The Republican Health Care Plan: Too Bad, So Sad

I don’t often post segments from The Ed Show, but he nailed Mittens with this one:

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  1. Josh Barro at Forbes has a blog entry on how the SCOTUS overturing Obamacare could ultimately lead to a single payer system. My sense is we could do better than the status quo, though I’m not so sure that single payer will produce the same result here as in Canada. I think we tend to bare a lot of the cost of medical and drug R & D that the rest of the wrold benefits from; it may not be possible to have as low an underlying cost of medical care as Canada.


    • Bruce,

      Barro at the end of that piece essentially explained why Democrats went the way they did on reforming the system: they thought the Romney model would appeal to conservatives who feared single-payer as a way to achieve universal coverage. They had no idea that the thing would be demagogued by many of the same folks who once supported that model. And to be fair, how could they have seen coming such an about-face? My problem was that they should have to come to that position after fighting for single-payer, which would give them a logical place to go politically if the ACA doesn’t survive scrutiny, telling the public that the ACA was their compromise and even it was rejected by Republicans. As it turned out, the ACA, which was a Republican creation, looked like a Democratic initiative.

      I have thought that the 2016 Democratic presidential candidate will actually run on single-payer, no matter what happens to the ACA via the Court. Or at least I hope that candidate will. I also believe there should be a groundswell of support for single-payer among Democrats running for Congress in 2014 and 2016, particularly, as Barro points out, since Republicans have no plan to achieve universal coverage. None. This is a winning issue for Democrats, whether the ACA survives its constitutional test. Single-payer, besides its obvious effectiveness in achieving what both parties says they want (coverage for everyone), has the virtue of being easy to explain to a public who largely does not pay attention to any level of detail on public policy.

      So, I agree with Barro that the GOP has, ironically, made single-payer much more likely in our near future than we could ever have dreamed. But contrary to what he says, I’m not “nervous” about the outcome of the Supreme Court case. Strategically, I think if the conservatives join together to strike all or part of it down, it does my side a big favor in the mid-term (Barro’s argument) but it also does us good in the short-term (the 2012 election). It will help to energize the Democratic base, likely energize Obama to boldness, and leave Republicans to explain what it is they plan on doing to achieve universal coverage.

      In some ways, the best thing that could happen to the country is for the radical conservatives to strike it down.



    • @ Bruce,

      I agree with you and Duane on this. If the SCOTUS completely overturns the ACA it seems to me there would be an immediate impact on people affected by pre-existing conditions and supporting children up to age 26 on their policies, and on some drug subsidies. Then, as Duane says, the GOP would own the problem.

      However, I can see the thing easily going a different route, despite Scalia’s assertion to the contrary – repeal of the individual mandate but retention of various provisions like those above. In fact I heard Justice Ginsberg muse about doing just that – letting Congress decide what to salvage from the core-less ACA. Congress is notorious for snatching defeat from the jaws of victory, just as they did in 1986 when they passed EMTALA, the phantom unfunded mandate that set us on the predictable course of today’s financial disaster.

      Wouldn’t it be interesting if someone sued to overturn EMTALA and that landed before the SCOTUS? What would the Justices say then? Of course that’s not going to happen, but it’s grimly amusing to think about.


      • I wonder what the reasoning was for exempting VA hospitals from EMTALA. Just curious.


        • @ Helen,

          The VA, since it operates under a separate government program does not participate in Medicare. Therefore, the government’s extortion threat of denying Medicare funds from the VA hospitals has no effect and they simply ignore its provisions.

          This raises an interesting question. Does anyone ever show up as an emergency patient at a VA hospital? And if they do, do they simply stabilize her and ship her off to another hospital? Anyone? We would be interested to know.


          • Jim,

            I found this:

            Nonvets must pay for emergency VA care

            Rick Maze – Army News Times

            Veterans hospitals may be open to non-veterans after a natural disaster or emergency, but private citizens who are neither veterans nor disaster workers will be billed for the cost of their treatment, Veterans Affairs Department officials announced.

            A notice in the Federal Register implements a 2002 law authorizing VA hospitals and clinics to provide disaster relief care. The federal government will pay for the cost of treating federal workers, including service members, and other disaster workers will be reimbursed under sharing arrangements.

            Other people will have to pay for care unless they are veterans, according to the new rule, which takes effect immediately.

            Treatment would not be automatic under the new policy. VA facilities could be open to the public in a major disaster or emergency declared by the president, or in a disaster or emergency in which the Health and Human Services Department orders the National Disaster Medical System to be activated, according to the notice.

            The VA Emergency Preparedness Act of 2002 allows VA to provide hospital care and medical services during and immediately following disasters and national emergencies to people who are not otherwise eligible. The law sets rules for how VA would be reimbursed by other government agencies, but left open whether private citizens receiving emergency care would have to pay for it.

            In the report accompanying the bill, lawmakers suggested that emergency care to private citizens could be free, but VA officials who decided to bill people for services said they worried free care would drain the veterans health care budget, as there was no assurance the government would offset the costs.

            The one exception is that veterans will not be charged, regardless of whether they are enrolled in the VA health care system.


          • @ Duane,

            Thanks for interesting research on VA emergency care.


      • Jim,

        First—and we may disagree about this—but I think EMTALA is absolutely necessary. I can’t imagine a society in which folks with emergencies but no money or insurance would be left to fend for themselves.  The problem with EMTALA is that no provision to pay for the mandated care accompanied the law. Whatever one may think of it, what the Affordable Care Act’s mandate essentially does is get folks to pay for EMTALA

        Second, EMTALA doesn’t entail “free care” for everyone who goes to the emergency room. Hospitals can try to get the money from the patient, if he or she has any.

        Third, the basis of any lawsuit against EMTALA is hard to see. Only “participating hospitals”—those that get public dough (which is almost all of them)—are required to give treatment to everyone who comes. Government money often comes with strings attached.

        But there is a certain logic (albeit attenuated) one could follow to get at a theoretical suit, along the lines of those who objected to the ACA’s mandate. That is, both laws require that the public purchase coverage for those who don’t have it. In the case of EMTALA the purchase is through the cost-shifting hospitals do to pay for the care of the indigent, and in the ACA it is directly through the purchase of insurance.

        In any case, I don’t know of any constitutional objections to EMTALA that the court would respect, do you? I suspect that one of the conservative justices would have raised the issue during oral arguments, if there were some basis for doing so.



  2. Duane,

    Allow me to quibble, if you will. I think we both agree that America needs and deserves a society that provides good healthcare to all its citizens regardless of individuals’ ability to pay for it. But your comment acknowledges that, “The problem with EMTALA is that no provision to pay for the mandated care accompanied the law.” That is the problem in a nutshell. It is what I have called a “phantom unfunded mandate” just for that reason – it mandates service without a means for paying for it. It really should have been supported by a tax, just like Social Security and Medicare, but the political reality was that the public would not have stood for that kind of tax at that time.

    Truth be known, I think American culture only tolerated Social Security and Medicare because those programs started small and then gradually ramped up to the point where the paycheck debits are now even indexed to inflation. It’s kind of like the “how to boil a frog alive” simile. Americans have always resisted taxes.

    The existence of the unfunded EMTALA has made the ACA vulnerable to attack by conservatives by creating an odd program that stands between what should have been two obvious alternatives:

    1. A capitalistic fee-for-service system, possibly subsidized by taxes but with significant skin in the game by patients, and insurance plans unaffordable by the seriously sick and the seriously at-risk.
    2. A single-payer, government-run system.

    But what we have under EMTALA, even with the ACA, is an unaffordable hybrid program that conceals its own weakness, unfunded ER access. While some patients may pay, as you note, my sense is that most such bills go unpaid, and they are massive. (I have that on very good and current authority.)

    Conservatives like to pretend that patients get what they pay for under the pre-ACA system while the uninsured are lured into gambling they won’t get sick, a gamble they always lose. I submit that if EMTALA were absent it would be immediately apparent that no. 2 above, or some form of it, is the only rational alternative for a civilized society. In other words, lacking the EMTALA alternative, wouldn’t the voting public then be clamoring for equal access under no. 2?

    Relative to your last question about possible constitutional objections to EMTALA, I’m no expert for sure. But it seems to me that ordering a private business (doctor, hospital) to spend money or dispense services they are unlikely to be reimbursed for ought to be against something in the Constitution. Isn’t that like ordering GM and Ford that they have to make extra cars and deliver them to poor people who probably can’t afford them?


    • Jim,

      Since you answered below my first objection to the constitutional issue, I can only say that I don’t disagree with your suggestion that absent EMTALA the rational thing for civilized people to do would be to go to single-payer. The problem I have is the word “rational.” I don’t think public opinion often works that way (your tax example is the best case in point: our current mess is partly caused by irrational Republican thinking on taxes which the public supports).

      I do think, though, that a threshold of common suffering will be reached even if EMTALA remains the law and the ACA goes down (or even if it remains whole). That suffering will likely be when employers en masse stop offering health insurance to their employees or offer it at such a high cost that lots of folks won’t take it. The results, while it might take a while, will move us toward rationality–toward a Medicare for all-type system.



  3. PS, on further reflection about the last paragraph above, one must recognize the disingenuousness of what was done under EMTALA. No one is “ordered” to do anything, merely threatened with a cutoff of half a hospital’s business, thus the charge of extortion. If they were selling iPads, it wouldn’t work, but they aren’t. They are selling something for which people don’t shop.

    It’s too much for me – any lawyers reading this out there?


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