Category Congress

Rand Paul: Health Care is Not a Right

Danny Vinik 2 Comments

Katrina Trinko has a nice piece at National Review on Rand Paul continuing to offer pro-bono healthcare work when he returns home to Kentucky. Trinko reports right from the operating room, where Paul is literally giving people back their vision through cataracts surgery. But, it’s what Paul said in a speech at the University of Louisville that is most interesting:

“There’s a philosophic debate which often gets me in trouble, you know, on whether health care’s a right or not,” Paul, in a red tie, white button-down shirt, and khakis, tells the students from the stage. “I think we as physicians have an obligation. As Christians, we have an obligation. . . . I really believe that, and it’s a deep-held belief,” he says of helping others.

“But I don’t think you have a right to my labor,” he continues. “You don’t have a right to anyone else’s labor. Food’s pretty important, do you have a right to the labor of the farmer?”

Paul then asks, rhetorically, if students have a right to food and water. “As humans, yeah, we do have an obligation to give people water, to give people food, to give people health care,” Paul muses. “But it’s not a right because once you conscript people and say, ‘Oh, it’s a right,’ then really you’re in charge, it’s servitude, you’re in charge of me and I’m supposed to do whatever you tell me to do. . . . It really shouldn’t be seen that way.”

There’s a nuisance nuance here that Paul misses. If I want to purchase food or water, I know I can do so at an affordable, reasonable rate. I may not have the money to do so, but I know that if I do make a bit of money, I’ll have the ability to feed and hydrate myself. Health care is not the same. If I have a pre-existing condition, health care providers may not offer me any coverage whatsoever, or may only offer plans that are way too expensive to be deemed reasonably affordable.

If Paul wants to make those markets more similar to each other, then he must require insurance companies to cover those with pre-existing conditions. That way everyone has the ability to purchase insurance. But if that happens, then the old and sick buy coverage while the young and healthy forego it. This creates a bad risk pool and leads to higher premiums, causing more young, healthy people to drop out of the market. Thus, the death spiral ensues. How do you stop that? By requiring or convincing young, healthy people to purchase health care. That’s what the Affordable Care Act does using both carrots (subsidies) and a stick (individual mandate). Paul’s comparison of health care to food and water demonstrates the need for greater regulation in the insurance market.

Paul’s answer to health care reform has always been that there needs to be greater competition in the industry. But greater competition isn’t going to help those with pre-existing conditions. If insurers don’t want to cover them, they aren’t going to cover them up – barring a requirement from the government that they do. That’s the type of requirement that makes the healthcare market more similar to the market for food or water. It’s also the type of requirement that Paul vehemently opposes. Nevertheless, that inherent contradiction doesn’t seem to bother the young senator as his speech at Louisville shows.

Do Obama’s Higher Ed Reforms Have a Chance in Congress?

Danny Vinik Leave a comment

Jonathan Chait is pessimistic:

But the comparison raises the question of whether his higher-education agenda will repel Republicans just as his health-care agenda did. Finding ways to get the government to spend less on education sounds pretty conservative.

…

If you put more weight on the ideological explanation [for Republican opposition to the ACA] , then Obama’s higher-education agenda stands a chance of attracting Republican support. Republicans might even take some visceral pleasure in making their cultural enemies in the academy squeal. If you put more weight on the political explanation, then Republicans will convince themselves that Obama’s plan is evil no matter what. Republicans will find themselves believing that free-market principles require that whatever money the government spends on college access must have absolutely no conditions attached.

Josh Barro is more optimistic:

I view scorched-earth Republican opposition to health care reform as having been driven mainly by neither ideology nor animus toward the president. I think the key was a desire to protect Republican constituencies who benefit from the health policy status quo: doctors and Medicare recipients.

In the case of higher education, the constituency getting its ox gored by cost control will be college professors and administrators, hardly a fixture of Republican fundraisers or Tea Party town halls. That bodes well for bipartisan compromise on this issue.

Hmm, I want to side with Barro here, but I can’t for one big reason: Republican rejection of the Medicaid expansion. A quick refresher: Obamacare expanded Medicaid to cover all individuals with income up to 133% of the federal poverty line. Since Medicaid is a state-run program, the government agreed to cover the full costs of the expansion until 2017. From 2017 to 2020, the federal government covers 95% of the costs and thereafter it’s 90%. It’s a great deal for states. But the Supreme Court ruling last summer allowed states to opt out of the expansion. This leaves a gaping hole in Obamacare. Individuals with incomes between 100 and 133 percent of the federal poverty line will still be eligible for tax subsidies, but those with incomes below 100% of the federal poverty line who aren’t eligible for Medicaid already will not receive coverage.

Why does this matter to whether Obama’s higher ed plan has a chance of passing in Congress? Because, as Barro and Chait write, it depends on whether Republicans will immediately reject the plan out of opposition to anything President proposes or whether they will be open to it. Barro’s optimism is based on the fact that Republican opposition to Obamacare was not just pure nihilism, but was also a play to protect their favored constituencies. Except Republican rejection of the Medicaid expansion shows that it was more nihilism than anything else.

That’s because rejecting the expansion will hurt one of Republicans favored constituencies: hospitals and doctors. Obamacare discontinues Disproportionate Share (DSH) payments, which were used to offset uncompensated health care costs of the uninsured pre-Obamacare. When Obamacare expanded Medicaid, those payments became unnecessary. Medicaid would now cover everyone up to 133% of the federal poverty line so uncompensated costs would basically disappear. Thus, there was no need for DSH payments to continue. Except hospitals in states that rejected the Medicaid expansion are still going to face significant costs of treating uninsured patients and now they receive no DSH payments to recoup those expenses. That’s why hospitals have been aggressively lobbying Republican states to expand Medicaid. There’s a lot of money on the line for doctors and hospitals.

But that lobbying has proved ineffective so far. Twenty one states have already rejected the expansion with six still debating it. It’s a great deal from the federal government that allows millions of poor Americans to receive health care coverage. Even more, hospitals are crying out for the expansion. Nope, Republicans are dead set against it. No matter how much hospitals and doctors favor them, Republicans aren’t budging. Republican opposition to Obamacare is less based on protecting Republican constituencies than rejecting anything the President proposes. I don’t see Republicans treating Obama’s education proposal any differently.

How Much Has the Obama Administration Defied the Law?

Danny Vinik Leave a comment

It’s a constant critique from the right that President Obama has ignored and flouted federal law more than any other administration in history. From not deporting DREAMers to the delaying the employer mandate* to not officially labeling Egypt’s coup a “coup” to today’s announcement by Attorney General Eric Holder that he’ll instruct prosecutors to leave out the amount of a drug found on low-level, non-violent criminal so that mandatory minimum laws are not invoked, the Administration has walked a tight line with regards to the law. Today’s announcement a major step for the Justice Department and has been greeted by applause by liberals. But is it legal?

As someone who is relatively new to political journalism, my biggest question is whether conservatives are right that the Obama Administration has ignored the law and used selective enforcement of different laws to advance its own agenda more than any other administration before it. That’s a pretty big charge – particularly after the Bush years – and if it’s right, it’s something we need to look at more closely. I’m going to look into this more, but I want to hear more experienced journalists chime in on this question. Those reporters who have been in DC for decades and have been around numerous administrations should be able to put this in context. The fact that I haven’t heard much from the MSM on this has led me to believe that the Obama Administration is, in fact, not ignoring the law more than any before it. But the last few weeks have seen the White House implement a couple of policies that should at least make us ask the question.

On the other hand, if conservatives are right and Obama has defied the law more than any before it, that’s a scary precedent. The combination of both President George W. Bush’s and President Obama’s disregard for federal law, plus a massive expansion of the surveillance state, is a scary path to be on. It’s bipartisan approval to ignore Congress. That’s not okay. The common saying is that the current Congress can’t bind future Congresses. After all, a future Congress can just pass a new law that overrides a past Congress. But the same cannot be said of the Presidency. The executive branch IS bound by the current Congress and only the current or a future Congress can change that. The President can’t simply decide to ignore past laws, but that seems to be exactly what President Obama has been doing.

I don’t have any answers here, but I want to lay out some questions:

  • Is this Administration’s selective adaptation of laws new?
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  • If so, is it acceptable? Are we comfortable with this level of Executive Branch autonomy?
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  • If not, is it still large enough to warrant increased coverage?
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  • After the last two administrations, how do we stop the White House from falling down “the slippery slope?” What safeguards can we erect so that no White House takes its power too far?
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  • If not, is it still large enough to warrant increased coverage?

The President’s refusal to label the coup in Egypt as a coup was particularly striking to me. Under any ordinary definition, what happened in Egypt was a coup. Except if the Administration had officially labeled it as one, it would have been required by law to cut off aid to Egypt. Of course, it had no desire to do that so it just refused to label it a coup and aid has continued. That’s not acceptable. I’m a proponent of foreign aid and understand its importance in the Middle East. But laws are laws. If Obama wanted aid to continue, he should have taken his case to Congress. Liberals may applaud Obama for finally acting proactively, but how would they react if a Republican President had ignored a law like that? They would’ve been furious and rightfully so. Presidents need to adhere to laws, both those passed during their administration and before it.

I know President Obama is fed up with the do-nothing Congress he’s stuck with and wants to find any means to sidestep it. unfortunately, the founders designed our Constitution to prevent exactly that so those workarounds are few and far between. Are we okay with the President stretching the definition of his authority when Congress is gridlocked? It’s yet another question we need to look at more closely, because over the past couple of years, the Administration has made a number of bold policy plays that are borderline, if not outright, illegal. It’s time we start asking ourselves how much of this is okay.

*Sarah Kliff had a good post on Wonkblog analyzing whether the Administration’s delay of the employer mandate was legal. It’s not entirely clear