The shouting must have been audible on the moon yesterday when President Obama signed into law the health insurance reform bill, after a year of political turmoil. Some of the shouts were of joy, others of anger.To this "old-style liberal," the moment was beyond historic. We were present at the minting of a new fundamental right, the right to adequate health care for all Americans.
The pundits from the right and from the left all had it pretty much correct on the op-ed page of The Washington Post yesterday, at least if you strip out the pejorative bias from the conservatives' columns. Arch-conservative George F. Will wrote in "A battle won, but a victory?" that
The accounting legerdemain spun to make this seem affordable — e.g., cuts (to Medicare) and taxes (on high-value insurance plans) that will never happen — is Enronesque.
Liberal Eugene Robinson, meanwhile, wrote in "The health-care bill: A glorious mess":
Even when the "fixes" that have to be approved by the Senate are made, the health-care bill will still be something of a mess ... It may take years to get the details right. The newly minted reforms are going to need to be reformed or at least fine-tuned, and those will not be easy battles.
They are both talking about the same things, among them the notion that (as moderate-conservative Michael Gerson wrote in "Obama shows a president can be both strong and wrong") "cuts in ... Medicare will [have to] be used to finance someone else's entitlement." To wit, there will have to be cuts in today's Medicare program to pay for the freshly minted health insurance entitlement for those under the age of 65.
If the "fixes" bill passed by the House alongside the main health bill passes the Senate and Obama signs it, the combined legislation "would cut an additional $60 billion [above the Medicare cuts in the main bill], bringing total cuts to the program to more than $500 billion over the next 10 years," according to the Post article "With Senate 'fixes' bill, GOP sees last chance to change health-care reform." That $500 billion would go largely toward
- paying to help the states expand Medicaid eligibility under the new law to cover individuals and families with incomes up to 133 percent of the federal poverty line
- paying for tax credits that will be used to subsidize purchases of health insurance on state-run exchanges by those who don't get insured by their employers, who aren't eligible for Medicaid, and who have incomes up to 400 percent of poverty ($43,320 for a single individual, $88,200 for a family of four)
In addition to promising cuts in Medicare, our existing federal health insurance program for those 65 and older, the new law imposes a tax on high-cost health insurance polices — one that supposedly takes effect in 2018 — and it creates a Medicare payroll tax on investment income for individuals earning more than $200,000 and for families earning more than $250,000 a year.
Future Medicare cuts, a union-offending tax on "Cadillac" health plans, an added payroll tax on high-earners: these are all postponed, politically poisonous promissory notes that were built into the health bill to keep it from busting the budget and scaring off deficit hawks ... among Democrats, that is, since no Republicans voted for it. Can we be frank? Not many people one either side of the ideological divide think all those things are likely to come to pass, on down the road. Thus Will's mention of "accounting legerdemain," Robinson's reference to "years to get the details right," and Gerson's concerns about how we are really going "to pay for the new health insurance entitlement."
Actually, some of the parameters of how to pay for it are already set by the new law. For one thing, the "young invincibles," people in their 20's and 30's who are never sick and often don't have health coverage today — they prefer a higher wage instead — will be forced into the risk pool. Insurance of any type, health or otherwise, is all about risk pools: those who don't receive payouts in effect subsidize those who do. In health insurance pools the well who never visit a doctor's office subsidize the sick who do — but only if the healthy are part of the pool in the first place. If they opt out, the premiums they or their employers would otherwise pay are missing from the pool and can't be used to buy care for those who get sick. Under the new law, anyone who voluntarily refuses health insurance will pay a penalty of at least $695 a year.
Another how-to-pay-for-it parameter is that your taxes and mine will be used to furnish insurance for the poor (Medicaid) and for the middle class up to 400 percent of poverty (tax credits to buy coverage on exchanges).
To this blogger, though, those are details. The key thing is the word entitlement. From now on, every American is entitled to insurance to pay for health care. Age doesn't matter. Pre-existing conditions count for nothing. You can't have your insurance cut off if you get sick. If your job doesn't cover you, you can get insurance on your own. If you can't afford it, you'll get a subsidy.
So there. We'll figure out how to pay for it later.
