A short while ago I asked a Boston cab driver how she liked the health care system there. “It’s a hassle,” she said. “I had to go down a list of two dozen doctors before I could find one who would see me.” Turns out, she was on MassHealth (Medicaid). So I asked, “Did the list of doctors come from the Yellow Pages?” “No,” she said, “MassHealth gave it to me.”
Why am I telling you this story? Partly because I live in two parallel universes. One is the universe of health policy conferences at the Brookings Institution and the American Enterprise Institute and articles published in such places as Health Affairs and the New England Journal of Medicine. In the other universe, I quiz taxi cab drivers and others about what their life is like. I would lose a lot of good friends if I told you which universe is more informative.
Yet the more important reason for the story is that fully half of all the people who will be newly insured under ObamaCare are going to be in Medicaid. And if Massachusetts reform is the guide, most of the rest will be in highly subsidized plans that pay doctors little more than what Medicaid pays.
That brings me to the second set of parallel universes I live in: the world of public policy and the world in which people talk about public policy. Those two worlds are as different as night and day. Consider that:
- While defenders of the new law have chattered endlessly about people who are uninsured because of pre-existing conditions (turns out there are only 12,500 of them) almost no one seems to have noticed that 16 million people are not only going to be forced into Medicaid, they are effectively going to be denied the right to buy any private insurance — whether or not they have a pre-existing condition.
- While the Obama administration takes every opportunity to boast about the removal of annual and life-time private health insurance benefit limits, almost no one seems to have noticed that we are about to put 16 million people into plans that routinely limit benefits — regardless of what was promised at the point of enrollment.
- While a case challenging the constitutionality of a federal mandate to buy insurance wends its way toward the Supreme Court, fully one-half of the newly insured under ObamaCare won’t be paying any premium at all and most of the rest will be paying premiums that are only a fraction of the real costs of the insurance.
It isn’t that what people talk about is unimportant. It’s that what they choose to talk about is only tangentially related to what they are about to do.
Let me briefly review the bidding. In the 2008 Democratic primary virtually all serious candidates endorsed the principle of “universal health insurance.” After Barack Obama became president, a Democratic Congress proceeded to draft legislation that would insure about 60% of the uninsured. These days, all of this seems to have been forgotten.
Just to keep perspective, insuring people who have been denied coverage because of a pre-existing condition is going to cost about $5 billion over 5 years. Insuring all the rest of the uninsured is going to cost almost $1 trillion over 6 years. Almost all the political conversation for the past two years has been about the $5 billion problem. No one is talking about the $1 trillion problem.
In terms of money spent, ObamaCare is mainly about the expansion of Medicaid and Medicaid-like private insurance. In fact, if the reform had done only this it not only would have insured about half the uninsured, there might have been no general voter interest in the law’s repeal!
This brings us to the third set of parallel universes: the world of the poor and the world of the middle class. Take the issue of a health insurance mandate. Whatever the argument for requiring middle class families to buy insurance, there is almost no valid argument for fining poor people if they do not enroll in a program for which no premium is charged in any event. Currently, there are about 10 million uninsured people who are eligible for Medicaid and S-CHIP, but who have not enrolled. In another three years, these people will be hit with fines totaling $695 per person by 2016. (Or will they get a hardship exception? Who knows?)
Does this make sense? I suppose you could argue that being uninsured is anti-social behavior, but so is a lot of other behavior. Should we fine poor people if they drop out of school? Smoke? Eat fatty foods? Have children out of wedlock? Fail to become employed? If these ideas appeal to you, you’ll love ObamaCare.
The final set of parallel universes is the world of the elderly and the world of the poor. But in this case, the universes are connected. Roughly half the cost of insuring low- and moderate-income families is being paid for by Medicare enrollees. Okay, in politics there are always winners and losers. But if you watch TV or listen to White House press conferences, you would be led to believe that only one of those two worlds actually exists.
How many television commercials have you seen touting new, free insurance that will soon be available to low-income families? I haven’t seen one. But Andy Griffith has been all over the cable channels, trying to explain to seniors why they should like health reform. Medicare has spent millions saying much the same thing.
It’s as though the White House has concluded that seniors matter and poor people don’t — at least in politics. If they’re right, ObamaCare is in big, big trouble.