anyone out there who doesn’t like that, might I suggest that you cash your check, send me the proceeds, and vote for Mitt Romney?

 

The Supreme Court Ruling Is Finally Here

After many months of speculating on the outcome of the Supreme Court’s ruling on the Affordable Care Act, the decision was finally announced today. The ruling essentially upholds the entire Affordable Care Act as constitutional. While this is certainly the outcome that I had been hoping for, I am also convinced that it is the correct one. I haven’t read the dissenting opinions yet, but I’m anxious to see how they justified that. I, for one, am glad to have this piece of the puzzle put in place, because it helps us to move forward with the goal of improving our health care system. Call it the ACA or call it “Obamacare” it is the constitutional law of the land, and there is no appealing that, so perhaps it’s time to get used to it, and figure out how to make it work for you.

That said, while Supreme Court majority and dissenting opinions are not terribly complex, they do have to be read rather carefully to be well understood. Perhaps that explains why CNN made me nauseous with its incorrect headline proclaiming “Breaking News: Supreme Court Strikes Down Individual Mandate” for about 10 minutes before it got the story straight. I just printed out the opinions, all 193 pages of them. I’m not surprised that someone skimming got it wrong in their attempt to be first, but they should have sensed something when they saw Chief Justice Roberts aligning with Justice Ginsburg.

Rather than exercise a similar rush to judgment, I’m planning to spend the weekend reading through everything and formulating my thoughts, which I will post here on Monday. For now, I’m going to go bask in the glow that comes from a conservatively appointed chief justice putting the law before partisan politics. This has renewed my faith in America a little bit.

 

Would More Americans Support Health Reform If Obama Was White?

Would more Americans support health reform is President Obama was white? According to a recent study conducted by Michael Henderson of the University of Mississippi and D. Sunshine Hillygus of Duke University, the answer is yes. The researchers modeled changes in support of health reform between 2008 and 2010, and what they found was striking. According to Henderson and Hillygus, among a group who supported health reform in 2008, whites were 19 percentage points more likely than blacks to be opposed to health reform by 2010. Keep in mind that this race effect is seen after controlling for party affiliation and political ideology. It also controls for income, age, gender, education, and worry over the cost of health care. Said another way, this race effect isn’t likely to be biased by the usual suspects.

Moreover, the researchers included a measure of racial resentment, and those with the highest levels of racial resentment were 29 percentage points more likely to go from supporting health reform in 2008 to opposing it in 2010. These effects are additive. That means that whites with high levels of racial resentment are a whopping 48 percentage points more likely to switch from supporting to opposing health reform in the course of two years, compared to their black counterparts with low levels of racial resentment. That’s a big deal, to paraphrase Joe Biden for a general audience.

That doesn’t mean that people’s concerns over health reform aren’t legitimate. It’s perfectly reasonable to be opposed to an individual mandate, for example. The question opponents of health reform need to ask themselves, though, is how they would feel about the Affordable Care Act if the man who signed it into law looked like them. I don’t think opposition to reform would disappear–after all, when Clinton tried to pass reform legislation in the 1990s, it failed spectacularly–but I do think the tone of the debate would have been a little different, and I don’t think we’d be seeing the continued opposition after passage that we’re seeing now. Just look to the recent past for proof: Medicare Part D is all the evidence you need that a white President can pass a budget-busting piece of legislation without so much as a second glance from the American people. If George W. Bush had been black, perhaps America’s seniors would still be without adequate prescription drug coverage.