Health Care Reform

[River]

Phew. Onwards.

[Primula Baggins]

I am so happy for all those millions of people, and for the survival of the plan itself, which has already made life easier for for my entire family.

And my understanding is that it's written in such a way that a future Republican president will not be able to remove the subsidies administratively.

Gotta run, but I'm look forward to reading some analysis when I get back! <wanders off w00ting quietly>

[Voronwë the Faithful]

There are a couple of ironies here. First, in addition to the millions of people saved from potential financial ruin, and the president himself, probably the happiest people in the country right now are the GOP leaders of Congress, who don't have to come up with a fix for the mess that would have resulted had the court ruled elsewhere. The second irony is that the last great hope for the opponents of the ACA to get rid of it is Bernie Sanders. If somehow he can overcome Hillary Clinton and win the nomination, we will have a GOP president, and probably still GOP majorities in both houses. By that time, the law might be so entrenched that even under those circumstances it won't be repealed, but I wouldn't bet on that.

Even before I heard anything about the opinions, I was thinking that the nickname should be changed to "RobertsCare" since once again the Chief has saved the day. We'll never know whether Kennedy would have still voted to uphold the law had the Chief not joined him, but it certainly made it a lot easier. Then I heard that Scalia, in his scathing dissent that he read from the bench, said that the law should be referred to as "SCOTUSCare". That does have a certain ring to it. Of course, he did not mean it kindly.

[Primula Baggins]

Still just basking here. Such good news, and it gets better the more I read about it (the decision precludes a future Republican president from ending the subsidies administratively; it would have to be done through legislation).

It's still a far-from-perfect law. But it's working, and costs are going down, and millions more people are insured. Now that won't all be derailed for ideological reasons.

[Voronwë the Faithful]

Still just basking here. Such good news, and it gets better the more I read about it (the decision precludes a future Republican president from ending the subsidies administratively; it would have to be done through legislation).

That's the part of the opinion that is most surprising to me, after the oral argument. Roberts was largely quiet, but his brief comments suggested that he might be willing to uphold the subsidies under what is known as Chevron deference, allowing an administrative agency to interpret an ambiguous statute. That would have allowed a new administration to reinterpret the ambiguous phrase. Instead, he basically said that this issue was too important to do that:

When analyzing an agency’s interpretation of a statute, we often apply the two-step framework announced in Chevron, 467 U. S. 837. Under that framework, we ask whether the statute is ambiguous and, if so, whether the agency’s interpretation is reasonable. Id., at 842–843. This approach “is premised on the theory that a statute’s ambiguity constitutes an implicit delegation from Congress to the agency to fill in the statutory gaps.” FDA v. Brown & Williamson Tobacco Corp., 529 U. S. 120, 159 (2000). “In extraordinary cases, however, there may be reason to hesitate before concluding that Congress has intended such an implicit delegation.” Ibid.
This is one of those cases. The tax credits are among the Act’s key reforms, involving billions of dollars in spending each year and affecting the price of health insurance for millions of people. Whether those credits are available on Federal Exchanges is thus a question of deep “economic and political significance” that is central to this statutory scheme; had Congress wished to assign that question to an agency, it surely would have done so expressly. Utility Air Regulatory Group v. EPA, 573 U. S. ___, ___ (2014) (slip op., at 19) (quoting Brown & Williamson, 529 U. S., at 160). It is especially unlikely that Congress would have delegated this decision to the IRS, which has no expertise in crafting health insurance policy of this sort. See Gonzales v. Oregon, 546 U. S. 243, 266–267 (2006). This is not a case for the IRS.

At that point, the decision could go one of two ways, either completely uphold the law, or completely eliminate the subsidies in federal exchanges. No middle ground. He then shows why, despite the laws numerous instances of "inartful drafting" when the entire statute is taken into account, only one reasonable conclusion can be reached. One of my favorite parts of his opinion is where he quotes the dissent in the first ACA case:

It is implausible that Congress meant the Act to operate in this manner. See National Federation of Independent Business v. Sebelius, 567 U. S. ___, ___ (2012) (SCALIA, KENNEDY, THOMAS, and ALITO, JJ., dissenting) (slip op., at 60) (“Without the federal subsidies . . . the exchanges would not operate as Congress intended and may not operate at all.”). Congress made the guaranteed issue and community rating requirements applicable in every State in the Nation. But those requirements only work when combined with the coverage requirement and the tax credits. So it stands to reason that Congress meant for those provisions to apply in every State as well.

I also really like his cogent analysis of the history of health care coverage and attempts to reform it that led to the passage of the ACA. But the best part is the conclusion:

In a democracy, the power to make the law rests with those chosen by the people. Our role is more confined—“to say what the law is.” Marbury v. Madison, 1 Cranch 137, 177 (1803). That is easier in some cases than in others. But in every case we must respect the role of the Legislature, and take care not to undo what it has done. A fair reading of legislation demands a fair understanding of the legislative plan. Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter. Section 36B can fairly be read consistent with what we see as Congress’s plan, and that is the reading we adopt.

[Primula Baggins]

Citing Marbury v. Madison! It's words-of-one-syllable time.

Meanwhile, the Republican presidential candidates are deploring the decision, but Republicans in general, especially in Congress, have to be tremendously relieved in at least one way: they don't have to choose between trying to rescue the law their base hates and throwing millions of people off of health insurance. And it gives them until 2016 now to not come up with a replacement plan, instead of not coming up with one this year in the face of a lot of public anguish.

I'm starting to believe that they are not going to be able to chip Obamacare loose now. And the longer it continues, the more people will benefit from it and (IMO) the more clear its fiscal benefits will become.

[Voronwë the Faithful]

As I said earlier, their last and only hope is to take the White House in 2016, while retaining sufficient control of both houses of Congress to pass a repeal. And, ironically, their best hope of doing that would be if Bernie Sanders, who is strong supporter of a single payer health care system, somehow was able to win the Democratic nomination, because he would have very little chance of winning the general election. Much as I agree with much of his views, his surprising early successes, at least in terms of crowd size and enthusiasm, makes me a little nervous.

[Primula Baggins]

I'm not worried. It's very early yet. And although I, too, prefer his views to Clinton's on many issues, I wouldn't risk electing a Republican to make that point. I'm sure there are many other liberal Democrat pragmatists. Incremental gains that are within reach trump lofty dreams that are not. Etc. The "middle ground" has moved so far toward conservatism in the past few decades that I can accept that it will take years to begin to push it back the other way.

[Inanna]

Yayyy. I hope the GOP shuts up about it now.


---------------
Please bear with my typos & grammar mistakes. Sent from my iPhone - Palantirs make mistakes too.

[Voronwë the Faithful]

No chance of that, Inanna. There will be more symbolic repeal votes in the House, and it will be a major subject in the GOP presidential primaries.

[Inanna]

Yes, you are right. All that wasted time and energy. Around 60 attempts to date...


---------------
Please bear with my typos & grammar mistakes. Sent from my iPhone - Palantirs make mistakes too.

[River]

I wonder why they haven't dedicated some of that time and energy to just instituting a replacement?

[Primula Baggins]

Basically, because they've discovered that the parts of Obamacare they dislike are essential to having it work at all—the mandate works because there's premium support, and the expanded care and insurance for pre-existing conditions only work because there's a mandate. It's a Rube Goldberg machine, but take out any part of it and it's a shambles. They cannot assemble a functional health care plan that accomplishes what Obamacare accomplishes, and still funnels everything through the insurance companies, unless it essentially is Obamacare.

[Voronwë the Faithful]

Or, because the only truly viable alternative is a true single payer, national health care plan. What became ObamaCare actually IS the Republican alternative.

[Frelga]

I don't disagree with you, V, but I do wonder a bit at the lack of even nonviable proposals. Even of a populist variety. The only thing I recall hearing is "it's better to pay the fine and stay uninsured." Which is not a proposal.

[Voronwë the Faithful]

If I recall correctly, there was the outline of a plan that was being circulated, but it never went anywhere because it became clear that it would not work.

One interesting detail that I read recently is that the GOP recently replaced the head of the CBO with a more conservative economist and instituted a controversial accounting practice that makes certain assumptions that many economists don't agree with, and then had them run another analysis of what result repealing the ACA would have on the deficit, and it STILL came out that repealing the law would very significantly increase the deficit.

http://thehill.com/policy/finance/24553 ... to-deficit

[Voronwë the Faithful]

According to the Journal of The American Medical Association, preliminary data is showing that the ACA is already significantly improving access to health care in the U.S, although not surprisingly those gains are limited in the states that refused to expand Medicaid.

http://jama.jamanetwork.com/article.asp ... id=2411283

Conclusions and Relevance The ACA’s first 2 open enrollment periods were associated with significantly improved trends in self-reported coverage, access to primary care and medications, affordability, and health. Low-income adults in states that expanded Medicaid reported significant gains in insurance coverage and access compared with adults in states that did not expand Medicaid

[Primula Baggins]

That's excellent news. So of course there's another repeal vote in the works. Just as soon as they get Planned Parenthood defunded because of yet more deceptively edited videos, so federal money isn't wasted on birth control and health care for low-income women.

It will be a full-on Gilded Age again just as soon as Congress can swing it. We all need to line up the best corners in advance so we can sell apples to our betters when we're old.

*explodes black mood* But I'm at the beach, and I shouldn't grump about things that probably won't happen.

[yovargas]

What is the solution to insanity like this???

http://observer.com/2015/10/over-5000-p ... n-shkreli/

Martin Shkreli, CEO of Turing Pharmaceuticals, quickly became one of the most hated people in America last month after purchasing the rights to the 62-year-old drug, Daraprim, and increasing the price from $13.50 a tablet to $750; over a five thousand percent hike.

Daraprim, the generic version of the pharmaceutical drug Pyrimethamine, is used to treat toxoplasmosis – a parasitic infection most common among those with compromised immune systems, such as HIV/AIDs patients. Left untreated, it can cause death in one to four weeks.

[River]

I have no idea. He's an extreme example of a trend and the regulators are starting to take notice. When industries get abusive in their practices the public demands something be done. We have the FDA because of that, we have the EPA and the Clean Water and Clean Air acts because of that, we have the ACA because of that. If pharma keeps it up, they'll get another regulatory hammer dropped on their bums, on top of the ones that already exist.

Until then...public shaming?