Running on empty
Can Democrats run on healthcare when they haven't gotten anything done?
NBC News reported today that former President Barack Obama will return to the White House for the first time since leaving office, to promote the Affordable Care Act and tout “the expansion of health care benefits under the law, as well as Biden’s efforts to further reduce health care costs and expand access to care.” I can only assume this is the start of a pivot towards the classic Democratic standby of running on healthcare, ahead of the 2022 midterm elections. I understand why they would return to the old faithful, given the tremendous uphill battle they’re facing, but I can’t quite see how they’re going to make the argument this time around.
If they’re talking about the ACA, on purpose and with cameras on and stuff, I have to hope that this indicates some confidence that they’ll be able to avoid the nightmare scenario outlined by Jon Walker for the American Prospect this week: The expiration of the enhanced insurance subsidies on the marketplace, which people will learn about just as they’re starting to fill out their ballots.
Most people who get their insurance on the Affordable Care Act exchanges qualify for subsidies, limiting their premium to a percentage of their income. For the first decade of the law’s existence, these subsidies had a very severe cliff at 400% of the federal poverty level; if you made 401% of the poverty level, you would have to pay whatever insurers would charge. This could be thousands of dollars a month for older people. Under the American Rescue Plan Act, the subsidies were expanded to be more generous for everyone and to cover all Americans regardless of income—arguably still too high, at 8.5% of income, but a major saving for millions of people nonetheless. Walker wrote:
Beyond broadly hurting 14 million people, the end of these subsidies will create thousands of uniquely horrific stories of financial devastation. Due to the weird interplay of the ACA’s insurance rules around age and the design of the subsidies, the most jaw-dropping price hikes will be among older middle-class Americans. Many of them will likely feel betrayed that Democrats made them financially worse off than before. This is a group that tends to turn out disproportionately in midterm elections. All of these stories will be news fodder to highlight in the weeks before the midterms.
If Biden is planning on bringing on Obama to the White House to pat each other on the back about the ACA, I must assume that means they have some trick up their sleeve to make sure these subsidies are renewed. Right? Right??? Joe Manchin, who is the reason the bill that would have made these expansions permanent didn’t pass, has previously indicated support for the enhanced subsidies; perhaps it’s unsurprising that it’s a lot easier to get him on board with giving extra money to insurance companies than giving money to poor parents. Still, as of now, we have no details on a plan to fix this. I’ll post my teenage poetry before I’ll make any predictions about a Build Back Better bill passing, but it’s certainly not a good feeling to have truly no idea whether this will be fixed.
It’s important to note that the one thing the Biden administration actually has permanently improved in healthcare has barely made a dent in the campaign. A poll published this week by the Kaiser Family Foundation found that a majority of Americans with private insurance, 56%, know nothing about the No Surprises Act, which bans most surprise bills (except those from the single biggest source of surprise bills, ground ambulances). These trends held across party lines, so it’s not just that it isn’t being talked about on Fox News. This is arguably the biggest healthcare achievement of this Congress that Democrats could point to—at least, the biggest one that isn’t slated to disappear at the end of the year—and no one knows anything about it. Unexpected medical bills are the public’s second highest financial concern, after gas prices. Running on having ended surprise bills—they absolutely did not do this, but they passed a law that got close enough to pretend they did—sounds completely sensible, which naturally explains why it’s not an issue at all and no one even knows it happened.
As for Biden’s other healthcare priorities, what is there to say to voters? What of drug prices, often the public’s greatest source of concern in healthcare costs? Manchin has reportedly proposed a drastically cut version of the Build Back Better bill that would include allowing Medicare to negotiate prescription drug prices, but we don’t know the specifics of how the version of this plan acceptable to him would work. David Dayen noted a few weeks ago that the version of prescription drug reform the other Problem Senator, Kyrsten Sinema, had supported was laughably weak:
Only hospital-administered drugs that have run out of patent protection would be eligible. Under the deal, out-of-pocket caps would be instituted for seniors with Medicare drug benefits, and clawbacks would be instituted for companies that raised prices above the rate of inflation. Estimates of the Sinema deal were at about $200 billion in savings over ten years, compared to more than twice that for the consensus House reform.
That is... Nothing, at least politically speaking. Most people don’t even think of drugs you get at the doctor’s office as “prescription drugs.” It would do nothing for people who routinely fear what the pharmacist at CVS will say to them each month, or who forego that trip entirely because of their staggering deductibles. If this is what Democrats end up trying to tout as “prescription drug reform,” it will be a disaster. (It will probably be a disaster anyway.) Congress may do something pretty good on just one drug, insulin; the bill the House passed last week would only cap co-pays for people with insurance, who will still have to meet their deductibles for other kinds of routine, frequent care that diabetes requires, and Republicans would still have to vote for it in the Senate. So the drug pricing landscape is not shaping up to be fertile ground for Democratic midterm messaging either.
There’s also the looming crisis of Medicaid redeterminations, as I wrote about a few weeks ago. Millions of people will lose Medicaid coverage when states are once again allowed to remove ineligible people from their rolls, including many people who are actually eligible. Once again, this is something that Build Back Better would have addressed; once again, without that, we have no idea how the administration will prevent the bloodshed.
Uninsured people may also get a nasty shock in the next few weeks as they try to access free Covid-19 testing, the widespread availability of which Biden was touting just a couple months ago. Federal funding has simply run out; reports are already surfacing of people declining testing once they learn it may cost $125 per test.
Republicans are of course blame for holding up the funding, but as Gregg Gonsalves, Associate Professor of Epidemiology at Yale, told NPR, “the cognitive dissonance of the downplaying of the pandemic and then the need to get more money from Congress” doesn’t help the messaging problem: “Either it's a crisis and you need more money, or it's not a crisis and you don't need more money."
None of this adds up to a convincing case for Democrats protecting and expanding your access to healthcare. A recent Politico article documented Biden’s trouble “delivering on the full promise of Obamacare,” which they described as his “one big unfinished task.” I mean, sure, but that’s an unfinishable task. No matter how good you make the ACA, how generous you make its subsidies or how smooth the website is to use, it still won’t fix American healthcare, because its design is flawed and it sits upon a completely broken system. You can keep adding strokes to the canvas, but the painting is never going to be good. It certainly wasn’t going to be if Joe Biden was holding the brush.
In 2018 and 2020, running on healthcare was an obvious winner for Democrats. It was much easier paper over the flaws of the ACA under Trump, right after the Republicans came so close to repealing it—which would obviously have been catastrophic, for all the law’s problems. Republicans simply could not figure out how to lie convincingly about their desire to make American healthcare even more nightmarish than it currently is, especially since Trump kept talking about high drug prices (which they love and want to kiss) without actually doing anything about them. Now that Democrats are actually in charge, but also hamstrung by the Republicans in Congress and the Republicans in the Democratic caucus, it is much harder to hold up the threat of the ACA going away. Instead, they have to argue that it’s all actually good, not just better than the alternative.
No wonder, then, that the administration is wheeling out Barack Obama. If they can just get people to focus on him, and reconnect with the better vibes of the early 2010s, perhaps no one will notice that we are once again hurtling towards health insurance becoming completely unaffordable for millions of people; that millions more may lose Medicaid this year; that drug prices continue to grow; and that programs to pay for testing and treatments for the uninsured are withering away. We will once again be told to be grateful that things aren’t worse, as things slowly and preventably get worse anyway. Big Fucking Deal.
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