Revenge of the Kludgeocrats


So.  It’s been awhile, about 3 years now, so it’s understandable that some of us may have already forgotten our bitter disappointment when the Affordable Care Act morphed, before our eyes, from a brave new universal healthcare plan, that would finally bring the US in line with the rest of the industrialized world, to a neoliberal Frankenstein’s monster designed to lead New Deal liberals and Reagan conservatives to a great post-partisan Kumbaya moment.

As we know, ACA barely made it, thanks only to a Democratic super-majority, without a single Republican vote.  And the result is a healthcare law that left liberals and conservatives both holding their noses over a law that hardly anyone approves of in its current form.

By the time, conservative-bait and liberal dreams were all present and accounted for, ACA had turned into a Rube Goldberg model of healthcare policy.

One of the interesting bits of ACA history is that it is based, in large part, on a 1989 Heritage Foundation blueprint of the conservative alternative to single-payer healthcare along the lines of Medicare. 

At that time, Republicans were not fond, at all, of the 1986 Emergency Medical Treatment and Active Labor Act which requires any hospital participating in Medicare (i.e., most, if not all) to provide emergency care to anyone who needs it, underwritten in large part, by the federal government.  Republicans hailed the Heritage Foundation plan, a market-based approach dependent on individual responsibility, much more to their liking.

In 1993, President Bill Clinton tried to stitch this all together into a healthcare reform bill that included an employer mandate to provide health insurance for all employees through a regulated exchange of HMOs.  Republicans, at the time, proposed an alternative that included an individual mandate, rather than an employer mandate and means-tested subsidies to be used in state-based insurance exchanges—sound familiar?

Supporters of that earlier Republican reform plan included Orrin Hatch, Chuck Grassley, Bob Bennett and Kit Bond who subsequently fell out of love with it when President Obama proposed it.  Whereupon they promptly pronounced their former brainchild unconstitutional and henceforth “dead to them.”

And, of course, we all know only too well the long, sad story of Romneycare which ended tragically when Daddy Warbucks disowned it.

Obamacare, as it turned out is, unfortunately, a cumbersome, clunky, unnecessarily hard to implement program specifically because of all the conservative policy goodies that had to be folded in if it were to succeed on a bipartisan level.  Things like individual mandates, means-testing, variable subsidies, state-level exchanges made up of private insurers, (except where the states opt out) all of the needless, counterproductive minutiae that characterize conservative social policy efforts

Meanwhile, ACA succeeded on a strictly partisan level and now we are all stuck with the 19th century gears and gizmos that had to be included to woo conservative votes that never materialized.  We could have had Medicare-for-all and, if we did, the 33 million uninsured would probably all be enrolled by now.

Which brings me to the most interesting part of all.  Despite all of the gloating, finger-pointing and nay-saying that Republicans are currently indulging in over the glitchy roll-out of Obamacare, this is exactly the unwieldy, non-starting system that Republicans like Paul Ryan would like to transtion your Social Security and Medicare to.  What fun!

This is the absolute zenith of hypocrisy, of course, but it’s exactly what the kludgeocrats of the GOP will be pushing whenever and wherever possible.  Right now, as we speak, and as Paul Ryan sits down to his budget conference, what Republicans want is for all of the current social insurance programs to migrate to Obamacare-for-all.

And fat chance that their hyper-partisan base will see through the hypocrisy.  I suspect that if Ted Cruz took a copy of the ACA, slapped a new cover on it and shopped it around as Cruzcare no Republican primary voter would catch on.

Republicans are determined to kludge up all of our time-tested, tried and true social insurance programs.  Take Social Security: they want to replace it with a program of mandates and/or incentives to build retirement funds in 401(k)-type savings accounts and then use those funds to purchase retirement annuities.  The poor would receive variably-adjusted, means-tested subsidies to do the same.

Likewise, Medicare would be bogged down with Obamacare-like mandates and coupons to buy their own elder-care health insurance and become much more complex and difficult to navigate for future seniors.  Anyone who thinks that isn’t a big deal? see Medicare, Part D roll-out.

As Michael Lind of Salon recently wrote:

If Obamacare — built on means-testing, privatizing and decentralization to the states — is treated by progressives as the greatest liberal public policy success in the last half-century, then how will progressives be able to argue against proposals by conservative Republicans and center-right neoliberal Democrats to means-test, privatize and decentralize Social Security and Medicare in the years ahead?

I predict that it is only a matter of time before conservatives and Wall Street-backed “New Democrats” begin to argue that, with Obamacare in place, it makes no sense to have two separate healthcare systems for the middle class — Obamacare for working-age Americans, Medicare for retired Americans.  They will suggest, in a great bipartisan chorus:  Let’s get rid of Medicare, in favor of Lifelong Obamacare!  Let’s require the elderly to keep purchasing private insurance until they die!

Already, though, Democrats and Progressives are taking their victories where they can and losing sight of how unnecessarily screwed-up Obamacare is because of its conservative-tickling features.  Right now, Democrats should be making the point to constituents that the problems with implementing Obamacare are those very conservative features that had to be included to bring Republicans along.  Future focus should be on using any political gains to reform the reform and try to make the ACA resemble something like the policy that liberals envisioned before bipartisanism took its toll.

So, here’s the deal . . . when Republicans inevitably start making noises about “updating” Social Security and Medicare along the lines of our beloved Obamacare, place fingers in ears and repeat after me “LALALALA!

And remember, Obamacare is not the policy that liberals and progressives dreamed of—it’s only slightly better than nothing.  So be careful what you settle for . . . if you decide that Obamacare is anything greater than a small step in the right direction,  you’re painting yourself into a corner where you might find yourself signing up for Lifelong Obamacare instead of the far, far superior Medicare that your parents and grandparents enjoy.

Posted by Bette Noir on 10/28/13 at 10:44 AM • Permalink

Categories: PoliticsBarack ObamaElection '14Health Care

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Already, though, Democrats and Progressives are taking their victories where they can and losing sight of how unnecessarily screwed-up Obamacare is because of its conservative-tickling features.

“Democrats” I’ll grant you, but I don’t know about “progressives” in that sentence. I’m mostly seeing folks say “see, we told you we should’ve just had medicare for everybody.” and stuff like that.

And this from Lind:

If Obamacare — built on means-testing, privatizing and decentralization to the states — is treated by progressives as the greatest liberal public policy success in the last half-century…

Yeah, as if! Nice pretty straw progressives he’s built though—good workmanship.

@OBS sounds like this got your progressive hackles up? good to remind me, though, that there’s a big difference between East Coast and West Coast progressives.

I’m bi-coastal, myself, but identify more strongly with East Coast progressives. In my opinion, ECPs are more socialist, live-and-let-live types while WCPs are more militant. 

For example, next weekend Stanford Law School will be hosting their annual Shaking the Foundations conference.  This year’s topic: Tools for Transformative Justice.

ECPs tend not to “shake” foundations.  Not to say they’re anti-change.  It’s a matter of style.

So. while you’re hearing from your fellow WCPs: “should’ve been single-payer or nothing;” ECPs, a vast number of whom live inside and outside DC are more inclined to think, OK. this is a beginning, let’s embrace it and make it our own.

If Lind is thinking ECPs, his “straw progressives” aren’t that far off.

Yeah, I guess life in the really-really-progressive part of an already progressive state is influencing me.  Out here what you’re describing are called “Moderates.”.

An ECP inserted an extra period into that comment. Good job Obama!

Um, yeah. Obamacare even in its current form is quite a bit more than “slightly better than nothing.” And I’m thrilled that it’s a step away from employment-based health insurance, which you seem to regret.
It’s possible to defend Medicare and SocSec, and work to improve Obamacare over time as those programs were improved, without being afraid to tout (or even recognize) the good things that the ACA is doing right now.
“If you love Obamacare so much you must want Medicare to be run just the same way” is what we’re supposed to be afraid of?

Medicare for all will never fly as long as the boogie words “socialized medicine” exist.  It beats me why single payer is considered practically communism by so many people.  But during the sausage making fest that churned out the ACA it was thrown out that letting 55 and overs buy in to Medicare could be a cost effective solution for older workers and even that pretty damn reasonable idea caused Bluedog Dems to wet their pants.  Needless to say it didn’t come close to making the final cut.

Single payer was never going to be a real part of the discussion but it might be possible to eventually include a public option on the exchanges which could eventually lead single payer or something like it. 

I do think that Obamacare is more than slightly better than nothing.  Especially after reading about people who have been unable to get affordable insurance and are desperately hoping their health & luck will hold out until Jan. 1 when their brand new health policies go into effect.

A few clarifications:

And I’m thrilled that it’s a step away from employment-based health insurance, which you seem to regret.

@KRK I’m not sure what in my post leads you to believe that I regret getting away from employment-based health insurance.

Actually, I said this (perhaps too subtly):

. . . now we are all stuck with the 19th century gears and gizmos that had to be included to woo conservative votes that never materialized.  We could have had Medicare-for-all and, if we did, the 33 million uninsured would probably all be enrolled by now.

The only reason that I feel that ACA is “slightly better than nothing” (words that I wish could unsay) is because it’s so junked up with conservative-pleasing provisions.  IMO ACA is the ultimate bi-partisan fail; when we should have been saying “we’ve got the votes, let’s roll!”

I, myself, enrolled the first week (by some weird IT twist of fate) and am delighted to not have to worry about the kinds of things that happen with some regularity at my age and that would blow my retirement plan out of the water.

Oh yeah, and @OBS—you never know when an extra period will come in handy.

ACA is much more than the health insurance part.  There are substantial provisions to improve Medicaid (the system for approving changes to state plans is entirely paper based - part of ACA is to provide an online system) to name just one.  Part of the problem is the rule making process which outlines the nuts and bolts. Even though it was passed in 2010, the process of defining what the program would really entail took longer as CMS had to draft policy which also had to go out for public comment.  Believe me, policy can change drastically based on that.  My understanding is that the policy was not nailed down until late in the game which makes it tough for a developer to implement in a timely fashion. I also have some knowledge of the procurement process under which CGI and QSSI got their respective awards. There was competition.

Um, Bette, you do know that out here we consider Stanford to be very conservative?

Comment by Stentor on 10/28/13 at 08:08 PM

Um, Stentor, I respectfully disagree that Stanford is “very conservative.”  Especially Stanford Law which is what I referred to.

In the 1960s and 1970s a number of progressive student organizations were started to focus on legal issues which largely affected Chicanos and women.

Female and black professors were added and the law school collaborated with Stanford Business School to create pretty cutting-edge (for the times) joint-degree programs.

In the 1980s and 1990s, Stanford Law redesigned its curriculum again to be even more progressive. Programs were offered focusing on law relating to technology, the environment, and intellectual property, and international law. 

And, the law school’s clinical program was established starting with the public interest East Palo Alto Community Law Project which has since added more community law projects.

In 2011, Stanford was listed with an “A-” in the “Diversity Honor Roll” of The National Jurist: a magazine for law students.

I have a hard time translating all of that as “very conservative” especially by East Coast standards.

On the other hand, I do know from living on the West Coast that there are some pretty deep regional biases both inside and outside California especially regarding older Calif. institutions.

GOP: “We have to render social services unworkable in order to fix them!”

Hm. Thinking about how I’m an ECP real-keeping mellow-wonking straight-talking stochastic flow radical on the downlow half-smiling freestyling representing not resenting East Side…

What were we talking about, now? Oh. Health care. Um, I’m going to go wild and call the ACA a possible first step to breaking our current system up, first and foremost by decoupling insurance-possession from job-possession, in the positive sense for a change, since we already have lots of crappy jobs out there that get people no insurance or bad insurance (I know people in unionized retail with minute-med coverage. Yep. Go stand on line at the clinic and we’ll cover the bare-ass minimum.) Putting some of these bare-minimum coverage plans out of everyone’s mercy is a good deal. I think it has to point to a single-payer option becoming desireable—and probably in places which are rural and red and have low market competition, out of necessity.

I get why critics from the Kochs to Suzanne Somers want to talk about socialism. They are changing the subject, though, by substituting a boogey-man word to generate fear (or, in her case, I think express annoyance at perceived lack of privilege) for a policy concept that acknowledges the health of a population as being its most obvious form of public welfare, in the sense not of handouts, but of a common trust we have with our fellow citizens to value each others liberty—and lives.

Umm, under the ACA I’m going to be able to get non-emergency medical care for the first time in decades. As far as I’m concerned, that’s more than a little better than “nothing”

I agree with LL. Hubs and I have been uninsured for ages. When we did have insurance, it was next to useless, and without the ACA, we’d be uninsurable because of my preexisting conditions. I should be on bp medication, have an emergency asthma inhaler, and be on ADHD meds. I’ve got none of them and had no hope of them until the ACA. I’ll take it.

I know a lot of people are finding themselves in deeper waters because of the ACA though. I wish that weren’t the case. I’ll never understand how keeping your population healthy is a bad thing.

@LL and @domynoe I’m in that same boat with you.  I was without insurance from age 57 - 62 with PECs.  I’m grateful to have ACA to get me to Medicare.

But from a political perspective I am sorely disappointed that Obama’s desire to blaze new trails in post-partisanism totally screwed over the healthcare reform for which he had a clear mandate.

Adding in all of the perennially crappy GOP “must-haves” only to be beat over the head with their pure crappiness is disappointing.  No?

I would love to live to see the day when Democrats don’t settle for less to keep the peace with their Republican counterparts.  I’m waiting for Democrats who fight as hard as Republicans for what they believe is right.

I have to comment on that whole 3.5 year thing. In the spirit of disclosure, I work for CMS but thankfully not on the Marketplace.  Once a law is passed the policy people have to define what that means.  They publish drafts of that policy (called rules) that the public has time to comment on.  This isn’t always a quick process. Speaking from the IT side who has implemented rule driven systems, the IT people don’t always get a lot of lead time. I worked on what turned out to be a very successful program that didn’t get the final rule until 3 months before go live.  Luckily, we were able to defer the more complex parts a few months.  Too little attention is paid to the non-individual mandate provisions that were successfully launched and this goes beyond the 26 year olds remaining on parent’s healthcre

Just got off the phone with my very conservative Republican brother who lives in Texas.  He is also self employed.  He has been surfing the health care website and was ecstatic to find that he and his wife can switch to a silver plan using their same insuror, so keep all their doctors, and save about $700 per month in premiums plus reduce their deductible by several thousands.

His daughter, who does not get any benefits with her job, will qualify for subsidies and her policy will be practically free.

Suddenly Obamacare is not a bad word to him any more.  And he’s not going to be the only one.  Problems or not, it’s here to stay.

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