In broad strokes, two of Barack Obama's largest legacies will be ISIS and Obamacare. Hillary Clinton cannot get away from the ISIS legacy - she helped construct and implement the policies which led to the rise of radical Islamic terrorism. However, as she tries to thread the needle between being the successor to a president who still has substantial popularity within the Democratic party, and being a candidate adequately acceptable to the surprisingly energized progressive wing of the party, she does have a choice between supporting (with a few changes) the healthcare system which has been the cornerstone of the Democratic establishment's domestic policies for the past seven years and Bernie Sanders' true progressive vision of government-run "Medicare for all." Before the election cycle is over, this will be a big deal.
Three years in, the country has had enough experience with Obamacare to allow a fact-based discussion. Overall popularity remains underwater by 8 to 10 % for several reasons:
- Since open enrollment began in October of 2013, some 10 million people have enrolled for subsidized payments through state or federal exchanges, and 14 million have been added to Medicaid rolls in the states which chose expanded coverage. The uninsured rate has dropped from about 16% to something over 10%, where it may have settled. Some 20 % of the uninsured are non-citizens (legal or illegal). Low income working families currently make up the bulk of the uninsured.
- The mandate that everybody must buy insurance to protect the insurance companies who must cover "preexisting conditions" does not work. The Orwellian-named "shared responsibility payment" for those not purchasing healthcare has increased from $95 in 2014, to $325 in 2015, to $695 in 2016. Some day there will be an audit of how thoroughly the mandate has been enforced.
- The mix of Medicare, Medicaid, employer-paid insurance, personally-paid insurance, and government-run exchanges with co-pays, deductibles, and coverage limits is complex beyond the ability of the average citizen to navigate, either for those interested in public policy or for those managing a personal checkbook. Fortunately, headache medicine is covered.
- When the federal government designs a mandated set of coverages for everybody, there will inherently be impositions on individual liberty, whether the Supreme Court accepts them or not.
Healthcare has been a tricky territory for Hillary since President Bill put her in charge of his administration's ill-fated signature initiative in 1993. Like Obamacare, the plan worked through the private sector, requiring employer-funded levels of coverage, and contained subsidies for the poor. There is no question that she understands all of the policy nuances and what is achievable politically; her decision to stand firm against Sanders' $1.4 trillion plan with its 2.2% increase for all taxpayers and 6.2% tax on companies reflects realism, but forms a significant part of the rift with the progressive wing of the party. When one ponders the 84% support that Sanders received from those under 30 in Iowa, one suspects that the Millenials prefer more free stuff to the requirement that they buy something that they do not want.
On the Republican side, everybody agrees with "Repeal" and cheers when Congress passes another symbolic effort, but there is no discussion of nuanced differences. Most candidates web sites have an innocuous plank for healthcare, but Trump and Cruz don't even bother. For now there isn't even enough difference between the candidates to form the basis of an attack on policy or personal history.
But in the general election, healthcare will be one of the handful of key issues. Hillary, having passed on the left wing enthusiasm for the government option, will be wedded to Obamacare with a few twists. The Republicans will have a passel of new things to talk about - health saving accounts, buying insurance across state lines, medical tort reform, government pools for high risk patients, tax credits for healthcare accounts, and a list of things from conservative think tanks like the Heritage Foundation and the Pacific Research Institute. And they will have a House of Representatives ready to deliver what the Republican candidate promises.
This week we have two videos from readers - Freshman Nebraska Senator Ben Sasse's powerful explanation of why Donald Trump is not a conservative; and a humorous advertisement from DNC pharmaceuticals for the key to Hillary Clinton's election.
bill bowen - 2/5/16