In his State of the Union address of February 12, President Obama was largely silent on his first term’s hallmark legislative achievement—the Affordable Care Act, or Obamacare—perhaps because he sees it as a battle won. But political and practical debates about the law rage on. Is the Medicaid expansion a good deal for the states? Will the health-insurance exchanges work as intended? How many Americans will get insured? Will Obamacare really help contain health-care costs? These questions will linger for years, and few serious observers believe that the law solved the nation’s most serious health-care challenges: uneven access, runaway costs, and wildly varying quality. How did we find ourselves with a law that spends so much, regulates so much, and yet fails to address the main problems?
CMS’ Center for Consumer Information and Insurance Oversight (CCIIO) on Tuesday provided the Senate Finance Committee with a breakdown of key Affordable Care Act milestones, which Chairman Max Baucus (D-MT) had requested during a recent hearing on the progress of health insurance exchanges.
The timeline is divided into four distinct categories — policy, operations and information technology, issuers & states, and consumer assistance. The abbreviated schedule starts this month, and ends with the Oct. 1 open enrollment date.
Now that Obamacare has survived a Supreme Court challenge and the 2012 election, it’s looking as if conservative activists are reverting back to their typical hibernation on the health care issue.
This is a big mistake. At some point in the future, liberals will be looking to build on Obamacare. Whenever conservatives point out problems with the law, liberals will counter that the problem is that the law left too much of the health care system in the hands of private insurers. Incrementally, liberals will seek to move the nation toward a true government-run, single-payer system.
And if conservatives spend the intervening years between now and then tuning out the health care issue, the liberals just may achieve their long-term goal.
The past few weeks have seen a number of optimistic headlines praising the Affordable Care Act (ACA) for reducing the growth in health care spending. Since all evidence points to health care cost growth as a key driver of our national debt, does this mean Americans no longer have to worry about the solvency of the US economy? Not quite. While slow growth rates are a positive development, yesterday’s report from the Government Accountability Office that examines the ACA’s long term budget impact, as well as a look at historical trends in healthcare cost growth, give a sobering reminder that there is still much to be done to reduce federal healthcare spending.
The House legislation would have had the federal government run the marketplaces while allowing states the option of taking over if they could demonstrate the ability to do at least as good a job. Consumer advocates hoped that the result would be a good national marketplace, with some exemplary states demonstrating how to do an even better job at providing quality coverage and good access while controlling costs.
But the Senate legislation, which became law, gave the primary responsibility to each state to set up a marketplace, with the federal government as backup. Advocates were not pleased for two reasons. The first was a concern that states would do a very minimal job of protecting consumers. The second worry was that states would fumble the complicated task of getting the exchanges up and running by October 1, 2013, when they are open for enrollment.
In reality, the reluctance of so many Republican governors to cooperate with ObamaCare has led to the creation of a system that looks more like the House bill. The federal government will run the exchanges in 25 states and will have primary responsibility, in partnership with states, in seven more.
Present social movements, as “Occupy Wall Street” or the Spanish “Indignados”, claim that politicians work for an economic elite, the 1%, that drives the world economic policies. In this paper we show through econometric analysis that these movements are accurate: politicians in OECD countries maximize the happiness of the economic elite. In 2009 center-right parties maximized the happiness of the 100th-98th richest percentile and center-left parties the 100th-95th richest percentile. The situation has evolved from the seventies when politicians represented, approximately, the median voter.
This paper focuses on the trends in debt levels among those ages 55 and older, as financial liabilities are a vital but often ignored component of retirement income security. The Federal Reserve Board’s Survey of Consumer Finances (SCF) is used in this paper to determine the level of debt. Debt is examined in two ways: (1) debt payments relative to income, and (2) debt relative to assets. Each measure provides insight regarding the financial abilities of these families to cover their debt before or during retirement. For example, higher debt-to-income ratios may be acceptable for younger families with long working careers ahead of them, because their incomes are likely to rise, and their debt (often related to housing or children) is likely to fall in the future. On the other hand, high debt-to-income ratios may represent more serious concerns for older families, which could be forced to reduce their accumulated assets to service the debt when their active earning years are winding down. However, if these high-debt-to-income older families have low-debt-to-asset ratios, the effect of paying off the debt may not be as financially difficult as it might be for those with high-debt-to-income and high-debt-to-asset ratios. The percentage of American families with heads age 55 or older that have debt held steady at around 63 percent from 2007-2010. Furthermore, the percentage of these families with debt payments greater than 40 percent of income — a traditional threshold measure of debt load trouble — decreased in 2010 to 8.5 percent from 9.9 percent in 2007. However, total debt payments as a percentage of income increased from 10.8 percent in 2007 to 11.4 percent in 2010, and average debt increased from $73,727 in 2007 to $75,082 in 2010, while debt as a percentage of assets increased from 7.4 percent in 2007 to 8.5 percent in 2010. Housing debt was the major component of debt for families with a head age 55 or older. The debt levels among those with housing debt have obvious and serious implications for the future retirement security of these Americans, perhaps most significantly that these families are potentially at risk of losing what is typically their most important asset — their home.
From a labor-market perspective, the Affordable Care Act has little in common with the 2006 health reform law implemented in Massachusetts.
Some employers are complaining about the $2,000 per-employee-per-year penalty they will pay beginning next year when the main provisions of the Affordable Care Act go into effect. The Congressional Budget Office also warned about the astonishing increase in marginal tax rates that middle-income Americans will experience, because the additional income earned by a family will be considered by the Internal Revenue Service as available for additional health insurance payments.
In the pursuit of truly evidence-based medicine (EBM) and the “learning health care system” that the Institute of Medicine has called for, both bioethicists and federal regulators are, happily, rethinking the way that we govern both biomedical research and medical practice, as well as the sharp boundary that the field has assumed can and should exist between them.
Meanwhile, a parallel conversation is taking place among legal scholars, political scientists, lawmakers and others, who increasingly argue that all decisions affecting human welfare — and not just medical decisions — should, wherever possible, be based on sound evidence about the comparative effects of available alternatives. Participants in this second conversation, explicitly invoking EMB and the gold standard for producing the evidence base underlying it, the randomized controlled trial (RCT), argue for widespread experimentation in law and policy to effect evidence-based practice (EBP) across several “practice” domains, including legal services, education, criminal justice, housing, voting practices, welfare reform, tax law, and environmental regulation.
This Politics and Policy column, forthcoming in the Hastings Center Report, argues that these conversations should not be separate. The problem with the EBP conversation proceeding on its own is that most of its participants are unaware (perhaps blissfully so) of the elaborate regulatory apparatus that govern all manner of knowledge production; they assume that informed consent is the only potential ethical-legal obstacle to EBP. And the problem with the EBM conversation proceeding on its own is that doing so threatens a repeat of the late 1970s, when regulations and ethical norms that came to govern knowledge production involving all disciplines and methodologies were developed by a relatively insular group within biomedicine.
The column ends by sketching some of the questions that diverse decision-makers will have to confront as they move towards a world in which research is integrated into various practice areas.
Collective Action and Individual Choice: Rethinking How We Regulate Narcotics and Antibiotics by Jonathan Anomaly :: SSRNFebruary 27, 2013
Governments across the globe have squandered treasure and imprisoned millions of their own citizens by criminalising the use and sale of recreational drugs. But use of these drugs has remained relatively constant, and the primary victims are the users themselves. Meanwhile, antimicrobial drugs that once had the power to cure infections are losing their ability to do so, compromising the health of people around the world. The thesis of this essay is that policymakers should stop wasting resources trying to fight an unwinnable and morally dubious war against recreational drug users, and start shifting their attention to the serious threat posed by our collective misuse of antibiotics.