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Posts Tagged ‘David Brooks’

One writer’s opinion of where Obamacare stands right now

By David Brooks of the New York Times

It was always going to be difficult to implement Obamacare, but even fervent supporters of the law admit that things are going worse than expected. Implementation got off to a bad start because the Obama administration didn’t want to release unpopular rules before the election. Regulators have been working hard but are clearly overwhelmed, trying to write rules that influence the entire health care sector — an economic unit roughly the size of France. Republicans in Congress have made things much more difficult by refusing to provide enough money for implementation.

By now, everybody involved seems to be in a state of anxiety. Insurance companies are trying to put out new products, but they don’t know what federal parameters they have to meet. Small businesses are angry because the provisions that benefited them have been put on the back burner. Health care systems are highly frustrated. They can’t plan without a road map. Senator Max Baucus, one of the authors of the law, says he sees a “huge train wreck” coming.

I’ve been talking with a bipartisan bunch of health care experts, trying to get a sense of exactly how bad things are. In my conversations with this extremely well-informed group of providers, academics and former government officials, I’d say there is a minority, including some supporters of the law, who think the whole situation is a complete disaster. They predict Obamacare will collapse and do serious damage to the underlying health system.

But the clear majority, including some of the law’s opponents, believe that we’re probably in for a few years of shambolic messiness, during which time everybody will scramble and adjust, and eventually we will settle down to a new normal.

What nobody can predict is how health care chaos will interact with the political system. There’s a good chance that Republicans will be able to use unhappiness with what is already an unpopular law to win back the Senate in 2014. Controlling both houses of Congress, they will be in a good position to alter, though not repeal, the program.

The law’s biggest defenders will then become insurance companies and health care corporations. Having spent billions of dollars adapting to the new system, they are not going to want to see it repealed or replaced.

The experts talk about the problems that lie ahead in cascades. First, there is what you might call the structural cascade. Everything is turning out to be more complicated than originally envisioned. The Supreme Court decision made the Medicaid piece more complicated. The decision by many states not to set up exchanges made the exchange piece more complicated. The lines of accountability between, for example, state and federally run exchanges have grown byzantine and unclear.

A law that was very confusing has become mind-boggling. That could lead people to freeze up. Insurance companies will hesitate before venturing into state exchanges, thereby limiting competition and choice. Americans are just going to be overwhelmed and befuddled. Many are just going to stay away, even if they are eligible for benefits.

Then there is the technical cascade. At some point, people are going to sit at computers and enroll. If the data process looks like some 1990s glitchmonster, if information doesn’t flow freely, then the public opinion hit will be catastrophic.

Then there is the cost cascade. Nearly everybody not in the employ of the administration agrees this law does not solve the cost problem, and many of the recent regulatory decisions will send costs higher. A study in California found that premiums could increase by an average of 20 percent for people not covered by federal subsidies. A study by the Society of Actuaries found that by 2017 costs could rise by 32 percent for insurers covering people in the individual exchanges, and as high as 80 percent in states like Ohio.

Then there is the adverse selection cascade. Under the law, young healthy people subsidize poorer, sicker and older people. But the young may decide en masse that it is completely irrational for them to get health insurance that subsidizes others while they are healthy. They’ll be better off paying the fines, if those are even enforced, and opting out. Without premiums from the young, everybody else’s costs go up even higher.

Then there is the provider concentration cascade. The law further incentivizes a trend under way: the consolidation of hospitals, doctors’ practices and other providers. That also boosts prices.

Over all, it seems likely that in some form or another Obamacare is here to stay. But the turmoil around it could dominate politics for another election cycle, and the changes after that — to finally control costs, to fix the mind-boggling complexities and the unintended consequences — will never end.

Regulatory regimes can be simple and dumb or complex and sprawling. When you build complex, it takes a while to work through the consequences. 

 

David Brooks of the NYT on the Republican vs. Republican Problem

Liberals are furious, but the gun issue will not significantly damage the Republican Party. Sure, it looks bad to oppose background checks, which have overwhelming popular support. Sure, the Republican position will further taint the party’s image in places like the suburbs of Philadelphia and Northern Virginia. Sure, the party looks extreme when it can’t accept a bill sponsored by the conservative Senator Joe Manchin and the very conservative Senator Pat Toomey.

Moreover, Democrats never made a compelling case that the bill would have been effective, that it would have directly prevented future Sandy Hooks or lowered the murder rate nationwide. Even many of the bill’s supporters were lukewarm about its contents.

The main reason the gun issue won’t significantly harm Republicans is that it doesn’t play into the core debate that will shape the future of the party. The issue that does that is immigration. The near-term future of American politics will be determined by who wins the immigration debate.

In the months since the election, a rift has opened between the Republicans you might call first-wave revolutionaries and those you might call second-wave revolutionaries. The first-wave revolutionaries (the party’s Congressional leaders) think of themselves as very conservative. They ejected the remaining moderates from their ranks. They sympathize with the Tea Party. They are loyal to Fox News and support a radical restructuring of the government.

These first-wave revolutionaries haven’t softened their conservatism, but they are trying to adjust it to win majority support. They are trying to find policies to boost social mobility, so Republicans look less like the party of the rich. They are swinging behind immigration reform, believing that Hispanics won’t even listen to Republicans until they put that issue in the rearview mirror.

The second-wave revolutionaries — like Rand Paul (on some issues), Jim DeMint, Ted Cruz and some of the cutting-edge talk radio jocks — see the first-wave revolutionaries as a bunch of incompetent establishmentarians. They speak of the Bush-Cheney administration as if it were some sort of liberal Republican regime run by Nelson Rockefeller and Jacob Javits. They argue that Republicans have lost elections recently because the party has been led by big-spending, mushy moderates like John McCain and Mitt Romney and managed by out-of-touch elitists like Karl Rove and Reince Priebus.

The second wavers are much more tactically aggressive, favoring filibusters and such when possible. What the party needs now, they argue, is an ultra-Goldwaterite insurgency that topples the “establishment,” ditches immigration reform and wins Hispanic votes by appealing to the evangelicals among them and offering them economic liberty.

The first and second wavers are just beginning their immigration clash. A few weeks ago, I would have thought the pro-immigration forces had gigantic advantages, but now it is hard to be sure.

The immigration fight will be pitting a cohesive insurgent opposition force against a fragile coalition of bipartisan proponents who have to ambivalently defend a sprawling piece of compromise legislation. We’ve seen this kind of fight before. Things usually don’t end up well for the proponents.

Whether it’s guns or immigration, it is easy to imagine that the underlying political landscape, which prevented progress in the past, has changed. But when you actually try to pass something, you often discover the underlying landscape has not changed. The immigration fight of 2013 might bear an eerie similarity to the fight of 2007.

The arguments that might persuade Republicans to support immigration reform are all on the table. They came on election night 2012. The arguments against are only just now unfolding.

It is just a fact that the big short-term beneficiaries of this law are not generally Republicans: the 11 million who are living in the shadows; the high-tech entrepreneurs who will get more skilled labor. The short-term losers, meanwhile, are often Republicans: the white working-class people who will face a new group of labor-market competition when they try to get jobs in retail; the taxpayers who, at least in the short term, will have to pay some additional costs.

In the past, Republican politicians have had trouble saying no to the latest and most radical insurgency. Even if they know immigration reform is eventually good for their party, lawmakers may figure that opposing it is immediately necessary for themselves.

It would be great if Republicans can hash out their differences over a concrete policy matter, especially immigration, which touches conservatism’s competing values. But if the insurgent right defeats immigration reform, that will be a sign that the party’s self-marginalization will continue. The revolution devours its own.