Perception and politics

Related and somewhat counterposed to, the discussion on my recent “Reason and compassion” post is this paragraph from a blogger over at Ace of Spades (emphasis mine):

Allah had a post last night saying Ted Cruz is rejecting the "let it burn" approach to ObamaCare. Watch the clip at the end of the post, I'm not sure where Cruz stands on this. Yes, he rejects the notion that the GOP should try [and] profit politically from the suffering ObamaCare is imposing. That's just basic politics. You don't win votes by calling people idiots for voting for this and then say, "now you must suffer". What Cruz doesn't do in that quote (though he may later) is what Rubio does...suggest an affirmative course of action to make ObamaCare "better".

In the Allah post he references, there’s this (emphasis again mine):

Imagine if HHS fixes the front end of the site, so that people can now easily register and enroll, but the back end of the site remains a complete mess, with insurance companies forced to try to process tens of thousands of garbled enrollments in December. People who signed up, especially those with preexisting conditions, will be eager to have their coverage take effect in January. “All we need is $100 million to fix the back end and get this coverage flowing,” O might say. What’s the compassionate play at that point? It’s almost unimaginable that the GOP would appropriate the money and acquiesce in funding Obama’s boondoggle; on the other hand, even if the money is withheld in the name of pressuring Obama to delay the law for awhile, there may be thousands of sick enrollees who’ve already made financial plans based on the expectation of coverage. (This, of course, was precisely the reason Cruz wanted the law stopped before it started. Once people become dependent on the program and its subsidies, it becomes very hard to undo.) So what’s the play then? Dig in, refuse the appropriation, and tell Obama to figure out a way to clean up his own mess, even if that means chaos for the sick and/or an industry death spiral? That would be, essentially, LIB [Let It Burn] in action. It’d be all Obama’s and the Democrats’ fault, but that doesn’t solve the problem of how to spare people a lot of suffering from their stupidity and incompetence.

This is the dilemma for Republicans especially and for conservatives more generally: How do Republicans refuse to make what appear to be minor concessions to “fix” ObamaCare without looking like they’re the bad guys? Allah is correct when he says chaos and destruction in the insurance industry would be “all Obama’s and the Democrats’ fault”. He’s wrong, however, if he thinks most of the voting public would see it that way. What they’d see (or, rather, believe) is that all that’s needed to fix things is a little tweak here and there - and the Republicans are refusing to co-operate because they’d rather see people suffer.

It seems to me Republicans (and conservatives) have two choices. One is to refuse to help “fix” ObamaCare. If they’re going to take that route, they need to be able to explain what the end game is. To use Allah’s example, they have to finish this explanation:

We are not going to appropriate $100 million to fix the back end so those people who think they’ve signed up for health insurance can actually get it in a timely fashion. The reason we’re not going to do it is because we believe the exchange problems prove what we’ve said all along: the Federal government has no business being in the health insurance sales business and we want the government out of it immediately. We understand our refusal will result in the people who think they’ve signed up for health insurance not getting it and in insurance companies having tens of thousands of fewer customers (and millions of dollars less revenue) than they planned on.
{Pick one of the following concluding statements to conclude this explanation:
1) This will not be a problem.
2) This will be a problem but we’re not going to address it because you idiots “will never learn [your] lessons about statism unless [you’re] forced to suffer the consequences of statist policies.”
3) This will be a problem but we’re not going to address it because [fill in the blank].
4) This will be a problem and we will address it by [fill in the blank].
5) Thank you for your attention.}

I don’t see this first choice - refusing to help “fix” ObamaCare - as a winning political strategy but I could certainly be wrong.

The second choice is to help “fix” ObamaCare. The “help” the AoS blogger is talking about is Marco Rubio proposing a delay in the individual mandate. (It actually sounds like what he wants to delay is the fine/tax which is sort of but not quite the same thing.):

He [Rubio] said it would be "prudent" to delay the requirement on individuals to buy health insurance -- set to kick in early next year -- until users can consistently access the main website.

"How are you going to go after people next year ... if the thing you're forcing them to buy isn't available to buy?" he asked, saying the site is "not working."

Rubio's plan would delay the mandate until the Government Accountability Office certifies the system is "up and running and effectively working for six months, consecutive." 

There are two problems with this kind of “help”. First, it doesn’t address the actual problem, which is not “I’m worried about paying the fine/tax” but rather “I can’t buy health insurance”. Second, it doesn’t advance the cause of getting rid of - or at least weakening - ObamaCare.* If the Republicans really want to help - as opposed to looking like they're helping - they need to think of something that will address the problem of people not being able to reliably buy health insurance and will also loosen some of the nuts and bolts of ObamaCare. I’m sure (well, hopeful) there are some smart people in the Republican Party who can come up with something but here’s one suggestion: Let people buy health insurance, including the subsidized kind, directly from insurance companies, without going through the exchanges.

There’s no question this will help fix people’s inability to buy health insurance on both the front (website is a hunk of junk) end and the back (insurance companies not getting usable info) end. It would be hard for the Democrats to oppose because it both sounds and is perfectly reasonable; the point is to get people health insurance, not to feed some giant government data base, right? So why not let people buy direct from insurance companies which have lots of experience in selling insurance; have working websites; and are already set up to handle the whole subsidy thing since they’re supposed to be taking feeds from the ObamaCare website?

The “See Plans and Prices in Your Area” capability in HealthCare.gov will show me all the insurance companies in my area that are offering policies so I know who to talk to. At least one of them, Horizon Blue Cross Blue Shield, took my age and sex and showed me all the possibilities - subsidizable and not - in about a nanosecond. Heck, it even has a comparison capability. And if I want to compare policies across insurance companies, I gather esurance.com will do that (although I’ve never used it). We could sweeten the deal for insurance companies by changing the percent they’re allowed to devote to administrative overhead from 20% (if I remember correctly) to 25% - and sweeten the deal for Democrats by bringing that percentage down one point at a time over the next four years (finally sticking at 21%) as the insurance companies get the tools in place to handle the subsidizable policies from beginning to end.

Yes, the next four years. This is not an "until ... the system is ‘up and running and effectively working for six months, consecutive’” change; this is a permanent change. The Feds can, of course, get HealthCare.gov running and if people eventually like it better they can certainly use it.** But being able to buy direct from insurance companies is forever. And part of the deal would be a full accounting of how much HealthCare.gov has already cost us and how much it costs us to fix - as it’s happening, not ten years from now. Say, a report every week.

And, in exchange for graciously agreeing to save the Democrats’ bacon, the Republicans should ask for something. Nothing too big, nothing that looks business friendly (like getting rid of the medical device tax), nothing that looks ideological (like removing birth control as a required coverage item). Something that looks small, something that ordinary people will like.

My choice would be allowing anyone who wants to to buy true catastrophic health insurance (high deductible, no carve-outs for paid-for preventive care) and not be fined/taxed for being insufficiently insured. I’d want to look at some numbers first, though; if it’s not pretty cheap and it’s not a good thing for insurance companies it may not be worth asking for. It can be framed as something good for those currently insured now cancelled who are suffering from sticker shock and those currently uninsured who are doing the same. After all, if they’re too rich to qualify for a subsidy they’re rich enough to carry a high deductible. Right?

Catastrophic insurance is my thing both personally and policy-wise.*** If it’s not yours, well, here’s something I’d really like to see: getting rid of the ObamaCare requirement that employers provide their employees with health insurance. Now, that’s bigger and can look both business-oriented and, if not strictly ideological, at least Running Dogs Of Capitalism Crushing The Masses-oriented. However, it could be sweetened with a requirement that employers who are currently providing health insurance can stop doing so if they give each employee who is currently getting health insurance a raise equal to the amount the employer pays for that employee’s health insurance (plus maybe some percent). Then add in the ability for individuals to take their health insurance premiums off their taxes (I would have thought ObamaCare did this but I can’t find anything that says it did). And point out that these moves:

1) Probably give the less well-off more disposable income since they get a pay raise; can get subsidized health insurance; and can take whatever they do spend on health insurance off their taxes;
2) Probably means we end up with more healthy people in the individual health insurance pool;
3) Gets rid of the ObamaCare deformations of hiring (like the 50-employee threshold and the 30-hour full-time definition); and
4) Gets rid of the problem of employers with religious objections to some of the insurance requirements - they can just pay their employees more and let them go buy their own insurance.

All of these moves - allowing people to get subsidies without using the exchanges; making true catastrophic health insurance count as “insured enough”; not requiring employers to provide health insurance - loosens the Federal government’s grip on health insurance. It’s certainly not a repeal of ObamaCare but it changes the structure enough to make further movement toward a better system easier.

Plus, it should give the Republicans some political credit. And, as a bonus, these changes might actually help some people who need it.

*****

Notes:

* There’s a third problem which is that if getting rid of the individual mandate actually makes a difference in who buys health insurance (I’m not convinced it would) then the chaos and death spiral Allah talks about would become more likely. This would advance the goal of getting rid of ObamaCare but it could very well also leave the private insurance industry in a shambles. Maybe Republicans are willing to risk that to get rid of ObamaCare but what happens if there is no viable private health insurance industry when the dust settles? Then again, maybe Democrats like that idea because it will lead to a demand for true government insurance. Or maybe Democrats don’t like that idea and they’ll be smart enough to never agree to delay the individual mandate/tax/fine because they know that would destroy ObamaCare.

** As an added bonus, I’d really like it if this fix could include language along the lines of:

People can buy health insurance direct from insurers, without going through the exchanges, and still get ObamaCare subsidies, regardless of whether their State has established its own exchanges or relies on the Federal exchange. The language of the Affordable Care Act that prohibits Federal subsidies for insurance bought in a State without its own exchange still stands. If you live in a State that didn’t set up its own exchange, you can only get Federal subsidies if you buy your health insurance direct from an insurance company.

I imagine the way to sell this language would be to dig out the reasoning that resulted in the prohibition on subsidies when using the Federal exchanges and wave it around, insisting that the original argument is still valid (I have no idea what it could have been) and, at the same time, also insisting that this new fix corrects a grievous injustice.

This should pretty much eviscerate the Federal exchanges.

*** I think the best way to control health care costs is to make people pay for their own health care insofar as they are able. Catastrophic health insurance means I’ll be careful about just nodding when my doctor says, “Let’s do an X-ray, an MRI, a blood test, and send you off to this neurologist.” I’m going to pay for all that until my insurance kicks in so I’m likely to say, “Do we really need to do all that because my knee hurts? Could we just, like, you know, first try me on some of that 500mg Naproxen that costs $5 for 20 tablets?” So I’ve just saved thousands of dollars and, if the Naproxen doesn’t do it, I can go back to my doctor and have a long conversation about which one of the things he wants to do next is most likely to be helpful.

At the same time, I don’t think people should be unable to get health care because they run out of money. The trick is to make what I have to pay hurt enough so I’ll only spend it if I really need to. That’s why I favor a variant of the McArdle plan. McArdle talks about catastrophic health plans where the deductible is a percent of a person’s income, say 15% or 20%; my variant is that the percent increases as income does. If we just say “20% of income” as the deductible, someone making $20,000 is going to find that hurts enough to make her careful; someone who makes $1 million is not. Yes, this is redistributionist.