What Will the Supreme Court’s Decision Mean for the November Election?

Thursday, when Chief Justice Roberts explained that the Affordable Care Act (ACA) is constitutional because the “penalty” that some Americans will have to pay is, for all practical purposes, a “tax,” you could hear tea cups shattering from Billings to Boca Raton. In conservative and libertarian circles, the initial reaction was shock, but it didn’t take long for President Obama’s opponents to rally.

The word “tax” might as well have been a pistol shot at a horse race. In the blink of an eye, Obama’s opponents were off and running, megaphones in hand, blasting the president for lying to the American people while hiking taxes under the guise of healthcare reform. Presidential candidate Mitt Romney’s campaign then began providing regular Twitter updates on the campaign contributions it was raking in following the decision. Friday, it announced that it had collected $5.5 million.

Will Republicans suceed in turning defeat into victory?

Sarah Palin is convinced that they will. On her Facebook page, she celebrated: “Thank you, SCOTUS. This Obamacare ruling fires up the troops as America’s eyes are opened.”   Palin, like Republican leader Mitch McConnell, believed that the Court’s ruling would galvanize Republic voters, sealing Romney’s victory in November.

This might be true if conservatives were not already so ardently committed to what McConnell has called his party’s “single most important” goal: “for President Obama to be a one-term president.”  As Democratic pollster Celinda Lake noted, “Republicans are already as energized as they can get.” It would be hard to turn up the dial on their passion. Opinion surveys have shown that Republican voters already were more motivated than Democrats to go to the polls this fall.   (In November, Obama’s challenge will be to get his supporters out, including those who are disillusioned that the president hasn’t done more to help the poor and the unemployed. )

 What the Polls Say

Sunday, a new poll released by Reuters/Ipsos indicates that Republicans have miscalculated: the Court’s decision has actually lifted support for health reform. In particular, it appears that the ruling has changed the minds of many Independents.  Among those swing voters, an online survey conducted after the ruling reveals that 38 percent support the healthcare overhaul–up from 27 percent in a Reuters/Ipsos poll taken days before the justices’ ruling. Among all registered voters, support for the law rose from 43 percent to 48 percent. A CNN poll released the next day confirmed Reuter’s findings, showing 52% of Americans favoring “all or most” of the health-care law, compared to 45% who said that in January 2011.

As for Republicans, the Reuters survey suggested that if anything, the Court’s decision has dampened their enthusiasm, if only by a thin margin: 81% opposed the legislation, down from 86% in the poll conducted June 19-23. Meanwhile, three-quarters of Democrats backed the bill, just as they had a week earlier.

Other polls indicate that the ruling that the mandate’s “penalty” is actually a “tax” has not hurt President Obama, or his signature legislation. A  USA Today/Gallup snapshot survey of 1,012 Americans, taken right after the court’s ruling, showed the country evenly split on the decision, 46%-46%,with independents marginally favoring it. .

But what  about the charge that when voters find out that when  health care reformers called the mandate’s fine a “penalty” rather than a “tax,” they will realize that the administration was deceiving the American people?  I suspect that few feel duped. Most of us understand that when the government insists that you fork over money, this is a “tax”– whether it’s called a “duty,” a “surcharge,” a “toll” or a “tariff.”  A tax by any other name . . .

Swing Voters & Roberts

The polls suggest that those who hated Obamacare in 2010 will continue to loathe it; those who embrace it will continue to look forward to 2014, when the law is slated to be fully implemented.

By contrast, many Independents were uncertain–or simply confused –by the din of conflicting arguments regarding “death panels,” “broccoli,” and so on. They didn’t know whom to believe.

Most didn’t trust the Supreme Court to clarify the issues.  Before the ruling was announced, polls showed that nearly three-quarters of the public assumed that the Court would vote along party lines. Since five of the nine judges are conservatives, this suggested that that the mandate would be struck down. 

But Justice Roberts didn’t let his politics determine his decision, and his unexpected vote may well have boosted faith in the Court–while simultaneously undermining the credibility of Tea Party claims about “Obamacare.” (According to a CNN poll conducted from Thursday through Sunday, the number of Independents who approved of the Supreme Court “has edged up five points, to 53%.”)

Very likely some Independents concluded that if a conservative justice ruled that the law is constitutional, it is—which means that Tea Partiers were simply blowing smoke. This could help explain why more Independents now appear to support Affordable Care.

As for Roberts, I believe he ruled as he did because he was concerned about protecting the court’s standing as an impartial institution that stands above the fray of beltway politics.

The vast majority of constitutional scholars (including conservatives) had publicly declared that the Affordable Care Act was constitutional. But while a June Bloomberg survey of professors who teach constitutional law at top-rated laws schools revealed than over 85% said that if the justices followed legal precedent, they would uphold the legislation, nearly two-thirds feared that the Supremes would let ideology trump the issues: “politics would play too big a role in their decision.”

“The precedent makes this a very easy case,” said Christina Whitman, a University of Michigan law professor. “But the oral argument indicated that the more conservative justices are striving to find a way to strike down the mandate.”  

Yale Law School professor Charles Fried, who represented Republican President Ronald Reagan’s administration at the Supreme Court as U.S. solicitor general from 1985 to 1989, agreed: “It’s become just a very partisan battle cry on behalf of an argument which a few years ago was thought to be completely bogus. For objective observers on all sides, this was thought to be a lousy argument and the only people who were making it were sort of the wing nuts.”

The fact is that this is “a high-profile, enormously controversial and politically salient case — to have it decided by the narrowest majority with a party-line split looks very bad, it looks like the court is simply an arm of one political party,”  University of Chicago Law Professor Dennis Hutchinson told Bloomberg. “We believe in something called the rule of law,” he added. “That’s why we have faith in courts, that they’re not just another arm of a political party.”

The bottom line: if five justices had struck down President Obama’s signature achievement, just a few months before a close presidential election, liberals would not have been the only ones to cry “Foul!” Both the public and constitutional experts would have seen the decision as blatantly political.

In that case, Roberts’ court would have gone down in history as nine politicians masquerading in black robes who were, in truth, old-fashioned “Pols” wielding their power with impunity, safe in the knowledge that could never be voted out of office. Supreme Court judges do not have to answer to the American people.

 What would this mean for the integrity of the court, not to mention the political stability of the nation? If Justice Roberts had joined the four justices who wanted to repeal the entire Affordable Care Act, he could have taken us to the brink of a constitutional crisis. New York’s Jonathan Chait summed up the Chief Justice’s moment of truth: “Roberts peered into the abyss of a world in which he and his colleagues are little more than Senators with lifetime appointments, and he recoiled.”

 A reader commenting on Freethoughtsblog.com put it another way: “I think Roberts stared into the abyss, took a small step to the left and said to Scalia ‘After you…’”  

Obama vs. Romney: The Bigger Picture

Roberts’ ruling helps the president, but it is important to note that Obama already had been gaining on Romney, largely by appealing to what The Hill callsthe Rising American Electorate” (youth, unmarried women, African Americans and Latinos) — the broad coalition of voters who supported him enthusiastically in 2008.”

 These voters are beginning to come back. “Obama has moved his vote up from 60 to 63 percent with the Rising American Electorate and Romney has slipped a like amount,” the Democracy Corp. a non-profit, progressive polling organization, announced Friday, adding that “in the nation as a whole, the president now leads Romney by a 49-46 percent margin. That’s a 3-point improvement for the president since the end of May, when the two candidates were deadlocked.”

The survey found that the president has boosted his numbers by paying attention to his original base, “pushing student loan reform, expanding access to contraception and halting the deportation of illegal immigrants who grew up in the United States.” They observed that “the president has also edged marginally ahead with independents — 46 to 44 percent — and Romney continues to struggle with a high negative favorability rating, hovering around 45 percent.”

Growing support for Obama has translated into “a more favorable view of the Affordable Care Act,” they added.”Voters now give the law its highest positive rating since our tracking began in the summer of 2010, led by women and young voters,” pollsters observed. “Negative judgments are at 44 percent — down from earlier periods.”

 But if those who support health reform–or President Obama himself—become at all complacent, they will wreck his chances of re-election.  An Obama victory in November will turn on whether the Rising American Electorate votes; and bringing people to the polls is a labor-intensive business.  Keep in mind that in 2008, Obama won just 43% of the white vote. Pew Research reports that among white voters only 41% of men cast their ballots for Obama ,last time around, although 46% of women supported him, along with 54% of white voters under 30.  Meanwhile “just 31% of southern whites” chose Obama over McCain, although “he garnered the support of about half of white voters living in other regions.” 

Those older men who didn’t vote for Obama in 2008 probably won’t vote for him this fall. The lines that divided liberals and conservatives four years ago have hardened. Meanwhile some who viewed Obama as a super-hero in 2007 (I recall young pundits who described the lanky candidate as “the Black Spiderman”), are now disappointed that the president didn’t deliver all that they expected. They have become “undecided” or “swing voters.” They could simply stay home.

Yet there are signs that the Court ruling is invigorating Obama’s base. A Kaiser Family Foundation survey released yesterday reports that the Supreme Court decision inspired “a newfound wave of enthusiasm” among Democrats, with 47 percent saying they take a “very favorable” view of the law compared with just 31 percent a month earlier.”

“It’s a win on the leadership side; voters admire people who get things done,” Robert Blendon, a professor of health policy and political analysis at Harvard explained to Bloomberg.   Thanks to the decision, some disenchanted former supporters are more likely to see Obama as a successful, effective president.  The president took on a challenge that has defeated decades of leaders who preceded him– and he won.  

Myths vs. Facts about the Mandate’s “Tax”

 Meanwhile, conservatives continue to fear-monger. Last week, a well-funded conservative group called “Americans for Prosperity” began pouring $9 million into an ad campaign charging that Obama’s health care law is actually “one of the largest tax increases in history.”

I would suggest that they are putting a match to their money. It is not at all clear that most Americans want to hear more about healthcare reform– or that swing voters will believe conservatives canards.The court challenge focused attention on the mandate and in the wake of the decision, more and more Americans are learning that it does not represent a “big” tax increase, let alone “one of the largest in history.” In 2014, an individual who decides not to purchase insurance would have to pay only $95. Even in 2016, when the penalty peaks, he would be taxed just $695 for not buying coverage. 

 “The individual mandate penalty is expected to produce less than 5% of the new revenue in the law after it’s phased in;” Doyle McMaus explained in Sunday’s Los Angeles Times. “The biggest new taxes, which will fall on high-income taxpayers [individuals in the top 3%, earning over $200,000] and insurance providers, were labeled as taxes all along.”  

Most importantly, as I pointed out in my last post, only those Americans who don’t have employer-based insurance, and don’t qualify for Medicaid or Medicare will be subject to the mandate.  And within that small pool, a great many low-income and middle-income Americans will qualify for subsides, making insurance far more affordable.  The Kaiser Family Foundation (KFF)  offers an excellent “subsidy calculator,” which estimates how much government assistance you can expect, based on your income, age, family size, and the average cost of care in your region.

 Finally, a poll released Monday by KFF indicates that56 percent of all Americans — including more than four in five Democrats and 51 percent of independents with no party leanings”–say that they are weary of healthcare and “would like to move into other issues”– further proof that Republicans are squandering those corporate campaign contributions as they continue to hammer “Obamacare.”

 Insofar as voters are interested the subject, Republicans might better spend their money on a positive message, spelling out their candidate’s plans for making medical care affordable. That, however, would mean admitting that the centerpiece of Romneycare is to do away with employer-based health insurance.

Many American workers enjoy generous health benefits, with their employers paying more than half of their premiums.  President Obama has told them that “if they like the insurance they have, they can keep it.”  But if Romney’s dreams come true, they would lose it.

In upcoming posts, I’ll write about “Who Wins and Who Loses” if Obamacare is replaced by Romneycare.

20 thoughts on “What Will the Supreme Court’s Decision Mean for the November Election?

  1. Welcome back Maggie. Your valuable and insightful perspective has been missed.

  2. Maggie, I keep thinking that no one has done a through job of telling us the real details of the ACA. Some one needs to take the time to go into detail and “sell” the ideas. there are so many misconceptions about the bill, Good luck with your new web. Clifton

    • Can’t agree more. Perhaps if the issues of affordable and excellence in health care were better understood those busy politicking for both parties would be “accountable” for working for reasonable health care for our nation. Dr. Price, a conservative, indicates we all need some way to insure that all Americans will be reasonably cared for.

      Who knows what role the Supremes verdict will make. Sure keeps the pundits all over very busy prognosticating.

    • Not only does the ACA need to be explained, but the likely result of doing nothing or just tinkering around the edges also needs to be explained. A non-sustainable system in a death spiral is not something that wishful thinking and reminiscence will overcome.

    • Thank you! I agree! I need a better explanation of the “inside details” of this care act and exactly what everything means in terms for the people as well as the healthcare workers and industry! There are too many mysteries and arguing from both parties!

  3. Clifton, Richard & NG

    Thank you for your comments. You’ve made me think about this problem.
    It’s not easily solved.

    It’s true that the majority of Americans don’t know what’s in the ACA– though
    a great many people have made good (even excellent ) attempts at explaining it.
    For example, just yesterday Smart money magzine pubished a piece titled “Making Sense of the Affordable Care ACt http://blogs.smartmoney.com/encore/2012/07/02/making-sense-of-the-affordable-care-act/ that offers links to
    several Kaiser Family Foundation (KFF) reports and tools that offer an oustanding overview of the legislation,
    Smart Money lists what KFF offers:
    A summary of the act and an interactive timeline that helps explain the act’s provisions.
    A flow chart and analysis of how the “individual mandate” – the requirement that most people carry a minimum level of insurance coverage – would work.
    A map that shows where individual states stand in developing insurance exchanges.
    A calculator that estimates tax subsidies for people who buy coverage through the exchanges.
    An infographic that illustrates employers’ responsibilities.
    Illustrated profiles that illustrate how the law’s coverage provisions might affect individuals and businesses.

    The problem is that in the case of the Affordable Care Act, “the good” is in the details, and there are so many good details.

    This is part of the strength of the law. For instance,it proposes lifting the quality of care while cutting costs in dozens of ways. ( It doesn’t assume that there
    is one “magic bullet.” ) Instead, it offers:
    — bonuses for doctors who manage chronic diseases well enough to keep their patients out of the hospital (by creating “medical homes”)
    —penalties for hospitals with high rates of preventable hospital-acquired infectoins;
    — penalties for preventable readmissions that occur when hospitals don’t do a good job of making sure that their patients understand their meds when they discharge them; have a follow-up appointment with a doctor; truly are ready to go home. This involves following up with the patient after he/she discharged,something that some hospitals are now beginning to do to avoid penalities later on.) This is one reason why Medicare spending on hospitals has already begun to slow.
    –financial incentives for doctors and hospitals that band together to create
    “Affordable Care Organizations”‘ wherethey are paid, not for the “quantity” of their work, but the for the “qualitiy” (outcomes) with doctors and hospitals sharing in the savings
    — greatly increased scholarships for Med students who will “go where no one else will go” to provide primary care–often poor rural areas as wel as certain inner cities. (If patients in these areas have access to good primary care, they’re much less likely to land in hospitals. Experience shows that most often,these doctors wind up staying in these communities for the rest of their careers.); Our problemis not that we don’t have enough doctors, but that they are poorly distributed.
    — funding for community health centers that doubles their capacity (these centers, which are open “off-hours” provide an excellent alternative for low-income families that nowgo to the ER for care–much less expensive,and better continuity of care) ;
    –scholarships and loans for nurses who want to become nurse practioners (many
    will staff community health centers; others will offer primary care, usually working with a primary care physician, so that together, they can offer care to more patients . (Reserach shows these NPs are particuarly good at listening to patients and teaching them how to help manage their own chronic diseases.) They also offer primary care in areas where doctors don’t want to practice
    —rewards for Medicare Advantage insurers that do a good job of keeping their
    patients healthy. Tthose with excellent outcomes will not have their government funding cut–in other words, they, lilke hospitals and doctors will be judged on the
    quality of what they provide. . For instance, they may offer preventive care without co-pays, which encourages seniors to get the check-ups they need (blood pressure, etc.) Or they may offer physical therapy without co-pays if a doctor recommends physical therapy for knee problems, hip pain,shoulder pain etc. Often, patients can avoid expensive, painful surgeries if they have physical therapy. (Some of the best Advantage plans now pay for this–without co-pays.)
    — no co-pays for preventive care offered by insurers in the Exchanges
    –no co-pays for preventive care women need (Pap smears, contraception, etc.
    — dental and vision care for all children covered by insurance sold in the Exchanges (will prevent costly probems down the road)
    –free breast pumps and lactation counseling for women who want to nurse (this cuts childhood obesitiy by as much as 30% if women nurse for one year– much less expensive, then trying to tackle obesity when the child is 8– or an adult
    — funding for reserach looking at which treatments work best for which patients;this information will be passed on to doctors and hospitals interested in
    improving outcomes by practicing “evidence-based medicine”
    –funding for information technology so that hospitals and health plans can keep
    records which will alow them to see which treatments are working for which patients (something that places like Mayo & Kaiser now do, with great success)
    — financial carrots and sticks to encourage hospitals to avoid milions of preventable errors ranging from bedsores (the most expensive preventable mistakesand sometimes fatal) to wrong-site surgeries and medication mix-ups
    — A 30% increase in payments to doctors who provide primary or preventive care to Medicaid patients.(Today,docs are paid an average of 30% less when treating Medicaidpatients than if they offered the same care to a Medicare patient.) This means that Medicaid recipients will have an easier time finding a doctor who will take them as patients. This will also help community health centers that see many Medicaid patients
    — expanding Medicaid– so that more low-income families have accesss to health care.The Fed govt is paying 100% of the cost of expanded Medicaid forthe first
    3 years; 90% after that.(Today,the federal govt pays just 57% of the cost of
    treating existing Medicaid patients.Despite the posturing, (governors pretending
    they won’t accept the fudning,) states will, in the end,take them up on the offer.)
    — reducing Medicare payments for “overvalued services” and increasing payments for “undervalued services”– based on medical evidence. The Secretary of HHS
    has the power to do this without going through Congress.This should lead to
    better pay for services like paliative care and lower fees for certain types of back surgery for certain types of patients (suffering from lower back pain)..

    People who say that the ACA dosn’t reduce the cost of healthcare just haven’t read the legislation. (I’ve now read all of it 3 times, some parts more often than that, and I still haven’t absorbed all of it.
    These are just some of the “good details” that come to mind regarding just one
    aspect of the ACA (improving quality while reducing costs.) Consider how long the list is, and how much explanation the details needed. This is why it is impossible
    to explain “what’s in the ACA” in 600 – 1000 words (about as much as most people want to read. in one sitting.

    NG–you may consider all of this “nibbling around the edges” but in fact, as Don
    Berwick’s “Institute for Health Improvement” and others have shown,this is
    how you improve healthcare. This is what other countries do to create a health care system that is much less expensive and offers care that is at least as good (in some ways better.) Btw, all countries in Western Europe use private sectori insurers– the difference is that they regulate them. This is something that we, too, will be doing under the ACA.(Another list of the ways they will be regulated.)

    Perhaps I should turn this answer into a post. Can anyone else suggest
    “details” that shoud be on this list?

    • Maggie,

      My post was referring to conservative efforts in lieu of ACA. I think much of the ACA methodology is about right at least for a conservative country like ours where a more single payer system would be harder to sell. However when advocates sell the benefits of the ACA, I am just suggesting that keeping the status quo or almost the status quo can not work for much longer either!

      • NG–

        NG,
        Sorry I misunderstood.
        I totally agree. The system we have is going to hit the wall soon– unless we replace it.
        It’s just too expensive because we a) pay too much for most things and b) undergo a great many treatments and tests that we don’t need.
        The ACA is designed to squeeze waste out of the systemm, mainly by rewarding everyone for better outcomes, rather than paying them for “doing more.”
        I also agree that single-payer isn’t an option in the U.S. in large part because many people want to keep the employer-sponsored insurance they have.
        They may not be thrilled with it,but it’s a “known” (in contrast to single-payer) and more importantly,their employer pays a large part of the premium.
        Josh Marshall recently made this point on TPM: Congress won’t vote for single-payer because so many of their constituents don’t want such a radical change.
        But I did think that we’re going to get a “public optoin” at some point (health insurance run by the government as an alternative to private sector insurance.)
        Then people under 65 can try the public option (a version of “medicare for all”) but they won’t be forced into it.

    • Thank you for some of these insights into what will occur on my side as a healthcare worker. I am in school for NP and wanted to make sure this is still a good advancement opportunity or should I just stay at bedside for now. It does seem that I will still be needed and can practice in a rural area and still do well. Thank you!

  4. In regard to the “biggest tax” claim, since you already made reference to “The Incidental Economist” elsewhere, I am going to give a link to Austin Frakt’s discussion of that claim, already cited and discussed by Ezra Klein on his Rachel Maddow show report.

    Frakt demonstrates that all the taxes in the entire ACA are in fact just the tenth largest tax increases since 1950, and virtually tied with tax increases made by George H. W. Bush and Bill Clinton, and lower than Ronald Reagan’s tax increase of 1982. In fact, when you add the 5 tax increases passed by Reagan together, he is second only to Harry Truman, who was trying to pay off a World War II deficit of more than 115% of GDP, in raising taxes.

    The link:
    http://theincidentaleconomist.com/wordpress/obamacare-is-the-biggest-tax-increase-in-history-if-you-ignore-history/

  5. Pat–

    Thanks so much– a brilliant chart!

    I urge everyone to look at the link to the chart which shows that “all the taxes in the entire ACA are in fact just the tenth largest tax increases since 1950, and virtually tied with tax increases made by George H. W. Bush and Bill Clinton, and lower than Ronald Reagan’s tax increase of 1982.”
    The chart is here :
    http://theincidentaleconomist.com/wordpress/obamacare-is-the-biggest-tax-increase-in-history-if-you-ignore-history

  6. If you’re looking for material for another post, I would love to see a discussion of the small segment of workers falling into the multiemployer crack (see my rather long comment on your previous post). This is a group of constituents who are natural supporters of the ACA, but are finding themselves in a position where employer contributions may be lost to them while they seek insurance on the exchanges. I count myself among them.

  7. Martha– I’m very glad that you commented again.
    I wrote a response to your last comment on the previous post, then lost it
    (With the relaunch o HeathBeat,I’m writing on WordPress rather than Typepad, and am adjusting to it.)

    In your previous comment, you explained that people in your healthplan are
    “under union contract for up to a dozen employers who contribute to a fund (Taft-Hartley) which is administered by union and employer trustees. “. .. .

    You then explained the many variables in your plan, including the fact that “most of us work fulltime, but not for one employer, so the employers will probably fall outside the mandate. When the size of our employers is determined [it is not clear whether ] all workers count toward the 50-worker mandate or just the ones working under our contract.” (You also described other variables in your mutti-empoyer plansl)

    You added: “Last I heard, HHS may disqualify our plans all together as creditable coverage which will then throw everyone onto the exchanges.”

    You concluded: “We think the Administration doesn’t want to be seen as doing favors for unions in an election year. . . . I don’t know what to tell my members. It’s keeping me up at night.”
    Martha, First, this multk-employer plan presents a very knotty problem. I can understand why it is taking HHS some time to figure out how the legislation applies to your plan.
    And keep in mind that nothing wil happen until 2014,when the Affordable Care ACT is fully implemented, so HHS has time to figture this out.
    Insofas as HHS is holding back because of the anti-union sentiment among
    conservatives, that won’t be a factor after the November election. Win or lose, Obama won’t have to worry about being re-elected, which would leave the administration freer to make decisions based on the merits of the case..
    Finally, I understand that your members want to hang onto their employer-based insurance–most people do.
    But they should reaize that if they wind up buying their own insurance in the
    Exchanges (and I don’t know enough about the multiemployer situattion to know whether this is likely) while they won’t have an employer’s contribution, both
    low-income and middle-[income famiies will be getting subsidies from the
    government to help cover premiums. (a family of 4 earning less than $92,000 will qualify for these subsidies. .
    In addition,the insurance plans sold int he Exchanges will be required to cover all “essential benefits”; they won’t be able to charge co-pays for preventive care, and deductibles will not apply for prevevntive care. Children will get dental and vision coverage. There r will be a cap on how much insurers can ask families to payout of pocket (in the form of copays and deductibles) and there will be no cap on how much an insurer pays out for care in a given year, or over the course of a
    lifetime. In other words, families will not be bankrupted by catastrophic medical
    expenses.
    In these ways the insurance plans sold in the Exchanges will provide a much better
    value for our dolars than most of the insurance that your members have today.
    I realize that everyone hates uncertainty, but if I were you I would urge your
    members to be patient–and to ignore the conservative fear-mongers.. This is likely to work out much better than they fear.

    S
    it is

    FFirs

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  8. Hi Maggie:

    Thanks for your reply. To say this is a knotty problem is an understatement. Just before the Supreme Court decision we had two employer trustees, two labor trustees (one was me), the plan administrator and an actuarial adviser from the Segal company. All of us were scratching our heads and the deeper we dug, the less we felt we knew.
    “And keep in mind that nothing wil happen until 2014,when the Affordable Care ACT is fully implemented, so HHS has time to figture this out.”
    Unfortunately, we don’t have that kind of time because we need to be able to give our participants adequate notice and since the compliance is in 2014 we really can’t wait until 2014. It feels very late in the game now. I understand the problems HHS is having; there is absolutely no language in the law that deals with this and they can’t write regulations out of thin air. NCCMP is feeling as though they are not getting a sympathetic hearing, however. Since I’m not at those meetings I can’t comment on that.
    “Finally, I understand that your members want to hang onto their employer-based insurance–most people do.
    But they should reaize that if they wind up buying their own insurance in the
    Exchanges (and I don’t know enough about the multiemployer situattion to know whether this is likely) while they won’t have an employer’s contribution, both
    low-income and middle-[income famiies will be getting subsidies from the
    government to help cover premiums. (a family of 4 earning less than $92,000 will qualify for these subsidies.”
    It is true, the coverage they get on the exchanges is likely to be better than what they are getting now, at least on the lower tiers. We are thinking about scrapping the two lowest levels (which are currently running under waivers to allow for a lower annual cap than would be permissible) and offering an ancillary plan like vision or dental. The problem is that it is not clear what impact this will have on our employers who may or may not be subject to the employer mandate and who may be required to offer a minimum level of coverage or pay a penalty. Remember, our employers do not determine the level, the trustees set the levels based on contributions. In the past that was a way to capture more people who might not be working enough to qualify otherwise. I do think they will be better off on the exchanges, the problem is what level of participation can we get from our employers?
    The other huge problem is one of churning. The qualification periods on our plan are every six months because of the volatile nature of our business. So people will fall on and off the higher levels of coverage, and after 2014 they will fall on and off the exchanges. It’s a nightmare. The other thing that I’m having a hard time wrapping my head around is this: does anyone think it was the intention of the legislation to force people off group plans such as this and onto the exchanges with the subsidies? Of course the exchanges are there for people who are unemployed or don’t have coverage for other reasons. But we are talking about people whose livings are cobbled together in a difficult industry and whose coverage has been similarly cobbled together. I wish there could be a way to have the exchanges be there so no one goes without coverage but also for there to be a way for my folks to still benefit from the pre-tax dollars that were bargained for and which are contributed on their behalf to help them obtain care. My members are patient and they are not listening to fear mongers, they actually are listening to me. I just wish I could tell them what they can expect before it is upon them.

  9. Hi Maggie:

    I am always amazed at the number of people who wish to have the ACA explained to them (spoon fed?) rather than finding the site for the ACA and reading it to gain an undertanding of it. The KFF sites were great as it dispels a lot of the misconception when the ACA is compared to the MA plan.

  10. Maggie:

    On Roberts who also suffers from a form on brain activity which renders him not cognizant of things around him, he is being deceptive in the long run. His ruling was not so much to side with the ACA; but, it was menat to set the stage for other rulings to which Kennedy will gleefully join in orer to rule with the majority as he did in the past with the liberal side. Knnedy is a fair weather friend.

    Myself and Beverly Mann at Angry Bear do not put much credence in Roberts ruling. We have much to look forward to in the future. Hopefully Scalia retires.

  11. run 75441

    I understand your frustration when people complain that no one has ever explained the ACA. (I have spent so many hours trying to do just that.)

    But the truth is that most people who are raising children and working one or two jobs just don’t have the time to assimilate information about what is in the Affordable Care Act.

    We’re not talking about 5 or 10 teaspoons of info. We’re talking about 100 to 300 teaspoons. It’s a complicated piece of legislation addressing an extremey complicated problem

    Moreover, the the provisions in the ACA are inter-related. -Unless you take them all in, it won’t be clear why we can’t get rid of the mandate without also elminating the rule that says that insurers cannot refuse to cover patients suffering from pre-existing conditions.

    And that’s just one, easy example of how the moving parts are connected.

    This is why, on HealthBeat, I have wound up writing 2000 to 2500 word posts. (Granted, if I had world enough and time, I could tighten them, cut 500 words, and make them much better. ) But the fact is that explaining the ACA takes more time than most people have time to read.

    I totally agree aboutthe KFF infromation. It is great!
    But when I went to Google to look for “summaries of the ACA”– I found thousands of entries.
    Some were not useful. Many were filled with misinformation.
    Then I decided to search “summaries of the ACA” and “Kaiser Family
    Foundation.” And I struck gold.

    But KFF is hardly a household name. Most people trying to find a good summary of the ACA on Google would not search “ACA & KFF”.
    It’s up to you and I– and others who write about heatlhcare –to try to draw attention to the best descriptions of heatlh care reform.

    (Ideally, the mainstream media would be doing this. But with some notable
    exceptions (Ezra Klein & his group at the Washington Post, for example) most journalists are not spending space and time trying to tell people what is actually in the ACA.
    Their editors and publishers want them to tell the stories that make headlines: ” Affordable CAre Act May Be Overturned by Supreme Court”
    or “States Threatening to Turn Down Medicaid Funding”

    Btw, I realize that Beverly Mann has been upset with me for some time .
    If memory serves, she was upset by my posts (several years ago) suggesting that PSA testing does not save lives– or perhpas my posts (also several years ago) suggesting that too many women are going for mammograms that lead to diagnosis of “pseudo-disease” (tumors that will never hurt them.)

    I could be wrong about Mann’s objections to my posts. I just recall that she was a very unhappy reader.

  12. run 75411–

    Replying to your 2nd comment.

    I’m not convinced that Roberts’ decision reflects a “form of brain inactivity”

    This is a notion that the Tea Partiers spread.

    Also,my response regarding Bevery Mann referred to this post, not your first post. (Readers, please scroll up)

    Finally, we’ll just have to wait and see what Roberts does going forward.

    I think he may want to take control of the Court, and make it his Court. This would mean joining with the liberals. (Reportedly the conservatives on the Court are now shunning him.)

    Roberts is a well-educated, intelligent attorney– and sane. This separates him from two of the conservatives.

    I have heard that he tried very, very hard to get Kennedy to vote with him on heatlh reform.Kennedy wouldn’t. I’m not surprised. In Kennedy’s case, emotions trump reason.

    If a rift has developed between Kennedy & Roberts, this would be another reason why Roberts would take a small step to the left in order to become, truly, the Chief Jurtice. (I think the liberals on the court would work with him to make this a Court that would go down in history as a rational court.)

    a

  13. Christina–

    Thanks for your response.

    I definitely think there will be more jobs for nurse practitioners (whoever is elected in Novmember.)

    And if you are interested in working in rural areas, you will be in demand.

    The vast majority of states will expand Medicaid in 2014– a few may drag their feet, but they too will expand Medicaid in the next year or two. They need the money.

    At this point in time, it’s a great career choice. I wish that more college graduates who cannot find jos would think about becoming NPs
    (But only if they want to. This is a hard job– not for anyone who has reservations about working with people who are sick or elderly,

    NPs bring compassion to the job. They have been taught not only to try to “cure” –which they do,– but to “care”, even in those cases where medicine cannot cure.

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