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When this series of commentaries began, almost four years ago, there was no specific conclusion in sight, just a challenge to tell the story of a major public policy debate in America, as it unfolded, from the perspectives of competitive politics and through an analysis of policy choices, hopefully comprehensible to the informed reader.

We found more material than anticipated: Obama’s election, financial collapse, a long tightrope walk across the legislative process, landmark legislation, political polarization, an historic Supreme Court decision, and now a political campaign with starkly differing visions of an American future, with the health-care discussion folded into the competing narratives.

Several months ago, we happened upon horse racing’s Triple Crown as an imperfect framing metaphor. Health reform, the promising stallion known as ObamaCare, faced three distinct contests across 2012. The Supreme Court would decide the first, which it did in a July photo finish. The second leg is the presidential campaign and the critical races for Congressional control. This commentary is written with the Republican Convention, pre-scripted narratives and Clint Eastwood’s performance art behind us, and an unknown Democratic spectacle ahead. The election has been framed, perhaps more starkly than any in memory, by the competing philosophies of the candidates and the composition of the parties.

The final leg of the circuit, after the election, may well be more grueling, more complicated, and more decisive as a lame-duck Congress and a reelected or defeated President grapple with a long-term-deficit debate as well as spending, budget-sequester issues and taxing policies, all of which have been set aside during the campaign but with looming end-of-year deadlines. We’ll conclude 2012 with the post-election racing form in early November.

As our last installment noted, the Supreme Court’s decision to affirm the constitutionality of the Affordable Care Act contained nuance and surprise. Seen as a mandate, the requirement to purchase insurance coverage stretched the Commerce Clause too far, but framed as an exercise of the Congress’ taxing authority won a 5-4 affirmation. Moreover, Medicaid could be expanded to uniform national standards across the states, the Obama Care strategy to cover the poor, but only with affirmation by the states, absent fiscal coercion from Washington.

The Scaliaesque dissent offered by the Court’s four most conservative justices offered a resounding condemnation of national authority in a total rejection of the health-care law. Ruth Bader Ginsburg wrote with competing eloquence in defense of national initiatives to address intractable problems. Chief Justice John Roberts, conservative to the core, crafted an affirmation of the law while simultaneously advancing the argument for limiting future federal action. The Supreme Court’s decision in National Federation of Independent Business vs. Sebelius — which is how future Constitutional law books will refer to this decision — affirmed a health-care future chosen by the elected branches of government. But as importantly, the decision articulated with eloquence and passion the competing narratives of our young republic.

Students of American history and our national vision will, and should, read it.

With the campaign leg of our Triple Crown dashing from the starting gate into the first turn, eloquence and depth have been lost from the debate. Political campaigns are driven by intense repetition of words and images, fueled by the three “M’s”of modern politics: money, money, and money. Experience in advertising has affirmed that the more negative the combination of elements, the more lethal they are to the opponent. However an observer may evaluate ObamaCare as a policy, the descent from the Court’s grand visions to the campaign’s distortion is jarring.

Prior to the Court decision, we failed to anticipate that Roberts would turn to the taxing authority of Congress to decide the case, even though the argument was presented (if somewhat buried) before the Court. With perhaps equal lack of insight, we predicted that Governor Romney as the Republican nominee would avoid the health-care debate during the fall campaign; lest he remind his cadre of newly-acquired conservative supporters of his role as Massachusetts Governor leading the adoption of an ObamaCare look-alike for that state. Obama might raise the contrast, we thought, but Romney would deflect the issue.

With the selection of House Budget Chairman Paul Ryan, (R-WI) as the party’s nominee for Vice President, on the surface that prediction has proven wrong. By outsourcing much of the campaign’s policy choices to the “Ryan budget,” Romney solidified enthusiastic conservative support for the ticket but also handed Democrats a high-visibility target in the form of Ryan’s post-2023 “premium support / voucher” plan to convert the popular Medicare program from a guarantee of services for beneficiaries to the provision of financial support for beneficiaries to take into a competitive health-insurance marketplace.

When it first surfaced in 2011, Chairman Ryan’s plan appeared to Democrats as a political gift, altering Medicare which, along with Social Security, forms the core of the twentieth century Roosevelt/Johnson legacy that combine to give post-65-year-old Americans a base of financial support in their sunset years. Seniors had eluded Obama in 2008 and had been among the Republicans’ core swing supporters in their 2010 ascent to the House majority. The initial wave of voter reaction, including an unexpected victory by a Democratic candidate to fill a House vacancy in a previously Republican upstate New York seat, affirmed the Democratic view.

In the fall of 2012, Ryan and the Republicans see the argument differently. With Americans caught in a stagnant recovery, they would use the Medicare argument as part of a broader attack on an economic future in need of dramatic change. Tell current seniors, indeed those currently over fifty-five years of age, that you will continue to receive current Medicare benefits and not be affected by the new formulation. Bring Mom Ryan onto the stage to personalize the pledge of support. And continue to assert to younger supporters that fiscal imbalance will eventually erode your benefits under any circumstances. In the face of Democratic glee, they do the unexpected. They use the Ryan Medicare plan as a proxy for dramatic change and . . . Attack!

Ryan/Romney added a second theme to the battle cry. Channeling a charge made initially in 2010 by Congresswoman, later Presidential candidate, Michelle Bachmann (R-MN), the Republican mantra was expanded to assert that ObamaCare had stolen, diverted, swindled (choose your pejorative verb), $700 billion from the Medicare program as part of the Affordable Care Act. The number, initially set at $500 billion, was restated as $716 billion in a July 24, 2012 letter from the Congressional Budget Office to House Speaker John A. Boehner as the amount by which Medicare spending would increase in the next ten years, over and above existing estimates, should the Affordable Care Act be repealed.

That the Ryan budget would have assumed the same $716 billion dollars in Medicare savings even if the ACA expansions and improvements were repealed is lost in a room full of campaign advisors and, hocus-pocus: a negative ad is born: Obama is stealing grandma’s money to pay for Obama Care.  In the age of a modern American presidential campaign, reality is having a difficult time competing with narrative.

Beyond the budget implications, repeal of the ACA, called for by the Ryan/Romney ticket, would: eliminate the future insurance coverage of 30 million people, eliminate a series of prescription drug and preventive-care improvements for seniors, end insurance reforms including those enabling young people to remain on their parents policies through age 26, and eliminate the myriad initiatives to reduce cost growth of the American health-care system. Analysts have pointed out that since the Medicare provisions in the ACA reduce the rate-of-growth of insurance company outlays and payments to providers for medical care, cost sharing by Medicare beneficiaries (Paul Ryan’s mother, amongst all the others) would actually increase with repeal. The solvency of the Medicare Part-A Trust Fund (the part of the Medicare program that is funded through a portion of the Social Security tax and provides for hospitalization, hospice care and skilled nursing) would be shortened as a result. For all of the campaigning on swindled funds and Medicare bankruptcy, repealing the ACA would actually make maintaining solvency of Medicare in the coming decade a greater challenge. Everyone in the game of designing policy, on both sides of the aisle, of course, knows this.

Still the CBO says Medicare would spend more on seniors without the ACA, so money must have been stolen or improperly diverted. So states the Republican ticket, and with that assertion the campaign has descended into outright distortion. At Romney’s insistence, Ryan has removed these savings from his plan. They are saying: trust us; we won’t go near any projected Medicare savings (at least not any that we will mention before returning to Washington for the post-election budget session.) At that point, with the election over, it’s hard to assume that negotiators for either party would walk away from more than $700 billion in projected Medicare savings as part of a multi-trillion-dollar deficit-reduction target.

But these are campaign statements — and focus-group-tested confusion trumps the truth.

Not to be outdone in choosing caricature over accuracy, Democrats, without actually saying it, will do all they can to exploit the fear of current seniors that their benefits are at risk. Oddly, the real political impact of the Medicare argument has remained hidden. In the upcoming decade both Ryan and the President would seek, by whatever means, to slow Medicare spending growth to one-half of one per cent above the overall growth of the economy. By framing his more dramatic revision for implementation in 2023, Ryan has managed to conflate two entirely different decades in the debate.

The Ryan plan “protects” those over fifty-five years of age. And while Democrats build their case on the fear of change, they have yet to point out the deeper reality of Ryan to a moderately younger demographic. If you are younger than fifty-five years of age, you will experience most, in some cases all, of your remaining working career paying taxes to support the Medicare benefits of the baby-boom generation which precedes you, only to lose Medicare’s guarantee when you get to retirement.

A real challenge to Ryan would be to implement his plan in 2014, comparable with the full phase-in of the ACA. If Mr. Ryan believes that we need to face a different reality and if premium support is superior to defined benefits, then why not apply the argument to current policy choices? Said more succinctly: if this is such a good idea, why not share it with your mother, now? But even Joe Biden is unlikely to risk a hypothetical-policy debate that might undercut the Democrats’ well-tested line of “ending Medicare as we know it.” The scripts are set on both sides, and unless there is an unexpected hemorrhaging in the polling numbers, improvisation is frowned upon — as Mr. Eastwood recently discovered ten minutes too late.

Not surprisingly, while any alteration to the Medicare program is put off for ten years by the Republican alternative, their changes to Medicaid would take place in 2013. Medicaid is the system that provides health-care coverage to the poor. Currently it is a program jointly funded by both the federal and state governments, while each individual state administers the program’s usage and payment structures. The ACA, as we’ve discussed in previous installments of this series, transitions the program to one where there is a uniform standard of care and coverage by all states, along with a commitment that the federal government will pick up a large portion of the increased funding for the first ten years and beyond. The Ryan/Romney Medicaid alternative presumes a repeal of these provisions and issues sharply reduced funding to the states in the form of block grants. Rhetorically, this gives the states greater leeway in determining how to provide health-care coverage to their poor. In reality, it would result in sharply reduced benefits to participants in the program, and a greatly contracted number of individuals eligible for coverage.

In the wake of the Supreme Court decision in July, a number of Republican governors made clear that they simply rejected the idea of increased enrollment in Medicaid, even with between 90-100 percent federal support. While the distorted debate about Medicare’s future takes center stage, the broader reality of the campaign is between the imperfect insurance expansion of the ACA and an alternative view which rejects the idea that government should attempt to expand coverage at all.


As the campaign proceeds, in addition to the skirmish about Ryan’s Medicare plan, two themes are central to the contrasting views of the political parties. Democrats will affirm the coverage expansions of the ACA. The Republican campaign would repeal that effort, and attack expanded government initiatives not just practically, but philosophically. And the dimensions of that debate cannot be minimized. Consider that we will still have twenty to thirty million people in the United States uninsured with full implementation of the ACA, but twice or three times that number (increasing over the years) with its repeal and a change in Medicaid that alters the funding methodology to block grants.

The Republican ticket will focus on achieving hard caps on outlays in government programs as essential to budget discipline while understating the risk of shifting future costs to individuals or businesses through increased premiums or cost sharing. Republicans will argue that price competition will reduce costs. The ACA alternative envisions myriad reforms in the delivery and financing of care, thus reducing cost growth through efficiencies demanded in other sectors of the economy. Creating starker market incentives, say the Democrats, creates winners and losers, with benefits to the healthy and prosperous, but no place for the sick and struggling. And, say the Democrats, an effective policy must reduce the overall costs of health care, not simply cap expenditures by government.

The health care Triple Crown continues to play out in an increasingly broad context. In the first race of the season, ObamaCare’s Derby victory before the Court allowed the justices to write at length and with depth about our government and society. The track-conditions of this campaign Preakness couldn’t be more different. The harsh simplicity and brash distortion from both sides affirm a finding presented in a late-summer poll conducted by the Washington Post and the Kaiser Family Foundation. Labeled the Dimensions of Partisanship Survey, the sponsors tracked a strengthening of our identification with the beliefs of our respective political parties. To the surprise of no one watching this second race, we are becoming more starkly divided — not only on health care, but on the role of government, the separation or integration of church and state, our acceptance of social diversity, even our definition of community itself. We are divided, but also more strongly identified with the orthodoxies of our tribes. “Polarization is the new normal,” states the report. And that increased polarization is perhaps more troubling than any issue of this campaign season, including health care.


Jim Tallon is the president of the United Hospital Fund, a think tank in New York City. He served previously as Majority Leader of the New York State Assembly.

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