Obamacare Yay, Democratic Party Nay: The Way Forward in a Big Country

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36 Responses

  1. First sentence, and on the front page: Medicaid, not medicare.Report

  2. Avatar Damon says:

    Really Saul? People like to be aligned with specific political parties but like the “free” goodies given by either? Hell that’s a win win. “I didn’t vote for that and didn’t want that, but now that it’s passed, I’ll sure as hell take advantage of it.”Report

  3. Avatar North says:

    It bears noting that the political messaging on the subject of the ACA in Kentucky has been very intentionally muddying the waters. Kynect (the KY incarnation of the ACA) is indeed quite popular. So popular in fact that Senator Mcconnell has been nakedly promising not to touch it even as he inveigles against the ACA and “Obamacare” in general. So for your average low info voter Kynect is not Obamacare.

    Grimers, McConnell’s opponent, has been very hands off the subject because of the uncertainty that surrounds the subject and because appearing to snuggle up to Obama himself is definitely a political loser in KY. Still, the fact that Senator Turtle Power has been forced to make kissyface with an incarnation of the ACA is proof that it’s been modestly successful (policy wise at least) and isn’t going anywhere.

    That is, no doubt, scant consolation for the Democratic Party and leftists in general who had hoped that ushering in a major health care overhaul would net them some gratitude from the electorate but eh, what can ya do?

    As for what happens going forward? In as the years pass when a very large fraction of the GOP base and electorate moves on to that great shuffleboard in the sky I think things will look very different.Report

    • Nob Akimoto Nob Akimoto in reply to North says:

      Kentucky (McConnell’s survival notwithstanding) is basically a slow motion realization of the GOP’s worst nightmare about the ACA: People are starting to actually see it implemented well and they like it.Report

      • Avatar Kim in reply to Nob Akimoto says:

        Exactly. And when folks start understanding “Oh, that’s Obamacare??” they’ll start questioning the stupid Republicans who wanted to get rid of such a popular law.Report

      • Avatar Dave in reply to Nob Akimoto says:

        @nob-akimoto

        People are starting to actually see it implemented well and they like it…

        That may be true, but we can’t overlook the immediate impact it is going to have on the hospitals and health systems, especially the not-for-profits.

        http://hcmatters.com/2014/08/moodys-report-us-non-profit-hospital-outlook-remains-negative-2014/

        None of this is new news to me since I work in the healthcare real estate business. Hospitals are going to experience increased pressure on their margins at a time when the ratings agencies are cracking the whip on them to improve them or risk losing their credit ratings. The not-for-profit hospitals may not be profit-driven but strong financials are an absolute must to keep their costs of borrowing down and ensure access to capital (mainly through the municipal bond markets).

        I think that the stronger not-for-profits will be fine, but the weaker hospitals and systems, the ones that tend to serve the lower income communities, are going to run into serious difficulty.

        In my opinion, it’s not unreasonable to suggest that one of the unintended consequences of the ACA is increased ownership of hospitals by for-profit entities like HCA, Tenet, Prime, etc. This will cause a lot of headaches politically at the local and state levels, especially since one of the trends amongst the for-profit hospitals is to not actually own the hospitals themselves.

        I know I’m a bit off-topic but I thought I’d share anyway.Report

      • Avatar Kim in reply to Nob Akimoto says:

        Dave,
        Does Highmark count as nonprofit or for-profit?
        It’s all nonprofits gobbling up health systems around here.
        Economies of scale were trending toward larger health systems anyway.
        (are the non-profits generally better at providing care? curious cat would like to know)Report

      • Avatar Dave in reply to Nob Akimoto says:

        @kim

        As far as I can tell, Highmark is a not-for-profit insurance company that recently bought Allegheny Health, which was a struggling system.

        I don’t see a lot of activity where the not-for-profit hospitals are buying other hospitals but I’m seeing a lot of activity where the hospitals are buying large physicians practices to help keep down their costs. This has been going on for a number of years and it’s really starting to step up in areas like oncology or cardiology. Even independent physicians have moved over to larger physician groups for purposes of scale.

        As far as which hospitals are better, typically, the not-for-profits, especially those affiliated with major universities or research institutions are amongst the top-ranked in the country.

        As a general matter, you can run into situations with the for profits that you won’t with the not for profits with respect to the bottom line and holding down costs. The for profits will be far more aggressive about this and that can affect the quality of care. Also, one difference I do know between the two types of hospitals is that the not-for-profits are far less aggressive when it comes to billing.

        That probably doesn’t give you the answer you’re looking for, but my specialty is more on the real estate side and not operations.Report

      • I was under the impression that hospital systems consolidation was something that was happening already well before ACA’s passage (and in fact I remember reading a bit about how the systems were adjusting to things like increased insurance costs, higher overhead, increasing expense of testing and the accessibility in rural areas)

        I’m not sure if the Moody’s report actually puts the blame on the ACA. Given that the law itself (and insurers in general) want to reduce the actual expenses associated with care and in the process provide compensation for doing so.

        One might note too, that the ACA will be funding a fair number of community clinics, which will probably give hospital systems incentive to reduce their own ownership of things like physician groups.

        I guess I suppose I’m not sure if the law is merely accelerating a process that would be happening anyway or if it’s causing that process.Report

    • Avatar Saul Degraw in reply to North says:

      “As for what happens going forward? In as the years pass when a very large fraction of the GOP base and electorate moves on to that great shuffleboard in the sky I think things will look very different.”

      Which states do you think this will help in? I have yet to see evidence that young people in Arkansas or Kentucky or any other red state are more liberal or Democratic than their older counterparts. Millennials are generally more liberal but I think the liberal ones might be moving to blue states.Report

      • It’s probably more a case that it’ll help fix house districting maps in nominally blue, but congressionally red states like Pennsylvania.Report

      • Avatar Dand in reply to Saul Degraw says:

        Here’s a map of the 2008 election among voters under 30

        Keep in mind that in many southern states democrats would win if they managed to get even 35% of the white vote.Report

      • Avatar Kim in reply to Saul Degraw says:

        Saul,
        young evangelicals are more environmentalist than older ones. Yep,people are getting more liberal. Attitudes change.Report

      • Environmentalism typically has greater support among the young. It’s pounded into your head at school, and of course you have more time left on our polluted planet. Then a lot of us see a different picture as we grow older.

        For me personally, ardent environmentalism was a no-brainer at 18, more complicated the further away from that age I got.Report

      • Avatar El Muneco in reply to Saul Degraw says:

        I don’t think this country’s issue is that people are getting more “liberal” – that’s a universal that predates Rome – but that a huge portion of the US right wing isn’t “conservative” (trying to keep social trends in play for as long as they are useful and only integrate new ones when they prove to be more useful than the ones they replace) as “radical reactionaries” (trying to aggressively mold society to a place that never actually existed, but is a product of a kind of unholy marriage between a medieval worldview and a modernist thought process).
        Yes, this generation’s conservatives are fighting to preserve the policies of last generation’s liberals while steadfastly denying that it’s not the way it had always been – that’s not a bug, it’s a feature. When things are working, both liberals and conservatives provide value. The real problem is that we don’t have any conservatives in the US anymore. Andrew Sullivan, maybe – but ironically (like John Cleese’s sheriff in “Silverado”), he’s not even from these parts.Report

    • Avatar Jim Heffman in reply to North says:

      “the fact that Senator Turtle Power has been forced to make kissyface with an incarnation of the ACA is proof that it’s been modestly successful”

      Giving free money to a majority of voters has long been a successful policy.Report

      • Avatar Kim in reply to Jim Heffman says:

        Free money while reducing the deficit is a good trick, don’t you think?Report

      • Avatar KatherineMW in reply to Jim Heffman says:

        If people like a program, benefit from a program, and the program reduces poverty and economic inequality, then I fail to see why the government providing that program is a bad thing.Report

      • Avatar Kim in reply to Jim Heffman says:

        Kat,
        some people like america being in debt.
        Jim, you sure you aren’t Chinese?Report

      • Avatar Troublesome Frog in reply to Jim Heffman says:

        “Giving away free stuff to people” is a description of just about everything in government from health care to building roads to public education. What some people deride as, “free stuff from the public trough,” other people see as, “government using tax dollars to fix stuff.” If there’s some clear philosophical principle that makes one of those types of free stuff obviously bad and the other type obviously good, I’m not seeing it.Report

      • Avatar Citizen in reply to Jim Heffman says:

        some clear philosophical principle?

        Basically are you getting what you are paying for?Report

      • Avatar Troublesome Frog in reply to Jim Heffman says:

        Sure, that works, but to use the throwaway “free money” line, you’d usually need to add the “we’re not getting what we’re paying for” part to it. “Free money” alone is just marklar.Report

      • Avatar Jim Heffman in reply to Jim Heffman says:

        ““Giving away free stuff to people” is a description of just about everything in government from health care to building roads to public education. ”

        Except for the part where, e.g., roads are paid for by user fees (gas taxes, vehicle registration costs). Not exactly “free money” there, unless your viewpoint is that anything paid to the government just goes in Scrooge McDuck’s big money vault and completely loses its identity.Report

      • Avatar Troublesome Frog in reply to Jim Heffman says:

        So the user fee model is the norm and not the exception? I thought that the majority of our taxes and expenditures really do go into and then come back out from a digital Scrooge McDuck style vault and the benefits we get from each program are almost never equal to the money we pay in, but apparently we’re better at balancing those flows than I knew.Report

      • Avatar Jim Heffman in reply to Jim Heffman says:

        “So the user fee model is the norm and not the exception?”

        Roads were your example, bro, not mine. Maybe you should have picked something else?

        Be careful that it’s not something like education or healthcare or retirement savings where there’s a huge debate about whether the government-provided version is worth having, and plenty of people claim straight-out that the only reason they’re taking it is that they’re legally required to.Report

      • Avatar Troublesome Frog in reply to Jim Heffman says:

        You’re doing a rocking job of dodging the forest in favor of the trees, but yes in a lot of states roads are at least partially funded from general funds and sources other than user fees. And there’s fire. And police. And the military. And a whole ton of generally uncontroversial stuff that is more often than not funded by use fees. So it remains that the wise and above-the-fray snorting contempt for programs that give people stuff they don’t pay for pretty much just boils down to “I don’t like government in general.” Great, we know. But it doesn’t really add a lot to a policy debate where one of the more basic assumptions is that government exists and that it sometimes does stuff.

        It’s kind of like the “taxation is theft” position. I suppose that for some definitions of theft, yes it is. But does that tell us something useful that we didn’t already agree on, or is it just wordplay?Report

  4. Avatar morat20 says:

    2014 is a “bad year” for Democrats due to the Senate races up for grabs. Basically, every really vulnerable Democrat seat is up for re-election (and the latest aggregates are now either flat even or leaning towards the Democrats retaining 50 votes). 2016 is a ‘good year’ in that the situation is reversed — the Democrats up for re-election in the Senate are all solid seats, whereas the Republicans have a lot of vulnerable seats up for grabs.

    Senate seats are six years, remember? Which means the folks up in 2014 were elected in 2008 — a Presidential year with very high Democratic turnout. Now it’s an off-year, traditionally poor for Democratic turnout AND the lame-duck period of a two-year President. Low turnout.

    The 2016 crop, on the other hand — it’s all 2010 victors, a mid-cycle that saw a lot of GOP seats being acquired that will be quite vulnerable in an election year.Report

  5. Avatar Kim says:

    “The Internet know makes it clear that the base is not likely to accept a Southern Democratic politician bashing environmental issues or being skeptical of gun control. ”

    http://www.dailykos.com/story/2012/07/26/1113885/-Party-Matters-Joe-Manchin-is-closer-to-Bernie-Sanders-than-he-is-to-any-Republican

    http://www.huffingtonpost.com/2010/10/11/joe-manchin-ad-dead-aim_n_758457.html

    Here’s about the ONLY bad press I can see from Manchin’s opposition:
    http://www.dailykos.com/story/2013/10/29/1251509/-Obamacare-repeal-still-the-GOP-s-big-goal-Really

    Seriously, the base doesn’t care what the fuck southern democrats do, so long as they get elected.

    Well, actually — look here:
    http://www.dailykos.com/story/2011/04/19/968442/-Senator-Manchin-protecting-healthcare

    Point is, you don’t expect southern democrats to act the same way Northern ones do. If you’re not in a liberal state, we ain’t gonna railroad you (unless you promise something, and then don’t deliver. Webb, here’s looking at you.)

    I seriously looked for any bad press that “the base” (here defined as dailykos) were giving Manchin. Not a scrap, not a sliver.

    People seem slightly teed off that he was providing support to the Kochs for pretty much no reason (read: not a campaign, and they really aren’t moderates by any stretch, so saying that they are is kinda weird).Report

  6. Avatar Doctor Jay says:

    I think you can’t take what people say quite as seriously as you seem to.

    People love to portray themselves as rocks – steadfast, unmovable, cannot be swayed or bought. But they do change. And they also die off.

    FDR engineered a massive shift in the attitudes of the electorate, and so did Ronald Reagan. This will happen again, but it’s hard to say exactly when.Report

  7. As a supporter of the ACA, I think the situation Saul describes is actually a reason to be happy. It seems to suggest that the policy has such widespread support that even the most “anti-Obamacare” Republicans will be wary of overturning it, or at least overturning it wholly. Not that they can’t do a lot of damage to the more vulnerable beneficiaries of the ACA.

    A few comments/observations about this:

    “Nobody don’t care for nobody no more, and I think he’s got a lot to do with that.” As a fan of ACA and a big supporter of the Democratic Party, this makes me want to throw my hands up in the air. What is the ACA but an attempt to help people?

    First, it’s a good thing the person interviewed used a triple negative. That really shows how ignorant and uneducated people in flyover can be. Of course, she said what she said, assuming the NYT quoted her right. It’s just very convenient for a certain narrative. By the way, Saul didn’t go there, and good on him. And I agree with his critique of the “things used to be better because we all looked after each other” viewpoint.

    Second, the NYT article doesn’t seem very clear on who the “he” is she’s referring to. I assume it means “Obama,” but it’s not clear.

    Third, my motivation for supporting the ACA is to help people. I assume that it’s a lot of, even most, others’ motivation as well. But there’s little denying that it can function in a way that helps certain people and certain entities, e.g., some insurance companies and, as @dave above points out, some for-profit hospitals, more than others. It can be, and now seems to be, a rent seeker’s dream. I still support the policy, but I do so more despite that effect than because of it.Report

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